Every finding on record at Waterford Crossing

Based on record review and interview, the facility failed to keep documentation of the facilities infection control surveillance records. This deficient practice had the potential to affect 73 of the 73 residents who resided in the facility. Finding includes: A review of the Infection Control Binder (ICB) was completed on 3/23/2026 at 10:37 A.M. The ICB included the infection control surveillance for January through March 2026, but did not include any other months before January 2026. During an interview with the Infection Prevention Nurse (IPN) at 3/23/2026 at 10:40 A.M., the IPN indicated she had not believed she was required to have kept any of the infection control surveillance information and she had been throwing away the monthly infection control surveillance information at the beginning of the next month. The IPN indicated the last annual survey had been December 2024. During an interview with the Region Nurse Consultant (RNC) on 3/23/2026 at 11:45 A.M., the RNC indicated monthly infection control surveillance documents should have been kept in the ICB from one annual survey until the next annual survey. The RNC indicated the facility did not have a policy for maintaining infection control surveillance information. 410 IAC 16.2-3.1-18(b)(1)(A)

Based on record review and interview, the facility failed to provide pneumococcal immunizations for 2 of 5 residents whose immunizations were reviewed. (Residents 39 & 40)Findings include: 1. Resident 39's record review was completed on 3/23/2026 at 10:00 A.M. Diagnoses included, but were not limited to: dementia, major depressive disorder and chronic pulmonary disease. Resident 39's record lacked the documentation indicating she had been offered or had been administered the pneumococcal vaccination in the last year. 2. Resident 40's record review was completed on 3/23/2026 at 10:05 A.M. Diagnoses included, but were not limit to: vascular dementia, hypertension, dysphagia and major depression. Resident 40's record lacked the documentation indicating she had been offered or had been administered the pneumococcal vaccination in the last year. During an interview with the Infection Prevention Nurse (IPN) on 3/23/2025 at 10:30 A.M., the IPN indicated vaccinations should be offered yearly and she would have to look to see if Residents 39 and 40 had been offered or had received the pneumococcal vaccination. During an interview with the Region Nurse Consultant (RNC) on 3/23/2025 at 11:30 A.M., the RNC indicated Resident 39 and 40 had not been offered or administered the pneumococcal vaccination, but they should have been. The RNC indicated the facility did not have a policy related to the pneumococcal vaccination. 410 IAC 16.2-3.1-13(a)

Based on interview and record review, the facility failed to honor a resident's shower preference for 1 of 1 resident reviewed for choices. (Resident 13) Finding includes: During an interview, on 12/13/2024 at 9:42 A.M., Resident 13 was unsure if the facility asked her about her preference for showers. She indicated she received a shower two times a week on the evening shift. She indicated she would like to have a shower daily on the day shift, as she had never showered in the evening before this admission. A record review for Resident 13 was completed on 12/16/2024 at 1:05 P.M. Diagnoses included, but were not limited to: anemia, end stage renal disease and celiac disease. An Admission Minimum Data Set (MDS) assessment, dated 10/26/2024, indicated Resident 13 was cognitively intact and it was important to her to choose between a tub bath, shower, bed bath or sponge bath. On 12/11/2024, the census information indicated Resident 13 had moved from room [ROOM NUMBER] to room [ROOM NUMBER]. A Shower Schedule, for the 200-hall, indicated room [ROOM NUMBER] received a shower on Mondays and Thursdays on day shift. A Shower Schedule for the 300-hall indicated Resident 13 received a shower on Mondays and Thursdays on the evening shift. During an interview, on 12/17/2024 at 2:46 P.M., CNA 9 indicated prior to Resident 13's admission to the facility, Resident 13 received showers on day shift in the assisted living setting. During an interview, on 12/18/2024 at 11:01 A.M., the Staff Development Director indicated residents were interviewed for their shower preference upon admission. She indicated the results of the preference interviews were documented on the shower sheet schedule. She indicated Resident 13 had moved from the 200-hall where she received a shower on day shift and moved to the 300-hall where Resident 13 may have just been placed in a shower slot that was available. She indicated the resident's preference should have been honored. A policy was provided by the Director of Nursing, on 12/18/2024 at 11:48 A.M. The policy titled, Resident Choice, , indicated, .Resident have the right to make choices regarding their care, daily routine, religious practices, and activity participation 3.1-3(u)(1)

Based on observation, interview and record review, the facility failed to ensure 1 of 7 nursing staff administering medications maintained professional standards of quality. (QMA 4) Findings include: During a medication observation, on 12/16/2024 at 8:25 A.M., QMA 4 was observed to remove a souffle medication cup from the top drawer of the 300-hall medication cart. Resident 56's name was written on the side of the souffle cup that contained 14 different medications. The top drawer of the medication cart also contained 2 more souffle cups with the names of Residents 13 and 134 written on the side of the cups. During an interview, on 12/16/2024 at 8:26 A.M., QMA 4 indicated he should not have preset the medications. On 12/18/2024 at 11:51 A.M., the Director of Nursing provided the policy titled, Medication Administration-General Guidelines, with a revision date of 11/2018, and indicated the policy was the one currently used by the facility. The policy indicated . 4. Medications are not pre-poured either in advance of the med pass or for more than one resident at a time 3.1-35(g)(1)

Based on observation, interview and record review, the facility failed to ensure over the counter medications were labeled appropriately for 1 of 2 medication storage carts. (300 hall- back medication cart). Finding includes: During a medication administration observation, on 12/17/2024 at 6:09 A.M., RN 11 obtained medication bottles from the cart. The following medications had labels indicating the ordering physician, resident's name or ordered dose: - a bottle of 81 mg (milligrams) aspirin. - multiple bottles of men's multi vitamin capsules - q bottle of vitamin B 12 - 5000 mg tablets - a bottle of multi-vitamins - a bottle of Acetaminophen 650 mg. During an interview, RN 11 indicated the medications observed without labels should have been labeled. On 12/17/2024 at 9:52 A.M., the Director of Nursing provided the policy titled, Medication Ordering and Receiving from Pharmacy- Medication Labels, dated 11/2018, and indicated the policy was the one currently used by the facility. The policy indicated . F. Resident-specific non prescription medications (not floor stock) that are not labeled by the pharmacy are kept in the manufacture's original container and identified with the resident's name. Facility personnel may write the resident's name on the container or label as long as the required information listed above (see B.) is not covered. B . 1) Resident's name . 3) Medication name. 4) Strength of medication. 5) Prescriber's name . 8) Beyond use (or expiration) date of medication 3.1-25(j)(l)

Based on observation, record review and interview, the facility failed to follow infection control practices regarding enhanced barrier precautions for 1 of 1 resident reviewed for dialysis care. (Resident 13) Finding includes: A record review for Resident 13 was completed on 12/16/24 at 1:05 P.M. Diagnoses included, but were not limited to: anemia, end stage renal disease and dependence on renal dialysis. An Admission Minimum Data Set (MDS) assessment, dated 10/26/2024, indicated Resident 13 had moderate cognitive impairment and received dialysis care. A Physician's Order, dated 11/2/2024, indicated staff were to use enhanced barrier precautions, wearing a gown and gloves at minimum, during high-contact care activities three times a day. A current Care Plan, initiated on 10/22/2024, indicated Resident 13 required enhanced barrier precautions (EBP) during high-contact care related to presence of dialysis treatment with a fistula. Interventions included, but were not limited to: don/doff and dispose of PPE (Patient Protective Equipment) systematically and appropriately per policy, face mask to be utilized as needed and utilize gown and gloves per EBP policy during high contact ADL (Activities of Daily Living) care (e.g. dressing, showering/bathing, hygiene, transfers, toileting/changing briefs) and during linen changes. During an observation, on 12/16/2024 at 1:29 P.M., no precautionary signage or personal protective equipment (PPE) was observed outside Resident 13's room. During an observation and interview, on 12/17/2024 at 11:04 A.M., Resident 13 indicated the staff did not wear PPE, including gowns, gloves and mask when they provided direct care. There was no signage outside the room that indicated enhanced barrier precautions were in place and no PPE equipment was inside or outside of the room. During an observation, on 12/18/2024 at 9:52 A.M., CNA 8 was providing care for Resident 13 in the bathroom. CNA 8 was dressing Resident 13 as the resident sat on the toilet. The CNA did not have on any PPE. CNA 8 indicated he did not think PPE was required for direct care with Resident 13. He indicated he had utilized only gloves when he provided personal care to Resident 13. During an interview, on 12/18/2024 at 9:54 A.M., RN 7 indicated Resident 13 was the only resident in her care that required enhanced barrier precautions. She indicated enhanced barrier precautions were only utilized when providing care for Resident 13's dialysis fistula. A policy was provided by the Director of Nursing, on 12/18/2024 at 11:48 A.M. The policy titled, Enhanced Barrier Precautions [EBP] Standard Operating Procedure, indicated, .1. Enhanced Barrier Precautions [EPB] will be in place during high-contact care activities for residents with the following conditions: ii. All Residents with indwelling medical devices .3. High-contact care activities include but are not limited to: morning and evening ADL [activities of daily living] care, toileting, and showers 3.1-18(a)

Based on interview and record review, the facility failed to ensure a care plan for vision needs was in place for 1 of 2 residents reviewed for communication and sensory needs. (Resident 8) Finding includes: During an interview, on 12/12/2024 at 10:25 A.M., Resident 8 indicated he could not read the newspaper or the Bible. A record review for Resident 8 was completed, on 12/13/2024 at 12:57 P.M. Diagnoses included, but were not limited to: metabolic encephalopathy, major depressive disorder and macular degeneration. A Quarterly Minimum Data Set (MDS) assessment, dated 9/9/2024, indicated Resident 8 had moderate cognitive impairment and had impaired vision and utilized corrective lenses. An Annual MDS assessment, dated 8/19/2024, indicated a CAA (care area assessment) was triggered for visual impairment for Resident 8, but a plan of care related to vision needs was not developed. A Social Service Comprehensive Note, dated 8/19/2024 at 3:36 P.M., indicated Resident 8 had impaired vision with ability to see large print but not regular print when reading newspapers or books. A care plan could not be located for impaired vision for Resident 8. During an interview, on 12/18/2024 at 11:11 A.M., the MDS (Minimum Data Set) Coordinator indicated a care plan had not been developed for vision needs for Resident 8. During an interview, on 12/18/2024 at 11:14 A.M., the Social Service Director indicated a care plan was not developed for vision needs for Resident 8 and a vision care plan should have been completed. A policy was provided by the Director of Nursing, on 12/17/2024 at 11:03 A.M. The policy titled, Comprehensive Care Plan Guidelines, indicated, .To ensure appropriateness of services and communication that will meet the resident's needs, severity/stability of conditions, impairment, disability, or disease in accordance with state and federal guidelines .b. Care plan interventions should be reflective of the risk area(s) or disease processes that impact the individual resident .6. Comprehensive care plans need to remain accurate and current 3.1-35(a)

During observation, interview, and record review, the facility failed to develop and implement a personalized care plan for 1 of 22 residents whose care plans were reviewed. (Resident 49) Finding includes: The record review for Resident 49 was completed on 1/23/2024 at 2:47 P.M. Diagnoses included, but were not limited to: Parkinson's Disease and obstructive sleep apnea. A Physician's Order, dated 9/18/2023, indicated oxygen- bilevel positive airway pressure (BiPap) at 10 cm water at 0 liters to wear during the night and as needed during the day. There was no care plan available for the resident's BiPap machine. During an interview on 1/24/2024 at 9:38 A.M., the MDS Support indicated that Resident 49 should have had a care plan for his BiPap. On 1/25/2024 at 9 A.M., the Clinical Support Nurse provided a policy titled, Comprehensive Care Plan Guideline, dated 12/31/22, and indicated the policy was the one currently used by the facility. The policy indicated . 6. Comprehensive care plans need to remain accurate and current. a. New interventions will be added and updated or directly following CCM meeting. b. Newly recognized problems will have a care plan developed and added after CCM meeting 3.1-35(a)

