Every finding on record at Valparaiso Care & Rehabilitation

Based on observation, record review, and interview, the facility failed to ensure a medication error rate of less than 5% for 2 of 5 residents observed during medication pass. Three errors were observed during 27 opportunities for errors during medication administration. This resulted in a medication error rate of 11.1%. (Residents M and N)Findings include:1. During an observation on 4/15/26 at 4:39 p.m., LPN 4 prepared Resident M's 4:00 p.m. medication of metoclopramide (stomach medication) 10 milligrams (mg). She placed one tablet in the plastic cup and indicated there was one tablet in the cup and she was ready to administer the medication. LPN 4 was stopped prior to entry of the room. She indicated the label on the medication card was metoclopramide 10 mg, administer 20 mg and indicated he should have two tablets of the medication.Resident M's record was reviewed on 4/16/26 at 8:40 a.m. The diagnoses included, but were not limited to, type one diabetes.A Physician's Order, dated 2/10/25, indicated metoclopramide 20 mg was to be administered four times daily at 8:00 a.m., 12:00 p.m., 4:00 p.m., and 8:00 p.m. 2. During an observation on 4/16/26 at 8:12 a.m., LPN 3 prepared Resident N's morning medication which included Fiberlax (fiber laxative) 625 mg, administer 1250 mg, and acetaminophen 325 mg, administer 650 mg. LPN 3 placed one tablet of Fiberlax and one tablet of acetaminophen in the plastic cup with the other medications and then indicated the medications were ready to be administered.LPN 3 was stopped prior to the administration. She indicated there should have been two tablets of the Fiberlax and two tablets of the acetaminophen in the medications cup.Resident N's record was reviewed on 4/16/26 at 8:40 a.m. The diagnoses included, but were not limited to, dementia and osteomylelitis.A Physician's Order, dated 1/17/25, indicated Fibercon (Fiberlax) 625 mg tablet, 1250 mg to be administered twice a day.A Physician's Order, dated 5/5/25, indicated acetaminophen 325 mg tablet, 650 mg to be administered twice a day.A facility medication administration policy, dated 4/2025, indicated the five rights of medication was to be performed, right resident, right medication, right dose, right route, and right time.This citation relates to Intakes 2970538, 2976557, and 2977293.410 IAC (Indiana Administrative Code) 16.2-3.1-48(c)(1)

Based on record review and interview, the facility failed to maintain clinical records that were complete and accurately documented related to behavior documentation for 1 of 12 records reviewed. (Resident B)Finding includes:An Indiana Department of Health reported incident, dated 3/28/26 at 8:01 a.m., indicated Resident B voiced an allegation of abuse against staff at the facility.The undated investigation of the incident indicated undated interviews were completed with CNA 1, CNA 2, LPN 1, and LPN 2. The staff indicated the resident had been yelling and calling staff vulgar names.There was no documentation in the progress notes that indicated the allegation had been voiced nor the behaviors of the resident.During an interview on 4/15/26 at 3:41 p.m., LPN 1 indicated she thought LPN 2 was taking care of the documentation.During an interview on 4/16/26 at 4:11 a.m., LPN 2 indicated she had not charted the incident since she had not witnessed the incident.This citation relates to Intake 2970538.410 IAC (Indiana Administrative Code) 16.2-3.1-50(a)(1)410 IAC 16.2-3.1-50(a)(2)

Based on record review and interview, the facility failed to ensure residents were administered medications and accuchecks (blood sugar testing) as ordered, for 3 of 4 residents reviewed for medications and accuchecks. (Residents B, K, and D)Findings include:1. During an interview on 4/15/26 at 9:53 a.m., Resident B indicated she did not always get her medications as ordered by the physician. Resident B's record was reviewed on 4/15/26 at 11:27 a.m. The diagnoses included, but were not limited to, diabetes mellitus and neuropathy. Physician's Orders, dated 1/29/26, indicated gabapentin (for nerve pain) 400 milligrams (mg) to be given four times a day, scheduled for 8:00 a.m., 12:00 p.m., 4:00 p.m., and 8:00 p.m., and hydroxyzine HCL (antihistamine) 25 mg to be given every six hours, scheduled at 12:00 a.m., 6:00 a.m., 12:00 p.m., and 6:00 p.m. The Medication Administration Record (MAR), dated 3/15/26 to 4/14/26, indicated the gabapentin had not been administered on 3/20/26 at 4:00 p.m. and 4/4/26 at 8:00 a.m. The hydroxyzine HCL had not been administered on 3/18/26 at 12:00 a.m. and 3/23/26 at 6:00 p.m. There was no documentation on the MAR nor the Nurses' Progress Notes that indicated why the medications were not given. The Director of Nursing (DON) was notified on 4/15/26 at 5:30 p.m., no further information was provided. 2. Resident K's record was reviewed on 4/16/26 at 2:27 p.m. The diagnoses included, but were not limited to, diabetes mellitus. A Physician's Order, dated 12/15/25, indicated lantus insulin 15 units was to be administered every day at 9:00 a.m. The Medicaton Administration Record (MAR), dated 3/17/26 through 4/16/26, indicated the lantus insulin had not been administered on 3/21/26 and 4/4/26. There was no documentation on the MAR nor the Nurses' Progress Notes why the lantus had not been administered. A Physician's Order, dated 3/27/26, indicated novolog insulin four units was to be administered at 8:00 a.m. daily. The MAR, dated 3/17/26 through 4/16/26, indicated the novolog insulin had not been administered on 3/21/26 and 4/4/26. There was no documentation on the MAR nor the Nurses' Progress Notes why the novolog had not been administered. A Physician's Order, dated 2/10/26, indicated an accucheck was to be completed twice a day at 6:00 a.m. and 4:00 p.m. The MAR, dated 3/17/26 through 4/16/26, indicated the 4:00 p.m. accucheck had not been completed on 3/24/26 and 3/28/26. There was no documentation on the MAR nor the Nurses' Progress Notes why the accucheck had not been completed. During an interview on 4/16/26 at 3:00 p.m., the DON was unable to find any further information. 3. During an interview on 4/15/26 at 10:12 a.m., Resident D indicated she had not received her levothyroxine (a thyroid medication) medication at times. The record for Resident D was reviewed on 4/15/26 at 9:41 a.m. Diagnoses included, but were not limited to, hypothyroidism. A Physician's Order, dated 4/21/25, indicated levothyroxine 50 micrograms (mcg) every morning. The Quarterly Minimum Data Set (MDS) assessment, dated 1/2/26, indicated the resident was cognitively intact. The Medication Administration Record (MAR), dated 2/2026, indicated the levothyroxine medication was not signed off as given on 2/12/26 and 2/23/26. The Medication Administration Record (MAR), dated 3/2026, indicated the levothyroxine medication was not signed off as given on 3/23/26. The Medication Administration Record (MAR), dated 4/2026, indicated the levothyroxine medication was not signed off as given on 4/7/26. During an interview on 4/15/26 at 3:45 p.m., the Director of Nursing was made aware of the blanks on the MARs. No further information was provided. A facility medication administration policy/procedure, dated 4/2025 and received from the DON as current, indicated medications would be administered with the right resident, right medication, right dose, right time, right route. This citation relates to Intakes 2970538, 2976557, and 2977293. 410 IAC (Indiana Administrative Code) 16.2-3.1-48(a)(6)

Based on observation, record review, and interview, the facility failed to ensure a gastrostomy tube (feeding tube) feeding was administered and documented at the rate ordered by the physician to assist with pressure wound healing for 1 of 2 residents reviewed for feeding tubes with pressure ulcers. (Resident E) Finding includes:During observations on 2/18/26 at 8:41 a.m., 2/18/26 at 11:30 a.m., and 2/19/26 at 2:25 p.m., Resident E was lying in bed and the liquid feeding of Jevity 1.5 calories was infusing at 45 cubic centimeters (cc's) per hour.During an interview on 2/18/26 at 11:30 a.m., the Wound Care Nurse Practitioner indicated the resident had two unstageable pressure sores (full thickness wounds) observed on admission, one on the left buttock and one on the left ischium. Both areas were still present and improving.Resident E's record was reviewed on 2/19/26 at 1:52 p.m. The diagnoses included, but were not limited cerebral palsy and gastrostomy tube.A Care Plan, dated 2/3/26, indicated enteral feeding (tube feeding) was required to meet the resident's nutrient needs. The interventions included the enteral feeding would be administered as ordered by the physician.A Care Plan, dated 2/3/26, indicated there were unstageable pressure ulcers to the left buttock and left ischium present on admission. The interventions included the enteral feeding would be administered as ordered by the physician.An admission Minimum Data Set, dated [DATE], indicated a feeding tube was present and was fed 51% or more of nutrition and 501 cc's of fluid daily via the feeding tube. There was no significant weight loss or gain. There were two unstageable pressure ulcers present on on admission.A Registered Dietician's Progress Note, dated 2/9/26 at 10:01 a.m., indicated the tube feeding of Jevity 1.5 was administered at 45 cc's per hour for 24 hours with the water flushes of 100 cc's every six hours. The feeding provided 1620 calories, 69 grams of protein and 821 cc's of water. The water flushes provided 400 cc's of water for a total of 1221 cc's of water. There were unstageable pressure ulcers on the left ischium and left buttocks. The recommendation was to increase the Jevity 1.5 to 55 cc's an hour over 24 hours. The new tube feeding rate provided 1980 calories, 84 grams of protein and 1003 cc's of water. The new rate provided greater then 75% of estimated protein and fluid needs.A Physician's Order, dated 2/17/26, indicated Jevity 1.5 was to be administered at 55 cc's per hour continuously.The Medication Administration Record, dated 2/2026, indicated the tube feeding was being administered at 55 cc's an hour on 2/18/26 on the day, evening, and night shift. There was no documentation that indicated the feeding was being administered on 2/19/26 day shift.A facility feeding tube policy, dated 1/2015 and received from the Director of Nursing as current, indicated the licensed nurse would implement the physician's orders for enteral therapy.This citation relates to Intakes 2716516 and 2732978.3.1-44(a)(2)

