Every finding on record at Woodland Manor

Based on observation, interview, and record review, the facility failed to provide a safe, functional, and clean environment related to dirty floors in the laundry rooms; cracked and buckled flooring in the 100, 200, and 300 units; and non-functioning electrical outlets. Findings include: 1.During an environmental tour on 11/21/2025 at 9:23 A.M., the floors in the dirty and clean laundry rooms were dirty with brown/black marks and debris. During an interview on 11/21/2025 at 9:50 A.M., the Housekeeping Director indicated the floors in the dirty and clean laundry rooms should have been clean. On 11/21/2025 at 11:13 A.M., the Corporate Quality Assurance Administrator provided a current policy dated August 2019, and titled, Cleaning and Disinfection of Environmental Surfaces. The policy indicated, .Housekeeping surfaces (e.g., floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled 2. During an environmental tour on 11/21/2025 at 9:23 A.M., the tiled floors on units 100, 200, and 300, were buckled and cracked. During an interview on 11/21/2025 at 10:15 A.M., the ED indicated she was aware the floors were a problem and they had been noted during the December 2024 survey. She indicated the facility had a plan to replace the floors, but there was no specific information provided. 4. During an interview on 11/17/2025 at 11:01 A.M., Resident 31's family indicated they had informed the facility that Resident 31 had been unable to watch television because the outlets in her room were not working. During an observation of Resident 31's room with the Quality Assurance Administrator (QAA) and the Executive Director on 11/19/2025 at 11:09 A.M., the ED tried plugging a fan into all four of the electric outlets under the resident's television. None of the outlets were working. During an interview with the Quality Assurance Administrator (QAA) on 11/19/2025 at 1:10 P.M., she indicated Resident 31's family had notified the facility about the nonworking outlets and the facility had believed a work order had been filled out. The QAA indicated the facility had not submitted a work order and Resident 31's outlets had not been working since July 2025. During an interview with the QAA on 11/20/2025 at 9:46 A.M., the QAA indicated the facility did not have a policy related to maintaining the building or keeping the building in working condition. 3.1-19 (f)

Based on observation, interview and record review, the facility failed to notify the physician of a resident's change in condition related to blood pressure, missed doses of medication and blood sugar for 2 of 3 residents review for physician notification. (Residents 71 and 34)Findings include: The clinical record of Resident 71 was reviewed on 11/19/2025 at 2:32 P.M. The resident's diagnoses included, but were not limited to: acute and chronic respiratory failure, chronic heart failure, diabetes mellitus, cirrhosis of the liver, cerebral infarction, morbid obesity, depression, anxiety, hypertension and cardiac murmur. An admission Minimum Data Set (MDS) assessment, completed on 8/16/25, indicated Resident 71 was cognitively intact. Current Physician orders included, but were not limited to: -Amlodipine Besylate oral tablet 10 mg (milligrams), one tablet by mouth one time a day for hypertension. -Carvedilol oral tablet 12.5 mg, two tablets by mouth two times a day for hypertension. -Hydralazine Hydrochloride oral tablet 25 mg, two tablets every 8 hours for hypertension. A Care Plan, initiated on 8/12/2025, indicated Resident 71 had a diagnosis of hypertension with interventions included, but not limited to: administer anti-hypertensive medications as ordered and observe for side effects such as orthostatic hypotension and observe for/record medication side effects and report to the physician as necessary. The August 2025 Medication Administration Record (MAR) indicated Resident 71 had not received Amlodipine Besylate on the following dates: 8/16/2025 and 8/24/2025. The August 2025 MAR indicated the resident had not received Carvedilol on the following dates/times: 8/16/2025 morning and 8/24/2025 morning. The August 2025 MAR indicated the resident had not received Hydralazine Hydrochloride on the following dates/times: 8/15/2025 6:00 A.M., 8/16/2025 6:00 A.M. and 8/21/2025 10:00 P.M. A Nurses' Note, dated 8/16/2025 at 9:18 A.M., indicated Resident 71's anti-hypertensive medications were held due to the resident's blood pressure being low. There was no documentation the physician had been notified of the low blood pressure assessments or the missed medications. During an interview, on 11/20/2025 at 9:08 A.M., the Quality Assurance Administrator provided text messages via Tiger Text (a secure messaging application for personal or business use) and indicated the provided texts contained notifications to the physician regarding Resident 71's low blood pressure and missing medications. The Quality Assurance Administrator indicated the texts used to be documented in the progress notes but were no longer being put in the resident's clinical record/chart. However, review of the provided Tiger Texts indicated there was no specific information regarding the resident's low blood pressure assessments or help medications. During an interview, on 11/20/2025 at 3:15 P.M., the Quality Assurance Administrator indicated the Tiger Text messages had not contained any physician notification for either low blood pressure assessments or the missing medications. On 11/20/2025 at 12:05 P.M., the Quality Assurance Administrator provided a policy titled, Medication Administration General Guidelines, dated 5/20/2020 and indicated the policy was the one currently used by the facility. The policy indicated .any vital medication(s) refused or more than one dose of a medication refused should be reported to the DON/designee and/or physician according to facility policy. On 11/20/2025 at 12:05 P.M., the Quality Assurance Administrator provided a policy titled, Acute Condition Changes – Clinical Protocol, dated 3/2018 and indicated the policy was the one currently used by the facility. The policy indicated .the nursing staff will contact the physician based on the urgency of the situation. 2. A record review for Resident 34 was completed on 11/19/2025 at 10:28 AM. Diagnoses included, but were not limited to: Parkinson's disease, anxiety disorder, major depressive disorder and diabetes mellitus type 2. A Quarterly Minimum Data Set (MDS) assessment, completed on 11/5/2025, indicated Resident 34 was cognitively intact and had received insulin injections for 7 days of the 7-day look back period. A current Physician's Order, initiated on 10/26/2025, indicated staff were to notify the physician or nurse practitioner for blood sugar results greater than 401 milligrams per deciliter (mg/dL) Blood sugar results, documented on 10/30/2025 at 5:05 P.M., were 487 mg/dL and, on 10/31/2025 at 5:47 P.M., the blood sugar results were 401 mg/dL for Resident 34. A Care Plan, initiated on 10/15/2024 and revised on 6/24/2025, indicated Resident 34 had diabetes mellitus. Interventions included, but were not limited to: administer diabetes medication as ordered by the physician and observe for/document side effects and effectiveness. During an interview, on 11/21/2025 at 12:05 P.M., the Quality Assurance Administrator indicated no documentation could be located for the notification of the high blood sugars on 10/30/2025 and 10/31/2025. A policy was provided by the Quality Assurance Administrator, on 11/20/2025 at 2:18 P.M. The policy titled, Diabetes-Clinical Protocols, indicated, .Monitoring and Follow-Up 1. The provider will order desired glucose targets and monitoring regimens, as well as parameters for reporting information related to blood glucose monitoring. 2. The staff will incorporate orders and reporting parameters into the Medication Administration Record and care plan. 3.1-5(a)(1)3.1-5(a)(2)3.1-5(a)(3)

Based on observation, record review and interview, the facility failed to ensure the correct dosage of an antipsychotic was ordered after a failed gradual dose reduction for 1 of 5 residents reviewed for unnecessary medications. (Resident 22)Finding includes: A record review for Resident 22 was completed on 11/18/2025 at 1:08 P.M. Diagnoses included, but were not limited to: brain damage related to a birth injury, epilepsy, unspecified psychosis, generalized anxiety, dementia and pseudobulbar affect.A Quarterly Minimum Data Set (MDS) assessment, dated 10/23/2025, indicated Resident 22 had moderate cognitive impairment, received an antipsychotic medication and the last gradual dose reduction had been attempted on 9/25/2025 with no clinical contraindications for the previous reductions.A Physician's Order, dated 3/10/2025 and discontinued on 9/25/2025, indicated Resident 22 was to receive Abilify 15 milligrams 0.5 tablet (7.5 milligrams) daily at bedtime for psychosis.A Physician's Order, dated 9/25/2025 and discontinued on 10/7/2025, indicated Resident 22 was to receive Abilify 5 milligrams one tablet at bedtime for psychosis.A Physician's Order, dated 10/7/2025, indicated Resident 22 was to receive Abilify 15 milligrams daily at bedtime for psychosis. The pharmacist, psychiatric nurse practitioner and director of nursing were aware.A Nursing Progress Note, on 9/25/2025 at 11:28 A.M., indicated a GDR (Gradual Dose Reduction) meeting had occurred and Resident 22's Abilify dosage was decreased from 15 milligrams to 5 milligrams daily. A Nursing Progress Note, on 9/28/2028 at 2:34 P.M., indicated Resident 22 had been shouting Get out of here, You're evil, and Don't touch my stuff. There were no staff members in Resident 22's room and Resident 22 appeared to have hallucinated.A Nursing Progress Note, on 10/1/2025 at 5:26 A.M., Resident 22 was observed agitated and yelling loudly in her room during the night shift. Resident 22 was calling out that she needed supplies with her on the bed. The facility staff attempted verbal redirection, but Resident 22 continued to yell, but eventually stopped banging the bed and yelling. A Progress Note, on 10/3/2025 at 10:27 A.M., the Social Services Designee spoke with the insurance company nurse practitioner, the psychiatric nurse practitioner, the interdisciplinary team and the floor staff regarding Resident 22's behaviors. Together the team decided decreasing the Abilify was a failed gradual dose reduction. The Psychiatric nurse practitioner indicated she would reinstate the Ability dose.A Progress Note, on 10/7/2025 at 11:35 A.M., indicated the Social Service Designee spoke with insurance company nurse practitioner and the psychiatric nurse practitioner and Resident 22 had failed a gradual dose reduction of Abilify. The new order indicated the Abilify was being restored to the previous dosage of 15 milligrams every day. However, the previous dose from 3/10/2025 through 9/25/2025 was 7.5 milligrams, with a dose reduction to 5 milligrams on 9/25/2025.A Care Plan, initiated on 2/3/2016 and revised on 2/6/2024, indicated Resident 22 took an antipsychotic medication for a diagnosis of psychosis and agitation. The care plan goal included Resident 22 to receive the lowest therapeutic dosage of medication. The interventions included, but were not limited to: administering medications as ordered, remain free of side effects/adverse reactions to medications, IDT (Interdisciplinary Team) to review medication for use and consideration for gradual dosage reduction. During an interview, on 11/21/2025 at 9:41 A.M., the Quality Assurance Administrator indicated she was not sure why the 7.5 milligrams of Abilify was skipped after a successful gradual dose reduction and the 15 milligrams of Abilify was ordered.An attempt was made to contact the psychiatric nurse practitioner, on 11/21/2025 at 10:05 A.M. The phone call was not returned. A current policy, revised on February 2025, was provided by the Quality Assurance Administrator, on 11/20/2025 at 2:18 P.M. The policy titled, Tapering Medications and Gradual Dose Reduction, indicated, .Policy Statement.2. Residents who use psychotropic medications receive gradual dose reductions, unless clinically contraindicated, in an effect to discontinue these medications.Policy Interpretation and Implementation 1. Gradual Dose Reduction [GDR] refers to the stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed at a lower dose or if a medication can be discontinued. 3.1-3(w)

Based on Interview and record review, the facility failed to hold quarterly care plan conferences and include the resident, or resident representative for 1 of 19 residents whose care plans were reviewed. (Resident 3)Finding includes:During an interview on 11/17/2025 at 10:57 A.M. Resident 3 indicated she had not been invited to any care planning conferences.A record review was completed on 11/18/2025 at 1:40 P.M. for Resident 3. Diagnoses included, but were not limited to, type 2 diabetes mellitus, chronic pulmonary obstructive disease, and bipolar disorder. The record indicated a care plan meeting was held on 1/8/2025 and the resident was in attendance. No further care plan meetings were found in the record.During an interview on 11/20/2025 at 11:23 A.M. the Social Worker indicated care plan meetings should have been done quarterly but had not been held.On 11/20/2025 at 12:12 A.M. a current policy, dated 9/2022 and titled, Care Plans, Comprehensive Person-Centered, was provided by the Corporate Quality Assurance Administrator. The policy indicated, .Each resident's comprehensive person-centered care plan will be consistent with the resident's rights to participate in the development and implementation of his or her plan of care, including the right to: Participate in the planning process; see the care plan and sign it after significant changes are made and .The Interdisciplinary Team must review and update the care plan at least quarterly, in conjunction with the required quarterly Minimum Data Set assessment 3.1-35(c)(2)(C)

Based on observation, record review and interview, the facility failed to identify skin conditions for 1 of 2 residents reviewed for skin conditions (Resident 8) and failed to administer blood pressure medications according to the ordered parameters for 1 of 5 residents reviewed for unnecessary medications (Resident 44).Findings include:1. During an interview on 11/17/2025 at 2:18 P.M., Resident 8 was not able to identify how he obtained a large dark bruise on the top of his right hand or why he had two scabs on his right temple and one scab under his right eye.Resident 8's record review was completed on 11/19/2025 at 2:15 P.M. Diagnoses included, but were not limited to: Alzheimer's disease, dementia and type 2 diabetes mellitus. A current Physician's order, initiated on 3/15/2025, indicated Resident was to receive a complete Weekly Skin Review assessment and staff were to report any new skin problem to the Director of Nursing and the Medical Director. Resident 8's current Care Plan, initiated on 8/5/2025, indicated Resident 8 was at risk of skin breakdown related to dementia, impaired nutrition and bowel and bladder incontinence. A Care Plan intervention, initiated on 3/13/2025, indicated Resident 8 was to have Weekly Skin Reviews by a licensed nurse.Resident 8's Weekly Skin Review assessment, completed on 11/17/2025 at 4:41 P.M., had not indicated the resident had a bruise on his right arm or scabs on the right side of his face. During an interview, on 11/19/2025 at 2:58 P.M., LPN 2 indicated any skin issue, including bruises and scabs, should be documented on the Weekly Skin Review assessment. If any new skin problems occurred after the skin assessment had been completed for the week, another Weekly Skin Review assessment should have been completed. LPN 2 was nor able to identify how Resident 8 had acquired the bruise on his left hand but believed the scabs on his face had been acquired from the resident scratching himself. LPN 2 indicated Resident 8's Electronic Medical Record (EMR) lacked the documentation regarding the bruise on his right hand and the scabs on the right side of his face. Both areas had not been added to the resident's Weekly Skin Review assessment and the Medical Provider and the DON had not been notified of the resident's new skin problems. 2. A record review was completed on 11/19/2025 at 2:58 P.M. for Resident 44. Diagnoses included. but were not limited to: essential hypertension.Physician Orders for Resident 44 included, but were not limited to, atenolol 25 milligrams (mg) give 0.5 tablet by mouth one time a day for essential hypertension, hold if systolic blood pressure (SBP) <110 or for heart rate <60.During the month of November 2025, the atenolol was administered outside of the blood pressure parameters. On the following dates Resident 44's systolic blood pressure was less than 110 (<110) and the atenolol was administered:11/1/2025 the SBP was 107.11/10/2025 the SBP was 101.11/12/2025 the SBP was 109.11/17/2025 the SBP was 104.11/19/2025 the SBP was 100.During an interview, on 11/20/2025 at 2:16 P.M., the Quality Assurance Administrator indicated the atenolol should not have been administered when Resident 44's SBP was less than 110.On 11/20/2025 at 11:42 A.M. an undated policy was provided by the Quality Assurance Administrator (QAA) who indicated it was the policy currently used by the facility. The policy titled, Skin and Wound Management System. The policy indicated, . 3. Ongoing weekly evaluations of resident's skin will be completed and documented on the Weekly Skin Evaluation form.On 11/20/2025 at 1:12 P.M. the Corporate Quality Assurance Administrator provided a current policy dated 3/17/2022 and titled, Physician Orders. The policy indicated, .The facility is obligated to follow and carry out the orders of the prescriber in accordance with all applicable state and federal guidelines 3.1-37(a)

