Every finding on record at Waters of Huntingburg, The

Based on observation, interview, and record review, the facility failed to ensure residents received care by qualified staff for 1 of 3 residents reviewed for death. QMAs (Qualified Medication Aide) documented the administration and effectiveness of as needed (PRN) medications without documentation of notification and approval from a licensed nurse. (Resident F)Finding includes:Record review on 8/12/26 at 9:45 A.M., Resident F's diagnoses included, but were not limited to chronic kidney disease and dementia. The most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated the resident had severe cognitive impairment. Resident F's physician orders included, but were not limited to; morphine sulfate oral solution 20 milligrams (mg) / 5 milliliters (ml) - give 0.5 ml by mouth every 15 minutes as needed for shortness of air (started 5/29/26 and discontinued 5/31/26), lorazepam oral tablet 0.5 mg - give one tablet every one hour as needed for air hunger/distress (started 5/30/26 and discontinued 5/31/26). Resident F's medication administration record (MAR) from 05/2026 indicated QMA 4 administered PRN morphine sulfate oral solution 0.5 ml on 5/31/26 at 1:03 P.M. and 3:52 P.M., and PRN lorazepam oral tablet 0.5 mg on 5/31/26 at 1:03 P.M. and 3:52 P.M.Nurse's progress notes included but were not limited to:5/31/26 at 3:51 P.M. - The administration of PRN morphine sulfate oral solution 0.5 ml on 5/31/26 at 1:03 P.M. was ineffective - created by QMA 4.5/31/26 at 3:51 P.M. - The administration of PRN lorazepam oral tablet 0.5 mg at 1:03 P.M. was ineffective - created by QMA 4.5/31/26 at 4:55 P.M. - The administration of PRN morphine sulfate oral solution 0.5 ml on 5/31/26 at P.M. 3:52 P.M. was ineffective - created by QMA 4.5/31/26 at 4:55 P.M. - The administration of PRN lorazepam oral tablet 0.5 mg at 3:52 P.M. was ineffective - created by QMA 4.Resident F's record contained no documentation that a licensed nurse was notified or approved the administration of PRN morphine and lorazepam prior to QMA 4 administering the medication on 5/31/26 at 1:03 P.M. and 3:52 P.M. The record contained no documentation that a licensed nurse assessed the resident for the effectiveness of those PRN medications administered by QMA 4. An interview on 8/12/26 at LPN 6 indicated the QMA staff should notify a nurse of any need for a PRN medication, but she has not been asked by a QMA at this facility. An interview on 8/12/26 at 1:53 P.M., RN 7 indicated if a QMA notified him of a need for PRN medication, he would assess the resident and document the assessment and need for medication. An interview on 8/12/26 at 1:55 P.M. QMA 8 indicated the QMA staff should notify a licensed nurse prior to administering a PRN medication. QMA 8 indicated she does not document the notification, but probably should.On 8/12/26 at 2:45 P.M., the Director of Nursing (DON) supplied an Indiana Nursing Academy QMA Scope of Practice, dated 2026. The scope of practice included, .11. Administer previously ordered pro re nata (PRN) medication only if authorization is obtained from the facility's licensed nurse on duty or on call. If authorization is obtained, the QMA must do the following: (A) Document in the resident record symptoms indicating the need for the medication and time the symptoms occurred. (B) Document in the resident record that the facility's licensed nurse was contacted. Symptoms were described, and permission was granted to administer the medication, including the time of contact. (C) Obtain permission to administer the medication each time symptoms occur in the resident. (D) Ensure the resident's record is co-signed by the licensed nurse that gave permission by the end of the shift, or if the nurse was on call, by the end of the nurse's next tour of duty .This citation relates to intake 3104559.410 AIC 16.2-3.1-14(j)

Based on interview and record review, the facility failed to ensure a resident's lab and vital signs were monitored following an increase in medication (digoxin) dosage per physician orders and the resident's plan of care that resulted in a hospitalization for 1 of 3 residents reviewed for hospitalizations (Resident D). Resident D was admitted to the hospital with a diagnosis of digoxin poisoning and life-threatening hyperkalemia (elevated potassium).Finding includes:Record review on 5/12/26 at 12:30 P.M., indicated Resident D's diagnoses included, but were not limited to, heart failure, atrial fibrillation (A-fib) and atrial flutter, hypokalemia, and hypertension. The most recent quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated the resident had moderate cognitive impairment. Physician orders included, but were not limited to: digoxin 125 micrograms (mcg) for atrial fibrillation (started 1/8/26 and discontinued 2/13/26), repeat digoxin level in two weeks 2/27/26 (ordered 2/13/26), digoxin 250 mcg for increased heart rate (started 2/14/26 and discontinued 4/27/26), and clonidine hydrochloride (HCl) 0.2 milligrams (mg) as needed for systolic blood pressure greater than 180 mm Hg (millimeters of mercury) (started 4/27/26).The care plan included, but was not limited to, resident has chronic A-fib with interventions - labs per order and medications per order (started 2/9/26), at risk for cerebrovascular accident (CVA) with an intervention of monitor labs as ordered (started 2/9/26), and at risk for increased blood pressure with an intervention to monitor blood pressure per physician order and facility policy (started 2/9/26). The Medication Administration Record (MAR) for the month of February 2026 included digoxin 125 mcg was administered daily until it was discontinued on 2/13/26. Resident D's heart rate was monitored and documented with each administration up until 2/13/26. On 2/14/26, digoxin 250 mcg was started and continued to be administered daily through February, March, and April with no documented heart rate monitoring with administration.Labs indicated the resident's most recent digoxin level was completed on 2/13/26. No digoxin level was obtained on 2/27/26 per the physician's order. Resident D's ordered digoxin level lab for 2/27/26 was not documented as completed. The MAR for the months of April and May 2026 indicated the as needed order for clonidine HCl 0.2 mg for systolic blood pressure greater than 180 mm Hg was never administered and since the new order was obtained from the hospital on 4/27/26, the resident's blood pressure had only been documented on two occasions. Documented vital signs from February 14, 2026, through May 2026 included the following heart rate and blood pressure monitoring: 2/17/26 - 98 beats per minute (bpm), 142/100 (systolic/diastolic) mm Hg 3/4/26 - 100 bpm, 140/88 mm Hg4/1/26 - 67 bpm, (no blood pressure)4/24/26 - 41 bpm, 145/64 mm Hg4/27/26 - 78 bpm, 130/84 mm Hg4/28/26 - 61 bpm, 109/70 mm HgNurse's progress notes included, but were not limited to:2/17/26 9:16 A.M. - Resident was readmitted to facility following hospitalization due to COVID-19 and atrial fibrillation with rapid ventricular response.4/24/26 12:30 P.M. - Resident was propelling herself to the dining room and began having trouble with locomotion. Resident was assisted by staff to the dining room where she continued to decline. Heart rate was 38-43 beats per minute. Resident was unable to Perform baseline activities of daily living. Resident was unsure of where she was. Resident was unable to feed self per her normal, Emergency Medical Service (EMS) arrived, and report was called to the emergency room. 4/24/26 at 6:50 P.M. - Resident admitted to intensive care unit with digoxin toxicity, hyperkalemia, and acute kidney injury. 5/12/26 at 9:12 A.M. - (Physician Provider Note) Resident was recently referred to therapy due to having an overall decline in her functional abilities that include decreased functional mobility, decreased transfers, reduced ability to ambulate safely, increased need for assistance, and reduced activities of daily living participation. Hospital records included emergency department provider notes, dated 4/24/26 at 1:02 P.M., that indicated the resident's blood pressure was 168/70 mm Hg and the resident's heart rate was 33 bpm. Lab values included a digoxin level of 2.39 nanograms/milliliter (ng/mL) (therapeutic range is 0.7 - 2.0 ng/mL), and potassium level of 9.4 milliequivalents/liter (mEq/L) (normal level is between 3.5 - 5.2 mEq/L). The emergency department assessment and plan included digoxin toxicity: concern for chronic overdose with suspected acute kidney injury (AKI). The emergency department course of treatment included, dialysis line placed. Patient to have potassium dialyzed as needed. STAT (immediate) potassium will be repeated after central line placement. Resident to be admitted to intensive care unit with diagnosis of digoxin poisoning. The hospital history and physical note dated 4/24/26 at 3:25 P.M., included that Resident D was admitted to the intensive care unit for life-threatening hyperkalemia.The hospital discharge summary note, dated 4/27/26 at 3:23 P.M., included Resident D's medications were modified significantly. Resident to start clonidine 0.2 mg two times daily as needed for systolic blood pressure greater than 180 mm Hg.During an interview on 5/12/26 at 1:55 P.M., the director of nursing (DON) indicated a resident's heart rate should be monitored prior to every administration of digoxin. During an interview on 5/13/26 at 12:10 P.M., RN 4 indicated Resident D's vital signs should be obtained at every medication pass, but that staff did not document every time vital signs were obtained. During an interview on 5/13/26 at 10:10 A.M., RN 6 indicated the facility did not have a policy regarding when vital signs should be obtained and indicated the facility would follow the physicians' orders.During a review of a facility training related to digoxin toxicity, an undated facility policy titled Lab Scheduling/Tracking. The policy included, Policy: It is the policy of the facility to ensure that laboratory tests ordered by the physician are systematically scheduled and tracked so that ordered lab work is obtained and results are received and reported timely.According to nursestudy.net, nursing considerations for the medication digoxin included, Assess vital signs, especially heart rate and rhythm. The apical pulse must be taken for a full minute before administration. Monitor serum digoxin levels (therapeutic range: 0.8-2.0 ng/mL) .This citation relates to intake 2975665.410 IAC (Indiana Administrative Code)16.2.3.1-37(a)

Based on interview and record review, the facility failed to ensure adequate pharmaceutical services were available to provide physician prescribed routine medications to 2 of 3 residents reviewed for pharmacy services. Residents did not receive physician prescribed routine medications timely following admisstion to the facilty due to the medications not being available. (Resident B, Resident C)Findings include:1. During an interview on 3/20/26 at 9:00 A.M., Resident B indicated that she had not recieved all of her prescribed medications since admitting to the facility. During record review on 3/20/26 at 11:20 A.M., Resident B's diagnoses included but were not limited to anxiety, bipolar disorder, and panic disorder.Resident B's physician orders included, but were not limited to, methadone hydrochlroide (used for chronic pain) hcl10 milligrams (mg) one tablet in the morning (started 3/15/26 and discontinued 3/17/26), methadone hcl 10 mg three tablets in the morning, (started 3/18/26), Lyrica (used for anxiety) 150 mg one capsule three times a day (started 3/14/26). Resident B's March 2026 Medication Administration Record (MAR) indicated the resident did not receive the prescribed medications due to the medications being unavailable on the following dates:Methadone hcl 10 mg one tablet in the morning - 3/15/26 and 3/17/26Methadone hcl 10 mg three tablets in the morning - 3/18/26 and 3/19/26Lyrica 150 mg one capsule three times a day - 3/18/26 (did not receive morning, noon, or night dose) and 3/19/26 (did not receive morning, noon, or night dose) Resident B's nurse's progress notes included but were not limited to:3/19/26 at 9:22 A.M. - Nurse called pharmacy on medications Lyrica (150 mg) and methadone hcl (10 mg). Pharmacy stated they need prescriptions. 2. During an interview on 3/202/6 at 9:15 A.M., Resident C indicated following his admission to the facility, he went nearly a full day without any routine medications. During record review on 3/19/26 at 11:20 A.M., Resident C's diagnoses included but were not limited to, paraplegia, chronic pain, and anxiety.Resident C's physician orders included, but were not limited to buspirone hcl (used for anxiety) 5 mg two times a day (started 2/26/26) and Lyrica (used for chronic pain and anxiety) 150 mg three times a day (started 2/26/26). Resident C's February 2026 MAR indicated the resident did not receive the prescribed medications due to the medications being unavailable on the following dates:Buspirone hcl 5mg three times daily - 2/26/26 (evening dose) and 2/27/26 (morning dose)Lyrica 150 mg three times a day - 2/26/26 (night dose) and 2/27/26 (morning, noon, or night dose)During an interview on 3/20/26 at 1:35 P.M., the Director of Nursing (DON) indicated if resident's admit to the facility later in the day and physician orders are not sent to pharmacy before the evening of admission, the residnet may not get their medications until the following evening. If resident medications are not available, staff should retrieve medications from the emergency drug kit (EDK), if available. On 3/20/26 at 1:08 P.M., RN 4 supplied a facility policy titled, Pharmacy Services, dated 03/2023. The policy included, .pharmacy agrees to perform the following pharmaceutical services, in addition to others that may be stipulated in the agreement: .Accurately dispensing prescriptions based on authorized prescriber orders . Providing routine and timely pharmacy service 7 days per week and emergency pharmacy service 24 hours per day, seven days per week .This citation relates to intake 2799537.410 IAC (Indiana Administrative Code) 16.2-3.1-25(a)

Based on interview and record review, the facility failed to esnure a base-line care plan was deveolped for a newly admitted resident within 48 hours of admission for 1 of 3 newly admitted residents with pressure ulcers. A resident's baseline care plan was not created. (Resident C)Finding includes:During record review on 3/19/26 at 11:20 A.M., Resident C's diagnoses included but were not limited to, paraplegia, chronic pain, and anxiety.Resident C was admitted to the facility on [DATE].Resident C had no baseline care plan in place. During an interview on 3/20/26 at 1:35 P.M., the Director of Nursing (DON) indicated Resident C's initial baseline care plan should have been completed. On 3/20/26 at 1:08 P.M., RN 4 supplied a facility policy titled, Baseline Care Plan Assessment / Comprehensive Care Plans, dated 3/23/21. This policy included, It is the policy of the facility to ensure that every resident has a Baseline Care Plan completed and implemented within 48 hours of Admission. The Baseline Care Plan is intended to promote continuity of care and communication among nursing home staff, increase resident safety, and safeguard against adverse events that are most likely to occur right after admission; and to ensure the resident and representative, if applicable, are informed of the initial plan of delivery of care and services by receiving a written summary of the Baseline Care Plan .This citation relates to intakes 2803022 and 2799537.410 IAC (Indiana Administrative Code) 16.2-3.1-30(a)

Based on interview and record reivew, the facility failed to ensure required resident admission assessments were completed timely for 1of 3 resident records reviewed. admission assesments were not completed within the first 14 days following admission. (Resident C)Finding includes:During record review on 3/19/26 at 11:20 A.M., Resident C's admission Minimum Data Set (MDS) assessment dated [DATE] was incomplete. Resident C was admitted to the facility on [DATE].During an interview on 3/20/26 at 1:35 P.M., the Director of Nursing (DON) indicated Resident C's admission assessment should have been completed. On 3/20/26 at 10:37 A.M., RN 4 supplied a facility policy titled, Guedelines for Assessments, dated 5/29/24. The policy included, Policy: It is the policy of the facility to ensure that assessments of the residents take place timely, athe the appropriate time and are accurate . admission (Comprehensive) . MDS Completion Date . No Later Than . 14th calendar day of the resident's admission .This citation relates to intakes 2803022 and 2799537.410 IAC (Indiana Administrative Code) 16.2-3.1-31(d)(1)

Based on interview and record review, the facility failed to ensure required resident admission assessments were completed timely for 2 of 4 resident records reviewed. admission assessments were not completed within the first 14 days following admission. (Resident C, Resident D)Findings include:1. During record review on 1/23/26 at 10:00 A.M., Resident C's admission Minimum Data Set (MDS) assessment dated [DATE] was incomplete. Resident C was admitted to the facility on [DATE]. 2. During record review on 1/23/26 at 10:40 A.M., Resident D's admission MDS assessment dated [DATE] was incomplete. Resident D was admitted to the facility on [DATE]. During an interview on 1/23/26 at 11:55 A.M., the MDS nurse indicated she had been busy working on a care plan project and had not gotten to all the due MDS assessments. On 1/23/26 at 2:25 P.M., the Director of Nursing (DON) supplied a facility policy titled, Guidelines for Assessments, dated 5/29/24. The policy included, Policy: It is the policy of the facility to ensure that assessments of the residents take place timely, at the appropriate time and are accurate . admission (Comprehensive) . MDS Completion Date . No Later Than . 14th calendar day of the resident's admission .3.1-31(d)(1)

Based on observation, interview, and record review, the facility failed to ensure physician prescribed diets were followed for 2 of 4 residents reviewed for dietary services. An order to receive ice cream with meals and an order to receive finger foods was not followed during 1 of 1 mealtimes observed. (Resident B, Resident F)Findings include:1. During an interview on 1/22/26 at 10:30 P.M., LPN 8 indicated the facility had no ice cream for the residents and that the kitchen did not keep ice cream in stock. During record review on 1/23/26 at 10:30 A.M., Resident F's physician orders included, but were not limited to, fortified foods with each meal, ice cream with lunch and dinner (started 12/22/25). During an observation on 1/23/26 at 12:15 P.M., Resident F received her lunch tray in the locked dementia unit. The resident's tray did not include ice cream. During an interview on 1/23/26 at 12:35 P.M., LPN 6 indicated the facility did not keep ice cream in stock unless the staff paid for it out of their own pocket. Residents with orders to receive ice cream do not receive it. 2. During record review on 1/23/26 at 10:00 A.M., Resident B's diagnosis included, but were not limited to, Alzheimer's disease and anorexia. Resident B's physician orders included but were not limited to, fortified foods with each meal, a finger food-focused diet (started 12/29/25). During an observation on 1/23/26 at 12:15 P.M., Resident B received her lunch tray in the locked dementia unit. The resident received the same meal as other residents, which included fish, noodles, cooked vegetables, and a roll. Resident B picked up her fork and poked at some of the items on her plate, but did take a bite.During an interview on 1/23/26 at 12:35 P.M., LPN 6 indicated that the residents with an order for finger foods do not usually get them; they get the same meal as everyone else. During an interview on 1/23/26 at 2:20 P.M., the Director of Nursing (DON) indicated the facility did not have a policy specific to following diet orders, but indicated it was the policy to follow all physician orders. This citation relates to intake 2714418. 3.1-21(b)

