Every finding on record at Wesleyan Health Care Center

A. Based on observation and interview, the facility failed to ensure food was prepared and served under safe and sanitary conditions regarding food handling and hand washing. This deficient practice had the potential to impact 100 of 102 residents who received their meals from the kitchen.B. Based on observation and interviews, the facility failed to store, prepare, and distribute food under safe sanitary conditions regarding the removal of dented food cans. This deficiency had the potential to impact 100 of 102 residents who received their meals from the kitchen.Findings include:A1. During a lunch service observation, on 1/20/26 at 11:57 a.m., the following food handling service concerns were observed:CNA 7 propelled a male resident to his seat in the dining room. CNA 7 then walked over and adjusted another male resident in his high back wheelchair. She grabbed the adjustment handle of his high back wheelchair and adjusted the resident forward, so he wasn't leaning back as far. After adjusting the male resident's wheelchair, CNA 7 grabbed a meal tray from the covered meal cart. She walked over to Resident 2 and placed the food in front of her. CNA 7 picked up the single piece of bread that was wrapped in plastic, and unwrapped the plastic and touched the piece of bread with her bare hands before placing it on the plate in front of Resident 2. No hand hygiene was performed in between touching the two male residents' wheelchairs and grabbing the meal tray.During an interview, on 1/20/26 at 12:11 p.m., CNA 7 indicated she did not perform hand hygiene after touching the two male residents wheelchairs, and she should not have touched Resident 2's bread with her bare hands. A2. During a lunch service observation, on 1/20/26 at 12:20 p.m., the following food handling and food service concerns were observed:Dietary Employee (DE) 13 pulled her hairnet down below her ears and touched her cheeks while waiting for a tray.DE 14 touched the inside portion of a bowl with his left thumb before placing food inside the bowl. Later in the observation, DE 14 touched the inside of a bowl with his left thumb, pointer and middle finger before placing mashed potatoes inside the bowl.The Assistant Dietary Manager placed four small pieces of chicken on a plate. He used his thumb and pointer finger to place the chicken together on the plate. Later in the observation, he placed the food portion of the plastic bowl covers against his shirt to help separate them. DE 13 bit on her right ring finger around her nail before she proceeded to touch the food portion of the plastic bowl covers. No hand hygiene was performed.DE 13 was observed using a fork and her bare fingers to remove the skin off a baked potato.During an interview, on 1/20/26 at 12:48 p.m., the Dietary Manager indicated DE 13 should have washed her hands after touching her face and adjusting her hair net. DE 13 should not have used her hands to remove skin off the potato. She should have used utensils. Her staff should not touch the inside food portion of bowls/plates/ or plastic food covers. Staff should not touch food with their bare hands.On 1/20/26 at 12:56 p.m., the Assistant Dietary Manager indicated he didn't recall placing the plastic bowl covers against his shirt or touching the food portion of the cover.On 1/20/26 at 1:03 p.m., DE 13 indicated she was not sure if she washed her hands after touching her face, but felt she probably did not. She did use a fork and her fingers when taking skin off the potato, but her bare hands did not touch the potato, just the skin part she removed. She should not have used her hands to remove the skin. She did not recall touching the food portion of the plastic bowl covers.On 1/20/26 at 1:05 p.m., DE 14 indicated he was rushing and his fingers could have gone into the food portion of the bowls.During an interview, on 1/22/26 at 1:26 p.m., Resident 48 indicated she had seen a lot of hygiene practice issues during meal service. She had seen staff touch/rub their face and arms without washing their hands afterwards. B1. During a kitchen observation, on 1/20/26 at 9:37 a.m., accompanied by the Dietary Manager, the following was observed:In the facility's dry storage area, one can of sliced apples was dented on the top seal. It had an intake date of 1/13/26. A can of peas and diced carrots had a dented seal with an intake date of 1/12/26. And a can of basic cheddar cheese had a dented bottom seal with an intake date of 1/9/26.The Dietary Manager indicated the dented cans should have been removed and placed on the upper shelf to receive credit from the supplier. There was signage posted to the left side of the can rack informing staff members what to look for regarding canned food.A current facility policy, dated 4/9/24, titled Food Safety Requirements, provided by the Administrator, on 1/27/26 at 11:43 a.m., indicated the following: .7b. Staff shall not touch food with bare hands, exhibiting appropriate use of gloves, tongs, deli paper, and spatulas A current facility policy, dated 7/2008 and revised on 6/21, titled Personal Hygiene and Jewelry, provided by the Administrator, on 1/27/26 at 11:43 a.m., indicated the following: .7. All employees of the Dining and Nutrition Services department shall follow approved policy and procedure for hand washing A current facility policy, dated 3/2025, titled Dented Cans, provided by the Administrator, on 1/27/26 at 11:43 a.m., indicated the following: .4a. There are two types of seams on a can: side and end seams. Side seams are on the side of the can and are usually covered by the label. End seams are on the top and bottom of the can. If there is a dent over any of these seams, the can has at least one major defect, meaning that it is unsafe 3.1-21(i)(3)

Based on interview and record review, the facility failed to follow physician orders regarding the administration of blood pressure medication according to ordered parameters for 1 of 5 residents reviewed for unnecessary medications (Resident 3). Finding includes:Resident 3's clinical record was reviewed on 1/22/26 at 9:50 a.m. Diagnoses included essential hypertension and atherosclerotic heart disease of native coronary artery without angina pectoris. Orders included losartan potassium (for blood pressure) 50 mg daily - hold if systolic blood pressure (SBP) (top number of reading) is less than 110 (1/21/25). A current care plan for hypertension, initiated 8/22/24 and revised 9/4/24, indicated the resident's goal was his blood pressure will be managed with his care plan interventions (initiated 8/22/24 and revised 1/10/26). Interventions included the resident's blood pressures will be taken as order and observed for any pattern changes and the resident will take his antihypertensive medications as ordered. The medication administration record (MAR) for 12/1/25 - 12/31/25 for the administration of losartan potassium 50 mg daily indicated the following: On 12/4/25 the resident's blood pressure (BP) was 109/50, on 12/5/25 the resident's BP was 101/52, on 12/25/25 the resident's BP was 108/64, on 12/26/25 the resident's BP was 109/79, and on 12/30/25 the resident's BP was 103/68. The MAR indicated the SBP was less than 110 on the above listed days, and the medication was not held. The MAR for 1/1/26 - 1/22/26 for the administration of losartan potassium 50 mg daily indicated the following: On 1/2/26 the resident's BP was 109/52, on 1/4/26 the resident's BP was 108/73, on 1/11/26 the resident's BP was 106/52, on 1/12/26 the resident's BP was 108/66, on 1/14/26 the resident's BP was 108/62, on 1/16/26 the resident's BP was 105/46, and on 1/21/26 was 107/55. The MAR indicated the SBP was less than 110 on the above listed days, and the medication was not held. During an interview, on 1/23/26 at 1:43 p.m., QMA 6 indicated some residents on her unit required monitoring of their blood pressure prior to medication administration. When the resident's blood pressure did not meet the parameters, she notified the nurse and waited for further instructions. The nurse was responsible to notify the physician. During an interview, on 1/27/26 at 9:39 a.m., QMA 20 indicated if the resident had blood pressure medication with ordered parameters, she held the medication if the blood pressure did not meet the parameters and notified the nurse. The nurse, sometimes, rechecked the resident's blood pressure, and gave the medication if the blood pressure met the parameters. She documented on the MAR if the medication was held and that she notified the nurse. During an interview, on 1/27/26 at 9:48 a.m., LPN 9 indicated when a resident received blood pressure medication, the blood pressure was taken prior to giving the medication. If a QMA took the blood pressure, LPN 9 rechecked the blood pressure. If the blood pressure was outside the parameters ordered, she held the medication. During an interview, on 1/27/26 at 1:04 p.m., QMA 6 reviewed the MAR and indicated she should have held the blood pressure medication when the resident's SBP was below 110. During an interview, on 1/27/26 at 1:15 p.m., the DON indicated she expected the staff to hold blood pressure medications if the blood pressure did not meet the ordered parameters. A current policy, last revised 4/2024, titled FOLLOWING PHYSICIAN ORDERS/PARAMETERS, provided by the Nurse Consultant on 1/27/26 at 3:01 p.m., indicated the following: .All licensed healthcare providers shall consult the resident's medical orders for the appropriate physician/clinician order prior to administering or performing a resident procedure. 1) Check MAR/TAR for physician/clinician order. 2) Licensed healthcare personnel will consult and follow the physician/clinician order when performing any resident procedures. 3.1-37(a)

Based on observation, interview, and record review, the facility failed to provide daily grooming assistance for nail care for 2 of 3 residents reviewed for Activities of Daily Living (ADLs). (Resident 43, Resident 12) Findings include: 1. During an observation, on 1/20/26 at 3:38 p.m., Resident 43 had long fingernails with a dried, dirty substance under his nails.Resident 43's clinical record was reviewed on 1/23/26 at 2:07 p.m. Diagnoses included major depressive disorder, dementia, and epilepsy (disorder causing seizures).A quarterly Minimum Data Set (MDS) assessment, dated 12/8/25, indicated Resident 43 had moderate cognitive impairment. No behaviors were identified during the assessment period. He required partial/moderate assistance with personal hygiene.A current care plan, revised on 4/21/22, indicated Resident 43 required assistance with ADL's related to dementia and his ADLs fluctuated due to dementia and schizophrenia. Interventions included the following: Resident 43 required physical assistance of one for his a.m. and p.m. care and he needed physical assistance with bathing.During an observation, on 1/23/26 at 2:25 p.m., Resident 43's right thumb and index fingernails remained long and the third and fourth fingernails were chipped and jagged. His left thumb and index fingernails remained long, and the third fingernail was chipped and jagged.During an observation, on 1/27/26 at 9:54 a.m., Resident 43's right thumb and index fingernail remained long, and the third fingernail was jagged, chipped, and broke off at an angle.During an observation, on 1/27/26 at 11:07 a.m., CNA 15 indicated Resident 43's nails were long and needed trimmed.December 2025 and January 2026 shower sheets for Resident 43 were provided by the Corporate Nurse Consultant on 1/27/25 at 2:55 p.m. The most recent shower sheets indicated Resident 43 received showers on 1/13/26, 1/17/26, 1/20/26, and 1/24/26.2. During an observation on 1/27/26 at 10:14 a.m., Resident 12 had tan dried substance under seven of ten fingernails. Resident 12's clinical record was reviewed on 1/22/26 at 3:38 p.m. Diagnoses included cerebral palsy, profound intellectual disabilities, and aphasia (impaired ability to speak).A quarterly Minimum Data Set (MDS) assessment, dated 10/20/25, indicated Resident 12 was rarely or never understood. A staff assessment indicated Resident 12 had severe cognitive impairment. Resident 12 had functional limitation in range of motion to both upper and lower extremities. She was dependent for all of her care except eating, sit to stand, and toilet transfer, which were non-applicable. A current care plan, dated 6/23/23, indicated Resident 12 required assistance with ADLs related to cerebral palsy. Interventions included the following: Resident 12 required total assistance by two staff members for her a.m. and p.m. care.A current care plan, revised on 10/1/23, indicated Resident 12 was not able to communicate due to her diagnosis of cerebral palsy and she was unable to make her needs known. Interventions included the following: please provide Resident 12 with aromatherapy, hand messages, hair brushing/massages, and manicures during 1:1 programming visitation.During an observation, on 1/27/26 at 11:12 a.m., CNA 15 indicated Resident 12's nails were dirty and needed cleaned with an orange stick (a versatile, disposable, double-ended wooden tool essential for manicures and pedicures).December 2025 and January 2026 shower sheets for Resident 12 were provided by the Corporate Nurse Consultant on 1/27/25 at 2:55 p.m. The most recent shower sheets indicated Resident 12 received a shower or bed bath on 1/12/26, 1/15/26, 1/19/26, and 1/22/26.During an interview, on 1/23/26 at 3:46 p.m., CNA 16 indicated fingernail care was to be completed by the CNAs at the time a resident received their shower. CNA 16 was unable to recall if nail care was listed on the shower sheets, but knew there was an area to document tasks completed, such as a linen change or shampooed hair. CNAs were responsible to trim and clean resident fingernails, but only if a resident requested it. Only nurses performed nail care for diabetic residents.During an interview on 1/27/26 10:08 a.m., QMA 17 indicated nail care was performed by CNAs on resident shower days and on an as needed basis. Nurses were responsible for performing nail care for residents with diabetes.During an interview on 1/27/26 at 10:30 a.m., RN 18 indicated resident fingernails were checked weekly by the CNAs, on each resident's shower day. The activity department usually performed nail care for the female residents, and the nurses were responsible to perform nail care on resident who were diabetic.During an interview on 1/27/26 at 11:07 a.m., CNA 15 indicated fingernail care was completed when a resident's nails were too long and/or dirty. Diabetic resident's nail care was performed by the nurses, otherwise CNAs were responsible. Nail care was part of each resident's regular routine and nail care was not documentedDuring an interview, on 1/27/26 at 12:49 p.m., the DON indicated residents received nail care on an as needed basis. Staff were to check resident nails on shower days.A facility policy, revised May 2017 and titled Personal Hygiene, provided by the DON on 1/27/26 at 12:40 p.m., indicated the following: Purpose: To ensure residents receive necessary care and assistance for personal hygiene tasks.Policy: 3. Nail care will be provided as needed. Diabetic nail care must be performed by a licensed nurse or podiatrist.3.1-38(3)(E)

Based on observation, interview, and record review, the facility failed to utilize infection control prevention and control practices for residents requiring enhanced barrier precautions (EBP) for 1 of 3 residents reviewed for infection control. (Resident 12) Finding includes: During an observation, on 1/20/26 at 3:38 p.m., Resident 12 was receiving a continuous enteral (tube) feeding. An magnet indicating EBP hung on the outside doorframe of Resident 12's room.Resident 12's clinical record was reviewed on 1/22/26 at 3:38 p.m. Diagnoses included cerebral palsy, dysphagia (difficulty swallowing), and gastrostomy status (a gastric feeding tube).Current physician orders included enhanced barrier precautions (5/14/24), provide g-tube care on day shift (7/10/25), and administer Osmolite (tube feeding formula) 1.2 at 49 milliliters every hour per PEG (percutaneous endoscopic gastrostomy)[feeding] tube, flush with 116 milliliters of free water every four hours, and change tube feeding tubing every shift (3/17/25).A quarterly Minimum Data Set (MDS) assessment, dated 10/20/25, indicated Resident 12 was rarely or never understood. A staff assessment indicated Resident 12 had severe cognitive impairment. Resident 12 had functional limitation in range of motion to both upper and lower extremities. She was dependent in all of her care except eating, sit to stand, and toilet transfer which were non applicable. Resident 12 had a feeding tube and received 51% or more of her total calories through tube feeding.A current care plan, revised on 3/29/24, indicated Resident 12 had a gastrostomy tube related to dysphagia and received nothing by mouth. Interventions included the following: orders for site care will be followed (6/23/23).A current care plan, revised 4/17/24, indicated Resident 12 required enhanced barrier precautions due to her gastrostomy tube. Interventions included the following: staff will follow enhanced barrier precautions with her care as needed (4/17/24) and she would have no complications related to her gastrostomy tube (4/17/24).A current care plan, revised 11/28/23, indicated Resident 12 had the potential for skin integrity impairment related to her gastrostomy tube. Interventions included the following: her care plan will minimize her risk for infection (7/25/23) and treatment as ordered (7/25/23).A current care plan, dated 6/23/23, indicated Resident 12 required assistance with her activities of daily living related to cerebral palsy. Interventions included the following: she had a tube feed and did not consume oral food (6/27/23).During an observation, on 1/22/26 at 3:45 p.m., a magnet indicating EBP hung on the doorframe outside of Resident 12's room. A yellow isolation gown in a plastic bag and a box of gloves hung on the wall beside the door the inside the room. Resident 12 was lying in her bed with the head of bed elevated approximately 30 degrees. Enteral feeding was being administered per her PEG tube. Unit Manager (UM) 18 prepared supplies to perform PEG site care. UM 18 performed hand hygiene and put on gloves. UM 18 informed Resident 12 she was going to clean her PEG site. UM 18 wet the washcloths and sat them on a dry towel on the bedside table. UM 18 searched for soap in nightstand drawer and on top of the nightstand. The soap was placed on the bedside table. UM 18 removed the old gloves and put on a new pair. UM 18 pulled Resident 12's blankets downward, just below the PEG site. UM 18 applied soap to washcloths and washed from insertion site outward. UM 18 used a different edge of wash cloth with each circular motion. A scant amount of tan drainage was observed on the washcloth as she cleansed the site. UM 18 obtained a new washcloth to rinse the soap. A dry towel was used to pat dry the PEG site. UM 18 adjusted Resident 12's clothing and replaced the blankets over Resident 12's abdomen. An isolation gown was not worn by UM 18 during Resident 12's PEG site care. UM 18 indicated isolation gowns were only needed if dealing with the tube feeding and motioned to the IV pole with the tube feeding pump. Gloves were to be worn for incontinence care and personal care. A gown only needed to be worn with PEG site care when PEG site is red, infected, inflamed, had drainage, or if splattering would occur. Staff were expected to wear an isolation gown with feeding administration due to the possibility that tube feeding formula could splatter.During an interview, on 1/27/26 12:49 p.m., the DON indicated EBP precautions were to be followed when staff performed personal care, such as emptying catheters and PEG site care. A gown was to be worn when Resident 12's PEG site care was performed. The PEG site was the reason Resident 12 required enhanced barrier precautions.During an interview, on 1/27/26 at 12:53 p.m., the DON indicated the Infection Preventionist (IP) had given her more information and since Resident 12's tube feeding was continuous and the tube feeding was not disconnected during the PEG site care observation, a gown was not needed. During an interview, on 1/27/26 at 12:55 p.m., the DON indicated the information received by the IP was wrong and a gown was needed to be worn for Resident 12's PEG site care.During an interview, on 1/27/25 at 4:45 p.m., the IP indicated she performed rounding to monitor for EBP and infection control. The weekend supervisor assisted with infection control rounding. Training for infection control had been done twice this year already, including EBP. She was not aware that a gown was to be utilized when performing Resident 12's PEG site care. Since the gastrointestinal tract was not sterile, there was no chance of splash and no prolonged contact, she did not feel a gown was needed. She would have done same as UM 18 because the PEG site was old, UM 18 did not stop and remove the feeding, and there was no drainage. During an interview, on 1/27/26 at 4:45 p.m., the Clinical Nurse Consultant indicated the Corporate Clinical Coordinator provided education regarding EBP and hand hygiene in the early Fall of 2025. A facility policy, reviewed/revised on 2/5/25, titled Enhanced Barrier Precaution, provided by the DON on 1/27/26 at 12:55 p.m., indicated the following: Policy: It is the policy of the facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Definitions: Enhanced barrier precaution (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities.2.b. An order for enhanced barrier precaution will be obtained for residents with any of the following: i.feeding tubes.3. Implementation of Enhanced Barrier Precautions: b. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities.4. High-contact resident care activities include: g. Device care or use: feeding tubes.10. Enhanced barrier precautions should be used for the duration of the affected resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk.3.1-18(a)

