Every finding on record at Waters of Clifty Falls, The

Based on interview and record review, the facility failed to ensure a resident was treated with respect and dignity related to a racial slur by a staff member for 1 of 3 residents reviewed for Resident Rights. (Resident E) Findings include:The clinical record for Resident E was reviewed on 08/17/2026 at 11:07 A.M. An admission Minimum Data Set (MDS) assessment, dated 07/03/2026, indicated the resident was rarely or never understood. The resident's diagnoses included, but were not limited to, anoxic brain damage (happens when the brain receives no oxygen for a period long enough to cause cell death). A facility reported Incident, dated 07/26/2026, was reviewed on 08/17/2026 at 1:08 P.M. The report indicated Certified Nurse Aide (CNA) 2 and CNA 3 were providing care for Resident E. CNA 4 came into the resident's room and made an inappropriate statement.The written statement from CNA 2, in the facility's investigation, indicated she and CNA 3 were going to lay the resident down. CNA 4 walked in the room and made the comment she wanted to see how the staff, Lay this n****r down.The written statement from CNA 3, in the facility's investigation, indicated she and CNA 2 were in Resident E's room getting ready to lay him down. CNA 4 walked into the room and said, I want to see how you guys lay this N***er down.During an interview, on 08/17/2026 at 1:48 P.M., CNA 2 indicated, on the day of the incident, the resident seemed a little restless after lunch, so she and CNA 3 went to lay him down. CNA 4 had recently been re-hired and was unfamiliar with the resident, so she wanted to observe how staff assisted him with transfers. CNA 4 walked into the room and indicated, I wanna see how you lay this ni***r down. CNA 2 and CNA 3 looked at each other, shocked at what they had heard. The resident was non-verbal, but CNA 2 knew he had heard it, too. It seemed like he had a delayed reaction. He turned his head and looked their way for a few moments and then turned back away from them. CNA 4 begged them not to report her. CNA 3 messaged the Assistant Director of Nursing (ADON) and told him what had happened. He asked both of them to write up statements. This happened around 2:00 P.M. CNA 4 did not have any further contact with the resident. CNA 2 did not see CNA 4 working in the facility again after that.During an interview, on 08/18/2026 at 9:18 A.M., the Director of Nursing (DON) indicated he was notified of the incident where two CNAs were providing care for a resident when CNA 4 referred to Resident E using a racial slur. The Assistant Director of Nursing had the CNAs write a statement as to what had occurred. The current facility policy titled, Resident Rights, dated 10/22/22, was provided by the Administrator on 08/18/2026 at 9:34 A.M. The policy indicated, .Each resident has the right to be treated with dignity and respect. Any interaction between a resident and a staff member, temporary staff member, volunteer, visitor, or any other person(s) must be conducted in such a way as to enhance the resident's self-esteem and self-worth while meeting the resident's needs . 410 IAC (Indiana Administrative Code) 3.1-3(a) 410 IAC 3.1-3(a)(2)(C)

Based on observation, interview and record review, the facility failed to ensure a resident (Resident C) received Indwelling catheter care every shift and failed to ensure Indwelling catheter care was in place (Resident D and Resident E) for 3 of 4 residents reviewed for catheter care. Findings include:1. The clinical record for Resident C was reviewed on 6/13/26 at 12:30 p.m. The resident's diagnosis included, but was not limited to, neurogenic bladder (nerve damage interrupts the communication between the brain and the bladder).The physician's order, dated 6/14/23, indicated the resident's indwelling catheter care was to be provided daily on day shift.The clinical record lacked documentation of the resident's indwelling catheter care every shift.During an interview, on 5/14/26 at 12:49 p.m., the Interim Director of Nursing indicated indwelling catheter care should be completed, at a minimum, every shift.On 5/14/26 at 1:36 p.m., the Regional Director of Operations provided a current copy of the document titled Guidelines for Indwelling Foley Catheter Care dated 10/16/24. It included, but was not limited to, Purpose.The main purpose of proper indwelling foley catheter care is to prevent catheter associated urinary tract infections. Trained clinical staff.will conduct indwelling foley catheter care. 2. The clinical record for Resident D was reviewed on 5/13/26 at 11:30 a.m. The resident's diagnosis included, but was not limited to, urinary retention (the inability to completely empty the bladder).The hospital Discharge summary, dated [DATE], indicated the resident's indwelling catheter was placed and the resident would discharge back to the facility with the indwelling catheter.The nurse's note, dated 4/20/26 at 2:49 a.m., indicated Resident D had an indwelling catheter in place.The skilled note, dated 4/23/26 at 2:36 a.m., indicated the resident's indwelling catheter had been removed on day shift. The resident had no urine output for 8 hours and an indwelling catheter was re-inserted.The clinical record lacked documentation of the indwelling catheter care provided to the resident from 4/18/26 through 4/24/26. 3. The clinical record for Resident E was reviewed on 5/13/26 at 2:33 p.m. The resident's diagnosis included, but was not limited to, neuromuscular dysfunction of the bladder (when brain, spinal cord, or nerve damage disrupts the signal's required to store and empty urine).During an observation, on 5/13/26 at 11:50 a.m., the resident was observed with an indwelling catheter.The March 2026 and April 2026 treatment administration record lacked documentation of catheter care provided to the resident. This Citation relates to Intake 2999684410 IAC (Indiana Authorization Code) 16.2-3.1-41(2)

Based on interview and record review, the facility failed to ensure a resident's (Resident D) readmission assessment accurately reflected an Indwelling catheter for 1 of 3 residents reviewed for medical records. Findings include:The clinical record for Resident D was reviewed on 5/13/26 at 11:30 a.m. The resident's diagnosis included, but was not limited to, urinary retention (the inability to completely empty the bladder).The hospital Discharge summary, dated [DATE], indicated an indwelling catheter was placed and the resident discharged back to the facility with the indwelling catheter.The nurse's note, dated 4/20/26 at 2:49 a.m., indicated Resident D had an indwelling catheter in place.The skilled note, dated 4/23/26 at 2:36 a.m., indicated the resident's indwelling catheter had been removed on day shift. The resident had no urine output for 8 hours and an indwelling catheter was re-inserted.The admission/readmission assessment, dated 4/18/26 at 6:50 p.m., indicated Resident D lacked documentation of an indwelling catheter on admission.During an interview, on 5/14/26 10:30 a.m., the Regional Director of Operations indicated the resident did have an indwelling catheter when admitted on [DATE].On 5/14/26 at 3:30 p.m., the Regional Director of Operations provided a current copy of the document titled Guidelines for Assessments dated 4/14/23. It included, but was not limited to, Policy.It is the policy of this facility to ensure that assessments of the residents take place timely.and are accurate.This Citation relates to Intake 2999684410 IAC (Indiana Authorization Code) 16.2-3.1-50(a)(2)

Based on observation, interview, and record review, the facility failed to ensure wound treatments were administered appropriately for 1 of 3 residents reviewed for treatment and services related to wound care. (Resident B) Findings include:During an observation and interview, on 04/07/2026 at 8:57 A.M., Resident B indicated he had a dressing on his right hip, and it had been about a week since anyone had changed it. A tan square bandage was observed on Resident B's right hip with the date and time of 03/31 at 8:53 A.M. with initials smuged and unidentifiable. During an interview, on 04/07/2026 at 9:03 A.M., RN 2 indicated whenever a dressing change is completed the dressing is timed, dated, and initialed. Resident B's dressing change was to be completed daily. If a dressing was dated 03/31 she would assume the dressing had not been completed since that date. She confirmed Resident B's dressing on his right hip should be changed daily with the current physician order. During an observation and interview, on 04/07/2026 at 9:08 A.M., the Assistant Director of Nursing (ADON) indicated the bandage should have been changed before now. The bandage was removed by the ADON. The resident's wound was observed to be a pen cap sized round opening with a scab covering the top. The bandage covering had a dried brown substance on it the size of a quarter. The clinical record for Resident B was reviewed on 04/07/2026 at 9:50 A.M. An admission Minimum Data Set (MDS) assessment, dated 02/24/2026, indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, rhabdomyolysis (a serious, potentially fatal syndrome resulting from damaged skeletal muscle breaking down and releasing contents like myoglobin into the bloodstream, which causes kidney damage) and muscle weakness. A Progress Note, dated 03/06/2026 at 11:11 A.M., indicated Resident B had an open area on the front of his right hip. Upon assessment the resident had a 1.2 centimeter (cm) by 1 cm by 0.2 cm open wound area. A current physician's order, dated 03/07/2026 at 6:00 A.M., indicated the resident's right front hip was to be cleaned daily and Medi-honey (wound treatment to promote healing and reduces inflammation) to be applied with a dressing. The current facility policy, dated 10/9/2023, titled, S-W-A-T Program (Skin-Weight-Assessment-Team Program), was provided by the Director of Nursing (DON) on 04/08/2026 at 1:18 P.M. The policy indicated, .Ensure that trained nurses are performing treatments. This citation relates to Intake 2968233. 410 IAC (Indiana Administrative Code) 3.1-40(a)(2)

Based on record review, observation, and interview, the facility failed to ensure accurate documentation was completed related to residents wound treatments for 1 of 3 residents reviewed for accuracy of records. (Resident B)Findings include:The clinical record for Resident B was reviewed on 04/07/2026 at 9:50 A.M. An admission Minimum Data Set (MDS) assessment, dated 02/24/2026, indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, rhabdomyolysis (a serious, potentially fatal syndrome resulting from damaged skeletal muscle breaking down and releasing contents like myoglobin into the bloodstream, which causes kidney damage) and muscle weakness. A Progress Note, dated 03/06/2026 at 11:11 A.M., indicated Resident B had an open area to the front if his right hip. Upon assessment, a 1.2 centimeter (cm) by 1 cm by 0.2 cm open area was noted. A current physician's order, dated 03/07/2026 at 6:00 A.M., indicated the resident's right front hip was to be cleaned daily and a wound treatment of Medi-honey (used to treat wounds, promotes healing and reduces inflammation) with a dressing. The April 2026 Electronic Medication Administration Record (EMAR) indicated the following dates were documented as completed for Resident B's right hip wound dressing: April 1, April 2, April 3, April 4, April 5, and April 6. During an observation and interview, on 04/07/2026 at 8:57 A.M., Resident B indicated he had a dressing on his right hip, and it had been about a week since anyone had changed it. A tan square bandage was observed on Resident B's right hip with the date and time of 03/31 at 8:53 A.M. and unidentifiable initials. During an interview, on 04/07/2026 at 9:03 A.M., RN 2 indicated whenever a dressing change was completed the dressing was timed, dated, and initialed. If a dressing was dated 03/31, she would assume the dressing had not been completed since that date. She confirmed Resident B's dressing on his right hip should have been changed daily with the current physician order. During an observation, on 04/07/2026 at 9:08 A.M., the bandage on Resident B was dated 03/31 and was removed by the Assistant Director of Nursing (ADON). The resident's right hip wound was observed to have a pen cap sized round opening with a scab covering the top. The bandage covering had a dried brown substance on it the size of a quarter. The DON indicated there was no specific policy related to accuracy of documentation. The current facility policy, dated 10/9/23, titled, S-W-A-T Program (Skin-Weight-Assessment-Team Program), was provided by the Director of Nursing (DON) on 04/08/2026 at 1:18 P.M. The policy indicated, .Ensure that trained nurses are performing treatments. This citation relates to Intake 2968233. 410 IAC (Indiana Administrative Code) 3.1-50(a)(2)

Based on record review and interview, the facility failed to follow physician's orders and change treatment orders in a timely manner related to a resident's wound care for 1 of 3 residents reviewed for quality of care. (Resident C)Findings include:The clinical record for Resident C was reviewed on 01/22/2026 at 9:43 A.M. An admission Minimum Data Set (MDS) assessment, dated 09/20/2025, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, Deep Vein Thrombosis (DVT- a serious condition where a blood clot forms in one or more of the deep veins) and diabetes. The resident had one venous/arterial ulcer (a painful, slow-healing sore on the lower leg, foot, or toes) on admission.A Wound Nurse Practitioner (NP) Note, dated 09/17/2025, indicated the resident had an arterial ulcer to the left heel that was 7.2 centimeters (cm) x (by) 7.5 cm x 0.4 cm, and was present on admission. The staff were to cleanse the wound with wound cleanser or normal saline, apply betadine, cover with an abdominal pad, and lightly wrap with a rolled gauze. The treatment was to be completed twice per day.The September and October 2025 Electronic Treatment Administration Record (ETAR) indicated the resident had a physician's order, dated 09/17/2025 through 10/20/2025, for staff to cleanse the wound with wound cleanser or normal saline, apply betadine, cover with an abdominal pad, and lightly wrap with a rolled gauze, once a day.A Wound NP Note, dated 10/15/2025, indicated the resident had an arterial ulcer to the left heel that was present on admission. The staff were to cleanse the wound with wound cleanser or normal saline, apply Santyl, cover with an abdominal pad, and lightly wrap with rolled gauze, daily.The October 2025 ETAR indicated the order was not initiated until 10/20/2025.A Wound NP Note, dated 10/29/2025, indicated the resident had an arterial ulcer to the left heel that was present on admission. The staff were to cleanse the wound with wound cleanser or normal saline, apply skin prep to the surrounding tissue or peri-wound, apply Dakins moistened fluffed gauze, and cover with silicone bordered superabsorbent dressing, twice a day.The November 2025 ETAR indicated a physician order, dated 11/04/2025 through 11/10/2025, indicated the staff were to cleanse the wound with wound cleanser or normal saline, apply skin prep to the surrounding tissue or peri-wound, apple Dakins moistened fluffed gauze, and cover with silicone bordered superabsorbent, daily.The order was not changed to twice a day until 11/10/2025.A Wound NP Note, dated 11/20/2025, indicated the resident had an arterial ulcer to the left heel that measured 4.6 cm x 4.0 cm x 0.4 cm and was present on admission. The staff were to cleanse the wound with wound cleanser or normal saline, apply skin prep to the surrounding tissue or peri-wound, apply Dakins moistened fluffed gauze, and cover with silicone bordered superabsorbent dressing, twice a day.During an interview, on 01/22/2026 at 2:24 P.M., Licensed Practical Nurse (LPN) 2 indicated the resident's wound treatments were to be documented in the ETAR. If there was a blank on the ETAR then that would mean the treatment wasn't completed. The Wound NP came to the facility to see residents, and the Assistant Director of Nursing (ADON) would round with her when she came. If she initiated any new orders the ADON would transcribe those orders. During an interview, on 01/22/2026 at 2:28 P.M., the ADON indicated the Wound NP would come in and complete her rounds with the residents. The NP would then leave the facility, and he (the ADON), would get a report from the NP within one to two days of her visit. The report wound contain any new orders. Once he got the report then he would change resident's orders if the NP had prescribed new orders. The facility did not go through the resident's primary physician for any new wound treatment orders. They would just follow the order of the Wound NP. The current facility policy titled, Guidelines for Physician Orders-(Following Physician Orders) dated 06/18/2023, was provided by the Director of Nursing on 01/22/2026 at 3:27 P.M. The policy indicated, .It is the policy of the facility to follow the orders of the physician.As assessments are completed, orders will be received from the physician to address significant findings of the assessment.All physician orders received pertaining to the resident will be implemented and followed throughout the course of the resident's stay in the facility as the orders are received.This citation relates to Intake 2712292. 3.1-37(a)