Based on observation, record review, and interview, the facility failed to ensure residents received the necessary treatment and services related to the lack of assessment and monitoring of skin discolorations for 1 of 2 residents reviewed for non-pressure related skin conditions. The facility also failed to ensure residents received medications as ordered by the physician for 1 of 1 resident reviewed for dialysis, 1 of 2 residents reviewed for constipation/diarrhea, and 1 of 1 resident reviewed for insulin administration. (Residents 10, 8, 3, and 18)Findings include:1. On 12/11/25 at 3:19 p.m., Resident 10 was observed sitting on a couch in the lounge area. There were purple discolorations observed to the tops of both hands. On 12/15/25 at 9:04 a.m., Resident 10 was observed sitting at a dining room table. The discolorations were still observed. On 12/16/25 at 10:08 a.m., Resident 10 was observed sitting at a dining room table. The discolorations were still observed. There were also 2 small scabbed areas observed to the top of his left hand and a discoloration to his left forearm. The discoloration to his left forearm was not entirely visible and unable to observe the size due to him wearing a long sleeve shirt. Record review for Resident 10 was completed on 12/15/25 at 9:15 a.m. Diagnosed included, but were not limited to, atrial fibrillation, hypertension, and dementia. The Significant Change Minimum Data Set (MDS) assessment, dated 11/6/25, indicated the resident was cognitively impaired. The resident required partial moderate assistance with bed mobility, transfers, and walking. A Weekly Skin Assessment, dated 12/15/25, indicated there were no alterations in the resident's skin including bruising. During an interview on 12/16/25 at 11:46 a.m., the Wound Care Nurse indicated she was unaware of the residents' discolorations, and they had not been assessed or monitored. A policy titled, Skin Management Program, and received as current from the facility on 12/17/25, indicated, .6. Any skin alterations noted by direct care givers during daily care and/or shower days must be reported to the licensed nurse for further assessment, to include but not limited to bruises. 2. Record review for Resident 8 was completed on 12/17/25 at 2:04 p.m. Diagnoses included, but were not limited to, hypertension, end stage renal disease, and obstructive uropathy. The admission MDS assessment, dated 11/11/25, indicated the resident was cognitively intact. The resident received antidepressant, diuretic, and antiplatelet medications. The resident received dialysis services. A Physician's Order, dated 11/4-12/15/25, indicated to administer calcitriol (synthetic active form of vitamin D3 primarily used to manage low blood calcium levels and bone diseases in patients with kidney failure) 0.25 micrograms (mcg) every day for end stage renal disease. The November 2025 Medication Administration Record (MAR) indicated the calcitriol was not administered on the following dates due to the drug item not being available and or waiting on arrival: 11/5, 11/12, 11/14, 11/15, 11/16, 11/18, 11/24, 11/25, and 11/27/25. During an interview on 12/17/25 at 4:03 p.m., the Director of Nursing (DON) indicated the medication was in the emergency drug kit (EDK) and the staff could have pulled the medication from there while waiting for pharmacy arrival. 3. Resident 3's record was reviewed on 12/16/25 at 3:48 p.m. Diagnoses included, but were not limited to, type 2 diabetes mellitus. The Quarterly Minimum Data Set (MDS) assessment, dated 10/22/25, indicated the resident was severely cognitively impaired. She had received insulin injections daily for the last seven days. A Care Plan, dated 4/1/25, indicated the resident was at risk for adverse effects of hyperglycemia (high blood sugar) or hypoglycemia (low blood sugar) related to the diagnosis of diabetes mellitus. Interventions included, but were not limited to, diet as ordered, provide medications as ordered, and monitor blood sugars as ordered. The December 2025 Physician's Order Summary indicated insulin lispro insulin pen 100 unit/milliliter (ml) four time a day per sliding scale and insulin glargine insulin pen 100 unit/ml 20 units subcutaneous daily. The November and December 2025 Medication Administration Records indicated the insulin lispro medication was not signed out as administered on 11/3/25 at 12:00 p.m., 11/16/25 at 6:00 p.m., 11/30/25 at 6:00 p.m., and 12/9/25 at 9:00 p.m. The insulin glargine medication was not signed out as administered on 11/2 at 9:00 a.m. and 11/19/25 at 9:00 a.m. During an interview on 12/17/25 at 8:57 a.m., the Director of Nursing (DON) indicated both nurses working during those shifts ran their EMAR Compliance which shows if there were any medications that were not marked as administered. The nurses indicated they did not have any of the medications show up as missed. The DON had no further information to provide. 4. Resident 18's record was reviewed on 12/16/25 at 1:43 p.m. Diagnoses included, but were not limited to, lung and bone cancer. The admission Minimum Data Set assessment, dated 11/28/25, indicated the resident was cognitively intact. She received antianxiety and opioid medications. The December 2025 Physician's Order Summary indicated buspirone (antianxiety medication) 5 milligram tablet three times a day, lactulose (laxative) 10 gram/15 milliliter solution 30 milliliters three times a day, ipratropium-albuterol nebulizer solution 0.5 milligram-3 milligram, 3 milliliter inhalation, oxycodone (narcotic pain medication) 20 milligram tablet every 12 hours, and lidocaine 5% cream four times a day to the lower back and knees. The November and December 2025 Medication Administration Record indicated the buspirone was not signed out as administered on 12/6/25 at 8:00 a.m., and 12/11/25 at 8:00 a.m. and 2:00 p.m. The lactulose solution was not signed out as administered on 12/6/25 at 8:00 a.m., and 12/11/25 at 8:00 a.m. and 2:00 p.m. The ipratropium-albuterol nebulizer was not signed out as administered on 11/15/25 at 8:00 p.m., 11/27 at 8:00 am., and 11/28/25 at 11:00 a.m. The oxycodone was not signed out as administered on 12/6/25 at 8:00 a.m. The lidocaine cream was not signed out as administered on 11/21/25 at 4:00 p.m., 11/24/25 at 8:00 a.m., and 11/25/25 at 4:00 p.m. During an interview on 12/17/25 at 8:57 a.m., the Director of Nursing indicated she had no further information to provide. 3.1-37(a)

Based on observation and interview, the facility failed to ensure a clean and sanitary kitchen related to dirty shelves, carts and the walk in refrigerator in the main kitchen. This had the potential to affect the 109 residents who received meals prepared in the kitchen.Findings include:During the initial kitchen tour on 12/11/25 at 9:15 a.m. with the Kitchen Manager, the following was observed:a. In the walk-in refrigerator, there was a white powdery substance build up on the motor fan, and patches of whitish substance on the ceiling and walls. There was a musty odor present in the refrigerator.b. There were two carts near the door to the dining room that had crumbs, dried liquid and food substances spilled on the shelves.c. The shelves below the counter had crumbs, liquid spillage and food substances.During an interview with the Dietary Manger during the kitchen tour, she indicated they cleaned the shelves weekly and she had tried to get the substance off the refrigerator walls and ceiling but was unable to remove it.During an interview on 12/11/25 at 10:15 a.m., the Maintenance Director indicated he was unaware of the white substance in the walk in refrigerator but would go look at it. During a follow up interview, the Maintenance Director indicated it had been cleaned off and was no longer there.3.1-21(3)

Based on observation and interview, the facility failed to maintain a sanitary, safe, and homelike environment related to accident hazards observed to the hallway on the dementia unit during construction, and dirty resident care equipment on both units. (Cottage, East Unit, [NAME] Unit) Findings include:1. On 12/11/25 at 10:30 a.m., the Cottage Dementia Unit was observed. There were multiple residents and staff observed in the dining area and lounge area. The hallway to the resident rooms had two fire doors closed. The door did not have windows to see into the hallway. Upon opening the door to the hallway, there was someone standing on a ladder. The door was then closed and staff were asked if people were able to go back there. The Memory Care Support Specialist (MCCS) indicated anyone could go back into the hallway. The facility staff were keeping the doors closed due to the dust coming from the construction that was taking place in the hallway. Upon entering the hallway, there were multiple construction workers in the hallway. There were drop cloths observed on the ground with multiple ladders. Not all the ladders were being used by the construction workers at that time. There were power tools observed on the floor. There were 4 residents who were observed in their rooms with the doors closed. The MCCS indicated 3 out of the 4 residents observed in their rooms were mobile and could walk unassisted or with a walker. There were no staff observed in the hallway or in the resident rooms. During an interview at the time of the observation, the MCCS indicated the staff had gotten the residents up and into the dining/lounge area earlier, but a few of the residents did not want to come out of their rooms yet. She did not have any staff stationed in the hallway to make sure if the residents did decide to come out of their rooms and into the hallway, that they had assistance to walk down the hallway safely with the drop cloths, ladders, and power tools in the hallway. Going forward, she would make sure a staff member was always stationed in the hallway if there were residents in their rooms and the hallway fire doors were shut during the construction. 2. During the group resident council interview on 12/16/25 at 2:02 p.m., the residents indicated the sit to stand lifts needed to be cleaned. The wheels were dirty and had hair stuck in them. During the environmental tour on 12/17/25 at 2:35 p.m. with the Maintenance Supervisor, the following was observed:-The East Wing sit to stand lift had a dried brown substance and crumbs on the bottom rails. There was hair and debris built up in the wheels.-The [NAME] Wing sit to stand lift had hair and debris built up in the wheels. During an interview with the Maintenance Supervisor at the time of the tour, he indicated the CNAs would clean the lifts in between uses but were probably focused on the handles and high touch areas. This citation relates to Intake 2653024. 3.1-19(e)

Based on record review and interview, the facility failed to maintain clinical records that were complete and accurately documented related to medication administration for 1 of 1 resident reviewed for dialysis. (Resident 8)Finding includes:Record review for Resident 8 was completed on 12/17/25 at 2:04 p.m. Diagnoses included, but were not limited to, hypertension, end stage renal disease, and obstructive uropathy. The admission MDS assessment, dated 11/11/25, indicated the resident was cognitively intact. The resident received antidepressant, diuretic, and antiplatelet medications. The resident received dialysis services.The December 2025 Physician's Order Summary indicated orders for the following medications:-furosemide (to treat fluid retention) 40 mg (milligrams) every day-losartan (manages high blood pressure) 50 mg every day-dialysis at dialysis center on Monday, Wednesday, and Friday at 11:00 a.m.The 2025 November and December Medication Administration Records indicated the medications were not administered on the following dates and times due to dialysis. The medications were ordered to be administered every day at 7:00 a.m.,-11:00 a.m.-losartan not administered on: 11/7, 12/1, 12/3, and 12/8/25 due to dialysis-furosemide not administered on: 12/8/25 due to dialysisDuring an interview on 12/17/25 at 3:40 p.m., the Director of Nursing indicated the medications were not administered due to the resident had refused them. The staff should have written that he refused them and not due to dialysis.3.1-50(a)(1)3.1-50(a)(2)

Based on observation, record review, and interview, the facility failed to ensure a resident's care plan was updated related to a suprapubic urinary catheter and enhanced barrier precaution isolation use for 2 of 26 residents whose care plans were reviewed. (Resident 2 and 79) Findings include:1. On 12/17/25 at 9:50 a.m., Resident 2 was observed in his bed while the Wound Nurse changed pressure ulcer dressings. Resident 2 had a suprapubic catheter that was draining clear yellow urine to gravity. Resident 2's record was reviewed on 12/12/25 at 3:17 p.m. Diagnoses included, but were not limited to, obstructive and reflux uropathy (blockage in the urinary system that prevents normal urine flow and urine flowing backward from the bladder to the kidneys) and acute and chronic respiratory failure. The Quarterly Minimum Data Set (MDS) assessment, dated 10/22/25, indicated the resident was severely impaired for daily decision making. The resident had an indwelling urinary catheter. A Physician's Order, dated 9/30/25, indicated the resident had a Foley catheter size 18 Fr with a 30 milliliter bulb. A Care Plan, dated 6/12/24, indicated the resident required an indwelling catheter related to obstructive uropathy. Interventions included, but were not limited to, change catheter per the Physician Order, use a 16 Fr, 10 milliliter catheter per the Physician's Order. A Progress Note, dated 9/27/25 at 1:10 p.m., indicated the resident arrived at the facility. A head-to-toe assessment was completed. The resident had a gastrostomy tube and an 18 Fr, 30 milliliter suprapubic catheter draining clear yellow urine. During an interview on 12/17/25 at 1:45 p.m., the Director of Nursing indicated she was unsure when the resident had the suprapubic catheter placed and the care plan would be updated to reflect the use of a suprapubic catheter. 2. On 12/12/25 at 9:44 a.m., Resident 79 was observed sitting up in bed. She had a tracheostomy and a gastrostomy tube. There was a sign on the door that indicated she was in enhanced barrier precautions. There was a bin nearby the door for personal protective equipment. Resident 79's record was reviewed on 12/15/25 at 2:52 p.m. The December 2025 Physician's Order Summary indicated the resident was in enhanced barrier precautions (EBP). There was no care plans related to the resident being in enhanced barrier precautions. During an interview on 12/17/25 at 4:25 p.m., the Infection Preventionist indicated there should have been a care plan initiated for the resident being in enhanced barrier precautions. 3.1-35(d)(2)(B)

Based on observation, record review and interview, the facility failed to ensure a hand splinting device was in place as ordered and restorative nursing care was provided as ordered for 1 of 2 residents reviewed for range of motion. (Resident 81)Finding includes: On 12/11/25 at 11:12 a.m. and 12/15/25 at 9:39 a.m., Resident 81 was observed in his bed. There was no hand splint or carrot in the resident's hand left hand which was contracted. On 12/15/25 at 1:27 p.m., the resident was in bed and there was no splint in place to the left hand. The resident indicated he was not receiving restorative nursing services but would like to.The resident's record was reviewed on 12/15/25 at 9:50 a.m. Diagnoses included, but were not limited to, hemiplegia (paralysis affecting one side of the body) left side, heart failure and unspecified mood disorder.The Quarterly Minimum Data Set (MDS) assessment, dated 11/14/25, indicated the resident was cognitively intact and was dependent for bed mobility, transfers and toileting. The resident had not received any therapy or restorative nursing services during the assessment period.A Physician's Order, dated 7/24/25, indicated palm protectors to the left hand, on in the morning, off in the evening.The December 2025 Treatment Administration Record (TAR) indicated the palm protectors were signed out every shift as on, no refusals were noted.A Care Plan, dated 6/25/25, indicated the resident required passive range of motion (ROM) to the left upper extremity for weakness and to decrease contractures. Approaches included passive ROM program 5-7 days a week. Resident will tolerate 10 repetitions x 2 sets of passive ROM to left upper extremity, one time daily.The Restorative Nursing Tasks for December 2025 indicated the resident received ROM one day on 12/7/25. In November 2025, the resident received ROM on 11/3, 11/20, 11/22, 11/26, 11/27 and 11/28. There were no refusals noted.During an interview on 12/15/25 at 1:38 p.m., the Director of Nursing was made aware the palm protectors were not in place as documented on the TAR. No additional information was providedDuring an interview on 12/15/25 at 1:41 p.m. the MDS Nurse indicated she was aware there were no refusals documented in the restorative charting. She indicated the resident refused frequently.3.1-42(a)(2)