Based on interview, record review, and observation, the facility failed to provide treatment for a skin tear and dry skin for 1 of 3 residents reviewed for non-pressure related skin conditions. (Resident 43) Finding includes: During an interview on 1/23/2023 at 10:39 A.M., Resident 43 indicated he had sores on both shins. He was scratching and broke the skin open. A record review was conducted on 1/24/2023 at 10:25 A.M. Diagnoses included, but were not limited to: diabetes mellitus type 2, Parkinson's disease, and Alzheimer's disease. An Annual Minimum Data Set (MDS) assessment, dated 11/25/2023, indicated Resident 43 had moderate cognitive impairment. Current Physician's Orders indicated a weekly skin assessment was to be completed. There were no orders for any treatment to the shins. A Shower Sheet, dated 1/22/2024, indicated no bruising or redness was observed. A weekly Skin Assessment, dated 1/22/2024, indicated no skin issue was observed. A Care Plan, dated 12/08/2022, indicated Resident 43 was at risk for skin breakdown related to incontinence and impaired mobility. The goal was for Resident 43's skin to remain intact. Interventions included, to conduct a weekly skin assessment. During an observation and interview on 1/25/2024 at 11:19 A.M., the Director of Nursing (DON) described the left shin as very discolored with dried scabs, and a skin tear that had not dried up. Dry skin was present. She indicated Resident 43 needed a treatment for the skin tear and lotion for the dry skin. As of 1/29/2024 at 9:07 A.M., the medical record had no new orders or documentation of the left shin. A policy was provided by the Regional Support Nurse on 1/29/2024 at 11:26 A.M. The policy titled, Bruise, Rash, Lesion, Skin Tear, Laceration Assessment Guidelines, indicated, .Utilized to describe and monitor bruises, rashes, lesions, skin tears, and laceration .1. May complete Skin Tear/Laceration Event in the EMR [electronic medical record] by an RN/LPN [registered nurse/licensed practical nurse] if the Skin Tear/Laceration warrants documentation due to the extent and/or location. 2. Complete one event for each Skin Tear/Laceration. 3. One weekly follow-up assessment may be completed to ensure Skin Tear/Laceration are resolved or in the progress of healing. If further follow-up is needed, documentation may be placed in a progress note 3.1-37(a)

Based on observation, record review, and interview, the facility failed to ensure respiratory equipment for oxygen and sleep apnea machines was stored and maintained according to professional standards for 3 of 3 residents reviewed for respiratory care. (Residents 37, 49 and 50) Findings include: 1. The record for Resident 37 was reviewed on 1/23/24 at 11:30 A.M. Diagnoses included, but were not limited to: status post pneumonia and sepsis, chronic respiratory failure and obstructive sleep apnea. The initial Minimum Data Set assessment, completed on 12/15/23, did not indicate oxygen therapy was in use for Resident 37. A Care Plan to address shortness of breath was initiated on 12/10/24, and included an intervention to utilize oxygen as needed per Physician's Orders. On 1/22/24 at 11:24 A.M., Resident 37 was observed in his room, seated in his recliner, holding his oxygen tubing. There was no date on the oxygen tubing, which was connected to a concentrator in his room. In addition, there was oxygen tubing draped over a wheelchair in the resident's room. There was no date on the tubing on the wheelchair. On 1/23/24 at 11:11 A.M., Resident 37 was observed resting in his recliner with oxygen via a nasal cannula. The oxygen tubing was connected to a humidifier on an oxygen concentrator in the resident's room. There was additional tubing with a nasal cannula, attached to a portable oxygen tank on the resident's wheelchair. There was no date on any of the oxygen tubing or humidifier water bottle. There was a plastic bag taped to the concentrator, but it was empty and not dated. On 1/24/24 at 9:26 A.M. Resident 37 was observed seated in his room in a recliner. He had oxygen via a nasal cannula in place, connected to a concentrator in his room. There was no humidified water bottle on the concentrator. There was a plastic bag taped to the concentrator with the portable oxygen tubing in the bag. There were no dates on the oxygen tubing or the plastic bag. On 1/25/24 at 8 45 A.M. Resident 37 was observed, seated in his recliner in his room. The resident had oxygen tubing in place via a nasal cannula. There was no date on the oxygen tubing. There was a bag taped to the oxygen concentrator in the room with portable oxygen tubing inside. There was no date on the portable oxygen tubing. During an interview with the Regional Nurse Consultant, on 1/24/24 at 11:20 A.M., she acknowledged there were no dates on the oxygen equipment and/or tubing for Resident 37. She indicated she would have to research his oxygen use. A policy and procedure, titled, Administration of Oxygen, provided as current by the Regional nurse Consultant on 1/25/24 at 10:59 A.M., indicated the following: .14. Date the tubing for the date it was initiated. a. Tubing should be changed monthly and PRN 44111 2. During an observation, on 1/22/2024 at 10:43 A.M., Resident 49's BiPap mask was behind the nightstand on the floor in a bag, and a partially filled gallon of distilled water was undated. During an observation, on 1/23/2024 at 10:29 A.M., the BiPap mask was laying on the nightstand, and the partially filled gallon of distilled water was undated. During an observation on 1/24/2024 at 9:10 A.M., the mask was hanging over the nightstand, and a partially filled gallon of distilled water was undated. The record review was completed for Resident 49 on 1/23/2023 at 2:47 P.M. Diagnoses included, but were not limited to: Parkinson's Disease, and obstructive sleep disorder. A Physician's Order, dated 9/18/2023, indicated oxygen- BiPap at 10 cm water at 0 liters to wear during the night and as needed during the day. During an interview, on 1/24/2024 at 9:15 A.M., RN 2 indicated when the BiPap was not in use, the tubing should be in a bag and the bottled water should have an opened date. 45120 3. During observations on 1/22/204 at 9:38 A.M., 1/23/2024 at 10:44 A.M., and 1/24/2024 at 3:12 P.M., Resident 50's CPAP (continuous positive airway pressure) mask was observed lying on the bedside table, and a gallon of distilled water was on the floor undated. A record review was completed on 1/25/2024 at 10:26 A.M. Diagnoses included, but were not limited to: pulmonary fibrosis, sleep apnea, and unspecified dementia. A Quarterly Minimum Data Set (MDS) assessment, dated 12/13/2023, indicated Resident 50 had a non-invasive mechanical ventilation device. A Physician's Order, dated 5/11/2022, indicated to wear the CPAP at night and as need during the day. A Care Plan, dated 5/26/2022, indicated Resident 50 had the potential for complications of functional and cognitive status decline related to respiratory disease, due to pulmonary fibrosis and sleep apnea with the use of a CPAP. During an interview on 1/25/2024 at 1:04 P.M., the Director of Nursing (DON) indicated the CPAP mask should be stored in a respiratory bag when it was not in use, and the gallon of distilled water should be dated when opened. On 1/29/2024, the Regional Support Nurse indicated a policy was not available for the use of CPAP/BiPap machines. 3.1-47(6)

Based on observation, interview, and record review, the facility failed to ensure a Physician reviewed a Medication Regimen Review (MRR) provided by the Pharmacist following a monthly MRR, for 1 out of 5 residants selected for unnecessary medication review. (Resident 225) Finding includes: A record review was completed for Resident 225 on 1/24/2024 at 2:43 P.M. Diagnoses included, but were not limited to: Alzheimer's disease, dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, neurocognitive disorder with Lewy body, and unspecified psychosis not due to a substance or known physiological condition. A Physician's Order, dated 12/9/2022, indicated doneprizil 10 mg (milligram) tablet, orally at bedtime. A Pharmacy Recommendation, dated 9/26/2023, indicated Resident 225 has an order for DONEPEZIL TAB 10 MG daily. The most recent BIMS [Brief Interview for Mental Status] score on file is < 7 which indicated severe impairment [BIMS =3 on 6/27/23]. The American Geriatric Society has found that deprescribing acetylcholinesterase inhibitors is not associated with negative effects to the resident, and is likely to help reduce the risk of falls and fractures in older nursing home residents with dementia. Please consider tapering off of DONEPEZIL TAB 10 MG at this time [Donepezil 5 mg QD [every day] x 2 weeks then d/c [discontinue] During an interview on 1/26/2024 at 10:15 A.M., the Regional Support Nurse indicated the Nurse Practitioner (NP) did not address the pharmacy recommendation in September of 2023. During an interview on 1/26/2024 at 11:00 A.M., the Regional Support Nurse indicated, when they receive the recommendations, the nurse initiates an Event if there is a GDR (gradual dose reduction), then it is printed out and placed in the NP's folder. The NP then reviews it, signs, and puts in a note in her progress note if she agrees or disagrees with the recommendation. The Assistant Director of Nursing then attaches the note before closing the recommendation. She acknowledged that the September recommendation got missed. On 1/26/2024 at 11:00 A.M., the Regional Support Nurse provided a policy titled, Consultant Pharmacist Reports, revised 11/2018, and indicated the policy was the one currently used by the facility. The policy indicated .E. Recommendations are acted upon and documented by the facility personnel and/or the prescriber. 10 Prescriber accepts and acts upon suggestion or rejects and provides an explanation for disagreeing 3.1-25(i)

Based on observation, record review, and interview, the facility failed to ensure 1 of 4 nursing staff (QMA 4) administering medications followed infection control policies regarding hand washing. Finding includes: During an observation of a medication administration pass, on 1/24/2024 at 11:01 A.M., QMA 4 administered a crushed oral medication to Resident 31. After he completed the medication administration for Resident 31, he then prepared medication for Resident 62. He assessed Resident 62's vital signs, and then crushed the medications and administered them to Resident 62. QMA 4 then pushed Resident 62 back to the dining table. Next, QMA 4 prepared a medication for Resident 63 and administered the oral medication. QMA 4 did not perform hand hygiene in between any of the three resident's medication preparations and administrations. During an interview with the Administrator, on 1/26/2024 at 2:31 P.M., she indicated the medication policy included instructions for handwashing during the medication administration process. The facility policy, titled, Preparation and General Guidelines provided as current by the Administrator on 1/26/2024 at 2:31 P.M., indicated the following: .2. Handwashing and Hand Sanitation: The person administering medications adheres to good hand hygiene before beginning a medication pass, prior to handling any medications, after coming into direct contact with a resident .b. Hand sanitization is done with an approved sanitizer between handwashings, when returning to the medication cart or preparation area, at regular intervals during the mediation pass such as after each room, again assuming handwashing is not indicated . 3.1-18(l)

Based on record review and interview, the facility failed to protect a residents' right to participate in a religious activity in the privacy of their own room, (Resident B). Findings include: On 2/22/23 at 10:30 A.M., the Executive Director (ED) provided an email communication dated 11/30/22 at 11:34 A.M., and indicated it was received from Resident B's family member and Emergency Contact 2. The email indicated, on 11/20/22 at approximately 4:00 P.M., the family member and a family friend were visiting Resident B in his room and, .[family friend] began praying for [Resident B] .in an elevated tone. After some time [Registered Nurse (RN) 2] came back in and said that [family friend] was being too loud and she needed to quiet down as she could be heard out to the nurse's station (the door was closed). I again closed the door and [family friend] got quieter. A couple minutes later, [RN 2] was at the door again. She said that we had to leave as religious ceremonies were not allowed in the rooms . On 2/22/23 at 10:13: A.M., the clinical record for Resident B was reviewed. Resident B was admitted on [DATE] with diagnoses that included but were not limited to, metabolic encephalopathy, pneumonitis, sepsis, bipolar disorder, and dementia. The most recent Minimum Data Set (MDS) dated [DATE], was an admission assessment that indicated Resident B had minimal difficulty in hearing and utilized hearing aids, was usually able to understand others, had moderate cognitive impairment, frequently felt depressed and hopeless. The resident demonstrated behaviors of rejection of care on 1-3 days in the previous 7 day look back period. The staff assessment of daily activity preferences indicated Resident B preferred to have family or significant other involved in his care discussions. Resident B's care plans included but were not limited to Activities, dated 10/13/22. The care plan indicated, While in this campus, it is important that I have the opportunity to engage in activities and opportunities that are meaningful to me. My interests include reading, music, and church .My faith is important to me, and it is important that I continue to engage in religious services or practices . 2/22/23 at 9:45 A.M., during an interview with the Executive Director, she indicated on 11/20/22 RN 2 heard loud noises in Resident B's room and was concerned. The Executive Director indicated RN 2 went to the residents room and a family friend and the resident's son were praying the demons out of the resident and became concerned because the resident was not able to give his consent to what was going on because he had a diagnosis of dementia. The Executive Director indicated Resident B did not have a roommate at the time. On 2/22/23 at 10:30 A.M., during an interview conducted with RN 2, the RN indicated she had gone to Resident B's room to administer care and the resident's son was at the bedside. Upon RN 2's entry, the family friend also came to the bedside. RN 2 indicated when she completed care and exited the room, she could hear the family friend's raised voice from the Nurse's station so returned to the room, knocked on the closed door and, .said I could still hear her at the nurses station and we could not have that here .she continued being loud after I left the room so I went back to the room and heard her say, 'I rebuke you.' [Resident B's] hands were raised and he was getting upset and I said [the son and family friend] had to leave the facility .[Resident B's] Bible was on his chest .I told them to take it off his chest . RN 2 indicated the resident was not asking for help or telling the family friend to stop praying, but that she felt the resident was agitated. RN 2 indicated Resident B's son was not happy with her when she had them leave. RN 2 indicated no other residents complained about the noise level in Resident B's room. RN 2 indicated Resident B was not wearing his hearing aids that evening. RN 2 indicated she did not document the events of the evening, her concerns, the resident's reactions, and she did not report the incident because, .I thought I nipped it in the bud. On 2/22/23 at 10:30 A.M., the Executive Director provided a policy titled, Resident Rights Guidelines, with an effective date of 11/21 with a revised date of 5/11/17 and indicated it was the current facility policy. The policy indicated, .Residents shall not leave their individual personalities or basic human rights behind when they move to a health campus .Our residents have the right to .Exercise choice in attending and participating in activities, including religious services . This Federal tag related to complaint IN00398501. 3.1- 3(m)

