Every finding on record at Westminster Village North

Based on interview and record review, the facility failed to ensure an allegation of physical abuse was reported to the state survey agency for 1 of 3 residents reviewed for abuse. (Resident B) Findings include:During an interview on 7/13/26 at 9:05 a.m., Resident B indicated during evening shift, on 6/22/26, CNA 1 refused to tell Resident B what CNA 1's name was and her badge was turned backward, so Resident B told CNA 1 that she would get CNA 1's name herself and reached up and grabbed her badge. Resident B indicated when she grabbed CNA 1's shirt, CNA 1 punched Resident B with her fist in Resident B's left arm. Resident B indicated she reported the incident to the nurse. During an interview on 7/13/26 at 12:07 p.m., the Administrator indicated, on 6/22/26, Resident B made an allegation that CNA 1 hit her during care. The allegation was investigated and was not substantiated because there were two CNA's in the room. Resident B had been care-in-pairs (two staff for all care) for approximately a year and a half due to making statements that were never substantiated. CNA 1's statement was that Resident B reached out and grabbed CNA 1's shirt and pulled CNA 1 down. CNA 1 removed her shirt from Resident B's hands and excused herself from the room. The allegation should have been reported to the state survey agency.The clinical record for Resident B was reviewed on 7/13/26 at 10:19 a.m. The diagnoses included, but were not limited to, low back pain, gout, and deep vein thrombosis.A quarterly Minimum Data Set (MDS) assessment, dated 4/23/26, indicated Resident B was not cognitively impaired.A Progress Note, dated 6/22/26 at 11:01 p.m., indicated Resident B informed the nurse that she had a bruise on her left forearm. The Director of Nursing had been made aware.On 7/13/26 at 9:36 a.m., the Administrator provided a copy of a facility policy, titled Abuse Policy, dated 11/23/16, and indicated this was the current policy used by the facility. A review of the policy indicated all allegations of abuse or suspected abuse are reported to the state department of health.This citation relates to Intake 3056461.410 IAC (Indiana Administrative Code) 16.2-3.1-28(c)

Based on interview and record review, the facility failed to ensure written discharge and bed hold information was provided directly to the resident and the resident's representative upon transfer for 4 of 5 residents reviewed for hospitalization. (Resident 7, 13, 1 and 4)Findings include: 1. The clinical record for Resident 7 was reviewed on 11/18/25 at 3:16 p.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease, major depressive disorder, anxiety disorder, personality disorder, mild neurocognitive disorder, spinal stenosis, dysphagia, hypertensive heart disease with heart failure, congestive heart failure, and type 2 diabetes mellitus. a. A progress note, dated 9/28/25 at 2:31 p.m., indicated Resident 7 was sent to the hospital. It did not indicate the son was notified. A transfer/discharge form, dated 9/28/25, indicated the form was sent with Resident 7. A progress note, dated 9/29/25 at 1:21 p.m., indicated the facility placed a call to the son regarding the bed hold policy since the resident was currently in the hospital. The call was unanswered, so the facility left a voicemail message and asked him to call back. A bed hold policy, dated 9/29/25, indicated the Medical Record Coordinator called Resident 7's brother and left a voice message regarding the bed hold policy. b. During an observation, on 11/18/25 at 11:00 a.m., Resident 7 was not located in the facility and had been transferred to the hospital for shortness of breath. A progress note, dated 11/18/25 at 10:37 a.m., indicated Resident 7's oxygen saturation levels ranged between 70% and 84% on 5 liters of oxygen. The resident had a bluish tint to her lips and oral cavity and increased drowsiness. The resident was sent to the emergency room to be evaluated and treated. The son was called twice, and the facility left a voicemail. A progress note, dated 11/18/25 at 11:05 a.m., indicated Resident 7 had been sent to the emergency department for evaluation and treatment. A transfer/discharge form, dated 11/18/25, indicated Resident 7 was sent to the hospital with low oxygen saturations. The form did not indicate the bed hold policy and written transfer information was given to the resident and the resident's representative. A progress note, dated 11/20/25 at 9:54 a.m., indicated the facility placed a call to the son regarding the bed hold policy and plan to return to the facility. There was no answer, so the facility left a voice message to call back. A nursing progress note, dated 11/21/25 at 1:31 p.m., indicated the facility placed another phone call to the son (emergency contact #1) and left a voice message to call back regarding an update and the bed hold information. A nursing progress note, dated 11/21/25 at 1:36 p.m., indicated the facility called Resident 7's daughter (emergency contact #2) to discuss the bed hold policy. The daughter indicated to hold the bed and the plan was for Resident 7 to come back to the facility after the hospital stay. During an interview, on 11/24/25 at 9:35 a.m., the Associate Executive Director indicated the facility's transfer procedure was to send the discharge paperwork and bed hold policy in the medical record packet with the resident to the hospital. The Medical Record Coordinator then called the resident's representative to determine their choice regarding the bed hold. The written bed hold policy was given to the resident or representative on admission, but at the time of a transfer, it was just a verbal decision. The written transfer information was not given directly to the resident or family at the time of transfer unless the resident was discharged home. During an interview, on 11/17/25 at 1:45 p.m., Resident 7 indicated she never received any written information when she was transferred to the hospital. 2. The clinical record for Resident 13 was reviewed 11/18/25 at 3:11 p.m. The diagnoses included, but were not limited to, hemiplegia and hemiparesis following a cerebral infarction which affected the right dominant side, bipolar type schizoaffective disorder, severe vascular dementia with agitation, behavioral disturbance and psychotic disturbance, post-traumatic stress disorder, and neuroleptic induced Parkinsonism. A Brief Interview for Mental Status (BIMS) assessment, dated 1/31/25, indicated the resident had severe cognitive impairment. A physician's order, dated 1/21/25, indicated to send the resident to the emergency room to evaluate the mental status change. A nursing progress note, dated 1/21/25 at 7:05 p.m., indicated the facility called 911 and the resident was taken to the hospital. The resident's family was called when the resident left. During an interview, on 11/18/25 at 9:57 a.m., the Director of Nursing (DON) indicated she did not find documentation the resident's representative was given a written bed hold policy and transfer paperwork. The transfer paperwork Resident 13 was placed in the packet which was given to the transporters for the receiving facility. It was not given directly to Resident 13. 3. The clinical record for Resident 1 was reviewed on 11/20/25 at 3:24 p.m. The diagnoses included, but were not limited to, idiopathic pulmonary fibrosis, acute and chronic respiratory failure with hypoxia, and interstitial pulmonary disease. A hospital document, dated 11/17/25, indicated Resident 1 was transferred to the emergency room for respiratory distress and would be admitted to the hospital for close monitoring. A progress note, dated 11/17/25, indicated the Medical Record Coordinator had placed a call to Resident 1's power of attorney (POA) to discuss the bed hold policy. No one answered the call, and a voice message was left. A progress note, dated 11/18/25, indicated the facility attempted to contact Resident 1's POA again regarding the bed hold policy. An email correspondence, dated 11/18/25, indicated the facility had verbally communicated with Resident 1's POA regarding the bed hold policy. A discharge document indicated Resident 1 was transferred or discharged on 11/17/25 to the hospital. The document was dated to have been issued on 11/18/25. There was no documentation in the clinical record that the resident or resident's representative had been given the bed hold policy or notice of transfer/discharge in writing, prior to or within a 24-hour period (in the event of an emergency hospitalization). During an interview, on 11/21/25 at 11:11 a.m., the Associate Executive Director indicated, on 11/18/25, a follow-up telephone call was placed to the POA regarding the bed hold policy which was documented on a bed hold agreement form at that time. The discharge form was completed with the issue date of 11/18/25 at the time of the telephone conversation. 4. The clinical record for Resident 4 was reviewed on 11/21/25 at 11:58 a.m. The diagnoses included, but were not limited to, repeated falls, fracture of an unspecified part of the neck of the left femur, and fracture of the sacrum. a. The clinical record indicated Resident 4 was transferred to the hospital after a fall on 10/25/25 and returned to the facility on [DATE]. A progress note, dated 10/27/25, indicated the facility contacted Resident 4's POA via telephone to discuss the bed hold policy. b. A progress note, dated 11/20/25, indicated Resident 4 had been transferred to a follow-up appointment and was admitted to the hospital from the appointment for a procedure. A progress note, dated 11/21/25, indicated the facility contacted Resident 4's POA via telephone to discuss the bed hold policy. There was no documentation in the clinical record that the POA had been given the bed hold policy or notice of transfer/discharge in writing, prior to or within a 24-hour period (in the event of an emergency hospitalization) for the two hospitalizations. During an interview, on 11/21/25 at 12:49 p.m., the Associate Executive Director indicated the resident's representative would be provided with the bed hold policy on admission and if a therapeutic leave would extend longer than 24 hours. If the therapeutic leave was unexpected, like from a doctor's appointment, a follow-up call would be placed to the POA. A current facility policy, titled discharge: Bed Hold, dated 5/28/25 and received from the Associate Executive Director on 11/21/25 at 11:00 a.m., indicated .Residents or their designated representative shall be informed of this policy in writing at admission, at the time of transfer to a hospital [(unless an emergency)], or at the time of a therapeutic leave which extends beyond twenty-four [(24)] hours. Written notification at the time of transfer shall include the Notice of Transfer and Discharge and a copy of this policy.In the event of an emergency hospitalization, the resident and/or a family member or legal representative shall be notified by written notice, within 24 hours, and asked to provide the facility with their decision regarding the resident's return. 3.1-12(25)(A) 3.1-12(25)(B) 3.1-12(26)

Based on interview and record review, the facility failed to ensure the clinical record did not contain conflicting physician's orders related to code status for 2 of 2 residents reviewed for advanced directives. (Resident 23 and 117)Findings include:1. The clinical record for Resident 23 was reviewed on [DATE] at 2:33 p.m. The diagnoses included, but were not limited to, paraplegia, lumbar spina bifida with hydrocephalus, and chronic osteomyelitis with draining sinus. An active physician's order, dated [DATE], indicated the resident was a full code. An active physician's order, dated [DATE], indicated the resident's preference was do not resuscitate with limited interventions.The clinical record contained two active physician's orders with conflicting code status. 2. The clinical record for Resident 117 was reviewed on [DATE] at 11:34 a.m. The diagnoses included, but were not limited to, persistent vegetative state, chronic obstructive pulmonary disease, and chronic kidney disease.An active physician's order, dated [DATE], indicated the resident was a full code.An active physician's order, dated [DATE], indicated do not resuscitate and comfort measure care.The clinical record contained two active physician's orders with conflicting code status. During an interview, on [DATE] at 8:33 a.m., LPN 2 indicated if there was a physician's order for both a full code and a do not resuscitate it needed to be clarified with the physician.A current facility policy, titled GUIDELINE FOR CARDIOPULMONDAY RESUSCITATION-CPR, dated [DATE] and received from the Executive Director on [DATE] at 2:50 p.m., indicated .the resident's Advance Directives and/or code status will be obtained .Once physician order is received related to Code Status, order will be added to the banner (in the record system) .3.1-4(f)(5)

Based on interview and record review, the facility failed to ensure a new Preadmission Screening and Resident Review (PASSAR) level I was completed after antipsychotic medications were initiated for 2 of 5 residents reviewed for PASSAR. (Resident 124 and 28)Findings include:1. The clinical record for Resident 124 was reviewed on 11/19/25 at 1:57 p.m. The diagnoses included, but were not limited to, anxiety disorder, dementia with psychotic disturbances, and hallucinations.A PASSAR level I, dated 3/27/25, indicated Resident 124 did not require a level II screen because there was no evidence of an intellectual/developmental disability or a serious behavioral health condition. The screening indicated if there was a change in condition or if new information refuted the findings, a new screen must be submitted. The PASSAR level I indicated Resident 124 did not currently or in the past 6 months take any mental health medications.A care plan, dated 4/26/25, indicated Resident 124 used psychotropic medications related to anxiety, restlessness, agitation, hallucinations, and insomnia.A care plan, dated 4/26/25, indicated Resident 124 would remain free of psychotropic drug related complications and to administer psychotropic medications as ordered by the physician.A psychiatric visit note, dated 4/29/25, indicated Resident 124's current psychotropic medications included quetiapine (an atypical antipsychotic medication) 50 milligrams (mg) started on 4/24/25, mirtazapine (an atypical antidepressant medication) 7.5 mg started on 4/24/25, and Depakote (a mood stabilizing medication) 250 mg started on 4/10/25.A physician's order, dated 5/29/25, indicated to administer olanzapine (an atypical antipsychotic medication) 10 mg every evening for dementia with psychotic disturbances.2. The clinical record for Resident 28 was reviewed on 11/18/25 at 3:25 p.m. The diagnoses included, but were not limited to, major depression disorder, dementia with mood disturbances, dementia with agitation, and dementia with psychotic disturbances.A PASSAR level I, dated 11/21/24, indicated Resident 28 did not require a level II screen because there was no evidence of an intellectual/developmental disability or a serious behavioral health condition. The screening indicated that although Resident 28 had a diagnosis of major depression, there were no indicators identified which would signify the need for further evaluation at that time. If Resident 28's symptoms increased or other information suggested a potential serious mental illness, then the nursing facility must submit an updated screen to reevaluate the need for a PASRR level II behavioral health evaluation.The clinical record indicated Resident 28 experienced increased disruptive behaviors, hallucinations, and aggression which required a psychiatric hospital stay for a mental health evaluation and medication adjustment.A hospital document indicated Resident 28 was admitted for a psychiatric evaluation on 8/5/25 and discharged with new antipsychotic medications on 8/18/25.A care plan, dated 8/18/25, indicated Resident 28 received psychotropic medications for dementia with behavioral disturbances prescribed during a psychiatric hospital stay from 8/5/25 to 8/18/25.A physician's order, dated 8/18/25, indicated to administer Risperdal (an atypical antipsychotic medication) 0.5 mg, by mouth, two times a day related to dementia with psychotic disturbances.A physician's order, dated 11/6/25, indicated to administer Risperdal 37.5 mg, 1 unit intramuscularly, once a day, every 14 days, related to dementia with psychotic disturbances.During an interview, on 11/20/25 at 12:01 p.m., the Social Service Director (SSD) indicated a new level I PASSAR should be submitted when a resident had new or increased mental health behaviors and when a resident was started on a new antipsychotic medication. She reviewed Resident 124 and 28's level I PASSAR and indicated both should have had a new level I submitted.A current facility policy, titled Social Service Policy, dated as last revised 4/25/23 and received from the SSD on 11/20/25 at 3:28 p.m., indicated .It is the policy.to provide medically-related social services to assist residents in attaining or maintaining their highest practicable physical, mental, and psychosocial well-being.Social Service shall.Update the PASSAR with diagnosis and medications as needed with changes.3.1-16(d)(1)(A)3.1-16(d)(1)(B)

Based on interview and record review, the facility failed to ensure regularly scheduled care plan meetings were held with the resident or resident's representative and documented in the clinical record for 1 of 2 residents reviewed for care plan conferences. (Resident 23)Findings include: The clinical record for Resident 23 was reviewed on 11/17/25 at 2:33 p.m. The diagnoses included, but were not limited to, paraplegia, lumbar spina bifida with hydrocephalus, and chronic osteomyelitis with draining sinus.There were no progress notes, documents, or assessments in the clinical record to indicate a care plan meeting had been held with the resident or resident's representative.During an interview, on 11/19/25 at 10:17 a.m., the Social Service Designee indicated she could not find information on a care plan meeting for Resident 23.During an interview, on 11/20/25 at 1:51 p.m., the Social Services Designee indicated she did not have any notes or documentation for a care plan meeting for Resident 23.A current facility policy, titled Care Planning-Resident Participation, dated 6/4/25 and received from the Administrator on 11/19/25 at 1:05 p.m., indicated .The facility will discuss the plan of care with the resident and/or representative at regularly scheduled care plan conference 3.1-35(d)(2)(B)

