Every finding on record at Willows of Shelbyville

Based on observation, interview, and record review, the facility failed to ensure residents' fall interventions were in place for 3 of 4 residents reviewed for care plan implementation. (Residents 7, 19, and 44)Findings include:1. The clinical record for Resident 7 was reviewed on 12/19/25 at 11:14 a.m. The resident's diagnoses included, but were not limited to: osteoporosis, Alzheimer's disease, anxiety, chronic obstructive pulmonary disease, and chronic pain. The Interdisciplinary Team (IDT) note, dated 11/13/25, indicated the resident had an unwitnessed fall on 11/12/25 in the common area. She was found on the floor beside a recliner. The resident complained of pain to her left hip. An x-ray was completed and returned positive for left hip fracture.The IDT note, dated 12/16/25, indicated the resident had an unwitnessed fall on 12/15/25. The resident was found laying on the floor next to her bed.The at risk for falls care plan, revised 11/28/25, indicated an intervention was to ensure appropriate footwear was worn, initiated 6/12/25.An observation of Resident 7 was made on 12/22/25 at 12:31 p.m. with Certified Nursing Assistant (CNA) 4. Resident 7 was sitting in her wheelchair at a table in the dining room. She was wearing a pair of black socks and no shoes. The socks were not non-skid socks. An interview was conducted with CNA 4 during the above observation on 12/22/25 at 12:31 p.m. The CNA 4 lifted Resident 7's foot and indicated the socks were not non-skid socks. Resident 7 should be wearing tennis shoes, and usually she did. CNA 4 continued to clean the dining room tables after this interview. An observation of Resident 7 and interview with the Weekend Supervisor was conducted on 12/22/25 at 12:50 p.m. Resident 7 remained sitting in her wheelchair at a table in the dining room. She was still wearing the same black socks with no shoes. The Weekend Supervisor indicated she would find some gripper socks for Resident 7. 2. The clinical record for Resident 44 was reviewed on 12/19/25 at 11:30 a.m. The resident's diagnoses included, but were not limited to: Alzheimer's disease, insomnia, chronic obstructive pulmonary disease, psychotic disorder, bipolar disorder, and anxiety.An interview was conducted with Family Member 5 on 12/19/25 at 11:33 a.m. They indicated Resident 44 had many falls at the facility. The IDT (Interdisciplinary Team) note, dated 11/27/25, indicated she had an unwitnessed fall in her room on 11/26/25.The IDT note, dated 8/8/25, indicated she had a witnessed fall on 8/7/25.The IDT note, dated 6/23/25, indicated she had a witnessed fall on 6/21/25 in the dining room. The IDT note, dated 6/4/25, indicated she had a witnessed fall on 6/3/25 in the common area. The at risk for injury related to falls care plan, revised 10/9/25, indicated to have non-skid strips to the right side of the resident's bed and in front of her chair, initiated 11/20/24.An observation of Resident 44's room was made on 12/22/25 at 12:15 p.m. There were non-skid strips on the floor along the side of her bed, but there were none in front of her recliner. An interview and observation of Resident 44's room was conducted with the Weekend Supervisor on 12/22/25 at 12:45 p.m. The Weekend Supervisor indicated she did rounds a while ago and knew the resident needed the strips in front of her bed, but she was unaware she needed them in front of her recliner. 3. The clinical record for Resident 19 was reviewed on 12/22/2025 at 3:13 PM. The resident's diagnoses included, but were not limited to, dementia and heart failure.A Quarterly Minimum Data Set Assessment, dated 12/4/2025, indicated Resident 19 was not cognitively intact, had one fall with injury since the last assessment, had no physical impairments, and needed substantial to maximal assistance with transferring.A fall care plan, revised 12/16/2025, indicated Resident 19 was at risk for falling for a multitude of reasons, including poor safety awareness. The interventions for Resident 19 included, but was not limited to, the use of a pommel cushion.During an observation, on 12/19/2025 1:21 PM, Resident 13 was leaning to the left side of her high back wheelchair without a pommel cushion in place. During interview and observation, on 12/22/2025 12:30 PM, Resident 13 was assisted back to her room and changed, then placed back into her high back wheelchair. When asked if Resident 13 had her pommel cushion in place, CNA 2 did not know what pommel cushion was. QMA 1 verified pommel was not in place because it like got soiled and needed to be washed.During an interview, on 12/23/2025 at 1:30 PM, DON indicated Hospice was responsible for providing the pommel cushion for Resident 13 but one had not been provided. The facility had been using a saddle cushion, but that was not reflected on the orders or care plan, until she edited it on 12/22/2025.A policy entitled, Use of Assistive Devices, was provided by the Executive Director on 12/22/2025 at 1:55 PM. The policy indicated the facility will provide assistive devices for residents who need them, including mobility devices.The Fall Management policy was provided by the DON (Director of Nursing) on 12/23/25 at 9:40 a.m. It indicated, Fall risk.2. A care plan will be developed at time of admission with specific care plan interventions to address each resident's fall risk factors. 3. The resident specific care requirements will be communicated to the assigned care team member utilizing the care plan/assignment sheets.3.1-35(g)(2)

Based on observation, interview, and record review, the facility failed to provide a resident's nutritional supplement, as ordered, and have their family member complete weekly menus, as care planned. (Resident 9)Findings include:The clinical record for Resident 9 was reviewed on 12/19/25 at 11:45 a.m. The resident's diagnoses included, but were not limited to: dysphagia, dementia, depression, malnutrition, and anxiety. The Skin, Wound, Assessment, Treatment (SWAT) note, dated 11/6/25, indicated the resident was reviewed due to a new 180-day significant weight loss. Her current weight was 87.9 pounds, a 16-pound loss in 180 days. She was admitted to the facility for long-term care and on hospice services. She ate meals in the dining room and required total assistance with feeding. The physician's orders indicated the resident was to be provided with a regular diet, thin consistency, finger foods with meals, as needed, and a magic cup at lunch, starting on 1/29/25. An observation of Resident 9 was made in the dining room during the lunch meal on 12/22/25 at 12:36 p.m. The resident was assisted with eating by Certified Nursing Assistant (CNA) 4. There was no magic cup observed with the resident's meal. The lunch meal ticket was on the table in front of Resident 7. It indicated, INSTRUCTIONS: MAGIC CUP. An interview was conducted with CNA 4 on 12/22/25 at 12:36 p.m. The CNA indicated the kitchen did not send the magic cup with the resident's meal, but she didn't notice. The nutrition care plan, revised on 9/8/25, indicated an intervention was to honor the resident's preferences/intolerances/allergies, and the resident's family member was to complete menus weekly, last revised on 5/28/24. An interview was conducted with Family Member 8 on 12/19/25 at 11:47 a.m. He indicated the facility served items to Resident 9 that she did not like and would not eat. They used to let him fill out a menu to choose what she ate, but they hadn't been doing that lately. An interview was conducted with the Dietary Manager (DM) on 12/22/25 at 2:37 p.m. She indicated she'd been the dietary manager since February, 2025. She sent menus to the memory care unit, where Resident 9 resided, but staff did not regularly complete them. She spoke directly with Family Member 8 two or three months ago, in regard to having him complete the weekly menus for Resident 9. They agreed she would leave a menu packet in Resident 9's room every week for him to complete and return. She usually left the packet for him on Wednesday or Thursday for the following week's meals. She did not give him a menu packet for completion for this week's menu. She'd missed giving him a packet, maybe three times, since they spoke about it. The DM was unaware Resident 9 did not receive her magic cup at lunch today. The dietary aide at the end of the line was responsible for reading the meal ticket and placing any necessary nutritional supplement onto the tray. The Nutritional and Dietary Supplements policy was provided by the DON (Director of Nursing) on 12/23/25 at 9:40 a.m. It indicated, The facility will provide nutritional and dietary supplements to each resident, consistent with the resident's assessed needs.3.1-46(a)(2)

Based on observation, interview, and record review, the facility failed to revise a resident's plan of care to address her behavior of picking/scratching herself and adequately monitor this behavior for 1 of 5 residents reviewed for dementia care. (Resident 53)Findings include:The clinical record for Resident 53 was reviewed on 12/23/25 at 1:00 p.m. The resident's diagnoses included, but were not limited to, Alzheimer's disease, chronic pain, depression, and dementia. An observation of Resident 53 in her wheelchair was made on 12/18/25 at 12:40 p.m. in the common area of the unit she resided. The resident had a quarter sized, reddish area with a partially scabbed center on her right cheek. There were no progress notes or assessments in the clinical record referencing the area on the resident's right cheek. An observation of Resident 53 and interview with Qualified Medication Aide (QMA) 6 were conducted on 12/23/25 at 11:52 a.m. QMA 6 indicated she hadn't noticed any areas on Resident 53's right cheek, so she went to Resident 53's room for an observation. Resident 53 was observed in bed with quarter sized, reddish areas on both cheeks. QMA 6 indicated, She's picking at it right now. She has areas on both cheeks now. QMA 6 indicated Resident 53 picked at her skin when she first admitted to the facility, and she remembered discussing it and being told to be cautious of it. Resident 53's care plans were reviewed with the Memory Care Facilitator (MCF) on 12/23/25 at 12:00 p.m. The resident's behavior care plan did not reference any picking or scratching behaviors. There were no care plans referencing the areas on the resident's cheeks. An interview was conducted with the MCF on 12/23/25 at 12:00 p.m. during the review of Resident 53's care plans. The MCF indicated she was responsible for doing the resident's care planning. The areas on her cheeks and her picking/scratching behavior should be on her skin condition and/or behavior care plan. An interview was conducted with the Director of Nursing (DON) on 12/23/25 at 12:07 p.m. The DON indicated Resident 53 was always messing with things, but if she was picking at her skin, that was a new behavior for her, and they needed to notify the nurse practitioner, care plan it, look at the areas on her cheeks, let the wound nurse know about the areas to see if they needed treatment, and inform their psychiatric provider, because Resident 53's medications were changed around lately. The DON reviewed Resident 53's clinical record and indicated she did not see any documentation referencing the areas on her cheeks. The MCF was responsible for care planning for that unit. An interview was conducted with the DON on 12/23/25 at 12:33 p.m. She indicated that the Assistant Director of Nursing (ADON) and Infection Preventionist (IP) saw Resident 53 take her hands and scratch her face one day last week. The ADON saw the area on her cheek today when she did wound rounds, but she didn't feel it needed a treatment. Scratching her face was a behavior for Resident 53 and it needed care planned. When a resident had a behavior, it should have been documented in point of care by the Certified Nursing Assistants (CNAs) or in a progress note by the nurses. She felt some of the residents on the unit were hard to manage, and if Resident 53's picking/scratching behavior was normal for her, staff didn't always document it, because they were so used to it. The December, 2025 progress notes and the December, 2025 Behavior Monitoring and Interventions Report from point of care did not indicate any scratching or picking or self-injury behaviors for Resident 53. The Mood and Behavior Management policy was provided by the DON on 12/23/25 at 1:27 p.m. It indicated Purpose: To provide interventions for residents exhibiting problematic or distressing moods and/or behaviors. Policy: It is the policy of [name of facility] to provide interventions for all residents with behavioral and/or mood indicators that may be problematic or distressing. Residents are provided a supportive environment that is aimed at prevention, relief, and/or accommodation of their behavior and/or mood in addition to interventions that are specific to the resident's individualized needs. Procedure: A care plan should be initiated for any mood and behavioral symptom that affects, or has the potential to affect, the resident or others.New or worsening behaviors are reviewed by the IDT (Interdisciplinary Team.)The IDT team reviews and discusses the behavior event, evaluates the interventions, presents any new interventions that may be applicable, and attempts to determine an underlying cause such as environmental factors, pain and related diagnoses.3.1-37(a)

Based on interview, observation, and record review, the facility failed to ensure indwelling urological devices were maintained in accordance with infection control measures for 3 of 3 residents reviewed for indwelling urological devices. (Resident 96, Resident 11, and Resident 6)Findings include:1. The clinical record for Resident 96 was reviewed on 12/19/2025 at 2:15 p.m. The resident's diagnoses included, but were not limited to, bladder cancer and urinary retention.An admission Nursing Assessment, dated 12/17/2025, indicated Resident 96 had a urostomy and was alert and oriented to person only.A care plan, dated 12/17/2025, indicated Resident 96 had a urostomy with the goal of no infections related to urostomy. The interventions indicated for staff to monitor the resident for signs and symptoms of infection, as well as to use enhanced barrier precautions.A physician's order, dated 12/17/2025, indicated for Resident 96 to have urostomy care daily.During an observation, on 12/18/2025 at 12:59 PM, Resident 96's drainage bag and tubing for urostomy were on the floor.During an observation, on 12/22/2025 at 12:35 PM, Resident 96's drainage bag and tubing for urostomy were making contact the floor.2. The clinical record for Resident 11 was reviewed on 12/23/2025 at 11:05 AM. The resident's diagnoses included, but were not limited to, Alzheimer's and urinary retention.An admission Minimum Data Set Assessment, dated 11/23/2025, indicated Resident 11 was cognitively impaired, used a wheelchair for mobility, had an indwelling urinary catheter, and was dependent on staff for transferring, toileting, and dressing activities of daily living.A care plan, dated 11/18/2025 and revised 11/29/2025, indicated Resident 11 utilized a suprapubic urinary catheter for the diagnosis of obstructive uropathy. The goal was indicated to have no complication with interventions of enhanced barrier precautions and catheter care every shift.During an observation, on 12/18/2025 at 1:38 PM, Resident 11 in wheelchair with his urinary catheter bag contacting the flooring. During an observation, on 12/22/2025 12:25 PM, Resident 11 in wheelchair with his urinary catheter bag contacting the flooring. 3. The clinical record for Resident 6 was reviewed on 12/23/2025 at 11:22 AM. The resident's diagnoses included, but were not limited to, femur fracture and urinary retention.A Significant Change MDS Assessment, dated 10/28/2025, indicated Resident 6 was cognitively impaired, utilized an indwelling urinary catheter, and was dependent on staff for transfers, hygiene, and grooming needs.A care plan, dated 9/11/2025 and revised on 11/04/2025, indicated Resident 6 utilized an indwelling urinary catheter for obstructive uropathy. Goals indicated the resident was to be free of complications related to the indwelling urinary catheter. The interventions indicated the staff were to use enhanced barrier precautions and provide catheter care every shift. During an observation, on 12/22/2025 at 12:16 PM, Resident 6 was in the dining room. The resident's urinary catheter bag was directly contacting the flooring. During an interview, on 12/23/2025 at 1:45 PM, the Infection Prevention Nurse indicated it was the expectation for staff to keep the residents catheter drainage bag and tubing free of contact with the floor to promote infection control measures. 3.1-18(b)(2)

