Every finding on record at Waters of Rushville Skilled Nursing Facility, The

Based on interview and record review, the facility failed to develop and implement a pain control care plan for 1 of 3 new admission reviewed. (Resident F) Findings include: The clinical record for Resident F was reviewed on 8/10/2026 at 1:02 PM. The medical diagnoses included, but were not limited to, depression and displaced comminuted fracture of the left tibia with routine healing.No baseline care plans including, but were not limited to pain, were indicated for Resident F.Physician's orders, dated 8/7/2026, indicated Resident F to use oxycodone every 8 hours as needed for pain. Physician's orders, dated 8/7/2026, indicated Resident F to use acetaminophen every 6 hours as needed for discomfort.During an interview with LPN 16, on 8/10/2026 at 12:19 PM, she indicated she was the nurse that admitted Resident F. Resident F wore a left leg immobilizer, was alert with confusion, and repeated questions. At admission, Resident F did not appear to be in pain. LPN 16 indicated around shift change Resident F's family had come in and then reported Resident F was in pain. When LPN 16 went to the room, Resident F reported a 5/10 pain around 10 PM on 8/7/2026. LPN 16 removed and reapplied the immobilizer as a non pharmacological comfort measure. LPN 16 indicated this was immediately effective for pain control. Per report from the discharging nurse, Resident F had last received as needed pain medication on 8/7/2026 at 3:16 PM and would not be due until 11:16 PM on 8/7/2026. LPN 16 indicated Resident F did not request pain medication and fell asleep. LPN 16 did not document the non-pharmacological intervention, but indicated interventions would have been listed on the baseline care plan. LPN 19 was scheduled to assume care of Resident F on 8/7/2026 at 10:00 PM. LPN 19 was unable to be reached for an interview related to Resident F's pain level. A nursing progress note, dated 8/8/2026 at 00:22 AM, indicated Resident F was sent to the emergency room per family request.During an interview, on 8/10/2026 at 1:29 PM, the Director of Nursing indicated he was alerted to an issue the morning of 8/8/2026 that Resident F was sent to the hospital. During an interview, on 8/10/2026 at 1:45 PM, the Regional Nurse Consultant indicated baseline care plans should be documented under the assessments and/or in the care plan tabs within the electronic medial records. She was unable to locate the baseline care plan for Resident F's 8/7/2026 admission.A policy entitled, GUIDELINES FOR PAIN MANAGEMENT, was provided by the Regional Nurse Consultant on 8/07/2026 at 12:10 PM. The policy indicated, .An interim care plan initiated on admission will address any pain. A policy entitled, Baseline Care Plan Assessment/Comprehensive Care Plans, was provided by the Regional Nurse Consultant on 8/10/2026 at 3:22 PM. The policy indicated, .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.This citation relates to Intake 3152775.

Based on interview and record review, the facility failed to administer vancomycin, as ordered, and to complete daily skilled nursing charting, including vital signs, for 2 of 2 residents reviewed for hospitalization. (Residents 43 and D)Findings include: 1. The clinical record for Resident 43 was reviewed on 8/4/26 at 11:54 a.m. Resident 43's diagnoses included, but were not limited to, C.Diff (Clostridioides difficile- a bacterium that causes severe colon inflammation and watery diarrhea. It typically happens after taking antibiotics, which kill helpful gut bacteria and let C.Diff overgrow. It spreads easily via spores on contaminated surfaces.) The care plan, initiated 6/17/26 and revised 7/15/26, indicated Resident 43 had C.Diff with an intervention to administer medication per physician's order. The August, 2026 physician's orders indicated to administer Vancomycin HCl Oral Capsule 125 mg Give 1 capsule by mouth four times a day for c-diff for 2 weeks and Give 1 capsule by mouth two times a day for C-diff for 7 days AND Give 1 capsule by mouth one time a day for c-diff for 7 days and Give 1 capsule by mouth one time a day every other day for c-diff for 14 days, starting 7/6/26 and ending 8/20/26. The July, 2026 Medication Administration Record (MAR) indicated the Vancomycin 1 capsule two times a day was not administered once on 7/24/26 and twice on 7/25/26, for a total of three missed administrations. The progress note, dated 7/24/26 at 7:10 p.m., indicated the Vancomycin was not administered due to awaiting refill from the pharmacy. The progress note, dated 7/25/26 at 7:29 a.m., indicated the Vancomycin was not administered due to on order. The progress note, dated 7/25/26 at 7:29 p.m., indicated the Vancomycin was not administered due to awaiting refill from the pharmacy. An interview was conducted with the Assistant Director of Nursing (ADON) who served as the facility's Infection Preventionist (IP) on 8/6/26 at 2:50 p.m. The ADON/IP indicated she was unsure if the pharmacy was out of the Vancomycin or if nursing did not order it timely. It was odd they ran out right in the middle of the same dose for the week, and she would look into it. An interview was conducted with the ADON/IP on 8/7/26 at 10:44 a.m. The ADON/IP indicated she spoke with the pharmacy and was informed there was an issue with the way the order was sent to them. The pharmacy sent out 56 pills initially to cover the first 14 days. They received the order in it's entirety, but the pharmacy only sent out instructions and enough medication for the first 14 days. Nursing then reached out to pharmacy and the medication was received on 7/26/26. The ADON/IP was unsure why Resident 43 did not run out of the Vancomycin sooner than 7/24/26, since pharmacy only sent enough to last 14. Based on that time frame, the Vancomycin would have ran out around 7/21/26. The ADON/IP was unable to find any verification the physician was notified of the missed administrations and how it should be handled moving forward with the current order. 2. The clinical record for Resident D was reviewed on 8/7/2026 at 11:05 AM. The medical diagnoses included, but were not limited to, falls and age-related debility. The admission Minimum Data Set (MDS) for Resident D, dated 4/27/2026, indicated that Resident D was admitted to the facility on [DATE], was cognitively intact and did not refuse care. Review of nursing assessment indicated Resident D had a nursing assessment entitled, INF – Daily Skilled Nursing Progress Note – V 3 completed on 4/27/2026. The note was Daily. No assessment under this name was completed on 4/25/2026 or 4/26/2026. Review of the vital signs for Resident D indicated that no vital signs were obtained on 4/26/2026. Vital signs completed on 4/27/2026 omitted respirations and oxygen saturation. Vital signs are basic clinical measurements which include temperature, pulse, respirations, blood pressure, and, when applicable, oxygen saturation. During an interview, on 8/7/2026 at 1:45 PM, the Regional Nurse Consultant indicated that the facility followed the RAI Manual when documenting nursing assessments. She indicated this included completing a daily nursing assessment, with daily vital signs, during a resident's skilled nursing stay. A policy entitled, GUIDELINES FOR ASSESSMENTS, was provided by the Regional Nurse Consultant on 8/07/2026 at 12:10 PM. The policy indicated, .It is the policy of the facility to ensure that assessments of the residents take place timely, at the appropriate time and are accurate.410 Indiana Administrative Code 16.2-3.1-37

Based upon interview and record review, the facility failed to completely and accurately document the assessment of a pressure area and initiate treatment of a pressure area for 1 of 1 resident reviewed for pressure areas. (Resident D) Findings include:The clinical record for Resident D was reviewed on 8/7/2026 at 11:05 AM. The medical diagnoses included, but were not limited to, falls and age-related debility. The admission MDS for Resident D, dated 4/27/2026, indicated that Resident 57 was cognitively intact and did not refuse care.A skin care plan, dated and initiated 4/27/2026, indicated Resident D was at risk for skin impairments. Interventions included, but were not limited to, notifying the provider of skin conditions as needed.A nursing admission assessment, dated 4/24/2026, indicated Resident D admitted with a stage two pressure area (open wound with partial thickness skin loss) to the sacrum. No length or width was recorded, but a depth of 0.1 was listed.Review of physician orders for Resident D, dated 4/24/2026, indicated there was no treatment implemented for a pressure area.During an interview with RN 14, on 8/7/2026 at 9:10 AM, she indicated that she admitted Resident D. RN 14 did not recall the exact details of the admission but indicated that her documentation reflected the findings at that time. She indicated that when a resident was admitted with a skin condition, she reviewed the hospital orders, changed the dressing if permitted by the order, and reported pertinent findings to the provider, including the need for treatment if no treatment was listed. She was not sure why this process was not completed for the sacral wound or why the measurements were not documented on the assessment for Resident D.A policy titled GUIDELINES FOR PREVENTION/TREATMENT OF PRESSURE INJURIES was provided by the Regional Nurse Consultant, on 8/06/2026 at 12:22 PM. The policy indicated that its purpose included, but was not limited to, the prevention and treatment of pressure areas. The policy indicated that documentation of pressure areas should include size, defined as perpendicular measurements of the greatest extent of length and width of the pressure injury or ulcer; depth; and the presence of any undermining, tunneling, or sinus tracts.This citation relates to Intake 2999383.410 Indiana Administrative Code 16.2-3.1-40(a)(2)

Based on observation, interview, and record review, the facility failed to ensure a resident's personal and medical information were protected from possible observation by other persons in the area during 5 medication administration observations with 5 staff and 11 residents. (Resident F and LPN 4)Findings include:During a medication administration observation on 8-21-25 at 1:16 p.m., a facility computer laptop was observed opened to Resident F's medical administration record, which had the resident's name and medical information visible. The computer was located on top of the medication cart, near the nurses' station and was visible for anyone walking near or by the medication cart. No staff were observed in the area until 1:20 pm. At that time, Licensed Practical Nurse (LPN) 4 returned to the medication cart. In an interview at 1:21 p.m., with LPN 4, she indicated she had been pulled away for care related to another resident and did not take the time to secure the computer.During a review of Resident F's medical record on 8-22-25 at 11:50 a.m., the record indicated she had multiple medical diagnoses and received multiple medications related to her diagnoses.In an interview with the Director of Nursing on 8-21-25 at 3:30 p.m., she indicated she had conducted an in-service (staff education) in the last month, addressing medication administration. She indicated she had educated all staff on the importance of securing all medications when staff were not present and staff were knowledgeable regarding keeping resident personal information secure.On 8-22-25 at 1:15 p.m., the Executive Director provided an undated copy of a policy entitled, Resident Rights. This policy indicated, Residents have a right to a dignified existence.The facility will protect and promote their rights.They have the right of privacy over their personal and clinical records.This citation relates to Intakes 1656340 and 2564836.3.1-3(o)

Based on interview and record review, the facility failed to ensure staff members correctly administered medications as ordered for 1 of 4 residents reviewed for accuracy of medication receipt. (Resident E and QMA 5)Findings include:In an interview with the Director of Nursing (DON) on 8-20-25 at 3:40 p.m. She indicated there was a medication error that had occurred since the most recent annual survey at the end of June 2025, and was identified on the day after it occurred. She indicated the staff member did not check the resident's medication administration record (MAR) as that staff member would have found out the pain medicine had been DC'd [discontinued]. I preach to the staff to read and double check those MAR's.A review of the progress notes for 7-16-25, failed to identify any documentation of Resident E receiving a dose of as needed, or PRN pain medication on the evening of 7-16-25. The Controlled Drug Receipt Record/Disposition Form, for Resident E's oxycodone 5 milligrams (mg) indicated Qualified Medication Aide (QMA) 5, administered one dose of this medication on 7-16-25 at 8:30 p.m. The last dose, prior to this dose, was received on 7-15-25 at 8:00 p.m. The form indicated the directions for this medication were to take one capsule orally every four hours as needed for pain for seven days, with the original start date listed as 7-9-25, and the form indicated 30 tablets had been received on 7-10-25, with the first dose received on 7-10-25 at 7:00 p.m. It indicated a total of seven doses had been administered to Resident E, including the last dose on 7-16-25 at 8:30 p.m., given by QMA 5. It indicated 23 doses of this medication were disposed of on 7-18-25, which was conducted by a staff nurse and the Assistant Director of Nursing.A review of the MAR for 7-16-25 failed to identify any documentation of Resident E receiving a dose of as needed, or PRN pain medication on the evening of 7-16-25. The entry for oxycodone 5 mg every four hours as needed for pain, indicated the order began on 7-9-25 and had a discontinue date of 7-16-25 at 11:45 a.m. In an interview on 8-22-25 at 9:10 a.m., with the DON, she indicated the facility's investigation identified QMA 5 had not signed the MAR or made an entry into the progress notes. She indicated the order had been discontinued on 7-16-25, on the same day the facility began staff education related to the facility's most recent annual survey related to medication administration citations. The DON indicated the facility did conduct a 72-hour follow-up on the resident with no complications identified. The DON indicated the discontinued order had been updated in the computer system and reflected on the MAR, but the med had not been pulled from the med cart yet, because the nurses aren't allowed to dispose of meds without the DON or ADON [Assistant Director of Nursing] being present. At the time, [name of QMA 5].had been employed about a month or so. In an interview on 8-22-25 at 1:58 p.m., with the DON, she indicated the facility couldn't find where QMA 5 had notified any of the nurses that he was going to give a prn, and since there were no notes or documentation on the MAR, apparently it was not done. The normal procedure for a prn the QMA's were wanting to give, they were to notify the licensed nurse and then put that in the notes either on the MAR that automatically places it in the progress notes, or they were to make a note in the progress notes about this. The clinical record for Resident E was reviewed on 8-21-25 at 3:28 p.m. His diagnoses included, but were not limited to, lung cancer. On 8-22-25 at 1:15 p.m., the Executive Director provided an undated copy of a document entitled, Qualified Medication Aide Scope of Practice. This document indicated, The following tasks are within the scope of practice for the QMA unless prohibited by the facility policy .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 the symptoms occur in the resident. (D) Ensure the resident's record is cosigned by the licensed nurse who gave permission by the end of the nurse's shift, or if the nurse was on call, by the end of the nurse's next tour of duty. This citation relates to Intakes 1656340 and 2564836.3.1-14(i)