Based on observation, interview and record review, the facility failed to ensure a resident's preferences were reevaluated to ensure the resident maintained the highest practicable level of mental and social needs for 1 of 1 resident reviewed for activities of daily living care. (Resident 8)Findings include:During an observation and interview, on 11/17/25 at 11:36 a.m., Resident 8 was in her room, wearing a hospital style gown, lying in bed, and watching television. She indicated she had not been out of bed since she was admitted to the facility and indicated if a staff member would ask if she wanted to get up, she would. She relied on assistance from the staff to get up because she could not do it on her own. She received meals in her room and bed baths on her shower days. There was a high back wheelchair in her room and a blue Hoyer pad in the wheelchair. She indicated she was unaware the wheelchair was in the room, as it sat next to a half wall which separated the bedroom and sitting room and was out of her sight.During an observation and interview, on 11/18/25 at 10:11 a.m., Resident 8 was in her room, wearing a hospital style gown, and lying in bed. She indicated she was feeling lonely and would like to talk to her sister. A puzzle book was noted on a shelf, adjacent to the foot of her bed.During an observation and interview, on 11/19/25 at 10:45 a.m., Resident 8 was in her room, wearing a hospital style gown, lying in bed, and tearful. She indicated she did not sleep very well the previous night and was feeling like a sad sack today. She would like a change of scenery and felt very lonely. She used to be a very sociable person, she felt like her room was so far away from everyone else and would like to be around people more often. Resident 8 was asked if a staff member came to help her get out of bed, would she get up? Resident 8 indicated she would very much enjoy getting out of bed.During an observation, on 11/19/25 at 10:58 a.m., Resident 8's room was 1 of 4 rooms noted to be at the end of the hall, furthest away from the nurse's station, furthest away from the activity and lounge area and the only room of the 4 at the end of the hall to be occupied.The clinical record for Resident 8 was reviewed on 11/19/25 at 11:14 a.m. The diagnoses included, but were not limited to, anxiety disorder, muscle weakness, and chronic congestive heart failure.An admission progress note, dated 10/30/25, indicated at the time of arrival at the facility, Resident 8 was crying out and grabbing care givers, would push care giver's hand away, and was resistive to being turned or repositioned in bed. Staff had difficulty gaining cooperation with assessments and difficulty gaining Resident 8's attention. Resident 8 could not answer questions regarding medications, code status, allergies, or needs/desires.An initial activity assessment, dated 10/30/25, indicated Resident 8 enjoyed watching television, movies, and working on puzzles. The questions asking if Resident 8 wished to participate in activities while in the facility or to participate in group activities were answered unknown.A care plan, dated 10/31/25, indicated Resident 8 had a terminal prognosis/life limiting illness and received hospice services. Interventions included, but were not limited to, adjusting her activities of daily living to compensate for her changing abilities, and to encourage her participation to the extent she wished to participate.A care plan, dated 11/4/25, indicated Resident 8 had little activity involvement related to her physical limitations, was able to communicate her needs and would benefit from individualized 1:1 room visits from staff for stimulation, emotional, social, and physical support. Interventions included, but were not limited to, providing her with leisure supplies upon her request, such as word search puzzles and reading material. Her preferred activities were listed as: watching CNN, Animal Planet and Hallmark movies.A care plan, dated 11/14/25, indicated Resident 8 had a self-care performance deficit related to hospice care, mobility, and cognitive status. Interventions included, but were not limited to, for the staff to anticipate her needs, she was able to communicate her needs, to encourage her to participate in her care, and she required assistance from 1 to 2 staff members for transfers between surfaces.A skilled nursing evaluation assessment, dated 11/4/25, indicated Resident 8 did not refuse care.An admission Minimum Data Set (MDS) assessment, dated 11/6/25, indicated Resident 8 had normal cognitive function.An admission care plan meeting, dated 11/6/25, did not have Resident 8 documented to have been in attendance. It did indicate nursing, social service, activities, and family members were present. Resident 8 was experiencing increased anxiety. The family had requested a change in her anxiety medication. A recreation goal was placed to increase the 1:1 visits in her room from staff and encourage family visitation.The behavior monitoring and interventions reports for Resident 8, dated 10/31/25 to 11/20/25, were reviewed and indicated Resident 8 had not refused any care provided or offered.During an interview, on 11/19/25 at 11:00 a.m., the Nurse Navigator indicated Resident 8 was a hospice patient and refused to get out of bed.During an interview, on 11/19/25 at 1:29 p.m., Resident 8's friend indicated they visited Resident 8 often and since her admission into the facility, they had not seen Resident 8 out of bed.During an interview, on 11/20/25 at 11:05 a.m., CNA 13 indicated if a resident refused care, she would document the refusal on the behavior monitoring and interventions report and report the refusal to the nurse.During an interview, on 11/20/25 at 11:10 a.m., Physical Therapist (PT) 12 indicated she had not worked with Resident 8 because the resident was on hospice but indicated she had not observed Resident 8 out of bed since being admitted into the facility.During an interview, on 11/20/25 at 12:10 p.m., the Social Service Director (SSD) indicated Resident 8 was placed on 1:1 visits with the social service staff yesterday and Resident 8 had been receiving 1:1 visits from the activity staff.During an interview, on 11/20/25 at 3:36 p.m., the Director of Nursing (DON) indicated Resident 8 refused to get out of bed a lot and preferred for staff to sit in her room with her. The staff should be documenting Resident 8's refusals and should be asking Resident 8 more than once if she would like to get up because she would refuse the first attempt.During an interview, on 11/20/25 at 3:36 p.m., the DON indicated the facility did not have a policy regarding accurate documentation and indicated the facility followed all State and Federal regulations.A nursing job description, dated last revised 3/24/25, indicated the duties and responsibilities included responsibility for admission and assessment of new residents and to document pertinent information in the residents' medical record according to the departmental policy and applicable State Department of Health regulations.A current facility policy, titled Activities of Daily Living [(ADL)], Supporting, dated a revised 3/2018 and received from the SSD on 11/20/25 at 3:28 p.m., indicated .Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living.refusal and information are documented in the resident's clinical record.appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with.mobility [(transfer and ambulation)].If residents with cognitive impairment.resist care, staff will.approach the resident in a different way or at a different time, or having another staff member speak with the resident may be appropriate.The resident's response to interventions will be monitored, evaluated and revised as appropriate.3.1-38(a)(2)(A)3.1-38(a)(2)(A)3.1-38(b)(4)3.1-38(b)(5)3.1-38(f)

Based on observation, interview and record review, the facility failed to notify the physician of a weight gain as ordered and to hold a blood pressure medication according to the physician's parameters for 2 of 2 residents reviewed for quality of care. (Resident 2 and 5)Findings include: 1. During an observation, on 11/17/25 at 2:04 p.m., Resident 2 had mild swelling in both ankles. The clinical record for Resident 2 was reviewed on 11/18/25 at 3:14 p.m. The diagnoses included, but were not limited to, hypertensive heart disease with heart failure, chronic diastolic congestive heart failure, and paroxysmal atrial fibrillation. A physician's order, dated 11/19/24, indicated obtain a weight once a day for congestive heart failure and to notify the physician of a weight gain greater than 2 pounds a day. The Medication Administration Record (MAR), dated September 2025, indicated the following: On 9/24/25, the weight was 182.5 pounds.On 9/25/25, the weight was 185.6 pounds (a gain of 3.1 pounds). The MAR, dated October 2025, indicated the following: On 10/8/25, the weight was 177.8 pounds.On 10/9/25, the weight was 180 pounds (a gain of 2.2 pounds). On 10/10/25, the weight was 177.6 pounds. On 10/11/25, the weight was 180.4 pounds (a gain of 2.8 pounds). On 10/19/25, the weight was 173.4 pounds.On 10/20/25, the weight was 178.6 lbs. (a gain of 5.2 pounds). During an interview, on 11/19/25 at 11:25 a.m., the Director of Nursing (DON) indicated the physician should have been called for the increase in weight. The physician was not notified on 9/25/25, 10/9/25, 10/11/25, or 10/20/95. The facility did not have a specific policy regarding following the physician's orders for congestive heart failure monitoring but did follow the regulations on following physicians' orders. During an interview, on 11/21/25 at 11:49 a.m., LPN 5 indicated if a weight gain of more than 2 pounds in a day or 5 pounds in a week was recorded, the physician should be notified according to the order. 2. The clinical record for Resident 5 was reviewed on 11/18/25 at 1:43 p.m. The diagnoses included, but were not limited to, atrial fibrillation, chronic combined systolic and diastolic congestive heart failure, and hypertensive heart disease with heart failure. A physician's order, dated 8/31/23, indicated to administer Cardizem (a medication which lowers blood pressure and heart rate) 120 milligrams (mg) once a day but to hold it for systolic blood pressure less than 110. The MAR, dated August 2025, indicated Cardizem was administered with a systolic blood pressure of 90 on 8/7/25. The MAR, dated September 2025, indicated Cardizem was administered with a systolic blood pressure of 102 on 9/30/25. The MAR, dated October 2025, indicated Cardizem was administered with a systolic blood pressure of 104 on 10/26/25 and 108 on 10/30/25. During an interview, on 11/21/25 at 11:52 a.m., LPN 5 indicated vital signs were obtained prior to administering a medication which had parameters. If the vital signs were below or above the hold parameter, then the nurse would not administer the medication. During an interview, on 11/19/25 at 11:25 a.m., the Director of Nursing (DON) indicated the nurses were to follow the physician's orders and hold the medications based on the vital signs and parameters. A current facility policy, titled Administering Medications, dated as revised 4/2019 and received from the Assistant Executive Director on 11/24/25 at 12:50 p.m., indicated .Medications are administered in a safe and timely manner, and as prescribed.Medications are administered in accordance with prescriber orders. 3.1-37(a)

Based on observation, interview and record review, the facility failed to ensure a gait belt was used during a transfer for 1 of 1 resident reviewed for accidents. (Resident 106)Findings include:During a random observation, on 11/17/25 at 3:11 p.m., Resident 106 was heard screaming no, no in their room. Upon entering the room with the Director of Nursing (DON), CNA 3 was observed behind Resident 106, who was on the floor. CNA 3 was observed wearing a gait belt around her waist. CNA 3 indicated she did not use the gait belt to transfer the resident.The clinical record for Resident 106 was reviewed on 11/21/25 at 12:48 p.m. The diagnoses included, but were not limited to, hemiplegia and hemiparesis following a cerebral infraction (weakness and paralysis on one side of the body from a stroke), repeated falls, and vascular dementia.The care plans for Resident 106 did not address using a gait belt for transfers.During an interview, on 11/17/25 at 3:20 p.m., CNA 3 indicated she did not have her resident assignment sheet with her and it was on a table outside of the room. She left the room and obtained the sheet. Upon her return, CNA 3 indicated she did use the assignment sheet and the sheet indicated Resident 106 required maximum assistance of 1 staff member and a gait belt was to be used.During an interview, on 11/19/25 at 8:31 a.m., QMA 4 indicated she looked at the assignment sheet to determine how to transfer a resident and gait belts were to be used on all residents who were not on mechanical lift transfers.A facility document, titled Assignment #2 (3 CNAs), undated and received from the Director of Nursing on 11/17/25 at 3:42 a.m., indicated Resident 106 was to be transferred with one staff member and the use of a gait belt. The document also indicated directions for all residents were .GAIT BELTS WITH ALL TRANSFERS & WHEN WALKING RESIDENTS A current facility policy, titled Use of Gait Belt, dated 2024 and received from the Assistant Executive Director on 11/17/25 at 3:53 p.m., indicated .It is the policy of this facility to use gait belts with residents that cannot independently ambulate or transfer for the purpose of safety 3.1-45(a)(2)

Based on observation, interview and record review, the facility failed to ensure assessments were accurately documented for 1 of 1 resident reviewed for accurate assessments. (Resident 134)Findings include:During an observation and interview, on 11/17/25 at 11:14 a.m., Resident 134 had a gastrostomy tube (g-tube) with enteral feed (liquid nutrition administered directly into the stomach through the tube) running. Resident 134 indicated he was readmitted to the facility 2 weeks ago after having a feeding tube placed in the hospital. Since he had the feeding tube placed, he had not been able to eat or drink anything by mouth except ice chips.The clinical record for Resident 134 was reviewed on 11/20/25 at 8:34 a.m. The diagnoses included, but were not limited to, severe protein-calorie malnutrition, gastrostomy tube (a surgically placed tube inserted through the abdomen directly into the stomach for nutrition), and depression.A hospital document, dated 11/12/25, indicated Resident 134 was discharged back to the facility with a g-tube and was tolerating the enteral feeding at the time of discharge.A physician's order, dated 11/12/25, indicated Resident 134 had a NPO (nothing by mouth) diet and could have ice chips after oral care.A care plan, dated 11/17/25, indicated Resident 134 had potential for nutritional problems and was readmitted into the facility, on 11/12/25, with a g-tube. The resident was to continue the NPO diet but could have ice chips after oral care.A review of the eight (8) skilled nursing evaluation assessments, from 11/13/25 to 11/20/25, indicated the nursing staff had documented Resident 134's nutritional needs were being received and met through oral nutrition.The nutrition section on the skilled nursing evaluation assessments indicated the options available to select included, but were not limited to, enteral feeding, oral, tube feed, or NPO.During an interview, on 11/20/25 at 3:02 p.m., the Assistant Director of Nursing (ADON) reviewed Resident 134's skilled nursing evaluations and indicated the documentation was not accurate. The expectation of the nursing skilled evaluation charting was to be accurate to ensure anyone looking at the documentation would be aware of the resident's condition.During an interview, on 11/21/25 at 11:47 a.m., RN 7 indicated the skilled nursing evaluations gave a picture of how the resident was doing. The assessments and documentation would be different for each resident and should be accurate for the resident being assessed.A nursing job description, dated as last revised 3/24/25, indicated the duties and responsibilities included, but were not limited to responsibility for admission and assessment of new residents and to document pertinent information in the residents' medical record according to the departmental policy and applicable State Department of Health regulations.3.1-50(a)(2)