Based on observation, record review and interview, the facility failed to obtain ordered laboratory tests for 1 of 5 residents reviewed for unnecessary medications. (Resident 22)Finding includes:A record review for Resident 22 was completed on 11/18/2025 at 1:08 P.M. Diagnoses included, but were not limited to: brain damage related to a birth injury, epilepsy, unspecified psychosis, generalized anxiety, dementia and pseudobulbar affect.A Quarterly Minimum Data Set (MDS) assessment, dated 10/23/2025, indicated Resident 22 had moderate cognitive impairment and received an anticonvulsant.A Physician's Order, dated 3/10/2025, indicated a phenobarbital and valproic acid blood level every six months and was scheduled on 6/13/2025. However, these laboratory tests had not been obtained.A Physician's Order, dated 9/25/2025, indicated a phenobarbital blood level and a complete blood count (CBC) to have been obtained. However, the phenobarbital level had not been obtained.A Physician's Order, dated 10/15/2025, indicated a phenobarbital and valproic acid blood level to have been obtained. However, the level had not been obtained.A Care Plan, initiated on 9/20/2018 and revised on 5/12/2025, indicated Resident 22 had a diagnoses of seizure disorder and had interventions that included, but were not limited to: obtain and monitor lab/diagnostic work as ordered, report results to the physician and follow up as indicated and obtain labs per physician orders and report any sub therapeutic or toxic results to the physician. During an interview, on 11/19/2025 at 2:02 P.M., the Quality Assurance Administrator indicated the ordered laboratory tests for 6/13/2025 and 10/15/2025 were not available. She indicated the CBC had been obtained, but not the phenobarbital blood level. On 11/20/2025 at 1:12 P.M., the Quality Assurance Administrator provided a current policy dated 3/17/2022 and titled, Physician Orders. The policy indicated, .The facility is obligated to follow and carry out the orders of the prescriber in accordance with all applicable state and federal guidelines 3.1-48(a)(3)

Based on interview and record review, the facility failed to ensure laboratory services were obtained timely for 1 of 5 residents whose labs had been reviewed. (Resident 31)Finding includes:During an interview on 11/17/2025 at 11:01 A.M., Resident 31's family indicated they had been notified several weeks ago that the resident was to have her urine tested for an infection, but the family had not received the results of the testing.Resident 31's record review was completed on 11/20/2025 at 3:30 P.M. Diagnoses included but were not limited to: Lewy Body Dementia, major depressive disorder and anxiety.A Physician's Laboratory order, marked as completed, had been initiated on 11/11/2025 and indicated Resident 31 was to have her urine collected and sent for UA (urinalysis) and C&S (culture and sensitivity test).A Nurse's Note, dated 11/17/2025 at 8:12 A.M., seven days after the initial physician's order had been received for the urinalysis testing, indicated the lab had reported Resident 31's urine test sample had been contaminated and a new specimen would be needed.During an interview with the Assistant Director of Nursing (ADON) on 11/20/2025 at 11:30 A.M., the ADON indicated the lab used to process orders for the UA and C&S was located in Kentucky and it was not unusual for the facility to wait more than 5 days for the laboratory results. The ADON indicated long turnaround times for labs were due to the fact that the sample took a day or longer to reach the lab and the facility had no other laboratory they could utilize to process the labs in a more timely manner.During an interview with a Customer Service Representative (CSR) for the laboratory the facility used, on 11/20/2025 at 12:05 P.M., the CSR indicated the expected turn around time for a UA and C&S was 72 hours from the time the lab received the sample to the time the results were communicated back to the facility with any culture and sensitivity results.On 11/20/2025 at 2:30 P.M., the Quality Assurance Administrator indicated the facility did not have a policy related to the timeliness of the facility's laboratory services.3.1-49 (a)

Based on record review, record review and interview, the facility failed to ensure the recommended dental services was completed timely for 1 of 1 resident reviewed for dental services. (Resident 22)Finding includes:A record review for Resident 22 was completed on 11/18/2025 at 1:08 P.M. Diagnoses included, but were not limited to: quadriplegia, brain damage d/t birth injury, intellectual disabilities and dementia. A Quarterly Minimum Data Set (MDS) assessment, completed on 10/23/2025, indicated Resident 22 had moderate cognitive dysfunction, had no oral issues and required assistance with oral hygiene practices.A Dental Assessment Note, dated 6/20/2025, indicated x-rays had been taken and suggested tooth #31 (right back tooth) be extracted with a community dentist.A Nursing Progress Note, dated 7/8/2025 at 2:42 P.M., indicated a dental referral for right back tooth pain had been received.A Nurse Practitioner Progress Note, dated 9/22/2025 at 11:59 P.M., indicated Resident 22 had pain to her back right molar. Resident 22 had expressed interest having a dental referral and management of the molar pain. A Care Plan, initiated on 5/12/2017 and revised on 10/29/2025, indicated Resident 22 was at risk for oral/dental problems related to activities of daily living deficits, cognitive deficits and physical limitations. Interventions included,but were not limited to: Coordination for arrangements for dental care, transportation as needed/as ordered and observe for/document/report to the physician/nurse practitioner of oral/dental problems that needed attention.During an interview, on 11/19/2025 at 2:02 P.M., the Quality Assurance Administrator indicated there was nothing in the chart that indicated the dental referral had been completed or the tooth extraction had been completed for Resident 22.A policy was provided by the Quality Assurance Administrator, on 11/20/2025 at 2:18 P.M. The policy titled, Mouth Care, indicated, .The purposes of this procedure are to keep the resident's lips and oral tissues moist, to cleanse and freshen the resident's mouth, and to prevent oral infection. The policy did not address dental visits or recommendations.3.1-24(a)(1)

Based on observation, interview, and record review, the facility failed to maintain infection control practices related to urinary catheters for 1 of 3 residents reviewed for urinary catheters. (Resident 3) Finding includes:A record review was completed on 11/18/2025 at 1:40 P.M. for Resident 3. Diagnoses included, but were not limited to, obstructive and reflux uropathy.Physician Orders for Resident 3 included, but were not limited to:3/10/2025 16 french (refers to the catheter size) foley catheter with a 10 cubic centimeters (cc) balloon with drainage bag to gravity. May change as needed for leakage.4/16/2025 Enhanced barrier precautions due to foley catheter. Gown and gloves must be worn for the following care dressing, bathing, showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, urinary catheter use or care, every shift due to foley catheter.A current Care Plan, initiated on 11/13/2025, indicated Resident 3 had a urinary tract infection. The resident was to receive the ordered antibiotic and staff were to monitor for further symptoms.During an interview and observation on 11/17/2025 at 11:12 A.M., Resident 3 indicated the catheter was hurting and she thought it was due to the large amount of urine in the drainage bag. The urinary drainage (UD) bag was noted to be laying on the floor with no barrier between it and the floor. CNA 4 entered the room to empty the UD bag, applied gloves and bent over to pick up the bag when Resident 3 reminded her to put on a gown. CNA 4 then went into the hall to put on a gown. Resident 3 indicated staff did not always use a gown when they should.During an interview on 11/20/2025 at 2:11 P.M., the Corporate Quality Assurance Administrator indicated CNA 4 should have worn a gown and the UD bag should not have been on the floor.On 11/20/2025 at 2:34 P.M. the Corporate Quality Assurance Administrator provided a current policy dated 9/2014, and titled, Catheter Care, Urinary. The policy indicated, .Be sure the catheter tubing and drainage bag are kept off the floor 3.1-18(a)

Based on observation, interview, and record review the facility failed to ensure behaviors were care planned, monitored and evaluated for 1 of 2 residents reviewed. (Resident A)During an observation on 9/15/25 at 10:09 AM the following was observed:Resident A was resting on his bed with the head of the bed elevated. The colostomy bag on the resident's left side of the abdomen was bent at an angel more than 90 degrees and ballooning to the shape of the colostomy bag.In an interview, on 9/15/25 at 10:10 AM, Resident A indicated his colostomy bag had opened unexpectedly in the past. He indicated staff only emptied the bag every couple of days and only when he would tell the staff it needed emptied. He indicated he would take care of the bag himself and hand the bag to the nurses. Resident A indicated caring for the colostomy made him anxious. A record review for Resident A began on 9/15/25 at 11:10 AM. Diagnoses included depression, attention-deficit hyperactivity disorder (ADHD), and hemiplegia and hemiparesis following a cerebral infarction affecting the left, non-dominant side.A review of Resident A's current quarterly MDS, dated [DATE], indicated their BIMS (Basic Interview for Mental Status) score was 15 (cognitively intact). The MDS indicated that the resident needed extensive assistance to use the toilet and was diagnosed with hemiplegia or hemiparesis (the inability to use one side of the body). A review of Resident A's current care plan, dated 8/11/25, titled Colostomy Status Post Bowel Surgery indicated the resident preformed their own colostomy care. Interventions included to change the colostomy bag after each bowel episode or when full, educate Resident A on proper care of the ostomy and how to change the bag, Education Resident A when to alert the nurse to change the bag. A review of Resident A's current care plan, dated 8/11/25, titled Colostomy Phalange indicated Resident A would unseal his colostomy at various times throughout the day. Interventions included a reminder to resident A, not unseal the colostomy (phalange) daily. Observe if resident had unsealed the colostomy, assist the resident with the colostomy seal as needed.A review of Resident A's current care plan, dated 8/11/25, titled depression indicated Resident A had depression after getting a colostomy. Interventions included administration of medications as ordered, psychiatry consultation, and observation of signs and symptoms of depression, including hopelessness, anxiety, sadness, insomnia, negative statements, repetitive anxious or health-related complaints, or tearfulness. There was no intervention related to Resident A's colostomy. A review of Resident A's current care plan, dated 8/11/25, titled Psychosocial well-being related to anxiety, depression, inability to meet role expectations, lack of acceptance to current condition, recent social isolation. One goal indicated the resident would identify coping mechanisms including keep busy, work with hands, and feeling useful. Interventions included allowing time for the resident to answer questions and verbalize feelings, perceptions, and fears, assist/encourage/support the resident to set realistic goals to promote emotional and physical safety. Initiate referrals as needed or increase social relationships. Observe for and document resident's feelings relative to isolation, unhappiness, anger, and loss. Provide opportunities for the resident and family to participate in care, assist, encourage, and support about identified problems that cannot be controlled. There were no interventions related Resident A's colostomy behaviors. A review of Resident A's current care plan, dated 8/11/25, failed to address Resident A's ADHD diagnosis and behaviors. There were no care plans to address Resident A's colostomy behaviors.A review of physician orders, dated 3/10/25 at 18:00, indicated colostomy care was to be completed by staff every shift and emptied as needed.A review of the Task Administration Record for August 2025 indicated the colostomy bag was emptied as needed on 8/3/25 at 11:05 PM. Routine colostomy care was documented as completed.A review of the Task Administration Record for September 2025 indicated routine colostomy care was not documented as completed on 9/2/25 during day shift.A review of the Bowel Elimination Task dated 9/2/25 to 9/15/25 indicated stool output was recorded only one time on 9/4/25 and 9/12/25.A review of psychiatry progress notes, dated 9/11/25, indicated the physician was not aware of Resident A's most recent depression scale score of 20, indicating severe depression, completed on 8/21/25. There was no mention in the notes of Resident A taking off his colostomy bag, or taking off the bag and flange. A review of progress notes from 8/19/25 to 8/25/25 indicated staff had not notified the physician of the depression scale score result of severe depression. There were no notes related to Resident A taking off his colostomy bag, with or without the flange intact and no notes to indicate Resident A had been educated regarding colostomy care or addressing colostomy behavior. A review of progress notes from 8/19/25 to 8/25/25 indicated staff had not documented when the resident was reminded not to unseal the colostomy (phalange) daily.In an interview, on 9/15/25 at 1:12 PM, LPN 2 indicated colostomy care included cleaning the skin around the colostomy area and emptying the bag of air and or stool. She indicated Resident A would spontaneously take the colostomy bag off including the flange and not tell the staff. In an interview, on 9/15/25 at 1:27 PM, the Assistant Director of Nursing indicated Resident A had taken the colostomy off in the past. The resident wanted to be independent at times and had a plan to move to assisted living. Resident A had the ability to empty the colostomy independently, but Resident A had not been consistent in completing his own care. Resident A had been offered support groups but the resident had refused.In an interview, on 9/15/25 at 1:57 PM, the Administrator indicated Resident A had unsealed his colostomy emptying stool on the floor around the front door of the facility.In an observation, on 9/15/25 at 1:58 PM, the front entrance of the facility was cleaned and rinsed of a large amount of stool. In an interview, on 9/15/25 at 3:33 PM, RN 2 indicated Resident A had not changed or burped their colostomy bag recently. Resident A had needed the colostomy bag emptied 2 or 3 times during most shifts. Regular education had been provided to Resident A about telling staff when the colostomy bag was full. Emptied colostomy tasks should have been documented on the TAR or in the Elimination Task flowsheet. Resident A would would carry the full bag detached from the flange to the nurse's station. In an interview, on 9/15/25 at 4:40 PM, the Social Services Director indicated Resident A had turned the call light on for staff and had been mentally and physically capable of leaving the facility. All facility physicians (providers) had access to all forms and assessments completed by staff. The providers talked with the Social Services Director weekly. On 7/2/25 the physician was notified of Resident A had been drinking alcohol and drove the wheelchair recklessly on 7/1/25, as reported by staff who witnessed the event. The SSD did not indicate the providers had been made aware of Resident A's behavior with his colostomy bag. The policy regarding behavior identification and tracking was requested. There was no further information or policies presented by time of exit. This citation is related to intakes 2614478 and 2567160. 3.1-43(a)(1)