Based on record review and interview, the facility failed to monitor nutritional intake for meals for a resident with history of weight loss for 1 of 1 resident reviewed for nutrition. (Resident 5) Finding includes:During an interview on 12/11/25 at 12:42 p.m., Resident 5's family member indicated he had weight loss recently and had been having problems eating. Record review for Resident 5 was completed on 12/16/25 at 9:06 a.m. Diagnoses included, but were not limited to, dementia, hypertension, anxiety, tremors, and dysphagia (difficulty swallowing food or liquids). The resident was admitted to the facility on [DATE].The admission Minimum Data Set (MDS) assessment, dated 11/17/25, indicated the resident was severely cognitively impaired. The resident required a setup for eating and had a weight loss of 5% or more. A Care Plan, dated 11/13/25 and revised 12/10/25, indicated the resident was a nutritional risk and had a significant weight loss. An intervention included to monitor the food and fluid intake at meals.A nutrition calculation indicated on 11/11/2025, the resident weighed 191.6 lbs. On 12/02/2025, the resident weighed 179 lbs, which was a 6.58% weight loss.The Intake - Breakfast, Lunch, and Dinner documentation was reviewed for the past 30 days. The following meal consumption amounts were not documented: - Breakfast: 11/22, 11/23, 11/30, 12/8, 12/11, and 12/14/25- Lunch: 11/22, 11/23, 11/24, 11/29, 12/2, 12/8, 12/12, and 12/14/25- Dinner: 11/28, 12/1, 12/3, 12/7, 12/8, 12/9, 12/11, 12/12, and 12/15/25During an interview on 12/17/25 at 11:04 p.m., the Director of Nursing indicated the staff should have been documenting the resident's meal intake amounts or when he refused. A policy titled, Food and Fluid Intake Record-EMR, and received as current from the facility on 12/17/25, indicated, .Upon completion of the meal a member of nursing staff (CNA, QMA or Licensed Nurse) will document the percentage of food and fluid consumption for the meal.3.1-46(a)

Based on observation, record review and interview, the facility failed to ensure infection control measures were implemented related to an indwelling urinary catheter bag on the floor for 1 of 2 residents reviewed for urinary catheters (Resident 62), glove use during tracheostomy care for 1 of 1 resident reviewed for tracheostomy care (Resident 2) and lack of orders and care plans for enhanced barrier precautions (EBP) for 1 of 3 residents reviewed for transmission based precautions. (Resident 141)Findings include:1.On 12/11/25 at 3:15 p.m. and 12/12/25 at 9:15 a.m., Resident 62 was observed lying in his bed. His indwelling urinary catheter bag was lying on the floor. On 12/12/25 at 9:28 a.m., LPN 1 was standing at the resident's bedside doing nail care. The catheter bag was lying on the floor next to her. When asked if it should be on the floor, the nurse then picked it up and hung it on the side of the bed. The resident's record was reviewed on 12/12/25 at 3:06 p.m. Diagnoses included, but was not limited to, metabolic encephalopathy, neuromuscular dysfunction of the bladder and chronic pain. The Quarterly Minimum Data Set assessment, dated 12/8/25, indicated the resident was cognitively intact, dependent for toileting and needed partial assistance for bed mobility. The resident had an indwelling urinary catheter. The Indwelling Catheter Care Plan, dated 12/13/23, included the approach to not allow tubing or any part of the drainage system to touch the floor. During an interview on 12/12/25 at 10:15 a.m., the Director of Nursing indicated the resident was putting the catheter bag on the floor and was educated not to put the bag on the floor. 2. On 12/17/25 at 1:15 p.m., Respiratory Therapist (RT) 1 was observed doing tracheostomy care for Resident 2. RT 1 cleansed his hands and donned a gown and gloves and then prepared his supplies. He opened the tracheostomy care kit. He removed his gloves and cleaned his hands. He attempted to don the sterile gloves provided in the kit; however, they did not fit his hands, so he removed them and attempted to don another pair. The second pair of gloves ripped and so he removed them. He indicated the sterile gloves provided have never fit his hands and tracheostomy care is really a clean procedure, so he was going to use regular gloves. He moved his gown with his hands and reached into his pants pocket and pulled out a single glove and donned it. He then reached into his pocket again and pulled out another glove and donned it. He proceeded to perform the tracheostomy care. During an interview on 12/17/2025 at 1:45 p.m., the Director of Nursing was notified and had no further information to provide. A facility policy titled, Tracheostomy Care, indicated .7. Using aseptic technique, open trach care kit & empty contents onto the drape. 8. Remove gloves & perform hand hygiene. 9. Aseptically put on sterile gloves & prepare field. 3. On 12/12/25 at 9:42 a.m., there was a sign posted on Resident 141's doorway indicating the resident was in enhanced barrier precautions. There was a bin nearby containing personal protective equipment. Resident 141's record was reviewed on 12/17/25 at 4:21 p.m. The December 2025 Physician's Order Summary indicated cleanse right heel with betadine cover with bordered gauze. There were no orders for enhanced barrier precautions. There was no care plans related to enhanced barrier precautions. During an interview on 12/17/25 at 4:25 p.m., the Infection Preventionist indicated the resident was in enhanced barrier precautions due to wounds. There should have been orders and a care plan for enhanced barrier precautions. 3.1-18(b)

Based on observation, record review and interview, the facility failed to ensure a resident with a gastrostomy tube (g-tube, feeding tube) received care and services as ordered by a Physician related to treatment of the area around the insertion site for 1 of 1 resident reviewed for tube feeding. (Resident 79)Finding includes:On 12/12/25 at 9:44 a.m., Resident 79 was observed sitting up in bed. The resident indicated she had a gastrostomy tube used for tube feedings and it had been bleeding for the last two months. The gastrostomy tube was observed with a split gauze that was soiled with dark colored drainage from the insertion site. Resident 79's record was reviewed on 12/15/25 at 2:52 p.m. Diagnoses included, but were not limited to, gastrostomy and tracheostomy status. The Quarterly Minimum Data Set (MDS) assessment, dated 12/4/25, indicated the resident was cognitively intact. Tube feeding was not marked. A Physician's Order, dated 4/1/25, indicated cleanse the gastrostomy site with soap and water, pat dry, and apply gauze every shift. A Care Plan, dated 12/2/24, indicated the resident was at risk for complications related to tube feeding. Interventions included, but were not limited to, cleanse around site as ordered, observe for and document any symptoms of intolerance such as infection at insertion site, pain at site, observe site for signs of infection such as redness, warmth, malodorous drainage, document findings and notify the physician. Resident 79 was observed on 12/17/2025 at 9:23 a.m. with the Director of Nursing present. Resident 79 was observed sitting up in bed. The insertion site of the gastrostomy tube had a buildup of dark colored discharge surrounding it. There was no gauze in place at the time. At the time, the DON indicated the gauze must have fallen off. She would get the insertion site cleaned up and place a new gauze. She was also going to contact the physician and see if there was an ointment to put around the insertion site to help with the irritation. 3.1-44(a)(2)

Based on observation, record review, and interview, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurately completed related to restraints, antipsychotic medication, and tube feeding for 3 of 26 MDS assessments reviewed. (Residents 59, 11, and 79) Findings include:1. Record review for Resident 59 was completed on 12/16/25 at 10:58 a.m. Diagnoses included, but were not limited to, dementia with behavioral disturbance, anxiety disorder, and type two diabetes mellitus. The Quarterly MDS assessment, dated 10/22/25, indicated the resident had not received any antipsychotic medication since the prior assessment. The prior MDS assessment was dated 8/1/25. The Physician's Order Summary, dated 12/2025, indicated Risperdal Consta (an antipsychotic medication) 25 milligrams (mg)/2 milliliters (ml), give 25 mg intramuscular injection every 2 weeks. The Medication Administration Record, dated10/2025, indicated the resident had received a Risperdal injection on 10/9/25. During an interview on 12/17/25 at 11:39 a.m., the MDS Coordinator indicated there was a data entry error regarding the antipsychotic medication. 2. On 12/12/25 at 10:57 a.m., Resident 11 was observed sitting in her wheelchair. There were no restraints observed to the wheelchair that would prevent the resident from rising. Record review for Resident 11 was completed on 12/15/25 at 10:56 a.m. Diagnoses included, but were not limited to, dementia, type two diabetes mellitus, and general anxiety disorder. The Quarterly MDS assessment, dated 11/3/25, indicated a chair restraint to prevent rising was used less than daily. There was a lack of any Physician's Orders or assessments to indicate a chair restraint had been used. During an interview on 12/17/25 at 11:39 a.m., the MDS Coordinator indicated the facility was restraint free and there had been a data entry error. 3. On 12/12/25 at 9:44 a.m., Resident 79 was observed sitting up in bed. The resident indicated she had a gastrostomy tube used for tube feedings and it had been bleeding for the last two months. The gastrostomy tube was observed with a split gauze that was soiled with drainage from the insertion site. Resident 79's record was reviewed on 12/15/25 at 2:52 p.m. Diagnoses included, but were not limited to, gastrostomy and tracheostomy status. A Physician's Order, dated 4/1/25, indicated cleanse the gastrostomy site with soap and water, pat dry, and apply gauze every shift. A Care Plan, dated 12/2/24, indicated the resident was at risk for complications related to tube feeding. The Quarterly Minimum Data Set (MDS) assessment, dated 12/4/25, indicated the resident was cognitively intact. Tube feeding was not marked. During an interview on 12/17/25 at 11:38 a.m., the MDS Coordinator indicated it was a data entry error and would be corrected immediately. 3.1-31(i)

Based on observation, record review, and interview, the facility failed to ensure medications were stored properly, with appropriate labeling and not expired, for 2 of 4 medication carts observed. (East Cart and Cottage Cart) Findings include: 1. On [DATE] at 1:28 p.m., the following was observed on the East Cart with LPN 1: - A Basaglar KwikPen (insulin) was dated with an open date on [DATE]. - A Rezvoglar KwikPen (insulin) was dated with an open date on [DATE]. - A Toujeo SoloStar (insulin) pen was opened with no open date written on the pen. - A Basaglar KwikPen was opened with no open date written on the pen. During an interview on [DATE] at 1:35 p.m., the East Unit Manager indicated the open insulins should have been dated and disposed of 30 days after opening. 2. On [DATE] at 1:41 p.m., the following was observed on the Cottage Cart with QMA 1: - An insulin lispro vial was dated with open date on [DATE]. - A Lantus (insulin) pen was opened with no open date written on the pen. - An insulin lispro pen was opened with no open date written on the pen. During an interview on [DATE] at 1:50 p.m., LPN 1 indicated the open insulins should have been dated and disposed of 30 days after opening. A policy titled, 5.3 Storage and Expiration Dating of Medications and Biologicals, and received as current from the Director of Nursing, indicated, .11. Once any medication or biological package is opened, facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the primary medication container (i.e., vial, bottle, inhaler) when the medication has a shortened expiration date once opened or opened .11.3 If a multi-dose vial of an injectable medication has been opened or accessed (e.g., needle-punctured), the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial . 3XXX,d+[DATE](j)

Based on observation and interview, the facility failed to provide privacy related to a shared bathroom for 1 of 1 resident reviewed for privacy. (Resident 57) Finding includes: During an interview on 8/6/24 at 9:23 a.m., Resident 57 indicated she felt she lacked privacy in the bathroom because she had to share the bathroom with the two men residing in the room next door. She no longer utilized the toilet due to her continence status, but felt she should be able to go in the bathroom to wash her hands or face without a man opening the door or worrying a man could be coming in the bathroom while she was in there. On 8/6/24 at 9:44 a.m., Resident 57's bathroom was observed. The shared bathroom was located in between her room (room [ROOM NUMBER]) and the room next door (room [ROOM NUMBER]). There were doors on each side of the bathroom leading to the resident rooms. There were 2 male residents currently residing in room [ROOM NUMBER]. The record for Resident 57 was reviewed on 8/8/24 at 4:19 p.m. Diagnoses included, but were not limited to, end stage renal disease, type 2 diabetes mellitus, and hypertension. The Significant Change Minimum Data Set assessment, dated 6/21/24, indicated the resident was cognitively intact. During an interview on 8/9/24 at 10:33 a.m., the Director of Nursing indicated the resident had never voiced any concerns regarding privacy in the bathroom. The resident did not use the toilet, but the bathroom was shared with the room next door where two men currently resided. The resident was currently out at dialysis, but she would follow up with her when she returned. 3.1-3(p)(1)

Based on observation, record review, and interview, the facility failed to ensure care plans were reviewed and revised to include changes related to resident infections and dialysis access points for 2 of 29 resident care plans reviewed. (Residents 69 and 57) Findings include: 1. On 8/6/24 at 9:17 a.m., Resident 69 was observed in his room. The resident indicated he had a surgical wound to the top of his right foot. He had been under precautions at one time for having an infection. He no longer had the infection and was not on precautions any longer. There were no signs posted for any TBP (Transmission Based Precautions) or any PPE (Personal Protective Equipment) bins located inside or outside of the room. Record review for Resident 69 was completed on 8/9/24 at 9:50 a.m. Diagnoses included, but were not limited to, heart failure, hypertension, diabetes mellitus and a history of MRSA (Methicillin-resistant Staphylococcus aureus - bacterial infection). The Significant Change Minimum Data Set (MDS) assessment, dated 7/5/24, indicated the resident was cognitively intact. The resident had a surgical wound and was not taking an antibiotic. A Care Plan, dated 4/29/24 and revised 6/29/24, indicated the resident had a need for Contact Isolation related to active infectious disease MRSA. Interventions included, but were not limited to, educate visitors on necessary precautions needed for the specific type of infection and to have adequate PPE available for staff and visitors. A Physician's Order, dated 3/1/24 and discontinued 6/6/24, indicated the resident was on isolation due to having an active infection related to MRSA in the right foot. During an interview on 8/9/24 at 10:48 a.m., the Wound Nurse indicated the resident did not currently have MRSA and did not require contact precautions. The care plan should have been updated to include a history of MRSA. 32788 2. The record for Resident 57 was reviewed on 8/8/24 at 4:19 p.m. Diagnoses included, but were not limited to, end stage renal disease, type 2 diabetes mellitus, and hypertension. The Significant Change Minimum Data Set assessment, dated 6/21/24, indicated the resident was cognitively intact and received hemodialysis. A care plan, updated 7/17/24, indicated the resident received hemodialysis and had a right chest permacath (dialysis catheter) for dialysis access. During an interview on 8/6/24 at 9:23 a.m., Resident 57 indicated she went to dialysis on Mondays, Wednesdays and Fridays. She had a right upper arm graft for her current dialysis access. She also had an old right arm fistula, but it was not working any longer. During an interview on 8/9/24 at 10:33 a.m., the Director of Nursing (DON) indicated she had called the dialysis center to confirm, and the resident had a right upper arm graft dialysis access site. They would update the care plan. 3.1-35(b)(1)