Based on interview and record review, the facility failed to ensure a medication that had been discontinued was not administered by facility staff to 1 of 4 residents reviewed for accuracy of medication receipt. (Resident E, QMA 5)Findings include:In an interview with the Director of Nursing (DON) on 8-20-25 at 3:40 p.m. She indicated this was the only medication error that had occurred since the most recent annual survey at the end of June 2025, and was identified on the day after it occurred. She indicated the staff member did not check the resident's medication administration record (MAR) as that staff member would have found out the pain medicine had been DC'd [discontinued]. I preach to the staff to read and double check those MAR's.The clinical record of Resident E was reviewed on 8-21-25 at 3:28 p.m. His diagnoses included, but were not limited to, lung cancer.A review of the progress notes for 7-16-25, failed to identify any documentation of Resident E receiving a dose of as needed, or PRN pain medication on the evening of 7-16-25. The Controlled Drug Receipt Record/Disposition Form, for Resident E's oxycodone 5 milligrams (mg) indicated Qualified Medication Aide (QMA) 5, administered one dose of this medication on 7-16-25 at 8:30 p.m. The last dose, prior to this dose, was received on 7-15-25 at 8:00 p.m. The form indicated the directions for this medication were to take one capsule orally every four hours as needed for pain for seven days, with the original start date listed as 7-9-25, and the form indicated 30 tablets had been received on 7-10-25, with the first dose received on 7-10-25 at 7:00 p.m. It indicated a total of seven doses had been administered to Resident E, including the last dose on 7-16-25 at 8:30 p.m., given by QMA 5. It indicated 23 doses of this medication were disposed of on 7-18-25, which was conducted by a staff nurse and the Assistant Director of Nursing.A review of the MAR for 7-16-25 failed to identify any documentation of Resident E receiving a dose of as needed, or PRN pain medication on the evening of 7-16-25. The entry for oxycodone 5 mg every four hours as needed for pain, indicated the order began on 7-9-25 and had a discontinue date of 7-16-25 at 11:45 a.m. In an interview on 8-22-25 at 9:10 a.m., with the DON, she indicated the facility's investigation identified QMA 5 had not signed the MAR or made an entry into the progress notes. She indicated the order had been discontinued on 7-16-25, on the same day the facility began staff education related to the facility's most recent annual survey related to medication administration citations. The DON indicated the facility did conduct a 72-hour follow-up on the resident with no complications identified. The DON indicated the discontinued order had been updated in the computer system and reflected on the MAR, but the med had not been pulled from the med cart yet, because the nurses aren't allowed to dispose of meds without the DON or ADON [Assistant Director of Nursing] being present. At the time, [name of QMA 5].had been employed about a month or so. This citation relates to Intakes 1656340 and 2564836.3.1-48(c)(2)

Based on observation, interview, and record review, the facility failed to ensure a medication was stored safely in the absence of staff for 1 of 1 medication during 5 medication administration observations with 5 staff and 11 residents. (Resident F and LPN 4)Findings include: During a medication administration observation on 8-21-25 at 1:16 p.m., a packet of medication, labelled, phenazopyridine 100 mg with one tablet inside and labelled for Resident F was observed lying on top of medication cart, located near the nurses' station. No staff were observed in the area until 1:20 pm. At this time, Licensed Practical Nurse (LPN) 4 returned to the medication cart. In an interview at 1:21 p.m., with LPN 4, she indicated she had been pulled away for care related to another resident and did not take the time to secure the medication into the medication cart in her absence. The medication cart was observed to be locked during this time.In a review of Resident F's medications on 8-22-25 at 11:50 a.m., she was physician ordered to receive phenazopyridine 100 milligrams every 8 hours for bladder spasms. Her medical diagnoses, included but were not limited to neuromuscular bladder dysfunction.In an interview with the Director of Nursing on 8-21-25 at 3:30 p.m., she indicated she had conducted an in-service (staff education) in the last month, addressing medication administration. She indicated she had educated all staff on the importance of securing all medications when staff were not present.This citation relates to Intakes 1656340 and 2564836.3.1-25(m)

Based on interview and record review, the facility failed to have a Registered Nurse (RN) on duty at the facility for 5 of 30 days reviewed for RN coverage. This had the potential to affect 43 of 43 residents that reside in the facility. Findings include: Review of the schedules provided by the Director of Nursing (DON), on 6/25/25 at 12:44 p.m., indicated the facility did not have RN coverage, 8 hours a day, on 1/7/25, 1/21/25, 1/22/25, 1/25/25, and 1/26/25. During an interview with the DON on 6/25/25 at 12:44 p.m., she indicated the facility did not have RN coverage on 1/7/25, 1/21/25, 1/22/25, 1/25/25 and 1/26/25. The DON indicated there was no resident care and/or assessments not completed due to no RN in the building on those dates. The DON indicated there was no negative outcome for residents on these dates due to no RN coverage. During an interview conducted with the Administrator on 6/26/25 at 1:33 p.m., she indicated the facility did not have a policy on sufficient nurse staffing. The facilities expectation was to have RN coverage for 8 consecutive hours a day, 7 days a week. This citation relates to Complaint IN00460358. 3.1-17(b)(3)

Based on observation, interview, and record review, the facility failed to timely coordinate counseling services for 1 of 5 residents reviewed for unnecessary medications. (Resident 12) Findings include: The clinical record for Resident 12 was reviewed on 6/26/25 at 11:25 a.m. The diagnoses included, but were not limited to, schizoaffective disorder, bipolar type, histrionic personality disorder, mild binge eating disorder, anxiety, and depression. She was admitted to the facility on [DATE]. The 2/3/25 PASRR (Pre-admission Screening and Resident Review) Level 2 care plan indicated the goal was for her Level 2 needs to be met at the facility. An intervention was mental health services-individual therapy, initiated 2/3/25. The 2/3/25 care plan indicated Resident 12 had a mood problem related to little interest in doing things, feeling down, difficulty sleeping, feeling tired, and being restless. The goal was for her to have improved mood state through the next review date. The 1/29/25 care plan indicated Resident 12 took psychotropic medications for disease management. The goal was for her to be free from signs and symptoms of bipolar/depression/anxiety through the next review date. Interventions were to encourage her to voice her feelings and concerns, initiated 1/29/25, and to offer support and reassurance, initiated 1/29/25. The 5/6/25 anxiety care plan indicated an intervention was to validate and provide assistance, initiated 5/6/25. The physician's orders indicated she was taking one five mg tablet of olanzapine (antipsychotic medication) at bedtime, effective 1/28/25, for schizoaffective disorder; one 15 mg tablet of buspirone (medication used to treat anxiety disorders) twice daily, for anxiety, effective 1/28/25; and one 150 mg tablet of lamotrigine (medication used to treat epilepsy and bipolar disorder) twice daily for schizoaffective disorder. The 5/15/25 pharmacy recommendation indicated to consider a gradual dose reduction of the five mg tablet of olanzapine to 2.5 mg at bedtime. The 5/19/25 provider response indicated they disagreed due to Resident 12's continued paranoia and delusional thought processes. A reduction at that time was not in her best interest. The 5/1/25 mental health visit note, written by the NP (Nurse Practitioner), indicated prior to her 1/28/25 facility admission, she was followed by a different mental health provider for medication management and counseling. Her mental health medications had not been adjusted since facility admission. She struggled with a lot of paranoia, mood swings, self-defeating behaviors and a lot of self-loathing. Staff often struggled with her very rapid mood swings. She required a lot of positive reassurance from nursing staff. She had a lot of negative self-talk about her current health conditions, yet did not comply with follow-up and recommendations of providers and specialists. Her mood was anxious and depressed. Her affect was congruent with mood. Her cognition was alert and oriented to all spheres and grossly intact. Her insight and judgement were poor. The Assessment/Plan section of the note indicated in regards to her schizoaffective disorder, bipolar type and histrionic personality disorder, she had poor mood regulation, maladaptive behaviors, manipulative behaviors, and to Refer for psychotherapy/counseling if patient is agreeable. In regards to her mixed anxiety and depressive disorder, to refer for psychotherapy/counseling if patient was open. The concern was patient's repeated refusal of going to outpatient appointments. Will continue with Buspar. Will continue to follow patient at facility. Will plan to follow up in 2 months or sooner if needed. There was no information in the clinical record to indicate Resident 12 received psychotherapy/individual counseling, as indicated in the 2/3/25 PASRR Level 2 care plan and 5/1/25 mental health visit note, or follow up with Resident 12, in regards to setting up psychotherapy/individual counseling after the 5/1/25 mental health visit. The 5/12/25 care plan meeting progress note, written by the SSD (Social Services Director), indicated Resident 12 was on medication in order to manage depression and anxiety levels, but Resident 12 stated she didn't feel it was helping as good as it could. The 5/18/25 behavior monitoring note, written by LPN (Licensed Practical Nurse) 11, indicated Resident 12 was crying loudly while laying in her bed and could be heard from the nurse's station. Resident 12 stated she was depressed, because of her condition. LPN 11 sat with Resident 12, talked for a short period of time, and gave fluids. Resident 12 was assisted to use the bed pan and repositioned in bed. This was effective and Resident 12 was no longer crying. An interview was conducted with the Nurse Consultant (NC) and Director of Nursing (DON) on 6/27/25 at 11:10 a.m. The NC indicated when she spoke with the NP, the NP informed her Resident 12 was unsure where she wanted to go for individual counseling/therapy, so the referral was just sent on 6/25/25, because the NP was waiting for Resident 12 to make up her mind. The 6/26/25, 2:48 p.m. general note, written by the NC, indicated, [Name and title of NP] stated that resident was debating whether she wanted to continue to see her previous counselor in [another city] or go somewhere else. [Name of NP] reports that resident has finally decided to go to [name of local mental health provider] and the referral for counseling was sent by [name of NP] to [name of local mental health provider] on 6/25/25. An interview was conducted with the NP on 6/27/25 12:04 p.m. She indicated she did not send a referral for counseling on 5/1/25, when she made the recommendation, because Resident 12 was already established with a mental health provider in another city. So, Resident 12 was still trying to determine if she wanted to see them or someone else locally. The NP did not follow up with Resident 12 after the 5/1/25 mental health visit, in regards to where she wanted to receive individual counseling. Resident 12 said something this past week at a care plan meeting, so she (NP) sent the referral this week. The NP was scheduled to see Resident 12 again, on 6/30/25, for her next mental health visit, so she would have followed up then. They probably discussed counseling for Resident 12 in the May, 2025 behavior meeting, at which the SSD (Social Services Director) was present and would have been involved. The NP indicated she was currently reviewing the May, 2025 behavioral meeting notes, and did not see any notes about counseling for Resident 12. This was something the facility could have followed up on, after reviewing Resident 12's 5/1/25 mental health note. No one at the facility asked the NP anything about it. The NP faxed all mental health visit notes to the front desk, and then let the SSD know they were there. An interview was conducted with the Administrator on 6/27/25 at 1:35 p.m. The SSD joined the interview on 6/27/25 at 1:40 p.m. The Administrator indicated Resident 12 had a choice and could have said where she wanted to go for counseling. Resident 12 did not like to go places, so that was why she did not give an answer right away. The NP should have made the referral. She stated, There's poor communication between our provider and us. The SSD indicated she never spoke to Resident 12 about individual counseling, but the facility discussed Resident 12 in behavior meetings. The SSD reviewed her behavior meeting notes and indicated, at the May, 2025 meeting, they discussed Resident 12 needed monitored more closely, but nothing about counseling. The SSD indicated when the mental health visit notes came in, she skimmed them. The Administrator indicated she thought the NP let it be until Resident 12 knew what she wanted. An observation and interview were conducted with Resident 12 in her room on 6/27/25 at 11:38 a.m. She indicated she was okay with seeing a counselor but would prefer to see them in her room. Resident 12 became teary eyed during this interview. 3.1-34(a)(2) 3.1-34(a)(3)