Based on observation, interview, and record review, the facility failed to maintain kitchen equipment in a clean manner and ensure a sanitizing bucket was at proper sanitization levels. This had the potential to affect 71 of 71 residents who reside in the facility. Findings include: A tour of the kitchen was conducted with the Dietary Manager (DM) on [DATE] at 10:35 a.m. Interviews were conducted with the DM at that time. During the tour, the DM indicated they did not have any test strips to test the stationary sanitization buckets used for wiping cloths. The DM indicated they could not test the solution for proper chemical levels. The DM indicated the facility used Cleanslate Disinfectant and Sanitizer with active ingredients including, dimethyl benzyl ammonium chlorides and ethylbenzyl ammonium chlorides in their sanitization buckets. During an interview with the DM, she indicated the test strips were noted to have been expired the week prior and at that time she notified the Executive Director (ED) that more needed to be ordered. During an interview with the ED on [DATE] at 11:00 a.m., she indicated the test strips for the sanitization buckets were noted to be expired a week ago and had expired in 2023. ED indicated they attempted to order some, but the provider they used for supplies was on back order, so they had to put an order in this week through another provider. The ED indicated the testing strips should be here today or tomorrow. During the tour of the kitchen on [DATE] at 10:35 a.m., an observation of the walk-in refrigerator was made. A brown fuzzy substance was noted to be all over the storage racks. The DM indicated she was aware of the brown fuzzy substance since she took her position on [DATE]. The DM indicated she had attempted scrubbing it, but it would not come off. DM indicated she notified maintenance and the ED and supplies for cleaning had been brought in, but she was waiting until it got warmer to do it and wasn't sure when it would be done. During an interview with the ED on [DATE] at 11:00 a.m., she indicated the DM notified her that there was a brown fuzzy substance in the refrigerator approximately a week after starting her position in February. The ED indicated they have the cleaning supplies and power washer to clean it but have not gotten around to doing it yet. The Dishwasher Policy and Procedure for Chemical Sanitizing Machines was provided by the ED on [DATE] at 11:20 a.m. The policy did not reference sanitization requirements for the sanitary buckets. The Cleaning Equipment Policy and Procedures was provided by the ED on [DATE] at 11:20 a.m. The policy indicated, .not using quat solution in buckets to clean with will spread dirt and bacteria .Walk-in refrigerator and racks are to be cleaned as often as possible. Every day they are to be checked . This citation relates to Complaint IN00454870. 3XXX,d+[DATE](i)(3)

Based on observation, interview, and record review, the facility failed to store food and silverware properly and wear hair restraints in the kitchen. This had the potential to affect 57 of 57 residents in the facility. Findings include: A tour of the kitchen was conducted with the DS (Dietary Supervisor) on 9/25/24 at 11:15 a.m. Interviews were conducted with the DS at that time. During the tour, an observation of the clean dish racks was made. The silverware was stored in a cylindrical container with the handles facing downward, instead of upward. During the tour, an observation of the dry storage room was made. Masking tape was used to keep an opened package of vanilla wafers, an opened package of vanilla milk shake thickener, and opened package of graham cracker crumbs sealed, but the tape was no longer sticking. There were three bottles of syrup on a rack with opened tops and no lids, exposing the syrup to air. The DS indicated the opened packages of vanilla wafers, graham cracker crumbs, vanilla milk shake thickener, and bottles of syrup with no lids could have saran wrap used to keep them sealed. During the tour, an observation of the walk-in cooler was made. There was an opened bag of celery on a shelf with the celery sticking out of the bag and resting directly on the shelf. During the tour, an observation of and interview with [NAME] 5 near the steam table was made. He just finished serving the lunch meal and was not wearing a beard cover over his beard. [NAME] 5 indicated he normally wore one, but he took it off, because they were done serving. During the tour, an observation of the stove hood was made. There was a large cobweb strung from the front of the stove hood to the back of the stove hood, and there was fuzzy debris hanging from the sprinkler heads. The DS indicated there was a company that was supposed to come to clean the stove hood, on 9/19/24, but they didn't come. During the tour, an observation of the food preparation counters in the back of the kitchen was made. There was debris hanging from the ceiling area surrounding a vent, over the food preparation counters. The ceiling light fixtures over the food preparation counters had a thick amount of debris on the ends of the light covers. Some of the light covers had dead insects resting in them. The DS indicated when they tried to clean the ceiling, parts of the ceiling would flake off. The DS was unsure about cleaning of the light fixtures. On 10/1/24 at 10:15 a.m., the Director of Nursing (DON) provided the Dietary Employee Cleanliness and Dress Code Policy. It read, Hair restraints shall be worn in a way that effectively keeps hair from contracting [sic] exposed food, clean equipment, utensils, linens and unwrapped single-use articles. On 10/1/24 at 10:15 a.m., the DON provided the General Storage Policy. It read, Dishes and Utensils 1.) Spoons, knives, and forks shall be stored in containers with handles upward. On 10/1/24 at 10:15 a.m., the DON provided the Cleaning Equipment Policy and Procedures. It read, Food Prep Areas/Dish Machine/3 Compartment Sink/All Counters/Garbage Disposal: All the areas listed above are to be kept free from dirt and germs. 3.1-21(i)(3)

Based on observation, interview, and record review, the facility failed to maintain the kitchen in a cleanly manner and in good repair for the potential to affect 57 of 57 residents in the facility. Findings include: A tour of the kitchen was conducted with the DS (Dietary Supervisor) on 9/25/24 at 11:15 a.m. Interviews were conducted with the DS at that time. The wall behind the ice chest was missing baseboard. There was a cracked wall corner cover by the handwashing sink. The dishwasher counter area had four missing tiles underneath it. There was one missing tile underneath the three-compartment sink. The dry storage room had a significant amount of dirt and debris, including macaroni, on the floor against the baseboards underneath the food storage racks. The baseboard under the racks was peeling away from the wall in the corner. There was a solidified brown liquid substance on the floor underneath one of the racks. The DS indicated the brown substance may have been from previous banana boxes. The walk-in cooler had spills all over the floor. The DS indicated one area on the floor may have been old rust with liquid over it. There were cracked and missing floor tiles underneath the steamer. There were three missing tiles directly in front of the back kitchen door. On 9/25/24 at 12:15 p.m., the DS provided the, August 2024 to present, weekly kitchen cleaning logs. The weekly cleaning logs for 8/28/24 to 9/3/24, 9/4/24 to 9/10/24, 9/11/24 to 9/17/24, and 9/18/24 to 9/24/24 were not signed off as having the following areas cleaned: walls and baseboards from the walk in cooler to around the back door; both prep tables in back area-bottom, wall, baseboard, drawers, and legs; the cook's help table on serving line; the walls and baseboards behind all dish carts on clean side of dish area; and the refrigerator/freezer next to the sink. The weekly kitchen cleaning logs for the first three weeks of August 2024 were missing. Cleaning Equipment Policy and Procedures were provided by the Director of Nursing on 10/1/24 at 10:15 a.m. It read, Walk-In Refrigerator .Floor is to be swept and mopped at least once a week. The racks are to be removed and the floors and walls scrubbed with sanitizing agent at least once a year . 3.1-19(f)

Based on observation, interview, and record review, the facility failed to redirect residents with wandering behaviors from other residents' rooms resulting in a lack of privacy for other residents for 5 of 8 residents reviewed for dementia care. (Residents 4, 22, 24, 27, 41, 157, 159) Findings include: 1. The clinical record for Resident 22 was reviewed on 10/1/24 at 1:10 p.m. The diagnoses included, but were not limited to, dementia. She resided on the memory care unit of the facility. The 6/16/24 care plan indicated she had alteration in mood and/or behavioral status related to depression, elopement risk, wanders, and history of hallucinations. Three of the five goals were for her to exhibit fewer episodes of physical/verbal behaviors toward others; to be accepting of redirection from triggered episodes of behavioral disturbances; and to be easily redirected and free from injury/adverse outcome related to wandering. Two of the interventions were to assist her with developing coping techniques that diminish/alleviate physical/verbal behaviors toward others and to redirect her from confrontational interactions as necessary. There was no intervention to intervene as necessary to protect the rights and safety of others. 2. The clinical record for Resident 41 was reviewed on 10/1/24 at 1:08 p.m. The diagnoses included, but were not limited to, Alzheimer's disease and anxiety. She resided on the memory care unit of the facility. The 6/10/24 care plan, revised 8/29/24, indicated she had the behavior of intrusive wandering and taking things that did not belong to her. The goal was for her to decrease this behavior. One of the interventions was to intervene as necessary to protect the rights and safety of others; to approach/speak in a calm manner; divert attention; and remove from the situation and take to an alternate location as needed, effective 6/10/24. Another intervention was to provide a program of activities that was of interest and accommodated the resident's status, effective 8/29/24. 3. The clinical record for Resident 27 was reviewed on 10/1/24 at 1:08 p.m. The diagnoses included, but were not limited to, Alzheimer's disease, psychotic disorder with delusions, and bipolar disorder. She resided on the memory care unit of the facility. The 6/10/24 care plan indicated she had the behavior of intrusive wandering in other residents' rooms and pushing objects/staff to get what she wanted. The goal was for her to have no evidence of behavior problems of intrusive wandering or pushing objects/staff to get what she wanted. One of the interventions was to intervene as necessary to protect the rights and safety of others; to approach/speak in a calm manner; divert attention; and remove from the situation and take to an alternate location as needed, effective 6/10/24. Another intervention was to provide a program of activities that was of interest and accommodated resident's status, effective 6/10/24 An observation was conducted on 9/26/24 at 12:26 p.m., Resident 27 was wandering down the hallway and went into an empty room, where she fiddled with the bedside table and bed. No staff intervened to redirect her out of the room, and there were no structured activities on the unit at that time. On 9/26/24 at 12:04 p.m., an interview was conducted with Resident 157, who was admitted to the memory care unit of the facility, on 9/9/24, and her husband was in her room. There was no stop sign for Resident 157's doorway, and there were no structured activities occurring on the unit at that time. Her husband indicated there were two or three different female residents who came in Resident 157's room uninvited and went through her drawers. Some of Resident 157's things went missing. None of the residents were aggressive with Resident 157, that he knew of, but he worried about Resident 157 at night when he wasn't there, that one of them may come in and whack her. An interview was conducted with Resident 157 and her husband in her room on 10/1/24 at 12:10 p.m. There were no structured activities occurring on the unit at this time. Resident 157 indicated the residents who entered her room uninvited came in and out quickly. One, or two, of them would touch her things and it bothered her. Resident 157's husband described Resident 22 as one of the residents who came in Resident 157's room uninvited, at least 15 to 20 times over the past week. Staff did not intervene any of those times, as he was the one who would direct her out of the room, and staff never discussed use of a stop sign in the doorway with them. On 9/30/24 at 2:15 p.m., an interview and observation were conducted with Resident 159, who was admitted to the memory care unit of the facility, on 9/27/24, in her room. During this interview, Resident 22 came into the room holding a cup with a red liquid inside. Resident 22 was repeatedly making statements such as okay, gotta go, going home, excuse me, etc. After leaving the room, Resident 22 went into the room across the hall, then came back into Resident 159's room, but this time she no longer had the cup she was holding. She left the room a second time, then came back into the room a third time. The third time, Resident 22 walked over to Resident 159's bed, touched her pillows and bedspread, and moved things around on Resident 159's bedside table. No staff came to intervene during any of these observations. Resident 159 indicated Resident 22 coming into her room bothered her, because she didn't know her. She stated, Ain't that sad? It's always her, four to five times a day. I don't know what to say to her . just makes me nervous. There was no stop sign for Resident 159's doorway, and there were no structured activities occurring on the unit at that time. An interview was conducted with Licensed Practical Nurse (LPN) 5 on 9/30/24 at 1:55 p.m. She indicated she worked second shift starting at 2:00 p.m. and left at 10:30 p.m. Resident 27 sometimes wandered into other residents' rooms. When she did, LPN 5 tried to redirect her. LPN 5 turned on music, gave her a snack, or danced a bit. Staff tried to keep Resident 27 in the common area until after residents ate their meals. An interview was conducted with LPN 4 on 10/1/24 at 12:20 p.m. There were no structured activities occurring on the unit at that time. She indicated some of the more alert residents, like Resident 24 and Resident 4, have complained to her about residents coming into their rooms. If staff saw it, they took them out of the room and brought them to an activity or gave them a snack. They used stop signs in the past for a resident who no longer resided on the unit, and it helped some. It was usually Resident 22 and Resident 41 who went into other residents' rooms. An interview and observation were conducted with LPN 4, on 10/1/24 at 1:21 p.m., at the nurse's station. During this interview, Resident 22 approached the nurse's desk and asked where to go, stated that she wanted to get going, and didn't know what to do. LPN 4 indicated they didn't currently have a regularly scheduled activity staff person for the unit. They used to have one, but they recently stopped working at the facility, so there were no routine activities scheduled right now. When there were activities, it was things like ball toss, balloon toss, or bubbles in the courtyard. Indoor activities were things like coloring, nails, bingo, card games, cooking activities, decorating cupcakes, etc. Resident 22, Resident 41, and Resident 27 would all participate, but Resident 22 was harder to stay focused. The Elopements and Wandering Residents policy was provided by the Director of Nursing (DON) on 10/1/24 at 10:15 a.m. It read, This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk .Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering .c. Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or minimize risks associated with hazards will be added to the resident's care plan and communicated to appropriate staff. d. Adequate supervision will be provided to help prevent accidents or elopements. e. Charge nurses and unit managers will monitor the implementation of interventions, response to interventions, and document accordingly. The Dementia Care policy was provided by the DON on 10/1/24 at 10:38 a.m. It read, 1. The facility will assess, develop, and implement care plans through an interdisciplinary team (IDT) approach that includes the resident, their family, and/or resident representative, to the extent possible. 2. The care plan goals will be achievable and the facility will provide resources necessary for the resident to be successful in meeting their goals 4. Care and services will be person-centered and reflect each resident's individual goals while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety. 5. Individualized, non-pharmacological approaches to care will be utilized to include meaningful activities aimed at enhancing the resident's well-being. 3.1-37(a)

Based on interview and record review, the facility failed to ensure neurological checks, that included vital signs, were fully conducted for a resident who experienced an unwitnessed fall for 1 of 4 residents reviewed for accidents. (Resident B) Findings include: The clinical record for Resident B was reviewed on 9/27/24 at 10:00 a.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease, dementia, hypertension, anxiety, weakness, and repeated falls. An Admission Minimum Data Set (MDS) assessment, dated 5/24/24, indicated moderate cognitive impairment, impairment to one side of the lower extremity, and substantial/maximal assistance with bathing, toileting, and personal hygiene. Resident B had a history of falls prior to admission to the facility and one fall since admission to the facility. A fall care plan, last revised on 8/5/24, indicated Resident B had a history of falls and required assistance from at least one staff member for safe transfers. The interventions included, but were not limited to, observe for and report changes in mobility and/or range of motion. A health status note, dated 8/2/24 at 11:44 p.m., indicated the following, .Res [Resident B] fell in bathroom and QMA [qualified medication aide] found her on the floor. 2 skin tears received, one on left wrist and one on left leg. Cleaned, non-stick dressing applied and kerlix applied. Family and NP [Nurse Practitioner] notified A document, dated 8/2/24, indicated Resident B had an unwitnessed fall on 8/2/24 at 11:00 p.m. Resident B was laying on her left side with oxygen in place and was incontinent of bowel. There was a skin tear to the left wrist and the left leg. Resident B was documented as being alert to person only, had gait imbalance, and impaired memory. The family member and nurse practitioner were notified. The document was indicative as not being a part of the clinical record. The next consecutive health status note, dated 8/3/24 at 9:15 p.m., indicated the following, .Hoted [sic; Noted] left arm and leg appears weaker. Left hand grip is good. Left leg with poor weight bearing. Denied pain/discomfort. Alert per baseline. Son poa [power of attorney] [name of POA] informed A fall follow up document, dated 8/3/24, indicated not applicable for documentation of physician and/or family notification, a head-to-toe assessment was completed, no new injury was discovered, and vital signs were documented, as obtained, on 8/3/24 at 9:14 p.m. A document titled Neuro Assessment, initiation date of 8/2/24, indicated neurological checks were being conducted after Resident B exhibited the fall on 8/2/24. The document indicated to conduct neurological checks every 15 minutes four times, every 30 minutes two times, every hour two times, every four hours five times, and every eight hours six times. The following was noted: - 8/3/24 at 6:45 p.m. included vital signs, pupil response, pain response, hand grasp, level of consciousness, and motor response, - 8/3/24 at 10:45 p.m. was left blank, and - 8/4/24 at 6:45 a.m. listed Resident B being at the hospital. A fall follow up document, dated 8/4/24, indicated to document physician and/or family notification was left blank, neurological checks continued, a head-to-toe assessment was completed, no new injury was discovered, and vital signs were documented, as the most recent, dated 8/3/24 at 9:14 p.m. There were no vital signs recorded for Resident B after 8/3/24 at 9:14 p.m., in the electronic health record. The next consecutive health status note, dated 8/4/24 at 8:25 a.m., indicated Resident B was sent to the hospital due to being unresponsive. The family and nurse practitioner were notified. A policy titled Fall Management, dated August 1, 2023, was provided by the Director of Nursing on 10/1/24 at 10:15 a.m. The policy indicated, .Post fall .A neurological assessment will be initiated on all un-witnessed falls and or resident with suspected head injuries every 15 minutes/x4 [times 4] = [equal] (1 hour), then every 30 min/x2 [every 30 minutes two times] = (1 hour), then every 1 hour x2 = (2 hour), then every 4 hours x 5, and lastly every 8 hours x 6 .This information will be found on (paper) Neuro Assessment .2. If there are no injuries, notify the physician during normal business hours .5. Fall follow up assessment will be completed and documented by licensed nurse every shift x 72 hours This citation relates to Complaint IN00444117. 3.1-37(a)