Based on observation, record review and interview, the facility failed to ensure a resident with edema was monitored or treated for 1 of 1 resident reviewed for edema (Resident 18), medications were given as scheduled and accuchecks were documented for 2 of 5 residents reviewed for unnecessary medications. (Residents 91 and 120) Findings include: 1. On 8/6/24 at 1:41 p.m., Resident 18 was observed seated in her room in a wheelchair. Her legs were elevated with the footrests and she indicated they were swollen. On 8/7/24 at 1:19 p.m. the resident was seated in her room in a wheelchair, her call light was on. She indicated she wanted someone to put the footrests on her wheelchair so she could elevate her legs because they were swollen. On 8/9/24 at 1:12 p.m., the resident was seated in her room in a wheelchair. She indicated her legs had been swollen for about a month and she had told the nurses about it, but did not know what they were doing about it. The resident's record was reviewed on 8/7/24 at 2:40 p.m. Diagnoses included, but were not limited to, diabetes mellitus, heart disease and chronic obstructive pulmonary disease. The Significant Change Minimum Data Set (MDS) assessment, dated 6/13/24, indicated the resident was cognitively intact and required substantial assistance for bed mobility and transfers. The Weekly Skin and Vitals Assessments, dated 7/26/24, 8/2/24 and 8/9/24, indicated there was no edema. The Daily Shift Report, dated 8/4/24, indicated the resident had bilateral lower extremity edema. There was no documentation in the resident's progress notes or documentation the physician had been notified of the edema. During an interview on 8/9/24 at 1:14 p.m., LPN 1 indicated he had completed the Weekly Skin and Vitals Assessment that day. He asked the East Unit Manager if she knew anything about the resident having edema. The East Unit Manager indicated yes and the Nurse Practitioner (NP) was aware of it. The East Unit Manager indicated there was no documentation because it was a telehealth visit and not in the electronic record. During an interview on 8/9/24 at 1:30 p.m., the Director of Nursing (DON) indicated the NP thought the edema may be related to recent intravenous fluids given. A Care Plan, dated 4/9/24, indicated adequate tissue perfusion would be maintained as evidence by blood pressure within normal limits, no change in mental status, no complaints of dizziness and no edema. Interventions included, but were not limited to, elevate lower extremities, observe and document pallor, dizziness, variations in blood pressure, edema and notify MD. 2. Resident 91's record was reviewed on 8/7/24 at 9:08 a.m. Diagnoses included, but were not limited to, Alzheimer's dementia, chronic pain and anxiety. The Quarterly MDS assessment, dated 7/10/24, indicated the resident had significant cognitive impairment and received anti-anxiety medications and opioids. A Physician's Order, dated 8/16/23, indicated to give hydrocodone-acetaminophen (opioid pain medication) 10 milligrams (mgs)/325 mgs every 6 hours for chronic pain. The July and August 2024 Medication Administration Records indicated the medication was not signed out as given or refused on the following dates and times: 7/5/24 2:00 a.m. 7/13/24 2:00 a.m. 7/16/24 2:00 a.m. 7/17/24 2:00 a.m. 7/18/24 8:00 p.m. 7/27/24 2:00 a.m. 7/29/24 2:00 a.m. 8/5/24 2:00 a.m. During an interview on 8/8/24 at 3:05 p.m., LPN 1 indicated if a medication was not given or was refused, it should be documented. The resident did not normally refuse medications. During an interview on 8/8/24 at 3:18 p.m., the DON indicated the missing doses were likely because the resident was sleeping at 2:00 a.m., and the schedule should be revisited. The current policy, General Dose Preparation and Medication Administration, indicated, .6. After medication administration, .Document necessary medication administration/treatment information (e.g. when medications are opened, when medications are given, injection site of a medication, if medications are refused, PRN medications, application site) on appropriate forms 45666 3. Resident 120's record was reviewed on 8/7/24 at 8:32 a.m. Diagnoses included, but were not limited to type 2 diabetes mellitus, dementia, and Parkinson's disease. The Significant Change Minimum Data Set (MDS) assessment, dated 5/22/24, indicated the resident was severely cognitively impaired for daily decision making. She received insulin injections. A Care Plan, dated 3/2/24, indicated the resident was at risk for adverse effects related to the use of glucose lowering medications and/or the diagnoses of diabetes mellitus. Interventions included, but were not limited to, monitor blood sugars as ordered, administer medications as ordered, and provide diet as ordered. The July 2024 Physician's Order Summary indicated a daily blood sugar check at 6:00 a.m. and Lantus Solostar U-100 (a diabetic medication) insulin pen 100 unit/milliliter 10 units subcutaneous at bedtime. The July 2024 Medication Administration Record (MAR) indicated the blood sugar check at 6:00 a.m. was blank on 7/7, 7/19, 7/22, 7/27, and 7/30/24. The Lantus Solostar medication was blank at 9:00 p.m. on 7/25/24. During an interview on 8/8/24 at 4:13 p.m., the Director of Nursing indicated the nurse who was working those days had not documented on the MAR, however the blood sugar checks and Lantus medication were administered. She was unable to provide any further documentation. 3.1-37(a)

Based on observation, record review, and interview, the facility failed to ensure a resident received the necessary care and treatment related to incorrect oxygen flow rate and a humidity bottle not changed for 1 of 4 residents reviewed for respiratory care. (Resident 70) Finding includes: On 8/5/24 at 1:29 p.m., Resident 70 was observed in a wheelchair. He had a nasal cannula in place and attached to a portable oxygen tank on the back of the wheelchair. The flow rate was set at 4 liters per minute (lpm). On 8/6/24 at 9:08 a.m., the resident was observed lying in bed with a nasal cannula in place attached to the portable oxygen tank. The tank was set to a flow rate of 4 lpm. The oxygen concentrator was also on and set at 4 lpm. The water bottle on the concentrator was dated 7/29/24. The resident's record was reviewed on 8/7/24 at 1:22 p.m. Diagnoses included, but were not limited to, Parkinson's disease and chronic obstructive pulmonary disease. The Quarterly Minimum Data Set assessment, dated 7/31/24, indicated the resident had moderate cognitive impairment and required substantial/maximum assistance for bed mobility and transfers. A Physician's Order, dated 2/27/24, indicated the resident was to be on oxygen at 2 lpm continuously. A Physician's Order, dated 7/18/23, indicated the oxygen tubing and water bottle was to be changed weekly on Sunday. The August 2024 Medication Administration Record indicated the water bottle had been changed on 8/4/24. During an observation and interview on 8/6/24 at 9:15 a.m., the Cottage Unit Manager observed the oxygen and indicated it was set at 4 lpm and the water bottle was dated 7/29/24. 3.1-47(a)(6)

Based on observation, record review, and interview, the facility failed to care for a PICC (peripherally inserted central catheter, intravenous catheter placed into the peripheral veins of the upper arm) line in accordance with professional standards of practice, related to flushing the PICC line for 1 of 5 residents observed during medication pass. (Resident 3) Finding includes: During medication pass, the Infection Preventionist (IP) was observed preparing an intravenous medication for Resident 3 on 8/8/24 at 2:13 p.m. The IP prepared meropenem (an antibiotic) reconstituted solution 1 gram per 100 cc of normal saline. She washed her hands and donned clean gloves. She bent the connection between the 100 cc normal saline bag and the vial of meropenem, squeezed the normal saline into the vial, and then shook the vial to dissolve the meropenem powder medication. She held the vial above the bag and squeezed air from the bag into the vial to force the liquid back into the bag. She spiked the normal saline bag with new tubing and primed the tubing. She connected the tubing thru the pump and set it to run at 100 cc's per hour. She reached into her scrub top pocket with her gloved hands, pulled out an alcohol swab, opened the package, cleaned off the PICC connection port, and then attached a 10 cc normal saline syringe. She injected 6 cc's of normal saline thru the PICC line, unattached the normal saline syringe, reached into her pocket with the same gloved hands, and pulled out a new alcohol swab. She opened the alcohol swab, cleaned the PICC connection port, and attached the primed tubing. She then started the medication pump and the infusion of meropenem began. Resident 3's record was reviewed on 8/8/24 at 2:30 p.m. The August 2024 Physician Order Summary indicated a normal saline 10 cc syringe injection, flush PICC line before and after antibiotic administration to maintain patency every 8 hours. During an interview on 8/8/24 at 2:33 p.m., the IP indicated she should have flushed with a total of 10 cc of normal saline prior to administering the antibiotics thru the PICC line. A facility policy, titled Vascular Access Device Flush Ordered, received as current, indicated, .Peripherally Inserted Central Catheter (PICC) valved catheters, flush with normal saline-10 ml before and after IV medication administration . 3.1-47(a)(2)

