Every finding on record at Westview Nursing and Rehabilitation Center

Based on observation, interview, and record review, the facility failed to ensure the bathroom seat riser was cleaned for 1 of 3 resident bathrooms reviewed for environment. (room [ROOM NUMBER])Findings include:On the following dates and times, the toilet seat riser in the bathroom of room [ROOM NUMBER] was observed to have a dry, brown substance on the surface and within the opening to the seat riser: On 12/11/25 at 10:40 a.m., 2:10 p.m., and 3:15 p.m.On 12/15/25 at 11:40 a.m., 1:45 p.m., and 3:25 p.m. During an interview on 12/15/25 at 3:30 p.m., the Administrator indicated the toilet seat riser was soiled and needed to be regularly cleaned. On 12/16/25 at 11:30 a.m., the Administrator provided the Resident Rights, revised 01/2025 and indicated these were the resident rights currently used by the facility. A review of the Resident Rights indicated, .The resident has the right to a safe, clean, comfortable, and homelike environment . 3.1-19(f)

Based on interview and record review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for 1 of 1 resident reviewed for accuracy of the MDS (Resident 61). Findings include: On 7/20/19 at 11:00 a.m., Resident 61's clinical record was reviewed. [DIAGNOSES REDACTED]. The (MONTH) 2019 physician's orders [REDACTED]. Resident 61's quarterly MDS assessment, dated 7/17/19, indicated, . K0300. Weight Loss. Loss of 5% or more in the last month or loss of 10% or more in the last 6 months . 1. Yes, on physician-prescribed weight-loss regimen . Interview, on 7/30/19 at 11:00 a.m., the MDS Coordinator indicated the MDS was coded incorrectly. 3.1-31(d)

Based on observation, interview, and record review, the facility failed to ensure a trapeze positioning bar was in a location that did not cause the resident risk of injury for 1 of 1 resident reviewed for accidents (Resident 223). Findings include: On 7/25/19 at 2:52 P.M., Resident 223 was observed in her room in bed. Above and to the left side of the resident's head was a metal trapeze positioning bar (a triangularly shaped bar which the resident could hold and pull herself into different positions while in bed) with a chain attached to it. The trapeze was resting a support bar, to which the chain was attached. Interview, on 7/25/19 at 2:53 P.M., the resident indicated the trapeze bar had recently fallen from the support bar and struck her in the face. It did not hurt her, but it scared her. She had asked staff if the chain could be shortened, because when the trapeze was fully extended on the chain it was level with her face. Staff told her the chain could not be shortened. Staff moved the bar to the left of her head so she could still access the bar, but she was constantly fearful the trapeze bar would slide off the support bar and hit her in the face or head and she wished they could just shorten the chain. On 7/29/19 at 11:40 A.M., Resident 223's clinical record was reviewed. The 4/12/19 Admission Minimum Data Set assessment indicated the resident was cognitively intact. A physician's orders [REDACTED].Positioning/Devices: Trapeze bar: enhance bed mobility . A nursing progress note, dated 7/22/2019 at 12:46 P.M., indicated, .Resident had made nurse aware, that triangle on trapeze bar, fell and hit resident on R (right) side of face . A nursing progress note, dated 7/23/2019 at 3:42 P.M., indicated, .Noc (nocturnal, night) shift nurse adjusted trapeze to left side of bed et (and) res now able to use to assist with pulling up in bed, but trapeze not directly over residents head . Interview, on 7/25/19 at 12:30 P.M., the Maintenance Assistant indicated the chain was long and needed to be shortened or replaced to keep the resident from feeling fearful of being struck in the face. On 7/30/19 at 12:35 P.M., the facility Administrator provided the Resident Rights, revised date 8/2018, and indicated these were the resident rights currently used by the facility. A review of the resident rights indicated, .the resident has the right to a safe .environment . 3.1-45(a)

Based on interview and record review, the facility failed to initiate a Dietician's nutritional recommendation for a resident with weight loss for 1 of 3 residents reviewed for nutrition. (Resident 61) Findings include: Resident 61's clinical record was reviewed on 7/30/2019 at 11:17 a.m. [DIAGNOSES REDACTED]. A review of Resident 61's weights indicated: -On 5/7/2019, the resident weighed 107. -On 5/29/2019, the resident weighed 103. -On 6/17/2019, the resident weighed 97. -On 7/8/2019, the resident weighed 95. -On 7/17/2019, the resident weighed 95. -On 7/23/2019, the resident weighed 94. This is an assessed 11.21% severe weight loss in 2 months. Physician Orders, dated 6/30/2019 through 7/30/2019, for Resident 61 included, . Diet: Supplement: Magic Cup TID (three times a day) . A review of the Dietician Progress Notes, dated 7/16/2019 at 10:57 a.m., for Resident 61 indicated, . (MONTH) weight 95 # (pounds) triggering for sig (significant) weight loss . resident is being offered Magic Cup at all meals . per staff, consuming small amounts of the Magic Cup . will suggest to offer 120 cc Ensure Plus TID (3 times a day) with med (medication) pass . A review of the July, 2019, Medication Administration Record [REDACTED]. Interview, on 7/30/2019 at 11:34 a.m., License Practical Nurse 1 indicated Resident 61 did not receive Ensure Plus with med pass. She is on a Magic Cup TID. Interview, on 7/30/2019 at 12:02 p.m., the Director of Nursing (DON) indicated Resident 61's son did not want the resident on a supplement because he believed she would gain weight if her diet was switched from a mechanical soft to a regular diet and she was able to eat what she wanted. The clinical record lacked documentation of the conversation with the son. Phone interview, on 7/30/2019 at 12:32 p.m., with Resident 61's son indicated the facility did not mention the dietician recommendation of Ensure Plus and he would not have had any problem with her being on the Ensure Plus. She was losing weight and needed to eat everything she could get. She had it at another facility and she liked it. On 7/30/2019 at 1:00 p.m., Minimum Data Set (MDS) nurse provided the facility's policy, Nutritional Recommendations dated 7/15, and indicated it was the policy currently being used by the facility. A review of the policy indicated, . 2. The dietary recommendations will be followed through with and implemented within three (3) business days . 3.1-46(a)(1)

Based on interview and record review, the facility failed to ensure a resident was discharged from the facility with the accurate medication for 1 of 3 residents reviewed for pharmacy services (Resident B, C). Finding include: During an interview, on 6/7/19 at 11:30 a.m., Resident B indicated she was discharged home with Resident C's [MEDICATION NAME] (a [MEDICATION NAME][MEDICATION NAME] which relaxes muscles in the airways and increases air flow to the lungs) inhaler. She knew this because Resident C's name was on the medication label. She called the facility and a staff member came and picked up Resident C's inhaler from her home. On 6/7/19 at 3:00 p.m., Resident B's closed clinical record was reviewed. [DIAGNOSES REDACTED]. Resident B's May, 2019, physician's orders [REDACTED]. On 5/10/19 (start date), the resident was ordered [MEDICATION NAME] sulfate every 6 hours as needed. On 6/7/19 at 2:30 p.m., Resident C's clinical record was reviewed. [DIAGNOSES REDACTED].O.P.D.). Resident C's May, 2019, physician's orders [REDACTED]. On 5/9/19 (start date), the resident was ordered [MEDICATION NAME] ([MEDICATION NAME] sulfate) aerosol inhaler, 2 puffs every 6 hours. During an interview, on 6/10/19 at 1:45 p.m., the Director of Nursing indicated the discharge nurse made a mistake and sent Resident B home with Resident C's inhaler. On 6/10/19 at 2:00 p.m., the Director of Nursing provided the facility policy, Discharge Planning, revised on October, (YEAR), and indicated it was the policy currently being used. A review of the policy indicated, 8. The inventory of the resident's personal belongings should be reviewed and signed by staff and resident's responsible party . This Federal tag relates to Complaint IN 680. 3.1-25(p)

Based on observation, interview, and record review, the facility failed to ensure staff provided assistance for walking in her room and failed to ensure implementation of non-skid footwear to maintain resident's safety from falls which resulted in a fall with right [MEDICAL CONDITION] that required medical intervention for 1 of 3 residents reviewed for accidents. (Resident 64) Findings include: On 06/15/18 at 12:02 p.m., Resident 64 was observed to be sitting in a high back wheel chair with yellow non skid socks on. On 06/15/18 at 02:14 p.m., Resident 64's clinical record was reviewed. The [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment, dated 3/28/18, indicated Resident 64 had severe cognitive impairment, required limited assistance of one with transfers, walking in room, and toilet use, and had 2 or more falls with no injury. A care plan, initiated on 11/15/16 and current through target date of 9/4/18, for Resident 64 indicated: PROBLEM: .Resident requires assistance with ADLs (activities of daily living) including bed mobility, transfers, eating and toileting related to: dementia, anxiety . GOAL: Resident will improve in ADLs to max (maximum) potential as tolerates .APPROACH: . assist with transfer as needed A care plan, initiated on 5/13/15 and current through target date of 9/4/18, for Resident 64 indicated: PROBLEM: .Resident is at risk for fall due to history of falls, use of routine pain medication, over age 80, impulsive, has urinary urgency/frequency, requires assist with transfers/ambulation, unsteady gait, has altered awareness of immediate physical environment, lacks understanding of ones physical and cognitive limitations . GOAL: Resident fall risk factors will be reduced in an attempt to avoid significant fall related injury .APPROACH .high fall risk .Non skid footwear. The care plans lacked updated approach of assist of one with transfer, walking in room, and toilet use after completion of quarterly MDS assessment, dated 3/2/18. Fall Risk Assessment Tool, dated 5/24/18, indicated a high risk for falls. Resident 64's progress notes indicated the following: -3/1/18 at 9:37 p.m., indicated staff heard a plate break. Resident 64 was attempting to get out of the bed. Resident 64 was sliding to the floor. Resident 64 did not have shoes or non-skid socks on. Two Certified Nurses Aide (CNA) assisted Resident 64 to the floor. Fall precautions implemented were non-skid socks on at all times with or without shoes (care plan lacked documentation to indicate having been updated with this fall intervention, of non-skid socks on at all times). -3/2/18 at 9:15 a.m., Interdisciplinary Team (IDT) met to review Resident 64 being lowered to the floor by staff. IDT feels Resident 64 needs a night light to ensure environment is well lit for trips to and from the bathroom. Non-skid socks to be worn at all times. -5/1/18 at 8:32 a.m., indicated Resident 64 had confusion due to [DIAGNOSES REDACTED]. -5/8/18 at 1:40 a.m., indicated Resident 64 had confusion due to [DIAGNOSES REDACTED]. -5/15/18 at 1:07 a.m., indicated Resident 64 was alert with confusion due to [DIAGNOSES REDACTED]. -5/15/18 at 8:08 p.m., indicated Certified Nurses Aide (CNA) called nurse to Resident 64's room. Resident 64 was laying on her left side on the floor beside bed. Resident 64 indicated she was going to the bathroom with her walker and reached out to open the bathroom door and lost her balance and fell straight back. Resident 64 complained of right hip pain and was yelling from the pain. The nurse called emergency room with report. -5/16/18 at 12:59 a.m., indicated Resident 64 was in the hospital with a right [MEDICAL CONDITION]. Resident 64's Fall Event, dated 5/15/18 at 8:08 p.m., indicated she was fully dressed, but had removed her shoes to lay down and still had regular socks on. The fall event lacked documentation of what time Resident 64 laid down and last time Resident 64 was checked on by staff. The progress notes and care plan lacked documentation of Resident 64 refusing to wear non skid footwear or the resident taking non skid socks off. Interview, on 06/18/18 at 10:23 a.m., Qualified Medication Aide (QMA) 1 indicated Resident 64's fall interventions were non skid socks. QMA 1 did not indicate, in the interview, the facility staff were to provide assistance of one while ambulating in the resident's room as a fall risk intervention. Interview, on 06/18/18 at 11:49 a.m., Licensed Practical Nurse (LPN) 1 indicated on 5/151/8, CNA 2 informed her Resident 64 fell on the floor. Resident 64 had gotten up on her own and went to the the bathroom. Interview, on 06/18/18 at 3:27 p.m., CNA 2 indicated she heard Resident 64 yelling help and CNA 2 found Resident 64 laying on the floor. Resident 64 had indicated to CNA 2 she was trying to reach for the door knob and go to the bathroom. Resident 64 did not have non skid socks on at the time of the fall. CNA 2 did not indicate, in the interview, the facility staff were to provide the assistance of one while ambulating in the resident's room as a fall risk intervention. On 6/18/18 at 4:30 p.m., the Assistant Director of Nursing Services provided the facility's policy, Fall Management Program, dated 11/2017, and indicated it was the policy currently being used by the facility. A review of policy indicated, It is the policy of American Senior Communities to ensure residents residing within the facility receive adequate supervision and or assistance to prevent injury related to falls . 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to provide food that was palatable and served at an appetizing temperature for 4 of 24 residents interviewed regarding food quality (Resident 47, 27, Resident 61, Resident 4), and 8 residents who attended the Resident Council meeting (Resident 48, Resident 56, Resident 49, Resident 41, Resident 37, Resident 15, Resident 46, Resident 20). This had the potential to affect 80 of 80 residents served meals from the kitchen. Findings include: During an interview, on 6/12/2018 at 2:54 p.m., Resident 47 indicated the food is always served cold. During an interview, on 6/13/2018 at 10:07 a.m., Resident 27 indicated the food is bad, served cold and not cooked properly. During an interview, on 6/13/2018 at 10:23 a.m., Resident 61 indicated the food is often served cold. During an interview, on 6/13/2018 at 1:44 p.m., Resident 4 indicated the food is always served cold. During the Resident Council meeting on, 6/14/2018 at 3:08 p.m., the council members indicated the food is often served cold, the meat is tough, the vegetables are cooked too long, the buns are soggy and the eggs have water in them. They have complained about it for a few weeks but, the facility has not done anything to correct the situation. There were 8 residents in attendance at the Resident Council meeting (Resident 48, Resident 56, Resident 49, Resident 41, Resident 37, Resident 15, Resident 46, Resident 20). On 6/18/2018 at 12:39 p.m., a test tray was obtained. The menu included, a fish sandwich with cheese on a bun, hash browns, cantaloupe and summer salad. The fish sandwich was observed to be warm with cheese on top that was not melted or warm, the hash browns were warm and dry with no taste, and the summer salad was tomato based with a sour taste. On 6/18/2018 at 2:30 p.m., the Administrator provided the handbook titled, Resident Handbook, Residents' Rights and Advanced Directives, with a revised date of 6/2016. A review of the handbook indicated, . Resident Rights . Receive care in a manner which promotes and enhances your quality of life. This includes food of the quantity and quality to meet your needs and preferences . On 6/18/2018 at 2:40 p.m., the Assistant Director of Nursing Services provided the facility's policy, Food Temperatures with the current date of 11/17, and indicated it was the policy currently being used by the facility. Review of the policy indicated, . 2. All hot and cold food items will be served to the resident at a temperature that is considered palatable at the time the resident receives the food . 3.1-21(a)(2)