Based on interview and record review, the facility failed to assure that an allegation of abuse was reported to the State Survey Agency (SSA) for 1 of 3 residents reviewed for abuse (Resident B). Findings include: On 2/22/23 at 10:30 A.M., the Executive Director (ED) provided an email communication dated 11/30/22 at 11:34 A.M., and indicated it was received from Resident B's family member and Emergency Contact 2. The email indicated, on 11/20/22 at approximately 4:00 P.M., the family member and a family friend were visiting Resident B in his room and, .[family friend] began praying for [Resident B]. She was still holding hands with him as he did not let go of her hands. [Family friend] was praying in an elevated tone. After some time [Registered Nurse (RN) 2] came back in and said that [family friend] was being too loud and she needed to quiet down as she could be heard out to the nurse's station (the door was closed). I again closed the door and [family friend] got quieter. A couple minutes later, [RN 2] was at the door again. She said that we had to leave as religious ceremonies were not allowed in the rooms. She said, 'What you are doing is abuse.' As [family friend tried to leave and let go of [Resident B's] hands go, he held on to her hands and [RN 2] had to separate herself from his hands . As we were walking out, she said, 'This is inappropriate.' I asked her, 'what is inappropriate?' 'what you are doing is abusive, struggling with a patient,' she said . On 2/22/23 at 10:13: A.M., the clinical record for Resident B was reviewed. Resident B was admitted on [DATE] with diagnoses that included but were not limited to, metabolic encephalopathy, pneumonitis, sepsis, bipolar disorder, and dementia. The most recent Minimum Data Set (MDS) dated [DATE], was an admission assessment that indicated Resident B had moderate cognitive impairment, frequently felt depressed and hopeless. The resident demonstrated behaviors of rejection of care on 1-3 days in the previous 7 day look back period. 2/22/23 at 9:45 A.M., during an interview with the Executive Director, she indicated on 11/20/22 RN 2 heard loud noises in Resident B's room and was concerned. The Executive Director indicated RN 2 went to the residents room and a family friend and the resident's son were praying the demons out of the resident and became concerned because the resident was not able to give his consent to what was going on because he had a diagnosis of dementia. On 2/22/23 at 10:30 A.M., during an interview conducted with RN 2, the RN indicated she had gone to Resident B's room to administer care and the resident's son was at the bedside. Upon RN 2's entry, the family friend also came to the bedside. RN 2 indicated when she completed care and exited the room, she could hear the family friend's raised voice from the Nurse's station so returned to the room, knocked on the closed door and, .said I could still hear her at the nurses station and we could not have that here .she continued being loud after I left the room so I went back to the room and heard her say, 'I rebuke you.' [Resident B's] hands were raised and he was getting upset and I said [the son and family friend] had to leave the facility .RN 2 indicated the resident was not asking for help or telling the family friend to stop praying, but that she felt the resident was agitated. RN 2 indicated Resident B's son was not happy with her when she had them leave. RN 2 indicated she did not document the events of the evening, her concerns, the resident's reactions, and she did not report the incident because, .I thought I nipped it in the bud. 2/22/23 at 12:37 P.M. during a second interview with the Executive Director, she indicated she did not believe the email received from Resident B's family member was an allegation of abuse and did not initiate an investigation in response to the email and did not report the allegation of abuse to the State Agency. On 2/22/23 at 3:15 P.M., the Executive Director provided a policy titled, Abuse and Neglect Procedural Guidelines, with an effective date of 8/29/19 with a revised date of 8/29/19 and indicated it was the current facility policy. The policy indicated, .The Executive Director and Director of Health Services are responsible for the implementation and ongoing monitoring of abuse standards and procedures .Mental/Emotional Abuse-Mental abuse is the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience .agitation .Investigation .the Executive Director is accountable for investigating and reporting .Ensure that all alleged violations involving abuse .are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse .to the administrator of the facility and to other officials (including to the State Survey Agency .in accordance with State law through established procedures This Federal tag related to complaint IN00398501. 3.1- 28(c)

Based on interview and record review, the facility failed to ensure a thorough investigation was completed for an allegation of abuse for 1 of 3 residents reviewed for abuse, (Resident B). Findings include: On 2/22/23 at 10:30 A.M., the Executive Director (ED) provided an email communication dated 11/30/22 at 11:34 A.M., and indicated it was received from Resident B's family member and Emergency Contact 2. The email indicated, on 11/20/22 at approximately 4:00 P.M., the family member and a family friend were visiting Resident B in his room and, .[family friend] began praying for [Resident B]. She was still holding hands with him as he did not let go of her hands. [Family friend] was praying in an elevated tone. After some time [Registered Nurse (RN) 2] came back in and said that [family friend] was being too loud and she needed to quiet down as she could be heard out to the nurse's station (the door was closed). I again closed the door and [family friend] got quieter. A couple minutes later, [RN 2] was at the door again. She said that we had to leave as religious ceremonies were not allowed in the rooms. She said, 'What you are doing is abuse.' As [family friend tried to leave and let go of [Resident B's] hands go, he held on to her hands and [RN 2] had to separate herself from his hands . As we were walking out, she said, 'This is inappropriate.' I asked her, 'what is inappropriate?' 'what you are doing is abusive, struggling with a patient,' she said . On 2/22/23 at 10:13: A.M., the clinical record for Resident B was reviewed. Resident B was admitted on [DATE] with diagnoses that included but were not limited to, metabolic encephalopathy, pneumonitis, sepsis, bipolar disorder, and dementia. The most recent Minimum Data Set (MDS) dated [DATE], was an admission assessment that indicated Resident B had minimal difficulty in hearing and utilized hearing aids, was usually able to understand others, had moderate cognitive impairment, frequently felt depressed and hopeless. The resident demonstrated behaviors of rejection of care on 1-3 days in the previous 7 day look back period. The staff assessment of daily activity preferences indicated Resident B preferred to have family or significant other involved in his care discussions. Resident B's care plans included but were not limited to Activities, dated 10/13/22. The care plan indicated, While in this campus, it is important that I have the opportunity to engage in activities and opportunities that are meaningful to me. My interests include reading, music, and church .My faith is important to me, and it is important that I continue to engage in religious services or practices . 2/22/23 at 9:45 A.M., during an interview with the Executive Director, she indicated on 11/20/22 RN 2 heard loud noises in Resident B's room and was concerned. The Executive Director indicated RN 2 went to the residents room and a family friend and the resident's son were praying the demons out of the resident and became concerned because the resident was not able to give his consent to what was going on because he had a diagnosis of dementia. The Executive Director indicated Resident B did not have a roommate at the time. On 2/22/23 at 10:30 A.M., during an interview conducted with RN 2, the RN indicated she had gone to Resident B's room to administer care and the resident's son was at the bedside. Upon RN 2's entry, the family friend also came to the bedside. RN 2 indicated when she completed care and exited the room, she could hear the family friend's raised voice from the Nurse's station so returned to the room, knocked on the closed door and, .said I could still hear her at the nurses station and we could not have that here .she continued being loud after I left the room so I went back to the room and heard her say, 'I rebuke you.' [Resident B's] hands were raised and he was getting upset and I said [the son and family friend] had to leave the facility .RN 2 indicated the resident was not asking for help or telling the family friend to stop praying, but that she felt the resident was agitated. RN 2 indicated Resident B's son was not happy with her when she had them leave. RN 2 indicated she did not document the events of the evening, her concerns, the resident's reactions, and she did not report the incident because, .I thought I nipped it in the bud. 2/22/23 at 12:37 P.M. during a second interview with the Executive Director, she indicated she did not believe the email received from Resident B's family member was an allegation of abuse and did not initiate an investigation in response to the email. On 2/22/23 at 3:15 P.M., the Executive Director provided a policy titled, Abuse and Neglect Procedural Guidelines, with an effective date of 8/29/19 with a revised date of 8/29/19 and indicated it was the current facility policy. The policy indicated, .The Executive Director and Director of Health Services are responsible for the implementation and ongoing monitoring of abuse standards and procedures .Mental/Emotional Abuse-Mental abuse is the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience .agitation .Investigation .the Executive Director is accountable for investigating and reporting .Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations .Focusing the investigation on determining if abuse .has occurred, the extent, and cause . This Federal tag related to complaint IN00398501. 3.1- 28(d)

Based on observations and interviews the facility failed to provide a sanitary refrigerator and storage for the residents' nutrition needs in 3 out of 3 unit nutrition pantries that were observed. Finding includes: During an observation of the 100-unit nutrition pantry with the Dietary Manager, on 12/13/2022 at 1:20 P.M., the refrigerator had ice buildup in the freezer compartment. The 200-unit refrigerator had spills on door shelves and the freezer had ice buildup that was discolored brown. The floor in the nutrition pantry had brown spills. The 300-unit refrigerator had spills noted on the bottom shelf and ice buildup in the freezer. The microwave had brown food particles on the bottom and the walls. Nail clippers and nail files were noted in the drawer with creamers and condiment packets. During an interview on 12/13/2022 at 1:34 P.M., RN 3 indicated nail care items should not be kept with food. During an interview on 12/13/2022 at 1:35 P.M., the Dietary Manager indicated there should not be ice buildup on the freezers. He also indicated he did not know the freezers in those refrigerators were supposed to be defrosted. 12/15/2022 at 10 A.M., the DON indicated they do not have a policy for cleaning and defrosting refrigerators in the nutrition pantries. 3.1-21(i)(3)

Based on interview, observation, and record review the facility failed to provide equipment (tubing, filter, mask and water chamber) replacements and routine sanitation of a continuous positive airway pressure (CPAP) machine for 13 residents reviewed for respiratory care. (Resident 9) Finding includes: During an initial interview on 12/08/2022 at 1:46 P.M., Resident 9 and his wife indicated the CPAP machine does not receive routine sanitation and equipment changes. A clinical record review was completed on 12/12/2022 at 10:55 A.M. Diagnoses included, but were not limited to: chronic diastolic (congestive) heart failure, type 2 diabetes mellitus with diabetic chronic kidney disease, obstructive sleep apnea and pulmonary fibrosis. An Annual Minimum Data Set (MDS) Assessment on 11/22/2022, indicated Resident 9 was cognitively intact and required oxygen use. A Physician's Order on 10/30/2022, indicated, .Auto CPAP set at Min [minimum] pressure 3 Max [maximum] pressure 14 with oxygen at 2 liters during NOC [night] and as needed during day .Special Instructions: Chart refusal to wear CPAP Once a Day On 11/14/2022, the Sleep and Allergy Medicine Nurse Practitioner provided an order for full face mask change every 6 months, a headgear change every 6 months, tubing change every 3 months, a non-disposable filter change every 6 months and a disposable filter change every month. A Nurse's Note on 11/14/2022 at 3:08 P.M., indicated, .Spoke with this resident's wife. She states the NP [Nurse Practitioner] at [name of the Sleep and Allergy Clinic] states [resident's name] needs a new CPAP machine. She states he tells her, it's not working and she received notice that it has been recalled. NP states he is only using it 20% of the time. This RN [Registered Nurse] reminded her he often refuses, when it is offered .This resident's wife is going to start the process of getting a new machine through the Sleep Clinic A care plan on 8/19/2016 and reviewed on 11/29/2022, indicated, .Resident has sleep apneas and has been prescribed a CPAP machine to reduce respiratory distress while sleeping. He sometimes refuses to wear CPAP On 12/12/2022 at 3:44 P.M., an observation of the C -PAP equipment was observed, A small amount of debris to full face mask, and soilage to headgear was observed. During an interview on 12/13/2022 at 11:11 AM, RN 4 indicated the CPAP cleaning is scheduled by the night shift staff once a week, and Resident 9 should have a physician order to complete this task. RN 4 indicated she was not aware of how the changing of equipment happens due to this task is a night shift duty and this task should have an order to change the equipment. RN 4 indicated she doesn't think the mask gets changed out that much. RN 4 reviewed the Physician's Order record and identified the settings of the CPAP. She indicated she did not see the orders for sanitation of the CPAP equipment or changing the CPAP equipment. RN 4 reviewed the discontinued orders and could not find any orders for sanitation of the CPAP equipment or changing the CPAP equipment. A policy for CPAP use and cleaning was request on 12/13/2022 at 2:00 P.M. The Executive Director indicated on 12/14/2022 at 9:46 A.M. a policy was not available. 3.1-18(a)