Based on interview, and record review, the facility failed to provide necessary treatment and services for 2 of 4 residents reviewed for dementia care. Resident behaviors were not monitored, and the plan of care was not updated following new behaviors, known behaviors were not documented, denture cleaning tablets were left unsecured in a dementia unit, and staff failed to offer redirection. (Resident B, Resident C)Findings include:1. During a review of facility-reported incidents on 1/22/26 at 2:30 P.M., an incident dated 1/15/26 at 6:45 P.M. indicated that Resident B was walking in a common area of the memory care unit when he used his right hand to make contact with the back of the neck of another resident. Both residents have impaired cognition. A facility reported incident dated 1/20/26 at 7:01 A.M., indicated Resident B walked into another resident's room and grabbed her left forearm. During record review on 1/22/26 at 2:40 P.M., Resident B's diagnoses included, but were not limited to, dementia with mood disturbance and major depressive disorder with psychotic symptoms.Resident B's most recent admission Minimum Data Set (MDS), dated [DATE], indicated the resident had severe cognitive impairment and displayed, Other behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) one - three (1-3) days during a 7 day review period.Resident B's care plan included, but was not limited to, the resident displays behavioral symptoms related to a dementia diagnosis (last revised 11/28/25). Interventions included, but were not limited to, conduct an evaluation of my behavioral symptom(s) to determine what strengths or abilities & needs are communicated via the behavior, and conduct an evaluation of my behavioral symptom(s) to determine what strengths or abilities and needs are communicated via the behavior (initiated 11/28/25).Resident B's nurse's progress notes included, but were not limited to:11/30/25 at 1:18 P.M. - Resident was lunging and swinging at staff and being verbally aggressive. The resident was also cursing at another resident and attempting to grab them. 12/1/25 at 1:19 A.M. - Resident was spontaneously aggressive with a staff member in the unit, yelling at staff, threatening staff, and attempting to hit staff.12/28/25 at 12:22 A.M. - Resident became aggressive with CNA upon redirection.1/20/26 at 8:11 A.M. - Resident went into another resident's room and grabbed the resident by the arm. 1/21/26 9:30 A.M. - Behavior Note - After further investigation by the Director of Nursing (DON), it was reported by CNA that on 1/19/26 resident was found in another resident's room, sitting on her bed with both of his hands around the resident's left wrist, a firm grip. The resident was yelling, We need to get rid of her because she is the devil. Staff attempted redirection without success. They removed his hands from the other resident's left wrist and escorted him from her room. He was unable to describe or remember the incident due to diagnoses. 1/22/26 at 11:06 A.M. - At approximately 11:02 P.M., Resident B was found eating a Polydent tablet. Poison control center contacted. This LPN was informed to watch the resident for the next 2-3 hours for excessive drooling, vomiting, swelling of the mouth or throat, or trouble breathing.Resident B's record contained no documentation regarding the incident dated 1/15/26. During an interview on 1/23/26 at 11:45 A.M., Activity Assistant 4 indicated Resident B's Polydent tablet was left in his room the night prior when the resident was found eating it. LPN 6 indicated denture tablets and other personal hygiene items should not be left in resident rooms on a dementia unit and should be stored away from resident access. During an interview on 1/23/26 at 11:55 A.M., the MDS nurse indicated the resident's plan of care should be updated following a new or increased behavior with a new intervention to help minimize or prevent behavior from recurring. During an interview on 1/23/26 at 2:15 P.M., the DON indicated there was no nursing documentation made in Resident B's record regarding the incident on 1/15/26. 2. During an observation on 1/22/26 at 9:05 P.M., Resident C was observed sitting on the floor in a common area in front of the nurse's station. CNA 9 was observed sitting in a reclining chair in the common area, and CNA 10 was observed standing at the nurse's station. Neither CNA was assisting the resident. The Facility Administrator knelt down next to Resident B to talk with her, and the resident was assisted to a couch in the common area. During an interview on 1/22/26 at 10:15 P.M., CNA 10 indicated Resident C sits herself on the floor at times. During record review on 1/23/26 at 10:00 A.M., Resident C's diagnoses included, but were not limited to Alzheimer's disease, anxiety, and unspecified psychosis. Resident C's care plan included, but was not limited to, the resident presents with an alteration in ability to communicate (initiated 12/23/25), the resident has the potential risk for injury and/orsocial isolation due to decreased visual acuity (initiated: 12/23/2025), with an intervention assess the environment. Make modifications as necessary to make the environment conducive to safety & ongoing interaction. Resident has impaired cognition/function or impaired thought process (initiated 12/23/25) with an intervention to cue, reorient, and supervise as needed. Resident displays behavior symptoms (initiated 12/23/25) with an intervention to intervene when inappropriate behavior is observed and use interventions that address the abilities and needs reflected in the specific symptom or symptoms. Resident C's care plan contained no plan of care regarding the resident's desire to sit on the floor. Resident C's nurse's progress notes contained no documentation of the resident sitting on the floor on 1/22/26 at 10:15 P.M. No observations or assessments were completed following the behavior. During an interview on 1/23/26 at 11:45 A.M., LPN 6 indicated that if a resident is on the floor, the nursing staff should document and assess the resident. During an interview on 1/23/26 at 12:40 P.M., LPN 8 indicated that staff should anticipate Resident C's needs and consider if the resident is displaying a behavior such as sitting herself on the floor, staff may consider why the resident is doing that. The resident may have been tired and needed assistance to bed. On 12/23/26 at 2:25 P.M., the Director of Nursing supplied a facility policy titled, Guidelines for Behavior Management Meetings Psychotropic Medication, dated 8/18/23. The policy included, .Standards: .2. The facility will investigate behaviors in an effort to determine the root cause of the behavior . Nursing . 2) Monitors for presence of target behaviors on a daily basis and documenting same .This citation relates to intake 2714418. 3.1-37(a)

Based on observation, interview, and record review, the facility failed to distribute and serve food in accordance with professional standards for 1 of 1 kitchen observed. Food temperature logs were not completed for all meals. Findings include:1. During an observation of the kitchen on 9/7/25 at 11:30 A.M., [NAME] 3 was plating chili mac, Italian vegetable blend, cornbread, and pears for the lunch meal. On 9/7/25 at 12:11 P.M., the Memory Hall cart went out of the kitchen. At that time, the log book for meal temperatures was reviewed and the page was completely blank. [NAME] 3 indicated the food temperature was taken when they got it out of the ovens and put it on the steam table. When the last cart went out, he would take the food temperatures again and that's when they get wrote into the log book. 2. On 9/8/25 at 12:05 P.M., the Dietary Manager was observed plating ham and cheese hoagies, baked french fries, baked beans, and lime gelatin with diced pears for the lunch meal. At that time, the food temperature log was reviewed. The dinner log for 9/7/25 was completely blank. The lunch log for 9/8/25 was written in pencil and not completely filled in. The Regional Director of Operations (RDO) was standing next to the log book with a pencil . At that time, the dietary manager indicated she had taken the temperatures, had them in her head, she had not wrote them in the book, but would write them in the log book later. During an interview on 9/8/25 at 12:27 P.M., the RDO indicated she expected kitchen staff to fill the food temperature log out after the tray line was complete. They should be putting the temperatures on paper and then writing in to the log from there. A copy of the food temperature log was requested at that time. On 9/8/25 at 12:35 P.M., copies of the requested food temperature log were provided by the RDO and the dinner log for 9/7/25 was filled in as well as the rest of the 9/8/25 lunch log. On 9/12/25 at 10:36 A.M., a current, non dated Food Temperature Policy was provided by the Administrator and indicated, . Temperatures of TCS (temperature controlled for safety) foods shall be recorded before being served from the steam table . 3.1-21(i)(2)3.1-21(i)(3)

Based on observation, interview, and record review, the facility failed to ensure residents received food at safe and appetizing temperatures for 1 of 1 meal trays tested for taste and temperature of food.Finding includes:On 9/8/25 at 10:30 A.M., three residents voiced concerns about the taste, variety, and temperatures of the food at the resident council meeting. On 9/8/25 at 12:30 P.M., a meal tray was obtained to test the taste and temperatures of the food. The hoagie sandwich (hamburger bun, slice of cheese, and piece of ham) felt and tasted cold and tested 107.7 degrees Fahrenheit. The fries were 96.7 degrees Fahrenheit and tasted cold. On 9/12/25 at 10:36 A.M., a current non dated Food Temperatures Policy was provided by the Administrator and indicated, . Hot Foods: Hold at 135 F or greater throughout the service process.3.1-21(a)(2)

Based on observation, interview, and record review, the facility failed to ensure physicians orders were followed for insulin administration and blood glucose monitoring (blood sugar testing) for 1 of 9 residents randomly observed during medication administration. Resident 2 was observed to receive the wrong dose of insulin and Resident 2 and Resident 8's medications were left blank on the Medication Administration Record (MAR). (Resident 8, Resident 2)Findings include:1. On 9/8/25 at 11:40 A.M., Registered Nurse 16 was observed administering insulin to Resident 2. His blood sugar was 537. She indicated for a blood sugar (BS) of 501-600, the resident should get 9.5 units. After obtaining the resident's Humalog insulin pen, she applied the needle, primed the pen with two units of insulin, used anti-bacterial hand rub (ABHR), and put on her gloves. Once she entered the resident's room, she dialed the pen to 9.0 units and administered the dose into the resident's abdomen. At that time, she indicated you can't give 9.5 units because the pen only allows one unit increments. The nurse did not call the physician for clarification of the order before administering the wrong dose of insulin to the resident. On 9/8/25 at 2:30 P.M., Resident 2's record was reviewed. Diagnoses included, but were not limited to, dementia and diabetes mellitus type II. Current Physician's orders included, but were not limited to, the following: Humalog Insulin Solution 100 units/milliter (mL) Inject as per sliding scale: if blood sugar (BS) 130-150 = 1 unit; 151-200 = 2 units; 201-250 = 3 units; 251-300 = 4 units; 301-350 = 6 units; 351-400 = 7.5 units; 401-500 = 8.5 units; 501-600 = 9.5 units; 601+ = 10.5 units subcutaneously three times a day for diabetes mellitus type II. Physician notification for BS greater than 400 or less than 70, ordered 1/7/25 A current Diabetes Care Plan, last reviewed 10/21/24, included an intervention to administer antidiabetic medications per order. The Medication Administration Record (MAR) for September 2025 indicated the resident received 9.5 units of Humalog insulin for his noon dose on 9/8/25. On 9/12/25 at 9:48 A.M., RN 16 indicated they should give medications as ordered and call for clarification if there is confusion. She indicated the dose of insulin was not able to be put into the MAR manually and since 9.5 units was the dose that should have been given as ordered on the sliding scale, that was the dosage that was entered even though she only gave 9.0 units. At that time, she indicated she was going to call the MD and get clarification of the sliding scale order. She indicated the dose given should be documented in the MAR. 2. On 9/9/25 at 10:58 A.M., Resident 8's clinical record was reviewed. Diagnosis included, but were not limited to, diabetes mellitus. The most recent significant change Minimum Data Set (MDS) assessment, dated 6/20/25 indicated Resident 8's cognitive status was unable to be determined, and she received insulin on 7 of 7 days during the look back window. Current Physician's Orders included, but were not limited to, Lantus (insulin).100 UNIT/ML (mililiter) Solution pen-injector. Inject 5 unit subcutaneously in the morning. dated, 5/15/25 Insulin Lispro 100 UNIT/ML Solution. Inject 6 unit subcutaneously four times a day. dated, 5/16/25 Current care plans included, but were not limited to, diabetes with current interventions to check blood sugars and administer medications per order, initiated 7/1/25. The facility failed to check Resident 8's blood sugar and administer the dose of insulin on the following dates and times during a 3 month look back period: June: 6-- insulin lispro 100unit/ml--6:00 PM blood sugar and dose given 14-- insulin lispro 100 unit/ml-- 6:00 PM blood sugar and dose given 19--insulin lispro 100 unit/ml-- 6:00 PM blood sugar and dose given 20-- insulin lispro 100 unit/ml--6:00 AM blood sugar and dose given 20-- Lantus 100unit/ml-- 6:00 AM blood sugar and dose given July: 2-- insulin lispro 100 unit/ml-- 6:00 AM blood sugar and dose given 14-- insulin lispro 100 unit/ml-- 6:00 PM blood sugar and dose given 29-- insulin lispro 100 unit/ml-- 6:00 PM blood sugar and dose given August: 9-- insulin lispro 100 unit/ml-- 12:00 PM blood sugar and dose given 9--insulin lispro 100 unit/ml-- 6:00 PM blood sugar and dose given 13-- insulin lispro 100 unit/ml-- 12:00 AM blood sugar and dose given 3. On 9/11/25 at 8:54 A.M., Resident 2's clinical record was reviewed. Diagnosis included, but was not limited to, diabetes mellitus. The most recent significant change Minimum Data Set (MDS) assessment, dated 8/11/25, indicated a severe cognitive impairment and no behaviors. Resident 2 had seven days of insulin injections. Current physician orders included, but were not limited to: Humalog injection solution 100 unit/mL (milliliter) inject as per sliding scale, dated 1/7/25. Blood glucose monitoring, check and record four times a day for diabetes mellitus, hold insulin if glucose is less than 80, dated 10/30/23. A current diabetes care plan, initiated 10/17/23 and revised 10/21/24, indicated to administer diabetic medications as ordered. Resident 2's Medication Administration Record (MAR) for July, August, and September 2025 indicated the following days that blood glucose monitoring was not completed, and Humalog was not given: 7/29/25 at 4:00 P.M. (MAR left blank) 8/24/25 at 4:00 P.M. (MAR left blank) 9/5/25 at 12:00 P.M. (MAR left blank) On 9/12/25 at 9:00 A.M., the Director of Nursing (DON) indicated she had been unable to find documentation about why resident's insulin had not been documented. At that time, the Regional Clinical Support indicated if a medication is refused or not given for any other reason, there are codes to indicate why it was not given in the resident's MAR and should have been entered. On 9/12/25 at 11:34 A.M., the Administrator provided a current Insulin Administration policy, dated 3/2023, that indicated Document administration and site on the Medication Administration Record . Monitor blood glucose as ordered and document the results per facility policy On 9/12/25 at 11:34 A.M., the Administrator provided a current Physician Orders policy, dated 6/18/23, that indicated 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 On 9/12/25 at 10:36 A.M., a current Following Physician's Orders Policy, dated 6/18/23, was provided by the Administrator and indicated, It is the policy of the facility to follow the orders of the physician . 3.1-35(g)(1)

Based on interview and record review, the facility failed to ensure accuracy of assessments for 3 of 21 residents reviewed for assessments. Minimum Data Set (MDS) assessments did not accurately reflect medications the residents were taking. (Resident 13, Resident 2, Resident 6)Findings include:1. On 9/11/25 at 10:33 A.M., Resident 13's clinical record was reviewed. Diagnoses included, but were not limited to, dementia, diabetes mellitus, and hypertension. The most recent significant change MDS assessment, dated 8/8/25, indicated a severe cognitive impairment. The MDS indicated Resident 13 used an anticoagulant medication, and indicated an antiplatelet medication had not been used. Physician orders included, but were not limited to:Aspirin Tablet Chewable (an antiplatelet) 81mg (milligram) every night for hypertension, dated 8/3/25 and discontinued 8/15/25. The clinical record lacked an order for an anticoagulant medication. Resident 13's Medication Administration Record (MAR) for August 2025 indicated he had taken Aspirin during the 8/8/25 MDS look back period. The MAR lacked documentation that an anticoagulant had been administered. 2. On 9/11/25 at 8:54 A.M., Resident 2's clinical record was reviewed. Diagnoses included, but were not limited to, diabetes mellitus, dementia, anxiety, and depression. The most recent significant change MDS assessment, dated 8/11/25, indicated a severe cognitive impairment. The MDS indicated use of an antipsychotic medication, and indicated an anticonvulsant medication had not been used. Current physician orders included, but were not limited to:Gabapentin Capsule (an anticonvulsant) 300mg by mouth with meals, dated 7/23/25. The clinical record lacked an order for an antipsychotic medication. Resident 2's MAR for August 2025 indicated he had taken Gabapentin during the 8/11/25 MDS look back period. The MAR lacked documentation that an antipsychotic had been administered. 3. On 9/8/25 at 11:43 A.M., Resident 6's clinical record was reviewed. Diagnoses included, but were not limited to, anxiety and psychotic disorder. The most recent significant change MDS assessment, dated 8/15/25, indicated a severe cognitive impairment. The MDS indicated an antidepressant had not been used. Current physician orders included, but were not limited to:Mirtazapine Oral Tablet (an antidepressant) 7.5mg in the evening, dated 6/28/25. Resident 6's MAR for August 2025 indicated he had taken Mirtazapine during the 8/11/25 MDS look back period. On 9/11/25 at 2:16 P.M., the MDS Coordinator indicated the medications for the most recent MDS assessments for Resident 13, Resident 2, and Resident 6 were entered in error. At that time, she indicated in lieu of a policy, the facility used the RAI (resident assessment indicator) manual for completion of the MDS.

Based on interview and record review, the facility failed to ensure proper notification following a change of condition for 1 of 3 residents reviewed for falls. (Resident 17)Finding includes:1. On 9/8/25 at 11:05 A.M., Resident 17's clinical record was reviewed. Diagnoses included, but were not limited to, dementia and psychotic disorder. The most recent significant change Minimum Data Set (MDS) assessment, dated 8/13/25, indicated a severe cognitive impairment and no behaviors. Resident 17 required partial to moderate assist (helper does half the effort) with toileting, substantial to maximum assist (helper does more than half the effort) with showers, and supervision or touching assist with eating. A current falls care plan, dated 7/29/25, indicated, but was not limited to, the following interventions: Notify and update MD as needed, dated 7/29/25. On 9/2/25 at 5:36 P.M., a nursing note indicated Resident 17 fell while coming through the doorway of the dining room. The resident hit their head with an open abrasion noted. The resident also had an abrasion to the nose and skin tear to the left hand. On 9/5/25 at 1:09 P.M., a nurses note indicated Resident 17 was very lethargic and more confused than usual. The resident was attempting to drink food and needed assistance with lunch (out of the norm for resident). The resident exhibited speech that was hard to comprehend. No parties were notified of the resident's change of condition at that time. Twenty six hours after the initial change of condition, a nurses note dated 9/6/25 at 3:00 P.M. indicated resident was lethargic and restless, unable to walk or get up without assistance. The resident was hard to awake, and had slurred speech. Resident 17 was then sent to the emergency room (ER) for evaluation and treatment. On 9/11/25 at 11:33 A.M., the Director of Nursing (DON) indicated staff had not notified Resident 17's physician after the change of condition on 9/5/25 due to trying to keep the residents in-house and treat at the facility instead of sending out. She indicated the following day (9/6/25), the resident seemed worse, so that was when the notification was made. On 9/12/25 at 11:34 A.M., the Administrator provided a current non-dated Registered Nurse (RN) job description that indicated Role Responsibilities - Nursing Care . Notifies the resident's attending physician and next-of-kin when there is a change in the resident's condition 3.1-5(a)(2)

Based on observation, interview, and record review, the facility failed to ensure implementation of care plan interventions for 2 of 3 residents reviewed for falls. A call light was observed out of reach, nonslip material was not placed under furniture, and a resident was not taken to the common area or toileted after a meal as indicated in risk for falls care plans. (Resident 6, Resident 35)Findings include:1. On 9/8/25 at 11:46 A.M., Resident 6's clinical record was reviewed. Diagnoses included, but were not limited to, renal failure, dementia, anxiety, and psychotic disorder. The most recent significant change Minimum Data Set (MDS) assessment, dated 8/15/25, indicated a severe cognitive impairment and no behaviors. Resident 6 required substantial to maximum assist (helper does more than half the effort) with eating, toileting, bed mobility, showers and transfers. Resident 6 had one fall with no injury. A current risk for falls care plan, initiated 6/15/21 and last revised 5/22/25, included, but was not limited to, the following interventions:Resident to be brought to common area after meals, dated 8/30/25.Resident to be toileted before and after meals, dated 7/10/25.On 9/9/25 at 12:15 P.M., Resident 6 was observed sitting in the dining room eating lunch. At 12:34 P.M., CNA 21 removed the plate in front of the resident and put it away. Resident 6 sat at the dining room table until 1:17 P.M. (43 minutes from the end of the meal) when CNA 21 and CNA 9 came and got the resident and wheeled in the wheelchair to his room. The resident was then transferred from the wheelchair to the bed at which time the resident's brief was checked. At that time, CNA 21 indicated they did not currently offer toileting for Resident 6 as he was incontinent. 2. On 9/8/25 at 11:46 A.M., Resident 35's clinical record was reviewed. Diagnoses included, but were not limited to, dementia, anxiety, depression, and psychotic disorder. The most recent significant change MDS assessment, dated 8/7/25, indicated a severe cognitive impairment and no behaviors. Resident 35 required partial to moderate assist (helper does less than half the effort) with toileting and showers, and supervision or touching assist with bed mobility and transfers. Resident 35 had one fall with no injury. A current risk for falls care plan, dated 12/20/22 and last revised 11/18/24, included, but was not limited to, the following interventions: Dycem (a nonslip material) under dining room table legs in common areas, dated 5/14/25. Keep call light in reach, revised 10/5/24. On 9/9/25 at 9:00 A.M., Resident 35 was observed sitting in a recliner in her room with the foot rest up. The resident had shoes on. A call light was observed coiled up and sitting on the floor well out of reach of the resident. At that time, the furniture in the dining room and common area were observed without dycem under the legs. On 9/12/25 at 11:34 A.M., the Administrator provided a current Comprehensive Care Plan policy, last revised 3/23/21, that indicated The Comprehensive Care Plan will further expand on the resident's risks, goals and interventions using the Person-Centered Plan of Care approach for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, physical functioning, mental and psychosocial needs . discuss and develop quantifiable objectives along with appropriate interventions in an effort to achieve the highest level of functioning and the greatest degree of comfort/safety and overall well-being attainable for the resident 3.1-35(b)(1)