Based on observation, interview, and record review, the facility failed to ensure a resident's preference for morning wake up time was honored for 1 of 1 resident reviewed for choices (Resident 28). Findings include: During an interview, on 6/13/18 at 2:07 P.M., Resident 28 indicated she preferred to wake up in the morning at 10:00 A.M., but staff awaken her early when they brought her breakfast. She wanted to wake and have breakfast at 10:00 A.M. On 6/15/18 at 9:24 A.M., the resident was observed dressed and asleep in a recliner, in her room, with the television on. On 6/18/18 at 9:31 A.M., the resident was observed dressed and asleep in a recliner, in her room, with the television on. During an interview, on 6/18/18 at 9:40 A.M., Certified Nursing Assistant (CNA) 1 indicated the resident was awakened daily around 6:30 A.M. or 7:00 A.M., when breakfast trays were served. During an interview, on 6/18/18 at 11:30 A.M., the resident indicated she had told a female CNA of her preference to not be awakened until 10:00 A.M. She did not know the name of the CNA or specific date and time she advised staff of her preference. During an interview, on 6/18/18 at 3:52 P.M., the Activities Director indicated she was unaware of the resident's preference to be awakened at 10:00 A.M. During an interview, on 6/18/18 at 4:00 P.M., the Activities Director indicated she had spoken with the resident who thought she had to wake up early in order to receive her breakfast tray. During an interview, on 6/18/18 at 4:10 P.M., the resident indicated she thought she had to wake up early in order to receive her breakfast tray. On 6/14/18 at 2:00 P.M., Resident 28's clinical record was reviewed. [DIAGNOSES REDACTED]. MDS (Minimum Data Set) Assessment, dated 4/4/18, indicated the resident was cognitively intact. A Preferences for Customary Routine and Activities document, dated 4/4/18, indicated the resident's preferred time to get out of bed was At breakfast time. There was no option on the document indicating the resident could sleep past the designated breakfast time and still receive her breakfast. On 6/18/18 at 2:30 P.M., the facility Administrator provided the Resident's Rights, revised date of 6/2016, and indicated these were the resident's rights currently being used by the facility. A review of the Resident's Rights indicated, .you have the right to be treated with respect and dignity in recognition of your individuality and preferences. 3.1-3(u)(1)

Based on interview and record review, the facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) to 1 of 3 residents reviewed for SNF Beneficiary Protection Notification (Resident 48). Findings include: On 6/18/18 at 2:59 p.m., Resident 48's clinical record was reviewed. [DIAGNOSES REDACTED]. The resident was admitted on [DATE]. A review of Resident 48's Minimum Data Set assessment, dated 4/27/18, indicated the resident began Speech, Occupational, and Physical therapy on 11/20/17 through 12/22/18. Speech, Occupational, and Physical resumed on 12/27/17 and ended on 2/15/17. On 6/18/18 at 3:00 p.m., Resident 48's SNF Beneficiary Protection Notification form was reviewed. The form indicated, Last covered day of Part A service: 2/15/18 . The facility/provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted . 1. Was an SNF ABN, Form CMA- provided to the resident? No . Other: Explain: Prior to ABN . During an interview, on 6/18/18 at 3:00 p.m., the Social Services Director indicated Resident 48 was not given a SNFABN form, because the facility only began completing the forms a month ago. The SNFABN form indicated to residents/beneficiaries so that they can decide if they wish to continue receiving the skilled services that may not be paid for by Medicare and assume financial responsibility. The facility must inform each resident of services available in the facility and the charges for those services not covered under Medicare/Medicaid or by the facility's per diem rate at least 60 days prior to implementation of changes made to charges for other items and services that the facility offers. The liability notice, of discharge from Medicare services without having exhausted the benefit days, must be made 48 hours prior to discharge of services. 3.1-4(f)(2)

Based on interview and record review, the facility failed to ensure a resident was monitored for a prescribed blood glucose (sugar) check and the medical doctor was notified of below normal results for 1 of 1 resident reviewed for death (Resident 76). Findings include: On [DATE] at 2:53, Resident 76's closed clinical record was reviewed. The resident was admitted on [DATE] and expired on [DATE]. [DIAGNOSES REDACTED]. A review of Resident 76's March, (YEAR), physician's orders [REDACTED]. Notify MD (medical doctor) if accu check is below 60 or greater than 400. A review of Resident 76's Diabetic Administration History indicated the following: [DATE] the resident's blood sugar was 82. The MD was not notified. [DATE] the resident's blood sugar was 89. The MD was not notified. [DATE] the resident's blood sugar was 87. The MD was not notified. [DATE] the resident's blood sugar was 93. The MD was not notified. [DATE] the resident's blood sugar was 66. The MD was not notified. [DATE] the resident's blood sugar was 100. The MD was not notified. There were no Accu Check results recorded on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. During an interview, on [DATE] at 1:00 p.m., the Assistant Director of Nursing Services indicated she could not find any other blood sugar results. 3XXX,[DATE](a)

Based on interviews and record review, the facility failed to ensure residents were free from misappropriation of property in that a resident's narcotic medications were taken by Licensed Practical Nurse (LPN) 1 for 1 of 3 residents reviewed for misappropriation of property. (Residents B, C, D). Findings Include: Review of Resident B's clinical record on 10/24/2017 at 1:00 p.m. The Resident B was admitted on [DATE] and was still in the facility. Physician orders [REDACTED]. On 10/24/2017 at 1:30 p.m., interview with ADNS (Associate Director of Nursing Services) and DNS (Director of Nursing Services) indicated they were doing a spot check audit of the MAR and the narcotic sheets to make sure that they were signed out properly, noted the narcotic count of Resident B's [MEDICATION NAME] and noted the narcotic had been signed out by LPN 1 on numerous occasions (Tuesday 8/29/17- 6 tablets, Friday 9/1/2017 - 6 tablets, Wednesday 9/6/2017 - 2 tablets, Friday 9/8/17 - 6 tablets, however per ADNS there was no documentation noted in Resident B's MAR (Medication Administration Record) to correlate with the controlled substance count sheets The ADNS indicated they interviewed Resident B and was advised that they had not requested any pain medication for a very long time. On 10/24/2017 at 12:40 p.m., the ADNS provided a copy of the investigation in regard to the misappropriation of Resident B's narcotics. The investigation indicated the following: On 9/11/2017, time unknown, the DNS began an investigation at that time and during an audit of Resident B's narcotics, it was noted narcotics had been signed out to them on 3 different dates by the same nurse, and Resident B indicated again they had not taken any narcotics for several weeks, the police were notified on 9/11/2017. LPN 1 was sent for a drug screen. An officer from the local police department came, took statements and started an investigation with case number 1036. On 9/14/2017, time unknown, the DNS, ADNS, and ED (Executive Director) indicated they interviewed LPN 1, at which time they stated he had not taken any medications. On 9/15/2017, time unknown, LPN 1's drug screen showed positive for [MEDICATION NAME] and Opiates. LPN 1 was again interviewed by DNS, ADNS, and ED and he admitted taking narcotic medication and would write a statement. The DNS indicated the Attorney General also notified. On 9/15/2017, time unknown, the DNS indicated LPN 1 was terminated from employment due to theft/misappropriation of funds. On 9/21/27, time unknown, the DNS indicated the local police department called the facility to advised that LPN 1 during questioning also admitted to taking narcotics from Resident C and Resident D. Record review for Resident C and Resident D was conducted on 10/24/17. Resident C was admitted on [DATE] and remains in the facility, and Resident D was admitted on [DATE], and has passed away, not related to the allegation. On 10/25/2017 at 11:51 a.m.,the ADNS provided a copy of the policy ABUSE PROHIBITION, REPORTING AND INVESTIGATION revised date 11/16, and indicated it was the one being currently used by the facility, indicated .Note: Includes any medication dispensed in the name of a resident This Federal tag related to complaint IN 399. 3.1-28(a)

Based on observation, interview, and record review, the facility failed to ensure staff handwashed after coughing and after touching their uniform while placing eye glasses in their pocket and taking the eye glasses out of their pocket to place on their face as indicated by the facility policy and the Center for Disease Control for 7 of 7 residents served a puree diet from the kitchen. Findings include: On 04/07/2016 12:13 a.m., Cook #1 was observed coughing over food while pureeing liver without covering her mouth. Cook #1 was also observed to take her glasses off and place the glasses in her pocket. Cook #1 was then observed to take her glasses out of her pocket and place them on her face. No handwashing was observed. This was done several time. Cook #1 indicated she should have handwashed. The Dietary Manager (DM) was informed of Cook #1's coughing over the food and provided Cook #1 with a face mask. Review of Center for Disease Control at ww.cdc.gov/handwashing/, dated December 16, 2013 indicated, When should you wash your hands? Before, during, and after preparing food . After blowing your nose, coughing, or sneezing . On 4/7/16 the Assistant Director of Nursing (ADON) provided the policy Dietary Personal Hygiene dated 07/2015, and indicated the policy was the one currently used by the facility. The policy indicated, 1. Proper handwashing is the most critical aspect of personal hygiene. Dietary employees must wash their hands before they start work and after: .c. Touching the hair, face, or body, d. Sneezing, coughing, or using a tissue, .j. Touching anything else that may contaminate hands, . 3.1-21(i)(3)

Based on interview and record review, the facility failed to ensure a resident was free from misappropriation of property in that a resident's narcotic medication and narcotic medication count sheets were taken by License Practical Nurse (LPN) #2 for 1 of 1 resident reviewed for abuse. (Resident #91) Findings include: Resident #91's clinical record was reviewed on 4/7/2016 at 1:30 p.m. The resident was admitted on [DATE], and was discharged to the hospital on [DATE]. The resident was not in the facility on 3/9/2016, when the narcotics and narcotic count sheets went missing. March 2016, Physician orders [REDACTED]. On 4/7/2016 at 11:28 a.m., an interview with Unit Manager (UM) #1 indicated on 3/9/2016, she was flipping through the narcotic book to see who needed narcotics reordered. At that time, she realized the narcotics and narcotic sheets were missing for Resident #91. She looked everywhere for them, because she thought they might have been destroyed by someone. She could not locate them and notified the DON (Director of Nursing) on 3/9/2016 at around 10:00 a.m., that the narcotics and narcotic sheets were missing for Resident #91. During an interview on 4/7/2016 at 2:35 p.m., LPN #1 indicated she counted the narcotics with LPN #2 on 3/8/2016 at 11:00 p.m. The narcotic count was correct and the narcotics and narcotic sheets were there, at that time, for Resident #91. During an interview on 4/7/2016 at 11:04 a.m., the Director of Nursing indicated on 3/9/2016 at approximately 10:00 a.m., she received a call from UM #1 regarding missing narcotics and narcotic sheets for Resident #91. The DON began an investigation at that time. Continued interview on 4/7/2016 at 11:04 a.m., with the DON, indicated on 3/8/2016 at 11:00 p.m., the narcotic count had been completed by LPN #1 and LPN #2 and was accurate for Resident #91. LPN #1 left for the night and LPN #2 worked the 11:00 p.m. to 7:00 a.m., shift alone. On 3/9/2016 at 7:00 a.m., LPN #2 and UM #1 completed a narcotic count, but UM #1 did not notice the narcotics and narcotic sheets were missing for Resident #91. After LPN #2 left for the day, UM #1 was going through the narcotic book to see who needed medications reordered and, at that time, noticed the narcotics and narcotic sheets were missing for Resident #91. After an extensive search for the narcotics and narcotic sheets, the DON was notified on 3/9/2016, time unknown. On 4/7/2016 at 11:55 a.m., the DON provided a copy of the investigation in regard to the missing narcotics and narcotic sheets for Resident #91. The investigation indicated the following: On 3/9/2016, time unknown, the DON was notified by UM #1 that twenty two [MEDICATION NAME] 10-325 milligram (mg) tablets and twenty seven [MEDICATION NAME] 0.25 mg tablets along with the narcotic count sheets were missing from the locked narcotic box for Resident #91. The DON began an investigation at that time and the police were notified. An officer from police department #1 took statements and opened a case number. All nurses involved were sent for drug screens. On 3/10/2016 at 4:30 p.m., the DON took a statement from LPN #2, in which LPN #2 admitted to taking the medications and the narcotic sheets for Resident #91. On 3/10/2016 at 5:30 p.m., the DON indicated a detective from Police Department #1 notified her that LPN #2 admitted to taking the medication and LPN #2 would be in the nursing facility on Monday to write out a statement. On 3/21/2016 at 12:00 p.m., the DON indicated LPN #2 was terminated from employment due to theft/misappropriation of funds. On 4/7/2016 at 1:47 p.m., the DON provided a copy of the policy Abuse Prohibition, Reporting, and Investigation and indicated it was the one currently being used by the facility. The policy indicated, It is the policy of (corporation name) to protect the residents from abuse including . misappropriation of resident property and/or funds . Misappropriation of Resident Funds or Property-the deliberate misplacement, exploitation, or wrongful temporary or permanent use of resident's belongings or money without the resident's consent . includes any medication dispensed in the name of the resident . (corporation name) will not permit residents to be subjected to abuse by anyone including employees This Federal tag relates to Complaint IN 396. 3.1-28(a)