Based on record review and interview, the facility failed to follow physician's orders related to treatments for 1 of 3 residents reviewed for pressure ulcers. (Resident B)Findings include:The clinical record for Resident B was reviewed on 01/22/2026 at 10:05 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 11/20/2025, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, diabetes, malnutrition, and depression. The resident had one Stage 4 (Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer. Slough and/or eschar may be visible on some parts of the wound bed) pressure ulcer that was present on admission. A Wound Nurse Practitioner (NP) Note, dated 08/27/2025, indicated the resident had a Stage 4 pressure ulcer to the sacrum the wound measured 5.4 centimeters (cm) x (by) 6.5 cm x 5.0 cm. There was undermining from from 6 o'clock to 4 o'clock, at 6.4 cm. The wound was present on admission on [DATE]. A Wound NP Note, dated 09/17/2025, indicated the resident had a Stage 4 pressure ulcer to the sacrum that was present on admission. A new wound treatment order indicated the staff were to cleanse the wound with Dakins solution, apply collagen, calcium alginate, and cover with a bordered dressing. The treatment was to be completed daily. The September 2025 Electronic Treatment Administration Record (ETAR) indicated the treatment was not initiated until 09/23/2025. A Wound NP Note, dated 10/22/2025, indicated the resident had a Stage 4 pressure ulcer to the sacrum that was present on admission. A new wound treatment order indicated the staff were to cleanse the wound with Dakins solution, apply collagen particles, and apply continuous wound vac therapy. The treatment was to be completed three times per week. The October 2025 ETAR indicated the resident had an order, from 10/22/2025 through 11/09/2025 to change the wound vac dressing to the coccyx every three days. The order lacked indication to cleanse the wound with Dakins solution or apply collagen particles. A Wound NP Note, dated 10/29/2025, indicated the resident had a Stage 4 pressure ulcer to the sacrum that was present on admission. A new wound treatment order indicated the staff were to cleanse the wound with Dakins solution, apply collagen particles, and apply continuous wound vac therapy. The treatment was to be completed on Wednesdays and Saturdays. The October ETAR lacked the treatment order was changed on 10/29/2025. A different treatment order was put into place on 11/12/2025.A Wound NP Note, dated 12/10/2025, indicated the resident had a Stage 4 pressure ulcer to the sacrum that was present on admission. A new wound treatment order indicated the staff were to cleanse the wound with Dakins solution, apply skin prep to the surrounding tissue or periwound, apply collagen with silver, calcium alginate, and cover with a silicone bordered superabsorbent dressing. The treatment was to be completed daily. The December 2025 ETAR indicated the treatment order was not initiated until 12/19/2025, and lacked documentation the treatments were completed on the following dates:-On 12/22/2025, -On 12/27/2025, -On 12/28/2025, and -On 12/29/2025.A Wound NP Note, dated 01/21/2026, indicated the resident had a Stage 4 pressure ulcer to the sacrum. The wound measured 4.3 cm x 4.0 cm x 3.4 cm. The wound had undermining from 3 o'clock to 8 o'clock at 4.8 cm. The wound was present on admission. During an interview, on 01/22/2026 at 2:24 P.M., Licensed Practical Nurse (LPN) 2 indicated resident wound treatments were to be documented in the ETAR. If there was a blank on the ETAR then that would mean the treatment wasn't completed. The Wound NP came to the facility to see residents, and the Assistant Director of Nursing (ADON) would round with her when she came. If the Wound NP initiated any new orders the ADON would transcribe those orders. During an interview, on 01/22/2026 at 2:28 P.M., the ADON indicated the Wound NP would come in and complete her rounds with the residents. The NP would then leave the facility, and he, the ADON, would get a report from the NP within one to two days of her visit. The report wound contain any new orders. Once he got the report then he would change resident's orders if the NP had prescribed new orders. The facility did not go through the resident's primary physician for any new wound treatment orders. They would just follow the order of the Wound NP. The current facility policy titled, Guidelines for Physician Orders-(Following Physician Orders) dated 06/18/2023, was provided by the Director of Nursing on 01/22/2026 at 3:27 P.M. The policy indicated, .It is the policy of the facility to follow the orders of the physician.As assessments are completed, orders will be received from the physician to address significant findings of the assessment.All physician orders received pertaining to the resident will be implemented and followed throughout the course of the resident's stay in the facility as the orders are received.The current facility policy titled, Guidelines for Prevention/Treatment of Pressure Injuries dated 10/09/2023 was provided by the Director of Nursing on 01/22/2026 at 3:27 P.M. The policy indicated, .In accordance with Federal Regulations and based on resident assessment, the facility will ensure: 2) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infections and prevent new ulcers from developing .This citation relates to Intake 2712292. 3.1-40(a)(2)

Based on observation, interview, and record review, the facility failed to prevent an accident during a transfer resulting in skin tears requiring sutures for 1 of 3 residents reviewed for accidents. (Resident B)Findings included:During an interview, on 11/18/2025 at 9:27 A.M., Certified Nurse Aide (CNA) 4 indicated Resident B had required a full body mechanical lift for transfers for a while. The resident was not interviewable and was dependent on staff for all other care. Prior to the resident requiring a full body lift she required two physical staff members assistance to pivot and transfer. The resident did not currently have any wounds or skin concerns but did have sutures recently from a skin tear.During an interview, on 11/18/25 at 9:32 A.M., CNA 2 indicated during a transfer on 08/23/2025 Resident B required two staff assistance. When they went to transfer the resident, they stood her up and then her legs got weak. The footrest folded up, and her legs scrapped the metal pieces on the chair. The resident received a skin tear. The resident had to go to the hospital and have sutures. During an observation, on 11/18/2025 at 9:38 A.M., CNA 2 showed on the resident's high back wheelchair where the resident's legs scrapped on the bottom corners under the foot pedal. There were metal edges exposed. The two outer corners of the bottom of the foot pedals were missing the plastic caps and the two inner corners had caps in place. The metal was felt and was rough to the touch. The CNA indicated the resident's legs were healed. The legs were observed with no current open areas. During an interview, on 11/18/2025 at 10:15 A.M., CNA 3 indicated her and CNA 2 were transferring Resident B to her high back wheelchair in the resident's room. When they stood the resident up her legs buckled and when they tried to pull the resident back up her legs got caught on the foot pedals and pushed the entire foot pedal mechanism up. Her legs scrapped the metal on the bottom. There were two metal pieces on the bottom that lined up where the resident's legs were. All the CNAs would inspect resident wheelchairs. If they noticed something wasn't right with them then they would take them to maintenance and get them fixed. She believed maintenance would inspect the wheelchairs daily.During an interview and observation, on 11/18/2025 at 10:28 A.M., the Therapy Manager indicated the resident, nor her wheelchair had been seen by their department since the incident in August. The resident chair should not have been missing the plastic pieces. The clinical record for Resident B was reviewed on 11/18/2025 at 11:05 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 05/25/2025, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, aphasia, vascular dementia, insomnia, and anxiety. The resident required substantial/maximum assistance with transfers.A Progress Note, dated 08/23/2025 at 7:00 A.M., indicated a CNA reported a skin tear to the nurse. Upon assessment, the nurse noted three small skin tears to the back of the right calf and a large skin tear on the back of the left calf. The areas were cleansed, and a dressing was applied. The Nurse Practitioner was updated, and an order was received to send the resident to the local emergency room. An emergency room Visit Note, dated 08/23/2025, indicated the resident presented to the emergency room when her legs got twisted up in a sharp part of the wheelchair causing some skin tears and lacerations of the lower extremities. The physical exam indicated the resident had a 5 centimeter (cm) circumferential laceration of the right lower leg, one skin tear proximal. On the right leg there were four small skin tears. All skin tears were 2 cm in length. The 5 cm laceration to the left lower leg was numbed using lidocaine, irrigated with high-pressure irrigation and 2 X (by) 4 sutures were placed in a running fashion to approximate each side. The total of 5 X 2 cm small skin tears were irrigated with normal saline and Dermabond (a skin adhesive to hold wounds together) was placed. A Progress Note, dated 08/23/2025 at 12:00 P.M., indicated the resident returned from the hospital. The resident was noted to have glue to the skin tears on the right calf and six sutures and skin glue to the wound on the left calf. There were new orders to cleanse the areas daily and monitor for redness, discharge, fever, or worsening in condition. The resident family was aware and at bedside. A Wound Assessment Report, dated 08/27/2025, indicated the resident had a skin tear to the left lower posterior leg. The wound measured 6.50 cm X 4.20 cm. The wound had sutures. A Wound Assessment Report, dated 08/27/2025, indicated the resident had a skin tear to the right lower posterior leg. The wound measured 10.10 cm X 2.50 cm. A Wound Assessment Report, dated 09/17/2025, indicated the residents skin tears to the right and left lower legs were healed. The current facility policy titled, GUIDELINES FOR INCIDENTS/ACCIDENTS/FALLS, dated 06/30/2023, was provided by the Administrator on 11/18/2025 at 1:21 P.M. The policy indicated, .The facility will ensure that incidents and accidents that occur involving residents are identified, reported, and resolved.This citation related to Intake 2598682.3.1-45(a)(1)3.1-45(a)(2)

Based on observation and interview, the facility failed to ensure resident care equipment was in safe operating condition for 1 of 2 high back wheelchairs reviewed.Findings include:During an interview, on 11/18/25 at 9:32 A.M., Certified Nurse Aide (CNA) 2 indicated during a transfer on 08/23/2025 Resident B required two staff assistance. On this day when they went to transfer the resident, they stood her up and then her legs got weak. The footrest folded up, and her legs scrapped the metal pieces on the chair causing a skin tear. The resident did have to go to the hospital and have sutures.During an observation, on 11/18/2025 at 9:38 A.M., CNA 2 indicated the location on the resident's specialized high back wheelchair where the resident's legs scrapped on the bottom corners where there was exposed metal. The two outer corners of the bottom of the foot pedals were missing the plastic caps, the two inner corners had caps in place. The metal was felt and was rough to the touch. The CNA indicated the resident's legs were healed. The legs were observed with no current open areas.During an interview, on 11/18/2025 at 10:15 A.M., CNA 3 indicated her and CNA 2 were transferring Resident B to her specialized high back wheelchair in the resident's room. When they stood the resident up her legs buckled and when they tried to pull the resident back up her legs got caught on the foot pedals and pushed the entire foot pedal mechanism up. Her legs scrapped the metal on the bottom. There were two metal pieces on the bottom that lined up where the resident's legs were. All the CNAs would inspect resident wheelchairs. If they noticed something wasn't right with them then they would take them to maintenance and get them fixed. She believed maintenance would inspect the wheelchairs daily.During an interview and observation, on 11/18/2025 at 10:28 A.M., the Therapy Manager indicated the resident, nor her wheelchair had been seen by their department since the incident in August. The resident's chair should not have been missing the plastic pieces. During an interview, on 11/18/2025 at 10:44 A.M., the Maintenance Director indicated the residents specialized high back wheelchairs were inspected by him if nursing requested for them to be looked at or if there was a work order for it. There wasn't a checklist to check off unless there was a work order. After Resident B's incident he did look at the resident's chair. He determined there were no adjustments needed to the chair. He didn't see anything wrong with the chair, nothing was out of place, and there were not any missing pieces. He transferred the chair back to the nursing department to reevaluate. During an observation and interview, on 11/18/2025 at 10:51 A.M., of Resident B's chair with the Maintenance Director, the chair was missing the black corner plastic pieces under the foot pedals. The Maintenance Director indicated that the pieces should have been on the chair. During an interview, on 11/18/2025 at 11:53 A.M., the Maintenance Director indicated he had spoke with the specialize high back wheelchair company and they told him that the black pieces that were missing from the chair were to just block water and dust plugs and were not a protector. He did not have a work order or any indication that he had inspected the resident's chair after the incident. He was the weekend manager on the day the incident happened, so he just looked at it at that time. During an interview, on 11/18/2025 at 11:59 A.M., a Representative with the specialized high back wheelchair company indicated the black cover pieces were used as water and dust covers. The plugs sit in the metal on the bottom of the foot pedal; she believed the plugs would help the skin from rubbing the metal because if the plugs were not in place the metal could be sharp from paint build up. It was the facilities responsibility to ensure the plugs were in place. If the pieces were missing, then they should have them replaced as it was part of the quality check when the chair was shipped. An emergency room Visit Note, dated 08/23/2025 indicated the resident presented to the emergency room when her legs got twisted up in a sharp part of the wheelchair causing some skin tears and lacerations of the lower extremities. The physical exam indicated the resident had a 5 centimeter (cm) circumferential laceration of the right lower leg, 1 skin tear proximal. On the right leg there were four small skin tears. All skin tears were 2 cm in length. The 5 cm laceration to the left lower leg was numbed using lidocaine, irrigated with high-pressure irrigation and 2 X (by) 4 sutures were placed in a running fashion to approximate each side. The total of 5 X 2 cm small skin tears were irrigated with normal saline and Dermabond (a skin adhesive to hold wounds together) was placed. A Progress Note, dated 08/23/2025 at 12:00 P.M., indicated the resident returned from the hospital. The resident was noted to have glue to the skin tears on the right calf and six sutures and skin glue to the wound on the left calf. There were new orders to cleanse the areas daily and monitor for redness, discharge, fever, or worsening in condition. The resident family was aware and at bedside.The current, undated, facility policy titled, Nursing-Annual Inspections, was provided by the Administrator on 11/18/2025 at 1:21 P.M. The policy indicated, .Wheelchairs: Check all wheelchairs for proper operation and needed repairs.This citation related to Intake 2598682.3.1-19(bb)

Based on interview and record review, the facility failed to ensure staff treated a resident with respect and dignity for 1 of 3 residents reviewed for resident rights. (Resident C) Findings include:The clinical record for Resident C was reviewed on 10/20/2025 at 10:10 A.M. An admission Minimum Data Set (MDS) assessment, dated 8/22/2025, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, heart failure, depression, and hypertension. During an interview, on 10/20/2025 9:28 A.M., Resident C indicated that Certified Nursing Assistant (CNA) 2 said a lot of hurtful things. She made comments to her that nobody at the facility liked her, and she was a difficult resident to take care of and roll over. She reported it to management, and the CNA no longer takes care of her. A Resident Interview Document, dated 10/8/2025, indicated Registered Nurse (RN) 5 interviewed Resident C. The Resident was upset that CNA 2 told her she was hard to roll, and that other staff members talked about her. CNA 2 apologized to her later, but the Resident still felt ridiculed and embarrassed. CNA 2 also stated, There is three types of people in this facility. Those that take care of themselves, those that need a little help, and like Resident C that can't do anything on their own. During an interview, on 10/20/2025 at 11:14 A.M., CNA 3 indicated that she was in the room with CNA 2 made comments to Resident C. CNA 2 told the resident she was a difficult resident to care for. During an interview, on 10/20/2025 at 11:38 A.M., CNA 4 indicated that she and another staff member were providing Resident C with care when CNA 2 walked into the residents room. The resident made a remark that she was easy to care for, and CNA 2 told her she was one of the most difficult people at the facility to care for. When CNA 3 and CNA 4 exited the room CNA 2 stayed behind in the residents room. When the resident turned her call light on to be assisted with post assistance hygiene CNA 2 was no longer in the room, and Resident C no longer wanted to get out of bed. The current undated facility policy titled, Your Rights and Protections as a Nursing Home Resident, was provided by the Administrator on 10/20/2025 at 2:50 P.M. The policy indicated, .You have the right to be treated with dignity and respect . This citation relates to Intake 2638439. 3.1-3(t)

Based on interview and record review, the facility failed to ensure an anti-anxiety medication was administered to a resident within the appropriate time frame and failed to ensure behaviors were documented prior to the administration of an anti-anxiety medication for 1 of 3 residents reviewed for significant medication errors.Findings Include:The clinical record for Resident B was reviewed on 7/10/25 at 10:04 a.m. The resident's diagnosis included, but was not limited to, restlessness and agitation.The progress note, dated 6/17/25 at 8:00 p.m., indicated the resident was in the dining room and stated, I want to leave. The resident was observed to be physically aggressive with staff. At approximately 7:30 p.m., the resident kicked the side window in the dining room. He then picked up a chair and attempted to throw it at the window. The staff grabbed the chair, and the resident put it down. He then flipped tables in the dining room in anger. He went to his room and attempted to open his window. After that, he picked up another chair and attempted to swing it at the exit doors. The resident then walked to the courtyard door and went outside, accompanied by two staff members. The resident then walked back to the dining room. The nurse practitioner was notified with a new order for Lorazepam (narcotic anti-anxiety medication), 0.5 mg (milligrams) intramuscularly (IM) every 8 hours as needed for anxiety.The June 2025 medication administration record indicated the resident received the IM Lorazepam at 8:15 p.m. The next dose, if needed, could be administered at 3:15 a.m. on 6/18/25.The progress note dated 6/17/25 at 10:51 p.m., indicated the staff were 1:1 supervision with the resident until he calmed down. He had been asleep since approximately 9:30 p.m. He aroused easily to verbal stimuli, and his speech was clear. He remained very confused and disoriented to place and time. He had no further aggression observed. The resident's insulin was not administered at bedtime.The June 2025 medication administration record indicated the resident received the Lorazepam on 6/18/25 at 2:30 a.m.The clinical record lacked documentation of the resident's behaviors to account for the second dose of Lorazepam administered on 6/16/25 at 2:30 a.m. During a telephone interview, on 7/14/25 at 10:02 a.m., Registered Nurse (RN) 5 indicated resident behaviors should be documented in the nurses' notes and medications can be administered an hour before or an hour after the time they are due.On 7/14/25 at 9:29 p.m., the Clinical Support provided a current, undated copy of the document titled Psychotropic Medication. It included, but was not limited to, Psychoactive medications include anti-anxiety.Nursing.Monitors for presence of target behaviors.and documents the same.On 7/10/25 at 3:16 p.m., the Clinical Support provided a current copy of the document titled Medication Administration dated 1/25/19. It included, but was not limited to, Procedure.Medications are administered in accordance with written orders of the physician.Medications are administered within 60 minutes of scheduled time.This Citation relates to Complaint IN004630313.1-37