Based on observation, record review, and interview, the facility failed to provide adequate supervision to prevent repeated falls for a cognitively impaired resident for 1 of 4 residents reviewed for accidents. (Resident 58) Findings include:During an observation, on 1/20/26 at 11:27 a.m., Resident 58 sat in her wheelchair at a dining table with a visitor. During an observation, on 1/21/26 at 9:10 a.m., Resident 58 sat in her wheelchair in the dining room with her head bowed and her eyes closed. During an observation, on 1/22/26 at 9:45 a.m., Resident 58 lay in her low bed with her eyes closed with her room door closed. Resident 58's clinical record was reviewed on 1/22/26 at 4:03 p.m. Diagnoses included dementia, major depressive disorder, recurrent, mild, bradycardia (slow heart rate), and atrial fibrillation (irregular heartbeat). Current orders included the following: may have bed against wall (9/20/25), losartan potassium (blood pressure) 12.5 mg daily - hold for SPB (systolic blood pressure [top number] less than 110 (2/27/25), sertraline (antidepressant) 50 mg daily (1/9/26), lorazepam (antianxiety) 0.5 mg every six hours as needed for anxiety/restlessness for 14 days (1/20/26), morphine sulfate concentrate 100 mg/5 mL - give 0.25 mL (5 mg) every four hours as needed for pain/air hunger (1/20/26), and tramadol 50 mg every six hours as needed for pain (1/6/26). A Minimum Data Set (MDS) assessment, dated 10/13/25, indicated the resident was severely cognitively impaired. She required partial/moderate staff assistance with showering/bathing, lower body dressing, putting on/taking off footwear, personal hygiene, moving from sitting to lying, moving from lying to sitting, chair/bed to chair transfers, toilet transfers, and walking 10 to 50 feet. She required substantial/maximal staff assistance with toileting hygiene and tub/shower transfers. She was frequently incontinent of bowel and bladder. She was short of breath with exertion. She had one fall with no injury since the prior assessment. A Minimum Data Set (MDS) assessment, dated 1/13/26, indicated the resident was severely cognitively impaired. She demonstrated disorganized thinking and inattention behaviors which fluctuated. She had verbal behavioral symptoms directed toward others that occurred one to three days during the assessment period. She required partial/moderate staff assistance with upper body dressing, putting on/taking off footwear, rolling left and right in bed, moving from sitting to lying, moving from lying to sitting, chair/bed to chair transfers, toilet transfers, and walking 10 feet. She required substantial/maximal staff assistance with toileting hygiene, showering/bathing, lower body dressing, and tub/shower transfers. She was frequently incontinent of bowel and bladder. She was short of breath with exertion. She had two or more falls with no injury, two or more fall with injuries, and one fall with a major injury since the prior assessment. A current care plan indicated the resident was at risk for falls related to not making good decisions, memory loss, history of falls, narcotic analgesics, and use of psychotropic medications. She had a fracture from a fall (initiated 2/25/25 and revised 1/19/26). Interventions included the following: 3 p.m. toileting (initiated 1/15/26), anti-roll back device used to lock wheelchair (initiated 1/20/26), encourage to stay in common areas while up in wheelchair and upon rising for the day (revised 11/17/25), wear non-slip footwear when in bed (initiated and revised 1/2/26), and when resident is restless, staff is to assist resident into wheelchair and into an area of increased supervision (12/28/25). A current care plan indicated the resident experienced a traumatic fracture (minimally displaced radial head fracture of right elbow) from a fall on 12/30/25 (initiated 1/6/26). Interventions included: the resident will follow up with orthopedic physician as scheduled. The resident refused to wear a sling (initiated 1/6/26) and refer to therapy as needed (initiated 1/6/26). A progress note, dated 12/24/25 at 4:45 p.m., indicated the resident sat in her wheelchair and attempted to transfer herself to her bed. The resident was found sitting on her buttocks on the floor beside her bed. The CNA indicated the resident had her shoes on, but she must have taken them off because the resident was only wearing her socks. A small bruise was noted to her right upper outer arm close to her elbow. Fifteen-minute checks were initiated, and non-skid slipper socks were placed on the resident. A progress note, dated 12/26/25 at 9:30 a.m., indicated the resident was walking to the bathroom and fell to the floor, with a large bowel movement noted on the floor. A fall IDT (interdisciplinary team) note dated 12/26/25 at 1:17 p.m., for the 12/24/25 fall at 4:15 p.m., indicated the resident was found sitting on the floor on her buttocks beside her bed. She had taken off her shoes and was wearing regular socks. The resident stated she was not hurt. The root cause of her fall was the resident was transferring without assistance, lost balance, and fell. Contributing factors included multiple diagnoses and severe cognitive impairment. She had dementia and demonstrated poor safety awareness. She had a history of falls, but none within the past 30 days. Multiple interventions were in place prior to the fall. The immediate intervention was the placement of nonskid socks on the resident and initiation of 15-minute checks. A revised intervention was a pull tab chair alarm. A fall IDT note dated 12/26/25 at 1:37 p.m., for the 12/26/25 fall at 9:30 a.m., indicated the resident was found on the floor in her bathroom next to a pile of feces. The resident indicated she fell. The root cause of her fall was the resident was transferring without assistance, lost balance, and fell. Contributing factors included multiple diagnoses and severe cognitive impairment. She had dementia and demonstrated poor safety awareness. The resident had a history of falls and already had a fall this week. Multiple interventions were in place prior to fall. The immediate intervention included assistance with resident's hygiene and updated bowel program. A progress note, dated 12/28/25 at 2:15 p.m., indicated the resident was found sitting on the floor beside the end of her bed. The resident could not explain to staff what she attempted to do. The wheelchair was close to the resident. The resident had her shoes on and had not been incontinent. No injuries were noted. Fifteen-minute checks were started. A fall IDT note dated 12/29/25 at 4:50 p.m., for the fall on 12/28/25 at 2:15 p.m., indicated the resident was found sitting on the floor in her room at the end of her bed. The resident was unable to state what happened. Her wheelchair was positioned near the resident. She was wearing appropriate footwear at the time of the fall. The root cause of the fall was that the resident was transferring without assistance, lost balance, and fell. During the investigation, it was found the resident was frequently standing to remove the chair alarm and place it in a variety of locations. Contributing factors included multiple diagnoses and severe cognitive impairment. She had dementia and demonstrated poor safety awareness. The resident had a history of falls and already had a fall this week. Multiple interventions were in place prior to fall. The immediate intervention was placement of the resident on 15-minute checks. The revised interventions included removal of the chair alarm due to the staff report of it causing the resident to have increased restlessness. The resident transferred herself unassisted and placed the alarm in the bathroom. A progress note, dated 12/29/25 at 5:30 p.m., indicated the resident was found near her bed. She did not have shoes on, only socks. She attempted to self-transfer and slid off her bed trying to get into her wheelchair. A bruise was found on her right upper arm. Fifteen-minute checks were continued. A fall IDT note dated 12/30/25 at 9:58 a.m., for the fall on 12/29/25 at 5:30 p.m., indicated the resident was found lying on the floor next to her bed. Her head was by the bed, and her feet pointed away. The resident stated she slid out of bed. The root cause of her fall was the resident slid out of her bed onto the floor. Contributing factors included multiple diagnoses and severe cognitive impairment. She had dementia and demonstrated poor safety awareness. The resident had a history of falls and already had a fall this week. Multiple inventions were in place prior to the fall. The immediate intervention was to place the resident back on 15-minute checks. The new intervention was to have the resident evaluated by the nurse practitioner (NP) for acute illness and to address pain. A progress note, dated 12/30/25 at 2:28 p.m., indicated the resident experienced right shoulder and elbow pain after her fall. She was seen by the NP. X-rays were ordered and reviewed. NP ordered a sling to be placed on the resident, and a repeat X-ray in one week. Tramadol 25 mg every six hours as needed was started. An x-ray of the right elbow with three views, completed on 12/30/25, indicated findings suggested fluid in the joint possibly due to a hidden radial head (top of the forearm bone where it meets the elbow) fracture. A progress note, dated 12/31/25 at 4:50 p.m., indicated the resident was found lying on the floor on her right side in her room. The wheelchair was by the window, and the resident was by the door. The resident was continent. She had one sock on her foot. Her shoes were by the bed. The resident was in her bed when the staff had last checked on her. No injuries were noted. Fifteen-minute checks were restarted. A fall IDT note dated 1/2/26 at 3:58 p.m., for the fall on 12/31/25 at 4:50 p.m., indicated the resident was found lying on the floor on her right side by the door. Her wheelchair was by the window. The resident had been in bed during the last check. The resident was unable to state what happened, but said she was not hurt. The root cause of the fall was the resident was ambulating without assistance, lost her balance, and fell. Contributing factors included multiple diagnoses and severe cognitive impairment. She had dementia and demonstrated poor safety awareness. The resident had a history of falls and already had a fall this week. Multiple inventions were in place prior to the fall. The immediate intervention was to place the resident back on 15-minute checks. The revised intervention was to place non-skid socks on the resident while in bed. A progress note, dated 1/3/26 at 5:45 p.m., indicated the resident was found lying on her back beside her recliner near the bathroom door. The resident's wheelchair and shoes were in the bathroom. No injuries were noted. The resident was assisted off the floor and into her wheelchair. She was taken to the dining room for supper. A fall IDT note dated 1/5/26 at 3:04 p.m., for the fall on 1/3/26 at 6:06 p.m., indicated the resident was found lying flat on her back beside her recliner near the bathroom door. The resident's wheelchair and shoes were in the bathroom. The root cause of the fall was that the resident ambulated without assistance, lost her balance, and fell. Contributing factors included multiple diagnoses and severe cognitive impairment. She had dementia and demonstrated poor safety awareness. The resident had a history of falls and already had a fall this week. Multiple inventions were in place prior to the fall. The immediate intervention was the resident was taken to an area of increased supervision. The revised intervention was that the toileting program was updated. A progress note, dated 1/6/26 at 5:16 a.m., indicated the resident was found lying on the floor on her fall mat. The resident indicated she put herself on the floor onto the fall mat and refused to get back in bed. The resident stated she was comfortable and did not want to get back into bed. An x-ray of the right elbow with three views, completed on 1/6/26, indicated a minimally displaced radial head fracture. A progress noted, dated 1/6/26 at 3:33 p.m., indicated the NP reviewed the repeat elbow x-ray. An appointment was made with the orthopedic provider. A progress note, dated 1/7/26 at 7:52 a.m., indicated the resident was found lying on the floor on her back at the bathroom doorway. The resident repeatedly stated she did not want the bed to get wet. No injuries were noted. Signage was added to the room that requested the resident to please use her call light. A fall IDT note dated 1/7/26 at 9:31 a.m., for the fall on 1/7/26 at 3:30 a.m., indicated the resident was found on the floor in her room in the doorway to her bathroom. She stated she did not want to get the bed wet. The root cause of the fall was the resident was ambulating without assistance, lost her balance, and fell. Contributing factors included multiple diagnoses and severe cognitive impairment. She had dementia and demonstrated poor safety awareness. The resident had a history of falls and already had a fall this week. Multiple inventions were in place prior to the fall. The immediate intervention was to hang a sign to remind the resident to call for help. The revised intervention was for labs to be drawn due to the increase in falls and behaviors. A progress note, dated 1/9/26 at 2:52 a.m., indicated the resident was sitting on the mat beside the bed on her buttocks. The resident came back from the bathroom and tried to transfer to the bed from her wheelchair and used the bedside table to get up out of the wheelchair. The CNA was in the hall and witnessed the resident try to use the bedside table for the transfer resulting in her falling on her buttocks onto the mat. No injuries were noted. The resident was assisted to bed, and 15-minute checks were initiated. A fall IDT progress note dated 1/9/26 at 4:46 p.m., for the fall on 1/9/26 at 1:45 p.m., indicated the resident was witnessed coming back from the bathroom to her bed. She attempted to transfer to the bed from her wheelchair and used the bedside table to get up out of the wheelchair. During the transfer, she lost her balance and fell to her bottom. The root cause of the fall was that the resident transferred herself and used the bedside table, lost her balance, and fell while getting into bed. Contributing factors included multiple diagnoses and severe cognitive impairment. She had dementia and demonstrated poor safety awareness. The resident frequently refused to take her wheelchair when going to the bathroom. Staff attempted to give the resident her wheelchair, but she waved them off. The resident had a history of falls and fell multiple times this month. Multiple inventions were in place prior to the fall. The immediate intervention was that the resident was placed on 15-minute checks. The revised intervention was the placement of a nonskid strip next to the resident's bed. A progress note, dated 1/15/26 at 3:45 p.m., indicated the resident fell at 3:30 p.m. in the common bathroom. The resident wheeled herself out of the common bathroom. She requested to speak with her daughter and stated she fell in the bathroom. A fall IDT progress note dated 1/16/26 at 4:18 p.m., for the fall on 1/15/26 at 3:30 p.m., indicated the resident was seen coming out of the bathroom. She stated to staff that she needed to speak to her daughter because she fell while using the bathroom. No injuries were noted. The resident was not observed on the floor as the resident indicated she got herself up. The staff assisted the resident to the bathroom. The root cause of the fall was behavioral. When resident found out the daughter was unable to visit like she usually did on Thursdays, the resident indicated she had fallen. Contributing factors included multiple diagnoses and severe cognitive impairment. She had dementia and demonstrated poor safety awareness. The resident had a history of falls and had fallen multiple times this month. Multiple inventions were in place prior to the fall. The immediate intervention was to bring the resident to an area of increased supervision. The revised intervention was to update the toileting program. A progress note, dated 1/18/26 at 9:00 a.m., indicated the resident wheeled herself back to her room after breakfast. A few minutes later, the resident was heard yelling help me. She was found sitting on the floor between her wheelchair and her bed. No injuries were noted. She was placed in her wheelchair and taken to the television room as she requested. A fall IDT progress note dated 1/19/26 at 5:33 p.m., for the fall on 1/18/26 at 9:00 a.m., indicated the resident was heard calling out for help. She was found sitting on the floor between her bed and her wheelchair. The resident wore appropriate footwear. The resident stated she was trying to get back in her bed. The root cause of the fall was the resident was transferring herself without assistance, lost her balance, and fell while getting in bed. Contributing factors included multiple diagnoses and severe cognitive impairment. She had dementia and demonstrated poor safety awareness. The resident had a history of falls and had fallen multiple times this month. Multiple inventions were in place prior to the fall. The immediate intervention was placement of the resident on hourly checks. The revised intervention was to continue the hourly checks on the resident. A progress note, dated 1/20/26 at 2:46 p.m., indicated, at 9:40 a.m., the resident was in her wheelchair when the staff left her room. She got on the floor after they turned around. The psychiatric-mental health NP spoke with the resident, and antiroll back devices were placed on the resident's wheelchair. A fall IDT progress note dated 1/20/26 at 5:11 p.m., for the fall on 1/20/26 at 9:40 a.m., indicated the staff had just assisted the resident into her wheelchair as she requested. As the staff exited the room, the resident stated she was on the floor. The resident was lying on her right side with her hand underneath her head between her bed and her wheelchair. She declined to answer questions about her fall, but stated she would do it again until her daughter came in. No injuries were noted. The root cause of the fall was the resident was transferring herself without assistance, lost her balance, and fell while getting into bed. Contributing factors included multiple diagnoses and severe cognitive impairment. She had dementia and demonstrated poor safety awareness. The resident had a history of falls and had fallen multiple times this month. Multiple inventions were in place prior to the fall. Anti-roll back devices were added to the resident's wheelchair, and her daughter came in to visit her. During an observation, on 1/22/26 at 2:47 p.m., the resident was lying in her low bed with her eyes closed. The door was open. During an observation, on 1/23/26 at 10:12 a.m., the resident was lying in her low bed with her eyes closed. The door was open. During an interview, on 1/23/26 at 1:38 p.m., QMA 6 indicated the resident had worn a sling on her arm for a short time. To prevent falls, the resident wore nonskid socks, had nonskid strips in front of her bed and toilet, her bed was in lowest position, her call light was within reach, a non-slip mat was on her wheelchair, she was kept in the common area when awake, and her room door was kept open when she was in bed. During an observation, on 1/23/26 at 4:14 p.m., the resident was lying in her low bed with her eyes closed. The door was closed. During an interview, on 1/23/26 at 4:19 p.m., CNA 8 indicated, to prevent the resident from falling, she gave her snacks, played a card game called garbage with the resident, and tried to distract her when the resident became restless. The specific interventions for falls were listed on the Kardex for all the residents. During an interview, on 1/27/26 at 12:58 p.m., CNA 7 indicated to prevent the resident from falling, she took the resident on walks. The resident also loved to read her Bible. The resident also liked to sit in her room and look out the window. The staff tried to keep her door open so they could keep an eye on the resident. The CNAs could look on the Kardex to see specific fall interventions for the residents. During an interview, on 1/27/26 at 1:08 p.m., Unit Manager 5 indicated the resident had fallen a lot lately. Some of those falls she attributed to maladaptive behaviors. The NP had seen the resident and believed the resident ran bradycardic (low heart rate) and that may have caused her falls. The cardiologist indicated a pacemaker was not warranted for the resident due to her age. The staff tried to keep the resident in common areas. They assisted her to bed between meals. Unit Manager 5 expected the door to remain open while the resident was in bed, but the roommate got up and closed the door at times. She indicated it was the roommate's right to have the door closed. During an interview, on 1/27/26 at 1:17 p.m., the DON indicated the resident had fallen multiple times in the last 30 days. The DON always staffed two to three staff members on the secured unit. The resident used to take care of herself and continued to try to get up on her own. The DON indicated the staff tried to keep the resident out of her room as much as possible, but that caused the resident to have behaviors. During an interview, on 1/27/26 at 3:01 p.m., the ADON indicated she believed a lot of the resident's falls were behaviors and associated with her heart. The family refused to pursue treatment for her heart condition. The staff tried to keep the resident out of her room as much as they could. During an interview, on 1/27/26 at 3:08 p.m., the DON indicated she felt like the facility had done everything they could to prevent the resident from falling. A current facility policy, last revised 8/2024, titled Fall Investigation and Risk Evaluation, provided by the Nurse Consultant on 1/27/26 at 3:01 p.m., indicated the following: .It is the policy of this facility to provide an environment that is free from accident hazards over which the facility has control and provides supervision and assisted devices to prevent avoidable accidents. 'Avoidable Accident' means that an accident occurred because the facility failed to: . Implement interventions, including adequate supervision and assistive devices, consistent with a resident's needs, goals, care plan and current professional standards of practice in order to eliminate the risk, if possible, and, if not, reduce the risk of an accident. 3.1-45(a)(2)