Based on observation, interview, and record review, the facility failed to ensure the environment remained free of hazards, in that the water temperatures in residents' bathrooms exceeded the allowable maximum temperature as indicated by the facility policy, for 11 of 35 residents reviewed in Stage 1. (Resident #5, Resident #137, Resident #139, Resident #39, Resident #32, Resident #23, Resident #86, Resident #62, Resident #10, Resident #27, and Resident #103) Findings include: 1.) On 2/19/15 at 1:57 p.m., Resident #86's bathroom sink water temperature measured 129.7 degrees Fahrenheit. Resident #86's Minimum Data Set assessment, dated 12/6/14, indicated the resident had a Brief Interview for Mental Status score of 13, with a score of 13-15 being cognitively intact. On 2/20/15 at 4:51 p.m., Resident #86's water temperature was rechecked. The Maintenance Supervisor's thermometer measured 100 and the surveyor's thermometer measured 125.2 degrees Fahrenheit. 2.) On 2/19/15 at 2:28 p.m., Resident #139's bathroom sink water temperature measured 124.6 degrees Fahrenheit. Resident #139's Minimum Data Set assessment, dated 2/12/15, indicated the resident had a Brief Interview for Mental Status score of 5, with a score of 0-7 being severely cognitively impaired, and required extensive assistance of 2 staff members to walk in their room. On 2/20/15 at 4:22 p.m., Resident #139's water temperature was rechecked. The Maintenance Supervisor's (MS) thermometer measured 96 degrees Fahrenheit and the surveyor's thermometer measured 120 degrees Fahrenheit. The MS indicated, "I think this thermometer is broken," and was observed to get a new thermometer from her office. 3.) On 2/19/15 at 2:42 p.m., Resident #5's bathroom sink water temperature measured 122.5 degrees Fahrenheit. Resident #5's Minimum Data Set assessment, dated 1/20/15, indicated the resident had a Brief Interview for Mental Status score of 4, with a score of 0-7 being severely cognitively impaired and required extensive assistance of 2 staff members to walk in their room. On 2/20/15 at 4:13 p.m., with the Maintenance Supervisor (MS) present, Resident #5's water temperature was rechecked with the new thermometer. The MS's thermometer measured 100 degrees Fahrenheit and the surveyor's thermometer measured 124 degrees Fahrenheit. 4.) On 2/20/15 at 10:34 a.m., Resident #23's bathroom sink water temperature measured 132.6 degrees Fahrenheit. Resident #23's Minimum Data Set assessment, dated 1/16/15, indicated the resident had a Brief Interview for Mental Status score of 2, with a score of 0-7 being severely cognitively impaired, and required extensive assistance of 1 staff member to walk in their room On 2/20/15 at 4:45 p.m., Resident #23's water temperature was rechecked. The Maintenance Supervisor's thermometer measured 100 degrees Fahrenheit and the surveyor's thermometer measured 122.5 degrees Fahrenheit. 5.) On 2/20/15 at 11:38 a.m., Resident #27's bathroom sink water temperature measured 133 degrees Fahrenheit. Resident #27's Minimum Data Set assessment, dated 11/15/14, indicated the resident had a Brief Interview for Mental Status score of 14, with a score of 13-15 being cognitively intact. On 2/20/15 at 4:17 p.m., Resident #27's water temperature was rechecked. The Maintenance Supervisor's thermometer measured 100 degrees Fahrenheit and the surveyor's thermometer measured 133.3 degrees Fahrenheit. 6.) On 2/20/15 at 11:02 a.m., Resident #10's bathroom sink water temperature measured 127.4 degrees Fahrenheit. Resident Minimum Data Set assessment, dated 1/13/15, indicated the resident had a Brief Interview for Mental Status score of 3, with a score of 0-7 being severely cognitively impaired, and required extensive assistance of 1 staff member to walk in their room. On 2/20/15 at 5:03 p.m., Resident #10's water temperature was rechecked. The Maintenance Supervisor's thermometer measured 100 degrees Fahrenheit and the surveyor's thermometer measured 118 degrees Fahrenheit. 7.) On 2/20/15 at 2:40 p.m., Resident #32's bathroom sink water temperature measured 129.7 degrees Fahrenheit. Resident #32's Minimum Data Set assessment, dated 1/28/15, indicated the resident had a Brief Interview for Mental Status score of 15, with a score of 13-15 being cognitively intact. On 2/20/15 at 4:17 p.m., Resident #32's water temperature was rechecked. The Maintenance Supervisor's thermometer measured 100 degrees Fahrenheit and the surveyor's thermometer measured 125.2 degrees Fahrenheit. 8.) On 2/20/15 at 2:42 p.m., Resident #62's bathroom sink water temperature measured 129.6 degrees Fahrenheit. Resident #62's Minimum Data Set assessment, dated 12/7/14, indicated the resident had a Brief Interview for Mental Status score of 8, with a score of 8-12 being moderately cognitively impaired. On 2/2/15 at 4:59 p.m., Resident #62's water temperature was rechecked. The Maintenance Supervisor's thermometer measured 100 degrees Fahrenheit and the surveyor's thermometer measured 120 degrees Fahrenheit. 9.) On 2/20/15 at 2:46 p.m., Resident #137's bathroom sink water temperature measured 129.6 degrees Fahrenheit. Resident's #137's admission assessment, dated 2/10/15, indicated the resident was alert and oriented. On 2/20/15 at 4:17 p.m., Resident #137's water temperature was rechecked. The Maintenance Supervisor's thermometer measured 100 degrees Fahrenheit and the surveyor's thermometer measured 133.3 degrees Fahrenheit. 10.) On 2/20/15 at 2:47 p.m., Resident #39's bathroom sink water temperature measured 129.6 degrees Fahrenheit. Resident #39's Minimum Data Set assessment, dated 12/21/14, indicated the resident had a Brief Interview for Mental Status score of 0, with a total score of 0-7 being severely cognitively impaired and required extensive assistance of 2 staff members to walk in their room. On 2/20/15 at 4:17 p.m., Resident #39's water temperature was rechecked. The Maintenance Supervisor's thermometer measured 100 degrees Fahrenheit and the surveyor's thermometer measured 133.3 degrees Fahrenheit. 11.) On 2/20/15 at 3:33 p.m., Resident #103's bathroom sink water temperature measured 124 degrees Fahrenheit. Resident #103's Minimum Data Set assessment, dated 12/7/14, indicated the resident had a Brief Interview for Mental Status score of 7, with a score of 0-7 being severely cognitively impaired and required extensive assistance of 2 staff members to walk in their room. On 2/20/15 at 5:12 p.m., Resident # 103's water temperature was rechecked. The Maintenance Supervisor's thermometer measured 100 degrees Fahrenheit and the surveyor's thermometer measured 122.2 degrees Fahrenheit. The survey teams' water temperature measurements were verified by using two different calibrated thermometers. Water Temperature Time Required for a 3rd Degree Burn to Occur: A water temperature of 140 degrees Fahrenheit takes 5 seconds for a 3rd degree burn to occur. A water temperature of 133 degrees Fahrenheit takes 15 seconds for a 3rd degree burn to occur. A water temperature of 127 degrees Fahrenheit takes 1 minute for a 3rd degree burn to occur. A water temperature of 124 degrees Fahrenheit takes 3 minutes for a 3rd degree burn to occur. A water temperature of 120 degrees Fahrenheit takes 5 minutes for a 3rd degree burn to occur. During an interview, on 2/20/15 at 3:58 p.m., The Maintenance Supervisor (MS) indicated the hot water line starts at the Vision Hall, then goes to the Augusta Cottages, and finally wraps around to the Moving Forward Hall at the other side of the building. MS indicated, "We were told to not use the digital thermometers to measure the water temps (temperatures)." The MS was observed to use a dial thermometer to check all of the residents' water temperatures. On 2/20/15 at 4:05 p.m., the Administrator provided the facility's "Daily Water Temperature" policy, undated, and indicated it was the one currently being used by the facility. The policy indicated, "Temperatures between 100-120 should be maintained in resident care areas." 3.1-19(r)

Based on observation, interview, and record review, the facility failed to ensure staff maintained clean privacy curtains, repaired damaged wallpaper, repaired doors, and replaced stained ceiling tiles for 7 of 10 residents observed for room furnishings. (Resident #86, Resident #72, and Resident #31, Resident #60, Resident #41, Resident #103, and Resident #27) Findings include: 1.) On 2/19/15 at 1:57 p.m., Resident #86's bedroom door was observed to be very hard to close. The resident indicated, "You have to really push to get the door to close all of the way." 2.) On 2/19/15 at 2:19 p.m. Resident #60's wallpaper on the wall behind the bed was observed to be wrinkled up and torn. There were 6 ceiling tiles observed to have light brown stains varying in size and 3 ceiling tiles had punctures in the bedroom. 3.) On 2/19/15 at 2:25 p.m., Resident #31's room door was observed to have multiple large gouges and jagged wood exposed to the outside bottom half of the door. 4.) On 2/19/15 at 2:26 p.m., Resident #41's wallpaper was observed to be torn, in the bathroom, above the soap dispenser and scuff marks were observed on the wall that adjoins the hallway next to resident's bed. 5.) On 2/20/15 at 11:33 a.m., Resident #72's privacy curtain was observed to be dirty with black marking at bottom. 6.) On 2/20/15 at 11:25 a.m., Resident #27's wallpaper was noted to be wrinkled up by the head of the bed and above the heater. Two ceiling tiles by the winder were observed to be stained light brown and varying in size. 7.) On 2/20/15 at 3:32 p.m., Resident 103's bedroom was observed to have a scuff marks and two half-dollar sized unfinished patches on the wall which adjoined the hallway. During a tour with the Maintenance Supervisor (MS), on 2/24/15 at 11:15 a.m., she indicated the facility will be going through renovations within the next year. The following interviews took place: On 2/24/15 at 11:18 a.m., when closing Resident #86's door, the MS indicated, "It feels like the door has failed." On 2/24/15 at 11:22 a.m., Resident #31 door was observed with the MS and she indicated, "It looks like the door has probably gotten chipped from moving the beds in and out." On 2/24/15 at 11:16 a.m., Resident #72 privacy curtain was observed with the MS and she indicated, "It look like those are ink stains from a pen." She also indicated the curtains were cleaned monthly. On 2/24/15 at 3:12 p.m., the Administrator (ADM) provided the facility's "(Facility Name); 2015 Budget Scope 6/11/14," and indicated the renovations listed would be provided by the corporation and would take place over the next year. The budget did not address repairing or replacing the wallpaper or ceiling tiles in the residents' rooms. The ADM indicated the the facility was also renovating rooms personally, but she was unable to provide any information regarding when the facility's personal renovations would take place, or what rooms it would affect. She indicated they planned to renovate rooms as they could "get to them." On 2/25/14 at 9:48 a.m., the Administrator and the MS indicated the facility did not have a policy regarding maintenance of the facility. 3.1-19(f)

Based on interview and record review, the facility failed to ensure physician's orders were followed for blood pressure upon return from [MEDICAL TREATMENT] for 1 of 1 resident reviewed for [MEDICAL TREATMENT] (Resident #125) and failed to ensure care plans were followed for monitoring of medication side effects and for an AIMS (Abnormal Involuntary Movement Scale) assessment having been completed for residents who received anti-psychotic medication for 2 of 5 residents reviewed for unnecessary medication use. (Resident #8, Resident #103) Findings include: 1. Resident #125's clinical record was reviewed on 2/24/15 at 11:04 a.m. [DIAGNOSES REDACTED]. Current February 2015, Physician's order dated 12/18/14 (date initiated), indicated [MEDICAL TREATMENT] 3 times a week on Monday, Wednesday and Friday. Physician's February 2015, orders indicated "...record blood pressure upon return from [MEDICAL TREATMENT]. Once A Day on Mon (Monday), Wed (Wednesday), Fri (Friday); 11:00 A.M.-01:00 PM. ..." The order start date was 12/18/14. On 2/24/15 at 3:30 a.m., the Director of Nursing (DON) indicated, "Her (Name of Resident #125) vital (indicating blood pressure) are taken when she returns from [MEDICAL TREATMENT]. The [MEDICAL TREATMENT] center will fax over their vital from the [MEDICAL TREATMENT] visit." On 2/25/15 at 9:30 a.m., the Moving Forward unit manager provided, "The Medication Administration History (MAH)" dated December 2014, January 2015 and February 2015, the MAH indicated, no blood pressures were taken upon return to the facility on [DATE],12/30/14, and 2/11/15, for Resident #125. The Moving Forward unit manager indicated, according to the MAH no blood pressures were documented for 12/28/14, 12/30/14, and 2/11/15. On 2/25/15 at 11:03 a.m., the Director of Nursing provided policy "[MEDICAL TREATMENT] Care" revision date September 2012, and indicated the policy was the one currently used by the facility. The policy indicated, " ...It is policy of American Senior Communities to ensure that the resident is rendered necessary services for the provision and maintenance of [MEDICAL TREATMENT] services through effective communication with the [MEDICAL TREATMENT] unit. ... 8. An assessment of the resident will be completed upon return from each [MEDICAL TREATMENT] visit to include vital signs, ..." 2a. Resident #103's clinical record was reviewed on 2/21/15 at 9:05 a.m. [DIAGNOSES REDACTED]. Physicians order dated 2/19/15, indicated Resident #103's medications included but, were not limited to: [MEDICATION NAME] tablet (an anti-psychotic medication used to treat [MEDICAL CONDITION] and [MEDICAL CONDITION] disorder) 0.125 mg every day for [MEDICAL CONDITION]. Current care plan dated 9/15/14 indicated, "PROBLEM: Resident is at risk for adverse side-effects related to the use of [MEDICAL CONDITION] (anti-psych, antidepressant, anti-anxiety) .... APPROACH: document side effects as observed and notify MD (Medical Doctor) .... Observe for side effects: Antipsychotic meds: dizziness, dry mouth, indigestion, drowsiness, constipation, impaired balance, weight gain, tremors, abnormal involuntary movements ...." The Wolters Kluwer Nursing 2015 Drug Handbook, 35th edition, copy right 2015, Black Box Warning for [MEDICATION NAME] include: " Elderly patients with dementia-related [MEDICAL CONDITION] treated with antipsychotics are at increased risk for death. Drug isn't approved to treat elderly patients with dementia-related [MEDICAL CONDITION] ....Alert: Watch for evidence of [DIAGNOSES REDACTED] (extrapyramidal effects, hyperthermia, autonomic disturbance), which is rare but can be fatal." The clinical record lacked documentation which indicated side effects were being monitored for Resident #103's [MEDICATION NAME]. On 2/25/15 at 9:49 a.m., an interview with RN (Registered Nurse) #2 indicated side effects are monitored and put in the computer each shift. RN #2 confirmed a side effect checklist was created on 2/24/15, for resident #103's [MEDICATION NAME] and indicated side effects were not being monitored up until that point. RN #2 indicated side effects for [MEDICATION NAME] included: lethargy, drunken walk, extrapyramidal side effects, weight gain, sedation and postural [MEDICAL CONDITION]. On 2/25/15 at 10:15 a.m. an interview with the Medical Records Director indicated she had looked through the computer back to Resident #103's admitted [DATE], and side effects had not been monitored on [MEDICATION NAME] until 2/24/15. On 2/24/15 at 11:00 a.m., an interview with the ADON (Assistant Director of Nursing) indicated she could not find where side effects were being monitored for [MEDICATION NAME]. "They are usually charted on the MAR (Medication Administration Record) but I cannot find them. I will get it put on the MAR indicated [REDACTED] 2b. Resident #8's clinical record was reviewed on 02/23/15 at 10:48 a.m. [DIAGNOSES REDACTED]. February 2015, physician's order indicated: December 2013 (date initiated), Resident #8 received [MEDICATION NAME] (anti-depressant) 100 mg (milligram) at bedtime and was decreased on December 2014, to 50 mg at bedtime. September 17, 2014 (date initiated), Resident #8 received [MEDICATION NAME] (antipsychotic) 0.25 mg (milligram) twice daily. March 17, 2014 (date initiated), Resident #8 received [MEDICATION NAME] (hypnotic) 7.5 mg (milligram) every bedtime as needed. The current care plan, initiated on 9/6/12, indicated a problem, "The resident is at risk for adverse side effects related to use of [MEDICAL CONDITION] medication (anti-psych, anti-depression, anti-hypnotic ... Approach: AIMS (Abnormal Involuntary Movement Scale) assessment two times a year." An AIMS assessment was completed on 10/28/13 and 11/26/14. No other AIMS assessment had been completed for 2013 nor 2014. On 02/24/15 10:00 a.m., interview with the MDS (Minimum Data Set) assessment Coordinator indicated an AIMS assessment is completed twice a year. This resident only had one done yearly. On 2/25/15 at 11:03 a.m., the Director of Nursing (DON) provided the policy, "[MEDICAL CONDITION] Management Policy" dated 5/2014, and indicated the policy was the one currently being used by the facility. The policy indicated, "... An AIMS assessment is required for residents who are taking antipsychotic medication. The assessment should be completed within 48 hours of a new order to initiate an antipsychotic and then every six months..." 3.1-35(g)(2)