Based on interview and record review, the facility failed to ensure a long-acting insulin order was accurately transcribed for 1 of 3 residents reviewed for significant medication errors.Findings Include:The clinical record for Resident B was reviewed on 7/10/25 at 10:04 a.m. The resident's diagnosis included, but was not limited to, type 2 diabetes. The hospital discharge order, dated 6/17/25, indicated the resident was to receive insulin glargine (long-acting insulin) 100 unit/ml (milliliters), 5 units at bedtime. The insulin was not to be mixed with other insulins. If the resident's blood glucose was less than 70, the staff were to follow the hypoglycemia protocol for glycemic control.The facility admission order, dated 6/17/25, indicated the resident was to receive insulin glargine, 70 units subcutaneously at bedtime. If the resident's blood glucose was less than 70, the facility protocol was to be implemented. The order was transcribed by Licensed Practical Nurse (LPN) 3.On 6/18/25 at 10:23 p.m., the order for the insulin glargine, 70 units at bedtime, was discontinued and not administered by RN (Registered Nurse) 5. A new order was implemented for the medication by RN 5 to be administered in the morning at 9:00 a.m.On 6/19/25 at 9:00 a.m., review of the June 2025 medication administration record indicated the resident received insulin glargine, 70 units subcutaneously to the right upper quadrant of the abdomen for diabetes. The resident's blood glucose was 164 at this time. The medication was administered by LPN 4.The progress note, dated 6/19/25 at 3:16 p.m., indicated the resident was alert to his surroundings and cooperative with care. The resident was assessed with no pain, agitation or diabetic distress observed.The progress note, dated 6/19/25 at 5:42 p.m., indicated the resident was found unresponsive in his bed and snoring. He was unable to be aroused. His blood pressure was 80/48, respirations 18, pulse 58 and oxygen saturation was 80% on room air. The family was notified and wanted the resident sent to the emergency department. The resident's granddaughter was at his bedside. The progress note, dated 6:10 p.m., indicated emergency medical services (EMS) were at the facility. The resident's blood glucose was 58 at this time and the resident was transferred to the hospital.The progress note, dated 6/19/25 at 11:44 p.m., indicated the family called the facility and reported the resident would be transferred to a different hospital. The resident had been intubated (mechanical ventilation used to assist with breathing) due to non-responsiveness.During a telephone interview, on 7/10/25 at 1:41 p.m., LPN 3 indicated he had been working a lot of night shifts at the facility. The only rationale thing he could think of was that he saw the 70 and put the order in wrong. He did not know why it was not caught in the chart check during the morning meeting the next day. During an interview, on 7/10/25 at 1:45 p.m., LPN 4 indicated she did administer the 70 units of insulin to Resident B on the morning of 6/19/25. LPN 4 did question the amount of insulin in her head, however, that was what the order was written for.During an interview, on 7/10/25 at 3:10 p.m., the Director of Nursing indicated that due to working night shifts, the chart review had been missed prior to the resident's hospitalization.On 7/14/25 at 9:42 a.m., a current copy of the document titled Guidelines for Physician Orders (Following Physician Orders) dated August 2017. It included, but was not limited to, Policy.It is the policy of the facility to follow the orders of the physician.Two nurses will review admission.order to serve as a double check for the accuracy of the orders.This Citation relates to Complaint IN004630313.1-48(a)(1)

3. During a continuous observation, on 05/29/25 from 1:38 P.M. through 1:44 P.M. the following was observed: - At 1:38 P.M., a computer screen was opened on Medication Cart 1 on the 100 Hallway that was sitting between resident rooms [ROOM NUMBERS]. The screen had Resident 66's name and medication list visible. - At 1:39 P.M., a resident in a wheelchair propelled by the cart and looked towards the computer and kept going, - At 1:40 P.M., LPN 8 who had been standing at Medication Cart 2 outside of room [ROOM NUMBER], approximently ten feet from Medication Cart 1, walked into room [ROOM NUMBER] next to Medication Cart 1 out of visible sight of both Medication Carts 1 and 2. The LPN did not close the open computer screen on Medication Cart 1. - At 1:41 P.M., a resident in a wheelchair propelled by the cart, - At 1:42 P.M., a staff member walked past the cart, and LPN 8 walked out of room [ROOM NUMBER] and returned to the second medication cart, - At 1:43 P.M., a resident in a wheelchair propelled by cart, spoke to LPN 8, turned around and went by the open computer screen again, - At 1:44 P.M., Qualified Medication Aide 11 went to the Medication Cart 1 and closed the computer screen. During an interview, on 06/04/25 at 9:41 A.M., LPN 5 indicated the computer screens should always be minimized or hidden from public view when the nursing staff were not at the computers. The current facility policy titled, MEDICAL RECORDS GUIDELINES, dated 01/09/23, was provided by the Administrator on 06/04/25 at 10:50 A.M. The policy indicated, .The clinical records of residents are the property of the facility. Residents Rights related to health information are recognized in accordance with the Privacy Rules of Health Insurance Portability and Accountability Act (HIPAA). Clinical records are used by authorized individuals, and stored in an easily accessible area that is protected .and should be locked . 3.1-3(o) Based on observation and interview, the facility failed to keep resident information private related to resident meal tickets and computer screens for 3 of 6 resident confidence of records information observations. (Residents 26, 73, 23, 36, 77, 42, 45, 57, 91, 34, 66 and Split Hall and 100 Hall) Findings include: 1. During an observation, on 05/29/25 at 12:11 P.M., the staff in the dementia unit were serving lunch. The staff members Activity Aide 7, Certified Nurse Aide 10, and Licensed Practical Nurse (LPN) 9, were serving the resident's their meals and then placing the resident meal cards with their names on them in the trash can. During an interview and observation, on 05/29/25 at 12:12 P.M., Activity Aide 7 indicated they had placed the resident's meal tickets in the regular trash can that would have been taken to the dumpster and they should have been placed in the shred container. She removed the following resident meal tickets from the trash can: Residents 26, 73, 23, 36, 77, 42, 45, 57, 91, and 34. During an interview, on 05/29/25 at 12:14 P.M., LPN 9 indicated the resident meal tickets should have been placed in the shred box. 2. During a continuous observation, on 05/29/25 from 2:19 P.M. through 2:23 P.M. the following was observed: - At 2:19 P.M., a computer screen opened on a medication cart in the Split hallway was sitting outside the nurse's station unattended. The computer screen had multiple resident names, pictures and room numbers visible on the screen, - At 2:21 P.M., a resident in a wheelchair propelled by the cart and looked towards the computer and kept going, - At 2:23 P.M., two staff members walked by the cart, and - At 2:24 P.M., a nurse went to the medication cart and closed the computer screen.

Based on record review, interview, and observation, the facility failed to follow physician's orders related to cardiac medication hold parameters and follow manufacturer's guidelines related to insulin pen usage for 5 of 20 residents reviewed for Quality of Care. (Residents 2, 93, 7, 78, and 29) Findings include: 1. Resident 2's clinical record was reviewed on 06/04/25 at 10:17 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 04/20/25, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, anemia, hypertension, and chronic kidney disease. An open-ended physician's order, with a start date of 01/31/25, indicated the nursing staff were to administer the resident's Metoprolol 12.5 milligrams (mg) daily at 9:00 A.M. and 9:00 P.M. for hypertension. The medication was to be held if the resident's systolic blood pressure (top number/heart at work) was less than 110, the diastolic blood pressure (bottom number/heart at rest) was less than 60, or the resident's heart rate was less than 60. The May 1 through June 3, 2025 Electronic Medication Administration Record (EMAR) indicated the resident had received the medication twice a day. The record lacked documentation of any assessment of the resident's blood pressure and heart rate for the 9:00 P.M. dose of the medication. The current facility policy titled PHYSICIAN ORDERS/FOLLOWING PHYSICIAN ORDERS GUIDELINE, with a review date of 02/12/24, was provided by the Administrator on 06/04/25 at 10:50 A.M. The policy indicated, .It is the policy of the facility to follow the orders of the physician . 2. The clinical record for Resident 93 was reviewed on 06/02/25 at 10:47 A.M. An admission MDS assessment, dated 05/01/25, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, hypertension and orthostatic hypotension. An open-ended physician's order, with a start date of 04/25/25, indicated the staff were to administer the resident's Midodrine 5 mg, twice a day for hypotension. The staff were to hold the medication if the resident's systolic blood pressure was greater than 120 or the diastolic was greater than 80. The May and June 2025 EMAR and Vitals Report lacked that the resident had the blood pressure monitored before administration of the medication from 05/07/25 at 9:00 P.M. through 06/03/25 at 9:00 A.M. 3a. The clinical record for Resident 7 was reviewed on 06/02/25 at 9:57 A.M. A Quarterly MDS assessment, dated 04/17/25, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, hypertension, diabetes, hyponatremia, and depression. An open-ended physician's order, with a start date of 12/30/24, indicated the staff were to administer the resident's Coreg 25 mg, twice a day for hypertension. The staff were to hold the medication if the resident's systolic blood pressure was less than 110 or the diastolic blood pressure was less than 60. The April and May 2025 EMAR indicated the resident had received the medication when their diastolic blood pressure was less than 60 on the following dates and times: - On 04/24/25 at 9:00 A.M., the resident's blood pressure was 200/51. - On 05/07/25 at 5:00 P.M., the resident's blood pressure was 111/58. - On 05/11/25 at 9:00 A.M., the resident's blood pressure was 159/58. - On 05/24/25 at 9:00 A.M., the resident's blood pressure was 113/59. 3b. An open-ended physician's order, with a start date of 05/20/25, indicated the staff were to administer the resident's Lisinopril 10 mg, once a day for hypertension. The staff were to hold the medication if the resident's systolic blood pressure was less than 110 or the resident's heart rate was less than 60. The May 2025 EMAR indicated the resident had received the medication when their heart rate was less than 60 on the following dates: - On 05/24/25 the resident's heart rate was 58. - On 05/25/25 the resident's heart rate was 58. - On 05/31/25 the resident's heart rate was 59. 4. The clinical record for Resident 78 was reviewed on 06/03/25 at 10:03 A.M. A Quarterly MDS assessment, dated 03/12/25, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, cerebral palsy, orthostatic hypotension, depression, pressure ulcer to the left buttock, and adult failure to thrive. A current physician's order, with a start date of 08/21/24, indicated the staff were to administer the resident's Midodrine 10 mg, every 8 hours for hypotension. The staff were to hold the medication when the resident's systolic blood pressure was greater than 100. The April, May, and June EMAR, indicated the resident had received the medication when their systolic blood pressure was greater than 100 on the following dates and times: - On 04/02/25 at 10:00 P.M., the resident's blood pressure was 109/60, - On 04/03/25 at 2:00 P.M., the resident's blood pressure was 101/65 and at 10:00 P.M., when the blood pressure was 112/67, - On 04/04/25 at 2:00 P.M., the resident's blood pressure was 116/79. - On 04/05/25 at 2:00 P.M., the resident's blood pressure was 111/69. - On 04/06/25 at 10:00 P.M., the resident's blood pressure was 116/71. - On 04/10/25 at 2:00 P.M., the resident's blood pressure was 113/72. - On 04/11/25 at 6:00 A.M., the resident's blood pressure was 110/58. - On 04/12/25 at 2:00 P.M., the resident's blood pressure was 110/64. - On 04/13/25 at 10:00 P.M., the resident's blood pressure was 106/68. - On 04/14/25 at 6:00 A.M., the resident's blood pressure was 102/58 and 2:00 P.M., when the resident's blood pressure was 109/66. - On 04/15/25 at 2:00 P.M., the resident's blood pressure was 110/54 and 10:00 P.M., the resident's blood pressure was 109/55. - On 04/16/25 at 10:00 P.M., the resident's blood pressure was 102/66. - On 04/18/25 at 2:00 P.M., the resident's blood pressure was 114/70. - On 04/19/25 at 10:00 P.M., the resident's blood pressure was 108/72. - On 04/22/25 at 2:00 P.M., the resident's blood pressure was 102/56. - On 04/24/25 at 6:00 A.M., the resident's blood pressure was 116/64. - On 04/25/25 at 6:00 A.M., the resident's blood pressure was 114/62. - On 04/27/25 at 2:00 P.M., the resident's blood pressure was 106/58. - On 05/06/25 at 2:00 P.M., the resident's blood pressure was 102/62. - On 05/08/25 at 6:00 A.M., the resident's blood pressure was 114/62 and 2:00 P.M., the resident's blood pressure was 104/62. - On 05/09/25 at 10:00 P.M., the resident's blood pressure was 102/58. - On 05/12/25 at 2:00 P.M., the resident's blood pressure was 107/64. - On 05/13/25 at 6:00 A.M., the resident's blood pressure was 108/63 and 10:00 P.M., the resident's blood pressure was 108/56. - On 05/15/25 at 2:00 P.M., the resident's blood pressure was 102/55. - On 05/18/25 at 2:00 P.M., the resident's blood pressure was 107/63 and 10:00 P.M., the resident's blood pressure was 103/59. - On 05/22/25 at 6:00 A.M., the resident's blood pressure was 103/53. - On 05/23/25 at 2:00 P.M., the resident's blood pressure was 102/60 and 10:00 P.M., the resident's blood pressure was 102/60. - On 05/25/25 at 2:00 P.M., the resident's blood pressure was 106/60. - On 05/26/25 at 2:00 P.M., the resident's blood pressure was 118/62. - On 05/31/25 at 10:00 P.M., the resident's blood pressure was 112/66. - On 06/01/25 at 6:00 A.M., the resident's blood pressure was 106/64. During an interview, on 06/03/25 at 2:02 P.M., Licensed Practical Nurse (LPN) 2 indicated when a resident's medication had hold parameters, she would obtain the vital sign before giving the medication. If the vital was outside the parameters, then she would not administer the medication. She would document in the EMAR that the medication was not administered. 5. During an observation and record review, on 06/02/25 at 9:03 A.M., LPN 2 gathered Resident 29's Lantus pen from the medication cart. The resident was to receive 34 units of Lantus. The LPN removed the cap, cleansed the top with an alcohol pad, placed the needle on the pen, and turned the pen to 34 units. She went into the resident's room and administered the insulin. The LPN did not prime the insulin pen prior to dialing up the required units or administering the Lantus. During an interview, on 06/04/25 at 11:53 A.M., LPN 5 indicated before administering insulin in a pen she would prime the pen with two units of insulin. The current Lantus insert, was provided by the Regional Director of Operations on 06/04/25 at 3:46 P.M. The insert indicated, .Do a safety test .Always do a safety test before each injection to: Check your pen and the needle to make sure they are working properly .Make sure that you can get the correct LANTUS dose .Select 2 units by turning the dose selector until the dose pointer is at the 2 mark. Press the injection button all the way in. When insulin comes out of the needle tip, your pen is working correctly . 3.1-37(a)

Based on observation and interview, the facility failed to store foods appropriately to prevent contamination for 1 of 2 kitchen observations. Findings included: 1. The initial kitchen tour was conducted on 05/29/25 at 10:48 A.M., and the following was observed: - A large clear plastic container sitting on a metal shelf contained flour. The lid was ill-fitting and not designed for the container, - A large clear plastic container sitting on a metal shelf contained sugar with a plastic scoop sitting inside. During an interview on 05/29/25 at 10:50 A.M., Dietary Aide 13 indicated the scoop should not have been left in the sugar and the lids were not the right ones for the containers. During the initial kitchen tour, the noon time meal was completely prepared and no staff were actively using the flour or sugar. An exterior door was within ten feet of the inappropriately sealed flour and sugar bins. The current facility policy titled, Food Storage (Dry, Refrigerated and Frozen), dated 08/12/23, was provided by the Administrator on 06/04/25 at 10:50 A.M. The policy indicated, .5. All open products (as able) will be sealed (rolled closed, wrapped closed, with lids closed, etc.) to ensure quality and prevent contamination against pest or rodents .Scoops stored outside of bin in clean, designated space . 3.1-21(i)(3)