Based on record review and interview and observation, the facility failed to assess, and monitor a skin issue for 1 of 3 residents reviewed for skin issues, failed to follow physician orders for pressure ulcer prevention and continuous positive airway pressure (CPAP) equipment changes. (Residents 45, 218 & 9) Finding includes: 1.During an interview, on 12/7/2022 at 2:26 P.M., Resident 45 was observed with a large dark purple bruise to the inner aspect of her right upper arm. The resident indicated the bruise to her arm was from the staff pulling her up in bed. A clinical record review was completed, on 12/09/2022 at 9:30 A.M. Resident 45's diagnoses included, but were not limited to: fractured right femur, protein malnutrition, anxiety, and had a pacemaker. An Admission MDS (Minimum Data Set) Assessment, dated 11/13/2022, indicated Resident 45 was severely cognitive impaired. Required extensive assist of 2 staff for bed mobility, transfers, dressing, toilet use and limited assist for eating. A current care plan, dated 11/25/2022, indicated the resident was at risk for excessive bleeding and bruising related to medications. Interventions included notify physician of abnormal bruising and or bleeding. Skilled Documentation, dated 12/7/2022, indicated the resident had normal skin integrity and no skin issues. Skilled Documentation, dated 12/8/2022, indicated the resident had normal skin integrity and no skin issues. Skilled Documentation, dated 12/9/2022, indicated the resident had normal skin integrity and no skin issues. A Nurses' Progress Note, dated 12/9/2022 at 10:57 A.M., indicated the aide and nurse were successful with assisting Resident 45 to change her gown, the bed clothes and receive a partial bed bath. Skilled Documentation, dated 12/11/2022, indicated the resident had normal skin integrity and no skin issues. During an interview, on 12/13/2022 at 11:42 A.M., RN 11 indicated she had seen the bruised area a couple weeks ago. RN 11 indicated if a resident had a new skin issue, the aide should tell the nurse about the area, the nurse should measure it and tell the wound nurse. During an interview, on 12/13/2022 at 1:58 P.M., C.N.A 14 indicated when they move the resident up in bed they will put the foot of the bed up, so gravity will help. We will use the lift sheet and then put our hands as close to the resident and lift her up. She indicated that they will at times lift her up in the wheel chair by her pants and around her arms, but she had not been of bed for awhile. A review of the Nursing progress notes, dated 12/1/2022 through 12/12/2022, lacked the documentation of the bruise, weekly measurements and a care plan for the new bruise. During an interview, on 12/14/2022 at 12:20 P.M., the Director of Nursing indicated she could not locate any documentation of the bruise. 2. During an observation on 12/08/2022 at 1:52 P.M., Resident 218 was laying in bed. The foot booties were on the floor at the end of the bed, and the low air loss mattress was set on standby. On 12/9/2022 at 8:56 A.M., Resident 218 was in the common area in her wheelchair, and had non-skid socks on her feet. On 12/9/2022 at 9:32 A.M., the foot booties were observed laying on the floor at the end of the bed. On 12/9/2022 at 10:04 A.M., the low air loss mattress was observed to be on standby. A clinical record review was completed on 12/9/2022 at 10:05 A.M. Diagnoses included, but were not limited to: anemia, pressure ulcer of sacral region, and type 2 diabetes mellitus. A 5-day Minimum Data Set (MDS) Assessment on 11/22/2022, indicated Resident 218 was severely cognitively impaired. She required extensive assistant with one staff member for bed mobility and toileting. She required extensive assistance with two or more staff members for transferring. She was at risk for developing pressure ulcers and was admitted with a stage 4 pressure ulcer to the sacrum. A Physician's Order on 9/9/2022, indicated, . Low Air Loss Pressure Reducing Mattress in place & functioning properly .Three Times A Day A Nurse's Note on 12/5/2022 at 1:52 P.M., indicated, .This writer notified by staff that resident has a red area to R [right] heel. Writer in to assess and finds R heel is red and blanchable. MD made aware and gave N/O [new order] skin prep to bilateral heels BID [twice daily] and protective boots at all times On 12/5/2022, a Physician's Order indicated, .Protective Boots BLE [bilateral lower extremities] at All Times Special Instructions: preventative Three Times A Day and .Skin Prep to Bilateral Heel BID [twice daily] Special Instructions: preventative Twice a Day During on observation on 12/12/2022 at 9:08 A.M., Resident 218 was observed sitting in her room in a wheelchair eating breakfast. Her feet were resting on foot pedals with no foot booties in place. On 12/12/2022 at 3:29 P.M., Resident 218 was observed lying in bed sleeping with blue non-skid socks on her feet. Her heels were not floated. The low air loss mattress is not turned on with no noted illuminated lights observed. On 12/13/2022 at 10:19 A.M., Resident 218 was observed sitting in her wheelchair in an activity. She did not have foot booties on her feet. On 12/13/2022 at 10:44 A.M., Resident 218 was observed lying in bed. The low air loss mattress had no illuminated lights and was not functioning, and her foot booties are not on feet. On 12/13/2022 at 1:33 P.M., Resident 218 was observed lying in bed. The low air loss mattress has no illuminated lights and was not turned functioning, and her foot booties are not on feet. During an observation and interview on 12/13/2022 at 1:37 P.M., 2 indicated the low air loss mattress did not have any illuminated lights. During an interview on 12/13/22 at 1:37 P.M., RN 3 indicated the physician order will indicate the pressure setting for the low air loss mattress. She indicated the settings had not changed recently. She indicated that foot booties are not needed with a low air loss mattress. RN 3 indicated physician orders should be followed. She observed the low air loss mattress and indicated the low air loss mattress was not turned on. She indicated when the mattress is on standby it is on hold and not inflating. During an observation on 12/14/2022 at 10:48 A.M., the heels were observed. RN 2 indicated a diabetic pressure ulcer was found this morning, and examined by the physician. Resident 218 had her foot booties on, and the low air pressure mattress was illuminated to indicate power. RN 2 indicated a diabetic ulcer to the right heel was found this morning. She described a left medial area filled blister with dried eschar callus like tissue to the ball of the heel. 3. During an initial interview on 12/08/2022 at 1:46 P.M., Resident 9 and his wife indicated the CPAP machine does not receive routine sanitation and equipment changes. A clinical record review was completed on 12/12/2022 at 10:55 A.M. Diagnoses included, but were not limited to: chronic diastolic (congestive) heart failure, type 2 diabetes mellitus with diabetic chronic kidney disease, obstructive sleep apnea and pulmonary fibrosis. An Annual Minimum Data Set (MDS) Assessment on 11/22/2022, indicated Resident 9 was cognitively intact and required oxygen use. On 11/14/2022, the Sleep and Allergy Medicine Nurse Practitioner provided an order for full face mask change every 6 months, a headgear change every 6 months, tubing change every 3 months, a non-disposable filter change every 6 months and a disposable filter change every month. A care plan on 8/19/2016 and reviewed on 11/29/2022, indicated, .Resident has sleep apneas and has been prescribed a CPAP machine to reduce respiratory distress while sleeping. He sometimes refuses to wear CPAP On 12/12/2022 at 3:44 P.M., an observation of the CPAP equipment was observed, A small amount of debris to full face mask, and soilage to headgear was observed. During an interview on 12/13/2022 at 11:11 AM, RN 4 indicated the CPAP cleaning is scheduled by the night shift staff once a week, and Resident 9 should have a physician order to complete this task. RN 4 indicated she was not aware of how the changing of equipment happens due to this task is a night shift duty and this task should have an order to change the equipment. RN 4 indicated she doesn't think the mask gets changed out that much. RN 4 reviewed the Physician's Order record and identified the settings of the CPAP. She indicated she did not see the orders for sanitation of the CPAP equipment or changing the CPAP equipment. RN 4 reviewed the discontinued orders and could not find any orders for sanitation of the CPAP equipment or changing the CPAP equipment. On 12/14/2022 at 12:20 P.M., the Director of Nursing provided the policy titled, Guidelines for Weekly Skin Observations, dated 1/7/2019, and indicated the policy was the one currently used by the facility. The policy indicated .The monitor the effectiveness of intervention for pressure reduction, identify areas of skin impairment in the early development stage and implement other preventative and/or treatment measures indicated. 1. A full body observation shall be completed weekly by the licensed nurse.6. IN addition to the Weekly Observation by the licensed nurse, the nursing assistant shall observe the skin for areas of impairment with bathing and daily dressing and pericare and notify the nurse if an area is identified A policy for CPAP use and cleaning was request on 12/13/2022 at 2:00 P.M. The Executive Director indicated on 12/14/2022 at 9:46 A.M. a policy was not available. A policy titled, Notification of Change in Condition ,was provided on 12/14/2022 at 9:46 A.M. by the Executive Director, and indicated, Purpose to ensure appropriate individuals are notified of change in condition. The facility informed the resident, consult with the resident's physician and if known the resident's legal representative . A policy titled, Pressure/Stasis/Arterial/Diabetic/Wound Guidelines, did not show indications of wound prevention. 3.1-5(a)(2) 3.1-37