Based on observation, interview, and record review, the facility failed to ensure communication between the facility and [MEDICAL TREATMENT] center was maintained in accordance with the care plan and facility policy for 1 of 1 resident reviewed for [MEDICAL TREATMENT]. (Resident #125) Findings include: Resident #125's clinical record was reviewed on 2/24/15 at 11:04 a.m. [DIAGNOSES REDACTED]. The current Minimum Data Set assessment ((MDS) dated [DATE], indicated a Brief Interview of Mental Status score (BIMS) was 14, with 8-15 being interviewable and cognitively intact. physician's orders [REDACTED]. On 2/25/15 at 8:30 a.m., the Director of Nursing indicated, The [MEDICAL TREATMENT] center sends the ([MEDICAL TREATMENT]) summary back with the resident." The current care plan dated 12/16/14, "Problem: Resident is receiving [MEDICAL TREATMENT] and is at risk for complications such as fluid imbalance, bleeding or infection sit: Left AV (arteriovenous) . ...GOAL: [MEDICAL TREATMENT] Monday/Wednesday/Friday, ...12/15/14 APPROACH: Assess [MEDICAL TREATMENT] every shift for excessive bleeding, drainage, swelling, redness, warmth, bruit/thrill (Bruits are rushing sounds heard over large and medium-sized arteries as a result of vibration in the vessel wall and buzzing sound) , ... observed for fluid volume deficit such as [MEDICAL CONDITION], orthostatic [MEDICAL CONDITION], ..." The clinical record lacked [MEDICAL TREATMENT] communication forms. On 2/24/15 at 3:00 p.m., request was made to the Director of Nursing to provide the [MEDICAL TREATMENT] communication documentation for Resident #125. On 2/25/15 at 8:26 a.m., the Director of Nursing (DON) provided "Transfer Summary" communication forms from the [MEDICAL TREATMENT] center dated: 12/26/14, 12/28/14, 12/30/14, 1/2/15, 1/5/15, 1/7/15, 1/9/15, 1/12/15, 1/14/15, 1/23/15, 1/26/15, 2/9/15, 2/11/15, 2/13/15 and 2/16/15. Theses forms were received by the facility, via fax from the [MEDICAL TREATMENT] center, on 2/24/15. On 2/25/15 at 11:03 a.m., the Director of Nursing provided policy "[MEDICAL TREATMENT] Care" revision date 9/2012, and indicated the policy was the one currently used by the facility. The policy indicated, " ...It is policy of American Senior Communities to ensure that the resident is rendered necessary services for the provision and maintenance of [MEDICAL TREATMENT] services through effective communication with the [MEDICAL TREATMENT] unit. ... 7. The nurse in charge at time of return will review paperwork for new orders and/or paperwork accompanying the resident." 3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure the residents' portable oxygen tanks were filled with oxygen during a dining observation in the main dining room for 4 of 6 residents who had portable oxygen tanks in the dining room. (Resident #8, Resident #35, Resident #97, Resident #138) Findings include: 1. Resident #138's clinical record was reviewed on 2/25/2015 at 9:30 a.m. [DIAGNOSES REDACTED]. A current physicians order dated 2/17/2015, indicated "Oxygen at 2 liters per nasal cannula. May titrate to keep sats (saturation) > (greater than) 90%." A careplan dated 2/18/2015, indicated a problem: "Resident has potential for impaired gas exchange related to: [MEDICAL CONDITION] and [MEDICAL CONDITIONS]. Approach: Administer oxygen as ordered...." On 2/19/15 at 11:42 a.m., an observation of Resident #138's oxygen tank indicated it was empty while in the main dining room. LPN (Licensed Practical Nurse) #3 removed the tank and brought the tank back refilled. 2. Resident #97's clinical record was reviewed on 2/25/2015 at 9:45 a.m. [DIAGNOSES REDACTED]. A current physicians order dated 10/16/2014, indicated "Oxygen at 2 liters per nasal cannula." The current careplan dated 8/12/2014, indicated a problem: "Resident has potential for impaired gas exchange related to" [MEDICAL CONDITIONS], Wears Oxygen. Approach: Administer oxygen as ordered...." On 2/19/15 11:41 a.m., an observation of Resident #97's oxygen tank indicated it was empty. CNA (Certified Nursing Assistant) #1 removed the oxygen tank and brought the tank back filled. 3. Resident #8's clinical record was reviewed on 2/25/2015 at 10:00 a.m. [DIAGNOSES REDACTED]. A current physicians order dated 11/22/2013, indicated "Oxygen at 2 liters per nasal cannula as needed to keep sats (saturation) > (greater than) 90%..." The current careplan dated 9/6/2012, indicated a problem: "Resident has potential for impaired gas exchange related to: [MEDICAL CONDITION] [MEDICAL CONDITIONS]. Approach: Administer oxygen as ordered...." On 2/19/2015 at 11:45 a.m., an observation in the main dining room of Resident #8's oxygen tank indicated it was empty. Resident #8's nasal cannula was removed and no oxygen was coming from the nasal cannula. Restorative CNA #1 removed the oxygen tank, refilled and brought it back to Resident #8. 4. Resident #35's clinical record was reviewed on 2/23/2015 at 12:49 p.m. [DIAGNOSES REDACTED]. A current physicians order dated 1/4/2015, indicated "Oxygen at 2 liters per nasal cannula, keep sats (saturation) > (greater than) 90%." The current careplan dated 1/5/2015, indicated a problem: "Resident has potential for impaired gas exchange related to: ([MEDICAL CONDITIONS], hx (history) of pneumonia, hx of rt (right) lower lobe ectomy). Approach: Resident receives oxygen...Administer oxygen as ordered...." On 2/19/15 at 11:50 a.m., an observation in the main dining room indicated Resident #35's oxygen tank was empty. LPN (Licensed Practical Nurse) #1 indicated, "It's pretty empty." Observed LPN #1 to remove the empty oxygen tank at that time. On 2/25/2015 at 11:03 a.m., the Director of Nursing provided the Filling Portable Oxygen Canister policy, revised on 12/2012, and indicated the policy was the one currently being used by the facility. The policy indicated, "...17. Return filled portable tank to resident...." 3.1-47(a)(6)

Based on interview and record review, the facility failed to ensure residents who received an anti psychotic medication were monitored for side effects and an AIMS (Abnormal Involuntary Movement Scale) assessment had been completed as indicated by the facility policy for 2 of 5 residents reviewed for unnecessary medication use. (Resident #103, Resident #8) Findings include: 1. Resident #103's clinical record was reviewed on 2/21/15 at 9:05 a.m. [DIAGNOSES REDACTED]. Physicians order dated 2/19/15, indicated Resident #103's medications included but, were not limited to: [MEDICATION NAME] tablet (an antipsychotic used to treat [MEDICAL CONDITION] and [MEDICAL CONDITION] disorder) 0.125 mg every day for [MEDICAL CONDITION]. Current care plan dated 9/15/14 indicated, "PROBLEM: Resident is at risk for adverse side-effects related to the use of [MEDICAL CONDITION] (anti-psych, antidepressant, anti-anxiety) .... APPROACH: document side effects as observed and notify MD (Medical Doctor) .... Observe for side effects: Antipsychotic meds: dizziness, dry mouth, indigestion, drowsiness, constipation, impaired balance, weight gain, tremors, abnormal involuntary movements ...." The Wolters Kluwer Nursing 2015 Drug Handbook, 35th edition, copy right 2015, Black Box Warning for [MEDICATION NAME] include: " Elderly patients with dementia-related [MEDICAL CONDITION] treated with antipsychotics are at increased risk for death. Drug isn't approved to treat elderly patients with dementia-related [MEDICAL CONDITION] ....Alert: Watch for evidence of [DIAGNOSES REDACTED] (extrapyramidal effects, hyperthermia, autonomic disturbance), which is rare but can be fatal." The clinical record lacked documentation which indicated side effects were being monitored for Resident #103's [MEDICATION NAME]. On 2/25/15 at 9:49 a.m., an interview with RN (Registered Nurse) #2 indicated side effects are monitored and put in the computer each shift. RN #2 confirmed a side effect checklist was created on 2/24/15, for Resident #103's [MEDICATION NAME] and indicated side effects were not being monitored up until that point. RN #2 indicated side effects for [MEDICATION NAME] included: lethargy, drunken walk, extrapyramidal side effects, weight gain, sedation, postural [MEDICAL CONDITION]. On 2/25/15 at 10:15 a.m. an interview with the Medical Records Director indicated she had looked through the computer back to Resident #103's admitted [DATE], and side effects had not been monitored on [MEDICATION NAME] until 2/24/15. On 2/24/15 at 11:00 a.m., an interview with the ADON (Assistant Director of Nursing) indicated she could not find where side effects were being monitored for [MEDICATION NAME] for Resident #103. "They are usually charted on the MAR (Medication Administration Record), but I cannot find them. I will get it put on the MAR indicated [REDACTED] On 2/25/15 at 12:00 p.m., requested a policy related to monitoring side effect for anti psychotics medications and the facility did not provide one. 2. Resident #8's clinical record was reviewed on 02/23/15 at 10:48 a.m. The [DIAGNOSES REDACTED]. Current February 2015 physician orders [REDACTED]. [MEDICATION NAME] (antidepressant) 50 mg (milligram) at bedtime, starting on 12/20/14; [MEDICATION NAME] (antipsychotic) 0.25 mg twice daily; and [MEDICATION NAME] (hypnotic) 7.5 mg every bedtime as needed. The current care plan, initiated 9/6/12, indicated a problem, "The resident is at risk for adverse side effects related to use of [MEDICAL CONDITION] medication (anti-psych, anti-depression, anti-hypnotic, Approach: AIMS (Abnormal Involuntary Movement Scale) assessment two times a year. An AIMS assessment was completed on 10/28/13 and 11/26/14. No other AIMS assessment had been completed for 2013 nor 2014. On 02/24/15 10:00 a.m., interview with the MDS (Minimum Data Set) Coordinator indicated an AIMS assessment is completed twice a year. This resident only had one done yearly. On 2/25/15 at 11:03 a.m., the Director of Nursing (DON) provided the policy, "[MEDICAL CONDITION] Management Policy" dated 5/2014, and indicated the policy was the one currently being used by the facility. The policy indicated, "... An AIMS assessment is required for residents who are taking antipsychotic medication. The assessment should be completed within 48 hours of a new order to initiate an antipsychotic and then every six months..." 3.1-48(a)(3)