Based on record review and interview, the facility failed to ensure residents were provided proper notice prior to an involuntary transfer or discharge for 1 of 4 residents reviewed for hospitalizations (Resident 49). Finding includes: A record review was completed for Resident 49 on 5/1/2025 at 11:32 A.M. Diagnoses included, but were not limited to: anxiety and depression. An admission Minimum Data Set (MDS) assessment, dated 3/13/2025, indicated Resident 49's cognition was mildly impaired and the resident was a current tobacco user. A review of Resident 49's census indicated she was discharged from the facility on 3/3/2025 and re-admitted to the facility on [DATE]. A Discharge assessment, dated 3/3/2025 indicated the resident was being discharged to (a local hotel name). A Physician's Order, dated 3/3/25 indicated to discharge the resident home with medications and discharge instructions. A review of a Nursing Progress note, dated 3/3/2025 at 11:25 A.M., indicated Resident 49 was informed due to her being a danger to others by smoking in the facility. The note indicated she was being immediately discharged . The resident was discharged to the (local hotel name). The note also indicated the facility had paid for the resident to stay at (local hotel name) for three nights. A Nursing Progress note, dated 3/3/2025 at 11:47 A.M. indicated Resident 49 had been notified of her pending discharge and was to be transported out of the facility on 3/3/2025 at 1:30 P.M. Resident 49's record lacked documentation that she received a 30 days notice prior to her involuntary discharge. A Nursing Progress note, dated 3/6/2025 at 4:49 P.M. indicated the Social Services Director went to (local hotel name) to make contact with Resident 49. SSD was informed the resident had not been compliant with the hotel's smoking policy and was being kicked out. The note indicated Resident 49 was returning to the facility for a short term stay due to being removed from the hotel. A Nursing Progress note, dated 3/6/2025 at 5:39 P.M. indicated Resident 49 was re-admitted to the facility. During an interview, on 5/5/2025 at 1:16 P.M., the Quality Assurance Administrator (QAA) indicated Resident 49 had been given 30 days notice. However, a subsequent interview with the QAA, on 5/5/2025 at 3:05 P.M. indicated she was unable to find documentation that Resident 49 had been given 30 days notice of an involunary discharge. On 5/2/2025 at 9:25 A.M., the QAA provided a policy titled, Transfer or Discharge Notices, no date and indicated it was the policy currently being used by the facility. The policy indicated, 1. Except as specified below, the resident and his or her representative are provided with a written notice of an impending transfer or discharge at least 30 days prior to the transfer or discharge

Based on observation, interview and record review, the facility failed to provide showers for 1 of 7 residents reviewed for ADL (Activities of Daily Living) care. (Resident 1) Finding includes: During an observation, on 4/30/2025 at 9:07 A.M., Resident 1 was noted to have a large amount of facial hair on her chin and her fingernails had a brown substance underneath them The record for Resident 1 was reviewed on 5/01/2025 at 1:25 P.M. diagnosed included, but were not limited to quadriplegia, epilepsy, blindness, arthritis and non-Alzheimer's dementia. A Quarterly MDS (Minimum Data Set) assessment, dated 4/22/2025, indicated the resident had severe cognitive impairment and required extensive assist of 2 staff for bed mobility transfers, toilet use and showering. A current Care Plan, initiated on 12/7/2021, indicated Resident 1 required assistance with ADL's due to her cognitive deficits, arthritis, blindness, and quadriplegia. Interventions included, but were not limited to: I prefer to complete bathing with staff assist and prefer my showers Monday and Thursday evening. Resident 1's shower schedule indicated she was to receive showers on Mondays and Thursdays on the day shift. The shower documentation, dated March 2025, indicated the resident had received a shower on the following dates: 3/18, 3/21 and 3/28, and bed baths on 3/11, 3/14, 3/18, 3/21 and 3/25/2025. The shower documentation, dated April 2025, indicated the resident had received a shower on 4/21, and bed baths on 4/7 and 4/17/2025. There was no documentation to indicate Resident 1 had received showers on 4/3, 4/10, 4/14, 4/21, 4/24 or 4/28/2025. There was no documentation of any shower refusals in the Nursing Progress Notes from March 1st to April 30th for Resident 1. During an interview, on 5/5/2025 at 3:27 P.M., the Director of Nursing indicated she could not provide any further shower documentation for Resident 1. On 5/5/2025 at 3:15 P.M., the Quality Assurance Administrator provided the policy titled, Activities of Daily Living (ADL) Supporting, dated April 2025, and indicated the policy was the one currently used by the facility. The policy indicated . Residents who are unable to carry out activities of daily living independently receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene . 5. Appropriate care and services are provided for residents who are unable to carry out ADL's independently, with consent of the resident, and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene (bathing, dressing, grooming, and oral care) 3.1-38(b)(2)

Based on record review and interview, the facility failed to notify the physician of abnormal blood sugars for 1 of 1 resident reviewed for insulin usage. (Resident 3) Finding includes: During an interview, on 4/29/2025 at 11:25 A.M., Resident 3 indicated she had recently had an abnormally high blood sugar reading of over 300 mg/dL (milligram per deciliter). A record review was completed for Resident 3 on 5/1/2025 at 9:47 A.M. Diagnoses included, but were not limited to: diabetes mellitus type 2, diabetes with polyneuropathy and acute kidney failure. A Quarterly Minimum Data Set (MDS) assessment, dated 12/23/2024, indicated Resident 3 was cognitively intact and received insulin injections. A current Care Plan, initiated on 4/9/2021 and revised on 10/6/2024, indicated Resident 3 had diabetes mellitus with a goal of Resident 3 would not exhibit signs of hypo/hyperglycemia. Interventions included, but were not limited to: administer medications as ordered by the physician and blood sugar monitoring as ordered by the physician. A Physician's Order, dated 11/13/2024, indicated Resident 3 was to receive Lantus insulin solution inject 10 units subcutaneously daily at bedtime. A Physician's Order, dated 12/21/2024, indicated Resident 3 was to have blood sugar monitoring at bedtime and to notify the physician for a blood sugar reading below 70 mg/dL or above 400 mg/dL. Blood sugar readings, outside the physician ordered parameters, were documented as follows: -12/25/2024 at 9:57 A.M. 60 mg/dL -12/30/2024 at 9:45 A.M. 59 mg/dL There was no documentation the physician had been notified of the blood sugar readings below 70 mg/dL. During an interview, on 5/2/2025 at 9:15 A.M., LPN 8 indicated Resident 3 must have requested a blood sugar level to have been obtained. She indicated the physician should have been notified of the blood sugars below 70 mg/dL. During an interview, on 5/5/2025 at 11:15 A.M., the Assistant Director of Nursing indicated residents have written orders for when the physician should be notified for abnormal blood sugar readings. He indicated that a blood sugar of 59 mg/dL or 60 mg/dL should have had physician notification documented. A policy was provided, on 5/5/2025 at 2:46 P.M., by the Quality Assurance Administrator. The policy titled, Acute Condition Changes, indicated, .Assessment and Recognition .8. The nursing staff will contact the physician based on the urgency of the situation .9. The attending physician will respond in a timely manner to notification of problems or changes in condition and status .Monitoring and Follow-Up .1. The staff will monitor and document the resident's/patient's progress and responses to treatment, and the physician will adjust treatment accordingly 3.1-37(a)

Based on observation, record review and interview, the facility failed to store respiratory equipment in a sanitary manor for 2 of 3 residents reviewed for respiratory care. (Resident 1 & 50) Findings include: 1. During an observation, on 4/30/2025 at 9:11 A.M., Resident 1's oxygen concentrator humidification bottle was dated 4/2/2025 and was not hooked up to the concentrator. The oxygen storage bag was dated 4/28/2025 and the nasal cannula tubing was not dated. The record for Resident 1 was reviewed on 5/1/2025 at 1:25 P.M. Diagnoses included, but were not limited to quadriplegia, blindness, arthritis, and non-Alzheimer's dementia. A Quarterly Minimum Data Set (MDS) assessment, dated 4/22/2025, indicated the resident had severe cognitive impairment and required the use of oxygen. Resident 1's current physician orders included: - Oxygen at 2 Liters per minute per Nasal Cannula on continuous to keep oxygen saturation above 90%. - Change the oxygen tubing, and humidification bottle; clean oxygen filter, and inspect easy foam wraps (replace if soiled or missing), on the night shift every Sunday. The oxygen tubing to be changed and dated weekly on night shift and as needed. A current Care Plan, initiated on 7/29/2022, indicated the resident had altered respiratory status: Difficulty breathing related to morbidly obese and SOB (shortness of breath) while flat. The residnet was at risk for alterations in oxygen levels and sometimes removed the oxygen tubing and had to be reminded to leave it in place. During an observation, on 5/1/2025 at 1:29 P.M., Resident 1's oxygen concentrator humidification bottle was still dated 4/2/2025 and was not hooked up to the concentrator. The oxygen nasal cannula tubing was still not dated. During an observation, on 5/1/2025 at 2:30 P.M., Resident 1's oxygen tubing was not hooked up to the humidification bottle, still dated 4/2/2025 and the oxygen tubing was still not dated. During an observation, on 5/2/2025 at 9:55 A.M., with LPN 2, Resident 1's oxygen tubing was not dated, the date on the humidification water bottle was 4/2/2025 and not attached to the concentrator to provide humidified oxygen. During an interview, on 5/2/2025 at 9:56 A.M., LPN 2 indicated the oxygen tubing should have been dated, the humidification water bottle should have been changed, dated, and should have been placed on the concentrator to provide humidified air. 45120 2. During an observation on 4/29/2025 at 9:36 A.M., Resident 50 was observed to have a portable oxygen tank, an oxygen concentrator, a nebulizer machine and a BiPap (bilevel positive airway pressure) machine on the bedside table. The portable oxygen tank was sitting on the floor with the undated nasal cannula on the floor, the oxygen concentrator was at the bedside with an undated nasal cannula tube lying in the upper drawer of the bedside table. The visibly soiled nebulizer mask was lying in the upper drawer of the bedside table and the BiPap mask was lying upright against the wall. There were no respiratory bags for storage of the nasal cannulas or masks noted in the room. During an observation, on 4/29/2025 at 1:54 P.M., the portable oxygen tank with the nasal cannula was observed on the floor, the oxygen concentrator and nasal cannula was observed draped over the top drawer of the bedside table, the visibly soiled nebulizer mask was observed lying in the top drawer of the bedside table and the BiPap mask was observed on the bedside table against the wall. During an observation, on 4/30/2025 at 9:34 A.M. and 5/1/2025 at 1:28 P.M., the portable oxygen tank was observed sitting on the floor. The nasal cannula tubing connected to the portable oxygen tank was also lying on the floor. The oxygen tubing connected to the oxygen concentrator was observed lying in the upper drawer of the bedside table. During an observation, on 5/5/2025 at 9:10 A.M., the nebulizer mask was observed lying in the top drawer of bedside table and the oxygen concentrator nasal cannula tubing was observed draped around the bedside table drawer's hardware. A record review for Resident 50 was completed on 5/1/2025 at 9:13 A.M. Diagnoses included, but were not limited to: chronic obstructive pulmonary disease (COPD), chronic bronchitis and anxiety. An Annual Minimum Data Set (MDS) assessment, dated 3/19/2025, indicated Resident 30 was cognitively intact and received oxygen therapy. Physician Orders included the following orders on 3/10/2025: -Ipratropium-Albuterol Solution 0.5-2.5 milligrams per 3 milliliters one vial inhalation via nebulizer every 6 hours as needed shortness of breath and wheezing related to COPD. -BiPap with two liters of oxygen bled in when napping during the day and sleeping at night related to acute respiratory failure with hypoxia and COPD. -Change oxygen tubing every night shift on Wednesday. -Oxygen at two liters per nasal cannula continuously to maintain oxygen saturations above 90 percent related to acute respiratory failure with hypoxia and COPD. A current Care Plan, initiated 9/1/2023 and revised on 12/19/2024, indicated Resident 30 had an altered respiratory status with difficulty breathing related to bronchitis, COPD and asthma. Interventions included, but were not limited to: -Administer medication/puffers as ordered. -BiPap as ordered. -Nebulizer treatments as directed. -Oxygen as ordered. During an interview, on 5/5/2025 at 11:37 A.M., Qualified Medication Assistant (QMA) 9 indicated respiratory equipment (masks, nasal cannulas) should be stored on a clean surface and stored in a respiratory bag when the equipment was not in use A policy was provided, on 5/5/2025 at 2:46 P.M., by the Quality Assurance Administrator. The policy titled, Respiratory Therapy-Prevention of Infection, indicated, .The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff .Infection Control Considerations Related to Oxygen Administration .8. Keep the oxygen cannulae and tubing used PRN [as needed} in a plastic bag when not in use .Infection Control Considerations Related to Medication Nebulizers/Continuous Aerosol: 7. Store the circuit in a plastic bag, marked with date and resident's name, between uses 3.1-47(a)(6)

Based on observation, record review and interview, the facility failed to attempt a gradual dose reduction of an antipsychotic medication for 1 of 5 residents reviewed for unnecessary medications. (Resident 20) Finding includes: During an observation, on 4/30/2025 at 9:34 A.M., 5/1/2025 at 2:46 P.M. and 5/5/2025 at 10:24 A.M., Resident 20 was observed seated in the doorway of his room looking into the hallway A record review for Resident 20 was completed on 5/1/2025 at 10:40 A.M. Diagnoses included, but were not limited to: post-traumatic stress disorder (PTSD), major depressive disorder, alcohol dependence with alcohol-induced dementia and other sexual disfunction. A Quarterly Minimum Data Set (MDS) assessment, dated 4/14/2025, indicated Resident 20 had moderate cognitive impairment and received an antipsychotic and antidepressant medications. A current Care Plan, initiated on 1/25/2024 and revised on 10/6/2024, indicated Resident 20 was at risk for yelling and cursing at staff due to a history of these behaviors and dementia. Interventions included, but were not limited to: -Administer medications as needed. -Offer resident snacks and drinks especially Pepsi, chips, and cookies. -Resident to be seen by in-house psych services. -Staff will monitor the resident's behaviors A current Care Plan, initiated on 10/21/2021 and revised on 10/6/2024, indicated Resident 20 had a history of sexually inappropriate comments and exposing himself to staff. Interventions included, but were not limited to: -Continue in-house psychological services. -Educate resident. -Offer resident snacks particularly Pepsi, pretzels, chips, and cookies. -Redirect resident by changing topic to golf, sports, current events, and food. -Redirect resident by encouraging him to participate in his favorite activities including cross word puzzles, bird watching, and watching television especially westerns and action movies. -The interdisciplinary team to review behavior management program quarterly and as needed. A previous Physician's Order, dated 4/19/2024-7/26/2024, indicated an order for Resident 20 to receive risperidone one milligram three times daily for major depressive disorder. A Physician's Order, dated 7/27/2024-2/24/2025, indicated risperidone 0.5 milligrams three times daily for major depressive disorder. A previous Physician's Order, dated 2/24/2025-3/10/2025, indicated an order for Resident 20 to receive risperidone 0.5 milligrams three times daily for alcohol induced-persisting dementia. A current Physician's Order, dated 3/10/2025, indicated Resident 20 was to receive risperidone 0.5 milligrams three times daily for alcohol induced-persisting dementia. A review of Resident 20's behaviors indicated the following behaviors were documented from December 2024 through May 5, 2025: -January 7, 2025 sexual behaviors six times with redirection and changed environment interventions. No other behaviors had been documented during this time period. A Behavioral Health Encounter Note, dated 1/17/2025 at 12:00 A.M., indicated staff were to have montiored for any clinically significant changes in mood or behaviors. A Behavioral Health Encounter Note, dated 1/27/2025 at 12:00 A.M., indicated staff had observed minimal negative behaviors affecting care or safety. Resident 20 had recently changed rooms due to friction with his previous roommate. Resident 20 showed subdued, constricted affect, slowed processing speed and was cooperative. A Behavioral Health Encounter Note, dated 1/30/2025 at 12:00 A.M., indicated Resident 20 was discussed in the behavior/gradual dose reduction meeting with the facility's interdisciplinary team. Staff had reported that Resident 20 had been making inappropriate sexual comments toward staff and had a recent improvement regarding exhibited behaviors since being moved from the locked memory care unit. The note indicated a clinical contraindication would be noted due to ongoing concerns and condition the resident's condition was not well controlled or stable. A Behavioral Health Encounter Note, dated 2/24/2025 at 12:00 A.M., indicated Resident 20 was subdued to somnolent, difficult to rouse and minimally cooperative. Resident 20 showed no signs of agitation or distress. Staff reported Resident 20 continued to be stable overall and had been able to be managed with his current regimen and interventions. Behavioral services were to continue with another provider. A Behavioral Health Encounter Note, dated 2/27/2025 at 12:00 A.M., indicated Resident 20 was discussed in the behavior/gradual dose reduction meeting with the facility's interdisciplinary team. The note indicated there were no pharmacy recommendations to review on this date. Resident 20 was continued on risperidone 0.5 milligrams three times a day with the last gradual dose reduction attempted, on 7/25/2024. An Initial Psychiatry Consult Note, on 3/12/2025 at 11:59 P.M., indicated Resident 20's mood was reported as okay during the visit. The note indicated there would not be any changes to the current medication regimen. Resident 20 would continue to be monitored for mood and adjustment to treatment will be made as necessary. A Pharmacy Recommendation, dated 3/31/2025, indicated a dose reduction for Resident 20's psychotropic medications was due. A reply was handwritten on the bottom of hte recommendation form which indicated no changes at this time. There was no indications as to why a gradual dose reduction was not being attempted. A Behavioral Health Encounter Note, dated 4/15/2025 at 11:59 P.M., indicated Resident 20 reported satisfaction with his current life situation. The note indicated Resident 20 was to be monitored for mood issues and adjustments to the treatment was to be made if necessary. There was no specific contraindication documented regarding the reason for not attempting to reduce the resident's antipsychotic medication. During an interview, on 5/5/2025 at 2:04 P.M., the Social Service Assistant indicated every three months, a gradual dose reduction of psychotropic medications was to be attempted. She indicated the psychiatrist had not wanted to reduce Resident 20's medications since his symptoms were stable. She indicated she did not know if Resident 20 was on the lowest amount of the risperidone to achieve the same symptom control. There was no further documentation provided regarding a reason or contraindication for not attempting to reduce the resident's antipsychotic medication. A policy was provided, on 5/5/2025 at 2:46 P.M., by the Quality Assurance Administrator. The policy titled, Antipsychotic Medication Use, indicated, .1. Residents will only receive antipsychotic medication when necessary to treat specific conditions for which they are indicated and effective. Continues [sic Continued] use of the medication will be reviewed at least quarterly. 2. The Attending Physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, symptoms, and risks .5. The Attending Physician will identify, evaluate and document, with input from other disciplines and consultants as needed, symptoms that may warrant the use of antipsychotic medications .13. Residents receiving antipsychotic medications will be reviewed at least quarterly by the Interdisciplinary team. Gradual dose reductions [GDR} will occur as required, unless clinically contraindicated. A GDR will be attempted within the 1st year of admittance to the facility [or initiation of the antipsychotic] in 2 separate quarters with at least 1 month in between attempts. [NAME] the 1st year, A GDR will be attempted annually unless clinically contraindicated 3.1-48(b)(2)

