Every finding on record at Timbers of Jasper the

Based on observation, interview, and record review, the facility failed to ensure resident safety during transportation for 2 of 3 residents reviewed for dementia care. Locked memory care unit residents with a history of falls and/or behaviors were transported to outside appointments without being signed out and without adequate supervision. (Resident B, Resident C)Findings include:1. Observation on 7/8/26 at 9:40 A.M., Resident B was sitting up in a Broda (high back) wheelchair in common dining/activity area. A review of grievances on 7/8/26 at 10:30 A.M., included a concern dated 6/8/26 at 9:00 A.M. from a family member regarding Resident B not having a facility attendant during a transportation / Leave of Absence (LOA) appointment. Record review on 7/8/26 at 10:45 A.M., indicated Resident B's diagnoses included but were not limited to Alzheimer's disease, dementia, anxiety, and repeated falls. The most recent quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated the resident was rarely to never understood, cognition skills were severely impaired, was dependent for activities of daily living and mobility, and had one fall with injury since the previous assessment. Resident B's care plan included but was not limited to Resident has a history of attempting to climb out of Broda chair (created 04/16/2026), Resident has a history of standing quickly fromher chair and attempting to run, or attempting to crawl out of recliner (created 6/20/24), Resident often chooses to attempt to ambulate on her own, despite safety concerns. Resident cognition severely impaired which hinders safety awareness (created 5/21/24), and Resident is at risk for falls due to weakness, decreased mobility, impaired cognition, poor safety awareness altered awareness of immediate physical environment, impulsive, lack of understanding of one's physical and cognitive limitations, history of self transfers, history of rolling out of bed, and history of falling out of Broda chair (created 11/15/23). Progress notes included but were not limited to:4/5/26 at 5:09 P.M. - Resident fell unwitnessed out of chair in common area of memory care unit. cottage. Resident being transferred to ER via ambulance.4/15/26 at 6:30 A.M. - Resident restless and attempting to climb out of Broda chair. 4/24/26 at 5:18 P.M. - Resident restless and trying to climb out of Broda chair. 6/8/26 at 10:00 A.M. - Contracted transportation service arrived to facility at 7:50 A.M. to pick up resident for an appointment scheduled at 9:30 A.M Just before 8:15 A.M., [office name] contacted facility and stated that resident had arrived for scheduled appointment 90 minutes early. Facility staff left facility at 8:15 A.M. to sit with resident until resident's daughter arrived at appointment.Interview on 7/8/26 at 1:30 P.M., the Memory Care Social Service Assistant indicated facility staff typically went with the memory care residents to their outside appointments if a family member could not accompany the resident. On 6/8/26 Resident B was picked up for her appointment by a contracted transportation service approximately one hour early. A family member was expected to meet the Resident B at the appointment, however the resident was dropped off for the appointment prior to the family member arriving and without a facility staff member present. When the office notified the facility that Resident B had arrived without family or staff, the Memory Care Social Service Assistant left the facility to sit with Resident B until a family member arrived. The Memory Care Social Service assistant indicated staff and/or drivers did not typically sign the resident out of the facility for medical appointments and that the LOA sign out forms are typically used for family outings. Interview on 7/9/26 at 1:00 P.M., Facility Transport Driver 2 and Facility Transport Driver 3 indicated a memory care resident should not be left without a staff attendant or family member when being dropped off for an appointment. A review of Resident B's June, 2026 LOA sign out forms on 7/9/26 at 1:15 P.M. included no documentation of the resident being signed out for her appointment on 6/8/26. 2. Record review on 7/8/26 at 2:00 P.M., Resident C's diagnoses included but were not limited to dementia and Guillain-Barre syndrome. The most recent quarterly MDS assessment dated [DATE], indicated the resident had severely impaired cognition. Resident C's care plan included but was not limited to, Resident frequently calls out for help and requests staff assistance to transfer. Upon staff approach and attempt to assist with transfers, resident becomes resistant and may throw self backward into chair or bed, yell out in pain, refuse movement, and verbally protest assistance. Behaviors place resident at an increased risk for falls, injury to self, functional decline, and injury to caregivers (created 5/11/26), Resident is at risk for falls due to: Alzheimer's disease which requires direction and cues from staff, takes 2 or more highfall risk medications, lack of understanding of one's physical and cognitive limitations,impulsive and altered awareness of immediate physical environment (created 6/10/25).Nurses progress notes included, but were not limited to; 6/14/26 at 1:17 P.M., Resident noted to be standing per self while staff were assisting other residents. Resident was trying to transfer self when his legs buckled and resident landed on his knees.Resident C's June & July Medication Administration Record / Treatment Administration Record (MAR/TAR) indicated the resident had routine outside appointments scheduled 6/9/26, 6/10/26, 6/11/26, 7/7/26, 7/8/26, and 7/9/26. The resident's record contained no documentation that included who accompanied the resident to the scheduled outside appointments. Interview and observation on 7/9/26 at 9:15 A.M., Facility Transportation Driver 3 indicated she would be transporting Resident C to his appointment and that Activity Staff 2 would accompany Resident C at the appointment. Facility Transportation Driver 3 indicated she would also accompany residents while at their appointments, at times. Facility Transportation Driver 3 then signed the resident out on the LOA sign out form at the nurse's station and assisted Resident C out of the Memory Care Unit for his outside appointment. Interview on 7/9/26 at 12:00 P.M., the Director of Nursing (DON) indicated Activity Staff 2 was not a CNA or licensed nursing staff. A review of Resident B's June & July, 2026 LOA sign out forms on 7/9/26 at 1:15 P.M. included no documentation of the resident being signed out for his appointment on 6/9/26, 6/10/26, 6/11/26, 7/7/26, or 7/8/26. The resident was signed out by facility staff on 7/9/26. On 7/8/26 at 10:09 A.M., the Facility Administrator supplied a facility policy titled, [Company Name] Facility Bus/Van Transportation Guidelines, dated 12/2025. The policy included, .3. Requirements for resident transportation . g. A nursing assistant or licensed nurse must accompany any resident that has physical, mental, or developmental limitations as determined by the [Interdisciplinary Team] IDT Team .On 7/9/26 at 1:16 P.M., the Facility Administrator supplied a facility policy titled, Leave of Absence (Personal Leave & Medical Appointment), dated 06/2019. The policy included, It is the policy of this facility that continuity of care and safety during resident Leave of Absence will be maintained . 5. The responsible person needs to sign the resident in and out of the facility on the Leave of Absence form prior to exiting the facility and upon return . 6. The licensed nurse will document resident status upon leave from the facility and upon return from leave, and any other pertinent information .This citation relates to intake 3039566.410 IAC 16.2-3.1-45(a)(1)410 IAC 16.2-3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure a sanitary environment to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents observed for incontinence care. Hand hygiene was not done, gloves were not changed between clean and dirty tasks, and the soiled incontinence pad was laid on the bedsheet. (Resident 45)Finding includes:On 1/29/26 at 8:57 A.M., incontinence care was observed on Resident 45 performed by Certified Nurse Aide (CNA) 14 and CNA 22.CNA 14 used Antibacterial Hand Rub (ABHR) and put gloves on. Then she used the bed control to put the bed down, touched the privacy curtain, grabbed the foot board of the bed, and then grabbed the resident's call light. CNA 22 did not sanitize hands before putting on gloves, used the bed control to lower and raise the bed and moved the call light. Both CNAs pulled down the resident's bed sheets and blanket. CNA 14 unfastened the resident's incontinence pad and held the resident on her left side while CNA 22 grabbed wipes and a clean incontinence pad from inside the bedside cabinet. CNA 22 wiped the surface of the buttocks with a wipe and then pulled out the soiled incontinence pad from under the resident and placed the soiled brief at the foot of the bed on the fitted sheet. CNA 22 grabbed the clean incontinence pad and pushed it under the resident using soiled gloves on the inside of the incontinence pad. The resident was assisted to roll on to her back and CNA 22 held the resident's leg with soiled glove. CNA 14 pulled the clean incontinence pad out from under resident and then wiped the outside of the resident's vaginal area. Both CNAs fastened the clean incontinence pad. CNA 22 opened the bedside cabinet and put the wipes inside. CNA 22 grabbed the soiled incontinence pad from the resident's bedsheet. Both CNAs pulled the sheets and blanket over the resident with same soiled gloves. CNA 14 pushed the bed back against the wall, adjusted the bed with the bed control, pulled the sheets and blanket over the resident, and placed the call light within reach with same soiled gloves. CNA 14 took off gloves but hand hygiene was not performed. CNA 14 grabbed a purple shirt from the resident's bed and placed it back into the closet. CNA 22 performed hand washing with a 13 second lather.During an interview on 1/30/26 at 8:53 A.M., the Infection Preventionist (IP) indicated staff should sanitize before putting on gloves, should sanitize and change gloves before touching resident after touching items, would expect to have all supplies first, and not lay a soiled incontinence pad on resident bedding. Staff should sanitize hands and change gloves after providing care before touching resident's items.On 1/30/26 at 1:30 P.M., a current Hand Hygiene Policy, last revised July 2022, was provided by the Administrator and indicated, . Vigorously rub hands for at least 20 seconds including palms, back of hands, between fingers, and wrists . On 1/30/26 at 1:30 P.M., a current Perineal Care Policy, last revised March 2023, was provided by the Administrator and indicated, . 3. Gather supplies including plastic bag at foot of bed or on chair for soiled linens. 4. Perform hand hygiene. 5. [NAME] gloves. 6. Assist resident to supine position and drape resident, if needed . 8. if able. Assist resident to spread legs and lift knees, if possible . Females: 12. Separate labia and wash urethral area first. 13. Wash between and outside labia in downward strokes. 14. Alternate from side to side wipe from front to back and from center of perineum outward. 15. Use a clean area of the washcloth with each wipe . 22. Assist resident to turn onto side away. 24. Clean anal area from front to back, using a clean area of washcloth with each wipe . 27. Assist resident to turn onto back and undrape resident. 28. Doff gloves. 29. Perform hand hygiene.3.1-18(b)3.1-18(l)

Based on interview and record review, the facility failed to ensure medications were given as ordered and a discharged resident was sent home with the correct medication for 1 of 3 closed records reviewed. A blood thinner was not given as ordered, and a resident was sent home with another resident's medications at discharge. (Resident B)On 1/30/26 at 4:00 P.M., the Administrator provided an incident form that indicated on 9/19/25 when Resident B was discharged from the facility, medications belonging to another resident had been sent home with them. The form indicated the facility attempted to contact Resident B's representative several times daily until 9/25/25 when contact was made and the medication was brought back to the facility the same day. On 1/29/26 at 11:32 A.M., Resident B's clinical record was reviewed. Resident B was admitted to the facility on [DATE] and discharged on 9/19/25. Diagnosis included, but was not limited to, fracture of the right lower leg. The most recent admission minimum data set (MDS) assessment, dated 9/11/25, indicated no cognitive impairment and no behaviors. Resident B required substantial to maximal assistance (helper does more than half the effort) with toileting, showering, and transfers. Physician orders included, but were not limited to: enoxaparin (a blood thinner) syringe; 30 mg (milligrams)/0.3 mL (milliliters); administer 30 mg/03 mL; subcutaneous, dated 9/5/25 and discontinued 9/19/25. Resident B's Medication Administration Record (MAR) indicated enoxaparin had not been given on the following days: 9/14/25 unavailable 9/15/25 unavailable, awaiting delivery 9/16/25 unavailable 9/18/25 blank, no note A discharge progress note, dated 9/19/25, indicated Resident was discharged home with all medications, signed by Licensed Practical Nurse (LPN) 3. On 1/30/26 at 10:29 A.M., the Emergency Drug Kit (EDK) machine was observed with LPN 5. The EDK contained enoxaparin 30 mg/0.3 mL syringe. At that time, LPN 5 indicated the machine was kept stocked, and if staff noticed it was running low on something, they would contact the pharmacy and they would be in either that day or the next day to restock it. LPN 5 also indicated when a resident was discharged with medications, two nurses would check that the medications sent home were correct and both would sign the discharge summary form. On 1/30/25 at 11:43 A.M., the Director of Nursing (DON) indicated LPN 3 was no longer on staff at the facility. At that time, she provided the discharge summary form for Resident B. The form was signed on 9/19/25 by Resident B's representative and one nurse, LPN 3. On 1/30/26 at 1:30 P.M., the Administrator provided a current Medication Administration competency form, last revised 4/25, that indicated medications should be administered as ordered. This deficiency relates to Intake 2622137. 3.1-25(a)

Based on observation, interview, and record review, the facility failed to implement the plan of care for a cognitively impaired resident at high risk of falling for 1 of 1 residents reviewed for falls. Fall care plan interventions were not in place. (Resident 14)Finding includes:On 1/28/26 at 3:33 P.M., Resident 14's clinical record was reviewed. Diagnoses included, but were not limited to, Alzheimer's disease, dementia without behaviors, and Guillain-Barre syndrome. The most recent quarterly Minimum Data Set (MDS) assessment, dated 1/21/26 indicated Resident 14's cognition was severely impaired, partial to moderate assist from staff (resident performs over half the effort) for bed mobility and transfers, and substantial to maximum assistance of staff (staff performs over half the effort) for toileting and bathing, and the resident has had two or more falls with no injury and 2 or more falls with injury (not major) since the last MDS assessment, dated 11/3/25.A current Fall Care plan, last revised 1/20/26, included, but were not limited to, the following interventions:keep urinal in reach, initiated 11/3/25bed in lowest position when resident in bed, initiated 11/12/25remove wheelchair from common area when resident in recliner, initiated 11/17/25On 1/28/26 at 10:22 A.M., Resident 14 was observed laying in his bed that was not in the lowest position. A urinal was not observed in the resident's room.On 1/28/26 at 2:47 P.M., Resident 14 was observed sitting reclined in a recliner in the common area of the locked dementia unit. A wheelchair was observed next to him on his left side. On 1/29/26 at 8:52 A.M., Resident 14 was observed asleep in his bed. A urinal was not observed in the resident's room.On 1/29/26 at 2:45 P.M., Resident 14 was sitting in a recliner in the common area of the locked dementia unit. A wheelchair was observed next to him on his left side.During an interview on 1/30/26 at 2:02 P.M., Licensed Practical Nurse (LPN) 32 indicated fall interventions should be followed. A urinal should be within reach when Resident 14 was in bed and wheelchairs should not be in reach in the common area while he was in the recliner.On 1/30/26 at 2:23 P.M., a current Care Plan Policy, last revised October 2025, was provided by the Administrator and indicated, It is the policy of this facility that each resident will have an interdisciplinary comprehensive person-centered care plan developed and implemented . 3.1-35(a)

Based on observation, interview, and record review, the facility failed to ensure medications were stored safely or under proper temperature controls for 2 of 15 residents sampled for medications on the floor, and 2 of 2 medication storage rooms. (Resident D, Resident M, 100 Hall Medication Storage Room, 300/400 Hall Medication Storage Room) Findings include: 1. On 10/15/24 at 9:19 A.M., the 100 Hall Medication Storage Room medication refrigerator log was observed to be missing temperatures. The 100 Hall medication refrigerator log lacked a temperature on days from 10/1/24 through 10/15/24. The 100 Hall medication refrigerator log was missing a temperature for night shift on 10/1/24, 10/2/24, 10/4/24, 10/5/24, 10/6/24, 10/7/24, 10/9/24, 10/10/24, 10/12/24, 10/13/24, and 10/14/24. At that time, QMA (Qualified Medication Aide) 11 indicated that temperatures were taken twice a day and logged for medication refrigerators. The 300-400 Hall medication refrigerator log was observed to be missing temperatures for day shift from 10/2/24 through 10/15/24. The log was observed to be missing a temperature for night shift on 10/10/24. A note on the temperature log indicated Medications must be kept 36-46 degrees F [Fahrenheit] in Refrigerator. The temperatures on night shift were recorded as the following: 10/1/24 30 10/2/24 32 10/3/24 28 10/4/24 20 10/5/24 30 10/6/24 33 10/7/24 32 10/8/24 32 10/9/24 30 10/11/24 32 10/12/24 34 10/13/24 34 During an interview on 10/17/24 at 2:35 P.M., the Administrator indicated the temperature in medication refrigerator should be in the range that was in the policy. Policy for Medication Storage indicated temperature range should be 36-46 degrees Fahrenheit. The Administrator indicated he would ask maintenance if there had been any work orders for the refrigerator. During an interview on 10/17/24 at 3:14 P.M., the Administrator indicated maintenance had not worked on the refrigerator, but he checked the temperatures and it was working correctly. 2. On 10/21/24 at 8:56 A.M., an oval peach colored pill was observed lying on the floor next to bottom of bed of Resident M. At that time LPN 15 indicated the pill was Namenda 5 mg which Resident M took twice a day. She verified the identity of the pill with the pill card in the medication cart. LPN 15 indicated she didn't know why the pill was on the floor or how long it had been there. She indicated she stayed with resident while he took his medication. On 10/21/24 at 10:06 A.M., Resident M's clinical records were reviewed. Diagnosis included, but was not limited to dysphagia, oropharyngeal phase, and dementia, unspecified severity. The most recent Significant Change in Condition MDS (Minimum Data Set) assessment, dated 10/3/24, indicated Resident M had moderate cognitive impairment and required extensive assistance of two for bed mobility, transfers and toilet use and supervision with set up for eating. Physician orders included, but was not limited to the following: memantine tablet (Namenda) (medication used to treat dementia) 5 mg; oral Twice A Day 07:00 AM - 11:00 AM, 07:00 PM - 11:00 PM, dated 9/20/2024. Review of the MAR (Medication Administration Report) for 10/20/24 and 10/21/24 indicated memantine had been given on 10/20/24 at 7:00 P.M. - 11:00 P.M. and on 10/21/24 from 7:00 A.M. - 11:00 A.M. Care Plan: Resident frequently spits his medication, pockets his medications in his mouth and spit his food out, Interdisciplinary Team (IDT) discussed crushing medications and resident declined Start date: 9/25/24 Approach Start Date: 9/25/24 Staff to encourage resident not to spit food/medications out or hold food in mouth. On 10/21/24 at 9:46 A.M., the Director of Nursing (DON) indicated Resident M would pocket medications and food sometimes, and an action plan had been started to make sure all residents were taking their medications when administered. At that time, she indicated no other residents had that concern. She indicated she had met with all staff administering medications on all shifts individually to go over the action plan. 3. On 10/21/24 at 9:11 A.M., Resident D's room was observed. A small pink round pill was observed on the floor under the bedside table with marking 1 on one side, and 30 on the other. At that time, Licensed Practical Nurse (LPN) 17 indicated it was a 10mg (milligram) rosuvastatin, which Resident D took once a day at around 4:00 P.M. On 10/21/24 at 10:02 A.M., Resident D's clinical record was reviewed. Diagnosis included, but were not limited to, diabetes mellitus, anxiety, and depression. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 8/18/24, indicated no cognitive impairment. Resident D required setup assistance with eating, and substantial to maximum assistance with showering, toileting, and transfers. Current physician orders included, but were not limited to: Crestor (rosuvastatin) 10mg once a day, at 5:00 P.M., dated 10/17/23. Resident D's Medication Administration Record (MAR) for October 2024 indicated the last time rosuvastatin was administered was at 5:00 P.M. the previous evening, 10/20/24. On 10/21/24 at 9:23 A.M., LPN 15 indicated when passing medications, staff should stay with the resident to make sure the pills were taken, and if one dropped, it should be put into the drug buster and a new pill administered. On 10/21/24 at 10:14 A.M., an action plan for medications on the floor was provided that was initiated 10/15/24. Actions to be taken from staff included, but were not limited to, asking resident to open mouth after taking medications to make sure they were swallowed, staff to offer additional water when taking medications to ensure they were swallowed, and guiding the resident's hand to mouth when taking medications. On 10/21/24 at 10:27 A.M., the DON provided a current General Dose Preparation and Medication Administration policy, dated 4/30/24, that indicated If a medication which is not in a protective container is dropped, facility staff should discard it according to facility policy . Observe the resident's consumption of the medication(s) On 10/17/24 at 1:30 P.M., a Medication Storage policy, dated August, 2022 was provided by the Administrator which indicated Temperature is maintained between 36-46 degrees Fahrenheit. Daily temperature logs must be maintained and visible. This citation relates to Complaint IN00445700. 3.1-25(m) 46882

Based on interview, observation, and record review, the facility failed to ensure food was stored and prepared safely in accordance with professional standards for food service for 1 of 2 kitchen observations. Foods were not labeled correctly, food was stored uncovered, and the facility failed to dispose of outdated food. Findings include: On [DATE] at 9:13 A.M., the following was observed in the kitchen: Freezer in the kitchen: -- 5 undated, uncovered, and unlabeled bowls of pink ice cream -- 5 covered bowls undated and unlabeled. Refrigerator in the kitchen: -- clear container with cheese that had a label printed on [DATE] with a discard date of [DATE] -- applesauce with an opened date of [DATE] and a discard date of [DATE] -- clear container of lettuce undated and unlabeled -- 3 trays of fruit with several bowls uncovered on all 3 trays -- silver container with hotdogs and hamburgers undated and unlabeled -- silver container with an unknown substance that was undated and unlabeled Walk in freezer -- apple roasted pork prepared on [DATE] with a discard date of [DATE] During an interview on [DATE] at 11:30 A.M., the Dietary Manager indicated if there are multiple items of the same food, staff only placed a label on one time. All items should be covered and all staff is required to dispose of expired items, and she does a morning walk through to discard of expired items. On [DATE] at 1:34 P.M., the Administrator provided a current Food Storage policy, reviewed ,d+[DATE], that indicated, .Leftover prepared foods .are to be stored in covered containers or wrapped securely. The food must clearly be labeled with the name of the product, the date it was prepared, and marked to indicate the date by which the food shall be consumed or discarded .Frozen Foods .should be covered or wrapped tightly, labeled, and dated with the date the item is being placed in the freezer . 3XXX,d+[DATE](i)(2) 3XXX,d+[DATE](i)(3)