Based on interview and record review, the facility failed to encode minimum data set (MDS) assessments accurately for 2 of 2 residents reviewed for MDS accuracy. (Resident 44 and Resident 53) Findings include: 1. The clinical record for Resident 44 was reviewed on 10/1/2024 at 11:00 a.m. The medical diagnoses included benign neoplasm of cerebral meninges (layers of membranous connective tissue that cover and protect the brain and spinal cord). A Quarterly MDS assessment, dated 9/4/2024, indicated Resident 44 had a six month or less life expectancy, but did not receive hospice services. A hospice plan of care, dated 6/20/2024, indicated Resident 44 was admitted to hospice on 7/31/2023. During an interview, on 10/1/2024 at 12:00 p.m., the MDS Coordinator indicated Resident 44 was admitted on hospice care, had received hospice services continuously since admission, and the, 9/4/2024, MDS assessment was coded inaccurately. 2. The clinical record for Resident 53 was reviewed on 9/30/2024 at 1:03 p.m. The medical diagnoses included dementia. An Admission MDS assessment, dated 8/13/2024, indicated Resident 53 received an anticoagulant medication in the seven days prior to the admission reference date. The physician orders, provided by the facility on 10/1/2024 at 1:00 p.m., for Resident 53 did not include an order for anticoagulant medication. During an interview with the MDS Coordinator, on 10/1/2024 at 12:00 p.m., they indicated Resident 53 had not been on an anticoagulant during the review period of the Admission MDS assessment, on 8/13/2024, and the assessment was coded in error. The facility's expectation was to code the MDS assessments to the most recent standards set forth in the Resident Assessment Instrument Manual. A policy entitled, Conducting an Accurate Resident Assessment, was provided by the DON on 10/1/2024 at 1:00 p.m. The policy indicated, The purpose of this policy is to assure that all residents receive an accurate assessment .

Based on interview and record review the facility failed to conduct care plan meetings for 1 of 4 residents reviewed for care plans. (Resident 10) Findings include: The clinical record for Resident 10 was reviewed on 9/30/24 at 11:02 a.m. The diagnoses included, but were not limited to, Parkinson's disease, chronic obstructive pulmonary disease, and major depressive disorder. During an interview with Resident 10 on 9/26/24 at 12:17 p.m., indicated they did not recall having care plan meetings. The Quarterly Minimum Data Set (MDS) assessment, dated 8/27/24, indicated Resident 10 was cognitively intact. The EHR (electronic health record) indicated Resident 10 had a comprehensive care plan meeting, on 12/14/23, with no further care plan meetings held until 7/1/24. During an interview with the Social Service Director (SSD) on 10/1/24 at 12:30 p.m., indicated he was unable to find where Resident 10 had a care plan meeting. The SSD indicated social services were responsible to set up care plan meetings and meetings were conducted quarterly and as needed. A Comprehensive Care Plan policy was provided by the Director of Nursing on 10/1/24 at 1:10 p.m. The policy indicated, .This facility supports the resident's right to be informed of, and participate in, his or her care planning and treatment (implementation of care) .10. The facility will discuss the plan of care with the resident and/or representative at regularly scheduled care plan conferences, and allow them to see the care plan 3.1-35(d)(2)(B)

Based on interview and record review the facility failed to accurately document a resident's code status in the clinical record for 1 of 1 resident reviewed for advanced directives (Resident 40). Findings include: The clinical record for Resident 40 was reviewed on [DATE] at 12:02 p.m. The resident's Indiana physician orders for scope of treatment (POST) form, dated [DATE], indicated the resident was to receive Cardiopulmonary Resuscitation (CPR) in the event the resident had no pulse and was not breathing. The form was signed by Resident 40 and the physician. The physician recapitulation (recap) orders for Resident 40, dated ,d+[DATE], indicated the resident was not to be resuscitated in the event the resident had no pulse and was not breathing. Review of the record of Resident 40, on [DATE] at 1:44 p.m., indicated the diagnoses included, but were not limited to, cerebral palsy, hypertension, anxiety, anemia, atrial fibrillation, and major depressive disorder. During an interview with the Director of Nursing (DON) on [DATE] at 1:58 p.m., indicated Social Services had an ongoing binder with the POST forms. Medical records were responsible to ensure that the POST form and physician orders matched. During an interview with the Social Service Director on [DATE] at 2:02 p.m., indicated Social Services did not have an ongoing binder with residents' current code status. During an interview with the DON on [DATE] at 10:13 a.m., indicated what she believed happened was when Resident 40 was readmitted back to the facility, on [DATE], the floor nurse had the resident sign the POST form without explaining to him what it really meant. The communication of code status policy provided by the DON, on [DATE] at 10:15 a.m., indicated the facility would adhere to the resident's right to formulate advanced directives and the facility would implement procedures to communicate a resident's code status to those individuals who needed to know this information. The nurse who notates the physician order was responsible for documenting the directions in all relevant sections of the medical record. The Social Services Director shall maintain a list of residents who have Advanced Directives on file. 3XXX,d+[DATE](f)(4)(A)(ii) 3XXX,d+[DATE](f)(5) 3XXX,d+[DATE](f)(7)

Based on observation, interview, and record review, the facility failed to ensure a resident's plan of care for behavioral health was implemented and evaluated after having physical behavioral symptoms directed towards staff and other residents, document a resident's behaviors in the clinical record, document interventions in response to such behaviors, document the reasoning for administration of an intramuscular (IM) injection of antianxiety and antipsychotic medications, and ensure other residents' safety was maintained during behavioral episodes to where a resident (Resident E) was found to have their hands around another resident (Resident F's) neck that resulted in redness. Resident F had felt fearful, anxious, and the need to relocate to another nursing facility. Findings include: 1a. The clinical record for Resident E was reviewed on 5/1/24 at 11:00 a.m. The diagnoses included, but were not limited to, Huntington's disease, extrapyramidal and movement disorder, psychosis, anxiety disorder, major depressive disorder, schizophrenia, and insomnia. A significant change minimum data set (MDS) assessment, dated 12/19/23, indicated severe cognitive impairment and physical behavior directed towards others that occurred in 1-3 days. A quarterly MDS assessment, dated 3/19/24, indicated severe cognitive impairment and physical behavior directed towards others that occurred in 1-3 days. An activities care plan, revised 4/25/24, indicated Resident E prefers to engage in independent leisure activities such as playing his X-box, watching TV/movies, listening to music, snacking, daily visits with family. At times, resident chooses to stay awake through the night playing video games and watching TV. The interventions included to encourage/invite Resident E to group activities and provide transportation to and from activities, provide a large activity calendar each month, and provide resident with activities supplies. A care plan, revised on 4/25/24, indicated Resident E has Huntington's disease and may experience: delusions, hallucinations, paranoia, lack of concentration, mental confusion, memory loss, involuntary movements, compulsive behaviors, irritability, lack of restraint, mood swings, and chorea (a symptom that causes involuntary, irregular or unpredictable muscle movements). The interventions included to administer medications as ordered and notify the medical director as needed as the only interventions. There had been no added interventions since 1/15/21. A care plan related to the diagnosis of schizophrenia and depressive disorder, revised 4/25/24, included the interventions to continue current mental health services, family involvement in care, therapy evaluations as needed, socialization/leisure/recreation activities, and supportive counseling from nursing facility staff. There had been no added interventions since 3/18/21. A care plan, revised 4/25/24 but initiated on 7/17/23, indicated Resident E had potential to appear physically aggressive at times with resident wanting to interact with others and due to tremors, it may cause unwanted contact with others. The interventions included administering medications as ordered, give resident choices about care and activities, modify environment, monitor for closeness in dining room with other residents, and psychiatric consult as needed. There had been no added interventions since 7/17/23. A care plan for physical aggression, dated 4/12/24, indicated a history of physical aggression towards others related to Huntington's disease and impulse control deficits. The interventions included, but not limited to, the following: - Administer medications as ordered, - Anticipate and meet the resident's needs, - Discuss the resident's behavior, if reasonable, - Intervene as necessary to protect the rights and safety of others, & - Monitor behavior episodes and attempt to determine underlying cause. A behavior note, dated 12/12/23 at 10:36 a.m., indicated the following, .IDT [interdisciplinary team] note. Resident in dining room for breakfast and left his table and went to another resident's table. Resident states that he was trying to get the attention of the other resident. Resident grabbed other resident's arm to get his attention causing a skin tear to other resident's left hand and bruising to left forearm. Staff with attempted to talk with, remove, redirect and offer care helped behaviors to decrease and eventually stop . A behavior communication form, dated 12/12/23, indicated Resident E grabbed another resident's arm to get their attention and caused a skin tear and bruising. There were interventions listed that were utilized and deemed effective. A behavior note, dated 12/13/23 at 6:12 a.m., indicated the following, .pt [patient] woke up at approx [approximately] 0500 [5:00 a.m.] agitated d/t [due to] unknown cause. pt started getting physically aggressive c [with] other pt in common area. when staff attempted to intervene [name of Resident E] began getting aggressive c [with] staff. staff eventually able to physically pick up patient and take to room. pt keeps attempting to come back out to common area to approach the same patient. poa [power of attorney] contacted, left vm [voicemail]. going to be in touch with hospice per day shift nurse when they open at 0700 [7:00 a.m.] A behavior communication form, dated 12/13/23 at 8:00 a.m., indicated Resident E was extremely agitated with repetitive verbalization and aggressively wheeling himself up and down the hallways. He was persistent with attempting to go up to other residents in an aggressive manner. Staff intervened before Resident E was able to approach any other resident. Resident E was combative with staff. Resident was grabbing arms, hands, and twisting while attempting to bite the staff. The PRN (as needed) intramuscular injection was administered and deemed effective. The two events where Resident E became physical with another resident was not reported to the Indiana Department of Health. There were no further names or description of the other residents that Resident E came into contact with on 12/12/23 and 12/13/23. There were no follow up notes in Resident E's clinical record to indicate if a root cause of the physical contact was discussed or determined. An administration note, dated 12/13/23 at 1:51 p.m., indicated a lorazepam (antianxiety) injection was administered to Resident E's left arm at 8:20 a.m. on 12/13/23 in regards to aggressive behavior. There was no indication of what was occurring with Resident E prior to administration of the antianxiety injection along with attempts that staff made in response to Resident E being aggressive. A physician order, dated 12/13/23, was noted for an intramuscular (IM) injection of Haldol and lorazepam every 6 hours as needed for aggression. A psychotherapy progress note, dated 12/13/23, indicated the following, .Three weeks ago, the patient's antipsychotic medication was increased by the Hospice provider due to behavioral disturbances, including recent physical aggression towards other residents .The patient's perception of reality was impaired, consistent with the psychotic disorder .Insight into mental health needs was poor, and judgement was compromised, as evidenced by the denial of reported behavioral disturbances .Recommendations .you may wish to consider the medical appropriateness of adding Haldol po [by mouth] bid [twice daily] for better control of psychosis resulting in aggression An administration note, dated 12/16/23 at 7:00 a.m., indicated PRN lorazepam injection was administered. There was no documentation on what behavior was occurring, staff response/interventions to any behaviors, and follow up to any behaviors that were occurring. An administration note, dated 12/16/23 at 10:00 a.m., indicated PRN Haldol injection was administered for aggression. There was no documentation on what behavior was occurring, staff response/interventions to any behaviors, and follow up to any behaviors that were occurring. An administration note, dated 12/16/23, indicated the PRN lorazepam and Haldol injections were listed as ineffective. A progress note, dated 12/16/23 at 1:24 p.m., indicated Resident E was sent to the emergency room at 10:45 a.m. due to extreme aggression. They returned to the facility the same day. A behavior communication form, dated 12/20/23, indicated Resident E had to be removed from 2 resident rooms due to him wandering into those rooms. A psychotherapy progress note, dated 12/26/23, indicated the following, .Recommendations .2. Facility staff should re-consult if current condition is exacerbated or new symptoms arise. Will follow up as appropriate An administration note, dated 1/8/24 at 4:00 p.m., indicated a lorazepam injection administration was effective. There were no indications on why the injection was administered or what interventions were attempted prior to the administration of the injection. An administration note, dated 3/17/24 at 9:45 a.m., indicated a lorazepam injection was administered due to aggressive behaviors towards staff and other residents. Resident E grabbed, squeezed, and twisted staff arms. Resident was grabbing belongings to other residents and attempting to hit. Resident E remained aggressive despite being taken to a less stimulating environment. The injection was listed as effective. An administration note, dated 4/4/24 at 12:32 a.m., indicated a lorazepam injection was administered but no indication why the injection was administered and what interventions were attempted prior to administration of the injection. The injection was listed as effective. An administration note, dated 4/11/24 at 5:40 p.m., indicated a lorazepam injection was administered but no indication why the injection was administered and what interventions were attempted prior to administration of the injection. The injection was listed as effective. A psychosocial note, dated 4/12/24 at 10:37 a.m., indicated the following, Resident could not verbalize recall of incident w/ [with] another resident on 4/11/24 An incident note, dated 4/12/24 at 3:54 p.m., indicated Resident E was put on 15-minute checks and redness was noted to Resident F's neck at the time of incident. Resident E's 15-minute checks were stopped on 4/12/24 at 3:15 p.m. Resident E had been pleasant watching video games at that time. An incident reported to the Indiana State Department of Health survey report system, dated 4/11/24 at 2:45 p.m., indicated staff responded to Resident F's room to where Resident E was observed to have his hands around Resident F's neck. The immediate action taken listed Resident E to continue to be followed by the facility psychiatric provider. There were no further psychiatric/psychotherapy notes for Resident E in the clinical record since 12/26/23. An interview conducted with Resident F, on 5/1/24 at 11:38 a.m., indicated she was choked. She indicated she was sitting in the doorway, in her wheelchair, with her back facing the entrance to her room. Resident E proceeded to approach her from behind and placed both of his hands around her neck. Resident F indicated it was very tight and made it difficult to breathe. She was anxious and fearful after the incident and ended up relocating to another nursing facility after the incident involving Resident E. The clinical record for Resident F was reviewed on 5/1/24 at 12:30 p.m. The diagnoses included, but were not limited to, cerebral infarction (damage to tissues in the brain due to loss of oxygen), hemiplegia (paralysis that affects only one side of the body), anemia, and hypertension. An admission MDS assessment, dated 1/17/24, indicated she was cognitively intact. An interview conducted with the Administrator in Training (AIT), on 5/1/24 at 1:25 p.m., indicated the incidents to where Resident E made physical contact with other residents on 12/12/23 and 12/13/23 did not appear to be reported to the Indiana Department of Health. AIT was not working at the facility during that time period. An interview conducted with Social Services Director (SSD), on 5/1/24 at 1:50 p.m., indicated the previous mental health provider went out of business. So, the mental health provider continued to see the residents, but it was pro [NAME] from January to March of 2024, and the provider did not leave any notes during that time period. We were going to switch to another provider, but we did not receive consents for Resident E to be seen by the new provider. We will be obtaining consent to Resident E can be seen by the current mental health provider. 1b. An observation conducted of Resident E, on 4/30/24 at 10:37 a.m., of him laying in bed with the television on. An interview conducted with Licensed Practical Nurse (LPN) 2, on 4/30/24 at 11:04 a.m., indicated she gets worried about Resident E. He had made contact with other residents in the past. His behaviors come in spurts but it's not an everyday thing. Resident E's behaviors are random, and you never know why he's doing it. It's very difficult to communicate with Resident E due to the difficulty in understanding him. An observation conducted of Resident E, on 4/30/24 at 3:00 p.m., of him up in his wheelchair propelling himself going into the dining room. At 3:05 p.m., he proceeded to propel himself out of the main dining room. There was a female resident sitting in the dining room looking outside. There were no nursing staff within a close distance to Resident E during the observations in the dining room. An observation conducted of Resident E, on 5/1/24 at 1:00 p.m., of him up in his wheelchair sitting in the doorway looking outside of his room. His television was on. There was activities going on in the activity room down the hallway. An observation conducted of Resident E, on 5/1/24 at 1:30 p.m., of him propelling himself in the wheelchair by the common area just outside of the nurses' station. There was activities going on in the activity room down the hallway. An observation conducted of Resident E, on 5/1/24 at 4:30 p.m., of him sitting up in his wheelchair in the common area just outside of the nurses' station. There were no activities going on at that time. Resident E's room was observed with a gaming system located beside his television. A policy titled Behavior Management Policy, dated 11/28/19, was provided by the AIT on 4/30/24 at 2:15 p.m. The policy indicated the following, .It is the policy of this facility that Residents with a need to address Behavioral Health will receive services, receive trauma related care and services from a clinician who has expertise and knowledge of this type of service and referrals will be made .PROCEDURE .3. For Residents who have been identified as having on-going behaviors/mood alterations, a Behavior Tracking should be utilized for all observed issues .4. Social Services Director will use Behavior Documentation to guide in IDT discussion regarding Residents with symptoms and the effectiveness of interventions .5. If behavior/mood interventions were not effective, the IDT will review and determine if new interventions should be initiated .6. Social Services Director will communicate recommended interventions to all staff via the Care Plan .10. At least quarterly interdisciplinary meetings will be held to discuss all Residents on the behavior management program as well as those Residents receiving psychoactive medication who may be due for reduction. During the meeting Behavior Tracking and care plans will be reviewed. Interventions will be discussed and changed if necessary A policy titled Reportable Incidents and Unusual Occurrence, Abuse Prevention, Reporting, and Investigation Policy, revised 8/28/23, was provided by the AIT on 4/30/24 at 2:15 p.m. The policy indicated the following, .3. Physical Abuse .a. Resident to resident. May be considered abuse and an investigation should occur This citation relates to Complaints IN00432416 and IN00432418. 3.1-37(a) 3.1-43(a)(1)