Based on observation, interview and record review, the facility failed to ensure medication storage areas were clean and free from loose medications and failed to ensure medications were labeled and dated when opened, during medication storage review in 2 of 2 medication carts reviewed. (medication cart 1 on 100/200 hall and Memory Care 400 medication cart). Findings include: 1. During a medication storage observation, on 5/2/2025 at 10:30 A.M., on the medication cart 1 with LPN 2 the following was observed: - An unopened tube of glucose for a discharged resident. - An opened and undated bottle of Milk of Magnesia. - An opened bottle of ant-acid tablets with no resident label on the container. - Fourteen loose pills in the medication cart. - An opened package of Albuterol inhalation vials with no resident identifier. The over flow medication cart had an unopened box of Omeprazole tablets with no resident identifiers on the box. During an interview, on 5/5/2025 at 10:48 A.M., LPN 2 indicated the medications should have been labeled and dated when opened, and there should be labels on the medication bottles. LPN 2 indicated there should have not been loose pills in the medication cart. 2. During a medication storage observation, on 5/5/2025 at 11:02 A.M., on the Memory Care Unit with LPN 7, the following was observed: - Four loose pills in the 2nd and 3rd drawers. During an interview, on 5/5/2025 at 11:10 A.M., LPN 7 indicated the loose pills should have not be in the cart. On 5/5/2025 at 1:58 P.M., the Quality Assurance Adminiww3ws22qstrator provided the policy titled, Medication Labeling and Storage, undated, and indicated the policy was the one currently used by the facility. The policy indicated . Medication Storage . 2. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner . Medication Labeling 1. Labeling of medications and biological's dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices . 8. If medication containers have missing, incomplete, improper or incorrect labels, contact the dispensing pharmacy for instructions regarding returning or destroying these items 3.1-25(j) 3.1-25(r)

Based on interview and record review, the facility failed to provide mail delivery on Saturdays. This deficient practice affected 10 of 10 residents who attended the resident /surveyor group meeting. Finding includes: During the resident/surveyor group meeting on 4/30/2025 at 1:30 P.M., 10 of 10 participating residents indicated mail was not delivered to them on Saturdays. Resident 271 indicated she delivered the mail during the week to the residents, but the Saturday mail was not available for delivery to the residents. She indicated she never delivers the mail to residents on Saturdays. During an observation on Monday, 5/5/2025 at 8:25 A.M., staff was observed to remove a large amount of mail from an outside mailbox. During an interview, on 5/5/2025 at 3:58 P.M., the Business Office Manager indicated the facility and resident mail was delivered Monday through Friday to the receptionist who separated out the resident's mail for Resident 271 to deliver to the residents. The Business Office Manger indicated the receptionist only worked during the weekdays and the BOM did not know who, if any staff, retrieved the mail on Saturdays. She thought on an occasional Saturday, the Activity staff might have gottent he mail from the mailbox but she was unsure if anyone actually delivered the mail to residents on Saturdays. A policy was provided, on 5/5/2025 at 4:10 P.M., titled, Resident Rights: Policy Interpretation and Implementation by the Quality Assurance Nurse. The policy did not describe how residents would be provided with their personal mail Monday through Saturday. 3.1-3(s)1

Based on observation, record review and interview, the facility failed to ensure a resident was not neglected (Resident T) and the facility failed to complete interventions in place to prevent neglect and abuse (Resident P and Q) for 3 of 4 residents reviewed for abuse. (Residents T, P & Q) . This deficient practice resulted in Resident T observed to be extensively incontinent of urine and bowel movement (BM), including his clothing, bed pad, sheet, and blanket and had not received incontinent care for an undetermined amount of time. In addition, using the reasonable person concept, resident T and Q could have had feelings of embarrassment, fear of neglect, hopelessness, or depression related to the lack of superivision. (Resident P and Q) Findings include: 1. During an initial tour on 2/27/25 at 9:44 A.M , a strong urine and BM odor was noted in the hallway outside Resident T's room. From the door of the room, the resident was observed laying on his right side in a low bed with an quarter side rail in the raised position. He was wearing plaid pajama pants and no shirt and had a blanket partially covering him. Upon permission from the resident, the room was entered and the odor was stronger closer to the resident. The resident was observed with soiled and wet pajamas bottoms, with wetness and soilage noted partially down his bottom and a saturated incontinent brief soiled with urine and dark brown/black BM. The BM on his lower back was in various stages from wet to drying. The bed pad was soiled with urine and BM and had drying stains in various stages of drying. The blanket, which had been partially covering the resident, was also wet and soiled with urine and BM, in various stages of drying, The facility was alerted of the situation and help was summoned at 9:50 A.M. During an interview with the resident at 9:54 A.M.,. he indicated he had not been changed since yesterday. LPN 14 arrived at 9:56 A.M and indicated at that time, the resident needed care. He then summoned CNA 12 to the room to provide care to the resident. At that time, CNA 12 indicated she was not assigned to this hall but came to assist LPN 14. Both LPN 14 and CNA 12 began providing care for the resident using wipes. They pulled down his pajamas and attempted to remove the incontinent brief and identified wipes would not provide the care he needed. The LPN exited the room to get more supplies. CNA 12 continued to provide care to Resident T. As the incontinent brief was pulled down and the resident rolled onto his back, it was observed his bottom and back were noted to be saturated with urine and BM in the front and back of his peri area and there was an area of scant bleeding coming from his scrotum. The CNA patted the blood off the scrotum with a cloth and a pinpoint open area was observed. The resident indicated he had to urinate. There was no urinal in the room, so the CNA placed a pad over him, and he was able to urinate. The sheet under the resident was observed to have a large area of brown/black BM, in various stages from wet to drying. There was also dried brown rings on the sheet. At 10:06 A.M., LPN 14 arrived back to the room with more linens for care and at 10:09 A.M., CNA 11 arrived to assist. At 10:10 A.M the Director of Nursing was summoned to the room to observe the condition of the resident. However, at 10:14 A.M , the RN Consultant arrived and during an interview at that time, indicated the DON was out sick. She observed and verified the condition of the resident. She left the room, and CNA 12 continued to attempt to provide care to the resident. CNA 12 indicated the resident would need a shower and the resident agreed. The stand-up lift was brought into the room at 10:20 A.M As the CNA's attempted to use (the lift ), the battery was dead. CNA 11 left the room to retrieve a new battery at 10:24 A.M. and returned at 10:26 A.M , and discovered another dead battery. CNA 11 again left the room to retrieve a new battery. She arrived back in the room at 10:30 A.M. with 2 batteries, one of which worked. The resident was then transferred into the shower chair and taken for a shower by CNA 12. At 10:52 A.M., CNA 12 returned the resident to his room and CNA 11 assisted to get him dressed and up in his wheelchair. CNA 12 began providing care to Resident T at 9:56 A.M and was continuously with the resident until 11:00 A.M CNA 11 was providing continuous care for Resident T from 10:09 A.M. to 10:35 A.M During an interview with CNA 11 at 10:45 A.M., she indicated she was assigned to the front hall and there were only two CNA's working on the unit. She indicated she was the CNA assigned to Resident T for the day. She indicated had arrived to work in the morning and found the night CNA watching movies on his phone. She indicated started getting residents up for breakfast after she had arrived. She indicated had had not been able to check or change Resident T. She stated Resident T looked like he had not been toileted all night. The record review for Resident T was completed on 2/27/25 at 1:24 p.m. Diagnoses include, but were not limited, to vascular dementia, mild and chronic kidney failure. A physician order, dated 2/24/25, indicated the resident was to be offered toileting at 12 A.M., 5 A.M., 8 A.M., 12 P.M., 3 P.M., 5: 30 P.M., and at bedtime. A Quarterly Minimum Data Set (MDS) Assessment, dated 1/15/25, indicated the resident had severe cognitive impairment, had feelings of being down, depressed, or hopeless several days, was frequently incontinent of bladder and bowel and required partial to moderate assistance with toileting and transfers. Care Plans revised on 12/6 24, indicated the resident had a self-care deficit in incontinence care and required up to 2 staff for participation in toileting and to provide assistance as needed. The resident was also at risk for skin breakdown related to incontinence and the resident's skin was to be kept clean and dry and staff were to offer toileting at 12 A.M., 5 A.M., 8 A.M., 12 P.M., 3 P.M., 5: 30 P.M., and at bedtime. An Activities of Daily Living task sheet reviewed on 2/27/25 at 2 p.m., indicated the resident last received incontinent care on 2/26/25 at 6:30 P.M. 45120 2. During an observation, on 2/27/2025 at 10:00 A.M., a stop sign was not observed across Resident P's doorway. Resident P was in bed with his eyes closed. During an observation, on 2/27/2025 at 1:38 P.M., a stop sign was not observed across Resident P's doorway. Resident P was in bed with his eyes closed. A record review for Resident P was completed on 2/27/2025 at 11:03 A.M. Diagnoses included, but were not limited to: Alzheimer's disease, bipolar disorder, anxiety disorder and major depressive disorder. A Quarterly Minimum Data Set (MDS) assessment, dated 11/7/2024, indicated Resident P had moderate cognitive impairment and had verbal behavioral symptoms directed towards others. A Progress Note, on 1/31/2025 at 8:19 A.M., indicated Resident P was found in his bed with resident Q partially clothed. Resident P was placed on one-on-one checks. An Interdisciplinary Team (IDT) Note, on 1/31/2025 at 11:12 A.M., indicated the team met and Resident P would have a stop sign placed in his doorway to prevent another resident from wandering into his room. An Interdisciplinary Team Note, on 2/3/2025 3:48 P.M., indicated one-on-one supervision was discontinued and 15-minute checks were to be continued for 72 hours. A Care Plan, initiated 2/3/2025, indicated Resident P demonstrated inappropriate sexual behaviors at times related to unspecified dementia, bipolar disorder with severe psychotic features. These diagnoses resulted in poor impulse control. The goal indicated Resident P would not touch any confused or non-consenting resident in a sexual or inappropriate manner. Interventions included, but were not limited to: Resident P was placed on one-on-one checks following the reported incident. A Care Plan, initiated on 1/31/2025, indicated Resident P was at risk for emotional distress related to another resident had entered his room. The goal indicated Resident P would not show any signs of emotional distress. Interventions included, but were not limited to: 15-minute checks initiated for 72 hours after the one-on-one staff supervision concluded. A document titled, Resident Specific Problem or Behavior Tracking Sheet, was provided by the Quality Assurance Administrator. The document was dated 1/30/25-1/31/25. The tracking began at 4:00 P.M. on 1/30/2025 and ended on 1/31/2025 at 11:45 A.M. There was empty tracking during the times of 1/31/2024 6:45 A.M. through 8:45 A.M. and 10:30 A.M. through 11:45 A.M. During an interview, on 2/28/2025 at 11:49 A.M., the Quality Assurance Administrator indicated the documents provided were the only documents that she could find in the facility. On 2/27/2025 at 2:14 P.M., CNA 5 documented a safety device for a stop across the door was in place. During an interview, on 2/27/2025 at 2:28 P.M., CNA 5 indicated the documentation of the stop sign across the doorway was incorrect. She indicated she had never seen a stop sign across Resident P's doorway, but she would obtain a stop sign for the doorway. During an observation, on 2/28/2025 at 4:07 A.M., 5:38 A.M., 6:22 A.M. and 715 A.M., a stop sign was not observed across Resident P's doorway. During an interview, on 2/28/2025 at 4:19 A.M., CNA 15 indicated he had not seen a stop sign across Resident P's door since the reported incident between Residents P and Q. During an interview, on 2/28/2025 at 4:29 A.M., LPN 6 CNA 4 had informed her there were two residents in bed together. CNA 4 informed LPN 6 Resident P was fully dressed and had gotten up and went to the bathroom and Resident Q was noted to have her top off. During an interview, on 2/28/2025 at 4:40 A.M., QMA 3 indicated she oversaw the medication cart on the dementia unit the night of 1/29/2025. She had worked alongside CNA 2 and CNA 15. She indicated CNA 15 informed her that Resident P and Resident Q were in Resident P's room together, but CNA 15 had not indicated what had happened. She indicated she ihad nformed LPN 6 that Resident Q had exited Resident P's room. During an interview, on 2/28/2025 at 10:15 A.M., the Quality Assurance Administrator indicated she was not sure if the facility had a door stop sign for Resident P's room. 3. During an observation, on 2/27/2025 at 10:28 A.M., Resident Q was observed in the hallway for 30 minutes. During an observation, on 2/27/2025 at 2:21 P.M., Resident Q was observed wandering on the dementia unit hallway. During an observation, on 2/28/2025 at 1:34 P.M., Resident Q was observed roaming the dementia unit hallway with another male resident. A record review for Resident Q was completed on 2/27/2025 at 1:36 P.M. Diagnoses included, but were not limited to: dementia and schizophrenia. A Quarterly MDS assessment, dated 1/20/2025 indicated Resident Q had severe cognitive impairment and had no behaviors documented during the assessment period. A Nursing Progress Note, dated 1/30/2025 at 3:30 P.M., indicated Resident Q was partially dressed and found in Resident P's room. A Nursing Progress Note, on 1/31/2025 at 11:02 A.M., indicated the IDT team met and discussed Resident Q having been found in Resident P's room. Resident Q was placed on 30-minute checks and was to be encouraged to participate in activities. A Care Plan, initiated on 1/31/2025, indicated Resident Q was at risk for emotional distress related to being partially clothed in another resident's room. The goal indicated Resident Q would not show any signs of emotional distress. Interventions included, but were not limited to: one-on-one supervision until the IDT team had discussed and determined Resident Q was no longer an acute risk of repeating the behavior and 30-minute checks were put into place. Documents titled, Resident Specific Problem or Behavior Tracking Sheet, were provided by the Quality Assurance Administrator. The documents had the following dates with missing documented checks: - 1/31/2025 started documentation at 10:45 A.M. Documentation into 2/1/2025 at 6:45 A.M. through 2:15 P.M was missing. - 2/1/2025 documentation from 3:30 P.M. through 5:30 P.M. was missing. - There was no documentation for 2/2/2025. - A document titled, Frequent Monitoring check sheet, dated 2/3/2025 had documentation from 12:00 P.M. through 8:30 P.M. and no other documentation was present. - 2/4/2025 documentation was recorded from 6:30 A.M. through 6:30 A.M. on 2/5/2025. No further documentation of 30-minutes checks were available after this documented time and date. A Facility Report Incident was reported to the Indiana Department of Health, on 1/30/2025. The report indicated the incident between Resident P and Q occurred on 1/29/2025 at 8:01 P.M. The investigation notes revealed: - A typed statement, signed by the Director of Nursing (DON) and the Executive Director (ED), indicated CNA 2 was interviewed on 1/30/2025. She indicated she was working on the dementia unit on 1/29/2025 from 2:30 P.M. through 10:30 P.M. CNA 15 requested her to go to Resident P's room. She indicated when she walked into the room, Resident Q was seated on Resident P's bed with her shirt off and her shirt was on Resident P's bed. - A typed statement by the ED, dated 1/30/2025, indicated the DON and herself were advised, at 4:00 P.M. on 1/30/2025, of Resident Q was in Resident P's bed without a shirt and Resident P was without his pants in the bed. The ED placed Resident P on one-to-one supervision for the evening. - A typed statement by the ED, indicated QMA 3 was working on 1/29/2025. QMA 3 indicated CNA 15 requested her to come to Resident P's room. She observed Resident P walking to the bathroom and Resident Q exiting Resident P's room. QMA 3 informed LPN 6 of her observations. CNA 15 did not inform QMA 3 or LPN 6 of his observations. During an interview, on 2/28/2025 at 11:49 A.M., the Quality Assurance Administrator indicated the documents provided were the only documents she d in the found in the facility. A policy was provided by the Quality Assurance Administrator, on 2/28/2025 at 12:03 P.M. The document titled, Abuse Policy, indicated, .The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in the subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to the resident's medical symptoms .Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers .The facility shall have a process in place to include screening, training, prevention, identification, protection, investigation, reporting and response to allegations of potential actual abuse and neglect . Sexual Abuse is defined as non-consensual sexual contact of any type with a resident The Abuse policy dated as reviewed 1/2020 was provided by the Quality Assurance Director on 2/28/25 at 12:03 p.m. The policy indicated The resident has the right to be free from abuse, neglect .Neglect is defined as the 'failure of the facility, its employees or services providers to provide goods and services to a resident that is necessary to avoid physical harm, pain, mental anguish or emotional distress This citation relates to complaint IN00452803. 3.1-27(a)(1) 3.1-27(a)(3)