Based on observation, interview, and records review the facility failed to provide timely physician notification of respiratory symptoms for 1 of 3 residents reviewed for respiratory care. (Resident 39) Finding includes: During an initial interview and observation on 12/8/202 at 9:09 A.M., Resident 39 indicated going to the bathroom causes shortness of breath. A productive cough was observed. Resident 39's roommate, indicated that Resident 39 has been coughing for the past 3 to 4 days, and was keeping her awake at night. On 12/08/2022 at 10:04 A.M., Resident 39 had a productive cough and signs and symptoms of shortness of breath. Resident 39 indicated she is short of breath with just walking from her recliner to the bathroom. During an observation on 12/08/2022 at 10:29 A.M., the therapy staff was observed in Resident 39's room. Resident 39 was coughing. The therapy staff was observed to inform Resident 39 to feel better as she refused therapy treatment.You sound like you have a lot of stuff in there On 12/9/2022 9:45 A.M., Resident 39 complained of coughing and shortness of breath. A clinical record review was completed on 12/9/2022 at 1:22 P.M. Diagnoses included, but were not limited to: pulmonary fibrosis, chronic obstructive pulmonary disease, centrilobular emphysema, and paroxysmal atrial fibrillation. A 5-day Minimum Data Set (MDS) Assessment on 11/23/2022, indicated Resident 39 was cognitively intact and required oxygen use. A Skilled Nursing Assessment on 12/5/2022 indicated regular and unlabored respirations with clear lung sound and no cough. On 12/6/2022, a Skilled Nursing Assessment indicated shortness of breath with exertion, diminished breath sounds in both lobes, and cough present with thin mucous On 12/8/2022, the Assessment indicated shortness of breath with exertion, diminished breath sounds in both lobes, cough present with thin mucous, and a congested nose. On 12/9/2022, the Assessment indicated shortness of breath with exertion, diminished breath sounds in both lobes, cough present with thin mucous, and watery eyes. During an observation on 12/9/2022 at 1:57 P.M., a report conversation was observed. RN 4 was observed telling LPN 5, she .Wants NP [Nurse Practitioner] to see her as cough is getting worse, she's had a cold for a while 12/12/22 . SOB [shortness of breath] with exertion, left side diminished with wheezes, right side clear, cough present with small amount thin mucous During an interview on 12/9/2022 at 1:35 P.M., the Program Director of Therapy indicated, no notes were available for the 12/8/2022 session. She indicated the documentation shows an X which indicated not seen for therapy. She indicated the therapist would most likely inform the nurse the resident indicated was not feeling well. On 12/9/2022 at 2:10 P.M., Resident 39's roommate was observed coming to the area on the 300 hall and requested to find the office of Nurse Practitioner. My roommate has been coughing for 3 days and 3 nights. A staff member immediately removed the resident from the area. During an interview on 12/9/0222 at 1:58 P.M., RN 4 indicated therapy was refused, but the therapist did not communicate the refusal. She indicated she had a cold awhile, and symptoms were worsening. She indicated a productive cough was noted two days ago. She indicated Resident 39 was on the nurse practitioner list to be seen today. RN 4 indicated a temperature had not been taken on Resident 39. RN 4 indicated, .She's always drinking all the time so it wouldn't be accurate A Nurse's Note on 12/9/2022 at 2:00 P.M., indicated, .Resident has productive cough with thick yellow sputum. She has declined to participate in therapy and has had her meals in her room today A Nurse Practitioner's note on 12/9/2022 at 2:46 P.M. indicated, .Acute Visit .Cough not feeling well Resident has been coughing for about 3-5 days, and it is not getting better. She has stopped participating in therapies, and is feeling worse. She does have the cough medicine, but she states it's not helping much. She does feel like she has to clear her throat multiple times a day. When she coughs, she coughs up clear liquid. She does have shortness of breath with exertion and it is getting worse. Denies any chest pain, heart palpitations .Cough: tested for covid 19. it was negative. Will start Mucinex 600 mg po BID [twice daily] x [times] 10 days, Flonase 1 spray BID x 10 days, albuterol inhaler 2 puffs q4hrs[every 4 hours] prn [as needed] for shortness of breath/wheezing On 12/12/2022 at 12:57 P.M., Resident 39 indicated, .I'm doing better than I was Resident stated she was still coughing and had shortness of breath, but her covid test was negative. She indicated what she coughs up is, .nasty She offered a cup full of sputum filled tissues to observed. She indicated the new medication helps get the sputum coughed up. She indicated coughing wears her out and she can't walk and go anywhere even the bathroom, She indicated it feels like she's walked a mile to go to the bathroom. A current policy titled, Notification of Change in Condition, was provided on 12/14/2022 at 9:46 A.M., by the Executive Director, and indicated, .Purpose To ensure appropriate individuals are notified of change in condition. The facility informed the resident, consult with the resident's physician and if known the resident's legal representative 3.1-5(a)(2)

Based on observation, record review, and interview, the facility failed to develop a person-centered care plan for 3 out of 23 residents whose care plans were reviewed (Residents 7, 41, and 46). Findings include: 1. During an interview on 12/07/2022 2:52 PM, Resident 7 indicated she had pain all over. The resident indicated pain medication was ordered but didn't work. A clinical record review on 12/09/2022 11:36 A.M., indicated Resident 7's diagnoses included, but were not limited to, unspecified sequelae of cerebral infarction and dorsalgia, unspecified. Physician's orders dated 11/14/2022 to 12/14/2022 indicated, but were not limited to, gabapentin 300 mg (milligram) for nerve pain, tizanidine 2 mg for muscle spasms, acetaminophen 325 mg for mild pain, biofreeze 4% menthol gel for chronic pain, aspercreme lidocaine 4% patch for pain, and oxycodone-acetaminophen 10-325 mg for pain. A Quarterly MDS (Minimum Data Set) assessment dated [DATE] included, but was not limited to, the following information: BIMS (Brief Interview for Mental Status) indicated a score of 13, which signifies intact cognition; extensive assist of 2 for transfers; extensive assist of 1 for dressing, personal hygiene, and toileting; routine and prn (as needed) pain meds; opioid use daily; and no special programs, hospice or dialysis. During an interview on 12/12/2022 at 01:21 P.M., RN 3 indicated medications usually worked, but she had also tried warm compresses which also helped. Employee further indicated resident reported if meds do not work. The care plan problem for pain dated 4/21/2021 indicated, but were not limited to, the following interventions: observe for and record verbal and non-verbal signs of pain, reposition as needed, notify MD of increased pain, administer medications as ordered and notify MD for any side effects observed or lack of effectiveness, attempt non-pharmacological interventions. 2. During an interview on 12/7/2022 at 2:20 P.M., Resident 41 indicated she had some depression. A clinical record review on 12/12/2022 at 9:16 A.M., diagnoses included, but were not limited to, Parkinson's; dementia, unspecified, without behavioral disturbances; major depressive disorder, single episode; and anxiety disorder, unspecified. Physician's orders dated 11/14/2022 to 12/14/2022 indicated, but were not limited to, Ativan 0.5 mg; Namenda 10 mg; paroxetine20 mg; and trazodone 150 mg. A Quarterly MDS assessment dated [DATE] included, but was not limited to, the following: BIMS was 15, signifying intact cognition; no behaviors; supervision of 1 for all activities of daily living but set up for eating and bathing; received an antidepressant and antianxiety medication daily; and no special programs, treatments, or procedures. A care plan problem dated 8/11/2022 for anxiety and depression included, but were not limited to, the following interventions: assist her in making contact with family/friends as needed; allow resident to vent feelings and frustrations; encourage resident to attend structured activities of preference and participate in leisure/pastime activities; provide supportive counseling contacts as needed; meds per orders; observe mood, affect, and behaviors with all hands on care and contacts. During an observation on 12/12/2022 at 9:42 A.M., resident was sitting on side of bed, still in her pajamas, with breakfast tray 1/2 eaten. During an interview at the same time, the resident indicated it was good, but she was done now. Indicates she prefers to stay in her room and watch her TV rather than go to activities. During an interview on 12/12/2022 at 3:25 P.M., the Social Service Director indicated that she was new and needs to talk to staff some more to update care plans with person centered interventions. 12/13/2022 3:01 P.M. During an interview, the DON indicated the care were not person centered. 38845 3. A clinical record review was completed on 12/12/2022 at 10:21 A.M. Resident 46's diagnoses included, but were not limited to: arthritis, Parkinson's disease, dementia, anxiety, depression, schizophrenia, psychosis and delusional disorder. An annual MDS ( Minimum Data Set) Assessment, dated 7/16/2022, indicated Resident 46 was severely confused. Received antipsychotic, antianxiety and antidepressant medications, with a GDR (gradual dose reduction) on 2/11/2022. A current care plan, dated 8/5/2021, indicated Resident 46 demonstrated physically abusive and resistive behaviors towards staff during hands on care. The resident frequently refuses personal grooming assistance such as shaving, face washing, nail cleaning and changing soiled clothing. Interventions included, but were not limited to: Re-approach with a different staff member or at a different time. Approach resident in a calm and unhurried manor to deliver care and provide services. Explain care process prior to delivery of care as needed. Observe for signs of sensory over stimulation and encourage resident to move into less stimulating environment as needed. Offer choices in all hands on care and contacts. A current carte plan, dated 8/5/2021, indicated Resident 46 had inappropriate behaviors including: physical aggression, verbal aggression, barricading self in room, and isolation from others. Interventions included, but were not limited to: Approach resident in a calm and unhurried manor to deliver care and provide services. Assess for pain and follow pain management regiment when applicable. Assess for unmet needs such as need for toileting, rest, food, companionship, etc. Assist resident to away from other residents as needed. Determine cause for inappropriate behavior and refer to physician as needed for intervention. Encourage participation in structured activities as appropriate. Observe for triggers of inappropriate behaviors and alter environment as needed. The care plans lacked individualized person centered interventions to prevent further behaviors. During an interview, on 12/13/2022 at 3:01 P.M., the Director of Nursing indicated the care plans were not person centered for the behaviors. On 12/14/2022 at 10:00 A.M, the Administrator provided the policy titled, Comprehensive Care Plan Guidelines, dated 5/22/2018, and indicated the policy was the one currently used by the facility. The policy indicated . b. Care plan interventions should be reflective of the risk area(s) or disease processes that impact the individual resident. c. Should new identified areas of concern arise during the residents stay, they should be addressed on the care plan. d. iii. Interventions should be reflective of the individual's needs and risk influences as well as the resident's strengths. 2 . Address problems that become ongoing or chronic with a new comprehensive care plan . The comprehensive care plan should be reviewed no less than quarterly with the completion of the OBRA assessment, and revised to reflect changes in the resident condition as they occur . 5. If the resident is readmitted to the campus, the previous care plan will be reviewed and updated to meet the resident's current needs. 6. Comprehensive care plans need to remain accurate and current 3.1-35(a)