Based on observation, interview, and record review, the facility failed to ensure adequate supervision was provided to prevent a cognitively impaired resident from leaving a secured memory unit unsupervised for 1 of 3 residents reviewed for dementia care. (Resident B)Findings include: The clinical record for Resident B was reviewed on 8/18/25 at 11:10 a.m. The diagnoses included, but were not limited to, vascular dementia and anxiety. She resided on the secured memory care unit. A care plan, last revised on 5/7/25, indicated Resident B had behavior problems related to repetitive movements such as pacing and rummaging, rearranging her room, taking and leaving items in others rooms, wandering, and exit seeking. The goal was for her to have fewer behavioral episodes. The interventions included, but were not limited to, address wandering behavior by walking, redirect from inappropriate areas, engage in diversional activity, be calm and self-assured and anticipate and meet Resident B's needs.An Elopement Evaluation, with an effective date of 7/8/25, indicated she had a history of elopement or attempted while at home and while at the facility. She wandered aimlessly or non-goal directed. Her wandering behavior was likely to affect the privacy of others. A score value of 1 or higher indicated being at risk for elopement.A Quarterly Minimum Data Set (MDS) assessment, completed 7/8/25, indicated she did not speak. She was sometimes able to make herself understood and sometimes able to understand others. She had poor short- and long-term memory. She could not recall the season, location of her room, staff names or faces and did not know she was in a long-term care facility. She had severely impaired decision-making abilities. She wandered without purpose for one to three days during the look back period of the assessment. She was able to walk 150 feet with supervision.An Incident Note, dated 7/25/25 at 6:15 p.m., indicated Resident B was observed sitting on a bench outside by staff. When staff spoke with Resident B she pointed toward the unit stating, that's my home. Resident immediately brought back inside. Resident assessed head- to- toe for injuries. No injuries were noted. The Director of Nursing, Executive Director, Nurse Practitioner and Power of Attorney were notified of the incident. A care plan, initiated 7/28/25, indicated Resident B was an elopement risk/ wanderer related to impaired safety awareness. The goal was for her safety to be maintained. The interventions were to distract her from wandering by offering pleasant diversions, structured activities, food, conversation, television, and books. Engage her in purposeful activities. Provide care in a calm and reassuring manner and provide clear simple instructions. Resident may attempt to follow others out of the door. Redirect her by offering to listen to music or watch television.On 8/18/25 at 1:00 p.m., the Executive Director (ED) provided the Incident Report, submitted to the Indiana Department of Health on 7/25/25, and the investigation file of the incident. The Incident Report, dated 7/25/25, indicated that Resident B had been observed by a staff member sitting on a bench outside. When the staff member asked Resident B what she was doing, Resident B stated that she needed to go back there and pointed toward the building. Resident B had been observed sitting in the building approximately 10 minutes prior to being found outdoors. Her elopement risk score was five on 7/8/25. The preventative measures, on 7/26/25, were an assessment of the unit revealed that the automatic closure of the doorway had an extended delay. The delay was immediately shortened to a five second egress. The codes for all doors on the unit were changed. All families were notified to ask for assistance when exiting the unit. Elopement risks had been completed for all residents residing on the unit. The follow up, added 7/30/25, indicated elopement assessments for all residents in the facility were completed. Care plans were updated as needed related to elopement risk. Elopement Risk Alert forms were completed for all residents at risk for elopement and elopement books were updated on all units. All staff were in-serviced regarding the elopement policy, elopement protocol, and elopement risk alert forms. Resident B continued to show no signs of injury and had no noted signs of psychosocial distress and no exit seeking. During an interview on 8/18/25 at 1:58 p.m., Registered Nurse (RN) 2 indicated, on 7/25/25, Resident B had been found outside of the secured memory care unit unsupervised. The facility security cameras were reviewed. The family member of another resident had left and used the handicap button to open the door. The family member had not paid attention, and Resident B had followed them out at 4:03 p.m. When staff found Resident B, she told the staff member she needed to go back in the same door she had used to leave. The family members had been educated, and the door had been changed to close more quickly. Family members no longer had the codes to the doors and staff were to let them in and out. On 8/18/25 at 3:45 p.m., the exit doors of the secured memory unit were observed with Licensed Practical Nurse (LPN) 3. LPN 3 opened the first exit door of the unit using a code and pushing the handicap accessible button. The first exit door opened and was observed to stay open for approximately five seconds before beginning to close. The entry area to the unit had a second door to access the outside. There was an additional keypad which controlled the second exit door. LPN 3 indicated the second keypad for the exit door to the outdoors had been added after Resident B had eloped. There was not a wander guard system on the exit doors of the unit. On 8/19/25 at 10:34 a.m., the bench that Resident B was found sitting on was observed with Certified Nurse Aide (CNA) 4. The bench was located around a half circle corner at the back of the memory care unit, away from the secured memory unit exit doors. The bench was not visible from the exit doors; however, it was visible from the road which enters the facility campus. CNA 4 indicated, on 7/25/25 at approximately 4:15 p.m., she had driven into the facility campus and saw Resident B sitting on the bench. CNA 4 had recognized Resident B as a resident of the memory care unit and wondered if she was okay. CNA 4 stopped her car and approached Resident B, who was sitting on the bench with a book, and assisted Resident B back to the secured memory care unit and informed the staff on the unit that she had found Resident B outside. On 8/18/25 at 2:47 p.m., the Director of Nursing provided the Elopement Prevention and Intervention Policy, dated 7/26/25, which indicated .It is the policy of Westminster Village to protect vulnerable residents from wandering into unsafe areas or from leaving the facility without appropriate supervision. Procedure: 1. Residents admitted with a diagnosis or signs/ symptoms of cognitive impairment will be screened for elopement risk at the time of admission, and with each MDS Assessment .4. The interdisciplinary team will develop and implement a plan of care to protect residents who are assessed to be at-risk, or otherwise demonstrate exit seeking behavior .This deficient practice was corrected on 8/1/25, prior to the start of the survey, and was therefore past noncompliance. The facility implemented a systemic plan that included the following actions: in-service education to nursing staff related to the policy and procedure regarding elopement, evaluated all residents to identity potential residents at risk for elopement, serviced the exit door regarding a keypad code and egress time, and conducted an elopement program evaluation to ensure assessments have been completed and documented with ongoing review presented to the Quality Assessment and Assurance (QAA) Committee for review.This citation relates to Intake 2572780 and Intake 2583098.3.1-45(a)(1)3.1-45(a)(2)

Based on interview and record review, the facility failed to ensure a newly ordered medication was received timely from the facility contracted pharmacy and administered, as ordered by the physician, for 1 of 3 residents reviewed for unnecessary medications. (Resident E)Findings include: The clinical record for Resident E was reviewed on 8/18/25 at 11:17 a.m. The diagnoses included, but were not limited to, congestive heart failure. A Quarterly Minimum Data Set assessment, dated 6/9/25, indicated she was severely cognitively impaired. A Skin/Wound Note, dated 7/25/25 at 12:03 p.m., indicated Resident E had swelling present to the left lower extremity and foot. Upon assessment, Resident E's limb had redness with areas that appeared to be blistering. The Nurse Practitioner (NP) was notified and would assess.A physician's order, dated 7/25/25 at 1:16 p.m., indicated Resident E was to receive furosemide (a diuretic medication used to help remove excess fluids from the body) 20 milligrams (mg) given twice a day for edema (swelling) for four days. A Health Status Note, dated 7/26/25 at 6:24 a.m., indicated Resident E continued to have edema in left lower extremity with no complaints of pain or discomfort. A Health Status Note, dated 7/26/25 at 11:14 p.m., indicated Resident E continued to have edema in her left lower extremity with redness in both legs. She had no complaints of pain or discomfort. The July 2025 Medication Administration Record (MAR) did not contain documentation that the furosemide 20 mg was administered on 7/25/25 in the evening, or 7/26/25 in the morning or in the evening. The first dose of furosemide 20 mg was documented as being given on 7/27/25 in the morning. Resident E's clinical record did not contain information that the facility pharmacy had been contacted about the delivery of Resident E's furosemide.During an interview on 8/19/25 at 11:20 a.m., the DON indicated furosemide 20 mg was available for use in the Emergency Drug Kit at the facility. On 8/19/25 at 12:50 p.m., the Director of Nursing (DON) provided the Packing Slip Proof of Delivery form that indicated Resident E's furosemide 20 mg tablets were delivered to the facility on 7/27/25 at 6:31 p.m. The facility pharmacy was unavailable for interview.On 8/19/25 at 1:11 p.m., the DON provided the facility pharmacy instructions for ordering and reordering medications which indicated Monday through Friday new orders needed to be received by 7:00 p.m., Eastern Standard Time. On Saturday and Sunday, new orders need to be received by 3:00 p.m., Eastern Standard Time.During an interview on 8/19/25 at 1:11 p.m., the DON indicated the pharmacy required new orders to be sent to the pharmacy by the listed times to be included in the nightly drug delivery. She was unsure why Resident E's furosemide had not been delivered until 7/27/25. There was no documentation available that furosemide 20 mg had been removed from the Emergency Drug Kit machine for Resident E. This citation relates to Intake 2583098. 3.1-25(a)

Based on observation, interview, and record review, the facility failed to ensure personal protective equipment (PPE) was worn during a wound treatment and to ensure hand hygiene was performed after doffing disposable gloves for 1 of 3 residents reviewed for wound care (Resident E).Findings include: The clinical record for Resident E was reviewed on 8/18/25 at 11:17 a.m. The diagnoses included, but were not limited to, congestive heart failure. A Quarterly Minimum Data Set assessment, dated 6/9/25, indicated she was severely cognitively impaired. A physician's order, dated 8/12/25, indicated to cleanse the area on the top of the right foot with wound cleanser, apply bacitracin to the wound bed, top with xeroform (petroleum gauze), cover with an ABD pad (type of wound dressing), wrap with kerlix (type of wound dressing) and secure with tape. On 8/19/25 at 10:05 a.m., Registered Nurse (RN) 2 was observed providing wound care to Resident E. RN 2 donned disposable gloves and removed the old dressing from Resident E's right foot. RN 2 went to the bathroom and removed her disposable gloves and applied a new pair. RN 2 did not perform hand hygiene after removing her used disposable gloves. RN 2 then cleansed the wound on the top of Resident E's right foot, applied xeroform gauze and wrapped Resident E's right foot with kerlix, securing the dressing with tape. RN 2 did not don a gown prior to beginning the treatment on Resident E's right foot. During an interview on 8/19/25 at 10:15 a.m., RN 2 indicated Resident E was in Enhanced Barrier Precautions (EBP) and she would normally wear a gown during a wound dressing change. Gowns were available on the back of the room door for use. She would normally perform hand hygiene after doffing a pair of gloves, prior to putting on a new pair of gloves. On 8/19/25 at 1:20 p.m., the Director on Nursing provided the current Enhanced Barrier Precautions Policy that indicated .It is the policy of the facility to ensure that additional and appropriate PPE [Personal Protective Equipment] is utilized, when indicated, to prevent the spread of Multidrug-resistant Organisms also known as MDRO's .Who is at 'High Risk' for acquiring or spreading a MDRO .Residents with wounds regardless of MDRO status .Examples of 'High Contact' Resident Care Activities at which time EBP is to be practiced are .Wound Care .Procedure: 1) When engaging in any of the afore mentioned 'High Contact' Resident Care Activities with a resident who has a known MRDO, or a colonized MRDO, or who would be at a high risk to contract a MRDO- use gloves and gowns [EPB] .This includes all required Hand Hygiene before and after donning/doffing gloves and gowns .3.1-18(b)(2)3.1-18(j)

Based on interview and record review, the facility failed to ensure Minimum Data Set (MDS) assessment accuracy for behaviors for 1 of 3 residents reviewed for behavior management. (Resident B) Findings include: The clinical record for Resident B was reviewed on 12/16/24 at 11:00 a.m. The diagnoses included, but were not limited to, senile degeneration of the brain, dementia with agitation, dementia with psychotic disturbance, and anxiety disorder. A Significant Change MDS assessment, dated 9/30/24, indicated Resident B exhibited no behaviors. Upon review of the progress notes, the following date(s) were indicative of Resident B exhibiting behaviors: 9/22/24, 9/23/24, 9/24/24, 9/25/24, 9/27/24, 9/28/24, & 9/29/24. An interview conducted with the MDS Coordinator, on 12/16/24 at 1:28 p.m., indicated Social Services was responsible for completing the MDS section regarding behaviors.

Based on interview and record review, the facility failed to ensure a resident with dementia and behaviors was care planned for behaviors along with resident specific interventions on approach to care, ensure visits were conducted of a mental health provider, and document approaches to care when Resident B exhibited behaviors for 1 of 3 residents reviewed for behavior management. Findings include: The clinical record for Resident B was reviewed on 12/16/24 at 11:00 a.m. The diagnoses included, but were not limited to, senile degeneration of the brain, dementia with agitation, dementia with psychotic disturbance, and anxiety disorder. An Admission MDS assessment, dated 5/24/24, indicated severe cognitive impairment, physical behaviors directed towards others occurred one to three days, significant risk for injury and interference with care regarding behaviors, and rejection of care every four to six days. A psychiatric visit form, dated 6/27/24, indicated Resident B had multiple behaviors including refusing medications and being combative with care. Treatment goals were for Resident B to have stabilization to mood and psychosis. A care conference document, dated 7/25/24, indicated discussion was held with Resident B's family regarding care preferences and being combative with care. The evaluation/goals had a suggestion to reach out to the Certified Nurse Aide (CNA) instructor for new techniques on how to approach resident during perineal care. A discussion to educate staff about Resident B's preferences and have a posting of strategies of approach in Resident B's room. A care conference document, dated 8/8/24, indicated Resident B's family wanted monitoring of staff interacting with Resident B to determine behaviors. Resident B becomes combative during perineal care and that had been consistent with every facility Resident B resided in. A Social Services Quarterly Note, dated 8/23/24, indicated Resident B exhibited behaviors that consisted of yelling out, refusal of medications, refusal of care, combative with facility staff, and physically aggressive with facility staff. A counseling progress note, dated 8/29/24, indicated Resident B was gradually modifying her behavior. The treatment objectives consisted of the current care plan with interventions to generally focus on reducing the problems of anxiety and depression. The plan was to continue to monitor, encourage, and educate. A counseling note, dated 9/12/24, indicated Resident B was not seen due to services terminated related to cognition decline and additional gains were becoming less likely. A Significant Change MDS assessment, dated 9/30/24, indicated Resident B exhibited no behaviors. A care plan for pain, revised 12/2/24, indicated Resident B had nonsensible responses and needs were anticipated by staff. The interventions included, but were not limited to, observe and report changes in usual routine, withdrawal, or resistance to care. A care plan for psychosocial well-being, initiated on 11/7/24 and revised on 12/12/24, indicated Resident B had a history of trauma and ineffective coping related to dementia to where she may become agitated and/or combative with care. The interventions included, but were not limited to, consult with Social Services, psych services as needed, explain the steps of care that you are providing prior to initiating services (initiated on 12/12/24), and give Resident B space and time to herself before attempting again (initiated on 12/12/24). There were no care plans specific to behaviors exhibited by Resident B and non-pharmacological and/or resident specific interventions listed for such behaviors until 12/12/24. The progress notes reviewed, from September 2024 to December 2024, indicated behaviors were exhibited for the following number of day(s): September 2024 consisted of 24 out of 30 days with behaviors exhibited, October 2024 consisted of 23 out of 31 days with behaviors exhibited, November 2024 consisted of 25 out of 30 days with behaviors exhibited, and December 2024 consisted of 11 out of 12 days with behaviors exhibited. A care plan for anxiety, initiated on 12/12/24, indicated Resident B may become agitated and yell out. The interventions included, but were not limited to, encourage resident to discuss her feelings, Resident B enjoyed sitting out in the common area, offer routine care plan meetings, and provide one-on-one visits as needed. The progress notes reviewed for Resident B indicated all behaviors exhibited by Resident B did not include the approach to the behavior by facility staff, documentation of resident specific approaches/interventions, and what interventions/approaches were successful or unsuccessful. An interview conducted with Nurse 4, on 12/16/24 at 11:30 a.m., indicated Resident B had verbal and physical aggression towards staff on a regular basis. The facility staff would attempt to redirect Resident B multiple times in an attempt to see what interventions would be effective, but nothing seemed to work. The staff would ask the resident what she wanted and when they returned with the items requested, Resident B would then deny those items. An interview conducted with the former Social Services Director, on 12/12/24 at 2:04 p.m., indicated the behavior management program was not appropriate at managing the residents with behaviors. There were no interviews conducted with resident, staff, and/or families to see what interventions could be implemented that were resident specific. The residents were given pharmacological interventions, and nothing was geared towards non-pharmacological interventions in an attempt to help with behaviors. How the staff approach the residents was important and it wasn't being discussed for implementation for the care plans regarding residents with behaviors. An interview conducted with the Director of Nursing (DON), on 12/16/24 at 3:00 p.m., indicated the charting wasn't reflective of interventions and approaches for Resident B's behaviors. Resident B was being seen by mental health providers, but her cognition became so poor, and she couldn't progress any further with the mental health services being provided. The facility staff have tried numerous attempts in response to Resident B's behaviors, but they were hardly effective. A policy entitled Behavior Health Services, undated, was provided by the Administrator on 12/16/24 at 11:06 a.m. The policy indicated the following, .Policy explanation and Compliance Guidelines .3. The facility will ensure that necessary behavioral health care services are person-centered and reflect the resident's goals for care, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety . 7. The facility utilizes the comprehensive assessment process for identifying and assessing a resident's mental and psychosocial status and providing person-centered care. The assessment and care plan will include goals that are person-centered and individualized to reflect and maximize the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety. Staff will . d. Evaluate whether the resident's distress was attributable to their clinical condition and demonstrate that the change in behavior was unavoidable .f. Assess and develop a person-centered care plan for concerns identified in the resident's assessment .g. Share concerns with the interdisciplinary team (IDT) to determine underlying causes of mood and behavior changes, including differential diagnosis . i. Ensure appropriate follow-up assessment, if needed . j. Discuss potential modifications to the care plan . k. Evaluate resident and care plan routinely to ensure the approaches are meeting the needs of the resident . 8. The resident, and as appropriate the resident's family, are included in the comprehensive assessment process along with the interdisciplinary team and outside sources, as indicated. The care plan shall . a. Have interventions that are person-centered . d. Account for the resident's experiences and preferences . f. Use pharmacological interventions only when non-pharmacological interventions are ineffective or when clinically indicated . 12. The Social Services Director shall serve as the facility's contact person for questions regarding behavioral services provided by the facility and outside sources such as physician, psychiatrists, or neurologists This citation relates to Complaint IN00447945. 3.1-37(a)