Based on interview and record review, the facility failed to ensure staff thoroughly and completely assessed a resident after a fall with head injury, failed to ensure the fall was effectively documented with specific fall details to ensure interventions were immediately implemented to prevent further falls, failed to effectively monitor the neurological status of the resident after a subdural hematoma was identified for 1 of 3 residents reviewed for falls. (Resident D) This deficient practice resulted in the resident experiencing right-sided shaking, slurred speech, altered mental status, and an active brain bleed that required a craniotomy to repair. Finding includes: A facility investigation of Resident D's fall on 6/13/24 included a handwritten, untimed, note signed by Therapy Assistant 4, dated 7/2/24. The note indicated that Resident D was walking with a staff member on 6/13/24 and went to kick a ball and fell . Nursing staff came to take the residents vital signs and staff assisted the resident up. Resident D stated she was fine and continued the walk. The investigation did not include new fall interventions were implemented to prevent further falls. On 8/27/24 at 9:45 A.M., a clinical record review indicated Resident D's diagnoses included, but were not limited to, hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting right dominant side, repeated falls, seizures, and weakness. A Quarterly Minimum Data Set (MDS) assessment, dated 6/17/24, indicated the resident had no cognitive impairment, required supervision of one staff member while walking, had one-sided impairment to both upper and lower extremities, and the resident had not experienced a fall during the assessment period. A care plan for fall risk, dated 6/25/24, included interventions of call light in reach (8/18/23), environmental changes (8/18/23), non-skid footwear (8/18/23), personal items in reach (8/18/23), therapy screen (8/18/23), bed in lowest position (8/23/23), 42-inch bed with bolster for larger sleep surface to provide tactile boundaries (8/28/23), bright colored tape on call light (9/15/23), non-skid strips in front of toilet (12/8/23), sign in bathroom to remind resident to ask for assistance (12/8/23), and non-skid strips from bed to dresser (12/26/23). The care plan for fall risk and the comprehensive plan of care, dated rom 6/13/24 through Resident D's discharge date of [DATE] did not include documentation to indicate the resident experienced an actual fall on 6/13/24 or to show interventions to prevent further falls were immediately implemented after the fall. An untimed, handwritten nurse's note signed by LPN 9, dated 6/13/24, indicated that Therapy Assistant 4 and Resident D approached her during medication pass to make aware that Resident D had lost footing in the therapy gym with resident falling against a door. LPN 9 indicated Resident D stated she did not want her emergency contact, or the DON notified of the fall because she didn't want a setback of being discharged from facility. Neurological checks were initiated. Resident was able to move bilateral upper extremities and bilateral lower extremities without complaints of pain or discomfort. No noted injuries. Resident D's clinical record contained no documentation in physician visit notes or nurse's progress notes that notification to the resident's physician had been made following the fall on 6/13/24. A handwritten neurological check form, dated 6/13/24, and signed by LPN 9 indicated Resident D did not demonstrate signs or symptoms of a significant head injury following the fall on 6/13/24. A handwritten note signed by the DON, dated 6/28/24, indicated the DON spoke with Resident D after being made aware on 6/28/24 that the resident had a fall in the therapy gym that was not reported. Resident D stated she went to kick a ball and fell and hit her head but denied pain. Resident D indicated that she did start having headaches at some time after the fall. Resident D indicated that she was able to get up immediately following the fall and requested that the nurse not be notified. Resident D indicated that Therapy Assistant 4 did notify LPN 9 and Resident D requested that the nurse not notify emergency contacts due to a fear that the fall would slow her progress of discharging to an assisted living arrangement. The note did not include sufficient documentation to determine when the resident's headaches began, but indicated the resident was feeling fine up until 6/28/24 when the headaches worsened. The note indicated the physician was updated about the fall on 6/13/24 and worsening headaches and a Computer Tomography (CT) scan was ordered. An untimed, handwritten note signed by LPN 9, dated 7/2/24, indicated Therapy Assistant 4 and Resident D informed her Resident D had stumbled while walking with supervision of Therapy Assistant 4 in the therapy room and hit the back of her head on the therapy door. Resident D stated she was fine and requested that emergency contacts not be informed of the fall. Neurological checks were initiated. Upon being busy this nurse left her shift without completing fall event. During an interview on 8/27/24 at 11:45 A.M., the Facility Administrator and Director of Nursing (DON) indicated that Resident D did experience a fall event on 6/13/24 while ambulating in the physical therapy room with Therapy Assistant 4. Resident D's nurse was notified of the fall and 15-minute neurological checks and vitals were completed by LPN 9. Resident D was in the process of finding placement and moving out of the facility and requested that the fall not be reported for fear that the fall may alter upcoming plans to move out of the facility. The DON could not indicate why LPN 9 failed to complete the facility's fall protocol, including initiation of a new fall intervention, notification to the physician, or documentation of the fall in the resident's clinical record. A CT scan of Resident D's head, dated 7/8/24 and electronically signed at 8:21 A.M., included study results indicated by chronic headaches. Findings included, Brain: Left-sided subdural hematoma measuring 14 [millimeters] mm in maximal thickness with some areas of hypodensity (abnormality that appears on CT scans that indicate possible open or fluid-filled spots) along the lower margins. Mild left-to-right midline shift (when the natural centerline of the brain is pushed to one side) measuring approximately 5 mm . Conclusion: Left-sided subdural hematoma with mild left-to-right midline shift is either acute on subacute or subacute . The comprehensive care plan, progress notes, neurological assessments, and event reports, dated from 7/8/24 through 7/17/24, did not include documentation to indicate a plan of care was developed related to the subdural hematoma, interventions were implemented to evaluate and monitor the neurological status of Resident D, interventions to prevent further falls were implemented, or attempts were made to set-up a neurology consultation. Nurse's progress note included the following: A note electronically signed by LPN 9, dated 7/18/24 at 12:54 P.M., indicated that a call was placed to neurosurgeon due to resident's results from recent CT scan of head with requested information sent to the neurosurgeon to evaluate. Neurology office indicated they would notify the facility if surgeon will accept the patient. The nursing notes, dated from 7/19/24 through 7/21/24, did not include documentation to indicate interventions were implemented to prevent further falls, a plan of care was developed related to the subdural hematoma, interventions were implemented to evaluate and monitor the neurological status of Resident D, or attempts were made to set-up a neurology consultation. A note electronically signed by LPN 9, dated 7/22/24 at 3:04 P.M., indicated a call was placed to neurosurgeon's office. Office indicated they are still reviewing referral at that time. The nursing notes, dated from 7/22/24 through 7/23/24, did not include documentation to indicate interventions were implemented to prevent further falls, a plan of care was developed related to the subdural hematoma, interventions were implemented to evaluate and monitor the neurological status of Resident D, or attempts were made to set-up a neurology consultation. A nursing note, dated 7/24/2024 at 7:30 A.M., indicated Resident D was not able to follow directions, had slurred speech, exhibited seizure-like activity, and the resident's vital signs were within normal limits. The note indicated the physician was notified and a new order was received to send the resident to Hospital 1. A nursing note, dated 7/24/2024 at 9:26 A.M., indicated Hospital 1 notified the facility the resident was transferred to Hospital 2 because active bleeding on the brain was identified. An untimed primary physician's facility visit note, dated 7/24/24, indicated Resident D experienced headaches, a subdural hematoma was identified, and a neurological consultation was pending for insurance approval. The note indicated while waiting for the approval, Resident D was alert, but developed right-sided shaking, slurred speech, and altered mental status. The note did not include documentation to indicate the facility effectively monitored the neurologic status of Resident D while the insurance approval was pending. A Medical Doctor (MD) acute visit note, dated 7/24/24, indicated Resident D had experienced a fall on 6/13/24. The note did not include documentation to indicate when the physician was notified of the fall or to show the facility effectively monitored the neurologic status of Resident D while the insurance approval was pending. The event reports, dated from 6/12/24 through 7/24/24, did not include documentation related to the fall on 6/13/24. Notes from Hospital 2, dated 7/25/24 at 10:28 A.M., indicated patient arrived at the Emergency Department from another Hospital 1 for an enlarging subdural hematoma. Emergency Medical Services (EMS) reported the original subdural hematoma was found on CT scan on 7/8/24. The notes included, Plan is for right craniotomy (surgical procedure that involves removing a portion of the skull to access the brain) for evacuation of [subdural hematoma] SDH . During an interview on 8/28/24 at 10:30 A.M., RN 6 indicated following a resident fall, the nurse should complete a full assessment including vital signs, skin assessments and range of motion. If resident is able and no apparent injuries, assist resident up. If fall is unwitnessed or if it was known that resident had hit their head, complete neurological checks every 15 minutes, which are documented by hand on a neurological check sheet. The nurse should notify the responsible party, the physician, and the DON of the fall event, document the fall in progress notes and create a new intervention to help prevent the fall from occurring again. On 8/28/24 at 10:00 A.M., the Facility Administrator supplied a facility policy titled, Fall Management Policy, dated 03/2024. The policy included, .Post Fall: Any resident experiencing a fall will be assessed immediately by the charge nurse for possible injury and necessary treatment will be provided . b. Staff member will document notification and actions taken in the clinical record . If there are no injuries, notify the physician by the end of the shift . a fall event will be initiated as soon as the resident has been assessed and cared for. a. The report will be completed in full to identify possible root cause of the fall and provide immediate interventions. All falls will be discussed by the interdisciplinary team [IDT] at the 1st clinical meeting after the fall to determine root cause and other possible interventions to prevent future falls. a. The fall event will be reviewed by the team. b. IDT note will be written. c. The care plan will be reviewed and updated. d. Fall event charting will be initiated post fall. On 8/28/24 at 11:30 A.M., the Facility Administrator supplied a facility policy titled IDT Comprehensive Care Plan Policy, dated 08/2023. The policy included, .Create an organized, resident-centered review on a routine basis to improve communication with residents, resident families and/or representative regarding the resident goals, total health status, including functioning status, nutritional status, rehabilitation and restorative potential . cognitive status, psychosocial status, sensory and physical impairments, as well as care services provided to maintain or restore health and well-being, improve functional level or relieve symptoms. The National Institute of Health, National Library of Medicine indicated the treatment/management of a subdural hematoma includes, .After stabilization and monitoring of the patient, a secondary plan of care should follow. The management must include the involvement of neurosurgery and neurological consultation with a consensus on the injury and a determination of the immediate and long-term consequences . This citation relates to complaint IN00440417. 3.1-37(a) 3.1-37(b)

Based on observation, interview, and record review, the facility failed to ensure resident safety during transportation for 1 of 3 residents reviewed for accidents. A resident was improperly loaded onto a transportation vehicle lift causing the resident to fall backwards from a wheelchair onto the lift platform. (Activity Assistant 3, Resident B) Finding includes: During a review of facility reported incidents on 6/19/24 at 10:35 A.M., an incident that occurred on 6/3/24 at 2:45 P.M., indicated that Resident B was being transferred out of the facility transportation van and fell off the lift. Resident B was sent to the emergency room and received eight sutures to the right shin. During an observation and interview on 6/19/24 at 11:00 A.M., Resident B was sitting in her wheelchair in the dining room. Resident B indicated that she had fallen off of the facility transportation vehicle when the vehicle lift was not out properly. Resident B indicated she needed 8 stitches to her right leg and thinks she landed on a metal part of the lift which cut her leg. Resident B indicated the driver of the transportation vehicle had assisted her with the lift before and had always been able to do it by herself, calling the incident a freak accident. During record review on 6/19/24 at 11:15 A.M., Resident B's diagnoses included, but were not limited to, morbid obesity, muscle weakness, and unsteadiness on feet. Resident B's most recent annual MDS (Minimum Data Set) assessment, dated 5/23/24, indicated that the resident had no cognitive impairment, used a wheelchair for mobilization, and required partial to moderate assistance in the wheelchair. Resident B's nurse's progress notes included, but were not limited to the following: - On 6/3/24 at 7:20 P.M., Resident B returned to the facility post fall while at appointment. Resident was sent to emergency room from appointment due to the fall. Resident complained of pain to right lower extremity which was noted to have a laceration. Eight sutures were applied to the laceration. - On 6/4/24 at 5:02 P.M., IDT (Inter-disciplinary team) review, Resident B was on the facility bus being transferred onto the lift to be taken off the bus. Resident had fallen off the lift and sustained a laceration to the right lower extremity. Interventions put into place to address the root cause of fall included; ensure resident is secure on lift and ensure resident wheelchair brakes are locked and staff education on use of lift and securement of items. Bus was inspected with no mechanical issues found. During a review of the facility's investigation into the incident on 6/19/24 at 11:30 A.M., a signed written statement by Activity Assistant 3, dated 6/5/24, included, on 6/3/24, Activity Assistant 3 and Resident B arrived at at appointment at 2:10 P.M. on facility bus. Activity Assistant 3 parked bus, engaged, emergency break, proceeded to the back door, and lowered the mechanical lift. Activity Assistant 3 rode the lift up and unbuckled Resident B and took the restraints off, then moved from the back of the bus to the front of the bus from inside the bus, removed the restraints and started backing resident out of bus onto the lift. Activity Assistant 3 noticed the mechanical lift was no longer all the way up. Activity Assistant 3 tried to pull Resident B back inside the bus but was not strong enough to pull her back in or hold her in place. Resident B, while in wheelchair, went off backwards. Activity Assistant 3 got off the bus and spoke to Resident B who was alert and oriented, then ran inside for help. Nurses came out and assessed Resident B and Emergency Medical Services were called. Resident B was loaded into ambulance and taken to hospital for evaluation. On 6/19/24 at 11:35 A.M., the DON (Director of Nursing) supplied a facility policy titled, Transportation, and dated 11/2015. The policy included, .Requirements for resident transportation: 1. The driver must complete and document pre-trip inspections of the bus/van prior to resident transport . During an interview and observation on 6/19/24 at 1:40 P.M., Activity Assistant 3 indicated that they completed a pre-trip inspection but did not document the inspection and do not use a check off sheet or inspection form to complete. Activity Assistant 3 then demonstrated what had happened on 6/3/24 while attempting to unload Resident B from the facility van/bus. Activity Assistant 3 indicated the lift was raised to allow her to get up in the back of the bus, however, when Resident B was being pushed backward onto the lift the lift had lowered due to an unknown reason to approximately six inches above the ground. This caused the metal plate that spanned the gap between the back of the van to the lift to rotate vertically, leaving a gap between the plate and the van. Activity Assistant 3 indicated Resident B's wheelchair went back into the gap and then flipped backwards allowing Resident B to fall an additional one foot onto the metal lift platform where she received a laceration to her right shin. Activity Assistant 3 indicated not knowing how the lift lowered after she had rode the lift up to the back of the van and indicated that the control may have been inadvertently pressed while getting around Resident B to detach the safety straps. During an interview on 6/19/24 at 1:55 P.M., the Maintenance Director indicated that the van and lift were inspected following the incident on 6/3/24 and that no mechanical issues were found and indicated that Resident B's fall was due to Resident B being improperly loaded onto the lift. On 6/20/24 at 11:21 A.M., Regional Nurse 5 supplied a facility policy titled Fall Management Policy, dated 3/2024. The policy included, It is the policy of [Facility] to ensure residents residing within the community have adequate assistance to prevent injury related falls. This citation relates to Complaints IN00436159 and IN00436199. 3.1-45(a)(1) 3.1-45(a)(2)

Based on interview, and record review, the facility failed to ensure the plan of care was implemented for 1 of 3 residents reviewed for ADL (activities of daily living) care provided. A resident was not assisted by two staff members during a transfer during incontinence care per the resident's plan of care. (Resident D, Resident C) Finding includes: During an interview on 2/6/24 at 10:35 A.M., Resident D indicated that they had reported CNA 9 for punching her in the stomach while providing care. Resident D indicated that CNA 9 transferred her from her wheelchair to her bed using a Hoyer mechanical lift prior to providing incontinence care. Resident D indicated that CNA 9 slipped and accidentally hit her stomach while providing care. During record review on 2/6/24 at 11:30 A.M., Resident D's diagnoses included, but were not limited to unspecified multiple injuries, person injured in unspecified motor vehicle accident, chronic pain, displaced commuted fracture of right patella, fracture of sternum, fracture of unspecified forearm, and fracture of right lower leg. Resident D's most recent Admission MDS (Minimum Data Set) dated 12/23/23, indicated the resident's cognition was moderately impaired, had upper extremity impairments to both sides, had lower extremity impairments to 1 side, required substantial to maximum assistance to roll left and right, and was dependent with form bed to chair. Resident D's physician orders included, but were not limited to; activity level: up as needed with two person assist (started 12/17/23). Resident D's care plan included, but was not limited to; Resident requires assistance with ADLs including bed mobility, transfers, eating and toileting related to: impaired mobility, recent motor vehicle accident, with multiple fractures, pain. An intervention included, two assist with transfers (started 12/18/23). During a review of facility reported incidents on 2/6/24 at 11:00 A.M., a facility reported incident dated 1/30/24 included that Resident D told Resident C that CNA 9 hit her in the stomach. During a review of the facility's investigation into the allegation involving an incident between Resident D and CNA 9, a typed statement signed by Resident C and dated 1/30/24, included, [CNA 9] was observed by [Resident C] using the Hoyer on room mate [Resident D] alone . A written interview between the facility administrator and DON (director of Nursing) and CNA 9, signed and dated 1/30/24, included, .[CNA 9] stated he used the Hoyer to transfer [Resident D] form (wheelchair) to bed. He stated she was wet (and) he changed her in bed During an interview on 2/6/24 at 1:45 P.M. LPN 8 indicated she was Resident D's nurse the date of 1/30/24 when an allegation of abuse was made against CNA 9. LPN 8 indicated she was unaware of any other staff members being in Resident D's room while CNA 9 provided care and was accused of hitting Resident D. During an interview on 2/6/24 at 1:50 P.M., CNA 3 indicated that if a resident is care planned for assistance of 2, staff should find a second staff member to assist during care. CNA 3 indicated that there should always be 2 staff members present when transferring a resident with a Hoyer mechanical lift. On 2/6/24 at 2:25 P.M., the DON supplied a skills validation sheet titled, Mechanical Lift, dated 3/2012. The validation sheet included, Two (2) staff is required at all times when using a mechanical lift. This citation relates to complaint IN00427390. 3.1-35(g)(2)

Based on observation, interview, and record review, the facility failed to ensure nursing care and services consistent with professional standards of practice were provided to a resident that required ostomy care. Staff did not appropriately change a resident's newly placed ostomy appliance, resulting in pain, psychological trauma and a fear of getting out of bed for 1 of 1 residents reviewed for ostomy care. (Resident 219) Finding includes: On 8/7/23 at 10:11 A.M., Resident 219 was observed lying in bed with several small towels and washcloths propped up against her right side and her gown raised up. At that time, she indicated she had just been admitted a few days prior from the hospital with a new ostomy on the right side of her abdomen. She indicated she had surgery to place the ostomy on 7/24/23, and had been at the facility since Tuesday 8/1/23. She indicated the ostomy bag was supposed to be changed for the first time on Friday, 8/4/23, and was not. It was changed Saturday 8/5/23 morning but leaked, and had been done three times since then, with leaking every time. She indicated the hospital staff had given her specific instruction how to change the bag, and she had tried to tell the facility staff how it needed to be done, but they had not listened. The two nurses Licensed Practical Nurse (LPN) 7 and LPN 15 that had changed it so far had not done it right, and had just ripped it off, irritating the skin around it, and had not used the adhesive remover as she had requested. Now the area was red, raw, irritated, and burned especially when it was leaking. Resident 219 indicated she was supposed to be in the facility to learn and become independent with changing the ostomy bag, as well as to maintain her strength for when she returned home. She indicated prior to the issues with the bag leaking, she was up walking the halls a lot, but since the leaking, she is scared to get up and felt trapped in the bed. At that time Resident 219 was observed to be tearful, indicating she was usually tougher than this, but was very upset about the situation. Treatment commenced at that time, Registered Nurse (RN) 21 was observed to change the ostomy bag. The skin under the adhesive wafer was observed to be pink with red marks in places. The stoma itself was observed to be bright red. As RN 21 wiped the reddened area with skin prep, the resident began breathing heavy and grimacing, indicating it burned bad. Resident 219 indicated she was worried that the area would get infected because it had been handled so much, and LPN 7 had only worn a glove on one hand the last time she had changed it. On 8/9/23 at 8:20 A.M., Resident 219's clinical record was reviewed. admitted was 8/1/23. Diagnosis included, but were not limited to, diverticulitis and surgical placement of ileostomy. The Admission MDS (Minimum Data Set) assessment had not been completed. Current Physician Orders included, but were not limited to: Change ileostomy bag, remove appliance gently using universal remover wipes . apply the prepared barrier appliance, press firmly around the stoma to ensure seal . every three days, dated 8/1/23. Change ileostomy bag as needed for leaking or burning, dated 8/1/23. A current Ostomy Care Plan, dated 8/2/23, indicated but was not limited to, the following interventions: keep site clean and dry, treatments as ordered/indicated. An Interdisciplinary Team (IDT) initial Wound Review note, dated 8/2/23, indicated Resident 219 had a new ileostomy to the right lower abdomen, which was pink and moist, and surrounding tissue was pink/normal An IDT Weekly Wound Review Note, dated 8/8/23, indicated Resident 219's stoma remained pink and moist, with the surrounding tissue normal with scattered areas of irritation from the ostomy wafer. On 8/10/23 at 10:00 A.M., the Treatment Administration Record (TAR) for 8/2023 indicated Resident 219's ostomy bag was changed on the following dates: 8/1/23 (scheduled) Resident 219 indicated it was not changed on that date 8/4/23 (scheduled) Resident 219 indicated it was not changed on that date 8/6/23 (as needed) 8/7/23 (scheduled) 8/10/23 (scheduled) Nothing was documented on Saturday 8/5/23 when Resident 219 indicated it had been changed and leaked. On 8/10/23 at 8:20 A.M., Resident 219 was observed sitting in a chair by the bed, dressed, and indicated she had a doctor's appointment that morning. She indicated the skin around the stoma was still very irritated and painful, and was not looking forward to having it changed the following day as scheduled. She also indicated she had gotten up the previous day for therapy, but because of the irritated area, she had to wear a gown. She indicated she would have rather worn regular clothes. On 8/11/23 at 8:15 A.M., an Infection Preventionist and Clinical Education Nurse Quality Assurance Tool calendar were provided. Neither form indicated a skills validation for ostomy care. At that time, the Administrator indicated he thought that nurses were checked off on ostomy care annually, and would provide those check off forms, but they were not provided. On 8/14/23 at 1:00 P.M., the Charge Nurse Position Job Description was provided, signed by LPN 7 on 7/29/20 and LPN 15 on 10/5/18 upon hire. The description indicated Monitors delivery of care and services throughout shift to ensure needs are met, tasks are completed, including complete and accurate resident documentation, and that work of direct care staff is of acceptable quality and quantity. Ensures compliance on unit with resident rights. A Charge Nurse Orientation Plan indicated a five day orientation plan with specific Skills Validations required prior to working on the unit independently. The skills did not include ostomy care. On 8/14/23 at 1:00 P.M., a Colostomy Bag - Empty and Clean and Colostomy Bag - Change Nursing policy and procedure - skills validation form, reviewed 9/2012, was provided. The policy listed step by step procedure steps for each task, with a place for the staff and nurse to sign at the bottom. 3.1-47(a)(3)

Based on observation, interview and record review, the facility failed to develop resident specific care plans and implement interventions for 4 of 4 residents reviewed for care plans. A resident's care plan indicated to encourage fluids when the resident was NPO (nothing by mouth). Two residents had orders that did not match care plans for dental services. A resident with falls did not have interventions in place. (Resident 6, Resident 49, Resident 51, Resident 62) Findings include: 1. On 8/8/23 at 10:05 A.M., Resident 62 was observed lying in bed with the head of her bed elevated 30 degrees, on her right side,eyes closed, moving her right arm around. Her tube feeding was infusing at 45 ml/hr (milliters/hour) per pump. An oxygen mask, dated 8/8/23, was over the tracheostomy. High flow humidified oxygen was on at 6 L/min (Liters per minute). Foley catheter was hanging on the right side of the bed covered with a bag and draining yellow urine with sediment. Suction machine was sitting on the bedside cabinet. Call light was within reach. On 8/11/23 at 8:51 A.M., Resident 62 was observed lying in bed with eyes closed. The head of the bed was elevated 30 degrees. The resident was coughing. Tube feeding was infusing at 45 ml/hr per pump. The humidified, high flow O2 (oxygen) was on at 6 L/min per tracheostomy mask. Foley catheter was hanging on the right side of the bed, draining yellow urine, and covered with a bag. On 8/9/23 at 1:19 P.M., Resident 62's clinical records were reviewed. She was admitted on [DATE]. Her diagnosis included, but were not limited to, generalized epilepsy and epileptic syndromes, intractable, with status epilepticus, pneumonitis due to inhalation of food and vomit, urinary tract infection, acute and chronic respiratory failure with hypoxia, persistent vegetative state, and cognitive communication deficit. The most recent Significant Change MDS (Minimum Data Set) Assessment, dated 7/26/23, indicated Resident 62 had severe cognitive impairment and was totally dependent on 2 assistants for bed mobility, transfers, toilet use and bathing and 1 assistant for eating. She required O2, tracheostomy, suctioning, catheter, and tube feeding. The Physician's Orders included, but were not limited to, the following: NPO, dated 5/19/23 Enteral feeding: Continuous feeding formula Jevity 1.5 at 45 ml/hr, dated 8/7/23 Trach (tracheostomy) orders: Routine trach care including oral care. Per standard of practice with sterile water and normal saline, dated 8/7/23 Cath (catheter) care: Foley catheter care, catheter securement device in place, nurse to record output every shift, dated 8/4/23 A care plan for Impaired Respiratory Function: Pneumonia, dated 8/7/23, included interventions to encourage fluids and food intake and encourage activity as tolerated, dated 8/7/23. A care plan for Urinary Tract Infection (UTI), dated 8/4/23 included an intervention to encourage fluids, dated 8/4/23. A care plan for an indwelling urinary catheter related to chronic vegetative state, dated 5/23/23 included an intervention to encourage fluids, dated 5/23/23. A care plan for skin breakdown due to: impaired mobility, epilepsy, morbid obesity, chronic respiratory failure with hypoxia, asthma, rectal abscess, sensory perception is very limited, skin is constantly moist, bedfast, mobility is completely immobile, probably inadequate nutrition, problem with friction and shear, dated 5/19/23, included an intervention to encourage resident to eat at least 75 % of meals, dated, 5/19/23. A care plan of Resident is NPO d/t (due to) continuous G-tube feedings, dated 5/19/23, included an intervention to assist resident with oral care, dated 5/19/23. During an interview on 8/14/23 at 12:17 P.M., the MDS Coordinator indicated care plans were resident specific. If a resident was NPO, the care plan should not list encourage fluids as an intervention. She indicated she picked general care plans and didn't remove encourage fluids from the interventions listed. 46416 2. On 8/7/23 at 12:04 P.M., Resident 6 was observed sitting in his room in his wheelchair. A fall mat was laying on the side of his bed. On 8/7/23 at 12:16 P.M., Resident 6 was observed in the main dining room sitting in his wheelchair wearing regular socks on both feet. On 8/7/23 2:21 P.M., Resident 6 was observed sitting by the nurses station in the common area in his wheelchair, watching TV, and wearing regular socks on both feet. On 8/10/23 at 1:25 P.M., Resident 6 was observed sitting in his room in his wheelchair and his urinal was hanging on the trash can. On 8/11/23 at 8:29 A.M., Resident 6 was sitting in his room in his wheelchair and his urinal was not within sight. On 8/10/23 at 9:03 A.M., Resident 6's clinical record was reviewed. Diagnoses included, but were not limited to, dementia with behaviors and diabetes mellitus type II. The most current significant change MDS Assessment, dated 7/17/23, indicated resident was severely cognitively impaired and was an extensive assist of 2 staff members for bed mobility, transferring, and toileting. Current Physician's Orders included, but were not limited to, the following: Up ad lib (at pleasure) in WC (wheelchair) with anti rollback with assist of 2 for transfers, dated 5/4/23 and discontinued 8/8/23 Up ad lib in WC with anti rollback with assist of 2 with hoyer lift for transfers, dated 8/8/23 Mat on floor to open side of bed, dated 7/20/23 and discontinued 8/9/23 A current falls care plan, dated 8/30/22, included, but was not limited to, the following interventions: Keep urinal at bedside at eye level, initiated 2/6/23 Keep pathways free of clutter, initiated 8/30/22 Non-skid footwear, dated 8/30/22 On 8/14/23 at 12:30 P.M., a current CNA (Certified Nurse Aide) assignment sheet was provided by the MDS Coordinator and included, but was not limited to, the following interventions: Keep pathways free of clutter Keep urinal at bedside at eye level Non-skid footwear During an interview on 8/11/23 at 8:35 A.M., RN (Registered Nurse) 6 observed the resident's urinal was not in sight at that time. After searching the room and questioning the resident, she indicated they would get him another one. During an interview on 8/11/23 at 2:04 P.M., LPN (Licensed Practical Nurse) 10 indicated staff dressed Resident 6 and he should wear non-skid socks and to her knowledge there was not a reason he shouldn't wear them. His urinal should be kept at eye level, usually on bedside table not the trash can. Staff could have put it on the trash can, but he could use it and move it too. At that time, she indicated care plan interventions should be followed. During an interview on 8/14/23 at 12:17 P.M., the MDS Coordinator indicated new interventions should be added to the care plan right away and if they were CNA task related, they would add them to their CNA sheets. Staff were expected to follow interventions for each resident. 38770 3. On 8/9/23 at 9:28 A.M., Resident 49's clinical record was reviewed. Diagnosis included, but were not limited to, diabetes mellitus and anxiety. The most recent Significant Change MDS Assessment, dated 7/5/23, indicated Resident 49 had a mild cognitive impairment, had refused care 1-3 days of the previous 7-day assessment period, and had no change in behavior from the previous assessment. Current Physician Orders included, but were not limited to: May be seen by Podiatrist, Dentist, Optometrist, and Audiologist, dated 6/29/23. Discontinued Physician Orders included, but were not limited to: May be seen by Podiatrist, Dentist, Optometrist, Audiologist from 4/15/22 through 5/10/23. May be seen by Podiatrist, Dentist, Optometrist, Audiologist, from 5/16/23 through 6/27/23. A current care plan, dated 4/27/22 and last revised 7/17/23, indicated Resident has declined ancillary services including dental, audiology, podiatry, and optometry. Potential for declines in condition related to lack of dental, audiology, optometry and podiatry care A social services note, dated 2/16/22, indicated . Declined ancillary during stay. States he has an Audiology appt 2/16/22. Res cancelled [sic] appt today and rescheduled for 2/18/22 . Admission paperwork, dated 4/15/22, indicated Resident 49 requested to be seen for audiology, eye care, and podiatry. Nothing was documented related to dentistry. 4. On 8/8/23 at 10:09 A.M., Resident 51 was observed lying in bed. She had missing and broken teeth. At that time, Resident 51 was confused, and not interviewable. On 8/9/23 at 10:04 A.M., Resident 51's clinical record was reviewed. Diagnosis included, but were not limited to, dementia and depression. The most recent Quarterly MDS Assessment, dated 6/20/23, indicated no cognitive impairment, and no dental concerns. Current physician orders included, but were not limited to: May be seen by Podiatrist, Dentist, Optometrist, Audiologist, dated 7/1/22. A current care plan, dated 8/29/21 and last revised 7/3/23, indicated Resident has declined ancillary services including dental. Potential for declines in condition related to lack of dental care A progress note, dated 10/7/22 at 9:29 A.M., indicated Resident 51 was seen by dental on 10/4/22. A progress note, dated 6/28/23 at 9:18 A.M. indicated Resident 51 was seen by the facility's dentist. An annual assessment/Social Service progress note, dated 3/28/23, indicated . Ancillary support services in place: Psychiatric, Dental . On 8/10/23 at 1:34 P.M., the Social Services Director (SSD) indicated Resident 51 was admitted with a note that dental services were declined. In 10/2021, a consent was signed for all ancillary services except dental. She indicated nothing could be found about a dentist who was a different provider, and she had seen the care plan where dental had been declined. She indicated that care plan was not correct and should have been updated. On 8/11/23 at 2:19 P.M., LPN 10 and RN 6 indicated upon admission every resident was assessed to implement resident-centered care plan, and revisions were completed as needed. If an intervention no longer applied, that intervention would have been removed or revised. LPN 10 indicated care plans were pre-populated within the computer system, but should always be revised to be resident-centered. At that time, LPN 10 indicated there was not a specific policy related resident-centered care plans. On 8/14/23 at 1:00 P.M., a current Comprehensive Care Plan Policy, revised 10/2019, indicated It is the policy of this facility that each resident will have a comprehensive person-centered care plan developed based on comprehensive assessment. The care plan will include measurable goals and resident specific interventions based on resident needs and preferences to promote the resident's highest level of functioning including medical, nursing, mental and psychosocial needs .Care plan problems, goals, and interventions will be updated based on changes in resident assessment/condition . 3.1-35(a) 3.1-35(b)(1)