Based on record review and interview, the facility failed to provide supervision to prevent an elopement of a cognitively and mentally impaired resident, who exited the facility unsupervised. The resident was last seen by an employee of the facility at 8:45 a.m. and exited out of the Main Dining Room door at 8:56 a.m. The facility was unaware the resident was not in the building for 4 1/4 hours. The Responsible Party/Power of Attorney was not notified for over 6 hours the resident had eloped and had not notified the local Police Department of the missing resident. The Responsible Party/Power of Attorney notified the local Police Department and the resident was located in a parking lot, 0.9 miles from the facility, for 1 of 5 residents reviewed for supervision. (Resident M) The immediate jeopardy began on 9/18/21 when the facility was unaware the resident had exited the facility without supervision. The alarm to the door he exited was activated upon exiting and an employee silenced the alarm with a code, without looking outside to see if anyone had left through the door. The Resident Representative/Power of Attorney was not notified in a timely manner, and the local Police Department was not notified of the missing resident for approximately 2 hours after the facility had realized the resident was missing. The resident had walked to a local restaurant, 0.9 miles from the facility, was located in a parking lot, and was brought back to the facility by the local Police Department. The Administrator and Director of Nursing (DON) were notified of the immediate jeopardy at 3:10 p.m. on 11/9/21. The immediate jeopardy was removed, and the deficient practice corrected on 9/30/21 prior to the start of the survey and was therefore Past Noncompliance. Finding includes: An Indiana Department of Health (IDOH) reportable incident, indicated on 9/18/21 at 1:01 p.m., the Administrator and the DON were informed Resident M was missing from the facility, a Code Silver (missing resident) was called. The video camera at the facility was reviewed to confirm the resident exited the building without supervision. The family and police were notified and the resident was brought back to the facility. The resident had left the facility to buy cigarettes. The resident's cognitive status was intact, though the Physician assessed the resident as incompetent. Resident M's record was reviewed on 11/9/21 at 9:25 a.m. The diagnoses included, but were not limited to, [CONDITION(S)], [CONDITION(S)], and [CONDITION(S)]. A Quarterly Minimum Data Set assessment, dated 7/12/21, indicated an intact cognitive status, and required supervision of one staff member for ambulation, no behaviors, and received an antipsychotic and an antidepressant medication for seven of the past seven days. An Elopement Risk assessment, dated 7/12/21, indicated a history of eloping from home or facility, had been assigned a security bracelet, and had a recent elopement in the past month. The Care Plans included: On 5/7/18, and discontinued on 9/29/21, indicated a risk for for elopement, he displayed an impaired cognitive function, ambulated independently, often requested to go home, and was pushing/pulling on an exit door. The interventions included, on 6/18/21, offer a drink or snack and redirect him to a different area, 2/23/21, encourage participation in activities, 7/8/21 - daily walks or sit outside daily with activities, 5/18/20 - 15 minute checks, offer and assist with going to the patio, offer to assist with a phone call or video chat with his family, 5/7/21 - all facility exits were secured and security bracelet was placed. On 9/6/18, has delusional or paranoid thinking, fearful of others harming him or conspiring against him. The interventions included, maintain consistent daily routine and Psychiatric services as needed. On 5/7/18, short and long term memory deficit with impaired decision making skills present. Wanders around the facility. The interventions included to encourage independence and cueing. On 5/7/18, he is unable to return to the community due to a need for 24 hour care secondary to multiple diagnoses that affect cognition and judgement. On 4/17/18, he was a risk for falls. The interventions included, non-skid footwear. A History and Physical from a prior facility, dated 1/25/17, indicated the resident a poor historian and had been deemed incompetent. A Preadmission Screening and Resident Review (PASRR) assessment, dated 9/17/21, indicated significant difficulty communicating, had difficulty recognizing familiar people or familiar objects, and had short and long term memory impairments. A Physician's Order, dated 4/27/18, indicated a Wanderguard security bracelet was initiated. A Speech Therapy Discharge Summary, dated 8/9/21, indicated a mild cognitive deficit was present. He had compromised recall, problem-solving, and safety awareness and judgement, and required continued 24-hour care for safety, and he was a safety and elopement risk. A Psychiatric Physician Assistant's Progress Notes, dated 9/7/21, indicated a sleep and energy deficit was noted and he was oriented only to person and place. A Licensed Clinical Social Worker's (LCSW) progress note, dated 9/11/21 at 8:42 p.m., indicated he was oriented to self and had displayed exit seeking behaviors. A Nurse's Progress note on 6/12/21 at 8:11 a.m., indicated at 7:50 a.m. the resident had exited the front door and was jogging down the street. The staff witnessed the exit and were able to divert him back into the facility. The Nurses' Progress Notes on 9/18/21 indicated: At 3:13 p.m., the Power of Attorney(POA) notified of the resident's elopement. She requested the local Police Department be notified and was informed by the Nurse she was unable to report the resident as missing due to his cognitive score indicated he had no cognition problems and he was considered as leaving against medical advice (AMA). The POA indicated she would notify the Police herself. The Administrator, DON, the Nursing Manager, and the Physician on call were notified. (this was the first documentation of the resident being missing) At 3:44 p.m., the resident was brought back to the facility by the local police. The resident had been found at a local restaurant and had been sitting at the restaurant since his elopement from the facility. The POA was notified the resident had returned to the facility. A Physician's Progress Note, Dated 9/20/21 at 9:57 a.m. and late entry on 9/29/21 at 10:04 a.m., indicated, cognition status was assessed and he was unable to make his own decisions. He was not able to completely grasp his situation or the danger when he exited the building on 9/18/21. During an interview with the Administrator on 11/9/21 at 8:15 a.m., she indicated she had watched a video of the facility on 9/18/21. He had exited the facility by a door in the Main Dining Room. The alarm on the door had been activated, and Employee 1 had come from the hallway, placed the code in the alarm box, and silenced the alarm. The video indicated the resident had kicked the door open. The last time he had been seen by staff was at 8:45 a.m. when the Nurse had given him his medication. He had been in the dining room eating breakfast, then exited the door at 8:56 a.m Employee 2 was scheduled to supervise the Dining Room, and had exited the same door, for an unknown reason, at 8:45 a.m. There were still a couple residents in the Dining Room when Employee 1 exited out the door. When the staff could not find the resident a Code Silver was announced. The facility was unable to reach the Administrator, so they notified the DON, who notified the Regional Manager, who indicated the resident had no cognitive deficits so the facility could not call it an elopement and to treat it as exiting against medical advice. The POA had not been notified due to the Regional Manager had indicated it was not an elopement. When the POA was notified, she was upset. The facility had notified the Police after notification of the POA. She indicated no staff members were interviewed about the elopement since she was able to see on the video what occurred. The Administrator presented an Email, dated 11/9/21 at 11:39 a.m., addressed to the Regional Manager on 9/19/21, which indicated, the resident ambulated throughout the facility independently, so it was not unusual for the staff not to know where the resident was at until the next meal. The video indicated the resident stood from the breakfast table in the Main Dining Room and pushed the Dining Room exit door open at 8:56 a.m. This door was used by staff to take trash out to the dumpster. Soon after the resident exited, Employee 1 entered the Dining Room from the hallway and used the key pad to silence the alarm. She assumed the alarm was going off, since he had entered the code. The family had not been notified until the facility could confirm the resident actually exited on his own. The Police were notified and informed them they had received a call earlier in the day, which a restaurant had concerns about a gentleman who had been there since 10 a.m. The Police had went to the restaurant and the gentleman had informed them he was homeless and had slept at the park the night before. The Police had informed the gentleman he had to leave the restaurant. Once the facility had notified the Police, they realized this was the missing resident and found the man walking in the parking lot and escorted him back to the facility.He is definitely not safe to go out During an interview on 11/9/21 at 11:58 a.m., Employee 1 indicated the alarm to the door in the Dining Room had been activated and the code was entered and the alarm was silenced. He had not looked outside to see who went out the door. During an interview on 11/9/21 at 1:21 p.m., Employee 2 indicated she had exited the Dining Room Door to go out to her car. She entered the code prior to the exit, so the alarm was not activated. She had not witnessed the resident outside of the facility. During an interview on 11/9/21 at 1:32 p.m., the POA indicated she was upset the facility had not called her until 3 p.m. since the resident had been missing since 9 a.m. She requested the Police be notified and was told she would have to call the Police because of his cognitive status. She indicated she had notified the Police and was told by the Police, the facility needed to call and report the missing resident. She notified the facility and told them they needed to call and report the resident as missing. The Police had seen the resident earlier when they entered the the restaurant. During an interview on 11/9/21 at 2:13 p.m., the Administrator indicated between 1 p.m. and the resident's return to the facility, she had watched the video. She indicated staff had searched the building and drove around the neighborhood. The facility had not wanted to call the POA until they knew the resident was no longer in the building and he goes out with family frequently so they were not sure if he was with family. A Police Report, dated 9/18/21, indicated the facility notified the Police of the missing resident at 3:23; p.m. The resident had left the facility approximately on 9/18/21 at 9 a.m. The resident was found in a parking lot at 3:26 p.m. and escorted back to the facility at 3:32 p.m. A facility policy, dated 10/2017, titled, Elopement Prevention and Response Program, received from the Administrator as current, indicated the facility staff were responsible for knowing the location of the residents under their care. If location of the resident was unknown, a Code Silver is activated, a head count is completed, the Leave of Absence sign out book is to be reviewed, a search of the facility and outside grounds are to be completed. If the resident was not found, the Police and the resident's Responsible Party would be notified, and the search would be expanded to the surrounding neighborhoods. The past noncompliance immediate jeopardy began on 9/18/21. The immediate jeopardy was removed and the deficient practice corrected by 9/30/21 after the facility implemented a systemic plan that included the following actions: the resident was placed on 15 minute checks, a stronger magnetic lock was placed on the exit door, the alarm was upgraded into the a centralized foyer to ensure it was also audible in the hallways. All but 14 staff had been re-educated on the elopement procedure and response to the door alarms. All staff not educated were either on leave or work as needed and would be educated prior to working at the facility. All residents were assessed for being an elopement risk. Staff were interviewed and were knowledgeable of the policy and procedure to follow with a missing resident, door alarm activation, and notification of family and police as needed per policy. 3.1-25(a)(2)

Based on observation, record review, and interview, the facility failed to ensure residents who were a high risk for falls received adequate assistance and supervision as care planned to prevent falls, which resulted in multiple falls, for 2 of 3 residents reviewed for falls.(Residents D and B) Two of the falls resulted in injuries of fractured nasal bones, swelling, and bruising for Resident D. Findings include: 1. On 7/16/19 at 11:39 a.m., CNA 3 and CNA 4 were observed to be walking side by side behind the wheelchair of Resident D. CNA 3 had both hands on the handles of the wheelchair and transported the resident from the Activity Room to her room. Neither CNA was in front of the the resident while guiding her to the destination nor were their hands placed on the resident during the transport. The resident was wearing non-slip socks. While in the room, CNA 3 removed the non-slip socks and placed hard soled shoes on the resident. CNA 3 and CNA 4 completed incontinence care and transferred her back to the wheelchair. CNA 3 then moved the wheelchair backward to the hallway, the resident's right foot dragged on the floor. CNA 3 turned the wheelchair forward and instructed the resident to hold her feet up, which she did. CNA 3 then transported the resident down the hall at a normal walking speed, both her hands were on the handles of the wheelchair, there was no other staff standing in front of the resident to guide her to the destination. Once she was in the hallway by the Dining Room, CNA 3 moved the wheelchair in a circle twice looking at each area she was going to take the resident, then transported the resident back down the hall to the Activity Room. CNA 3 kept both hands on the handles of the back of the wheelchair and walked at a normal pace. There was no staff in front of the wheelchair to guide her to the destination. CNA 3 was interviewed, at the time of the observation, and indicated the Profile Sheet has all the interventions to be used to prevent falls. Resident D's record was reviewed on 7/15/19 at 2:59 p.m. The [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) assessment, dated 5/7/19, indicated long and short term memory problems, severely impaired decision making skills, no behaviors, extensive assistance of two for transfers, had one fall without injury and two falls with injuries. A care plan, dated 12/19/16, indicated there was a risk for falls due to self transfers without assistance and placed her feet down when being pushed in a wheelchair, causing her to fall forward out of the chair. The interventions included, 7/2/19 - encourage resident to follow staff, extend your hand when trying to direct her to a specific place, and utilize non-skid socks instead of shoes; 6/21/19 - to be seated near the exit (dining room); 4/19/19 - ensure a hand is on the resident while pushing her in the wheelchair and push the wheelchair slowly due to she puts her feet down without notice; 5/7/18 - she is to be assisted out of the dining room after meals. The Profile Sheet, identified as containing interventions for care of the resident for the CNA's, indicated,7/2/19 - encourage resident to follow staff, extend your hand when trying to direct her to a specific place; 5/17/19 - after the resident is finished eating she is to be assisted out of the dining room; and 4/19/19 - ensure a hand is on the resident while pushing her wheelchair and push the wheelchair slowly due to she puts her feet down unannounced. An Event Progress Note, dated 6/5/19 at 1:45 p.m., indicated the resident was being transported in the wheelchair by an Activity Aide when the resident placed her feet down and fell forward out the chair onto the floor. A Nurse's Progress Note, dated 6/5/19 at 1:46 p.m., indicated the resident hit her face on the floor, the injuries were a swollen and bloody nose with bruising and was transferred to the Hospital emergency room . The emergency room information, dated 6/5/19, indicated a CT scan of the face was completed with the results of extensive soft tissue swelling and acute displaced bilateral nasal bone fractures. The discharge [DIAGNOSES REDACTED]. A Nurse's Progress Note, dated 6/6/19 at 12:46 p.m., indicated there was bruising to the forehead which extended to the cheeks and a bruise on the chin. The Fall Investigation, dated 6/5/19, indicated a written statement by the Activity Aide, As I was wheeling her she put her feet down and started falling forward .fell face first out of wheelchair to floor . The Interdisciplinary Team (IDT) Note, dated 6/6/19 at 2:43 p.m., indicated the staff was educated on the fall interventions. An Event Progress Note, dated 6/8/19 at 2:06 p.m., indicated she was sitting in the East Unit Lounge/Dining Room and was found lying on her right side. The intervention to prevent further falls was to keep the resident within staff sight when she was in a wheelchair. A Nurse's Progress Note, dated 6/8/19 at 2:08 p.m., indicated the Nurse was called to the East Unit Lounge/Dining Room by a family member. The resident was found lying on the floor on her right side. Prior to the fall she had been sitting in the wheelchair in the Lounge/Dining Room after lunch. No further injuries were assessed. The Fall Investigation, dated 6/8/19, indicated the fall intervention implemented was to keep the resident within staff's sight when she was out of the bed. An IDT Note, dated 6/10/19 at 11:05 a.m., indicated an intervention to provide resident with simple tasks after meals. An Event Progress Note, dated 6/20/19 at 6:30 p.m., indicated there was an unwitnessed fall in the East Unit Lounge/Dining Room. The resident was eating dinner and was then found on floor lying on her left side. The intervention implemented was to not leave the resident unattended in the Dining Room/Lounge after meals. A Nurse's Progress Note, dated 6/20/19 at 6:30 p.m., indicated she was found on her left side on the floor in front of the wheelchair in the Dining Room/Lounge on the East Unit. No injuries were assessed and the she was not to be left unattended in the Dining/Room Lounge after meals. The IDT Note, dated 6/21/19 at 10:22 a.m., indicated the resident was to be seated near an exit of the Lounge/Dining Room due to the root cause of the fall was she was trying to maneuver herself from the back of the room. A Nurse's Progress Note, dated 6/28/19 at 8 a.m., indicated a CNA was transporting the resident by wheelchair in the hallway and she fell from the wheelchair. A Fall Event Progress Note, dated 6/28/19 at 9:51 a.m., indicated a CNA was transporting the resident in the wheelchair when the resident fell forward out of the chair. The Staff Witness Statement, dated 6/28/19 at 8:00 a.m., indicated the CNA was transporting the resident in the wheelchair, she leaned forward and fell from the chair. A Fall Event Progress Note, dated 6/28/19 at 7:38 p.m., indicated she was being transported to her room, the Nurse's hand was on her left upper arm, when the resident brought her legs down to stop the chair and fell forward to the ground. A Nurse's Progress Note, dated 6/28/19 at 8:20 p.m., indicated she was being transported to her room, the Nurse's hand was on the upper left arm and right hand on the handle of the wheelchair. She brought her legs down to stop the chair and fell forward onto the ground. The nose began to bleed and chin was bruised. She was transferred to the emergency room . The emergency room information, dated 6/28/19, indicated a CT scan of the face was completed with results of bilateral nasal bone fractures and mild soft tissue swelling surrounding the nose. A Nurse's Progress Note, dated 6/29/19 at 3:14 p.m., indicated bruising to the face. The IDT Note, dated 7/1/19 at 12:31 and late entered on 7/2/19 at 12:31 p.m., indicated an intervention to encourage the resident to self propel to destinations. During an interview with the DON (Director of Nursing) and the Administrator, on 7/15/19 at 3:45 p.m., the DON acknowledged the interventions on the CNA Profile form were in place prior to the falls and not implemented. The Administrator indicated they had a care plan meeting with the family to discuss ways to prevent further falls and interventions the facility would like to try. The DON indicated the intervention of standing in front of the resident and encourage her to propel herself would decrease the falls. 2. Resident B's record was reviewed on 7/15/19 at 12:55 p.m. The [DIAGNOSES REDACTED]. An Admission/5-Day MDS (Minimum Data Set) assessment, dated 6/18/19, indicated a moderately impaired cognition status, no behaviors, required extensive assistance of one for transfers, ambulation, dressing, hygiene, and toileting, has had falls prior to admission, and no falls since admission. A Fall Risk Assessment, dated 6/11/19, indicated a high risk for falls. A care plan, dated 6/21/19, indicated a high risk for falls related to falls in past, impaired cognition, and has had a high number of falls secondary to transferring without assistance. The interventions included, do not leave in the bathroom alone. The CNA Profile, listed an intervention dated 11/28/18, of do not leave resident unattended in the bathroom. The Physical Therapy Plan of Care, dated 6/12/19, indicated a fall risk, memory impairment and impaired decision making, was able to maintain static (standing still) standing with hand held support and constant minimal assistance. He was unable to to completed dynamic (movement) standing without a loss of balance. An Event Progress Note, dated 6/20/19 at 9:00 a.m., indicated an unwitnessed fall in the bathroom. He was standing at the sink washing himself, lost his balance and fell into the wall. He had hit his head and no other injuries were found. The intervention to prevent further falls, was to have the resident sit in a wheelchair at the sink when completing hygiene care. A Nurse's Progress Note, dated 6/20/19 at 9 a.m., indicated the resident was observed on the floor against the wall. He stated he was washing himself, lost his balance and fell backwards into the wall and hit his head. The back of the head was assessed and had redness. The Physician and family was notified. A Fall Investigation, dated 6/20/19, indicated the CNA walked with the resident to the bathroom and he refused to allow the CNA to assist or supervise him while in the bathroom. The CNA Statement indicated he was outside the bathroom in the room at the time of the fall. The IDT note, dated 6/21/19 at 10:40 a.m., indicated the root cause of the fall was a loss of balance while self care was performed at the bathroom sink. The intervention added to prevent further falls was to have the resident sit in a wheelchair in front of the sink while completing self hygiene care. During an interview, on 7/15/19 at 2:28 p.m., CNA 1 indicated he had assisted the resident into the bathroom and when he entered the bathroom with him, the resident told him to get out and he did not want to wash himself in front of a man. CNA 1 informed the resident he needed to stay with him and the resident said he could do it himself. CNA 1 could not recall what the Profile Sheet had as interventions to prevent falls. During an interview, on 7/15/19 at 2:34 p.m., with the DON and the Administrator, the DON indicated he refused to have the male CNA stay in the bathroom with him. The sequence of events happened too quickly and the CNA did not have enough time to get the nurse. No call light was used to ask for assistance when the resident refused care assistance. During an interview, on 7/15/19 at 11:36 a.m., CNA 1 indicated the Profile Sheets had all the interventions for caring for the residents, including fall interventions. Residents with a high risk of falls were not to be left in the bathroom alone. During an interview on 7/15/19 at 1:56 p.m., CNA 2 indicated the Profile Sheets had all the interventions for caring for the residents, including fall interventions. Residents with a high risk of falls were not to be left in the bathroom alone. A facility policy, dated 11/2017, titled, Fall Management Program, received by the Administrator as current, indicated .to ensure residents residing within the facility receive adequate supervision and or assistance to prevent injury related falls .implement comprehensive, resident-centered fail prevention plans for each resident at risk for falls or with a history of falls .resident specific care requirements will be communicated to the assigned caregiver utilizing resident profile or CNA assignment sheet .a fall event will be initiated .provide immediate interventions . This Federal tag relates to Complaint IN 610. 3.1-45(a)(2)