Based on interview and record review, the facility failed to ensure services for bed mobility were provided with two staff members present to a dependent resident who required total assistance of two staff for bed mobility for 1 of 3 residents reviewed for falls. (Resident 99) This deficient practice resulted in Resident 99 falling from the bed and sustaining a fracture left knee joint. Findings include: Resident 99's clinical record was reviewed on 12/13/14 at 11:29 a.m. Diagnoses included, but were not limited to, quadriplegia (a severe medical condition characterized by the partial or total loss of function in all four limbs and the torso), left elbow contracture, left shoulder contracture, left wrist contracture, left hand contracture, right shoulder contracture, right wrist contracture, right hand contracture, major depressive disorder, bipolar disorder, restless leg syndrome, and generalized anxiety disorder. A current care plan, dated 3/1/24, revised on 5/28/24, and reviewed on 12/2/24, indicated Resident 99 required assistance with activities of daily living (ADLs) related to quadriplegia. Interventions included a total assist of two staff members with bed mobility. She required a total assist of 1-2 staff when toileting and required a total assist of one to two staff members with bathing. A quarterly Minimum Data Set (MDS) assessment, dated 8/20/24, indicated she had upper and lower extremity impairment on both sides. She was dependent on toileting hygiene, shower/bathing, upper and lower body dressing, eating, and rolling to the left and right in bed. She was cognitively intact. The resident did not have any falls since the prior assessment. A Significant Change MDS assessment, dated 11/18/24, indicated she had upper and lower extremity impairment on both sides. She was dependent on toileting hygiene, shower/bathing, upper and lower body dressing, eating, and rolling to the left and right in bed. She was cognitively intact. An MDS progress note, dated 11/18/24 at 3:40 p.m., indicated Resident 99 had complaints of frequent neck pain and overall generalized discomfort in the past five days. The worst pain was a five on a 0-10 pain scale. The resident received routine and as needed pain medications which she stated was effective. The resident voiced occasional shortness of breath with exertion and at rest. The resident was non-ambulatory and used a mechanical lift for transfers. The resident was totally incontinent of bowel and bladder and utilized incontinence products and moisture barrier cream. A nursing progress note, dated 11/29/24 at 8:30 p.m., indicated the CNA reported assisting Resident 99 in her bed without assistance. He rolled her to the left side of the bed to adjust the bed sheets and incontinence pad, when the residents right leg went over the side of the bed. The resident stated she went onto the floor and hit her head. The resident ended up developing a skin tear to her sacrum that was 2 centimeters (cm) long by 0.2 cm width with no depth. Range of motion was normal per resident's current physical condition. Neurological checks were initiated, within defined limits, and she was alert and oriented times four. Four staff members assisted in getting the resident off the floor and back into her bed. There were no progress notes documented between 11/29/24 at 8:30 p.m., when the fall occurred, and 11/30/24 at 6:36 a.m., when the resident had complaints of pain. A nursing progress note, dated 11/30/24 at 6:36 a.m., indicated the CNA notified the nurse that the resident was experiencing 10/10 pain following her fall the previous night. Her left leg and back caused the majority of her pain. Upon assessment, the resident's left leg was extremely swollen and painful to touch. The nurse spoke with both the resident and family who indicated they wanted her sent to the emergency room (ER) for evaluation A nursing progress note, dated 11/30/24 at 7:08 a.m., indicated the resident's representative arrived at the facility and Emergency Medical Services (EMS) was contacted for transport. A hospital imaging service report, dated 11/30/24 at 10:03 a.m., indicated findings of a depressed medical tibial plateau fracture. A nursing progress note, dated 11/30/24 at 12:37 p.m., indicated the resident returned from the emergency room with a diagnosis of medial tibial plateau (concave part of the tibial plateau, which is the flat top of the tibia bone in the knee) fracture and a urinary tract infection (UTI). A nursing progress note, dated 12/2/24 at 1:11 p.m., indicated the resident requested for her bed to be put back the way it was prior to her fall, so she could see out the window and watch her television. The DON was notified. An Interdisciplinary Team (IDT) note, dated 12/2/24 at 1:52 p.m., indicated the root cause of her fall was that the resident's leg rolled over further than the staff member expected. Since the resident had no control over her body, the momentum pulled her to the floor. Other contributing factors included quadriplegia, other cord compression, chronic pain syndrome, muscle spasms, spinal stenosis, chronic obstructive pulmonary disease, major depression, anxiety, sick sinus syndrome, critical illness myopathy, and contractures. Interventions in place prior to fall included her call light and personal items were within reach and to remind the resident to change position slowly. New education included proper ADL care of the resident and resident requested to have her bed moved up against the wall to make her feel safer. The fall care plan had been reviewed and updated. Current physician orders, on 12/13/24, included amitriptyline (antidepressant) 25 milligram (mg) daily, aripiprazole (atypical antipsychotic) 10 mg daily, Eliquis (anticoagulant) 5 mg daily, gabapentin (anticonvulsant) 200 mg twice daily, and oxycodone-acetaminophen (narcotic) 7.5-325 mg every six hours. A current care plan, dated 9/6/24 and revised on 12/2/24, indicated the resident was at risk for falls related to immobility, use of narcotics, use of psychotropics, and pain. An intervention, dated 9/6/24, indicated the resident would have her personal items within reach. An intervention, dated 9/6/24, indicated her call light would be within reach. An intervention, dated 9/6/24, indicated she needed to be reminded to change her position slowly. A post fall intervention, dated 12/1/24, indicated she would have her bed against the wall as it made her feel safe. The resident had chosen to move her bed away from the wall in order for her to look out of her window, dated 12/1/24. A post fall intervention, dated 12/2/24, indicated the resident was to wear proper footwear or non-slip footwear when she was up. A current care plan, initiated 11/30/24 and revised on 12/6/24, indicated the resident had a traumatic fracture to her left depressed medical tibial plateau due to fall. An intervention, dated 11/30/24, indicated the implementation of her pain care plan. A current care plan, initiated 3/1/24 and revised on 12/6/24, indicated the resident has chronic pain syndrome, osteoarthritis right knee, and osteoporosis. She was at risk for acute pain related to surgical site left lower quadrant abdominal and left umbilicus, muscle spasm, Chronic Obstructive Pulmonary Disease (COPD), spinal stenosis, constipation, and urinary retention, irritable bowel syndrome, gastroesophageal reflux disease (GERD), depression and left depressed medical tibial plateau fracture on 11/30/24. Interventions, dated 3/1/24, indicated her pain medication would be administered as ordered, observe for increased sedation, constipation, and respiratory depression, staff would observe to determine if she was experiencing non-verbal signs of pain, and when she was experiencing pain to check for decrease external stimulation as much as possible. A current care plan, initiated 3/6/24 and revised on 7/3/24, indicated the resident was totally incontinent and not a candidate for a bowel program due to irritable bowel syndrome. Interventions included applying barrier cream as indicated, receive medications as ordered, check for incontinence every two hours, and more frequently as needed and assist the resident with incontinence care. During a random observation, on 12/11/24 at 10:54 a.m., Resident 99 was lying in bed on her back, covered with a sheet. A small travel pillow was around her neck for support. The bed was located away from the wall. During a random observation, on 12/11/24 at 2:36 p.m., Resident 99 was lying on her back in bed with her eyes closed, covered with a sheet. A small travel pillow was around her neck for support. The bed was located away from the wall. During a random observation, on 12/12/24 at 10:49 a.m., Resident 99 was lying on her back in bed, covered with a sheet. The bed was located away from the wall. During a random observation, on 12/12/24 at 2:17 p.m., Resident 99 was lying on her back in bed with her eyes closed. The bed was elevated and a touch call pad was within reach. A small travel pillow was around her neck for support. The bed was located away from the wall. During an interview, on 12/13/24 at 2:08 p.m., Resident 99 indicated, on 11/29/24, that CNA 4 had changed her bed sheets and incontinence pad. The resident advised CNA 4 that he needed to have a second staff member help with changing her incontinence pad and bedding. CNA 4 assured her that he could do it by himself. CNA 4 rolled her back and forth a few times. She was lying on her left side at the edge of the bed, her right leg went forward off the bed, causing her to roll off the bed. She hit her head and upper back on the chair beside her bed. During an interview, on 12/13/24 at 2:30 p.m., Resident 99 indicated, on 11/29/24, she had been lying flat in bed during incontinence care. Her bed was away from the wall. She was on her left side, on the edge of the bed. She felt like both of her legs ended up sliding off the bed, which caused the rest of her body to fall off the bed. It happened so fast she didn't have time to say anything to the staff member before falling off the bed. Her upper bed rails were up, and she flipped over the top bedrail. She hit the back of her head and the top part of her back on the chair at her bedside. She had back pain after the fall occurred. The following morning, she was sent out to the hospital where she was diagnosed with a left knee fracture. She saw the orthopedic physician today, and he would see her back in 4 weeks for a follow-up appointment. When provided care, she usually scrunched up in a ball, as she was contracted in her extremities. Being rolled around in bed caused her to be in pain. During an interview, on 12/13/24 at 2:40 p.m., LPN 3 indicated facility staff knew to use two people when assisting the resident with care. However, if they were familiar with her, one person could provide care for her. Everyone who worked for this facility used two people for her care. During an interview, on 12/13/24 at 3:33 p.m., CNA 4 indicated, on 11/29/24, he had assisted Resident 99 when she needed cleaned up and her bedding changed. CNA 4 had rolled the resident onto her left side, which was on the opposite side of the bed from the CNA. When he rolled Resident 99 over to change her brief, her right leg went over the side of the bed where he was standing. He had his hand on her side, near her waist, and was able to keep her from fully falling off the bed. He was able to run around the bed, get behind the resident, and lowered her to the ground. He didn't feel like the resident's knees touched the floor. He was able to get right up behind her and lowered her to the ground. He was unsure how she hurt her knee. He was told by other staff members that it was easy to provide incontinence care to the resident, but just to be careful as she was contracted. The resident was not scrunched up or contracted while he was providing care. The nurse was right outside her door when the fall occurred. Resident 99 was not hollering or calling out. He denied the resident hit her head or back on anything. The nurse assisted him with lowering the resident to the floor. He indicated he did not have access to the facility's computer system. During an interview, on 12/13/14 at 4:04 p.m., RN 5 indicated, on 11/29/24, she was outside the resident's door when the fall occurred. She heard the resident scream. When she entered the room, Resident 99 was already on the floor. The resident was a two-person physical assist during care. CNA 4 was from another facility, and they had informed him that the resident was a two-person physical assist before providing care. RN 5 didn't feel CNA 4 could have lowered the resident to the floor by himself. RN 5 felt the resident slid out of the bed. The resident preferred to have her bed elevated. RN 5 did not see any swelling or redness to the resident's knee during the assessment after her fall. Later that next morning, the resident was sent out to the ER for complaints of knee pain. She was diagnosed with a fracture of her left knee. A point of care task, retrieved on 12/13/24 at 4:25 p.m., indicated staff members documented Resident 99 required one person assist with bed mobility 10 out of 11 days prior to her fall from 11/18/24 to 11/29/24, and 10 out of 14 days after her medial tibial plateau fracture, from 12/1/24 to 12/13/24. During an interview, on 12/16/24 at 8:40 a.m., CNA 6 indicated Resident 99 was a two-person physical assist for bed mobility and incontinence care due to her contractures. During an interview, on 12/16/24 at 8:41 a.m., CNA 7 indicated Resident 99 was a two-person physical assist with care. One person could do it on their own, but CNA 7 wouldn't recommend it due to the resident being a quadriplegic and contracted. During an interview, on 12/16/24 at 9:53 a.m., the DON indicated, on 11/29/24, she interviewed Resident 99 and CNA 4 once the resident returned from the hospital. The resident indicated that CNA 4 was trying to turn Resident 99 over in bed and that the resident was close to the edge of the bed. CNA 4 had his hand on Resident 99's waist. CNA 4 indicated Resident 99's knees went off the bed and the momentum pulled Resident 99 to the ground. CNA 4 tried to stop the resident from falling. The DON talked to the resident regarding an intervention of moving her bed against the wall so she would feel safe during care. Resident 99 was agreeable, but later wanted her bed moved back to where it was originally located. The DON provided education to all staff members that Resident 99 was a two-person physical assist with bed mobility. CNA 4 had access to the facility computer system. She verified that the resident was a two-person assist for bed mobility, and it did show that information on the care plan. During an interview, on 12/16/24 at 1:30 p.m., the Corporate Nurse provided documentation of CNA 4 accessing the clinical record from November 11, 2024 through December 5, 2024. During an interview, on 12/17/24 at 10:23 a.m., the DON indicated that CNA 4 was toileting (incontinence care) Resident 99 at the time of her fall. Her care plan indicated she was a 1-2 staff member assistance for toileting (incontinence care) and bathing. She was unsure why she was marked as a two-person assist for bed mobility. She was in the process of changing the resident's care plan to two-person assist for toileting (incontinence care) and bathing. During an interview, on 12/17/24 at 10:37 a.m., CNA 9 indicated Resident 99 was a two person assist with bed mobility. Bed mobility included rolling from left to right and providing During an interview, on 12/17/24 at 10:49 a.m., the DON indicated all staff members have been educated that Resident 99 was a two person assist for incontinence care and that Resident 99 was agreeable with using bolsters while in bed. During an interview, on 12/17/24 at 10:58 a.m., Resident 99 indicated she was incontinent and used a brief. When staff toileted her, they changed her brief and bed pad. During an interview, on 12/17/24 at 11:00 a.m., LPN 10 indicated Resident 99 was incontinent and unable to use the bedpan due to quadriplegia with contractures. The resident did not have any feeling from her upper chest down to her toes. She could move her arms enough to hit her call light, but she was unable to grasp or pull. During an interview, on 12/17/24 at 11:24 a.m., CNA 9 indicated Resident 99 was fully paralyzed and unable to tell when she needed to use the restroom. They used a disposable bed pad for her. She was unable to wear briefs due to her contractures. When they were providing toileting care, they were rolling her to either side of the bed. A current policy, titled Fall Investigation and Risk Evaluation, provided by the Corporate Nurse, on 12/16/24 at 3:52 p.m., indicated the following: .It is the policy of the facility to provide an environment that is free from accident hazards over which the facility has control and provides supervision and assisted devices to prevent avoidable accidents 3.1-45(a)

Based on observation and interview, the facility failed to ensure a resident's call light was within reach for 1 of 3 residents reviewed for environment. (Resident 39) Findings include: During a random observation, on 12/11/24 at 10:50 a.m., Resident 39 was propelled in a high-backed wheelchair to his room by a staff member. The resident was left facing his television. His call light was not in reach. During an interview, on 12/11/24 at 11:55 a.m., Resident 39 indicated his call light was not within his reach. He was waiting for someone to place him in his bed so he could lay down. He had been waiting for over an hour for assistance. During a random observation, on 12/11/24 at 2:50 p.m., Resident 39 was lying in bed. The call light was sitting on top of his roommate's nightstand, located between his bed and his roommates' bed, not within his reach. During an interview, on 12/11/24 at 2:50 p.m., the resident indicated he was unsure where his call light was located. During an interview, on 12/11/24 at 2:54 p.m., LPN 11 went down to the resident's room to look for his call light. She indicated it was sitting on top of his roommate's nightstand located between their beds and not within his reach. She thought staff forgot to put it back within his reach when they replaced his bedsheets earlier in the day. Resident 39's clinical record was reviewed on 12/13/24 at 9:29 a.m. Diagnoses included flaccid hemiplegia affecting his left nondominant side, vascular dementia, unspecified severity, with other behavioral disturbance, nontraumatic intracerebral hemorrhage, unspecified, and unspecified tremor. A quarterly Minimum Data Set (MDS) assessment, dated 9/5/24, indicated he was cognitively intact. His upper extremity had impairment on one side and his lower extremities had impairment on both sides. He was dependent on oral hygiene, toileting, shower/bathing, lower body dressing and rolling to the left and right. He required substantial/ maximal assistance for upper body dressing and personal hygiene. A care plan, dated 9/11/19 and revised on 9/9/24, indicated the resident was at risk for falls related to his history of falls, left sided hemiplegia, use of total mechanical lift, use of anti-depressants and anti-anxiety medications. Interventions included having his call light within reach while in his room. During an interview, on 12/17/24 at 2:54 p.m., the DON indicated call lights were to be within the reach of residents. A current policy, titled Call Lights: Accessibility and Timely Response, provided by the Corporate Nurse, on 12/16/24 at 3:52 p.m., indicated the following: .1. All staff will be educated on the proper use of the resident call system, including how the system works and ensuring resident access to the call light. 5. Staff will ensure the call light is within reach of resident and secured, as needed 3.1-3(v)(1)

Based on observation, record review, and interview, the facility failed to maintain a homelike environment by failing to repair a damaged wall for 1 of 3 residents reviewed for environment. (Resident 103) Findings include: Resident 103's clinical record was reviewed on 12/13/24 at 10:09 a.m. Diagnoses included multiple sclerosis, atherosclerosis, peripheral vascular disease, and major depressive disorder. An annual Minimum Data Set (MDS) assessment, dated 9/7/24, indicated the resident was cognitively intact and independent with eating, oral hygiene, and bed mobility. She required minimal assistance with toileting hygiene, showering, and personal hygiene. During an observation of Resident 103's room on 12/11/24 at 11:47 a.m., something blue could be seen at the bottom left corner of the heating/cooling unit. During an interview with Resident at the same time, she indicated the blue glove(s) had been pushed into the hole by an x-ray technician who was performing an x-ray on her. She could not provide a date, but indicated the technician felt cold air coming through the hole and plugged it up. The original unit had caulking around it which sealed the unit from the outside air. However, the unit had been replaced and no caulking had been applied around the new unit. The unit was on a north-facing wall and a lot of cold air came through on cold days. She had asked, one more than one occasion, for the hole to be repaired. She could not remember the dates of the requests. She had asked TLC management to repair the hole. During an interview with the administrator on 12/13/24 at 12:14 p.m., she indicated there had been no work orders submitted to fix the hole in the residents wall. She did not know anything about a hole. She went to the resident's room to observe the hole in the wall. The blue glove(s) used to plug the hole would not have come from the facility because they did not use blue glove(s) in the facility. During an interview with the administrator on 12/17/24 at 8:48 a.m., she indicated there was no work order to indicate the heating/cooling had been replaced, but it had, indeed, been replaced. During an interview with the maintenance director on 12/17/24 at 9:08 a.m., he indicated the unit must have been replaced before 6/2/24 because the resident's room received a deep clean on 6/2/24. He provided a picture, dated 6/2/24, of the heating/cooling unit in Resident 103's room. The lower left corner of the unit was not visible, but he was able to identify it as a new unit based on the type of plug visible in the picture. During an interview with the administrator on 12/17/24 at 2:03, she indicated it was impossible a hole in a wall would have been ignored. She put much effort into keeping the facility in good condition and there was no way she would have left a hole in the wall. She rounded the facility often and would have seen the hole. It was obvious from the surrounding environment that great effort was put into making the facility look nice and filling in a hole was an easy fix. At that time, a hole in the wall of the Director of Nursing's office was noted on the wall behind the DON's desk. During an interview with the corporate nurse on 12/17/24 at 2:05 p.m., she indicated the facility had a massive guardian angel program, the wound nurse saw the resident regularly for wound dressing changes, and other nurses provided daily care as well. Someone would have seen the hole. During an interview with the administrator on 12/17/24 at 2:08 p.m., she indicated the facility did not have a policy pertaining to maintenance or upkeep of the physical property or resident's rooms.

Based on observation, record review, and interview, the facility failed to provide daily grooming assistance for 1 of 3 residents reviewed for activities of daily living (ADLs). (Resident 112) Findings include: During an observation, on 12/11/24 at 11:03 a.m., Resident 112 sat in a chair in the dining/activity area and participated in a kick ball type activity. He was not shaved. During an observation, on 12/12/24 at 8:13 a.m., Resident 112 sat at the dining table feeding himself breakfast. He was not shaved. During an observation, on 12/16/24 at 8:14 a.m., Resident 112 sat at the dining table feeding himself breakfast. He was not shaved. During an observation, on 12/16/24 at 10:08 a.m., Resident 112 sat in a chair in the dining/activity area participating in exercises. He was not shaved. His facial hair length was the length of the thickness of two quarters stacked upon each other. Resident 112's clinical record was reviewed on 12/13/24 at 8:08 a.m. Diagnoses included Alzheimer's disease, unspecified and unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Physician's orders included quetiapine fumarate (antipsychotic) 25 milligrams (mg) - give 12.5 mg by mouth at bedtime for 14 days - started 12/11/24. A 10/24/24 quarterly Minimum Data Set (MDS) assessment indicated the resident was severely cognitively impaired. He required supervision/touching assistance with personal hygiene. He received restorative therapy in range of motion and dressing and grooming seven days of the seven-day assessment period. A care plan initiated on 9/24/24 and last reviewed on 11/3/24 indicated the resident needed assistance with his ADLs related to a change in his mobility and his cognitive status. The clinical record lacked resident refusals for ADL care/assistance or behaviors in the past 14 days. During an interview, on 12/16/24 at 10:36 a.m., CNA 16 indicated both men and women were shaved at least one time a week. Resident 112 required the staff to shave him. He did have some beard growth. She shaved him with showers, and he was due for a shower tomorrow. During an interview, on 12/16/24 at 10:42 a.m., CNA 17 indicated men and women residents were generally shaved on shower days and not between times. During an interview, on 12/16/24 at 11:01 a.m., CNA 18 indicated shaving of the men and women residents was performed on shower days. For men residents she shaved them at least every other day if it was needed. During an interview, on 12/16/24 at 3:34 p.m., the Director of Nursing (DON) indicated the staff should attempt to shave male residents daily. She was unable to locate documentation of Resident 112's refusals or behaviors with ADL care/assistance. A facility policy, dated 6/2013 and last revised 6/2021, provided by the Nurse Consultant, titled Personal Hygiene indicated the following: .Personal hygiene will be performed 2 times daily in the morning and before bed .Personal hygiene may include, but is not limited to: .Shaving 3.1-38(a)(3)(D)

Based on observation, interview, and record review, the facility failed to arrange dental appointments for a resident who misplaced or lost their dentures for 1 of 1 resident reviewed for dental services. (Resident B) Findings include: During observations on 12/11/24 at 3:39 p.m., 12/12/24 at 2:48 p.m., and 12/13/24 at 2:40 p.m., the resident's top denture was visible when she smiled, but the lower denture plate was not present. During an interview with Resident B's representative, on 12/12/24 at 9:34 a.m., they indicated Resident B was admitted in February of 2023. At that time, the resident had a full set of dentures (top and bottom plates). Within approximately 3 months, the bottom plate went missing. The facility recommended Company A, which they used for dentures. An appointment was made for Resident B. After a significant delay,which the facility could explain, the bottom plate never arrived. By September of 2023, the resident still did not have a lower denture. The family canceled the insurance with Company A and decided to take the resident to Company C to get the denture replaced. Within 3 weeks, the resident had the new lower denture. In December of 2023, the lower plate went missing again. Five months later, in May of 2024, a social services representative indicated the facility would arrange an appointment to have the denture replaced. Twelve months later, in December of 2024, the resident still had no lower plate denture. The representative indicated the facility had left it to the family to get a replacement. Social services was supposed to be working on it, but nothing had transpired to date. Resident B's clinical record was reviewed on 12/13/24 at 3:41 p.m. Diagnoses included, but were not limited to, hypertension, heart failure, unspecified dementia, chronic obstructive pulmonary disease, and depression. Review of the resident's personal inventory, dated 3/2/23, indicated the resident had both upper and lower dentures. A Minimum Data Set (MDS) annual assessment, dated 11/6/24, indicated the resident had a diagnosis of dementia and was severely cognitively impaired. Resident B's care plan lacked indication of the use of dentures. A progress note, dated 4/5/23, indicated the dentist from Company A had made a house-call for the initial placement of both the upper and lower dentures. A dental note, dated 5/13/23, indicated the resident was informed by a dentist from Company A that she had a minimal lower ridge and might need to use adhesive on her lower dentures for a proper fit. Upper and lower impressions were taken and shipped to the lab. A dental note, dated 8/14/23, indicated no upper or lower removable appliances were present upon examination by the dentist from Company A. The resident was edentulous (without teeth). The resident wanted a new set of dentures. She was a good candidate for dentures because she previously had worn dentures. A reprint was sent in that day to make a new upper and lower denture set. The reprint was necessary because the previous set of dentures, made by Company A, had been lost in the mail. The clinical record lacked documentation to indicate the replacement dentures were received by the facility or provided to Resident B. A social service note, dated 9/15/23 at 10:15, indicated the resident had felt like crying on 9/12/23 but had been easily redirected when she heard her dentures would be delivered soon. During an interview with the Social Services Director, on 12/16/24 at 10:26 a.m., she indicated the resident had twice misplaced her lower set of dentures. The resident often removed them. She still had her upper dentures. The SSD did not know how long Resident B had been without the lower denture, but it was a simple fix to get it replaced. The SSD had spoken to Resident B's representative in recent months but had no documentation of any conversations with him, nor from the resident's record regarding dentures. During an interview with LPN 20 on 12/16/24 at 11:51 a.m., she indicated Resident B had not had her lower denture for awhile, but did not know for how long. She could not find documentation about the resident's dentures in the clinical record. During an interview with the Administrator on 12/17/24 at 8:50 a.m., she indicated she did not understand why new dentures would be purchased because the resident took out the lower plate and refused to wear it. She did not know if the repeated removal of the lower plate was because it did not fit properly. The facility would not continue to replace a denture for someone who refused to wear it. During an interview with the SSD, on 12/17/24 at 4:31 p.m., she provided a document from Company A. The document, dated 8/14/23, indicated the dentures had been lost in the mail. There was a hand-written note on the document that indicated the resident's representative refused to accept a spare set of dentures. The SSD indicated the administrator had written the note. There was no statement from the company to indicate the spouse had refused to accept the dentures. A Cancellation of (Company A) Insurance document, dated 10/7/23, was provided by the DSS on 12/17/24 at 4:31 p.m. The document indicated the insurance policy for Resident B had been canceled, with an effective date of 9/30/23. A current facility policy, dated 3/5/24 and titled Dental Services, provided by the Corporate Nurse Consultant on 12/16/24 at 3:52 p.m., indicated the following: .It is the policy of this facility to assist residents in obtaining routine (to the extent covered under the State plan) and emergency dental care. Definitions: Routine dental services - means an annual inspection of the oral cavity for signs of disease, diagnosis of dental disease, dental radiographs as needed, dental cleaning, fillings (new and repairs), minor partial or full denture adjustments. Policy Explanation and Compliance Guidelines - 1) The dental needs of each resident are identified through the physical assessment and MDS assessment processes, and are addressed in each resident's plan of care . b) Oral care and denture care shall be provided in accordance with identified needs and as specified in the plan of care. Staff shall be mindful of resident dentures when providing care and alert to situations where dentures may be displaced, such as common with residents with dementia or those known to remove dentures at will and place them in areas other than the denture cup. c) Referrals to .dental provider shall be made as appropriate .5) The facility will not be responsible for lost or broken dentures unless it is determined that it was the fault of the facility. a) A blanket policy of facility non-responsibility for the loss or damage of dentures is prohibited. b) The facility shall determine responsibility for the loss or damage of dentures on a case-by-case basis, considering the circumstances surrounding the loss/damage, resident characteristics, and the resident's plan of care. 6) For residents with lost or damaged dentures, the facility will refer the resident for dental services within three days .d) The resident and/or resident representative shall be kept informed of all arrangements .8) For residents or resident representatives who do not wish to be referred for dental services .c) The resident's plan of care will be revised to reflect preferences. 9) All actions and information regarding dental services, including any delays related to obtaining dental services, will be documented in the resident's medical record This citation relates to Complaint IN00448390. 3.1-24(a)(3)