3. The clinical record for Resident 52 was reviewed on 06/03/25 at 2:08 P.M. A Quarterly MDS assessment, dated 02/24/25, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, a stroke, depression, obesity, and weakness. An open-ended physician's order, with a start date of 06/02/25 at 2:31 P.M., indicated the resident was in enhanced barrier precautions for a pressure wound. During an observation, on 06/03/25 at 2:09 P.M., the resident's door had a sign on it that indicated staff were to STOP and that the resident was in ENHANCED BARRIER PRECAUTIONS. Staff must wear a gown and gloves for high contact resident care activities, including but not limited to, Wound Care: any skin opening requiring a dressing. Supplies, including gowns and gloves were in a plastic container with drawers outside the resident's room. LPN 17 and NP 16 entered the resident's room and provided wound care to the resident's pressure ulcer without donning gowns. Based on observation, interview, and record review, the facility failed to follow infection control guidelines related to the placement of urinary catheter tubing and drainage bag and Enhanced Barrier Precautions (EBP) for 4 of 20 residents reviewed for infection control. (Residents 31, 84, 52, and 78) Findings include: 1. On 05/29/25 at 1:59 P.M., Resident 31 was observed propelling herself in her wheelchair. The resident's urinary catheter bag was hanging under her wheelchair, and the bag and tubing were dragging on the floor under the chair. Cloudy yellow urine was observed in the bag and tubing. During an interview, on 05/29/25 at 2:05 P.M., the resident indicated staff always assisted her into her wheelchair and placed her catheter bag under the wheelchair. The catheter bag was always dragging. The resident propelled herself around in her room and the drainage bag was hanging close to the wheel of the wheelchair, dragging on the floor. She wanted a leg bag, and they tried it once, but they taped it to her leg and that didn't work out. They've never used a dignity pouch; they did put the drainage bag inside a plastic bag once. She had a urinary tract infection last month. The resident's clinical record was reviewed on 06/04/25 at 2:14 P.M. A Quarterly Minimum Data Set (MDS) assessment, dated 03/06/25, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, stroke, hypertension, and diabetes. On 06/02/25 at 10:27 A.M., the resident was observed in her room sitting in her wheelchair. The resident's catheter bag was hanging under the wheelchair. The bag was folded over, with several inches of it resting on the floor. On 06/02/25 at 1:55 P.M., the resident was observed propelling herself in her wheelchair in the main dining room. The resident's catheter bag and tubing were dragging on the floor under the wheelchair as she went by. On 06/04/25 at 2:10 P.M., the resident was observed with the Assistant Director of Nursing (ADON). The resident was in her wheelchair in the hallway near her room. The resident's drainage bag was hanging under the wheelchair. The catheter tubing was resting on the floor. The resident's urine was yellow and cloudy with sediment in the tubing. The ADON walked by the resident and indicated the resident's catheter tubing and drainage bag should not touch the floor. The ADON instructed the CNA on the resident's hallway to reposition the resident's drainage bag and tubing off of the floor. The current facility policy, titled :GUIDELINES FOR INDWELLING FOLEY CATHETER CARE, dated 10/16/24, was provided by The Regional Director of Operations on 06/04/25 at 2:56 P.M. The policy indicated, The main purpose of proper indwelling foley catheter care is to prevent catheter associated urinary tract infections . 2. Resident 84's clinical record was reviewed on 06/02/25 at 2:44 P.M. A Quarterly MDS assessment, dated 02/27/25, indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, traumatic brain injury, quadriplegia, and respiratory failure. The resident had an indwelling urinary catheter, a gastrostomy tube (G-tube), a tracheostomy, a peripherally inserted central catheter (PICC line), and pressure ulcers. The resident's current physician's orders included, but were not limited to, an open-ended order, with a start date of 04/14/25 for Enhanced Barrier Precautions every shift. During an observation on 06/03/25 at 1:49 P.M., the resident's door had a sign on it that indicated staff were to STOP and that the resident was in ENHANCED BARRIER PRECAUTIONS. Staff must wear a gown and gloves for high contact resident care activities, including but not limited to, Wound Care: any skin opening requiring a dressing. Supplies, including gowns and gloves were in a plastic container with drawers outside the resident's room. Nurse Practitioner (NP) 16 and Licensed Practical Nurse (LPN) 17 entered the resident's room and provided wound care to the resident's pressure ulcer without donning gowns. 4. The clinical record for Resident 78 was reviewed on 06/03/25 at 10:03 A.M. A Quarterly MDS assessment, dated 03/12/25, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, cerebral palsy, orthostatic hypotension, depression, pressure ulcer to the left buttock, and adult failure to thrive. An open-ended physician's order, with a start date of 03/10/24, indicated the resident was in enhanced barrier precautions for a pressure wound. During an observation, on 06/03/25 at 1:52 P.M., the resident's door had a sign on it that indicated staff were to STOP and that the resident was in ENHANCED BARRIER PRECAUTIONS. Staff must wear a gown and gloves for high contact resident care activities, including but not limited to, Wound Care: any skin opening requiring a dressing. Supplies, including gowns and gloves were in a plastic container with drawers outside the resident's room. NP 16 and LPN 17 entered the resident's room and provided wound care to the resident's pressure ulcer without donning gowns. During an interview, on 06/03/25 at 2:38 P.M., the ADON indicated that Residents 84, 52, and 78 were on EBP. The staff, providing wound care, should have worn gowns and gloves while in the room providing direct care. The current facility policy titled, Guidelines for Enhance Barrier Precautions, was provided by the Director of Nursing on 06/03/25 at 3:18 P.M. The policy indicated, .It is the policy of the facility to ensure that additional and appropriate PPE [Personal Protective Equipment] is utilized, when indicated, to prevent the spread of Multidrug-resistant Organisms .Enhanced Barrier Precautions are defined as the use of PPE [gowns and gloves] during high-contact resident care activities . 3.1-18(b)

Based on observation, record review, and interview, the facility failed to store medications appropriately for 1 of 1 resident reviewed for self-administering medications. (Resident 7) Findings include: During an observation and interview, on 05/29/25 at 12:04 P.M., Resident 7 was lying in his bed. His over the bed table was sitting beside the bed and contained two medicine cups. One cup had one pill in it and the other had seven pills in it. The resident indicated the medications had been there for some time. He believed the medication was his gabapentin, muscle relaxer, and his cholesterol medications. He was unsure what the others were. There were no nursing staff in the room. The clinical record for Resident 7 was reviewed on 06/02/25 at 9:57 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 04/17/25, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, hypertension, diabetes, hyponatremia, and depression. The clinical record lacked an assessment for the resident to self-administer his medications or a physician order to self-administer medications. During an interview, on 06/03/25 at 2:02 P.M., Licensed Practical Nurse (LPN) 2 indicated if a resident self-administered medications, then they would have a physician's order to do so and have an assessment completed. During an interview, on 06/04/25 at 10:09 A.M., the Assistant Director of Nursing (ADON) indicated the resident did not have an order to self-administer medications and should not have had the medications sitting at his bedside unattended. The current facility policy titled, Self-Administration of Medications by Residents, dated March 2023, was provided by the Director of Nursing on 06/03/25 at 3:18 P.M. The policy indicated, .Self-administration medications will be encouraged if it is desired by the resident, safe for the resident, and other residents of the facility, ordered by the attending physician, and approved by the Interdisplinary Team .If the resident demonstrates the ability to safely self-administer medications, a further assessment of the safety of bedside medication storage is conducted .A physician order is obtained to self-administer medications if the above storage and skill assessment has been approved for the resident by the interdisplinary team. The order is recorded on the MAR [Medication Administration Record] . 3.1-11(a)

Based on record review and interview, the facility failed to ensure a Minimum Data Set (MDS) assessment was transmitted to the Centers for Medicare and Medicaid Services (CMS) in a timely manner for 1 of 20 resident assessments reviewed. (Resident 85) Findings include: The clinical record for Resident 85 was reviewed on 06/03/25 at 12:11 P.M. A Discharge assessment, dated 12/28/24, indicated the resident admitted to the facility from the hospital on [DATE]. The resident discharged from the facility on 12/28/24. The discharge was unplanned, and the resident went home. The assessment history indicated the assessment was never added to a batch to be transmitted to CMS. During an interview on 06/04/25 at 2:36 P.M., the Regional MDS Coordinator indicated it didn't look like the discharge assessment was transmitted. It should have been sent out sooner. The facility did not have a policy related to transmitting MDS assessments. They followed the RAI (Resident Assessment Instrument) manual. 3.1-31(a)

Based on observation, record review, and interview, the facility failed to revise a resident's care plan related to the resident's leg prosthesis for 1 of 20 residents reviewed for care plans. (Resident 75) Findings include: Resident 75 was observed in his room on 05/29/25 at 11:30 A.M. The resident was sitting in his wheelchair. The resident had a below the knee amputation of his left leg and was wearing a prosthetic leg. On 06/02/25 at 10:57 A.M., the resident was observed in his room with a family member. The resident was wearing his prosthetic leg. On 06/03/25 at 12:02 P.M., the resident was in his room with a family member. The resident was wearing his prosthetic leg. The resident indicated he had the prosthetic for 3 or 4 years. He had no problems with it. Nursing staff assisted him with putting it on every day. He did not put it on himself. The clinical record for Resident 75 was reviewed on 06/04/25 at 1:25 P.M. A Quarterly Minimum Data Set (MDS) assessment, dated 05/16/25, indicated the resident was severely cognitively impaired. The diagnoses included, but were not limited to, heart failure, diabetes, non-Alzheimer's dementia, and acquired absence of the left leg. The resident had an impairment on one side of their lower extremity. There was no indication the resident had a limb prosthesis. The resident admitted to the facility on [DATE]. During an interview on 06/04/25 at 2:30 P.M., the MDS Coordinator indicated the MDS assessment did not indicate the resident wore a prosthetic leg. He didn't wear a prosthesis when he admitted to the facility. The resident did have a care plan for assistance with activities of daily living (ADLs) related to the below the knee amputation. During an interview, on 06/04/25 at 2:38 P.M., Licensed Practical Nurse 5 indicated the resident had worn the prosthetic leg since she had taken care of him. During an interview, on 06/04/25 at 2:40 P.M., Certified Nurse Aide (CNA) 6 indicated she was familiar with the resident. Every time she assisted the resident with care, she would help him get cleaned up and get dressed and put his prosthetic on. The resident's Care Plans were reviewed on 06/03/25 at 3:00 P.M. The resident's Care Plan for assistance with ADLs related to the below the knee amputation lacked any indication the resident had a prosthetic leg. During an interview on 06/04/25 at 3:21 P.M., the Assistant Director of Nursing indicated he was aware that the resident had a prosthetic leg. The resident's Care Plan should reflect the use of the prosthetic; there should be some direction for the CNAs. The current facility policy, titled Baseline Care Plan Assessment/Comprehensive Care Plans, with a revision date of 03/23/21, was provided by the Regional Director of Operations on 06/04/25 at 3:40 P.M. The policy indicated, .The Comprehensive Care Plans will be reviewed and updated every quarter at a minimum. The facility may need to review the care plans more often based on changes in the resident's condition 3.1-35(b)(1)

Based on observation, interview, and record review, the facility failed to follow physician's orders related to wound treatments for pressure ulcers for 1 of 4 residents reviewed for pressure ulcers. (Resident 78) Findings include: Resident 78 was observed on 06/03/25 at 1:52 P.M., with the Wound Nurse Practitioner (NP) and the Assistant Director of Nursing (ADON). The resident had a wound to the left ischium (lower hip bone area) that had no signs of infection and measured 0.5 centimeters (cm) by (X) 0.3 cm X 0.2 cm, and the resident had a wound to the sacrum (bottom of the spine) that measured 0.8 cm X 0.8 cm X 0.4 cm. The clinical record for Resident 78 was reviewed on 06/03/25 at 10:03 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 03/12/25, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, cerebral palsy, orthostatic hypotension, depression, pressure ulcer to the left buttock, and adult failure to thrive. A Wound NP Assessment Report, dated 10/28/24, indicated the resident had a Stage 4 (full-thickness tissue loss with exposed muscle, tendon, or bone) pressure ulcer to the left ischium. The wound measured 1 cm X 0.6 cm X 0.3 cm. The treatment order was to be changed to cleanse the wound with Dakins solution, apply collagen to the wound bed, and cover with border gauze, daily. The physician's order, dated 10/28/24, was not initiated untill 11/08/24. A Wound NP Assessment Report, dated 12/16/24, indicated the resident had a Stage 4 pressure ulcer to the left ischium. The wound measured 0.6 cm X 0.5 cm X 0.2 cm. The treatment order was to be changed to cleanse the wound with Dakins solution, apply collagen with silver, and cover with border gauze, daily. The physician's order, dated 12/16/24, was not initiated untill 12/20/24. A Wound NP Assessment Report, dated 01/08/25, indicated the resident had a Stage 4 pressure ulcer to the left ischium. The wound measured 1.4 cm X 1 cm X 0.5 cm. The treatment order was to be changed to cleanse the wound with Dakins solution, apply Dakins moistened fluffed gauze to the wound, and cover with border gauze, twice a day. The physician's , dated 01/08/25, was not initiated untill 01/12/25. A Wound NP Assessment Report, dated 01/20/25, indicated the resident had a Stage 4 pressure ulcer to the left ischium. The wound measured 1.4 cm X 1 cm X 0.8 cm. The treatment order was to be changed to cleanse the wound with Dakins solution, apply collagen particles, and cover with border gauze, daily. The physician's order, dated 01/20/25, was transcribed for a twice a day treatment instead of daily. A Wound NP assessment Report, dated 02/26/25, indicated the resident had a Stage 4 pressure ulcer to the left ischium. The wound measured 1.8 cm X 1 cm X 0.8 cm. The treatment order was to be changed to cleanse with Dakins solution, apply collagen particles, and apply negative pressure wound therapy, three times a week. The order was transcribed to cleanse the wound with wound cleanser, apply collagen particles, and cover with border gauze every 12 hours from 02/27/25 through 03/14/25. A Wound NP assessment Report, dated 03/05/2025, indicated the resident had a Stage 4 pressure ulcer to the left ischium. The wound measured 1.8 cm X 1 cm X 0.8 cm. The treatment order was to be changed to cleanse with Dakins solution, apply collagen particles, and apply negative pressure wound therapy, on Wednesday and Saturdays. The order for the wound was not changed until 03/15/25. The December 2024 through May 2025 Electronic Treatment Administration Record (ETAR) lacked documentation for Resident 78's left ischium being completed on the following dates: - 12/07/24, - 12/12/24, - 12/19/24, - 01/03/25, - 01/20/25 at evening, - 01/30/25 at evening, - 02/09/25, - 05/08/25, - 05/16/25, - 05/19/25, and - 05/23/25. During an interview, on 06/04/25 at 10:04 A.M., the ADON indicated they would follow the orders of the Wound NP. The Wound NP came to the building weekly. Within 24 hours of her visit, she would send him (the ADON) new orders or recommendations. He would transcribe and implement the new orders within 24 hours of receiving them. During an interview, on 06/04/25 at 2:57 P.M., the ADON indicated the resident's treatments should have been followed per the Wound NP's orders. They were either transcribed wrong or not implemented timely. If there was a blank in the ETAR it meant the treatment was not completed. The current facility policy titled PHYSICIAN ORDERS/FOLLOWING PHYSICIAN ORDERS GUIDELINE, with a review date of 02/12/24, was provided by the Administrator on 06/04/25 at 10:50 A.M. The policy indicated, .It is the policy of the facility to follow the orders of the physician . 3.1-40 (a)(2)