Based on record review and interview, the facility failed to prevent and identify pressure injuries for 2 of 3 residents reviewed for pressure injuries (Residents E & F). The deficient practice resulted in wounds developed to a Stage 3 pressure ulcer for Resident E and an unstageable wound for Resident F. Findings include: 1. A record review was completed for Resident E on 2/27/2025 at 10:18 A.M. Resident E was admitted to the facility on [DATE]. Diagnoses included, but were not limited to: type 2 diabetes, moderate protein calorie malnutrition and iron deficiency anemia. A Nursing Admission Evaluation, dated 9/18/2024, indicated Resident E was at mild risk for pressure ulcers. Care plans, initiated on 9/19/2024 and reviewed as current through 12/25/2024 included a plan to address the resident's potential for impaired skin integrity related to incontinence and limited mobility. Interventions, included but were not limited to: educate resident/family/caregivers on causative factors and measures to prevent skin injury, encourage good nutrition and hydration in order to promote healthier skin, keep skin clean and dry, use lotion on dry skin. Do not apply to open areas, treatments as ordered by MD. A care plan to address the resident's ADL (activities of daily living needs, included an intervention for staff to provide extensive assistance for toileting, transfers and bathing needs. A Weekly Skin Review, dated 10/27/2024, indicated Resident E's skin was dry, intact and without any skin alterations. A Weekly Skin Review, dated 11/13/2024, lacked documentation of any abnormal skin issues for Resident E. Review of a quarterly Minimum Data Set (MDS) assessment, completed on 11/17/2024 indicated Resident E was severely cognitively impaired, required moderate assistance for hygiene and transfer needs, had an indwelling urinary catheter, was frequently incontinent of bowels and required extensive staff assistance for toileting and bathing needs. A Physician's Order, initiated on 12/7/2024 and discontinued on 12/13/2024, indicated to cleanse area to sacrum with normal saline and apply mepilex every day and as needed. Resident E's December Medication Administration Record (MAR) indicated on 12/7/2024, 12/8/2024, 12/10/2024 and 12/11/2024 there was no indication the treatment of normal saline and mepilex to the sacrum had been completed. A Physician's Wound note, dated 12/11/2024, indicated Resident E had a stage three pressure wound to his sacrum of full thickness. Documentation indicated the wound had been present for greater than 14 days. Wound measurements were documented at 2.4 cm x 1.0 cm and depth was immeasurable due to the presence of nonviable tissue and necrosis (dead tissue). No further nursing skin evaluations were completed until 12/11/2024 after the Physician's Wound note. The 12/11/2024 skin evaluation indicated Resident E had a stage three pressure ulcer to his sacrum. A Weekly Pressure Ulcer Injury Evaluation, dated 12/11/2024, indicated Resident E had an in-house acquired stage three pressure injury to his sacrum, with an onset date of 12/11/2024. The resident's wound measurements were documented at 2.4 centimeters (cm) x 1 cm. A Care Plan, revised on 12/12/2024, indicated Resident E had a stage three pressure ulcer to his sacrum. Interventions included, but were not limited to: Administer treatments as ordered and observe for effectiveness A Physician's Order, initiated on 12/14/2024 and discontinued on 2/25/2024, indicated to cleanse area to sacrum with normal saline and apply calcium alginate and cover with island border gauze one time a day for wound management. A Significant Change Minimum Data Set (MDS) assessment, dated 12/15/2024, indicated Resident E had significant cognitive impairment, was dependent on staff for bed mobility and transfer needs and had impaired range of motion to both lower extremities Resident E's December MAR indicated from 12/15/2024 through 12/24/2024 and on 12/27/2024, 12/29/2024 and 12/31/2024 there was no indication the treatment of calcium alginate to the sacrum had been completed. A Physician's Wound note, dated 2/24/2025, indicated the wound had been present for greater than 89 days. Wound measurements were documented at 3 cm x 1.2 cm x 0.4 cm. A treatment plan indicated to apply a hydrocolloid sheet three times per week and as needed for 16 days. A Current Physician's Order, dated 2/27/2025, indicated to cleanse the sacrum, pat dry, apply hydrocolloid sheet, cover with border gauze three times per week every Monday, Thursday, and Saturday. During an interview on 2/27/2025 at 2:49 P.M., LPN 9 indicated residents usually had their skin assessments completed weekly. He indicated CNA's were required to notify the nurse if an abnormal skin issue was identified. The nurse was to have performed an assessment and document the findings under a new skin evaluation. During an interview on 2/27/2025 at 2:58 P.M., the Quality Assurance Director indicated CNA's did not use shower sheets and CNA's were to complete skin observations during showering and when providing incontinence care. The observations should be documented in the computer. The CNA's documentation of Resident E's skin observations for the month of December lacked documentation of an open area on the resident's sacrum. The skin observations documented on 12/10/2024 and from 12/12/2024 through 12/31/2024 indicated Resident E had no new skin abnormalities. During an interview on 2/28/2025 at 8:26 A.M., CNA 10 indicated Resident E was able to roll from side to side in bed if requested. She indicated the resident was unable to scoot himself up in bed and was unable to help staff scoot him up in the bed. During an interview on 2/28/2025 at 9:17 A.M., the Regional Director of Care Services indicated she was unsure how the resident had developed a stage three pressure injury. She indicated the aides did a skin observation every shift and any new skin findings should have been documented in the computer. During an interview on 2/28/2025 at 10:38 A.M., the Regional Director of Care Services indicated she was unable to find anything in the resident's electronic record indicating the resident had a skin abnormality prior to 12/11/2024. 2. A record review was completed for Resident F on 2/27/2025 at 9:24 A.M. The resident was readmitted to the facility on ,d+[DATE]. Diagnoses included, but were not limited to: malnutrition, polyosteoarthritis and muscle weakness. An Admission Minimum Data Set (MDS) assessment, dated 12/2/2024, indicated Resident F was cognitively intact, required supervision or touch assistance with bed mobility and had no current pressure areas, but was at risk for pressure injuries. A Weekly Skin Review, dated 12/15/2024, indicated Resident F had no pressure abnormalities to his skin. A Weekly Skin Review, dated 12/23/2024, indicated Resident F's skin was intact with no skin alterations. Resident F's record lacked documentation that any weekly skin review assessments had been completed since 12/23/2024. A Braden Scale assessment (assessment for predicting pressure sore risk), dated 1/20/2025, indicated Resident F was at mild risk for pressure injury development. A Nursing Progress Note, dated 1/22/2025, indicated Resident F complained of severe pain to both feet. Upon assessment, the nurse had observed both great toes to be red and painful when touched. Resident F also complained of pain when repositioning his feet and in both heels. The Physician was notified. There was no further documentation regarding any skin abnormality until 2/10/2025 and no physician response in regards to the notification of red/painful toes and painful feet and heels noted on 1/22/2025. A Weekly Non-Pressure Injury Review, dated 2/10/2025, indicated Resident F's only skin abnormality was a skin tear to his right upper arm. No pressure abnormalities were documented. A Physicians Wound Note, dated 2/10/2025, indicated Resident F had a non-pressure wound of the right upper arm. No other pressure related skin abnormalities were documented. However, a Physician's Wound Note, dated 2/17/2025, indicated Resident F had wounds to his right upper arm, left heel and left plantar foot. The note indicated the resident had an unstageable pressure wound to his left heel of full thickness. Wound measurements were documented at 1 cm x 0.8 cm x immeasurable depth. Wound duration was documented at greater than 7 days. Resident F also had an unstageable pressure wound to his left plantar foot of full thickness. Wound measurements were documented at 1 cm x 1.8 cm x immeasurable depth. Depth was immeasurable for both pressure injuries due to the presence of nonviable tissue and necrosis. A Nursing Progress Note, dated 2/19/2025, indicated Resident F's skin was assessed and noted a small necrotic area on the tip of the resident's left great toe measuring 0.5 cm x 0.5 cm. A Weekly Non-Pressure Injury Review, dated 2/19/2025, indicated Resident F's non-pressure injury was facility acquired and was located on the left great toe. A Physician's Progress Note, dated 2/19/2025, indicated the resident was to be evaluated by the podiatrist and a wound physician. A Physician's Order, dated 2/20/2025, indicated betadine external solution to be applied to resident's left heel and left plantar foot topically one time a day for 30 days for wound management. A Care Plan, initiated on 2/21/2025, indicated Resident F had an unstageable pressure injury to the left heel. Interventions included, but were not limited to: elevate foot while in bed and treatment to area as ordered. During an interview on 2/28/2025 at 1:57 P.M., the Regional Director of Care Services indicated weekly skin assessments should have been completed on Resident E and Resident F. She indicated Resident E's stage three pressure injury and Resident F's unstageable pressure injuries should have been prevented and identified. She indicated the residents should have had Braden Assessments completed every week for four weeks post admission. She indicated Resident E's treatments should have been completed on the days where there were no documented treatments. Resident E and F's pressure areas were unable to be observed due to hospitalization at this time for both residents. On 2/28/2025 at 1:38 P.M., the Quality Assurance Director provided a policy titled, Skin and Wound Management System, dated 4/2017, and indicated it was the policy currently being used by the facility. The policy indicated .Policy: It is the policy of this center's Skin Management System to identify and assess residents with wounds and/or pressure ulcers, as well as those at risk for skin compromise. Such residents are then provided appropriate treatment to encourage healing and/or integrity. Ongoing monitoring and evaluation are then provided to ensure optimal resident outcomes . 3. Ongoing weekly evaluations of resident's skin will be completed and documented in PCC on the Weekly Skin Evaluation form A policy regarding the prevention of pressure injuries was requested but one was not provided prior to the survey exit. This citation relates to complaint IN00453447. 3.1-40(a)(1)