Based on observation, interview, and record review, the facility failed to ensure medications were administered free of error for 1 of 5 residents reviewed for medication administration. A resident was administered the wrong dose of (2) medications, resulting in an error rate of 8%. (Resident 65) Findings include: On 8/10/23 at 7:11 A.M., Qualified Nurse Aide (QMA) 9 was observed to administer medications to Resident 65 that included, but were not limited to, the following: Auryxia (an iron supplement medication) 210mg (milligram) tablet (one tablet) hydralazine (a blood pressure medication) 100mg tablet (one tablet) Breakfast was not provided at the time of the medication administration. On 8/11/23 at 1:51 P.M., Resident 65's clinical record was reviewed. Diagnosis included, but were not limited to, diabetes and anxiety. The most recent admission MDS (minimal data set) Assessment, dated 7/26/23, indicated no cognitive impairment. Resident 65 required extensive assistance of two staff with bed mobility, transfers, and toileting. Current physician orders included, but were not limited to, the following: Auryxia (ferric citrate) 210mg tablet, give 420mg with meals three times a day, dated 7/27/23. hydralazine 50mg tablet, give 50mg three times a day, dated 7/28/23. On 8/11/23 at 1:43 P.M., the medication cart that held Resident 65's medications was observed with QMA 33. At that time, a discontinued medication card for hydralazine 100mg was turned around backward in the back of the cart, with a discontinued date of 7/28/23. A current medication card for hydralazine 50mg was observed with Resident 65's other medication cards, facing the front of the cart. At that time, QMA 33 indicated Resident 65's Auryxia was supplied in 210mg tablets, and staff was supposed to administer two tablets for a total of 420mg. On 8/14/23 at 1:00 P.M., a current Medication Pass Procedure, reviewed 6/2016, was provided, and indicated Medications checked 3 times to verify order with label . 3.1-48(c)(1)

Based on observation, interview, and record review, the facility failed to ensure assessments were conducted and completed following an emergency room visit where all insulin medications were discontinued for a diabetic resident for 1 of 3 residents reviewed for change of condition. (Resident 31) Findings include: On 8/7/23 at 2:25 P.M., Resident 31 was observed sitting in a wheelchair in the dining room. At that time, he was observed sweating, with a yellow substance in the outer corner of the left eye, and a built up white substance on his teeth at the gum line. On 8/9/23 at 9:57 A.M., Resident 31's clinical record was reviewed. Diagnosis included, but were not limited to, heart failure and diabetes. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 7/26/23, indicated no cognitive impairment, no behaviors, required extensive assistance of two staff with bed mobility and toileting, supervision of one staff with eating, and was totally dependent of two staff with transferring and bathing. Resident 31 did not receive insulin in the 7-day look back period. Physician Orders included, but were not limited to: Diet: Regular Special Instructions: cups with handles. Double protein with all meals per resident request, from 6/10/21 through 6/21/23. Diet: Regular Special Instructions: cups with handles with meals & Double protein with all meals per resident request, ordered 6/21/23 through current. Accu check as needed for signs and symptoms of hypo/hyperglycemia, dated 2/9/23 through current. Physician Orders prior to admission to a hospitalization on [DATE] included, but were not limited to: insulin lispro solution; 100 unit/mL (milliliter); 30 units; subcutaneous, give with meals three times a day, ordered 12/29/22 through 2/8/23. Levemir U-100 Insulin (insulin detemir u-100) solution; 100 unit/mL; 94 units; subcutaneous, twice a day, ordered 12/29/23 through 2/8/23. BMP; CBC w/diff; on the 11th of March and September, ordered 12/29/22. HgbA1c; on the 11th of March and September, ordered 12/29/23. A current diabetes care plan, dated 12/12/19, indicated observe resident for symptoms of hyperglycemia and hypoglycemia, monitor blood sugars as ordered, labs as ordered, and diet as ordered. A current refusal of medications and insulin care plan, dated 1/7/21, indicated to provide resident and representative with education regarding risk/benefits, review choice and options with attending physician, and revisit options as needed. Progress Notes included, but were not limited to, the following: 2/07/2023 at 12:24 P.M. Family thinks resident is over medicated and would like a med review completed and concerned about him not eating or drinking much. Explained to family that NP [Nurse Practitioner] would be in to see him today . 2/7/23 at 12:28 P.M. NP here to see resident. Coordinated with [psych services] and several medications D/C [discontinued] with labs ordered for tomorrow . Resident 31's insulin was not discontinued at that time. 2/7/23 at 2:50 P.M. EMS [Emergency Medical Services] called and report called to ER [emergency room ] . Resident alert, but O2 sats [oxygen saturation] 86-88% 2/9/23 at 2:00 P.M. indicated Resident 31 returned from the hospital and an admission assessment was completed. Admission assessment requested and not provided. 2/10/23 at 12:22 A.M. indicated Nurse helped res. to reposition in bed, and res. wanted to be re-adjusted more. Nurse stated she had to get another staff member to help. Nurse left to do a tx [treatment] in another room, and ten minutes later res. was screaming help me. Staff entered room and res. was having a panic attack. Res. kept trying to swing legs over side of bed. Res. stated he was having a panic attack because they took him off all his medication . At that time, a blood sugar was not checked. 2/11/23 at 1:41 P.M. indicated resident was sitting in a wheelchair by the nurses station rocking back and forth with heavy breathing noted. Resident indicated he as having a panic attack. An as needed anti-anxiety medication was administered. At that time, a blood sugar was not checked. 2/13/23 at 11:56 A.M. indicated Called and spoke with sister regarding med changes. She expressed her concerns with over medicating resident. Explained to her that meds had been d/c and that the hospital had started them back up. Informed her that [NP] was calling in today to review meds and that we would let her know the changes Hospital progress notes included, but were not limited to, the following: 2/8/23 . Suspect AKI [acute kidney injury] secondary to post renal obstruction from urinary retention given patient's polypharmacy [use of multiple medications]. Urine output is adequate. Renal [kidney] function is improving. All medications have been held . Blood sugars reasonable on carb [carbohydrate] controlled diet without any supplemental insulin at this time. Patient on very high levels of insulin as an outpatient. Suspect this is secondary to his diet 2/9/23 . Nearly all the patient's medications were held during this hospitalization and was [sic] AKI resolved with which [sic] evacuation of his bladder and IV [intravenous] fluid . Patient is a diabetic with a recent A1c [blood test to measure average blood sugar levels over the past 3 months] of 7.7% [normal: below 5.7%]. While on a carb consistent diet at the hospital his blood sugars were never elevated greater than 185 [normal: between 70 and 100]. Home regimen of insulin was significant with 94 units of Levemir and 30 units of Humalog at meals. Discussed with patient that he does not need large amounts of insulin if he is able to control his diet. Would recommend dietary modification and initiation of metformin [an anti-diabetic medication] with goal to titrate up and start either SGOT 2 inhibitor [a class of anti-diabetic medication] or GLP agonist [a class of anti-diabetic medication] if able in the future. Additionally his blood sugars are better controlled and does not require significant dosages of insulin is highly likely that his blood pressure will improve. It was reasonably controlled without any medications during this [2 day] hospitalization . Patient was held on a consistent carb diet and did not require any insulin . Patient strongly encouraged to continue with constant carb diet. Metformin will also be added and his insulin will be stopped. The note indicated an adult diet consistent carbs was effective 2/7/23. 2/10/23 at 9:51 P.M. Patient was brought by ambulance from the nursing home for evaluation of back pain and left leg pain. Patient has had longstanding issues with radiculopathy. He was recently taken off/reduced on his medications for treatment of the radiculopathy. He was felt to be overmedicated. Patient has been having increasing pain since. The nursing home states he could control his pain and sent him here [sic]. He complains of pain radiating down the anterior aspect of his left leg. He has had several back surgeries. There has been no recent history of injury falls or trauma . The patient was recently hospitalized here and discharged back to nursing home yesterday. The hospitalist service had discontinued multiple medications as the patient was felt to be overmedicated . A nutrition review note, dated 2/20/23, written by the registered dietician, indicated .Resident remains at nutrition risk r/t . COPD, diabetes, heart failure, heart disease, major depressive disorder, vitamin D deficiency, vitamin B12 deficiency anemia, dysphagia and muscle weakness. On metformin for blood glucose management (potential for weight change), and receives supplemental vitamin D3 . Resident continues on a regular diet with double protein with meals per resident request. Currently with fair-good oral intakes, 41% breakfast, 71% lunch and 100% dinner. He is able to self-feed with set up assistance, utilizes adaptive equipment of cup with handles to promote independence as well . Resident 31's clinical record lacked information related to the CCHO ordered from the hospital being added when the resident returned from the hospital, or refusal from the resident at that time. An evaluation, dated 2/16/23 at 6:19 P.M., indicated resident was refusing meds related to not being able to swallow pills, and continued to be upset with staff with behaviors. Multiple medications discontinued as per most recent ER orders and family request. Insulins were discontinued as per ER orders, accuchecks three times a day and trends reviewed, will continue to monitor for hyper/hypoglycemic episodes, and CCHO diet recommended. Most recent HgbA1c (hemoglobin A1c) was 8.30% on 9/13/22 with a routine HgbA1c ordered. Resident 31's labs for the last 12 months indicated, but were not limited to, the following abnormal values: 9/13/22 HgbA1c 8.30% (reference range: 4.00 - 6.00 %) 9/13/22 blood glucose 152 (reference range: 74 - 106) 2/7/23 blood glucose 177 (reference range: 74 - 106) 2/9/23 HgbA1c 7.70% (reference range: 4.00 - 6.00 %) 2/10/23 Urine ketones trace (reference range: negative) 2/10/23 blood glucose 163 (reference range: 74 - 106) 3/11/23 blood glucose 177 (reference range: 74 - 106) 5/9/23 blood glucose 224 (reference range: 74 - 106) 6/20/23 urine glucose >=1000 (reference range: negative) A Progress Note dated 6/20/23 at 9:06 A.M. indicated (Doctor) here and reviewed urine results, normal, no new orders. No reference was made related to urine glucose >=1000. Resident 31's Medication Administration Record (MAR) for January 2023 indicated Resident 31 had an order for an accu check four times a day from 12/29/22 through 2/8/23. Resident 31's blood sugars ranged from 94 to 388, with an average of 173.7. One accu check was missed. Resident 31's MAR for February 2023 (until discontinued on 2/8/23) indicated blood sugars ranged from 106 to 208, with an average of 136.6. One accu check was missed. Resident 31's MAR for February 2023 through August 2023 indicated an accu check was not done until requested on 8/9/23, which was 497 at 1:49 P.M. Follow up accu checks were as follows: 8/9/23 5:05 P.M. 378 8/9/23 7:19 P.M. 394 8/10/23 4:21 A.M. 380 A copy of the MAR that included insulin administration from January 2023 through August 2023 was requested and not provided. Resident 31's clinical record lacked an Interdisciplinary Team (IDT) meeting note upon return from the hospital on 2/9/23 or on 2/10/23 related to the abrupt discontinuance of insulin. The clinical record lacked an assessment or review of medications upon returning from the hospital on 2/9/23 or 2/10/23. Resident 31's clinical record lacked an assessment related to the result or potential outcome of the abrupt discontinuance of insulin from the hospitalization on [DATE] through current. On 8/9/23 at 1:35 P.M., Resident 31 indicated he was unaware of signs and symptoms to watch out for with a high blood sugar (hyperglycemia). He indicated staff had not educated him on what to watch out for or to tell staff if he were to experience them. He indicated at that time he was not feeling well, but could not explain why. Only that he had not felt normal for several weeks. On 8/9/23 at 1:42 P.M., a blood sugar was requested for Resident 31. Licensed Practical Nurse (LPN) 10 completed the test and Resident 31's blood sugar was 497. At that time, LPN 10 indicated some things to watch out for with hyperglycemia might include fatigue or confusion. At that time, LPN 10 reported the blood sugar reading to LPN 7, who was Resident 31's nurse. On 8/9/23 at 2:22 P.M., LPN 10 indicated she notified the doctor of Resident 31's blood sugar reading, and that he was coming in the following day to probably order labs. On 8/9/23 at 2:06 P.M., LPN 10 and LPN 6 indicated on 2/7/23, Resident 31 went to the ER for low O2 sats. He had been refusing medications and meals for a few days prior to the ER visit. Resident 31's power of attorney (POA) had been notified about his condition and indicated they though he was being overmedicated and wanted his medications reviewed. The facility coordinated with the NP and psych services and sent him out. He came back on 2/9/23. On 2/10/23, Resident 31 was having behaviors, so was sent to the ER again to rule out a medical condition related to complaints of pain. At that time, LPN 10 indicated Resident 31's diet never changes and that he was on a regular diet with double protein per resident request that would only change if he came back from the hospital with a new diet order. LPN 10 indicated the Medical Director took over for the facility in May, 2023 and would need to come in to review Resident 31's recent labs to determine if new labs needed to be done related to his diabetes. She indicated prior to the hospitalization on [DATE], Resident 31's blood sugars were up and down. She also indicated Resident 31's insulin use had not been assessed since his hospitalization on [DATE] because the doctor at the hospital discontinued the insulin, and staff at the facility did not question the doctor's orders. She indicated when a doctor gives an order, staff should follow that order. At that time, RN 6 indicated at times, such as when Resident 31 ordered food from outside, staff may want to check his blood sugars, but because of his refusals in the past, that was not being done. On 8/9/23, the following order was made for Resident 31: metformin 500mg once a day (same order was already in place from 2/9/23). On 8/10/23, the following orders were placed for Resident 31: HgbA1c; PSA; Other Test: (EP2) on the 2nd Tuesday of April. CBC w/diff; Chem 20; HgbA1c; on the 4th Tuesday of October. CBC w/diff; Chem 14; HgbA1c; on the 4th Tuesday of January and July. FreeStyle Libre 14 Day Sensor (flash glucose sensor), once a day on Friday, every 2 weeks, to start 8/14/23. On 8/14/23 at 11:12 A.M., Certified Nurse Aide (CNA) 3 indicated symptoms that needed to be reported to the nurse related to hypoglycemia included paleness. At that time, she was not sure of any symptoms related to hyperglycemia. Notes related to education given to Resident 31 related to his diet, or information related to importance of insulin when needed were requested and not provided. On 8/14/23 at 1:00 P.M., a current Nursing Admission/Return Admission Policy, dated 6/2023, was provided and indicated It is the policy of [company name] to provide baseline and accurate documentation of the mental and physical condition of each resident admitted or readmitted to the facility . Admission Medication Regimen Review completed upon admission or as close to admission as possible per policy . 3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure residents that were self-administering medications were assessed for capability to self administer medications for 1 of 2 residents reviewed for accidents and 1 of 5 residents reviewed for medication administration. Resident clinical records lacked a self administration of medication assessment. (Resident 6, Resident 65) Findings include: 1. On 8/11/23 at 8:29 A.M., Resident 6 was observed sitting in his room in his wheelchair. At that time, there was a medicine cup sitting on his bedside table with 1 white, circular pill in it. On 8/10/23 at 9:03 A.M., Resident 6's clinical record was reviewed. Diagnoses included, but were not limited to, dementia with behaviors and diabetes mellitus type II. The most current significant change MDS (Minimum Data Set) Assessment, dated 7/17/23, indicated resident was severely cognitively impaired and was an extensive assist of 2 staff members for bed mobility, transferring, and toileting. Resident 6's clinical record lacked a physician's order for self administering medication. Resident 6's clinical record lacked a self administration of medications care plan. Resident 6's clinical record lacked a self administration of medication assessment. During an interview on 8/11/23 at 8:35 A.M., RN (Registered Nurse) 6 indicated the medication should not be left with the resident to take on his own. At that time, she indicated the resident did not self administer medication. She looked at the resident's medications in the medication cart and spoke with the QMA (Qualified Medication Aide) 33 that passed the pills to the resident that morning and they agreed it was the resident's metformin. 38770 2. On 8/10/23 at 7:11 A.M., QMA 9 was observed to take Resident 65 a medication cup with her morning medications. QMA 9 entered the room, greeted the resident, then sat the medication cup on the bedside table in front of the resident. QMA 9 left the room without observing the resident take the medications. On 8/11/23 at 1:51 P.M., Resident 65's clinical record was reviewed. Diagnosis included, but were not limited to, diabetes mellitus and anxiety. The most recent Admission MDS Assessment, dated 7/26/23, indicated Resident 65 was cognitively intact and required extensive assistance of two staff with bed mobility, transfers, and toileting, supervision of one staff with eating, and was totally dependent of two staff with bathing. Resident 65's clinical record lacked a self administration of medications order. Resident 65's clinical record lacked a self administration of medications care plan. Resident 65's clinical record lacked a self administration of medications assessment. On 8/11/23 at 1:45 P.M., LPN 10 indicated Resident 65 did not have a self administration of medications assessment, and staff was supposed to wait for all residents to take their medications prior to leaving their room. On 8/14/23 at 1:00 P.M., a current Self Administration of Medications policy, dated 1/2015, was provided and indicated If a resident desires to participate in self-administration, the Interdisciplinary Team will assess the competence of the resident to participate by completing the Self-Administration of Medication Assessment observation . A physician order will be obtained specifying the resident's ability to self-administer medications . The resident's care plan will be updated to include self administration 3.1-11(a)

Based on observation and interview, the facility failed to ensure the resident's right of dignity was promoted and protected for 2 of 3 residents reviewed for dignity. A visibly soiled resident was not stopped by staff on his way to the dining room and a resident receiving incontinence care was told the staff was going to change his diaper. (Resident 35, Resident 40) Findings include: 1. On 8/7/23 at 3:09 P.M., Resident 35 was laying in bed with a urinary catheter hanging on the right side of his bed. On 8/9/23 at 1:30 P.M., Resident 35's clinical record was reviewed. Diagnoses included, but were not limited to, diabetes mellitus type II, prostate cancer, stroke, and hemiplegia on left side. The most recent Admission MDS (Minimum Data Set) Assessment, dated 7/7/23, indicated the resident was moderately cognitively impaired, an extensive assist of 2 staff for bed mobility and toileting, and had a urinary catheter but was incontinent of bowel movements. On 8/10/23 at 2:55 P.M., incontinence care given by CNA (Certified Nurse Aide) 14 and CNA 28 was observed on Resident 35. During that care, CNA 14 unfastened both sides of the incontinence pad and told the resident We are going to change your diaper. During an interview on 8/14/23 at 11:12 A.M., CNA 3 indicated they are not supposed to use the word diaper to describe a resident's incontinence pad. When she is going to provide incontinence care, she will introduce herself, ask the resident if it is ok to change them, and will call the incontinence pad a brief if she needs to. At that time, she indicated it was not right to say change your diaper to an adult. 38770 2. On 8/10/23 at 11:55 A.M., LPN (Licensed Practical Nurse) 10 was observed performing a glucose check for Resident 40. LPN 10 left the door open while performing the check, and the resident was in full view of the roommate on the other side of the room. At that time, Resident 40 was observed with a darkened wet spot in his groin area, the inside of his thighs, and the bottom of his shirt. When completed, LPN 10 indicated to Resident 40 he could go on down the hall to the dining room for lunch. Resident 40 left the room at the end of the hall and propelled himself down the length of the hall and into the dining room passing six staff members, before RN (Registered Nurse) 6 indicated to the resident she needed to escort him back to his room to get cleaned up. On 8/11/23 at 2:32 P.M., Resident 40's clinical record was reviewed. Diagnosis included, but were not limited to, diabetes mellitus. The most recent annual MDS Assessment, dated 6/26/23, indicated no cognitive impairment. Resident 40 required extensive assistance of two staff with toileting, extensive assistance of one staff with dressing, and was frequently incontinent of urine. On 8/11/23 at 2:35 P.M., RN 6 indicated Resident 40 would not have been able to tell staff that he was wet, and all staff would be expected to assist a resident to clean up if a wet spot was observed on them. On 8/14/23 at 1:00 P.M., a current Resident Rights policy, dated 7/2023, indicated All staff members recognize the rights of residents at all times and residents assume their responsibilities to enable personal dignity, well being, and proper delivery of care 3.1-3(t)

Based on observation, interview, and record review, the facility failed to ensure posted nurse staffing sheets contained the correct information daily for 5 of 6 days during the survey. Findings include: On 8/7/23 at 11:30 A.M., a posted nurse staffing sheet was observed posted on the wall next to the nurse's station facing the dining room. The posted nurse staffing sheet indicated the facility name, current date, census, and the number of staff scheduled for the following disciplines: CNA (Certified Nurse Aide) and NA (Nurse Aide that was not yet certified). The nurse column did not specify RNs (Registered Nurse) and LPNs (Licensed Practical Nurse) working and the facility's actual hours worked were not included on the posting. On 8/11/23 at 10:30 A.M., posted nurse staffing sheets were provided for the following dates: 8/7/23 8/8/23 8/9/23 8/10/23 8/11/23 Each posted nurse staffing sheet lacked specific number of hours worked and the separation of RNs and LPNs on each shift. During an interview on 8/11/23 at 10:35 A.M., the Scheduler indicated a lot of their staff worked 12 hour shifts and weekend option but occasionally they would also work 4 hours at a time during the week if needed. At that time, she indicated the posted nurse staffing sheets were computer system populated and if there were 3 nurses there anytime during an 8 hour shift, it would indicate how many nurses were there, but not the specific hours worked for each. On 8/14/23 at 1:00 P.M., a current Posted Nurse Staffing policy was provided by the Administrator and indicated The facility must post the following information at the beginning of each shift . d. The total number and actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: i. Registered Nurses ii. Licensed Practical Nurses . 6. The total hours columns should be all hours worked during each specific shift. Total hours should include the total actual hours worked on each shift including partial shifts. 7. The total hours columns should be broken down by total hours worked by RN, LPN, and CNA .