Based on interview and record review, the facility failed to revise care plans with new interventions to prevent falls for 3 of 3 residents reviewed for falls. (Resident 17, Resident 6, Resident 35)Findings include:1. On 9/8/25 at 11:05 A.M., Resident 17's clinical record was reviewed. Resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, dementia and psychotic disorder. The most recent significant change Minimum Data Set (MDS) assessment, dated 8/13/25, indicated a severe cognitive impairment and no behaviors. Resident 17 required partial to moderate assist (helper does half the effort) with toileting, and substantial to maximum assist (helper does more than half the effort) with showers. The MDS assessment indicated one fall since the prior assessment on 7/29/25 with no major injury. A current falls care plan, dated 7/29/25, indicated the following interventions: Attempt to keep areas free of clutter, dated 7/29/25. Keep call light in reach, dated 7/29/25. Notify and update MD as needed, dated 7/29/25. Therapy screen as indicated, quarterly and as needed, dated 7/29/25. Hourly rounding, dated 8/22/25. Non skid strips to left side of bed under fall mat, dated 8/22/25. Tennis balls are properly positioned and in place on walker legs, dated 8/29/25. Make sure gripper socks stay in place to prevent falls, dated 8/29/25. Fall mat to open side of bed on top of non skid strips., dated 8/30/25. Offer toileting to resident when doing rounding on unit, dated 8/30/25. Social Services to have family get nonskid shoes for resident, dated 9/2/25. Resident 17's clinical record included, but was not limited to, the following falls: Fall 1On 8/3/25 at 10:34 A.M., a nursing progress note indicated the resident fell when they lost balance when walking with walker out the dining room door. The clinical record lacked a new intervention to the falls care plan following the fall. Fall 2On 8/8/25 at 6:30 A.M., a nurses note indicated the resident was found sitting on buttocks beside the bed in resident's room. The note indicated staff to encourage resident to wear gripper socks as fall prevention. The intervention was not added to the care plan for 21 days (8/29/25). Fall 3On 8/30/25 at 1:30 A.M., a general note indicated resident was found in room next to the bed lying on the left side. Resident 17 had a red bruise to the left forearm. The floor was noted to bed wet and two grip strips placed next to resident's bed. The clinical record lacked the new intervention to the falls care plan following the fall. Fall 4On 8/30/25 at 11:30 P.M., a general note indicated resident was found on the left side on the floor in front of the bed. A pressure reduction concave mattress was applied to the bed. The clinical record lacked the new intervention to the falls care plan following the fall.2. On 9/8/25 at 11:46 A.M., Resident 6's clinical record was reviewed. Diagnoses included, but were not limited to, renal failure, dementia, anxiety, and psychotic disorder. The most recent significant change Minimum Data Set (MDS) assessment, dated 8/15/25, indicated a severe cognitive impairment and no behaviors. Resident 6 required substantial to maximum assist (helper does more than half the effort) with eating, toileting, bed mobility, showers and transfers. Resident 6 had one fall with no injury. A current risk for falls care plan, initiated 6/15/21 and last revised 5/22/25, indicated the following interventions:Attempt to keep areas free of clutter, dated 6/15/21.Keep call light in reach, dated 6/15/21.Therapy screen as indicated, quarterly and as needed, dated 6/15/21.Encourage to use enabler bars when getting out of bed for stabilization, dated 10/7/21.Keep bed in lowest position, dated 9/22/22.Offer toileting every two hours, dated 5/21/23.Dycem to cushion, dated 12/22/23.Anti-roll backs to wheelchair, dated 6/24/24.Keep all frequently used items within reach, dated 10/5/24.Non-skid socks while in bed, dated 5/22/25.Resident to be toileted before and after meals, dated 7/10/25.Resident to be brought to common area after meals, dated 8/30/25.Resident 6's clinical record included, but was not limited to, the following falls:Fall 1A nurses note, dated 6/5/25 at 12:50 A.M., indicated resident was found lying on the floor next to the bed during bed checks. The immediate intervention noted was a low bed. The clinical record lacked a new intervention to the falls care plan following the fall. Fall 2A nurses note, dated 8/11/25 at 1:56 A.M., indicated resident was found sitting on the floor next to roommates bed. A skin tear was noted to the left elbow. The note indicated resident to be encouraged to wear gripper socks when in bed as a fall prevention intervention. At that time, the care plan already had in place an intervention to wear gripper socks in bed, dated 5/22/25. The clinical record lacked a new intervention to the falls care plan following the fall. 3. On 9/8/25 at 11:46 A.M., Resident 35's clinical record was reviewed. Diagnoses included, but were not limited to, dementia, anxiety, depression, and psychotic disorder. The most recent significant change MDS assessment, dated 8/7/25, indicated a severe cognitive impairment and no behaviors. Resident 35 required partial to moderate assist (helper does less than half the effort) with toileting and showers, and supervision or touching assist with bed mobility and transfers. Resident 35 had one fall with no injury. A current risk for falls care plan, dated 12/20/22 and last revised 11/18/24, indicated the following interventions: Keep call light in reach, revised 10/5/24. Notify and update MD as needed, revised 10/5/24. Attempt to keep areas free of clutter, revised 10/5/24. Therapy screen as indicated, quarterly and as needed, revised 10/5/24. Therapy evaluation, dated 12/2/24. Pain medication evaluation, revised 12/31/24. Encourage to use walker with ambulation, dated 3/17/25. Dycem under dining room table legs in common areas, dated 5/14/25. Resident 35's clinical record included, but was not limited to, the following falls: Fall 1A nurses note, dated 6/11/25 at 5:10 P.M., indicated resident was found scooting on the floor towards the doorway in another resident's room. The clinical record lacked an updated care plan intervention following the fall. Fall 2A nurses note, dated 8/7/25 at 10:56 P.M., indicated resident was found sitting on buttocks on the floor near her bed. The note indicated staff to ensure resident wearing gripper socks when not wearing shoes as an immediate fall prevention intervention. The clinical record lacked the new intervention to the falls care plan following the fall. On 9/11/25 at 11:35 A.M., the Director of Nursing (DON) indicated when a resident experienced a fall, an IDT meeting should be held the following morning, or if on a weekend the following Monday. Any new falls interventions discussed should then be placed into the resident's care plan that same day. On 9/12/25 at 10:32 A.M., the Administrator provided a current Incident/Accident/Falls policy, last revised 4/5/22, that indicated . Each fall needs a new care plan intervention rolled out 3.1-35(d)

Based on observation, interview, and record review, the facility failed to ensure staff provided a sanitary environment to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents observed for incontinence care and 4 of 9 residents observed during medication passes. Multiple items were touched with gloved hands and the same gloves were used to perform care, hand hygiene was not done between dirty to clean tasks, a resident was left with a brown substance on his bottom, staff washed hands with less then 15 second lather, and staff did not sanitize hands between residents during medication passes. (Resident 5, Resident 14, Resident 33, Resident 36, Resident 27)Findings include: 1.On 9/7/25 at 11:02 A.M., Licensed Practical Nurse (LPN) 22 was observed prepping medications for Resident 14 and did not sanitize hands before or after the medication pass. On 9/7/25 at 11:10 A.M., LPN 22 was observed prepping medications for Resident 33 and washed hands with a seven second lather after administering the medications. On 9/7/25 at 11:21 A.M., Registered Nurse (RN) 16 was observed prepping medications for Resident 26 and did not sanitize hands before or after the medication pass. On 9/8/25 at 8:53 A.M., Qualified Medication Aide (QMA 35) was observed prepping medications for Resident 27 and did not sanitize hands before or after the medication pass. 2. On 9/9/25 at 9:43 A.M., Certified Nurse Aide (CNA) 11 was observed to perform incontinence care for Resident 5. CNA 11 used gloved hands to raise the head of the bed using a remote, moved the call light, opened a drawer to remove wipes, then removed Resident 5's blankets. CNA 5 then failed to change gloves and perform hand hygiene before she unfasted the brief, wiped the resident's perineal area, walked to the other side of the room and carried a trashcan with her right gloved hand, and wiped with 2 wipes on the perineal area with the same hand. She then failed to change gloves and perform hand hygiene prior to obtaining a clean brief. Resident 5 rolled to the right side, and CNA 11 used 3 wipes to wipe a bowel movement off. After the 3rd wipe, the wipe was still observed to be brown and Resident 5's buttocks still had a brown substance on it. CNA 11 had then ran out of wipes, threw the empty wipe package in the trashcan, and failed to obtain another package of wipes. She then removed her left glove, tucked the clean brief under Resident 5 with her right gloved hand, fastened the brief, and then removed the right glove, failed to perform hand hygiene before she pulled up Resident 5's blankets, then used the remote to lower the bed. During an interview on 9/11/25 at 1:43 P.M., the Infection Preventionist indicated staff should wash hands using a 20 second scrub/lather time and nursing should sanitize their hands between each resident during medication passes. She further indicated for incontinence care, staff should perform hand hygiene and change gloves after items are touched and prior to incontinence care as well as between dirty and clean. At that time, she indicated staff should hit the call light and request more wipes or remove gloves, perform hand hygiene, and leave the room to obtain more wipes if the resident was not fully cleaned up. On 9/12/25 at 10:36 A.M., a current Handwashing Policy, dated 7/7/23, was provided by the Administrator and indicated . Vigorously scrub hands and arms for 10-15 seconds. Clean under fingernails and between fingers . The whole process should take at least 20 seconds – the time it takes to sing the Happy Birthday song twice . On 9/12/25 at 10:32 A.M., a current Guidelines for Incontinence Care policy, dated 9/21/23, indicated, .4. Perform hand hygiene 5. Apply latex free non-sterile gloves.7. Assist resident to side lying position by turning towards caregiver .8. If feces present, remove with toilet paper or disposable wipe by wiping from front of perineum toward rectum. Discard soiled materials and gloves. 9. Perform hand hygiene. 3.1-18(b)3.1-18(l)

Based on observation and interview, the facility failed to post up-to-date nurse staffing information on the posted nurse staffing form for 6 of 6 days reviewed for posted nurse staffing. The posted nurse staffing form did not have specific hours listed for the nursing staff. (9/7/25, 9/8/25, 9/9/25, 9/10/25, 9/11/25, 9/12/25)Findings include: On 9/7/25 at 8:50 A.M., the posted nurse staffing form was observed by the nurse's station, dated 9/6/25, with a census of 40 residents listed. There was no nursing staff listed on the evening shift from 2:00 P.M.-10:00 P.M. The day shift (6:00 A.M.-2:00 P.M.) included 1 Registered Nurse (RN) for 11.5 hours, 1 Licensed Practical Nurse (LPN) for 8.5 hours, 3 Certified Nurse Aides (CNAs) for 34.5 hours, and 1 Qualified Medication Aide (QMA) for 11.5 hours. The night shift (10:00 P.M.-6:00 A.M.) included 1 RN for 11.5 hours, 1 LPN for 11.5 hours, and 2.5 CNAs for 34.5 hours. On 9/8/25 at 8:00 A.M., the posted nurse staffing form was observed. There was no nursing staff listed on the evening shift from 2:00 P.M.-10:00 P.M. The day shift (6:00 A.M.-2:00 P.M.) included 1 RN for 11.5 hours, 1 Licensed Practical Nurse (LPN) for 8.5 hours, 3 CNAs for 34.5 hours and 1 Qualified Medication Aide (QMA) for 11.5 hours. The night shift (10:00 P.M.-6:00 A.M.) included 1 RN for 11.5 hours, 1 LPN for 11.5 hours, and 2.5 CNAs for 34.5 hours. On 9/9/25 at 9:15 A.M., the posted nurse staffing form was observed. There was no nursing staff listed on the evening shift from 2:00 P.M.-10:00 P.M. The day shift (6:00 A.M.-2:00 P.M.) included 2 LPNs for 23 hours, 3 CNAs for 35 hours and 1 QMA for 12 hours. The night shift (10:00 P.M.-6:00 A.M.) included 1 RN for 12 hours, 1 LPN for 12 hours, 2.5 CNAs for 34.5 hours, and 1 QMA for 12 hours. On 9/10/25 at 8:30 A.M., the posted nurse staffing form was observed. There was no nursing staff listed on the evening shift from 2:00 P.M.-10:00 P.M. The day shift (6:00 A.M.-2:00 P.M.) included 3 LPNs for 36 hours and 3.5 CNAs for 44 hours. The night shift (10:00 P.M.-6:00 A.M.) included 1 RN for 12 hours, 2.5 CNAs for 28 hours and 1 QMA for 12 hours. On 9/11/25 at 9:00 A.M., the posted nurse staffing form was observed. There was no nursing staff listed on the evening shift from 2:00 P.M.-10:00 P.M. The day shift (6:00 A.M.-2:00 P.M.) included 1 RN for 12 hours, 1 LPN for 12 hours, and 3 CNAs for 40 hours. The night shift (10:00 P.M.-6:00 A.M.) included 1 RN for 12 hours, 1 LPN for 12 hours, and 3 CNAs for 36 hours. On 9/12/25 at 8:15 A.M., the posted nurse staffing form was observed. There was no nursing staff listed on the evening shift from 2:00 P.M.-10:00 P.M. The day shift (6:00 A.M.-2:00 P.M.) included 1 RN for 12 hours, 3 CNAs for 36 hours, and 2 QMAs for 24 hours. The night shift (10:00 P.M.-6:00 A.M.) included 1 RN for 12 hours, 1 LPN for 12 hours, and 3 CNAs for 36 hours. The posted nurse staffing forms lacked specific hours worked for nursing staff. During an interview on 9/8/25 at 8:00 A.M., LPN 22 indicated she came in at 7:00 A.M., was the only nurse on the floor at that time (covering for the memory unit as well as working out front), and would leave at 1:00 P.M. The night nurse left at 7:00 A.M. and RN 16 would not come in until 11:00 A.M. There was 1 QMA working on the floor at that time. During an interview on 9/12/25 at 10:46 A.M., Regional Clinical Support indicated they don't update the posted nurse staffing forms for accuracy until the next day. She was unaware it needed to be in real time while posted. On 9/12/25 at 10:36 A.M., a current, non dated Posted Nurse Staffing Policy was provided by the Administrator and indicated, It is the policy of the facility, in cooperation with Medicare/Medicaid Services, (CMS), to comply with the requirement of daily posting of nursing staff in the facility . must post daily, at the beginning of each shift, the facility specific shift schedule for the 24 hour period, the number and category of nursing staff employed or contracted by the facility for each 24 hour period, as well as the total number of hours worked by licensed and licensed nursing staff who are directly responsible for resident care . Data must be updated as changes arise-Example-a call in that changes the staffing number reported on the BIPA [sic] form . Note: CMS does not require that the daily census (calculated at midnight the previous night), be posted as part of this [BIPA] Rule .

Based on interview and record review, the facility failed to ensure accurate receiving of routine medications for 1 of 3 residents reviewed for unnecessary medications. A physician's order was entered incorrectly which led to an interruption of a resident's routine medication and an unprescribed dosage reduction. (Resident B)Finding includes:A record review on 7/22/25 at 10:30 A.M., Resident B's diagnoses included, but were not limited to, unspecified polyneuropathy.Resident B's most recent quarterly Minimum Data Set (MDS) assessment, dated 4/15/25, indicated the resident had moderate cognitive impairment and received routine pain medication. Resident B's physician's orders included, but were not limited to; Lyrica Oral Capsule 100 milligrams (mg) give one (1) capsule two times a day for pain (started 5/10/24 and discontinued 6/24/25), Lyrica Oral Capsule 100 milligrams (mg) give two (2) capsules at bedtime related to polyneuropathy (started 11/5/24 and discontinued 6/24/25), Lyrica Oral Capsule 100 mg give one (1) capsule every morning and at bedtime for pain (started 6/24/25 and discontinued 6/28/25), Lyrica Oral Capsule 100 mg give one (1) capsule one time a day for pain (started 6/28/25 and discontinued 6/30/25), Lyrica Oral Capsule 100 mg give one (1) capsule one time a day for pain (started 6/30/25 and discontinued 6/30/25), Lyrica Oral Capsule 100 mg give two (2) capsules at bedtime (started 6/30/25 and discontinued 6/30/25), Lyrica Oral Capsule 100 mg give one (1) capsule one time a day and give one (1) capsule one time a day and give two (2) capsules at bedtime for pain (started 6/30/25).Resident B's medication administration record (MAR) for June 2025 indicated the resident did not receive a routine Lyrica 100 mg capsule at the ordered time of 12:00 P.M. on 6/23/25, did not receive the bedtime dose of 200 mg on 6/23/25, did not receive the morning dose of 100 mg on 6/24/25, and did not receive the noon dose of 100 mg on 6/24/25. Starting on 6/24/25 through 6/29/25, Resident B received only a 100 mg dose of Lyrica at bedtime and only received one 100 mg dose during the day.Resident B's progress notes included, but were not limited to: 6/24/25 at 5:15 A.M. - Lyrica oral capsule 100 mg held, will resume upon delivery, pharmacy and physician aware. 6/24/25 at 12:41 P.M. - Lyrica oral capsule 100 mg - Pharmacy stated they did not receive this. The hard script was faxed again today.6/24/25 at 6:24 P.M. - Resident's Lyrica did not arrive at the facility. Called the pharmacy to get information regarding this. The pharmacy stated the prescription had not been received. 6/29/25 at 12:09 A.M. - Resident complained of pain in legs during evening shift due to Lyrica reduction. 6/29/25 at 3:40 P.M. - Resident stated, My feet hurt so bad I can barely walk. The nurse stated to the resident that her Lyrica was decreased from four (4) capsules per day to two (2) capsules. The resident was unaware. Physician notified about the resident's complaint after reduction. 6/30/25 at 1:58 A.M. - Resident complained of foot pain at times due to Lyrica reduction.6/30/25 at 7:12 A.M. - Resident complained of leg and foot pain at times due to Lyrica reduction. Awaiting response from physician. 6/30/25 at 9:30 A.M. - Nurse practitioner clarified resident's Lyrica order - Lyrica 100 mg one capsule twice a day in the morning and at noon, and two capsules (200 mg) at bedtime. On 7/22/25 at 11:05 A.M., LPN 4 indicated Resident B's routine Lyrica order was changed from four capsules a day to two capsules a day by the facility without the physician's knowledge and without an order to do so. On 7/22/25 at 1:15 P.M., RN 6 indicated there was no order to change Resident B's Lyrica medication. An original order was being put into the electronic record and was entered incorrectly by facility staff. On 7/22/25 at 1:50 P.M., RN 6 supplied a facility policy titled Guideline for Physician Orders - (Following Physician Orders), dated 6/18/23. The policy included, It is the policy of the facility to follow the orders of the physician . 4) 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 deficient practice was corrected on June 25, 2025 after the facility implemented a systemic plan that included the following actions: Ad HOC QAPI meeting was held on June 25, 2025 an action plan included inservice review of policy for physicians orders and other documentation in the residents records with staff, and the on going monitoring of the transcribing physicians orders and documentation.This citation relates to Complaint 2561130.3.1-25(a)