Based on observation, interview, and record review, the facility failed to ensure infection control practices were followed as indicated by facility policy and Center for Disease Control related to hand washing and glove change during personal care and wound care for 1 of 1 resident observed for pressure ulcers (Resident #125) and 1 of 1 randomly observed resident for personal care. (Resident #125) (CNA #1, CNA #2, CNA #3, RN #1, Executive Director) Finding include: 1). On 2/25/25 at 11:50 a.m., RN #1 was observed to provide wound care on Resident #125's right foot amputee. She put on gloves and cleansed area with iodine, then placed a Vaseline gauze on, wrapped with kerlix, and secured with tape. No change of glove nor handwashing was observed at that time. She removed the gloves and placed in a trash can. RN #1 entered the bathroom and handwashed. RN #1 walked over to the wall and retrieved a pair of gloves and put them on. She applied skin prep to the left ear. No handwashing nor change of gloves observed. RN #1 applied skin to both heels and then with dirty gloves still on she positioned Resident #125's heels on a cushion and covered with the bed spread. She then removed the dirty gloves and went into the bathroom to handwash. She removed the trash bag from the trash can. She then removed the dirty towels from the bedside table with the iodine gauze remaining on the towel and placed the items a plastic bag to take to laundry. No handwashing was observed. RN #1 was observed to exit the room at that time. On 2/25/15 at 12:03 p.m., RN #1 indicated, "You should handwash after removing soiled dressing, after applying clean dressing, from clean to dirty, I was not aware that iodine was cleansing, it is part of her treatment. I did place the dirty iodine gauze on the towel. I should have hand washed after removing trash and the towel." 2). On 2/19/15 at 2:45 p.m.., the Executive Director (ED) was observed to enter the room of Resident #4 to answer the call light. No handwashing was observed. Resident #4 indicated, "I need to get off the bedpan." At that time the ED was assisting Resident #4 and 3 Certified Nursing Assistants (CNA) were observed to enter the room to assist. CNA #3 was observed to assist in removing the bedpan from underneath Resident #4 while the ED was holding Resident #4 on her side. CNA #3 walked into the bathroom with her dirty gloves on and moved the electric wheelchair out of the way. CNA #3 was observed to empty the bedpan and with the dirty gloves on received clean wash cloths from CNA #2. With the dirty gloves still on CNA #3 was observed to wet the clean wash cloths. She removed one dirty glove and walked back to the bedside with one dirty glove still on. CNA #3 was observed to place a second glove on and began personal care for Resident #4. After completing personal care CNA #3 and the ED were both observed with dirty gloves on to assisted Resident #4 up in bed. CNA #3 with the dirty gloves on covered Resident #4 with a blanket that was on her bed. The ED was observed to remove her gloves, and enter the bathroom and handwash for 10 seconds. CNA #2 indicated, "We should handwash upon entering the room, after care and when in doubt handwash." CNA #3 indicated, " I should handwash anytime I change my gloves. I didn't change my gloves nor handwash after I contaminated them." CNA #1 was observed to get clean linen to change the bedding on Resident #4's bed. On 2/25/15 at 11:03 a.m., the Director of Nursing provided policy "HAND HYGIENE" review date 03/2012, and indicated the policy was the one currently used by the facility. The policy indicated, " Procedure Steps: ...6. Use friction for at least 20 seconds. ...5 Moment of required hand hygiene: ..After body fluid exposure risk, After patient contact, After contact with patient surroundings." On 2/26/15, review of Center for Disease Control at www.cdc.gov/handwashing/, dated December 16, 2013 indicated, " When should you wash your hands? ...food Before and after caring for someone who is sick, Before and after treating a cut or wound, After touching garbage, ...How should you wash your hands?Wet your hands with clean, running water (warm or cold), turn off the tap, and apply soap. Scrub your hands for at least 20 seconds. Need a timer? Hum the "Happy Birthday" song from beginning to end twice. ... " 3.1-18(l)

Based on observation, interview and record review, the facility failed to ensure residents at risk of and with a history of falls were supervised to ensure their safety from falls, resulting in Resident #54 suffering a second hip fracture and Resident #92 having repeated falls, for 2 of 6 residents reviewed with falls in the sample of 17. Resident # 54 and 92. Findings include: 1. On the initial tour, on 11/28/11 at 8:40 A.M., the Director of Nursing indicated Resident # 54 had cognitive impairment, utilized a lap buddy but could remove it. The clinical record for Resident # 54 was reviewed on 11/28/11 at 11:15 A.M. The record indicated Resident # 54 had [DIAGNOSES REDACTED]. The MDS (minimum data set) assessment, dated 11/10/11, indicated Resident # 54 had short and long term memory problems. Resident # 54 required extensive assistance of two with transfers, ambulation and toilet use. Resident # 54 utilized a trunk restraint daily in chair. An Admission Nursing Care Plan, dated 6/24/11, indicated a problem of "Problem: Fall Risk related to fracture- neck of femur. The interventions were "Observed for fall risk contributors such as medications, hypotension, pain, unsteady gait. Encourage and remind resident to use call light. Refer to therapies for screening. Provide assistance for transfers, bed mobility. Fall risk assessment. Provide appropriate assistive devices such as walker, low bed, mats on floor, alarms on chairs/bed." A Fall Risk Assessment, dated 6/24/11, indicated "...Did the resident have any fracture related to a fall in the 6 months prior to admission? yes...Resident has had a history of [REDACTED].? yes...Resident is noncompliant or had history of noncompliance? yes. Resident is confused and/or disoriented? yes. If any answer above is yes the resident is at risk for experiencing a fall..." The Progress Notes, dated 06/25/2011 04:54 PM, indicated "Resident is confused to place and time. Did recognize family member who came in earlier to mark clothing. Refused to have vital signs taken, kept pulling at bp (blood pressure) cuff, chewing on thermometer, and removing pulse ox probe. Grabs at staff and clings to their hands. Has attempted to get up unassisted x 2 this shift. Alarms remain on bed and chair and are functioning appropriately..." The Progress Notes, dated 07/01/2011 11:15 PM, indicated "Resident has attempted to stand several times this shift. Resident ate in restorative dining room. Resident went to bed after meal and has not attempted to get up..." The Progress Notes, dated 07/02/2011 03:21 PM, indicated "Resident has been restless and has attempted to stand multiple times, although she hasn't been able to fully rise from her seat due to weakness. Continues to reach out to staff and visitors and grab on to their hands. Has also been seen pushing along dynamap and grabbing at the clean medication cups on the side of the med cart..." The Progress Notes, dated 07/03/2011 04:54 PM, indicated "Resident became increasingly upset this shift. She refused to stay in bed, sit in wheelchair or lay in recliner. She began hitting staff with her hands and objects. She was kicking at staff. This went on for approx 1 hr. Staff was sitting with resident one on one. At 3pm (doctors name) was called and received an order to give 1mg IM injection of Ativan. Since then resident has been sleeping in recliner. Family was notified and reported, "you have to do what you have to do". The Progress Notes, dated 07/04/2011 09:03 PM, indicated "Resident has not been aggressive this evening. She has tried to get up multiple times and has needed continuous observation this evening. Resident was toileted and repositioned but this didn't seem to alleviate her desire to attempt to stand up repeatedly. Chair alert in place per orders..." The Progress Notes, dated 07/11/2011 06:06 PM, indicated "Resident continues to attempt to get up multiple times per shift. Has been hitting at staff when she is assisted to sit back down. Has been offered activities to do to distract her with little affect." The Progress Notes, dated 07/29/2011 03:30 PM, indicated "Resident was witnessed by aide fell backwards in wheelchair. Alarms were sounding. Resident fell on to floor hitting her right hip and back of head. Resident complained of pain to head and right hip. Neuro checks started. Anti tippers applied to wheelchair front and back." The Progress Notes, dated 07/29/2011 03:40 PM, indicated "MD was notified of fall and order received to send to ER by Dr. (name) on call for Dr. (name). Order written ambulance called. Called (name) ER and gave report to ER nurse." The Progress Notes, dated 07/29/2011 07:25 PM, indicated "Resident returned to facility with dx of right greater trochanter non displaced hip fracture. Bedrest as tolerated for 2 days. May use walker as tolerated. X-ray of right hip in 1 week then follow-up with ortho of choice after x-ray complete. Reported new orders to (name) for (name). (Name) advised of residents anxiety and behaviors and said if behaviors increased to call for PRN (as needed) order." The Progress Notes, dated 07/29/2011 07:30 PM (Recorded as Late Entry on 08/02/2011 10:23 AM), "Res has been moved to room (room number documented), which is closer to nurses station, as intervention to today's fall..." The fall care plan was updated on 7/29/11 to include the intervention of "W/C anti tip bars front and back and moved to room closer to nurses station." The Progress Notes, dated 07/30/2011 05:41 PM, "Resident remains on bedrest for R (right) hip fx (fracture) r/t (related to) fall. Resident remains on low bed with bed alarm in place and mat next to bed on floor. Neuro checks have been WNL (within normal limits). Has been medicated with PRN pain med r/t c/o (complaints of) leg pain." The Progress Notes, dated 07/31/2011 12:30 PM (Recorded as Late Entry on 08/01/2011 06:23 AM), "Resident has set bed alarm off multiple times. Remains in low bed with mat on the floor. Has been medicated for c/o leg pain with good results." The Progress Notes, dated 08/01/2011 09:10 AM, "CNA came to say resident was on the floor. Resident was on the floor in her room at the foot of her bed, Lying on her left side. Resident was asking for help to get up. No blood noted on resident or on the floor. R/T resident's recent fall with hip fracture, resident was left in position on the floor while Dr. (name) and the ambulance was called. Staff stayed with the resident at all times. She was made as comfortable as possible while awaiting the ambulance's arrival..." The Progress Notes, dated 08/01/2011 09:30 AM, "Ambulance staff assisted resident to lie on her back and then lifted her onto the stretcher. Resident was transported to (name) Hospital emergency department for evaluation. There were no obstacles or spills in the floor around the resident's bed. Bed was in the low position with the mat on the floor beside the bed. Resident was off the matt at the end of the bed when she was found after her fall. The bed alarm had been in place. The resident was barefoot. She had not been incontinent. She had been in bed approximately 1/2 hour when she fell . She had previously been up for breakfast and was toileted prior to laying down. No morning medication had yet been administered. No PRN pain meds had been given. The Resident did have her Fentanyl patch in place per her routine order." The Progress Notes, dated 08/01/2011 10:30 AM (Recorded as Late Entry on 08/03/2011 01:33 PM), "IDT (interdisciplinary team) met to review fall that occurred 7/30/11. Resident was witnessed by aide falling backwards in wheelchair. Wheelchair turned over with resident. Alarms were sounding. Resident fell on to floor hitting her right hip and back of head. Resident complained of pain to head and right hip. Neuro checks started. Resident sent to ER, returned with Diagnosis: [REDACTED]. New interventions include moving resident to room closer to nurses station and applying anti tippers to front and back of wheelchair." The Progress Notes, dated 08/01/2011 10:50 AM, "Report received from (name) Emergency department that the resident was being returned to the facility. Bilateral hip xrays were done along with a head CT (CAT scan). These showed no changes since the ones done on 7/29." The Progress Notes, dated 08/01/2011 04:01 PM, "Resident remains on Q 15 minute monitoring, but has had to stay with a staff member all shift since return to facility, as she has continually tried to stand up. Has set her chair alarm off multiple times this shift. Family has arrived at this time to monitor her for awhile. Cannot be reasoned with. Denies pain." The fall care plan was updated on 8/1/11 to include the interventions of "15 minute checks." The Progress Notes, dated 08/02/2011 10:36 PM (Recorded as Late Entry on 08/03/2011 01:41 PM), indicated "IDT met to review fall that occurred 8/1/11. Resident lying on floor next to her bed. Resident with dementia and is unable to tell staff what happened. Resident assessed for injury. No injuries apparent. Resident was sent to ER due to recent [DIAGNOSES REDACTED]. Neurochecks initiated. Resident has low bed, mat on floor, bed alarm. Will place scoop mattress on bed." The fall care plan was updated on 8/2/11 to include the intervention of "scoop mattress." The Progress Notes, dated 08/03/2011 01:31 PM, indicated "Resident has continually attempted to transfer unassisted since after lunch. Resident is easily redirected but will attempt to transfer unassisted with in less than 30 seconds. Writer walked Resident in the hallway per her request with gait belt and peer nurse assistance, resident walked approx 5 feet before asking to sit back down. Re directive ideas have been used through out shift; visits with managers, yarn, magazines, paper and pen, toileting, tape and paper, gentle massage without effectiveness. Resident also received PRN pain medication for s/sx of pain. Alarms in place." The Progress Notes, dated 08/06/2011 05:13 PM, indicated "Resident has been extremely restless today, attempting to stand up continually for 20-30 minutes at a time. Required someone to sit directly with her telling her to sit down over and over. Resident does not follow directions to sit down and continues to try to stand up. Has stood multiple times on her fractured leg. Unable to stop her from standing up even with someone sitting right with her at all times. No obvious further injury, resident has been medicated for pain. No apparent lessening of behaviors noted with Ativan." The Progress Notes, dated 08/08/2011 06:28 PM, indicated "IDT met to review fall on 8/7/2011 at 6:00 am. Staff found resident on floor, left side of bed off of the floor mat. Resident unable to tell staff how she fell due to dementia. Bed alarm was not sounding and staff had not started alarm checks, nurses was giving report. Last alarm check was at 10:30 pm. Head to toe assessment done by nurse with no injury noted. Resident had regular socks on. Neuro checks initiated. MD notified and order to send to ER was given. This nurse talked with Dr (name) today and order was given for hipsters to prevent injury. Resident is to wear non skid socks at all times. Will continue alarms, low bed and mat on floor next to bed. Care plan updated." The Progress Notes, dated 08/08/2011 09:10 PM (Recorded as Late Entry on 08/09/2011 03:10 AM), "cna called nurse to room res. res laying on floor on her right side to back. res beside bed legs are on matt but rest of body laying on the floor. hipsters are on, bed low and matt on floor alarm on. res has no new injuries noted at this time. res moving arms and legs without difficulty. paged Dr (name)." The Progress Notes, dated 08/08/2011 09:30 PM (Recorded as Late Entry on 08/09/2011 03:19 AM), "Dr (name) called n/o received. 1)send to ER for eval post fall xray hips res has non displaced Fx.2) 15 min monitoring. called husband and reported wife's fall and we are going to send her to ER. talked with Don /reported to her sending res to ER before i called her husband. family cant come set 1 on 1 with res husband only one who lives here." The fall care plan was updated on 8/8/11 to include the intervention of "Non skid footwear/socks at all times and hipsters." The Progress Notes, dated 08/09/2011 01:45 AM, indicated "res returned from ER via amb with paramedics. 15 min monitoring started. called (company initials documented) to come set 1 on 1 with res .nurse will be 1 on 1 till (company initials documented) gets here. res in recliner at this time. alarm on and functioning. res at nurses desk. no new orders from ER DX UTI res already started ATB for this. no change in orders. no new fractures. per report from er. neuro checks wnl. hosp remove soft set from abd.called pharmacy to stat one out.iv edk only has one which was used to start and taken out at (name of hospital) er.search for one in med room .none found." The Progress Notes, dated 08/09/2011 10:06 AM, indicated "IDT met to review fall on 8/8/2011 at 9:10 pm. Residents alarm sounding and when staff found resident she was lying on the floor with her legs on the mat and body on the floor. Bed was in low position. Head to toe assessment was done by nurse. Resident complained of back pain. She could not tell staff how she fell due to dementia. MD notified and order to send to ER for evaluation was given. Family was notified. Neuro checks continued. Will have motion sensor used in room to alert staff when resident starts to sit up. Will have therapy screen. This nurse will discuss with Dr (name) the use of a lap buddy due to residents poor safety awareness. Care plan updated. Resident continues with staff one on one supervision." The fall care plan was updated on 8/9/11 to include the intervention of "Lap buddy when in chair." The fall care plan was updated on 8/10/11 to include the intervention of "motion sensor and pressure alarm mat." 2. Resident #92 was identified on the initial tour of the facility locked dementia unit, on 11/28/11 at 9:00 A.M. with the Director of Nursing, as cognitively impaired and having had recent falls. Resident #92 was observed sitting at the nursing station, in a wheelchair at the time of the tour. The resident was observed to stand up from the chair, the alarm ring and fall before staff could get to the resident. The unit manager was heard to tell the director of nursing the resident had refused her lap buddy that morning. Resident #92's clinical record was reviewed on 11/29/11 at 1:00 p.m. [DIAGNOSES REDACTED]." The admission MDS (minimum data set) assessment, dated 10/29/11, indicated the resident was unable to balance without human assistance during transfers, walking and moving on or off the toilet. The CAAs( care area assessment) for the assessment dated [DATE], indicated the resident was at risk of falls related to the balance issues while walking, transferring, moving on and off toilet. A care plan, dated 10/20/11, upon admission, included "fall risk" with interventions of : bed alarm, chair alarm, stationary chair 10/28/11, an update dated 11/9/11, included interventions of "chair and bed alarm, 11/11/11 bed in lowest position, bed against wall and mat to open side of bed." A care plan, dated 11/27/11 indicated "fall risk related to history of falls, dementia," interventions included additional interventions of " 11/28/11 hipsters to wear at all times." An additional problem, dated 11/28/11 for lap buddy restraint. A telephone physician's orders [REDACTED]. Remove for meals and activities." Progress notes included: "IDT (interdisciplinary team) met to review fall on 10/20/2011 at 5:20 am. Staff heard alarm coming from residents room. Staff found resident sitting on roommates floor alarm on floor next to roommates bed with multiple layers of clothes on and her pants down around her legs. Head to toe assessment done by nurse with no injury noted. Neuro checks initiated and...and family notified... and bed alarm applied..." "10/27/2011 09:47 AM Resident was ambulating with a peer in hallway, staff witnessed resident begin to lose balance. Resident caught self on roommate's walker and lowered self to the floor. Peer did not fall or have other injury related to this resident catching self with walker. No injury noted. ROM (range of motion) wnl (within normal limits). Resident was dressed and had appropriate footwear on. Chair alarm placed on resident to prevent further fall. Therapy to screen. Family and MD (Medical Doctor) notified, order obtained for chair alarm." "10/28/2011 02:50 PM fall witnessed by this nurse, this nurse was standing at the sink in the Cottage dining room, res was sitting in w/c across the dining room, res (resident) stood herself without assist, res attempted to sit back down, w/c wheeled backward away from her, res slid down the front of the w/c landing on the floor on her buttocks, denies discomfort at present... 2 staff assist to bring res to standing position, res bears weight bil without difficulty, no external rotation of BLE (Bilateral lower extremity) noted, no apparent injury noted..." "10/31/2011 09:38 AM IDT(Interdisciplinary Team) met to review fall on 10/28/11 at 12:50 pm. Resident was sitting in wheelchair in the dining room when staff observed her stand up and try to sit back down when wheel chair rolled backwards and resident slid down to floor on buttocks. Head to toe assessment done by nurse with no injury noted. MD/NP(Nurse Practitioner) and family notified. New orders received for anti roll backs on wheelchair and labs due to unsteady gait. Therapy discussed on 10/28 that resident should be in a stationary chair and staff should ambulate with resident due to poor safety awareness and unsteady gait" "11/11/2011 04:45 PM (Recorded as Late Entry on 11/12/2011 12:19 AM)Staff calls writer into resident's room at this time. Resident was lying on the floor next to her bed with legs extended outward. Resident tried to get up out of bed without assistance and fell to floor. Fall was unwitnessed. Resident denies pain at this time. Family..., and DON (Director of Nursing) notified of fall. ROM done without pain or difficulty. No skin tears, bruising or wounds noted from fall. Resident assisted to her wheelchair per 2 staff without difficulty. Resident alert and able to voice needs et wants. Floor mats placed on both sides of bed and bed put in lowest position..." "11/19/2011 05:20 PM This nurse was alerted to shower room by CNA. Witnessed resident laying on right side. Was bleeding from laceration above right eye. CNA stated that resident was attempting to sit down onto toilet and fell forward and to the right hitting head on floor. CNA also stated that resident was refusing to let CNA help her. CNA gave resident 2-3 ft of space. Resident was pulling down pants and brief and resident fell forward. CNA was unable to catch resident at time of fall. Resident stated that she had pain to her right hip. APROM was not preformed R/T (related to) resident c/o (complaints of) hip and head pain." "11/19/2011 10:38 PM CNA walking down hall observed this res climb out of bed onto knees on bedside mat.Res stating she wanted to get out of bed et purposefully moved out of bed... " '11/20/2011 12:30 AM Res lying in bed with eyes open. Neurochecks done. Upper and lower extremities strong, equal. Pupils PERRL(pupils equal react to light).. Skin tear above R (right) eye with moderate amount bloody drainage. Area cleansed et (and) steri strips reapplied. Bruise beginning to form around R eyebrow. Res states head "hurts a little but not a lot" c/o back pain also..." "11/24/2011 08:40 AM res chair alarm going off, noted res sitting in h/w(hallway) on buttocks beside w/c, res immediately stated 'I slipped out of that chair get me back in there', res had been attempting to stand, had her slipper shoes on, slippers slid causing res to fall to floor, 2 staff assist to transfer from sitting to standing position, res bears weight bil without difficulty, BLE notably weak, bil grasps =/strong, PERL, denies discomfort at present..." "11/25/11 1115 a.m. Resident was visiting with her (family member) in the sun room. staff heard alarm sound and immediately respond to find resident sitting on her buttocks in front of her wheelchair, legs out in front of her and leaning back against the wheelchair..." "11/28/2011 09:27 AM Resident removed lap buddy and tossed aside. Resident ambulated length of hallway x 2 with staff assist, then began asking for son. Agreed to call son. Refused to allow this writer to put lap buddy back on. Call placed to resident's son and resident given phone. Approx 5 minutes later alarm sounded, this writer responded to find resident sitting on floor in front of wheelchair on buttocks, legs straight out in front. Denied pain/discomfort at this time. ROM WNL. Resident assisted back into wheelchair with assist of 2 staff. Allowed lap buddy to be placed back on. Resident taken to activities as immediate intervention, will ask for therapy screen...." During interview with the DON on 11/29/11 at 2:00 P.M. she provided a teachable moment dated 11/20/11, for the CNA who had assisted the resident to the bathroom on 11/19/11 which indicated " stay within arms reach of resident when tilting...get assist as needed if residents are combative or high fall risk..." The DON further indicated the residents had 11 falls at home prior to admission to the facility., but did not know this until the first care plan meeting. 3.1-45(a)(2)