Based on observation, record review, and interviews, the facility failed to ensure there were effective interventions implemented and adequate supervision to prevent falls for 2 of 3 residents reviewed for falls. (Resident #52 and #57) This deficient practice results in repeated falls and a head injury requiring 7 staples for 1 of 3 residents reviewed for accidents/falls. (Resident #57) In addition, the facility failed to ensure hazardous chemicals were not accessible in 1 of 35 resident rooms. (Resident #57) Findings include: 1. The clinical record for Resident #57 was reviewed on 6/18/15 at 11:12 A.M. Resident #57 was admitted to the facility, on 07/18/14, with diagnoses, including but not limited to, right shoulder fracture, history of coronary artery disease, hypertension, history of urinary tract infection and dehydration, gastric esophageal reflux disease, [DIAGNOSES REDACTED], anxiety and history of deep vein thrombosis. The admission nursing assessment, completed on 07/18/14, indicated the resident had a right humerus fracture, needed half bedrails one both sides, a wheelchair for safety, and had experienced a fall prior to admission. The assessment further indicated the resident required staff assistance of one for grooming, transferring, wheelchair use, ambulation, bathing, dressing, bed mobility, eating, oral care, and toileting. The assessment also indicated she was illogical with her speech, confused at times, and easily distracted. The resident was to have staff assistance, of one person, for transfers and ADL's (activities of daily living). A fall risk assessment, completed on 07/18/14, indicated the resident had impaired mobility as a fall risk factor and had an individualized care plan initiated to address the risk factors. The care plans for Resident #57 on 7/19/14 indicated the resident's bed was to be at a proper height to facilitate safe transfers, her call light and frequently used items were to be in easy reach, the pathways in her environment were to be free of clutter, she was to have a personal alarm on her bed and chair, she was educated on locking her wheelchair brakes before transferring, she was to ask for assistance to remove her socks, nursing staff was to leave a night light on at night, her trash can was to be placed out of the walkway to the bathroom. An updated care plan dated, 2/21/15, indicated the wheelchair was to be utilized due to poor balance, she was to be assisted for dressing and moving furniture, she was to receive assist with transfers, extensive assist with toileting as she was not safe to walk alone. A review of the Profile History Report for Resident #57 indicated she had fallen on 01/13/15 while reaching for her phone. The intervention was to put frequently used items close by her including her phone. She fell again on 01/22/15 while she was up walking alone in her dark room. The intervention was to place a night light in her room. She fell again on 02/07/15 when she tripped on a trash can on her way to the bathroom. The intervention was to make sure the trash can was not on her walking pathway to the bathroom. She fell again on 02/21/15, caught her arm in a door handle and injured her arm. The intervention was to put safety alarms on her bed and chair and have her start using a wheelchair. She fell again on 03/02/15 as she had turned off her alarms. The intervention was because the alarms were upsetting her they were discontinued. She fell again on 03/20/15 as she forgot to put the brakes on her wheeled walker. She and her boyfriend were educated on using the brakes. The Quarterly Minimum Data Set (MDS) assessment, completed on 04/17/15, indicated the resident's BIMS (Brief Interview Mental Status) score was a 5 (severe dementia) and required supervision of one person for transfers and locomotion. She was set up and supervision only for ambulation. She was unsteady but able to regain her balance without assistance. A Fall Circumstance, Assessment and Intervention form, dated 4/24/15 at 5:00 P.M., indicated Resident #57 had a witnessed fall in her room (the report did not say who witnessed the fall) The resident was evidently changing her clothes and moving furniture. The fall risk re-assessment indicated the resident had cognitive and judgement impairment that affects her safety, had difficulty understanding instructions and following directions, had a history of [REDACTED]. The intervention implemented after the 04/24/15 fall was for the resident to request assistance with dressing. This intervention was implemented even though the resident was cognitively impaired and had just been assessed to have problems understanding and following instructions. In addition, on 09/24/14 and again on 02/24/15 the care plan had already been updated with instructions to provide assistance for the resident anytime she was walking, extensive assistance with toileting and assistance with ADL's (activities of daily living). A Fall Circumstance, Assessment and Intervention form indicated Resident #57 was found on the floor on 5/14/15 at 4:00 A.M. She complained of left hip pain and was sent to the emergency room . The form indicated the call light was out of reach and her room lighting was inadequate. The resident had improper footwear on, and was attempting to ambulate. The intervention was to leave the bathroom light on at night. The fall risk re-assessment indicated the resident did not require assistance to transfer or ambulate. The Root Cause indicated Balance issues, unstable. Nursing note, on 5/15/15 at 8:00 P.M., indicated the resident was admitted to an acute care facility due to the results of the x-ray. The resident was readmitted to the facility, on 05/19/15, after having her fractured femur and left hip repaired. A new fall risk assessment, completed on 05/18/15 (sic) indicated the resident's fall risk factors now included: cognitive impairment, mobility impairment, incontinence, medications, and medical condition/diagnosis. The assessment indicated the resident's fall risk care plan addressed the risk factors. The care plan related to her fall risk remained unchanged for Resident #57 after her fall with a hip fracture. A Fall Circumstance, Assessment, and Intervention form, dated 05/31/15 at 7:15 A.M., indicated the resident had an unwitnessed fall in her room. The form indicated the resident was reaching for her shoes while sitting in her unlocked wheelchair and fell . The Fall Risk Re-Assessment indicated the resident required assistance to transfer, ambulate, and was unable to maintain her balance. The form further indicated she fell because her shoes had fallen off of her feet and she wanted to pick them up. The intervention was to make sure her shoes had backs on them and to put anti-tip back bars on her wheelchair. A Fall Circumstance, Assessment, and Intervention form, dated 06/03/15 at 9:00 A.M., indicated the resident had an unwitnessed fall in her room while attempting to transfer herself. The resident was documented as having been recently agitated. There were no additional interventions implemented after her 06/03/15 fall. A Fall Circumstance, Assessment, and Intervention form, dated 06/11/15 at 12:20 P.M., indicated the resident had an unwitnessed fall in her room. The resident complained of pain in her right leg and hip and was sent to the emergency room for an evaluation. The resident had been transferring herself, had improper foot wear, and had been documented as having been recently agitated. The intervention implemented was to teach/encourage call light use. This intervention had been attempted several times unsuccessfully in the past. A Social Service Progress Note, dated 06/15/15, indicated Resident #57's daughter had been notified regarding the resident's increased behaviors of wandering, resisting care, agitation, and confusion. The note indicated the social worker wanted to transfer the resident to an inpatient psychiatric facility but the resident's daughter was resistive. The Social Service Director documented I assured dtr (daughter) we were not duping (sic) res (resident) out of facility but we can not provided 1:1 care which is what res is needing.' There were no interventions added to the resident's care plan regarding provided increased and/or 1:1 supervision. A Fall Circumstance, Assessment, and Intervention form, dated 06/16/15 at 11:00 A.M., indicated the resident had an unwitnessed fall in her room. The resident was attempting to transfer herself. It was unclear if she was transferring herself from the bed or from her wheelchair or recliner. The Environmental and Personal Inspection of the form was left blank. The intervention implemented after the fall was to send a urinalysis to see if the resident had a urinary tract infection. On 06/16/15 at 2:30 P.M., Resident #57 was observed seated in her room in a recliner with the door almost all the way closed. The resident's room was around the corner from the nurse's station and 2/3 down the length of the hall. A Fall Circumstance, Assessment, and Intervention form, dated 06/16/15 at 5:45 P.M., indicated the resident had an unwitnessed fall in her room, had hit and lacerated the right side of her head. The form indicated the door to the room was shut, the alarms were not plugged in and her boyfriend had left. The resident was attempting to ambulate when she fell . The intervention was for the resident's room door to remain open. The resident was sent to an acute care facility and received 7 staples to repair the laceration to her head. On 06/18/2015 at 8:47 A.M., Resident #57 was observed seated in her recliner by herself, no staff were in the room. There was a motion seat alarm noted. The resident was calm and awake and indicated she did not feel very well. On 06/19/2015 at 8:45 A.M., Resident #57 was observed seated in her room, alone in her recliner awake. There were no visitors in the room and no facility staff in the room, no staff were visible in the hallway, or at the nurse's station. On 06/19/15 at 9:00 A.M., Resident #57 was observed seated in her wheelchair in her room and RN #3, the facility corporate nursing consultant, was observed standing in the doorway to the room, looking up and down the hallway. She indicated she was looking for some staff that might know what was going on with Resident #57. When she was queried as to the need for 1:1 supervision, she replied No comment. Resident #57 was observed, on 06/19/2015 at 9:18 A.M., lying in her bed awake. Her boyfriend was in the room and two home health agency were in the room. The middle side rails were elevated on both sides of her bed. On 6/19/2015 at 11:51 A.M., Resident #57 was observed in the 200 unit lounge sitting in her wheelchair. She was awake, dressed, and alert. Her daughter and boyfriend were sitting with her. On 6/22/2015 at 8:52 A.M., Resident #57 was observed seated in her wheelchair beside the 200 unit nurse's station. There were two staff members at the nurse's station in view of the resident. Resident #57 was alert, dressed, and conversing. She was calmly sitting in her wheelchair and a motion alarm was noted connected to her wheelchair. During an interview, on 06/22/15 at 9:10 A.M., RN #2 indicated before her fall with the leg fracture Resident #57 was ambulatory independently with supervision but after her fall she became wheelchair dependent and was an extensive assist of one staff for transfers and ambulation needs. RN #2 was getting something out of the medication cart, on 06/22/15 at 9:13 A.M., when Resident #57 stood up utilizing the handrail and set off her motion alarm. Her wheelchair was held by a visitor so it did not roll backwards and she then sat back down and the nurse got to her and handed her a banana She peeled the banana ate a bite and then wheeled her wheelchair a few more feet, put her banana back in the fruit bowl and stood up again, setting off her alarm once again. The nurse got to her and assisted her to sit back down and then asked her what she wanted to do. The resident kept showing her hands and asking what should I do with these? Nurse indicated Lets go for a walk and pushed the resident's wheelchair down the hallway. On 06/22/2015 at 9:28 A.M., Resident #57 was observed sitting with RN #2 in the 200 unit lounge. The Resident then stated if she had a room to go to she wanted to go back to her room. The nurse gave her a baby doll per her request to hold and pushed her back to her room, which was located approximately 1/2 way down the hallway. On 06/22/2015 at 9:49 A.M., Resident #57 was observed in her room by herself sleeping in her recliner with alarms attached and the door open. The nurse was at the nurse's station and there were no other staff noted in the hallway within visualization of the resident. At 10:20 A.M., the resident was still sleeping and her boyfriend was now in the room sitting beside her. On, 6/22/15 at 1:50 P.M., Resident #57 was observed sleeping in her recliner in her room, alone. Her door was open but there were no staff in the hallway to visualize the resident. RN #2 was observed to exit a room down the hallway, obtain some medication from the cart and go into another room to administer the medication. A CNA on the hall was noted to be in the kitchen getting some thickened water for another resident. No staff were on the hallway supervising the resident. On 6/22/15 at 2:13 P.M., Resident #57 was observed awake, her feet were between the recliner chair and elevated footrest. The resident was trying to refold her blanket. No staff were in the hallway, a CNA was sitting at the nurse's station and no one was visualizing the resident. She was alone in the room. During an interview, on 06/22/15 at 10:30 A.M., the MDS coordinator, RN #5 indicated the one to one intervention was going to be added (to the care plan) by the end of today. He further indicated the CNAs used the acute care plan to provide the up to date accurate fall interventions for the resident. During an interview, on 6/22/15 at 11:28 A.M., RN #3, the nursing consultant indicated the facility did not implement on one to one supervision for Resident #57 but had placed her on increased supervision. She indicated increased supervision meant as much as the staff was able we would keep her in our sight. They indicated they did not implemented 1:1 supervision. 2. On 6/19/15 at 8:47 A.M., a review of the clinical record for Resident #52 was conducted. The record indicated the resident was admitted on [DATE]. The resident's [DIAGNOSES REDACTED]. A Fall Circumstance, Assessment and Intervention form, dated 6/3/15, indicated the resident had a fall. The form indicated the resident fell while a Certified Nursing Assistant (CNA) was helping the resident off the toilet. The report indicated the resident leaned to the left and fell to the floor. The CNA tried to catch the resident, however the resident slid to floor. The resident received no injuries related to the fall. The form further indicated the resident was educated to keep both hands on the bar to help assist her until CNA indicated to the resident it was ok to sit. The careplan for ADL's (Activities of Daily Living), undated, indicated the resident was an .extensive assist of two with bed mobility, transfers and toileting. Extensive assist of one with all other ADLs. An admission care plan indicated the resident was at risk for falls related to right sided weakness, post CVA. During an interview, on 6/22/15 at 10:15 A.M., CNA #26 indicated the Care Tracker would indicate what assistance a resident would need with transfers. CNA #26 was observed going to a Care Tracker and bringing up the Resident #52's ADL section on the Care Tracker screen. CNA #26 referred to the transfer and toileting section which indicated the resident was an extensive assist of two persons with bed mobility, transfers, and toileting. During an interview, on 6/22/15 at 10:33 A.M., the ADON indicated the careplan was current and the resident required a two person assist with transfers on and off the toilet. 3. On 6/16/15 at 10:15 A.M., an observation of Resident #57's room indicated there was a half full spray bottle of (store brand name) 91% Isopropyl alcohol on the bedside stand. Resident #57 who resides in room 207 was observed resting in her bed at that time. On 6/17/15 at 3:21 P.M., an observation of the room indicated there was a half full spray bottle of 91% Isopropyl alcohol on the bedside stand. Resident #57 was resting in her recliner with the bedside stand beside her. On 6/22/15 at 10:09 A.M., an observation of the room indicated resident #57 was resting in her recliner with her eyes closed, an observation of the bathroom indicated there was a full bottle of hand sanitizer and a half full spray bottle of 91% Isopropyl alcohol on top of a Rubbermaid container. An interview at that time with the Director of Nursing indicated there should not be any hazardous chemicals in the resident's rooms. On 6/22/15 at 10:36 A.M., record review indicated Resident #57's [DIAGNOSES REDACTED]. A quarterly MDS (Minimum Data Set) assessment, dated 4/19/15, indicated the resident required supervision only for locomotion on and off the nursing unit, and the resident scored a 5 on the BIMS (Brief Interview for Mental Status) assessment which indicates the resident had severe dementia. During an interview, on 6/22/15 at 1:42 P.M., RN #11 indicated there is currently no policy regarding hazardous chemicals in resident rooms. 3.1-45(a)(1) 3.1-45(a)(2)