Based on observation, interview and record review, the facility failed to ensure adequate staff was available on a locked dementia unit. A licensed nurse was not stationed on the unit during 2 of 2 days during the survey, monitoring and documenting of behaviors was not being completed during a 30-day review period, and staffing patterns did not meet the facility's Alzheimer's/Dementia Special Care Unit staffing specifications. (Memory Springs unit, Resident C, Resident D) Findings include: 1. During an observation and interview 2/4/25 at 9:50 A.M., LPN 2 entered Memory Springs (locked dementia unit). LPN 2 checked in and then exited then unit. One Certified Nurse Aide (CNA) 5 and one activity assistant (AA) 3 were on the Memory Springs unit. CNA 5 indicated that the Memory Springs unit nurse floated from the front hall located at the front of the building. The nurse or other staff come on the unit periodically to check in, administer medications, or will come to the unit if needed and contacted by the CNA. During a review of the daily schedule for 2/4/25, no nursing staff and no Qualified Medication Aide (QMA) were assigned to the Memory Springs locked dementia unit during day shift, evening shift, or night shift. One CNA was assigned to the unit during the day, evening, and night shifts. A review of the facility census, on 2/4/25, indicated there were nine residents that resided on the Memory Springs locked dementia unit. During a confidential interview on 2/4/25, a nursing staff member indicated while working the front hall of the building they have to float back to the Memory Springs locked dementia unit. The staff member indicated that nursing was not able effectively monitor the dementia unit and that the one CNA on the dementia unit could not keep up. The staff indicated the dementia unit should be staffed better. The facility's Alzheimer's / Dementia Special Care Unit dementia disclosure form dated, 12/30/24, indicated, the resident census and number of full time equivalent (FTE) direct care staff for each shift of the dementia care program / unit: (one FTE = 8 hours) At that time, the dementia unit census was 10. The form indicated the following staffing patterns: Day / Morning - 1 LPN, 1 CNA, 1 QMA, 1 activity staff, 1 social worker Afternoon / Evening - 0.5 LPN, 1 CNA, 1 QMA, 0.5 activity staff Night - 1 LPN, 1 CNA A review of the facility's daily staffing schedule from 1/22/25 through 2/4/25 indicated that no nurse or QMA was assigned to the Memory Springs locked dementia unit during the day shift. One QMA was assigned to the unit from 7:00 P.M. - 7:00 A.M. on 1/25/25, 1/26/25, 2/1/25, and 2/2/25. On those dates that a 7:00 P.M. - 7:00 A.M. QMA was scheduled to the unit, no CNA was scheduled to be on the unit during that time frame. During an observation on 2/5/25 at 9:35 A.M., AA 3 was sitting at a table with a resident in a common activity area. AA3 indicated the CNA was assisting a resident with bathing. No other staff were on the unit until 9:37 A.M. when the Administrator in Training (AIT) came onto the unit and sat with another resident in the common area. The Facility Administrator along with other staff members then came onto the unit. 2. During an interview on 2/4/25 at 9:55 A.M. CNA 5 indicated that she had to watch Resident C because he liked to joke around on the dementia unit and the other residents did not realize he was joking. Resident C's diagnoses included, but were not limited to, Alzheimer's disease, vascular dementia with mood disturbance, cognitive communication deficit, and anxiety. Resident C's most recent quarterly Minimum Data Set (MDS), dated [DATE], indicated the resident had severe cognitive impairment, and wandered daily. Resident C's physician orders included, but were not limited to, behavioral monitoring every shift for depression, withdrawn, anxiety, pacing (started 8/23/24), reside on secure unit due to Alzheimer's dementia (started 9/25/24), and cimetidine 300 milligrams (mg) one time a day for sexual behaviors (ordered 1/21/25). Resident C's CNA charting from 1/6/25 to 2/4/25 indicated Resident C had the following behaviors on the following dates: 1/21/25 at 5:59 A.M. - Resident was physically aggressive towards others, expressed frustration / anger at others, and displayed public sexual acts.(no specific sexual acts were documented) 1/27/25 at 4:28 A.M. - Resident displayed public sexual acts,(no specific sexual acts documented) was anxious / restless, and was wandering. 2/2/25 at 11:01 A.M. - Resident displayed public sexual acts (no specific sexual acts documented) A facility investigation timeline, signed by the Facility Administrator and Director of Nursing (DON) and dated 1/15/25 indicated, on 1/15/25 the DON was told by CNA 5 that Resident C was demonstrating sexually inappropriate behaviors the night prior. The DON questioned the MDS nurse, who had been the charge nurse for the building during the night of 1/14/25, about Resident C's behavior. The MDS nurse indicated that the CNA on the Memory Springs locked dementia unit had informed her that Resident C was making sexually inappropriate comments to staff during the night shift. Resident C's nurse's notes contained no documentation of sexually inappropriate behaviors on 1/14/25, 1/15/25, 1/21/25, 1/27/25, or 2/2/25. 3. On 2/4/25 at 12:00 P.M., a review of a facility investigation timeline, signed by the Facility Administrator and Director of Nursing (DON) and dated 1/15/25 indicated, on 1/14/25 the MDS nurse was called to the Memory Springs locked dementia unit at 8:16 P.M., to assist in locating Resident D after the CNA assigned to the unit could not locate the resident. Resident D was found in another resident's room, in their bed, asleep with the resident. Resident D's diagnoses included, but were not limited to, altered mental status, dementia with behavioral disturbances and psychotic disturbances, and Alzheimer's disease. Resident D's most recent annual MDS assessment, dated 1/6/25, indicted the resident had severe cognitive impairment and displayed behavioral symptoms directed towards others. Resident D's physician orders included, but were not limited to, behavioral monitoring every shift (started 2/21/24). Resident D's care plan included, but was not limited to, resident is at high risk for wandering due to dementia with behaviors (initiated 3/18/24), resident is at risk for decline in mood due to depression (initiated 2/14/24). An intervention included monitor for effectiveness of medications and interventions. Resident D's CNA charting indicated, on 1/21/25 at 7:33 A.M., Resident D was sad / tearful. Resident D's Treatment Administration Record (TAR) for January 2025, indicated the resident behavioral monitoring had been completed with the resident having no behaviors during the month of January, 2025. Resident D's nurse's notes contained no documentation of Resident D's behavior on the night of 1/14/25 or the resident's sadness / tearfulness on 1/21/25. During an interview on 2/4/25 at 1:20 P.M., LPN 11 indicated that if a resident is displaying a behavior, nursing staff should document the behavior in the resident's clinical record. During an interview on 2/5/25 at 12:15 P.M., the DON indicated that the facility did not have policy related to staffing. This citation relates to complaint IN00452251. 3.1-17(a) 3.1-17(c)(5)

Based on interview, and record review, the facility failed to provide necessary treatment and services for 2 of 3 residents reviewed for dementia care. Resident behaviors were not monitored and known behaviors were not documented by nursing staff. (Resident C, Resident D) Findings include: 1. During an interview on 2/4/25 at 9:55 A.M. CNA 5 indicated that she had to watch Resident C because he liked to joke around on the dementia unit and the other residents did not realize he was joking. Resident C's diagnoses included, but were not limited to, Alzheimer's disease, vascular dementia with mood disturbance, cognitive communication deficit, and anxiety. Resident C's most recent quarterly Minimum Data Set (MDS), dated [DATE], indicated the resident had severe cognitive impairment, and wandered daily. Resident C's physician orders included, but were not limited to, behavioral monitoring every shift for depression, withdrawn, anxiety, pacing (started 8/23/24), reside on secure unit due to Alzheimer's dementia (started 9/25/24), and cimetidine 300 milligrams (mg) one time a day for sexual behaviors (ordered 1/21/25). Resident C's care plan included, but was not limited to, resident demonstrates verbal inappropriate sexual comments due to dementia (initiated 1/21/25). One intervention was created prior to development of the care plan that included, redirect resident to room and offer toileting when making sexual comments (initiated 1/15/25). Resident C's CNA charting from 1/6/25 to 2/4/25 indicated Resident C had the following behaviors on the following dates: 1/21/25 at 5:59 A.M. - Resident was physically aggressive towards others, expressed frustration / anger at others, and displayed public sexual acts (no specific sexual acts documented). 1/27/25 at 4:28 A.M. - Resident displayed public sexual acts ( no specific sexual acts documented), was anxious / restless, and was wandering. 2/2/25 at 11:01 A.M. - Resident displayed public sexual acts(no specific sexual acts documented) A facility investigation timeline, signed by the Facility Administrator and Director of Nursing (DON) and dated 1/15/25 indicated, on 1/15/25 the DON was told by CNA 5 that Resident C was demonstrating sexually inappropriate behaviors the night prior. The DON questioned the MDS nurse, who had been the charge nurse for the building during the night of 1/14/25, about Resident C's behavior. The MDS nurse indicated that the CNA on the Memory Springs locked dementia unit had informed her that Resident C was making sexually inappropriate comments to staff during the night shift. Resident C's nurse's notes contained no documentation of sexually inappropriate behaviors on 1/14/25, 1/15/25, 1/21/25, 1/27/25, or 2/2/25. 2. On 2/4/25 at 12:00 P.M., a review of a facility investigation timeline, signed by the Facility Administrator and Director of Nursing (DON) and dated 1/15/25 indicated, on 1/14/25 the MDS nurse was called to the Memory Springs locked dementia unit at 8:16 P.M. , to assist in locating Resident D after the CNA assigned to the unit could not locate the resident. Resident D was found in another resident's room, in their bed, asleep with the resident. Resident D's diagnoses included, but were not limited to, altered mental status, dementia with behavioral disturbances and psychotic disturbances, and Alzheimer's disease. Resident D's most recent annual MDS assessment, dated 1/6/25, indicted the resident had severe cognitive impairment and displayed behavioral symptoms directed towards others. Resident D's physician orders included, but were not limited to, behavioral monitoring every shift (started 2/21/24). Resident D's care plan included, but was not limited to, resident is at high risk for wandering due to dementia with behaviors (initiated 3/18/24), resident is at risk for decline in mood due to depression (initiated 2/14/24). An intervention included monitor for effectiveness of medications and interventions. Resident D's CNA charting indicated, on 1/21/25 at 7:33 A.M., Resident D was sad / tearful. Resident D's Treatment Administration Record (TAR) for January 2025, indicated the resident behavioral monitoring had been completed with the resident having no behaviors during the month of January, 2025. Resident D's nurse's notes contained no documentation of Resident D's behavior on the night of 1/14/25 or the resident's sadness / tearfulness on 1/21/25. During an interview on 2/4/25 at 1:20 P.M., LPN 11 indicated that if a resident is displaying a behavior, nursing staff should document the behavior in the resident's clinical record. On 2/5/25 at 12:30 P.M., the DON supplied a facility policy titled, Guidelines for Handling and Addressing Behavioral Emergencies, dated 3/18/23. The policy included, Assess whether the anger/acting out is related to . dementia . Look for: .4. A change in behavior - Notify medical staff for evaluation . B. Immediate Approaches . 7. Any interventions implemented for behavior control will be monitored by nursing staff and/or SSD (Social Service Director) daily until the behavior is considered to be managed . 11. Every resident behavior will be assessed and addressed individually . C. Documentation 1. Record specifics related to the behavior incident(s). Include time, place, duration, actions observed by the resident, statements or vocalizations made by the resident, possible causative factors, persons involved other than the resident, witnesses, behavior intensity, interventions, notifications, orders received and resolutions . This citation relates to complaint IN00452251. 3.1-37(a)

Based on interview and record review, the facility failed to provide supervision for a resident at risk for falls, and failed to develop and implement appropriate interventions to prevent falls, resulting in multiple right foot fractures and neck sprain, for 1 of 3 residents reviewed for accidents. (Resident B) Findings include: The closed clinical record of Resident B was reviewed on 5/25/22 at 11:45 A.M. The resident was admitted to the facility on [DATE] with diagnoses including, but not limited to, dementia, [CONDITION(S)], and weakness. A Physician's order, dated 4/25/22, indicated, Up ad lib [as desired] with assistance. Nurses notes included the following notations: 4/25/22 at 12:32 P.M.: Resident arrived to facility via family transport. Resident arrived on oxygen et with her rollator .[CONDITION(S)]. Family states resident has dementia that they believe is progressing A Care Plan, dated 4/26/22, indicated: [Resident B] is moderate risk for falls r/t [related to] Psychoactive drug use. The Interventions included: 4/26/22 Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. 5/4/22 Bed against the wall to exit on right side of bed. 5/2/22 Bed to be in appropriate height for resident to get in and out of bed safely. 4/26/22 Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. 4/26/22 Follow facility fall protocol. Nurses notes continued: 5/2/22 at 4:30 A.M.: CNA notified this nurse that res [resident] on floor next to bed with 02 [oxygen] off and incont [sic] [incontinent] of BM .Res cleaned up and assisted back to bed. Notified MD, Dtr [daughter], and DON [Director of Nursing]. 5/2/22 at 9:06 A.M.: Social Service Note . Resident is interviewed .She is understood with clear speech and understands as she answers interview questions appropriately. She scored 09/15 on BIMS [brief interview for mental status] indicating moderate cognitive impairment 5/2/22 at 12:35 P.M.: Resident was found by CNA sitting on floor beside her bed facing the window. Resident was sitting up without her oxygen on. Resident has been educated on keeping 02 on at all times. Resident also found to be sitting in bowel movement. Resident states she ¨got tangled in the covers trying to get up and slipped on them and fell on her bottom. Denies hitting head .Resident 02 was applied et [and] resident bed was cleaned. Resident changed et put back in bed. Resident 02 92% with 02 on. No injuries noted. Staff to check on resident frequently to ensure 02 is on et bed check resident Daughter notified. MD aware. DON aware. A Fall Risk Review, dated 5/2/22 at 12:30 P.M., indicated the resident had a history of falls in the previous 3 months, was receiving medication that affected awareness, judgement or safety, ambulated with assistance, and had decreased muscular coordination/jerking movements with her gait/balance. The Fall Risk Score was 12, which indicated a high risk for falls. An admission Minimum Data Assessment (MDS), dated [DATE], indicated Resident B had moderately impaired cognition, required extensive assistance of two or more staff for transfers and walking, and had fallen 2 or more times since admission. Nurse's notes continued: 5/4/22 at 10:24 A.M.: Team met r/t [related to] recent falls. First fall on 5/2/2022 at 0430 intervention to lower bed to appropriate height for resident to get in et out of bed safely. Second fall on 5/2/2022 at 1235 intervention to move bed against wall so resident can exit on right side. MD et Family aware of interventions. Will continue to monitor. A Daily Skilled Nursing Note, dated 5/6/22 at 1:47 P.M., indicated Resident B was forgetful/confused, and had unsteady balance/gait. The note indicated, [Resident B] is limited assist with ADL's [activities of daily living] .She will remove oxygen at times, makes unsafe transfers at times .Will continue to monitor. Nurse's notes continued: 5/12/22 at 1:30 A.M.: Resident was calling, I entered her room and saw resident lying on the floor on her left side, no open areas noted, her right foot was discolored light green in color and swollen. Up to feet with 2 assist walked 4 feet to her bed . [Name of physician], [Name] ADON [Assistant Director of Nursing], and Hospice all notified. 5/12/22 at 1:30 A.M.: The Change In Condition/s reported on this CIC Evaluation are/were: Falls . Outcomes of Physical Assessment: Positive findings reported on the resident/patient evaluation for this change in condition were: Mental Status Evaluation: No changes observed, Functional Status Evaluation: Fall .Neurological Status Evaluation: Nursing observations, evaluation, and recommendations are: Neuro checks continue due to unwitnessed fall Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: awaiting response, sent to ER for evaluation and treatment. B. New Testing Orders: X-ray C. New Intervention Orders: Oxygen (if available). 5/12/22 at 8:30 A.M.: This nurse evaluated resident right foot from fall earlier. This nurse noted bruising et swelling to foot. Notified hospice et PCP [primary care physician] with order to send to ER for eval [evaluation] et treat. Guardian aware The resident was transferred to the hospital on 5/12/22. A hospital ER note, dated 5/12/22, indicated, Chief Complaint Patient presents with Fall Foot Injury . presents to the emergency department from the [name of facility] after a fall. The fall was unwitnessed and patient was found around 2:00 a.m. on the ground. Patient was assisted back to bed and this morning it was found that the patient had a swollen, painful right foot. Patient was brought to the emergency department for evaluation. Patient reports she is only having pain to the right foot. She denies hitting her head. Patient does have a history of dementia and is alert and oriented . Right foot: .Swelling and tenderness present. Normal pulse. Comments: Very edematous [swollen] and ecchymotic [bruised] right foot . A right foot x-ray is consistent with 2nd through 5th metatarsal [foot] fractures. Patient was placed in a walking boot and will be non- weightbearing . CT C-spine is concerning for a ligamentous injury at C4-C5 [neck sprain] On 5/26/22 at 9:45 A.M., LPN 1 was interviewed. LPN 1 indicated she was the nurse working when Resident B had fallen on 5/12/22. Resident B was a frequent [NAME] upper. She wouldn't keep her oxygen on. Staff were doing checks, and found Resident B on the floor on 5/12/22 at 1:30 P.M. Staff never heard her fall. They had checked on her approximately 45 minutes previous to the fall, and she was lying in bed. She was found in the middle of the floor on her left side. Her right foot was green looking at that time, and then turned purple later that morning. She did not call the physician or hospice at that time. When the day shift came in, notifications were made and the resident was transferred to the emergency room . On 5//26/22 at 11:45 A.M., the Administrator and Assistant Director of Nursing (ADON) were interviewed regarding Resident B's fall. The ADON indicated she had been called on 5/12/22 at approximately 1:30 A.M. by LPN 1, but did not hear the call. The ADON indicated she was not on call that night, and was unsure why she was called. She called LPN 1 at approximately 4:30 A.M., and told LPN 1 to notify hospice at that time. Hospice would then contact the physician. She did not know why LPN 1 did not notify hospice then. Neither the Administrator nor the ADON knew why the documentation indicated LPN 1 did notify the physician and hospice at 1:30 A.M., or why LPN 1 did not call the family. When the DON came in at approximately 7:00 A.M., and assessed the resident, she called the family and hospice, and transferred the resident to the emergency room . On 5/26/22 at 11:30 A.M., the Administrator provided the current facility policy, Incidents/Accidents/Falls, undated. The policy included: 'In the case of a fall, the resident will have a head to toe assessment to include a pain assessment and assessment as to any change in their ROM [range of motion] ability/function .The nurse will notify the resident's attending physician/Nurse Practitioner, DON [Director of Nursing], Administrator, and the resident's responsible party. The physician will be notified of any changes in condition related to the fall that have been identified. Orders for treatment and any interventions will be obtained .All falls will have a site investigation by appropriate staff in an effort to define the 'root cause' of the fall. This will help provide information to enable staff to roll out interventions to prevent another similar occurrence .Based on the results of the incident/accident/fall, the resident's care plan will be addressed to ensure that any needed points of focus have measurable goals with appropriate interventions in place This Federal tag relates to Complaint IN 476. 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to prevent falls for 3 of 4 residents reviewed for accidents. Fall interventions were ineffective, interventions were not in place, and immediate assessments were not conducted by qualified staff following multiple falls. Residents experienced multiple falls resulting in a resident receiving an occipital calvarial fracture (skull fracture), a resident receiving a pelvic fracture, and a resident receiving rib fractures. (Resident C, Resident F, Resident J) Findings include: 1. During record review on 1/7/22 at 12:00 P.M., Resident C's diagnoses included, but were not limited to, dementia, amnesia, wandering, history of falling, dizziness, difficulty in walking, muscle weakness, and lack of coordination. Resident C's most recent quarterly MDS (Minimal Data Set), dated 11/30/21, indicated the resident's cognition was severely impaired, the resident required extensive assistance with transfers and mobility, and experienced 2 or more falls since the prior assessment. Resident C's care plan included, but was not limited to, resident is at risk for falls due to history of falls. Interventions included, but were not limited to, staff to do frequent checks on resident (initiated 11/19/21), request medication review from physician due to [MEDICATION(S)] use (initiated 11/29/21), make sure all staff members are aware that resident is a high risk for falls . (initiated 12/8/21), request labs from physician (initiated 12/27/21), request medication review from physician (initiated 12/27/21). A fall risk assessment dated [DATE], indicated Resident C was a high risk for falls. Resident C's nurse's notes included, but were not limited to the following; 11/18/2021 at 2:49 P.M., Resident reported that they had a fall last night. Resident is impulsive, has an unsteady gait, poor balance, decreased safety awareness, self transfers from bed, chair and wheelchair. Resident will also walk up the hallway without assistive device, easily redirected. Resident complained of right arm pain. 11/27/2021 at 6:53 P.M., Resident was standing at doorway to room, went to see what they needed, Resident then turned to go back to bed and fell to left side. Resident did not hit head . 11/29/2021 at 2:03 P.M., Resident noted to be standing in the hallway by their room, resident turned and then he fell backwards before this nurse could get to them. Resident hit head . 12/7/2021 at 2 P.M., Resident being assisted to the bathroom with assist of 2 CNAs when resident became weak and unable to bear weight. Resident lowered to the floor without injury or incident . 12/10/2021 at 11:10 P.M., Nurse witnessed resident holding onto handrail in hallway, then took a few steps and fell backwards on buttocks . 12/13/2021 at 3:18 P.M., Resident was found on knees holding onto the rails. Resident then laid self on the floor . Resident is impulsive with gait imbalance and is unable to be easily redirected. 12/16/2021 at 05:55 A.M., Resident was found by staff on floor near end of both beds with a small scalp laceration to right side of head. He was unable to explain what happened. Pleasant, but confused & cooperative. Registered Nurse notified . 12/17/2021 at 3:58 A.M., Resident walked out of their room into hallway and fell on to floor by doorway. Resident received a laceration to right eyebrow with some swelling noted and a skin tear to right elbow . 12/18/2021 at 5:00 P.M., Resident was standing in doorway when they started to holler for someone. Nurse looked down the hallway and found resident standing in doorway, weak and unsteady. Upon further inspection it is noted resident has a knot to left eyebrow area. No additional confusion noted. Resident states they fell out of bed et crawled to pick self back up. Resident was standing in hallway. Knot to left eyebrow is hard et resident denies pain to area . 12/22/2021 at 4:07 A.M., Resident was found on the floor with the bedspread around him. Resident stated they wanted to go to the bathroom. Resident presented with an approximately 6 centimeter circular skin tear to left elbow. 12/23/2021 at 12:30 A.M., Staff heard noise and went to investigate and found resident kneeling on mat beside bed . 12/25/2021 at 7:40 P.M., Resident was sitting in front lounge when they got up from wheelchair and started walking and fell . Resident was previously in room with activity aide and she took smokers out. This is when resident fell .Resident previously had told this nurse and staff member they didn't trust us and called us profanity names. 12/29/2021 at 4:30 A.M., Heard a thud, CNA (Certified Nurse Aide) entered room and saw resident lying on right side with one pant leg off and urinating on the floor . 12/31/2021 at 5:43 A.M., Resident found on floor unresponsive near chest close to bed in room. Easily returned to responsiveness, but a swollen area noted at base of his skull. Assessment done and assisted back to bed . Physician notified and orders received to transport to emergency department for CT scan (computerized tomography scan) of head/neck . Resident C's Hospital records dated 12/31/21, included a CT scan of the head that concluded, Multi compartment hemorrhage overlying the mainly anterior brain . Associated left occipital calvarial fracture is identified extending into the skull base During an interview on 1/10/22 at 2:45 P.M., the ADON (Assistant Director of Nursing) indicated the facility was unable to prevent Resident C from falling, that the resident had a history of falling prior to admitting to the facility, and the resident could stand up by themselves, and was very quick. 2. During record review on 1/10/22 at 9:30 A.M., Resident F's diagnoses included, but were not limited to, [CONDITION(S)], [CONDITION(S)] disorder, vascular dementia, lack of coordination, weakness, difficulty walking, unsteadiness on feet, and [CONDITION(S)]. Resident F's most recent quarterly MDS dated [DATE], indicated the resident had moderately impaired cognition, required extensive assistance with transfers and mobility, and experienced 1 fall with no injury and 1 fall with injury since the prior assessment. Resident F's care plan included, but was not limited to, resident exercises right to make unsafe transfers and resident at risk for falls, and resident requires staff assistance with ADL's (activities of daily living). Interventions included but were not limited to, staff to anticipate residents needs. Resident F's nurse's notes included, but were not limited to; 12/22/21 at 1:38 P.M., Nurse called to resident room because resident was sitting on the floor near bathroom door. Resident stated they thought they were sitting down in a chair when they fell to the floor. 12/31/21 at 10:18 A.M., Resident was found by another CNA on the floor at 8:15 A.M. Resident had a cover over them and pillow under head. Resident was not moved from the spot they were in until EMT (Emergency Medical Technician) arrived. Resident was in excruciating pain when moved. Unable to extend legs. Complained of head, back, and leg pain. Rated pain at a 9 out of 10 on pain scale. 12/31/21 at 7:00 P.M., Resident will be returning to facility. Report given by ER (emergency room ) nurse. Resident has multiple pelvic fractures and [CONDITION(S)]. During an observation on 1/10/22 at 11:02 A.M., Resident F was lying in bed with leg up over the bedside table. The Resident's bed was not in the lowest position. Resident F indicated they wanted to get up. CNA 6 indicated the resident could not get out of bed because of a recent fall with a pelvic fracture. CNA 6 removed the resident's leg from the bedside table and adjusted the resident's brief. CNA 6 placed 3 pillows under the resident's left leg and left the room without lowering the bed. During an interview and observation on 1/10/22 at 11:19 A.M., LPN 5 indicated Resident F's bed was not in the lowest position, then obtained the bed remote and lowered the bed to it's lowest position. 3. During record review on 1/10/22 at 10:30 A.M., Resident J's diagnoses included, but were not limited to, dementia, difficulty in walking, history of falling, weakness, unsteadiness on feet, lack of coordination, and [CONDITION(S)]. Resident J's most recent significant change MDS, dated [DATE], indicated the resident has severely impaired cognition, required extensive assistance with transfers and mobility, and had 2 or more falls since the prior assessment with 1 fall resulting in injury. Resident J's care plan included, but was not limited to, Resident has experienced an alteration in musculoskeletal status due to a fracture of the 8th and 9th ribs from a recent fall (initiated 1/7/22), and resident is at risk for falls. Interventions included, but were not limited to, have family take clogs home and replace with skid proof footwear (initiated 11/26/21), be sure resident has skid proof footwear on at all times (initiated 12/6/21), make sure all staff members are aware that resident is a high risk for falls . (initiated 12/6/21), consult with hospice for additional fall intervention ideas (initiated 12/14/21). Resident J's nurse's notes included, but were not limited to; 11/5/21 at 3:05 P.M., Resident sitting on floor next to bed and wheelchair. Resident stated, I was taking my shoes off and fixing my blanket on my bed, and I slid out of my chair. 11/29/21 at 3:53 P.M., Resident found in room lying on abdomen. Appeared as if resident had walked from wheelchair and lost balance and fell . Socks on at time . 12/2/21 at 6:54 P.M., Resident found on floor inside of nurse's station. Resident returned to wheelchair and resident asked to be placed in room and in bed. Nonskid footwear placed to bilateral feet . 12/5/21 at 2:15 A.M., Resident observed on bed linens in the middle of the room on the floor . 12/8/21 at 3:00 A.M., CNA notified nurse that resident was on the floor. Found resident sitting on floor next to bathroom door. No footwear on due to resident removing gripper socks. 12/10/21 at 2:23 P.M., Nurse was notified that resident was on the floor down the hallway . resident had been wandering hallways all shift and get up walking unassisted. Resident had been redirected several times with no success. 12/12/21 at 5:46 P.M., (late entry) at 9:45 A.M Nurse saw resident sitting on the floor in room . The resident was wearing gripper socks . 1/1/22 at 5:09 P.M., Resident got out of bed and fell to floor at 11:10 A.M. Resident complained of left side pain . orders received for X-ray of left side . 1/7/22 at 6:43 A.M., Resident rested quietly in bed this shift. Resident has pain with movement due to rib fracture . During an observation on 1/10/22 at 1:40 P.M., CNA 6 and CNA 10 were changing Resident J's depends. Resident was lying on back in bed and was crying out that they were hurting. Resident J did not have gripper socks on. CNA 10 indicated the resident was really hurting when they moved her. CNA 6 and CNA 10 put gripper socks on the resident's feet. During a confidential interview, staff indicated the night shift was, at times, short staffed and could not properly supervise the residents. During a confidential interview, staff indicated the day shift was, at times, insufficiently staffed. During an interview on 1/10/22 at 1:30 P.M., the ADON indicated that on night shift, while the facility had a red zone due to COVID positive residents, a QMA was, on occasion, scheduled to work the front hall while a nurse was scheduled to work the red zone. Nurses were not able to exit the red zone to enter any other part of the facility, so if a fall were to happen during the night, the QMA was instructed to call the MDS director or the ADON to come in and complete an assessment. During an interview on 1/10/22 at 2:15 P.M., CNA 6 indicated they do not use CNA information/assignment sheets. On 1/10/22 at 12:45 P.M., the Facility Administrator supplied an undated facility policy titled, Incidents/Accidents/Falls. The policy included, .1. If a resident is involved in an incident/accident an immediate assessment of the resident will be completed by a nurse . 16. The CNA information sheet will be updated as indicated to reflect the plan of care. This Federal tag relates to Complaint IN 421. 3.1-45(a)(2)