Based on observation, interview and record review, the facility failed to ensure there were staff available to provide care in a timely manner to residents who required assistance(Resident T and H) and failed to ensure staff did not work greater than 20 hours in a day. (QMA 3 and LPN 6) Using the reasonable person concept, resident T could have feelings of embarrassment, fear of neglect, hopelessness, or depression. Findings include 1. Resident T was observed on 2/27/25 at 9:44 a.m., to be visibly soiled urine and bowel movement (BM), that saturated his pull-up, bed pad, bed linens, and blanket. The resident was to be on a toileting schedule, and documentation indicated he had not been toileted as schedule. Cross Reference: F600 2. Resident H did not have her call light answered timely in order to have to have her care needs met. Cross Reference F 550 3. The posted staffing for 2/27/25 indicated there were 2 CNA's for Unit 1 and Unit 2. There were 39 residents residing on Unit 1 and Unit 2. During an interview, on 2/27/2025 at 3:09 p.m., CNA 12 indicated if there are three aides on Unit 1 and 2, then the showers could get done. If there were just two aides, then not all of them (showers) were completed. There were 10 showers on the day shift, and staff were too busy getting residents up, assisting with meals, and laying the residents down to complete showers. During an interview, on 2/27/2025 at 3:10 p.m., CNA 11 indicated if there were three aides assigned, showers were provided, but any less than three aides, the assigned work could not be completed and this occurred all the time. During an interview, on 2/28/25 at 10:42 a.m. the Quality Assurance Director (QAD) indicated the facility usually did not have a lot of staff call-offs and they tried to replace them. The DON, Administrator, and scheduler had been out sick, and the scheduler had just returned back to work today. There had been staff call -offs for today and the scheduler was working to have staff come in to cover. There was an LPN and QMA that were still working from the prior shift ,which had started at 6:30 P.M. on 2/27/25. The QAD indicated if the facility could not find replacements for the staff who had been working greater than 16 hours already, then the corporate nurse would have to work on a medication cart. The Corporate nurse was not seen working any unit. The QAD indicated bonuses were offered to staff if they picked up shifts During an interview, on 2/28/25 at 12:18 P.M., QMA 3 indicated she was staying over to cover a call off for day shift and there had been no communication about a replacement from anyone. She indicated she was not offered a bonus. On 2/28/2025 at 3:35 P.M., before the survey exit, QMA 3 and LPN 6 were still observed working on the floor, over 20 hours straight. The Facility Assessment was received from the RN consultant on 2/27/25 at 11:59 A.M. The assessment was dated 12/9/24 and had been reviewed by the Quality Assurance team on 12/20/24. The assessment indicated it would be used to: .Inform staffing decisions to ensure that there are a sufficient number of staff with the appropriate competencies and skill sets necessary to care for its residents' needs identified through resident assessments and plans of care; Consider specific staffing needs for each resident unit in the facility and adjust as necessary based on the changes to its resident population; average daily census (ADC) 56-72 .Resident Acuity Affecting Nurse Aides (including facility specific not already listed) Assistance Provided with Dressing 35 Assistance Provided with Bathing 58 Assistance Provided with Transfers 27 Assistance Provided with Eating 5 Assistance Provided with Toileting 35 Assistance Provided with Mobility 29 Assistance Provided with Splint braces 2 Assistance Provided with Behavior symptoms 35 . SERVICES AND CARE WE OFFER BASED ON OUR RESIDENT'S NEEDS Activities of Daily Living Dressing, oral care, toileting, eating, bathing, bed mobility, transfers, ambulation . Bowel and Bladder Three day void to assess incontinence and determine if a scheduled toileting program is required. Residents who meet the requirement are then place on a written toileting program including care planning. Information about our staff . INFORMATION ABOUT OUR STAFFING PATTERNS Average Nurse Aide/Resident Ratio (Direct Care Staff) 1 to 6 . Administration Staffing as described above is adequate as evidence by: All care requirements are met daily and by shift Although the facility assessment indicated the direct care staffing ration was to be at a 1 staff to 6 resident ration, the ratio observed on 2/27/2025 on the 100 and 200 units, during the day shift was at a 1 staff to 13 resident ratio. (2 CNAs and 1 nurse for 39 residents) This citation relates to complaint IN00453989 and complaint IN00453447.

Based on record review, and interview the facility failed to ensure the Memory Care Unit (MCU) was free from incontinence brief debris and failed to ensure adequate supervision was provided to a cognitively impaired resident on the MCU to prevent ingestion of the debris for 1 of 3 residents reviewed for accidents. This deficient practice resulted in Resident C experiencing a blocked airway, a change in level of consciousness and requiring emergent treatment from Emergency Medical Services (EMTs). (Resident C) Finding includes: A record review for Resident C was completed on 6/21/24 at 11:30 A.M. Diagnoses included, but were not limited to: dementia, depression, anxiety, congestive heart failure, chronic obstructive pulmonary disease, atrial fibrillation. A Quarterly Minimum Data Set (MDS), assessment, dated 3/21/24, indicated Resident C was severely cognitively impaired and displayed no behaviors. The resident required extensive assistance with all Activities of Daily Living, was ambulatory and did not require mobility devices to assist with walking. A review of Resident C's Indiana Physician's Orders for Scope of Treatment (POST) form, dated 11/17/24, indicated Resident C was a DNR (Do Not Resuscitate). A late entry nursing progress note authored by the Director of Nursing (DON), dated for 6/8/24 at 10:25 P.M., indicated staff found Resident C on the floor of the activity room, had a white substance in the mouth, and had labored breathing. The note indicated nursing staff performed a finger sweep, but the resident was resistant to the procedure. Resident C independently moved to a standing position, continued coughing, nursing staff transferred him to a chair and activated a 911 call. The EMTs (Emergency Medical Technicians) arrived, continued with removing the white substance from the resident's mouth. Resident C became pulseless and respirations ceased during EMT care. On 6/21/24 at 10:45 A.M. the Administrator provided the daily assignment sheet for 6/8/24. The daily assignment sheet indicated RN 3 and CNA 2 were scheduled to work on Unit 4 (Memory Care) the evening and night shifts of 6/8/2024 into 6/9/2024. Review of CNA 2's punch history, indicated on 6/8/24 the CNA punched in at 8:12 P.M. and punched out at 10:16 P.M. During an interview on 6/21/24 at 9:56 A.M., Registered Nurse (RN) 3 indicated she had worked the evening shift on the Memory care unit on 6/8/24. The CNA who was scheduled to work with her on the evening and night shift from 6:30 P.M. to 6:30 A.M., called off work. RN 3 indicated CNA 2 agreed to come in to help put the residents in the Memory Care to bed. RN 3 indicated she was working on the Memory unit alone after CNA 2 left, and indicated the unit was usually staffed with 1 nurse and 1 CNA on the evening and night shifts. CNA 2 was observed to put everyone to bed except 3 male residents, including Resident C. RN 3 indicated CNA 2 told her something was all over the floor in the activities area and she had cleaned it up and disposed of it outside the unit in the trash container. CNA 2 was going to go home around 10:15 P.M RN 3 had gone to the activities area and 3 male residents and CNA 2 were there and everything seemed fine. She asked CNA 2 if she would stay while she went to her car to get her lunch bag. RN 3 indicated when she returned to the unit, she announced her return to the unit, and then CNA 2 left to go home. RN 3 briefly went to another hall and returned to the Memory Care unit. When she returned to the unit, another resident called to her and told her Resident C was eating popcorn. RN 3 indicated she went to the dining room where and found Resident C on the floor, gray in color and non-responsive. RN 3 thought he may have had a seizure so she turned him to his side. When she turned him, she saw something in his mouth, and while he was still unresponsive, she performed a mouth sweep 3 times and each time she removed a fluffy white material. RN 3 briefly left the area to call another nurse, Licence Practical Nurse (LPN) 4, from the next unit and asked her to continue to perform mouth sweeps while she ran to call EMS. RN 3 indicated Resident C was doing better at that time and he got up in chair and was breathing. She went to the front doors to let the EMTs in the building while LPN 4 stayed with the resident. When the EMTs got to Resident C, he was non-responsive again. The EMTs layed the resident down and removed pieces of the Depends from the airway, but the resident still was not breathing During an interview on 6/21/24 at 10:51 A.M., CNA 2 indicated she was not scheduled to work on 6/8/24 on the evening shift, but another CNA called off, so she agreed to work from 8:00 P.M. to 10:00 P.M., to help get residents ready for bed. When she arrived to the Memory Care unit, at 8:15 P.M., there was 1 nurse working the floor. CNA 2 indicated on arrival she found fluff all over the hall and dining room. She cleaned it up and placed the fluff in the trash on the housekeeping cart that was by the time-clock. She returned the cart with the fluff to the area of the time-clock, which was not accessible to the residents. She did not put Resident C to bed because he could be combative with care. Resident C was walking around in the dining room with 2 other male residents. CNA 2 left the facility at about 10:15 P.M. and no one replaced her. When she left there were no concerns with Resident C. During an interview on 6/21/24 at 12:45 P.M., the facility Corporate Nurse indicated there should always be at least 1 nursing staff member present on the Memory Care unit at all times. On 6/21/24 at 3:06 P.M., the Administrator provided a policy titled,Staffing, dated 2017, indicated, Staffing .Licensed nurses and certified nursing assistants are available 24 hours a day to provide resident care services . This citation relates to Complaint IN00436291. 3.1-45(a)