Based on observation, interviews and record review, the facility failed to follow physician's orders for 1 of 6 residents whose records were reviewed for accuracy of medications. This deficit practice resulted in the resident receiving two types of incorrect medications (insulin and eye medication)and the omission of two additional medications (blood thinner and appetite stimulant.) The resident sustained [REDACTED]. Resident B Findings Include: 1. During the orientation tour, on 2/14/11 at 9:00 a.m., the Director of Nursing (DoN) identified Resident B as being a recent admission to the facility and having had a fall in the early morning hours of 2/14/11. The resident was observed to have abrasions on the forehead and both sides of his face. The right eye was beginning to turn dark in color. The clinical record of Resident B was reviewed, on 2/14/11 at 10:50 a.m., and indicated the resident had been admitted to the facility on [DATE], from the Veteran's Administration Healthcare System (VA). His [DIAGNOSES REDACTED]. The admission orders INSULIN, [MEDICATION NAME], HUMAN 100 UNIT/ML INJ INJECT 12 UNITS UNDER SKIN THREE TIMES DAILY BEFORE MEALS." This order had been transcribed as "Human 100u/ml 12 U subq (subcutaneous) tid (three times daily) (before) meals." The [MEDICATION NAME]is [MEDICATION NAME] which has an onset in 15 minutes, with 1 to 2 hours peak and 3-5 hours duration. The Human is [MEDICATION NAME] which is Regular insulin with an onset of 0.5 -1 hour, and a peak in 2.5-5 hours and duration of 8-12 hours. The Human was the wrong type of insulin. This information was obtained from a fact sheet provided by the corporate nurse and DoN, on 2/14/11 at 1:30 p.m.. The order also included "INSULIN, [MEDICATION NAME], HUMAN 100 UNIT/ML INJ (INJECT) 45 UNITS UNDER SKIN AT BEDTIME DO NOT MIX WITH OTHER INSULINS" This order had been transcribed as "Human R 100u/ml (100 units per milliliter) 45 u (units) subq (every) hs (hour of sleep)." The [MEDICATION NAME]is [MEDICATION NAME] with an onset of 1.5 hours, constant peak and 24 hours duration. The [MEDICATION NAME] is long acting insulin and the order had been transcribed for short acting insulin. This information was obtained from a fact sheet provided by the corporate nurse and DoN, on 2/14/11 at 1:30 p.m.. The admission orders [REDACTED]." This order had not been transcribed on the medication record. Resident B had not received the correct insulin for any of the 7 days he had been in the facility and had received no coverage for blood sugars above 180. Twelve times the glucometer checks indicated the blood sugar was above the parameter for coverage. Observation of the insulin in the medication cart, on 2/14/11 at 11:00 a.m., indicated only one vial of insulin for Resident B. It was [MEDICATION NAME] R 100 units/ ml. and the label indicated, " use 12 units sub-q 3 times a day with meals and 45 units sub-q at bedtime." The nurse (LPN #4) giving medications on Resident B's hall was queried about his insulin, on 2/14/11 at 11:10 a.m., and she indicated it was the only one used for him. Review of the clinical record for Resident B, on 2/14/11 at 10:50 a.m., indicated the night nurse had recorded in the nurse's notes at 12:10 a.m., "Res (resident) found lying on floor next to bed on l (left) side. Res not responding to verbal or physical stimuli. B/P (blood pressure) 130/76, P (pulse) 101, R (respirations) 18. res has abrasions to forehead, nose, and both (upper) cheek bones, bleeding minimally--Res BS (blood sugar) @ (at) 23. [MEDICATION NAME] injection given and 911 EMT (emergency medical technicians) called. Res remains unresponsive. BS @ 24. 0030 (12:30 a.m.) EMT'S arrive, more glucose given by EMTs. Res after 5 mins (minutes) able to answer simple questions, often with wrong response. attempted c (with) EMT, to put res back in bed. While attempting to set res upright, Res. verbalized large amt (amount) of pain in back. EMT's placed on gurney and removed res. from building to (local hospital)., family, Dr and unit manager notified. Will inform Dr of Res need for f/u (follow up) c (with) BS (blood sugar) and insulin." The hospital report, dated 2/14/11, indicated no fractures. Resident B was sent back to the facility, on 2//14/11 with orders to decrease is insulin to 8 units at meal times and 30 units at bedtime. Orders for Keflex (antibiotic) 500 mg four times daily for 10 days and [MEDICATION NAME] to the wounds three times daily until they were healed were sent by the hospital on [DATE]. The physician was notified of the errors in insulin administration, on 2/14/11 and ordered the correction to [MEDICATION NAME] 45 units at bedtime, [MEDICATION NAME] 8 units at mealtime and coverage with [MEDICATION NAME] R as had been originally ordered at the time of admission from the VA. Resident B had received 22 doses of the wrong type of insulin and missed 12 coverage doses, during the period from his admission on 2/7 to 2/14/11. 2. The admission orders [REDACTED]." This order had been transcribed as "[MEDICATION NAME] 0.5% ([MEDICATION NAME]) instill 1 drop in both eyes BID." The resident had received the wrong eye drops for 7 days. [MEDICATION NAME] is a medication for [MEDICAL CONDITION] eye disease. Observation of the eye drops in the medication cart, on 2/15/11 at 8:00 a.m., indicated the only eye drops for Resident B were [MEDICATION NAME]. 3. The admission orders [REDACTED]." This order had not been transcribed and the resident had not received any of the doses of the injectable blood thinner. 4. The 2/7/11 admission orders [REDACTED]." This order had not been transcribed and the resident had not received any doses of the appetite stimulator. 3.1-35(g)(2)

Based on observation, interviews and record review, the facility failed to ensure 1 of 3 residents who received insulin, in a sample of 6, received the correct insulin dosages and coverages. The facility also failed to ensure medications were transcribed and administered as ordered to 1 of 6 residents whose records were reviewed for accuracy of medications. This deficit practice resulted in the resident receiving two types of incorrect medications (insulin and eye medication) and the omission of two additional medications (blood thinner and appetite stimulant.) The resident sustained [REDACTED]. Resident B Resident B Findings Include: 1. During the orientation tour, on 2/14/11 at 9:00 a.m., the Director of Nursing (DoN) identified Resident B as being a recent admission to the facility and having had a fall in the early morning hours of 2/14/11. The resident was observed to have abrasions on the forehead and both sides of his face. The right eye was beginning to turn dark in color. The clinical record of Resident B was reviewed, on 2/14/11 at 10:50 a.m., and indicated the resident had been admitted to the facility on [DATE], from the Veteran's Administration Healthcare System (VA). His [DIAGNOSES REDACTED]. The admission orders INSULIN, [MEDICATION NAME], HUMAN 100 UNIT/ML INJ INJECT 12 UNITS UNDER SKIN THREE TIMES DAILY BEFORE MEALS." This order had been transcribed as "Human 100u/ml 12 U subq (subcutaneous) tid (three times daily) (before) meals." The [MEDICATION NAME]is [MEDICATION NAME] which has an onset in 15 minutes, with 1 to 2 hours peak and 3-5 hours duration. The Human is [MEDICATION NAME] which is Regular insulin with an onset of 0.5 -1 hour, and a peak in 2.5-5 hours and duration of 8-12 hours. The Human was the wrong type of insulin. This information was obtained from a fact sheet provided by the corporate nurse and DoN, on 2/14/11 at 1:30 p.m.. The order also included "INSULIN, [MEDICATION NAME], HUMAN 100 UNIT/ML INJ (INJECT) 45 UNITS UNDER SKIN AT BEDTIME DO NOT MIX WITH OTHER INSULINS" This order had been transcribed as "Human R 100u/ml (100 units per milliliter) 45 u (units) subq (every) hs (hour of sleep)." The [MEDICATION NAME]is [MEDICATION NAME] with an onset of 1.5 hours, constant peak and 24 hours duration. The [MEDICATION NAME] is long acting insulin and the order had been transcribed for short acting insulin. This information was obtained from a fact sheet provided by the corporate nurse and DoN, on 2/14/11 at 1:30 p.m.. The admission orders [REDACTED]." This order had not been transcribed on the medication record. Resident B had not received the correct insulin for any of the 7 days he had been in the facility and had received no coverage for blood sugars above 180. Twelve times the glucometer checks indicated the blood sugar was above the parameter for coverage. Observation of the insulin in the medication cart, on 2/14/11 at 11:00 a.m., indicated only one vial of insulin for Resident B. It was [MEDICATION NAME] R 100 units/ ml. and the label indicated, " use 12 units sub-q 3 times a day with meals and 45 units sub-q at bedtime." The nurse (LPN #4) giving medications on Resident B's hall was queried about his insulin, on 2/14/11 at 11:10 a.m., and she indicated it was the only one used for him. Review of the clinical record for Resident B, on 2/14/11 at 10:50 a.m., indicated the night nurse had recorded in the nurse's notes at 12:10 a.m., "Res (resident) found lying on floor next to bed on l (left) side. Res not responding to verbal or physical stimuli. B/P (blood pressure) 130/76, P (pulse) 101, R (respirations) 18. res has abrasions to forehead, nose, and both (upper) cheek bones, bleeding minimally--Res BS (blood sugar) @ (at) 23. [MEDICATION NAME] injection given and 911 EMT (emergency medical technicians) called. Res remains unresponsive. BS @ 24. 0030 (12:30 a.m.) EMT'S arrive, more glucose given by EMTs. Res after 5 mins (minutes) able to answer simple questions, often with wrong response. attempted c (with) EMT, to put res back in bed. While attempting to set res upright, Res. verbalized large amt (amount) of pain in back. EMT's placed on gurney and removed res. from building to (local hospital)., family, Dr and unit manager notified. Will inform Dr of Res need for f/u (follow up) c (with) BS (blood sugar) and insulin." The hospital report, dated 2/14/11, indicated no fractures. Resident B was sent back to the facility, on 2//14/11 with orders to decrease is insulin to 8 units at meal times and 30 units at bedtime. Orders for Keflex (antibiotic) 500 mg four times daily for 10 days and [MEDICATION NAME] to the wounds three times daily until they were healed were sent by the hospital on [DATE]. The physician was notified of the errors in insulin administration, on 2/14/11 and ordered the correction to [MEDICATION NAME] 45 units at bedtime, [MEDICATION NAME] 8 units at mealtime and coverage with [MEDICATION NAME] R as had been originally ordered at the time of admission from the VA. Resident B had received 22 doses of the wrong type of insulin and missed 12 coverage doses, during the period from his admission on 2/7 to 2/14/11. 2. The admission orders [REDACTED]." This order had been transcribed as "[MEDICATION NAME] 0.5% ([MEDICATION NAME]) instill 1 drop in both eyes BID." The resident had received the wrong eye drops for 7 days. [MEDICATION NAME] is a medication for [MEDICAL CONDITION] eye disease. Observation of the eye drops in the medication cart, on 2/15/11 at 8:00 a.m., indicated the only eye drops for Resident B were [MEDICATION NAME]. 3. The admission orders [REDACTED]." This order had not been transcribed and the resident had not received any of the doses of the injectable blood thinner. 4. The 2/7/11 admission orders [REDACTED]." This order had not been transcribed and the resident had not received any doses of the appetite stimulator. 3.1-25(b)(9)