Based on interview and record review, the facility failed to notify the physician and obtain an order to catheterize a resident, based on the recommendations from the psychiatric team who had previously treated the resident, resulting in increased agitation, physical aggression, sleeplessness, pacing, and exit seeking. The resident was transferred to the hospital, while in the emergency room the resident received an antipsychotic medication by intramuscular injection, received an antianxiety medication, the resident received a urinary catheterization and 500 cc of urine was returned. This affected 1 of 3 residents reviewed for bladder function, in a sample of 5. (Resident B) Findings include: The closed clinical record of Resident B was reviewed on 5/6/21 at 12:15 P.M. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurses Notes included the following notations: 4/26/12 at 4:12 P.M.: Resident arrived to facility .Resident was cooperative with care. Confusion noted. Resident can not carry on a conversation or answer questions appropriately. Cont. of B&B[continent of bowel and bladder] at this time 4/27/21 at 2:49 A.M.: Alert to self with confusion .Toilets self in his room .So far he has not been asleep or even in bed tonight .Will continue to monitor. 4/27/21 at 4:31 A.M.: Swing at wife, agitated, began swinging at wife .has not been asleep the whole night. Interventions attempted: offered snack and water. Effectiveness of the interventions: still agitated and loud in hallway. 4/27/21 at 5:20 A.M.: [Name of physician] notified of resident's increased agitation and swinging at wife and staff, new orders to give [MEDICATION(S)] 50 mg [an anti-psychotic] now, and if continues hitting at Folks, send to [name of psychiatric unit at hospital] for further evaluation. 4/27/21 at 6:00 A.M.: Resident in front lobby talking with staff restless sitting then standing, wife concerned and wants Dr called to get sedation, explained to her Dr was notified and we are trying the medication. 4/27/21 at 9:00 A.M.: Res [resident] is up ambulating per self .Once res had calmed down did take po [by mouth] meds as per order. 4/27/21 at 9:35 A.M. (Social Services Director note): Exit seeking, sprinting to door, unable to be redirected by three staff members .Redirection, offered to take resident to courtyard with staff .Ineffective. The next note was a progress note from the Social Services Director (SSD), and dated 4/27/21 at 5:11 P.M.: Resident pacing, entering resident's rooms .becomes agitated and has attempted to hit staff. Resident still pacing throughout the facility and exit seeking .Interventions attempted: Redirection, asked resident to sit with staff. Effectiveness of the interventions: Ineffective. A Nurses Note, dated 4/27/21 at 6:43 P.M., indicated, Resident up most of afternoon pacing, attempting to enter other residents rooms. Became aggressive several times with staff .Attempted to give prn [as needed] [MEDICATION(S)] .spit pill out .Order to send to ER An emergency room Nurse's note, dated 4/27/21 at 7:43 P.M., indicated, Chief Complaint: Agitated and Aggressive Behavior The resident required an IM injection of an antipsychotic and anti-anxiety medication at 7:58 P.M. The ER Nurses note, dated 4/27/21 at 8:02 P.M., continued: Pt's [patient's] wife reports pt becomes irritable when bladder is full. Verbal orders to bladder scan pt obtained. Bladder scan reports 554 mL of urine noted .in/out catheterization placed .Return of 500 ml amber-colored cloudy urine; odor is foul-smelling A hospital Behavior Screening/Intake, dated 4/27/21 at 10:36 P.M., indicated, Pt was discharged from [hospital psychiatric unit] on 4-26-21 to [name of facility]. Per [facility] since being admitted to their facility he has been pacing, exit seeking, wondering [sic] in and out of rooms, attempting to hit staff and pt wife, and not allowing staff to catheter [sic] him. Pt has not been catheterized since being at their facility, and this is typically done every 6 hours. The facility did contact [hospital] Behavioral Health team on several occasions throughout the day to report pt attempting to leave the facility and attempting to hit his wife and staff. They were instructed to treat pt's urinary retention and to create rapport with pt A hospital Behavioral Health Services Note, dated 4/28/21 at 4:25 P.M., indicated, Patient presented to the emergency room from [name of facility] .[Name of facility] staff report patient has been pacing, exit-seeking, wandering in and out of rooms, and has attempted to hit staff and wife. Patient reportedly was not calm enough to allow staff to catheterize him. The facility social worker called inpatient behavioral health unit early morning of April 27, 2021 reporting continued behaviors. Inpatient staff attempted to provide guidance by asking if they had performed bladder scans and were told the nursing facility does not have a bladder scanner. When asked if they have catheterized him the response was no one had time to do that there. They were instructed to treat the urinary retention and may need to contact their on call provider to obtain an order for [MEDICAL RECORD OR PHYSICIAN ORDER] .Recent discharge 4/26/21 to [name of facility]: Patient was recently admitted to inpatient behavioral health on April 20, 2021 and discharged on [DATE] .Discharge summary of that hospitalization included description of behaviors that appeared to be a direct result of constipation and urinary retention. The summary states bladder scanning was ordered and in and out catheterizations to be performed for results >500 .Patient displayed behaviors of agitation, restlessness, and was physically aggressive on 4/21/21 .[In/out] cath yielded results of 700 ml of retained urine .Post void residual bladder scans decrease [sic] to ~300 mls or less, not requiring further catheterization A Discharge Summary, dated 5/2/21 at 10:14 A M., indicated, Discharge Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] On 5/6/21 at 3:15 P.M., the Social Services Director (SSD) was interviewed. She indicated Resident B was calm when he was admitted to the facility on [DATE]. When she came into work on 4/27/21 at 8:15 A.M., the resident was agitated and restless. The resident had been up during the night. She contacted the hospital behavior unit a couple of times. They suggested bladder scanning the resident, but the Administrator indicated the facility did not have a bladder scanner. The hospital behavior unit suggested catheterizing the resident, but she was unsure if anyone pursued that suggestion. The SSD indicated Resident B was calm when he was sleeping. On 5/6/21 at 3:40 P.M., the Director of Nursing (DON) was interviewed. She indicated Resident B was very restless and wanted to leave. The night shift nurse did call the physician, and he did not want to order a sedative. The DON was unsure if anyone contacted the physician again to inform him of the hospital behavior unit's recommendation to catheterize the resident. The DON indicated the resident was very restless, and staff would have been unable to catheterize him anyway. On 5/6/21 at 4:25 P.M., the Administrator was interviewed. She indicated when the resident was going to be admitted , the hospital discharge planner mentioned a bladder scan. The Administrator indicated she informed the discharge planner that the facility did not have a bladder scanner, and that the discharge planner told her it would not be a problem. On 5/7/21 at 10:50 A.M., the Administrator indicated the facility did not have a specific policy regarding maintaining bladder function. At that time, the Administrator provided the current facility policy, Behavior Management Program, undated. The policy included: Each resident of the facility identified as exhibiting problematic behavior will be observed in a manner to identify the casual [sic] factor, if possible, of the behavior as well as seek approaches/interventions for the same This Federal tag relates to Complaint IN 848. 3.1-41(a)(2)