Based on observation, interview, and record review, the facility failed to provide nursing services in a safe and sanitary manner to prevent the transmission of communicable diseases and infections related to not sanitizing the glucometer (portable machine used to test blood sugar levels) between uses for 2 of 16 residents (Residents 29 & 5) randomly observed for glucose monitoring. The facility identified 2 of the 5 residents with bloodborne communicable disease who resided in the facility used the shared glucometer. (Residents 28 & 38) This deficient practice resulted in a high potential risk for disease transmission for the 16 residents in the facility who required glucometer blood sugar testing. The facility also failed to ensure services were effectively provided to prevent the development of infections for 1 of 1 resident reviewed for indwelling urinary catheter care (Resident 33), 1 of 1 resident randomly observed for accessing an ice chest (Resident 3), 3 of 3 residents randomly observed for nursing care by 2 of 3 nursing staff (Resident 4, Resident 7, Resident 46, LPN 2, CNA 8), and 1 of 1 resident reviewed for respiratory care. (Resident 54). The immediate jeopardy began on 5/13/24 when facility staff was observed attempting to complete glucometer blood sugar testing on a resident after prior resident testing without the shared glucometer being sanitized. There were two residents requiring blood glucose testing in the facility who were also identified as having a bloodborne disease. The Executive Director (ED) was notified of the immediate jeopardy at 3:46 P.M. on 5/15/24. The immediate jeopardy was removed on 5/17/2024 at 2:2:7 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. Findings include: 1. During a continuous random observation on 5/13/2024 from 11:08 A.M. through 11:26 A.M., QMA 2 was observed to go in Resident 29's room with the glucometer to check a blood sugar. At 11:10 A.M., QMA 2 was observed to leave the resident's room, place the glucometer on top of the medication cart, and place the glucometer in the right-side top drawer of the medication cart without sanitizing the device. At 11:26 A.M., QMA 18 was observed to take the same glucometer out of the top drawer and go into Resident 5's room. QMA 18 used a lancet to obtain a blood sample for the blood sugar check. When QMA 18 went to place the testing strip with the glucometer up to Resident 5's finger, QMA 18 was stopped from completion of the testing. When questioned about the practice of sanitation when blood sugars were obtained, QMA 18 indicated she should have cleaned the glucometer, and confirmed she had not cleaned the glucometer since the prior resident's blood sugar test had been completed. On 5/13/2024 at 11:43 A.M., a list of residents residing in the facility with bloodborne pathogens was requested from the Director of Nursing. On 5/13/2024 at 2:09 P.M., the list of residents with bloodborne pathogens provided by the DON was reviewed. The list indicated there were three residents with viral hepatitis C, one resident with hepatitis B, and one resident with human immunodeficiency virus (HIV) disease that reside in the facility. Two of these five residents, through record review, were identified to require blood sugar checks, Residents 28 and 38. During an interview on 5/16/2024 at 1:20 P.M., the Director of Nursing indicated the proper procedure for blood glucose monitoring included the following: wash hands, don gloves, place the glucose monitor on a clean field, place a new lancet with a spring load that is disposable on the clean field, wipe the area with an alcohol wipe, obtain the blood sample, discard the lancet into a sharps container, clean the device after use, and place it in the proper storage device after cleaning. The appropriate disinfectant used to clean the device was Microdot bleach wipes with a sit time on the machine of 1 minute. a. A record review for Resident 29 was completed on 5/15/24 at 2:30 P.M. Diagnoses included, but were not limited to, type 2 diabetes mellitus. A Quarterly Minimum Data Set (MDS) assessment, dated 4/25/24, indicated the resident was cognitively intact. A Care Plan, dated 7/23/2023, indicated Resident 29 had a diagnoses of diabetes mellitus which placed him at risk for medical complications. The goal indicated to have no medical complications through the next review on 7/26/2024, with an intervention of blood sugar checks as ordered by the physician. A Physician's Order, dated 2/7/24, indicated blood sugar (BS) testing before meals and at bedtime related to type 2 diabetes mellitus. b. A record review for Resident 5 was completed on 5/15/24 at 2:21 P.M. Diagnoses included, but were not limited to, diabetes mellitus type 2, carrier of MRSA (methicillin-resistant Staphylococcus aureus), resistance to vancomycin, and ESBL resistance (extended-spectrum beta-lactamases) A Quarterly MDS assessment, dated 4/18/24, indicated the resident was cognitively intact. Diagnoses included diabetes mellitus and multi-drug resistant organism. She received insulin injections. A Physician's Order dated 2/7/2024, indicated blood sugar checks before meals, bedtime, and as needed. A Care Plan, revised on 4/19/2024, indicated Resident 5 had a diagnoses of diabetes mellitus which placed her at risk for medical complications with an intervention of blood sugar checks as ordered by the physician. c. A record review for Resident 28 was completed on 5/13/2024 at 2:11 P.M. Diagnoses included, but were not limited to, personal history of other infectious and parasitic diseases, unspecified viral hepatitis B without hepatic coma, and diabetes mellitus type 2. A Quarterly MDS assessment, dated 4/24/2024, indicated Resident 28 was cognitively intact. Diagnoses included viral hepatitis and diabetes mellitus. A Physician/Nurse Practitioner Note, dated 3/8/2024 at 11:49 A.M., indicated lab results were received. HBsAg (a protein that indicates an active or chronic hepatitis B infection), Anti-HBC IgM (an antigen that indicates a new infection with hepatitis B), Hep B Core Ab IgM (antibody that indicates past or ongoing hepatitis B) were all positive. A Physician/Nurse Practitioner Note, dated 3/8/2024 at 10:43 P.M., indicated lab results came back positive for acute hepatitis B, and the DON had notified the county health department of the positive hepatitis B result. The county health department indicated Resident 28 needed to be in contact isolation and seen by infectious disease. A Physician/Nurse Practitioner Note, dated 3/12/2024 at 10:42 A.M., indicated the Nurse Practitioner informed the DON that Resident 28 should be placed in a private room. A Physician's Order, dated 4/23/24, indicated blood sugar monitoring before meals and at bedtime. A Care Plan, revised 11/7/2023, indicated Resident 28 had a diagnoses of diabetes mellitus which placed him at risk for medical complications. The goal indicated to have no medical complications through the next review on 5/14/2024 with an intervention of blood sugar checks as ordered by the physician. During an interview, on 5/13/2024 at 2:58 P.M., Resident 28 indicated he had a continuous blood sugar monitor system the nursing staff used, but he had frequently received fingerstick blood sugar checks with the facility glucometer when his device was charging or if the nursing staff did not know how to use the device. d. A record review for Resident 38 was completed on 5/13/24 at 2:47 P.M. Diagnoses included but were not limited to, human immunodeficiency virus (HIV) disease, anogenital herpes viral infection, and diabetes mellitus type 2. A Quarterly MDS assessment, dated 4/24/24, indicated Resident 38 was cognitively intact. She had a diagnose of diabetes mellitus and received insulin injections. A Physician's Order, dated 12/6/23, indicated blood glucose monitoring before meals and at bedtime. The facility's most current policy was provided on 5/17/2024 at 5:37 A.M. The policy titled, Blood Sampling-Capillary [Finger sticks], indicated, .The purpose of this procedure is to guide the safe handling of capillary-blood sampling devices to prevent transmission of bloodborne disease to residents and employees .1. Always ensure that blood glucose meters intended for reuse are cleaned and disinfected between resident uses The immediate jeopardy that began on 5/13/24 was removed on 5/17/24 when the facility inserviced licensed nurses and QMAs regarding proper cleaning of glucometers after use and implemented a system of personal glucometers stored in a labeled bag for each resident. The noncompliance remained at the lower scope and severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because of the facility's need for continued monitoring and inservicing of any absent and future staff. 2. During observations of Resident 33 on 5/13/2024 at 7:43 A.M. and 8:48 A.M., an indwelling catheter drainage bag could be seen touching the floor while hanging on the frame of the bed with the bed in the lowest position, and the dignity bag hung beside the indwelling urinary catheter bag, touching the floor, without a basin placed to keep the indwelling catheter drainage bag off the floor. A record review was completed on 5/15/2024 at 10:29 A.M. Diagnoses included, but were not limited to, obstructive and reflux uropathy, hydronephrosis, benign prostatic hyperplasia, and hemiplegia affecting dominant side. A Care Plan, revised 1/17/2024, indicated Resident 33 had an indwelling urinary catheter related to obstructive uropathy and hydronephrosis. The interventions included, but were not limited to, keeping a basin at the bedside to place the catheter in when the resident was in bed and ensure the bed was in the lowest position. A Significant Change MDS assessment, dated 2/20/2024, indicated Resident 33 had an indwelling urinary catheter. A Physician's Order, dated 2/21/2024, indicated Resident 33 was to receive indwelling urinary catheter care every shift. During an observation on 5/16/2024 at 9:07 A.M. and 5/17/2024 at 8:28 A.M., Resident 33's bed was in the lowest position and the indwelling catheter drainage bag placed in a dignity bag and touched the floor without a basin in place. During an interview on 5/17/2024 at 8:08 A.M., the DON indicated when a resident's bed was in the low position, a basin should be placed underneath the indwelling catheter drainage bag. She indicated the indwelling drainage catheter bag should not touch the floor. The facility's most current policy was provided by the DON on 5/17/2024 at 8:00 A.M. The policy titled, Catheter Care, Urinary, indicated, .Be sure the catheter and tubing and drainage bag are kept off the floor 3. During a random observation on 5/17/2024 at 2:43 P.M., Resident 3 was observed retrieving ice with her bare hand from the community ice cooler in the hallway and placing the ice in her Styrofoam cup. Two staff members, RN 13 and another unidentified staff member, were talking at the medication cart by the nurse's station and the community ice cooler. RN 13 and the unidentified staff member did not intervene and limit Resident 3's access to the community ice cooler. At 5/17/2024 at 2:55 P.M., RN 13 was informed of Resident 3 getting into the ice cooler with her bare hand. RN 13 indicated Resident 3 knew better, and asked if she was standing there when this occurred. A record review for Resident 3 was completed on 5/17/2024 at 3:02 P.M. Diagnoses included, but were not limited to, dermatitis and parasitic environmental infestation. A Quarterly MDS assessment indicated Resident 3 had severe cognitive impairment. The facility's most current policy was provided by the Director of Nursing on 5/17/2024 at 3:14 P.M. The policy titled, Ice Machine and Ice Storage Carts indicated, 1. Ice-making machines, ice storage chests/containers, and ice can all be contaminated by: a. Unsanitary manipulation by employees, residents, and visitors .d. Improper storage or handling of ice. 22. To help prevent contamination of ice machines, ice storage chests/containers or ice, staff shall follow these precautions: a. Limit access to ice machines or ice storage chests/containers to employees only 38845 4. During an observation on 5/14/2024 at 2:42 P.M. with QMA 15, Resident 4's left foot had a quarter-sized blister on the inner aspect of the left heel. The dressing was halfway off with no date and a foul odor was noted. On 5/14/2024 at 3:00 P.M., LPN 2 was observed doing a skin treatment to Resident 4 foot. LPN 2 washed her hands and applied gloves. She then opened a gauze package and a calcium alginate package. She placed the packages back on a towel that was under the resident's left leg. She opened a sure prep pad and a mepilex dressing. LPN 2 dated the dressing and then removed her gloves and applied another pair of gloves, without sanitizing her hands. She moistened a gauze pad with normal saline and cleansed the area to Resident 2's left heel. LPN 2 removed her gloves and applied new gloves, again without washing her hands. LPN 2 then applied the calcium alginate and the mepilex dressing. She indicated she needed more tape and gloves. LPN 2 removed her gloves, placed them in the trash, then left the room with the trash bag, without washing her hands. LPN 2 returned and applied new gloves without washing her hands. LPN 2 then taped the dressing and removed her gloves. During an interview on 5/14/2024 at 3:17 P.M., LPN 2 indicated she should have washed her hands after removing her gloves. 5. On 5/16/2024 at 3:44 A.M., CNA 8 was observed providing perineal care to Resident 7. CNA 8 applied gloves and unfastened the resident's brief and tucked it under the resident's buttocks. Using a washcloth, CNA 8 completed perineal care. CNA 8 then put the dirty washcloth on the headboard of the bed. During the time she was washing the buttocks, the washcloth had fallen on the floor. The resident had had a small bowel movement. The aide used the brief to wipe away the stool. She removed the brief and put it on the floor. CNA 8 then put all the dirty linens on the floor. After the peri care was completed, with her dirty gloves still on, CNA 8 touched the residents' blankets, moved the call light to the bed, touched the bed control and the resident's pillow. CNA 8, with her dirty gloves still on, then went into the hallway to get a trash bag. She returned and placed the dirty linens in the bag and the trash in a bag and placed the bags in the hallway by the resident's door. CNA 8 then removed her gloves and walked down to the dining room to wash her hands. 6. During an observation on 5/16/2024 at 4:03 A.M., CNA 8 applied gloves, then assisted Resident 46 to the bathroom. When asked if the resident was wet, she removed the extra pad and stated he was wet (with her gloved hand touching it). With her now dirty gloved hand, she opened the resident's room door and went into the hallway to retrieve a trash bag. CNA 8 then placed the linens in the bag and, with the same gloved hand, left the room again to get a towel. She returned and applied a gown to the resident without removing her dirty gloves and washing her hands. She then assisted the resident back to bed, straightened the comforter and moved the resident's pillow with her dirty gloved hands. During an interview on 5/16/2024 at 4:10 A.M., CNA 8 indicated she should have removed the gloves and washed her hands. On 5/16/2024 at 4:50 A.M., the Director of Nursing provided the policy titled, Handwashing/Hygiene, dated January 2019, and indicated the policy was the one currently use by the facility. The policy indicated, .6. Use an alcohol -based hand rub alternatively, or soap (antimicrobial or non-antimicrobial) and water for the following situations: . d. Before performing any non-surgical invasive procedures; e. Before and after handling an invasive device (e.g., urinary catheters) . g. Before handling clean or soiled dressings, gauze pads, etc.; .k. After handling uses dressings, contaminated equipment, etc., l. After removing gloves . Applying and Removing Gloves. 1. Perform hand hygiene before applying non-sterile gloves. 2. Perform hand hygiene upon removal On 5/16/2024 at 4:50 P.M., the Director of Nursing provided the policy titled, Perineal Care', dated 2/2018, and indicated the policy was the one currently used by the facility. The policy indicated, .9. Discard disposable items into designated containers. 10. Remove gloves and discard into designated container. 11. Wash and dry hand hands thoroughly. 12. Reposition the bed covers. Make the resident comfortable . 14. Clean wash basin and return to designated storage area. 15. Clean the bedside stand. 16. Wash and dry hands thoroughly 38121 7. During an observation on 5/13/2024 at 2:13 P.M., Resident 54 was observed in her bed. The bilevel positive airway pressure (BiPAP) mask and tubing were resting directly on the floor under her bed and clothes were observed laying on top of the mask and tubing. During an observation on 5/13/2024 at 3:58 P.M., Resident 54 was seated on her bed. The BiPAP mask was located on the bed and the tubing was on floor, under the bed. During an observation on 5/14/24 at 10:36 A.M., Resident 54 was not in her room. The BiPAP mask was located on a bedside table with a breakfast plate and the tubing was observed wrapped around the bedside table and was visibly dirty 3.1-8(a) 3.1-41(a)(2)

Based on observation, interview, and record review, the facility failed to ensure Resident C, a resident with dementia, was free from resident-to-resident sexual abuse by Resident B, for 2 of 2 residents reviewed for sexual abuse. Using the reasonable person concept, it is likely this would lead to fear, confusion and anxiety for Resident C. Findings include: An IDOH (Indiana Department of Health) Incident #432, dated 2/15/24 at 3:52 P.M., indicated Resident B was observed by a staff member, sitting on Resident C's bed while she was asleep. Resident B's fingers were partially touching Resident C, inside her brief. Resident B was immediately removed from the room and placed on 1:1 observation until he was discharged to a behavioral health facility. Resident C did not recall the incident. 1. On 3/6/24 at 10:15 A.M., a review of the clinical record for Resident C was conducted. The resident's diagnoses included, but were not limited to: dementia, anxiety, depression and a history of trauma. Quarterly Minimum Data Set (MDS) Assessment, dated 2/15/24, indicated the resident's cognition status was severely impaired. A Care Plan, dated 1/9/24, indicated the resident had a history of trauma, physical and mental abuse from an ex-spouse. The interventions were to allow resident time to express concerns, fears, feelings and expectations, reassure resident she was safe, have resident meet with psych services, offer resident a [NAME] stuffed animal to hold, and redirect by using positive conversation. A Care Plan, dated 11/12/23, indicated the resident had impaired cognitive function/dementia. The interventions were to keep routines consistent, provide consistent care givers, provide activities that accommodated the resident's abilities, administer medications as ordered, communicate with resident/family/caregivers regarding the resident's capabilities, identify self with each interaction, provide necessary cues-stop & return if agitated. A NeuroBehavioral Exam, dated 1/29/24, indicated .Staff observe negative behaviors affecting care and safety, fall risk. Adaptive weaknesses, delusions, agitation, aggression, anxiety, elation/euphoria, disinhibition, irritability/lability. Shown in bed shouting most of the day, wandering the hallways; most often searching for her mother, reliving periods of her life. Believes peopled are trying to sleep with her for sex. Married 3x; son believes 3rd marriage resident sustained physical and emotional abuse . A Progress Note, dated 2/15/24 at 4:52 P.M., indicated Staff allege another resident was sitting on this resident's bed while she was sleeping with his fingers partially touching her inside her brief. Resident was wearing clothing on upper torso and had a brief on. Staff removed other resident immediately from room. Head to toe assessment completed .Police in A Progress Note, dated 2/16/24 12:36 A.M., indicated the resident was resting in bed with her eyes closed and there had been no signs or symptoms of distress noted. On 3/6/24 at 10:34 A.M., the resident was observed in activity, sitting in wheelchair. The resident was alert to self only. She did not participate in the activity, but her eyes followed voices. During an interview, on 3/6/24 at 10:36 A.M., an Activity Assistant (AA) 2 on the dementia unit indicated she was the staff member who found Resident B in Resident C's room. AA 2 indicated when she walked in, Resident C's room. Resident B had one hand on the Resident C's thigh and the other hand inside her brief, near her private parts. AA 2 told him to stop touching her and he immediately removed his hand from inside her brief. AA 2 could not visualize where his fingers were, but indicated hand was near Resident Cs private parts. Resident B was escorted out of the room and provided a diversion activity. AA 2 indicated Resident C was asleep when she entered her room and did not wake up while she was removing Resident B from the room. AA 2 indicated the male resident had the habit of wandering the unit, but she had never seen him in another resident's room. AA 2 indicated the two residents had never shown any interest in one another, as the female hollers out if anyone came near her. During an interview on 3/6/24 at 10:53 A.M., Qualified Medication Assistant (QMA) 3 indicated she had never seen Resident B approach another resident; however QMA 3 had seen him in his room touching himself. QMA 3 had seen him go into another resident's room, but not often and Resident B was always redirected out of the room. 2. On 3/6/24 at 1:05 P.M., a review of the clinical record for Resident B was conducted. The resident was admitted on [DATE]. The Resident's diagnoses included, but were not limited to: non-traumatic brain dysfunction, Alzheimer's Disease, anxiety, sexual dysfunction and depression. A Pre-Admission Evaluation, dated 12/6/23, indicated the resident had hypersexual behaviors in the past, which consisted of exposing himself and wandering the facility. A Care Plan, dated 1/12/24, indicated the resident had a history of exposing himself to staff and being combative during care. The interventions were to: administer medications as ordered, anticipate needs, explain all procedures and provide a program of activities. On 1/15/24, the following interventions were added: offer activities related to past work experience, offer snacks, offer music-resident enjoys classic rock, offer resident to watch TV, redirect resident back to his room and resident to be assessed by psych services. A Care Plan, dated 1/12/24, indicated resident had an alteration in neurological status related to Alzheimer's Disease. The interventions included, but were not limited to: medication, cueing, reorienting and lab work as ordered. A Progress Note, dated 1/12/24 at 11:41 A.M., indicated the resident had arrived to the facility accompanied by his wife. Resident was oriented to his room and bathroom. At 3:01 P.M. the Progress Note indicated the resident was placed on 15 minute-checks to monitor adjustment to the facility. A Physician's Order Note, dated 1/13/24 1:15 P.M., indicated there was an order for Climara Transdemal patch to be applied daily for a sexual dysfunction. A Behavior Note, dated 1/14/24 at 1:44 A.M., indicated the resident occasionally wandered into other resident rooms, but was redirected easily. A Behavior Note, dated 1/15/24 at 12:44 P.M. indicated a CNA was unable to change the resident's clothes, as he attempted to remove the CNA's clothes. The resident was groping staff, and multiple attempts to redirect him were unsuccessful. A Behavior Note, dated 1/15/24 at 6:16 P.M., indicated the resident remained on 15 minute-checks for attempting to remove CNA clothing, no other behaviors noted. A Behavior Note, dated 1/27/24 at 4:15 P.M., indicated a CNA noted the resident to be in another resident's room, touching the resident on the leg. Resident B was easily redirected out of room, to his room and remained on 15 minute checks. A Behavior Note, dated 2/1/24 at 4:09 P.M., indicated, .Resident observed in the hallway outside of the Activity Room with privates out, hand on top stroking. He was looking in the direction of the Activity Assistant Program Director redirected him to zip up his pants. I then educated him that if he would like to do that he needs to be in his room with the curtain drawn and door shut. Resident shook head with understanding and returned to his room. Resident was then laying down in bed watching television A review of the Progress and Behavior Notes, dated 2/7/24 through 2/14/24, indicated Resident B did not have incidents or behaviors noted, but remained on 15 minute-checks. A Progress Note, dated 2/15/24, indicated staff alleged resident was sitting in another resident's room, on her bed with his fingers partially touching other resident, inside her brief. Staff removed resident immediately from the room. His wife, a physician and police were notified of the incident and resident was placed on 1:1 observations. During an interview, on 3/6/24 at 10:56 A.M., CNA 4 indicated she worked the dementia unit and she had seen Resident B be friendly with himself but staff just would close the curtain or redirect him. She indicated he wandered the hallways and had always been on 15 minute checks, since he was admitted to the facility. On 3/6/24 at 3:08 P.M., CNA 4 indicated she was the one he tried to grope shortly after his admission. She described the resident as being inappropriate with his words, for example he would say, Do you want to touch it. CNA 4 indicated he had attempted to reach out to touch her breasts when she had been providing care. When she got his pants on, he pulled out his penis over top of pants and she had to tell him to put it back inside pants. She indicated he was easy to redirect and would listen to her if she said stop or don't do that During an interview, on 3/6/24 at 11:31 A.M., the Dementia Director indicated Resident B was a new admission approximately 1 month ago. He had a history of being sexually inappropriate with himself - undressing and touching his private parts. When he entered the facility, he was placed on 15 minute checks, and had been occasionally found with hands in his pants and playing with his penis. Staff would pull the curtain to ensure no one else saw him or would redirect him to his room. She indicated he had been to a behavioral health facility since the incident and was put on some medications to decrease his sexual behaviors and would return to the facility today. During an observation, on 3/6/24 at 2:34 P.M., Resident B was observed participating in an activity. He was sitting, at the end of the table, with no female resident's near him except for AA 2. The resident was on 1:1 observations per staff. On 3/6/24 at 2:34 P.M., the Director of Nursing (DON) provided a policy titled, ABUSE POLICY', dated 11/28/16 and revised on 9/2022 and indicated the policy was the one currently used by the facility. The policy indicated .The resident has the right to be free from abuse .Residents must not be subject to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. The Facility shall have processes in place to include screening, training, prevention, identification, protection, investigation, reporting and response to allegations of potential or actual abuse .Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .It includes verbal abuse, sexual abuse, physical abuse, and mental abuse .Sexual abuse: is defined as non-consensual sexual contact of any type with a resident This citation relates to Complaint IN00428613. 3.1-27(a)(1)