Based on interview and record review, the facility failed to ensure a resident with dementia had a care plan with resident-specific interventions in regards to making inappropriate comments towards staff, monitoring of behaviors and documentation of such behaviors in the clinical record; document interventions in response to such behaviors, and ensure the safety of other residents to where a resident (Resident H) was found to have touched another resident's (Resident G's) breast for 3 out of 5 residents reviewed for behavioral health. (Resident G and Resident H and Resident J) Findings include: 1. The clinical record for Resident G was reviewed on 4/30/24 at 3:00 p.m. The resident's diagnoses included, but were not limited to, dementia, psychotic disturbance, mood disturbance, and neurocognitive disorder with Lewy bodies. The 4/23/24 Quarterly MDS (Minimum Data Set) assessment indicated Resident G was severely cognitively impaired. 2. The clinical record for Resident H was reviewed on 4/30/24 at 2:45 p.m. The resident's diagnoses included, but were not limited to, disorientation, dementia, psychotic disturbance, mood disturbance and anxiety. The 4/10/24 Quarterly MDS (Minimum Data Set) assessment indicated Resident H was moderately cognitively impaired. A care plan date initiated 12/1/22 indicated Resident H has a hx [history] of being sexually inappropriate towards others r/t [related to] dementia and impulse control deficits interventions .Will have no evidence of behavior problems such as sexual comments and grabbing staff in a sexual manner by. Resident H's behavioral care plan developed for sexually inappropriate behaviors did not include interventions to address those behaviors. A care plan dated 10/9/22 indicated Doctor has determined resident needs long term stay d/t [due to] safety awareness .Interventions .Provide resident's services according to care plans in an effort to enhance optimum well-being . A care plan dated 12/13/22 indicated Resident has impaired cognitive function and impaired communication r/t Dementia .Interventions: Administer meds as ordered .Ask simple questions .Present only 1 thought, idea or question at a time .Report changes to MD/NP [medical doctor/Nurse Practitioner] .Try to keep routine consistent when possible. The residents care plan addressing his dementia diagnosis did not include person center interventions to address the resident's dementia. A physician order dated 8/2/23 indicated Resident H was to receive 150 milligrams of Depo-Provera every 14 days for sexual behavior. A behavioral note written by social services for Resident H dated 8/9/23 indicated Resident with 2 episodes of refusing showers and making sexually inappropriate statements to staff. Staff with attempts to talk with and reproach ineffective as behaviors continued. A behavioral note written by social services for Resident H dated 1/10/24 indicated Resident with 2 episodes of making sexually inappropriate comments to staff. Staff with attempts to talk with, redirect and offer space ineffective as behaviors continued. The resident's clinical record did not include behavior monitoring and/or implementation of new interventions to address the resident's sexually inappropriate behaviors. A behavior note written by social services dated 4/18/24 indicated Resident H was witnessed to be touching another resident [G] inappropriately on 4/18/2024. Residents were immediately separated and [Resident H] was put on 1-1 supervision w/ [with] 15 minute checks starting at 6:00 p.m. on 4/18/2024 .[Resident H] was moved off the unit on 4/19/2024 .Once moved [Resident H] settled into his new room and went to lunch in the main dining room A reportable incident dated 4/18/24 indicated .brief description of incident .Male resident [Resident H] was witnessed to be inappropriately touching female resident [Resident G] .Action Taken .Male resident was put on 1:1 .Follow up: 4/23/24 [Resident H] remained 1:1 following incident and then placed on 15-minute checks. Care conference held with [Resident H's Representative] and resident and both parties agreeable to move [Resident H] to an alternative room in the facility, as resident will be able to socialize more with peers. Social services followed up with both residents x [times] 72 hours with no concerns. [Resident G] is unable to recall incident and is participating in normal routine. No adverse psychosocial effects noted. [Resident H] is participating in normal routine and continues to deny that the incident ever occurred The investigation file for the reportable incident between Resident G and Resident H was provided by the Administrator in Training (AIT) on 5/2/24 at 8:41 a.m. The file included the following: An incident physical assessment for Resident H indicated Staff responded to resident [H] inappropriately touching resident [G] once reported by [Resident G Representative] .Resident [H] stated 'He never touched anyone's boobs. An incident physical assessment for Resident G indicated [Resident G's Representative] reported to license nurse that he witnessed resident [H] inappropriately touching [Resident G] . Resident G was unable to provide statement. A 15-minute safety check document indicated Resident H was placed on 15-minute checks. They were started on 4/18/24 at 6:00 p.m. and discontinued on 4/19/24 at 10:45 a.m. A room change document indicated Resident H was moved to a different room in the facility off the memory care unit. Resident H's care plan for sexually inappropriate behaviors was revised on 4/19/24 indicated .interventions .1:1 initiated, and then room move 4/19/24, .administer medications as ordered date initiated 4/10/24, redirect [Resident G] if he is being inappropriate as needed .Redirect w/ [with] games, bible books, phone calls to friends, .refer to psych as needed, .Remove [Resident G] from the situation if he is a harm to himself or others. 3. The clinical record for Resident J was reviewed on 5/1/24 at 1:00 p.m. The resident's diagnoses included, but were not limited to, dementia, psychotic disturbance, mood disturbance, and neurocognitive disorder with Lewy bodies. The 3/19/24 Quarterly MDS (Minimum Data Set) assessment indicated Resident J was severely cognitively impaired. A behavior note written by social services on 4/24/24 indicated .Resident J reported to nursing that [Resident H] touched her inappropriately in the common area. She stated he had attempted to do the same yesterday but was not able. Residents have been separated. [Resident H] is on one-one observation. [Resident H] has a hx [history] of this type of bx [behavior]. He has recently been moved off another unit for touching another female resident [G]. referral has been sent to [name of psych hospital] for placement. A behavior note written by social services on 4/24/24 at 3:47 p.m., indicated Resident H had been transferred to psych hospital. An investigation file regarding the incident between Resident H and Resident J was provided by the AIT on 5/2/24 at 8:41 a.m. The file included the following: A written statement by Activities Director on 4/24/24 indicated Resident [J] came to my office very upset stating that her and a guy where (sic) sitting in the common area on the couch when he tried to touch her boob. I ask her to tell me what the guy looked like and she told me a homeless looking man with a cap on. A statement by Administrator on 4/24/24 indicated Writer interviewed Resident [J]. Writer asked [Resident J] if she had any problems with anyone today. Resident [J] stated yeah 'that homily looking man wanted to touch my boobs.' I asked her if he touched her boobs. She said 'oh no, he brushed my shoulders and I told him to go on and he did.' Writer went and got Director of nursing .to come with and talk to resident again to have resident repeat the conversation. Resident again stated that, 'he did NOT touch her breasts . An interview was conducted with License Practical Nurse (LPN) 3 on 4/30/24 at 11:35 a.m. She indicated Resident H was very complimentary to the staff's appearance. He liked the attractive female staff to care for him. An interview was conducted with the Social Services Director on 4/30/24 at 3:15 p.m. He indicated Resident H had a history of sexually inappropriate behavior toward staff. The intervention implemented after the incident with Resident G on 4/18/24, was to move Resident H out of the memory care unit and place him in a room outside of the unit. Resident H's 15-minute checks had been discontinued prior to the incident that occurred on 4/24/24, but the staff was closely monitoring the resident. After the incident with Resident J on 4/24/24, SSD had made arrangements for Resident H to be transferred to a psych hospital due to his behaviors. Resident H will return on Friday. He has had medication adjustments. An interview was conducted with AIT on 4/30/24 at 2:47 p.m. She indicated the staff should be monitoring and documenting the residents' behaviors. She had witnessed the incident between Resident H and Resident J on 4/24/24. The two residents were in the common area, and the two residents had rubbed shoulders. Resident H had not touched her breasts. A Dementia Care policy was provided by the AIT on 5/2/24 at 8:41 a.m. It indicated .Policy: It is the policy of this facility to provide the appropriate treatment and services to every resident who displays signs of or is diagnosed with dementia, to meet his or her practicable physical, mental, and psychosocial well-being .Policy Explanation and Compliance Guidelines: 1. The facility will assess, develop, and implement care plans through an interdisciplinary team (IDT) approach that includes the resident, their family, and/or resident representative, to the extent possible .3. The care plan interventions will be related to each resident's individual symptomology and rate of dementia (or related disease) progression with the end result being noted improvement or maintained of the expected stable rate of decline associated with dementia and dementia-like illnesses. 4. Care and services will be person-centered and reflect each resident's goals while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety .7. The care plan goals and interventions will be monitored on an ongoing basis for effectiveness, and will be reviewed/revised as necessary. 8. Appropriate referrals will be made if current interventions are ineffective or resident shows a decline in psychosocial, mood, or behavioral status (i.e. physician, mental health provider, licensed counselor, pharmacist, social worker) . This citation relates to Complaints IN00433278 and IN00432991. 3.1-37(a)

Based on interview and record review, the facility failed to ensure narcotic medication was administered per physician orders for 2 of 3 residents reviewed for medication administration. (Resident E and Resident D) Findings include: 1. The clinical record for Resident E was reviewed on 5/1/24 at 11:00 a.m. The diagnoses included, but were not limited to, Huntington's disease, extrapyramidal and movement disorder, psychosis, anxiety disorder, major depressive disorder, schizophrenia, and insomnia. A quarterly minimum data set (MDS) assessment, dated 3/19/24, indicated severe cognitive impairment and physical behavior directed towards others that occurred in 1-3 days. A physician order, dated 12/28/23, was noted for diazepam 10 milligrams (mg) twice daily for hyperkinesia due to Huntington's disease. The narcotic log sheets for Resident E's diazepam tablets was reviewed and indicated the following date(s)/time(s) were noted without documentation of the medication administration: 3/4/24 for both doses, 3/5/24 for both doses, 3/14/24 at 8:00 p.m., 3/15/24 at 8:00 p.m., 3/17/24 at 8:00 p.m., 4/13/24 at 8:00 a.m., 4/21/24 for both doses, 4/22/24 for both doses, 4/25/24 at 8:00 p.m., 4/26/24 at 8:00 a.m., & 4/27/24 at 8:00 a.m. 2. The clinical record for Resident D was reviewed on 4/30/24 at 3:15 p.m. The diagnoses included, but were not limited to, heart failure, fibromyalgia, anxiety disorder, and low back pain. A quarterly minimum data set (MDS) assessment, dated 4/9/24, indicated Resident D was cognitively intact. An interview conducted with Resident D, on 4/30/24 at 10:47 a.m., indicated there have been issues with receiving her scheduled pain medication. A physician order, dated 2/3/24 and discontinued on 4/8/24, indicated the use of Norco 5-325 milligrams; give one tablet three times a day at 6:00 a.m., 2:00 p.m., and 10:00 p.m. A physician order, dated 4/8/24, indicated the use of Norco (hydrocodone-acetaminophen) 5-325 milligrams: one tablet three times a day at 8:00 a.m., 2:00 p.m., and 10:00 p.m. The narcotic log sheets were reviewed for Resident D's Norco tablets. The following date(s)/time(s) were noted without the documentation of the medication administration: 4/12/24 at 10:00 p.m., 3/29/24 at 6:00 a.m., 3/11/24 at 10pm 3/9/24 all scheduled doses, 3/8/24 all scheduled doses, 3/7/24 all scheduled doses, 3/6/24 all scheduled doses, & 3/5/24 10:00 p.m. dose. A policy titled Controlled Substance Storage, dated 02/20, was provided by the Administrator in Training (AIT) on 5/2/24 at 2:16 p.m. The policy indicated the following, .F. A controlled substance accountability record is prepared by the pharmacy/facility .I. Current controlled substance accountability records are kept in the MAR [medication administration record], or designated book. Completed accountability records are submitted to the director of nursing and kept on file A policy titled Medication Administration, undated, was provided by the AIT on 5/2/24 at 12:28 p.m. The policy indicated the following, .Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection This citation relates to Complaint IN00429302. 3.1-25(b) 3.1-25(e)(2)