Based on observation, interview, and record review, the facility failed to ensure a resident admitted without pressure ulcers was provided effective interventions to prevent the development of a pressure area on the left buttock, mid-back and thigh areas for 2 of 4 residents who were reviewed for pressure ulcers. A resident developed stage III pressure injuries to the mid-back and to the right posterior thigh. (Resident 38, Resident 51) Findings included: 1. On 3/20/18 at 8:40 A.M., during a record review, Resident 51's [DIAGNOSES REDACTED]. The most recent Quarterly MDS (Minimal Data Set) assessment, dated 2/1/18, indicated Resident 51 had not exhibited any rejection of care, has an unhealed stage I or greater pressure area, required extensive assistance with bed mobility, locomotion, dressing, toilet use, and personal hygiene, and was totally dependent with transfers. Resident 51's care plans included, but were not limited to; A focus dated 9/14/17 indicated the resident was admitted with pressure injuries. A focus dated 1/26/17 indicated the resident had an area to the right upper back of thigh/gluteal area. Interventions included observe for signs of infection, treatment as ordered, weekly skin checks. A focus dated 1/23/18 indicated the resident required a restorative program for bed mobility to maintain ability to move side to side and reposition self, the resident will perform 5 to 10 repetitions of turning on right side with 15 second hold and repeat for left side 6-7 days a week. A focus dated 9/26/17 indicated resident had potential for skin breakdown such as pressure injuries due to having pressure upon admission, the resident will have no further skin breakdown and existing areas will resolve without complications, prevent friction/shearing with bed mobility, skin assessments per facility policy, and provide treatments as ordered. A focus dated 2/22/18 indicated the resident had an infection of wound and was receiving antibiotics. No specific care plan noted for pressure injury to back. A Braden scale assessment completed on 12/15/17 indicated the resident was at low risk for skin integrity. Another Braden scale assessment on 2/7/18 indicated the resident was at moderate risk for skin integrity. Physician orders [REDACTED]. (3/19/18) cleanse right posterior thigh with normal saline pat dry and cover with [MEDICATION NAME] border every two days and as needed, (3/7/18) occupational therapy 5 times a week for 4 weeks, (3/7/18) resident may be transferred with mechanical lift, and (3/7/18) Juven packet, give one packet by moth two times a day for wound healing Wound care clinic orders included an order not entered into the facility physician orders [REDACTED]. Progress notes included, but were not limited to; 9/13/17 - Resident 51 was admitted with pressure areas on coccyx and right buttock. 1/22/18 - a skin assessment indicated shearing to the spine with discoloration surrounding the area, areas to left and right buttock, right gluteal fold, right knee scab, and left heel continued with eschar 1/24/18 - resident's buttock healed. No areas on buttocks 1/24/18 - area of shearing noted to resident's spine, area thought to be caused by removal of Hoyer lift sling 1/25/18 - area noted to back of right thigh, measured 2 cm (centimeters) x 0.4 cm, new orders received and noted, family, DON (Director of Nursing) aware 1/31/18 - Returned from wound care clinic with new orders 2/1/18 - area to right gluteal fold improving 2/16/18 - Hospital return with increase in pressure ulcers 2/19/18 - Keflex 500 mg give three times a day for wound infection for 10 days 2/20/28 - Treatment continues to areas on buttock and mid-back, dressing intact and dry 2/21/18 - Antibiotic/MRSA ([MEDICAL CONDITION]-resistant Staphylococcus aureas) of wounds 2/21/18 - Antibiotic for wound infection, resident complains of pain to coccyx, doctor notified 2/25/18 - Antibiotic/MRSA of wounds continues . 2/27/18- Continues antibiotic for wound infections . 2/28/18 - Continues antibiotic for wound infections . 3/1/18 - Last dose of antibiotic for wound infections . 3/2/18 - Continues with pressure ulcers, goes to wound center . 3/3/18 - Cleanse right posterior gluteal fold with wound cleanser, pat dry . change every three days and as needed . 3/14/18 - pressure ulcers healing slowly . On 3/20/18 at 3:28 P.M., the DON indicated the following wound measurements were not located in the medical records but were in the DON's office: Right posterior thigh or Right gluteal (as indicated on wound measurement sheets) - 2/7/18 - 0.6 cm x 3.5 cm x 0.1 cm 2/14/18 - Stage II 0.5 cm x 3.4 cm x 0.1 cm 2/21/18 - Stage II 0.4 cm x 1.3 cm 3/7/18 - Stage II 2.0 cm x 1.0 cm 3/14/18 - Stage II 0.7 cm x 0.7 cm Back - 2/21/18 - Stage II 1.2 cm x 1 cm 3/7/18 - Healed On 3/21/18 at 8:25 A.M., the DON provided the following wound measurements for Resident 51: Right Gluteal fold - 2/14/18 - Stage II 0.5 cm x 3.4 cm x 0.1 cm 2/21/18 - Stage II 0.4 cm x 1.3 cm On 3/21/18 at 2:15 P.M., the ADON (Assistant Director of Nursing) / Wound care nurse provided the following wound measurements from the wound care center: Right posterior thigh - 2/21/18 - Unstageable - New order for treatment 2/28/18 - Unstageable 6.0 cm x 2.0 cm (Yellow slough) (deteriorated) - New order for treatment 3/9/18 - Unstageable (Yellow slough) (Improved) 3/21/18 - Stage III 7.5 cm x 1.5 cm x 1.0 (deteriorated) Back - 2/21/18 - Stage II pressure ulcer - New order for treatment 2/28/18 - 100% epithelized 3/9/18 - 100% epithelized 3/21/18 - Stage III 3.0 cm x 2.0 cm x 0.1 cm (deteriorated) The National Pressure Ulcer Advisory Panel defines a pressure injury as, localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. The National Pressure Ulcer Advisory Panel defines a Stage III pressure area as, full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. On 3/22/18 at 11:20 A.M., during an observation, Resident 51 was sitting in the resident's room in a wheelchair. LPN 12 lifted the resident's shirt and pulled back the dressing on the resident's back to expose the pressure injury. The dressing had bright red drainage and the wound bed was open and red. The surrounding tissue appeared dark pink in color and excoriated. The skin further away from the wound was dry and flaky. LPN 12 indicated drainage was noted earlier that day during a dressing change and that Resident 51 had been complaining the area had been itching. The physician had been contacted earlier to update on the drainage. LPN 12 indicated the wound on the right posterior thigh was healing. During an interview with Resident 51 on 3/22/18 at 10:05 A.M., the resident indicated not knowing how the pressure areas were acquired but thought the areas were doing better. On 3/21/18 at 2:15 P.M., the ADON/Wound care nurse indicated the area on the resident's back may have came from the resident's necklace. The resident wore a necklace with a large cross and while the resident was in bed, the necklace flipped around and the cross left marks on the resident's back. Staff was not sure where the marks were coming from at first, then staff realized the necklace could be the cause. The resident then was no longer supposed to wear the necklace while lying down. The ADON also indicated that as the wound care nurse, the wound measurements are supposed to be put in weekly but often times the ADON had to work as the nurse on the floor and did not have time to get all wound measurements. During those times, the nurse on the floor should have recorded wound measurements, but not all measurements had been recorded. Resident 51 had been going to the wound care clinic for wound treatment and wound measurements were recorded there. Not all wounds were staged the same at the wound care clinic, but the ADON indicated the facility had to go by what the wound care clinic staged the wounds at. The wound on the resident's right posterior thigh could have been caused by sheering from the resident's brief. During an interview on 3/22/18 at 8:54 A.M., the ADON / Wound care nurse indicated the areas to the back and to the right posterior thigh were developed at the facility either by sheering or from transferring with the Hoyer lift. During an interview on 3/22/18 at 10:12 A.M., OT 1 (Occupational Therapist) indicated therapy worked with the resident with bed mobility 5 times a week and the resident is not resistant to care. OT 1 provided treatment from the last for 4 therapy sessions. On 3/21/18 and 3/20/18 the resident received bed mobility exercise while in bed. On 3/19/18 the resident received strengthening exercise and did not receive bed mobility exercises from therapy. OT 1 indicated the CNAs should have provided bed mobility exercises with the resident, but the CNAs did not document exercises. During an interview on 3/22/18 at 10:45 A.M., LPN 10 indicated Resident 51 developed an infection in the wounds located on the resident's back and right gluteal fold. LPN indicated the resident had green drainage from the wounds. No culture was obtained and the resident started an antibiotic. LPN 10 provided an infection surveillance report form dated 2/19/18 that stated the antibiotic Keflex was ordered for 10 days. During an interview on 3/22/18 at 11:13 A.M., the Director of Nursing indicated it was the policy of the facility to initiate pressure relieving interventions for residents at risk for pressure as well as ensure implementation of the interventions to ensure the pressure area did not worsen. 2. During an observation on 3/20/18 at 12:15 P.M., Resident 38 was observed sitting in the lounge area on a recliner without a pressure relieving cushion on the chair. During an observation and interview on 3/20/18 at 2:23 P.M., Resident 38 was observed in the lounge area sitting with head down and slouching half off a recliner without a pressure relieving cushion in the chair. CNA 31 was made aware of Resident 38's positioning on the chair and that the resident was not sitting on a pressure relieving cushion. CNA 31 indicated Resident 38 should have had a pressure relieving cushion on the recliner while sitting in the chair, but CNA 31 was unsure where the cushion was located. CNA 31 went to Resident 38's room, but was unable to locate the cushion. The medical record of Resident 38 was reviewed on 3/20/18 at 9:38 A.M. The record indicated the [DIAGNOSES REDACTED]. The Quarterly MDS (Minimum Data Set) assessment, dated 1/21/18, indicated Resident 38 experienced cognitive impairment and required the assistance of one staff for transfers, bed mobility, and toileting. A care plan for, .(Resident's name) has a stage 2 pressure ulcer to left buttock .Date initiated: 1/31/2018 . but were not limited to, interventions of, .pressure reducing mattress/cushion in chair 01/31/2018 .skin checks weekly . A Progress Note, dated 1/31/18 at 8:35 A.M., read as follows: .Therapy requested this nurse look at resident's bottom due to area on left buttock. Noted stage 2 pressure area measuring 0.7 L (length) x (by) 0.5 W (width) x 0.1 D (depth) with clear drainage to left buttock . A physician's orders [REDACTED].Cleanse (L) inner buttock with wound cleanser and pat dry. Apply Foam border dressing to area Change QD (everyday) until healed and PRN (as needed) if soiled or dislodged . The pressure area on the left buttock was documented on a form (which had multiple residents and multiple measurements, not a part of the medical record) and provided by the Director of Nursing, on 3/20/18 at 3:28 P.M., and it indicated the following: A WORKSHEET FOR PRESSURE ULCER read as follows: .1-31-18 .L (left) buttock .Stage 2 .Length 0.7 .Width 0.5 .Depth 0.1 . A Wound Rounds form dated 2/7/18 read as follows: .L buttock stage 2 .0.3 x (by) 0.5 x less than 0.1 . A Wound Rounds form dated 2/14/18 read as follows: .L buttock stage 2 .0.4 cm x 0.5 cm . A Wound Rounds form dated 2/21/18 read as follows: .L buttock stage 2 .0.2 cm x 0.5 cm . A WORKSHEET FOR PRESSURE ULCER read as follows: .2-28-18 .L (left) buttocks .Stage 2 .Length 0.2 .Width 0.3 .Depth 0.05 .[MEDICATION NAME] border dressing . A Wound Rounds form dated 3/7/18 read as follows: .L buttock stage 2 .0.3 cm x 0.3 cm . A Wound Rounds form dated 3/14/18 read as follows: .L buttock stage 2 .0.3 cm x 0.5 cm . During an observation and interview on 3/20/18 at 2:57 P.M., Resident 38 was observed sitting up straight in the recliner and positioned on a pressure relieving cushion. CNA 31 indicated that he had located Resident 38's pressure relieving cushion. The cushion had been cleaned and that was why it could not be located. CNA 31 was made aware that there was no dycem located under the cushion. CNA 31 asked, He needs dycem, too? I will need to go and get some from the supply room. RN 12 found the dycem at the nurses' station and CNA 31 placed it between the cushion and the chair. During an interview on 3/20/18 at 3:05 P.M., RN 12 indicted Resident 38 had a stage 2 pressure area on his left buttock and needed to sit on a pressure relieving cushion while sitting in the chair. During an interview on 3/20/18 at 3:20 P.M., the Wound Care Nurse (WCN) indicated he measured pressure wounds on Wednesdays, but the Director of Nursing (DON) measured the wounds whenever he (the WCN) worked the floor as a nurse. The WCN nurse indicated Resident 38 had a pressure area on his left buttock and that he (the WCN) had measured the wound, but the WCN did not enter the information into Resident 38's medical record. The WCN said that the measurements were kept in the DON's office in a file. The WCN nurse indicated that he had entered the last couple of measurements in the medical record. The WCN said, .to be honest, I just don't have time. I am the infection control nurse, the wound care nurse, I administer the TB Test and I work on the floor. During an interview on 3/20/18 at 3:25 P.M., the Director of Nursing indicated neither she nor the Wound Care Nurse have had time to enter the wound measurements in the medical records for the residents in the facility. The DON continued to say that the facility was not necessary short staff, rather the staff call-ins caused the problems and she frequently had to work the floor herself. The DON also said that there were a lot of staff who had been sick. The DON indicated Resident 38's wound was discovered on 1/31/18 and that most of the measurements for that wound had not been entered in the medical record. During an observation and interview on 3/21/17 at 10:00 A.M., RN 32 indicated the pressure wound was located right where Resident 38 sat. RN 32 cleaned and measured the pressure wound. The pressure wound measured 0.5 cm x 0.5 cm. RN 32 applied a foam dressing to area. 3.1-40(a)(1) 3.1-40(a)(2)

Based on interview and record review, the facility failed to provide supervision to prevent accidents, resulting in a fall with fractures, for 1 of 3 residents reviewed with falls, in a sample of 14. (Resident C) Findings include: The closed clinical record of Resident C was reviewed on 2/8/18 at 11:10 A.M. [DIAGNOSES REDACTED]. Nurse's Notes included the following notations: 5/17/17 at 2:30 A.M.: A&Ox3 (alert and oriented to person, place, time) forgetful assisted as needed with ADLs (activities of daily living) transfers self ambulates in room PT (Physical Therapy) and OT (Occupational Therapy) daily 5/19/17 at 8:20 A.M.: .Transfers with 1 assist and to w/c (wheelchair). ADLs with 1 assist 5/21/17 at 2:36 A.M.: House Keeper (sic) was in hallway, just got done mopping resident's room. Housekeeper put a Wet Sin (sic) up in room and told resident to remain in her recliner until it drys (sic). A few minutes later, the house keeper was yelling for Nurse and CNA. Upon entering room, resident was sitting on floor in the middle of room .Resident started to c/o (complain of) R (right) lower back pain, but nothing else at that time .Resident then c/o of tail bone pain and some around lower R hip .M.D. paged for xray of R hip .Family came in to sit with resident. 6/16/17 at 1:51 A.M.: A&Ox3 forgetful assisted with ADLs transfers self ambulates in room PT and OT (Occupational Therapy) daily 6/23/17 at 5:35 P.M.: Late Entry: Resident got up from swivel rocker to walk to her bed, walker within reach but she did not use it. L (left) ankle rolled et (and) gave out on her, did not hit her head. C/O pain d/t (due to) straining her chest muscles trying to get herself up without help by pulling up on bed rail w/o (without) help 6/26/17 at 9:39 A.M.: IDT (interdisciplinary team) .Discussed fall .Resident to have sign posted in room to remind resident to call for help before attempting to ambulate. 8/25/17 at 4:07 A.M.: Summoned to residents (sic) room by LPN resident sitting on floor next to bed resident stated she must have slipped assessed for injury .stated she bumped head on w/c was on way back from BR (bathroom) .resident wearing ted (support) hose only immediate intervention will be gripper socks or resident to wear shoes when ambulating 8/25/17 at 10:31 A.M.: IDT reviewed fall .Resident got out of bed and fell . Intervention to be non-skid strips on floor. 10/2/17 at 1:58 A.M.: CNA looked into resident's room just as resident was falling. This nurse heard a crash and the CNA yelled out that she needed help .CNA states, 'She grabbed her wheelchair for support and the wheelchair moved on her.' When this nurse asked the resident what happened and (sic) the resident stated, 'I was just trying to go the bathroom, but I fell . I forget that I can't get around and do things on my own like I use (sic) to.' .Immediate intervention: Placed bed alarm on resident's bed. Reminded resident to call for assistance when needed and placed call light on top of her blankets so she could reach it easier. Also, removed wheelchair from room and moved walker within reach of resident. 10/2/17 at 4:35 P.M.: IDT reviewed fall in AM meeting. Resident fell while trying to take self to BR (bathroom). Resident remind (sic) to use call light and sign placed in room to remind resident to use walker. 10/3/17 at 7:06 P.M.: Resident found on floor in room on left side. CNA walking past room heard resident call out for help .Bruising noted to the left hip area, outward rotation noted. Hematoma (raised bruise) noted to back of scalp The resident was transferred to the hospital on [DATE] at 7:15 P.M. Nurses Notes continued: 10/4/17 at 10:58 A.M.: IDT reviewed fall . Resident got up by herself and fell . Resident sent to hospital D/T (due to) hematoma on head. Hospital called this AM said they admitted resident for heart and kidney failure nothing to do with fall. The resident returned to the facility on [DATE] at 3:03 P.M. Nurses Notes continued: 10/5/17 at 4:35 P.M.: Resident back from hospital. Fall of 10-3-1 again discussed .Because W/C (wheelchair) had rolled with when (sic) resident reached for it, intervention is to be pink take (sic) on brake levers to make them more visible and anti-rollbacks to be placed on W/C when available. A Physical Therapy (PT) evaluation included: Risk Factors: Due to the documented physical impairments and associated functional deficits, the patient is at risk for: falls, further decline in function, immobility and decreased ability to return to prior level of assistance. Nurses Notes continued: 10/28/17 at 9:47 A.M.: Resident is non-compliant with asking for assistance to and from bathroom. Resident is getting up and turning alarm off herself and putting herself back to bed and turning alarm off (sic). Res (resident) educated on importance of asking for help. Res voiced understanding. 12/5/17 at 5:29 P.M.: Nurse heard loud thump as nurse was coming out of residents (sic) room and saw resident in doorway of room, sitting on the floor with her legs beside her. Resident states she got up to go to the DR (dining room) and was using the doors to hold onto for balance, when door swung and knocked her off balance and she fell to the floor .small skin Tear on top of Right hand noted .Resident assist per 2 to feet and walked back to w/c. Alarm placed on w/c A PT Discharge Summary, dated 12/6/17, included: Pt (patient) completes SBA (stand by assistance) with bed mobility tasks, requires CGA (contact guard assistance) with transfers using RW (rolling walker) Nurses Notes continued: 1/1/18 at 4:50 P.M.: Resident was found by laundry aide sitting in doorway of bathroom .this nurse went to residents (sic) room and found resident sitting in doorway of bathroom, blood noted on bathroom floor, Immediately had a staff call 911, resident has small laceration on right eye brow, Right eye is bruised and puffy, pressure applied to right eye, some bleeding noted right nostril .Water and broken water cup on the floor .Resident did not have call light turned on. Resident states she had to go to the bathroom and thought she could make it without help. Resident c/o (complains of) pain in L leg .Resident taken to hospital to eval and tx (evaluate and treat) 1/2/18 at 12:00 A.M.: Resident returned from ER via daughter. Report from ER obtained. Resident has R maxillary sinus (cheekbone area) fractures 1/2/18 at 9:38 A.M.: IDT reviewed fall .Resident got up from W/C and slipped in water on floor and fell . Resident was trying to go to BR and did not turn on call light. Alarm in w/c did not sound because resident disconnected it. Intervention to be to put alarm box underneath w/c out of reach of resident. A resident care plan, dated 12/22/17, indicated: (Resident C) chooses to exercise her right not to use call light when needing help. The Interventions included: Staff to encourage resident to use call light. Staff to respond when resident calls out for help. An additional care plan, dated 4/20/17, indicated, (Resident C) is at risk for falls D/T history or recent fall. The Interventions included: 1-1-18 Move alarm box out of reach. 5/21/17 Only wet mop when she is out of room d/t short term memory loss. 10/02/2017 Call light available and resident reminded to call for assist as needed. On 2/9/18 at 1:40 P.M., the Director of Nursing (DON) was interviewed regarding Resident C's numerous falls. The DON indicated Resident B was forgetful at times. The DON stated, She would not ring her call light. On 2/9/18 at 2:00 P.M., the DON provided the current facility Fall Prevention Program, dated 6/2013. The policy included: The Falls Prevention Program is designed for use .to encourage a creative and interdisciplinary approach to falls reduction .Falls Coordinator .Identify and maintain effective methods to gather falls prevention and fall related information with a focus on awareness is 'key .' present each individual incident for discussion and review - validate that a new intervention was put into place - evaluating the appropriateness of the new intervention .Determine the 'root cause' of the fall - making certain that there is an intervention to address the specific root cause This Federal tag relates to Complaint IN 883. 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure residents were free of mental and verbal abuse for 1 of 3 allegations reviewed. This deficient practice caused a feeling of humiliation for Resident F. (Resident F, Resident R) Findings include: During an interview with CNA #4 on 9/2/16 at 5:30 A.M., she indicated she had reported an allegation of abuse to the nurse last week. She indicated Resident F had indicated CNA #15 had refused to assist her with using the bedpan and instructed her to just go in her brief. She indicated Resident F was pretty upset by the occurrence and she had told the nurse as soon as she was told about it. CNA #4 indicated she was told the allegation had been taken care of. The facility reportable's were provided on 9/2/16 at 10:33 A.M., they included, but were not limited to, a .INDIANA STATE DEPARTMENT OF HEALTH .SURVEY REPORT SYSTEM .Incident Number 39 .Incident Date: 08/27/2016 .Incident Time 07:15 AM (sic) .Residents Involved (Resident F) .(Resident R) Staff Involved .(CNA #15) .Brief Description of Incident .8/26/2016 .Two roommates allege staff member refused to provide care per resident's request. (Resident F) states she requested to be taken to the bathroom and had to wait for the CNA .(Resident R) states Staff member took her meal tray too soon and wasn't able to finish her meal. Both roommates were upset with the CNA .Type of Injury .No injury noted on either resident . The facility investigation was reviewed and included the following: An untimed statement dated 8/24/16 included, .(Resident F) reported to me that she asked (CNA #15) for a bedpan .She sates that (CNA #15) told her 'You have a diaper on. Just go in it and I will change you after supper . The statement was signed by Resident F. The page also contained a handwritten statement on 8/24/16 indicated the incident had been reported to LPN #10 at 7:00 P.M. An untimed typed statement dated 8/24/16 included, .I was working on Unit 1. I walked down Unit 2 hall to drop off a chart to the nurse and (Resident R) walked out of her room and asked me 'Can I please have my potatoes back?' I said I wasn't sure what she was talking about, She said someone .had taken her potatoes and she wanted them back . An untimed written statement dated 8/24/16 included but was not limited to, .Suppertime bout (sic) 5:25 I went into (Resident R) to see if she was eating. She was doing bead work. I said let me move this plate out of the way .She said you're stupid. I said that's not nice to say at all she said well you are. So she told LPN #5 .Time to pass out trays (Resident F) replied she had too (sic) go pee. I said well just turn on the light when you're done and Ill (sic) change your diaper . The statement was signed by CNA #15. During an interview with the DON on 9/2/16 at 10:44 A.M., she indicated on 8/24/16 a staff member called her and reported an incident. She she had instructed to start the investigation, suspend the CNA and report the incident to the Administrator as she was on vacation at the time. She indicated when she returned to the facility on [DATE] and learned the allegation had been reported to the State late (2 days). The clinical record for Resident F was reviewed on 9/2/16 at 11:10 A.M., [DIAGNOSES REDACTED]. An Minimum Data Set (MDS) assessment dated [DATE] indicated Resident F had a BIMS (Brief Interview Mental Status) score of 15 indicating she was cognitively intact with no behaviors. The MDS indicated Resident F required extensive assistance of two persons for bed mobility, and toileting and dressing. The MDS further indicated Resident F required, total dependence of two people for transfers. The MDS indicated Resident F experienced occasional incontinence of urine and bowel. The care plans included, but were not limited to, the following: A care plan for anxiety, initiated 8/22/16. The interventions included, have resident voice feelings. A care plan for risk for decline in mood initiated 8/22/16. The interventions included, but were not limited to, antidepressant per order, encourage out of room activities, honor residents wishes, notify MD (medical doctor), family and IDT (interdisciplinary team) of any changes. The nursing notes from 8/24/16 lacked any documentation of the allegation or concern. Resident R was observed on 9/2/16 at 10:00 A.M., to be laying in bed with her eyes closed. Resident R appeared to be in no apparent distress. The clinical record for Resident R was reviewed on 9/2/16 at 12:00 P.M. The [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] included a BIMS score 12 of 15 indicating Resident R had slight cognitive loss, with no behaviors. The care plans included, but were not limited to, the following: A care plan for decline is psychosocial wellbeing, dated 5/3/16. The interventions included, but were not limited to, encourage out of room activities, encourage to vent feelings. A care plan for assistance with ADL's chronic pain indicated 5/3/16. The interventions included, but were not limited to, Assist as needed so resident is clean and dry, encourage resident to complete as much as they are able, keep call light in reach, A care plan for risk for decline in mood initiated 5/3/16. The interventions included, but were not limited to, medications as ordered, encourage family involvement, encourage out of room activities, encourage to vent feelings, honor residents wishes, notify MD, family and IDT of any changes, offer choices, psych services per order. The nursing notes dated 8/24/16 lacked any documentation of the allegation. During an interview with the DON on 9/2/16 at 12:34 P.M., she indicated the allegation against CNA #15 had been substantiated because it occurred. She indicated the residents had been provided assistance by other staff members and CNA #15 was suspended pending an investigation and terminated for poor customer service. During an interview with CNA #55 on 9/2/16 at 12:50 P.M. she indicated refusing to assist residents to the restroom could be considered abuse. During an interview with Resident F on 9/2/16 at 1:00 P.M., she was observed to be sitting up in her wheel chair on the facility front porch. Resident F appeared to be in no apparent distress. she indicated she had reported the incident on 8/24/16. She indicated she had requested assistance to use the bedpan from CNA #15 and the CNA had gotten upset and told her No, just use your brief, I'll change you when you are done. Resident F continued and indicated CNA #15 was constantly stating how overworked she was and how she was going to quit. Resident F indicated she felt the remark was verbally abusive, they made her feel bad and being instructed to use her diaper was humiliating. She indicated she had experienced incontinence as a result of CNA #15 not assisting her to the restroom. She stated It's bad enough I can't get on the toilet anymore but to be told to pee on myself it humiliating, you can't do that to people. Resident F indicated other than that incident she had no other concerns at the facility. The time card for CNA #15 was provided by the facility on 9/2/16. It indicated CNA #15 had worked on 8/24/16 from 1:59 P.M., to 10:15 P.M., (3 hours after the allegation had been reported to LPN #10). The time card indicated CNA #15 had been suspended on 8/25/16 and terminated on 8/26/26. During an interview with the Administrator on 9/2/16 at 1:15 P.M., she indicated she indicated the allegation was substantiated and she had reported the allegation to the State department of heath on 8/26/16 because she was unable to access the portal. She indicated she had sent the incident to the facility corporate office for review but had not contacted the Indiana State Department of Health for any recommendations on how to send in the allegation of abuse. She indicated the CNA #15 had been suspended effective 8/24/16 at 10:00 P.M., (3 hours after the allegation was reported) and the allegation was sent to the State on 8/26/16 (2 days) after it was reported to her. A policy dated 1/2007 titled ABUSE REPORTING' included but was not limited to, It is the polity of the facility to encourage and support all residents, staff, and family members to feel free to report any suspected acts of abuse, neglect, .The facility will take all measures possible to assure that residents, staff and families are free from reprisal, when reports or incidents are reported to the facility .Any persons witnessing or having knowledge of potential or actual abuse must contact and report the incident to the Administrator and/or designee immediately .The Incident Documentation and Investigation Tool form is to be submitted to the Administrator or designee as soon as possible within 24 hours for further investigation. The Administrator (or designee) will report Abuse/Neglect to the Department of Health within 24 hours per the Indiana Department of Health reporting guidelines .Any Individual who is accused of resident abuse whether physical or verbal will be suspended until further investigation has been completed .The Director of Nursing or Charge Nurse will complete the investigation form with a writing, dated, and signed statement from all persons involved .If abuse is suspected or substantiated, the employee will be immediately sent home. A undated policy titled, ABUSE PROHAVITION POLICY AND PROCEDURE, included, but was not limited to . It is the policy of this facility to maintain an environment free of abuse and neglect. The resident as the right to be free from verbal and mental abuse .Residents will not be subjected to such events by anyone .This facility shall comply with all federal and state requirements to .train, prevent, identify, Investigate, protect, and report .Abuse: willful infliction of injury .or punishment with resulting physical harm, pain or mental anguish. This includes the deprivation by an individual, including a caretaker of goods or services that are necessary to attain or maintain physical, mental and psychosocial well being .Mental Abuse: This includes, but is not limited to humiliation .Neglect: A failure to provide goods and services necessary to avoid physical harm, mental anguish . This Federal tag relates to Complaint #IN 924 3.1-27(b)