Based on interview and record review, the facility failed to ensure a narcotic pain medication was administered per the physician orders for 1 of 3 residents reviewed for pain management. (Resident B) Findings include: The clinical record for Resident B was reviewed on 12/16/24 at 11:00 a.m. The diagnoses included, but were not limited to, senile degeneration of the brain, dementia with agitation, dementia with psychotic disturbance, and anxiety disorder. A physician order, dated 10/20/24, indicated a fentanyl patch (narcotic pain-relieving patch) 12 mcg (micrograms) was to be applied every three days. This order ended on 11/19/24. A hospice note, dated 11/6/24, indicated an order to increase Resident B's fentanyl patch from 12 mcg to 25 mcg and change the patch every three days. A physician order, dated 11/7/24, indicated to apply a 25 mcg fentanyl patch to Resident B every three days. A controlled drug use record form for Resident B's 25 mcg fentanyl patch indicated one was administered on 11/10/24. A controlled drug use record form for Resident B's 12 mcg fentanyl patch indicated one was administered on 11/10/24. An incorrect dose was administered of a total of 37 mcg, on 11/10/24, when the physician order was for only 25 mcg at that time. A hospice note, dated 11/26/24, indicated to increase the fentanyl patch from 25 mcg to 37 mcg by applying a 25 mcg patch and a 12 mcg patch every three days. An interview conducted with the Director of Nursing (DON), on 12/16/24 at 3:00 p.m., indicated the nursing staff were to follow physician orders for medication administration. A policy titled Nursing - Medication Administration, undated, was provided by the DON on 12/16/24 at 3:00 p.m. The policy indicated medications were to be administered in accordance with the prescriber orders, including any required time frame. This citation relates to Complaint IN00446258. 3.1-25(b)

Based on interview and record review the facility failed to assure residents were treated with dignity and respect for 3 of 9 residents interviewed during Resident Council and 2 of 2 residents reviewed for dignity. (Resident B, P, 52, N, and K) Findings include: 1. The clinical record for Resident N was reviewed on 7/11/24 at 10:04 a.m. The diagnoses included, but were not limited to, unspecified injury of the cervical spinal cord and diabetes. A Significant Change of Status MDS (Minimum Data Set) Assessment, dated 4/8/24, indicated she was cognitively intact. During an interview for Resident Council, on 7/11/24 at 2:30 p.m., Resident N indicated the CNAs (Certified Nurse Aides) would come into her room and turn the call light off, telling her they would be back in a minute, but they never came back. When the staff does not assist with her needs, when her call light was on, she felt neglected and uncared for. She was to the point where she just lets it roll. 2. The clinical record for Resident P was reviewed on 7/10/24 at 10:49 p.m. The diagnoses included, but were not limited to, diabetes and cervical spinal stenosis. A Quarterly MDS Assessment, dated 5/1/24, indicated Resident P was cognitively intact. During an interview, on 7/10/24 at 10:49 a.m., Resident P indicated, a couple of months ago, a nurse had answered her call light. She asked the nurse to assist her with wiping and the nurse asked her what in the world did she (Resident P) do at home, and told her that she had never done this for someone before. 3. The clinical record for Resident 52 was reviewed on 7/11/24 at 2:45 p.m. The diagnoses included, but were not limited to, hypertension and stroke. A Quarterly MDS Assessment, dated 4/19/24, indicated she was cognitively intact. During Resident Council meeting, on 7/11/24 at 2:35 p.m., Resident 52 indicated she felt as if the residents in the health center were being treated like step children. The other parts of the campus had tablecloths on the tables, but the health center did not. 4. The clinical record for Resident B was reviewed on 7/11/24 at 2:50 p.m. The diagnoses included, but were not limited to, diabetes and hypertension. A Quarterly MDS assessment, dated 4/12/24, indicated Resident B was cognitively intact. An interview conducted with Resident B, on 7/11/24 at 9:49 a.m., indicated there were long delays with toileting. He would turn the call light on, and staff would enter his room rather quickly. The staff would turn off the call light and state they would return but would never return. He felt like the residents here were treated like the ugly step children. 5. An interview conducted with Resident K, on 7/10/24 at 11:41 a.m., indicated she had been waiting a long time for incontinent care. She had voiced her concerns to the CNA when she finally came in to provide care. The CNA's response was, I at least deserve a thirty minute break. A resident rights policy was provided on 7/17/24 at 4:00 p.m. The policy indicated the following, .The resident has a right to a dignified existence, self-determination, person centered care, communication with and access to persons and services inside and outside the facility, including: treating each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. It is the responsibility of the facility to protect and promote the rights of the resident . 3.1-3(a) 3.1-3(t)

Based on observation, interview, and record review, the facility failed to promptly act on a resident council grievance about tablecloths in the dining room. This had the potential to affect 9 of 123 residents who attend resident council. Findings include: On 7/11/24 at 1:24 p.m., the ADM (Administrator) provided the resident council minutes for April, May, and June 2024. The Resident Council Minutes, dated April 11, 2024, indicated that Resident 52 did not like the tablecloths removed from the dining rooms and the Administrator (ADM) had encouraged her to give the changes of the dining room experience a chance. A Resident Council meeting was held on 7/11/24 at 2:30 p.m. There were 9 residents in attendance. The council indicated the facility had stopped utilizing tablecloths in the health center dining rooms. The assisted living and the independent living dining rooms had tablecloths. The council had expressed concerns about not utilizing tablecloths in resident council meetings. They had not received any follow-up on the grievance of not having tablecloths, other than the new company had decided to stop using them. The council felt that they were being treated differently because they were in the health center. On 7/17/24 at 8:47 a.m., the dining room was observed in the assisted living part of the facility. There were white tablecloths on the tables. DS (Dietary Staff) 12 indicated that the dining room had tablecloths for each meal served. During an interview, on 7/17/24 at 10:28 a.m., the ADM indicated there were no grievances from resident council for April, May, or June 2024. During an interview, on 7/17/24 at 10:34 a.m., the AD (Activity Director) indicated she assisted with the resident council each month. She had not filled out grievance forms in resident council. She heard the residents' concerns about not having tablecloths in the dining room. The AD had never filled out grievance for the resident council as a general concern. On 7/15/24 at 9:30 a.m., the DON (Director of Nursing) provided the Resident and Family Grievances policy, updated 3/2020, and indicated the following, .Complaints and concerns expressed by the Resident Council will be promptly addressed by the department manager, and a follow-up response will be provided to the Council . 3.1-3(l)

Based on interview and record review, the facility failed to timely address resident grievances, provide dates that grievances were resolved, provide dates that follow up was done with the individual who brought forward the grievance, indicate that grievances were confirmed or not confirmed, and to provide a means for residents to file a grievance anonymously for 7 of 7 grievances reviewed. (Residents N, P, and R) Findings include: 1. The clinical record for Resident N was reviewed on 7/11/24 at 10:04 a.m. The diagnoses included, but were not limited to, unspecified injury of the cervical spinal cord and diabetes. A Significant Change of Status MDS (Minimum Data Set) Assessment, dated 4/8/24, indicated she was cognitively intact. A care plan, last revised on 4/23/24, indicated Resident N had a potential for alteration in mood related to depression, flat affect, reports little interest in doing things, tearful episodes, and critical of staff and routine. The goal was for her to demonstrate an improved mood. The interventions included, but were not limited to, encourage and allow open expression of feelings, initiated 11/8/23, and support my strengths and coping skills, initiated 11/8/23. During an interview, on 7/11/24 at 10:03 a.m., Resident N indicated she expressed concerns to the SSA (Social Services Assistant) about the CNAs (Certified Nursing Assistants) being rude and disrespectful. She did not always receive follow up about her concerns. On 7/12/24 at 2:05 p.m., the SSD (Social Services Director) provided Investigation and Follow-up of Grievance/ Complaint forms for Resident N dated 5/7/24 and 5/21/24. The Follow-up of Grievance/Complaint form, dated 5/7/24, indicated the following, .Detailed description of complaint: Res [Resident] reported CNA on evening shift 5/6/24 had poor customer service [sic]. Department Involved: Nursing. Corrective Measures: CNA educated on customer service and providing proper care. Manager of Department Involved Must Complete Steps Below: Date of follow-up response: 5/10/24. Date written notification regarding action needed to be offered per policy: [blank] There were no documents attached to the Follow-up of Grievance/Complaint form, dated 5/7/24, and the form did not contain information if the grievance had been confirmed or not confirmed. The Follow-up of Grievance/ Complaint form, dated 5/21/24, indicated the following, .Detailed description of complaint: NOC [night] 5/21/24 Res[sic] had complaint related to customer service issues. Department Involved: Nursing. Corrective Measures: Initiated in-service R/T [related to] resident's concern- proper transfers, following CNA assignment sheet R/T transfers. Always use 2 nrsg [nursing] staff for hoyer transfers, ice water pass q [every] shift and prn [as needed] .Manager of Department Involved Must Complete Steps Below: Date of follow-up response: [blank]. Date written notification regarding action needed to be offered per policy: [blank]. Signature of individual responsible for follow-up and notification [Director of Nursing signature present], Signature of Social Service Manager or designee [SSD signature]. Signature of Administrator [ADM signature] . The Follow-up of Grievance/Complaint form, dated 5/21/24, did not contain information if the grievance had been confirmed or not confirmed. A copy of a note was attached to the Follow-up of Grievance/Complaint form dated 5/21/24. The note indicated evening shift did not utilize 2 staff when putting Resident N in the mechanical lift. Resident N had asked for water on the NOC (night shift) and had not received the water. Resident N was told not to drink as much so she did not need changed as often. An evening shift CNA had complained about how she had to work a double and being overworked. The NOC shift had been very disruptive when changing Resident N. An education/ training sign-in form was attached to the Follow-up of Grievance/Complaint form dated 5/21/24. The education/ training form was signed by six staff members and indicated the topics discussed were proper transfers, following the CNA assignment sheets, water and fluids, ice water was to be passed every shift and as needed, and work concerns/complaints are not to be discussed with residents. During an interview, on 7/17/24 at 11:15 a.m., the DON (Director of Nursing) indicated she normally responded to the grievance forms within 48 hours. She did not usually put a date of when she followed up on the concern. She did not offer copies of the grievance forms to the person filing the grievance. Customer service concerns could indicate not addressing a concern properly. The note attached to the Follow-up of Grievance/Complaint form, dated 5/21/24, could have been written by the SSA (Social Service Assistant). The DON did not have any other notes or documentation from the investigation of the grievance from Resident N, dated 5/21/24. During an interview, on 7/17/24 at 2:25 p.m., the SSA indicated she had written the note attached to the Follow-up of Grievance/Complaint form dated 5/21/24. SSA could not recall if Resident N had provided names of the staff members involved. Resident N did not have a history of making false allegations. 2. The clinical record for Resident P was reviewed on 7/10/24 at 10:49 p.m. The diagnoses included, but were not limited to, diabetes and cervical spinal stenosis. A Quarterly MDS Assessment, dated 5/1/24, indicated Resident P was cognitively intact. During an interview, on 7/10/24 at 10:49 a.m., Resident P indicated she had filed grievances about an evening shift nurse. The nurse had refused to give her insulin correctly and had a disagreement with her and her son about blood pressure medications. The nurse had yelled at her son and was rude. Resident P had requested to speak to a supervisor but was told there was no supervisor. The disagreement about her blood pressure medications had happened on a Friday evening and she had filed the grievance on a Monday. No one had followed up with her regarding a resolution to the grievances. Resident P would prefer that she had another nurse rather than Licensed Practical Nurse (LPN) 11, but there was no one else available. Resident P did not always file grievances about concerns because the nurses could care for her again. On 7/12/24 at 2:05 p.m., the SSD (Social Services Director) provided Investigation and Follow-up of Grievance/ Complaint forms for Resident P dated 5/7/24, 5/24/24, and 6/10/24. The Investigation and Follow-up of Grievance/Complaint form, dated 5/7/24, indicated the following, .Detailed description of complaint: Res [resident] reported customer service issue w/ [with] nurse evening of 5/6/24. Department Involved: Nursing. Corrective Measures: Verbal one on one education given to nurse in training on customer care and following MD [physician] orders. Manager of Department Involved Must Complete Steps Below: Date of follow-up response: 5/7/24. Date written notification regarding action needed to be offered per policy: [blank]. Signature of individual responsible for follow-up and notification [ADON signature present], Signature of Social Service Manager or designee [SSD signature]. Signature of Administrator [ADM signature] . There were no documents attached to the Follow-up of Grievance/ Complaint form, dated 5/7/24, and did not contain information if the grievance had been confirmed or not confirmed. The Investigation and Follow-up of Grievance/Complaint form, dated 5/24/24, indicated the following, .Detailed description of complaint: Res [resident] reported issues with insulin timing. Department Involved: Nursing. Corrective Measures: Education and risk were explained to nurse . Nurse reports offering her insulin at different times and resident will refuse but will then sometimes ask for her insulin after the meal. Educated nurse on documentation .Manager of Department Involved Must Complete Steps Below: Date of follow-up response: [blank]. Date written notification regarding action needed to be offered per policy: [blank]. Signature of individual responsible for follow-up and notification [DON signature present], Signature of Social Service Manager or designee [SSD signature]. Signature of Administrator [ADM signature] . There were no documents attached to the Follow-up of Grievance/Complaint form, dated 5/24/24, and did not contain information if the grievance had been confirmed or not confirmed. The Investigation and Follow-up of Grievance/ Complaint form, dated 6/10/24, indicated the following, .Detailed description of complaint: Res [resident] reported issues w/ [with] medication delivery and issues w/ [sic] customer service evening of 6/7/24 . Department Involved: Nursing. Corrective Measures: Investigated situation. Per charge nurse she did hold her [Resident P] medication that could lower her BP even more which was the direction of the NP [nurse practitioner]. Nurse acknowledged the resident was not prescribed the med for BP [blood pressure], but it could cause hypotension .resident wanted to argue the situation and continued to demand the medication, but nurse refused. Nurse reports son came to the facility and when it was explained to him, he voiced understanding. The charge nurse did ask evening supervisor to come to unit and per supervisor . she went to discuss situation. Charge nurse reports the conversation with son was not disruptive to any other residents and was not heated. Manager of Department Involved Must Complete Steps Below: Date of follow-up response: [blank]. Date written notification regarding action needed to be offered per policy: [blank]. Signature of individual responsible for follow-up and notification [DON signature present], Signature of Social Service Manager or designee [SSD signature]. Signature of Administrator [ADM signature] . The Follow-up of Grievance/Complaint form, dated 6/10/24, did not contain information if the grievance had been confirmed or not confirmed. A typed note was attached to the Investigation and Follow-up of Grievance/ Complaint form, dated 6/10/24, which indicated that Resident P reported that LPN 11 had brought Resident P her evening medications and checked her vital signs. Resident P's blood pressure was low, and LPN 11 had prepared her medications. Resident P noticed her orange pills were not there and told LPN 11 the 3 orange pills were prescribed for heart rate, not blood pressure. LPN 11 had indicated she was going to mark down that Resident P refused the medication. Resident P had asked to speak to the supervisor and was told by LPN 11 she did not have a supervisor. LPN 11 had come back into the room a few minutes later to administer medication to the roommate. Resident P had attempted to speak to LPN 11, but LPN 11 had ignored Resident P. Resident P had called her son to come help diffuse the situation. When the son arrived and asked to speak to LPN 11. LPN 11 had loudly replied to the son that She was being rude to me. Resident P's son had told LPN 11 not to raise her voice at him. LPN 11 and Resident P's son had gone to the hallway and were yelling at each other for several minutes. LPN 11 continued to provide care for Resident P. During an interview, on 7/17/24 at 11:15 a.m., the DON indicated she had investigated the grievance on 6/10/24. DON had spoken with LPN 11 and the evening supervisor about the grievance. She had documented the information about the investigation on the grievance form and signed the form on the back. The DON did not have any other information or documentation about the grievance resolution. During an interview, on 7/17/24 at 2:34 p.m., the SSA indicated she remembered the grievance from 5/7/24 and 6/10/24. The SSA believed the nurse involved in both incidents was LPN 11. The incident, dated 5/7/24, was regarding insulin administration. LPN 11 had offered the insulin sooner than Resident P preferred to take it. Later, Resident P had asked for the insulin and LPN 11 had told her she had already documented it as refused. The incident, dated 6/10/24, was about blood pressure medications. Resident P and LPN 3 had a disagreement about blood pressure medications. Resident P had become upset with LPN 11 over her blood pressure medication. Resident P had called her son about the disagreement. When the son came in, Resident P reported that LPN 11 and her son had yelled at each other in the hallway. The SSA had offered to look into Resident P administering her own medication or to look into an assisted living environment for her. Resident P did not want to pursue either of those options. During an interview, on 7/17/24 at 2:50 p.m., the ADON (Assistant Director of Nursing) indicated she had investigated and followed up on Resident P's grievance, dated 5/7/24. The ADON found out that Resident P had not wanted to take insulin when it was offered from LPN 11. Resident P requested later that LPN 11 administer the insulin that had been offered earlier in the shift, and LPN 11 had told Resident P that she could not receive the insulin because the insulin was documented as refused. LPN 11 was new to the facility at the time and the ADON had educated LPN 11 on getting a one-time order from the physician to give the insulin if that scenario happened again. The grievance form had been filled out by the SSA. The SSA had indicated customer service issue on the grievance form but had come to the ADON and verbally explained the grievance in greater detail. 3. The clinical record for Resident R was reviewed on 7/12/14 at 11:29 a.m. The diagnoses included, but were not limited to, adult failure to thrive and severe dementia with psychotic disturbance. On 7/12/24 at 2:05 p.m., the SSD (Social Services Director) provided two Investigation and Follow-up of Grievance/Complaint forms for Resident R dated 3/4/24. The first Investigation and Follow-up of Grievance/Complaint form, dated 3/4/24, indicated the following, .Detailed description of complaint: Res [resident] family concerned of nursing communication, in regards to res [sic] care and res [sic] being NPO [nothing by mouth]. Department Involved: Nursing. Corrective Measures: Family has posted signs r/t [related to] NPO. CNA Assignment sheet, care plan, and orders updated. Manager of Department Involved Must Complete Steps Below: Date of follow-up response: [blank]. Date written notification regarding action needed to be offered per policy: [blank]. Signature of individual responsible for follow-up and notification [DON signature present], Signature of Social Service Manager or designee [SSD signature]. Signature of Administrator [ADM signature] . The second Investigation and Follow-up of Grievance/Complaint form, dated 3/4/24, indicated the following, .Detailed description of complaint: Residents family has complaints in regards to requesting x-ray for res [sic] back due to res. complaining to family of back pain. Department Involved: Nursing. Corrective Measures: upon investigation with nursing staff resident did not c/o [complaints of] [sic] pain to them. She was transferring and ambulating without complaints. No request for x-rays per charge nurse. Manager of Department Involved Must Complete Steps Below: Date of follow-up response: [blank]. Date written notification regarding action needed to be offered per policy: [blank]. Signature of individual responsible for follow-up and notification [DON signature present], Signature of Social Service Manager or designee [SSD signature]. Signature of Administrator [ADM signature] . The Follow-up of Grievance/Complaint forms, dated 3/4/24, did not contain information if the grievances had been confirmed or not confirmed On 7/16/24 at 2:01 p.m., the bulletin board on the [NAME] unit was observed. The bulletin board had a sign which indicated Grievance Officer Information, which indicated the Grievance Officer was the SSD, and to file a grievance in person or anonymously, to contact the SSD. On 7/16/24 at 2:15 p.m., the [NAME] unit was observed with RN (Registered Nurse) 7. RN 7 indicated there were grievance forms behind the nurses' station, but not out on the unit. On 7/17/24 at 10:15 a.m., the Heatherwood unit was observed with CNA 10. CNA 10 indicated that grievance forms were available behind the nurses' desk in a drawer. There were no grievance forms available on the unit. On 7/17/24 at 10:17 a.m., the Juniper unit was observed with RN 5. RN 5 indicated that there were no grievance forms available in the common areas of the unit. On 7/17/24 at 10:09 a.m., the Cedar Unit was observed with SSA 3. SSA 3 indicated that there were no grievance forms available without asking staff. During an interview, on 7/17/24 at 10:34 a.m., the SSD indicated her role in the grievance process is to track and make sure the managers are addressing the grievances and completing the forms. She provided information about grievances to the Quality Assurance committee. The individual managers of the departments are responsible for addressing the concerns. If a resident or family would like to file a grievance anonymously, they could use a piece of paper and put it under my door. There are no grievance forms available on the units without asking for one. During an interview, on 7/17/24 at 11:15 a.m., the DON indicated she normally responded to the grievance forms within 48 hours. She did not usually put a date of when she followed up on the concern. She did not offer copies of the grievance forms to the person filing the grievance. Customer service concerns could mean not addressing a concern properly. On 7/15/24 at 9:30 a.m., the DON provided a copy of the Resident and Family Grievance Policy, last updated 3/2020, which indicated the following, .Policy: It is the policy of [name of facility] that residents may voice complaints and grievances with respect to treatment and care that is or fails to be furnished, and recommend changes in policy and services without fear of discrimination, reprisal or interference . The Grievance Official is responsible for overseeing the grievance process; receiving and tracking grievances through to their conclusion; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances; issuing written grievance decisions to the resident; and coordinating with state federal agencies as necessary in light of specific allegations. Concern/ Suggestions forms are available at the nurse's station, at the customer service in the Social Services offices and upon request. Staff members must report the concern/ suggestion and complete a concern/ suggestion form. Residents or family members may complete the form personally . If the complaint is not resolved within five [5] days, the Director of Health Center Operations, Executive Director or a Designee determine the reason for the delay .The findings of each investigation and actions taken in response to those findings will be reported in writing the individual[s] who registered the original complaint or concern upon request. Ensuring that all written grievance decisions include the date the grievance was received a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concern[s], a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued . The individual voicing the complaint or concern will receive follow-up information .Resolution conference reports will be signed by all involved parties . This citation relates to Complaint IN00430036. 3.1-7(a)(1) 3.1-7(a)(2) 3.1-7(a)(3) 3.1-7(b)