Based on observation, record review, and interview, the facility failed to ensure infection prevention and control strategies for transmission-based precautions were followed for 2 of 2 residents reviewed for COVID-19 isolation precautions. (Resident 35 and 67) Findings include: 1. During a random observation, on 12/16/24 at 8:22 a.m., Resident 35's door was closed with an over-the-door organizer containing gown, gloves, and N95 masks hanging on the door. The organizer lacked face shields, and the door lacked a sign indicating what precautions were required. During a random continuous observation, on 12/16/24 at 12:11, RN 12 applied a gown, gloves, and an N95 mask and entered Resident 35's room. She wore regular glasses. The door lacked a sign indicating what precautions were required, and the organizer did not contain face shields. During an interview, upon leaving Resident 35's room, RN 12 indicated the resident was on isolation for COVID-19 though there was no sign on the door. She had not applied a face shield because she wore glasses and had been told if glasses were worn, no face shield was required. During a random observation, on 12/16/24 at 1:25 p.m., Resident 35's door was closed. The door lacked a sign indicating what precautions were required. The over-the-door organizer lacked face shields. During a random observation, on 12/16/24 at 3:45 p.m., Resident 35's door was closed. The door lacked a sign indicating what precautions were required. The over-the door organizer lacked face shields. Resident 35's record was reviewed on 12/16/24 at 10:02 a.m. A physician's order for the resident to be in strict single isolation due to positive COVID test every shift for 10 days was started on 12/15/24. A care plan initiated on 12/15/24, with a revision on 12/16/24, indicated the resident required strict single room isolation related to COVID-19. During an interview, on 12/16/24 at 3:47 p.m., QMA 13 indicated Resident 35 was in isolation for COVID-19. The door typically would have a sign indicating what personal protective equipment (PPE) was required. For COVID-19 isolation, she wore a gown, N95 mask, gloves, and a face shield to enter the room. During an interview, on 12/16/24 at 3:51 p.m., RN 5 indicated when a resident was on COVID-19 isolation, a gown, N95 mask, gloves and a face shield were required to enter the room. She wore a face shield with her glasses. During an interview, on 12/16/24 at 3:57 the Infection Preventionist (IP) Nurse indicated a sign indicating the precautions required would typically be on a resident's door in isolation. Face shields were required with glasses unless the glasses were goggles to enter a COVID-19 isolation room. 2. During a continuous random observation, on 12/16/24 at 12:15 p.m., CNA 15 placed an N95 mask over her surgical mask, applied gloves and gown, and then entered Resident 67's room to deliver a meal tray. LPN 3 spoke briefly to CNA 15 before she entered the room. On Resident 67's door was a sign that indicated the resident required contact and droplet isolation. During an interview, after leaving the room, CNA 15 indicated she normally put the N95 mask on first. She had done it backwards and knew the N95 mask should not go over the surgical mask. LPN 3 had told her the N95 mask should not be placed over the surgical mask. CNA 15 wanted to make sure meals were delivered in a timely manner. Resident 67's clinical record was reviewed on 12/16/24 at 1:34 p.m. A physician's order for the resident to be in strict single isolation due to positive COVID test every shift for 10 days was started on 12/13/24. A care plan initiated on 12/13/24 indicated the resident required strict single room isolation related to COVID-19. During an interview, on 12/16/24 at 3:57 p.m., the IP nurse indicated the N95 mask should not have been placed over the surgical mask when CNA 15 entered a COVID-19 isolation room. Infection Control Guidance: SARS-CoV-2 (June 2024) was retrieved on 12/19/24 from the Centers for Disease Control and Prevention (CDC) website on 12/19/24. The guidance included the following .HCP [health care providers] who enter the room of a patient with suspected or confirmed SAR-CoV-2 infection should adhere to Standard Precautions and use a NIOSH [National Institute for Occupational Safety and Health] Approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face) How to Use Your N95 Respirator (May 2023) was retrieved on 12/19/24 from the National Institute for Occupational Safety and Health website. The guidance included the following . N95 respirators must form a seal to the face to work properly A facility policy, implemented 11/1/23 and revised on 5/29/24, provided by the Nurse Consultant on 12/16/24 at 3:52 p.m., titled COVID-19 Prevention, Response and Reporting, indicated the following: HCP who enter the room of a resident with suspected or confirmed SARS-CoV-2 infection should adhere to standard precautions and use a NIOSH-approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection 3.1-18(a)

Based on observation, interview, and record review, the facility failed to ensure urinary catheter outputs were monitored and documented for 3 of 3 residents reviewed for urinary catheters (Residents D, H, and J), resulting in Resident D being transferred to the hospital with a large amount of urine retained from a blocked urinary catheter. Findings include: 1. Resident D's clinical record was reviewed on 5/2/24 at 1:22 p.m. Diagnoses included, but were not limited to, neuromuscular dysfunction of bladder, unspecified focal traumatic brain injury (TBI) with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, and need for assistance with personal care. The physician's orders included, but were not limited to, cefdinir (antibiotic to treat urinary tract infections) 300 mg via gastrostomy tube for five days, change catheter bag every 30 days and as needed, flush catheter with 30 ml (milliliters) daily and as needed (1/31/24), and flush catheter with 100 cc (cubic centimeter) daily and as needed for sediment (3/7/24). A 1/30/24, admission, Minimum Data Set (MDS) assessment indicated Resident D was rarely/never understood, and was dependent on staff for personal care and toileting. He had a urinary catheter. A current care plan indicated a problem of an indwelling catheter related to neurogenic bladder related to TBI (1/27/24). Interventions included change catheter system when clinically indicated or ordered (1/27/24), staff would care for his catheter, personal hygiene needs and proper positioning of the drainage bag (1/27/24), and staff to observe for changes in the color, consistency, and odor of urine, changes in mental status, changes in amount of urine produced, and pain in lower back or lower abdomen (1/27/24). Resident D's February and March 2024 urinary output documentation indicated the following: On 2/27/24 at 3:33 a.m., 250 cc (cubic centimeters)[a unit of measure] urine output and at 9:59 p.m., 500 cc urine output, totaling 750 cc of urine output for the day. On 2/29/24 at 5:16 a.m., 200 cc urine output. The clinical record lacked documentation of additional urine output. On 3/1/24 at 4:41 a.m., 300 cc urine output. The clinical record lacked documentation of additional urine output. On 3/3/24, the clinical record lacked urine output documentation. On 3/4/24, the clinical record lacked urine output documentation. On 3/5/24, the clinical record lacked urine output documentation. On 3/6/24 at 5:29 a.m., 650 cc urine output and at 1:59 p.m., 750 cc urine output, totaling 1400 cc of urine output for the day. The history and physical note from a local hospital, dated 3/4/24 at 10:08 p.m., indicated Resident D was in the hospital with respiratory failure and was agitated. In the emergency department, it was discovered that Resident D's urinary catheter was clogged and upon changing the catheter, over a liter and a half (1500 cc) of urine had came out and Resident D felt a lot more comfortable. He would be admitted to the hospital with a urinary tract infection and started on Rocephin (antibiotic). The hospitalist impression/plan was (1) acute hypoxic respiratory failure, this was transient in nature and likely secondary to urine backup. (2) urinary tract infection (UTI), initiated Rocephin intravenously twice daily. (3) pressure ulcer, this was a known chronic entity. (4) encephalomacia (damaged brain tissue due to inflammation or bleeding); Resident D was chronically aphasic (unable to speak) secondary to TBI and subsequent encephalomalacia. The clinical record lacked indication of reason for transfer to the hospital on 3/4/24. During an interview with the DON, while reviewing Resident D's urinary output documentation, on 5/3/24 at 1:26 p.m., she indicated there was no documented urinary output for Resident D on 3/3/24. Resident D went out to the hospital on 3/4/24 at 5:30 a.m., and returned to the facility on [DATE] at 1:00 p.m. Sometimes, staff did not document the resident's urinary outputs. Resident D was non-responsive, but moaned at times during care. He tracked staff with his eyes at times. He had been in and out of the hospital for UTIs and respiratory problems. 2. Resident H's clinical record was reviewed on 5/6/24 at 10:31 a.m. Diagnoses included quadriplegia and retention of urine. The current physician's orders included 16 French Foley catheter (urinary catheter) with 30 cc balloon change once every 30 days, change catheter bag as needed every 30 day(s), change catheter as needed for occlusion and/or dislodgement every 24 hours as needed for replace catheter (2/29/24), change catheter bag as needed for if leaking (3/1/24), and urine output every shift at end of shift (5/6/24). A quarterly MDS assessment, dated 4/1/24, indicated Resident H was moderately cognitively impaired and required from substantial/maximal assistance to total dependence on staff for personal care. A current care plan indicated a problem of an indwelling catheter related to urinary retention/wounds (3/1/24). Interventions included change catheter system when clinically indicated or ordered (3/1/24), she would receive teaching on how to care for my catheter, personal hygiene needs, and proper positioning of the drainage bag (3/1/24), she would report and would observe for changes in the color, consistency, and odor of urine, changes in mental status, changes in amount of urine produced, and pain in the lower back or lower abdomen (3/1/24). Resident H's April and May 2024 urinary output documentation indicated the following: On 4/21/24 at 11:34 a.m., 600 cc urine output. On 4/22/24 at 3:40 a.m., 1000 cc urine output and at 9:58 p.m., 800 cc output, totaling 1800 cc of urine output for the day. On 4/23/24 at 5:23 a.m., 150 cc urine output and at 9:03 p.m., 1400 cc output, totaling 1550 cc of urine output for the day. The clinical record lacked urine output documentation for 4/24/24 through 4/27/24. On 4/28/24 at 7:03 a.m., 900 cc urine output and at 4:49 p.m., 1000 cc output, totaling 1900 cc of urine output for the day. On 4/29/24 at 12:20 p.m., 600 cc urine output and at 9:59 p.m., 725 cc output, totaling 1325 cc of urine output for the day. On 4/30/24 at 5:09 a.m., she had 950 cc urine output and at 8:16 p.m., she had 1000 cc output totaling 1950 cc of urine output. The clinical record lacked urine output documentation for 5/1/24 through 5/4/24. On 5/5/24 at 5:59 a.m., she had 950 cc urine output and at 1:52 p.m., she had 600 cc output totaling 1550 cc of urine output. 3. Resident J's clinical record was reviewed on 5/6/24 at 1:15 p.m. Diagnoses included, but were not limited to, other artificial openings of urinary tract status, neuromuscular dysfunction of bladder, benign prostatic hyperplasia without lower urinary tract symptoms, retention of urine, calculus of kidney, and hydronephrosis with renal and ureteral calculous obstruction. The current physician's orders included change catheter bag monthly and as needed, maintain suprapubic catheter 20 French/10 cc bulb and urine output every shift at end of shift (5/6/24). An admission MDS assessment, dated 3/7/24, indicated she was cognitively intact and was dependent on staff for personal care. Resident J had a care plan problem of a suprapubic catheter related to neurogenic bladder and urinary obstruction (6/22/22). Interventions included change catheter system when clinically indicated or ordered (8/7/23), consult with MD/NP as indicated (11/14/23), he would have extra fluids offered with medications (8/7/23), and he would report and staff would observe for changes in the color, consistency, and odor of urine, changes in mental status, changes in amount of urine produced, and pain in lower back or lower abdomen (6/11/22). Resident J's urinary output documentation indicated the following: On 4/21/24 at 5:59 a.m., he had 1700 cc urine output and at 10:44 p.m., he had 600 cc output totaling 2300 cc of urine output. On 4/22/24 at 3:28 a.m., he had 1200 cc urine output and at 5:17 p.m., he had 550 cc output totaling 1750 cc of urine output. On 4/23/24 at 5:21 a.m. he had 700 cc urine output. The clinical record lacked urine output documentation for the remainder of the day. The clinical record lacked urinary output documentation for 4/24/24 and 4/25/24. On 4/26/24 at 5:50 a.m., he had 675 cc urine output. The clinical record lacked urine output documentation for the remainder of the day. On 4/28/24 at 4:48 a.m., he had 900 cc urine output and at 9:59 p.m., he had 800 cc output totaling 1700 cc of urine output. On 4/30/24 at 5:59 a.m., he had 2650 cc urine output and at 12:53 p.m., he had 600 cc output totaling 3250 cc of urine output. On 5/1/24 at 4:29 a.m., he had 900 cc urine output and at 1:59 p.m., he had 500 cc output totaling 1400 cc of urine output. The clinical record lacked urinary output documentation for 5/2/24 and 5/3/24. On 5/4/24 at 5:57 a.m., he had 650 cc urine output and at 9:59 p.m., he had 900 cc output totaling 1550 cc of urine output. On 5/5/24 at 5:59 a.m., he had 2000 cc urine output and at 11:55 a.m., he had 1100 cc output totaling 3100 cc of urine output. During an interview with LPN 34, on 5/3/24 at 3:36 p.m., she indicated the urinary catheters were to be emptied and the output amount documented every eight hours by the CNAs. The CNAs would notify the nurse if there was a concern with little to no output or if the urine was dark or foul smelling. The nurses checked to see if outputs were documented. During an interview with QMA 15, on 5/3/24 at 4:00 p.m., she indicated anyone could empty a catheter. The CNAs documented the outputs, and the catheters were emptied every shift and as needed. She would report discoloration, smell, or blood in the urine and if there was no to low urine output, to a nurse. During an interview with LPN 13, on 5/6/24 at 3:35 p.m., she indicated she forgot how to check the charting for urinary output, but Unit Manager 5 checked the charting to make sure it was completed. During an interview with RN 27, on 5/6/24 at 3:45 p.m., she indicated CNAs emptied the catheter bags and documented the urinary outputs. The nurses checked to make sure the documentation was completed and thought when it was not documented it will turn up red on the charting. During an interview with Unit Manager 5, on 5/6/24 at 3:39 p.m., she indicated herself and the nurses checked the CNAs' documentation. She checked day shift while she was working and then checked the other shifts' charting the following morning. If the urinary outputs were not documented, she would go to the resident's room first to make sure the catheter drainage bag wasn't full so it wasn't backing up into the resident's bladder, then she would counsel the staff for not documenting the outputs. A current facility policy, titled Catheter Care, provided by the DON on 5/6/24 at 12:33 p.m., indicated the following: .Policy Explanation .8. Empty drainage bag every shift .Document care and report any concerns noted to the nurse on duty This citation relates to Complaint IN00432308. 3.1-41(a)(2)

Based on observation, record review, and interview, the facility failed to ensure a resident received supervision per physician order and facility policy during the administration of a nebulized medication for 1 of 1 resident during a random observation. (Resident G) Findings include: During a random observation on 5/2/24 at 12:37 p.m., Resident G was lying in bed with a nebulizer mask on her face. A nebulizer machine was sitting on her bedside table and was in operation. There was no nurse present in the room, nor in the hallway. At 12:41 p.m., Nurse Manager 9 was passing hall trays for lunch and passed Resident G's room. At 12:44 p.m., Nurse Manager 9 entered Resident G's room, placed her tray on her overbed table, turned off the nebulizer machine, and placed the nebulizer mask on top of the machine. Resident G's clinical record was reviewed on 5/6/24 at 12:55 p.m. Diagnoses included, but were not limited to, morbid (severe) obesity with alveolar hypoventilation, obstructive sleep apnea, acute respiratory failure with hypoxia, acute respiratory failure with hypercapnia, chronic obstructive pulmonary disease with (acute) exacerbation and acute on chronic diastolic (congestive) heart failure. The current physician's orders included budesonide 0.5 mg (milligram)/2ml (milliliter) inhale orally twice daily to be administered by clinician and ipratropium-albuterol inhale 3 ml twice daily to be administered by clinician. During an interview with Nurse Manager 9, on 5/2/24 at 12:51 p.m., she indicated Resident G should have been supervised during the nebulizer treatment. During an interview with LPN 13, on 5/6/24 at 3:35 p.m., she indicated she was supposed to supervise Resident G while receiving the nebulizer treatment, but another resident down the hall needed help with his shoes. A current facility policy, titled Nebulizer Therapy, provided by the DON, on 5/6/24 at 2:57 p.m., indicated the following: Care of the Resident .14. Observe resident during the procedure for any change in condition 3.1-47(a)(6)

Based on interview and record review, the facility failed to administer insulins as ordered and scheduled for 2 of 3 residents reviewed for insulin administration (Resident B and C). Findings include: 1. Resident B's clinical record was reviewed on 5/2/24 at 1:06 p.m. Diagnoses included type 2 diabetes mellitus without complications and type 2 diabetes mellitus with diabetic neuropathy. The current physician's orders included insulin glargine (long-acting insulin) 30 units subcutaneously at bedtime, tirzepatide (improve blood sugars) 10 mg (milligram) every seven days, and insulin aspart (short-acting insulin) per sliding scale subcutaneously before meals. The Medication Administration Records (MAR) indicated the following: Insulin glargine 30 units was scheduled for 3/23/24 at 8:00 p.m. and was administered on 3/23/24 at 11:44 p.m. Insulin glargine 30 units was scheduled for 3/24/24 at 8:00 p.m. and was administered on 3/25/24 at 1:41 a.m. Insulin glargine 30 units was scheduled for 4/20/24 at 8:00 p.m. and was administered on 4/20/24 at 11:37 p.m. Insulin aspart 4 units was scheduled for 4/21/24 at 5:30 p.m. and was administered on 4/21/24 at 10:33 p.m. 2. Resident C's clinical record was reviewed on 5/2/24 at 2:40 p.m. Diagnoses included type 2 diabetes mellitus with unspecified diabetic retinopathy without macular, type 2 diabetes mellitus with diabetic polyneuropathy, and type 2 diabetes mellitus with hyperglycemia. The March and April 2024 physician's orders included insulin glargine 25 units at bedtime. The MAR indicated the following: Insulin glargine 25 units was scheduled for 3/2/24 at 8:00 p.m. and was administered on 3/3/24 at 2:29 a.m. Insulin glargine 25 units was scheduled for 3/23/24 at 8:00 p.m. and was administered on 3/23/24 at 11:20 p.m. Insulin glargine 25 units was scheduled for 3/24/24 at 8:00 p.m. and was administered on 3/25/24 at 1:08 a.m. Insulin glargine 25 units was scheduled for 4/21/24 at 8:00 p.m. and was administered on 4/22/24 at 4:01 a.m. During an interview with the DON, on 5/3/24 at 1:26 p.m., she indicated the residents were given insulins on time, but the nurses were not documenting it at them time it was administered. A current facility policy, titled Timely Administration of Insulin, provided by the DON on 5/6/24 at 2:57 p.m., indicated the following: .Policy: It is the policy of this facility to provide timely administration of insulin in order to meet the needs of each resident and to prevent adverse effects on a resident's condition. Policy Explanation and Compliance Guidelines: 1. All insulin will be administered in accordance with physician's orders .5. Procedure .e. Administer insulin at appropriate times. f. Document on the medication administration record the time and location of the insulin injection This citation relates to Complaint IN00432015. 3.1-37(a)