Based on interview and record review, the facility failed to ensure a resident with a [MEDICAL CONDITION] received appropriate care in that the physician was not notified of the resident vomiting several times and the need for suctioning, did not have a Respiratory Therapist (RT) to care for the resident as ordered by the physician, did not assess the resident for respiratory complications when the resident was less responsive, and did not notify the physician when the resident exhibited decreased consciousness, resulting in the resident's admission to the hospital, for 1 of 1 residents reviewed with tracheostomies, in a sample of 5. Resident D Findings include: On 6/24/16 at 9:45 A.M., during the initial tour, the Assistant Director of Nursing (ADON) indicated the facility had recently become certified on taking tracheotomy residents. The closed clinical record of Resident D was reviewed on 6/24/16 at 1:45 P.M. [DIAGNOSES REDACTED]. An Admission Assessment, dated 6/17/16 at 4:00 P.M., indicated, Arrived via Wheelchair .Most Recent Blood Pressure: 114/60 .Pulse: 52 .Respiration: 20 .Verbalizes/Demonstrates use of: Call bell, Bed controls, Side rails, TV .Color normal .LOC (level of consciousness) Alert, Orientation Person, Place .Breath Sounds, Clear Both .[MEDICAL CONDITION] Yes. Type/Size: 6. Cuff inflated, Unable to determine Admission Physician orders, dated 6/17/16, included: Speaking valve as tolerated by RT (respiratory therapist). Titrate O2 (oxygen) to keep sats above 88% per RT.[MEDICAL CONDITIONS] everyday and PRN (as needed) per RT one time a day. Nurse's Notes included the following notations: 6/16/16 at 3:00 P.M.: Res (resident) admitted into facility at this time per facility at this time per facility vehicle. Oriented to room.[MEDICAL CONDITION] provided per nursing. Tranfered (sic) from w/c (wheelchair) to bed per hoyer lift. Resting in bed at this time .92% O2 with O2 per trach. Weight 254.5. 6/17/16 at 1:24 A.M.: [MEDICATION NAME] Solution .for SOB (shortness of breath), wheeze for SOA (shortness of air) with mucousy (sic). 6/17/16 at 1:41 A.M.: [MEDICATION NAME] Solution .Administration was effective. 6/17/16 at 1:53 A.M.: .SpO2 %92 (sic) Lung sounds dim. (diminished) bil. (bilaterally) .Res. suctioned several times and PRN neb tx (nebulizer treatment) administered and helpful for episode of SOA.[MEDICAL CONDITION] performed. The next entry of Nurse's Notes, dated 6/17/16 at 9:00 A.M., indicated, Nurse unable to administer 8am (sic) medications due to res current level of consciousness. Res is drowsy and difficult to wake. Don (Director of Nursing) notified. Documentation that vital signs were obtained, the resident's respiratory status was assessed, or that the physician was notified at that time of the resident's decreased of level of consciousness was not found in the clinical record. The next entry of Nurse's Notes, dated 6/17/16 at 12:00 P.M., indicated, At 11:30 am Res showing s/s (signs and symptoms) of respiratory distress at this time. O2 between 78-80 % with 10 L per trach. Res indicated by gestures she is having trouble breathing. Suctioned orally and via trach, thick pale green seceretions (sic) with scant amount of blood retrieved via trach. PRN neb treatment started. Continues to have difficulty despite suctioning. MD contacted at 11:50 am, orders received and noted to send res to ER for eval and treat at (name of hospital). Family notified at 11:55 am. O2 remains between 80-85% at this time. (Two (2) hours and 50 minutes passed from the time the resident was unable to receive her 8:00 A.M. medications, and changes with her level of consciousness, until the physician was notified.) 6/17/16 at 12:10 P.M.: EMS here at this time to transport res to (name of hospital) ER A hospital ER record, dated 6/17/16 at 12:34 P.M., included: Chief Complaint: Dyspnea (shortness of breath) and possible aspiration. (Patient was transferred to nursing home yesterday from another facility and reportedly vomited multiple times on the transferred (sic) down to nursing home. Nursing home and (sic) has had a difficult time obtaining good O2 sats and was sent for evaluation for possible aspiration). Is still present. The dyspnea is severe .Clinical Impression: .aspiration with acute respiratory difficulty and [MEDICAL CONDITION] (low oxygen in the blood) On 6/24/16 at 3:00 P.M., during an interview with the Director of Nursing (DON), she indicated the Assistant Director of Nursing (ADON) accompanied the resident from her previous facility to this facility. She indicated the other facility was 4 hours away. The DON indicated the resident vomited frequently on the way and was suctioned several times. The DON indicated the resident was suctioned every 30 minutes throughout the night. The DON indicated, We couldn't maintain her O2 sats, so I made the decision to send her to the hospital. The DON indicated she thought the resident was unstable, and the van drive did her in. She indicated she was unsure if the physician had been notified that the resident had vomited several times. She indicated the facility did not have a respiratory therapist in the facility or contracted for daily services to the facility. On 6/24/16 at 3:05 P.M., during an interview with the ADON, she indicated she accompanied Resident D to the facility. She indicated the resident vomited several times in the van, and that she suctioned the resident 3-4 times. She indicated she had a portable suction machine in the van with her. On 6/24/16 at 3:10 P.M., during an interview with the Clinical Education Nurse, she indicated staff had been inserviced [MEDICAL CONDITION] on 5/13/16. She indicated there had not been any new staff hired since that date. When it was brought to the Clinical Education Nurse's attention that LPN # 2 had worked the night of 6/16/16 and her name was not on the list of staff inserviced, she indicated, She was on vacation. She indicated she did not know if LPN # 2 had been inserviced [MEDICAL CONDITION]. On 6/27/16 at 9:35 A.M., the DON was again interviewed. The DON indicated that on the morning on 6/17/16, Resident D was difficult to arouse, not unresponsive. The DON indicated the staff didn't notify the physician on the morning of 6/17/16, because they were busy working with the resident in her room. She indicated the staff suctioned the resident several times, and were busy trying to care for her. On 6/27/16 at 9:45 A.M., during an interview with LPN # 1, she indicated she was the admitting nurse for Resident D. She indicated she heard the resident got car sick and vomited. She indicated on 6/17/16, the resident was drowsy, and she didn't feel like it was safe to give the resident her medications. She indicated she notified the DON of the resident's status. LPN # 1 indicated she suctioned the resident a few times between 9:00 A.M. and 12:00 P.M., and was obtaining thick secretions. She indicated they kept trying to clear the resident's airway, and then finally called 911. LPN # 1 indicated the facility did not have a respiratory therapist. On 6/27/16 at 10:20 A.M., during an interview with the Clinical Education Nurse, she indicated she was in and out of Resident D's room. She indicated, We couldn't get her O2 sats to stay up. She indicated the resident kept saying she couldn't catch her breath. She indicated she was trying to keep the oxygen mask on her while LPN # 1 was suctioning her, but the resident remained short of breath. She indicated another nurse called 911 and the resident was transferred to the hospital. This Federal tag relates to Complaint IN 455. 3.1-47(a)(4)

Based on interview and record review, the facility failed to have a system in place to determine code status and failed to perform Cardiopulmonary Resuscitation (CPR) on a resident who was a full code (Resident E). The facility also failed to ensure advanced directive/code status was clearly and consistently documented for 4 of 6 residents reviewed with advance directives, in a sample of 6. (Resident E, C, B, and F) This deficient practice resulted in Immediate Jeopardy. The Immediate Jeopardy began on [DATE] when the nursing staff failed to provide CPR for a resident who had requested to be a full code. The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy at 5:45 P.M. on [DATE]. The Immediate Jeopardy was removed on [DATE], but noncompliance remained at the lower level scope and severity level of pattern, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Findings include: 1. The closed clinical record of Resident E was reviewed on [DATE] at 11:30 A.M. [DIAGNOSES REDACTED]. Indiana Physician Orders for Scope of Treatment (POST), dated [DATE], indicated, A. Cardiopulmonary Resuscitation (CPR): Patient has no pulse AND is not breathing. Attempt Resuscitation/CPR. B. Medical Interventions: If patient has pulse AND is breathing OR has pulse and is NOT breathing. Full Intervention: .use intubation, advanced airway interventions, and mechanical ventilation as indicated. Transfer to hospital and/or intensive care unit if indicated to meet medical needs A Physician's order, initial date unknown and on the [DATE] recertification orders, indicated, Advanced Directives, Full Code. A Care Plan, undated, indicated, Code Status: full .Interventions: Wishes will be honored. Nursing Progress Notes, dated [DATE] at 7:36 A.M., indicated, Blood sugar at 4:45 am 130. Resident refused insulin coverage, as she frequently does. Upon entering room at 6:50 am to get resident up for breakfast, CNAs found resident deceased . Resp (respirations) ceased, no heartbeat, skin cold and mottled. CPR not initiated, deemed ineffective. Husband, Dr., ED (Executive Director), and DON (Director of Nursing) notified. On [DATE] at 4:00 P.M., during an interview with RN # 1, she indicated she was working on the morning of [DATE]. She indicated it was right at change of shift when a CNA went in the room to get the resident up for breakfast. RN # 1 indicated the CNA, came and got me, and when I went into the room (Resident E) was cold, stiff, and mottled half way up. RN # 1 indicated she thought, This just didn't happen. CPR is not going to bring this woman back. RN # 1 indicated she was so shocked, and had thought about calling the ambulance, but she thought the EMTs would just tell me to call the coroner. RN # 1 indicated the resident had no pulse, no respirations, and no blood pressure. On [DATE] at 4:20 P.M., during an interview with the DON, she indicated she did find notes that she had written regarding the incident. The DON indicated she had inserviced RN # 1, and told her, You can't do that. The DON indicated she inserviced her that if a resident is a full code, she needed to perform CPR. The DON indicated that since that incident, if staff called her regarding a resident, she always asked, What's their code status? On [DATE] at 1:50 P.M., during an interview with CNA # 2, she indicated she was working on the morning of [DATE]. She indicated she and CNA # 1 had just started getting residents up, when CNA # 1 went into Resident E's room. She indicated CNA # 1 came out of the room and told CNA # 2, I think (Resident E) has passed away. CNA # 2 indicated she went into the room and found the resident was not breathing. CNA # 2 indicated they then both went and informed RN # 1. 2. On [DATE] at 10:30 A.M., the Assistant Director of Nursing (ADON) provided a CNA assignment sheet. The assignment sheet indicated Resident C was a Full Code. The clinical record of Resident C was reviewed on [DATE] at 1:55 P.M. [DIAGNOSES REDACTED]. An Indiana Physician Orders For Scope of Treatment, dated [DATE], indicated, A. Cardiopulmonary Resuscitation (CPR): Patient has no pulse AND is not breathing. Attempt Resuscitation/CPR A Resident Information Sheet, dated [DATE], included: Code Status, FULL. There was no sticker on the face sheet which indicated the resident's code status. A Social Service Note, dated [DATE] at 8:51 A.M., indicated, .Resident is DNR (Do Not Resuscitate) A Care Plan, dated [DATE], indicated, The resident's code status is DNR .Interventions, Respect resident and family choices, Review code status at care plan meetings. A Social Service Note, dated [DATE] at 5:09 P.M., indicated, .Resident is FULL code - reviewed with no changes The current Physician orders, dated [DATE], indicated, Advanced Directives and was left blank. On [DATE] at 3:15 P.M., during an interview with RN # 2, she indicated that if she found a resident without a pulse, and was not breathing, she would check the resident's chart for the code status. She indicated she would first look for the sticker on the face sheet, which indicated if the resident was a DNR or Full Code. She indicated if the sticker was not there, she would either check the Advanced Directive, or POST, sheet or would check the Physician orders. On [DATE] at 3:35 P.M., during an interview with LPN # 1, she indicated that if she found a resident without a pulse or respirations, she would check the resident's chart for the code status. She indicated she would check the sticker on the face sheet, or check the Physician's orders. 3. On [DATE] at 10:30 A.M., the Assistant Director of Nursing (ADON) provided a CNA assignment sheet. The assignment sheet indicated Resident B's code status was DNR. The clinical record of Resident B was reviewed on [DATE] at 3:10 P.M. [DIAGNOSES REDACTED]. A Resident Information Document, or face sheet, dated [DATE], indicated, Code Status, DNR. A sticker was on the sheet which indicated, Code Status, DNR. An Indiana Physician Orders for Scope of Treatment, dated [DATE], indicated, Do Not Attempt Resuscitation (DNR). The form was not signed by the physician. Current Physician orders did not include an order for [REDACTED].>4. On [DATE] at 10:30 A.M., the Assistant Director of Nursing (ADON) provided a CNA assignment sheet. The assignment sheet indicated Resident F's code status was Full Code. The clinical record of Resident F was reviewed on [DATE] at 9:30 A.M. [DIAGNOSES REDACTED]. An Admission Record face sheet, dated [DATE], indicated, Advanced Directives and was left blank. A sticker on the document indicated, Code Status DNR. An Indiana Physician Orders for Scope of Treatment, dated [DATE], indicated, Do Not Attempt Resuscitation A computerized Profile indicated Resident F was a Full Code. On [DATE] at 10:20 A.M., the DON indicated the facility was auditing the clinical records regarding consistent CPR status, but had not yet audited the CNA assignment sheets or the Profiles/Face sheets. 5. On [DATE] at 4:20 P.M., during an interview with the DON, she indicated when a resident chooses his code status, a sticker regarding that information is placed on the resident's face sheet, the POST paper regarding the Advance Directive is completed, and a physician's order is obtained. On [DATE] at 5:15 P.M., the DON provided the current facility policy on Cardio-Pulmonary Resuscitation, dated ,[DATE]. The policy included: It is the intent if the facility to ensure that all residents suffering a cardiac or respiratory arrest will receive the treatment of [REDACTED]. Defined: Basic CPR is defined as artificial respiration accompanied by external cardiac compressions. Responsibility: .1. CPR will be performed by licensed nursing or staff trained in CPR. 2. Residents who request FULL CODE STATUS will receive CPR if they arrest . Procedure: 1. Check chart for code status. 2. Assess resident to determine respirations have ceased, palpate or auscultate for absence of pulse/heartbeat .4. If the resident has a cessation of heartbeat or cessation of respiration and if the resident wished to be resuscitated delegate a person to page for assistance, call 911 On [DATE] at 10:20 A.M., during an interview with the DON, she indicated she was unable to locate a facility policy regarding Advanced Directives, but that the facility was going to do away with the stickers on the face sheets, and utilize purple DNR Post Sheets if the resident requested DNR status. At that time, the DON provided a list of staff who were CPR certified. The list indicated 12 staff members were CPR certified, and 10 staff members who did not have proof of CPR certification. RN # 1 was documented as not having proof of CPR documentation. The DON indicated at that time that she had scheduled a CPR certification class for the next week. The immediate jeopardy that began on [DATE] was removed on [DATE] when the facility began inservicing staff on performing CPR and how to determine a resident's code status, and auditing clinical records, but the noncompliance remained at the lower scope and severity level of pattern, no actual harm with potential for more than minimal harm that is not immediate jeopardy, because not all of the employees had been inserviced . 3XXX,[DATE](f)(5)