Based on interview and record review, the facility failed to ensure accurate submission of all direct care staffing data into the Payroll-Based Journal (PBJ) system for the reported period of January 1, 2023 through March 31, 2023. One entry, March 11, 2023, was triggered in error for low weekend staffing due to inaccurate staffing information submitted. Finding includes: During a review of the facility's PBJ information on 8/10/23 at 9:24 A.M., low weekend staffing was triggered in the second reporting quarter of January 1, 2023 through March 31, 2023. During an interview on 8/10/23 at 11:20 A.M., the Administrator indicated home office reports staffing to PBJ, but they did not notify him that it had triggered for low staffing. On 8/11/23 at 2:45 P.M., the schedules for staff were reviewed for all weekends in January, February, and March of 2023. At that time, the Administrator indicated on the weekend of 3/11/23, there were 6 admissions and several call ins from staff. A CNA (Certified Nurse Aide) who worked activities and transported residents also worked the floor for 2 hours which was not reported accurately to PBJ. On 8/14/23 at 1:14 P.M., a current Payroll-Based Journal Reporting policy was provided by the Administrator and indicated Employee IDs are assigned numerically by our timekeeping system. When an employee arrives for their shift, they clock in at the timeclock [sic]. At the end of their shift, they clock out at the timeclock [sic]. If any of the hours worked were for training or were worked in another position the hours are moved to that position in the timeclock [sic]. The hours are submitted from the timeclock [sic] through an XML file [data stored in plain text format] to CMS [Centers for Medicare and Medicaid Services] . 3.1-17(a)

Based on observation, interview, and record review, the facility failed to maintain a resident's dignity for 1 of 1 residents reviewed for ostomy care. A resident was not furnished with supplies or qualified assistance for colostomy care while being transported to and from an appointment. (Resident B) Finding includes: During an observation on 3/16/23 at 11:00 A.M., Resident B was sitting up in a wheelchair in their room. Resident B indicated they were in the facility for rehabilitation following an accident. The resident indicated they had wound to the abdomen as well as a colostomy. The colostomy bag often popped off due to a build-up of gas, and the resident indicated he knew when to ask for assistance to prevent the colostomy bag from becoming detached. During record review on 3/16/23 at 1:30 P.M., Resident B's diagnoses included, but were not limited to; fracture of right wrist and hand, multiple fractures of right side ribs, contusion of abdominal wall, and lack of coordination. Resident B's most recent admission MDS (Minimal Data Set) dated, 2/8/23, indicated the resident had no cognitive impairment, had an ostomy, required extensive assistance with bed mobility, was totally dependent for transfers, and required extensive assistance with personal hygiene. Resident B's physician orders included, but were not limited to; change colostomy bag every 3 days, colostomy care every shift, and appointment with (physician's name) on 3/27/23 located in Bloomington, IN special instructions: send extra colostomy with resident to appointment. Resident B's care plan included, but was not limited to; Resident has double barrel ostomy (started 2/1/23). Interventions included, but were not limited to; assist resident with stoma changes as needed. Resident B's clinical observations included an appointment on 2/6/22 at 9:15 A.M., in Bloomington, Indiana. A Concern/Grievance form dated, 2/24/23 included, Resident B's family member indicated they felt Resident B should have had a nurse sent with them while transported to their appointment and that Resident B's ostomy bag was leaking. A physician's progress note for Resident B, dated 2/9/23, included, .Underwent ileocectomy with ileostomy due to Ogilvie's syndrome . His biggest concern is leakage around his ileostomy bag. During an interview on 3/16/23 at 10:55 A.M., RN 3 indicated that Resident B has a colostomy and staff did have trouble with the colostomy bag staying on due to the resident having a wound vac next to the ostomy site, however the wound vac had been discontinued and the colostomy bag was able to create a better seal. During an interview on 3/16/23 at 12:35 P.M., RN 4 indicated Resident B had an issue during a transportation to an appointment when the seatbelt caused the colostomy bag to come lose. There was no trained staff available to assist the resident with his colostomy. Resident B had not been educated to do change the bag themselves due to the resident recovering from injuries. During an interview on 3/16/23 at 1:10 P.M., Resident B indicated while transporting to a doctor's appointment in the facility van, the seatbelt caused his colostomy bag to come loose. There was no one on the bus besides the resident and the bus driver. The resident did not have an extra colostomy bag so they found a bowl on the bus and the resident held it over the ostomy site to prevent a mess. During an interview on 3/16/23 at 1:15 P.M., the Director of Nursing (DON) indicated the facility did fail to send an extra colostomy bag and extra clothes with Resident B to an appointment and the facility bus seatbelt cased the resident's colostomy bag to come lose. The DON indicated the staff at the resident's appointment did not change the residents colostomy bag and the resident was sent back to the facility with the bag still leaking. The DON indicated this was Resident B's first appointment following their admission on 2/2/23. On 3/16/23 at 12:15 P.M., the DON supplied a copy of the facilities Bus/Van Transportation Guidelines, dated 07/2013. The guideline included, 7. A nursing assistant or licensed nurse must accompany any resident that has physical, mental, or developmental limitations as determined by the IDT Team (Interdisciplinary Team). This Federal tag relates to complaint IN00402594. 3.1-37(a) 3.1-37(b)

Based on interview and record review, the facility failed to ensure a resident who was dependent for care received adequate hydration, which resulted in hospitalization with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .(Resident B). Findings include: The closed clinical record of Resident B was reviewed on 11/4/21 at 11:20 A.M. The resident was admitted to the facility on [DATE] with the primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Additional diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A hospital Registered Dietician note, dated 9/22/21 at 10:17 A.M., indicated the resident required approximately 1292 cc of fluid daily, based on the resident's weight of 113 pounds. Nurses Notes included the following notations: 9/24/21 at 1:50 P.M.: Resident arrived via ambulance on stretcher An admission assessment, dated 9/24/21 at 1:50 P.M., indicated the resident was alert, oriented to person only, and had current health problems of heart problems, high blood pressure, and memory loss. A Hydration Review, dated 9/24/21 at 2:30 P.M., indicated the resident was on nectar thickened liquids, and needed individualized interventions to meet fluid needs. The Additional Resident specific fluid interventions area of the assessment was left blank. The Hydration Review indicated: (Please update care plan). An admission Event, dated 9/24/21 at 3:03 P.M., indicated, Monitor for s/s [signs or symptoms] of psychosocial distress R/T [related to] new admission isolation. A care plan, dated 9/24/21, indicated, Resident is at risk for altered nutritional status due to new admission to facility. The Approaches indicated: Regular pureed, nectar thicken [sic] liquids. Notify MD/family of significant weight changes. Offer substitute if 50% or less of any meal is consumed. An additional care plan, dated 9/24/21, indicated, Resident requires assistance with ADLs [activities of daily living] including .eating .related to: [CONDITION(S)] and [CONDITION(S)] following cerebral infarction affecting right dominant side .dementia .altered mental status . The Approaches indicated: Assist with eating and drinking as needed. An Initial Nutrition Review, dated 9/27/21 at 10:52 A.M., included: Weight 112, Underweight, On thickened liquids/puree diet prior to admitting, Assistance needed for meals, Recommendations: Weekly weights x 4 weeks. The Nutrition Review did not indicate how much daily fluid the resident required. A Progress Note, dated 9/27/21 at 12:15 P.M., indicated: [Recorded as Late Entry on 09/29/2021 09:32 AM] .spoke with daughter and wife about residents [sic] meals. Family has chosen to bring in meals .due to allergies .Resident is on a pureed diet .Dietary also provides honey thickened liquids for resident . The Progress Note did not document the resident refusing fluids. A care plan, dated 9/27/21, indicated, Resident is at risk for fluid imbalance due to: [CONDITION(S)] following cerebral infarction affecting right dominant side, Type 2 Diabetes Mellitus, Dementia, [CONDITION(S)], [CONDITION(S)] [prostate difficulties], dysphagia [difficulty swallowing], hypertensive [CONDITION(S)], [CONDITION(S)], altered mental status, [CONDITION(S)], muscle weakness, polyneuropathy. The Approaches included, Administer medications as ordered. Document and notify MD of signs and symptoms of fluid volume deficit: dry mucous membranes, thirst, weight loss, decrease blood pressure, weak/rapid pulse, change in mental status, decreased urine output, abnormal labs, poor skin turgor. Encourage fluids. Labs as ordered. Record intake. Nurses Notes continued: 9/27/21 at 1:51 P.M.: .Appetite poor, fed per 1 assist .No acute distress noted. 9/27/21 at 10:47 P.M.: .poor appetite, would not swallow food, resident was pocketing food .unable to swallow meds this pm. 9/28/21 at 12:10 P.M.: Resident blood sugar 495 with resident having not eaten breakfast. [Physician] contacted with no new orders at this time and to continue insulin as ordered 9/28/21 at 1:13 P.M.: Daughter [name] at bedside and is upset that resident is not eating his lunch. Responds to verbal and tactile stimuli .Took noon med without difficulty 9/28/21 at 9:33 P.M.: .Unable to make needs known .Meal consumption: 0-25% 9/29/21 at 7:30 A.M.: .Attempt to feed res, res clamps mouth shut when offered fluids et [and] food.Will continue to observe et attemt [sic] to give fluids. 9/29/21 at 9:30 A.M.: .This nurse updated wife regarding res clamps mouth shut when offering fluids .[wife] demanding res be sent to hosp. Notified [physician] An Intake report from 9/24/21-9/29/21 indicated the resident's daily intake of fluids as the following: 9/24/21: 60 cc. 9/25/21: 840 cc. 9/26/21: 1080 cc. 9/27/21: 440 cc. 9/28/21: 180 cc. 9/29/21: 120 cc. The resident was transferred to the hospital on 9/24/21 at 10:04 A.M. An ambulance report, dated 9/24/21, indicated the facility staff stated the resident had stopped eating and drinking. A hospital emergency physician's note, dated 9/29/21 at 10:28 A.M., indicated: . a history of dementia, diabetes who presents to the emergency department via EMS from a local nursing facility. Patient was recently discharged from this hospital to the [name] nursing facility. Family is concerned that the patient has progressively went down hill over the last several days. Reportedly, the patient stopped eating and drinking several days ago and has progressively became less responsive. The patient has issues with confusion at baseline, is a full assist, unable to ambulate. However, since at least yesterday, the patient has been lying in bed unresponsive. Family requested that the patient be transferred to the hospital today .Physical exam: Appearance: He is ill-appearing. Comments: Cachectic [physical wasting with loss of weight], lying in bed minimally responsive, will moan and can follow very simple commands. Mouth: Mucous membranes are dry .Clinical Impression: AKI [acute kidney injury] Dehydration [CONDITION(S)] [high potassium] Acute metabolic [CONDITION(S)] [[CONDITION(S)] related to an imbalance in the blood chemistry]. Hospital lab reports, dated 9/29/21, indicated the resident had critical lab values of Glucose 695 (normal 74-106) and Potassium 6.0 (normal 3.5-5.1). Other abnormal labs included: BUN 94 (normal 9-20) and Creatinine 2.59 (normal .66-1.25). A hospital history and physical, dated 9/29/21 at 3:26 P.M., indicated, 9/29/21 at 3:26 P.M. Chief complaint: Altered Mental Status History of Present Illness [Resident B] is a 69 y.o. male presenting with past medical history significant for advanced dementia as well as diabetes mellitus type 2 requiring insulin. The patient was placed at the nursing home recently and has been unconscious since yesterday. He was brought to the emergency department and he was found to be it a coma state. Blood sugar was 773 .Gen.: No apparent distress. Comatose and poorly responsive . Neurological: Comatose and poorly responsive . Psychiatric: Comatose. No signs of agitation. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/5/21 at 10:40 A.M., the Director of Nursing (DON) was interviewed. The DON indicated the resident did not drink or eat from the time he was admitted . The DON indicated the physician was aware the resident was not eating or drinking. She would contact the physician, and see if he would document a note. On 11/5/21 at 11:25 A.M., the resident's clinical record was again reviewed. A Physician's note, dated 11/5/21 at 11:07 A.M., indicated: [Resident B] . with multiple medical problems the main being [CONDITION(S)] and [CONDITION(S)] following a [CONDITION(S)] [CONDITION(S)] disorder, diabetes type 2 dementia with behavioral problems .he was initially admitted to the facility on [DATE], but after admission he started having worsening behaviors,poor nutritional intake non compliant with care occasionally kicking at staff and resisting care I was notified by the nursing staff multiple times about this along with the patient's poor nutritional intake, due to worsening behaviors and history of [CONDITION(S)] disorder the patient was treated with antipsychotics x1 and S [sic] antipsychotics were readjusted, he was continued to monitor but occasionally he day [sic] refused medications his blood sugars were going very high up to the ranges of 491 in spite of not eating well, after continued problems with the patient the family decided to take him to the emergency room patient was sent to [Name of hospital] emergency room at that time. On 11/5/21 at 12:45 P.M., the Administrator provided the current facility policy on Hydration Management, dated November 2017. The policy included: If IDT [interdisciplinary team] Hydration Review deems that a hydration plan is necessary, the plan should be individualized to the resident such as additional 240 cc of fluids each shift, additional 120 cc fluid at med pass, extra fluids on tray ticket, specifics based on resident preferences .The Registered Dietician will determine daily fluid requirements for each resident. A comprehensive care plan will be written and reviewed by IDT with resident specific interventions .Fluid intake will be planned to include at least 480 ml/meal for each resident This Federal tag relates to Complaint IN 536. 3.1-46(b)

Based on interview and record review, the facility failed to ensure a resident who was started on a routine anti-psychotic medication had adequate indications for its use, or a plan in place to treat the resident's behaviors prior to medication. The resident then had an anti-psychotic medication increased. This affected 1 of 3 residents reviewed for [CONDITION(S)] drug use (Resident B). Findings include: The closed clinical record of Resident B was reviewed on 11/4/21 at 11:20 A.M. The resident was admitted to the facility on [DATE] with the primary diagnosis of [CONDITION(S)] and [CONDITION(S)] (weakness and paralysis on one side of the body) following a stroke. Additional diagnoses included, but were not limited to, unspecified dementia without behavior disturbance and [CONDITION(S)] disorder. Discharge orders from the hospital, dated 9/24/21, included, [MEDICATION(S)] 2.5 mg, Commonly known as: [MEDICATION(S)] [an anti-psychotic medication]. Take 1 tablet (2.5 mg) by mouth if needed at bedtime (agitation). Nurses Notes included the following notations: 9/24/21 at 1:50 P.M.: Resident arrived via ambulance on stretcher An admission assessment, dated 9/24/21 at 1:50 P.M., indicated the resident was alert, oriented to person only, and had current health problems of heart problems, high blood pressure, and memory loss. The next entry, dated 9/24/21 at 9:08 P.M., indicated, Mental status: Alert .Very restless this shift. Did settle down and rest after 50 mg [milligrams] of [MEDICATION(S)] [an anti-psychotic medication]. Documentation of the resident's behaviors, or interventions attempted to manage the behaviors, was not found in the clinical record at that time. A verbal physician's order, dated 9/24/21, indicated the resident was to receive [MEDICATION(S)] 50 mg at every bedtime. The resident's Medication Administration Record, dated September 2021, indicated Resident B [MEDICATION(S)] 2.5 mg at 5:56 P.M. for a behavior issue, and the medication was slightly effective. The resident received [MEDICATION(S)] 50 mg on 9/24, 9/25, and 9/26. Documentation of further restlessness on those dates was not found. Event charting, dated 9/24/21 at 8:44 P.M., indicated, New Order Documentation/Temporary Care Plan, [MEDICATION(S)] 50 mg PO [by mouth] at HS [bedtime]. A care plan regarding the resident's restless behavior was not found in the clinical record. A Care Plan Summary, dated 9/27/21 at 8:09 A.M., included: Family concerned with use of antipsychotics. DNS [Director of Nursing Services] explained that res [resident] had behaviors of combativeness towards staff during care and was restless. Informed family that res was receiving PRN[as needed] IM [injection] [MEDICATION(S)] at hospital. Informed that meds would be reviewed and changed per MD. A Nurses Note, dated 9/27/21 at 2:50 P.M., indicated, Alert, very restless. Squirmed onto mat beside the bed .Kicking at staff and resisting care. [Name of physician] notified and orders received An IDT (interdisciplinary team) note, dated 9/28/21 at 10:45 A.M., indicated, Recorded as Late Entry on 09/29/2021 10:48 AM .IDT reviewed progress note on 9/24/21 at 9:50 pm, stating res [resident] was restless. [Physician] gave order for [MEDICATION(S)] 50 mg at HS [bedtime]. IDT reviewed progress note dated 9/27/21 at 2:50 pm, stating res was restless; squirming to get out of bed, and combative, resisting care .Tried to comfort res with conversation, and position change, all ineffective. Notified [Physician] on 9/27/21 and orders received to [discontinue] PRN [as needed] [MEDICATION(S)] and change to routine 2.5 mg BID [twice daily] and [discontinue] [MEDICATION(S)] mg at HS. Gave order to make [MEDICATION(S)] routine, 2.5 mg BID. Family aware. A Behavior Administration History, initiated on 9/28/21, indicated, Behavior 1: Resident may become combative with care, restless, agitated, etc .Intervention 1: Assure res is comfortable - check sugar, assure not in pain, room temperature, noise, etc. Intervention 2: Offer hand/back massage. Intervention 3: sit next to res and talk to him, contact his wife to speak to him or come in and sit with him. Intervention 4: play music such as the beatles [sic], roset, etc. Intervention 5: Medication per order. On 11/5/21 at 10:40 A.M., the Director of Nursing (DON) was interviewed. The DON indicated she had told the nurse who obtained the initial [MEDICATION(S)] on 9/24/21 to document a behavior event. The behavior event would trigger behavior charting. The DON searched the clinical record and indicated she could not find a behavior event or a care plan. The DON indicated the resident was restless and agitated during his stay. On 11/5/21 at 11:20 A.M., the Director of Nursing provided the current facility [CONDITION(S)] Management Policy, dated 9/2017. The policy included: Definition: a [CONDITION(S)] drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include .Anti-psychotic .Residents are not given [CONDITION(S)] drugs unless the medication is necessary to treat a specific condition as diagnosed , and this is documented in the medical record. Each resident receiving [CONDITION(S)] medication will have an adequate indication for use and supporting diagnosis for use which is documented in the clinical record. 2. Prior to initiating a [CONDITION(S)] medication, an assessment by the IDT [interdisciplinary team] will be made of the resident including other potential causes of the behavior; as well as non pharmacological interventions that have been attempted. Symptoms and therapeutic goals must be clearly documented prior to initiating or increasing a [CONDITION(S)] medication .All residents who are taking antipsychotic .medication are required to have a behavior monitoring program in place identifying targeted behavioral symptoms being monitored as well as personalized non pharmacological interventions This Federal tag relates to Complaint IN 536. 3.1-48(a)(4) 3.1-48(b)(2)

Based on observation, interview, and record review, the facility failed to ensure feeding tube placement was checked prior to flushing the tube, and failed to accurately monitor the feeding tube intake of residents, for 2 of 3 residents reviewed with feeding tubes, in a sample of 6. This resulted in one resident being hospitalized with a [DIAGNOSES REDACTED]. Residents B and D Findings include: 1. On 6/1/18 at 9:40 A.M., during the initial tour, Medical Records Staff 1 indicated Resident B had a feeding tube. She indicated Resident B had [MEDICAL CONDITION](stroke), had a [MEDICAL CONDITION], did not communicate, and was basically non-responsive. On 6/1/18 at 10:25 A.M., the clinical record of Resident B was reviewed. An admission Minimum Data Set (MDS) assessment, dated 4/17/18, indicated Resident B had a short term and long term memory problem, received 51% or more total calories through his feeding tube, and 501 cc or more average fluid intake by the feeding tube. A Care Plan, dated 4/10/18, indicated, Problem: Resident at risk for complications related to enteral feeding. The Approaches included: Check placement and residuals .Tube feedings as ordered. Water flushes as ordered. An additional Care Plan, dated 4/10/18, indicated, Problem: Resident is at risk for fluid imbalance due to: NPO (nothing by mouth) and requires feeding and hydration through [DEVICE] (gastrostomy, or feeding tube) . The Approaches included: NPO - [DEVICE] flushes as ordered. Record intake. An additional Care Plan, dated 4/10/18 and reviewed 4/25/18, indicated: Problem: Resident is at risk for altered nutritional status due to new admission to facility; NPO requires [DEVICE] feedings. The Approaches included: Free water flushes as ordered. [MEDICATION NAME] 1.5 @ 65 cc/hr. NPO. A physician's orders [REDACTED]. A Registered Dietician's (RD) note, dated 4/25/18, included: .Pressure area coccyx .Estimated fluid needs: 1772-2220 .Received enteral nutrition for 100% of nutrition needs. A RD note, dated 5/16/18, indicated, Enteral rate increased r/t (related to) wt (weight) fluctuation .[MEDICATION NAME] therapy initiated on 4/18 .Current enteral regime is providing free water from formula alone; Free water flushes providing additional 900 cc for total yield 2267 .Enteral regimen providing 100% of RDI's (Reference Daily Intake) .Will increase rate to 85 cc/hr. Nurses Notes, dated 5/20/18 at 8:45 P.M., indicated, At (YEAR) (8:15 P.M.) family requested that res (resident) be assessed so res could go to hospital for eval (evaluation) .T (temperature) 101 .Order to send to hospital A hospital History and Physical, dated 5/21/18, included: .The patient presented to (name of hospital 1) last PM and was found to have evidence of left-sided pneumonia on CXR (chest x-ray). Patient's lab work was significant for a sodium level of 180 (normal sodium 135-145) .Assessment/Plan: Severe [MEDICAL CONDITION]: Patient with a reported sodium level of 180 at the outside hospital .this is likely represents a chronic [MEDICAL CONDITION], most likely secondary to lack of free water with PEG tube use .Will .check NA (sodium) level every 3 hours A hospital Discharge Summary, dated 5/25/18, included: .He also had significant [MEDICAL CONDITION]. He was treated with IV fluids and his sodium numbers improved with free water flushes through peg tube The resident was readmitted to the facility on [DATE]. Physician orders [REDACTED]. Special instructions: Check residual with flush, report to MD if more than 100 ml residual. Flush tube with 250 ml H2O every 4 hours. Continuous Feeding Formula [MEDICATION NAME] 1.5 @ 85 ml per hour. Documentation of an intake record, recording how much the resident received through his feeding tube in a 24 hour period, was not found in the clinical record. On 6/4/18 at 9:10 A.M., Resident B was observed lying in bed. His feeding tube was running at 85 cc/hr. CNA 1 and CNA 2 were providing care, and requested that LPN 1 come in and turn off the resident's feeding so that they could turn him. LPN 1 entered at that time, turned off the resident's feeding pump, and plugged the tube. On 6/4/18 at 10:00 A.M., LPN 1 indicated she was going to give Resident B his medications. The resident's feeding was off, and the feeding tube was plugged. LPN 1 unplugged the feeding tube, and inserted a syringe. She then poured approximately 30 cc of water into the syringe in the feeding tube. After the water flush, she put the plunger back in the syringe, and inserted air into the syringe while listening for the air on the resident's abdomen with her stethoscope. She did not check the residual. LPN 1 was questioned at that time if she usually instilled water in a resident's feeding tube prior to checking for correct placement with the stethoscope. LPN 1 indicated, Yes, that's how I do it. 2. On 6/1/18 at 9:40 A.M., during the initial tour, Medical Records Staff 1 indicated Resident D had a feeding tube. Resident D was observed sitting up in a broda chair at that time. On 6/1/18 at 12:00 P.M., Resident D was observed sitting up in a broda chair. Her feeding was turned off, and the feeding tube was plugged. On 6/1/18 at 2:30 P.M., the clinical record of Resident D was reviewed. [DIAGNOSES REDACTED]. A Care Plan, dated 5/3/18, indicated: Problem: Resident at risk for complications related to enteral feeding. The Approaches included: Check placement and residuals. Tube feedings as ordered. Water flushes as ordered. An additional Care Plan, dated 5/3/18, indicated, Resident is at risk for altered nutritional status due to .NPO (nothing by mouth); dependent on [DEVICE] for nutrition/hydration. The Approaches included: [MEDICATION NAME] via [DEVICE] feeding; nothing by mouth. An admission Minimum Data Set (MDS) assessment, dated 5/10/18, indicated Resident D had a memory impairment, received 51% or more total calories through her feeding tube, and 501 cc or more average fluid intake by the feeding tube. Physician orders [REDACTED]. Flush tube with 150 ml H2O every 6 hours. Continuous Feeding Formula Glucerna 1.2 @ 70 cc/hr. Documentation of an intake record detailing how much fluid the resident actually received daily was not found in the clinical record. On 6/1/18 at 3:00 P.M., Resident D was observed lying in bed. Her feeding was infusing at 70 cc/hr via a feeding pump. On 6/4/18 at 9:30 A.M., LPN 1 indicated she was going to administer medications to Resident D. LPN 1 stopped the [DEVICE] feeding, and plugged the feeding tube. She inserted a syringe, and instilled approximately 30 cc water into the tube. She then placed the plunger in the syringe, and instilled air into the feeding tube while listening for placement on the resident's abdomen with her stethoscope. She then administered the medications. On 6/4/18 at 10:15 A.M., the Director of Nursing (DON) provided the current facility policy, Enteral Tube - Medication Administration, dated 1/2010 and reviewed 1/2018. The policy included: .Check enteral tube for patency & gastric content .Remove plunger from syringe and attach barrel to feeding tube. Flush tubing with 30 cc water On 6/4/18 at 3:45 P.M., the DON provided the current facility policy, Enteral Therapy, revised 1/2016. The policy included: It is the policy of this facility that the licensed nurse, in cooperation with other healthcare team members, must carefully monitor the resident's response to the enteral feeding and feeding techniques to ensure the attainment of therapeutic goals .Placement of the enteral therapy tube (Gastric tube, PEG tube .) is to be assessed by the licensed nurse no less than once every shift and before any substance is administered through the tube On 6/4/18 at 2:10 P.M., during an interview with the DON, she indicated that there was no specific place to document a resident's intake from a feeding tube. She indicated the dietician makes recommendations of how much fluid and formula the resident requires, and the nurses sign off on the treatment record if they are administering the flushes or fluids. The DON indicated the resident's treatment record, if initialed, was to serve as a record of the resident's intake. She indicated if the resident would not receive something it would be documented. On 6/4/18 at 2:55 P.M., the Registered Dietician was interviewed. She indicated she had been at the facility since (MONTH) (YEAR). She indicated she participated in the facility's NAR (Nutrition at Risk) meetings, and wounds were also discussed, so she takes that into consideration when recommending formula and water flushes. She indicated the team discusses wound drainage amounts, most current weights, and calorie intake. When questioned regarding how she knew how much fluid the resident was actually receiving daily, she indicated, I've been told that signing off on the emar (electronic medicine administration record) shows that it was addressed. If there was some variable, it would be charted. We don't put it in our system. The RD indicated, In the future, we are getting new pumps that will automatically provide flushes, and give accurate intakes. The RD indicated she had informed the staff they need to let her know if a resident's pump is turned off for a length of time. On 6/4/18 at 3:45 P.M., the DON provided the current facility policy, Food and Fluid Intake Record, revised 2/2015. The policy included: Upon completion of the meal a member of nursing staff .will document the percentage of food and amount of fluid consumption .Also document the amount of fluids in ml's (milliliters) the resident consumed during the meal .Each shift will document the amount of additional fluids other than at mealtime in the EMR (Electronic Medical Record) under the 'fluids' tab or on the MAR (Medication Administration Record). The DON indicated at that time that there was no accurate way of measuring the intake for those residents receiving [DEVICE] feedings. She indicated the policy does not really address where to record the intake. The DON indicated she was unsure if the feeding pumps could be cleared at the end of the shift, or the day, to record the actual amount infused. This Federal tag is related to Complaint IN 485. 3.1-44(a)(2)