Based on interview and record review, the facility failed to ensure 1 of 3 sampled residents reviewed for facility bus transfers received timely assessment and care after the resident had fallen forward out of her wheelchair and lay face down on the floor of the van for approximately 1 and 1/2 hours resulting in the resident sustaining several bruises and abrasions. (Resident A) The Immediate Jeopardy began on 7/12/11 when Resident A was transported in the facility wheelchair van without a seat belt being in place. The driver of the van had to slam on his brakes when someone pulled in front of the van causing the resident to be propelled out of her wheelchair. The Resident laid on the van floor without medical assistance for approximately an hour and a half while the facility drove from Bedford to Indianapolis to assess her. The Administrator, RN Corporate Consultant and Director of Nursing were notified of the Immediate Jeopardy at 3:10 P.M. on 7/28/11. The immediate jeopardy was removed on 07/29/11 at 2:00 p.m., but noncompliance remained at the lowered scope and severity of isolated, at no actual harm, with potential for more than minimal harm that is not immediate jeopardy. Findings Include: During interview of Resident A on 07/28/11 at 10:30 a.m., she indicated she had a "bad accident two weeks ago." Resident #A indicated she had gone out for a doctor's appointment in Indianapolis. Resident A indicated the driver had secured her wheel chair with straps, but she had refused to wear the seat belt due to she was too heavy and didn't like the way the seat belt "squeezed" her. Resident #A indicated upon arriving at the hospital she was told the appointment had been canceled. Resident A indicated she left the hospital with the driver and continued to not wear her seat belt. Resident A indicated they were on the interstate and a car swerved in front of them and the driver had to slam on his brakes and she fell forward "almost to the front of the bus." Resident A indicated the driver pulled over to the side of the road and attempted to get her up off the floor but was unable to because she was too heavy. Resident A indicated she told the driver she was o.k. and the driver called the facility to report what had happened. Resident A indicated the bus driver told her that he was instructed by the facility to leave the resident on the floor until the facility arrived to help her. Resident A indicated it was very uncomfortable on the floor and she couldn't believe she had to lay on the floor until the facility arrived. The resident indicated she was on the floor 2 hours before the Administrator and LPN #1 arrived to assist her up. Resident A indicated the Administrator and the driver turned her over and sat her up and LPN #1 assessed her. Resident #A raised her shirt at this time and seven bright red ridges, approximately 4 centimeters in length and 0.5 centimeters in width were observed across the resident's abdomen. Resident A indicated the ridges were due to laying on the bus floor. Interview of LPN #1 on 07/28/11 at 11:15 a.m., indicated it took about 1 hour to get from the facility to Greenwood. LPN #1 indicated the Administrator had called a sister facility near the area of the facility bus and were told that staff from the sister facility would leave immediately to assist the resident. LPN #1 indicated she called the driver and told him the sister facility was on their way. LPN #1 indicated the driver had given an incorrect location and the sister facility was on the west side and the facility bus was on the east side. LPN #1 indicated the driver had followed Resident #A's instructions to get off of the interstate and had moved the bus with the resident laying on the floor. LPN #1 indicated when she and the Administrator found out that the facility bus was at a different location they called the sister facility and instructed them not to come due to the Administrator and LPN#1 were on their way and were closer to the location of the bus than the sister facility. LPN #1 indicated she assessed the resident and she was moving all extremities. LPN #1 indicated Resident #A was face down on the mat when they arrived and was the exact same width as the aisle. LPN #1 indicated the resident denied any pain. LPN #1 indicated she and the Administrator slid a gait belt under the resident and after 3 attempts were able to move the resident to the back of the aisle where they could sit her up. LPN #1 indicated upon assessment of the resident, the resident was found to have red ridges across her abdomen, red blotches on her knees, and a bleeding elbow. LPN #1 indicated Resident A was able to tell her her name and where she lived and Resident A denied pain except a sore ankle. Interview of the Administrator on 07/28/11 at 11:40 a.m., indicated it didn't occur to him to call EMT's (Emergency Medical Technicians) due to the resident saying she wasn't hurt. The Administrator indicated he had called the sister facility and they said they would go to assist the resident. The Administrator indicated he then called the van driver to confirm the location and the van driver told him he had moved the van and had driven about 8 miles farther. The Administrator indicated he then realized he was closer to the van than the sister facility so he called the sister facility and told them not to come. The Administrator indicated the resident didn't request EMT's. Interview of the DON (Director of Nursing) on 07/28/11 at 2:15 p.m., indicated when the van driver called the facility to report what happened, her first thought was to call 911 due to EMT's would arrive sooner. The DON indicated the Administrator said he had talked to the resident and she was o.k. and a sister facility was going to the van location to help the resident. Interview of the Nurse Practitioner on 07/28/11 at 2:30 p.m., indicated Resident A had requested an increase in her [MEDICATION NAME] ( anti-anxiety medication) on 07/14/11 due to the resident having trouble sleeping. The Nurse Practitioner indicated that on 07/19/11 the resident complained of pain under her left breast. The Nurse Practitioner indicated the ridges on the resident's abdomen had opened and the dressing was sticking. The Nurse Practitioner indicated she palpated the resident's abdomen and the resident didn't complain of pain. Review of Resident A's clinical record on 07/28/11 at 12:55 p.m., indicated the following: Resident A had [DIAGNOSES REDACTED]. A Resident Progress Note, dated 07/12/11 at 6:45 a.m., indicated, "Resident (A) LOA to Dr...(name of doctor) in Indy via facility provided transportation." A Resident Progress Note, dated 07/12/11 at 11:00 a.m., indicated Resident A's vital signs were taken at that time and were as follows: Temperature - 97.3, heart rate - 80, respirations - 20, and blood pressure - 130/60. A Resident Progress Note, dated 07/12/11 at 1:00 p.m., indicated, "Arrived at van @ 11:00 a.m. resident lying face down in the floor/aisle of the van. Res (Resident A) denied any pain at this time. Res A&O (alert and oriented) to place, name, and staff present. Assessed face/neck, feet/ankles, and both arms for mobility. Denies any pain during the assessment. Gait belt was placed under the resident by ED (Executive Director) and LPN #1 & was hooked on her (Resident A) back side. ED lifted res slightly up while LPN #1 moved res towards the back of the bus from the aisle. 3 attempts and successful. ED and LPN #1, and (driver of van) lifted res with gait belt and each leg to reposition res in a sitting position. Head to toe assessment done per this nurse. All vital signs WNL. Right elbow bleeding from a previous injury. Pressure applied. Bruising on both knees, sheering on her belly. Purpura (areas of discoloration) on left forearm. Small abrasion on left elbow. Secured resident in wheelchair with should (shoulder) strap and lap belt and 4 point wheel belts. ED drove van and resident back to facility. This nurse notified DNS and DNS reported to (resident's physician), NP (Nurse Practitioner) at 12:30 p.m. regarding this incident." A Resident Progress Note, dated 07/12/11 at 1:15 p.m., indicated, "Resident returned from MD (Medical Doctor) appointment...." An X-ray, dated 07/12/11, indicated Resident A had "soft tissue swelling" of her right ankle. A Resident Progress Note, dated 07/13/11 at 1:46 p.m., indicated, "Resident up with assistance this shift. Resident received PRN (as needed) pain medication once this shift for general all over discomfort with effect. Resident was screen (screened) by therapy this shift and therapy is going to pick Resident up on caseload. Resident is propelling self in wheel chair to meals. Bruising continues to inferior left breast, purple in color. Slight discoloration also noted to left knee. Abrasions to abdomen have no signs or symptoms of infection. vital (sic) signs within normal limits, neuro checks WNL (within normal limits). Call light in reach." A Resident Progress Note, dated 07/13/11 at 3:30 p.m., indicated, "IDT (Interdisciplinary Team) met to review residents fall on 7/12/2011 at 9:20 a.m. Resident fell out of chair while being transported to MD via facility van. Resident has several bruises and abrasions. Resident stated when the van stopped she fell out of her chair on to the van floor. When this nurse asked if she was belted in, resident stated, 'I wont (sic) wear a seat belt and if they put it on I (sic) just unhook it and hold it after they start to drive.' Neuro checks were started at the scene with nurse doing a head to toe assessment. MD/NP (Medical Doctor/Nurse Practitioner) and family notified. X ray to right foot and ankle done with no evidence of fracture. PT (Physical Therapy) OT (Occupational Therapy) to screen." A Resident Progress Note, dated 07/13/11 at 4:48 a.m., indicated, "Resident continues on F/U (follow-up) fall. Resident requested pain meds (medications) at 2:30 a.m. d/t (due to) hurting all over. Bruising noted to body in numerous places. Resing (Resting) quietly abed at this time." A Resident Progress Note, dated 07/13/11 at 5:15 p.m., indicated, "(Name of Resident A's physician) here to see res (Resident A). Rec'd (Received) w.o. (written order)." A Resident Progress Note, dated 07/13/11 at 10:14 p.m., indicated, "Resident cont (continues) on f/u (follow-up) for fall. Resident has had some complaint of pain this shift. Complaint of genral (sic) pain all over. Pain medication given. Resident stated it did help...." An X-ray, dated 07/20/11, indicated Resident A had no rib fractures. An investigation form completed by the Director of Nursing, dated 7/12/11, indicated "...7/12/11 at 9:20 AM (sic) during morning meeting E.D. (Executive Director) received call from van driver (bus driver name). ED came to this nurse during meeting and told this nurse he and LPN #1 was going to assist van driver. ED stated van stopped and resident fell out of chair onto floor. After morning meeting at 10:10 AM (sic) this nurse called ED who was in route to van stating ambulance should be called in case of injury. ED had called sister facility in Indianapolis whom was close and DNS (Director of Nursing Services) with her staff was going to assess resident and assist if ambulance needed to be called. ED explained he had talked with van driver and resident whom stated she was fine. 7/12/2011 LPN (name) stated she did head to toe assessment and initiated neuro checks when she arrived at van location, on resident. ED drove van back to facility. 7/13/2011 This nurse did head to toe assessment and measured each bruise and abrasion.... 7/12/2011 xray of R (right) foot and ankle. No fracture or dislocation. 7/20/2011 Xray ribs no fracture, NP (Nurse Practitioner) saw and examined resident on 7/15/2011 and 7/19/2011." Documentation titled "Timeline for (Resident A)" incident was provided by the Administrator on 07/29/11 at 11:10 a.m. The documentation was dated July 12, 2011. The Documentation indicated the following: "9:20 a.m. - Received call from bus driver that (name of resident) had fallen from her wheelchair and was on the floor of the van in indpls (Indianapolis). Spoke with driver and (name of resident) on that call and determined that (name of resident) was not feeling any pain and in her words was alright. Told the driver that we would be coming to help and he told us their location. 9:30 a.m. - ED (Executive Director) and Nurse set out to help. ED needed to get to the site since it sounded like the driver had been careless allowing the resident to fall and thus, the driver should not drive the bus or the resident any further. 10:17 a.m. - The drive was going to be about an hour and a half, so in route, we contacted our ASC building (sister facility) just west of Indpls. I asked if they could assist by going to the location of our bus, checking out the resident and waiting for us to arrive to the location. They said, yes. 10:25 a.m. - Spoke with our bus driver and told him that we had called another center. The other center would be coming to his location to assist. Asked the driver to confirm his location. He informed us that he had driven to another location that 'has less traffic.' His new location was now closer to us and further from the (name of sister facility) team that was in route to help. I told the driver to not drive any place and to stay at that location until our arrival. 10:30 a.m. - I called the (name of the sister facility) DNS (Director of Nursing Services) and told her that we were now closer than they were. They were in route to assist us. I thank (sic) them for their effort. 11:00 a.m. - We arrived at the location. Nurse performed initial assessment. We spoke with (name of resident) who said she was alright. We positioned (name of resident) better to get her into a sitting position. Nurse continued the assessment. We stood (name of resident) and placed her into her wheelchair. Nurse completed the assessment. 1:30 p.m. - Arrived back to (name of facility). ED had driven the van back after confirming that driver had not properly seat-belted the resident allowing her to fall. Resident was wheeled into the center and then she wheeled herself into the main dining room and began setting the room up for the afternoon Bingo game." Documentation titled "RE: Incident with Van Driver and Resident on 7/12/11" was provided by the Administrator on 07/29/11 at 1:30 p.m. The documentation was dated, 07/28/11. The documentation listed interventions the facility implemented to correct the immediate jeopardy. The facility immediately inserviced van drivers that any resident being transported were to be properly seat belted and drivers were instructed on what to do when a resident refused to wear a seat belt. Resident A was care planned addressing her refusal to wear a seat belt and the driver involved in the incident was terminated. In the event of a fall/accident while en route during a transport, and a resident is not accompanied by nurse to provide immediate assessment, 911 will be called for immediate assessment for the resident and the DON and Administrator will immediately be contacted. The immediate jeopardy that began on 07/12/11 was removed on 07/29/11 when the facility inserviced all drivers on steps to take when a resident refused to use a seat belt and on steps to take if an accident occurs during resident transport without nursing staff present to assist. The non-compliance remained at the lowered scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy because of the need for continued monitoring to ensure the policies and practices put in place were effective. This federal tag relates to Complaint IN 639 and Complaint IN 264. 3.1-37(a)