Based on interview and record review, the facility failed to ensure the Infection Preventionist (IP) had sufficient time to perform IP responsibilities by requiring the full-time DON to assume the (at minimum) part-time IP role with a facility census of 96 residents. This deficient practice had the potential to affect 96 of 96 residents who resided at the facility. Finding includes: During an interview, on 11/27/23 at 10:13 a.m., the DON indicated she was both the full-time DON and the infection preventionist for the facility. The facility census provided on 11/27/23 at 10:13 a.m. by the DON, indicated the facility census was 96. During an interview, on 12/4/23 at 2:55 p.m., the DON indicated she oversaw the infection prevention and control program at the facility. The unit managers turned in individual infection sheets daily as needed. She transferred those to her surveillance sheets and facility maps of infections. She gathered much of her daily information at morning meetings. She monitored infections daily. She was unable to account for times she functioned as the DON or the IP as she did not document such and was uncertain of the breakdown of times. She was the only facility staff person with the required infection control and prevention training. The facility had not offered the pneumococcal conjugate vaccine (PCV) 20 (for pneumonia) to residents who had previously received the pneumococcal conjugate vaccine (PCV) 13 (for pneumonia) or the pneumococcal polysaccharide vaccine (PPSV) 23 (for pneumonia) as recommended by the Centers for Disease Control and Prevention (CDC). According to the CDC website page Adult Immunization Schedule, https://www.cdc.gov/vaccines/schedules/hcp/imz/adult.html#note-pneumo, accessed on 12/5/23 at 10:39 a.m., indicated for those [AGE] years of age or older: 1. If previously received only the PCV13 then one dose of PCV20 or one dose of PPSV23 should be given at least one year after the administration of the PCV13. 2. If previously received only the PPSV23 then one dose of pneumococcal conjugate vaccine (PCV) 15 or one dose of the PCV20 should be administered at least one year after the administration of the PPSV23. 3. If both the PCV13 and the PPSV23 were received, but no PPSV23 was received after the age of [AGE] years or older then one dose of PCV20 should be administered or one PPSV23 should be administered at least five years after the last vaccine dose. 4. If both PCV13 and PPSV23 were administered, and PPSV23 was received at [AGE] years or older, then based on shared clinical decision-making, one dose of PCV at least five years after the last pneumococcal vaccine dose should be given. A current facility job description for Infection Preventionist, revised 1/17/20, provided by the Consultant Nurse on 12/4/23 at 3:30 p.m., indicated the IP must provide the following: .Oversight of the IPCP [infection prevention and control program], which includes .a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors .following accepted national standards .assess the need for, develop, and present IPCP in-service education for individual departments, general orientation, and annual review as needed; education includes but is not limited to .Resident immunization programs The working conditions included, .At times needed to work beyond normal working hours such as weekends/holidays and on other shifts A current facility job description for the Director of Clinical Services (also called the DON), revised on 12/5/19, provided by the Consultant Nurse on 12/4/23 at 3:30 p.m., indicated .The primary purpose of this position is to set resident care standards for all direct care standards for all direct care providers and provide complete supervision/management for the nursing department. This position includes planning, organizing, implementing, evaluating and directing the overall operation of Nursing Services within the guidelines of the facility policies and with strict adherence to all local, state and federal regulations . The working conditions included .At times needed to work beyond normal working hours such as weekends/holidays and on other shifts

Based on interview and record review, the facility failed to ensure the activity director completed the required education to meet the qualifications for an activity director. Finding includes: Employee records were reviewed on 11/29/23 at 4:00 p.m. The records lacked documentation of the required training for the Activity Director. During an interview on 11/30/23 at 10:19 a.m., the Administrator indicated the Activity Director began her position on 9/28/23. She was not currently certified. During an interview on 11/30/23 at 10:25 a.m., the Activity Director indicated she had registered for the Activity Director course on 11/30/23. Review of a current job description for the Activity Director, revision date 5/1/09, and provided by the Nurse Consultant on 12/4/23 at 3:30 p.m., indicated the following: .Desired qualifications include: Being a graduate of a state approved Activity Director course preferred, but not required

Based on observation, record review, and interview, the facility failed to implement care plan interventions to reduce the risk of falls for 1 of 3 residents reviewed for accidents. (Resident 95) Findings include: During an observation, on 11/28/23 at 11:17, Resident 95 was in his room, seated in his wheel chair. A record review performed on 11/29/23 at 1:18 p.m. indicated the following: Review of Resident 95's clinical record was completed on 11/29/23 at 1:18 p.m. Diagnoses included vascular dementia without behavioral disturbance, transient ischemic attack (TIA), and type 2 diabetes mellitus with diabetic polyneuropathy. The resident's care plan, initiated on 9/20/23, indicated he was at risk for falls related to impaired balance, moderate cognitive deficits, and use of psychotropic medications. A progress note, dated 10/14/23 at 2:45 p.m., indicated the resident tried to transfer to the restroom without his walker. The immediate intervention was to remind the resident to use his walker when up, use his call light, and to wait for help to walk to the bathroom. A sign was posted in the room to remind the resident to call for help. An interdisciplinary team (IDT) note, dated 10/16/23 at 2:07 p.m., indicated a new intervention to make sure non-slip socks were on the resident at all times. A progress note, dated 11/21/23 at 12:31 p.m., indicated the IDT determined the fall to be related to the resident's loss of balance. CNA 3 was reminded she should have another staff member with her when transferring the resident. An IDT progress note, dated 11/22/23 at 11:09 a.m., indicated the resident was to have two staff members to assist with his transfers. A progress note, dated 11/23/23 at 10:06 a.m., indicated the resident was assisted to the restroom by one staff member, CNA 3. During the transfer, he lost his balance and fell . A progress note, dated 11/30/23 at 8:19 p.m., indicated the resident was found lying on the floor next to his bed. The immediate intervention was to replace the resident's regular socks with non-skid socks (which was previously developed on 10/16/23). During an interview with CNA 3, on 12/4/23 at 9:30 a.m., she indicated the fall on 11/23/23 happened when the resident had initially refused to go to the restroom when she offered assistance. His daughter was present at the time and encouraged him to go ahead and let the CNA take him to the restroom. It was during the transfer to the restroom that the resident fell . During an interview with the Director of Nursing (DON), on 12/4/23 at 1:40 p.m., she indicated the resident had dementia and was very impulsive. He tried to get up by himself repeatedly and, as a result, she had implemented many interventions. The resident had been educated about the need to ask for assistance when transferring. He could be educated, but did not remember the education later. The staff was updated on interventions using a Kardex system. The Kardex system was available in a hard copy and electronically. The unit manager also updated staff about changes to the care plan. The CNA had been updated on the intervention to provide two staff members present when assisting the resident. CNA 3 had found the resident already in the restroom and was just trying to help the resident when the fall occurred. The CNA was more concerned about helping him at the moment than trying to find another staff to assist her with the transfer. Regarding the lack of non-skid socks when the resident fell on [DATE], he had been wearing shoes and socks. After dinner, he had taken off his shoes and put himself in bed. When he fell out of his bed, he had been wearing the regular socks. A facility document, titled Fall Investigation and Risk Evaluation, with a revised date of 6/22, was provided by the DON. The policy indicated the following: .It is the policy of this facility to provide an environment that is free from accident hazards over which the facility has control and provides supervision and assisted devices to prevent avoidable accidents .All residents will have a care plan developed that includes the resident's complications and risks, an attainable and measurable goal, and individualized interventions to decrease their risk of falls 3.1-45(a)(2)

Based on observation, record review, and interview, the facility failed to ensure a resident did not receive an antipsychotic without an indication of use for 1 of 5 residents reviewed for unnecessary medications (Resident 31). Findings include: During an observation, on 11/29/23 at 1:50 p.m., Resident 31 was sitting in his room. During a wound observation, on 12/1/23 at 2:03 p.m., the resident was cooperative with care. His clinical record was reviewed on 11/28/23 at 2:03 p.m. Diagnoses included major depressive disorder, recurrent, mild and anxiety disorder. Current physician orders included observe for side effects (antipsychotic, antidepressant, antianxiety, hypnotic) (3/24/22), Seroquel (antipsychotic) 50 mg tablet, give half tablet (25 mg) two times a day for depression(7/26/23), lorazepam (antianxiety) oral concentrate 2 mg/ml, give 0.25 ml for 0.5 mg every evening for anxiety (8/4/23), and Zoloft (antidepressant) 25 mg tablet, give one tablet once a day for major depressive disorder, recurrent, mild (8/17/23). A 10/24/23 significant change MDS (Minimum Data Set) assessment indicated he was cognitively intact. He had verbal behavioral symptoms directed towards others (example; threatening others, screaming at others, cursing at others). Behavior of this type had occurred one to three days during assessment period. This behavior did not put him at significant risk for illness or injury, did not significantly interfere with his care or his participation in activities or social interactions. He had rejection of care for one to three days of the assessment period. There had not been a change in his behavior or other symptoms since the prior MDS assessment. He had received an antipsychotic, antianxiety, and antidepressant. A current care plan, with a revision date of 11/9/23, indicated he was at risk for side effects related to the use of antidepressants, antianxiety and antipsychotics. His goal was he would not have adverse effects from the use of his medication for his mental health and psychological well being. Interventions included he would report and staff would observe for adverse side effects related to the need for an antidepressant, and for adverse side effects related to the need for an antipsychotic to treat his mental health, his psychotropic medications would be reviewed quarterly by a pharmacist and the interdisciplinary team to ensure the need for continued use and the appropriateness for a gradual dose reduction, he would be educated of the risks of refusing care, the benefits of care, and his rights to choose would be respected, if he started yelling and cursing, set boundaries, tell him staff would return in a certain number of minutes, staff would return within the given timeframe and report behaviors to the nurse or social services, redirected with quick intervention when behavior began as to avoid escalation. A current care plan, with a revised date of 11/13/23, indicated he utilized antianxiety medication for a diagnosis of anxiety. His symptoms included, rushing others, restlessness, worry, nervousness, and repetitive phrases. The goal indicated he would have less than two episodes a week of anxiousness and anxiety would be calmed within five minutes of staff interventions. Interventions included staff answered his questions and met his immediate care needs, invited him to food related and special event activities related to his preference, listened to his feelings and reframed his thoughts to positive such as talking about what I used to do, and provided reassurance. A current care plan, with a revised date of 11/9/23, indicated he utilized an antipsychotic medication and an antidepressant medication for the diagnosis of depression and major depressive disorder. It was displayed in frustration/anger, resisting care, threats, unrealistic expectations of care, and repetitive movements or phrases. The goal indicated he would have less than two episodes a week of mood distress and mood distress would be calmed within five minutes of staff intervention. Interventions included he would be allowed to express his feelings, he was educated on signs, symptoms, care, and treatment options, encouraged to actively participate in his activities of daily living, he received his medications as ordered, he reported and staff observed for changes in his depression symptoms. A Behavior Sheet note, dated 10/15/23 at 5:31 a.m., indicated Resident 31 had been verbally aggressive and threatened staff he would have them fired. A staff member explained to him that everyone was doing their best. He continued to yell and curse. A Behavior Sheet note, dated 10/15/23 at 4:34 p.m., indicated he had yelled out of his door for help and his call light was on. A staff member explained to him that they had quite a few residents and only so many staff members, and told him as soon as they were done they would make sure they came to him. He indicated his light had been on since 1:30 p.m. and staff member explained they didn't arrive until 2:00 p.m. A Behavior Sheet note, dated 12/1/23 at 8:09 a.m., indicated he had repetitive verbalizations and yelling/screaming that had been moderate in intensity. Staff approached him in a calm manner and validated his feelings, which improved his behavior. A review of behaviors in the look-back report of his clinical record indicated on 10/22/23 at 1:59 p.m., he had behaviors of yelling/screaming, abusive language, and threatening behavior. Interventions had been refused. A Geri-Psych Note, dated 10/26/23 at 1:00 a.m., indicated his PHQ-9 (Patient Health Questionnaire) for depression on 10/26/23 was zero out of 27, with no self-reported depressive symptoms. During the session, he presented as neutral with flat affect. Supportive therapy, cognitive stimulation, empathetic listening, and emotional support to help explore and promote adaptive management of negative affect and mood were provided. Psychological services were recommended to monitor cognitive changes and related behavioral issues. A Geri-Psych Note, dated 11/9/23 at 12:00 a.m., indicated he had been referred for psychological evaluation and treatment to establish care for ongoing monitoring and management of mood and behaviors. He had a history of depression and anxiety. During the session, he presented as depressed with flat affect. Supportive therapy, cognitive stimulation, empathetic listening, and emotional support to help explore and promote adaptive management of negative affect and mood were provided. Psychological services were recommended to monitor cognitive changes and related behavioral issues. The long term goal for his depression was to reduce the frequency, intensity, and degree of impairments related to depression symptoms to improve his daily functioning. An Interdisciplinary Team note, dated 11/9/23 at 9:39 a.m., indicated the team had reviewed and adjusted his behavioral, mood, and cognitive care plans to meet his current needs. He had been noted to be content without concerns. A Behavior Management Team Review, dated 11/24/23 at 9:17 a.m., indicated he had been placed back on behavior management for increased demanding/verbal aggression behavior. In the past 30 days, he had experienced three occurrences and two alerts. Medical considerations for behaviors included stroke, dementia. Participating and contributing factors lacked patterns. Medications were reviewed and included Zoloft 25 mg daily, Seroquel 25 mg twice a day, and lorazepam 0.5 mg every evening. A Geri-Psych Note, dated 11/28/23 at 12:00 a.m., indicated he was seen for a follow up to assess his current psychiatric status and review psychotropic medications. The SSD had reported he was at his baseline. Staff had indicated he continued to refuse care at times and had verbal aggression towards staff when approached. He continued to receive Seroquel and Zoloft for depression as well as lorazepam for anxiety. He was observed in his room, lying in bed with his eyes closed. He appeared to be calm and comfortable. He had three behaviors in the past month and two alerts, per the SSD. Staff were to observe for significant changes in mood/behaviors including sadness, anhedonia (lack of interest, enjoyment or pleasure from life's experiences), tearfulness, hopelessness, isolating in room, feelings of guilt, and decreased appetite. A Geri-Psych Note, dated 11/30/23 at 12:00 a.m., indicated he had been referred for psychological evaluation and treatment to establish care for ongoing monitoring and management of mood and behaviors. He had a history of depression and anxiety. The session summary included SSD (Social Service Director) had indicated he had some irritability and agitation recently. During the session, he presented as depressed with flat affect, he was sleepy and in bed. His affect, tone, and demeanor indicated depression. Supportive therapy, cognitive stimulation, empathetic listening, and emotional support to help explore and promote adaptive management of negative affect and mood were provided. Psychological services were recommended to monitor cognitive changes and related behavioral issues. A Social Service Behavior note, dated 12/1/23 at 12:11 p.m., indicated he had been noted for yelling and cussing at staff, called them names, and demanded a lift chair from the facility. Interventions included staff redirected him and validated his feelings. He was transferred into his bed where he was more comfortable and was able to calm down. During an interview, on 12/4/23 at 10:50 a.m., LPN 5 indicated Resident 31 occasionally had behaviors of hollering out if he thought care had not been provided timely and redirection was effective. During an interview, on 12/4/23 at 10:56 a.m., CNA 12 indicated he yelled and screamed if his light didn't get answered right away. The interventions used included leave and re-approach and try another care-giver During an interview, on 12/4/23 at 11:06 a.m., QMA 7 indicated he he yelled out and resisted care at times. During an interview, on 12/4/23 at 11:07 a.m., the ASSD (Assistant Social Service Director) indicated the resident believed his care should be a priority above others and was non-complaint with care. He had different responses to different staff, if staff explained they needed to tend to another resident and would be right back that was effective at times. During an interview, on 12/4/23 at 11:13 a.m., the SSD indicated the resident was monitored for verbal aggression and demanding behaviors. He was not a patient person, interventions included to reassure him, give him time frames, divert his attention, and engage him in conversation. He was seen by a geri-psych service, a counselor came twice a month and the nurse practitioner came one a month. For the monthly behavior meetings they reviewed behavior sheets and behavior alerts, they summarized what had happened during the month to see if new interventions were needed. He received an antianxiety medication for anxiety, an antidepressant for depression, and an antipsychotic for depression as an adjunct to the antidepressant. His life history included not being a patient person and had a bad temper. Review of a current facility policy, titled PSYCHOACTIVE MEDICATIONS/GRADUAL DOSE REDUCTION (GDR)/UNNECESSARY MEDICATIONS POLICY, with a revised date of 4/23 and provided by the DON on 12/4/23 at 11:49 a.m., indicated the following: .Policy: It is the policy of this facility that a resident will receive medications and psychoactive medications only when it is necessary to improve the resident's overall psychosocial health status .14. UNNECESSARY DRUGS - Every resident's drug regimen is to be free from unnecessary drugs. An unnecessary drug is any drug when used: .Without adequate indications for its use; * Medication is prescribed for a diagnosed condition and not being used for convenience or discipline. * Medication is clinically indicated to manage a resident's symptoms or condition where other causes have been ruled out. * Signs, symptoms, or related causes are persistent or clinically significant enough (e.g., causing functional decline) to warrant the initiation or continuation of medication therapy Review of the FDA (Food and Drug Administration) website, https://www.accessdata.fda.gov/drugsatfda_docs/label/2013/020639s061lbl.pdf, indicated the following indications and uses for Seroquel: schizophrenia, bipolar disorder, and special considerations in treating pediatric schizophrenia and bipolar I disorder. 3.1-48(a)(4)

Based on interview and record review, facility failed to ensure residents received accurate, up-to-date information on currently available vaccinations for 3 or 5 residents reviewed for immunizations (Residents 7, 22, 82). Findings include: 1. The clinical record for Resident 22 was reviewed on 11/29/23 at 1:14 p.m. Diagnoses included Parkinson's disease without dyskinesia, chronic obstructive pulmonary disease, acute and chronic respiratory failure without hypercapnia. She was hospitalized for double pneumonia in June 2023. Resident 22 had received pneumococcal polysaccharide vaccine (PPSV) 23 on 12/28/04 and pneumococcal conjugate vaccine (PCV) 13 on 10/7/15. She was not educated on the new PCV 20 vaccination, which came out on 6/8/21. CDC recommendations indicated to give one dose of PCV 20 at least 5 years after the last pneumococcal vaccine dose. 2. The clinical record for Resident 82 was reviewed on 11/28/23 at 2:16 p.m. The diagnoses included chronic obstructive pulmonary disease and type 2 diabetes. Resident 82 was educated and declined PPSV 23 on 3/23/22. He was not educated or offered the new PCV 20 vaccination. 3. The clinical record for Resident 7 was reviewed on 11/28/23 at 2:17 p.m. The diagnoses included type 2 diabetes, immunodeficiency due to conditions elsewhere, and Parkinson's disease without dyskinesia. Resident 7 was educated and declined PPSV 23 on 7/16/19. He was not educated or offered the new PCV 20 vaccination. During an interview, on 12/4/23 at 2:55 p.m., DON indicated they have not offered the PVC 20 vaccine to any residents who previously had the PCV 13 or PPSV 23. The facility had gone to the PCV 20 vaccinations for new residents wanting the vaccine on admission. A current facility policy, titled RESIDENT VACCINATION POLICY, last revised on 6/2023 and provided by the DON on 11/27/23 at 10:13 a.m., indicated the following: .Policy All residents will be offered recommended vaccinations annually at minimum (Influenza, Pneumococcal, COVID) per CDC recommendations to encourage and promote benefits to protect against these illnesses to assist in reducing this populations significant risks .Policy Implementation .3. Pneumococcal vaccines may be offered and received at any time deemed necessary. A review of the resident's vaccine history on currently recommended pneumococcal vaccines will be done and if deficient, CDC recommended vaccines will be offered 3.1-13(a)