Based on interview and record review, the facility failed to ensure a resident's preference for frequency of bathing was honored on a regular basis for 1 of 4 residents reviewed for bathing. (Resident B) Findings include: The clinical record of Resident B was reviewed on 2-20-24 at 9:42 a.m. Her diagnoses included, but were not limited to chronic obstructive pulmonary (lung) disease (COPD), dementia, diabetes, chronic respiratory failure, unspecified heart failure, fibromyalgia, chronic atrial fibrillation, high blood pressure and glaucoma. Her most recent Minimum Data Set analysis, dated 1-8-24, indicated she is moderately cognitively impaired, requires a walker or wheelchair for mobility and requires substantial assistance with bathing. In an interview on 2-20-24 at 1:41 p.m., with Resident B, she indicated she prefers to receive bedbaths as opposed to a shower or tub bath and is scheduled for Tuesdays and Friday evenings. She indicated in recent weeks, this has only happened once a week with her last bedbath one week ago. A review of Resident B's bathing records for January and February, 2024 were reviewed. It indicated she was scheduled for bathing on Tuesday and Friday evenings. In January, it indicated she did not receive a bedbath on 3 of 4 Fridays, specifically 1-5-24, 1-12-24 or 1-26-24. In February, it indicated she did not receive a bedbath on 1 of 3 Fridays, specifically 2-16-24. A care plan for activities of daily living (ADL) self-care performance deficit, initiated on 1-27-22, and revised most recently on 7-31-23, failed to identify specific bathing needs for Resident B or her preference for bedbaths twice weekly. It identified various care needs, such as eating, dressing, toileting, oral care and sleep location preference,and included level of assistance required, varying from limited to extensive assistance. This Federal tag relates to Complaint IN00427915. 3.1-38(a)(2)(A) 3.1-38(b)(2)

Based on observation, interview and record review, the facility failed to ensure oxygen therapy supplies were maintained in a clean and hygienic manner for 1 of 3 residents reviewed for oxygen therapy services. (Resident F) Findings include: During a care observation on 2-21-24 at 3:30 p.m., Resident F was observed receiving supplemental oxygen via a nasal cannula at 3 liters per minute. Her oxygen concentrator (machine delivering supplemental oxygen) was observed to have oxygen tubing without any identifier as to the date the tubing was replaced. Additionally, there was not a storage bag for oxygen tubing for the concentrator. Her portable oxygen tank tubing had an identifier to indicate it had been most recently changed on 2-18-24, and had a storage bag for the oxygen tubing. This was verified by CNA 4, who was present at that time, due to care provision to Resident F. A review of Resident F's physician orders, dated 1-28-24, indicated, Change O2 [oxygen] tubing and bag weekly and date every day shift every Sun [Sunday]. She was physician-ordered to receive supplemental oxygen at 3 liters per minute continuously, as of 1-23-24. A review of Resident F's February, 2024, treatment administration record indicated facility staff had signed off to indicate the weekly oxygen tubing and bag change had been conducted on 2-4-24, 2-11-24 and 2-18-24. In an interview on 2-22-24 at 12:45 p.m., with the Director of Nursing, she indicated she could not locate a specific policy or procedure for the frequency of changing the oxygen tubing. She added it is her expectation that staff will follow the physician orders to change the oxygen tubing and supply bags at least every 7 days and as needed. She indicated the facility's contracted oxygen company assumes responsibility for replacement of the oxygen concentrator's filters on an annual basis or as needed. Staff are to monitor the oxygen settings for any resident receiving supplemental oxygen therapy. This Federal tag relates to Complaint IN00427915. 3.1-47(a)(6)

Based on observation, interview and record review, the facility failed to ensure an insulin pen was properly labeled for use for 1 of 4 residents observed during 1 of 2 medication pass observations with 3 staff members with 4 residents. (Resident H, LPN 3) Findings include: During a medication pass observation on 2-19-24 at 7:41 p.m., LPN 3 was observed to obtain a Lispro (type of insulin) Kwikpen from the medication cart. There were no directions for use on the pen and LPN 3 was unable to locate the pen's bag with the label directions for use. Additionally, there was not a date identified in which the insulin pen had been opened. LPN 3 indicated insulin pens should include the date it was opened and should be kept in the bag it was dispensed in as the bag contains the directions for use. LPN 3 attempted to locate another Lispro Kwikpen, but failed to find one, but she was able to obtain an equivalent insulin from the facility's emergency drug kit. At 8:07 p.m., LPN 3 administered 6 units of Humalog insulin subcutaneously (under the skin) for Resident H's blood glucose level of 266. The physician's order for the insulin, dated 2-12-24, indicated, Insulin Lispro (1 Unit Dial) 100 UNIT/ML Solution pen-injector Inject as per sliding scale: of 0 - 150 = 0; 151 - 200 = 2; 201 - 250 = 4; 251 - 300 = 6; 301 - 350 = 8; 351 - 400 = 10, subcutaneously four times a day for Diabetes Mellitus. On 2-21-24 at 1:15 p.m., the Director of Nursing provided a copy of a policy entitled, Infection Control - Blood Glucose Machine Safe Injection Practices to Prevent Resident Transmission of Bloodborne Pathogens. This policy had a revision date of 10-20-22, and was indicated to the current policy utilized by the facility. This policy indicated, Prepare insulin in medication area using the insulin assigned to the individual resident and check the label contains the resident name, date opened and is within the expiration guidelines. 3.1-25(j)(5) 3.1-25(j)(6)

Based on observation, interview and record review, the facility failed to ensure facility staff appropriately sanitized a glucometer (testing machine for blood sugar levels) utilized for multiple residents. (Resident H and QMA 2) Findings include: During 1 of 2 medication pass observations with 3 staff members with 4 residents, QMA 2 was observed to obtain a blood sugar level for Resident H on 2-19-24 at 7:33 p.m. Upon completion of the procedure, QMA 2 was observed to use an alcohol wipe to cleanse the glucometer. She indicated this is how she normally cleans the glucometers after using them. LPN 3 intervened at this time and indicated the facility's policy does not utilize alcohol wipes to sanitize the glucometer, but utilizes a bleach solution product to clean and sanitize the glucometer and to leave it wrapped in the bleach solution product to keep it wet for a designated amount of time. LPN 3 was observed to obtain a bleach solution container from the medication cart and demonstrated to the QMA how to sanitize the glucometer. In interviews conducted on 2-22-24 with QMA 5, QMA 6 and QMA 7, each indicated the facility provides annual, or more often, training on diabetic care, including glucometer use and how to sanitize the glucometer after each use with the bleach solution product. Each QMA indicated all 3 medication carts in the building has a glucometer and is used to check blood sugars to more than one resident. A review of Resident H's physician orders indicated she was ordered, effective 10-19-23, for blood sugar testing at bedtime for diabetes mellitus with result parameters of notifying the physician for results less than 70 or greater than 350. Resident H's results were elevated at 266. In an interview with the Director of Nursing (DON) on 2-22-24 at 10:50 a.m., she provided a listing of 16 of 65 current residents who currently have physician orders to receiving blood glucose testing. She indicated there are currently no residents she is aware of with any type of bloodborne pathogen or diagnoses. She indicated the facility does not have any specific policies or procedures regarding to how to sanitize the glucometer, but provided a copy of the manufacturer's recommendations for disinfecting the glucometer with a product containing a bleach disinfectant. The DON provided documentation of QMA 2's annual training record which identified her most recent documented diabetic testing education occurred March, 2023. On 2-21-24 at 1:15 p.m., the DON provided a copy of a policy entitled, Infection Control - Blood Glucose Machine Safe Injection Practices to Prevent Resident Transmission of Bloodborne Pathogens. This policy had a revision date of 10-20-22, and was indicated to the current policy utilized by the facility. This policy indicated, It is the policy of this facility to prevent the spread of infections and bloodborne pathogens when using blood glucose testing devices .Clean and disinfect blood glucose machine environmental surface with an EPA approved germicide before and after testing the resident's blood glucose and between each resident use . 3.1-18(b)(2) 3.1-18(b)(4)

Based on interview and record review, the facility failed to ensure 1 of 4 residents reviewed for pain medication received pain medications as ordered by their physician. (Resident B) Findings include: In an interview on 2-20-24 at 1:41 p.m., with Resident B, she indicated her primary concern is getting her pain medication as ordered. She indicated it is ordered routinely at 6:00 a.m., 2:00 p.m., and 10:00 p.m., and also has an as needed order for the same medication that she can receive one tablet every 12 hours as needed for pain. She indicated some staff give her pain medication too early and some administer it late, which can make it hard to keep her pain at bay. The clinical record of Resident B was reviewed on 2-20-24 at 9:42 a.m. Her diagnoses included, but were not limited to, chronic obstructive pulmonary (lung) disease (COPD), dementia, diabetes, chronic respiratory failure, unspecified heart failure, fibromyalgia, chronic atrial fibrillation, high blood pressure and glaucoma. Her most recent Minimum Data Set analysis, dated 1-8-24, indicated she is moderately cognitively impaired, requires a walker or wheelchair for mobility and receives scheduled and as needed (PRN) pain medications. A review of Resident B's narcotic pain medications orders were as follows: -Norco Oral Tablet 5-325 milligram (mg) (Hydrocodone-Acetaminophen), give 1 tablet by mouth every 12 hours as needed for moderate to severe pain was ordered on 2-1-24. -Norco Oral Tablet 5-325 mg (Hydrocodone-Acetaminophen), give 1 tablet by mouth three times a day at 6:00 a.m., 2:00 p.m. and 10:00 p.m., effective 2-1-24. This was a time change order from the previous administration times of 7:00 a.m., 3:00 p.m. and 11:00 p.m. A review of Resident B's January and February, 2024 narcotic logs for her Norco and her medication administration records (MAR) revealed the following: -The routinely scheduled Norco was ordered to be administered at 7:00 a.m., 3:00 p.m., 11:00 p.m. during the month of January. -1-5-24, the 7:00 a.m. dose was given late at 8:30 a.m., but documented on the MAR as given at the scheduled time. -1-5-24, the 11:00 p.m. dose was given early at 9:00 p.m., but documented on the MAR as given at the scheduled time. -1-8-24, the 11:00 p.m. dose was given late on 1-9-24 at 12:06 a.m., but documented on the MAR as given at the scheduled time. -The routinely scheduled Norco administration time was changed on 2-1-24 to 6:00 a.m., 2:00 p.m., and 10:00 p.m. -2-3-24, the 6:00 a.m. and 2:00 p.m. doses were not documented on the narcotic log, but were documented on the MAR as given at the scheduled time. -2-9-24, the 6:00 a.m. dose was not documented on the narcotic log, but was documented on the MAR as given at the scheduled time. -2-17-24 and 2-18-24, the 10:00 p.m. dose was administered too early at 8:00 p.m., but were documented on MAR as given at the scheduled time. Resident B's care plans for pain/discomfort r/t [related to] osteoporosis and chronic left knee pain and fibromyalgia, was initiated on 1-27-21, and most recently revised on 5-9-23, indicated as an intervention, Administer pain medication per MD order. On 2-21-24 at 1:15 p.m., the Director of Nursing provided an undated copy of a policy entitled, Medication Administration. This policy indicated, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection .Administer within appropriate time frame prior to or after scheduled times unless otherwise ordered by physician. In an interview with the Direction of Nursing on 2-22-24 at 8:40 a.m., she clarified the medication administration policy, referring to appropriate time frame. She indicated this means within one hour before or one hour after the scheduled administration time. This Federal tag relates to Complaint IN00427915. 3.1-37(a)