A. Based on record review, interview, and observation, the facility failed to ensure 1 resident was free of burns related to electrode stimulating (e-stim) therapy treatments. (Resident #33) B. Based on record review, interview, and observation, the facility failed to ensure residents were free from falls for 2 of 5 residents who met the criteria for falls. (Residents #J and #111) Findings include: A. Resident #33's record was reviewed on 1/30/14, at 11:23 p.m. The record indicated resident #33 was admitted with [DIAGNOSES REDACTED]. Progress Notes, dated 12/27/13 at 1:14 p.m., indicated: "Therapy presents pt (patient) with report of burn marks from electrodes on front of right shoulder and back of rt shoulder, pt denies any pain or discomfort, areas are white in color, no blistering or redness at this time, spouse informed, md aware, no new orders at this time, cont(inue) to monitor areas, therapy to evaluate equipment. 130/72 (blood pressure) -72 (heart rate) -20 (respirations) T 97." Progress Notes, dated 12/28/13 at 12:07 p.m., indicated: "Upon assessment at this time to areas anterior and posterior right shoulder there is noted blisters from incident yesterday. MD and husband notified resident denies any pain or discomfort will continue to monitor q (every) shift and PRN (as needed). B/P 178/69 P 86 R 18 T 98.8." Progress Notes, dated 12/28/13 at 2:23 p.m., indicated: "Cont(inue) to monitor blister areas on right post(erior) and front shoulder area no c/o (complaints of)pain no open areas or drainage bp 156/78 r 16 p 88 t 98 oxygen (saturation) 92%." Progress notes, dated 12/31/13 at 6:49 a.m., indicated: "Res(ident) rested quietly abed all noc (night) with no c/o voiced. Blisters to right shoulder cont. blisters are intact, edges light pink with scabbing in the center. No s/s (signs or symptoms) infection to area. Res. denies any pain." Progress notes, dated 1/3/14 at 1:02 p.m., indicated: "Blisters on front & back of R shoulder are beginning to crust over, no drainage noted, res continues to have no c/o pain/discomfort at the area, will continue to monitor." A social service progress note, dated 1/6/14 at 4:00 p.m., indicated: "Late Entry: Note Text: Completed quarterly assessment for Martha. BIMS (brief interview for mental status) =15 (resident is cognitively intact)...." A progress note, dated 1/17/14 at 1:31 p.m., indicated: "RD (registered dietitian) note: Res has burn area on shoulder. Area is Scabbed over. Continue with current diet. Intake is 5-100% with refusal of breakfast every morning...." On 1/31/14 at 10:12 a.m., the Director of Nurses (DoN) indicated that after therapy, Resident #33 had white areas on her skin, and the next day they had turned into blistered areas. She indicated the e-stim (electrode stimulating therapy machine) was put out of commission and they started the reportable incident. Therapy did an inservice and they got a new e-stim machine. The Administrator indicated, at that time, they had been doing an annual machine check and now they do it every 6 months. She indicated the calibration was off and the blisters were in the shape of the pad. Physician's telephone orders, dated 1/27/14 at 2:00 p.m., indicated: "OT (Occupational Therapy) clarification order - pt to cont skilled OT services 3X/wk X30 days to include self care, therx (therapeutic exercises) therapeutic activities, NMRED (neuro-muscular re-education." Physician's telephone orders, dated 1/30/14 at 12:00 p.m., indicated: "Clean areas to (R) shoulder (with) N/S (normal saline) apply Silvadene cream cover (with) dry dressing (change) BID (twice a day)." On 1/31/14 at 10:46 a.m., Occupational Therapist #1 brought in an e-stim unit. She indicated: "There is a setting to select a higher intensity, for example if you want to get a muscular contraction, can use it to increase circulation." She indicated she "gets good results from stimulating the muscle to get the message to the brain", example: if she wanted to get the wrist moving, would put the pad proximal to the wrist to get the message to the wrist to get the muscle moving to get stimulation. She indicated Resident #33 was receiving e-stim for pain management and he pads were placed on her right shoulder. Occupational Therapist #1 provided a package of "Dura-Stick Plus Self-Adhesive Tens Stimulating Electrodes" that are used with the e-stim. The Dura-Stick pad was 2 inches round. The indications for use on the package indicated: "...16. Using stimulation electrodes that are too small or incorrectly applied could result in discomfort or skin burns...." Occupational Therapist #1 indicated they had used them several weeks, and Resident #33's pain was decreasing. She said the skin "was red immediately after, and had a white area. The area was warm immediately after the e-stim." She indicated she called her supervisor and told her what happened, her supervisor called the company to calibrate the machines, and they "locked the machines up and did not use them until they were calibrated." During an interview, on 1/31/14 at 12:04 p.m., Resident #33 indicated the area on her right shoulder has not hurt, it was "just one of those things", and she has been getting the treatments for awhile and has had no problems. The area on her right upper shoulder was covered with a small bandage, the resident pulled the neck of her top over an inch and the small bandage was visible. B. 1. Resident #J's record was reviewed on 1/28/14 at 3:55 p.m. The record indicated Resident #J was admitted with [DIAGNOSES REDACTED]. A fall risk assessment dated [DATE] indicated a score of 10. The assessment indicated the resident was alert, chair bound, had no falls in the last 3 months, vision was adequate, was unable to participate in the gait balance assessment, and resident takes 3-4 meds on the medication list that could increase falls. A quarterly Minimum Data Set assessment (MDS), dated [DATE], indicated Resident #J had no falls since the last assessment. A care plan, dated 5/21/13, indicated: "Resident is at risk for falls D/T (due to) history or recent fall. Goals: Resident will have no injuries due to falls TNR (through next review). Interventions: Attempt to keep areas free of clutter. Keep call light in reach. Maintain T (toileting) time as indicated. Maintenance to check safety belt and all connections weekly. (8/3/13 fall) Monitor seatbelt every shift for proper functioning. (3/6/13) Notify and update MD as needed. Therapy screen as indicated, quarterly and prn (as needed). (5/21/13)" Progress Notes, dated 8/3/13 at 7:00 a.m., indicated: "Heard noise. Looked toward sound and seen pt. (patient) on floor in front of w/c (wheel chair). alarm not sounding. Safety belt noted to be broken on L) side of w/c. ROM WNL (range of motion within normal limits) for pt. NO (new order) inversion of feet noted. Denied pain with ROM. Skin assessment with abrasions noted on R) brow area, R) elbow, and R) knee. No bleeding, just top layer of skin off. Maintenance notified and pt. transferred to bed while repairs made to w/c. Neuro checks initiated and WNL. 140/80 (blood pressure) 96 (temperature) 70 (pulse) 18 (respirations) 02 (oxygen saturations) - 94%. MD and (name of family member) notified of fall. CNAs to check safety belt and all connections and make sure alarm working when getting pt up." An "Incident Documentation and Investigation Tool", dated 8/3/13, indicated Resident #J had an unwitnessed fall on 8/3/13 at 7:00 a.m., and received abrasions on the right brow, right elbow, and right knee. The resident was leaning forward and fell from the wheel chair, and the seat belt alarm did not sound. Maintenance was called and came in and fixed the problem of the safety belt. A new intervention was added to the care plan to "check safety belt and all connections weekly' and a "therapy screen". On 1/31/14 at 12:06 p.m., the Corporate Nurse Consultant provided a copy of the treatment records dated August 2013. She indicated this was the documentation of the seat belt and alarm checks, for Resident #J, that staff had been doing. The documentation indicated the belt alarm and pressure alarm placement and function was checked every shift, the close call alarm placement and function was checked every shift, and the battery was changed on the 15th of each month. B. 2. Resident #111's clinical record was reviewed on 01/28/14 at 09:30 a.m. The record indicated Resident #111 was admitted with [DIAGNOSES REDACTED]. A Fall Risk Assessment, dated 02/04/13, indicated resident's total score was 18, whereas a total score of 10 or above represents high risk. Resident Admission assessment dated [DATE], indicated Resident #111 used a manual wheelchair, had an unsteady gait, was with diminished eyesight, was alert and oriented to self and confusion, and had a fall in the last 30 days. A plan of care, dated 05/03/13, "Potential for falls r/t new surroundings, impaired vision, impaired mobility, Diagnosis: [REDACTED]. Goals: will have no significant injury from falls TNR (till next review). Intervention (initiation date 06/26/13/revision date 11/18/13) do not leave in room unattended in w/c (wheelchair)". An "Incident Report " for Resident #111 was provided by the DoN, on 01/28/14 at 4:55 p.m. The report indicated, but was not limited to, nurse (LPN #12) was called to resident's room on 01/21/14 at 6:10 p.m., and found resident on floor by bed with back resting on bed and had been in his wheelchair. The resident indicated he was going to the bathroom to wash up. The resident was assessed/assisted to wheelchair and to bathroom to get washed up and neurological checks started. Resident #111 was brought up by the nurse's station after finished washing up and nurse (LPN #12) noted that "staff member educated ". During an interview, on 01/31/14 at 9:56 a.m., LPN #12 indicated that she was the nurse that went to resident #111's room on 01/21/14 at 6:10 p.m. She indicated that this fall happened right at shift change time and she heard alarm sounding and when she got to room she found resident as she noted in the incident report. She indicated that Resident #111 had been in his wheelchair when he attempted to get up and that he was alone in the room at the time. She indicated that the plan of care was not followed as resident was alone in room in the wheelchair. She did educate the staff person (a CNA) about the plan of care intervention (do not leave in room unattended in w/c). A "Care Plan intervention edit" , dated 01/21/14, was provided by the DoN, on 01/24/14 at 3:25 p.m. The document indicated a new intervention "to get resident up at 5:30 in the am clean up and bring to the lobby to wait for breakfast". A policy and procedure for "Fall Risk Management Program Falls, Identification of Residents at Risk For", was provided by the Administrator on 1/27/14 at 2:40 p.m. The policy indicated, but was not limited to, "Purpose: Too identify those residents who may be at risk for falls. Policy: Upon completion of the initial, annual, or significant change resident assessment, those residents who trigger the area of "Falls" shall be identified and evaluated for potentially needed intervention. Procedure...2. RAP (Resident assessment protocol) trigger analysis will identify those residents who are potentially at risk for falls...5. As necessary, the Fall Risk Assessment shall be completed and recommendations made for interventions accordingly. Interventions addressed could include but not limited to recommendations for the following: a. Psychological Evaluation/Psychoactive Medication Review b. Assessment for potential drug therapy interactions causing gait difficulty c. PT, OT evaluations...7. Interventions will be addressed on the individual plan of care." This Federal tag relates to Complaint IN 516. 3.1-45(a)(2)

Based on record review and interview, the facility failed to ensure a resident was free of a significant medication error, resulting in [MEDICATION NAME] toxicity requiring hospitalization for treatment, for 1 of 3 residents reviewed for a medication error in a sample of 3. (Resident # C) Findings include: Resident # C's record was reviewed on 4/24/13 at 3:30 p.m., [DIAGNOSES REDACTED]. A handwritten readmission recapitulation order dated 3/14/13 included, but was not limited to, "[MEDICATION NAME] 0.25mg 1 1/2 tab QD, afib, 9am." Typed physician recapitulation orders dated 4/1/13 to 4/30/13 included, but was not limited to, "[MEDICATION NAME] tab 0.125mg, take one tablet with 0.25mg (total dose =0.375mg) by mouth once daily (DX: A fib) *check & record pulse*...3/14/13 (order written). [MEDICATION NAME] tab 0.25mg take 1 tablet with 0.125mg (total dose = 0.375) by mouth once daily (DX: A fib) *check & record pulse* 3/14/13 (order written)." Physician orders [REDACTED]. "3/22/13 128 (a.m., or p.m., not noted) (handwritten) Hold [MEDICATION NAME] til (symbol for after) dig level drawn 3/25/13." "3/27/13 145 p (handwritten) Restart [MEDICATION NAME] 0.25 mg po (by mouth) QD (every day), re (check mark) dig level in 2 wks. due 4/10/13." "4/4/13 418 p ...Dig level in AM...." "4/5/13 1. DC (discontinue) [MEDICATION NAME] orders. 2. Check dig level & chem (chemistry) 14 on 4/6/13 notify MD of any (symbol for changes)." "4/6/13 Send to (local hospital) ER." "4/19/13 [MEDICATION NAME] level every month starting 5/6/13." A review of the MAR indicated [REDACTED]. For 3/23/13 through 3/27/13, the medication was on hold. A review of the MAR indicated [MEDICATION NAME] tab 0.125mg, take 1 tablet with 0.25mg (total dose = 0.375mg) by mouth once daily (DX: A-Fib) *Check & record pulse* (order written 3/14/13) 9am. [MEDICATION NAME] tab 0.25mg take 1 tablet with 0.125mg (total dose=0.375mg) by mouth once daily (DX: A-fib) *Check & Record pulse* (written 3/14/13) 9am." Nurse's notes dated 4/5/13 11:50 p.m., included, but was not limited to, "Med (medication) error noted @ this x (time), (physicians name) on call for (physician's name), (physician's name) notified @ this x, recheck dig level in am, chem 14 [MEDICATION NAME] dc'd (discontinued) @ this x, ...aware of lab results & new orders, will continue to monitor." A lab result dated 3/22/13 1706 (5:06 p.m.) indicated, "Test: [MEDICATION NAME], result: 4.6, Flag: H (high), Reference: 0.8-2.0 ng/ml." A lab result dated 3/26/13 at 22:20 (10:20 p.m.), indicated "[MEDICATION NAME], result-1.4, reference 0.6-1.2 ng/ml." On 3/27/13 the following was handwritten on the lab result dated 3/26/13, "[MEDICATION NAME] 0.25mg, 1 1/2 tab QD, A fib, has been on hold since 3/23/13. Restart at 0.25mg, QD (was on previously) and re (check mark) dig level in 2 wks, restart on 3/28/13, (physician's signature)." A [MEDICATION NAME] lab result for 4/5/13 "result: (symbol for greater than) 5.0, Normal range: 0.9-2.0 ng/ml." A review of lab results dated 4/6/13 indicated "Result: [MEDICATION NAME] 5.7, Flag: H (high), reference level: 0.8 to 2.0. ng/ml." A handwritten note on the lab result indicated, [MEDICATION NAME] 0.125 po qd, with a line drawn through it, 0.375 mg, dc [MEDICATION NAME], re (check mark) dig level on 4/6/13, chem 14, notify of any changes, (physician's signature)." A review of Resident #C's H&P (history and physical) dated 4/6/13, (from the local hospital) included but was not limited to: "prior episode of dig ([MEDICATION NAME]) toxicity, recently in the hosp (hospital)[MEDICATION NAME] toxicity...she was [MEDICATION NAME]. I believe up to 0.375 mg daily and I was called about the [MEDICATION NAME] level Friday night, of 5.2. The labs were repeated as of Saturday morning and she was noted to have a [MEDICATION NAME] level up to 5.7. There is report of hallucinations and she is noted to have a BUN (blood test for blood urea nitrogen) of 52 and creatinine (blood test for renal health) up to 1.7. She was seen in the emergency room and felt to have [MEDICATION NAME] toxicity...Assessment: admission with [MEDICATION NAME] toxicity and nausea, auditory and visual hallucinations at the nursing home with evidence of multifactoral [MEDICAL CONDITION] and toxic metabolic [MEDICAL CONDITION]. [MEDICATION NAME] has been held, We will check levels today and tomorrow." Resident #C's discharge summary for the local hospital, dated 4/10/13, was reviewed and included, but was not limited to, "...Last time she was in the hospital...her [MEDICATION NAME] was subtherapeutic despite 0.25 mg every day on a reg basis. That was increased. In the nursing home, she showed levels of elevated [MEDICATION NAME] and her dose was backed down, but was never relayed to nursing and never got changed. She came in primarily agitated with a [MEDICATION NAME] level of 5.7. She was having hallucinations and had acute [MEDICAL CONDITION] with a BUN of 59 and creatinine of 1.7 and was admitted to the hosp, she was placed on IV... (physician's name) saw her in consultation for her heart issues, He reviewed the labs and just thought that her [MEDICATION NAME] if it was reinstituted should be started again at a very low dose." A handwritten document, dated 4/1/2013 by Nurse #1, included but was not limited to, "...regarding order I had transcribed on (resident # C) on [MEDICATION NAME]. I reviewed the chart; I did take the order off. Reviewed the MAR indicated [REDACTED]. I did not notice that the held order was for [MEDICATION NAME] 0.25 mg 1 1/2 tabs Q (every) day instead of (symbol for one) tab Q day. (signed nurse #1) 4-1-13." An interview on 4/25/13 at 1:30 p.m., with the Administrator and DON (Director of Nursing) indicated, "(Nurse #1) transcribed the [MEDICATION NAME] dose incorrectly...used the previous dose of medication." A form entitled "Employee memorandum" (This form is to be discussed with the employee) and dated 4/11/13, included, but was not limited to, "Name of Employee: (Nurse #1); State subject or code of conduct rule violated: Poor work quality...; Describe in detail information you have available which supports taking the above course of action...Nurse transcribed a med incorrectly; State what corrective action you feel the employee may take to eliminate the above problem area: Verify 5 rights of medications to ensure accuracy." A form titled "Medication discrepancy report" for Resident #C, and dated 4/5/13 at 11:10 p.m., was reviewed. "Employee discovering discrepancy: Nurse # 2; The actual discrepancy: [MEDICATION NAME] dose suppose to be 0.25 mg, res (Resident # C) getting 0.375 since 3/27/13 when (symbol for changed); How did you discover the discrepancy? Critical high dig ([MEDICATION NAME]) level received MD notified, noted order for 0.25 mg [MEDICATION NAME] ordered 3/27/13 MAR indicated [REDACTED]& MD notified, notify MD of any status (symbol for changes). Physician notified, (physician's name), Date: 4/5/13, Time: 1150 pm, Nurse's signature: (nurse # 2); Employee responsible for discrepancy (nurse #1); physician order [REDACTED].? Order was written but not transcribed to MAR (signed by DON)." An interview with Resident # C on 4/26/13 at 10:30 a.m., indicated that she was in the hospital recently with a "high medication level." "I was crazy for two days then I woke up and I was okay. It was a high medication level. I woke up after two days and was okay." This federal tag is related to complaint IN 389. 3.1-25(b)(9) 3.1-48(c)(2)