Based on interview and record review, the facility failed to ensure timely administration of insulin per physician orders for 4 of 4 residents reviewed for insulin administration (Resident B, C, D and E). Findings include: 1. Resident B's clinical record was reviewed on 10/12/23 at 8:57 a.m. Diagnoses included type 2 diabetes mellitus without complications and type 2 diabetes mellitus with diabetic neuropathy. A quarterly Minimum Data Set (MDS), dated [DATE], indicated he was cognitively intact. He had a current care plan for fluctuating blood glucose levels related to diagnosis of diabetes (2/21/23). His interventions included he would receive his insulin as ordered (9/15/23) and he preferred to have his insulin before breakfast (revised 10/12/23). His Medication Administration Records (MAR) indicated the following: Insulin glargine (long-acting insulin) 30 units was scheduled to be administered on 9/4/23 at 9:30 p.m., and was administered on 9/4/23 at 6:48 p.m. Insulin glargine 30 units was scheduled to be administered on 9/16/23 at 9:30 p.m., and was administered on 9/17/23 at 1:08 a.m. Insulin glargine 30 units was not administered on 9/17/23 or 9/23/23 at 9:30 p.m. Novolog (short acting insulin) per sliding scale was scheduled to be administered on 9/2/23 at 8:00 a.m., and was administered on 9/2/23 at 10:04 a.m. Novolog per sliding scale was scheduled to be administered on 9/15/23 at 8:00 a.m., and was administered on 9/15/23 at 9:51 a.m. During an interview with Resident B, on 10/12/23 at 9:49 a.m., he indicated he was considered a brittle diabetic. His meal trays were delivered to his room, and he had to wait to receive his insulin before he ate. By then, his food was cold. 2. Resident C's clinical record was reviewed on 10/12/23 at 9:27 a.m. Diagnoses included type 2 diabetes mellitus with hyperglycemia and morbid (severe) obesity due to excess calories. A significant change MDS, dated [DATE], indicated he was cognitively intact. He had a current care plan for fluctuating blood glucose levels related to diagnosis of diabetes (4/23/21). His interventions included he would receive his insulin as ordered (4/23/21). His Medication Administration Records (MAR) indicated the following: Insulin glargine 70 units was scheduled to be administered on 9/3/23 at 7:00 a.m., and was administered on 9/3/23 at 12:46 p.m. Humalog (short acting insulin) 8 units and per sliding scale was scheduled to be administered on 9/3/23 at 7:30 a.m. Both were administered on 9/3/23 at 12:45 p.m. Insulin glargine 70 units was scheduled to be administered on 9/12/23 at 7:00 a.m., and was administered on 9/12/23 9:51 a.m. Insulin glargine 70 units was scheduled to be administered on 9/16/23 at 7:00 a.m., and was administered on 9/16/23 at 9:51 a.m. Insulin glargine 50 units was scheduled to be administered on 9/16/23 at 8:00 p.m., and was administered on 9/17/23 at 2:19 a.m. Insulin glargine 70 units was scheduled to be administered on 9/23/23 at 7:00 a.m., and was administered on 9/23/23 at 9:03 a.m. Humalog 8 units was scheduled to be given on 9/23/23 at 5:30 p.m., and was administered on 9/23/23 at 7:42 p.m. Insulin glargine 50 units was not administered on 9/23/23 at bedtime. Insulin glargine 70 units was scheduled to be administered on 10/10/23 at 7:00 a.m., and was administered on 10/10/23 at 8:48 a.m. Humalog 8 units and per sliding scale was scheduled to be administered on 10/11/23 at 11:30 a.m. Both were administered on 10/11/23 at 1:40 p.m. Insulin glargine 70 units was scheduled to be administered on 10/12/23 at 7:00 a.m., and was administered on 10/12/23 at 9:31 a.m. Humalog 8 units and per sliding scale was scheduled to be administered on 10/12/23 at 7:30 a.m. Both were administered on 10/12/23 at 9:28 a.m. During an interview with Resident C, on 10/12/23 at 3:20 p.m., he indicated he liked to receive his pills and insulin before breakfast. Sometimes his insulin was not given to him before meals, and he had to ask for the insulin to be given. The staff would give him excuses as to why they had not given it to him and said they were too busy. 3. Resident D's clinical record was reviewed on 10/12/23 at 11:14 a.m. Diagnoses included type 2 diabetes mellitus with diabetic neuropathy, type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema and morbid (severe) obesity due to excess calories. A quarterly MDS, dated [DATE], indicated he was cognitively intact. He had a current care plan for being at risk for his blood sugars to fluctuate related to diabetes mellitus. He preferred regular pop, many snacks outside of diet, fast food, chips, etc. His blood sugar ran high due to his choices (12/9/22). His interventions included he would receive insulin per orders (12/12/22). His Medication Administration Records (MAR) indicated the following: Insulin glargine 45 units was scheduled to be administered on 10/1/23 at 3:00 p.m., and was administered on 10/1/23 at 5:07 p.m. Insulin glargine 45 units was scheduled to be administered on 10/2/23 at 3:00 p.m., and was administered on 10/2/23 at 5:15 p.m. Insulin glargine 45 units was scheduled to be administered on 10/4/23 at 3:00 p.m., and was administered on 10/4/23 at 5:05 p.m. Insulin glargine 45 units was scheduled to be administered on 10/5/23 at 7:00 a.m., and was administered on 10/5/23 at 10:58 a.m. Humalog per sliding scale was scheduled to be administered on 10/5/23 at 7:30 a.m., and was administered on 10/5/23 at 9:24 a.m. Insulin glargine 45 units was scheduled to be administered on 10/6/23 at 7:00 a.m., and was administered on 10/6/23 at 8:56 a.m. Insulin glargine 45 units was scheduled to be administered on 10/7/23 at 3:00 p.m., and was administered on 10/7/23 at 5:10 p.m. Insulin glargine 45 units was scheduled to be administered on 10/9/23 at 7:00 a.m., and was administered on 10/9/23 at 9:45 a.m. Humalog per sliding scale was scheduled to be administered on 10/10/23 at 7:30 a.m., and was administered on 10/10/23 at 9:37 a.m. Insulin glargine 45 units was scheduled to be administered on 10/11/23 at 7:00 a.m., and was administered on 10/11/23 at 9:58 a.m. 4. Resident E's clinical record was reviewed on 10/12/23 at 3:45 p.m. Diagnoses included anemia in chronic kidney disease, end stage renal disease, type 2 diabetes mellitus with diabetic neuropathy, and morbid (severe) obesity due to excess calories. A quarterly MDS, dated [DATE], indicated he was cognitively intact. He had a care plan for fluctuating blood glucose levels related to diagnosis of diabetes. He often ordered fast food and had snacks in his room (11/18/14). His interventions included he preferred to take his insulin after his meal instead of before my meals at times (4/10/23). His Medication Administration Records (MAR) indicated the following: Humalog per sliding scale were scheduled to be administered on 9/10/23 at 5:30 p.m., and was administered on 9/10/23 at 9:02 p.m. Insulin glargine 20 units was scheduled to be administered on 9/10/23 at 8:00 p.m., and was administered on 9/11/23 at 1:51 a.m. Insulin glargine 20 units was not administered on 9/23/23 at bedtime. Insulin glargine 20 units was scheduled to be administered on 10/7/23 at 8:00 p.m., and was administered on 10/8/23 at 1:10 a.m. Insulin glargine 20 units was not administered on 10/8/23 at bedtime. During an interview with Resident E, on 10/12/23 at 3:36 p.m., he indicated he was getting his insulin after meals and he didn't know why. During an interview with QMA 12, on 10/12/23 at 12:31 p.m., she indicated when she worked up front (Fireside hall), she would have the Fireside hall, the long hall of [NAME] and the Assisted Living hall. She tried to make it to [NAME] hall by 9:00 a.m. During an interview with RN 4, on 10/12/23 at 2:04 p.m., she indicated at times, a resident's blood sugar was low and she would see how much the resident ate before giving them insulin. Sometimes the resident was maybe in therapy and she would not go to therapy to give them insulin. During an interview with the DON, on 10/12/23 at 2:29 p.m., she indicated she felt the staff were not giving medications late, they were just documenting late. She had some staff who would document the medications given after the medication pass. Everyone knew medications should be documented as soon as they were administered. During an interview with LPN 13, on 10/12/23 at 2:47 p.m., she indicated medications could be documented at late because multiple residents may need assistance, or she would get stopped during her medication pass. Medications were always given on time especially her insulin's. It was her responsibility to document medications were given as soon as the medications were given. A current facility policy, titled Medication Administration, provided by the DON, on 10/12/23 at 2:43 p.m., indicated the following: .a. Documentation is completed on the MAR/eMAR immediately after medication(s) ingested by the resident This citation relates to Complaint IN00417630. 3.1-37(a)

Based on record review and interview, the facility failed to ensure supervision during dining for 1 of 4 residents reviewed for accidents. (Resident B) This deficient practice resulted in the resident choking and requiring placement on a ventilator at the hospital. Findings include: Review of a facility self-reportable to the State Agency, dated 8/5/23 at 7:01 p.m., indicated Resident B had an episode of choking at dinner time. The resident had a diet of pureed, and mechanical soft upon request, and was currently receiving speech therapy. During dinner, a table mate gave the resident a sandwich, which the resident began eating, and staff noticed the resident began choking. The nurse was notified and the resident required the Heimlich maneuver and suctioning to be done in the dining room. He was sent to the hospital. Resident B's clinical record was reviewed on 8/10/23 at 11:08 a.m. His diagnoses included chronic obstructive pulmonary disease (COPD), vascular dementia, oropharyngeal dysphagia, and hoarding disorder. A Minimum Data Set (MDS) assessment, dated 7/22/23, indicated he was severely cognitively impaired and required extensive assistance of one staff member for eating. Current physician orders, dated 4/6/22, indicated his diet was regular, pureed texture, with thin consistency liquids, and may have mechanical soft food items upon request with close supervision. A current careplan, dated 8/2/19, indicated his eating ability was at risk for decline related to his dementia diagnosis. Intervention approaches included to alternate solids and liquids: 3 to 1, cue me to pick up glass/cup and take a drink, cue me to pick up utensil and take a bite, cue me to take small bites/sips, lingual sweep and swallow, swallow completely before taking next bite, and finish meal with a liquid wash. An activities of daily living (ADL) careplan, dated 8/31/15, indicated he required assistance related to his dementia diagnosis. Intervention approaches included requiring supervision with set up for eating. A current cognition care plan, dated 7/12/22, indicated he would eat food off other people's trays. A current discharge summary, dated 8/5/23, indicated Resident B was hospitalized after a choking incident. The pulmonologist note included the diagnosis of acute left mainstem bronchus occlusion with food particle or foreign body (food stuck in his lung). The resident remained intubated (tube placed to assist with breathing) and transferred to a secondary hospital for further care and possible surgery options to remove the food obstruction. During an interview, on 8/11/23 at 10:15 a.m., QMA 2 indicated staff had been told multiple times to watch Resident B while eating. He would take food from other people's tray and hide food items in his pockets to eat. She had caught him before with food that did not follow his diet order. The dining room assignment was supposed to be filled out daily so staff would be able to assist both in the dining room and with the residents remaining on the hall for meals. There should be two CNAs and one QMA from [NAME] Lane, and one CNA from [NAME] Lane, at lunchtime in the dining room. Review of an 8/11/23 at 12:22 p.m. incident report and investigation of Resident B's choking, provided by the DON, indicated three staff members in the dining room during the meal service - CNA 3, CNA 4 and RN 5. The DON's interview with CNA 4 indicated he had transported residents back to their rooms and was not present in the dining room when Resident B choked. The investigation report lacked interviews with the two remaining employees present in the dining room at the time of the resident's choking. During an interview, on 8/11/23 at 12:26 p.m., the DON indicated she had confirmed the meal tray served to Resident B was pureed. The kitchen staff had served a ham sandwich to another resident, per request, who was sitting at the same table during dinner. During an interview, on 8/11/23 at 12:37 p.m., the DON indicated the care plan interventions requiring supervision during eating for Resident B were old and he no longer required those interventions. Resident B's speech therapy evaluation, dated for certification period 7/21/23-8/19/23, provided by the DON on 8/11/23 at 1:19 p.m., indicated the following recommendations: close supervision of oral intake, cues to slow rate of eating, and to alternate bites/sips frequently. During a phone interview, on 8/11/23 at 1:00 p.m., CNA 3 indicated she was assisting someone at the table for dependent residents, and had a view of Resident 14's profile at another table across the room. She did not remember what was on the tray in front of Resident B, but he had been seated with his roommate and another resident, or maybe two. CNA 4 and RN 5 had left the dining room prior to the resident choking. There were no staff members sitting at the table with Resident 14. CNA 4 and RN 5 were not available for interview during the survey. The National Dysphagia Diet, reviewed on 8/14/23 at 2:30 p.m., at https://www.[NAME]-[NAME].org/health-library/tests-and-procedures/d/dysphagia-diet-level-1.html., indicated that patients with dysphagia diagnosis should eat only pureed food and avoid coarse foods. This Federal tag relates to Complaint IN00414590. 3.1-45(a)(2)

Based on interview and record review, the facility failed to protect cognitively impaired residents from a resident with sexually aggressive behaviors in 2 of 2 encounters (Resident B, Resident C, and Resident D). This deficient practice resulted in a non consensual sexual act with a cognitively impaired resident. The immediate jeopardy began on [DATE] when Resident B was observed to be touching and rubbing a female residents leg (Resident D) while attempting to place her hand on his private area. The Administrator was notified of the immediate jeopardy on [DATE] at 12:42 p.m. Findings include: Review of a behavior sheet, dated [DATE] at 1:01 p.m., indicated Resident B was observed to be touching and rubbing a female resident's leg while attempting to place her hand on his private area. Resident B was asked to stop by staff and he left the area. An undated, written statement by the Social Service Director (SSD) was provided by the Director of Nursing (DON) on [DATE] at 10:12 a.m. The statement indicated she received a call from a nurse who stated she did not witness the interaction between Resident B and Resident D. Other staff reported Resident B was rubbing Resident D's leg in the lounge and she did not respond back. She did not feel this was inappropriate but informed the nurse to separate them and to keep an eye on them. She did not feel the behavior warranted an urgent intervention. A behavior sheet, dated [DATE] at 3:36 p.m., indicated Resident B was in Resident C's room. Resident C was sitting on the bed and Resident B was standing in front of her with his pants and brief down. He was guiding the residents head to his penis and his penis was in the resident's mouth. Resident B was removed from the room by staff and taken to the SSD office. A SSD progress note, dated [DATE] at 3:53 p.m., indicated she was made aware of the sexually inappropriate behaviors. The female residents that Resident B was pursuing were not able to state they would consent to his touch. Resident B was placed on security checks and the female residents were removed from the situation. A SSD progress note, dated [DATE] at 8:29 a.m., indicated Resident B was noted to be in the lounge touching Resident D's legs in a sexual manner and later found in Resident C's room with his pants down and his penis in her mouth. An Indiana Department of Health (IDOH) reportable was provided by the DON on [DATE] at 2:00 p.m. The reportable, dated [DATE] at 3:01 p.m., indicated a male resident was found in a female residents room with his penis in her mouth. The residents were separated and the Administrator was notified. The male resident was placed on 15-minute checks and the female resident was moved to the Memory Care Unit. A resident to resident abuse form was provided by the DON on [DATE] at 3:30 p.m. The form indicated the incident occurred on [DATE] at 3:00 p.m. A QMA found a male resident in a female resident's room with his penis in her mouth. The residents were separated and the female resident was moved to another hall and the male resident was placed on 15-minute checks. A statement by QMA 3, dated [DATE], indicated the resident would not stay out of female resident rooms during the first-shift and when 2nd shift started, he continued the behaviors. When she entered the room, she saw Resident B being inappropriate with Resident C. During an interview on [DATE] at 4:33 p.m., QMA 3 indicated she came in for second shift and was counting narcotics with the nurse while the other nurses' were receiving report. The second shift CNA asked the day-shift nurse to come and help get Resident B out of Resident C's room. The nurse asked her to help the aide while she paged the SSD. When she got to the room she saw what was happening because the door was open. She told Resident B they don't do that here and to have a seat. While taking the resident to see the SSD, they met her in the hallway and he was placed on 15-minute checks. A review of the 15-minute check-off sheet, the first documented location of the resident was on [DATE] at 1:45 p.m. Resident B remained in his room until [DATE] at 1:00 p.m. when he was moved to another hall and the 15-minute checks continued. During an interview on [DATE] at 9:57 a.m., Housekeeper 4 indicated she was cleaning Resident D's room while Resident D was sitting in the lounge. She saw Resident B go to the lounge. She kept an eye on him and noticed him attempt ,d+[DATE] times to move Resident D's hand towards his groin area. She did not actually see her hand on his groin. She indicated Resident B may be declining. The resident did wander but she did not recall seeing any sexual behaviors in the past. During an interview on [DATE] at 9:25 a.m., Resident B indicated he used to live at the facility with his wife, but she has since died . He indicated it was his first day in current room and he slept there the prior night. He did have a lady friend but she lived on another level. The name of the lady friend he provided was not a current or former resident. a. The record for Resident B was reviewed on [DATE] at 2:03 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly Minimum Data Set (MDS) assessment, dated [DATE], indicated the resident admitted to the facility on [DATE]. The resident was moderately cognitively impaired. A health care plan, dated [DATE] and revised [DATE], indicated the resident had behavioral symptoms such as disturbing others, wandering around the hall when he could not sleep and waking up his roommate. Interventions included, but were not limited to, allow resident to express his feelings and observe for changes in behavior. b. Resident C's record was reviewed on [DATE] at 2:31 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly MDS assessment, dated [DATE], indicated the resident was severely cognitively impaired. During an interview on [DATE] at 9:15 a.m., Resident D indicated she was admitted less than 2 months ago. She did not have any relationships with male residents because she was married. c. Resident D's record was reviewed [DATE] at 9:35 a.m. A review of her most recent MDS assessment, dated [DATE], indicated she was moderately cognitively impaired. Review of a current facility policy, dated ,d+[DATE] and revised ,d+[DATE], titled Abuse, Neglect and Misappropriation of Resident Property, which was provided by the DON on [DATE] at 2:04 p.m., indicated the following: Policy: This facility's policy is the resident has the right to be free from verbal, sexual, physical and mental abuse .but not limited to, facility staff, other residents, consultants .other individuals. .Sexual Abuse: Is non-consensual sexual act of any type with a resident lacking the capacity to consent .Policy Interpretation and Implementation .5. The facility shall prevent abuse by (iv) Ongoing assessment, care planning and monitoring of residents with needs and behaviors The Immediate Jeopardy (IJ) that began on [DATE] was removed on [DATE] when the facility began inservicing staff on abuse and the reporting process. The noncompliance remained at the lower scope and severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because monitoring was on-going. This Federal tag relates to Complaint IN 985. 3.,d+[DATE](b)