Based on observation, interview, and record review, the facility failed to: 1. Complete a fall risk assessment and implement fall interventions resulting in a fall requiring 6 staples, and failed to thoroughly investigate the root cause of a fall and maintain the resident's bed in a safe position. (Resident 43) 2. Utalize two staff for bed mobility for a resident assessed as requiring two assistance, resulting in the resident falling out of bed and requiring 16 sutures to the facial and scalp area. (Resident 14). This affected 2 of 3 residents reviewed for falls. Findings include: 1.) Interview with LPN 1 on 3/29/17 at 1:42 p.m., indicated Resident 43 fell out her wheelchair on 3/19/17 and was sent to the emergency room and required staples to the top of her scalp. During observation on 03/30/2017 10:29 a.m., Resident 43 was lying in bed with the bed with no staff present in the room, the bed was in the highest position. LPN 1 came into the resident's room and lowered the bed into the lowest position and indicated the resident should not of been left with the bed in the highest position. During observation on 3/31/17 at 2:04 p.m., Resident 43 was laying in bed awake. Resident 43 had no fall prevention interventions observed. Review of the record of Resident 43 on 4/3/17 at 10:10 a.m., indicated the resident's [DIAGNOSES REDACTED]. The record of Resident 43 indicated the resident was admitted to the facility on [DATE] for respite care. The record had no documentation of a fall risk assessment or fall interventions implemented. The Admission Minimum Data Set (MDS) assessment for Resident 43, dated 1/18/17, indicated the resident was severely impaired for daily decision making, the resident was totally dependent of two people for bed mobility, transfers, dressing and toilet use, the resident did not ambulate. The resident had no history of falls in the past 1 to 6 months prior to admission. The nursing occurrence initial assessment for Resident 43, dated 3/19/17 at 7:00 a.m., indicated the resident was in her room and had a fall with injury. The resident was found on the floor at the foot of the bed and had fell out of her wheelchair. The resident's head was against the wheel of the bed. There were a large amount of blood coming from her head and she had a 10 centimeter gash at the top of her scalp. The resident was sent to the emergency room . The local hospital notes for Resident 43, dated 3/19/17, indicated the resident had an unwitnessed fall out of the wheelchair at the facility and suffered a large laceration at the crown of her head. At baseline, the patient is quite demented and screams and curses frequently. The resident had 5 staples placed in her scalp. The post occurrence Interdisciplinary Team (IDT) and fall assessment for Resident 43, dated 3/20/17, indicated the resident was found on the floor at the foot of her bed where she had fallen out of her wheelchair. The resident's head was against the wheel of the bed. The resident had a laceration to her head. The root cause was fell from wheelchair. The IDT recommendations were the resident was not to be left alone in her room if she was up in the wheelchair. Interview with the MDS Coordinator on 4/4/17 at 11:48 a.m., indicated Resident 43 did not have a fall careplan with intervention in place to prevent falls or an fall risk assessment completed. The MDS Coordinator did have a paper copy of fall assessment in her office dated, 1/18/17, which indicated the resident was at high risk for falls. The MDS Coordinator had not entered the fall risk assessment into the resident's record. The MDS Coordinator was going to check the facility policy to see who was responsible to complete a fall assessment and implement fall interventions for newly admitted residents. Interview with the MDS Coordinator on 4/4/17 at 12:31 p.m., indicated the admitting nurse should have completed a fall assessment on 1/9/17 when Resident 43 was admitted . The MDS Coordinator was responsible to implement the fall interventions within 7 days of admission. Interview with Unit Manager 1 on 12:13 p.m., indicated the root cause of Resident 43's fall was she fell out of her wheelchair. The resident was demented and unable to tell us what happened. The Unit Manager was not aware what had the resident been doing prior to the fall, staff were not questioned who were caring for the resident or if the resident was the resident incontinent at the time of the fall. Unit Manager 1 indicated the only thing the IDT knew was the resident was in her room alone. Unit Manager 1 acknowledged a fall care plan with interventions was not implemented and the Director Of Nursing (DON) was responsible to implement the new intervention of not leaving Resident 43 alone in her wheelchair in her room to the careplan. 2.) Review of Resident 14's record on 3/30/17 at 2:10 p.m., specified [DIAGNOSES REDACTED]. A quarterly Minimum Data Set assessment, dated 2/7/17, showed Resident 14's cognition was moderately impaired. Bed mobility was extensive assistance of two staff members. Observation of Resident 14 on 3/30/17 at 2:10 p.m., indicated resident lying in bed with dark purple/bluish bruising and sutures on her forehead, left temple with purple/bluish bruising and sutures, left cheek with purple/bluish bruising and sutures. An interview with the Administrator on 3/30/17 at 2:20 p.m., she stated, they should have had two CNA's when turning Resident 14. Interview with the Director of Nursing on 3/30/17 at 2:45 p.m., she stated, there should have been two CNA's with Resident 14 and she wouldn't have rolled out of bed. Review of incident report dated 3/30/17, indicated, Incident Date: 3/29/17, 5:01 p.m. Brief Description of Incident: 3/30/17, When CNA was providing care resident slid out of bed onto floor, CNA immediately got nurse (5:00 p.m.), nurse arrived, resident was laying face down on floor between beds, noted to have 3 lacerations on face, had no c/o's, stated get me up. Resident assessed, vital signs taken. Physician called and received order to send to ER for eval and treatment, son notified. Returned from ER with sutures in 3 places: area on forehead measures 1.5 cm with 3 sutures, left temple is 2.9 cm with 5 sutures, and left cheek is 3.4 cm with 8 sutures. Ombudsman and APS notified. Immediate Action Taken: Resident assessed and Physician notified. Preventive Measures Taken: cradle mattress to bed, education to staff. Review of Employee Teaching Form dated 3/29/17, Problem: CNA was changing Resident 14 and rolled her out of bed. Solution: Resident in question is to always have 2 staff provide care for her while in bed. Review of the Nursing - Occurrence Initial assessment dated [DATE] at 10: 04 p.m., . Staff called writer to room, resident laying face down on floor between beds, noted x 3 lacerations to left forehead, resident had no c/o, stated get me up. Review of the Post Occurrence assessment dated [DATE], the CNA was providing care to resident in bed. When she rolled her over she slid out of bed . Type of Injury: lacerations to forehead x 3. Root cause: ADL care with assist x 1. IDT recommendations: cradle mattress on bed and 2 staff for care. Fall Risk assessment dated [DATE] at 12:37 a.m., specified, Resident 14 was at risk for falls. Care plan for falls dated 3/29/17, with new interventions, cradle mattress, two staff to provide care. Care plan for Activities of Daily Living stipulated, Bed Mobility: resident requires an extensive to total assist of two staff members. Date Initiated 8/8/16. Review of the Fall Risk Assessment policy dated 3/23/16, stipulated, Purpose: To assess all residents for risk factors that may contribute to falling and to provide planned interventions identified by the team as appropriate for resident use in maintaining or returning to the highest level of physical, social and psychological functioning as possible. Procedure: Complete the fall risk assessment located in EMR (electronic medical record) upon admission . The interdisciplinary health care plan team will review the risk factors and determine if further which interventions are most appropriate for reducing the risk of falls and/or injuries related to falls. Review of a policy titled Care Planning (no date) and indicated Policy: Health Care Plan meetings are scheduled routinely and after a significant change to enable the staff, family and residents to develop an interdisciplinary plan that would allow the resident to reach his/her highest level of mental, physical, spiritual and psychosocial well-being. The Fall Policydated 9/2017, specified, Purpose: To identify residents at risk for falls, initiate interventions to prevent falls and reduce potential for injury. Policy: All residents will have a Fall Risk Assessment on admission; quarterly; annually and with any fall that may occur . Procedure: 1. Residents with a risk for falls will have fall intervention put into per Care Plan. 2. Following any fall, the interventions currently in place will be assessed and updated as appropriate . 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to evaluate a new onset of pain resulting in delayed [DIAGNOSES REDACTED].#53). Finding includes: Resident #53 indicated he had been experiencing unrelieved pain in his right foot and ankle on 2/25/16 at 1:53 p.m The resident indicated the facility had given him pain medicine for the pain, but sometimes it did not relieve the pain. In an interview with the Wound Nurse on 2/29/16 at 1:02 p.m., indicated Resident #53 had a pressure ulcer on his right ankle. The Wound Nurse indicated she had changed his dressing on this day. The Wound Nurse indicated the resident had a little bit of pain during the dressing change. The Wound Nurse indicated no usually he isn't given pain medication prior to the dressing change. Review of the Medication Administration Record [REDACTED]. On 3/1/16 at 2:45 p.m., LPN #1 was providing wound care to Resident #53's pressure ulcer on his right ankle and lateral outer aspect of his right foot. Resident #53 screamed in pain during the dressing change. The resident's entire right foot was moderately swollen. The resident indicated on pain scale from 1-10 his pain was above a 10 (the worst pain possible). The resident indicated he was unable to stand on his right foot at all. The resident had facial grimacing and wincing during the dressing change on his right foot. LPN #1 indicated she had been aware of the resident's right foot pain for a week or so. She indicated she was a float nurse and when she started investigating the resident's pain today, she became aware he had not had an x-ray so requested an x-ray to be done. LPN #1 indicated she was getting off work, but would tell the oncoming nurse to give the resident pain medicine. Review of the record of Resident #53 on 3/1/16 at 2:15 p.m., indicated the resident's [DIAGNOSES REDACTED]. The pain careplan for Resident #53 had a revision, date of 10/23/15, there were no interventions on the care plan related to pain of his right foot. The record of Resident #53 indicated the last pain assessment completed was, dated 12/31/15, with a report of no pain. The Quarterly Minimum Data Set (MDS) assessment for Resident #53, dated 1/6/16, indicated he was able to make himself understood and had the ability to understands others and had not experienced pain in the last 5 days Progress note dated, 2/9/16 at 3:51 p.m., indicated complaints of right ankle pain, mild swelling noted, Nurse Practitioner (NP) to evaluate, no orders at this time. Electronically Signed by LPN #1. The Physician order [REDACTED]. The NP progress note for Resident #53, dated 2/11/16, indicated the resident had right ankle swelling with pain. The note indicated the resident complained of right ankle pain which was also swollen. The note indicated the resident reported It really hurts right now when you touch it. The resident has an open area to the ankle with a treatment in place. Review of the Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]foot pain The MAR indicated [REDACTED]. The progress note for Resident #53, dated 2/29/16 at 9:48 p.m., indicated the resident continued with right ankle pain, was holding his leg up on sit to stand lift and would not bear weight. The note indicated an x-ray had not been ordered and one was to be requested and will refer to therapy for further transfer assessment. Electronically Signed by LPN #1. The NP progress note for Resident #53, dated 3/1/16 (no time), indicated they were asked by the Medical Doctor (MD) to see the resident who complained of having right ankle pain and swelling. The note indicated the resident reported no improvement and experienced pain when palpated or with range of motion. The NP wrote an order for [REDACTED]. Review of Resident #53's Medication Record Administration (MAR) for March 2016, indicated the resident did not receive pain medication ([MEDICATION NAME] 50 milligrams) on 3/1/16 at 8:00 p.m., which was 4 hours and 15 minutes after he expressed a pain level greater than 10. The progress note for Resident #53, dated 3/2/16 at 3:10 p.m., indicated the resident was ordered an orthopedic consult, non-weight bearing of the right leg and hoyer (mechanical lift) lift for all transfers. . On 3/2/16 at 10:36 a.m., Resident #53 indicated he did not feel good and his right foot was hurting him. He said it had been hurting for days. The resident indicated it has been a living h---. He indicated his entire right foot was painful. and he could not put any weight on it. The resident had on an ace bandage on his right foot. He indicated he would like to know what was going on and he was suppose to have an x-ray. Interview with LPN #2 on 3/2/15 at 11:06 a.m., indicated she gave Resident #53 his PRN [MEDICATION NAME] at 11:00 a.m. for complaints of right foot pain and the resident had indicated it was a 10 on 1-10 pain scale. On 3/2/16 at 11:08 a.m., CNA #3 and CNA #4 transferred Resident #53 from his wheelchair to the bed, using a stand up mechanical lift. The resident was trying to keep weight off his right foot during the transfer, with only the tips of his toes on the right touching the lift. The resident had moaning and facial grimacing during the transfer. CNA #1 and CNA #2 indicated the resident had been experiencing pain with his right foot for awhile now. In an interview on 3/2/16 at 12:40 p.m. the Director Of Nursing (DON) indicated Resident #53 had not had a pain assessment since 12/31/15. The DON indicated the nurse caring for Resident #53 should of completed a pain assessment after the new on set of right foot pain on 2/9/16. The DON indicated the resident did not receive any pain medication on 3/1/16 until 8:00 p.m. The DON indicated the nurses communicate from shift to shift about pain during a verbal report. The DON indicated she was unable to find documentation of monitoring for the effectiveness of the pain medication ([MEDICATION NAME]) ordered on [DATE] for the resident's right foot pain. The Radiology report for Resident #53, dated 3/2/16, indicated and x-ray was completed of the right ankle and indicated a fracture involving the distal fibula (bone between the knee and ankle) with mild displacement. The pain policy provided by the Director Of Nursing (DON) on 3/2/16 at 11:40 a.m., the purpose was to identify those resident who utilize frequent PRN or routine medications for pain control and evaluate efficacy thereof. The policy was each resident shall be assessed for presence of complaint of pain and/or lack of pain relief following currently ordered pain medication administration. If ineffective relief is noted, a pain assessment shall be completed in an effort to assess location, frequency, etc and notify the physician accordingly to ensure currently ordered pain medication is evaluated and revised as necessary. If a resident verbalizes pain, unaffected by the currently ordered pain medication, and/or exhibits non-verbal communication that pain is present, the resident shall be identified and reviewed per pain assessment to ensure said pain symptoms are evaluated and communicated to the attending physician. Any change in condition affecting pain and/or medication shall be evaluated by the Interdisciplinary team during careplan review and notification made to the physician. The plan of care for the individual resident shall be reviewed to ensure pain management is addressed accordingly. 3.1-37(a)