2. The clinical record for Resident 12 was reviewed on 6/26/25 at 11:25 a.m. The diagnoses included, but were not limited to, type 1 diabetes mellitus. She was admitted to the facility on [DATE]. The physician's orders indicated to administer ten units of insulin lispro (fast-acting insulin) injection solution 100 UNIT/ML (units per milliliter) with meals, effective 6/15/25; 15 units twice daily, effective 3/7/25; and sliding scale for blood sugar readings as follows, effective 6/15/25: 151 - 200 = two units; 201 - 250 = four units; 251 - 300 = six units; 301 - 350 = ten units; 351 - 400 = 12 units, subcutaneously three times a day, and to call the physician if blood sugar reading was below 60 or above 400. The 5/14/25 physician's order indicated to set up an appointment with Resident 12's endocrinologist. This order was revised on 6/2/25 to include the specific endocrinologist. The 6/11/25 nursing progress note indicated, Called and left a message with endocrinology [name of endocrinologist] through [name of provider network] to set up a follow up apt [appointment]. There were no progress notes prior to or after the above 6/11/25 nursing progress note to indicate an endocrinology appointment was scheduled after the 5/14/25 order to do so. An interview was conducted with Resident 12 on 6/27/25 at 11:38 a.m. She indicated she would like to see an endocrinologist, because of her diabetes. No one at the facility said anything to her about having an appointment scheduled. An interview was conducted with the NP (Nurse Practitioner) on 6/27/25 at 12:04 p.m. She indicated Resident 12's need for an endocrinology appointment stemmed from her having a lot of specialists upon admission, so she (NP) was trying to cover all the bases. Resident 12 was very brittle with her diabetes, so the NP thought they should get endocrinology back on board. The NP would have left the information regarding Resident 12's need for an endocrinology appointment with the DON or ADON (Assistant Director of Nursing). They had prior issues with appointments not being scheduled and orders not being followed through upon, so they agreed orders would be given directly to one of the two of them. An interview was conducted with the DON on 6/27/25 at 11:10 a.m. She indicated they had just scheduled Resident 12's endocrinology appointment yesterday, 6/26/25. The Guidelines For Resident Appointments Outside The Facility were provided by the DON on 6/27/25 at 11:50 a.m. It indicated, While the facility has in-house physician visits to residents per policy and State/Federal regulatory mandates, there are times when the resident may need to be seen outside of the facility by a provider that does not physically travel to the nursing home. This includes but is not limited to such services as: .Doctor Appointments (such as a follow up from a surgery or a consult .) Upon receiving a physician's order for a situation or event that will require the resident to need transport services, the nurse who processes the order will notify the staff member who coordinates transport orders so that appropriate transport can be scheduled. This citation relates to Complaint IN00460358. 3.1-37(a) Based on interview and record review, the facility failed to provide wound dressings as ordered (Resident C) and failed to timely schedule and follow-up on an endocrinology appointment (Resident 12) for 2 of 2 residents reviewed for quality of care. Findings include: 1. The clinical record for Resident C was reviewed on 6/25/25 at 9:42 a.m. The diagnoses included, but were not limited to, anxiety disorder, osteoarthritis, and neuromuscular dysfunction of the bladder. The Annual Minimum Data Set (MDS) assessment, dated 6/5/25, indicated Resident C was cognitively intact and had moisture-associated skin damage (MASD). A weekly wound evaluation, dated 6/3/25, indicated Resident C had erythema intertrigo (red, inflamed skin found in skin folds due to moisture, friction, and lack of ventilation) to the distal rectum. The current treatment indicated to cleanse with 0.125% Dakins solution (a diluted antiseptic solution, used for cleaning and disinfecting wounds) and pack with Dakins moistened gauze and border foam twice daily and as needed. The June 2025 Treatment Administration Record (TAR) indicated an order, dated 6/3/25, to cleanse the distal rectum with Dakins 0.125% solution and pack the wound with Dakins 0.125% moistened gauze and cover with border foam two times a day for wound care. The treatment times were 5:00 a.m. (0500) and 8:00 p.m. (2000). The June 2025 TAR indicated the following days and times that the wound dressings were omitted: -Friday, 6/6/25 at 2000, -Saturday, 6/7/25 at 2000, -Sunday, 6/8/25 at 2000, -Tuesday, 6/10/25 at 0500, -Wednesday, 6/11/25 at 0500 and 2000, -Friday, 6/13/25 at 2000, -Saturday, 6/14/25 at 0500, -Monday, 6/16/25 at 2000, -Tuesday, 6/17/25 at 0500, -Saturday, 6/21/25 at 0500 and 2000, -Sunday, 6/22/25 at 0500, and -Monday, 6/23/25 at 0500. The plan of care for Resident C, dated 5/15/25, indicated the resident had an alteration in skin integrity with potential for worsening due to impaired healing due to diabetes and incontinence. The interventions included, but were not limited to, providing treatment as per MD (Medical Doctor) order. During an interview with the Director of Nursing (DON) on 6/26/25 at 10:22 a.m., she indicated some missed dressing changes were due to having a Qualified Medication Aide (QMA) working down a hall where there was not a nurse scheduled. The QMA was to notify a nurse of any dressing changes due so they could be completed. The DON indicated either the QMA did not notify the nurse that a dressing down her hall needed to be changed, or the nurse did it and did not document it since it was not one of her scheduled residents for the shift. During an interview with Resident C on 6/26/25 at 11:30 a.m., he indicated occasionally the staff would miss doing the treatments to his bottom twice a day. The Following Physician's orders policy was provided by the Administrator on 6/26/25 at 1:20 p.m. It indicated, .it is the policy of the facility to follow the orders of the physician .

Based on observation, interview, and record review, the facility failed to follow-up on optometry (eye and vision professional) recommendations and orders for 1 of 1 resident reviewed for optometry services. (Resident 25) Findings include: The clinical record for Resident 25 was reviewed on 6/25/25 at 9:42 a.m. The diagnoses included, but were not limited to, migraines and glaucoma. The Annual Minimum Data Set assessment, dated 4/24/25, indicated Resident 25 was cognitively intact and had a diagnosis of glaucoma. During an interview with Resident 25 on 6/24/25 at 10:52 a.m., she indicated she was waiting to hear something back from the facility about going back to the eye doctor. Resident 25 indicated she had been seen in February of 2025, but had not heard when she would be seen again about her eyes and new glasses. An Eye Care Chart Note, dated 2/11/25, was provided by the Director of Nursing (DON) on 6/26/25 at 9:55 a.m. The note indicated the follow-up orders included: Return in 2-4 months for IOP (Intraocular Pressure) check and to return in 1-3 months for ERG (electroretinography, an eye exam that measures the electrical activity of the retina in response to light). During an interview with the Social Service Director (SSD) on 6/25/25 at 10:08 a.m., she indicated Resident 25 was seen by the optometry provider, on 2/11/25, and her next appointment was scheduled for 8/8/25. The SSD indicated she did not know that there should have been a follow-up appointment scheduled for Resident 25. The SSD indicated that the optometry provider they used should let the facility know if a resident needed to follow-up with those services. During an interview with Resident 25 on 6/26/25 at 9:51 a.m., she indicated she had what they call white heads, little white zit appearing nodules lining her eyelids. During an observation at that time of Resident 25's eyelids, she did have what appeared to be tiny white nodules lining her eyelids. Resident 25 indicated the white heads irritated her eyes. The plan of care for Resident 25, dated 4/25/24, indicated the resident had impaired visual function. The interventions included, but were not limited to, arranging consultation with an eye care practitioner as required. During an interview with the DON on 6/26/25 at 10:27 a.m., she indicated nursing staff were responsible for making sure any new orders were followed and implemented from ancillary services. 3.1-39(a)(1)

Based on observation, interview, and record review, the facility failed to ensure physician instructions for medication administration were followed for 1 of 4 residents observed during 1 of 3 medication administrations with 1 of 3 staff. (Resident D and Qualified Medication Aide 2) Findings include: During a medication administration observation on 6-23-25 at 7:32 p.m., Qualified Medication Aide (QMA) 2 was observed to prepare oral medications for Resident D, plus, he indicated he was to remove the resident's Lidocaine 5% patch, with directions to apply the patch topically to the lower back every 12 hours for pain and to remove the patch at bedtime. This order had an effective date of 6-11-25. The medication administration record (MAR) indicated Resident D had refused this medication on the morning of 6-23-25. QMA 2 was observed to query Resident D if he could remove the patch during the administration of the oral medications. Resident D responded there was not a patch on his back. QMA 2 was not observed to request of Resident D if he could observe the area in order to verify if a patch was present. During a medication administration observation on 6-23-25 at 7:32 p.m., QMA 2 was observed to prepare medications for Resident D. The medications were to include temazepam (a benzodiazepine or central nervous system depressant, used for insomnia) 7.5 milligrams (mg) at bedtime for insomnia. QMA 2 indicated this medication was unavailable to administer at this time due to an issue being able to refill the medication. A review of the medication administration record indicated the facility had received an incorrect dosage of 15 mg of the medication on 6-23-25. On 6-27-25 at 10:20 a.m., the Administrator provided a copy of a document, dated February of 2017, entitled Tips For Safe Medication Administration. This document indicated, Follow good infection control practices .Cleanse hands when contact is made with a medication .Never touch any of the medication with fingers .Accurately dispense medications to residents .Punch medications directly into cup and never into your hands . On 6-27-25 at 10:20 a.m., the Administrator provided a copy of a document, dated February of 2017, entitled Medication Administration. It indicated its purpose was to administer all medications safely and appropriately .Read and follow any special instructions written on labels. 3.1-25(a) 3.1-25(b)(3)

Based on observation, interview, and record review, the facility failed to ensure safety precautions were adhered to by failure to keep a medication cart locked and unsupervised during 1 of 3 medication administration observations with 1 of 3 staff and failed to ensure labeling of three insulin syringes, located in the west hall medication cart, included the dates each were opened or the date to dispose of the insulin during an observation of the medication carts for of 2 of 4 medication carts observed. (Resident 18, Qualified Medication Aide 2, and Registered Nurse 3) Findings include: 1. During a medication administration observation on 6-23-25 at 7:42 p.m., with Qualified Medication Aide (QMA) 2, the lighter colored medication cart on the east hall was observed to be unlocked, upon return to the medication cart after provision of medication to a resident. The cart was located in the hall, directly in front of the nurse's station and accessible to anyone passing by the medication cart. Upon bringing this to the attention of QMA 2 at that time, he indicated, My bad. I guess I forgot. 2. During an observation of 1 of 2 medication carts on the west hall with Registered Nurse (RN) 3 on 6-24-25 at 2:05 p.m., two insulin pens of Fiasp Flexpen and one insulin pen of Basaglar for Resident 18 were located in the medication cart. Each insulin pen contained a label present for when opened and when to discard and all three insulin pens were noted with blank dates on each pen. In an interview with RN 3, at the time of the observation, she indicated if the insulin syringe or pen was in the medication cart, it was assumed to be in use and should have the date it was opened and the date it was to be disposed of present. In an interview with the Director of Nursing on 6-27-25 at 1:15 p.m., she indicated for any insulin pens that were located in the cart, each one should have the date it was opened and the date it was to be discarded, based on the manufacturer's recommendations. On 6-27-25 at 10:20 a.m., the Administrator provided a copy of a policy, dated February of 2017, and entitled Prescription Labels. This policy indicated, Medications are labeled in accordance with State and Federal laws as well as facility requirements .Accessory labels indication [sic] storage requirements and special procedures. Example: 'Shake well,'; 'Take on empty stomach 1 hour before or 2 hours after meals. On 6-27-25 at 10:20 a.m., the Administrator provided a copy of a policy dated, February of 2017, and entitled Medication Storage In The Facility. This policy indicated, Medications and biologicals are stored safety [sic], securely and properly following the manufacture [sic] or supplier recommendations . On 6-27-25 at 10:20 a.m., the Administrator provided a copy of a document, dated February of 2017, and entitled Medication Administration. It indicated its purpose was to administer all medications safely and appropriately .Read and follow any special instructions written on labels. 3.1-25(j) 3.1-25(m)