Based on observation, interview, and record review, the facility failed to ensure incident reports were completed after each fall event, post fall assessments were completed on every shift (morning, evening, and night) for 72 hours, and fall interventions were in place for 5 of 8 residents reviewed for accidents. (Residents E, C, F, M, and D) Findings include: 1. The clinical record for Resident E was reviewed on 7/12/24 at 10:30 a.m. The diagnoses included, but was not limited to, dementia and a displaced comminuted (broken in at least two places) fracture of the right femur. A Quarterly Minimum Data Set (MDS) assessment, dated 2/4/24, indicated Resident E required substantial/maximal assistance with transfers to and from bed/chair, toileting, and moving from a sit to stand/stand to sit position. Resident E was not cognitively intact. 1a. A nursing note, dated 12/24/23 at 12:23 p.m., indicated Resident E's Certified Nursing Assistant (CNA) had observed Resident E walking back from her bathroom and witnessed her fall in the bedroom. Resident E complained of a headache and left leg pain. No further progress notes from that day indicated what/if any new interventions were put in place to prevent another fall. Resident E's post fall assessment, dated 12/24/23 at 12:00 p.m., indicated the post fall assessments were to be completed every shift for three days post fall event. Resident E only had one other post fall assessment completed regarding the fall, on 12/24/23, and it was dated 12/24/23 at 10:06 p.m. 1b. A nursing note, dated 1/28/24 at 5:52 p.m., indicated Resident E was sitting in the dayroom with other residents when she got up from her chair to follow another resident, and got tangled in an oxygen line, tripped, and fell on to her left side. The note stated, initially, Resident E did not complain of pain but then complained of right knee pain at a 3 or 4 out of 10 on a numeric pain scale. Her right knee had a small area that looked like a rug burn on her knee. No x-ray was ordered at the time. No further progress notes from that day indicated what/if any new interventions were put in place to prevent another fall. A fall incident report, dated 1/28/24 at 5:42 p.m., indicated the immediate action was to obtain vital signs and assist resident off the floor; injuries observed at time of incident were none; level of pain was 3 out of 10; the predisposing factor was other; nothing was check marked for predisposing environmental factors; predisposing psychological factors were: impaired memory, confusion, and other with no description; and predisposing situation factors were: active exit seeker, ambulating without assistance and wandering. The incident report did not include if any new interventions were put into place to prevent Resident E from further falls nor was the incident report part of Resident E's clinical record. At the bottom of the incident report it indicated, the report was Not part of the Medical Record. An IDT note, dated 1/29/24, indicated Resident E ambulates and tripped over another resident's oxygen tubing in the activity common area. Nursing staff and activities directed to be more mindful of environment, although resident with oxygen does frequently get up and move about. Resident E's post fall assessments (every shift for three days) were completed on: 1/29/24 at 4:57 a.m., 1/29/24 at 8:46 p.m., and 1/30/24 at 6:12 a.m. The post fall assessments for Resident E's fall, on 1/28/24, were not completed every shift for three days. Resident E's fall care plan, last revised on 5/20/22, included but not limited to, a fall intervention, dated 9/2/19, to ensure that floors are free of clutter and spills. Resident E's care plan was not updated with a new intervention for falls following the fall on 1/28/24. 1c. A nursing note, dated 2/10/24 at 7:35 p.m., indicated Resident E had an unwitnessed fall at about 5:55 p.m. Resident E had attempted to throw out some food her family had brought in for her. Resident E denied pain and was assisted back into her chair. The nursing note made no mention of starting neurological assessments on Resident E following an unwitnessed fall. No further nursing notes from that day indicated what/if any new interventions were placed to prevent another fall. The fall incident report, dated 2/10/24 at 6:42 p.m., indicated Resident E fell out of her wheelchair and onto her knees while trying to throw away food. Immediate actions taken were: vital signs taken, body inspection, no noted swelling or bruises, and resident denied having any pain. No injuries were noted at the time and the predisposing factor was impaired memory. The fall incident report did not indicate neurological assessments were to be conducted following an unwitnessed fall. An IDT note, dated 2/12/24, indicated Resident E had poor safety awareness and lost her balance while trying to throw away food. Resident E was in her wheelchair at the time of the fall. The IDT note indicated the following, Will continue with close observation. Resident E's post fall assessments were completed on: 2/10/24 at 7:54 p.m. and 8:09 p.m., 2/11/24 at 4:41 a.m., 2/12/24 at 6:28 a.m., and 2/12/24 at 6:26 p.m. The post fall assessments for Resident E's fall, on 2/10/24, were not completed every shift for three days. Resident E's fall care plan, last revised on 5/1/2022, included, but were not limited to, a fall intervention, dated 9/2/19, to ensure personal items were within reach and anti-roll back to wheelchair to reduce falls, dated 3/3/20. Resident E's care plan was not updated with a new intervention following the fall event on 2/10/24. 1d. A nursing note, dated 2/14/24 at 2:35 p.m., indicated Resident E was sitting in a chair by the activity room door and, when the nurse returned to the area approximately five minutes later, Resident E was found sitting on the floor. Her wheelchair was still next to the activity room door and Resident E was leaning on the wall next to the dining room door, which was approximately six feet away from her wheelchair. She was tapping on the door to the dining room and was unable to explain what had occurred but denied pain. Resident E was assisted back into the wheelchair and assessed. No injuries were noted, and neurological checks were initiated per protocol. No further nursing notes from that day indicated what/if any new interventions were placed to prevent another fall. A fall incident report, dated 2/14/24 at 2:30 p.m., indicated Resident E was noted to be sitting on the floor, with her back against the wall and tapping on the dining room door which was approximately six feet from where her wheelchair was located. Immediate actions taken were: assisted resident up off the floor back into her wheelchair and was placed next to a CNA, she was assessed for injuries and vital signs, and neurological checks were initiated. A predisposing factor was crowding. The post fall assessments for Resident E were completed on 2/14/24 at 2:45 p.m. and 10:57 p.m., 2/15/24 at 4:09 a.m., 2/16/24 at 6:04 a.m. and 9:33 p.m. The post fall assessments for Resident E's fall, on 2/14/24, were not completed every shift for three days. An IDT note, dated 2/15/24, indicated Resident E attempted self-ambulation from her wheelchair. The IDT note indicated the following, Will continue with close observation and activities of choice .encouraged to spend time in the activity room for closer observation, but will wander off . Resident E's fall care plan, last revised on 5/1/2022, included, but were not limited to, a fall intervention, dated 9/2/19, to ensure personal items were within reach and anti-roll back to wheelchair to reduce falls, dated 3/3/20; encourage resident to attend activities, initiated on 2/5/20, and Resident transfers and attempts self-ambulation. Resident E's care plan was not updated with a new intervention following the fall event on 2/14/24. 1e. A nursing note, dated 3/19/24 at 5:00 p.m., indicated Resident E was up walking around in her room when staff attempted to redirect her towards her wheelchair. She became aggressive towards the staff and fell from her waist down onto her left side. No injuries were noted, and staff called Resident E's daughter to see if she would come to the facility to be with the resident. A nursing note, dated 3/19/24 at 7:15 p.m., indicated Resident E was up walking around in her room when a CNA asked her to use her wheelchair. Resident E became aggressive with staff members and was cursing at them when she fell on her left side from her waist down. Resident E's daughter was called to come to the facility. No further nursing notes from that day indicated what/if any new interventions were placed to prevent another fall. A fall incident report, dated 3/19/24 at 8:31 p.m., indicated Resident E had been up walking around her room without the use of her wheelchair and when staff asked her to use her wheelchair, she became aggressive with staff when she fell on to her left side. Resident indicated the two staff members were telling her what to do. Immediate actions taken included assisting the resident off the floor, called her daughter, and attempted to get vital signs but the resident was not allowing them by moving her hands around. No injuries were noted, predisposing environmental factors were poor lighting, and predisposing situation factors was ambulating without assistance. An IDT note, dated 3/20/24, indicated Resident E was upset with staff for attempting to redirect her to sit in her wheelchair for safety when she fell . The note indicated the following, Behaviors/mood will be observed for any necessary interventions. Staff is aware to give her space when anxious .Poor safety awareness due to impaired cognition Resident E's fall care plan, last revised on 5/1/2022, included, but was not limited to, interventions, dated 9/2/2019, were to ensure that resident wears non-skid footwear when ambulating or propelling the wheelchair and maintain adequate lighting with room and hallways. Resident E's care plan was not updated with new interventions following the fall event on 3/19/24. 1f. A nursing note, dated 3/20/24 at 5:29 p.m., indicated Resident E was sitting in the common area with staff and peers present, when a staff member had got up to assist another resident, and Resident E got up from her wheelchair at the same time then walked from the dining room door to the activity room door and fell into the activity room. Resident E was not able to explain what had occurred but did report pain in her knee. The note indicated neurological checks were initiated per protocol and range of motion was maintained. A fall incident report, dated 3/20/24 at 5:15 p.m., indicated Resident E was sitting in common area when she got up and walked toward the activity room and fell in the doorway of the activity room landing on her side. Immediate actions taken were: vital signs taken, resident assessed, pain medication given, and neurological checks were initiated per protocol. Predisposing physiological factors were confusion, gait imbalance, and impaired memory. Predisposing situation factors were ambulating without assistance. A nursing note, dated 3/20/24 at 11:22 p.m., indicated, Resident E, while resting in her bed, complained of knee pain rating a 7 out of 10 on the numeric scale. Her right knee was noted to be swollen, tender to touch, and would only move her leg when necessary. The note indicated the knee did not look out of place and no signs of broken bones. No further nursing notes from that day indicated what/if any new interventions were placed to prevent another fall. An IDT note, dated 3/21/24, indicated the following, continue with close observations and keeping her busy as possible with activities. Resident is impulsive and [sic, has] poor safety awareness. A nursing note, dated 3/21/24 at 6:40 a.m., indicated Resident E fell the previous evening and called Resident E's physician. An order for a portable x-ray was received for the right knee which was swollen and painful. A nursing note, dated 3/21/24 at 4:13 p.m., indicated Resident E had a displaced comminuted fracture of the distal femur. The nurse practitioner and family were notified and would be in to see the resident that day. A nursing note, dated 3/21/24 at 5:15 p.m., indicated Resident E's family requested she be sent to the local emergency department related to the fracture of the distal femur. Resident E was later sent to the local emergency room and did not return to the facility until 3/28/24. No further progress notes, from 3/21/24 until 4/1/24, indicated what/if any new interventions were put in place to prevent another fall. A nursing note, dated 4/1/24 at 7:47 p.m., indicated Resident E remained on increased monitoring for recent hospitalization for right distal femur fracture secondary to a fall. Dressings to Right femur and Right knee removed this day revealing 49 staples to R [sic, right] femur and 4 staples noted to R [sic] knee . An interview conducted with Resident E's family member, on 7/15/24 at 12:28 p.m., indicated Resident E's repeated falls were concerning. She indicated she could possibly understand the first fall, on the day before Christmas, because she was in her room ,but when her mom was still falling in the common area where more supervision was supposed to occur then they were concerned. Resident E's daughter indicated she was told the facility was going to have her mom spend more time in the common area with peers so more staff would be able to watch her, but that didn't seem to prevent her from falling. Resident E's daughter further indicated they themselves requested for Resident E to be sent to the hospital as the facility was going to treat her fracture medically. She indicated not only was Resident E sent to surgery to repair the fractures, but she also had a brain bleed. 2. The clinical record for Resident C was reviewed on 7/16/24 at 1:49 p.m. The diagnoses included, but was not limited to, congestive heart failure (CHF), dementia with anxiety and mood disturbance, and anxiety disorder. A Quarterly MDS assessment, dated 2/16/24, indicated she had moderate cognitive impairment and required supervision/touching assistance with toileting, personal hygiene, transferring on/off toilet, moving from a lying to sitting position/sitting to lying position, transferring from chair to bed/bed to chair, and was independent to walk 10 feet. A Significant Change MDS assessment, dated 4/19/24, indicated her cognitive status declined and was totally dependent on assistance for toileting, personal hygiene, transferring on/off toilet, moving from a lying to sitting position/sitting to lying position, transferring from chair to bed/bed to chair and walking 10 feet was not attempted due to safety concerns. A physician's order, dated 4/12/24, indicated Resident C was to be admitted to hospice. 2a. A nursing note, dated 4/2/24 at 8:30 a.m., indicated Resident C continued to cry out that morning, asking her roommate to call for help, and yelling for her roommate. Resident C also attempted to get out of her recliner several times while the writer of the note attempted to put her back in chair several times, and explained for her to call for staff assistance, and not her roommate as the roommate was being disturbed. Resident C indicated, she understood, but continued to call for roommate. Resident C attempted to get out of chair and attempted to fall onto the ground, when the writer had to hold resident's arm to prevent and break the fall. Resident C was placed in her wheelchair and taken to the dining room for breakfast. An IDT note for the fall event, dated 4/2/24, was not located by DON. 2b. On 4/4/24 at 6:45 p.m., a nursing note indicated facility staff was alerted that Resident C had fallen out of the recliner and was in front of the recliner lying flat on her back and had pulled her oxygen off. Resident C was assessed, and a neurological assessment was within normal limits. No injuries or pain were noted. The 72-hour neurological assessments were initiated. No further progress notes from that day indicated what/if any new interventions were put in place to prevent another fall. An IDT note, dated 4/5/24, indicated positioning in the chair was assessed and the resident was checked on frequently through the night. The call light was within reach. The post fall assessments for Resident C were completed on 4/4/24 at 6:45 p.m., 4/5/24 at 10:44 p.m., 4/6/24 at 2:39 p.m., and 4/6/24 at 5:42 p.m., and then Resident C had another fall. The post fall assessment were not completed as the form indicated which was every shift for three days (72 hours). On 4/6/2024 at 2:33 p.m., a nursing note indicated Resident C had been up in her wheelchair and had tried to stand up from the wheelchair multiple times. At 3:20 p.m., a nursing note indicated Resident C was on fall follow-up with neurological checks and vital signs being completed. The nursing note indicated the following, Will continue monitoring and report changes per protocol. The note did not indicate what/if any new interventions were put in place to prevent another fall. 2c. On 4/6/2024 at 5:38 p.m., a nursing note indicated Resident C had been sitting in her big chair in her room when she got up, with no shoes on, and was wearing her anti-embolism stockings when she had an unwitnessed fall. Resident C was unable to explain what had occurred. Her range of motion, neurological status, and vitals were assessed. A new 72-hour neurological assessment was initiated, and the resident was transferred to her wheelchair and taken to the television lounge. A nursing note, dated 4/6/24 at 10:32 p.m., indicated her daughter had visited and placed footies on her mom. No further progress notes from that day indicated what/if any new interventions were put in place to prevent another fall. A post fall assessment for Resident C was completed on 4/6/24 at 5:42 p.m. and 4/7/24 at 7:22 a.m., then Resident C had another fall. The post fall assessments were not completed every shift. 2d. A nursing note, dated 4/7/24 at 7:14 a.m., indicated Resident C was found on the floor after walking into her neighbor's room without a walker. Resident C was found to have a knot to the back of head and was complaining of a slight headache. No further progress notes from that day indicated what/if any new interventions were put in place to prevent another fall. 2e. A nursing note, dated 4/8/24 at 2:00 a.m., indicated Resident C was found on the floor of her room naked. She had taken off her incontinent brief and had an incontinent episode on the floor which was beside her. Resident C was confused and speaking incoherently. She was assisted off the floor into her wheelchair and taken to the common area where she could be more closely monitored by staff. The writer of the nursing note indicated they were instructed to just continue to monitor resident per facility protocol. Will continue to monitor. Later that day, on 4/8/24, Resident C was found to have a urinary tract infection. No further progress notes from that day indicated what/if any new interventions were put in place to prevent another fall. Post fall assessments for Resident C were completed on 4/8/24 at 2:00 a.m., 4/8/24 at 8:02 p.m., 4/9/24 at midnight, and 4/10/24 at 11:55 p.m. The post fall assessments were not completed every shift. An IDT note, dated 4/8/24, indicated Resident C had an increase in anxiety and behaviors. The note indicated the following, Frequent checks in place and the resident was brought to the common area for closer observation. Another IDT note, dated 4/8/24, indicated Resident C had poor safety awareness and was brought to the dining room for the morning meal. 2f. A nursing note, dated 6/30/24 at 10:00 a.m., indicated Resident C was found on the floor in her room. A post fall assessment, dated 6/30/24, indicated Resident C's fall was unwitnessed. She was attempting to toilet herself. Resident C's electronic health record (EHR) nor her physical chart contained the 72-hour neurological assessments for the falls on 4/6/24, 4/7/24, or 4/8/24. An interview conducted with DON, on 7/17/24 at 1:19 p.m., indicated no further neurological assessments were found for Resident C's fall events. Resident C's fall care plan, dated 5/16/23, indicated to ensure the resident was wearing non-skid footwear when ambulating or propelling wheelchair, initiated on 5/16/23, and had not been revised to include new interventions to prevent a future fall. 34850 3. The clinical record for Resident F was reviewed on 7/10/24 at 2:00 p.m. The diagnosis included, but was not limited to, Alzheimer's disease. An Admission MDS assessment, dated 6/13/24, indicated Resident F was cognitively impaired. A care plan, dated 6/10/24, indicated Resident F had a potential for falls r/t [related to] deconditioning gait/balance problems, unaware of safety needs. fall in the home, down unknown length of time, seen in ER [emergency room ] and admit to hospital. Fall in facility impulsive. no injuries . During a Confidential Interview, they indicated Resident F had fallen, on 6/10/24, and the staff had not assessed or monitored the resident after her fall. A fall incident report for Resident F, dated 6/10/24, indicated the following, .Writer found resident sitting on the floor while doing his rounds inside her room beside her bed. Resident's back is leaning on her wheelchair .When writer asked resident why she is sitting on the floor, resident replied 'I am trying to transfer myself to my bed, I slid down from my wheelchair .Resident was assessed for any injury, resident claimed that she did not hurt herself and she is not in any pain. Neuro check was started, vitals was taken, after assessing the resident is free from pain or injury, resident was helped get back to her bed safety by two person using a gait belt . The medical provider and the resident's Power of Attorney was made aware of the incident. A nursing progress note, dated 6/11/24, indicated the following, .Writer found resident inside her room sitting on the floor with legs spread apart, she was beside her bed and she is leaning back on her wheelchair, she said she was trying to transfer her self from chair to bed, she said she slid down from her wheelchair, no injury, no pain noted as of this time, neuro check, skin assessment started, notified [Power of Attorney] .ADON [Assistant Director of Nursing] notified. Resident was transferred back safely to her bed using two person assist with gait belt, placed call light within reach. Endorsed to oncoming nurse. The post fall assessments for Resident F were provided by the DON on 7/15/24 at 9:30 a.m. The assessments indicated the staff were to assess the resident after a fall, every shift, for three days. The following dates and times indicated a post fall assessment was conducted on Resident F: 6/10/24 at 11:13 p.m., 6/11/24 - there were no post fall assessments conducted, 6/12/24 at 10:59 a.m., and 6/13/24 at 2:33 a.m. The resident's clinical record did not include post fall assessments that were conducted on every shift for Resident F's fall that had occurred on 6/10/24. A nursing progress note for Resident F, dated 6/21/24, indicated the following, .Resident was on the floor in Aspen activity room. She said she got up from her wheel chair and sat on the floor. She denied falling. She was taken back to the room. The resident's clinical record did not include assessments and monitoring of the resident at the time of the fall, on 6/21/24, or post fall assessments, every shift, for 3 days. A medical provider note for Resident F, dated 6/21/24, indicated the following, .She had a fall a few days today [sic] and another one today unwitnessed without injury. Per nursing, patient was found in activity room and reported getting up from her wheelchair to sit on the floor .Patient resting in bed, does not recall fall earlier today. She reports no current pain A written statement by License Practical Nurse (LPN) 3, dated 7/9/24, indicated the following, .I was walking to the unit where I was to work on that day and I saw this lady [Resident F] sitting upright on the floor, I asked if she was okay, she said yes, I asked if she fell , she answered no. I saw the aid walking towards her and I asked the aid if he knew who she was, the aid said yes and that he was going to get her to her room and then for breakfast. I walked pass. I reported to the NP [Nurse Practitioner] that day how I met the resident and that I went ahead to check her v.s. [vital signs] when I realized she was in the unit I was assigned to work that day. She denied falling and denied having any pain at the time I asked. An interview was conducted with the DON on 7/15/24 at 2:46 p.m. She indicated, on 6/21/24, Resident F did have a fall. The nurse did not consider the resident had fallen after observing Resident F sitting on the floor in the activity's room. During an interview, LPN 3 had stated to the DON she had arrived on the unit and had observed a resident sitting on the floor in the activity room. She places herself on the floor all the time, so she did not consider it a fall. The DON indicated a fall assessment, incident report, and fall post assessments, every shift, should have been conducted after Resident F had fallen on 6/21/24. 4. The clinical record for Resident M was reviewed on 7/10/24 at 2:30 p.m. The diagnosis included, but was not limited to, stroke. A nursing progress note for Resident M, dated 7/8/24, indicated the following, .At approximately 7:10 a.m. the [Certified Nursing Assistant] CNA reported witnessed fall. CNA stated she was preparing resident for transfer when he slipped out of bed. Writer went in to assess resident. Res [Resident] lying on floor in supine position. Pillow under head for comfort. Bed sheet appears to be slightly off bed. Res assessed for injuries. No injuries observed at this time. No c/o [complaints of] pain or discomfort at this time. VS [vital signs] obtained .Will continue to monitor resident . A fall incident report, dated 7/8/24, indicated the following, CNA called writer into room stating she had to lower resident to floor. Writer walked in resident lying in supine position. Pillow under head. No clutter observed. Sheets slightly off bed .Assess for pain/injuries. vs [vital signs] obtained. Res [Resident] M assisted to w/c [wheelchair] via hoyer lift [mechanical lift] An IDT (Interdisciplinary Team) note, dated 7/8/24, indicated the following, Per charge nurse report CNA was getting resident ready for the morning and ready for transfer. He was sitting on the side of the bed and prior to CNA getting assist with the transfer resident slid from the bed. Resident not to sit on side of bed without 2 person assist. A post fall evaluation for Resident M, dated 7/9/24, was in the clinical record, but there was nothing documented under the fall evaluation. The clinical record did not include post fall assessments every shift for three days after the fall event on 7/8/24. An interview was conducted with Resident M on 7/17/24 at 9:42 a.m. He indicated he was sitting on the edge of the bed reaching for the handles of the stand-up lift (mechanical lift) and slid from the bed to the floor. He landed on his buttocks. He does not recall hurting himself. An interview conducted with the DON, on 7/15/24 at 2:46 p.m., indicated fall assessments, incident reports, and post fall assessments should be conducted every shift after fall events. 40287 5. The clinical record for Resident D was reviewed on 7/10/24 at 2:20 p.m. The diagnoses included, but were not limited to, left sided hemiplegia (paralysis of left side) and dependence on wheelchair. A care plan, dated 5/9/24, indicated Resident D had a potential for falls related to a history of traumatic brain injury, immobility, non-ambulatory, and abnormal posture due to hemiplegia affecting his left dominant side. He was non-compliant with transferring self and refused the Hoyer lift. The goal was for him to be free of falls. The interventions included, but were not limited to, ensure non-skid footwear when ambulating or propelling wheelchair, initiated 5/9/24, reacher at bedside, initiated 5/15/24, and reacher at bedside and personal items in reach, revised 6/17/24. A Health Status Note, dated 5/12/24, indicated that Resident D had been found sitting on the floor. Resident D indicated he was reaching for a pair of pants on the back of his chair and slid out of his wheelchair. Resident D had denied pain and discomfort at the time. The physician and family were notified. An Admission MDS assessment, dated 5/14/24, indicated Resident D was cognitively intact and used a wheelchair for mobility. He had a history of falls in the 6 months prior to admission and had experienced 1 fall without injury since his admission to the facility. A Fall Note, dated 6/16/24 at 11:50 a.m., indicated Resident D was found on the floor with a laceration to the back of the scalp. Resident D indicated he was trying to fix his shoe when he fell , although both of the resident's shoes appeared to be on his feet appropriately. The physician and the family had been notified and Resident D had been sent to an acute care hospital due to his head laceration. A Health Status Note, dated 6/19/24 at 9:38 p.m., indicated Resident D was found on the floor lying on his back in front of his bed. Resident D indicated that he was trying to turn off his light when he fell . The physician was notified, and the facility had attempted to notify the family. An Incident Note, dated 7/12/24 at 3:05 p.m., indicated Resident D was transferring to the toilet with a CNA (Certified Nursing Assistant) and slipped off. The clinical record did not contain IDT (Interdisciplinary Team) notes regarding the review to the fall events for 6/16/24, 6/19/24, and 7/12/24. During an interview, on 7/15/24 at 10:32 a.m., the TM (Therapy Manager) indicated that falls were discussed in the morning meetings. During an interview, on 7/16/24 at 10:09 a.m., the DON indicated that the IDT notes about falls were not in the clinical record. The incident reports/ fall risk assessments were internal documents and not part of the clinical record. The IDT notes were on the incident reports. An incident report should be filled out after each fall occurrence. The IDT team informed staff of new interventions and added the interventions to the assignment sheet. On 7/16/24 at 10:21 a.m., the DON provided the incident reports for Resident D's falls. There was not an incident report completed for the fall that happened on 6/19/24. During an interview, on 7/16/24 at 10:53 a.m., Resident D indicated he did not have a reacher in his room. He used to have a reacher but could not find it. He would use one if he had it. Resident D had fallen in the bathroom on 7/12/24. He did not use the toilet riser that was present in his bathroom because it was too small for him. He would like to have a bar on the right side of his toilet so that he could pull himself up from the wheelchair when he needed to use the toilet. On 7/16/24 at 12:44 p.m., Resident D's room was observed with the DON. The DON indicated she did not see a reacher in his room and would get him a new reacher. During an interview, on 7/16/24 at 12:52 p.m., the DON indicated that post fall assessments should be conducted each shift for three days following a fall. On 7/15/24 at 9:30 a.m., the DON provided the current Fall Risk and Post Fall Assessment Policy which indicated the following, . Purpose: To identify treatable conditions and improve the overall quality of life for the resident. To conduct appropriate assessments prior to and after falls. To intervene when possible to break a fall. To detect reversible causes of falls a [TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure a clean, sanitized, and well maintained kitchen by staff who failed to wear beard restraints to prevent hair from contacting food, ensure proper storage of food products by keeping track of when to discard perishable foods stored in the refrigerator, maintain a minimum washing temperature in 1 of 2 dishwashers in the facility, and failed to sanitize rolling kitchen carts before placing them in the storage room in kitchen 1 of 2 where food products are stored with the potential to affect 97 of 123 residents who receive food from the kitchen. (Facility) Findings include: 1. An observation of the facility kitchens 1 and 2 was conducted, on 7/10/24 at 10:20 a.m., with the Kitchen Manager (KM 2) and the Dining Service Director (DSD). An observation was conducted of kitchen 1, on 7/10/24 at 10:20 a.m., of the walk-in refrigerator. There was an open box containing individual Jello cups with the expiration date, of 6/29/24, and an open box of exposed hot dogs with the expiration date of 6/27/24. A Production, Purchasing, Storage Policy was received, on 7/16/24 at 12:10 p.m., from the Assistant Director of Nursing (ADON). The policy indicated the following, Foods past the use by, sell by, best by, or enjoy by date should be discarded .Cover, label and date unused portions and open packages .All food shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. 2. An observation was conducted of kitchen 2, on 7/10/24 at 10:55 a.m., with KM 2 and DSD. It was observed that the dishwasher wash cycle temperature reached 147 degrees Fahrenheit (F). An interview was conducted with DSD, and he indicated that the machine needed to be at least 150 degrees and he would put in a work order. A second attempt to reach the proper temperature was made, on 7/11/24 at 9:25 a.m., after the maintenance man had been in to service the dishwasher and the dishwasher temperature reached 148 degrees F. [NAME] 2 placed an out of order sign on the dishwasher and the manufacturer was called. During an interview, on 7/15/24 at 12:44 p.m., Resident 22 indicated her silverware was dirty when she unwrapped it from the cloth napkin. An observation was conducted on 7/15/24 at 1:40 p.m. The dietary staff brought in two test trays with five plates, three of which were dirty with food debris. A [NAME] manufacturers instruction manual for the dishwasher located in kitchen 2 was provided, on 7/16/24 at 12:10 p.m., by ADON. The manual indicated the following, Operating temperatures for all models are as follows: Hot Water minimum wash temperature is 150 degrees F, and the recommended wash temperature is 150 degrees F. 3. A tour of kitchen 1 was conducted, on 7/10/24 at 10:20 a.m., with KM 2 and DSD. Three soiled rolling carts were observed in the food storage area. An interview conducted, on 7/10/24 at 10:25 a.m., with KM 2 indicated that the carts should be cleansed prior to being placed in the storage area. An observation conducted of kitchen 1, on 7/12/24 at 9:57 a.m., noted 5 soiled rolling carts found in the storage area. A Diversey Food Carts cleansing guide was provided, on 7/16/24 at 12:10 p.m., by ADON. The guide indicated recommended products, frequency, time required and procedures for cleaning the rolling carts. A Sanitation and Infection Prevention / Control for the Cleaning of Food and Nonfood Contact Surfaces policy was provided, on 7/16/24 at 12:10 p.m., by ADON. The policy indicated the following, To prevent cross-contamination, kitchenware and food-contact surfaces of equipment shall be washed, rinsed, and sanitized after each use and following any interruption of the operations during which time contamination may have occurred. 4. An observation and interview were conducted, on 7/12/24 at 9:57 a.m., in kitchen 1. [NAME] 2 and Kitchen Aid 2 (KA 2) were observed standing in the food preparation area without beard coverings. Both [NAME] 2 and KA 2 had facial hair and beards exceeding 1/4 of an inch in length. An interview conducted, on 7/12/24 at 9:59 a.m., with [NAME] 2 indicated he was unaware beard covers were needed. An observation and interview were conducted of kitchen 2 on 7/12/24 at 10:34 a.m. Chef 2 indicated he was unaware beard covers were needed and he would check with the new supply company to get beard covers that are appropriate. An Associate Conduct Personal Appearance and Handwashing policy received, on 7/16/24 at 12:10 p.m., from the ADON indicated the following, For Associates working in food service restrain all facial hair with a beard net/restraint. 3.1-21(i)(2) 3.1-21(i)(3)