Based on interview, observation, and record review, the facility failed to ensure 1 of 3 sampled residents reviewed for facility bus transfers was properly secured during the transfer resulting in the resident falling forward and laying face down for approximately 1 and 1/2 hours awaiting facility assistance. (Resident A) The Immediate Jeopardy began on 7/12/11 when Resident A was transported in the facility wheelchair van, without a seat belt being in place. The driver of the van had to slam on his brakes when someone pulled in front of the van causing the resident to be propelled out of her wheelchair. The Resident lay on the van floor without medical assistance for approximately an hour and a half while the facility drove from Bedford to Indianapolis to assess her. The Administrator, RN Corporate Consultant and Director of Nursing were notified of the Immediate Jeopardy at 3:10 P.M. on 7/28/11. The immediate jeopardy was removed on 07/29/11 at 2:00 p.m., but noncompliance remained at the lowered scope and severity of isolated, no actual harm, with potential for more than minimal harm, that is not immediate jeopardy. Findings Include: During interview of Resident A on 07/28/11 at 10:30 a.m., she indicated she had a "bad accident two weeks ago." Resident #A indicated she had gone out for a doctor's appointment in Indianapolis. Resident A indicated the driver had secured her wheel chair with straps, but she had refused to wear the seat belt due to she was too heavy and didn't like the way the seat belt "squeezed" her. Resident #A indicated upon arriving at the hospital she was told the appointment had been canceled. Resident A indicated she left the hospital with the driver and continued to not wear her seat belt. Resident A indicated they were on the interstate and a car swerved in front of them and the driver had to slam on his brakes and she fell forward "almost to the front of the bus." Resident A indicated the driver pulled over to the side of the road and attempted to get her up off the floor but was unable to because she was too heavy. Resident A indicated she told the driver she was o.k. and the driver called the facility to report what had happened. Resident A indicated the bus driver told her that he was instructed by the facility to leave the resident on the floor until the facility arrived to help her. Resident A indicated it was very uncomfortable on the floor and she couldn't believe she had to lay on the floor until the facility arrived. The resident indicated she was on the floor 2 hours before the Administrator and LPN #1 arrived to assist her up. Resident A indicated the Administrator and the driver turned her over and sat her up and LPN #1 assessed her. Resident #A raised her shirt at this time and seven bright red ridges, approximately 4 centimeters in length and 0.5 centimeters in width were observed across the resident's abdomen. Resident A indicated the ridges were due to laying on the bus floor. Resident A indicated she left the facility at 6:45 a.m. and arrived at the hospital in Indianapolis at about 8:45 a.m. Interview of LPN #1 on 07/28/11 at 11:15 a.m., indicated it took about 1 hour to get from the facility to Greenwood. LPN #1 indicated she was told by the driver and Resident #A that the wheelchair had been fastened in all 4 points, brakes were on, and tie down straps were on front and back, but the seat belt was not fastened. LPN #1 indicated the Administrator had called a sister facility near the area of the facility bus and were told that staff from the sister facility would leave immediately to assist the resident. LPN #1 indicated she called the driver and told him the sister facility was on their way. LPN #1 indicated the driver had given an incorrect location and the sister facility was on the west side and the facility bus was on the east side. LPN #1 indicated the driver had driven over to the east side with the resident on the floor of the bus. LPN #1 indicated the driver had followed Resident #A's instructions to get off of the interstate. LPN #1 indicated when she and the Administrator found out that the facility bus was at a different location they called the sister facility and instructed them not to come due to the Administrator and LPN#1 were on their way and were closer to the location of the bus than the sister facility. LPN #1 indicated she assessed the resident and she was moving all extremities. LPN #1 indicated Resident #A was face down on the mat when they arrived and was the exact same width as the aisle. LPN #1 indicated the resident denied any pain. LPN #1 indicated she and the Administrator slid a gait belt under the resident and after 3 attempts were able to move the resident to the back of the aisle where they could sit her up. LPN #1 indicated upon assessment of the resident, the resident was found to have red ridges across her abdomen, red blotches on her knees, and a bleeding elbow. LPN #1 indicated Resident A was able to tell her her name and where she lived and Resident A denied pain except a sore ankle. Interview of the Administrator on 07/28/11 at 11:40 a.m., indicated it didn't occur to him to call EMT's due to the resident saying she wasn't hurt. The Administrator indicated he had called the sister facility and they said they would go to assist the resident. The Administrator indicated he then called the van driver to confirm the location and the van driver told him he had moved the van and had driven about 8 miles farther. The Administrator indicated he then realized he was closer to the van than the sister facility so he called the sister facility and told them not to come. The Administrator indicated he wanted to make sure the resident was "seat belted in" when she returned to the facility so he made a special trip to insure the resident was properly secured during the transport back to the facility. The Administrator indicated he fastened the resident's seat belt, but did not realize that as soon as he turned his back she unfastened the seat belt and had it placed across her lap as if secured. The Administrator indicated the resident didn't request EMT's (Emergency Medical Technicians). The Administrator indicated he was not aware the resident refused to wear seat belts. Interview of the DON on 07/28/11 at 2:15 p.m., indicated when the van driver called the facility to report what happened, her first thought was to call 911 due to EMT's would arrive sooner. The DON indicated the Administrator said he had talked to the resident and she was o.k. and a sister facility was going to the van location to help the resident. The DON indicated she was not aware the resident did not wear seat belts until the accident occurred, no one had reported this to her. Interview of the Nurse Practitioner on 07/28/11 at 2:30 p.m., indicated Resident A had requested an increase in her Xanax ( anti-anxiety medication) on 07/14/11 due to the resident having trouble sleeping. The Nurse Practitioner indicated on 07/19/11, the resident complained of pain under her left breast. The Nurse Practitioner indicated the ridges on the resident's abdomen had opened and the dressing was sticking. The Nurse Practitioner indicated she palpated the resident's abdomen and the resident didn't complain of pain. Review of Resident A's clinical record on 07/28/11 at 12:55 p.m., indicated the following: Resident A had [DIAGNOSES REDACTED]. A quarterly MDS (Minimum Data Set) assessment, dated 07/01/11, indicated the resident was moderately cognitively impaired and was able to complete an interview for mental status, the resident required assistance of two staff for transfers and walking. A Resident Progress Note, dated 07/12/11 at 6:45 a.m., indicated, "Resident (A) LOA to Dr...(name of doctor) in Indy via facility provided transportation." A Resident Progress Note, dated 07/12/11 at 11:00 a.m., indicated Resident A's vital signs were taken at that time and were as follows: Temperature - 97.3, heart rate - 80, respirations - 20, and blood pressure - 130/60. An X-ray, dated 07/12/11, indicated Resident A had "soft tissue swelling" of her right ankle. A Resident Progress Note, dated 07/12/11 at 1:00 p.m., indicated, "Arrived at van @ 11:00 a.m. resident lying face down in the floor/aisle of the van. Res (Resident A) denied any pain at this time. Res A&O (alert and oriented) to place, name, and staff present. Assessed face/neck, feet/ankles, and both arms for mobility. Denies any pain during the assessment. Gait belt was placed under the resident by ED (Executive Director) and LPN #1 & was hooked on her (Resident A) back side. ED lifted res slightly up while LPN #1 moved res towards the back of the bus from the aisle. 3 attempts and successful. ED, LPN # 1, and(driver of van) lifted res with gait belt and each leg to reposition res in a sitting position. Head to toe assessment done per this nurse. All vital signs WNL. Right elbow bleeding from a previous injury. Pressure applied. Bruising on both knees, sheering on her belly. Purpura (areas of discoloration) on left forearm. Small abrasion on left elbow. Secured resident in wheelchair with should (shoulder) strap and lap belt and 4 point wheel belts. ED drove van and resident back to facility. This nurse notified DNS and DNS reported to (resident's physician), NP (Nurse Practitioner) at 12:30 p.m. regarding this incident." A Resident Progress Note, dated 07/12/11 at 1:15 p.m., indicated, "Resident returned from MD (Medical Doctor) appointment...." A Resident Progress Note, dated 07/13/11 at 1:46 p.m., indicated, "Resident up with assistance this shift. Resident received PRN (as needed) pain medication once this shift for general all over discomfort with effect. Resident was screen (screened) by therapy this shift and therapy is going to pick Resident up on caseload. Resident is propelling self in wheel chair to meals. Bruising continues to inferior left breast, purple in color. Slight discoloration also noted to left knee. Abrasions to abdomen have no signs or symptoms of infection. vital (sic) signs within normal limits, neuro checks WNL (within normal limits). Call light in reach." A Resident Progress Note, dated 07/13/11 at 3:30 p.m., indicated, "IDT (Interdisciplinary Team) met to review residents fall on 7/12/2011 at 9:20 a.m. Resident fell out of chair while being transported to MD via facility van. Resident has several bruises and abrasions. Resident stated when the van stopped she fell out of her chair on to the van floor. When this nurse asked if she was belted in, resident stated, 'I wont (sic) wear a seat belt and if they put it on I (sic) just unhook it and hold it after they start to drive.' Neuro checks were started at the scene with nurse doing a head to toe assessment. MD/NP (Medical Doctor/Nurse Practitioner) and family notified. X ray to right foot and ankle done with no evidence of fracture. PT/OT to screen. Facility will no longer transport due to seat belt non compliance." A Resident Progress Note, dated 07/13/11 at 4:48 a.m., indicated, "Resident continues on F/U (follow-up) fall. Resident requested pain meds (medications) at 2:30 a.m. d/t (due to) hurting all over. Bruising noted to body in numerous places. Resing (Resting) quietly abed at this time." A Resident Progress Note, dated 07/13/11 at 10:14 p.m., indicated, "Resident cont (continues) on f/u (follow-up) for fall. Resident has had some complaint of pain this shift. Complaint of genral (sic) pain all over. Pain medication given. Resident stated it did help...." An X-ray, dated 07/20/11, indicated Resident A had no rib fractures. The Bus Driver Job Specific Orientation Program signed by the bus driver and dated 6/26/10, indicated "...Seatbelt (Required for all passengers/driver)..." An investigation form completed by the Director of Nursing, dated 7/12/11, indicated "...7/12/11 at 9:20 AM (sic) during morning meeting E.D. (Executive Director) received call from van driver (bus driver name). ED came to this nurse during meeting and told this nurse he and LPN (name) was going to assist van driver. ED stated van stopped and resident fell out of chair onto floor. After morning meeting at 10:10 AM (sic) this nurse called ED who was in route to van stating ambulance should be called in case of injury. ED had called sister facility in Indianapolis whom was close and DNS (Director of Nursing Services) with her staff was going to assess resident and assist if ambulance needed to be called. ED explained he had talked with van driver and resident whom stated she was fine. 7/12/2011 LPN (name) stated she did head to toe assessment and initiated neuro checks when she arrived at van location, on resident. ED drove van back to facility. 7/13/2011 This nurse did head to toe assessment and measured each bruise and abrasion. This nurse asked resident how fall occurred. Resident stated (Bus driver name) stopped van and I fell in the floor. I asked if she hit her head and she stated no. No bruises or redness noted on resident's face. This nurse ask if resident was wearing seat belts and resident stated 'No I won't wear a seat belt and if they put it on me I just unhook it and hold it after they start to drive. I unhooked my seatbelt when (Administrator's name) was driving me back and he didn't even know it.' This nurse asked resident if she knew why the bus driver had driven while she was still in the floor. Resident stated "(bus driver name) kept saying get up (Resident A name) so I yelled at him to just drive and get me home." She also told this nurse she did not want (bus driver name) fired. This nurse explained to resident the possible injuries she could have had and the danger of driving without a seatbelt on. Resident stated 'I don't care I am not wearing a seatbelt.' Therapy to screen. Facility will not transport resident d/t (due to) non compliance with seat belt. Facility will arrange transport with (name) or (name) transit. 7/12/2011 xray of R (right) foot and ankle. No fracture or dislocation. 7/20/2011 Xray ribs no fracture, NP (nurse practitioner) saw and examined resident on 7/15/2011 and 7/19/2011." On 7/28/11 at 2:50 P.M., in an interview with the Administrator, he indicated the facility would no longer transport Resident A because she refused to wear seat belt during transport. He further indicated he had spoken with the drivers and told them not to transport anyone who refused to wear a seatbelt, but he had not done an inservice. On 7/28/11 at 3:15 P.M., in an interview with the Administrator he indicated there was no written statement taken from the bus driver concerning the incident with Resident A. He did indicate during an interview with the bus driver he had indicated Resident A had refused to wear her seat belt. The Administrator indicated the bus driver had been terminated because he violated facility policy because they are not to transport any resident without a seat belt. Documentation titled "Activity Assistant/Bus Driver Job Specific Orientation Program" was provided by the Administrator on 07/28/11 at 11:00 a.m. The documentation was dated, 02/28/07. The documentation indicated, "...Transportation...Seatbelt (Required for all passengers/driver)...." The facility van was observed on 07/28/11 at 4:30 p.m., to have narrow aisles which were approximately 20 inches wide. Two other resident charts were reviewed for transport of residents and indicated these residents did wear seat belts. Documentation titled "RE: Incident with Van Driver and Resident on 7/12/11" was provided by the Administrator on 07/29/11 at 1:30 p.m. The documentation was dated, 07/28/11. The documentation listed interventions the facility implemented to correct the immediate jeopardy. The facility immediately inserviced van drivers that any resident being transported were to be properly seat belted and drivers were instructed on what to do when a resident refused to wear a seat belt; Resident A was care planned addressing her refusal to wear a seat belt; the driver involved in the incident was terminated. In the event of a fall/accident while en route during a transport, and a resident is not accompanied by nurse to provide immediate assessment, 911 will be called for immediate assessment for the resident and the DON and Administrator will immediately be contacted. The immediate jeopardy that began on 07/12/11 was removed and the deficient practice corrected on 07/29/11 when the facility provided information, dated 07/29/11 at 1:30 p.m., which indicated the driver of the bus had been immediately suspended and terminated after the investigation; all bus drivers were inserviced on not transporting residents unless they were properly seat belted; Resident A was care planned to no longer be transported by the facility due to her non-compliance with seat belts. Alternative transportation will be arranged as needed. The documentation indicated, "No resident will be transported without a seatbelt and/or wheelchair safety belt." The non-compliance remained at the lowered scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy because of the need for continued monitoring to ensure the policies and practices put in place were followed and effective. This federal tag relates to Complaint IN 639 and Complaint IN 264. 3.1-45(a)(1) 3.1-45(a)(2)