2. On 6-23-25 at 7:46 p.m., during a medication administration observation, QMA 2 was observed to prepare five (5) oral medications for Resident 99. Those medications and their physician instructions included the following: - atorvastatin 40 milligrams (mg) at bedtime for elevated blood fats. - tab-a-vite one tablet once daily for unspecified vitamin deficiency. - hydroxyurea 500 mg twice daily on Monday, Wednesday and Friday and once daily on Tuesday, Thursday, Saturday and Sunday for gout: wear gloves when handling or crushing; do not crush. - furosemide 40 mg twice daily for congestive heart failure. - metoprolol succinate extended-release 50 mg twice daily for high blood pressure. QMA 2 was observed to touch each medication with his bare hands during the preparation of the medications. When queried about touching the hydroxyurea with his bare hands and the labeled instructions, he responded, I guess I didn't see that. When queried regarding touching each pill with bare hands, he indicated that he should not have done that and would now need to replace the medications. On 6-27-25 at 10:20 a.m., the Administrator provided a copy of a document, dated February of 2017, entitled Tips For Safe Medication Administration. This document indicated, Follow good infection control practices .Cleanse hands when contact is made with a medication .Never touch any of the medication with fingers .Accurately dispense medications to residents .Punch medications directly into cup and never into your hands . On 6-27-25 at 10:20 a.m., the Administrator provided a copy of a document dated, February of 2017, entitled Medication Administration. It indicated its purpose was to administer all medications safely and appropriately .Read and follow any special instructions written on labels. 3.1-18(b)(1)(A) Based on observation, interview, and record review, the facility failed to adhere to infection control standards of storing respiratory equipment in a clean plastic bag when not in use (Resident 14), ensure an indwelling urinary catheter drainage bag and tubing were free from contact with the floor (Resident 14), and utilize appropriate handling of medication (Resident 99) for 2 of 7 residents reviewed for infection control standards. Findings include: 1. The clinical record for Resident 14 was reviewed on 6/25/2025 at 1:30 p.m. The diagnoses included, but were not limited to, urinary tract infection and chronic obstructive pulmonary disease. An admission Minimum Data Set assessment, dated 6/10/2025, indicated Resident 14 was cognitively intact, needed substantial/maximal assistance with toilet hygiene and transfers, and utilized an indwelling urinary catheter. A respiratory care plan, initiated on 4/23/2025 and revised on 4/23/2025, indicated to utilize CPAP (Continuous Positive Airway Pressure) device as directed. A urinary care plan, initiated on 6/11/2025 and revised on 6/12/2025, indicated Resident 14 was at risk for developing urinary tract infections. An intervention was listed as providing catheter care and position catheter tubing to facilitate drainage. A physician order, dated 6/3/2025, indicated Resident 14 to utilize a CPAP device. A physician order, dated 6/3/2025, indicated Resident 14 to utilize an indwelling urinary catheter. During an observation on 6/24/2025 at 11:50 a.m., a CPAP mask was noted to be lying on Resident 14's bedside table in Resident 14's private room. No plastic storage bag for respiratory equipment was visible in the room. During an observation on 6/24/2025 at 12:04 p.m., Resident 14 was noted to be propelling himself back to his room in his wheelchair. Resident 14's urinary catheter drainage bag and tubing were noted to be contacting the ground. During an observation and interview on 6/24/2025 at 12:14 p.m., Resident 14 was in his room. He indicated that he utilized a CPAP at nighttime and when he naps, but he doesn't have anything to store it in. He stated the staff have not helped him clean it since he had been here, but the staff do fill up the water reservoir when he forgets to. Resident 14 was sitting in his wheelchair at this time. Resident 14's urinary catheter drainage bag was contacting the ground. During an observation and interview on 6/24/2025 at 12:22, Resident 14 was sitting in his room in his wheelchair. Qualified Medication Aide (QMA) 2 came in to reposition Resident 14's catheter drainage bag. QMA 2 indicated that Resident 14's urinary catheter bag and tubing were contacting the floor, the drainage bag and tubing should not be contacting the ground, and it should have been positioned in the back to ensure it was free of the ground. Resident 14's CPAP mask continued to be laying on the bedside table without a storage bag. During an interview on 6/26/2025 at 1:34 p.m., the Administrator indicated it was the expectation of the facility to have urinary catheter drainage bags and tubing free of contact with the floor. A policy entitled Continuous Positive Airway Pressure (CPAP), was provided by the Administrator on 6/25/2025 at 12:50 p.m. The policy indicated .When the CPAP machine is not in use the face mask is stored in a plastic bag at the beside .

2. During an interview with Resident B on 6/24/25 at 12:32 p.m., they indicated the resident had to wait up to 30 minutes for the call light to be answered. The resident indicated they had a cell phone and timed how long they had to wait. Resident B indicated because they had to wait 30 minutes, it caused them to be incontinent of bowel and bladder. The resident indicated it was embarrassing to have the Certified Nurse Aides (CNAs) clean them up when this happened. The resident indicated they could not get out of bed by themselves due to frequent falls. Resident B indicated the weekends were when it happened the most. The resident did report this to the staff at the time it happened. Review of the Record of Resident B, on 6/25/25 at 1:20 p.m., indicated the diagnoses included, but were not limited to, weakness, lack of coordination, osteoarthritis, congestive heart failure, and repeated falls. The Quarterly MDS assessment, dated 5/13/25, indicated the resident was cognitively intact for daily decision making. The resident was consistent and reasonable. The resident had no behaviors. The resident utilized a wheelchair for mobility. The resident required substantial to maximal assistance with toileting and transfers. The resident rights policy was provided by the Administrator on 6/26/26 at 1:20 p.m. The policy indicated all residents would have their well-being and self-esteem and self-worth enhanced during all care service interactions. The staff were to treat each resident with respect and dignity. This citation relates to Complaints IN00456924 and IN00458111. 3.1-3(t) Based on interview and record review, the facility failed to promote dignity for a resident when requesting pain medication (Resident G), and failed to answer a call light timely, resulting in a resident being incontinent of bowel and bladder (Resident B) for 2 of 2 residents reviewed for dignity. Findings include: 1. The clinical record for Resident G was reviewed on 6/25/25 at 9:44 a.m. The diagnoses included, but were not limited to, presence of left artificial knee joint, pain in the left knee, and muscle weakness. The Quarterly Minimum Data Set (MDS) assessment, dated 5/9/25, indicated Resident G was cognitively intact and used opioid medication. During an interview with Resident G on 6/25/25 at 12:27 p.m., Resident G indicated on third shift, the night after she returned from the hospital on 6/20/25, she had an issue with Qualified Medication Aide (QMA) 4 when asking for pain medication. Resident G indicated she called out for a pain pill because her leg was hurting. Resident G indicated she told QMA 4 she needed pain medication and QMA 4 said, oh, you really need a pain pill? Resident G indicated QMA 4 brought the pain pill back to her, and QMA 4 said, Here! Here is your pain pill, is that all you are here for is pain medicine? Resident G indicated QMA 4 then said, I don't know what else I can do for you, I'm out of here. Resident G indicated QMA 4 speaking to her in that manner hurt her feelings.

Based on interview and record review, the facility failed to ensure a resident who was admitted to the facility with a pressure ulcer received thorough assessment upon admission, initiated a treatment timely for an identified pressure ulcer, and initiated treatment changes per the wound provider promptly for 1 of 3 residents reviewed for pressure ulcers. (Resident C) This deficient practice was corrected on 2/14/25, prior to the start of the survey, and was therefore past noncompliance. The facility implemented a systemic plan that included the following actions: in-service education to nursing staff related to the policy and procedure regarding pressure ulcers, reviewed all wound reports from the wound care provider for January and February of 2025 to identity potential residents, and conducted a review of residents with pressure ulcers to ensure assessments have been completed and documented with ongoing review presented to the Quality Assessment and Assurance (QAA) Committee for review. Findings include: The clinical record of Resident C was reviewed on 2/20/25 at 10:00 a.m. The diagnoses included, but were not limited to, peripheral vascular disease, diabetes mellitus, congestive heart failure, and hypertension. Resident C was admitted to the facility on [DATE]. An Admission Minimum Data Set (MDS), dated [DATE], indicated one unstageable pressure ulcer was noted. An admission nursing assessment, dated 2/5/25, indicated a pressure ulcer to the left heel with no further information regarding description, measurements, odor, drainage, and/or wound characteristics. There was noted redness and excoriation to the left and right buttock with no further description, measurements, odor, drainage, and/or wound characteristics. A skin integrity care plan, dated 2/10/25, indicated Resident C had a pressure ulcer to the right buttock. The interventions included, but were not limited to, provide treatment per physicians' order. A Wound Assessment Report, dated 2/7/25, indicated a stage 3 pressure ulcer to the right buttocks. The pressure ulcer contained 80% granulation tissue, 20% slough tissue, and measured 2.5 centimeters (cm) x 2.5 cm x 0.1 cm in depth. The treatment was listed to cleanse the wound with wound cleanser, apply medical grade honey, apply a bordered foam dressing, and change daily. The medication administration record (MAR), dated February 2025, did not reflect a treatment to the right buttock until 2/10/25. A physician order, dated 2/10/25, indicated the utilize medical grade honey, an abdominal pad, and bordered foam to bilateral buttocks daily. The order was discontinued on 2/13/25. The MAR, dated February 2025, indicated the treatment of the bilateral buttocks with medical grade honey was not signed off, as ordered, on 2/10/25 and 2/13/25. A Wound Assessment Report, dated 2/11/25, indicated a stage 3 pressure ulcer to the right buttocks and the pressure ulcer was improving without complications. The treatment was noted to cleanse the pressure ulcer with soap and water, pat dry, and apply triad, and leave open to air. A physician order, dated 2/13/25, indicated to cleanse the right buttock with soap and water, pat dry, apply triad paste, and leave open to air three times daily. An interview conducted with the Director of Nursing (DON), on 2/21/25 at 10:21 a.m., indicated the facility recognized the concern related to the lack of wound assessments, follow up pertaining to the wound care provider, and treatment completion. The DON indicated she was out on leave and the Assistant Director of Nursing (ADON) was overseeing the DON duties while the DON was out on leave. The ADON did not ask for assistance in covering the daily duties during the DON absence. There was an abrupt departure of the ADON, Scheduler, and a few staff nurses. The DON was working on the floor to cover staffing and did not have the time to work on the wound report. A policy entitled Guidelines For Prevention/Treatment of Pressure Injuries, dated 2019, was provided by the DON on 2/20/25 at 4:30 p.m. The policy indicated the following, .If upon any assessment an actual pressure ulcer/pressure injury is found immediate steps will be taken to ensure that all notifications to the physician and the resident and the resident's Responsible Party/POA [power of attorney] are made. Also, to ensure that a treatment is in place as well as any appropriate interventions related to area(s) . A trained clinician in staging will assess the wounds and record dimensions to include length, width, and depth. The wound bed and the peri-wound will be assessed and described. Any odor or drainage will be described . Treatment of Pressure Injuries . whether identified on admission or readmission or after admission or readmission have the factors that influenced its development defined. This will allow appropriate interventions to be put into place to guard against further development of more areas or worsening of current area(s) 3.1-40(a)(2)