Based on record review and interview, the facility failed to ensure interventions were implemented to prevent falls while administering peri-care for a resident who required extensive to dependent assistance with activities of daily living (ADL's). This resulted in the resident falling from the bed and receiving fractures to both lower extremities, for 1 of 3 residents reviewed for falls in a total sample of 6. (Resident C) Finding includes: Resident C's record was reviewed on 08/04/17 at 9:30 a.m. [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set assessment, dated 04/13/17, indicated moderately impaired cognition, extensive assistance of two staff for bed mobility and hygiene, dependent on two staff for locomotion, toileting and bathing, and always incontinent of bowel and bladder. A care plan, dated 04/19/17, indicated assistance was needed with ADL's related to impaired mobility. The interventions included, 04/19/17 - two assist with bed mobility and incontinent care. A care plan, dated 02/24/17, indicated the resident was a risk for falls due to impaired mobility. Interventions included, call light in reach and on 07/07/17 - two assist with turning and positioning was added. A Fall Event Form, dated 07/07/17 at 7:02 p.m., indicated a witnessed fall, staff was administering peri-care, found sitting on floor with back against the night stand table, complained of bilateral lower extremity pain, and stated she could not move her legs and the resident was transferred to the emergency room . A Nurse's Note, dated 07/08/17 at 2:27 a.m., indicated the resident returned to the facility with bilateral knee immobilizers in place. [DIAGNOSES REDACTED]. X-rays, dated 07/07/21 indicated: Left lower leg - acute minimally displaced fracture of the proximal tibia across the tibial component as well as the fibular head and a nondisplaced transverse fracture of the distal tibial metaphysis. Right femur - acute mildly displaced spiral fracture of the mid to distal femur extending to the femoral prosthesis. An Interdisciplinary Team Note, dated 07/10/17 at 10:51 a.m., indicated the CNA was providing incontinent care and changing the brief. The resident was asked to roll towards the CNA to the right side of the bed and the resident threw her legs to the left side of the bed and rolled off the bed onto the buttocks with her back against the night stand. The legs were straight out. The resident complained of pain in the bilateral lower extremities. During an interview on 08/04/17 at 10:40 a.m., the Director of Nursing indicated the bed was waist high when the resident fell and acknowledged the care plan interventions were to use two staff for bed mobility and incontinent care. A facility policy, dated 07/2016, titled, Fall Management Program, received from Medical Records as current, indicated, .Residents who are categorized as moderate to high risk should have fall interventions implemented based on resident specific risk factors .The resident specific care requirements will be communicated to the assigned caregiver . This Federal Tag relates to Complaint IN 628. 3.1-45(a)(2)

Based on record review and interview, the facility failed to ensure a resident received adequate supervision and assistive devices to prevent accidents, which resulted in injuries from the falls that required sutures and hospitalization for the injuries for 1 of 3 residents reviewed for falls in a total sample of 6. (Residents #D) Finding includes: Resident #D's record was reviewed on 5/12/16 at 11 a.m. The resident's [DIAGNOSES REDACTED]. A Significant Change MDS (Minimum Data Set) assessment, dated 1/7/16, indicated the resident's cognition was moderately impaired, required extensive assistance of two staff for transfers, extensive assistance of one staff for ambulation, was a risk for falls, and had two falls without injury and one fall with injury since the last review. A care plan, dated 3/23/15 and reviewed on 1/14/16, indicated the resident was at risk for falls due to unsteady gait/standing balance, poor safety awareness, and had a history of [REDACTED]. A physician's orders [REDACTED]. A Nurses' Progress Note, dated 3/30/16 at 6:15 p.m., indicated, res (resident) noted in west wing lounge at the table eating dinner, While (sic) writer was feeding another resident, writer suddenly heard a loud thump, writer turned back and observed res lying on the floor sideways, writer went to help res and noted bleeding from a laceration to L (left) side of head immediately applied pressure to site, neuro checks initiated, res eyes partially open but not responding to verbal stimuli. 911 called. The Hospital History and Physical, dated 3/31/16, indicated a CT of the head showed a left frontal cortical and intraparenchymal (left front of the skull) hemorrhage. A Hospital Neurosurgical Consult, dated 3/31/16, indicated the resident had a left frontal lobe contusion. The note indicated the area was a very small contusion area of the brain. The impression indicated there was a small cerebral contusion and no surgery was needed. A Progress Note, dated 4/18/16, indicated the resident received three sutures in the emergency room to close the laceration of the head. The Fall Investigation, indicated a statement was received and signed by CNA #1 on 3/30/16, I was in the dining area feeding a res with myself facing the res. I heard a loud noise and turned around to see what it is (sic) was. The res was on the floor. A nurse that was in the dining area also went to his aid. A statement received and signed by RN #2, dated 3/30/16, indicated, res was @ west lounge @ table eating dinner while I was feeding another resident, I heard a loud thump. I turned back and observed res was on the floor .laceration to L side of head .was not responding to verbal stimuli. A statement signed by CNA #3 (assigned to resident #D), dated 3/30/16, indicated, I was feeding (resident name) .(resident #D name) was roaming in his w/c (wheelchair). I saw no reason to put him in a chair with the risk of falling when his tray wasn't here yet. The Fall Investigation, dated 3/30/16, indicated the resident had remained in the wheelchair in the West Lounge at dinner time and had not been seated in a stationary chair with the alarm on the chair. The Investigation indicated the self-release alarm belt was not on the resident at the time of the fall. During an interview on 5/12/16, the Director of Nursing (DON), indicated the self-release belt was not on the resident because he was up at the table. The DON indicated the resident's care plan approach and physician's orders [REDACTED]. During an interview on 5/12/16 at 1:30 p.m., the DON indicated CNA #3 had not placed the resident in the stationary chair because the resident was still roaming around in the wheelchair. The DON acknowledged the self-release belt alarm was not on the resident and if the resident was still in the wheelchair roaming around the self-release belt alarm was to be on the resident. A facility policy, dated 2/2015, titled, Fall Management Program, received from the DON as current, indicated, .A care plan will be developed at time of admission specific to each resident's fall risk factors. 4. The resident specific care requirements will be communicated to the assigned caregiver . This Federal Tag relates to complaint IN 104. 3.1-45(a)(2)