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance to prevent falls for 4 of 8 residents reviewed for falls. Two of the residents' falls resulted in a major injury. (Resident 217, Resident 54, Resident 61, Resident B) Findings include: 1. On 12/15/17 at 9:16 A.M., Resident 217 was observed in the 500 Hall common area, on the Cottages Memory Care unit, sleeping in broda chair with a blanket over her, leaning to the left side. No chair alarm was observed. At that time, RN 4 indicated all chair and bed alarms in the facility were discontinued recently. On 12/18/17 at 9:00 A.M., Resident 217 was observed in the 500 Hall common area sleeping in a Broad chair with a blanket over her, leaning to the left side. On 12/15/17 at 8:40 A.M., Resident 217's clinical record was reviewed. Resident 217's Admission MDS (Minimum Data Set) assessment, dated 9/7/17, indicated Resident 217 required one person assist for bed mobility, transfers, and toileting. An Admission MDS assessment, dated 12/7/17, indicated Resident 217 had severe cognitive impairment, change in assistance was documented, two person assist with bed mobility, transfers, and toileting. Care plans included, but were not limited to: Resident is at risk for fall, started on 9/5/17. Interventions included, but were not limited to, call light in reach, clean and clutter free pathways with adequate lighting, and non skid footwear (9/5/17), mattress on floor next to bed on right side (10/9/17). The Progress Notes included, but were not limited to: 10/8/17 at 10:05 P.M. EMS here to transport resident to (local hospital name) at this time . 10/8/17 at 2:09 A.M. Resident back from hospital via (county ambulance name) EMS . 10/9/17 at 5:47 A.M. Since returning from hosptial (sic) has been combative anxious grabbing things that arent (sic) there has required one on one was offered drink food and was toileted and at times x 2 assist gait unsteady unable to walk alone weighted vest tried gait belt on at all times and attempted to wheel her up and down the hall eyes have been closed most of the (sic). 10/9/17 at 6:06 A.M. Red bruises noted on bilat (bilateral) wrists after return from hospital. Res. anxious, crying, reaching out, 1:1 care provided per staff. 10/9/17 at 7:20 A.M. Dr. (name) notified of current condition, orders received to give [MEDICATION NAME] 5mg as i (sic) time dose . 10/9/17 at 10:57 A.M. IDT (interdisciplinary team) follow up . nursing trying to find out medication given at hospital to check side effects. Hospital has been contacted and IDT awaiting response. Res is currently resting . Fall 1: 10/9/17 at 11:26 A.M. Fall Event: Resident was lying on floor next to mattress on the floor that res was previously sleeping on. Resident was lying on back with urine puddled around the area where she was found. Her pants were down by her ankles et (and) wet. Upon assessing resident, she began to cry out in pain while checking ROM (range of motion). Res stated that her left hip was hurting severely . Resident was in ER prior to fall within the last 12 hour et (and) was given medications that she is not usually given. Resident was sent to ER. A Radiology Report, dated 10/9/17 at 3:19 P.M., read as follows: .Complete [MEDICAL CONDITION] femoral neck. 10/9/17 at 3:08 P.M. Memorial Hosp ER nurse phoned to report resident being admitted for L femoral neck fx . 10/10/17 at 7:34 A.M. IDT note for fall on 10/9/17 .Root cause may be that the medication received in ER (emergency room ) had an adverse reaction causing res. to be incont. which is not normal for res Fall 2: 10/20/17 at 7:11 P.M. Resident was found sitting on her buttocks in the hallway fully clothed with gripper socks intact, she was incont. (incontinent) .she is currently taking [MEDICATION NAME] (anticoagulant) for recent fx. (fracture) of the L. (left) hip and has had medication changes for pain control .Immediate intervention was to initiate neuro checks and family was contacted and provided 1:1 monitoring. Res. has a mattress on the R. side of bed and bed alarm as a current intervention, the bed alarm was turned off at the time of the fall. Future intervention is to educate the staff to assure that interventions are used and working properly . The eMAR (electronic medication administration record) for 10/20/17 - 11/19/17 indicated the following: Resident 217 had a bed alarm from 10/12/17 - 10/23/17. Resident 217 received [MEDICATION NAME] (lorazapam) , an antianxiety medication, - Schedule IV tablet; 0.5 mg (milligrams), three times a day, from 10/19/17 - 10/23/17. Resident 217 received [MEDICATION NAME] ([MEDICATION NAME]), an antipsychotic, 5 mg disintegrating tablet, once a day, from 10/12/17 - 10/23/17. Resident 217 received [MEDICATION NAME] ([MEDICATION NAME]), an antidepressant, tablet; 30 mg, at bedtime, from 10/16/17 - 10/23/17. During an interview on 12/12/17 at 1:25 P.M., Resident 217's family member indicated staff had asked family to sit with her at night. During an interview on 12/19/17 at 12:30 P.M., RN 4 indicated Resident 217 should have been placed on a toileting schedule of every 2 hours after coming back from the hospital before the fall on 10/9/17. RN 4 also indicated Resident 217's alarm was discontinued on 10/23/17 when she was sent to the hospital, and was not reassessed for alarm use upon her return to the facility. 2. On 12/11/17 at 9:16 A.M., Resident 54 resided on the Cottages Memory Care unit, was observed in common area of 500 Hall, sitting in a wheelchair, dressed, with glasses on. On 12/15/17 at 9:14 A.M., Resident 54 was observed in bed sleeping. Mattress observed on the floor by the bed. On 12/18/17 at 11:18 A.M. Resident 54 was observed in the 500 Hall, sitting in a wheelchair. CNA 9 was observed to go to Resident 54's room, obtained her glasses, came back to Resident 54 and put glasses on resident. On 12/15/17 at 8:33 A.M., Resident 54's clinical record was reviewed. Resident 54's Significant Change MDS assessment dated [DATE], indicated Resident 54 required two person assist for bed mobility, transfers, and toileting. The MDS indicated Resident 54 had severe cognitive impairment. Care plans included, but were not limited to: Resident is at risk for fall, started 4/3/17. Interventions included: mattress to floor on left side of bed (11/13/17), right side of bed up against wall (11/13/17), toilet upon rising (between 5am and 6am); before or after meals, at bedtime and check every 2 to 3 hours during the night (10/23/17), assist of 1 for transfers, uses W/C (wheelchair) for mobility (5/1/17), call light in reach (4/3/17), clean and clutter free pathways with adequate lighting (4/3/17), non skid footwear (4/3/17), personal items in reach (4/3/17), therapy screen (4/3/17). Resident requires toileting program, started 10/23/17. Progress notes included, but were not limited to: Fall 1: 10/14/17 at 6:50 A.M. Fall Event: Resident was observed sitting at end of bed with on bottom (sic) with knees bend (sic), she stated she was going to the bathroom. Resident was saturated with urine. Full body assessment done, abrasion noted to R eyebrow and two abrasions to R knee. No complaints of pain. Neuro checks started and WNL (within normal limits). Assisted to bathroom per two assist. MD notified of fall and injuries. Gripper socks applied. No documentation for new interventions in medical record found. Fall 2: 10/23/17 at 5:28 A.M. Progress note: (Staff member) phoned this nurse stated that (Resident) was in the floor. Immediately entered cottages and found resident sitting upright on floor with back propped up against wall of bathroom. Is complaining of left shoulder pain but no deformities or bleeding/bruising noted . 10/23/17 at 5:37 A.M. Faxed to Dr (name) telling of unwitnessed fall that occurred. Also stated that resident was c/o (complaining of) some left shoulder pain and asked if she would like an xray to be obtained . 10/23/17 at 5:41 A.M. (Family member) residence phoned by this nurse. Wife answered and states he is at work. Notified of resident having an unwitnessed fall. Informed that resident had appeared to be going to the bathroom unassisted and that resident was c/o of some left shoulder pain. Wife states, Doesn't she have an alarm? I mean she's fallen once before! Stated that we would put alarm on and that IDT would address in morning meeting . No documentation of alarm use in IDT note from morning meeting 10/23/17 at 2:30 P.M. Resident asked for ice pack to shoulder. CNA applied ice pack in bag and skin protected from cold was check (sic) every 15 minutes. 10/23/17 at 4:09 P.M. Dr. (name) aware of uncontrolled shoulder pain, N.O. (new order) received to send to ER for eval (evaluation) et. tx (treatment) . 10/23/17 at 7:05 P.M. Progress note: emergency room called report on resident. [DIAGNOSES REDACTED]. Fall 3: 11/11/17 at 6:40 A.M. Fall Event: CNA staff enters resident's room at this time to find resident sitting on the floor beside her bed in front of bedside dresser. Resident sitting on buttocks with feet extended .Resident's brief changed et resident cleansed, lights were turned on .gripper socks donned. Immediate intervention is to move bed against the wall and place mattress on the floor beside resident's bed d/t (due to) decreased safety awareness . During an interview on 12/19/17 at 12:00 P.M., RN 4 indicated Resident 54's bed and chair alarms were discontinued because she had not set them off in so many days. Interventions put into place at the time of alarm discontinuance were bed against the wall, and mattress on the floor by the bed. 3. On 12/15/17 at 9:20 A.M., Resident 61 resided on the Cottages Memory Care unit, was observed sitting in a wheelchair at a dining room table in the 500 Hall, dressed, nonskid socks on. On 12/18/17 at 9:08 A.M., Resident 61 was observed being pushed in a wheelchair down the 500 Hall hallway by therapy, dressed, nonskid socks on. On 12/13/17 at 10:18 A.M., Resident 61's clinical record was reviewed. [DIAGNOSES REDACTED]. Resident 61's Admission MDS assessment dated [DATE], indicated Resident 61 required two person assist for bed mobility, transfers, and toileting. The MDS indicated Resident 61 had severe cognitive impairment. Care plans included, but were not limited to: Resident is at risk for fall, started on 11/21/17. Interventions included: left side of bed up against wall (12/4/17), 2 assist with transfers (11/24/17), perimeter mattress to bed to provide a tactile boundary (11/24/17), call light in reach (11/21/17), clean an clutter free pathways with adequate lighting (11/21/17), environmental changes: new to facility (11/21/17), non skid footwear (11/21/17), observe for medication side effects: sedation, drowsiness, ataxia, morning hangover (11/21/17), personal items in reach (11/21/17), therapy screen (11/21/17), toilet upon rising, before or after meals, at bedtime and as needed during the night (11/21/17). Res (resident) struggles with sundowning and becomes verbally aggressive at times. Res may scream at staff, started on 11/22/17. Progress notes included, but were not limited to: 10/17/17 at 9:40 P.M.Res attempted to get up by self. She is risk of fall, so we keep her nurse station supervise.(sic) 11/19/17 at 12:52 A.M.Res was trying to get out of bed by throwing legs over the side . 11/19/17 at 9:09 A.M.According to staff, res does ok throughout the day but at 4 or 5, res experiences sever sun-downing with episodes of screaming and the possibility of aggression with staff . 11/20/17 at 10:46 A.M.Resident this evening was up and down wanted out of wheelchair. Ambulated self to chair from wheelchair before staff could be within reach of resident . 11/21/17 at 1:50 P.M.Resident has been getting up out of w/c this shift and trying to walk. She has done this multiple times and staff has kept and eye on her to make sure she did not fall. Resident also tried to get out of bed. 11/21/17 at 9:47 P.M. Resident continues to get out of wheelchair without assistance from staff present. After this resident wanted to go to bed, CNA was doing safety check and found resident trying to get out of bed alone . 11/22/17 at 12:24 A.M. Resident had been constantly up and down in wheelchair can not get comfortable . Fall 1: 11/22/17 at 8:15 P.M. Progress note: Res found sitting on the floor .sitting against the chair in her room. When I asked what happened she started blowing kisses. Able to moved (sic) all extremities .Family stated she had done this before. No injuries documented. 11/24/17 at 11:36 A.M. IDT note: .Immediate intervention was to place a nonskid strip by bed. IDT concludes d/t dx (diagnoses) dementia, weakness, lack of coordination and reduced mobility, resident has poor safety awareness and is unaware of boundaries. Future intervention is to place a perimeter mattress on bed to provide a tactile boundary for resident and remove non-skid strip . 11/24/17 at 5:50 P.M. Resident continues to try to get out of w/c and stand. Resident has no perception of safety. Resident is not strong enough to stand and walk and if she continues this bxs (behaviors) she will eventually fall. Every intervention tried has failed to reduce this bx . 11/25/17 at 9:34 P.M.has been attempting to get up out of chair constantly . 11/26/17 at 5:49 P.M. Resident continues to get out of wheelchair before staff can assist in standing . 12/1/17 at 4:27 P.M. Resident has been attempting to get up on her own et walk unassisted continuously this shift . Fall 2: 12/3/17 at 4:21 P.M. Fall Event: No injuries noted form (sic) fall. Resident was laying in bed when roommate came to get nurse saying resident is trying to get get (sic) ot of bed. Activity Aide went to check on resident. Resident was laying on floor up next to bed .upon assessment resident had no injuries to note. Resident told this nurse she was in no pain . Fall 3: 12/7/17 at 5:27 A.M. CNA discovered resident laying on the floor beside her bed. Resident was laying flat on her back. She was naked from the waist down, no pants, no brief and no socks on (gripper socks were laying on the floor near her feet. Bedclothes were wet with urine. Resident unable to tell us what happened. Complete assessment done. small bruise/scratch on R hip, no other injuries noted .Intervention is to check and change resident every two hours. During an interview on 12/19/17 at 12:00 P.M., RN 4 indicated Resident 61 has never had nor been assessed for use of an alarm. 4. On 12/12/17 at 10:42 A.M., Resident B was observed in bed, awake. Resident B moaned and grimaced, indicated he was in pain all over. On 12/15/17 at 8:55 A.M., Resident B was observed in bed, awake. Resident B indicated staff had not been in to get him up yet, and complained of his feet being cold. On 12/18/17 at 9:10 A.M., Resident B was observed in bed, awake. Resident B indicated he was doing well. On 12/15/17 at 8:30 A.M., Resident B's record was reviewed. [DIAGNOSES REDACTED]. Current physician order [REDACTED]. Current care plans included, but were not limited to, Resident is at risk for fall, started 7/12/12. Interventions included, but were not limited to, Hoyer lift for transfers (10/13/16). A current CNA sheet, dated 12/12/17, indicated Hoyer lift to be used for transfers, started on 10/13/16. A Falls Event report, dated 12/2/17, indicated Resident B had a witnessed fall on 12/2/17 at 11:44 A.M. The event report indicated during a transfer with a mechanical lift, Resident B's knees became weak, and he was lowered to the floor. Intervention put into place: Hoyer lift at all times. An IDT progress note, dated 12/4/17, indicated during Resident B's assisted fall, he .was being transferred in a stand aid . During an interview on 12/8/17 at 11:48 A.M., QMA 21 indicated he was present during Resident B's fall on 12/2/17. QMA 21 indicated Resident B was being transferred in a stand aid, and when he was raised in the lift, his arms raised up and he was unable to support himself whatsoever, and began sliding out of the lift. QMA 21 further indicated there was miscommunication between therapy and nursing at to which lift should have been used for Resident B. He indicated nursing wanted to use the full body lift, which QMA 21 indicated staff refers to as a Hoyer lift. He indicated therapy wanted to use a stand aid, that he indicated only supported under the arms. QMA 21 indicated communication was not good at the time, documentation was not good, and there was confusion between the two departments. No documentation found for use of a stand aid for Resident B. During an interview on 12/19/17 at 8:35 A.M., the DON indicated all alarms in the facility were discontinued a few weeks ago. She indicated staff could not get to the residents quickly enough when the alarms sounded so they were not needed. On 12/19/17 at 8:28 A.M., a Fall Management Program policy was provided. The policy indicated its purpose to ensure residents residing within the facility receive adequate supervision and or assistance to prevent injury related to falls. The policy indicated post fall, all falls will be discussed by the IDT to determine root cause and other possible interventions to prevent future falls .The care plan will be reviewed and updated, as necessary. 3.1-45(a)

Based on interview and record review, the facility failed to assess a resident, with a [MEDICAL CONDITION], new symptoms of diarrhea, vomiting, and abnormal vital signs, resulting in a hospitalization for a small bowel obstruction, for 1 of 1 residents reviewed with colostomies, in a sample of 18. Resident B Findings include: The closed clinical record of Resident B was reviewed on 7/20/16 at 2:15 P.M. [DIAGNOSES REDACTED]. A resident Care Plan, initially dated 7/3/15 and updated 3/29/16, indicated, Resident has an ostomy. The Approaches included: Monitor BM's (sic), notify MD of abnormal findings. A Minimum Data Set (MDS) assessment, dated 4/1/16, indicated the resident scored a 3 out of 15 for cognition, with 15 indicating no memory impairment. The resident required extensive assistance of two + staff for toilet use. The MDS assessment indicated the resident had an ostomy, or did not have a bowel movement for the entire 7 days. A Vital Signs report, dated 6/14/16, indicated the resident's blood pressure was 120/68, pulse was 70, and temperature was 97.3. A Physician's Note, dated 6/21/16, indicated, Tolerating [MEDICAL CONDITION] - Continue with current meds/tx (treatments) Progress Notes included the following notations: 6/26/16 at 1:53 A.M.: Resident resting quietly at present. Resident had emesis (vomiting) earlier this shift x 1, will cont. to monitor. HOB (head of bed) elevated, no SOA (shortness of air) noted d/t [MEDICAL CONDITION]. Documentation of vital signs, or an abdominal assessment, was not found in the clinical record. A Vital Signs report, dated 6/26/16 at 1:49 P.M., indicated the resident's blood pressure was 89/50, blood sugar was 243 High, and pulse was 98. Progress Notes continued: 6/26/16 at 1:54 P.M.: Res. (resident) is not feeling good this day, he is cool and clammy, not eating, but is drinking well. He stated 'I feel O.K.' Blood sugar running higher than normal and was given s/s (sliding scale) insulin as order. B/P (blood pressure) is running low. Place a cool cloth on res. head. Res. is alert to name, touch, and can answer questions appropriated (sic). An Event Report, dated 6/26/16 at 2:00 P.M., indicated, Low B/P and higher (sic) than normal. The report indicated the physician was not notified of the resident's change in condition at that time. Progress Notes continued: 6/26/16 at 7:30 P.M.: Resting quietly in bed. When questioned, states feels ok. Skin is cool to touch, but dry. Only ate fruit for supper, but is drinking well. Has had no vomiting, but cont with watery stools per [MEDICAL CONDITION]. VS (vital signs) 90/60, (temperature) 96.7, (pulse) 100 .[MEDICATION NAME], 2.5 mg 1 po (by mouth) for watery stools. 6/26/16 at 1:13 A.M.: [MEDICAL CONDITION] bad and flange (sic) changed as ordered. Resident stoma noted to be irritated from diarrheal stools noted earlier Color pale skin warm and dry. A Vital Signs report at that time indicated the resident's temperature was 99.3. 6/27/16 at 1:20 P.M.: This nurse called to res room noted res to be cool and clammy. ABD (abdomen) hard and distended. No BS (bowel sounds) noted. Res had emesis x 1 this shift. Res has a nonproductive cough .Temp 100.1. (Name of physician) notified N.O. (new order) received may send to (name of hospital) ER for eval (evaluation) and treat .Message left for sister (name) awaiting return call. The resident was transferred to the hospitalER on [DATE] at 1:50 P.M. A hospital ER physician documentation note dated 6/27/16 at 2:40 P.M., indicated, Chief Complaint: Abdominal Pain .presents to the emergency department today with some abdominal distention .does have a [MEDICAL CONDITION] on the left side .Physical Exam: .Abdomen: .Abnormal bowel sounds. Distention with tympany to percussion .Not soft .Progress and Procedures .while in the emergency department the patient had a workup performed which showed a small bowel obstruction .admitted to the Intensive Care Unit .Clinical Impression: small bowel obstruction,[MEDICAL CONDITIONS] (low blood pressure). On 7/20/16 at 2:50 P.M., during an interview with the Director of Nursing (DON), she indicated she did speak to LPN # 4 regarding the resident's symptoms and lack of a thorough assessment on 6/26/16. She indicated LPN # 4 told her that she notified the physician and family of the resident's symptoms, but there was not documentation of notification. She indicated LPN # 4 told her that people vomit and have diarrhea every day, and she didn't necessarily call the doctor every time. The DON indicated she educated staff that if a resident with a [MEDICAL CONDITION] had watery stools, they needed to investigate the reason for them. She indicated LPN # 4 no longer worked at the facility. On 7/20/16 at 3:20 P.M., LPN # 1 was interviewed. LPN # 1 indicated she was the nurse working who send the resident to theER on [DATE]. She indicated the resident could answer questions, but he had dementia, so didn't know how to say if he was feeling bad. LPN # 1 indicated she thought she was the first one to notify the doctor of the resident's symptoms. LPN # 1 indicated the resident's [MEDICATION NAME] was an old order. It had not been used for a long time. This Federal tag relates to Complaint IN 951. 3.1-47(a((3)

Based on interview and record review, the facility failed to notify the resident's physician and family member of a change in condition, for 1 of 3 residents reviewed regarding notification, in a sample of 18. Resident B Findings include: The closed clinical record of Resident B was reviewed on 7/20/16 at 2:15 P.M. [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment, dated 4/1/16, indicated the resident scored a 3 out of 15 for cognition, with 15 indicating no memory impairment. The resident required extensive assistance of two + staff for toilet use. The MDS assessment indicated the resident had an ostomy, or did not have a bowel movement for the entire 7 days. A Vital Signs report, dated 6/14/16, indicated the resident's blood pressure was 120/68, pulse was 70, and temperature was 97.3. A Physician's Note, dated 6/21/16, indicated, Tolerating [MEDICAL CONDITION] - Continue with current meds/tx (treatments) Progress Notes included the following notations: 6/26/16 at 1:53 A.M.: Resident resting quietly at present. Resident had emesis (vomiting) earlier this shift x 1, will cont. to monitor. HOB (head of bed) elevated, no SOA (shortness of air) noted d/t [MEDICAL CONDITION]. A Vital Signs report, dated 6/26/16 at 1:49 P.M., indicated the resident's blood pressure was 89/50, blood sugar was 243 High, and pulse was 98. Progress Notes continued: 6/26/16 at 1:54 P.M.: Res. (resident) is not feeling good this day, he is cool and clammy, not eating, but is drinking well. He stated 'I feel O.K.' Blood sugar running higher than normal and was given s/s (sliding scale) insulin as order. B/P (blood pressure) is running low. Place a cool cloth on res. head. Res. is alert to name, touch, and can answer questions appropriated (sic). An Event Report, dated 6/26/16 at 2:00 P.M., indicated, Low B/P and higher (sic) than normal. The report indicated the physician nor family was notified of the resident's change in condition at that time, but on 6/28/16 at 8:47 A.M. Progress Notes continued: 6/26/16 at 7:30 P.M.: Resting quietly in bed. When questioned, states feels ok. Skin is cool to touch, but dry. Only ate fruit for supper, but is drinking well. Has had no vomiting, but cont with watery stools per [MEDICAL CONDITION]. VS (vital signs) 90/60, (temperature) 96.7, (pulse) 100 .[MEDICATION NAME], 2.5 mg 1 po (by mouth) for watery stools. 6/26/16 at 1:13 A.M.: [MEDICAL CONDITION] bad and flange (sic) changed as ordered. Resident stoma noted to be irritated from diarrheal (sic) stools noted earlier Color pale skin warm and dry. A Vital Signs report at that time indicated the resident's temperature was 99.3. 6/27/16 at 1:20 P.M.: This nurse called to res room noted res to be cool and clammy. ABD (abdomen) hard and distended. No BS (bowel sounds) noted. Res had emesis x 1 this shift. Res has a nonproductive cough .Temp 100.1. (Name of physician) notified N.O. (new order) received may send to (name of hospital) ER for eval (evaluation) and treat .Message left for sister (name) awaiting return call. The resident was transferred to the hospitalER on [DATE] at 1:50 P.M. On 7/20/16 at 2:50 P.M., during an interview with the Director of Nursing (DON), she indicated she did speak to LPN # 4 regarding the resident's symptoms on 6/26/16. She indicated LPN # 4 told her that she notified the physician and family of the resident's symptoms, but there was not documentation of notification. On 7/20/16 at 3:20 P.M., LPN # 1 was interviewed. LPN # 1 indicated she was the nurse working who send the resident to theER on [DATE]. She indicated the resident could answer questions, but he had dementia, so didn't know how to say if he was feeling bad. LPN # 1 indicated she thought she was the first one to notify the doctor of the resident's symptoms. On 7/21/16 at 10:30 A.M., the Administrator provided the current facility policy on Resident Change of Condition, dated 1/2015. The policy included: It is the policy of this facility that all changes in resident condition will be communicated to the physician and family/responsible party, and that appropriate, timely, and effective intervention takes place .Any sudden or serious change in a resident's condition manifested by a marked change in physical or mental behavior will be communicated to the physician .The responsible party will be notified that there has been a change in the resident's condition and what steps are being taken. All nursing actions/interventions will be documented in the medical record as soon as possible after resident needs have been met This Federal tag relates to Complaint IN 951. 3.1-5(a)(2)