Based on record review, observation, and interview, the facility failed to ensure a resident with poor bed mobility received necessary services to prevent pressure areas, in that her heels were not floated off the bed and pressure ulcers developed on both heels. This affected 1 of 3 residents reviewed for pressure ulcers in a sample of 9. (Resident #D) Findings include: Resident #D's record was reviewed on 9/7/12 at 12:07 p.m. The record indicated Resident #D was admitted on [DATE] with [DIAGNOSES REDACTED]. A pre-surgery "Consultation Note" dated 4/22/12, for the coronary bypass surgery, included a physical that indicated, but was not limited to: "...Extremities are normal with pulses palpable at the popliteal (behind the knee) level, but difficult to palpate at the pedal (foot) level. Nevertheless, there is no evidence of arterial insufficiency atrophic changes. The right lower extremity is of normal caliber without evidence of phlebitis, varicosity, or [MEDICAL CONDITION]. The left lower extremity has thickening and skin changes consistent with chronic congestion...SKIN: Integrity is otherwise normal...." An admission Minimum Data Set assessment dated [DATE] indicated Resident #D was independent, decisions consistent/reasonable in cognitive skills for daily decision making, required extensive assistance of two or more for bed mobility and transfers, was at risk for developing pressure ulcers, and had no pressure ulcers, and no venous or arterial ulcers present upon admission. An assessment titled "Braden Scale - for predicting pressure sore risk", dated 5/2/12, indicated a total score of 16, which indicated a low risk for pressure ulcer development. A care plan initiated on 5/2/12 indicated a problem/need for impaired skin integrity related to sheared area to coccyx, surgical wound on chest, and surgical wound to right leg where a vein was removed (for the bypass surgery). Interventions included: "Notify MD & family of changes in condition, Tx (treatment) per order, Monitor VS (vital signs) as indicated. Monitor for s/s of increase &/or decrease in size of area, [MEDICATION NAME] (skin treatment) to coccyx per order. [MEDICATION NAME](antibiotic) per order (5/23/12)." A care plan dated 5/2/12, indicated "Resident requests use of side rails" with approaches that addressed turning and repositioning the resident every two hours and as needed. A care plan updated on 5/31/12, indicated a problem/need for impaired skin integrity related to 1) open blistered area on her left heel and intact blistered area to right heel. The care plan was updated again on 6/5/12, "open blister area to (R) heel." The interventions included treatment changes of [MEDICATION NAME] fluff to the right heel (6/5/12), then skin prep to blistered area on the right heel (6/8/12), an ortho(pedic) shoe from therapy (no date), santyl ointment to the left heel (6/6/12), and [MEDICATION NAME] nonadhesive and wrap with kerlix (6/8/12). There was no documentation in the care plans or nurse's notes that indicated Resident #D's heels were floated off the bed to reduce pressure on the heels. A physician's telephone order dated 6/19/12, indicated: "Transfer to (local hospital), open draining wound (L) foot." An admission history and physical from the local hospital, dated 6/19/12, indicated, but was not limited to: "History of present illness: (Resident's name) is a complex patient who comes into the hospital at this time with pressure sores on both feet. The left is worse than the right. There is some breakdown on the left with some drainage...The patient has not been mobile. She has been bedridden...The right lower extremity has some [MEDICAL CONDITION] in it. The left lower extremity has the previous saphenous vein graft. She has poor arterial flow believed to be present. Pressure sores are being evaluated by surgery...." A consultation report dated 6/26/12 indicated, but was not limited to, "...she is a (her age) year-old woman with a nonhealing ulceration of the left heel. Patient is about 2 months after coronary artery bypass surgery. She was convalescing in a nursing home and developed these heel ulcerations. She gives no prior history of ulceration...She says her ulcer is slowly healing. I suspect the etiology is primarily pressure, although inadequate vascular supply might be preventing resolution. Assessing her vascular insufficiency is difficult because of her [MEDICAL CONDITION] joint disease...." During interview on 9/7/12 at 1:45 p.m., LPN #1 indicated she did not see any documentation of where Resident #D's heels were elevated off the bed. On 9/7/12 at 2:00 p.m., the resident's right heel was observed with LPN #1. Resident #D's right foot had a sock and sneaker covering the foot, and the foot and leg rested on a pillow. The right heel had a tiny, scabbed area on the back of the heel. No redness or open areas were observed. The resident's left lower leg had been amputated while she was hospitalized . On 9/7/12 at 2:05 p.m., during interview, Resident #D indicated no one placed a pillow or anything under her legs to keep her heels off the bed until she got the sore areas on her heels. A Policy and Procedure for "Quality Assurance Skin Assessment" was provided by LPN #1 on 9/7/12 at 3:18 p.m. The policy indicated, but was not limited to, "Guideline" It is the intent of the facility we will monitor the residents' skin integrity regularly, document and treat as appropriate any identified skin conditions...." A policy and procedure for "Wound Care Treatment Protocols", dated 7/1/11, was provided by LPN #1 on 9/7/12 at 3:18 p.m. The policy indicated, but was not limited to, "Guideline: It is the practice of this facility to provide appropriate care and treatment to residents identified as having any skin conditions, abnormalities...." This Federal tag relates to complaint IN 395. 3.1-40(a)(1) 3.1-40(a)(2)