Based on observation, interview and record review, the facility failed to provide adequate supervision to prevent a resident from falling resulting in fractures for 1 of 8 residents reviewed for falls (Resident 67), failed to ensure residents had call lights in reach during a random observation (Resident 85) and failed to follow care plan interventions for a dependent resident to prevent falls for 1 of 8 residents reviewed for falls (Resident 102). Findings include: A. During an observation, on 8/18/21 at 9:54 a.m., Resident 67 was lying in bed hollering out, a floor mat was on the floor beside her bed, and the other side of the bed was against the wall. The resident's clinical record was reviewed on 8/17/21 at 1:57 p.m. Diagnoses included, but were not limited to, dementia, fracture of lateral malleolus of left fibula, and fracture of left calcaneus. An X-ray report, dated 8/4/21, indicated left tibia and fibula findings included, but were not limited to, comminuted fractures had been present and involved the proximal tibia. A current care plan, dated 9/15/17, indicated the resident was at risk for falls related to pain, history of falls, use of narcotic analgesics, use of anti-depressant, impaired balance, unsteady gait, and fracture. The goal indicated interventions would minimize her risk for falls resulting in serious injury. Interventions included, but were not limited to, the resident had chosen to take the risk of falls to maintain her independence initiated 5/5/21, resident educated to use walker when she was up walking at all times initiated 5/18/21, educate and encourage her to have non-skids socks on at all times initiated 6/26/21, Dycem to bed initiated and she would sleep/rest in a bed with mat on the floor to assist decreasing risk of injury when she rolled out of bed, 7/1/21, and room change closer to nurses station initiated 8/4/21. A Quarterly Risk Evaluation, dated 2/25/21, indicated she was at moderate risk for falls, her score was 8.0. A significant change MDS (Minimum Data Set), dated 7/13/21, indicated she had moderate cognitive impairment, required limited assistance with transfers, and supervision to walk in her room. A walker and wheelchair were used as mobility devices. A progress note, dated 5/4/21 at 5:41 p.m., indicated she had fallen in her room sometime in the night, she had become dizzy and hit the door. She reported the incident to the hospice that evening. Several areas with bruising to neck, chest, and breast, the immediate intervention was for the resident to let the nurse know right away when she became dizzy or fell . An IDT (Interdisciplinary Team) note, dated 5/5/21 at 12:48 p.m., indicated the root cause of the fall had been related to the resident's diagnosis of dementia, major depressive disorder, [CONDITION(S)], and anxiety disorder. Her care plan was updated to indicate the resident chose risk of falls to maintain independence. A progress note, dated 5/9/21 at 7:25 a.m., indicated the resident had two skin tears to her left forearm, areas measured 2.0 cm (centimeter) X 1.5 cm and 1.5 cm X 0.5 cm. The resident indicated she had obtained skin tears when she had gone through the doorway from the bathroom. A progress note, dated 5/18/21 at 12:00 p.m., indicated she had fallen in the hallway and was lying on her right side. She had been ambulating with walker. An IDT note, dated 5/19/21 at 12:28 p.m., indicated the root cause of the fall had been ambulating without a walker, had been having hallucinations, dementia, and low hemoglobin that had not been treated as per plan of care. Her care plan was updated to remind resident to always have walker when ambulating. A Quarterly Risk Evaluation, dated 5/25/21, indicated she was at high risk for falls, her score was 20.0. A progress note, dated 6/6/21 as 12:00 a.m., indicated the resident had fallen in her room and a small red spot had been noted to the back of her head. She was encouraged to use call light when getting up. A progress note, dated 6/26/21 8:45 p.m., indicated the resident had been found sitting on her bottom on the floor. An IDT note, dated 6/28/21 at 1:29 p.m., indicated the root cause of the fall had been her getting up out of bed and slipped. Her care plan was updated to wear gripper socks at all times. A progress note, dated 6/30/21 at 9:15 a.m., indicated she had fallen in her room, had been found on floor next to her bed, indicated she had slid off her bed. A progress note, dated 6/30/21 9:37 p.m., indicated she had been found on the floor beside her bed at 9:00 p.m. She had indicated she had been looking for shoes. A progress note, dated 7/1/21 4:40 a.m., indicated the resident had been found on her knees in front of the toilet. An IDT note, dated 7/1/21 at 10:55 a.m., indicated the root cause of the fall had been the resident's weakness, forgets/refuses to use call light to ask for assistance due to wanting to maintain independence. The care plan was updated to place Dycem (a non-skid surface) on bed to prevent sliding. An IDT note, dated 7/1/21 at 11:05 a.m., indicated the root cause of the fall had been the resident's weakness, forgets/refuses to use call light to ask for assistance due to wanting to maintain independence. The care plan was updated to put into action the Dycem placement on the bed to help prevent sliding out of bed from previous fall on 6/30/21, to add a low profile mat on floor beside bed, and the resident re-educated and reminded on importance of call light. An IDT note, dated 7/1/21 at 11:14 a.m., indicated root cause of fall was forgets/refuses to use call light to ask for assistance due to wanting to maintain independence. The care plan was updated to place voiding diary into action and continued education and reminders to resident of importance of call light use. A progress note, dated 7/1/21 at 12:29 p.m., indicated the resident had increased pain to the bottom of left foot, new order was received to obtain an X-ray of the left foot. A progress note, dated 7/2/21 at 2:52 p.m., indicated X-ray results had indicated suspect a lateral calcaneal fracture. A progress note, dated 7/2/21 at 6:04 p.m., indicated the resident had fallen at 3:00 p.m. She had been found sitting on floor behind the door and had indicated she was trying to find the bathroom. An eINTERACT SBAR (Situation Background Assessment Recommendation), dated 7/2/21 at 7:38 p.m., indicated change of condition related to altered mental status and urinary incontinence. The resident had been sent to local hospital. A progress note, dated 7/4/21 at 5:15 a.m., indicated the facility had received a call from the hospital, the resident was admitted for a urinary tract infection, critical hemoglobin, and fracture of left heel. A progress note, dated 7/5/21 at 11:30 a.m., indicated the resident had returned to the facility. A Quarterly Risk Evaluation, dated 7/5/21, indicated she was at high risk for falls, her score was 19.0. An IDT note, dated 7/6/21 at 3:46 p.m., indicated the root cause of the fall had been her son had requested to send her to the emergency room , blood transfusion was refused, was septic from urinary tract infection, and a fracture after the last two falls. Care plan updated to add low profile mat to the floor beside her bed to aid in prevention of significant injuries. A MDS note, dated 7/13/21 at 8:24 a.m., indicated she complained of constant pain all over in last five days. Resident indicated pain disturbed sleep and limited day to day activities, rated worst pain in last five days an eight, received routine [MEDICATION(S)] (an opioid), and she had limitation to her left lower extremity due to recent fracture. A progress note, dated 8/4/21 at 5:20 a.m., indicated the resident had been found on the floor in her room, in the doorway to the bathroom, and she was lying on her back. She had been assessed and assisted into the bed. A progress note, dated 8/4/21 at 6:45 a.m., indicated the local hospital emergency room had been contacted for an emergency transport. A Social Service progress note, dated 8/4/21 at 1:47 p.m., indicated the son had agrees to move the resident closer to the nurses' station. The son had reported the resident had a fracture below her knee, would be at the hospital for 24 hours and then return to the facility. A Quarterly Risk Evaluation, dated 8/7/21, indicated she was at high risk for falls, her score was 17.0. During an interview, on 8/20/21 at 8:52 a.m., LPN 7 indicated the resident was weak, would fall frequently, and wanted to maintain her independence. During an interview, on 8/20/21 at 11:50 a.m., the DON indicated the resident had fallen and sustained fracture. Review of a current facility policy, titled Fall Investigation and Risk Evaluation, with a revised date of 6/21 and provided by the DON, on 8/20/21 at 2:26 p.m., indicated the following: Policy: It is the policy of this facility to provide an environment that is free from accident hazards over which the facility has control and provides supervision and assisted devices to prevent avoidable accidents .Avoidable Accident means that an accident occurred because the facility failed to: identify environmental hazards and/or assess individual resident risk of an accident, including the need for supervision and/or assistive devices; and/or .monitor effectiveness of the interventions and modify the care plan as necessary B. On 8/20/21 at 10:45 a.m., Resident 85 was in his room, seated in his high-backed wheelchair. He was sliding down in the chair, with his feet pushing against his roommate's bed. His oxygen tubing had pulled off of his face and was tangled in his catheter tubing on the side of the chair. His call light was tangled up and on the side of the bed, which was behind the resident, out of reach. The resident indicated he was not able to call for help and needed assistance. During an interview, on 8/20/21 at 10:50 a.m., CNA 22 indicated the resident's call light should be in reach. Review of Resident 85's clinical record was completed on 8/17/21 at 12:58 p.m. Diagnoses included, but were not limited to, [CONDITION(S)], palliative care, and [CONDITION(S)] disease. A 7/29/21, 14-day, Minimum Data Set (MDS) assessment indicated he was moderately cognitively impaired, required extensive assistance with bed mobility, and was dependent for transfers. Review of a current facility policy, titled CALL LIGHT, dated 4/2020 and provided by the DON on 8/20/21 at 11:22 a.m., indicated the following: .The call light should be within reach of the resident whether in bed, sitting in a chair in the room .The intent of this requirement is that residents .have a means of directly contacting caregivers C. During an interview with Resident 102, on 8/16/21 at 2:55 p.m., he indicated he had fallen out of bed recently, the staff left his bed up too high, and the floor mat was not beside his bed. On 8/17/21 at 1:54 p.m., Resident 102 was observed in his bed, his bed was at thigh height, a staff member was standing at his bedside, a floor mat was not lying on the floor beside his bed and his over bed table was at the end of his bed. On 8/18/21 at 2:19 p.m., the resident was in bed, the floor mat was folded up at end of the bed and his bed was at waist height. The resident's clinical record was reviewed on 8/18/21 at 10:05 a.m. Diagnoses included, but were not limited to, [CONDITION(S)] without cataplexy, flaccid [CONDITION(S)] affecting left nondominant side, acquired absence of right leg above knee and left leg below knee. His medications included, but were not limited to, [MEDICATION(S)] ([MEDICATION(S)]) ([CONDITION(S)]) 5 milligram (mg) three times daily, [MEDICATION(S)] HCl (antidepressant) 30 mg daily, [MEDICATION(S)] (nerve pain) 25 mg twice daily, [MEDICATION(S)] ([CONDITION(S)]) 20 units subcutaneously at bedtime and insulin [MEDICATION(S)] ([CONDITION(S)]) subcutaneously per sliding scale before meals and at bedtime. A significant change Minimum Data Set (MDS), dated [DATE], indicated the resident was cognitively intact, he required total assistance with bed mobility and transfers. He had an impairment his upper extremity on one side and to both sides on his lower extremities. He had one fall since last assessment with no injury. He had a fall care plan, initiated on 11/18/14, that indicated he was at risk for falls related to impaired balance related to [CONDITION(S)] secondary to [CONDITION(S)] accident ([CONDITION(S)]), fluctuating blood sugars, history of falls, pain, amputations resulting in phantom pain. His interventions included, but were not limited to, he would sleep/rest in a bed low to the floor with a mat on the floor to decrease the risk of injuring himself when he rolled out of the bed, initiated on 12/31/20. His risk assessments, fall progress notes and Interdisciplinary (IDT) notes indicated the following: A 7/10/21, fall risk assessment indicated the resident was a moderate risk for falls. A progress note, dated 7/18/2021 at 6:45 a.m., indicated the resident was found lying at his bedside on the floor and was trying to get up. The resident was a bilateral below the knee [CONDITION(S)]. The resident indicated he was trying to get up out of bed. Immediate intervention was he was assessed for injuries and assisted to bed per two assist. A fall IDT note, dated 7/19/21 at 5:50 p.m., indicated the root cause of fall was the resident attempted to get out of bed without any type of assistance, he was a double below the knee [CONDITION(S)] and a Hoyer lift. The care plan was updated to educate the resident to ask for assistance when he wanted to get up or lie down. A fall nurses note, dated 7/31/21 at 12:30 a.m., indicated the resident was found on the floor next to his bed and he was unable to give a description of the fall. The immediate intervention was to place a fall mat on the floor next to the resident's bed. A 7/25/21, quarterly fall risk assessment indicated the resident was at a high risk for falls. A fall IDT note, dated 8/2/21 at 10:03 a.m., indicated the root cause of the fall was the resident was restless at all times and laid in bed crossways and stated it was more comfortable. He was care planned for a low bed with special mat while in bed. The mat was not in place at the time of the fall. A fall nurses note, dated 8/9/21 at 5:00 p.m., indicated the resident was found on the floor by a CNA, the resident stated he had just slipped off the bed. The immediate intervention was the bed was put in low position and mat put into use. A fall IDT note, dated 8/10/21 at 9:38 a.m., indicated the root cause of the fall was the resident's bed was not in ordered low position nor was mat on floor. He was very restless at all times. The care plan was updated to change out mattress to regular mattress. During an observation and interview with LPN 71, on 8/18/21 at 2:29 p.m., she walked out of the resident's room, she indicated his fall interventions were, as she pointed to the resident's mat that was folded up at the end of his bed, should had been on the floor next to his bed and his bed should had been in the lowest position. Review of a current facility policy, titled Fall Investigation and Risk Evaluation, with a revised date of 6/21 and provided by the DON, on 8/20/21 at 2:26 p.m., indicated the following: Policy: It is the policy of this facility to provide an environment that is free from accident hazards over which the facility has control and provides supervision and assisted devices to prevent avoidable accidents .Avoidable Accident means that an accident occurred because the facility failed to: identify environmental hazards and/or assess individual resident risk of an accident, including the need for supervision and/or assistive devices; and/or .monitor effectiveness of the interventions and modify the care plan as necessary 3.1-45(a)(1) 3.1-45(a)(2)

Based on observation, interview and record review, the facility failed to ensure a cognitively impaired resident, who was at risk for elopement, received the supervision to prevent elopement from the facility for 1 of 5 residents reviewed with exit seeking behaviors. This failure resulted in the resident leaving the locked unit and then the facility, walking alone in cold weather, and being picked up in a vehicle by a passerby. The resident was then driven to a family members house (Resident B). The immediate jeopardy began on [DATE], when Resident B eloped from the facility. The Administrator, DON, ADON, and Nurse Consultant 3 were notified of the immediate jeopardy on [DATE] at 3:24 p.m. The immediate jeopardy was removed on [DATE], but the noncompliance remained at the lower scope and severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: Resident B's clinical record was reviewed on [DATE] at 8:29 a.m. [DIAGNOSES REDACTED]. A [DATE] admission/5 day Minimum Data Set (MDS) assessment indicated she was severely cognitively impaired and did not wander. She required extensive assistance with ADLs, walking, and locomotion. A [DATE], quarterly,MDS assessment indicated she was moderately cognitively impaired and did not wander. She required extensive assistance with ADLs, limited assistance with locomotion, and supervision with walking. She did not have a careplan problem of risk for elopement. She had a current, [DATE], care plan problem of behaviors such as hitting staff. She had a current care plan problem, revised [DATE], for a cognitive deficit related to dementia and [MEDICAL CONDITION], and she resided on a secure unit. Review of an elopement assessment, dated [DATE], indicated she wandered, had poor judgement, searched for her spouse/family, and stood at the door waiting for someone to let her out. She had attempted to go out alone. Review of (MONTH) 2019 Progress Notes indicated the following: On [DATE] (the note was timed for 8:32 p.m.), the resident was missing from Memory Lane (the dementia unit). After staff had finished passing supper trays, they tried to look for the resident, but she was nowhere to be found. Another resident's family member told staff they had seen the resident walk out the Memory Care door and through Harbor lane. Staff went to look for her inside and outside, and called 911. A call was placed to the resident's family, and staff were informed she was with her husband. The resident was found by someone who recognized her on Adams Street and had driven her to her husband's house. On [DATE] at 7:35 p.m., a call was placed to inform Resident B's family about the resident's situation. The note indicated the actual call was placed between approximately 6:30 p.m. and 6:40 p.m. (Late entry completed [DATE] at 8:25 p.m.) On [DATE] at 8:00 p.m., the facility was notified the family was taking Resident B to the emergency department for evaluation, as they were concerned over the resident having hypothermia (low body temperature). On [DATE] at 8:55 p.m., the emergency department had called for information on the resident. She was discharged from the emergency department at 10:09 p.m. and arrived back at the facility per private vehicle at 10:45 p.m. Review of a [DATE] emergency department report indicated she was examined at 8:14 p.m. and complained of being cold, as it was very cold outside, but she was wearing a coat and gloves. She seemed very weak, but did not complain of any pain. Her hands and feet were cold, but pink. She gradually got warm and became more alert. She was discharged back to the nursing home. Review of a facility Resident Elopement investigation report indicated she had been located on [DATE] at 7:10 p.m., by a passerby, who then took her home. She was located less than a mile away (,[DATE] of a mile). The weather was 15 degrees with clear skies. She was wearing a black coat, gloves, and a purse, with her shoes on. She had an unsteady gait, but ambulated independently. She had been last seen at 6:41 p.m., on Harbor Lane, by the memory care door. She had last been seen by CNA 5 on the Harbor Lane unit at 6:41 p.m., and had last spoken to staff at 6:00 p.m. She had previously voiced desire to leave or seemed upset, but not on that day. She had been on a locked unit, which was ineffective because a family member of another resident had let her out. Camera footage was reviewed by the facility and it was deemed she was let off of the unit via the Harbor Lane/Memory Lane door by another resident's family member. She then exited the building through the Harbor Lane door by entering the code herself. A written statement from CNA 15 indicated she had observed Resident B on Harbor Lane, outside of the Gold Dining Room, on [DATE] during supper. She had thought she was a visitor until she had been told there was a missing resident. Review of the Resident Elopement investigation report and interview with the Administrator, DON, ADON, and Nurse Consultant 3, on [DATE] at 11:12 a.m., indicated the following: The DON indicated the resident had been located near a store in south Marion by a passerby, who had observed her stumbling, and they picked her up and took her to the resident's husband's home. The person who had let her off of the unit had denied doing so, but it was observed on the video. Observation of a time marked video, during the interview, indicated on [DATE] at 6:38 p.m., the resident had walked past the nurses station, walking toward the south end of the hallway and entered a room on the right side of the hall. At 6:39 p.m., she re-entered the hallway, wearing a black coat and carrying a hand bag. She walked to the south door of the unit. A visitor (identified by the ADON as the son of another resident) walked in the direction of the same door, carrying a tray. He entered a room on the left, then re-entered the hallway. He approached the resident, and the door could be observed being opened and the visitor held it open, as the resident left the unit. He returned in the direction of the camera. Review of additional video footage indicated at 6:41 p.m., she was standing in the entry way of the Harbor Lane doors (facing 36th Street), between the two sets of doors. The resident was observed to have her arm in the direction of the key pad, to the left of the door. CNA 7 walked past the nurses station, in an eastern direction, and looked in the resident's direction; he proceeded out of the camera angle. At 6:42 p.m., CNA 12 walked by the nurses station, in an eastern direction, and then back again, just as the resident walked out the second set of doors to the outside, and turned right, walking outside in a western direction. During a phone interview, on [DATE] at 11:57 a.m., LPN 13 indicated he had been on duty on the dementia unit when Resident B had eloped. He had last observed the resident around 6:20 p.m. through 6:30 p.m., when staff had been passing supper trays. The resident had not wanted to eat, but he did not note when she left the dining room. After all the trays were passed, they had two more residents who had not yet made it to the dining room, so they went down the hall to get them. He then realized he didn't think Resident B was present on the unit. Staff then checked every room and bathroom, went to the other halls and asked staff if they had seen her. During a phone interview, on [DATE] at 12:03 p.m., a family member of Resident B's indicated she had been present at the resident's spouse's home after the resident had been brought there. She gave the name of the passerby, who had picked up the resident, and indicated they did not know the passerby prior to her having picked up the resident in her vehicle. She and the resident's spouse had taken the resident to the emergency department for evaluation, due to her being very cold. During an interview, on [DATE] at 12:39 p.m., the resident's spouse indicated the resident had arrived at his home just before 7:00 p.m. He had been shocked to see his wife with a stranger at the door. The passerby had informed him she had picked up the resident at 31st Street and Branson Street, and given her a ride home because Resident B had told her the car she was driving had broken down. The resident was cold and exhausted upon arrival to the house. She had a history of [REDACTED]. He thought the facility had called around ,[DATE] minutes after she had arrived at his house to inform him she was missing, and he informed the caller she was with him at the house. During a phone interview, [DATE] at 12:52 p.m., the passerby indicated she had observed the resident near 32nd Street and Branson Street, walking very slowly and taking very small steps. It was really cold outside, so she stopped to check on her. When she got the resident in the car, she had told her that her car had died on 40th Street. She gave the passerby the address and even showed her the house. She had stumbled while getting out of the car, and almost collapsed, so she had walked her to the door. The resident's husband was totally shocked when they arrived. She waited at the house until a family member the husband had called had arrived. The facility had not contacted her about the resident. During an interview, on [DATE] at 1:18 p.m., the ADON, indicated there had not been a careplan in place for elopement the morning of [DATE]. During a phone interview, on [DATE] at 9:21 a.m., CNA 15 indicated she did not know the resident, as she had only worked on the dementia unit once. She usually worked on Harbor Lane. Review of google.com/maps indicated the resident was picked up by the passerby 0.8 mile from the facility (at 32nd Street and Branson Street). The distance from the store to her husband's home was an additional 0.8 mile. Review of a weather report for (MONTH) 5, 2019 for Marion, IN indicated a there was a high of 20 degrees F (Fahrenheit) for the day and the low temperature had been nine degrees F. Review of a current facility policy, titled ELOPEMENT/MISSING RESIDENT, revised ,[DATE] and provided by Nurse Consultant 3 on [DATE] at 12:24 p.m., indicated it was the responsibility of all personnel to report a cognitively impaired resident found outside of the facility or attempting to leave the facility to the charge nurse immediately. The immediate jeopardy that began on (MONTH) 5, 2019 was removed on (MONTH) 10, 2019 when the facility educated staff on elopement, updated the resident clinical record and changed the door codes, but the non-compliance remained at the lower scope and severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy because monitoring and education was ongoing. This Federal Tag relates to complaint IN 079. 3XXX,[DATE](a)