Based on observation, interview and record review, the facility failed to provide necessary respiratory care and services to residents. This deficiency affected 2 of 3 residents with oxygen, and 2 of 2 with C-pap (continuous positive pressure) or Bi-pap (bi-level positive airway pressure) machines, who were reviewed, in a sample of 10. (Resident #F, R, S and Q ) This deficient practice resulted in Immediate Jeopardy. The Immediate Jeopardy was identified on [DATE] and began on [DATE]. The Administrator and Director of Nursing were notified of the Immediate Jeopardy on [DATE]. The Immediate Jeopardy was removed on [DATE], but the facility remained out of compliance at the level of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy for resident's receiving respiratory care because the facility planned to inservice staff regarding oxygen and [MEDICAL CONDITION] procedures and notify the physician regarding changes in the resident's respiratory status. Further, the facility planned to assure admission orders [REDACTED]. Finally, the facility planned to monitor respiratory care provided. Findings include: On [DATE] at 9:00 a.m., during the orientation tour, accompanied by the DON (Director of Nursing), Resident #F was observed in his room. He was receiving oxygen by nasal canula. The DON indicated Resident #F was admitted to the facility yesterday ([DATE]), for rehabilitation, following back surgery. On [DATE] at 10:00 a.m., the DON indicated Resident #F had coded that morning, and had been sent to the hospital. The clinical record of Resident #F was reviewed on [DATE] at 10:30 a.m. and indicated the Resident had been admitted to the facility on [DATE] at 5:55 p.m. from the hospital. The hospital discharge summary, dated [DATE], indicated the resident had a lumbosacral decompression and fusion on [DATE] and had [DIAGNOSES REDACTED]. admission orders [REDACTED] [MEDICAL CONDITION] (Bi-level positive airway pressure) FiO2 (Fraction of insired oxygen) at 40% "@ noc (at night) & PRN (and as needed)", Biox (pulse oximeter that measures oxygen saturation rates) every shift, [MEDICATION NAME] inhaler 1 puff twice daily for [MEDICAL CONDITION], [MEDICATION NAME]/[MEDICATION NAME] per nebulizer every four hours as needed for [MEDICAL CONDITION], [MEDICATION NAME] inhaler 1 or 2 puffs four times daily as needed for [MEDICAL CONDITION]. Hospital transfer orders, dated [DATE], indicated the resident was to receive oxygen at 3 liters continuously, and the [MEDICAL CONDITION] was to be "continuous during night time." These instructions were not noted on the facility admission orders [REDACTED] The admission assessment, dated [DATE], indicated the resident had diminished lung sounds but the section for oxygen saturation was blank. The vital sign record indicated Resident #F's oxygen saturations were low and oxygen flow rates were as follows: on [DATE] (no time listed), 81% (normal ,[DATE]%) at 3 liters, and on [DATE], "noc", (no time listed) 81% at 3 liters. On [DATE] at 4:00 a.m., nursing notes indicated "Resident was restless, O 2 sats were ,[DATE]% on O 2 (oxygen) 4 L. (liters). Had [MEDICAL CONDITION] on at bedtime but complained that he felt that he wasn't getting enough air and requested to just have nasal canula. O 2 sats went up to 87% with the NC (nasal canula) and resident fell asleep...." On [DATE] at 2:00 a.m., nursing notes indicated Resident #F was sleeping soundly with no distress. The note indicated the resident's [MEDICAL CONDITION] was on and functioning. On [DATE] at 5:55 a.m. (3 hours and 55 minutes later), the next nursing note, indicated "nurse entered room for med pass & (and) to check blood sugar. Res. (Resident) unresponsive. O 2 per N/C (nasal cannula) on @ (at) 5L (liter), [MEDICAL CONDITION] off. Attempted to rouse by calling his name & gently shaking s (without) success. Blood sugar 349: Vital signs B/P ,[DATE] pulse 61 Biox 47%. Called 911, crash cart obtained second set of vitals determined no pulse, CPR (Cardio [MEDICAL CONDITION] Resuscitation) initiated..." Subsequently, the resident was transported to the hospital. The hospital discharge summary, dated [DATE], indicated the resident's ventilator was discontinued and he died at 9:24 a.m. The summary indicated "cause of death is felt to be cardiopulmonary arrest probably from his [MEDICAL CONDITION] pending autopsy report." There was no indication the resident's respiratory status or the functioning of the [MEDICAL CONDITION] machine was monitored by the licensed nurse between 2:00 a.m. and 5:55 a.m. on [DATE]. On [DATE] at 3:50 p.m., RN #10, who worked on [DATE], on the night shift on Resident #F's hall, was interviewed by phone. RN #10 indicated she peeked in at 2:00 a.m. and Resident #F was sleeping. RN #10 indicated she did not check the resident again until 5:55 a.m. The RN indicated when she entered the room, at 5:55 a.m., the resident's [MEDICAL CONDITION] was off and the resident was receiving oxygen per cannula at 5 liters. The nurse indicated she did not remove the [MEDICAL CONDITION] and did not start the oxygen per nasal cannula or set the oxygen flow rate at 5 liters. The nurse indicated she assumed the resident removed the [MEDICAL CONDITION]. Although Resident # F had low oxygen saturation rates on [DATE], [DATE], and [DATE] and complained of not getting enough air on [DATE], there was no documentation he was given as needed nebulizer or inhaler medications to improve his respiratory status. On [DATE] at 12:30 p.m., the corporate nurse indicated the prn respiratory medications were available in the emergency medication supply kept in the facility. Although nursing note documentation indicated the oxygen flow rate was increased on [DATE] and [DATE], there was no documentation the physician was consulted regarding parameters for titrating the oxygen flow to the oxygen saturation rate. Further, there was no documentation the physician was notified regarding the resident's low oxygen saturation rates, and the removal of the [MEDICAL CONDITION]. On [DATE] at 4:00 p.m., the DON was interviewed and indicated she could find no evidence the resident was given PRN breathing treatments or that physician had been notified regarding Resident #F's low oxygen saturation rates. On [DATE] at 4:35 p.m. , Resident #F's physician, was interviewed by phone. The physician indicated Resident #F had [MEDICAL CONDITION] and he should have been notified about the resident's low oxygen saturation rates. The physician indicated the resident should have had the [MEDICAL CONDITION] on when he was sleeping. The policy for "Change in a Resident's Condition or Status (undated), was provided by the DON and was reviewed on [DATE] at 3:45 p.m. The policy indicated "our facility shall promptly notify the resident, his attending physician and representative (sponsor) of changes in the resident's condition and or status....6. If a significant change in the resident's physical...condition occurs, a comprehensive assessment of the resident's condition will be conducted...." 2. The clinical record of Resident # R was reviewed on [DATE] at 10:40 A.M., and indicated an admission date of [DATE], and [DIAGNOSES REDACTED]. The resident was observed on [DATE] at 10:35 A.M., sitting in a wheelchair in the therapy department. A portable oxygen unit was observed on the back of the wheelchair and the resident was receiving oxygen through a nasal cannula. The oxygen flow rate was set at 4 liters a minute (lpm). Review of the undated admission nursing assessment indicated the resident was receiving oxygen per nasal cannula at 6 liters per minute and had an oxygen saturation level of 95%. On [DATE] at 3:20 P.M., nurse #5 indicated the assessment had been completed at the time of admission on [DATE]. There were no physician orders for oxygen on the hospital discharge orders or on the admission orders [REDACTED]. Documentation on the MAR (medication administration record) indicated the oxygen saturation level had been checked on the 2 - 10 PM shift on [DATE], and on the 10 AM to 6 PM shift on [DATE], however there were no levels listed. 3. The clinical record of Resident S was reviewed on [DATE] at 12 noon and indicated an admission date of [DATE] and [DIAGNOSES REDACTED]. The nursing assessment, dated [DATE], indicated the resident was receiving oxygen per nasal canula at 2 liters per minute and the oxygen saturation level was 94%. There were no orders for the oxygen on either the hospital discharge orders or on the physician's admission orders [REDACTED]. 4. The clinical record of Resident Q was reviewed, on [DATE] at 11:40 a.m., and indicated the resident had been admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident had been admitted with orders for a C-pap at night. The admission orders [REDACTED]. Observation of the resident, on [DATE] at 3:30 p.m., indicated she was in bed with the C-pap machine on the table beside her. During an interview with the resident, at 3:30 p.m., she indicated she used the machine at night. She also indicated she had gone to bed at 9:00 p.m., on [DATE], because she was so tired. She indicated she had been wearing the C-pap when she went to bed. The original order indicated the blood oxygen saturation level was to be checked every hour for 24 hours. The order had been revised, later in the evening (no time specified) to every 15 minutes while the C-pap was in place. The resident had been admitted at 6:00 p.m., on [DATE] and the initial oxygen saturation had not been checked at the time of admission. The first recorded level was recorded at 12:00 midnight, three hours after the resident indicated she had gone to bed with the C-pap machine in place. This deficient practice resulted in Immediate Jeopardy. The Immediate Jeopardy was identified on [DATE] and began on [DATE]. The Administrator and Director of Nursing were notified of the Immediate Jeopardy on [DATE]. Based on observation, interviews and record review, the facility inserviced staff, monitored residents and reviewed admission orders [REDACTED]'s receiving respiratory care. This federal tag relates to Complaint Number IN 191 3XXX,[DATE](a)

Based on observation, interview and record review, the facility failed to provide supervision to a resident, who had a history of [REDACTED]. This deficiency affected 1 of 4 residents who were reviewed with falls in a sample of 10. (Resident #B) Findings include: On 1/5/11 at 9:45 a.m., during the orientation tour, accompanied by the DON (Director of Nursing), Resident #B was observed sitting in a wheelchair in her room. An alarm was on the wheelchair and the right side of Resident B's face was bruised. The DON indicated the resident had fallen on 1/1/11 and had sustained a suborbital fracture. The Unit Director was interviewed on 1/5/10 at 10:00 a.m. and indicated the resident still attempted to get up without assistance because she did not want to be a burden. The unit director indicated they were continuing the use of the alarms, reminding her to ask for assistance and although there was no formal monitoring, staff were checking her frequently. The clinical record of Resident #B was reviewed on 1/5/11 at 10:00 a.m. and indicated the resident was admitted to the facility from the hospital on [DATE] with [DIAGNOSES REDACTED]. The hospital history and physical, dated 10/28/10, indicated the resident was hosptalized on [DATE], with a subdural hematoma, after several falls at home. An admission assessment, dated 10/31/10, indicated the resident had risk factors related to falls which included but were not limited to, the following: A history of falls, and mobility impairment. The fall risk care plan, dated 10/31/10, indicated the following interventions; use fall risk assessment, report falls, report negative side effects of medication, call light in reach, adequate glare free lighting, area free of clutter bed/chair alarms, monitor use of walker and wheelchair, lock brakes on bed, chair before transferring, and educated resident to request assistance prior to transfer. On 11/1/10, a physician's orders [REDACTED]. Check placement q (every) shift." Nursing notes indicated the following: On 12/29/10, at 1:30 p.m., the Resident had bed and chair alarms but was "non-compliant with ringing for assistance before transferring..." On 12/29/10, 2nd shift (no time listed) "resident has bed & (and) chair alarms in place. Non-compliant c (with) asking for staff assistance and turns alarms off when she can. Numerous attempts at unassisted transfers. She states 'I want to (sic) it myself,'..." On 1/1/11, at 7:00 a.m., the Resident was heard calling out and when the nurse entered the room Resident #B was found on the bathroom floor. The Resident had facial bruising, a laceration under her chin, a skin tear on her left leg and was subsequently transferred to the hospital. The hospital emergency room report, dated 1/1/10 and the discharge summary, dated 1/2/10 indicated the resident had sustained a right subdural hematoma, and a comminuted displaced fracture of the right medial orbital wall. In addition, the report indicated a previous left subdural hematoma, from the last admission on 10/28/10, had decreased in size. LPN #11, who was on duty when resident #B fell , was interviewed on 1/5/11 at 10:30 a.m. The nurse indicated, on 1/1/10 at 6:30 a.m., she heard Resident #B calling and when she entered the room she found the resident covered with blood on the bathroom floor with her wheelchair off to the side. She indicated the resident had gotten out of bed and into the wheelchair but no one heard her alarms sounding. LPN #11 indicated she checked the alarms on the wheel chair and bed and they were functioning but the resident would turn her alarms off. LPN #11 indicated Resident #B continued to transfer herself without assistance after her return from the hospital and that morning, 1/5/11, Resident #B had transferred herself into the chair without assistance. Although the resident had a history of [REDACTED]. On 1/5/11 at 3:00 p.m., the DON indicated Resident #B was placed on 15 minute checks, received a floor mat, and was going to have a therapy safety screening. The DON indicated these interventions were implemented on 1/5/11 and were not in place before the Resident's fall. The Fall Management Program Guidelines Policy, revised 3/08, provided by the DON, was reviewed on 1/6/10 at 9:15 a.m. and indicated, "Trilogy health Services (THS) strives to maintain a hazard free environment, mitigate fall risk factors and implement preventative measures...." This federal tag relates to Complaint Number IN 191. 3.1-45(a)(2)

Based on interviews and record review, the facility failed to follow the physician's orders to provide medication to 1 resident in a sample of 6 who was having diarrhea. (Resident B) Findings include: The closed clinical record of Resident B was reviewed, on 11/29/10 at 11:30 a.m., and indicated the resident had been admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The care plan, dated 1027/10, included care for the tube feeding, but did not address the issue of the resident having diarrhea related to the feeding formulas. Physician's orders, dated 10/19/10, indicated the resident could be given [MEDICATION NAME] liquid 2 mg (milligrams) via (through) the [DEVICE] for diarrhea. The order was written a second time on 11/2/10, and indicated "[MEDICATION NAME] 2 mg via [DEVICE] q4h (every 4 hours) X (times) 4 doses in 24 hours in 24 hours (sic) for diarrhea." The [MEDICATION NAME] tube feeding rate had been decreased on 11/1/10 to 40 cc per hour due to the diarrhea and then increased to 50 cc (cubic centimeters) per hour on 11/2/10. Nurses notes, of 11/1/10 for the second shift indicated the resident had two episodes of diarrhea. Nurses notes on 11/8/10 at 3:30 p.m., indicated Resident B had three loose stools and at 6:00 p.m., the nurse wrote "Res (resident) incont (incontinent) of stool x (times) 6 this shift. Smeared stool allover herself 1." Review of the Medication Administration Records (MAR) for October and November of 2010 indicated no [MEDICATION NAME] had been given to control the resident's episodes of diarrhea. During an interview with RN # 1, on 11/30/10 at 11:10 a.m., she indicated she did not know why the [MEDICATION NAME] had not been given to control the resident's diarrhea. This federal tag relates to complaint IN 665. 3.1-35(g)(2)