Based on record review and interview, the facility failed to ensure residents received adequate supervision and assistive devices to prevent accidents, which resulted in injuries from the falls that required sutures for the injuries. (Residents #G and # M). The facility also failed to thoroughly investigate the falls for the root cause and failed to initiate precautions to prevent falls for 4 of 4 residents reviewed for falls, in a total sample of 10. (#C, #G, #H, and #M) Findings include: 1. Resident #M's record was reviewed on 01/25/16 at 9:48 a.m. The resident's [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) assessment, dated 09/04/15, indicated the resident's cognition was intact, required extensive assistance of two for bed mobility and transfers, had not ambulated, and had one fall without injury and two with injury since the last assessment completed. The care plan, dated 03/23/15, indicated the resident was a risk for falls. The interventions included, 05/20/15-sensor alarm to the bed and 06/24/15-scoop mattress and clip alarm to the wheelchair. The Fall Event form, dated 10/14/15 at 11:30 a.m., indicated the resident was found in the lobby of the facility lying on his left side, and the resident had a bruise to his left shoulder. The resident or witness statement of how the fall occurred indicated the fall was unwitnessed. The Fall Investigation, dated 11/14/15 at 11:30 a.m., indicated the resident fell out of the wheelchair. There was no further investigation documented. The fall investigation had not indicated the resident's wheelchair alarm had been activated with the fall. A Interdisciplinary Team Note (IDT), dated 10/15/15 at 10:56 a.m., indicated the resident was observed on the floor in the front lobby, the resident propels self independently throughout the facility and the clip alarm and side tray was in place. During an interview on 0125/16 at 11:29 a.m., the Director of Nursing (DoN), indicated the fall had not been thoroughly investigated for the root cause and the use of the chair clip alarm. The Fall Event form, dated 11/15/15 at 1 a.m., indicated the resident was found sitting on the floor taking his socks off in his room and had received a skin tear to the right hand. The resident or witness statement of how fall occurred, indicated unwitnessed The Fall Investigation, dated 11/15/15 at 1 a.m., indicated the resident had a fall resulting in a skin tear to the right hand. The IDT Note, dated 11/16/15 at 10:01 a.m., indicated the resident had been sitting on the floor and taking off his socks and was incontinent. During an interview on 01/25/16 at 11:29 a.m., the DoN indicated she was unsure if the bed alarm had been activated. The DoN indicated the investigation had not included if the fall interventions were in place. The Fall Event Form, dated 11/21/15 at 11:30 a.m., indicated the resident was found on the floor in the dining room, had no injuries, and the resident or witness statement of how the fall occurred indicated, unwitnessed fall The Fall Investigation, dated 11/21/15 (no time), indicated the Nursing Staff were alerted of the resident's fall by a Housekeeper. There was no investigation if the chair alarm had been activated and the root cause of the fall. The IDT Note, dated 11/23/15 at 9:20 a.m., indicated the resident was in the wheelchair with the lap tray and alarm in place and was noted sitting on buttocks in the main dining room without injuries. During an interview on 01/25/16 at 11:29 a.m., the DoN indicated there had been no investigation for the root cause of the fall and if the chair alarm had been activated. The Fall Event form, dated 12/09/15 at 7:41 p.m., indicated the resident was in his room waiting to go to be and was found on the floor outside of the resident's room with no injuries. The resident statement indicated the resident thought he was going to bed. The Fall Investigation, dated 12/09/15, indicated the fall occurred at 7:15 p.m. and 20 minutes prior to the fall the resident had asked to go to bed. The IDT Notes, dated 12/10/15 at 9:05 a.m., indicated the resident was in his room getting ready for bed then the CNA found the resident on the floor. The resident had no shirt, no pants, and his shoes were off. The Root cause of the fall was documented as he doesn't ask for assistance with the transfers and to continue to use the personal clip alarm. During an interview on 01/25/16 at 11:29 a.m., the DoN indicated no one had assisted the resident into bed when he requested to go to bed and the fall was not investigated thoroughly to determine why the staff had not assisted the resident to bed and if the chair alarm had been activated with the fall. The Fall Event form, dated 12/11/15 at 4:52 p.m., indicated the resident was observed walking across the mattress on the floor next to his bed, transferring himself to the wheelchair from the bed and the staff were not able to get to the resident in time to prevent the fall. The Event indicated the staff would be re-educated on the alarm and the alarm was to be turned on when the resident was in bed. The Fall Investigation indicated the fall occurred on 12/11/15 at 2:20 p.m., the resident fell on the mattress on his floor and was witnessed. The resident had no injuries. The IDT Note, dated 12/14/15 at 9:30 a.m., indicated the resident had transferred out of bed independently and had walked on the mattress on the floor and fell on the mattress going to the wheelchair. The noted indicated the facility would remove the mattress on the floor and replace it with a mat and replace the sensor alarm with a call light activator bed alarm. During an interview on 01/25/16 at 11:29 a.m. the DoN indicated the resident's bed alarm had not been on and a call light activator bed alarm should have been initiated. The Fall Event form, dated 12/18/15 at 4:30 p.m., indicated the resident was found sitting on the mat on the floor next to the bed and the resident had a 4 centimeter laceration over his right eye. The resident or witness statement of how the fall occurred, indicated the resident stated, I don't know. The intervention put into place to prevent another fall was a bed alarm with call light activation. A Nurses' Note, dated 12/18/15 at 5:10 p.m., indicated the resident was transferred to the emergency room . A Nurses' Note, dated 12/18/15 at 8:10 p.m., indicated the resident returned to the facility with seven sutures over the right eye, and the right eye had bruising and swelling. The IDT Note, dated 12/21/15 at 9:29 a.m., indicated the bed alarm had not alarmed, the resident received a laceration over his right eye and received sutures, the root cause of the fall was dementia and the resident attempts to transfer himself out of the bed. The IDT team agreed to bed alarm with call light activation system. During an interview on 01/25/16 at 11:29 a.m., the DoN indicated the alarm had not been on the resident's bed and the call light activated alarm had not been initiated after the fall on 12/11/15. 2. Resident #G's record was reviewed on 01/22/16 at 1:16 p.m. The resident's [DIAGNOSES REDACTED]. A Change of MDS assessment, dated 11/24/15, indicated the resident's cognition was severely impaired, required extensive assistance of two for transfers, and had no falls since the last MDS assessment. A care plan, dated 06/09/15, indicated the resident was a risk for falls. The interventions included, 06/09/15-therapy screen, personal items in reach, non-skid footwear, call light in reach, 06/10/15-Transfer assist of one, 07/30/15-personal alarm in bed, alarm to chair, 12/21/15-scoop mattress, offer to lay the resident down after breakfast and lunch, mat next to bed, and 01/05/16-late bedtime as tolerated. The Fall Event form, dated 12/01/15 at 4:15 p.m., indicated the resident was sitting in his wheelchair by the Nurses' Station playing with the silver cap on the floor and was then found laying on the floor face down. The resident hit his head and bleeding was noted from the forehead and right hand. The Nurses' Progress Notes indicated: 12/01/15 at 4:27 a.m., Res (resident) fell directly on his face, and sustained laceration to the L. (left) forehead and a skin tear to the R. (right) hand .Transport to (Hospital Name) ER (emergency room ) . 12/01/15 at 9 p.m., Res returned from ER via ambulance .has 8 stitches to the l. (left) eyebrow. The Emergency Department Discharge Instructions, dated 12/01/15, indicated the sutures were to be removed in seven days with a [DIAGNOSES REDACTED]. The Interdisciplinary Team Note, dated 12/02/15 at 9:37 a.m., indicated the resident was playing with the silver cover on the floor prior to the fall, which activated the alarm on the wheelchair, the resident was repositioned back into the wheelchair and the alarm was re-attached. The resident was then found on the front hall with the alarm sounding and was found face down on the floor. The Fall Investigation, dated 12/01/15, indicated the resident fell due to trying to pick up the silver plate off the floor. The Investigation indicated 5-10 minutes prior to the fall the resident was seen trying to grab the sliver, sewer covers off the ground (silver plates located on the tile floor), the staff asked the resident to sit back in the hair and the alarm was replaced. There were no interventions initiated to assist in diverting the resident from leaning over and trying to play with the silver plate cover on the floor after the first attempt of leaning over. During an interview on 01/25/16 at 11:29 a.m., the Director of Nursing (DoN) indicated the resident propels himself in the wheelchair and had went propelled further down the hall when the fall occurred. The DoN indicated when the resident was found leaning over trying to pick up the silver plate from the floor, the staff should have provided the resident with a diversional activity. The Fall Event form, dated 12/19/15 at 3:36 p.m., indicated the resident had an unwitnessed fall and was found lying face down. The resident's alarm was activated at the time of the fall and the resident was sleeping in the wheelchair prior to the fall. The Nurses' Progress Notes, indicated: 12/19/15 at 3:53 p.m.,Responder to alarm sounding. Observed resident lying face down, bleeding from his mouth, nose and forehead. Resident c/o (complains of) back pain. 911 called . 12/19/15 at 6:28 p.m., resident returned from (Hospital Name). Resident has a fractured nose and split to forehead . The hospital Discharge Instructions, dated 12/19/15, indicated [DIAGNOSES REDACTED]. The Fall Investigation, dated 12/19/15, indicated the resident had an unwitnessed fall on 12/19/15 a 2:50 p.m. The Staff Witness Statement indicated, When was the last time you assisted the resident before the fall occurred? Put chair alarm back on (no time documented). What did you assist the resident to do when you last provided assistance? Sat resident upright in wc (wheelchair) and put alarm back on . Another staff statement, dated 12/19/15, indicated at 2:45 p.m. the resident was sleeping in the wheelchair. The Interdisciplinary Team (IDT) Note, dated 12/21/15 at 9:33 a.m., indicated the resident's alarm was sounding and the resident was found lying face down, bleeding from the nose and forehead and the resident was observed sleeping earlier in the wheelchair and the cause of the fall was probably due to the resident sleeping in the chair. The staff did not initiate an intervention to prevent a the fall when he was found sleeping in the wheelchair. During an interview on 01/25/16 at 11:29 a.m., the DoN indicated the staff member who observed the resident sleeping in the wheelchair should have alerted the nursing staff. The DoN indicated she was unsure what time the Nurse had put the chair alarm back on the resident and sat the resident upright in the wheelchair. The Fall Event form, dated 12/21/15, at 4:24 a.m., indicated the resident had an unwitnessed fall and was found lying on the floor off of the mattress. The Fall Investigation, dated 12/21/15, indicated the resident was lying on the floor in the room, off the mattress next to the bed. The statement from the staff form was left blank. The IDT Note, dated 12/21/15 at 9:47 a.m. indicated the resident had been sleeping since 10:30 p.m. , the alarm was activated, and the staff observed the resident lying on the floor. During an interview on 01/25/16 at 11:29 a.m., the DoN indicated there was no investigation to determine the root cause of the fall. The Fall Event form, dated 01/04/16 at 3:33 a.m., indicated the alarm was sounding and the resident was found on the floor next to the bed and had a left elbow laceration and a wound on the right knee re-opened. The Fall Investigation, dated 01/04/16, indicated the resident was found on the floor. A staff statement indicated the last time the resident was assisted was at 3 a.m. when the resident's alarm was sounding and the resident was sitting on the bedside. The staff member indicated they assisted the resident to lay back down in the bed. The IDT note, dated 01/05/16 at 9:26 a.m., indicated the resident was transferring himself without assistance. During an interview on 01/25/16 at 11:29 a.m., the DoN indicated there was no investigation to determine the root cause of the fall or an intervention used when the resident was found sitting up in the bed 30 minutes prior to the fall to assist in preventing the fall. 3. Resident #H's record was reviewed on 01/22/16 at 1:55 p.m. The resident's [DIAGNOSES REDACTED]. A Quarterly MDS assessment, dated 10/20/15, indicated the resident's cognition status was severely impaired, required extensive assistance of two or more staff for bed mobility and transfers, and had no falls since the last MDS assessment. The Fall Event form, dated 12/18/15 at 8 a.m., indicated the resident was found sitting on the floor next to the bed in the room. The area which stated, Resident or witness statement of how fall occurred, indicated unknown. The fall follow up notes indicated: 12/18/15 at 8:20 a.m., Resident had a unwitnessed fall. Res. (resident) was sitting on floor next to bed, assisted with staff getting resident to bed .Resident appears to be sleepy . 12/21/15 at 9:36 a.m., IDT (Interdisciplinary Team) team to met (sic) to review fall on 12-18-15 in the morning. Resident had an unwitnessed fall .Position rails will be applied to bed . The fall investigation, dated 12/181/5, indicated the resident had an unwitnessed fall in the room and was found sitting on the floor next to the bed. During an interview on 01/26/16 at 11:29 a.m., the DoN indicated the fall had not been investigated for the root cause of the fall. The Fall Event form, dated 12/23/15 at 4:15 a.m., indicated the resident had an unwitnessed fall and was found sitting upright on the floor next to the bed. The form indicated the resident had attempted to transfer independently from the bed to the wheelchair. The Nurses' Progress Note, dated 12/23/15 at 4:50 a.m., indicated the resident stated he fell from the bed. The Investigation of the fall, dated 12/23/15 at 4:15 a.m., indicated the fall occurred when the resident had transferred from the bed to the chair independently. There was no investigation as to why the resident had attempted to transfer independently or why the resident was wanting out of bed and into the chair. The Staff Statement Worksheet indicated the fall was unwitnessed, there was no time listed when the staff last assisted the resident and when the resident was last toileted. During an interview on 01/25/16 at 11:29 a.m., the DoN indicated the investigation had not been thoroughly investigated to determine a root cause for the fall. 4. Resident #C's record was reviewed on 01/21/16 at 12:45 p.m. The resident's [DIAGNOSES REDACTED]. An Admission MDS assessment, dated 08/06/15, indicated the resident's cognition was intact, required extensive assistance of one for bed mobility and extensive assistance of two for transfers, required supervision of ambulation, and had one fall without injury. The Fall Event form, dated 09/08/15 at 6:27 p.m., indicated the resident was found on the floor in his room with a small amount of blood present, with a 2 x 3 (centimeter) scab to his forehead and the resident stated he was trying to get up. The Post Fall Investigation, dated 09/08/15, 3-11 (p.m.) shift, indicated, .What was the resident doing or attempting to do at the time of the fall? self transfer . The Fall Event form, dated 09/08/15 at 10:30 p.m., indicated the resident was sitting in a chair at the Nurses' Station and was then found on the floor lying on his left side by the West Dining Room. There was no injuries seen and the resident was sent to the Hospital emergency room for an evaluation. The Post Fall Investigation, dated 09/08/15, 3-11 shift, indicated the resident had attempted to get out of the wheelchair. A Hospital CT of the cervical spine report, dated 09/09/15 at 1:31 a.m., indicated there was a probable non displaced fracture of the C2 (neck) vertebral body. A Interdisciplinary Team Note, dated 09/09/15 at 9:47 a.m., indicated the resident was found lying on the floor in his room. The resident stated he was trying to get out of bed. The resident was assisted into a wheelchair and brought to the Nurses' Station. He was noted on the floor by the wheelchair and complained of hip pain and was sent to the Emergency Department for an evaluation. During an interview on 01/25/16 11:29 a.m., the DoN indicated the investigation had not included the root cause of why the resident was attempting to get up on his own. A facility policy, dated 02/2015, titled, Fall Management Program, received from the ADoN as current, indicated, .Post fall .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 meeting after the fall to determine root cause and other possible interventions to prevent future falls . This Federal Tag relates to complaint IN 987. 3.1-45(a)(2)