Based on interview and record review, the facility failed to ensure 3 of 3 residents reviewed for falls had a minimum of 72 hours post-fall assessments, including neurological (neuro) checks as appropriate. (Residents B, F and G) Findings include: 1. The clinical record of Resident B was reviewed on [DATE] at 2:56 p.m. His diagnoses included, but were not limited to, alcohol dependency with unspecified withdrawal, weakness, difficulty in walking and repeated falls. An admission note, dated [DATE] at 10:43 p.m., indicated he was weak and unsteady with his balance and gait. A fall risk assessment, dated [DATE], indicated he was at high risk for falls. His Admission Minimum Data Set (MDS) assessment, dated [DATE], indicated he was moderately cognitively impaired, and he had sustained falls in the one month and two to six month time periods prior to admission. Resident B's care plans addressed both cognitive impairments and being at risk for falls. A nursing progress note, dated [DATE] at 5:45 a.m., indicated Resident B sustained an unwitnessed fall and was found lying on the floor of his room, but was unable to identify what he was doing prior to the fall and appeared disoriented. It indicated he was alert to person only. A review of the fall investigation, dated [DATE], included a document entitled, Post Fall 72-hour Monitoring Report. It indicated, This assessment should be completed at the following intervals for follow up for all falls. A fall that is unwitnessed, or in which the head is struck, requires neurological checks. Any change in resident condition requires a phone call to the primary care physician. Initial assessment (B) [baseline]; followed by q15 min [every 15 minutes] x4 [for first hour post fall], q30 min x2 [for second hour post fall]; every hour x2 [for hours 3 and 4 post-fall]; [then] once per shift for 72 hours [post fall]. The document reflected Resident B's neuro checks were initiated at 5:45 a.m. and continued at 6:00 a.m., and lastly at 6:15 a.m., with no changes denoted in neurological status or vital signs. No additional entries were documented regarding Resident B's neurological status or vital signs after 6:15 a.m., on this document. No additional progress notes to reflect Resident B's general status following his earlier fall were located in the clinical record until [DATE] at 7:45 a.m. A nursing progress note, dated [DATE] at 7:45 a.m., indicated, This nurse was called to residents room at 7:15 Am by CNA who was delivering breakfast tray. Resident was found to be without a pulse and no respiration. CPR [cardiopulmonary resuscitation] was performed by staff till [sic] medics arrived on scene. It indicated Resident B was pronounced deceased at 7:36 a.m., by the emergency medical services team. A documented handwritten Timeline, dated [DATE], but unsigned by facility staff, indicated Resident B had been observed on [DATE] at 6:10 a.m., by Staff 4, sleeping/snoring, in his recliner and by Staff 5, on [DATE], at approximately 7:00 a.m., to speak with the staff member, while in his chair. In an interview on [DATE] at 10:56 a.m., with the Director of Nursing (DON), she indicated she was not present at the facility on [DATE]. I did not locate any neurochecks; the nurse [LPN 6] did not do any neurochecks. She said she was not aware to do this; our policy is to conduct neurochecks on any unwitnessed fall and she was inserviced on this. 2. The clinical record of Resident F was reviewed on [DATE] at 9:34 a.m. His diagnoses included, but were not limited to diabetes, a rare genetic autoimmune disorder, weakness, fatigue, unspecified dementia, difficulty in walking and a need for personal care assistance. His most recent Minimum Data Set (MDS) assessment, an annual assessment, dated [DATE], indicated he was severely cognitively impaired, was dependent on staff for toileting needs, required substantial assistance with bathing and hygiene, required moderate assistance for mobility, transfers and walking, and used a walker or wheelchair for mobility. It indicated he had two or more falls since his last MDS assessment. It indicated he was receiving physical therapy services from the facility. A review of falls for the time period of [DATE] through [DATE], indicated Resident F had multiple falls without injury during this time period with three of the falls having incomplete documentation of his 72 hour post fall status, as follows: - A nursing progress note, dated [DATE] at 6:53 p.m., indicated Resident F was heard calling out for help. When staff arrived to assist the resident, he was witnessed sliding out of his recliner. The resident was unable to explain what he was doing prior to his fall from his recliner. The note indicated he was assessed to have no injuries and had no change in his prior condition. An interdisciplinary note, dated [DATE], as a review of his fall, indicated the root cause of the fall was he slid out of his recliner. In an interview with the Director of Nursing (DON) on [DATE] at 1:10 p.m., she indicated she was unable to locate any documentation of monitoring conducted for 72 hours after this fall. - A fall investigation record, dated [DATE] at 5:12 a.m., indicated Resident F sustained an unwitnessed fall and was found lying on the floor in his room. It indicated Resident F was unable to explain what he was doing prior to being found on the floor. It indicated he did not sustain any injuries at that time. This document did not address his mental status, his mobility status, and identified predisposing physiological or situational factors only as, Other, with no further explanation. The accompanying, Post Fall 72-hour Monitoring Report, dated [DATE], indicated the fall occurred [DATE] at 4:30 a.m. This document indicated, This assessment should be completed at the following intervals for follow up for all falls. A fall that is unwitnessed, or in which the head is struck, requires neurological checks. Any change in resident condition requires a phone call to the primary care physician. Initial assessment (B) [baseline]; followed by q15 min [every 15 minutes] x4 [for first hour post fall], q30 min x2 [for second hour post fall]; every hour x2 [for hours 3 and 4 post-fall]; [then] once per shift for 72 hours [post fall]. The document reflected Resident F's neuro checks were initiated at 4:30 a.m. and continued through [DATE] at 8:30 a.m. This form failed to specify any assessments conducted in regards to Resident F's cognition or skin status. A progress note, dated [DATE] at 2:00 p.m., indicated neurological checks continued and were within normal range. However, it was noted Resident F had a hematoma to his forehead, an abrasion to the bridge of his nose, bruising to his left hand and a s/t [skin tear] to his L [left] arm, and abrasion to his L knee. A progress note, dated [DATE] at 2:05 p.m., indicated the physician was made aware of the changes to Resident F's status. In an interview with the DON on [DATE] at 1:10 p.m., she indicated the 72 hour post fall report was incomplete. -A nursing progress note, dated [DATE] at 1:40 p.m., indicated Resident F had a witnessed fall from his wheelchair with staff present at 11:00 a.m. It indicated he did not strike his head when he fell to the floor. A corresponding fall investigation, indicated Resident F had a witnessed fall on [DATE] at 11:00 a.m., while being pushed in his wheelchair by facility staff. It indicated the fall occurred when the resident put his feet down onto the floor, causing him to fall forward onto his knees. The resident was unable to offer any explanation of the event when requested to do so by staff. Resident F was assessed post fall and was identified with an abrasion to the left lower leg and swelling to the right lower leg. A corresponding Post Fall 72-hour Monitoring Report was not provided by the facility. 3. The clinical record of Resident G was reviewed on [DATE] at 11:30 a.m. Her diagnoses included, but were not limited to coronary artery disease, recent femoral artery graft with infection, arteriosclerotic heart disease, diabetes, peripheral vascular disease, anxiety and depression. Her Admission Minimum Data Set (MDS) assessment, dated [DATE], indicated she was cognitively intact, used a walker for mobility, required moderate assistance with bed mobility, transfers, walking, toileting, bathing and hygiene. It indicated she had no falls or fractures in the six months prior to her admission to the facility. In an interview with the Executive Director on [DATE] at 3:50 p.m., she provided a copy of a document which indicated Resident G had a fall on [DATE]. The Executive Director indicated the facility did send Resident G to the local emergency room and a chest x-ray indicated she did have a rib fracture, but its origin was of an indeterminate date. A review of the fall investigation indicated Resident G sustained an unwitnessed fall on [DATE] at 2:07 p.m. It indicated staff heard the resident yelling in her room and found her lying on the floor. Resident G indicated she was ambulating by using her IV pole to assist herself to the bathroom. It indicated the resident was determined to have no injuries at the time of the fall. It indicated when the physician was notified of the fall, on [DATE] at 2:16 p.m., he ordered for the resident to be sent to the local emergency room for further evaluation and treatment. The Post Fall 72-hour Monitoring Report, indicated Resident G refused the initial neurological assessment on [DATE] at 2:13 p.m. and was in the hospital for the time periods of [DATE] at 2:30 p.m., through [unknown time]. The Post Fall 72-hour Monitoring Report, instructions indicated, This assessment should be completed at the following intervals for follow up for all falls. A fall that is unwitnessed, or in which the head is struck, requires neurological checks. Any change in resident condition requires a phone call to the primary care physician. Initial assessment (B) [baseline]; followed by q15 min [every 15 minutes] x4 [for first hour post fall], q30 min x2 [for second hour post fall]; every hour x2 [for hours 3 and 4 post-fall]; [then] once per shift for 72 hours [post fall]. Upon Resident G's return to the facility on [DATE], the Post Fall 72-hour Monitoring Report, dated [DATE], indicated neurological checks began on [DATE] at 8:15 p.m. and was dated to reflect neurological checks, including vital signs, were to be conducted, as evidenced by handwritten dates and times of [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE], at 8:15 p.m., on these dates. The form was incomplete, with documentation of assessments for neurological check, but no assessments for skin assessment, for [DATE], [DATE] and [DATE] at 8:15 p.m. The document failed to reflect neurological assessments each shift from [DATE], beginning upon return from the hospital and continuing through [DATE] at/around 2:15 p.m. In an interview with the Director of Nursing on [DATE] at 1:10 p.m., she indicated the 72 hour post fall report was incomplete. On [DATE] at 3:37 p.m., the Corporate Nurse provided a copy of a policy entitled, Guidelines for Incidents/Accidents/Falls, and dated ,d+[DATE]. This policy indicated, It is the policy of the facility to ensure that any incidents/accident to include falls is reported immediately to the nurse or appropriate person designated to be in charge. After the resident has had immediate attention and their safety is established, a written report will be entered into Risk Management (usually Risk Management section of PCC [an electronic health records system]). The facility will ensure that incidents and accidents that occur involving residents are identified, reported, investigated and resolved. The facility will create a data base related to incidents/accidents as part of the QAPI [quality assurance and performance improvement] process to enable trending and tracking. This information will be used to implement corrective actions to include any needed training to prevent reoccurrences when possible .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 the ROM [range of motion/movement] ability/function. Further, residents who have an unwitnessed fall much have neuro checks started and continued per policy. Neuro checks will be initiated even if the resident states they did not hit their head in an unwitnessed (by staff), fall .The occurrence will be documented (usually in the Risk Management section of PCC). The progress note within the resident's medical record is to be included. Documentation in the Medical Record should include the following: Description of the occurrence- to include time and place; Physical and mental status of the resident .Documentation of the physical and mental status of the resident(s) involved will be completed each shift (every 8 hours minimally) over at least the next 72 hours or until the resident(s)'s condition improves. Neuro checks will be completed after any head trauma as well as any unwitnessed fall (even if the resident states they did not hit their head) as per policy. The occurrence is to be communicated shift to shift as part of the report until the resident is stabilized and at least 72 hours post fall . On [DATE] at 4:05 p.m., the Executive Director provided a copy of an undated procedure entitled, Accident and Incident: Neurological Checks Guidelines. This procedure indicated, If a resident is involved in an incident/accident an immediate assessment of the resident is completed by the nurse .If a resident has an unwitnessed fall and is unable to express that their head was not impacted during the fall or the fall was witnessed and it can be verified that the resident did hit their head, neurological checks will be completed at intervals to ensure that a head injury has not occurred. Neurological checks consist of the obtain [sic] of vital signs, pupillary [eye] responses, orientation status, skin check, and range of motion ability. The intervals after a suspected head injury from a fall to complete neurological checks are as follows: Every 15 minutes x4 to equal 1 hour; Every 30 minutes x2 to equal 1 hour; Every 1-hour x2 to equal 2 hours; Once per shift x 72 hours. At any point during the neurological assessment time frame, if the resident presents with cognitive or neurological changes, appropriate individuals should be notified. 3XXX,d+[DATE](a)(1) 3XXX,d+[DATE](a)(2)

Based on interview and record review, the facility failed to ensure residents who admitted to the facility had their orders transcribed correctly into the electronic health record (EHR) that resulted in medication errors for 1 of 3 residents reviewed for medication administration. (Resident D) This deficient practice was corrected on 2/12/25, prior to the start of the survey, and was therefore past noncompliance. The facility implemented a systemic plan that included the following actions: in-service education to nursing staff related to the policy and procedure regarding transcribing physician orders and the admission process, reviewed all newly admitted residents to identity potential residents, and ongoing review of newly admitted residents during the morning clinical meetings have been completed and documented with ongoing review presented to the Quality Assessment and Assurance (QAA) Committee for review. Findings include: The clinical record for Resident D was reviewed on 2/20/25 at 2:10 p.m. The diagnoses included, but were not limited to, weakness, cognitive communication deficit, and Parkinson's disease. Resident D was admitted to the facility on [DATE]. The hospital discharge instructions, dated 2/3/25, indication the instructions to take Sinemet (carbidopa-levodopa) (medication used to treat Parkinson's disease) 25 mg - 100 mg (milligrams); two tablets four times a day. A physician order, dated 2/3/25, indicated the use of Sinemet 25-100 milligrams (mg), one tablet, four times a day for Parkinson's disease. The order did not match the discharge order from the hospital. The medication administration record (MAR), dated February 2025, indicated Sinemet 25-100 mg, one tablet, was administered on 2/4/25 for three administrations and 2/5/25 for two administrations. An interview conducted with the Director of Nursing (DON), on 2/20/25 at 3:45 p.m., indicated the following day, after a new admission arrived at the facility, she reviews the discharge orders and double checks them compared to what was entered into the electronic health record (EHR) for accuracy. There should be two nurses to double check and sign off on the review of the physician orders for newly admitted residents. An interview conducted with the Nurse Practitioner (NP), on 2/20/25 at 4:18 p.m., indicated there had been a concern regarding errors with transcribing orders from the hospital discharge instructions into the EHR. The NP reviews newly admitted residents and reviews their discharge orders from the hospital and compares such to the EHR. Resident D was a concern she noticed when the order for Sinemet was initially inputted for one tablet four times a day instead of two tablets four times a day as noted on the hospital discharge instructions. This citation is related to Complaint IN00453443. 3.1-48(c)(2)

Based on interview and record review, the facility failed to ensure eight hours of consecutive RN coverage for 9 of 91 days reviewed. This deficient practice had the potential to affect 34 residents. Findings include: The PBJ (Payroll Based Journal) Staffing Data Report CASPER Report 1705D FY (Fiscal Year) Quarter 1 2024 (October 1 - December 31) reviewed on 3/25/2024 at 1:45 p.m. indicated that nine days were noted without eight hours of consecutive RN coverage. An interview on 3/26/24 at 1:34 p.m. with Corporate Payroll indicated that he did not report any RN coverage for those aforementioned nine days due to no RN being on the skilled nursing facility. An interview with Regional Nurse Consultant on 3/27/2024 at 1:20 p.m. indicated that the facility was unable to find RN coverage for that time. During that time, they were utilizing their own staff and agency, but could not fill RN coverage consistently. An interview with Regional Nurse Consultant on 3/27/2024 at 2:20 p.m. indicated they did not have a specific policy for RN coverage, but the facility would follow the Center for Medicare and Medicaid regulation.

Based on interview and record review, the facility failed to accurately code Section J regarding falls for 2 of 17 residents reviewed for Minimum Data Set accuracy. (Resident 14 and Resident 16) Findings include: 1. The clinical record for Resident 14 was reviewed on 3/25/2024 at 2:45 p.m. The medical diagnosis included dementia. An Annual Minimum Data Set (MDS) Assessment, dated 1/27/2024, indicated Resident 14 had one fall without injury during that review period. A nursing progress note, dated 1/13/2024, indicated that Resident 14 was found lying on her right side on her floor mat with a bruise to the right elbow. 2. The clinical record for Resident 16 was reviewed on 3/25/2024 at 2:10 p.m. The medical diagnosis included dementia. An Annual MDS Assessment, dated 9/26/2023, indicated that Resident 16 had one fall without injury during that review period. An intradisciplinary note for Resident 14, dated 8/23/2023, indicated she had a fall that resulted in head laceration requiring staples for closure. An intradisciplinary note for Resident 14, dated 9/13/2023, indicated she had slid off the bed without injury. An interview with the MDS Nurse on 03/27/24 at11:38 a.m. indicated that the facility codes MDS assessments to the Resident Assessment Instrument. After reviewing the two aforementioned assessments, she will be entering modifications of records to accurately reflect the falls.