Based on interview and record review, the facility failed to ensure a resident did not receive another resident's medication, resulting in the resident becoming somnolent and unresponsive and requiring emergent care with the use of a medication to reverse the effects of the unresponsiveness for 1 of 3 residents reviewed for the receipt of incorrect medications in a sample of 3. (Resident #B) Findings include: Resident #B's clinical record was reviewed on 4-18-16 at 10:20 a.m. It indicated his [DIAGNOSES REDACTED]. In an interview with LPN #2 on 4-19-16 at 11:23 a.m., she indicated on the evening of 3-26-16, she was orienting a new nurse, RN #3. She indicated she was observing RN #3 with the entire bedtime medication pass. Instructed (her) to get (Resident #C)'s blood sugar and get his meds ready while I went to check on two other residents. When I stepped back in the hall, she (RN #3) was gone and I heard her in (name of Resident #B)'s room. (When I got to his room), she was bent over and ready to give him insulin, [MEDICATION NAME], and I stopped her. (Name of Resident #B) does not receive insulin. Saw an empty med cup. She gave (name of Resident #C)'s oral meds to (name of Resident #B). She indicated the physician and family were also notified of the incident, and passed along information to the next shift as to the incident and the physician's orders [REDACTED]. I just wish she would have waited for me like I told her and to ask if she wasn't sure which resident was which, if she wasn't sure. Review of a Medication Incident Report, dated 3-26-16 and signed by LPN #2, indicated on 3-26-16 at 9:30 p.m., Resident #B received [MEDICATION NAME] (used for narcotic pain reliever), [MEDICATION NAME] (used for neuopathic pain), [MEDICATION NAME] ( used for mood stabilization), Sinoment (sic) (used for [MEDICAL CONDITION]), [MEDICATION NAME] (used for [MEDICAL CONDITION]), [MEDICATION NAME] (used for benign prostate hypertrophy) related to Nurse administered medication to the wrong resident. Resident #C's recapitulation orders for April, 2016 indicated his oral medications due for 9:00 p.m., or bedtime were the following medications: [REDACTED] -[MEDICATION NAME] 125 mg (milligrams) and [MEDICATION NAME] 250 mg, 3 tabs, to equal a total of 875 mg. -[MEDICATION NAME] 600 mg. -[MEDICATION NAME] CR (continuous release formula) 50/200 mg. -[MEDICATION NAME] 40 mg. -[MEDICATION NAME] 0.4 mg. -[MEDICATION NAME] 5/325 mg every four hours by mouth as needed for pain. In review of Resident #B's recapitulation orders for April, 2016, he was not ordered to receive any of the medications he received in error. On 4-18-16 at 2:05 p.m., the Administrator provided a copy of a policy entitled, Medication and Treatment Incidents. This policy had a revision date of 9-15-15 and was indicated to be the current policy utilized by the facility. This policy indicated, Purpose: To safeguard the Resident from recurrent medication and treatment incidents. Policy: Medication/Treatment incidents are to be reported to the physician and responsible party/family member. A Medication/Treatment incident report are to be completed by the individual noting the error. Medication errors will be reported to ISDH if treatment beyond ER visit required .The Resident is to be observed for adverse reaction to the error. Documentation must be thorough and change in condition reported to the physician. Necessary in-service/re-education of involved individuals and/or all licensed/qualified nursing staff shall be conducted based upon the cause, nature and extent of the error . This Federal tag relates to Complaint IN 728. 3.1-35(g)(2)