Based on observation, interview and record review, the facility failed to ensure staff were educated and fall precautions were in place for 1 (Resident A) of 3 residents in the sample of 5 reviewed for falls . This failure resulted in 2 roll offs from an over inflated air mattress with a fracture of the tibia/fibula, hospitalization and placement of an immobilizer. Findings include: Resident (A) was observed in bed asleep during the [DATE], 9:,[DATE]:30 A.M., entrance tour. Resident (A) had two ,[DATE] side rails up and was on a regular pressure reduction mattress. Registered nurse (RN #1), during the tour of the unit, indicated Resident (A) had recently had two falls within a day. RN #1 indicated Resident (A) had been on an air mattress at the time of the falls. RN #1 indicated the first fall occurred on the third shift. RN #1 indicated a maintenance man had checked the controls of the air mattress following the fall and had found a change from the original setting. RN #1 indicated the second fall had occurred the following day during a bed check between the first and second shifts. RN #1 indicated the air mattress was removed following the second fall. RN #1 indicated the maintenance department had done re-education for all staff on the air mattress. The record of Resident (A) was reviewed at 2:10 P.M., [DATE], and indicated a ,[DATE] initial admission with a [DATE], re-admitted . [DIAGNOSES REDACTED]. A [DATE], 4:09 A.M., nursing note, documented by Licensed Practical Nurse (LPN #1), indicated Resident (A) was found on floor in the room. Vital signs were taken and a blood sugar was checked at 116. Documentation indicated the writer was walking by the room and noted the resident laying on the floor beside the bed on his left side. Range of motion was documented as usual. Documentation indicated the fall was unwitnessed and neuro checks were started. The immediate intervention was pillows placed on both sides of the resident in bed. A message was forwarded to the physician and the responsible family member was to be forwarded in the AM. A [DATE], 9:17 A.M., note indicated Lortab (narcotic) was given as needed for moderate pain, and a complaint of, "body aching..." Documentation indicated Resident (A) was moaning during activities of daily living. A [DATE], 11:38 A.M., post fall note indicated no skin discoloration, no swelling,no deformity of limbs and range of motion within normal range. Documentation also indicated no internal/external rotation of lower limbs. A [DATE], 4:05 P.M., nursing note, documented by RN #1, indicated Resident (A) received a new specialty air mattress yesterday and fell out of bed this A.M. No injuries noted and no complaints voiced. Intervention: the level of air in mattress re-adjusted per maintenance today so that mattress not as inflated. A [DATE], 7:50 P.M., nursing note indicated a post fall evaluation with no internal or external rotation of lower limbs. A [DATE], 1:25 A.M., nursing note indicated no limb rotation noted. A [DATE], 9:30 A.M., note indicated a CNA noticed during shower that the left lower leg was swollen. This nurse (LPN #2) called to room and examined. Swelling was noted to the left shin area from below the knee to lower shin. The area was slightly pink without bruising. Resident (A) moaned out in pain when turned, re-positioned, and area palpated. The nurse practitioner was paged and returned a call with orders for a stat (immediate) lower leg x-ray. Pain medication was administered. Documentation indicated the staff would monitor. A [DATE], 10:10 A.M., nursing note, documented by LPN #2, indicated slight pinkness with swelling note to the left lower leg from below knee to lower shin. Range of motion was documented as usual. Documentation indicated Resident (A) was moaning out in pain with movement of the left leg. A [DATE], 12:33 P.M., nursing note indicated Mobile (x-ray) department at facility to obtain x-ray of left lower leg. Awaiting results. A [DATE], 2:00 P.M., nursing note, documented by LPN #2, indicated Resident (A) was found on the floor by bed. The vital sign,. temperature, and oxygen saturation level were taken. The fall was documented as unwitnessed. Range of motion was documented as per usual. Neuro checks were initiated. Documentation indicated no injuries noted. Resident (A) was assisted by mechanical lift. The physician and power of attorney were notified. A [DATE], 3:41 P.M., nursing note indicated (Resident A) fell out of bed and previously fell out of bed on [DATE]. Resident (A) was placed on a new air mattress due to open areas. Air was adjusted in mattress after first fall, the beds were changed after this fall ([DATE]). Intervention: replaced bed with previous mattress at this time per maintenance. Will also continue with all previous interventions in place. A [DATE], 6:44 P.M., nursing note indicated the x-ray results were received and called to the physician. Documentation indicated orders to send to the local hospital emergency room for evaluation and treatment. A 12//,[DATE], 11:56 P.M., note indicated a call was received from the hospital stating Resident (A) was to be admitted with tibia/fibula fracture and an orthopedic consult. Documentation indicated an [DATE], care plan concern of potential for falls with a goal of no injury. Interventions included the call bell to be pinned to the gown when in bed; evaluation of the effectiveness and side effects of psychotropic drugs and possible reduction if necessary; and ensure the environment was free of clutter. A [DATE], update created by RN #1, indicated air mattress in place at correct level of air, with a [DATE], update. Documentation indicated a revision by the Director of Nursing (DoN), undated. CNA #1 was interviewed at 11:50 A.M., [DATE], and indicated she had been at the facility over 1 year and had not received an inservice on the air mattress prior to the one following the accident with Resident (A). CNA #1 indicated at the inservice she had learned not to touch the firmness button and to tell the nurse if changes in (firmness) of the mattress. CNA #2 was interviewed [DATE], at 12:20 P.M., and indicated she had been employed 2 months. CNA #2 indicated she had not been orientated to the air mattress function until after the falls of Resident (A). The DoN was interviewed at 3:30 P.M., [DATE], and indicated Resident (A) had the first fall on night shift and was found on the floor by a CNA. The DoN indicated Resident (A) had been assessed with [REDACTED]. The DoN indicated the fall was not witnessed. The DoN indicated the maintenance man had placed the mattress and had adjusted the settings according to the manufacturer's manual. The DoN indicated a teachable moment about the air mattress had been done with the direct care staff on the unit following the [DATE], fall. The DoN indicated the next fall was on [DATE], and was also unwitnessed. The DoN indicated a maintenance man had checked the mattress following the second fall and the settings were correct. The DoN indicated at one point after the first fall, Resident (A) had been assessed with [REDACTED]. The DoN indicated an x-ray had been ordered prior to the second fall on [DATE]. The DoN indicated Resident (A) had upper side rails in place at the time of both falls. The DoN indicated Resident (A), who had only one lower limb, would use the side rails to assist in self positioning. The DoN indicated Resident (A) had not had a previous fall since 2007, five years ago. On [DATE], the DoN provided copies of the inservices following the [DATE], fall. The second shift staff was inserviced by maintenance on [DATE], the third and first shifts on [DATE]. The [DATE], teachable moment to the staff on the unit where the fall of Resident (A) had occurred indicated they were not to change any setting on the specialty mattress. The inservice information indicated the settings were to be changed only by maintenance or the wound care nurse. CNA #3 was interviewed at 3:50 P.M., [DATE], and indicated she had worked at the facility for 7 years. CNA #3 indicated she knew a little bit about the air mattress prior to the recent in-service. CNA #3 indicated she had known not to use pads on the mattress and not to adjust the controls. CNA #3 indicated there had been recent staff turn over and they had not been familiar with the air mattress functions. Maintenance Personnel #1 was observed placing a new air mattress on the bed of Resident (A) at 9:10 A.M., [DATE]. Maintenance #1 secured 10 mattress straps, 3 on each side,and 2 each on the front and bottom, underneath the bed. Maintenance #1 also closed the CPR (cardio pulmonary resuscitation) valve, attached to the mattress to maintain the inflation process. Maintenance #1 indicated to CNA #4, who was placing linens on the bed, Resident (A) should not be placed on the mattress for ,[DATE] minutes to allow the air to fill up and firm. CNA #4 indicated Resident (A) was out of the facility at a physician appointment and would not be back for at least an hour. Maintenance #1 indicated he had checked the air mattress adjustments following the first fall of Resident (A) on [DATE]. Maintenance #1 indicated he had initially placed the air flow control on a setting of 3 (for a stage IV decubitus) and somebody had apparently placed it on a setting of 9. Maintenance #1 indicated a setting of 9 would be over inflated causing too large a cradle within the mattress surface. Maintenance #1 indicated he gave an inservice sometime in between the first and second fall. Maintenance #1 indicated some of the CNAs had never been trained on the air mattress before. CNA #4 was interviewed at 9:20 A.M., [DATE]. CNA #4 indicated she had worked at the facility for 2 years and had not been inserviced on the air mattress prior to [DATE]. LPN #2 was interviewed at 9:50 A. M, [DATE], and indicated a CNA (#5) had come to her at shift change [DATE], and said Resident (A) was on the floor. LPN #2 indicated she observed Resident (A) on the floor, on his back, laying beside the bed. LPN #1 indicated she assessed Resident (A) with range of motion and he was transferred by a mechanical lift. LPN #2 indicated following the first fall ([DATE]), Resident (A) had pain and swelling of the left leg and the facility was in the process of getting an x-ray. LPN #2 indicated she had assessed Resident (A) with no additional injuries and he was transferred to the hospital the evening of [DATE]. LPN #2 indicated the air mattress was removed following the second fall. LPN #2 indicated to her knowledge the settings on the mattress had not been adjusted between the first and second falls. LPN #2 indicated the falls were unwitnessed and it was thought the cause was the air mattress. LPN #2 indicated Resident (A) did not have a history of falls prior to placement of the air mattress. LPN #2 indicated Resident (A) would use the side rails to re-position himself. LPN #2 indicated Resident (A) had never attempted to get out of bed on his own. CNA #5 was interviewed at 10:25 A.M., [DATE], and indicated at the 2:00 P.M., shift change [DATE], Resident (A) had his call light on. CNA #5 indicated she responded and saw him on the floor by the bed. CNA #5 indicated she had worked at the facility 1 year and was first inserviced on the air mattress following the [DATE], fall of Resident (A). CNA #5 indicated they were educated during the inservice to never touch the settings of the air mattress. LPN #1 was interviewed by telephone at 10:25 A.M., [DATE], and indicated every thing had been fine at the beginning of the [DATE], night shift. LPN #1 indicated at 4:00 A.M., she was going down the hall and saw Resident (A) laying on the floor. LPN #1 indicated she did an assessment. LPN #1 indicated Resident (A) was able to move the arms and his good leg (left). LPN #1 indicated 3 staff used a mechanical lift to place Resident (A) back into bed. LPN #1 indicated she was unable to recall if the air mattress was checked at the time. LPN #1 indicated she was later told the settings on the mattress had been changed between the [DATE], placement and the [DATE] fall. LPN #1 indicated the staff were inserviced on the air mattress settings following the fall. CNA #6 was interviewed [DATE], at 11:10 A.M., and indicated she had worked the night shift on [DATE]. CNA #6 indicated she and another CNA had turned Resident (A) 1 hour prior before he rolled off the bed. CNA #6 indicated she had worked at the facility for 6 months and had not been trained on the air mattress until after the [DATE] fall. CNA #6 indicated she had not known how to tell the mattress settings prior to the inservice. LPN #3 was interviewed [DATE], at 2:30 P.M., and indicated she had just come on duty at the 2:00 P.M., shift change when the [DATE] fall occurred. LPN #3 indicated the mattress was removed from the bed following the fall. LPN #3 indicated a decision had been made the mattress was over inflated. LPN #3 indicated she had been told the mattress was at fault. LPN #3 indicated she had always been told not to change the settings, but to call the company if adjustments were needed. The Administrator was interviewed at 3:00 P.M., [DATE], and indicated the reportable investigation of the two falls of Resident (A) had been inconclusive. The Administrator indicated the cause was probably human error. The Administrator indicated one possibility was the bed had been unplugged to raise the level for transfer, then plugged in again with a change of pressure. The Administrator indicated all staff had been inserviced 2 years ago with the purchase of new air mattresses. The Administrator indicated there had not been training with the turn over of staff and new hires. The Direct Supply Panacea Air Max (no date) manufacturer's guidelines was provided for review [DATE], and indicated the flotation mattress provided pressure management therapy, by alternating pressure and low air loss modes. Descriptions of the power on/off and soft firm adjustments were included. The mode button was used to switch between different therapy options of alternating, ,[DATE] minute cycles, low air loss, and maximum inflation. A power failure/low air loss light illuminated if a hose was disconnected. The manufacturer's instructions contained a warning of failure to comply with all directions which could result in injury or death. Point #8 under directions for use indicated a common method for sizing an air mattress was to check if suitable pressure was selected by sliding one hand between the air mattress and the air/foam base under the resident's buttocks. Users should be able to feel the space between their hand and the resident's buttocks with an acceptable range of ,[DATE] ,[DATE] inches. The hand check procedure was issued by the Agency for Health Care Policy and Research. Warning #4 indicated the product was not intended to replace good care giving practices including direct resident supervision, adequate care planning and training of staff for entrapment and fall precautions, and inspection and testing before use. This federal tag relates to Complaint IN 950. 3XXX,[DATE](a)(2)

Based on record review and interview, following a hyperglycemic episode, the facility failed to assess the condition and monitor the blood sugars, vital signs, and level of consciousness,every 15 minutes as specified in facility policy, for 1( Resident A) of 6 residents among the sample of 10, sampled for diabetic monitoring. Resident (A) experienced a change of condition, and 3 hours following the hyperglycemic episode, was found with cessation of respirations (expired). Findings include: The record of (Resident A) was reviewed at 3:40 P.M., [DATE], and indicated a [DATE], admission. [DIAGNOSES REDACTED]. Resident (A) was legally blind . On [DATE], the physician ordered [MEDICATION NAME] Insulin to be given on a sliding scale basis which included 8 units for a blood sugar between 301 to 350. The physician was to be notified if the blood sugar was greater than 400. On [DATE], the physician ordered the accuchecks (blood sugar readings) to be tested three times daily (8:00 A.M., 12:00 P. M., and 4:00 P. M.). On [DATE], the physician increased the scheduled doses of Levimir Insulin to 12 units every 8:00 A.M., and 8:00 P.M. The ,[DATE], documentation log of abnormal blood sugars for (Resident A) indicated the following fluctuations: 505 at 6:00 P.M., [DATE], with coverage , 302 on re-check, within 15 minutes and physician notification; 586 at 11:30 A.M., [DATE], with coverage, 421 on re-check and physician notification with an order for [REDACTED]., [DATE], with a re-check of 456, physician notification, and a one time order for 15 units of [MEDICATION NAME] Insulin. The [DATE], plan of care for [MEDICAL CONDITION], current through a target date of [DATE], indicated Resident (A) was to be monitored for signs and symptoms, including fatigue, dry skin, muscle cramps, deep labored breathing (Kussmaul), [MEDICATION NAME] (fruity) breath, stupor, and coma. The physician was to be notified if the resident had signs and symptoms of [MEDICAL CONDITION]. Registered nurse (RN #1) documented on a [DATE], 12:21 P.M., nursing note, the family of Resident (A) were in to visit, were concerned with her well being, and requested she be sent to the hospital for an evaluation. Documentation indicated the family were concerned Resident (A) was shaking badly and had extreme weakness. RN#1 documented she assessed Resident (A), who was seated on the toilet following a loose bowel movement. RN #1 indicated (Resident A) was not noticeably shaking. The blood sugar was checked and found to be, "what (Resident A) typically runs at lunch time, 343, vital signs were all stable and (Resident A) stated she was feeling pretty good." Documentation indicated a pulse of 90, blood pressure ,[DATE], respirations, 20, and an oxygen saturation of 98% (room air or on oxygen not indicated). RN #1 documented (Resident A) wanted to lay down due to the bottom hurting and was assisted to bed. RN #1 documented (Resident A) refused lunch, stating she was not hungry, showed no signs of dehydration, and fluids were encouraged. RN #1 documented the attending physician was aware. Documentation did not indicate further assessment of the condition nor a re-check of the blood sugar by RN#1. The next nursing note documentation was at 3:35 P.M., [DATE], and indicated Licensed Practical Nurse (LPN #1) was called to the room by a housekeeper to check on Resident (A). LPN #1 documented (Resident A) was lying in bed and was pale. Resident (A) did not respond to sternal rub. No pulse was found and no respirations were noted. LPN #1 documented the body was still warm. The Director of Nursing (DoN) was notified. The family was called and a message was left to call the facility. A [DATE], 4:00 P.M., nursing note indicated family member #1 returned a call, was informed (Resident A) had expired and stated he would be there shortly. At 4:12 P.M., [DATE], the physician was notified. Documentation indicated at 5:21 P.M., [DATE], the family arrived and gave directions for a funeral home to be called. The [DATE], Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].M., [DATE], for a blood sugar of 343. Family member #2 of (Resident A) was interviewed by telephone at 4:15 P.M., [DATE], and indicated family member#1 had said the blood sugar was over 300 and (Resident A) was shaking. Family member #2 indicated the facility refused the family's request to send (Resident A) to the hospital for an evaluation. RN #1 was interviewed by telephone at 4:30 P.M., [DATE], and indicated (Resident A) had sliding scale insulin coverage. RN #1 indicated if there was an abnormal blood sugar,the physician parameters were to be followed and a resident was to be checked every 20 minutes. RN #1 indicated if the blood sugar was above or below the ordered parameters, the physician was to be notified. RN #1 indicated Resident (A) had been up in the room the morning of [DATE]. RN #1 indicated Resident (A) had ,[MEDICAL CONDITION]. difficle ([MEDICAL CONDITION]), was incontinent, and had been up to toilet. RN #1 indicated the family had been in and had expressed concerns. RN #1 indicated she had assessed (Resident A) for signs and symptoms of dehydration and had found no outward manifestation. RN #1 indicated she had spoken with the attending physician who had relied on her assessment of (Resident A). RN #1 indicated she recalled she had mentioned the family was concerned. RN#1 indicated the family had left by that time and she never spoke with them again. RN #1 indicated she had conveyed to the physician exactly what she had documented in the [DATE], nursing notes. RN #1 indicated she could not recall, but believed the physician must have said no need to send (Resident A) to the hospital. RN #1 indicated she did not check Resident (A) following the initial assessment for [MEDICAL CONDITION]. LPN #1 was interviewed at 5:30 P.M., [DATE], and indicated she was unsure what the blood sugar of (Resident A) had been on [DATE]. LPN #1 indicated it was not uncommon for Resident (A) to run a high blood sugar. LPN #1 indicated the protocol was to follow up with the individual physician's parameters for blood sugars. LPN #1 indicated she had come in at 2:00 P.M., [DATE], and was told in report the family of (Resident A) had wanted her sent to the hospital. LPN #1 indicated she did not check on Resident (A) when she first came on duty because RN#1 had just checked the resident earlier. LPN #1 indicated at 3:30 P.M., [DATE], a housekeeper came and told her she thought (Resident A) had expired. At 2:40 P.M., [DATE],Housekeeping Supervisor #1 was interviewed. Housekeeping Supervisor #1 indicated she had noticed Resident (A) up in the chair at lunch time on [DATE]. House keeping Supervisor #1 indicated at 3:10 P.M., on [DATE], she was sweeping carpets, went by the room of Resident (A), thought she did not look right and stepped into the room. House keeping Supervisor r#1 indicated she went for a nurse because Resident (A) did not appear to be breathing. House keeping Supervisor #1 indicated she could not find a nurse, went back to the room, called the name of (Resident A), got no response, found LPN #1 and told her she thought the resident was gone. At 5:45 P.M., [DATE],Certified Nursing Assistant (CNA #1)who had been on duty the evening of [DATE], was interviewed and indicated on first rounds, ,[DATE]:30 P.M., she had answered a light in a room adjacent to (Resident A). CNA#1 indicated she had seen (Resident A) shaking the head, and she thought (Resident A) had looked uncomfortable. CNA #1 indicated she had gone to answer another light and had told CNA#2 (Resident A) needed to be re-positioned. CNA# 2 was interviewed at 2:15 P.M., [DATE], and indicated she had come on at 2:00 P. M., and had waited on a trainee to arrive. CNA #2 indicated day shift CNA #3, had taken (Resident A) to the bath room earlier on first shift. CNA #2 indicated after shift change she had gone to the room of (Resident A) who had said she did not need anything. CNA#2 indicated she passed ice water and was going to check on (Resident A) to see if she needed the bath room (time unknown). CNA #2 indicated the DoN was in the hallway and told her (Resident A) had just passed away. CNA #3, who had worked the day shift on [DATE], was interviewed by telephone at 2:50 P.M., [DATE]. CNA# 3 indicated she had last checked on (Resident A) at 1:30 P.M., [DATE]. CNA #3 indicated she recalled (Resident A) had not wanted lunch. CNA #3 indicated she had to keep raising her voice for (Resident A) to hear. CNA#3 indicated she recalled (Resident A) had been tired and had slept most of the day. The attending physician #1 of (Resident A), who was also the facility's Medical Director, was interviewed at 3:15 P.M. [DATE]. Physician #1 indicated Resident (A) had a massive [MEDICAL CONDITION] infarction 3 ,[DATE] years ago but had compensated well. Physician #1 indicated Resident (A) probably needed a defibrillator, but a decision had been made not to proceed with a cardiac work-up or consulation. Physician #1 indicated Resident (A) was a do not resuscitate status. Physician #1 indicated (Resident A) was a brittle diabetic with blood sugars ranging from the 30(s) to over 300. Physician #1 indicated his usual protocol was to tell the nurse to send a resident out to the hospital for an evaluation if the family made a request. Physician #1 indicated he was unsure what RN#1 had told him about the family request for a hospital transfer on [DATE]. Physician #1 indicated he had accessed the death certificate web site of the Indiana State Department of Health with his entry code. Physician #1 indicated he had been unable to print off a copy of the death certificate, but had written down the information which indicated ischemic cardio [DIAGNOSES REDACTED] as the cause with pneumonia and type II diabetes mellitus as secondary. During a [DATE], 8:50 A.M., interview ,Corporate RN Consultant #1 indicated she had reviewed the record of (Resident A). Corporate RN consultant #1 indicated a physician's orders [REDACTED]. Inservice records were requested [DATE]. At 11:00 A.M., [DATE], the DoN provided a copy of a ,[DATE]-[DATE], all house [MEDICAL CONDITION]/diabetic coma/ketoacidosis-treatment inservice. The DoN indicated she had checked records and could not find an inservice had been given during the past year for diabetic monitoring or hypo-[MEDICAL CONDITION] protocols. The facility's revised ,[DATE], policy for [MEDICAL CONDITION]/diabetic coma, ketoacidosis-treatment was provided by theAdministrator on [DATE]. Procedures #1 and #2 indicated a physician's orders [REDACTED]. Protocol #3 indicated the vital signs, status, and repeat glucometer would be tested every 15 minutes until the [MEDICAL CONDITION] resolved. Protocol #6 indicated if the condition remained the same or became worse, the nurse was to prepare to send the resident to the emergency room if ordered by the physician. Rationale #1 indicated blood sugar monitoring was necessary when a change in status was observed and hypo or [MEDICAL CONDITION] was suspected. Rationale #3 indicated a resident's status could change quickly and become life threatening. This federal tag relates to complaint IN 695. 3XXX,[DATE](a)