Based on record review, observation, and interview, the facility failed to insure an effective system was in place to identify residents who refused to wear seat belts when transported in facility vehicles and failed to have an effective system in place to guide staff on procedures to follow when an incident occurred during van/bus transportation. This actually affected 1 of 3 residents reviewed for seat belt used during transportation. (Resident A) The Immediate Jeopardy began on 7/12/11 when Resident A was transported in the facility wheelchair van without a seat belt being in place. The driver of the van had to slam on his brakes when someone pulled in front of the van causing the resident to be propelled out of her wheelchair. The Resident lay on the van floor without medical assistance for approximately an hour and a half while the facility drove from Bedford to Indianapolis to assess her. The Administrator, RN Corporate Consultant and Director of Nursing were notified of the Immediate Jeopardy at 3:10 P.M. on 7/28/11. The immediate jeopardy was removed on 07/29/11 at 2:00 p.m., but noncompliance remained at a lowered scope and severity level of isolated, no actual harm, with potential for more than minimal harm, that is not immediate jeopardy. Findings Include: During interview of Resident A on 07/28/11 at 10:30 a.m., she indicated two weeks ago she left the facility at 6:45 a.m., for a doctor's appointment at a hospital in Indianapolis. Resident A indicated she allowed the facility bus driver to secure her wheelchair with straps, but refused to be seat belted in her wheelchair. The Resident indicated upon arrival to the hospital at about 8:45 a.m., she was told her appointment had been canceled. Resident A indicated on the way home a car cut in front of the facility bus and the driver had to slam on his brakes, which caused the resident to be thrown to the front of the bus. The Resident indicated she was lying face down in the aisle of the bus and couldn't get up. The Resident indicated the bus driver immediately pulled over and attempted to get the resident up but was unable to. The bus driver called the facility and was instructed to leave the resident on the floor until help arrived. The Administrator had talked to the bus driver on the phone and was told by the driver that the resident was not hurt. The Administrator contacted a sister facility in Indianapolis and made arrangements for the sister facility to go to the location of the resident and provide assistance as needed. The Administrator left the facility at Bedford to go to the location of the bus at Indianapolis to drive the Resident back to the facility. Interview of the DON on 07/28/11 at 2:15 p.m., indicated when the van driver called the facility to report what happened, her first thought was to call 911 due to EMT's (Emergency Medical Technicians) would arrive sooner to help the resident. The DON indicated she suggested calling an ambulance in case the resident was hurt. The DON indicated she was told by the Administrator that he had talked to the resident and she was O.K. and the sister facility was on their way to provide assistance. During the trip to Indianapolis, the Administrator called the bus driver to confirm his location and found the bus driver had driven the bus farther and was no longer at the first location. The Administrator realized he was closer to the location than the sister facility so he phoned the sister facility and told them not to come. The Resident was assessed by LPN #1 upon arrival to the bus and was found to have right elbow bleeding from a previous injury, bruising on both knees, and sheering on her belly. Purpura (areas of discoloration) on left forearm and a small abrasion on left elbow. Review of Resident A's clinical record on 07/28/11 12:55 p.m., indicated the following: Resident A had [DIAGNOSES REDACTED]. A quarterly MDS (Minimum Data Set) assessment, dated 07/01/11, indicated the resident was moderately cognitively impaired and was able to complete an interview for mental status, the resident required assistance of two staff for transfers and walking. A Resident Progress Note, dated 07/12/11 at 6:45 a.m., indicated, "Resident (A) LOA to Dr...(name of doctor) in Indy via facility provided transportation." Documentation titled "Activity Assistant/Bus Driver Job Specific Orientation Program" was provided by the Administrator on 07/28/11 at 11:00 a.m. The documentation was dated, 02/28/07. The documentation indicated, "...Transportation...Seatbelt (Required for all passengers/driver)...." The facility van was observed on 07/28/11 at 4:30 p.m., to have narrow aisles, which were approximately 20 inches wide. Two other resident charts were reviewed for transport of residents and indicated these residents did wear seat belts. Documentation titled "Timeline for (Resident A) incident was provided by the Administrator on 07/29/11 at 11:10 a.m. The documentation was dated July 12, 2011. The Documentation indicated the following: "9:20 a.m. - Received call from bus driver that (name of resident) had fallen from her wheelchair and was on the floor of the van in indpls (Indianapolis). Spoke with driver and (name of resident) on that call and determined that (name of resident) was not feeling any pain and in her words was alright. Told the driver that we would be coming to help and he told us their location. 9:30 a.m. - ED (Executive Director) and Nurse set out to help. ED needed to get to the site since it sounded like the driver had been careless allowing the resident to fall and thus, the driver should not drive the bus or the resident any further. 10:17 a.m. - The drive was going to be about an hour and a half, so in route , we contacted our ASC building (sister facility) just west of Indpls. I asked if they could assist by going to the location of our bus, checking out the resident and waiting for us to arrive to the location. They said yes. 10:25 a.m. - Spoke with our bus driver and told him that we had called another center. The other center would be coming to his location to assist. Asked the driver to confirm his location. He informed us that he had driven to another location that 'has less traffic.' His new location was now closer to us and further from the (sister facility name) team that was in route to help. I told the driver to not drive any place and to stay at that location until our arrival. 10:30 a.m. - I called the (name of the sister facility) DNS (Director of Nursing Services) and told her that we were now closer than they were. They were in route to assist us. I thank (sic) them for their effort. 11:00 a.m. - We arrived at the location. Nurse performed initial assessment. We spoke with (name of resident) who said she was alright. We positioned (name of resident) better to get her into a sitting position. Nurse continued the assessment. We stood (name of resident) and placed her into her wheelchair. Nurse completed the assessment." On 7/28/11 at 3:15 P.M., in an interview with the Administrator, he indicated there was no written statement taken from the bus driver concerning the incident with Resident A. He did indicate during an interview with the bus driver he had indicated Resident A had refused to wear her seat belt. Interview of the Administrator on 07/28/11 at 1:30 p.m., indicated the Administrator was not aware of the facility having a policy regarding transport of residents. The immediate jeopardy that began on 07/12/11 was removed on 07/29/11 when the facility implemented the plan to immediately call 911 in the event of a resident who is not accompanied by a nurse has a fall/accident while en route during transport and inserviced all drivers as to what steps to take if a resident refuses to wear a seat belt. The non-compliance remained at a lowered scope and severity of isolated, no actual harm with potential for no more than minimal harm that is not immediate jeopardy because of the need to continue to monitor and ensure the policies and practices put in place were followed and were effective. Refer to F-309 related to the failure of the facility to ensure immediate assessment and care were provided to Resident A after the resident fell from her wheelchair on to the floor of the facility bus. Refer to F-323 regarding the failure of the facility to ensure Resident A was secured with a seat belt during transportation in facility vehicles, resulting in the resident falling from the wheelchair and being wedged in the aisle of the van. This federal tag relates to Complaint IN 639 and Compliant IN 264. 3.1-13(c) 3.1-13(q)