Based on interview and record review, the facility failed to ensure a resident receive the correct medications, resulting in the resident becoming somnolent and unresponsive and requiring emergent care with the use of a medication to reverse the effects of the unresponsiveness for 1 of 3 residents reviewed for the receipt of incorrect medications in a sample of 3. (Resident #B) Findings include: Resident #B's clinical record was reviewed on 4-18-16 at 10:20 a.m. It indicated his [DIAGNOSES REDACTED]. Review of Resident #B's nursing progress notes indicated an entry on 3-18-16 at 9:57 p.m., regarding blood work that was to be obtained on 3-21-16. The next entry, dated 3-27-16 at 3:00 a.m., indicated the resident's physician contacted the facility to continue to monitor for repertory (sic) distress. If respirations fall below 15, then look at sending resident out to hospital for evaluation. Let resident rest today in bed. Encourage water. Call if any change in status. An entry on 3-27-16 at 6:04 a.m., indicated resident was monitored with vital signs and with the resident being groggy, but able to respond to staff. An entry on 3-27-16 at 10:21 a.m., indicated the attending physician was contacted related to the resident being verbally unresponsive, B/P 109/53, T 97.2 ax, O-2 (sat) 92 (%) RA, P 62 RR 14, Pupils unresponsive to light. It indicated an order was received to send the resident to an area emergency room for evaluation and treatment and left the building at 10:17 a.m. via ambulance transport. In an interview with LPN #1 on 4-18-16 at 12:05 p.m., she was queried if she was aware of any issues with medication errors with Resident #B in the past month. She explained she would need to review his clinical record as she had been absent from work for a period of time in the last month. She indicated, upon review of the clinical record, it appeared he had no such event. She continued, that he did have a past history of fluctuating blood pressure readings, looks like that was the case, in relation to him being sent out to the emergency roiagnom on [DATE]. In an interview with the Administrator on 4-18-16 at 1:25 p.m., she indicated Resident #B did have a medication error. He received the wrong medications. In an interview with LPN #2 on 4-19-16 at 11:23 a.m., she indicated on the evening of 3-26-16, she was orienting a new nurse, RN #3. She indicated she was observing RN #3 with the entire bedtime medication pass. Instructed (her) to get (Resident #C)'s blood sugar and get his meds ready while I went to check on two other residents. When I stepped back in the hall, she (RN #3) was gone and I heard her in (name of Resident #B)'s room. (When I got to his room), she was bent over and ready to give him insulin, [MEDICATION NAME], and I stopped her. (Name of Resident #B) does not receive insulin. Saw an empty med cup. She gave (name of Resident #C)'s oral meds to (name of Resident #B) .(Upon notification to the weekend supervisor), I was told by my supervisor not to document anything in the computer (nursing progress notes), just do a hand-written note about the incident. She indicated shortly after speaking with her supervisor, she received a call from the Assistant Director of Nursing to inquire about the incident. She indicated the physician and family were also notified of the incident, and passed along information to the next shift as to the incident and the physician's orders [REDACTED]. I just wish she would have waited for me like I told her and to ask if she wasn't sure which resident was which, if she wasn't sure. Review of a Medication Incident Report, dated 3-26-16 and signed by LPN #2, indicated on 3-26-16 at 9:30 p.m., Resident #B received [MEDICATION NAME] (used for narcotic pain reliever), [MEDICATION NAME] (used for neuropathic pain), [MEDICATION NAME] ( used for mood stabilization), Sinoment (sic) (used for [MEDICAL CONDITION]), [MEDICATION NAME] (used for [MEDICAL CONDITION]), [MEDICATION NAME] (used for benign prostate hypertrophy) related to Nurse administered medication to the wrong resident. Resident #C's recapitulation orders for April, 2016 indicated his oral medications due for 9:00 p.m., or bedtime were the following medications: [REDACTED] -[MEDICATION NAME] 125 mg (milligrams) and [MEDICATION NAME] 250 mg, 3 tabs, to equal a total of 875 mg. -[MEDICATION NAME] 600 mg. -[MEDICATION NAME] CR (continuous release formula) 50/200 mg. -[MEDICATION NAME] 40 mg. -[MEDICATION NAME] 0.4 mg. -[MEDICATION NAME] 5/325 mg every four hours by mouth for pain. In review of Resident #B's recapitulation orders for April, 2016, he was not ordered to receive any of the medications he received in error. Review of the ambulance company's report of the transportation of Resident #B from the facility to the area emergency room , dated 3-17-16, indicated at 10:16 a.m., he was initially found to be responsive only to verbal stimuli .pupils pinpoint with a respiratory rate of 12 breaths per minute. In indicated he was administered [MEDICATION NAME] (used as an opioid antagonist) 0.4 mg via IV at 10:24 a.m., with the resident than able to state his name and date of birth, but continued drowsy. Review of the emergency room visit documentation, dated 3-27-16, indicated the resident had an accidental drug ingestion, and was unresponsive upon the arrival of the EMS (emergency medical services) staff to the facility. But improved with IV (intravenous) [MEDICATION NAME]. Per brother, back to baseline. Labs showed opiates in UDS (urine drug screen) .Pt (patient) is stable and plan to return back to nursing home . On 4-18-16 at 2:05 p.m., the Administrator provided a copy of a policy entitled, Medication and Treatment Incidents. This policy had a revision date of 9-15-15 and was indicated to be the current policy utilized by the facility. This policy indicated, Purpose: To safeguard the Resident from recurrent medication and treatment incidents. Policy: Medication/Treatment incidents are to be reported to the physician and responsible party/family member. A Medication/Treatment incident report are to be completed by the individual noting the error. Medication errors will be reported to ISDH if treatment beyond ER visit required .The Resident is to be observed for adverse reaction to the error. Documentation must be thorough and change in condition reported to the physician. Necessary in-service/re-education of involved individuals and/or all licensed/qualified nursing staff shall be conducted based upon the cause, nature and extent of the error . This Federal tag relates to Complaint IN 728. 3.1-25(b)(2) 3.1-25(b)(7) 3.1-25(b)(9) 3.1-48(c)(2)