A. BASED ON RECORD REVIEW AND INTERVIEW, THE FACILITY FAILED TO: - IDENTIFY INEFFECTIVE ALARM USE WHICH RESULTED IN A RESIDENT'S FALL WITH FRACTURE, (RESIDENT #80) - IDENTIFY AND DOCUMENT ALL AVAILABLE INFORMATION RELATED TO THE CIRCUMSTANCES SURROUNDING RESIDENTS' FALL TO IDENTIFY POTENTIAL, CAUSAL FACTORS, IN AN ATTEMPT TO PREVENT RE-OCCURRENCES. (RESIDENT #80, #18 AND #7) - ENSURE CERTIFIED NURSING ASSISTANTS PROPERLY OPENED THE BASE OF A HOYER/ MECHANICAL LIFT IN A SAFE MANOR WHICH RESULTED IN A RESIDENT'S FALL, (RESIDENT #84) - UTILIZE A CLOSE CALL ALARM PROPERLY, RESULTING IN A FALL. (RESIDENT # 92) THIS AFFECTED 5 OF 7 RESIDENTS IN A SAMPLE OF 20 (#80, #18, #7, AND #92) AND 1 OF 3 IN A SUPPLEMENTAL SAMPLE OF 3 REVIEWED FOR SUPERVISION TO PREVENT ACCIDENTS AND ACCURACY OF INCIDENT INVESTIGATION. (RESIDENT #84) B. BASED ON INTERVIEW, OBSERVATION, AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE SUPERVISION TO PREVENT MULTIPLE EPISODES OF ELOPEMENT. THIS AFFECTED 1 OF 1 RESIDENTS REVIEWED FOR ELOPEMENT IN A SAMPLE OF 20 (RESIDENT # 10) AND 2 OF 3 RESIDENTS REVIEWED FOR ELOPEMENT IN A SUPPLEMENTAL SAMPLE OF 3. (RESIDENTS #6 AND 203) FINDINGS INCLUDE: A. 1. RESIDENT #80'S RECORD WAS REVIEWED ON 8/4/2010 AT 3:49 P.M. THE RECORD INDICATED RESIDENT#80 WAS admitted , WITH [DIAGNOSES REDACTED]. AN ADMISSION MINIMUM DATA SET ASSESSMENT, DATED AS COMPLETED ON 12/17/2009, INDICATED THE RESIDENT WAS MODERATELY IMPAIRED FOR DECISION MAKING REQUIRING CUES AND SUPERVISION. THE RESIDENT HAD LONG AND SHORT TERM MEMORY PROBLEMS. THE RESIDENT REQUIRED EXTENSIVE PHYSICAL ASSIST OF ONE STAFF MEMBER FOR TRANSFERS. A FALL RISK ASSESSMENT, DATED 12/31/2009, INDICATED THE RESIDENT WAS AT HIGH RISK FOR FALLS WITH A TOTAL SCORE OF 15. A TOTAL SCORE ABOVE 10 IDENTIFIED THE RESIDENT AT HIGH RISK FOR FALLS. A CARE PLAN WITH AN IDENTIFIED PROBLEM/NEED OF "POTENTIAL FOR FALLS R/T (RELATED TO) NEW SURROUNDINGS, CONFUSION, H/O (HISTORY OF) FALLS AT HOME, UNSTEADY GAIT, CHAIRBOUND AND POOR VISION," WHICH BORE AN INITIAL IDENTIFICATION DATE OF 12/8/2009, INCLUDED, BUT WAS NOT LIMITED TO, THE FOLLOWING INTERVENTION: "CLOSE CALL ALARM ON AT ALL TIMES." A NURSING NOTE OF 3/3/2010 AT 6:00 P.M., INDICATED: "RESIDENT ON FLOOR OUT IN HALLWAY, LYING ON (LEFT) SIDE...RESIDENT'S CLOSE CALL ALARM UNDONE PER RESIDENT. RESIDENT WAS NOTED TAKING ALARM OFF PRIOR TO INCIDENT AND HAD BEEN PROPERLY RE-APPLIED BY THE WRITER...." AN INCIDENT DOCUMENTATION AND INVESTIGATION TOOL, INDICATED THE resident sustained [REDACTED].M., WHEN THE RESIDENT UNCLIPPED HER ALARM. THE FALL WAS WITNESSED BY A FACILITY QUALIFIED MEDICATION AIDE. DURING AN INTERVIEW ON 8/10/2010 AT 3:05 P.M., THE DIRECTOR OF NURSING INDICATED IF A RESIDENT UNCLIPS THEIR PERSONAL ALARM, THE ALARM SHOULD BE PLACED OUT OF THE RESIDENT'S REACH OR STAFF SHOULD CHANGE TO A PRESSURE ALARM. A HISTORY AND PHYSICAL REPORT, DATED 3/5/2010, INDICATED THE FOLLOWING: "HISTORY OF PRESENT ILLNESS, THIS...(RESIDENT) ENTERED THE HOSPITAL VIA THE emergency room BECAUSE OF AN ACUTE SUBCAPITAL LEFT FEMORAL NECK FRACTURE WITH MILD IMPACTION. THE PATIENT fell AT THE NURSING HOME ON 3/3/2010 AROUND 6:00 P.M.. A PORTABLE HIP X-RAY ON 3/4/2010 DID NOT SHOW A FRACTURE. HOWEVER PATIENT CONTINUED TO HAVE LEFT HIP PAIN AND WAS REFERRED TO THE emergency room . IN THE ER SHE WOULD STAND BUT WAS UNABLE TO TO TAKE A STEP. AN X-RAY OF THE LEFT HIP WAS REPEATED, AND THIS TIME THE FRACTURE WAS FOUND...." A CARE PLAN WITH AN IDENTIFIED PROBLEM/NEED OF "FALLS," WHICH BORE AN INITIAL IDENTIFICATION DATE OF 3/3/2010, IDENTIFIED THE FOLLOWING INTERVENTIONS: "PRESSURE ALARM WHILE RES. (RESIDENT) (UP) IN W/C (WHEELCHAIR) OR IN BED." A QUARTERLY MINIMUM DATA SET ASSESSMENT, DATED AS COMPLETED ON 6/18/2010, INDICATED THE RESIDENT #80 WAS MODERATELY IMPAIRED FOR DECISION MAKING REQUIRING CUES AND SUPERVISION AND LONG AND SHORT TERM MEMORY PROBLEMS. THE RESIDENT REQUIRED EXTENSIVE PHYSICAL ASSIST OF TWO STAFF MEMBERS FOR TRANSFERS AND REQUIRED PARTIAL PHYSICAL ASSIST FOR THE TEST OF SEATED BALANCE, BUT WAS NOT ABLE TO FOLLOW INSTRUCTIONS FOR THE TEST. A NURSING NOTE, DATED 6/20/2010 AT 7:30 A.M., INDICATED: "CALLED TO RESIDENT'S ROOM, CNA IN BATHROOM (WITH) RESIDENT. RESIDENT SITTING ON FLOOR IN FRONT OF COMMODE. RESIDENT DENIED ANY C/O (COMPLAINTS OF) PAIN...." THE INCIDENT DOCUMENTATION AND INVESTIGATIONAL TOOL, FAILED TO CAPTURE THE FOLLOWING INFORMATION RELATED TO THE CIRCUMSTANCES SURROUNDING THE RESIDENT'S FALL OF 6/20/2010: - DID THE RESIDENT FALL FROM THE COMMODE OR WHEELCHAIR. - HOW DID THE RESIDENT GET INTO THE BATHROOM, WHEN THE MINIMUM DATA SET ASSESSMENT OF 6/18/2010 INDICATED THE RESIDENT REQUIRED PHYSICAL ASSIST OF TWO STAFF MEMBERS FOR TRANSFER. - IF THE RESIDENT WAS TAKEN INTO THE BATHROOM WAS THE RESIDENT ASSISTED BY TWO STAFF MEMBERS AS INDICATED IN THE 6/18/2010 ASSESSMENT. - THE INVESTIGATIONAL TOOL INDICATED THE RESIDENT HAD AN ALARM IN PLACE THAT WAS SOUNDING AT THE TIME OF THE RESIDENT'S FALL. THE TOOL FAILED TO INDICATE WHAT TYPE OF ALARM WAS IN USE THAT COULD HAVE BEEN UTILIZED AT THE TIME OF THE RESIDENT'S FALL. A. 2. RESIDENT #18'S RECORD WAS REVIEWED ON 8/4/2010 AT 10:20 A.M. THE RECORD INDICATED RESIDENT #18 WAS admitted to the facility on [DATE] WITH A [DIAGNOSES REDACTED]. A QUARTERLY MINIMUM DATA SET ASSESSMENT, DATED AS COMPLETED ON 3/26/2010, INDICATED THE RESIDENT WAS INDEPENDENT FOR DECISION MAKING. THE RESIDENT REQUIRED EXTENSIVE PHYSICAL ASSIST OF ONE STAFF MEMBER FOR TRANSFERS AND DID NOT AMBULATE. THE RESIDENT WAS CONTINENT OF BOWEL AND BLADDER. A FALL RISK ASSESSMENT, DATED 3/23/2010, IDENTIFIED THE RESIDENT AT HIGH RISK FOR FALLS WITH A TOTAL SCORE OF 13. A TOTAL SCORE ABOVE 10 IDENTIFIED THE RESIDENT AT HIGH RISK FOR FALLS. A NURSING NOTE, DATED 5/19/2010 AT 4:15 P.M., INDICATED: "PT. (PATIENT) FOUND ON FLOOR IN HER BR (BATHROOM). (ELEVATED) COMMODE SEAT TIPPED (WITH) PT. (PATIENT)...C/O (COMPLAINTS OF) L (LEFT) WRIST AND FINGERS AND (LOWER) BACK & BILAT. (BILATERAL) HIP PAIN...KNOT APPEARING ON TOP OF L (LEFT) WRIST, ICE APPLIED...." A NURSING NOTE, DATED 5/19/2010 AT 10:00 P.M., INDICATED: "SPOKE (WITH) (HOSPITAL INITIALS). RES. (RESIDENT) admitted (WITH) DX (DIAGNOSES) L (LEFT) WRIST FX (FRACTURE) & (AND) PELVIS. PERSON I SPOKE (WITH) DID NOT KNOW WHICH SIDE OF PELVIS WAS FX (FRACTURED)." AN INCIDENT DOCUMENTATION AND INVESTIGATION TOOL, DATED AS COMPLETED ON 5/19/2010, INDICATED THE resident sustained [REDACTED].M. THE INVESTIGATION INDICATED THE FALL WAS UNWITNESSED BY STAFF. THE INVESTIGATIONAL TOOL FAILED TO CAPTURE THE FOLLOWING INFORMATION RELATED TO THE CIRCUMSTANCES OF THE FALL: - HOW DID THE RESIDENT GET ONTO THE TOILET, WHEN THE MINIMUM DATA SET ASSESSMENT INDICATED THE RESIDENT REQUIRED PHYSICAL ASSIST OF ONE STAFF MEMBER FOR TRANSFERS AND DID NOT AMBULATE. - DID THE RESIDENT ACTIVATE THE CALL SYSTEM TO REQUEST ASSISTANCE FOR TRANSFER OFF THE COMMODE. - IF ACTIVATED DID THE CALL SYSTEM FUNCTION PROPERLY. THE RESIDENT WAS RE-admitted to the facility on [DATE], WITH [DIAGNOSES REDACTED]. LEFT DISTAL RADIUS FRACTURE, LEFT ULNAR FRACTURE, LEFT SUPERIOR RAMUS FRACTURE, LEFT MEDIAL PUBIC BONE FRACTURE, COMPRESSION FRACTURES OF THORACIC SPINAL DISC T5, T7, T11 AND T12. DURING AN INTERVIEW ON 8/10/2010 AT 4:10 P.M., THE DIRECTOR OF NURSING WAS MADE AWARE OF THE CIRCUMSTANCES RELATED TO THE INFORMATION LACKING FROM THE INVESTIGATIONAL TOOL AND THE FACILITY WAS UNABLE TO PROVIDE FURTHER DOCUMENTATION OR EXPLANATION. A. 3. RESIDENT #7'S RECORD WAS REVIEWED ON 8/3/2010 AT 1:18 P.M. THE RECORD INDICATED RESIDENT WAS admitted TO THE FACILITY, WITH [DIAGNOSES REDACTED]. A SIGNIFICANT CHANGE MINIMUM DATA SET ASSESSMENT, DATED AS COMPLETED ON 5/20/2010, INDICATED THE RESIDENT WAS MODIFIED INDEPENDENT FOR DECISION MAKING, WITH SOME PROBLEMS IN NEW SITUATIONS ONLY. THE RESIDENT REQUIRED EXTENSIVE ASSIST OF ONE STAFF MEMBER FOR TRANSFERS AND AMBULATION. A CARE PLAN WITH AN IDENTIFIED PROBLEM/NEED OF "FALLS R/T (RELATED TO) RECENT FALLS, IMPULSIVE...," WHICH BORE AN INITIAL IDENTIFICATION DATE OF 11/21/2008, IDENTIFIED, BUT WAS NOT LIMITED TO THE FOLLOWING APPROACHES: "PRESSURE ALARM IN BED AND WHEELCHAIR." THE APPROACH BORE A REVISION DATE OF 5/11/2010 A NURSING NOTE, DATED 6/22/2010 AT 6:30 P.M., INDICATED: "PT'S (PATIENTS) ROOMMATE (SIC) YELLING 'HELP.' CNA ENTERED RM (ROOM) PT. (PATIENT) ON FLOOR IN FRONT OF CLOSET SITTING (UP) ON BUTT. (NO) ALARM SOUNDING...(NO) INJURY...." AN "INCIDENT DOCUMENTATION AND INVESTIGATION TOOL," INDICATED THE resident sustained [REDACTED].M. THE FOLLOWING WAS NOTED IN THE SECTION TITLED "CAUSAL RELATIONSHIP ASSOCIATED WITH THE DEFINED INCIDENT/PROBLEM": A CHECK MARK INDICATED AN ALARM WAS IN USE BUT DID NOT SOUND. IN THE SECTION OF THE FORM TITLED "WHICH CAUSES IF REMOVED/CHANGED WILL PREVENT RECURRENCE": THE FOLLOWING WAS HAND WRITTEN IN THE SPACE PROVIDED: "APPLY NON-SKID SOCKS @ (AT) HS (BEDTIME) THE INVESTIGATIONAL TOOL FAILED TO CAPTURE THE TYPE OF ALARM IN USE AT THE TIME OF THE RESIDENT'S FALL AND FURTHER FAILED TO INCLUDE THE REASON WHY THE ALARM FAILED TO SOUND AT THE TIME OF THE RESIDENT'S FALL. THE FOLLOWING WAS HANDWRITTEN AT THE BOTTOM OF THE FORM: "NON SKID SOCKS @ (AT) HS (BEDTIME). REPOSITIONING OF BED ALARM." DURING AN INTERVIEW ON 8/10/2010 AT 4:10 P.M., THE DIRECTOR OF NURSING WAS MADE AWARE OF THE CIRCUMSTANCES RELATED TO THE INFORMATION LACKING FROM THE INVESTIGATIONAL TOOL AND THE FACILITY WAS UNABLE TO PROVIDE FURTHER DOCUMENTATION OR EXPLANATION. A. 4. A POLICY AND PROCEDURE TITLED "MANUAL LIFT," IDENTIFIED BY THE DIRECTOR OF NURSING AS THE CURRENT POLICY AND PROCEDURE, WHICH BORE AN AFFECTIVE DATE OF 7/2006, INDICATED THE FOLLOWING IN THE SECTION TITLED "PROCEDURE": "...MOVE LIFT TO OPEN END OF HORSESHOE BASE UNDER SIDE OF BED OR AROUND WHEELCHAIR. KEEP LEGS OF LIFT OPEN THROUGHOUT THE PROCEDURE...." RESIDENT #84'S RECORD WAS REVIEWED ON 8/9/2010 AT 3:25 P.M. THE RECORD INDICATED RESIDENT WAS admitted TO THE FACILITY, WITH [DIAGNOSES REDACTED]. AN ADMISSION MINIMUM DATA SET ASSESSMENT, DATED AS COMPLETED ON 4/6/2010, INDICATED THE RESIDENT WAS INDEPENDENT FOR DECISION MAKING. THE ASSESSMENT INDICATED THE RESIDENT REQUIRED EXTENSIVE PHYSICAL ASSIST OF TWO STAFF MEMBERS FOR TRANSFERS AND A WHEELCHAIR WAS THE RESIDENT'S PRIMARY MODE OF TRANSPORTATION. THE RESIDENT'S WEIGHT WAS DOCUMENTED AT 214 POUNDS AT THE TIME OF THE ASSESSMENT. DURING AN INTERVIEW WITH THE RESIDENT ON 8/9/2010 AT 4:10 P.M., THE RESIDENT INDICATED SHE HAD SUSTAINED A FALL FROM A HOYER LIFT, WHEN TWO CNAS FAILED TO ADEQUATELY PREPARE THE BASE OF THE LIFT, CAUSING THE LIFT TO TIP. WHEN THE LIFT TIPPED THE UPPER BAR WHICH THE SLING ATTACHED TO STRUCK THE RESIDENT IN THE BACK OF THE NECK PINNING HER CHIN TO HER CHEST. THE RESIDENT INDICATED SHE WAS SENT OUT TO THE emergency room FOR X-RAYS OF THE NECK, BUT SHE REPORTED NO FRACTURES WERE FOUND. A NURSING NOTE, DATED 6/28/2010 AT 11:00 A.M., INCLUDED: "LATE ENTRY - 2 STAFF TRANSFERRING (WITH) FULL BODY LIFT WHEN INCIDENT OCCURRED & (AND) LIFT TIPPED. RESIDENT PLACED IN W/C (WHEELCHAIR) DID NOT FALL TO FLOOR. BAR TO LIFT HIT RESIDENT IN HEAD & NECK (WITH) SMALL AREA MEASURING APPROX. (APPROXIMATELY) 4 CM (CENTIMETER) X (BY) 6 CM NOTED ON HEAD...." A INCIDENT DOCUMENTATION AND INVESTIGATION TOOL INDICATED THE resident sustained [REDACTED].M. THE FOLLOWING WAS NOTED IN THE SECTION TITLED "WHICH CAUSES, IF REMOVED/CHANGED, WILL PREVENT RECURRENCE": BE CERTAIN BASE OF LIFT IS WIDE ENOUGH TO PROPERLY ACCOMMODATE A WIDE W/C (WHEELCHAIR), INSTRUCT STAFF IN PROPER PROCEDURES CONCERNING FULL BODY LIFT. A MANUFACTURER'S OPERATIONS MANUAL FOR OPERATING THE STAND UP LIFT, INDICATED THE FOLLOWING IN THE SECTION TITLED "CLOSING/OPENING THE LEGS OF THE BASE..."NOTE": "THE LEGS OF THE STAND-UP LIFT MUST BE IN THE MAXIMUM OPEN POSITION AND THE SHIFTER HANDLE LOCKED IN PLACE FOR OPTIMUM STABILITY AND SAFETY...." A. 5. RESIDENT #92'S RECORD WAS REVIEWED ON 8/9/2010 AT 11:00 A.M. THE RECORD INDICATED RESIDENT #92 WAS admitted WITH [DIAGNOSES REDACTED]. physician's orders [REDACTED]. A MINIMUM DATA SET AN INITIAL MINIMUM DATA SET ASSESSMENT, DATED 3/29/10, INDICATED RESIDENT 92 HAD SHORT TERM MEMORY PROBLEMS, WAS MODERATELY IMPAIRED - DECISIONS POOR; CUES/SUPERVISION REQUIRED IN COGNITIVE SKILLS FOR DAILY DECISION MAKING, MADE HIMSELF UNDERSTOOD, UNDERSTOOD OTHERS, REQUIRED EXTENSIVE ASSISTANCE OF ONE PERSON PHYSICAL ASSIST FOR WALKING AND BED MOBILITY, WAS CONTINENT OF BOWEL AND BLADDER, AND HAD FALLEN IN THE PAST 30 DAYS. A CARE PLAN, DATED 3/19/10, INDICATED A PROBLEM ONSET OF: POTENTIAL FOR FALLS R/T (RELATED TO) NEW SURROUNDINGS AND RECENT FALL. GOAL & TARGET DATE: WILL HAVE NO FALLS TNR (THROUGH NEXT REVIEW). APPROACHES: CALL LIGHT IN REACH, KEEP PATH FREE FROM CLUTTER, REFER TO PT/OT AS INDICATED, CLOSE CALL ALARM 3/29/10, 15 MIN(UTE) CHECKS 3/29/10, REMOVE EXTRA CUSHIONS FROM ROCKING CHAIR 3/29/10, NOTIFY MD AND FAMILY OF FALLS, (3/25/10) EDUCATED THERAPY ON ALARM." NURSE'S NOTES, DATED 3/19/10 AT 11:30 P.M., INDICATED: RESIDENT RESTING WELL (WITH NO COMPLAINTS)...NON-COMPLIANT (WITH) PSA (PERSONAL SAFETY ALARM)...." NURSE'S NOTES, DATED 3/22/10 AT 8:00 P.M., INDICATED: "(UP) IN CHAIR 02@3L/NC (NASAL CANNULA) T (TEMPERATURE) 97.6 DENIES SOA (SHORTNESS OF AIR) NO C/O VOICED. REMOVES PSA EACH TIME STAFF ATTACHES. SL(IGHT) CONFUSION NOTED THIS PM." NURSES NOTES, DATED 3/25/10 1:45 P.M., INDICATED: PT FOUND SITTING ON W/C FOOTPEDALS. STATES WAS TRYING TO GET SELF IN BED. HAD JUST BEEN RETURNED (TO) ROOM BY P.T. PERSONAL ALARM WAS NOT CLIPPED (TO) SHIRT. CALL LIGHT IN PTS HANDS BUT NOT ACTIVATED. PHYSICAL ASSESSMENT COMPLETED. SKIN TEAR 2 CM OF (R) HAND NOTED. CLEANSED & DRSD (DRESSED) (WITH) POLYSKIN. NO PAIN (WITH) ROM (RANGE OF MOTION) OF ALL EXTREMITIES. NO OTHER WOUNDS NOTED. ALERT & ORIENTED X3. PROBLEM ADDED (TO) CARE PLAN." AN INCIDENT DOCUMENTATION AND INVESTIGATION TOOL, DATED 3/25/10, INDICATED THE RESIDENT WAS TRYING TO TRANSFER SELF FROM W/C TO BED WHEN THE FALL OCCURRED, THE RESIDENT WAS SITTING ON FOOT PEDALS OF THE WHEEL CHAIR THE ALARM WAS NOT CLIPPED TO HIS SHIRT, PHYSICAL THERAPY HAD JUST BROUGHT HIM BACK TO ROOM, AND THE NEW INTERVENTION WAS TO APPLY NON-SLIP SLIPPERS OR SHOES. ON 8/10/10 AT 9:45 A.M., THE DIRECTOR OF NURSES INDICATED SHE HAD SPOKEN TO THE PHYSICAL THERAPIST AND HE TOLD HER HE HAD FORGOTTEN TO PUT THE CLIP BACK ON THE RESIDENT'S SHIRT AFTER HE HAD COMPLETED THERAPY. B. A POLICY AND PROCEDURE TITLED "MISSING RESIDENT," IDENTIFIED AS THE CURRENT POLICY BY THE DIRECTOR OF NURSING, WHICH BORE AN EFFECTIVE DATE OF 4/2006, INDICATED THE FOLLOWING IN THE SECTION TITLED "POLICY": "...EACH UNIT CHARGE NURSE DURING THEIR RESPECTIVE TOUR OF DUTY WILL BE AWARE AND RESPONSIBLE FOR KNOWING THE LOCATION OF THEIR RESIDENTS AT ALL TIMES...." A POLICY AND PROCEDURE TITLED "WANDERING RISK DECISION TREE," IDENTIFIED BY THE DIRECTOR OF NURSING AS THE CURRENT POLICY AND PROCEDURE, WHICH BORE AN EFFECTIVE DATE OF 8/2008, INDICATED THE FOLLOWING IN THE SECTION TITLED "PURPOSE": TO ESTABLISH GUIDELINES FOR IDENTIFYING AND PROVIDING A SAFE ENVIRONMENT FOR RESIDENTS WHO ARE AT RISK TO WANDER. THE FOLLOWING WAS NOTED IN THE SECTION TITLED "POLICY": "1. AS PART OF THE PRE-ADMISSION ASSESSMENT/SCREENING, ALL NEWLY admitted RESIDENT'S CLINICAL STATUS WILL BE ASSESSED TO DETERMINE THEIR RISK FOR WANDERING UTILIZING THE WANDERING RISK DECISION TREE. a. REASSESSMENT AS FOLLOWS: i. REASSESS QUARTERLY AND WHENEVER THERE IS A CHANGE IN A RESIDENT'S CLINICAL STATUS." "2. RESIDENTS WHO ARE IDENTIFIED AT RISK TO WANDER MUST HAVE AN INDIVIDUALIZED PLAN OF CARE." THE WANDERING RISK DECISION TREE INSTRUCTIONS, AS WRITTEN, INDICATED A PRE-ADMISSION SCREENING WOULD BE DONE ON ALL RESIDENTS PRIOR TO ADMISSION TO THE FACILITY. THE INSTRUCTION FAILED TO CLEARLY INDICATE IF BOTH PRE AND POST ADMISSION ASSESSMENTS WERE REQUIRED. REVIEW OF THE ABOVE POLICY FAILED TO INCLUDE DIRECTIONS TO STAFF AND THE NEED TO COMPLETE AN ASSESSMENT AND DEVELOP CARE PLANS RELATED TO ELOPEMENT. THE WANDERING RISK DECISION TREE DOES INCLUDE SCREENING FOR POSSIBLE ELOPEMENT. ON 8/4/2010 AT 9:00 A.M., REQUESTED A POLICY AND PROCEDURE FOR ELOPEMENT. DURING INTERVIEW WITH D.O.N.