Based on interview and record review, the facility failed to provide supervision to prevent falls; failed to ensure residents' bed mattresses had bed bolsters and were in the lowest position as care planned and/or ordered by the physician, resulting in a fall from bed which resulted in head lacerations and a collarbone fracture; and utilized alarms in place of supervision, resulting in a fall with a head laceration, for 3 of 6 residents reviewed for falls, in a sample of 11. Resident B, Resident F, Resident G Findings include: 1. On 2/18/16 at 9:40 A.M., during the initial tour, LPN # 1 indicated Resident B had recently fallen. LPN # 1 indicated Resident B was no longer a resident at the facility. The closed clinical record of Resident B was reviewed on 2/18/16 at 11:15 A.M. [DIAGNOSES REDACTED]. A significant change Minimum Data Set (MDS) assessment, dated 11/10/15, indicated Resident B scored a 5 out of 15 for cognition, with 15 indicating no memory impairment. The MDS assessment indicated the resident required extensive assistance of two+ staff for bed mobility and transfer, and did not ambulate. A test for balance indicated Not steady, only able to stabilize with staff assistance while moving from seated to standing position, moving on and off the toilet, and surface-to-surface transfer. A physician's orders [REDACTED]. A physician's orders [REDACTED]. Progress Notes included the following notations: 1/2/16 at 7:30 P.M.: This nurse et (and) CNA were right outside resident's room et heard a loud crash .This nurse went into room et saw large amount of blood near resident's head et R (right) arm .Resident has large hematoma et deep laceration to R side of head. Resident also has skin tear to RAC (right inner elbow area). MD notified et new order to sent resident to ER to eval et treat 1/3/16 at 1:23 A.M.: Resident returned from ER .transferred to bed by 4 staff members .showing s/s (signs/symptoms) of pain, facial grimacing, gaurding (sic), and crying out .resident got 6-7 stitches to right forehead and mepitel one dressing to right elbow. An Event Report, included: Event Date: 02/04/2016, 06:15 AM .Was fall witnessed, No. Describe what the resident was doing prior to fall .Lying in bed. Describe the position of the resident when first observed after the fall .Lying on the floor in front of the bed on the right side .Is the resident in pain and or experiencing difficulty in movement of extremities, Yes - c/o (complains of) head hurting. Did the resident hit his/her head, Yes .Describe injuries .hematoma (raised bruise) to above Left eye measuring 7.5 x 5 and a skin tear measuring 5.6 x 1.1 and a hematoma to above right eye measuring 5 x 6.5 and a open area measuring 1.5 x 0.5 and a skin tear to left hand measuring 1.5 x 1.6. Areas cleansed with wound cleanser and strips applied to skin tear above left eye and to skin tear to left hand .What intervention (s) was put into place to prevent another fall, neuro checks started. 15 min (minute) checks .Physician Notified: Date/Time: 02/04/2016, 07:43 AM, Family Notified: Yes, Date/Time: 02/04/2016. Vitals .Pulse 84/per minute (Time 07:09 AM) .Blood Pressure, 128/94 (Time 07:09 AM) A Discharge/Transfer form, dated 2/4/16 at 7:20 A.M., indicated: .Reason for transfer, Res (resident) rolled out of bed and is c/o (complaining of) pain and guarding right shoulder An ambulance report, dated 2/4/16 at 7:43 A.M., indicated, .Chief Complaint .Pain to right shoulder and neck .Staff states that the pt. (patient) fell out of bed and was found at 0615 (6:15 A.M.) .Arrived to find pt. seated in wheel chair .Noted bandaging to pt. arms and forehead. Noted improvised sling to pt. right arm A hospital emergency room history, dated 2/4/16 at 8:19 A.M., indicated, .fell (pt was found by the NH (nursing home) on the floor and the staff thought pt rolled out of bed onto the floor. NH staff had already gotten the pt up off the floor and into the wheelchair and they had steri stripped the forehead lacerations .Rt (right) shoulder X-ray: right distal clavicle (collarbone) fx (fracture) .Clinical Impression: Fall, closed head injury, right distal clavicle fx, left forehead superficial laceration steri strip repaired A facility progress note, dated 2/5/16 at 10:31 A.M., indicated: .Resident was found by morning shift on floor next to bed .IDT (Interdisciplinary team) feels root cause to be resident rolling to side and air mattress continuing momentum, causing resident to fall to floor On 2/18/16 at 11:30 A.M., during an interview with Resident B's family member, she indicated she was phoned on 2/4/16 at 7:45 A.M., and was informed that Resident B was on the way to the hospital with severe head injuries and a broken collarbone. On 2/18/16 at 1:20 P.M., during an interview with LPN # 1, she indicated she was working the morning of 2/4/16. She indicated she had just gotten report at approximately 6:15 A.M., when a CNA alerted her that Resident B had rolled out of the bed. LPN # 1 indicated the resident had bleeding and a hematoma on her head. LPN # 1 indicated the resident was lying on her right side, and so was unable to do range of motion on that side. She indicated she did shine a flashlight in her eyes, and that was ok. LPN # 1 indicated when they rolled the resident over, you could tell something was wrong with her right arm. She indicated the resident's arm was drooping, and she thought it might be broken. She indicated 4 staff members lifted the resident to a wheelchair, and the CNAs took the resident to the shower to wash the blood out of her hair. LPN # 1 indicated when the resident was in the shower, staff noticed a bruise on the resident's right upper arm, and that she was guarding her arm. She indicated she was not the primary nurse of Resident B on that day. LPN # 1 indicated the resident had been on an air mattress, but that the bed was not in the low position. On 2/18/16 at 1:30 P.M., during an interview with LPN # 2, she indicated, We had just got report when the restorative aide yelled. (LPN # 1) went in first. LPN # 2 indicated the resident was found lying on the floor on her right side. She indicated the resident had 2 knots on her left and right forehead, and she applied steri-strips to those areas. LPN # 1 indicated the bed was not in the lowest position. She indicated, 4 of us got her up with a gait belt. She was complaining of a headache. She indicated staff took the resident to the shower to get the blood out, and that staff noticed a bruise on the resident's shoulder. She indicated the resident was complaining of pain in the right arm, and that she called the physician. She indicated the resident was transferred to the emergency room . On 2/18/16 at 1:40 P.M., during an interview with CNA # 1, she indicated she found Resident B on the floor at approximately 6:15 A.M. on 2/4/16. She indicated, Her face was awful. She had 2 big hematomas on each side of her head, and blood was dried on her head. She indicated when staff sat the resident up, they noticed a bruise on her right shoulder. She indicated the CNAs informed the nurses about the bruise. CNA # 1 indicated, They only checked her eyes. CNA # 1 indicated they were told to give the resident a shower. CNA # 1 indicated the resident complained about head and shoulder pain. She indicated that following the shower, the resident's bruise appeared bigger, and she informed the nursing staff and the Director of Nursing. She indicated LPN # 1 indicated, We need to send her out. CNA # 1 indicated the resident's bed was not in the lowest position, but was at normal height. On 2/18/16 at 1:50 P.M., during an interview with CNA # 2, she indicated at approximately 6:10-6:15 A.M., she and CNA # 1 went to Resident B's room, and did not see her in bed. She indicated the resident was found on the floor with dried blood all over her, and 2 giant hematomas over her head. She indicated, The nurse said to put her in the chair. CNA # 2 indicated, (LPN # 1) looked in her eyes. CNA # 2 indicated the resident was transferred with a stand-aid mechanical lift to the shower chair from the wheelchair and back, and the resident had a hard time lifting her arm. She indicated the resident kept stating, Please don't hurt me. CNA # 2 indicated the resident had a dark bruise on her right upper arm. She indicated CNA # 1 and herself notified the nurses of the resident's bruising and pain, and that she was sent to the emergency room . On 2/19/16 at 9:15 A.M., during an interview with the Executive Director (ED) and the Director of Nursing Services (DNS), the DNS indicated Resident B's bed was not in the lowest position as ordered, and the mattress did not have bolsters. The DNS indicated he did write up the nurse. The DNS and ED indicated staff are to check their CNA assignment sheets, located in the computerized kiosk, prior to starting care, to determine which residents required beds in the lowest position. 2. On 2/18/16 at 9:40 A.M., during the initial tour, LPN # 1 indicated Resident F had recently fallen. The clinical record of Resident F was reviewed on 2/19/16 at 11:50 A.M. [DIAGNOSES REDACTED]. An admission MDS assessment, dated 12/29/15, indicated Resident F scored a 5 out of 15 for cognition, with 15 indicating no memory impairment. The MDS assessment indicated the resident required extensive assistance of two+ staff for bed mobility and transfer, and did not ambulate. A test for balance indicated, Not steady, only able to stabilize with staff assistance while walking, moving on and off toilet, and surface-to-surface transfer. Resident Progress Notes included the following notations: 12/30/15 at 1:26 A.M.: Resident's roommate put on call light to alert staff of resident's fall. Resident was found laying on left side with R leg still partially on the bed. Resident had pillow still remaining under head .assisted back to bed with 3 assist .Pad alarm placed on bed as immediate intervention .Will cont (continue) to monitor. 12/30/15 at 9:58 A.M.: IDT note .IDT feels root cause to be residents (sic) position on low air loss mattress causing her to slide off onto floor .Future interventions include leaving pad alarm to bed .and bolster to mattress 1/15/16 at 6:00 A.M.: Resident was observed lying on L (left) side on floor next to bed with head in trash can. Noted blood on floor from skin tear on R thumb. When asked what resident was doing she stated 'I was just in this bed.' .Noted red mark to L side of neck, and skin tear to R thumb .Area to R thumb skin approximated and steri strips applied after cleansed. Mat placed on floor next to L side of bed Documentation regarding an alarm sounding was not found in the clinical record. Progress notes continued: 1/15/16 at 10:23 A.M.: IDT note .IDT feels root cause to be decreased safety awareness and noncompliance with assist level. Resident has been observed attempting to sit on edge of bed without assistance and has been informed of the dangers .Future interventions included bed in lowest position, mat to right side of bed, and bed to be placed with left side against wall 1/22/16 at 2:02 A.M.: This nurse et CNA were at the nursing station .heard resident yell that she was falling. This nurse ran into resident's room et resident was laying on forehead with coccyx on the mattress wing. Resident has a laceration on R side of forehead measuring 3 cm x 0.4 cm. Resident c/o (complains of) lower back et R hip pain 1/22/16 at 10:15 A.M.: IDT note for unwitnessed fall .Prior to fall resident had been seen sitting up in bed .Rsd (resident) has pressure pad alarm, but rsd. had removed battery from alarm box prior to falling. Immediate intervention was to send rsd. to ED (emergency department) for evaluation et replace alarm .Future interventions to include: low bed frame, change alarm to wireless alarm 1/22/16 at 3:46 P.M.: .Area to head above right eye stitches and dressing remains intact On 2/22/16 at 9:30 A.M., Resident F was observed lying in bed, with a bedside table in front of her. The bed was at standard height. The bed control pad was in the resident's bed, within reach of the resident. At that time, CNA # 4 was alerted, and indicated, Her bed is supposed to be at the lowest height. The girl must have forgotten to lower it. CNA # 4 immediately lowered the bed. On 2/22/16 at 12:30 P.M., during an interview with the ED and DNS, the DNS indicated he was unable to find documentation regarding whether or not the resident's alarm sounded on 1/15/16. He indicated the resident removed the batteries from the alarm box on 1/22/16 herself, and so he had to assume the resident's alarm was in place on 1/15/16. 3. On 2/18/16 at 9:40 A.M., during the initial tour, LPN # 1 indicated Resident D had recently fallen. The clinical record of Resident D was reviewed on 2/18/16 at 3:00 P.M. [DIAGNOSES REDACTED]. An annual MDS assessment, dated 12/15/15, indicated Resident D scored a 5 out of 15 for cognition, with 15 indicating no memory impairment. The MDS assessment indicated the resident required extensive assistance of two+ staff for bed mobility and transfer, and did not ambulate. A test for balance indicated, Not steady, only able to stabilize with staff assistance while moving from seated to standing position and surface-to-surface transfer. An Event Report, dated 2/7/16 at 8:45 P.M., indicated, .Was fall witnessed, No .Describe the position of the resident when first observed after fall .The bed was in high position with HOB (head of bed) all the way up, although when was put to bed, bed was left in low pos (sic) with HOB slightly up. Bed controller was not within reach of res .Describe injuries .Has raised area to L side of head just above forehead, measures 5.5 cm (centimeters) in diameter. Bil (bilateral) knees look red, with L knee having blue tint to it. Resident or witness statement .Res (resident) not a good historian but when asked if just rolled out of bed, said yes, it hurts (rubbing head, stating 'what do I do?' .What intervention (s) was put into place to prevent another fall. Assure bed low, controller out of reach, of coarse that's (sic) how it was in this case Progress notes included the following notations: 2/8/16 at 9:54 A.M.: This nurse called MD office to make sure MD is aware of res. fall. This nurse left message with MD phone nurse explaining fall and asked for a call back. This nurse also called brother to make sure he was aware of res. fall .Red knot/bruise remains to L side of head/forehead .Bed is in lowest position with bed remote out of reach and call light within reach. Will cont. to monitor. 2/8/16 at 10:12 A.M.: IDT note for fall .Resident was resting in bed when (sic)staff found her lying on floor with gown and gripper socks on. Resident was asked if she rolled out of bed, she stated yes, although resident is a poor historian. Resident c/o pain to head with a raised bruised area noted. Bilateral knees with redness, and slight bruising to L knee .environmental factors noted of bed in high position with head of bed elevated .IDT feel root cause to be residents (sic) change in position in bed along with head of bed being elevated allowed her to roll from bed .MD and family not notified, notifications made by team this am 2/8/16 at 12:27 P.M.: MD called facility back and gave orders to send res. to (name of hospital) to have CT of head done A resident care plan, initially dated 2/20/8 and updated with a goal target date of 10/29/15, indicated, Resident is at risk for all due to: Dx (diagnosis) of arthritis .use of assistive devices, Hx (history) of falls .non-compliance with asking for help .poor safety awareness, confusion .has frequent attempts to try and stand w/o (without) assistance. The approaches included: 2/8/16 Pressure redistribution mattress with side bolsters. 7/8/15 Pull tab alarm to W/C (wheelchair). 7/17/15 Bed in lowest position. 11/26/14 Pad alarm afixed (sic) to upper portion of the bed. On 2/19/16 at 10:00 A.M., the ED provided the current facility policy Fall Management Program, revised 2/2015. The policy included: It is the policy of (name of corporation) to ensure residents residing within the facility will maintain maximum physical functioning through the establishment of physical, environmental, and psychosocial guidelines to prevent injury related to falls . A care plan will be developed at time of admission specific to each resident's fall risk factors. A resident specific care requirements will be communicated to the assigned caregiver utilizing resident profile or CNA assignment sheet The ED and DNS indicated at that time that they had recently inserviced nursing staff on fall assessment, documentation, and interventions post fall. The DNS indicated they provided staff with a list of interventions other than alarms to try to prevent falls. This Federal tag relates to Complaint IN 114, Complaint IN 329, and Complaint IN 939. 3.1-45(a)(1) 3.1-45(a)(2)