Based on interview and record review, the facility failed to ensure precautionary safety measures were taken while undressing a nonweight bearing resident sitting in a wheel chair. This resulted in an urgent transfer from a wheel chair to the bed resulting in a femoral fracture to 1 of 3 residents reviewed for accidents. (Resident #116) Findings include: The clinical record for Resident #116 was reviewed on 11/24/15 at 9:00 a.m. The [DIAGNOSES REDACTED]. Resident #116 was a 2 person assist for bed mobility, a 2 person assist for transfers, and 1 person assist for dressing according to a minimum data set assessment, dated, 8-9-15. A care plan initiated on 5/27/14 and revised on 8/8/15, indicated Resident #116 was to be transferred by (brand name of mechanical lift). The goal for Resident #116 was to have safe transfers for mobility. Resident #116's interventions included, but were not limited to, a 2 person transfer using a (brand name of mechanical lift), and the staff was to monitor Resident #116's limbs during transfers to avoid injury. An interview was conducted with Resident #116's daughter on 11/18/15 at 2:29 p.m. She indicated Resident #116 had broken her left leg in the facility in August. Resident #116 begun to slip out of the wheelchair while certified nursing assistant (CNA) #22 was undressing her. CNA #22 transferred Resident #116 from the wheel chair to the bed to avoid her falling on the floor. Resident #116 indicated she had banged her leg during the transfer. Resident #116 now wears an immobolizer on her leg and has to keep it on at all times for several weeks. She indicated she feels Resident #116 has declined, since this incident. A progress note dated, 8/8/15 at 10:43 p.m., indicated CNA came and got writer from hallway. CNA states she was undressing resident, when resident began sliding out of her wheelchair. CNA pivoted resident into her bed. Resident states LLE (left lower extremity) and L (left) hip hurt. No visible bruising/tears. Minimal swelling to left knee. Complaints of pain upon movement. PRN (as needed) Tylenol given. New orders per (name of physician office) for stat (immediately) x-ray to lle (left lower extremity), left hip. Son made aware of incident and new order. Resident resting in bed with eyes closed. A progress note dated, 8/9/15 at 2:37 a.m., indicated radiology report received, and Resident #116 had fractured distal femur of the left leg. Resident #116 was sent to emergency room for evaluation and treatment per physician order. The 8/9/15 hospital records for Resident #116 indicated, .presents to ED (emergency department) via EMS (emergency medical services) from ECF (extended care facility) L (left) leg pain s/p (post) fall while getting into bed from wheelchair on 8/8/15 at approx 2000 (8:00 p.m.) Per nurse ECF described injury LLe (left lower extremity) getting twisted in process of transfer. She doesn't ambulate baseline Clinical impression 1. Closed fracture of shaft of left femur unspecified fracture morphology, initial encounter. An interview was conducted on 11/23/15 at 11:20 a.m. RN #15 indicated she was Resident #116's nurse on the night when Resident #116 had broken her leg. She indicated CNA #22 had been undressing Resident #116 and had to make a quick decision when Resident #116 began slipping out from the wheel chair. CNA #22 picked up Resident #116 and transferred her to the bed to prevent the resident from falling on the floor. She indicated Resident #116 was a 2 person assist with a (brand name of mechanical lift), because she did not bear weight on her lower extremities. Resident #116's legs did not pivot with CNA #22 during the transfer. An interview was conducted with the DoN on 11/23/15 at 2:00 p.m. She indicated Resident #116 was cognitively intact, at that time. Resident #116 indicated she had bumped her leg on the bed during the transfer. This was the conclusion to how the fracture on the leg occurred. An incident report was provided by the Director of Nursing (DoN) on 11/23/15 at 2:40 p.m. It indicated the DoN conducted an interview on 8/11/15 with RN #15 regarding Resident #116's incident. RN#15 indicated CNA #22 advised her that Resident #22 had started to slide out of her wheel chair, and she had prevented the resident from sliding to the floor by catching the resident and pivoted her into the bed. CNA #22 indicated Resident #116 had indicated at that time she had bumped her leg, and it was hurting. A statement from CNA #22, dated 8/10/15, indicated Resident #116 was sitting in her wheelchair. CNA #22 indicated as she had begun to remove Resident #116's shirt she was not sitting all the way back in her chair. As the shirt was removed, Resident #116 leaned forward to facilitate removal of the shirt. In doing so, Resident #116 began to slide out of her wheel chair. CNA #22 indicated she moved the wheel chair closer to the bed and placed her knee between the resident's legs. She grabbed Resident #116 and pivoted her onto the bed. At that time, Resident #116 indicated her leg hit the bed, and it was hurting. There was no other staff members in the room during this time. CNA #22 indicated she wanted to get the resident ready for bed as much as she could before getting another staff member to assist in the transfer. An interview was conducted with CNA #22 on 11/24/15 at 1:29 p.m. She indicated she was removing Resident #116's shirt and leaned the resident forward to pull her shirt up in the back when Resident #116 began to scoot out of the wheel chair. CNA #22 indicated at that time, she panicked and made a sudden decision to brace Resident #116 from falling with her own legs and transferred her from the wheel chair to the bed. CNA #22 can not recall if the wheel chair was locked, and she can not determine if pulling Resident #116 back up in the chair would have been safer. She has asked herself that question many times, but the decision to transfer Resident #116 was a sudden decision out of panic. She indicated it is easier to undress Resident #116 in the wheel chair versus in the bed when Resident #116 has a long sleeved shirt on. CNA #22 indicated if she could do it all over again she would first not panic and scream for help since the door was closed. An interview was conducted with CNA #28 on 11/24/15 at 1:45 p.m. She indicated she never undresses and dresses residents in the wheelchair. CNA #28 indicated if a resident requires a (brand name of mechanical lift) for transfers it was easier to dress him or her in the bed, because you have to roll the resident back and forth to either place or remove the (brand name of mechanical lift). pad underneath him or her. An interview was conducted with CNA #29 on 11/24/15 at 1:55 p.m. She indicated she only dresses and undresses residents in the bed, because it is easier and safer versus the wheel chair. CNA #29 indicated if a resident needs the (brand name of mechanical lift). for assistance in transfers it was easier, because of the placement and removal of the pad to dress or undress the resident in the bed. An interview was conducted with the DoN on 11/24/15 at 3:07 p.m. She indicated if a resident was being dressed or undressed in a wheel chair, and was unable to assist the staff, it would be more appropriate if there was assistance of 2 staff members. An interview was conducted with Unit Manager #2 on 11/23/15 at 11:05 a.m., during a wound dressing observation. She indicated Resident #116 has to wear the immobolizer on her left leg at all times, and that Resident #116 yells out in pain just by touching her. 3.1-45(a)(2)

Based on interview and record review, the facility failed to ensure adequate supervision of a resident during a nebulizer treatment (type of breathing treatment) while sitting in her wheelchair. The resident fell from the wheelchair and was subsequently hospitalized related to respiratory-related issues. This deficient practice relates to 1 of 3 residents reviewed for falls in a sample of 3. (Resident #A) Findings include: The clinical record of Resident #A was reviewed on 1-23-15 at 10:40 a.m. Her [DIAGNOSES REDACTED]. In review of Resident #A's initial/assessment dated [DATE], it indicated she was alert and oriented to person, place, time and event; she was weak with poor balance and an unsteady gait; was unable to bear weight for more than a few seconds at a time and her family had communicated she had periods of hallucinations when her carbon dioxide levels were elevated. Her admission weight was listed as 79.6 pounds. She had a history of [REDACTED]. She required 1-2 persons to assist her with mobility, transfers, personal hygiene and toileting. In review of Resident #A's admission Minimum Data Set (MDS) assessment, dated 12-19-14, it indicated she was moderately cognitively intact with little energy and trouble concentrating several days of the week; required extensive assistance of 1 person with bed mobility, dressing, personal hygiene and toileting; required extensive assistance of 2 or more persons with transfers; was dependent of 1 person with bathing; experienced shortness of breath with activity, sitting at rest or lying flat; utilized supplemental oxygen. The care plan for Resident #A included a focus (area of concern) related to the resident's history of COPD and 12-29-14 [DIAGNOSES REDACTED]."(sic) The goals for these areas of concern included, but were not limited to, optimal breathing patterns daily and resolution of the respiratory infection. The interventions for these areas of concern included, but were not limited to, "...Give aerosol or bronchodilator's as ordered. Monitor/document any side effects and effectiveness...Monitor for difficulty breathing (Dyspnea) on exertion. Remind resident not to push beyond endurance. Monitor for s/sx (signs and symptoms) of respiratory insufficiency: Anxiety, Confusion, Restlessness, SOB (shortness of breath) at rest, Cyanosis (blue cast to skin, suggestive of oxygen deficiency), Somnolence (sleepiness)..." In an interview on 1-23-15 at 2:45 p.m., the Administrator described Resident #A as a frail-looking woman with many breathing problems. The Director of Nursing (DON) indicated Resident #A as a person with end-stage COPD. The Administrator indicated Resident #A was no longer a resident of the facility as she transferred to another nursing facility upon her discharge from the hospital. In an interview with CNA #1 on 1-26-15 at 10:05 a.m., she recalled assisting Resident #A with care. She recalled this resident was usually cognitively intact with occasional periods of confusion; was on supplemental oxygen at all times; "would get winded easily; was a "very small" person; "took all her breath away to go to the bathroom"; had poor balance and required the use of a wheelchair for all transportation. In an interview with CNA# 2 on 1-26-15 at 10:19 a.m., she recalled assisting Resident #A with care. She recalled this resident was usually alert and oriented, but had periods of confusion; preferred to remain in her room; preferred to stay in bed most of the time; "had real bad breathing problems,"; during assistance with care requiring the resident to be turned in bed, the resident would have to take rest periods in order to catch her breath, often requiring up to 25 minutes to be able to turn and reposition in bed; wore supplemental oxygen and did not recall the resident removing it; the resident "still had a rough time breathing" despite wearing her supplemental oxygen. In review of the nursing notes, dated 1-10-15 at 2:40 p.m. and signed by RN #3, the notes indicated Resident #A was seated in her wheelchair with her bedside table in front of her. An unnamed CNA notified RN #3 of the resident making "random confusing comments" and yelling out for her daughter. RN #3 documented she assessed the resident and found her oxygen saturation level at 94% (acceptable range), was "increasingly confused," with no complaints of pain, but lung sounds denoted increased wheezing (abnormal lung sounds). "Scheduled neb (nebulizer) treatment was applied. Minutes later, CNA alerted writer to resident's room. Resident was found lying on her back, next to her wheelchair and bedside table. Neb mask and NC (nasal cannula) oxygen had been removed. 3 staff members assisted resident into the bed. O2 (oxygen) was applied via mask. HOB (head of the bed) was elevated. O2 (oxygen saturation rate) registered at 48% (extremely/dangerously low level). O2 quickly rose up to 90% (acceptable range) on 5L (liters of oxygen). Resident still was having SOB (shortness of breath) and gasping for air. Resident's body was checked for any bruises. No injury present. Resident denies any pain. ROM (range of motion) intact. 911 (emergency services) was contacted, related to resident's oxygen saturation being low and resident's increased chest congestion." The notes continued to include the attending physician's office was notified and a message was left for the family of the resident's change in condition. The notes continued to include the resident initially refused to go to the hospital, but agreed to go to the hospital after 10 minutes of discussion by staff with the resident. In an interview with RN #3 on 1-26-15 at 3:33 p.m., she indicated Resident #A was usually alert and oriented with periods of confusion. She recalled the resident had multiple diagnoses, but the primary problem was her respiratory problems. She recalled the resident experienced a great deal of shortness of breath with transfers, such as to the bathroom, which required assistance of one person and she used a wheelchair to go from the bed to the bathroom. The resident wore oxygen at all times with the oxygen rate at 4 liter per minute via nasal cannula. She recalled the resident's oxygen saturation baseline rate was about 88% to 94% on the 4 liters of supplemental oxygen and she frequently had wheezes when she assessed her lungs. RN #3 recalled Resident #A's oxygen saturation level had been in the low 90's prior to the last nebulizer treatment she assisted her with on 1-10-15. She recalled she did not remain in the resident's room to supervise the nebulizer treatment. She indicated, "I felt, based on my nursing judgement, that (name of Resident #A) was stable enough to leave unattended for her neb treatment. She was not a fall risk, was fairly stable for her respiratory status and seemed to be in no distress at the time." She recalled she had stepped out of Resident #A's room to her medication cart in the hallway. She recalled, "Five minutes later, (name of CNA #6) notified me she (Resident #A) was on the floor. When I went, I found her flat on her back. She had no wheelchair alarms. Oxygen and neb mask was off. She was breathing, but blue. Alert to name, but unable to speak to us." She recalled, she assessed the resident and found no injuries and was not grimacing as if pain. She recalled she alerted others for more help. She recalled the resident's oxygen saturation level was 48% and she applied an oxygen mask at 5 liters and the resident quickly responded by opening her eyes, speaking and being able to correctly identify the date and day of the week. In an interview with LPN #5 on 1-26-15 at 9:57 a.m., she indicated the facility's policies regarding nebulizer treatments included, but were not limited to, assessing lung sounds, checking the oxygen saturation level, obtaining vital signs before and after the treatment and remaining with the resident during the nebulizer treatment. In an interview with LPN #4 on 1-26-15 at 11:00 a.m., she indicated the facility's policies regarding nebulizer treatments included, but were not limited to, assessing lungs sounds, heart rate, respiration rate, oxygen saturation level before and after a nebulizer treatment. She stated, "We are supposed to stay with the resident to ensure (he/she) receives the full treatment." In an interview with RN #3 on 1-26-15 at 3:33 p.m., she indicated facility staff are to check the lungs and oxygen saturation of a resident prior to beginning a nebulizer treatment. She commented that upon completion of a nebulizer treatment, the staff member is to recheck the resident's oxygen saturation level and lung sounds if the resident appears to be short of breath or having respiratory problems. On 1-26-15 at 1:45 p.m., the Director of Nursing provided a copy of procedure entitled, "Nebulized Mist Inhalation Treatment." This procedure had a development date of 5-22-1997 and was identified as the policy in current use by the facility. This procedure indicated, "Purpose: To deliver microscopic moisture droplets into the lower respiratory tract. To sooth irritated mucous membranes. To aid in removal of thick secretions from the lower respiratory tract...Remain with the resident sufficiently long enough to ensure technique and use of all medication..." On 1-26-15 at 4:00 p.m., the Director of Nursing provided copy of a packet of information entitled, "Respiratory Specialists Aerosolized Medication Therapy." The Director of Nursing indicated the information contained within the packet included the information the facility provides to new employees who are licensed nurses regarding breathing treatments. Included in the packet was a procedure entitled, "Procedure for Medicated Aerosol Treatment." This procedure was undated. This procedure indicated, prior to beginning the treatment, to assess the resident's breath (lung) sounds, pulse rate and instruct the resident on how to hold the hand-held nebulizer or determine if the resident needs a specialized mask for the nebulizer treatment. During the treatment, "Monitor pulse, respiratory rate and breath sounds. Stop treatment if pulse rate increases 20 BPM (beats per minute) or resident reveals intolerance..." Documentation includes, but is not limited to breath sounds pre and post treatment and resident's tolerance of the treatment. A copy of a test with the answer key included, entitled, "Respiratory Specialists Nebulizer & Oxygen Device Quiz,"posed the statement of "The nurse should stay in the patient's room while the breathing treatment is nebulizing." The answer key indicated the corresponding correct response as "True." This Federal tag relates to Complaint IN 694. 3.1-35(a)(2)

Based on record review and interview, the facility failed to ensure a resident who entered the facility without pressure sores (Resident F) did not develop a pressure sore after admission for 1 resident of 3 reviewed for pressure sores who developed a pressure sore which progressed to a stage lll in a sample of 4. Findings included: 1. The record of Resident F was reviewed on 1/18/12 at 9:00 a.m. [DIAGNOSES REDACTED]. An admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident F had no cognitive or communication deficits, and required staff assistance for all activities of daily living. Records indicate Resident F was re-admitted to the facility on [DATE]. A Nursing Admission assessment dated [DATE] indicated Resident F had no pressure sores on admission to the facility. A "Skin Condition Report" dated 11/26/11 indicated "Appearance: Pink coccyx..." An admission "Nutritional Assessment" dated 12/01/11 includes a hand written note "Red Coccyx." Nurse's notes indicated: 12/13/11 9:00 p.m. "While doing res (resident) tx (treatment)...noted that she has develop (sic) open area in coccyx size 2.8 x 1.9 cm (centimeters) superficial stage..." 12/17/11 3:00 a.m. "...skin care provided no changes in condition of coccyx area..." 1/01/12 7:30 p.m. "...res open area in coccyx healing slow..." A "Skin Condition Report" dated 12/13/11 indicated "Size: 2.8 x 1.9 cm...Appearance: open area coccyx stage lll..." A "Skin Condition Report" dated 12/22/11 indicated "..Appearance: stage lll to coccyx..." A "Sunnyside (Resident F's unit) Wound Log Report" Dated 12/16/11 indicated Resident F had a stage lll pressure sore to her coccyx, the onset date was 12/13/11, and that the wound was facility acquired. A physician's orders [REDACTED].A.L. (low air loss) mattress in bed." A "30 Day Nutritional Assessment" dated 12/21/11 indicated "Skin condition: Stage lll coccyx...given new pressure ulcer resident may require add'l (additional) food/fld (fluid) for wound healing. Spoke (symbol for "with") Resident- she is trying to increase pro (protein) foods but wants fortified fds/supps (foods, supplements) to aid in healing..." During an interview on 1/18/12 at 3:00 p.m. the Health Center Food Service Director indicated that dietary interventions, including fortified foods and supplements, had been started immediately following the 12/21/11 assessment noted above. She also indicated no nutritional assessment or interventions had been implemented between the identification of Resident F's stage lll pressure ulcer on 12/13/11 and the assessment done on 12/21/11. During an interview on 1/18/12 at 3:45 the Assistant Director of Nursing indicated Resident F had a low air loss mattress ordered during her previous stay in the facility, and that it remained on her bed when she was readmitted from the hospital on [DATE]. She also indicated that Resident F's current record contained no order for a low air loss mattress, and no documentation that it had been in use since her readmission. During an interview with the Director of Nursing 1/18/12 at 4:20 p.m. she indicated that prior to the identification of Resident F's stage lll pressure sore on 12/13/11, there had been no order for [MEDICATION NAME] ointment or other preventive treatment, and no documentation any preventive treatment had been done following the identification of pink/reddened areas to her coccyx on admission. 2. A Facility document titled "Wound Protocols" and signed as authorized by the Medical Director on 9/14/06 and indicated by the Director of Nursing to be a current facility policy indicated: "The attending physician must be advised at the first sign of a persistent reddened area and/or an open area of the skin. In an effort to allow prompt treatment of [REDACTED]. Pat dry. Apply [MEDICATION NAME] Cream. This treatment is to be performed twice daily and as needed..." This federal tag relates to Complaint IN 963. 3.1-40(a)(1)