Based on observation, interview, and record review, the facility failed to provide supervision for a resident who was dependent on staff for toileting needs that resulted in a fall with a right [MEDICAL CONDITION] for 1 of 3 residents reviewed for accidents. (Resident 61) Findings include: During an interview and observation with Resident 61's family, on 9/18/19 at 2:31 p.m., the resident told his family member his right leg was painful. The resident was observed rubbing his right leg while talking to his family member. Review of the clinical record for Resident 61, on 9/20/19 at 12:55 p.m., indicated the resident's [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) assessment, dated 5/8/19, indicated the resident's cognitive status was undetermined. The resident required extensive assistance of two people for transfers and toileting needs and did not ambulate. The resident was not steady to move on and off the toilet and was only able to stabilize with staff assistance. The resident had impairment on one side of his upper and lower extremities. The fall risk assessment, dated 6/11/19 at 6:30 a.m., indicated the resident was confused and had forgetfulness. The resident had [MEDICAL CONDITION], incontinence, and pain. He used a wheelchair as an assistive device, required staff physical support to transfer, had difficulty rising from a chair, and had difficulty getting on or off a toilet. The initial nursing occurrence assessment, dated 8/3/19 at 9:00 a.m., indicated the resident had a fall with injury. The resident was found in the restroom laying on the right side with his wheelchair on top of him. The resident had a small laceration to the left ring finger. The resident was unable to verbalize pain and was rubbing his right knee and lower leg with facial grimacing. The hospital discharge summary, dated 8/12/19, indicated the resident had a femoral neck fracture that occurred, on 8/3/19, from a fall off the commode at the Extended Care Facility (ECF). The nursing assessment, dated 8/16/19 at 7:30 p.m., indicated the resident had returned from the hospital. The resident had a right hip surgical incision 15 centimeters long with sutures. During an interview with Certified Nurse Aide (CNA) 4, on 9/24/19 at 1:34 p.m., she indicated she was taking care of the resident, on 8/3/19, when he fell off the toilet. She and another CNA assisted him to the toilet that day with a gait belt. The resident liked his privacy, so they left the resident alone in the restroom. The other CNA had checked on him and he was fine at that time. Then the resident was found on the floor and had to be sent to the hospital. During an interview with the Director of Nursing (DON) on 9/25/19 at 10:30 a.m., she indicated the resident had bowel movement problems and wanted to sit on the toilet for long periods of time. The facility did not have a care plan or any documentation of the resident wanting privacy while toileting. The fall policy was provided by the DON on 9/24/19 at 1:10 p.m. The policy indicated the purpose was to assess all residents for risk factors that may contribute to falling and to provide planned interventions for the resident to use in maintaining or returning to the highest level of physical, social, and psychological functioning as possible. 3.1-45(a)(2)

Based on interview and record review, the facility failed to ensure the use of a gait belt while assisting a resident with ambulation, which resulted in a fall when the resident lost his balance and the resident sustained [REDACTED]. Findings include: The clinical record of Resident C was reviewed on 9-15-17 at 2:18 p.m. His [DIAGNOSES REDACTED]. His most recent Minimum Data Set (MDS) assessment, dated 8-9-17, indicated he was moderately cognitively impaired, required extensive assistance of two or more persons with transfers from bed to chair or to a standing position, required limited assistance of one person with ambulation in his room or the hall, but required extensive assistance of one person with locomotion on and off the unit, required the use of a walker or wheelchair for mobility. The MDS assessment indicated he received restorative nursing assistance with walking five times weekly. A Nursing Occurrence Initial Assessment, dated 8-22-17 at 7:15 a.m., specified Resident C was being ambulated by a nursing assistant down hallway when the resident lost his balance and fell on to his left side. The initial assessment revealed no apparent injuries, however, resident c/o (complained of) left shoulder pain and noted with limited ROM (range of motion). It stated the resident reported he struck his head on the floor with the fall and neurological assessment at the time was within normal range with no redness or swelling denoted. The resident's attending physician and family were notified promptly. The attending physician ordered an xray of the left shoulder which revealed a non-displaced fracture of the left clavicle and additional orders were received for a left arm sling, ice to the affected area and the following day, as needed pain medication was received. In review of the Facility Post Occurrence IDT (Interdisciplinary Team) and Fall Risk Assessment, dated 8-23-17, cited the root cause of the fall was related to the resident losing his balance while ambulating. It cited fall risk factors of confusion/forgetfulness, use of an assistive device for mobility, requiring the physical assistance of staff with transfers, and use of medications which included, narcotics or psychoactive medications and diuretics. This form did not specify which, or if any, devices were in use at the time of the fall, such as a walker, a wheelchair or gait belt. In an interview with the Director of Nursing (DON) on 9-18-17 at 3:52 p.m., she clarified, after talking with the nursing assistant involved with the fall, BNA 2, a gait belt was not used for Resident C at the time of the fall on 8-22-17. In an interview with the DON on 9-18-17 at 2:30 p.m., she reported, Our policy on gait belts is essentially that we are to use them on pretty much anyone with transfers or with walking them, unless they are steady on their feet. So, I would have expected that he would have had a gait belt in use with getting him up and walking him. A care plan, initiated on 3-30-15, demonstrated he was at risk for falls, related to risk factors of weakness, intermittent confusion, unsteady gait and use of an unspecified assistive device. A new intervention was added on 8-22-17, for staff to use a gait belt for all transfers and ambulation. On 9-18-17 at 3:35 p.m., the DON provided a copy of a policy entitled, Gait Belt Use Procedure. This policy was dated 7-27-12. It stated, Purpose: To ensure safety in transfer and ambulation. To provide a point of contact and increased support from the staff and prevent injuries to staff and residents who are unable to transfer or ambulate independently. Gait belts will be used as indicated on the individual's plan of care . This Federal tag relates to Complaint IN 225. 3.1-45(a)(2)