Based on observation, record review and interview, the facility failed to ensure residents at risk for pressure ulcer development received interventions to prevent pressure ulcers. This resulted in Resident #F developing a stage 2 pressure ulcer that progressed to a stage 4, was referred to the wound clinic on 11/30/15 when the wound failed to heal, then required hospitalization on [DATE] for further treatment of [REDACTED].#J was found with a stage 3 wound under a brace; and Resident # E acquired 2 stage 2 pressure ulcers on his right ear from unpadded oxygen tubing. The immediate jeopardy began on 8/24/16 when Resident #F acquired a pressure ulcer while a resident of the facility. The Administrator and Director of Nursing were notified of the immediate jeopardy, related to pressure ulcers, on 1/21/16 at 4:20 p.m. The immediate jeopardy was removed on 1/22/16 at 5:55 p.m., but noncompliance remained at the lower scope and severity level of isolated no actual harm with potential for more than minimal harm that is not immediate jeopardy, because not all staff had been inserviced on policies, reporting and documenting changes in skin condition. Findings include: 1. Resident #F's record was reviewed on 1/19/16 at 9:42 a.m. Current physician's orders [REDACTED]. Current physician's orders [REDACTED]. Supplements indicated: prostat 30 milliliters twice a day, a therapeutic vitamin with minerals once a day, and calcium [MEDICATION NAME] 600 milligrams with 200 international units of vitamin D. Current physician's orders [REDACTED]. and left heel 2 X a day (12/7/15) Braden scale assessments for predicting pressure ulcer risk, one dated 7/2/15 and one dated 9/2/15, indicated a total score of 12, which indicated a high risk for pressure ulcers. A quarterly Minimum Data Set Assessment (MDS) assessment, dated 9/3/15, indicated Resident #F was severely impaired in cognitive skills for daily decision making, rarely/never made decisions, was totally dependent on two of staff for bed mobility, did not ambulate, required assist of one staff for eating and bathing, was always incontinent of bowel and bladder, was at risk for pressure ulcers, and had one stage two pressure ulcer that was not present upon admission. A significant change MDS assessment, dated 11/28/15, indicated Resident #F was severely impaired in cognitive skills for daily decision making, rarely/never made decisions, was totally dependent on two of staff for bed mobility, did not walk, required assist of one staff for eating and bathing, was always incontinent of bowel and bladder, was at risk for pressure ulcers, and had two stage two pressure ulcers and one unstageable pressure ulcer with eschar (slough or dead tissue). A Skin Condition Report was initiated on 8/24/15, with a stage 2 (top layer of skin was gone) pressure ulcer on the sacral area that measured 1 centimeter by 1.5 centimeters, had no depth, was red in color with no drainage or odor present. This area was measured weekly, and on 10/12/15 the area was 2 centimeters by 2 centimeters and 0.1 centimeters in depth, was assessed as unstageable, was yellow in color, and had serous drainage and no odor. A Physician Orders/patient Instructions from a wound center, dated 11/30/15, indicated the [DIAGNOSES REDACTED].low air loss bed, up in chair for meals only, turn side to side (every) 2 hours. A Physician Orders/patient Instructions from a wound center, dated 12/14/15, indicated: .Keep weight off of wound. A Physician Orders/patient Instructions from a wound center, dated 12/21/15, indicated .Not to be in chair (no) longer than 1 hour. On 1/22/16 at 3:44 p.m., the Director of Nurses indicated When the wound center sends recommendations they would be entered as an order and put on the care plans. A care plan, initiated 8/24/15, indicated a focus of (Resident #F) has pressure ulcer to coccyx development r/t (related to) immobility. Goal: The resident's pressure ulcer will show signs of healing and remain free from infection by/through next review date (12/11/15). Interventions: 30 ml (milliliters) prostat (high protein supplement) BID (twice a day) w/meds (with medications). Date initiated: 12/11/15. 4 oz (ounces) healthshake TID (three times a day) w/meds. Date initiated: 1/18/16. 4 oz pureed cottage cheese @ L&S (lunch and supper). Date initiated: 12/11/15. Administer treatments as ordered and monitor for effectiveness. Date initiated: 8/24/15. Anchored Foley catheter Date initiated: 11/25/15. Assess/record/monitor wound healing Measure length, width and depth where possible. Assess and document status of wound perimeter, wound be and healing progress. Report improvements and declines to the MD. Date initiated: 8/24/15. Avoid positioning the resident on her back. Date initiated: 8/24/15. Educate the caregivers as to causes of skin breakdown; including: transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning. Date initiated: 8/24/15. Follow facility policies/protocols for the prevention/treatment of [REDACTED]. Inform the resident/family/caregivers of any new area of skin breakdown. Date initiated: 8/24/15. Low air loss mattress to bed and pressure reducing cushion to WC. Date initiated: 8/24/15. Monitor dressing to ensure it is intact and adhering. Report loose dressing to nurse. Date initiated: 8/24/15. Monitor nutritional status. Serve diet as ordered, monitor intake and record. Date initiated: 8/24/15. Monitor/document/report PRN (as needed) any changes in skin status: appearance, color, wound healing, s/sx of infection, wound size (length X width X depth), stage. Date initiated: 8/24/15. Staff to lay (Resident #F) down after meals. Date initiated: 10/21/15. Supercereal @ B (breakfast). Date initiated: 1/18/16. The resident needs 2 person assistance to turn/reposition at least every 2 hours, more often as needed or requested. Date initiated: 8/24/15. The resident requires supplemental protein, vitamins, as ordered to promote wound healing. Date initiated: 11/25/15. Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate. Date initiated: 8/24/15. Wound clinic weekly. Date initiated: 11/25/15. On 1/19/16 at 9:20 a.m., Resident #F was observed sitting up in bed, with the head of her bed up 30 degrees. CNA #2 indicated she was going to lower the head of her bed and turn Resident #F onto her side. CNA #2 indicated Resident #F has been sitting up since she ate breakfast, about an hour and a half. CNA #4 entered the room to assist CNA #2 to turn the resident. Resident #F had heel guards on both heels and her heels were not floated off the bed. Both hands were clenched and CNA #4 opened the hands; the fingernails were long, jagged and discolored. The incontinence pad under Resident #F was saturated, about 1/4 of the pad directly under the resident's buttocks, and CNA #4 indicated it was from the wound seeping. The wet incontinence pad was removed and a clean one placed under the resident. The dressing and adhesive covering over the wound on the sacrum was also wet. The CNAs turned the resident on her right side, placed a folded sheet between her knees, and raised the head of the bed up about 10 -15 degrees. The resident's heels were not floated off the bed and she was not wearing her compression stockings. During an observation, on 1/19/16 at 11:31 a.m., Resident #F remained on her right side, and LPN #3 indicated she was waiting for LPN #1 to do the wound treatment. Resident #F had not had the dressing changed after it was observed to be saturated. On 1/19/16 at 12:40 p.m., CNA #2 was observed feeding Resident #F while the resident was sitting up in bed with the head of the bed raised 30 - 35 degrees. During an anonymous interview, Resident #F was reported to have been observed sitting up in her wheelchair from 4:30 p.m. to 9:00 p.m. one night, and from 4:30 p.m. to 7:30 p.m. one night. During an interview, on 1/22/16 at 9:30 a.m., Resident #M indicated she has observed Resident #F sitting up for 3 to 4 hours at at time in her wheelchair. On 1/19/16 at 1:53 p.m., the dressing on the sacral area was changed by LPN #1 with assistance from LPN #3. The resident was laying on her left side, the saturated dressing was removed, and the packing inside the wound was removed. The wound was observed to be a stage 4 pressure ulcer, black inside an area that was approximately 3 inches by 3 inches round inside the wound and deep into the sacrum. The wound had yellow drainage with an odor that permeated the room. The inside of the wound was cleansed with normal saline and santyl ointment was applied to gauze that was then placed on the inside of the wound, packed with gauze, and covered with an adhesive coverall. LPN #1 used skin prep on the areas on the resident's left foot; the inner heel of the left foot had a stage 2 pressure ulcer, and the base of the left toe had an unstageable pressure that was approximately 1 centimeter by 2 centimeters. A folded sheet was placed between her knees, she was wearing the heel protectors, and her heels were not floated off the bed. When queried, LPN #1 indicated Resident #F's heels are supposed to be floated, left the room and brought a pillow in, then placed it under the lower legs to raise her heels up off the bed. During an interview, on 1/20/16 at 1:46 p.m., LPN #1 indicated if a dressing is saturated with drainage from a wound, the CNA should tell the nurse and she should go down and assess the dressing. LPN #1 indicated Resident #F's pressure area started in August 2015 as a stage 2 area, then progressed rapidly. The nurses had her check it, and the nurse practitioner was here on 10/19/15 and looked at it. 10/26/15 was the first date it was documented as unstageable. 11/30/15 was the first time Resident #F went to the wound care clinic; it was staged as unstageable and debrided there. Resident #F went to the wound clinic today (1/20/16) and they didn't do a culture, but the physician there said it was a possibility. LPN #1 also indicated Resident #F had been given zinc 220 milligrams and Vitamin C 500 milligrams for 30 days. During an interview, on 1/21/16 at 1:40 p.m., CNA #2 indicated Resident #F should sit up no longer than an hour and a half, then would be laid down as soon as possible. During an interview, on 1/21/16 at 2:14 p.m., CNA #12 indicated Resident #F gets up for one meal now, she gets up for lunch, then lays down an hour to an hour and half when she finishes eating; we lay her down. A Physician Orders/patient Instructions from a wound clinic, dated 1/20/16, indicated: .Go to ER. emergency room notes for the hospital Resident #F was sent to, dated 1/20/16, indicated Patient presents from (name of physician) office, (name of town), because of the report of this patient having increased findings of her sacral decubitus, he has been [MEDICATION NAME] this and has noticed a sudden change. Concern [MEDICAL CONDITION] as the patient also said change in mental status with this. Upon arrival patient is nonverbal she will not open her eyes to verbal command. She will however (call) out in pain when she is rolled on her side. Patient is febrile on arrival .Have spoken with (wound clinic physician). Wound is not improving at all with debridement. It appears to me that the wound has enteral contents, possible rectal fistula .will not improve even with aggressive care to include diverting [MEDICAL CONDITION]. In my opinion, patient best treated with comfort care/hospice .On re-exam patient's condition has not changed. She will not open her eyes to verbal stimuli .A culture of the wound is collected and sent to the lab. Patient's urinalysis is positive for infection, and this is another possible source .will admit the patient .sepsis due to unspecified organism .Disposition .Acute care .Condition: Serious. 2. Resident #J's record was reviewed on 1/21/16 at 11:35 a.m. Current physician's orders [REDACTED].#J was admitted with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. physician's orders [REDACTED]. During an interview, on 1/21/16 at 1:22 p.m., Physical Therapy Assistant #7 indicated CNAs were trained on how to put the brace on initially and how to fasten the strap. The CNAs were trained on tightening it more while he was walking due to his ankle would roll out to the side. She said the strap that is on there is designed to pull his ankle into a more neutral position and as he progressed with his walking the tightening wasn't needed. On 1/20/16 at 12:56 p.m., with LPN #1 and LPN #5, Resident #J's left lateral ankle was observed and had an area about 1.5 cm by 1.5 cm with depth. A line of dried blood about 3/4 of an inch long had seeped from the wound and dried on the skin below the wound. The wound was cleansed with normal saline and a xeroform treatment covered with a foam dressing was applied. Dried blood was observed inside the padded area of the brace where his outer left ankle would touch. LPN #1 indicated at that time, Resident #J has been referred to physical therapy for evaluation of the brace on his shoe to see if it is causing the pressure area. Resident #J indicated, on 1/20/16 at 1:08 p.m. that his foot falls to the left if he doesn't wear the brace, and about 5 weeks ago when the CNAs took off his TED (compression stockings) hose at night, there was blood on them and after it happened a few times the CNAs let LPN #1 know. He indicated his brace was repaired yesterday. A Weekly Wound Assessment dated 1/18/16, indicated the onset of the wound was 1/18/16, the wound was acquired in facility, and was a stage 3 pressure ulcer when found. A Skin observation tool dated 1/11/16, indicated Skin warm, dry and intact. No skin alterations to report at this time. CNA Skin Check Forms, completed during showers or baths, dated 1/12/16 and 1/15/16, did not have any skin issues identified during the resident's shower/bath. A quarterly Minimum Data Set assessment (MDS), dated [DATE], indicated Resident #J was cognitively intact, required extensive assistance of one for bed mobility and transfers, required limited assistance for walking in his room and the hallway, had impairment on one side for functional limitation in range of motion, used a cane and a wheelchair, and was at risk for developing pressure ulcers. A care plan, dated 6/10/15 and last revised on 12/4/15 indicated a focus of: (Resident #J) requires AFO (Ankle/Foot Arthrosis) brace left side for stabilization at all times. Goal: (Resident #J) will have AFO brace on left leg at all times except for bathing. Interventions: Ensure left leg brace is on. Drags foot without brace on. Report to nurse any discolored/open areas possibly caused by brace. Refer to therapy as needed for any changes in abilities or problems with brace. Remove brace for bathing and reapply. If you do not know how to apply brace, see nurse. Report to nurse if (Resident #J) refuses to wear left leg brace. During an interview, on 1/20/16 at 1:46 p.m., LPN #1 indicated she does skin assessments weekly and found the area; she spoke with physical therapy and they came out yesterday and adjusted a strap that was loose. She had not been informed of any skin problems; was told on Monday that it was a stage 3. It is on his affected side, he had a stroke and has had issues with that foot. She also indicated he hasn't had any skin issues for awhile; he was walking to and from the dining room and stretched the leather out. She said a stage 3 could have developed quickly especially because he wears a brace. He gets a lotion applied every night to his feet, and needs assistance to go to bed, and the CNAs take his compression stockings off. During an interview, on 1/21/16 at 4:40 p.m., CNA # 6 indicated she has observed blood a couple of times on Resident #J's TED hose, and she washed them out then reported it to the nurse. She indicated the area of blood was slightly larger than a quarter. During an interview, on 1/21/16, at 4:50 p.m., CNA #13 indicated she has observed blood. During an interview, on 1/22/16 at 9:43 a.m., Resident #J indicated 6 or 7 weeks ago, it would bleed when the CNAs took the TED hose off at night. He would see blood on the TED hose and it had rubbed and bled at least 6 weeks. During an interview, on 1/22/16 at 10:08 a.m., the Director of Nurses indicated the brace was not on the current physician's orders [REDACTED]. 3. Resident #E's record was reviewed on 1/19/15 at 11:20 a.m. Current physician's orders [REDACTED]. A significant change MDS, dated [DATE], indicated Resident #E was severely cognitively impaired, was at risk for pressure ulcer development, used oxygen therapy and did not require suctioning. A care plan, initiated on 3/4/15, indicated a focus of: Risk for skin breakdown secondary to Pruritis, hx (history of) [MEDICAL CONDITION], weight loss, and decrease mobility. Goal: Skin will remain free of breakdown thru next review. Interventions: Assist with ADL care to extent needed. Call light in reach. Diet per order. Meds as ordered. Monitor condition of skin during routine daily care. Report any discolored, open or sore areas to nurse. Notify Hospice of skin breakdown or concerns. Pressure relieving mattress on bed. Refer to dietitian PRN (as needed). Supplements as ordered. Therapy if ordered. Up in (specialty wheelchair) daily for meals as tolerated. Weekly skin assessment by a nurse. A Skin Observation Tool dated 1/18/16, indicated beside right ear, scab lesion area, length 1 (centimeter) width 0.5 (centimeter) and 0.1 (centimeter) depth. The note on the Skin Observation Tool indicated: Area beside right ear with dry scab. No redness or s/s infection. No exudate. Spoke with (Resident's family member) on 1-13-16 about area and condition. Current physician's orders [REDACTED]. During an observation, on 1/20/16 at 11:26 a.m., Resident #E was in bed, the head of his bed was up 35 degrees, his eyes were closed, his oxygen tubing was in place and across the tops of both ears. Over the right ear, where the oxygen tubing touched the skin, two small stage two open areas were observed; the open area closer to the top of his head had no drainage, and the open area closer to his ear was moist. The tubing laid on the moist open area and the tubing was not padded. A family member was present when these two open areas were observed. During an interview, on 1/20/16 at 1:46 p.m., LPN #1 indicated the areas on his ear were discovered today, he wears oxygen every day and has had the tubing covered with foam in the past; the nurses and CNA's usually monitor it. During an interview, on 1/21/16 at 12:58 p.m., Hospice CNA #14 indicated she has not observed the oxygen tubing padded where it touches his ears. A Skin Condition and Pressure Ulcer Assessment Policy was provided by the Director of Nurses on 1/21/16 at 9:35 a.m. The policy indicated, but was not limited to, Purpose: To establish guidelines for assessing, monitoring, and documenting the presence of skin breakdown and pressure or other ulcers and assuring interventions are implemented. Policy: It is the policy of this facility that pressure, other ulcers and skin problems will be assessed and measured at least every seven (7) days by a licensed nurse and recorded on the facility skin report form. Any significant changes between seven (7) day assessments will be recorded in the nursing progress notes and skin report record .5. Each resident will be observed for skin breakdown daily during care and on the assigned bath day by the CNA. Changes shall be promptly reported to the charge nurse who will perform the detail assessment. 6. If a resident receives a shower, it will be necessary to have the resident stand or be returned to bed to visualize the buttock and groin areas. 7. Caregivers are responsible for promptly notifying the charge nurse of skin observations that include. g. any type of lesion .wound drainage . The immediate jeopardy that began on 8/24/15 was removed on 1/22/16 at 5:55 p.m., when the facility educated staff on policies, reporting and documenting changes in skin condition, but noncompliance remained at the lower scope and severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy, because not all staff had been inserviced on policies, reporting and documenting changes in skin condition. This Federal tag relates to Complaint IN 948. 3.1-40(a)(1) 3.1-40(a)(2)

Based on record review, observation, and interview the facility failed to ensure a resident was transferred safely, utilizing a sit to stand lift, which resulted in a fractured right ankle for 1 of 3 residents reviewed for accident/hazards. (Resident #B) Findings include: Resident #B's record was reviewed on 6/22/15 at 3:45 p.m. The record indicated Resident #B was admitted with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment, dated 5/18/15, indicated Resident #B had no impairment in cognitive skills for daily decision making, had no long term memory or short term memory problems, required extensive assist of 2 for transfers, did not walk, and used an electric wheelchair for mobility. A fall risk assessment, dated 4/9/15, indicated a total score of 15, where a score above 10 indicated a high risk for falls. A care plan, with a revised date of 6/15/15, indicated, but was not limited to, Requires use of mechanical lift and 2 staff assist for transfers. Goal: No injuries related to use of mechanical lift x90 days. Interventions.Do not move lift quickly while (Resident #B) is in the air. Move slow to decrease fear of fall r/t (related to) quick movements. Left lift down slowly. A Change in Condition form, dated 6/2/15 at 4:00 p.m., indicated: Resident was being assisted for transfer from w/c (wheelchair) to toilet using mechanical lift when her legs became weak and knees buckled causing her to twist lt. (left) foot/ankle. Assisted to sitting position by nurse/CNA. A progress note, dated 6/3/15 at 10:26 a.m., indicated: ITD (Interdisciplinary) team met to review incident that happened 6-2-2015 resident was being transferred to the toilet from the wheelchair and during transfer residents legs became weak and twisted and resident was unable to recover footing. This resulted in a nurse lowering the resident to the floor, resulting in a controlled fall. Immediate assessment completed and during the assessment resident complained of ankle pain. MD (Physician) and family notified orders received to complete X-ray of the ankle which revealed a fracture to the lower tibia (leg bone). Resident to see ortho(pedic) appt. (appointment) to be made. An Employee Counseling Record for CNA #7, dated 6/8/15, indicated Employee was in orientation and was transferring a resident via stand up lift. Employee was unaware that using a lift required 2 people. Resident legs gave out and twisted under resident. Another employee assisted this employee to lower resident to the ground. The corrective action was: (1) Always have CNA ticket with you (employee unaware of tickets). (2) Utilize 2 people with all mechanical/stand up lifts. On 6/22/15, at 4:15 p.m., Resident #B was observed in bed with a splint type cast on her lower left leg. She indicated she broke her ankle and her nurse was getting her something for pain. During an interview, on 6/25/15 at 9:35 a.m., Resident #B indicated she didn't think the girl was properly trained, and dropped her and fractured her leg on June the second, the day before her birthday. She said she hasn't walked in several years, didn't remember how many used the (sit to stand) lift on that day, but they use the ***** (brand name of assistive transfer device) lift now when they transfer her. During an observation, on 6/25/15 at 10:20 a.m., Resident #B was transferred from her bed to her motorized wheelchair by CNA #4, CNA #5, and RN #6. Resident #B was pleasant, talked and laughed with the staff and was not afraid during the transfer. During an interview, on 6/25/15 at 2:24 p.m., CNA #7 indicated she had been told Resident #B used the sit to stand lift, and she got her up to go to the bathroom. When she got her up, her right leg got off the platform and she went to get help and they had to lower her to the floor. She said she was told Resident #B could, and then was later told she couldn't, be transferred with the sit to stand lift and she didn't have a CNA assignment sheet that day. She indicated this was the second day she was back to work, and found out later she was supposed to have a trainer and that wasn't communicated to her. The Administrator provided an Operation Manual for the utilization of the sit to stand lift and the care lift on 6/25/15 at 9:30 a.m., as their policy and procedure. The manual indicated, but was not limited to, .While we believe that one person can safely operate our equipment, each facility has its own policies and procedure regarding the safe lifting and transfer of patient/residents.We advocate that your facility staff members follow your policies and procedures in all circumstances. The Administrator indicated the mechanical lifts must be used by two staff at all times. This Federal tag relates to Complaint IN 476. 3.1-45(a)(2)