Based on observation, interview, and record review, the facility failed to ensure care was provided, in that, a resident admitted without a pressure ulcer, developed a pressure ulcer for 1 of 3 residents who met the criteria for review of pressure ulcers. This deficient practice resulted in the Resident #27 experiencing a Stage IV pressure wound. (Resident #27) Findings include: During an interview on 09/09/14 at 3:43 P.M., LPN #10 indicated Resident #27 had a facility acquired pressure wound on the left heel. The clinical record of Resident #27 was reviewed on 09/15/14 at 9:13 A.M. The record indicated Resident #27 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Admission MDS (Minimum Data Set) assessment dated [DATE], indicated Resident #27 experienced moderate cognitive impairment, no pressure wounds, and required the extensive assistance of two staff for bed mobility. The Physician's admission orders [REDACTED] An Interim Care Plan dated 06/25/14 lacked any identified problem related to Resident #27 being at risk for skin impairment. A Care Plan dated 06/30/14 for, "potential for pressure ulcer development r/t (related to) immobility" included, but was not limited to, an intervention for "The resident requires Pressure relieving/reducing device on bed/chair..." A Care Plan dated 07/04/14 for "Skin integrity impaired r/t area to left heel" identified interventions of, "Notify MD (Medical Doctor) and family of change in condition, observe for s/s/ (signs/symptoms) of increase in size of area, observe VS (vital signs) as indicated, treatment per order" The care plan lacked any interventions related to pressure relief to the left heel. The Admission Braden Scale assessment dated [DATE] indicated Resident #27 was at risk for the development of pressure related skin impairment. The Admission Nursing assessment dated [DATE] indicated Resident #27 experienced no skin impairment to the left heel. A Nursing note dated 07/04/14 at 2:54 P.M., indicated, "...Area noted to left heel..." A Nursing note dated 07/06/14 at 6:02 P.M., indicated, "...Wound on left heel is weeping an raw. Boot to foot..." A Nursing note dated 07/07/14 at 4:05 A.M. indicated, "...WOUND ON LEFT HEEL WEEPING AND RAW. PRESSURE RELIEF BOOT TO LEFT FOOT..." The Nursing notes from 07/04/14 through 07/11/14 lacked any documentation related to the size and/or characteristics of the left heel wound. A Weekly Skin Sheet Dated 07/05/14 indicated Resident #27 experienced, "left heel opened blister that has peeled off. Area is red and raw..." A Weekly Skin assessment dated [DATE] indicated Resident #27 experienced, "...Left heel...Stage IV...5.0 X 5.5 with black area 3 X 1.5...Pink 70%...Black/Eschar 30%...Worsening..." The Assessment further indicated, "...4. Stage IV-Full thickness tissue loss...Slough or eschar may be present on some parts of the wound bed..." A Physical Therapy Progress note dated 07/17/14 indicated, "...E-stim (Electircal stimulation) to LLE (left lower extremity) heel for wound healing...selective debridement for removal of necrotic tissue to promote wound healing.." During an interview on 09/09/14 at 2:15 P.M. the DON (Director of Nursing) indicated Resident #27 had developed the Stage IV wound after admission to the facility and no documentation could be provided to indicate services had been provided to relieve pressure to the left heel. The Policy and Procedure for Pressure Ulcer Assessment and Staging provided by RN #10 on 09/15/14 at 12:44 P.M., indicated, "'...Stage IV Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures..." 3.1-40(a)(1)

Based on interview and record review, the facility failed to ensure a resident received her prescribed medications, but instead received another resident's medications, resulting in confusion, a change in vital signs, and breathing difficulties and resulting in an emergency room visit. This affected 1 of 6 residents reviewed for medications, in a sample of 9. Resident B Findings include: 1. The clinical record of Resident B was reviewed on 8/11/14 at 2:00 P.M. [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment, dated 5/12/14, indicated the resident scored 15 out of 15 for cognition, indicating no memory impairment. Progress Notes included the following notations: 7/30/14 at 1:15 A.M.: "Resident states she is tired, PEARLA (pupils equal and reactive to light), grasps equal, no complaints voiced, will monitor." 7/30/14 at 2:00 A.M.: "B/P-170/100, T- 97.4, P-64, R (respirations) 12, O2 (oxygen) sat 95% on RA. Breathing labored Cushmal (sic) (deep, labored, gasping breathing) respirations noted, resident has slurred speech skin cool and wet, accucheck 159 mg/d., when offered a cup she could not hold it, she c/o (complained of) dry mouth, resident sl. confused she didn't recognize she had a brief on...Complained she was having trouble breathing, and weakness. Will monitor." 7/30/14 at 2:40 A.M.: "(Name of physician) notified and orders received to send to emergency room for evaluation and treatment, resident still having labored breathing." A transfer report, dated 7/30/14 at 2:37 A.M. (sic), indicated, "Chief complaint (reason for transfer), ER (emergency room ) for Eval (evaluate) and treat, change in cognition - slurred speech, sl confused, weakness...(change) in vital signs...Resident suffered a Med. Error and was given another Resident's meds...Medication given: [MEDICATION NAME] 150 mg - 1 (an antipsychotic medication), [MEDICATION NAME] 60 mg - 1 (an antidepressant medication), [MEDICATION NAME] 325 mg - 1 (an iron supplement), [MEDICATION NAME] DM 3-600 ER - 1 (a cough medication), [MEDICATION NAME] ER cap 100 mg - 2 (a medication used to prevent [MEDICAL CONDITION]), Tiagabine HCL 4 mg - 1 (a medication for [MEDICAL CONDITION]), Carb/Levo ER ,[DATE] mg - 1 (a medication used for [MEDICAL CONDITION]), [MEDICATION NAME] 10/325 mg - 1 (a pain medication), Carb/Levo 25/100 mg - 2 (a Parkonsin's disease medication), Entacapone 200 mg - 1(a [MEDICAL CONDITION] medication), ? (sic)[MEDICATION NAME] 10 gm/15 - 60 ml (a laxative) given." The resident was transferred by ambulance to the emergency roiagnom on [DATE] at 3:25 A.M. A hospital ER report, dated 7/30/14 at 4:00 A.M., indicated, "Course of Care: after initial presentation it was found out that the patient was also sent for evaluation for medication given in error. poorly (sic) at 8 PM last night the patient was given [MEDICATION NAME] sulfate, is next DM (sic), [MEDICATION NAME], tiagabine, carbo/[MEDICATION NAME], entacapone and [MEDICATION NAME] last night in error. She was given another nursing home residence (sic) medications. She was watched for a time and (physician) was notified. She was sent here because of some increased lethargy and fatigue. Patient was given a duo neb (respiratory treatment) treatment in route and her shortness of breath symptoms remained improved through her ER stay...Presently the patient is stable she is slightly somnolent (abnormally drowsy) but easily arouseable to voice. Her shortness of breath symptoms have not worsened...Clinical Impression: Acute dyspnea (resolved), Multiple medication ingestion/error...." A facility nursing Progress Note, dated 7/30/14 at 1:24 P.M., indicated, "Late Entry for 7/29/14: During evening medication pass it came to my attention that I had given the wrong medications to this resident d/t (due to) I had set up medications for another resident with the same initials because she had quite a few meds and I thought I would save time. When, at 8:30 pm I realized my mistake, I called (name of physician) answering service to have him paged. I then went into the resident's room and checked her eyes, PERL, and bilateral hand grips were equal. I talked to the resident and asked her how she was feeling and she said she felt ok. (Physician) returned my call at approx. 9:15 PM and informed me to monitor her for oversedation and perform neuro checks q (every) 1 hour x 6 hours and to call him back if she showed signs of oversedation...called resident's son...he didn't want her to know because she would have an anxiety attack...At 10:00 PM resident's vital signs were: BP 129/77, T 98.1, R 18...." On 8/11/14 at 3:30 P.M., during an interview with the Director of Nursing (DON), she indicated LPN # 1 prepared the residents' medications prior to administering them, and gave Resident B the wrong medications. She indicated LPN # 1 gave Resident B the medications she had set up for Resident D. On 8/11/14 at 4:00 P.M., during an interview with the Administrator and DON, the Administrator indicated LPN # 1 was terminated over this medication error. On 8/13/14 at 1:00 P.M., during an interview with the DON, she indicated staff were not to set up their medications prior to administering them, and she had inserviced staff after this incident. 2. According to "Nursing 2014 Drug Handbook," the medications that the resident received included the following adverse reactions: [MEDICATION NAME]: dizziness, headache, somnolence, [MEDICAL CONDITION](rapid heart rate), dyspnea (shortness of breath) [MEDICATION NAME]: fatigue, headache, somnolence, hypertension, increased heart rate [MEDICATION NAME]: nausea, diarrhea [MEDICATION NAME]: decreased coordination, mental confusion, slurred speech Tiagabine: somnolence, confusion, generalized weakness Carbo/[MEDICATION NAME]: confusion, dizziness, cardiac irregularities, hypertension, dyspnea Entacapone: somnolence, fatigue, dyspnea [MEDICATION NAME]: abdominal cramps, diarrhea, nausea 3. On 8/13/14 at 1:00 P.M., the DON provided the current facility policy, "Drug Administration - General Guidelines," dated June 19, 2012. The policy included: "Medications are administered at the time they are prepared. Medications are not pre-poured unless the nurse is using a med card specifying the resident's name, the medication, dose and frequency...Six 'Rights' for Administration of Medications, 1. The right resident...2. The right drug...3. The right dose...4. The right dosage form...5. The right time...6. The right route...." This Federal tag relates to Complaint IN 773. 3.1-25(b)(5) 3.1-25(b)(9)

A. Based on observation, interview, and record review, the facility failed to ensure water temperatures in resident care areas were at a safe range for 4 of 6 randomly checked bathrooms in use by 4 residents capable of independent sink use on 2 of 3 units. This had the potential to affect 30 residents, capable of independently utilizing sinks, on the 100 and 300 units from a total census of 73. Residents #91, #30, # 86, #97 The Immediate Jeopardy began on 5/10/12, at 3:10 P.M., when the facility failed to ensure water temperatures in resident care areas were in a safe range. The Administrator and the Director of Nursing (DON) were notified of the Immediate Jeopardy on 5/10/12 at 6:05 P.M. The Immediate Jeopardy was removed on 5/11/12 at 5:15 P.M., but the facility remained out of compliance at a level of a pattern, no actual harm with potential for more than minimal harm that was not Immediate Jeopardy. B. Based on observation, interview and record review, the facility failed to ensure side rail gaps between the headboard and the top of the side rail and/or enabler were measured and assessed, and were safe, for 1 of 1 specialty bed and 1 of 1 enabler in use on a bed for 2 residents' beds randomly observed. Resident #79, Resident #57 Findings include: A 1. On 5/10/12 at 3:10 P.M., the Administrator was made aware the hot water at the sink in the bathroom used by Resident #97 felt extremely hot when tested by placing your hand under the running hot water. The Administrator placed his hand under the running hot water. He indicated the water temperature was hot and close to the highest range of safe temperatures. The Administrator then at 3:15 P.M., went to the dietary department and brought back a dial thermometer to check the hot water temperatures. The thermometer dial went slowly to the 90 degree Fahrenheit (F) range but the water continued to feel extremely hot when checked by holding a hand under the running water. The Administrator agreed the dial thermometer was not working correctly. On 5/10/12 at 3:24 P.M., the Administrator returned with a digital thermometer and rechecked the hot water of the bathroom sink used by Resident #97. The temperature registered 128 degrees Fahrenheit. The Administrator indicated the facility's water temperatures would have to be adjusted. On 5/14/12 at 8:45 A.M., Resident # 97's clinical record was reviewed. Her current Minimum Data Set Assessment ((MDS) dated [DATE], indicated [DIAGNOSES REDACTED]. An occupational therapy assessment for visit date of 4/13/12, included, "...continues to require stand by assistance... due to...concerns with safety/judgement during ADL (activities of daily living)...." On 5/10/12 at 3:25 P.M., the Administrator checked the bathroom sink hot water of room 132 which was 128 degrees F. On 5/10/12 at 3:26 P.M., the Administrator indicated at this time he wanted the facility's water temperatures to be 120 degrees F or less. Then, at 3:27 P.M., the hot water at the sink in the bathroom used by Resident #91 was checked and was 122 degrees Fahrenheit. On 5/14/12 at 8:45 A.M., Resident's #91's clinical record was reviewed. Her current Minimum Data Set Assessment ((MDS) dated [DATE], indicated [DIAGNOSES REDACTED]. The MDS cognition score was an 8 (8-12 moderate impairment). This MDS indicated Resident #91 was independent in transfers and toilet use. The clinical record included a plan of care dated 2/8/12, which addressed the following problem: Stroke with hemiparesis. Approaches included, but were not limited to, the following: severely impaired cognition with name on door to find room; and remind resident of what she is doing when she forgets. On 5/10/12 at 3:28 P.M., the Administrator checked the temperature of the hot water in the bathroom shared by Resident #30 and Resident #86. The temperature registered 122.8 degrees F. Earlier in an interview on 5/10/12 at 11:36 A.M., Resident #30 indicated, "... my hands are numb; I have carpal tunnel...." On 5/14/12 at 8:45 A.M., Resident #30's current Minimum Data Set Assessment (MDS) dated 4/19/12, was reviewed. His total cognition score was 14 (cognition intact). This MDS indicated a functional range of motion (ROM) of the upper extremities as impairment of both sides. This MDS indicated independence in toileting, bed mobility and transfers. On 5/14/12 at 8:45 A.M., the clinical record of Resident #86 was reviewed. [DIAGNOSES REDACTED]. A care plan, dated 3/12, addressed the following problem: "My cognition is moderately impaired." Approaches included, but were not limited to, the following: "When speaking to me, speak slow using short direct questions or statements; give me verbal cues/reminders when I appear to not be able to remember." On 5/10/12 at 3:45 P.M., the Administrator provided the facility's water temperature log for May 2012. The log indicated the following locations and water temperatures: 5/1/12: Unit 1 shower room --- 126 F Resident Room 310 --- 123F 5/3/12: Park Place Shower Room--- 123 F. 5/4/12: Resident Room 320 was 122 F 5/7/12: Park Place Unit Room 305 ----123 F 5/8/12: Park Place Resident Room 308 --- 122 F 5/9/12: Unit 1 Shower Room ---- 123 F Resident Room 315 --- 122 F 5/10/12: Park Place Unit Restroom--- 123 F On 5/10/12 at 3:55 P.M., the Administrator was interviewed regarding the elevated water temperatures logged on the May 2012 facility water temperature log. The Administrator indicated the maintenance staff member had been told by the facility's Property Director (corporate staff) that water temperatures around 123 degrees F or 125 degrees F were okay. On 5/10/12 at 6:05 P.M., during interview, the Administrator indicated a cracked mixing valve on the boiler was the causative factor affecting elevated water temperatures. On 5/11/12 at 10:35 A.M., during interview LPN #1, identified 15 residents in the unit 100 population who were capable of independently capable of utilizing bathroom sinks. On 5/11/12 at 10:45 A.M., during interview, QMA #1, identified 15 residents in the 300 unit who were capable of independently utilizing bathroom sinks. On 5/14/12 at 10:15 A.M., the DON (Director of Nursing) was interviewed. She provided inservices provided to the CNAs (certified nursing assistants) on 1/10/12. The inservice included, but was not limited to, the following showering procedures with the following direction: "...turn on water and have resident check water temperature. Resident's sense of touch may be different than yours, therefore, resident is best able to identify a comfortable water temperature." Documentation was lacking to indicate staff were informed of safe water temperature ranges for residents. The DON indicated staff were provided requisitions for maintenance to be submitted when there were problems requiring maintenance intervention. Documentation was lacking to indicate staff (using water for their handwashing and resident care) were alert to and/or perceived water temperatures were too hot at times and reported it to maintenance. The State Operational Manuel (SOM) was reviewed on 5/14/12 at 11:22 A.M., regarding water temperatures. This interpretative guideline indicated the following: For a water temperature of 127 degrees Fahrenheit (F) the time required for a third degree burn to occur would be 1 minute. With a water temperature of 120 degrees F the time required for a third degree burn would be 5 minutes. The Immediate Jeopardy that began on 5/10/12 at 3:10 P.M., was removed on 5/11/12 at 5:15 P.M., when the facility implemented a system to ensure safe water temperatures by replacing a water valve and continued monitoring of water temperatures. Facility staff were also inserviced on the safe range of water temperatures and immediate notification of administrative and maintenance staff if unsafe water temperatures occur. The noncompliance remained at the lower scope of severity level of a pattern of no actual harm with the potential for more than minimal harm which was not immediate jeopardy, because monitoring of water temperatures was still being done to ensure a consistent safe range. B 1. On 5/9/12 at 12:45 P.M., Resident # 79's bed was observed. Both upper side rails were in the up position. When looking at the bed, from the foot of the bed, only the right lower side rail was up. Both the upper and lower side rails were perpendicular to the foot board and the head boards on the bed. The resident was not in the bed at the time. The HOB (head of bed) was in the down position and flat. The gap area between the edge of the top headboard and the top of the siderail on the side of the bed measured 7 inches with a standard ruler. The gap area between the edge of the foot board and the edge of the lower side rail was 11 inches, also measured with a standard ruler. On 5/9/12 at 2:20 P.M., the Administrator was interviewed and made aware of the gap measurements. He indicated the facility only had one of these types of beds. He indicated this was a speciality type bed. At 2:35 P.M. the lower siderail was observed to be lowered. On 5/9/12 at 2:30 P.M., Resident #79's clinical record was reviewed. [DIAGNOSES REDACTED]. Documentation was lacking of a side rail assessment. On 5 /9/12 at 3 P.M., the DON (Director of Nursing) was interviewed. She indicated the resident had been using this current speciality bed since August of 2011 and had not had any problems with it regarding the side rails. On 5/10/12 at 10 A.M. the clinical record was again reviewed. At this time a side rail assessment screen was dated 5/9/12. This form indicated the following: "The side rail has been measured and the gaps between the rail(s) themselves and the gaps between the side-rail and the mattress are conducive to resident safety as based on this individual resident." This comment was checked "Yes." The following comment was also checked "yes": "Head of the bed was elevated to conduct a visual review to assess that the mattress and the side rail did not have a gap large enough to impose a resident safety issue/concern based on this individual resident." B.2. On 5/11/12 at 11 A.M. the Administrator was made aware of the gap measurement between the headboard and the "enabler" bolted to the each side of the bed, near the head of the bed. This bed was in Resident #57's room. The "enablers" are observed to be in an inverted "U" shape and are bolted to each side of the bed, near the head of the bed. When measured with a standard ruler, the gap between the headboard and the edge of the enabler closest to the headboard, measured 9 inches. The head of the bed was flat when this measurement was obtained. The resident was not in the bed at the time the measurement was obtained. On 5/11/12 at 11:30 A.M. the clinical record of Resident #57 was reviewed. A Side Rail Assessment Screen, was dated 4/17/12. This form was partially completed; documentation was incomplete: The "Side-Rail Safety" portion has the following choices: "side rail has been measured and the gaps between the rails themselves and the mattress are conducive to resident safety as based on this individual resident" and/or "head of the bed was elevated to conduct a visual review to assess the mattress and the siderail did not have a gap large enough to impose a safety issue/concern based on this resident" and /or "visual review has been performed to assess the mattress does not shift/slide allowing for an increased gap between the bed and the side rail." This review resulted: "No safety issues/concerns." This entire area was blank in addition to the lower section of the form, which indicated the following: "Based upon the above assessment findings, the resident will not utilize side rails at this time" or "Based upon the above assessment findings, the side-rail(s) is not a restraint and will be utilized to enable the resident to attain or maintain his/her highest practicable level and/or based upon the above assessment findings, the resident will utilize side rails and they will be considered a restraint." On 5/11/12 at 4:11 P.M., the Maintenance Man was interviewed. He indicated he is taking all the side rails off of all the beds. He is now working in the 200 hall. On 5/16/12 at 3:15 P.M., the bilateral enablers remained on the resident's bed. Documentation remained incomplete for assessment of the enablers on the clinical record. On 5/16/12 at 9:55 A.M., the DON provided a current copy of the facility policy and procedure for "Side Rails." This policy was dated 7/1/11. The guideline included, but was not limited to, the following: "It is the intent of this facility to provide the licensed nurse with a process for the evaluation, documentation needs...relating to side rails evaluation and utilization..." On 5/17/12 at 4:15 P.M. the Facility Consultant was interviewed. She indicated the facility views enablers as side rails and the guidelines apply for both. The Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment-Guidance for Industry and FDA Staff issued March 10, 2006 indicates the FDA ( Food and Drug Administration) recommends openings within the rail, between rail supports, under the rail or next to a single rail support and between the rail and mattress should be small enough to prevent the head from entering or being entrapped. The "Hospital Bed Safety WorkGroup (HBSW)" and the "International Electrotechnical Commission (IEC)" along with the FDA recommend the space be less than 4 3/4 inches. The FDA recommends the space under the rail - at the ends of the rail be small enough to prevent neck entrapment. The HBSW and the IEC along with the FDA recommend this space be less that 2 3/8 inches and greater than a 60 degree angle. 3.1-19(a) 3.1-19(r)(5) 3.1-45(a)(1)