Based on observation, record review, and interview, the facility failed to ensure residents' were administered oxygen as ordered by the Physicians' and were thoroughly assessed for the need for oxygen, related to discontinuing a resident's oxygen without a Physician's order and not assessing the oxygen saturation levels after the discontinuation. The resident had also been prescribed [MEDICATION NAME] (narcotic pain medication), the resident's oxygen levels decreased, the resident was transferred to the hospital and required intubation (Resident #R) and a resident's oxygen was not administered on the correct flow rate (Resident #U), for 2 of 3 residents reviewed for oxygen in a total sample of 17. (Resident #R and #U) Findings include: 1. Resident #R's record was reviewed on 09/02/15 at 2:24 p.m. The resident's [DIAGNOSES REDACTED]. The resident had been admitted into the facility on [DATE]. The Hospital Transfer Orders, dated 03/27/15, included the [DIAGNOSES REDACTED]. The Physician's Recapulation Orders, dated 03/27/15 through 04/01/15, indicated the following oxygen orders: 03/28/15-Oxygen at 2 lpm (liters per minute) per nasal cannula as needed (discontinued on 03/28/15) 03/28/15-Oxygen at 2 lpm as needed every 12 hours (discontinued on 03/30/15) 03/30/15-Oxygen at 2 lpm per nasal cannula as needed twice a day (discontinued on 03/30/15) 03/30/15-Oxygen at 2 liters per nasal cannula. May titrate to keep sats (oxygen saturation levels) >92% (above 92%) every shift (discontinued on 04/01/15 at discharge) 03/28/15-Oxygen sats bi-monthly as needed (discontinued on 03/30/15) 03/28/15-Oxygen sats as needed (discontinued on 03/30/15) 03/30/15-Oxygen sats bi-monthly on the first and fifteenth of the month. A Physician's Order, dated 03/29/15, indicated [MEDICATION NAME] extended release, 60 mg (milligrams) every eight hours. A Professional Resource, titled, Nursing 2014 Drug Handbook, page 951-954, reviewed on 09/03/15 at 7 p.m., indicated, .[MEDICATION NAME] sulfate .adverse reactions .respiratory depression . A Respiratory Therapy Evaluation, dated 03/27/15, indicated the resident had decreased breath sounds in all lobes of the lungs with wheezing in the lower lobes, had an oxygen saturation of 93% on room air and had an order for [REDACTED]. The Ventilator Flowsheet (oxygen monitoring form by Respiratory Therapy), dated 03/15, indicated the resident had oxygen at 2 liters continuously on March 27, 28, and 29, 2015. The oxygen saturation was assessed on 03/30/15 in the morning (no actual time documented) and was 96% (required by order to be above 92%). There were no further initials to indicate the oxygen was continued on 03/30/15 after the oxygen saturation level was obtained. There were no results of an oxygen saturation assessment being completed after the morning of March 29, 2015. An Oxygen Rounds form, dated 03/30/15, no time documented indicated the resident's oxygen was pulled (discontinued) and the Nurse was notified. There was no Nurses' Progress Notes to indicated the resident's Physician had been notified for an order to discontinue the oxygen. There was no Physician's Order to indicated the oxygen had been discontinued by the Physician. The Medication Administration Record, [REDACTED] The Nurses' Progress Notes indicated: A Nurses' Progress note, dated 03/28/15 at 4:36 a.m., indicated, lung sounds diminished in the bases of the lungs. A 72-hour Admission Shift Charting, dated 03/30/15 at 3:04 p.m., indicated no oxygen had been used. The Nurses' Progress Notes indicated: 03/31/15 at 8:36 a.m., head of the bed is elevated to prevent shortness of breath while lying flat due to [MEDICAL CONDITION]. 03/31/15 at 2:15 p.m.-Family was concerned due to the resident was usually more awake and had been informed by the staff the resident had been up all day and when transferred to bed the resident had been yelling. 03/31/15 at 10:12 p.m.-No adverse reaction to the [MEDICATION NAME]. 04/01/15 at 7:35 a.m.-No adverse reaction to the [MEDICATION NAME]. 04/01/15 at 9:25 a.m.-The resident was observed in distress and was pale. The Respiratory Therapist was called to the room and the resident's oxygen saturation was 72% (the oxygen had been pulled by the RT on 03/30/15), a non-rebreather mask had been initiated and oxygen was administered at 15 liters and the resident was transferred by ambulance to the emergency room . 04/01/15 at 3:04 p.m.-The resident had been admitted into the hospital with respiratory distress and had been intubated. The emergency room Notes, dated 04/01/15, indicated the resident's [DIAGNOSES REDACTED]. A Physician's Consultant History and Physical, dated 04/02/15, indicated, .family suggested that overnight was without his oxygen and this morning . was found unresponsive in respiratory distress .confirmed acute hypoxic [MEDICAL CONDITION], was intubated and placed on mechanical ventilator . The Hospital Discharge Summary, dated 04/04/15, indicated, .Bilateral lung infiltrates. Healthcare-associated pneumonia .Acute [MEDICAL CONDITION] .hypoxic and was brought to the emergency room .In the ER he was in [MEDICAL CONDITION] and was intubated . During an interview on 09/02/15 at 4:05 p.m., LPN #1 indicated she had not taken care of the resident prior to 04/01/15 and when she went into the resident's room she found the resident in distress. During an interview on 09/02/15 at 4:21 p.m., RT (Respiratory Therapist) #2 indicated when Resident #R arrived at the facility there had been no oxygen being administered and the resident's oxygen saturation was 93% and applied oxygen on the resident at 2 liters due to the Physician's Order for oxygen at 2 liters. During an interview on 09/02/15 at 4:21 p.m. the Medical Records Nurse, indicated all the changes in the oxygen orders were clarification of the orders and the original order should have been written as oxygen at 2 liters per nasal cannula. May titrate to keep sats >92%. During an interview on 09/03/15 at 8:05 a.m., the RT Supervisor indicated RT #3 had discontinued the oxygen because the oxygen saturation was 96% on room air. She indicated RT #3 had notified the Nurse, because the RT's were not allowed to obtain the orders. The RT Supervisor indicated the resident's Physician would have needed to be called for the order to discontinue the oxygen. She indicated Respiratory Therapy did not have a protocol on checking the resident's oxygen saturations and they, spot check to see how the resident was doing. She indicated there had not been an assessment with the discontinuation of the oxygen and there was not a policy to complete an assessment with the discontinuation of oxygen. During an interview with the RN Corporate Consultant and the West Unit Manager on 09/03/15 at 10:37 a.m., the RN Corporate Consultant indicated there should have been a documented assessment and oxygen saturations completed. The West Unit Manager indicated the oxygen saturations should have been assessed with [REDACTED]. The West Unit Manager indicated there had been no order received from the Physician to discontinue the oxygen. She indicated LPN #1 had been assigned to the resident on 03/30/15 and should have been the Nurse to notify the Physician for a discontinuation order. During an interview on 09/04/15 at 8:13 a.m., the RN Corporate Consultant indicated the facility did not have a policy on weaning a resident off oxygen. During an interview on 09/04/15 at 10:17 a.m., RT #3 indicated she could not remember what Nurse she talked to when she discontinued the oxygen. 2. Resident #U was observed on 09/03/15 at 8:03 a.m. and 09/04/15 at 9:21 a.m. The resident's oxygen was being administered at 2.5 liters per nasal cannula. During an interview on 09/04/21 at 9:21 a.m., LPN #4 indicated the resident's oxygen was set at 2.5 liters and the Physician's Order was for 3 liters per nasal cannula. Resident #U's record was reviewed on 09/04/15 at 9:25 a.m. The resident's [DIAGNOSES REDACTED]. A Physician's Order, dated 05/29/15, indicated oxygen at 3 liters per nasal cannula continuously. A care plan, dated 05/29/15, indicated the resident had a potential of impaired gas exchange related to [MEDICAL CONDITION]. The approaches included, administer oxygen as indicated. An undated facility policy, received from the RN Corporate Consultant as current on 09/04/15 at 8:13 a.m., titled, Oxygen Therapy and Devices, indicated, .Oxygen is a drug which must be ordered by a physician .Apply device to the patient with appropriate liter flow . This Federal Tag relates to complaint IN 528. 3.1-47(a)(6)

Based on record review and interview, the facility failed to ensure a resident received adequate supervision and assistance to prevent accidents related to an unsafe transfer due to transferring a resident without the indicated amount of assistance, which resulted in a fracture of the resident's leg, for 1 of 11 residents reviewed who required the use of a hoyer lift for transfers in a sample of 24 and failed to implement fall interventions to prevent further falls for 1 of 7 residents reviewed for falls in a sample of 24 residents. (Resident #74 and #131) Findings include: 1. Resident #74's record was reviewed on 3/8/11 at 8:52 a.m. Resident #74's [DIAGNOSES REDACTED]. A quarterly MDS (Minimum Data Set) assessment, dated 2/23/11, indicated Resident #74 cognitive status was intact, and dependent on two staff for bed mobility, transfer, toilet use and bathing. The MDS assessment lacked documentation of the resident having falls since admission. A care plan for risk for falls, dated 10/19/10, indicated "hoyer lift and 2 staff...." A Resident Care/Need sheet, dated 11/19/10, indicated Resident #74 required a hoyer lift with two assist. A Nurses' Note, dated 11/20/10 at 10:00 a.m., indicated "CNA's put res (resident) in bed for rest, writer called to room. Res L (left) knee area & (and) outer side c/ (with) 15 cm (centimeters) x (by) 8 cm purple blue bruise et (and) swollen from knee & ankle, warm to touch but not excessive.... A Nurses' Notes, dated 11/20/10 at 1:00 p.m. indicated the resident was admitted to the hospital. A History and Physical from the hospital, dated 11/20/10, indicated "...Acute fractured tibia and fibula...." Review of the facility's investigative report, dated 11/20/11, indicated the CNA providing Resident #74's care transferred the resident using a hoyer lift by herself into the wheelchair. The report indicated the CNA did not follow the resident's care plan of using two staff members when using a hoyer lift. During an interview on 3/8/11 at 1:20 p.m., the DoN (Director of Nursing) indicated the CNA did not follow the transfer policy. The DoN indicated she thought the CNA "tried to cut corners" and placed the resident in the wheelchair by standing him up and not using the hoyer lift. The DoN indicated another CNA had seen the resident sitting on the edge of his wheelchair and the resident was yelling. The DoN indicated the CNA got help and when they placed the resident into the bed they noticed the discoloration of the resident's leg. A professional resource, titled, "Indiana State Department of Health Division of Long Term Care Nurse Aide Training Program July 1998", Topic 22 Transferring, indicated, "...4. A mechanical lift..have at least one co-worker assist when using a mechanical lift..." 2. Resident #131's record was reviewed on 3/9/11 at 1:10 p.m. Resident #131's [DIAGNOSES REDACTED]. An admission MDS assessment, dated 1/13/11, indicated Resident #131's cognitive status was intact, required limited assistance of one staff member for transfer, toilet use and bathing. The admission MDS assessment indicated the resident had fallen prior to admission and had fractured in a fall. A fall care plan, dated 12/13/10, indicated the intervention to keep the resident's wheelchair at bedside and easily accessible was added on 2/7/10. A Resident Care/Need sheet, dated 2/21/11, indicated '...Place w/c next to bed when res in bed...." An IDT (Interdisciplinary Team) progress note, dated 2/7/11, indicated "...Fall on 2/6/11 at 7:45 p.m. Res was in his room in bed & stood up from bed, walked over to room mates side of bed to get his w/c (wheelchair) & walked backwards c/ w/c & fell to floor on buttocks & back hitting wall...w/c to be kept @ (at) bedside & easily accessible...." A Nurses' Note, dated 2/20/11 at 6:00 p.m., indicated "Res found on floor in front of bed on buttocks. Fall charting started c/ neuro assessments...small abrasion noted to L rear thigh...." A Fall Circumstance Report, dated 2/20/11, indicated "...he said he reached for his chair and it was not there..." During an interview on 3/9/11 at 2:05 p.m., the West Hall Unit Manager indicated the resident's wheelchair was not in place. 3.1-45(a)(1) 3.1-45(a)(2)