(DIRECTOR OF NURSING) ON 8/4/2010 AT 9:30 A.M., THE D.O.N. INDICATED THAT THEY DO NOT HAVE A POLICY AND PROCEDURE FOR ELOPEMENT. B. 1. RESIDENT #6'S RECORD WAS REVIEWED ON 8/10/10 AT 11:45 A.M., THE RECORD INDICATED RESIDENT #6 WAS admitted WITH [DIAGNOSES REDACTED]. A MINIMUM DATA SET ASSESSMENT, DATED 1/02/10, INDICATED RESIDENT #6 WAS MODERATELY IMPAIRED - DECISIONS POOR, CUES/SUPERVISION REQUIRED IN COGNITIVE SKILLS FOR DAILY DECISION MAKING, HAD SHORT TERM AND LONG TERM MEMORY PROBLEMS, WAS ABLE TO MAKE SELF UNDERSTOOD AND UNDERSTOOD OTHERS, WALKED IN HER ROOM, NEEDED LIMITED ASSIST OF ONE PERSON FOR WALKING IN CORRIDOR, AND NEEDED PARTIAL PHYSICAL SUPPORT DURING STANDING BALANCE TEST. PHYSICIAN'S RECAPITULATION ORDERS, DATED 3/2010, INDICATED RESIDENT #6 HAD AN ORDER "MAY GO LOA (LEAVE OF ABSENCE) WITH MEDS AND SUPERVISION." AN INCIDENT, DATED 3/8/10, ENTITY SELF-REPORTED FOR RESIDENT #6 INDICATED RESIDENT WAS LET OUT OF FACILITY BY A FAMILY MEMBER AND FOUND ON THE FACILITY BUS. REVIEW OF INCIDENT DOCUMENTATION AND INVESTIGATION TOOL, DATED 3/8/2010, FOR RESIDENT # 6'S ELOPEMENT ON 3/8/2010 INDICATED RESIDENT "WANDERING AROUND FACILITY & FAMILY MEMBER LET HER OUT DOOR ON END OF 200 HALL D/T RES (RESIDENT) STATED SHE WANTED TO GET ON THE FACILITY BUS & ASSISTED HER ONTO BUS & STAYED WITH HER. THE MEDICAL RECORDS STAFF PERSON CAME OUT OF FACILITY AND THE FAMILY MEMBER ALERTED HER THAT THE RESIDENT WAS ON THE FACILITY BUS WITH HER." THE MEDICAL RECORDS PERSON ASSISTED RESIDENT BACK INSIDE THE FACILITY TO THE NURSE, "TOTAL BODY ASSESSMENT WITH VITAL SIGNS DONE IMMEDIATELY, ONCE INSIDE WITH NO AREAS NOTED." "PLACED ON 15 MINUTE CHECKS, IMMEDIATELY CLOSED THE DOUBLE DOORS LEADING TO THE 200 HALL, THE DIRECTOR OF NURSING AND CEO NOTIFIED." STATEMENT FROM EMPLOYEE #3/DIETARY FROM THE FACILITY INVESTIGATION, DATED 3/9/10, INDICATED RESIDENT # 6 WAS AT THE "JUNCTION OF 100 HALL AND 200 HALL BEHIND HIM", APPROXIMATELY 8-10 FEET AWAY, "WHEN I ASSISTED A VISITOR WHO WAS HAVING TROUBLE WITH CODE PAD TO GO OUT." "AFTER I LET THE VISITOR OUT, I PAST (RESIDENT #6), AS I HEADED DOWN 100 HALL RESIDENT WAS STILL AT THE JUNCTION, SHE HAD STOPPED MOVING AND WAS STANDING IN THE MIDDLE OF THE HALL." "AS I WAS HEADING DOWN THE 100 HALL HEARD THE DOOR ALARM START TO SOUND. I STARTED TO HEAD BACK TO THE DOOR PEOPLE CAME IN AND TURNED OFF THE ALARM." "RESIDENT # 6 WAS NO LONGER IN THE JUNCTION. I ASSUMED SHE HAD WENT BACK DOWN 200 HALL SO I CONTINUED DOWN THE HALL TOWARDS THE FRONT DESK THEN DOWN TOWARDS DINING ROOM. I DIDN'T KNOW RESIDENT # 6 HAD LEFT THE BUILDING UNTIL ASKED IF I LET HER OUT". REVIEW OF STATEMENT, DATED 3/9/2010, FROM VISITOR WHO ASSISTED RESIDENT ON TO THE FACILITY BUS ON 3/8/2010 INDICATED "I SAW A WOMAN WITH A DOLL COME OUT OF THE DOOR FOLLOWED BY ANOTHER WOMAN. THINKING TO MYSELF THE DAUGHTER IS TAKING HER OUT FOR THE DAY." "SHE (LADY WITH DOLL) THEN TRIED TO GET ON BUS (BELONGING TO THE WATERS') COULDN'T, SO I GOT OUT OF CAR AND PROCEEDED TO PUT HER ON BUS, SEAT BELT HER IN AND WAIT FOR DRIVER." NURSES NOTES, DATED 3/8/10 AT 4:15 P.M., INDICATED THE RESIDENT WALKED OUT THE 200 HALL DOOR WITH VISITOR AND WAS ASSISTED ON TO THE FACILITY BUS BY VISITOR. THEN STAFF MEMBER ASSISTED RESIDENT BACK INTO THE FACILITY AND NOTIFIED THE NURSE AND FULL BODY ASSESSMENT WAS COMPLETED WITH NO AREAS NOTED. THE RESIDENT WAS PLACED ON EVERY 15 MINUTE CHECKS AND THE DOUBLE DOORS TO 200 HALL WERE CLOSED. ON 3/15/10 AT 2:45 P.M., NURSES NOTES INDICATED THE RESIDENT DID ATTEMPT TO GO OUT A DOOR AS A VISITOR ENTERED THE BUILDING, BUT SHE WAS REDIRECTED BACK TO LIVING ROOM, 15 MINUTE CHECKS CONTINUE. A CARE PLAN, DATED 3/25/10, INDICATED RESIDENT #6 HAD ANXIETY AS EVIDENCED BY PACING/WANDERING WITH RISK OF ELOPEMENT. THE GOAL WAS: THE RESIDENT WILL HAVE NO WANDERING WITH NO ELOPEMENT EVERY DAY THROUGH NEXT REVIEW AND SIGNS AND SYMPTOMS WILL BE EASILY REDIRECTED 5 -10 MINUTES AFTER INTERVENTIONS. APPROACHES INCLUDED: ENCOURAGE RESIDENT TO VOICE FEELINGS, ENCOURAGE FAMILY INVOLVEMENT DURING TIMES OF INCREASED WANDERING, 15 MINUTE CHECKS TO ENSURE SAFETY, PROVIDE ACTIVITIES OF INTEREST, ENCOURAGE RESIDENT TO REST, ANTI-DEPRESSANT PER ORDER, INFORM MD AND FAMILY OF CHANGES, AND ANTI-ANXIETY PER ORDER. ON 3/28/10 AT 3 P.M., THE NURSES NOTES INDICATED CONTINUE 15 MINUTE CHECKS, THE RESIDENT ATTEMPTED TO LEAVE FACILITY TIMES 1, BUT EASILY RE-DIRECTED. ON 4/10/10 AT 3:30 P.M., THE NURSES NOTES INDICATED THE RESIDENT WAS WANDERING ALL A.M. AND WAS ON 15 MINUTE CHECKS. THE RESIDENT WAS ABLE TO OPEN THE DOUBLE DOORS PER SELF. RESIDENT WENT OUTSIDE IN PARKING LOT. 1 ON 1 AT PRESENT, STAFF SITTING WITH THE RESIDENT. THE FACILITY FAILED TO INVESTIGATE, DUE TO THE ELOPEMENT WAS NOT REPORTED TO DON OR ADMINISTRATOR AS INDICATED BY DON IN INTERVIEW ON 8/11/2010 AT 11:54 A.M. TELEPHONE INTERVIEW WITH EMPLOYEE #4/LPN ON 8/12/2010 AT 4:15 P.M., THE LPN INDICATED THE STAFF SAW RESIDENT GO OUTDOORS ON 4/10/10 AND THEY FOLLOWED HER OUT AND BROUGHT HER BACK IN THE BUILDING AND PLACED THE RESIDENT ON 1:1 WITH STAFF MEMBER UNTIL HER HUSBAND RETURNED. ON 5/13/10 AT 3:15 P.M., THE NURSES NOTE INDICATED RESIDENT WENT OUT THE DOOR ON 200 HALL AND WENT TO THE FRONT OF THE BUILDING. "REMAINED IN VISION OF STAFF AT ALL Xs (TIMES). ENTICED BACK INSIDE WITH SUGGESTION OF MILK AND COOKIES- NO INJURY NOTED." ON 5/18/10 AT 10 P.M., THE NURSES NOTE INDICATED THE RESIDENT ATTEMPTED TO OPEN THE EXIT DOOR WITH STAFF PRESENT. THE RESIDENT AMBULATED T/O (THROUGHOUT) THE FACILITY, TOILETED AND WAS ASSISTED BACK TO BED, 15 MINUTE CHECKS CONTINUE. ON 6/17/10 AT 1 P.M., THE NURSES NOTES INDICATED THE RESIDENT WITH INCREASED ANXIETY, ATTEMPTING TO LEAVE, FAMILY IN TO VISIT AND RESIDENT CONTINUED TO ATTEMPT TO GO OUTSIDE. CONTINUED 15 MINUTE CHECKS, SNACKS, AND FLUIDS OFFERED AND REFUSED, 1:1 WITH STAFF. ON 6/18/10 AT 1 P.M., THE NURSES NOTES INDICATED RESIDENT NOTED WITH MULTIPLE EPISODES OF WANDERING ATTEMPTED TO GO OUT DOORS SEVERAL TIMES WITHOUT SUCCESS. "INTERVENTIONS OF SNACKS, WALKS ETC (ETCETERA) DONE WITH SUCCESS". REMAINS ON 15 MINUTE CHECKS. ON 6/22/10 AT 2:15 P.M., THE NURSES NOTES INDICATED THE RESIDENT WANDERING A LOT TODAY-HAS TRIED TO GO OUT FRONT DOOR TIMES 2 AND STAFF STOPPED HER. ON 6/27/10 AT 3:30 P.M., NURSES NOTES INDICATED WANDERING AND ATTEMPTING TO OPEN DOORS. A POST ADMISSION/ROUTINE "WANDERING RISK DECISION TREE" WAS DONE ON 8/11/10 WITH THE DECISION TO INITIATE ONE-ON-ONE SUPERVISION AND TO CONTACT THE DON AND ADMINISTRATOR IMMEDIATELY. NO OTHER "WANDERING RISK DECISION TREE" WERE IN THE CLINICAL RECORD. THE FACILITY FAILED TO HAVE A WANDERING RISK ASSESSMENT COMPLETED PRIOR TO 8/11/10. ON 8/10/2010 AT 11:40 A.M., THE RESIDENT WAS OBSERVED AT THE FRONT DOOR AND A STAFF MEMBER REDIRECTED AND ASSISTED THE RESIDENT AWAY FROM DOOR AND TO THE FRONT LOUNGE. B. 2. RESIDENT #10'S RECORD WAS REVIEWED ON 8/4/2010 AT 8:12 A.M. THE RECORD INDICATED RESIDENT WAS admitted on [DATE], WITH [DIAGNOSES REDACTED]. A "WANDERING RISK DECISION TREE" ASSESSMENT COMPLETED PRIOR TO ADMISSION, DATED 12/30/2009, INDICATED "THE RESIDENT WAS AMBULATORY OR SELF MOBILE IN WHEELCHAIR." INSTRUCTIONS ON THE FORM INDICATED THE FOLLOWING TWO ITEMS WERE TO BE DOCUMENTED BY A CHECKMARK IN BOTH BOXES BEFORE THE RESIDENT WAS DETERMINED SAFE TO GO ON UNSUPERVISED LEAVE OF ABSENCE. THE BOX WHICH INDICATED: "DOES RESIDENT HAVE MD (PHYSICIAN'S) ORDER TO GO LOA (LEAVE OF ABSENCE)," WAS LEFT BLANK. THE SECOND REQUIRED BOX HAD A CHECKMARK WHICH INDICATED: "...THE RESIDENT VOICED UNDERSTANDING OF THE LOA (LEAVE OF ABSENCE) POLICY AND PROCEDURE." A CHECKMARK WAS PLACED, ONLY, IN ONE OF THE TWO REQUIRED BOXES WHICH WOULD INDICATE THE RESIDENT WAS SAFE FOR UNSUPERVISED LEAVE OF ABSENCE. AN ADMISSION MINIMUM DATA SET ASSESSMENT, DATED AS COMPLETED ON 1/13/2010, INDICATED THE RESIDENT WAS MODERATELY IMPAIRED FOR DECISION MAKING DECISIONS POOR, CUEING AND SUPERVISION REQUIRED. THE PHYSICIAN'S RECAPITULATION ORDERS, DATED 2/2010 AND 3/2010, INDICATED: "MAY GO LOA (LEAVE OF ABSENCE) WITH MEDS (MEDICATIONS) AND SUPERVISION." A POST ADMISSION RESIDENT ASSESSMENT RELATED TO WANDERING WAS NOT REQUIRED BY THE WANDERING RISK DECISION TREE. THE FACILITY IDENTIFIED NO CHANGES IN THE RESIDENT'S ABILITY TO GO ON LEAVE OF ABSENCE UNSUPERVISED. NURSING NOTES DATED 3/7/2010 AT 2:00 P.M., INDICATED: "STAFF MEMBER CALLED FACILITY TO INFORM OF RES. (RESIDENT) WALKING ON CROSS AVENUE. RES. (RESIDENT) RETURNED (WITH) NURSE (WITHOUT) DIFF. (DIFFICULTY)...INSTRUCTED TO INFORM STAFF IF LEAVING FACILITY AND HAVE SOMEONE ACCOMPANY HIM...." NO POST ELOPEMENT ASSESSMENT WAS COMPLETED FOLLOWING THE ELOPEMENT OF 3/7/2010, AS THE WANDERING RISK DECISION TREE ONLY REQUIRED REASSESSMENT IF THERE WAS AN IDENTIFIED CHANGE IN THE RESIDENT'S CLINICAL STATUS. DURING AN INTERVIEW ON 8/4/2010 AT 4:55 P.M., THE DIRECTOR OF NURSING WAS QUERIED RELATED TO SYSTEM FOR ASSESSING RESIDENTS FOR ELOPEMENT RISK POST ADMISSION. THE DIRECTOR OF NURSING INDICATED THE FACILITY DOES NOT UTILIZE AN ELOPEMENT RISK POLICY AND PROCEDURE, THE FACILITY USES A "WANDERING RISK DECISION TREE" ASSESSMENT WHICH IS COMPLETED PRE-ADMISSION, QUARTERLY AND WITH CHANGE IN CLINICAL CONDITION. THE FACILITY DOES NOT UTILIZE AN ELOPEMENT POLICY AND PROCEDURE, BUT WE DO HAVE A "MISSING RESIDENT POLICY AND PROCEDURE." B. 3. A FACILITY REPORTED INCIDENT DATED AS SENT TO ISDH ON 5/11/10 INDICATED: "1. BRIEF DESCRIPTION OF INCIDENT: REPORTED THAT RESIDENT OPENED DOOR LEADING FROM SERVICE HALL TO PARKING LOT AND WENT OUTSIDE - FOLLOWED CONTOUR OF BUILDING TO THE RIGHT THEN TO SIDEWALK LEADING TO AREA WHERE STAFF TAKE BREAK OUTSIDE. STAFF MEMBER ASSISTED RESIDENT BACK INTO BUILDING. 2. TYPE OF INJURY: NONE. 3. IMMEDIATE ACTION TAKEN: DOOR TO SERVICE HALL WAS CLOSED - RESIDENT MONITORED ONE-ON-ONE - RESIDENT EDUCATED ABOUT ALERTING STAFF WHEN HE DESIRES TO GO OUT. 4. PREVENTIVE MEASURES TAKE: TALKING TO FAMILY - POSSIBLE REFERRAL TO MORE SECURE FACILITY - INITIATE CLUB STAR PROGRAM." RESIDENT #203'S RECORD WAS REVIEWED ON 8/11/10 AT 8:25 A.M. THE RECORD INDICATED RESIDENT #203 WAS admitted WITH [DIAGNOSES REDACTED]. AN INITIAL MINIMUM DATA SET assessment dated [DATE] INDICATED RESIDENT #203 WAS MODERATELY IMPAIRED - DECISIONS POOR; CUES/SUPERVISION REQUIRED IN COGNITIVE SKILLS FOR DAILY DECISION MAKING, HAD A SHORT TERM MEMORY PROBLEM, MADE HIMSELF UNDERSTOOD, UNDERSTOOD OTHERS, AND REQUIRED EXTENSIVE ASSIST OF ONE FOR AMBULATION. A CARE PLAN, DATED 4/29/10, INDICATED: "PROBLEM/NEED: RES (RESIDENT) AT RISK FOR ELOPEMENT /WANDERING. GOAL & TARGET DATE: RES WILL HAVE (NO) ELOPEMENT DAILY. WANDERING WILL NOT AFFECT OTHER RESIDENTS OR CAUSE DANGER FOR RESIDENT. APPROACHES: (1) 15 MINUTE CHECKS (2) ENC (ENCOURAGE) FAMILY INVOLVEMENT (3) MAKE SURE RES GOES OUT AT DESIGNATED SMOKING TIMES (4) REMIND RESIDENT PRN (AS NEEDED) (5) PROVIDE ACT(IVITY) OF INTEREST (6) ENC CLUB STAR (7) INFORM MD & FAMILY OF (CHANGE)." NURSE'S NOTES, DATED 5/10/10 AT 5:00 P.M., INDICATED: "DIETARY MGR (MANAGER) REPORTS FINDING (RESIDENT #203) OUTDOORS (WITHOUT) STAFF IN ATTENDANCE B/P 130/80 P72 R16 T 98.9 LCTA (LUNGS CLEAR TO AUSCULTATION) ABD(OMEN) SOFT MD & FAMILY NOTIFIED. NO INJURIES NOTED." AN INCIDENT DOCUMENTATION AND INVESTIGATION TOOL, DATED 5/10/10, INDICATED: "...TYPE OF INCIDENT: RES ELOPEMENT. TYPE OF INJURY: NONE...WHAT DID THE RESIDENT SAY ABOUT THE INCIDENT? "I WENT OUTSIDE " TO SMOKE IN GAZEBO. WHERE WAS THE RESIDENT? OUTDOORS IN GAZEBO. WHAT WAS DONE IMMEDIATELY? RES ESCORTED BACK INTO (BUILDING)...IMMEDIATE ACTIONS: CP (CARE PLAN) REVISION, CNA ASSIGN. REVISION, STAFF/RESIDENT TRAINING...." A HANDWRITTEN NOTE AT THE BOTTOM OF THE INCIDENT DOCUMENTATION AND INVESTIGATION TOOL INDICATED: "RESIDENT WAS WANTING TO SMOKE & WENT OUTSIDE TO SMOKING AREA TO DO SO. PLACED ON 1 ON 1'S, DOORS TO SERVICE HALLWAY SHUT. A RESIDENT TRANSFER FORM, DATED 5/24/10, INDICATED RESIDENT #203 WAS discharged TO ANOTHER FACILITY. ON 8/12/10 AT 12:05 P.M., THE DIRECTOR OF NURSES INDICATED RESIDENT # 203 DID NOT HAVE A WANDERING RISK DECISION TREE ASSESSMENT COMPLETED. 3.1-45(a)(1) 3.1-45(a)(2)