Based on interview, observation and record review, the facility failed to completely assess a resident following a fall, and instead moved, showered, and dressed the resident, resulting in complaints of pain, for 1 of 4 residents reviewed for fall assessments, in a sample of 8. Resident B Findings include: On 2/18/16 at 9:40 A.M., during the initial tour, LPN # 1 indicated Resident B had recently fallen. LPN # 1 indicated Resident B was no longer a resident at the facility. The closed clinical record of Resident B was reviewed on 2/18/16 at 11:15 A.M. [DIAGNOSES REDACTED]. A significant change Minimum Data Set (MDS) assessment, dated 11/10/15, indicated Resident B scored a 5 out of 15 for cognition, with 15 indicating no memory impairment. The MDS assessment indicated the resident required extensive assistance of two+ staff for bed mobility and transfer, and did not ambulate. A test for balance indicated Not steady, only able to stabilize with staff assistance while moving from seated to standing position, moving on and off the toilet, and surface-to-surface transfer. A physician's orders [REDACTED]. A physician's orders [REDACTED]. An Event Report, included: Event Date: 02/04/2016, 06:15 AM .Was fall witnessed, No. Describe what the resident was doing prior to fall .Lying in bed. Describe the position of the resident when first observed after the fall .Lying on the floor in front of the bed on the right side .Is the resident in pain and or experiencing difficulty in movement of extremities, Yes - c/o (complains of) head hurting. Did the resident hit his/her head, Yes .Describe injuries .hematoma (raised bruise) to above Left eye measuring 7.5 x 5 and a skin tear measuring 5.6 x 1.1 and a hematoma to above right eye measuring 5 x 6.5 and a open area measuring 1.5 x 0.5 and a skin tear to left hand measuring 1.5 x 1.6. Areas cleansed with wound cleanser and strips applied to skin tear above left eye and to skin tear to left hand .What intervention (s) was put into place to prevent another fall, neuro checks started. 15 min (minute) checks .Physician Notified: Date/Time: 02/04/2016, 07:43 AM, Family Notified: Yes, Date/Time: 02/04/2016. Vitals .Pulse 84/per minute (Time 07:09 AM) .Blood Pressure, 128/94 (Time 07:09 AM) A Discharge/Transfer form, dated 2/4/16 at 7:20 A.M., indicated: .Reason for transfer, Res (resident) rolled out of bed and is c/o (complaining of) pain and guarding right shoulder An ambulance report, dated 2/4/16 at 7:43 A.M., indicated, .Chief Complaint .Pain to right shoulder and neck .Staff states that the pt. (patient) fell out of bed and was found at 0615 (6:15 A.M.) .Arrived to find pt. seated in wheel chair .Noted bandaging to pt. arms and forehead. Noted improvised sling to pt. right arm A hospital emergency room history, dated 2/4/16 at 8:19 A.M., indicated, .fell (pt was found by the NH (nursing home) on the floor and the staff thought pt rolled out of bed onto the floor. NH staff had already gotten the pt up off the floor and into the wheelchair and they had steri stripped the [MEDICAL CONDITION] .Rt (right) shoulder X-ray: right distal clavicle (collarbone) fx (fracture) .Clinical Impression: Fall, closed head injury, right distal clavicle fx, left forehead superficial laceration steri strip repaired On 2/18/16 at 11:30 A.M., during an interview with Resident B's family member, she indicated she was phoned on 2/4/16 at 7:45 A.M., and was informed that Resident B was on the way to the hospital with severe head injuries and a broken collarbone. On 2/18/16 at 1:20 P.M., during an interview with LPN # 1, she indicated she was working the morning of 2/4/16. She indicated she had just gotten report at approximately 6:15 A.M., when a CNA alerted her that Resident B had rolled out of the bed. LPN # 1 indicated the resident had bleeding and a hematoma on her head. LPN # 1 indicated the resident was lying on her right side, and so was unable to do range of motion on that side. She indicated she did shine a flashlight in her eyes, and that was ok. She did not indicate that she took the resident's vital signs. LPN # 1 indicated when they rolled the resident over, you could tell something was wrong with her right arm. She indicated the resident's arm was drooping, and she thought it might be broken. She indicated 4 staff members lifted the resident to a wheelchair, and the CNAs took the resident to the shower to wash the blood out of her hair. LPN # 1 indicated when the resident was in the shower, staff noticed a bruise on the resident's right upper arm, and she was guarding her arm. She indicated she was not the primary nurse of Resident B on that day. On 2/18/16 at 1:30 P.M., during an interview with LPN # 2, she indicated, We had just got report when the restorative aide yelled. (LPN # 1) went in first. LPN # 2 indicated the resident was found lying on the floor on her right side. She indicated the resident had 2 knots on her left and right forehead, and she applied steri-strips to those areas. She indicated, 4 of us got her up with a gait belt. She was complaining of a headache. She indicated staff took the resident to the shower to get the blood out, and that staff noticed a bruise on the resident's shoulder area. She indicated the resident was complaining of pain in the right arm, and that she called the physician and received orders to transfer the resident to the hospital. On 2/18/16 at 1:40 P.M., during an interview with CNA # 1, she indicated she found Resident B on the floor at approximately 6:15 A.M. on 2/4/16. She indicated, Her face was awful. She had 2 big hematomas on each side of her head, and blood was dried on her head. She indicated when staff sat the resident up, they noticed a bruise on her right shoulder. She indicated the CNAs informed the nurses about the bruise. CNA # 1 indicated, They only checked her eyes. CNA # 1 indicated they were told to give the resident a shower. CNA # 1 indicated the resident complained about head and shoulder pain. She indicated that following the shower, the resident's bruise appeared bigger, and she informed the nursing staff and the Director of Nursing. She indicated LPN # 1 indicated, We need to send her out. On 2/18/16 at 1:50 P.M., during an interview with CNA # 2, she indicated at approximately 6:10-6:15 A.M., she and CNA # 1 went to Resident B's room, and did not see the resident in bed. She indicated the resident was found on the floor with dried blood all over her, and 2 giant hematomas over her head. She indicated, The nurse said to put her in the chair. CNA # 2 indicated, (LPN # 1) looked in her eyes. CNA # 2 indicated the resident was transferred with a stand-aid mechanical lift to the shower chair from the wheelchair and back, and the resident had a hard time lifting her arm. She indicated the resident kept stating, Please don't hurt me. CNA # 2 indicated the resident had a dark bruise on her right upper arm. She indicated CNA # 1 and herself notified the nurses of the resident's bruising and pain, and that she was sent to the emergency room . She indicated, Thinking back, no one ever took her vitals or anything until after the shower. On 2/19/16 at 10:00 A.M., the Executive Director (ED) provided the current facility policy Fall Management Program, revised 2/2015. The policy included: Post Fall, 1. Any resident experiencing a fall will be assessed immediately by the charge nurse for possible injuries and provide necessary treatment. A neurological assessment will be initiated on all un-witnessed falls. A neurological assessment will be initiated on all residents hitting their head. 2. If the resident experienced an injury from the fall, contact facility DNS (Director of Nursing Service)/ ED per facility policy. The physician will be contacted immediately, if there are injuries, and orders will be obtained .The family will be notified immediately by the charge nurse of falls with injury The ED and DNS indicated at that time that they had recently inserviced nursing staff on fall assessment, documentation, and interventions post fall. This Federal tag relates to Complaint IN 114, Complaint IN 329, and Complaint IN 939. 3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure adequate supervision and effective interventions to prevent accidents and injuries were provided for 5 of 6 residents reviewed for accidents. This deficient practice resulted in Resident #107 experiencing a subarachnoid hemorrhage and requiring hospitalization . (Resident #53, Resident #81, Resident #100, Resident #107, Resident #105, ) Findings include: 1. During an interview on 8/19/15 at 3:42 P.M., LPN #30 indicated Resident #107 had fallen twice on 8/12/15, at 5:50 A.M., and again at 8:30 A.M. LPN #30 indicated Resident #107 had received a laceration above the left eye and had been sent to the hospital on [DATE]. Resident #107 had a [DIAGNOSES REDACTED]. During an observation on 8/19/15 at 12:15 P.M., Resident #107 was sitting in a dining room chair at the table. Resident #107 was eating lunch and was observed to have a large amount of bruising on the left side of her face. The clinical record of Resident #107 was reviewed on 8/19/15 at 3:21 P.M. The record indicated Resident #107 was admitted on [DATE]. The [DIAGNOSES REDACTED]. A Care Plan Resident is at risk for fall . was initiated on 8/5/15 and it read as follows: clean et (and) clutter free pathways with adequate lighting .call light within reach .personal items in reach . A resident profile used to guide staff with care for Resident #107 was provided on 8/18/15 at 3:52 P.M. by the Director of Nursing. The Profile Care Plan Approaches read as follows: .8/12/15 1 assist with transfers .Pad alarm to all surfaces .Resident to sit in eye view of nurses station at meals . Fall #1 A Safety Events -- .Fall Event report indicated Resident #107 experienced an unwitnessed fall on 8/12/15 at 5:50 A.M. Resident #107 was found face down on the floor in her room. Resident #107's blood pressure was documented at the time of the fall as 74/55. An IDT (interdisciplinary team) note dated 8/12/15 at 10:12 A.M. read as follows: .review of unwitnessed fall that occurred on 8/12/15 at 5:50 am (sic) .Alarm was sounding and Res (Resident) was found face down on floor near doorway of room .Res did hit her head .Res on an anticoagulant (blood thinner) .Laceration noted to left eyebrow and skin tear to right hand .Roommate bedside table near doorway .MD (physician) decreased Cardizem (medication used to lower blood pressure) .root cause of fall loss of balance. New intervention: Bedside table moved away from door .Res noted to have low b/p (blood pressure) upon assessment after fall . Fall #2 A Safety Events .Fall Event report indicated Resident #107 experienced an unwitnessed fall on 8/12/15 at 8:30 A.M. Resident #107 was found in the dining room, lying on the floor, on her right side. An IDT (interdisciplinary team) note dated 8/13/15 at 10:12 A.M. read as follows: .review of unwitnessed fall that occurred on 8/12/15 at 8:30 am - resident was sitting in dining room chair at dining room table prior to fall - had finished eating breakfast --resident stated she was trying to stand and feet got tangled and fell - resident was found lying on her left side .Resident did hit her head .laceration to right ear noted .Resident is on an anti-coagulant .Root cause of fall - resident states feet tangled - however resident was observed trying to lean over and spit in trash can once sitting back in chair after fall - IDT feels resident possibly was trying to spit when fall occurred - and recent low blood pressure contributing to causing loss f (sic) balance . A Progress Note dated 8/12/15 at 5:01 P.M. read as follows: MDS completed for the 5 day, BIMS (Brief Interview for Mental Status) score of 3 (indicating severe impaired cognition). A Care Plan Resident is at risk for fall . was initiated on 8/5/15 and revised on 8/12/15 and it read as follows: 1 assist with transfers .pad alarm to all surfaces .resident to sit in eye view of nurses station at meals .clean et (and) clutter free pathways with adequate lighting A Discharge/Appointment/Transfer report dated 8/14/15 3:45 P.M. indicated Resident #107 was transferred to the emergency room by ambulance due to a change in cognition. A .Hospital Transfer Report dated 8/14/15 read as follows: .Patient fell two days ago and hit head .patient has been having pain to her posterior head. Resident #107 was admitted to the ICU with traumatic injury from a fall. The admitting [DIAGNOSES REDACTED]. 2. On 8/19/15 at 9:31 A.M., Resident #81 was observed in bed and his/her call light was hanging over the drawer pull on the night stand. Resident #81 was leaning over the side of the bed, stretching towards the call light, but was unable to reach it. At that time, NA #2 (Nursing Assistant) was observed in the doorway and was made aware Resident # 81 could not reach his/her call light. NA #2 said, We are not supposed to let him/her have it. It is not to be clipped to her because she is schizophrenic and she just twists it around. During an interview on 8/19/15 at 10:30 A.M., LPN #32 indicated that on 7/27/15, Resident #81 had elevated his/her bed to the high position and then fell from the bed while trying to get up, which resulted in an avulsion fracture to her left foot. LPN #32 further indicated staff was to keep the bed in low position and tape the remote under the bed so Resident #81 would not be able to elevate the bed again. On 8/19/15 at 1:37 P.M., Resident #81 was observed lying in bed with the bed elevated. The bed remote and the call light were lying on the floor next to the bed and the bedside table was pushed to the right side of the bed. At that time, CNA #10 was walking down 400 hall and was made aware Resident #81's bed was elevated. Upon entering the room, CNA #10 indicated dietary should have lowered her bed to the lowest position after her lunch tray was taken away. A resident profile used to guide staff with care for Resident #81 was provided on 8/18/15 at 3:52 P.M. by the Director of Nursing. The Profile Care Plan Approaches read as follows: .3/16/15 Bed in lowest position . Resident #81's profile lacked documentation the call light should be within reach. The clinical record of Resident #81 was reviewed on 8/19/15 at 3:21 P.M. The record indicated Resident #81 was admitted on [DATE] and had experienced 6 falls on the following dates: 2/1/15 at 9:27 A.M., 3/13/15 at 10:44 A.M., 4/18/15 at 11:45 A.M., 4/24/15 at 8:30 P.M., 7/27/15 at 12:10 P.M., 8/18/15 at 2:05 A.M., one of which resulted in an avulsion fracture to the left ankle. The [DIAGNOSES REDACTED]. The Quarterly MDS (Minimum Data Set) assessment dated [DATE], indicated Resident #81 experienced mild cognitive impairment, no behaviors, no rejection of care, required the extensive assist of two staff for transfers. A Care Plan for Resident is at risk for fall . was initiated on 1/14/15 and read as follows: 03/16/2015 .Bed in lowest position .01/14/2015 .Call light in reach .07/27/2015 .Remote out of reach of resident .Mats to floor on bilateral sides of bed . An Admission Assessment dated 1/14/15 indicated Resident #81 was at a high risk to fall due to his/her previous history of falls and needed the extensive assistance of 2 staff and a Hoyer Lift for transfers. A Progress Note dated 7/27/15 at 12:06 P.M. read as follows: Resident was found on floor in room. Resident raised bed to elevated position and was trying to get up when resident fell .Resident then complained of pain to left hip .Resident sent to ER (emergency room ) for Eval (evaluation) and treatment. A Progress Note dated 7/28/15 at 10:00 A.M. read as follows: IDT review of unwitnessed fall that occurred on 7/27/15 at 12:10 (pm ER reported that res (resident) had an avulsion FX (fracture) to left ankle/foot. Res is non-weight bearing to LLE (lower left extremity) . Fall #1 A Safety Events .Fall Event report indicated Resident #81 experienced an unwitnessed fall on 7/27/15 at 12:10 P.M. Resident #81 had raised the bed to the elevated position and was trying to get up when the fall occurred. Resident #81 indicated post fall pain in left hip and was sent to the emergency room for evaluation. The emergency room reported indicated Resident #81 had experienced an avulsion fracture to left ankle/foot. Fall #2 A Safety Events -- ASC Fall Event report indicated Resident #81 experienced an unwitnessed fall on 8/18/15 at 2:05 A.M. Resident #81 was heard yelling, help me, and was found on the mat on the floor next to the bed. Resident #81 indicated he/she was trying to remove his/her depends and rolled out of bed. The policy and procedure Fall Management Program was provided by the Corporate Nurse on 8/20/15 at 1:30 P.M., and it read as follows: .4. Resident specific care requirements will be communicated to the assigned caregivers utilizing resident profile or CNA assignment sheet. During an interview on 7/24/15 at 4:00 P.M , the Nurse Consultant was made aware of the observations on 8/19/15 concerning the call light, which was not within reach, and that the bed was left elevated without staff in the room, and indicated it was a concern. 3. During an observation on 8/20/15 at 10:20 A.M., Resident #105 was observed sitting in a wheelchair trying to enter another resident's room. The clinical record of Resident #105 was reviewed on 8/21/15 at 2:45 P.M. The record indicated Resident #105 was admitted on [DATE] and the [DIAGNOSES REDACTED]. The Admission MDS (Minimum Data Set) assessment dated [DATE] indicated Resident #105 experienced severe cognitive impairment, required the extensive assist of two staff for transfers, and was frequently incontinent. A Care Plan for Resident is at risk for fall . was initiated on 6/26/15 and it read as follows: call light within reach .up ad lib (up at liberty) .personal items in reach . The care plan for falls was updated on 7/8/15 and it read as follows: .1 assist with transfers . The care plan for falls was updated on 7/23/15 and it read as follows: .resident not to sit in rocking chair .2 assist with transfers . A PT (Physical Therapy)- Therapy progress note dated 7/3/15 for Resident #105 was provided by PTA #3 and the progress note indicated the following: .The patient is able to safely turn corners and change directions unsupported with CG (contact guard assist) to stand by assist (close enough to reach patient if assist needed). Fall #1 A Safety Events . Fall Event report indicated Resident #105 experienced an unwitnessed fall on 7/7/15 at 8:56 P.M. Resident #105 was found lying flat on his/her back. Resident #105 had a laceration to the back of his/her head. An IDT (interdisciplinary team) note dated 7/7/15 at 8:56 P.M. read as follows: .review of unwitnessed fall that occurred on 8/12/15 at 5:56 PM. Res was sitting in chair in TV lounge prior to fall . Res was found lying on back on floor. Nurse noted cut to back of head upon assessment .res c/o pain to head .Resident stated she stumbled and fell .Resident was sent out to ER .Resident returned from ER with .3 staples to the back of head. Fall #2 A Safety Events .Fall Event report indicated Resident #105 experienced a witnessed fall on 7/23/15 at 5:08 P.M. Resident #105 was to be transferred from a rocking chair in the lounge area to the dining room. While attempting to stand up from the rocker with the assistance of 1 staff person, Resident #105 lost his/her footing and fell to the floor on her left side. An IDT note dated 7/24/15 at 2:33 P.M. read as follows: .review of witnessed fall that occurred on 7/23/15 at 5:08 PM. Res was being assisted with 1 assist and gait belt to transfer from rocking lounge chair and lost footing while attempting to stand up. Res was lying on left side .Elbow noted to be slightly red . Fall #3 A Safety Events .Fall Event report indicated Resident #105 experienced an unwitnessed fall on 8/9/15 at 1:52 P.M. Resident #105 was in the TV room and got up from her wheelchair and fell on her right side. Resident was incontinent at the time of the fall. Interventions put into place: toilet every 2 hours. An IDT (interdisciplinary team) note dated 8/10/15 at 9:54 P.M. read as follows: .review of unwitnessed fall that occurred on 8/9/15 at 1:58 PM. Res was sitting in w/c in tv room prior to fall. Res was found laying on her right side .Res was incontinent at time of fall .immediate intervention: Toilet every 2 hours . During an interview on 8/24/15 at 12:40 P.M., PTA #3 (Physical Therapy Assistant) indicated Resident #105 was evaluated by physical therapy on 6/29/15 and at that time Resident #105 needed cues for safety and contact guard assist when walking. Resident #105 needed standby assistance of 1 staff when standing up from a sitting position. Resident #105 needed to have someone with him/her when going to bed or bathroom. 4. During a random observation on 8/18/15 at 12:45 P.M., Resident #100 was observed to have a large bruise to the left side of his face. The clinical record for Resident #100 was reviewed on 8/20/15 at 9:35 A.M., [DIAGNOSES REDACTED]. The clinical record indicated Resident #100 was admitted as a 2 assist for transfers, on 7/16/15. An MDS assessment dated [DATE] indicated Resident #100 BIMS (Brief Interview for Mental Status) score was 3 indicating he was significantly cognitively impaired, and required extensive assistance of 2 for transfers, bed mobility and extensive assistance of 1 for ambulation. The care plans were reviewed and included, but were not limited to, at risk or wandering initiated 7/27/15 interventions included, but not limited to toilet every 2 hours and PM, encourage resident to engage in activities of choice, offer food and during, pull tab alarm. toileting program (8/1/15), pad alarm to all sitting surfaces (8/4/15) A care plan for falls was initiated 7/16/15, the interventions included, but were not limited to, therapy screen, personal items in reach, pad alarm to bed, non skid footwear, clutter free pathways, call light in reach and 2 assist for transfers, initiated 7/16/16. Fall #1 A fall event report dated 8/4/15 at 3:16 P.M., indicated Resident #100 was found laying face down on floor in the T.V. room of the Cottage (secured dementia care unit). A nurse ' s note dated 8/4/15 at 3:21 P.M., included nurse heard resident yelling out and noted resident had fallen out of w/c (wheel chair) onto the floor. resident had a cut to this forehead and skin tear to right elbow. Resident noted to be very lethargic et (and) pupils very pin point. The immediate intervention following return from the hospital was to replace the personal (pull tab) alarm with a pressure pad alarm. Fall #2 A fall event report dated 8/8/15 at 9:40 A.M., indicated Resident #100 had been sitting in a recliner in the Cottage T.V room and was found lying on his left side. Resident #100 was observed to have a hematoma to his left forehead. The document continued to include Resident or witness statement of how fall occurred . Resident was restless and moving around and caused recliner to tip forward causing resident to slide to the floor.The immediate intervention was to remove Resident #100 from the recliner. Fall #3 A fall event report dated 8/15/15 at 2:20 P.M., indicated Resident #100 was witnessed ambulating in the 300/400 T.V. room, prior to staff being able to reach Resident #100 he sat on the footboard of another resident's chair and fell to the floor in a seated position. The document continued to include Describe resident appearance at time of fall .clip alarm not attached to shirt . The immediate intervention was to remove the personal (pull tab) alarm and put a pressure pad alarm. During an interview with the Nurse Consultant on 8/21/15 at 10:02 A.M., she indicated: Resident #100's admission transfer orders were to be up with 1 assistance and a walker, a pressure alarm to bed and non skid footwear. Fall #1 had occurred on 8/4/15 at 3:16 P.M., in the Cottage T.V room, she indicated the fall was unwitnessed and Resident #100 had suffered a laceration that required sutures to his forehead and skin tears. She indicted the intervention added was to take off the pull tab alarm and place a pressure pad alarm to alert staff when attempting to rise. Fall #2 had occurred on 8/8/15 at 9:40 A.M., she indicated Resident #100 had tipped the recliner he was sitting in over and received a hematoma to the left forehead. She indicated the interventions were to remove Resident #100 from the recliner and to not elevate Resident #100's feet when in a recliner. Fall #3 had occurred on 8/15/15 at 2:20 P.M., she indicated Resident #100's personal alarm had come unattached from his shirt and he was seen ambulating in the 300 hall T.V. room. She indicated staff attempted to get to resident but he sat on another residents foot rests and fell off onto the floor with no injuries. The intervention put into place was to remove the personal alarm and place Resident #100 on a pressure alarm pad. 5. During a random observation on 8/19/15 at 10:56 A.M., Resident #53 was observed to be sitting on the side of the bed. The alarm was heard to be sounding briefly. The resident was observed attempting to remove the pad alarm from under his body and the alarm went on and off for approximately 2 minutes. Staff were observed to be standing at the nurses' station not responding to the alarm until notified by the surveyor. On 8/19/15 at 9:59 A.M., Resident #53's clinical record was reviewed. Resident #53 had been admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. His admission physician orders [REDACTED]. His admission Minimum Data Set assessment dated [DATE], indicated, a cognitive summary score of 9 (moderate cognitive impairment), and extensive assistance of 2 or more staff for bed mobility and transfers. The assessment indicated extensive assistance of 1 staff was needed for walking in the room and the corridor. A care plan dated 7/16/15, addressed the problem of at risk for falls. Interventions included, but were not limited to, call light and personal items in reach, gripper socks while in bed, and clutter free pathways. An admission assessment dated [DATE], indicated no falls in the past 6 months. The following falls were reviewed with the Nurse Consultant on 8/21/15 at 10:45 A.M.: Fall Event documentation on 7/17/15 at 12:00 A.M., indicated a witnessed fall had occurred. .Res. (resident) stated was 'getting up to plug in phone.' . The position of the resident after the fall was .lying on L. (left) side on floor between bed et wall . The documentation indicated Resident #53 had been wearing . t-shirt only. Bare feet . The location of the fall was in between bed et (and) w(with)/window, parallel w/bed, head toward ft (foot) of bed . .S/T (skin tear) to LFA (left forearm) near elbow, 4.0 x 2.0 cm (centimeter), lg.(large) amt. (amount) of bleeding, cleansed et (and) applied 3 steri-strips, covered w (with) / telfa et secured w/ kerlix. Bruise surrounding S/T covering L (left) elbow et LFA, 16.5 x 5.0 cm dk (dark) purple. Dk purple bruise to above webbing of L thumb/index finger, 1.0 x 1.5 cm. Dk purple bruise to L outer wrist 3.0 x 1.5 cm. Pinkish purple bruise to R (right) of coccyx, 3.0 x 0.9 cm. Bottom of L gr. (great) toe T shaped dk brown area . A progress note dated 7/17/15 at 3:41 A.M., indicated, Resting quietly in bed at this time. Ext.(extensive) assist w (with)/ ADL's (activities of daily living). Transfer post -fall w/3 assist. PRN (when needed) Ativan (antianxiety medication) et (and) Roxanol (pain medication) req (requested) et given for anxiety et back pain prior to fall, unrelieved by repositioning, fluids et distraction. Both PRN Ativan et Roxanol eff. (effective). No new pain noted from fall. S/T (skin tear) to LFA (left forearm) near elbow, numerous bruises to LUE (left upper extremity) et sm. (small) one to L (left) of coccyx. ROM (range of motion) WNL (within normal limits). Fall witnessed by this nurse. Education provided to call for assist, pressure alarm placed, res. (resident) voiced understanding. Will cont. (continue to observe). A IDT (Interdisciplinary Team) review of witnessed fall that occurred on 7/17/15 at 12 A.M., indicated, Resident was in bed prior to fall . . Res (resident) was incontinent at time of fall . Nurse states she was walking by room and witnessed fall but was unable to reach res in time to prevent fall. No environmental factors noted. Immediate intervention was pad alarm on bed and education to use call light for assistance. IDT feels root cause of fall is resident's increased weakness and new environment. New intervention of gripper socks donned per staff at night as well as room modification to ensure cell phone charger within resident's reach . A progress note dated 8/5/15 at 6:37 A.M., indicated a 2nd fall had occurred. The documentation indicated, Resident was on 100 hall by marketing room waiting for 'nurse' to get there. Resident stood up out of wheelchair. When resident was asked to sit back down resident's wheelchair moved away from him due to wheels not being locked. Full assessment done. No complaints of pain or discomfort voiced at this time . On 8/21/15 at 10:45 A.M., during interview with the Nurse Consultant, she indicated Resident #53 had resided in same room on the 400 hall since admission to the facility on [DATE]. The Nurse Consultant indicated Resident #53 after first admitted utilized a w/c. The Nurse Consultant was made aware at the time of the 8/5/15 fall Resident #53 was on another unit of the facility at 6:37 A.M., and concern of adequate supervision being provided to prevent falls. The fall documentation (8/5/15) was reviewed with the Nurse Consultant at that time. The Nurse Consultant was made aware that documentation was lacking of an intervention being initiated after the 8/5/15 fall. Documentation was also lacking also lacking that an IDT (interdisciplinary team) review of the 8/5/15 fall. Nurse Consultant agreed documentation was lacking of an intervention initiated after the 8/5/15 fall and of an Interdisciplinary team review note of the fall. A 3rd fall (witnessed fall) occurred on 8/19/15 at 5:05 A.M. The Event documentation indicated the resident .stood up from bed et (and) sat down on floor . At time of fall, .T-shirt brief et gripper socks worn. Resident had taken O 2 (oxygen) off . A progress note dated 8/19/15 at 6:40 A.M., indicated, This nurse was entering resident's room to answer call light, noted resident standing up from bed ET (and) sat on floor. Alert, oriented to self only, confused speech nonsensical. AROM (active range of motion) to all extremities. Resident had taken O2 (oxygen) cannula off, assisted to put O2 back on. No c/o (complaints) discomfort. Resident was not incontinent. Was wearing gripper socks. Assisted to stand by 2 staff with the use of gait belt et (and) transferred back to bed without difficulty. Was cooperative with care. Noted skin tear 1 cm length R (right) medial wrist, skin tear R posterior upper arm 3 cm length et scattered small abrasions L (left ) posterior upper arm, sure site applied to areas after cleansed. Skin edges well approximated. Dr (physician's name) notified of fall et injuries. Bed pad alarm placed under resident's shoulders. An IDT (Interdisciplinary team) note dated 8/19/15 at 5:19 P.M., indicated, . Root cause-IDT feels resident was possibly getting up due to confusion, restlessness and anxiety from removing O2 (oxygen) -replaced-resident is non compliant with keeping O2 on- resident offered mask and declined, resident also with decline in medical condition due to lung cancer dx (diagnosis)-Resident assessed for injury and placed back in bed-ensuring pad alarm under shoulders. New intervention- will offer resident to get up in broda chair when restless . During interview with the Nurse Consultant on 8/21/15 at 10:45 A.M., the Nurse Consultant was made aware documentation was lacking of the alarm sounding before the 8/19/15 witnessed fall and that the bed pad alarm had to be repositioned. The care plan intervention to put the pad alarm under the resident's shoulders had been initiated on 7/17/15 before the 8/19/15 fall. The intervention of a Broda chair and foot rest had also been initiated on the care plan on 8/17/15 before the 8/19/15 fall. A Fall Event documented a witnessed fall on 8/21/15 at 5:57 P.M. Documentation indicated Resident #53 had been in bed and then observed sitting on buttocks on mat beside bed. Documentation indicated Resident #53 was wearing pants, shirt and socks. A progress note dated 8/21/15 at 6:09 P.M., indicated, res (resident) slid out of bed onto floor on mat. This nurse couldn't reach res in time. No injuries noted from fall. Res denies pain and discomfort. Res incont (incontinent) at the time . A late entry note on 8/24/15 at 8:31 A.M., indicated, Resident found on floor by nursing staff. No injury noted by this nurse upon placing resident back into bed. New intervention applied, wedge support to support resident while in bed. Another Fall Event documented a unwitnessed fall on 8/22/15 at 6:05 A.M. The documentation indicated, prior to the fall the resident had been awakened to take medications. The resident was found beside air bed .sitting with BLE (bilateral lower extremities) bent to left side under him. Hands/arms holding his upper torso up with bedrail . On 8/24/15 at 12:52 P.M., Nurse Consultant was interviewed regarding the falls of 8/21/15 and 8/22/15. The Nurse Consultant was made aware of documentation lacking of the pad alarm sounding regarding the 8/21/15 and 8/22/15 falls. The RN Consultant indicated at that time, a wedge cushion had been initiated after the 8/21/15 fall. The Nurse Consultant indicated after the 8/22/15 fall a mattress was placed beside the bed and Resident #53's bed was positioned against the wall. The Nurse Consultant indicated Hospice staff had come to the facility for medication evaluation regarding the medication, Ativan after the 8/22/15 fall. The Nurse Consultant indicated hospice staff was going to sit with the resident 1:1 after the 8/22/15 fall. The Nurse Consultant was made aware at that time of the problem of a lack of adequate supervision being provided to prevent falls for Resident #53. The facility policy entitled, Fall Management Program (last revision 2/2015) was received and reviewed on 8/20/15. The policy included but was not limited to, .Post fall 4. A fall event will be initiated as soon as the resident has been assessed and cared for. The report must be completed in full in order to identify possible root causes of the fall and provide immediate interventions. 5. All falls will be discussed by the interdisciplinary team at the 1st IDT (Interdisciplinary) meeting after the fall to determine root cause and other possible interventions to prevent future falls. The fall event will be reviewed by the team. IDT note will be written . 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to identify a leg rest causing pressure until a pressure sore developed; failed to properly apply a lateral support pressure relieving device; and failed to treat the area as ordered (Resident F). The facility also failed to identify a pressure area until it was unstageable and failed to assess the area with measurements and appearance when first found (Resident E). The facility failed to treat another pressure area as ordered (Resident D). This affected 3 of 3 residents reviewed with pressure areas in a sample of 9. Findings include: 1. On 12/30/13 at 11:45 A.M., LPN # 3 indicated Resident F had a pressure area on his left shin. LPN #3 indicated the pressure area was caused by the wheelchair leg. On 12/30/13 at 1:05 P.M., Resident F was observed sitting up in his wheelchair in the dining room. No cushioning or padding was observed on either wheelchair leg. On 12/30/13 at 2:50 P.M., 4:25 P.M., and 7:10 P.M., Resident F was observed sitting up in his wheelchair in the hallway. No cushioning was observed on either wheelchair leg. On 12/30/13 at 7:05 P.M., CNA # 3 indicated Resident F "liked to stay up for a long time." LPN # 4 indicated at that time that Resident F had a dressing on his left leg, and she would change it later that night. On 12/31/13 at 9:00 A.M., a request was made of LPN # 3 to observe the pressure area on Resident F's leg at some time that day. On 12/31/13 at 3:15 P.M., an additional request was made of the Clinical Education Coordinator to observe the resident's pressure area. On 12/31/13 at 3:20 P.M., an assessment was made of Resident F's pressure area on his left shin. No dressing was on the area. The area was approximately the size of a half dollar, with a red and yellow base. LPN # 2 indicated at that time that the "left leg rest caused it." There was no padding or cushion on the left leg rest. LPN # 2 indicated she had not taken off the resident's dressing, but that she had just asked the CNAs to put shorts on him for easier observation. At that same time, CNA # 4 was interviewed. She indicated she had just got the resident changed and dressed into shorts. She indicated the resident did not have a dressing on his left leg. On 12/31/13 at 3:40 P.M., LPN # 4 was interviewed. She indicated she worked the evening of 12/30/13, but that the resident "was already in bed and didn't want me to mess with his leg." LPN # 4 indicated, "He had a shower though last evening." LPN # 4 indicated the CNAs would have removed his dressing when they gave him his shower. On 12/31/13 at 3:50 P.M., CNA # 3 was interviewed. She indicated she worked the evening of 12/30/13, and that Resident F did not receive a shower. She indicated she could check the "shower book" for sure. CNA # 3 then checked the "shower book," and indicated, "No, he gets one tonight." The clinical record of Resident F was reviewed on 12/31/13 at 3:00 P.M. [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment, dated 10/28/13, indicated Resident F scored a 3 out of 15 for cognition, with 15 indicating no memory impairment. Resident F required extensive assistance of two+ staff for bed mobility, transfer, and personal hygiene. The resident required extensive assistance of one staff for locomotion on and off of the unit. The resident had no pressure ulcers. A Progress Note, dated 11/25/13 at 2:25 P.M., indicated, "IDT (interdisciplinary team) wound note: resident has pressure areas to left LE (lower extremity) to proximal lateral LE and distal lateral LE. New interventions include to pad w/c (wheelchair) at leg rest where LE hits to reduce pressure and risk for injury. New order for TAO (triple antibiotic ointment) to open areas, cover with non-stick [MEDICATION NAME], cover with Kerlix, and ACE wrap from toes to knees." A Pressure Wound Report, dated 11/25/13, included: "New area. Wound present on admission, No...Stage II, Most severe tissue type, Slough (Yellow or while tissue adhering to ulcer bed)...Describe measurements in cm (centimeters) (Lenght x Width x Depth) 3.5 x 2 x 0.2..Describe wound color, red/yellow, Describe wound drainage, clear to yellow...." A Care Plan, dated 11/25/13, included: "Problem, Resident has impaired skin integrity: L (left) shin. Approach, Pressure reducing/redistribution cushion in chair, Pressure reducing/redistribution mattress on bed, Treatment as ordered, Turn and reposition every 2 hours." A physician's orders [REDACTED]." The Treatment Administration Record (TAR) indicated the treatment was to be done at bedtime. A Pressure Wound Report, dated 12/26/13, included: "...Stage II, Slough, left shin, 1.8 x 1.4 x 0.3...90% red 10% yellow, small amount of clear drainage...cleanse area with wound cleanser, apply TAO, cover with non stick [MEDICATION NAME] and wrap with kerlix and ace bandage." The most recent progress wound note, dated 12/26/13 at 3:24 P.M., indicated: "IDT wound note: Resident has area to left shin. Width and depth of wound have increased this week with small amount of clear drainage noted. Wound bed is red with scattered yellow tissue. Peri wound is bright red, dry and scaly with increased [MEDICAL CONDITION]. Current tx is to apply TAO to area and cover with non stick [MEDICATION NAME] and wrap with ACE bandage toe to knee and cover with Kerlix... Resident prefers to sit in his wheelchair throughout day and evening hours with BLE (bilateral lower extremities) unelevated...Wheelchair has been modified by therapy due to wound on leg...turned and repositionned every two hours...." On 12/31/13 at 4:15 P.M., during interview with the Administrator, she indicated the resident was to have his wheelchair leg rest padded. She indicated, "We ordered a lateral leg support because he picked at the other cushioning." The Administrator also indicated the resident had refused his dressing change on 12/31/13 evening. On 1/2/14 at 3:15 P.M., during interview with the Therapy Manager, she indicated the resident had a temporary lateral support in his wheelchair to reduce pressure, and a gelatin pad was on order. The Therapy Manager indicated she assessed the resident on 12/31/13, and the resident had the lateral support applied incorrectly. She indicated the Occupational Therapist had started inservicing all staff on the correct positioning of the support. 2. On 12/30/13 at 11:45 A.M., LPN # 3 indicated Resident D had a pressure area on his coccyx or buttocks. On 12/30/13 at 4:20 P.M., Resident D was observed out of his room, sitting in a wheelchair. On 12/30/13 at 6:50 P.M., CNA # 5 and CNA # 6 indicated they were going to lay Resident D down in bed. The CNAs transferred the resident to bed and a skin assessment was requested at that time. There was no dressing on the resident's buttocks or coccyx. The resident's bilateral inner buttocks were reddened, with superficial open areas on both buttocks. Old, scar-like areas were also observed. CNA # 5 indicated the areas "flare up sometimes." On 12/31/13 at 2:35 P.M., the clinical record of Resident D was reviewed. [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment, dated 12/16/13, indicated the resident required extensive assistance for bed mobility and transfer, and did not ambulate. The MDS assessment indicated the resident had one Stage II pressure ulcer. A Pressure Wound Skin Evaluation Report, dated 12/19/13 at 3:09 P.M., indicated: "New area, Wound present on admission, No, Stage II, Granulation, right buttock, 1 x 2.4 x <0.1, red shallow wound bed with red/white maceration to surrounding bilateral buttocks...." A physician's orders [REDACTED]. (Change) on Thurs/Sundays and prn (as needed) for soilage/dislodgement til healed...." The most recent wound note, dated 12/26/13 at 3:52 P.M., indicated, "IDT wound note: Stage II area to right buttock remains. Wound bed 100% red granulation tissue. Peri wound is red blanchable. Bilateral buttocks is red/white macerations and is blanchable...Resident has impaired mobility, confusion, [MEDICAL CONDITION], renal insufficency, incontinence of urine and [MEDICAL CONDITION]." A Pressure Wound Skin Evaluation Report, dated 12/26/13, indicated: "Stage II, .5 x .8 x <0.1, wound color red, current treatment, cleanse with wound cleanser, apply skin prep and cover with [MEDICATION NAME] dressing, applying calazyme cream to maceration to buttocks." On 12/31/13 at 4:45 P.M., during interview with the Administrator, she did not offer information why the resident did not have a dressing on as ordered by the physician. 3. On 12/30/13 at 11:45 A.M., LPN # 3 indicated Resident E had a pressure area on his right heel. On 12/30/13 at 7:10 P.M., a skin assessment on Resident E was requested. The resident was lying on an air flow mattress with a pressure relieving boot on his right leg. A pressure area was observed on the resident's right heel. The wound bed was covered in brownish scabbed-like tissue. LPN # 4 indicated she thought the resident may have been admitted with the area. The clinical record of Resident E was reviewed on 12/31/13 at 1:55 P.M. A Care Plan, dated 5/9/13 and updated 7/10/13, indicated the following problem: "Resident is at risk for skin breakdown due to impaired mobility due [MEDICAL CONDITION] left sided paralysis, dx (diagnosis) of diabetes, [MEDICAL CONDITIONS], slides down in bed/chair, incontinence, confusion/memory problems, hx (history) of pressure wounds." The Approaches included: "Assess and document skin condition weekly and as needed. Notify MD of abnormal findings." A MDS assessment, dated 9/4/13, indicated the resident had a short-term and long-term memory problem, and was severely impaired in cognitive skills for daily decision making. The resident required extensive assistance of two+ staff for bed mobility, transfer, and personal hygiene. The resident had 1 Stage II pressure area. A Weekly Nursing Summary and Skin Assessment, dated 9/23/13 at 6:38 P.M., indicated: "Residents skin is warm and dry, pink...Indicate any NEW areas of skin alteration in past 7 days, None...If resident has an open area, do they have pain at the site, N/A...." A Resident Progress Note, dated 10/3/13 at 1:54 P.M., indicated, "Resident noted to have area on R heel and open area on R and L buttock. Pressure relieving boots on at this time. MD notified. DON (Director of Nursing) aware." A Pressure Wound Skin Evaluation Report, dated 10/3/13, indicated: "R heel, New area, Stage (left blank), Most severe tissue type (left blank), Describe measurements (left blank), Describe wound color (left blank)...Physician Notified: No, Family notified: No, Care Plan Revieiwed: No...." A Weekly Nursing Summary and Skin Assessment, dated 10/7/13 at 6:30 P.M., included: "Residents skin is warm and dry, pink...Indicate any NEW areas of skin alteration in past 7 days, None...If resident has an open area, do they have pain at the site, N/A...." The next notation regarding the right heel, dated 10/8/13 at 12:57 P.M., indicated, "...Continues to rec. (receive) TX (treatment) as per orders to R heel...Will continue to monitor." A Pressure Wound Skin Evaluation Report, dated 10/9/13, indicated: "Right heel...Date area originally ordered 10/03/2013, Stage III, Most severe tissue type, Slough (Yellow or white tissue adhering to tissue bed), Describe measurements in cm, 3 x 3.4, Describe wound color, re (sic), yellow...." A Progress Note, dated 10/14/13 at 7:28 A.M., indicated, "Wound/NAR (nutrition at risk) note. Resident has areas to Left buttock and Right buttock...." Documentation of the right heel pressure ulcer was lacking at that time. On 12/31/13 at 5:00 P.M., during interview with the Administrator, she indicated she had been at the facility since the end of October. She indicated she "walked the former DON out" related to issues such as identification and documentation of skin issues. 4. On 12/31/13 at 4:15 P.M., the Administrator provided the current facility policy on the "Skin Management Program," revised 9/2013. The policy included: "...Weekly skin assessments will be completed on all residents with or without alterations in skin integrity. Alterations in skin integrity will be reported to the physician and family member(s)...All alterations in skin integrity will be documented in EMR (electronic medical record). Pressure reduction devices are to be put in place immediately...The care plan will be initiated/revised addressing any new areas. Direct care givers will be notified of skin alterations and specific care needs...Wound rounds will be completed on a weekly basis to assess all wounds...." 5. STAGES OF PRESSURE ULCERS, AMDA - 2008, included: Stage I: Intact skin with nonblanchable redness of a localized area, usually over a bony prominence...Note: This area may be painful, firm, soft, warmer or cooler compared to adjacent skin. Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink ulcer bed without slough. May also present as an intact or open/ruptured serum filled blister. Stage III: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV: Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the ulcer bed. Often includes undermining and tunneling. Unstageable: Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown or black) in the ulcer bed. Note: Until enough slough or eschar is removed to expose the base of the ulcer, the true depth and therefore stage, cannot be determined. This Federal tag relates to Complaint IN 009. 3.1-40(a)(1) 3.1-40(a)(2)