Based on interview and record review, the facility failed to ensure a resident was free from a significant medication error, resulting in a 3 day hospitalization for an inadvertent drug overdose with medications that were not her own, for 1 of 6 residents reviewed for unnecessary medications. (Resident #52) Findings include: The clinical record for Resident #52 was reviewed on 12/11/14, at 10:30 a.m. The [DIAGNOSES REDACTED]. An interview was conducted with Resident #52 on 12/10/14, at 1:40 p.m. She indicated, "One nurse gave me someone else's pills, and near about killed me....I had to go to the hospital for 4 days. They pumped my stomach. She got fired, (name of nurse), when the facility found out how bad it was. She looked high all the time. I know the cup was about full. The doctor said I was that close (Resident #52 put her thumb and index finger in the air, and pinched them almost together) to dying." I was out of it at the hospital. I don't remember nothing (sic). One of the aides found me, I guess. I don't even remember going to the hospital. I guess I fought the people at the hospital, because I was so out of it." An interview was conducted with the DON (Director of Nursing) on 12/11/14, at 11:00 a.m., regarding whether there was an unusual occurrence with Resident #52 a few months prior. She indicated, "There was an unusual occurrence with her. We had an impaired nurse in the building, and she was definitely impaired, because I came in and saw her. It was (full name of nurse). I immediately took her off the floor. I asked her to do a drug test, and she wouldn't. She was escorted out of the building. Later on that night, (name of Resident #52) said she wasn't feeling right, so we sent her out to the hospital. I told them to do a drug screen. The only meds (medications) we found missing at that time were benzos (benzodiazapines). She tested negative for benzos. She did test positive for tricyclics. [MEDICATION NAME] (not a tricyclic) is on her scheduled med (medication) list. The nurse was scheduled from 3-11 (p.m.). I escorted her out of the building at 8:30 or 9:00 (p.m.). Another staff member called me to say she was impaired. (Name of Resident #52) said she didn't feel good....Her psyche doctor said she may have had a psyche reaction. I counted all the meds, all the narcotics, put a new system in place. I think the discharge summary said she potentially got too many meds. Her own doctor, (name of Resident #52's doctor) said it was [MEDICATION NAME]. I know [MEDICATION NAME] is not a tricyclic, but there is some sort of relationship to that. I never thought about that she could have received someone else's meds and that person didn't get there's, in which case our count wouldn't be off, but any of those residents would have told me, if they didn't get their meds. The impaired nurse is the one who gave (name of Resident #52) her evening meds." The 8/25/14, 3:00 a.m., Hospital emergency room records indicated the following: "Physician Comments:...presents to the emergency department with altered mental status. According to report from EMS (emergency medical staff), the patient might have been given an extra dose of medication this evening. EMS states that the nurse reports that she had one dose of medicine at her usual time. A second nurse then came to give her medication later in the evening. According to report from EMS, patient told the nurse that she had already received her evening medications but took the second set of medications as well. It is unknown what was given at that time. Unfortunately the nurse to distribute these medicines has gone missing. The patient was found at 2:30 in the morning to be unresponsive. According to nursing staff, she will usually easily aroused (sic) when they turn the lights on. They were unable to wake her up this morning. EMS reports that the patient was difficult to arouse. They did not check an oxygen saturation initially. It is unknown what her respiratory rate was. EMS reports that she did have pinpoint pupils. EMS gave 0.5 mg of [MEDICATION NAME]. Patient then violently awoke and became extremely confused and combative. She is very anxious and hallucinating. She had episodes of dry heaves but has not vomited. She was incontinent of urine. The patient cannot articulate any specific complaints at this time, stating only that she has pain all over and feels very cold. She takes [MEDICATION NAME] and scheduled and prn (as needed). She also has a [MEDICATION NAME]....Medical Decision Making:...Differential includes narcotic overdose, medication reaction, polypharmacy, infection, intercranial hemorrhage among others....Progress Notes: Patient continues to have severe agitation with tremors, [MEDICAL CONDITION] hypertension. We will give additional dose of [MEDICATION NAME]. After additional dosing of [MEDICATION NAME], patient continues to be very symptomatic. I was concerned that she might have received other medications I cannot detect. We will give an additional dose of [MEDICATION NAME] as well as IV fluids. I did attempt to contact the nursing staff at (name of nursing facility). I spoke to (name of nurse) who is the patient's night shift nurse. She reports that there were several discrepancies in the system tonight but does not know the exact medications. She suggested that I call the director of nursing, (name of DON). I did speak to (name of DON) and she states that there was a call tonight because of concern about an impaired nurse. It (sic) this nurse was taking care of my patient. She was given 2 medication cups tonight, but is not known what medications the patient actually received. Initially this sounded like a narcotic overdose for polypharmacy. The patient had a very severe reaction to [MEDICATION NAME] and has prolonged symptoms and apartment now. It appears the only major discrepancies that workup tonight were with narcotics and 3 missing benzodiazapines. The director of nursing is unsure if there are any other medications like sedatives, hypnotics or other medications that could cause [MEDICATION NAME] type symptoms. We will continue to monitor. Patient will likely need admission to the hospital. Urine drug screen reveals positive opiates with positive [MEDICATION NAME]. This is on the patient's chronic medication list. Surprisingly, the patient also tested positive for tricyclics. This medicine is not on the patient's list. Poison Center was contacted. Patient's medicine list was reviewed for possible evidence of medications that would test positive for tricyclic antidepressants. Again none of her prescription medicines would test positive. Medications were also reviewed to evaluate for possible [MEDICATION NAME] effects. I believe the patient's symptoms were more like [MEDICATION NAME] effects including severe agitation, tremors, [MEDICAL CONDITION] dry mouth and hallucinations. Patient is also taking a lot of items. Poison Center reports the appropriate on (sic) can cause [MEDICATION NAME] symptoms. They report [MEDICATION NAME] can also cause [MEDICAL CONDITION] hypertension, confusion, [MEDICAL CONDITION], and tremors. They also state that over the counter medicines like [MEDICATION NAME] can cause a positive tricyclic screen as well as [MEDICATION NAME] symptoms. Also after reviewing the EMS report, it appears that the patient was found to be [MEDICAL CONDITION] with initial set of vital signs before [MEDICATION NAME] was given. I am concerned that she might have already been having a toxydrome at this time." The 8/25/14, 4:10 p.m., History and Physical from the hospital indicated the following: "History: ...In the emergency room , she was quite obtunded. She did test positive for tricyclics, which she is not prescribed. There is apparently quite a bit of suspicion that she was given the wrong medications by an impaired nurse. Detail: Patient is too obtunded to really answer any questions. Her family says that 24 hours prior to her hospitalization she seemed "fine." Labs: Urine opiates screen was positive for [MEDICATION NAME] and Tricyclics. Assessment: 1. Significantly altered mental status likely secondary to medication error.... Plan: 1. General supportive care with IV fluids and close observation. 2. Sliding scale insulin. 3. Will hold essentially all of her medicines including her pain medicine at this point. 4. Broad-spectrum antibiotics for skin infection pending culture results." The 8/27/14, 2:15 p.m. Hospital Discharge Summary indicated the following: "Discharge Diagnosis: [REDACTED]. 2. Acute altered mental status secondary to the above.... 4. Fevers felt to be secondary to medication effect." 3.1-25(b)(9) 3.1-48(c)(2)

1. Based on observation, interview, and record review the facility failed to supervise a resident with known wandering and exit seeking behaviors to prevent an elopement from the locked dementia unit and failed to implement a plan for supervising another resident on the dementia unit with known wandering behaviors for 1 of 3 residents reviewed for elopement risk. (Resident #108) This deficient practice resulted in Immediate Jeopardy. The Immediate Jeopardy was identified on 9/27/12 and began on 9/19/12. The Administrator and Director of Nursing were notified of the Immediate Jeopardy on 9/27/12. The Immediate Jeopardy was removed on 9/28/12, but the facility remained out of compliance at the level of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. 2. Based on observation, interview, and record review, the facility failed to ensure potentially hazardous materials were locked up with the potential to affect 7 of 25 residents residing in Heritage Haven/memory care unit, during an random observation (Resident #63, #109, #97, #41, #54, #60, #75) Findings include: 1. The clinical record for Resident #108 was reviewed on 9/27/12 at 11:30 a.m. Resident #108 was admitted to the facility on [DATE]. The [DIAGNOSES REDACTED]. Review of an incident report faxed to the ISDH (Indiana State Department of Health) by the DON (Director of Nursing) on 9/22/12 at 3:13 p.m. indicated, "At approximately 2:40 p.m. unit nurse was aware that visitors on memory care unit were leaving and without direct observation she heard south door to unit close. At 2:45 p.m. an employee of (name of facility next door) adjacent to south facility parking and entrance, notified unit nurse that resident was at parking lot stating he was looking for his car. Unit staff without incident escorted resident back into facility. This resident newly admitted to facility on 9/19/12." Review of a prescription dated 9/17/12 by Resident #108's doctor indicated, "Rx: Emergency admit to skilled facility (lock unit) -dx: Dementia severe 290.0 (wandering)..." Review of the 9/19/12 admission assessment entitled "Resident-Data Collection" indicated, "Orientation To Facility...Unable To Orient (reason)...Need to be told often were (sp) room is @ this time." The assessment also indicated Resident #108 was independent in ambulation. No information could be found in the clinical record to indicate an elopement risk assessment was completed for Resident #108. A care plan for elopement potential was dated 9/22/12, the day Resident #108 was found in the parking lot by a staff member from another facility .There was no care plan developed for the resident's elopement risk prior to 9/22/12 and no specific approaches developed or implemented to prevent the resident's actual elopement on 9/22/12. During an interview on 9/28/12 at 10:40 a.m. with the Care Plan Coordinator, she indicated she would create a care plan for elopement if staff told her the resident was trying to get out or that they did get out, when it's brought to her attention. She indicated no one brought anything to her attention until after Resident #108 eloped from the building on 9/22/12. She indicated she made the elopement care plan on 9/22/12 after his elopement. Review of the nurses notes indicated the following: 9/20/12 7:21 a.m. "Res (symbol for "up and down") many x's (symbol for "throughout") NOC (night). 9/20/12 10:25 a.m. "Res (symbol for "up") et (and) about on unit. Ambulatory (symbol for "with") steady gait." 9/20/12 12:15 p.m. "Res (resident) has begun questioning nurse re: how to get out, why he has to stay, why family did this, etc. Reassurance offered by all staff present." 9/20/12 7:00 p.m. "Stands @ door frequently asking staff to unlock door so he can go home." 9/21/12 6:24 a.m. "Res. restless @ start of shift. Wanting to leave & go home. More difficult to redirect than from prev. (previous) NOC." 9/21/12 10:20 a.m. "Upon first awakening this AM, res. reported to be irritible (sp) and refused to go to DR (dining room) for meal." 9/22/12 2:45 p.m. "Resident left the unit through south doors, staff from children's center informed writer there was a man looking for his car in parking lot, redirected resident in easily." 9/22/12 2:50 p.m. "Resident placed on 15 min. checks." 9/22/12 3:58 p.m. "Wanderguard placed on resident." 9/22/12 4:30 p.m. "Resident continues (symbol for "with") 15 min (minute) (symbol for "checks") stated "do what you got to do, I'll get it off (wonder guard) (sp) - one way or another", resident continues trying doors @ south east et (and) west halls..." During an interview with LPN #1 on 9/27/12 at 12:25 p.m. regarding Resident #108's elopement , she indicated, "I was standing at the nurse's desk. He (Resident #108) was nearby and I could see him." She indicated she saw visitors going towards the south exit doors. She heard the door click, but was down the hallway at the time, and Resident #108 was out of her vision when she heard the door click. She indicated she came back to the nurses station and sat down. She stated, "(Name of facility next door) came over and said there was someone in the parking lot looking for their car. I went outside. It was (name of Resident #108) and I easily redirected him back inside. I almost had a heart attack. There's always a transition period for a new person." An interview with the DON regarding whether, when, and for whom elopement risk assessments are completed was conducted on 9/27/12 at 1:23 p.m. She paused and indicated, "I'm coming up with a blank." She indicated admission assessments include: pain, bowel and bladder, dental, skin, dehydration, fall, and incontinence. She stated, "We do not do an elopement risk assessment on admission. It's not in our packet." During another interview with the DON on 9/27/12 at 2:20 p.m. she indicated elopement risk assessments are not done in the facility at all. She indicated the facility would know if a resident was at risk for elopement if they paced, wandered, and commented on wanting to leave. At this time, she reviewed Resident #108's emergency order for placement regarding wandering and indicated she was unaware of it. She indicated anyone on the dementia unit was an elopement risk. "We tell staff to make sure the door latches before walking away. We remind visitors. My understanding is he followed visitors out the door." The "Missing/Wandering Resident" policy was provided by the DON on 9/27/12 at 2:20 p.m. It indicated the purpose was "To locate the missing or wandering resident as soon as possible." The policy did not include any proactive measures to prevent elopement. An Immediate Jeopardy was identified on 9/27/12 at 2:00 p.m. The Immediate Jeopardy began on 9/19/12 when a resident was admitted to the facility with an order indicating "Rx: Emergency admit to skilled facility (lock unit) -dx: Dementia severe 290.0 (wandering)...". The Administrator and Director of Nursing were notified on 9/27/12 at 3:05 p.m. of the Immediate Jeopardy related to lack of supervision to prevent elopement. The Immediate Jeopardy was removed on 9/28/12 when through observations, interviews, and record reviews, it was determined that the facility had implemented the plan of action to remove the Immediate Jeopardy and that the steps taken removed the immediacy of the problem. Even though the facility's corrective action removed the Immediate Jeopardy, the facility remained out of compliance at a reduced scope and severity level of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. 2. During the initial tour of the facility, on 9/19/12 at 12:10 p.m., the door to the bathroom/shower room across from room 10 A on the Heritage Haven/memory care unit, was unlocked and open. There was no staff in the vicinity of the bathroom/shower room. The following products were within reach and accessible: Derma Rite hand/body lotion, Derma Rite body wash/shampoo, Renson shaving cream, Dynarex shaving cream, and Dawn mist powder. In an interview with the DoN (Director of Nursing), on 9/19/12 at 1:45 p.m., she indicated the personal care products listed above should have not been in the bathroom/shower room. The following Material Safety Data Sheets (MSDS) were provided by the DoN on 9/20/12 at 11:35 a.m. The MSDS for Derma Rite hand/body lotion, dated 4/1/99, indicated the lotion was a health hazard, if ingested, and to induce vomiting, if swallowed. The Dawn mist powder MSDS, dated 11/15/10, indicated to be cautious of inhalation and to call a physician or Poison Control Center immediately, if ingested. The MSDS for Dynarex shaving cream, dated 7/10, indicated to avoid contact with eyes, because irritation to eyes may occur. The Freshscent Aerosol/Renson shaving cream MSDS, dated 3/12, indicated ingestion may cause nausea, vomiting, and diarrhea. The same MSDS also indicated the product was an aspiration hazard and inhalation may produce anesthetic effects and feeling of euphoria, while prolonged exposure can cause rapid breathing, headache, dizziness, unconsciousness, and death from asphyxiation depending on concentration and time of exposure. A list of 18 independently mobile residents, who could move throughout the Heritage Haven/memory care unit without physical assistance, was provided by the DoN, on 9/20/12 at 11:35 a.m. The list also included the BIMS (Brief Interview of Mental Status) scores for the independently mobile residents, residing in the Heritage Haven/memory care unit. The BIMS scores were as follows: Resident #63 used a walker-BIMS of 4 (indicative of severe cognitive impairment) Resident #109 used a walker-BIMS of 3 (indicative of severe cognitive impairment) Resident #97 used a cane-BIMS of 5 (indicative of severe cognitive impairment) Resident #41 used a wheelchair-BIMS of 5 Resident 54 used a wheelchair-BIMS of 4 Resident #60 used a walker-BIMS of 4 Resident #75 was up ad lib (no device)-BIMS of 5 On 9/20/12 at 2:15 p.m., the DoN indicated 25 residents resided in the Heritage Haven/memory care unit. 3.1-45(a)(1)