Based on observation, interview and record review, the facility failed to determine an appropriate root cause analysis, implement appropriate interventions, and ensure restorative rehabilitation services for ambulation and toileting and close supervision were provided for a resident who was a candidate for restorative programs and required close supervision when she continued to fall, resulting in sutures, skin tears, and bruising for 1 of 3 residents reviewed for accidents of 3 who met the criteria for accidents. (Resident #A) Findings include: Resident #A's record was reviewed on 6/3/16 at 10:37 a.m. Her [DIAGNOSES REDACTED]. A Nursing-Occurrence Initial Assessment' for Resident #A indicated on 3/31/16 at 1:30 a.m., she had stood up from a recliner in the resident's lounge and had fell on her right side. She had complained of right leg pain with movement and had been transferred to a hospital for evaluation and treatment. A Nursing-Acute-Return from short there stay for Resident #A indicated she had returned to the facility on [DATE] at 6:15 p.m., by ambulance from a hospital where she had a broken hip surgically repaired. A plan of care for Resident #A initiated 3/29/16, indicated she was a fall risk characterized by risk factors that included weakness, lack of safety awareness, medications, and a recent fall that resulted in a hip fracture. Her goal indicated her risk factors would be reduced in an attempt to avoid significant injury related to her falls. Resident #A's admission Minimum Data Set (MDS) assessment dated [DATE], indicated she was understood and had the ability to understand others. She was severely impaired for cognitive daily decision making skills. She required extensive assistance of 2 persons for transfers and toileting. She had not walked and utilized a wheelchair for mobility. She had impairment on 1 side of her lower body. She had occasional pain of 3 on a pain scale of 0 to 10. She had a fall with injury within 6 months of her admission. She had 1 fall since admission with no injury. A Bladder Continence and Toileting Ability Assessment documented on Resident #A's Nursing-Supplemental Combo 3.0-for annual and sig (significant change assessment dated [DATE] at 9:54 a.m., indicated she was occasionally incontinent. She had a voiding pattern completed on 4/12/16, and a pattern was detected. She was mentally and physically aware of the need to void and able to use the toilet. She was mentally and physically able to resist voiding for attempting a bladder retraining program. A toileting program was not being used to manage her urinary incontinence. A Nursing-Occurrence Initial Assessment for Resident #A indicated on 4/14/16 at 9:30 p.m., she had got out of her recliner in her bedroom while it was reclined and landed on her buttock. Her alarm had been in place and working. No injury resulted from the fall. A Post Occurrence IDT & Fall Risk Assessment for Resident #A dated 4/15/16 at 9:30 a.m. indicated the root cause of the fall on 4/14/16 at 9:30 p.m., was she had wanted to go to bed. The Interdisciplinary Team (IDT) recommendation was she would offered to go to bed around 9:00 p.m. A Nursing-Occurrence Initial Assessment for Resident #A indicated on 4/24/16 at 8:30 p.m., she had attempted to transfer herself from her wheelchair to her bed and slid to the floor. She had been assisted to bed by staff. No injury resulted from the fall. A Post Occurrence IDT & Fall Risk Assessment for Resident #A dated 4/25/16 at 9:48 a.m., indicated the root cause of the fall on 4/24/16 at 8:30 p.m., was she had attempted to transfer herself to bed. The IDT recommendation was she would be assisted to bed after supper. A Nursing-Occurrence Initial Assessment for Resident #A indicated on 4/28/16 at 8:00 p.m., she had attempted to transfer herself from her wheelchair to her bed and had fallen to the floor bumping her right foot. She had complained of lower back discomfort. She had a skin tear that measured 1.0 centimeter (cm) by 2 cm on her right anterior foot with a small amount of bleeding. The area had been cleansed and op-site had been applied. A Post Occurrence IDT & Fall Risk Assessment for Resident #A dated 4/29/16 at 8:52 a.m., indicated the root cause of the fall on 4/28/16 at 8:00 p.m., was she had attempted to transfer herself to bed. She had been offered to go to bed after supper but had declined at that time. The IDT recommendation was she would be offered to get in her recliner or to go to bed after supper. A Nursing-Occurrence Initial Assessment for Resident #A indicated on 4/29/16 at 1:30 p.m., she had attempted to transfer herself from her wheelchair to a lounge chair in the west wing lounge and fell . She had been assisted back to her wheelchair by staff. Neurological checks were initiated per facility protocol. No injury resulted from the fall. A Post Occurrence IDT & Fall Risk Assessment for Resident #A dated 5/2/16 at 9:53 a.m., indicated the root cause of the fall on 4/29/16 at 1:30 p.m., was she had no safety awareness. The IDT recommendation was staff would check on her every 30 minutes. A PT-Therapist Progress & Discharge Summary for Resident # A dated 5/2/16, indicated she had received physical therapy for a [DIAGNOSES REDACTED]. She had shown partial gains in her functional activity which required minimal assistance of 2 persons. She was discharged with a recommendation for the facility to continue providing functional assist of 2 persons. An OT-Therapist Progress & Discharge Summary for Resident #A dated 5/2/16, indicated she had received occupational therapy for a [DIAGNOSES REDACTED]. She had shown gains in strength, standing balance and tolerance which allowed for improvement with her self care and mobility skills. A Nursing-Occurrence Initial Assessment for Resident #A indicated on 5/4/16 at 2:50 a.m., she was in her bedroom and had attempted to take herself to the bathroom and fell on her buttock, resulting in a skin tear to her left elbow that measured 5 cm. The area had been cleansed and 3 steri-strips had been applied and then covered with a dressing. Staff had not heard her alarm sound and had heard her yelling for help. Neurological checks had been initiated. A Post Occurrence IDT & Fall Risk Assessment for Resident #A dated 5/5/16 at 9:34 a.m., indicated the root cause of the fall on 5/4/16 at 2:50 a.m., was she had to go to the bathroom in the middle of the night. She had been assisted to the bathroom an hour and half earlier. The IDT recommendation was the facility would do a urine dip. A Nursing-Occurrence Initial Assessment for Resident #A indicated on 5/6/16 at 6:00 a.m., she had got out of bed on the opposite side of bed from her floor alarm. She had not had a bed alarm on her bed at that time. No injury resulted from the fall. A Post Occurrence IDT & Fall Risk Assessment for Resident #A dated 5/9/16 at 9:40 a.m., indicated the root cause of the fall on 5/6/16 at 6:00 a.m., was she got up unassisted. The IDT recommendation was she would have a floor alarm on the side of her bed and a pad alarm under her in bed. Staff would continue to check on her every 30 minutes. A Nursing-Occurrence Initial Assessment for Resident #A indicated on 5/9/16 at 10:00 a.m., she had been sitting in her wheelchair in the east wing nurses station attempting to get out of her chair to look for her daughter. She had calmed down. After a few minutes she had attempted to get up and walk and fell . She had been trying to find her daughter. No injury resulted from the fall. A Post Occurrence IDT & Fall Risk Assessment for Resident #A dated 5/10/16 at 9:21 a.m., indicated the root cause of the fall on 5/9/16 at 10:00 a.m., was she was looking for her daughter and stood up unassisted. She had called out for her daughter multiple times through out the day to all the people walking in the hallway. The IDT recommendation was the facility would do a urine dip to rule out a urinary tract infection. A Consult Urine Dipstick Test Result for Resident #A dated 5/10/16, indicated the test was negative. A Nursing-Occurrence Initial Assessment for Resident #A indicated on 5/17/16 at 3:00 a.m., she was in her bedroom and tried to get up and go to the bathroom and fell on her bottom. No injury resulted from the fall. A Nursing-Occurrence Initial Assessment for Resident #A indicated on 5/17/16 at 12:00 p.m., she was in the dining room and had attempted to maneuver around her own wheelchair while attempting to ambulate and fell over her wheelchair. No injury resulted from the fall. A Progress Note for Resident #A dated 5/17/16 at 5:43 p.m., indicated a new order was received for a self release alarming seat belt in place when she was seated in her wheelchair. She would be checked every hour and released every 2 hours. A Post Occurrence IDT & Fall Risk Assessment for Resident #A dated 5/18/16 at 9:45 a.m., indicated the root cause of the fall on 5/17/16 at 3:00 a.m., and 5/17/16 at 12:00 p.m., was she didn't have any safety awareness and would not ask for assistance when transferring and ambulating. The IDT recommendation was she would have a self release alarming seat belt to alert staff of unassisted transfers. She was able to release the seat belt. A Nursing-Occurrence Initial Assessment for Resident #A indicated on 5/24/16 at 3:30 a.m., she was in her bedroom and tried to get up and go to the bathroom unassisted and tripped over her oxygen cord and fell . She had hit her forehead, resulting in a cut to her forehead and a scrape to the top of her nose. Both alarms had been sounding at the same time. A nurse and a CNA had been in the residents room next door. The CNA went to Resident #A's room and was unable to stop Resident #A from falling and observed her hit her head on the floor. Resident #A was sent to a hospital for evaluation and treatment. A Post Occurrence IDT & Fall Risk Assessment for Resident #A dated 5/25/16 at 9:57 a.m., indicated the root cause of the fall on 5/24/16 at 3:30 a.m., was she had been attempting to go to the restroom. The IDT recommendation was she was sent to the emergency room for evaluation, and the MD would be notified of her frequency in urine. A Progress Note for Resident #A dated 5/27/16 at 4:00 p.m., indicated a new order was received to discontinue her self release alarming seat belt and she would have a break away lap buddy while she was seated in her wheelchair. She would be checked every hour and released every 2 hours. A Nursing-Occurrence Initial Assessment for Resident #A indicated on 6/1/16 at 3:15 a.m., she apparently turned off her seat alarm and no one had heard her get up in the east wing lobby. She had fell on her buttock and sustained a skin tear to the top of her right hand measuring 1.2 cm in length. Staff had tried to explain to Resident #A about asking for help to get up and she had said what happens, happens. The area on top of her right hand had been cleansed and a dressing had been applied. A Post Occurrence IDT & Fall Risk Assessment for Resident #A dated 6/1/16 at 12:03 p.m., indicated the root cause of the fall on 6/1/16 at 3:15 a.m., was she frequently became active around 3:00 a.m. and had no sense of safety awareness. She would attempt to walk without assistance. The IDT recommendation was staff would offer her to get ready for the day at 3:00 a.m., if she was awake, because she was frequently restless at that time. The facility had not initiated close supervision for Resident #A or placed her on a walking or toileting restorative program after she had suffered 11 falls since her re-admission to the facility on [DATE], from a hospital where she had a surgical hip repair. The facility initiated a restorative grooming, walking, and toileting program following an interview with the MDS Coordinator on 6/2/16 at 10:50 a.m. A Nursing-Occurrence Initial Assessment for Resident #A indicated on 6/6/16 at 12:30 a.m., a CNA heard Resident #A's alarm sounding and rushed into her bedroom. When the CNA had turned on Resident #A's light she had seen Resident #A fall over her oxygen tank hitting her head on her bedside table. When a nurse had entered Resident #A's bedroom she had observed Resident #A sitting on the floor beside her bedside table, attempting to get up. Resident #A had been able to move all extremities and had no complaint of pain or no sign of injury. Neurological checks were initiated and were within normal limits. Resident #A had become frustrated with staff and stated just get me up I've got to go pee. Resident #A had been assisted to the bathroom and back to bed. A Post Occurrence IDT & Fall Risk Assessment for Resident #A dated 6/7/16 at 7:40 a.m., indicated the root cause of the fall on 6/6/16 at 12:30 a.m., was she had needed to go to the bathroom and had not asked for assistance. The IDT recommendation was she got up in the middle of the night to go to the bathroom. She had been offered to go to the bathroom at 3:30 a.m., nightly. She had continued to be checked every 2 hours. The facility would increase staff during the night hours to provide 1:1, to supervise her more closely. On 5/31/16 at 12:26 p.m., Resident #A was observed seated upright in her wheelchair in the dining room with a break away alarming lap buddy connected to the arms of her wheelchair. She had a dark scab on her forehead, and purplish discoloration around her left eye and forehead. Her lap buddy was removed by staff and she was positioned up close to the dining table. The lap buddy alarmed when it was removed from her wheelchair. On 6/2/16 at 10:45 a.m., LPN #4 indicated Resident #A was no longer in therapy. She was occasionally incontinent. She was not on a toileting program. An interview with the MDS Coordinator on 6/2/16 at 10:50 a.m., indicated he had spoke with a therapy staff approximately 2 weeks prior and discussed what residents may benefit from a restorative program. He indicated Resident #A was not on any restorative programs but he planned to put her on a restorative toileting, walking, and grooming program. On 6/2/16 at 12:30 p.m., Resident #A was observed seated upright in her wheelchair in the dining room at a dining table with a pad alarm on her wheelchair seat and a break away alarming lab buddy connected to the arms of her wheelchair. She had a skin tear on the top of her right hand covered with a clear film dressing. She continued to have a dark scab on her forehead and purplish discoloration around her left eye and forehead. She has a scratch across the bridge of her nose. An interview with Resident #A's daughter on 6/2/16 at 2:32 p.m., indicated her mother had fell and blackened her eye last week and had to have stitches in her head. The facility had informed her that her mother had tripped over her oxygen tubing and fell . She indicated the facility had called her once or twice a week and informed her that her mother had fell . She indicated her mother had fallen in the facility in February 2016 and had broken her hip. On 6/3/16 at 12:14 p.m., Resident #A stood up independently from a dining chair in the dining room and began to ambulate. The Assistant Director of Nursing (ADON) joined Resident #A and assisted her to ambulate outside the facility's front doors with the use of a gait belt. Once outside, Resident #A sat down on a bench. On 6/6/16 at 9:42 a.m., Resident #A was observed seated in a soft recliner in the TV room across from the nurses station. She asked do you know where the restroom is? RN #2 and RN #3 assisted Resident #A to the bathroom with the use of a gait belt. Resident #A ambulated to the bathroom adjoined to her bedroom and lowered her slacks and brief as she sat down on the toilet. Resident #A urinated in the toilet and cleaned herself with toilet paper before getting up. Resident #A had been pleasantly confused and had not recognized her own bedroom when she had exited the bathroom, and stated I have a bedspread just like that. When Resident #A was finished in the bathroom she ambulated through her bedroom and back to the TV room assisted by RN #2 and RN #3 with the use of a gait belt and sat back down in the soft recliner. On 6/6/16 at 10:09 a.m., Resident #A was observed ambulating outside the facility's front doors with assistance from the ADON and LPN #5 and use of a gait belt. Once outside, Resident #A sat down on a bench. On 6/6/16 at 10:47 a.m., Resident #A was observed still seated outside on a bench with peers and staff. She was seated upright and had her legs crossed. An interview with Physical Therapist Assistant #1 on 6/6/16 at 10:56 a.m., indicated Resident #A had been discharged from all therapies and staff should be asking her to walk daily. She indicated she felt Resident #A was a candidate for a walking restorative program. She was not sure if it was a program that could be followed through by Resident #A on a daily basis. When Resident #A was in therapy there were days she wouldn't walk because she didn't feel like it and then other days she would. Therapy staff tried to catch Resident #A when she was getting up on her own and trying to walk. The MDS Coordinator and herself had discussed a walking program to meals for Resident #A and they had just decided staff would ask Resident #A to walk and give her the option. They had never set up a walking restorative program. An interview with the Director of Nursing (DON) on 6/6/16 at 12:41 p.m., indicated Resident #A's 30 minute checks had been discontinued when she received an order for [REDACTED].#A currently used a break away lap buddy and staff checked her every hour and released the lap buddy every 2 hours. Resident #A was actually checked more often because she was busy and tried to get up. The staff were seeing a trend in Resident #A falling at night. When staff were doing bed checks at night it took 2 staff so there was not much supervision at night. She indicated the facility was adding a staff member so staff could monitor Resident #A while the other 2 staff did bed checks. Resident #A seemed to get up around 3:00 a.m., so she was having staff offer to toilet her and get her up if she wanted. Resident #A had fell in her room that morning at 12:30 a.m. The staff were doing neurological checks because they had not seen her fall. Resident #A had said she was going to the bathroom. Resident #A typically told staff when she needed to go to the restroom. Resident #A was on a toileting program for every 2 to 3 hours through the night, upon rising, before and after meals, and at bedtime. The facility had done a post void residual for Resident #A times 3 to see if she had urinary retention, but were not seeing a problem. The facility had also done a urine dip that was negative. Resident #A was most often continent of her bowel and bladder and it seemed like that was what Resident #A was always trying to do when she got up and that was why she was on a toileting restorative program. She had spoke with the MDS Coordinator and he informed her he was developing Resident #A a walking and grooming restorative program. She was unsure why Resident #A wasn't on any restorative programs prior. On 6/7/16 at 11:25 a.m., Resident #A was observed seated upright in her wheelchair in the TV room across from the nurses station. She had a break away alarming lap buddy attached to the arms of her wheelchair. She continued to have a dark scabbed area on her forehead, faded purplish discoloration around her left eye and forehead, and a skin tear on top of her right had covered with a clear dressing. She pulled on her lab buddy and it hadn't broke away or alarmed. On 6/7/16 at 11:38 a.m., Activity Staff #1 checked Resident #A's lap buddy and the alarm sounded. She propelled Resident #A to the dining room in her wheelchair. The Restorative Nursing Program Procedures provided by the Administrator on 6/8/16 at 11:00 a.m., indicated the following: A. Purpose: 1. To provide services which promote the highest level of functioning in activities of daily living. 2. Restorative nursing services include: a. Passive and active range of motion exercises. b. Assistance and instruction in activities in daily living. c. Maintenance programs after formal therapy programs. d. Use of self help devices. e. Ambulation programs for gait training and transfers. f. Bowel and bladder training and/or incontinence management This federal tag relates to Complaint IN 001. 3.1-45(a)(2)

BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE CONTINUITY OF CARE AND TIMELY ASSESSMENTS AND treatment for [REDACTED].#B). FINDING INCLUDE: REVIEW OF THE RECORD OF RESIDENT # B ON 11-29-10 AT 10:40 A.M. INDICATED THE RESIDENT'S [DIAGNOSES REDACTED]. THE MINIMUM DATA SET (MDS) ASSESSMENT FOR RESIDENT #B DATED 6-3-10 INDICATED THE FOLLOWING: COGNITIVE SKILLS FOR DAILY LIVING- MODERATELY IMPAIRED, MAKING SELF UNDERSTOOD- USUALLY UNDERSTOOD, ABILITY TO UNDERSTAND OTHERS- UNDERSTANDS, BED MOBILITY- EXTENSIVE ASSISTANCE OF TWO PEOPLE, TRANSFER- EXTENSIVE ASSISTANCE OF TWO PEOPLE, WALK IN ROOM- EXTENSIVE ASSISTANCE OF TWO PEOPLE, TOILET USE- EXTENSIVE ASSISTANCE OF TWO PEOPLE, BLADDER CONTINENCE- OCCASIONALLY INCONTINENT AND TIME AWAKE- MORNING, AFTERNOON AND EVENING. THE PROGRESS NOTES FOR RESIDENT #B DATED 8-14-10 AT 6:30 P.M. INDICATED THE RESIDENT'S APPETITE AND FLUID INTAKE WERE POOR. THE RESIDENT WAS SLEEPING A LOT AND THE RESIDENT COMPLAINED ABOUT BEING TIRED. THE RESIDENT WAS INCONTINENT OF DARK YELLOW URINE WITH STRONG FOUL ODOR. THE RESIDENT COMPLAINED OF ABDOMINAL AND BLADDER PAIN WITH PALPATION. THE RESIDENT'S VITAL SIGNS WERE BLOOD PRESSURE- 124/70, PULSE- 87, RESPIRATIONS- 20 AND TEMPERATURE 98.3 ORALLY. THE PHYSICIAN AND FAMILY WERE NOTIFIED. THE PHYSICIAN TELEPHONE ORDER FOR RESIDENT #B DATED 8-14-10 AT 7:00 P.M. INDICATED THE RESIDENT WAS ORDERED TO HAVE A IN AND OUT CATHETER TO OBTAIN AN URINALYSIS AND CULTURE AND SENSITIVITY. THE RESIDENT WAS TO START [MEDICATION NAME] DS (ANTIBIOTIC USED FOR URINARY TRACT INFECTION) TWO TIMES A DAY FOR 10 DAYS. THE NURSING INFECTION ASSESSMENT FOR RESIDENT #B DATED 8-14-10 AT 9:35 P.M. INDICATED THE RESIDENT HAD MEDIUM YELLOW URINE WITH FOUL ODOR. A SMALL AMOUNT OF CLEAR THICK DRAINAGE WAS NOTED. THE RESIDENT COMPLAINED OF ABDOMINAL, BLADDER PAIN AND LOWER BACK PAIN. THE NEW MEDICATION OR CHANGED MEDICATION FOLLOW UP FOR RESIDENT #B DATED 8-15-10 AT 10:58 P.M. INDICATED THE RESIDENT COMPLAINED OF SLIGHT ABDOMINAL, BLADDER TENDERNESS WITH PALPATION AND LOWER BACK TENDERNESS. THE NURSING INFECTION ASSESSMENT FOR RESIDENT #B DATED 8-16-10 AT 2:16 P.M. INDICATED THE RESIDENT HAD MEDIUM YELLOW URINE WITH A FOUL ODOR. THE RESIDENT HAD AN INCREASE IN LETHARGY. THE PROGRESS NOTE FOR RESIDENT #B DATED 8-16-10 AT 3:26 P.M. INDICATED BOTH OF THE RESIDENT'S LOWER LEGS WERE STARTING TO SWELL AND HAD DEVELOPED DIABETIC BLISTERS ON BOTH HEELS. THE RESIDENT WAS NOT EATING WELL AND WAS MORE SLEEPY. THE PHYSICIAN WAS NOTIFIED. THE NOTE WAS ELECTRONICALLY SIGNED BY THE UNIT MANAGER. THE NEW OR CHANGED MEDICATION FOLLOW UP FOR RESIDENT #B DATED 8-16-10 AT 11:44 P.M. INDICATED THE RESIDENT COMPLAINED OF SLIGHT TENDERNESS OF THE ABDOMEN AND BLADDER WITH PALPATION. THE RESIDENT'S URINE WAS DARK YELLOW WITH A FOUL ODOR. THE RESIDENT COMPLAINED OF LOWER BACK, ABDOMEN AND BLADDER TENDERNESS. THE DOCUMENT WAS ELECTRONICALLY SIGNED BY LPN #1. THE PROGRESS NOTE FOR RESIDENT #B DATED 8-16-10 AT 11:53 P.M. INDICATED THE RESIDENT VOMITED 300 MILLILITERS OF UNDIGESTED FOOD AND FLUID AT 6:00 P.M. THE RESIDENT'S OXYGEN SATURATION LEVEL WAS 74 % AT 6:45 P.M. AND OXYGEN WAS PLACED ON THE RESIDENT VIA NASAL CANNULA AT 2 LITERS. THE RESIDENT'S OXYGEN SATURATION LEVEL AT 7:30 P.M. WAS 90 % ON 2 LITERS OF OXYGEN. THE RESIDENT'S VITAL SIGNS WERE BLOOD PRESSURE- 111/53, PULSE- 86, RESPIRATIONS- 20 AND TEMPERATURE WAS 97.9. THE DOCUMENT WAS ELECTRONICALLY SIGNED BY LPN #1. THE PROGRESS NOTE FOR RESIDENT #B DATED 8-17-10 AT 7:35 A.M. INDICATED THE NURSE ENTERED THE RESIDENT'S ROOM A FEW MINUTES BEFORE 2:30 A.M. ON 8-17-10 TO ASSESS THE RESIDENT. THE RESIDENT DID NOT SPEAK AND WAS MAKING SOFT NOISES. THE RESIDENT HAD A TEMPERATURE OF 100.3 AND PULSE OF 39. THE NURSE WENT TO GET TYLENOL AND WHEN SHE CAME BACK TO THE RESIDENT'S ROOM, THE RESIDENT'S RESPIRATIONS WERE 6. THE RESIDENT PASSED AWAY AT 2:30 A.M. THE DOCUMENTATION WAS ELECTRONICALLY SIGNED BY LPN #2. THERE WAS NO DOCUMENTATION OF AN ASSESSMENT OF THE RESIDENT FOR SEVEN HOURS, BETWEEN 8-16-10 AT 7:30 P.M. AND 8-17-10 AT 2:30 P.M. THE URINALYSIS REPORT FOR RESIDENT #B DATED 8-14-10 INDICATED THE RESIDENT HAD TOO NUMEROUS TO COUNT (TNTC) WHITE BLOOD CELLS (AN INDICATION OF INFECTION). THE URINARY CULTURE AND SENSITIVITY FOR RESIDENT #B DATED 8-14-10 INDICATED THERE WAS GREATER THAN 100,000 OF ESCHERICHIA COLI (E COLI) (A BACTERIA NOT NORMALLY FOUND IN URINE) WAS DETECTED. THE FOOD AND FLUID INTAKE FOR RESIDENT #B INDICATED THE FOLLOWING: ON 8-14-10 THE RESIDENT ATE LESS THAN 25 % OF BREAKFAST, ATE LESS THAN 25% OF LUNCH AND DECLINED SUPPER. ON 8-15-10 THE RESIDENT ATE LESS THAN 25% OF BREAKFAST, ATE LESS THAN 25% OF LUNCH AND ATE 76%- 100% OF SUPPER. ON 8-16-10 THE RESIDENT ATE LESS THAN 25% OF BREAKFAST, 76%-100% OF LUNCH AND LESS THAN 25% OF SUPPER. THE INDIANA STATE DEPARTMENT OF HEALTH CERTIFICATE OF DEATH FOR RESIDENT #B DATED 8-17-10 INDICATED THE CAUSE OF DEATH WAS (A.) UROSEPSIS (THE MICROORGANISM THAT CAUSED THE URINARY TRACT INFECTION SPREAD TO THE BLOOD STREAM), (B.) URINARY TRACT INFECTION AND (C.) ALZHEIMER'S DEMENTIA. INTERVIEW WITH RESIDENT #B'S FAMILY MEMBER ON 11-29-10 AT 10:30 A.M. INDICATED ON 8-16-10 RESIDENT #B'S STOMACH WAS BLOATED, THE RESIDENT WAS VERY SLEEPY AND WAS NOT EATING. THE RESIDENT'S FAMILY MEMBER INDICATED THEY KEPT TELLING THE STAFF SOMETHING WAS WRONG WITH RESIDENT#B, BUT RESIDENT #B WAS NEVER SENT TO THE HOSPITAL OR EVALUATED BY A PHYSICIAN. INTERVIEW WITH THE UNIT MANAGER ON 11-29-10 AT 2:45 P.M. INDICATED SHE WAS CARING FOR RESIDENT #B ON 8-16-10. THE UNIT MANAGER INDICATED THE RESIDENT HAD A CHANGE IN CONDITION OF DIABETIC ULCERS ON BOTH HEELS, HAD NOT BEEN EATING WELL AND WAS MORE SLEEPY. THE UNIT MANAGER INDICATED SHE NOTIFIED THE PHYSICIAN BY A FAX, BUT DID NOT GET A RESPONSE BACK FROM THE PHYSICIAN. THE UNIT MANAGER INDICATED SHE PASSED ON IN SHIFT REPORT TO LPN #1 THAT RESIDENT #B HAD THE CHANGE IN CONDITION AND THE FACILITY WAS WAITING FOR A RESPONSE BACK FROM THE PHYSICIAN. THE UNIT MANAGER INDICATED IF A PHYSICIAN DOES NOT RESPOND TO A FAX THEN THE FACILITY CAN CALL THE "ON CALL" DOCTOR IF IT IS AN EMERGENCY OR RE FAX THE PHYSICIAN THE NEXT MORNING AND THEN IF YOU DON'T GET A RESPONSE YOU CAN CALL THE PHYSICIAN. THE UNIT MANAGER INDICATED SHE REMEMBERED NOTIFYING RESIDENT #B'S HUSBAND OF THE RESIDENT'S CHANGE IN CONDITION BECAUSE SHE REMEMBERED THE RESIDENT'S HUSBAND HAD VOICED A CONCERN THAT THE RESIDENT HAD BEEN ON AN ANTIBIOTIC FOR TWO DAYS BUT THE RESIDENT WAS STILL NOT ACTING CORRECT. INTERVIEW WITH LPN #1 ON 11-29-10 AT 3:15 P.M. INDICATED SHE CARED FOR RESIDENT #B ON 8-16-10. LPN #1 INDICATED THE UNIT MANAGER DID TELL HER IN SHIFT REPORT THAT RESIDENT #B HAD A CHANGE IN CONDITION AND WAS WAITING FOR THE PHYSICIAN TO RESPOND BACK ABOUT THE RESIDENT'S CONDITION. LPN #1 INDICATED THE UNIT MANAGER TOLD HER RESIDENT #B WAS NOT EATING WELL. LPN #1 INDICATED THE RESIDENT WOKE UP LONG ENOUGH TO EAT A LITTLE SUPPER THAT EVENING AND THEN VOMITED IT UP. LPN #1 INDICATED THE RESIDENT ALSO REQUIRED TO BE PUT ON OXYGEN THAT EVENING BECAUSE HER OXYGEN LEVEL DROPPED. LPN #1 INDICATED SHE DID NOT NOTIFY THE PHYSICIAN. LPN #1 INDICATED SHE PASSED ON IN SHIFT REPORT TO LPN #2 THAT RESIDENT #B HAD A CHANGE IN CONDITION. INTERVIEW WITH LPN #2 ON 11-30-10 AT 10:10 A.M. INDICATED SHE WAS CARING FOR RESIDENT #B ON THE NIGHT SHE PASSED AWAY ON 8-17-10. LPN #2 INDICATED LPN #1 DID TELL HER IN SHIFT REPORT THAT RESIDENT #B HAD A CHANGE IN CONDITION. LPN #2 INDICATED SHE DID NOT REMEMBER IF LPN #1 HAD TOLD HER THE FACILITY WAS WAITING ON A RESPONSE FROM THE PHYSICIAN. LPN #2 INDICATED LPN #1 HAD TOLD HER THE RESIDENT HAD VOMITED, LPN #2 INDICATED SHE DID NOT REMEMBER IF SHE WAS TOLD THAT THE RESIDENT HAD A CHANGE IN HER LEVEL OF CONSCIOUSNESS. LPN #2 INDICATED WHEN SHE CHECKED ON RESIDENT #B A FEW MINUTES BEFORE 2:30 A.M. THE RESIDENT WAS RUNNING A FEVER. LPN #2 INDICATED SHE SAID THE RESIDENT'S NAME AND THE RESIDENT DID NOT SAY ANYTHING BUT KIND OF GRUNTED. LPN #2 INDICATED SHE DIRECTLY WENT TO THE MEDICATION CART AND GOT TYLENOL FOR THE RESIDENT AND WENT STRAIGHT BACK TO THE RESIDENT'S BEDROOM. LPN #2 INDICATED SHE NOTICED THE RESIDENT'S RESPIRATIONS HAD SLOWED DOWN TO 6 RESPIRATIONS PER MINUTE. LPN #2 INDICATED THEN THE RESIDENT STOPPED BREATHING. LPN #2 INDICATED THE REASON THERE WAS A 7 HOUR TIME BETWEEN RESIDENT #B'S ASSESSMENTS WAS BECAUSE WHEN A RESIDENT IS SLEEPING SHE DOES HER VITALS AND ASSESSMENTS DURING BED CHECKS. INTERVIEW WITH RESIDENT #B'S FAMILY MEMBER ON 11-30-10 AT 12:30 P.M. INDICATED RESIDENT #B'S CHANGE IN CONDITION BEGAN ON 08-15-10. THE FAMILY MEMBER INDICATED THE RESIDENT WAS SLEEPING ALL THE TIME AND THIS WAS NOT NORMAL FOR THE RESIDENT. THE FAMILY MEMBER INDICATED THE RESIDENT STOPPED EATING ALSO AND THE RESIDENT WAS USUALLY A GOOD EATER. THE FAMILY MEMBER INDICATED THE STAFF KEPT TELLING THE FAMILY THEY WERE WAITING TO HEAR FROM THE PHYSICIAN. THE FAMILY MEMBER INDICATED THEY TALKED WITH THE UNIT MANAGER AND LPN #1 ABOUT THE RESIDENT'S CONDITION. THE FAMILY MEMBER INDICATED THE RESIDENT WAS USUALLY LOUD AND CONTRARIOUS, BUT ON 8-16-10 THE RESIDENT WOULD NOT EVEN RESPOND TO THE FAMILY. THE FAMILY MEMBER INDICATED THE FAMILY FELT THE RESIDENT SHOULD HAVE BEEN EVALUATED BY A PHYSICIAN. THIS FEDERAL TAG RELATES TO COMPLAINT IN 158. 3.1-37(a)