Based on observation, interview, and record review, the facility failed to ensure a resident at risk for falls was supervised, in that alarms were used in place of supervision, resulting in a fall with a head laceration requiring sutures, for 1 of 3 residents reviewed for falls, in a sample of 9. Resident B Findings include: 1. On 12/30/13 at 11:45 A.M., LPN # 3 indicated Resident B had fallen recently. The clinical record of Resident B was reviewed on 12/30/13 at 1:45 P.M. [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment, dated 10/11/13, indicated the resident scored a 0 out of 15 for cognition, with 15 indicating no memory impairment. The resident required extensive assistance for bed mobility, transfer, and toilet use. A test for "Balance during Transitions and Walking" indicated the resident was "Not steady, only able to stabilize with staff assistance" while moving from seated to standing position, walking, turning around, and surface-to-surface transfer. A "Fall Event" note, dated 12/9/13 at 3:22 P.M., included: "Slid down recliner to floor. Was fall witnessed, Yes. Describe what the resident was doing prior to the fall, Res (resident) sitting in recliner in TV room, leaned recliner fwd (forward) (with) foot pedal on floor et slid down to floor...Was resident incontinent at time of fall, Yes...What intervention(s) was put into place to prevent another fall, Will not attempt recliner." A "Fall Event" note, dated 12/11/13 at 2:40 P.M., included: "Fall. Was fall witnessed, No. Describe what the resident was doing prior to the fall, In bed...Was resident incontinent at time of fall, No...What intervention(s) was put into place to prevent another fall, bed in lowest position with mat." A "Fall Event" note, dated 12/13/13 at 12:22 P.M., included: "Unwitnessed fall. Was fall witnessed, No. Describe what the resident was doing prior to the fall, resting in bed...Did the resident hit his/her head? Unwitnessed...Was resident incontinent at time of fall, No...Document any environmental factors observed in area of fall, Floor clear, mat at bedside, bed in low position, pad alarm in place et functioning properly. What intervention(s) was put into place to prevent another fall, bed in low position." Progress Notes included the following notations: 12/15/13 at 10:00 A.M.: "Resident witnessed crawling out of bed onto floor mat by staff, res wanted to be in his w/c, bed was in lowest position when resident crawled onto floor mat next to bed." A Progress Note, dated 12/22/13 at 7:16 A.M., indicated: "Res. slept well but did try to crawl out of (sic) twice last night...." A "Fall Event" note, dated 12/22/13 at 6:50 P.M., included: "Fall. Was fall witnessed, No. Describe what the resident was doing prior to the fall, eating dinner. Describe the position of the resident when first observed after fall, Res sitting on buttocks, back up against bed, bed side table tipped over, and food scattered all over room. Describe resident appearance at time of fall, Beeding (sic) noted to forehead. Area cleansed noted cut...Did the resident hit his/her head? Yes...Order to send to ER to eval and tx (evaluate and treat)...Was resident incontinent at time of fall, No...Document any environmental factors observed in area of fall, Bed side table. What intervention(s) was put into place to prevent another fall, Res to eat in d/r (dining room). So res can be monitored more closely." A hospital emergency room note, dated 12/22/13, included: "...Chief complaint: Injury to head and face patient was sent from the nursing home after he reportedly rolled out of bed and fell to the floor. He sustained a laceration to his mid forehead region...The patient complains of mild pain...Forehead: 3.0 laceration of the central forehead...." A Progress Note, dated 12/23/13 at 8:20 A.M., indicated, "Received report from (name) at (name of hospital) ER at 10:00 pm on 12-22-13. Res. received 4 sutures to the forehead from the fall and a small abrasion to the R (right) hip...." A "Fall Event" note, dated 12/24/13 at 2:27 P.M., included: "Fall. Was fall witnessed, No. Describe what the resident was doing prior to the fall, lying in a bed. Describe the position of the resident when first observed after fall, lying on his right side on a pillow. Describe resident appearance at time of fall, clothes on, no shoes, just socks...Did the resident hit his/her head? Unwitnessed...Was resident incontinent at time of fall, No...Document any environmental factors observed in area of fall, none. What intervention(s) was put into place to prevent another fall, pull tab alarm to bed." An IDT Fall review, dated 12/26/13 at 11:07 A.M., indicated, "Res had a fall on 12/24/13 at 2:27 P.M...Res has pad alarm to bed per care plan. Neuro checks were already in progress from previous fall. Res will have pull tab alarm placed on while in bed to alert staff when res leans forward while in bed...." A Care Plan, initially dated 12/18/12 and updated 12/24/13, indicated: "Resident is at risk for fall due to: New environment, fx (fracture) to hip, dx (diagnosis) of seizures, hx of fall in past 3 months...incontinence, impaired gait/balance, us of assistive device, hx of non-compliance." Approaches included: "12/24/13 Pull tab alarm while in bed, 12/23/13 Resident to eat meals in dining room, 12/11/13, Bed in lowest position with mat,12/22/13 personal alarm to wheelchair, 12/18/12 Call light in reach." An additional Care Plan, dated 12/16/13, indicated: "Resident crawls out of bed onto the floor." The 2 approaches listed were: "Encourage resident to wait for assistance from staff before getting out of bed. Ensure residents (sic) bed is in lowest position." On 12/30/13 at 4:20 P.M., Resident B was observed lying in bed. 4 sutures were observed on the resident's mid-forehead. On 1/2/14 at 5:25 P.M., during interview with the Administrator, she indicated the alarms were sounding during the resident's falls. The Administrator indicated, "With him, it's a behavior. He crawls out of bed." The Administrator indicated she was doing an audit regarding the number of alarms in the facility, and was trying to reduce the number of alarms. 2. On 12/31/13 at 11:00 A.M., the Administrator provided the current facility policy on the "Fall Management Program," revised 9/2013. The policy included: "It is the policy...to ensure residents residing within the facility will maintain maximum physical functioning through the establishment of physical, environmental, and psychosocial guidelines to prevent injury related to falls...All falls will be discussed by the interdisciplinary team...to determine root cause and other possible interventions to prevent future falls...." This Federal tag relates to Complaint IN 622. 3.1-45(a)(2)

Based on record review and interview, the facility failed to ensure adequate hydration for 1 of 3 residents discharged from the facility to the hospital. Resident A Findings include: The clinical record of Resident A was reviewed on 1/25/13 at 8:30 AM. [DIAGNOSES REDACTED]. The resident had been admitted on [DATE]. An undated admission hydration risk assessment scored the resident at a risk of 12 ( a score of 10 or above being considered at risk). On 11/28/12 the Dietary Service Manager DSM assessed the resident fluid requirement, based on height and weight, to be 1612.5 cc (cubic centimeters) to 1935 cc. That had been calculated by the standard of 30 cc/KG of body weight/24 hours. A three day 24 hour fluid intake summary from 11/27, 28, 29, 30/2012 was recorded and totaled to be 600 cc, 300 cc, 720 cc, and 960 cc, respectively. On 11/27/12, a Care Plan was initiated and addressed the "risk for fluid imbalance due to : infection, swallowing difficulty, needs assist with food and fluids, on thickened liquids, unable to ask for fluids, routine laxatives, use of 9 or more medications, cognitive deficits." It indicated a goal of "Resident will be free from signs and symptoms of fluid volume deficit." Approaches included: "encourage fluids" and "notify MD of signs and symptoms of fluid volume deficit..." The 24 hour totals (totalled at time of review) in days prior to the Registered Dietician's (RD) progress report on 12/06/12 were below the minimal calculated need of 1612.5 cc as follows: 12/01/12- 960 cc, 12/02/12- 600 cc, 12/03/12 documentation errors prevented calculation, 12/04/12-1080 cc, 12/05/12-480 cc. The RD progress note of 12/06/12 did not address the hydration status of the resident. The 24 hour totals (totalled at the time of review) in the days prior to hospitalization on [DATE] were as follows: 12/21/12-480 cc, 12/22- 690 cc, 12/2- 480 cc, 12/24-480 cc, 12/25-600 cc, 12/26-720 cc, 12/27-720 cc, 12/28 lacked any documentation, 12/2- 680 cc, 12/3- 600 cc, and 12/3- 680 cc. The physician discharge summary on 1/07/13 for the 1/01/13 hospitalization indicated the resident "Discharge Diagnosis: [REDACTED]. The BUN (blood urea nitrogen) and creatinine were elevated; BUN was 95 on admission and it is 10 on discharge (normal range 9-20); the creatinine was 2.07 on admission and is 0.7 on discharge (normal range 0.6-1.25). Documentation was lacking to indicate staff were assessing fluid intake data collected or informing the physician of the inadequate fluid intake. The Care plan interventions were not changed or developed after admission to address the continued deficit of fluid. The care plan continued to fail to specify goal ranges by which to assess results of "encourage fluid" intervention. On 1/25/13 at 2:30 P.M., the RD and DSM were interviewed regarding Resident A and the hospitalization . The RD indicated she had not reviewed the status of hydration on 12/06/12 when addressing the resident nutrition status. She indicated she was aware of the fluid needs calculated by the DSM. The DSM indicated she relied on nursing to assess the status of the hydration and she was responsible for the weight status. On 1/25/13 at 3:00 P.M., the Director of Nursing (DON) was interviewed. She indicated the admission 3 day fluid intake summary noted above should have been reviewed in the IDT (Interdisciplinary Team) meeting but it was not. She also indicated there had not been specific analysis of fluid intake data or 24 hour totaling on a periodic, routine or ongoing basis although implementation of those services was in progress. The facility Policy and Procedure for Hydration originated in 11/01 and was most recently revised in 6/12. It was reviewed on 1//25/13 at 3:30 P.M. It contained the following directives: "...3. New admissions scoring 10 or more on the Hydration assessment will be placed on a hydration plan and proceed with IDT review and documentation...6. A comprehensive care plan will be written after completion of the Hydration assessment and review by IDT with Specific resident needs and preferences as deemed necessary by IDT assessment....13. 24 hour fluid totals will only be calculated for those residents on a fluid restriction or as ordered by physician." This federal tag relates to complaint #IN 069 3.1-46(b)

A. Based on observation, record review and interview, the facility failed to ensure correct infection control practices were followed to prevent infections during dressing changes for 3 of 4 residents in a sample of 15. This deficient practice had the potential to impact 53 of 62 residents in the facility for whom staff provided care. Resident #11 Resident #26, Resident#45 This deficient practice resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 2/15/11. The Administrator and the Director of Nursing were notified on 2/23/11 at 3:05 P.M. The Immediate Jeopardy was removed on 2/24/11 at 2:30 P.M., but the facility remained out of compliance at a level of pattern, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. The Director of Nursing/Designee will complete random monitoring of hand washing/glove usage profiencies (sic) for 5 staff daily to include all shifts within each week of the next 30 days, then 5 staff weekly including all shifts for 30 days then 5 staff randomly each quarter. All results will be reviewed at Quarterly Quality Assurance Meetings to ensure continued compliance. B. Based on observation, interview, and record review, the facility failed to ensure Intravenous (IV) Antibiotic Medication solutions were provided after adequate handwashing for 1 of 2 residents observed for Antibiotic IV administration in a sample of 15. Resident #45 Findings include: A.1. The clinical record of Resident #11 was reviewed on 2/15/11 at 10:40 A.M. The resident had a [DIAGNOSES REDACTED]." The Resident had been admitted on e week earlier with severely impaired cognition, was not responding to verbal stimuli and was unable to voluntarily move. The resident had a tracheostomy and physician orders [REDACTED]. On 2/15/11 at 11:30 A.M., LPN #1 proceeded to provide daily trache care and change the inner trache cannula and dressing. The nurse opened the disposable sterile trache care set. She washed her hands, donned sterile gloves which were too small, contaminating them in the process of trying to pull them on. She used the soiled gloves to remove the inner disposable trache cannula and then handled the sterile replacement cannula, guiding it in by holding the tube itself, rather than the exterior end. The facility Policy and Procedure, effective 6/20/03, for Clinical standards of tracheostomy care was reviewed on 2/22/11 at 9:00 A.M. It indicated the disposable inner cannula was to be replaced with a sterile inner cannula. The facility reference book provided at the nurses station was the Lippincott Manual of Nursing Practice 9th edition. It was reviewed on 2/22/11 at 9:44 A.M. The reference included procedures for routine trache care on page 227. Excerpts included: "...7. If disposable inner cannula is used, replace the new cannula...touching only the external portion to avoid contamination of the inner portion ...." On 2/16/10 at 8:15 A.M. CNA #1 and CNA #2 were observed caring for Resident #11. The CNAs had just finished cleaning incontinent BM from the resident. With the same contaminated gloves, CNA #1 was wiping mucous from around the trache site dressing, using a corner of the towel which had been in use for the pericare. When informed of the possibility of cross contamination she indicated she was not familiar with the care of the resident, and applied new gloves to her unwashed hands. CNA#2 used gloves for the pericare, handled Foley catheter tubing and bag and then, with the same gloves, repositioned the tubing of the respiratory misting unit and the mask over the trache. Later at 10:20 A.M. on the same day, the same 2 CNAs #1 and #2 cleansed Resident #11 of B.M. Both CNAs began caring for the resident without hand washing but after donning gloves. They cleansed the resident of BM and completed pericare. CNA#2 applied skin protestant with her right hand glove and changed only that glove, contaminating the new right hand glove with her left hand glove. The CNAs had dropped 2 to 3 wash cloths on the floor and picked them up, CNA #2 handed the gloves from the floor to CNA#1. With contaminated gloves, they continued care of the resident. CNA#2 rearranged the residents feeding tube and applied lotion to the resident's hands and arms and arranged the hair around the resident's face while CNA#1 handled the feeding tubes and hand of the resident. On 2/16/11 at 11:00 A.M. LPN#1 was observed preparing to change the feeding tube dressing of Resident #11. The LPN was carrying dressing supplies in one hand as she approached the resident's room. There was a house keeping cart blocking her entry to the doorway. The LPN moved the cart by holding inside rim of it's 3/4 full trash bin using both her hands and also contacting the packaged supplies she was holding in her right hand .She entered the room to change the feeding tube dressing and failed to wash hands. She got 2 clean gloves from the box and applied the left one. She held the second glove with her left hand while she used her bare, soiled, right hand to adjust the misting mask over the resident's trache site. She applied the right hand glove and removed the soiled dressing from around the feeding tube. She cleansed the area around the tube, applied a new dressing, taped the new dressing in place. She rummaged in her right side pocket ,which also held the med room keys until she found a roll of tape and an indelible felt tip marker. She dated the new dressing, disposed of trash. She washed her hands and then the cleaning agent, the tape and the felt marker in her pocket with her keys. She went into the med room, using the keys and put the cleaner in the resident's drawer and kept the tape and marker in her pocket. She got ear drops for Resident # 18 and went to that resident directly. Failing to hand wash, she applied gloves, instilled the drops and put the bottle in her right pocket with the keys and tape. She used hand sanitizer and then went back to the med room and put the bottle of drops from her pocket into that resident's drawer. The undated facility Hand Hygiene Guidelines Fact sheet was reviewed on 2/16/11 at 2:30 P.M. It included "The use of gloves does not eliminate the need for hand hygiene. The 1/07 facility Procedure for Dressing change was reviewed on 2/22/11 at 2:16 P.M. It included: "...1. Wash hands...4. Open dressing pack. 5. Put on first pair of disposable gloves. 6. Remove soiled dressing and discard in plastic bag. 7. Dispose of gloves in plastic bag. 8. Wash hands. 9. Put on second pair of gloves. 13. Apply dressings and secure. 14. Remove gloves and discard with all unused supplies in plastic bag. 16. Wash hands..." A.2. Resident #26's clinical record was reviewed on 2/11/11 at 8:40 A.M. His current [DIAGNOSES REDACTED]. His current Minimum Data Set Assessment (MDS) dated 1//18/11, included but was not limited to a non ambulatory status and upper and lower range of motion impairment bilaterally. On 2/16/11 at 9:05 A.M., LPN #1 and the Director of Nursing (DON) indicated they were to change the wound vac(vacuum) dressing. LPN #1 and the DON upon onset of procedure applied gloves without handwashing. LPN #1 began removing the plastic dressing of the left hip pressure sore. A moderate amount of green drainage was observed on the flat sheet of the bed. Resident #26 at this time had a large formed BM in an incontinent pad provided by the nurses. The incontinent pad with the BM was removed from the bed and incontinence care was provided. After incontinence care was provided both nurses removed their gloves. LPN #1 used a sanitizing gel and then both nurses applied new gloves without handwashing. The dressing change continued with LPN #1 using a wound cleanser, Carra Klenz at the wound site. LPN #1 removed the packing from the wound area. After the packing was removed LPN#1 removed her gloves and applied new gloves without handwashing. LPN #1 used a q-tip to pack the left hip wound with wound vac packing. A plastic wrap dressing was applied over the left wound area. After dressing completion LPN #1 and the DON applied a clean flat sheet to the mattress of the bed. The DON without a bag for the soiled linen placed the soiled sheet at the foot of the bed on the edge of the clean sheet until a bag for the soiled linen was obtained. On 2/17/11 at 9:00 A.M., the DON provided a policy entitled, "Dressing Change, Clean." This policy included but was not limited to: "...purpose: ... to prevent infection and spread of infection... procedure: 1. Wash hands 2. Place plastic bag near foot of bed to receive soiled dressings. 3. Create clean field. 4. Open dressing pack. 5. Put on first pair of disposable gloves. 6. Remove soiled dressing and discard in plastic bag. 7. Dispose of gloves in plastic bag. 8. Wash hands..." A.3. On 2/16/11 at 8:22 A.M., Resident #45's left and right hip pressure sore dressings were to be changed. LPN #2 and the Director of Nursing (DON) began the dressing change procedure by applying gloves without handwashing. After the procedure had started Physical Therapy staff member (PT staff #1) entered Resident #45's room and also applied gloves without handwashing. After LPN #2 removed the right hip dressing she applied clean gloves without handwashing. PT#1 using plastic wound measuring sheets measured the upper right hip area and then removed gloves and applied clean gloves. PT staff #1 then using a new plastic wound measuring sheet measured the right lower hip pressure sore. After the right pressure sore wound packing was applied by LPN #2, the DON and LPN #2 removed their gloves and applied clean gloves. LPN #2 then removed the Left hip pressure sore dressing and wound packing. LPN#2 then removed her gloves and without handwashing applied clean gloves. PT staff #1 measured the left hip pressure sore. PT staff #1 then removed her gloves and washed her hands in the resident's bathroom. LPN #2 with clean gloves on applied packing to the left hip wound area and then completed the dressing change. On 2/18/11 at 8:35 A.M., during interview with the DON, she indicated she was aware of the facility policy in regard to hand washing before dressing changes and after soiled dressings removed. B.1. On 2/16/11 at 11:25 A.M., LPN #2 brought IV supplies to Resident #45's room to administer the IV antibiotic [MEDICATION NAME] (500 mg). LPN #2 applied clean gloves as the IV procedure began without handwashing. The IV antibiotic solution was prepared and primed from the pump ready for administration. LPN #2 removed her gloves and applied clean gloves to access the IV port site. At this time LPN #2 was made aware of handwashing lacking since IV procedure had begun. LPN #2 removed her gloves and entered the resident's bathroom and washed her hands before continuing with the IV procedure. On 2/18/11 at 8:35 A.M., during interview with the DON, she indicated she was aware of the facility IV policy in regard to handwashing procedures. On 2/17/11 at 1:05 P.M., the DON provided a facility policy for IV fluid/medication administration. The policy was entitled "Administration of an Intermittent Infusion (policy date 2008)." this policy included but was not limited to: "...Procedure: 1. Verify physician order. 2. Identify resident using appropriate identifiers. 3. Explain procedure to resident/significant other. 4. Wash hands. 5. Assess venous access site..." The Immediate Jeopardy began on 2/15/11 when the facility failed to ensure practices to prevent the spread of infection in regard to tracheostomy care. The Immediate Jeopardy was removed on 2/24/11 at 2:30 P.M. when through review of inservicing, care observation, and staff interview, it was determined that the facility had implemented the plan of action to remove the Immediate Jeopardy and that the steps taken removed the immediacy of the problem. Staff were aware of the infection control principles of when to wash hands in conjunction with glove use and when to change gloves prior to performing clean or sterile procedures as well as the principles of objects acting as carriers of infection. Staff were observed to adhere to the principles in practice. Ongoing monitoring of practice was being provided to ensure compliance. 3.1-18(j) 3.1-18(l)

Based on observation, interview, and record review, the facility failed to provide tracheal suctioning and proper routine [MEDICAL CONDITION] care and/or provide preparation for emergency [MEDICAL CONDITION] care for 1 of 1 residents with [MEDICAL CONDITION] in a sample of 15 and 1 of 1 from a supplemental sample of 1 additional resident with a [MEDICAL CONDITION]. Resident # 11 Resident #9 This deficient practice resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 2/15/11. The Administrator and Director of Nursing were notified on 2/23/11 at 3:05 P.M. The Immediate Jeopardy was removed on 2/24/11 at 2:30 P.M., but the facility remained out of compliance at a level of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. The Administrator will ensure the continued clinical support of a Respiratory Therapist for ongoing competency audits beginning with daily rotation shift monitoring for 2 weeks, and then 3 audits per week for one month decreasing to quarterly for 6 months. Ongoing reporting of results to the Director of Nursing and Administrator will continue until compliance standard maintenance is assured for [MEDICAL CONDITION] care. The Director of Nursing/Designee will complete random monitoring of handwashing/glove usage profiencies for 5 staff daily to include all shifts within each week of the next 30 days, then 5 staff weekly including all shifts for 30 days then 5 staff randomly each quarter. All results will be reviewed at Quarterly Quality Assurance Meeting to ensure continued compliance. Findings include: 1. The clinical record of Resident #11 was reviewed on 2/15/11 at 10:40 A.M. [DIAGNOSES REDACTED]." The Resident had been admitted on e week earlier with severely impaired cognition, was not responding to verbal stimuli and was unable to voluntarily move. The resident had a [MEDICAL CONDITION] and physician orders [REDACTED]. The resident was to receive a Full Code in the event of arrest. The resident had been admitted from a hospital where she had been treated from 2/06/11 to 2/09/11 following a stay at another nursing home. The hospital discharge [DIAGNOSES REDACTED]. The 2/09/11 nursing admission assessment indicated the resident was totally dependent for all care and anticipation of needs and was non responsive to verbal stimuli. On 2/15/11 at 11:30 A.M. LPN #1 was observed as she began providing daily trache care and inner cannula change. The nurse indicated the resident was a "new trache," estimating it to have been in place about a month with stitch scars still fresh. The resident eyes were open but no tracking movements were present nor was she responsive to verbal stimuli. On interview at that time LPN#1 indicated she was aware the resident was to be Full Code in the event cardio resuscitation was required. She stated she did not know if the emergency ventilation Ambu bag would fit the trache or would need an adaptor. There was no emergency device in the room to maintain the airway in case of trache dislodgement. After the interview, LPN #1 proceeded directly with the care. She noted the resident had approximately a tablespoon of thick yellow mucous around the trache site on the dressing pad and was coughing and gurgling. The LPN did not suction the resident or auscultate but directed the resident to "Cough it up. Go ahead that's right, caught it up. I like them to cough it up themselves." The resident spontaneously coughed for approximately 4 minutes and approximately 3 tablespoons were expelled. The nurse then opened the disposable sterile trache care set. She washed hands, donned sterile gloves which were too small, contaminating them in the process of trying to pull them on. She used the soiled gloves to remove the inner disposable trache cannula and then handled the sterile replacement cannula, guiding it in by holding the tube itself, rather than the exterior end. A brush was provided in the kit for use when cleansing the soiled inner cannula, before reinserting it into the resident, when a new one was not being used. Following tube replacement, the nurse took the cleaning brush, inserted it into the new cannula which was in the resident. She inserted it approximately 2 to 2.5 inches, wiggled it removed it for unknown rationale. The nurse indicated the facility did not have a respiratory therapist in house stating "We're it." The facility Policy and Procedure, effective 6/20/03, for Clinical standards of [MEDICAL CONDITION] care was reviewed on 2/22/11 at 9:00 A.M. It directed the nurse or respiratory therapist to suction the resident if needed prior to the procedure. It also indicated the disposable inner cannula was to be replaced with a sterile inner cannula. It indicated the cleaning procedure with brush was to be utilized for nondisposable inner cannula's which had been removed for cleaning. The facility reference book provided at the nurses station was the Lippincott Manual of Nursing Practice 9th edition. It was reviewed on 2/22/11 at 9:44 A.M. It included "Nursing Care for Patients with Artificial Airways General Care Measures ...External Tube Site Care...3. Have available at all times at the patient's bedside a replacement ET (endotracheal tube) in the same size as the patient is using, resuscitation bag, oxygen source, and mask to ventilate the patient in the event of accidental tube removal. Anticipate your course of action in such an event..." The reference also included procedures for routine trache care on page 227. Excerpts included: "... 1. Suction the trachea and pharynx thoroughly before [MEDICAL CONDITION] care...7. If disposable inner cannula is used, replace the new cannula...touching only the external portion to avoid contamination of the inner portion .... If inner cannula is reusable, remove it...clean using brush or pipe cleaners." On 2/16/10 at 8:15 A.M. CNA #1 and CNA #2 were observed caring for resident #11. The CNAs had just finished cleaning incontinent BM from the resident. With the same contaminated gloves, CNA #1 was wiping mucous from around the trache site dressing, using a corner of the towel which had been in use for the peri care. When informed of the possibility of cross contamination she indicated she was not familiar with the care of the resident, and applied new gloves to her unwashed hands. CNA#2 used gloves for the peri care, handled Foley catheter tubing and bag and then repositioned the respiratory misting unit tubing and mask over the trache. 2. The clinical record of Resident #9 was reviewed on 2/15/11 at 1 P.M. [DIAGNOSES REDACTED]. On 2/16/11 at 2:30 P.M. the resident was observed in her room with a tracheotomy in place. No emergency supplies such as the inner cannula and/or ambu bag were observed in the resident's room. On 2/16/11 at 3 P.M., the DON toured the resident's room and was unable to locate any inner cannula's for the tracheotomy and/or an ambu bag readily available in the resident's room. She indicated she would place inner cannula's at the resident's bedside and an ambu bag. The Immediate Jeopardy began on 2/15/11, when the facility had failed to ensure minimum staff proficiencies of routine and emergency care and infection control for residents with [MEDICAL CONDITION]. The Immediate Jeopardy was removed on 2/24/11 at 2:30 P.M. when through observation of practice, review of inservicing and interview, it was determined that staff were applying principles of safety and [MEDICAL CONDITION] care within compliance. The facility had acquired clinical consultation with Respiratory Therapy for ongoing compliance assurance in conjunction with monitoring and auditing by the Director of Nursing and Administration. 3.1-47(a)(4)