Based on record review and interview, the facility failed to ensure a resident who received a pureed diet for frequent choking episodes did not receive food items other than pureed consistency for 1 of 1 residents reviewed for dietary needs. (Resident B) The Immediate Jeopardy began on [DATE] when the facility failed to ensure Resident B was provided the appropriate diet consistency as a snack during an activity, resulting in her choking and requiring the [MEDICATION(S)] manuever and CPR (cardiopulmonary resuscitation) before being admitted to the hospital. The Administrator was notified of the Immediate Jeopardy on [DATE] at 4:40 P.M. The Immediate Jeopardy was removed on [DATE], but noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Finding includes: On [DATE] at 10:30 A.M., a review of Resident B's clinical record was conducted. Resident B was admitted on [DATE] with diagnoses included, but not limited to, [CONDITION(S)] disorder, [CONDITION(S)], dementia in other cases classified elsewhere with behavioral disturbance. A Nursing Progress Note, dated [DATE] at 1: 25 P.M., indicated . Resident noted choking on candy, resident was able to cough up the candy. Resident orientation the same as baseline prior to choking incident. No further choking incidents noted this shift Will continue to monitor A swallow study was completed, on [DATE], and indicated recommendations were mechanical soft solids with ground meats, supervision with meals due to impulsivity, thin liquids and may consider use of controlled flow rate cup due to impulsivity. Crush med's. Upright at 90 degress during PO and 45 minutes after meal. She would benefit from a skilled dysphagia feeding, exercise and or management plan directed by Speech Therapy. A Nursing Progress Note, dated [DATE] at 3:47 P.M., indicated .Res [resident] had 1 choking episode at lunch today. Res was observed by staff very rapidly eating lunch, begin coughing, then had small emesis of undigested food. No difficulty with respirations, no symptoms of aspiration noted A Nursing Progress Note, dated [DATE] 09:03 A.M., indicated .Interdisciplinary Note Late Entry: regarding choking incident on [DATE]. resident was eating and taking large bites of food, started coughing and regurgitated all food in her mouth. res states I ate too fast. therapy to have speech eval.resident educated on eating slowly and making sure to chew food she verbalizes understanding at this time. CP [care plan] reviewed and updated A Nursing Progress Note, dated [DATE] at 12:23 P.M., indicated .Care Plan Note: Care conference held with [Resident B], her brother did not call in. [Resident B] says she is happy with her care and has no complaints with anything. [Resident B's name] is on a mech soft diet. [Resident B's name] participates in group activities, bingo, food, and special events. [Resident B's name] will continue with [psych] services for no further mood decline. [Resident B's name] will remain in the facility long term. A Nursing Progress Note, dated [DATE] 6:28 P.M., indicated .Res sat at nurses' station with this nurse observing. Needed frequent reminders to slow down et to take smaller bites. Consumed meal without any choking noted . A Therapy dysphagia/Self-feeding Screen, completed on [DATE], indicated the reason for the screen was for a choking episode. She received a mechanical soft diet with thin liquids and was observed at dinner. The observation included, but were not limited to, dentition/dentures impacted her ability to eat. No dental exams present for review. On [DATE] at 1:50 P.M., the ED indicated she had no dental service documented since admission ([DATE]). Physician's order indicated on [DATE] to [DATE] she received a mechanical soft diet with thin liquids and required close supervision with all meals. Her diet changed on [DATE] to a pureed diet, thin liquids for frequent choking episodes. A Nursing Progress Note, dated [DATE] at 2:07 P.M., indicated .This nurse observed res for both meals today. Needed frequent cuing to take smaller bites, chew food more thoroughly, et to slow down eating. No choking episodes noted A Nursing Progress Note, dated [DATE] at 12:56 P.M., indicated .Behavior Note: Res was in hallway being observed by staff during lunch. Res became choked x [times] 2 despite being watched et cued. Res placed large amounts of food in her mouth both times she became choked; was able to clear her throat with much coughing. Res being placed on pureed diet per orders, et will continue with staff closely monitoring A Physician's Order, dated [DATE], indicated .Regular diet. Puree texture, thin consistency, for frequent choking episodes A Nursing Progress Note, dated [DATE] at 10:01P.M., indicated .Interdisciplinary Note: Discussed recent eating behavior with team. Resident has history of attention seeking behavior. she was being monitored at time of incident and Nurse that was with her believes she was attention seeking at that time. she did not choke, she took large bites and coughed and spit all food out onto plate. to be safe we changed her to a pureed diet after event. further coughing noted. CP reviewed and updated A Care Plan, dated [DATE], indicated .I have attention seeking behavior of filling my mouth to full during meals, eating to fast causing coughing episode. Nursing provide cues and reminders to take small bites and to eat at slower pace, but I continue to overfill my mouth. I will not overfill my mouth during meals daily. Notify Dr and family of any changes. Nursing Observe for increased cough, changes in respiratory status, cyanosis. Provide cues and reminders to eat slow and take small bites. Provide diet as ordered A Care Plan, dated [DATE], indicated .I have the potential for aspiration related to I put to much food in my mouth at one time. I will be free from s/sx [signs/symptoms] of aspiration through the next review. Allow me ample time for swallowing. Elevate the HOB as needed and as I tolerate. Observe for coughing or clearing of throat after swallowing. Provide my diet as ordered A Nursing Progress Note, dated [DATE], indicated .at approximately 150pm CNA [Certified Nurses Aide] called for help as resident was not breathing in dining room on 400. 911 called by floor nurse. resident blue in the face and her hands. no pulse palpated radially or carotid and resident not breathing. laid her down on floor and started cpr. ADON [Assistant Director of Nurses] brought crash cart, orally suctioned with nothing out but clear liquid. cpr [Cardio Pulmonary Resuscitation] ongoing until EMS [Emergency Medical Services] arrived at 205pm. still no pulse or respirations noted. ems transported resident to ER [emergency room ] at 220pm During an interview, at 12:07 P.M. on [DATE], CNA 1 indicated the activity aide came and got her saying she needed help in the 400 hall dining room. When she arrived Resident B was standing unresponsive so she asked LPN 1 to come help them. LPN 1 administered the [MEDICATION(S)] maneuver. Resident B then slumped over after the [MEDICATION(S)] maneuver was conducted and was lowered to the floor and cardiopulmonary resuscitation was initiated. She indicated she did not know what had happened but that she knew the resident was on a modified diet of puree consistency because she ate and drank fast. During an interview, at 12:19 P.M. on [DATE], LPN 1 indicated she was asked to assist in the 400 hall dining room, on [DATE], because a resident was choking. She indicated it was Resident B and that she had performed the [MEDICATION(S)] maneuver approximately 10 times before the resident just collapsed and they lowered her to the floor and initiated cardiopulmonary resuscitation until the emergency medical personal came and took over. She indicated she did not know what had happened as she was not present when the incident occurred, but she had been told that the activity assistant had given the resident a cookie. During an interview, at 12:30 P.M., on [DATE], CNA 2 indicated the activity aide came down the hall calling out for help in the dining room. When she got to the dining room, Resident B was sitting in a chair with her hands up against her throat and chest area. She indicated her fingertips and lips were blue. She asked the resident to move her hands up in the air and she got behind her and did the [MEDICATION(S)] maneuver. She approximated she did the maneuver 3 times before the nurse arrived and continued trying. She indicated the resident then slumped over and cardiopulmonary resuscitation was initiated until the ambulance arrived and they took over. She indicated she did not witness the incident but she heard the activity aide tell the staff that were assisting in the dining room, that she had given Resident B a cookie. Activity Aide 1 was unavailable for interview, but in a documented statement, provided by the Administrator on [DATE] at 10:00 A.M. she indicated there was an activity going on and they were handing out cookies as part of a food related activity. She said Resident B was in the activity room at the time but had gotten up and walked away. She was checking on her when she saw her in the dining room by the sink. She told the Administrator she thinks she heard her cough and may have been breathing funny. She stated Resident B was following direction at the time and asked her to sit down, she called for CNA 2 to come help and she ran to the dining room and began performing the [MEDICATION(S)] maneuver. The Administrator asked the Activity Aide if she knew the Resident was on a pureed diet and she stated she did know she was on a puree diet but thought since the cookie was soft it would be alright to give it to her. An emergency room Urgent Care Report, dated on [DATE] at 8:54 A.M., indicated .The patient is a [AGE] year old female who presents to the Emergency department today from a nursing home status post [CONDITION(S)]. The patient was in the cafeteria eating when she had a choking episode and then went into [CONDITION(S)]. CPR was immediately initiated. EMS arrived and emesis was suctioned from the patient's throat and mouth. She was intubated with a 6.5 French endotracheal tube. CPR was continued by EMS and she received 3 rounds of [MEDICATION(S)] with spontaneous return of circulation. A Chest Tube Insertion r/t [related to] Rt. Pneumothorax and she was transitioned to a Ventilator.Impression/Assessment/Plan:Cardiopulmonary Arrest,Pneumothorax,Shock, Multiple Rib Fractures,Sternal Fracture, Lactic Acidosis,Leukocytosis, and choking episode. admitted under critical care on ventilator management and IV fluid resuscitation During an interview, on [DATE] at 1:00 P.M., the facility Administrator indicated she had reported an incident in which a resident of the Dementia Unit, had a potential choking episode and was sent to the hospital. She indicated an activity aide had given the resident a cookie during an activity that was going on that day. She indicated that all personnel that had anything to do with dietary knew diet orders and that they all had a list indicating residents with special diets. A policy, titled, Physician's Diet Order, with a revision date of [DATE], was provided by the Administrator on [DATE] at 1:03 P.M The policy indicated .All diets are precribed in writing by the physician in terms used in the approved diet manual. The diet manual is available in the Culinary& Nutrition Services Office, the Administrator or DON [Director of Nurses] office, as well as at each nursing station. 4. The Culinary & Nutrition Services Manager, or designee, will record the diet order in the electronic meal tracking system and prepare a diet tickket with the information. This diet ticket is placed on the meal tray for reference and identification when serving meals The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility completed a whole house diet audit, audited the resident diet communication system and inserviced staff on only serving residents food that is in accordance with their physician ordered diet, but the 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 of the need for continued inservicing and monitoring. This Federal tag is related to Complaint IN 677. 3.,d+[DATE](a)

Based on observation, interview and record review, the facility failed to ensure a cognitively impaired resident with known recurrent behaviors was not restrained to keep him from getting up from his room recliner for 1 of 1 randomly observed residents. (Resident 41) The Immediate Jeopardy began on 7/21/2021 when the facility failed to ensure Resident 41 was not restrained from rising from his room recliner and leaving his room. The Administrator was notified of the Immediate Jeopardy at 2:35 P.M. on 7/23/2021. The Immediate Jeopardy was removed on 7/26/2021, but noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Finding includes: On 7/21/2021 at 3:02 P.M., Resident 41 was observed to be sitting in his recliner with his feet elevated. A straight back chair sitting at the foot of the recliner, with a white blanket covering him from his chest down over his legs and feet and up over the top of the back of the straight back chair. A small amount of blood was observed on the white blanket. Splatters of blood the shape of half circles, silver dollar sized, were observed on the floor of his room surrounding his recliner. Nurse 5 pulled down the blanket, which showed that the straight back chair was lodged under the foot of the recliner, holding it in an upright position. Resident 41's right great toenail was observed to be bent upwards and bleeding. Resident 41 was unable to get up out of his chair. A clinical record review was conducted, on 7/19/2021 at 3:54 P.M., and indicated Resident 41 was admitted on [DATE] and his diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Behavior Note, dated 4/5/2021, indicated .Again in another resident's room. He was making the empty bed. We encourage him to go to his room and he refused. We pulled the curtain to do AM care but he pulled the blanket off the other resident's bed and started to put it on the empty bed. The CNA[certified nurses assistant] and I took an arm each and pulled him down the hall and put him in his room and closed the door. The male CNA opened the door and ask this resident [NAME] [how] he was doing. He yelled back Get out A Behavior Note, dated 5/12/2021 indicated .During the evening this resident went into multiple rooms and removed personal items of residents in each room. I redirected over and over and returned the items he removed. I gave him a PBJ sandwich and he ate all the sandwich. After about 2200 [10:00 P.M.] we put this resident in his room and stationed a CNA in front of his door. CNA redirected this resident multiple times and did not allow him to leave his room. At this point he has not tried to open his door for about 15mins [minutes] A Behavior Note, dated 5/14/2021, indicated . Resident remains very restless and unable to stay still. He continues going in and out of rooms and taking items. When this resident is placed in his room with a CNA at the door, he pulls apart anything and everything. He is now sitting in a chair sleeping During an interview, on 7/22/2021 at 12:38 P.M., the DON (Director of Nursing) shook her head and acknowledged the incident that occurred on 4/5/2021. During an interview, on 7/23/2021 at 11:05 A.M., the Administrator indicated CNA 7 admitted to putting the chair under the foot of Resident 41's room recliner. A policy was provided by the Administrator, on 7/23/2021 at 4:25 P.M., titled Restraints: Emergency Use, dated 9/15/2001, revised 6/1/2021, and indicated this was the policy currently used by the facility. The policy indicated .2. Obtain order for emergency use of a restraint either during the application of the restraint or immediately after the restraint has been applied The Immediate Jeoppardy that began, on 7/21/2021, was removed, on 7/26/2021, when the facility removed the chair from under the footrest, removed the employee involved from the schedule, observed residents to ensure there were not any unnecessary restraint devices, in -serviced staff on what constitutes a restraint and that an unnecessary restraint is not to be initiated and created/implemented and an audit tool to ensure unnecessary restraint devices are not in place. The noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy, because of the need for continued inservicing and monitoring. 3.1-3(w) 3.1-26(o)

Based on observation, interview and record review, the facility failed to provide adequate care and supervision, including behavior care planning and interventions, to prevent a confused resident from repeatedly acting out against other residents, resulting in imminent danger to himself and other residents. (Resident 41) In addition to the residents in Immediate Jeopardy, the facility failed to ensure adequate supervision to prevent falls, consistently implement appropriate and individualized interventions to reduce risk of further falls, monitor the effectiveness of each residents' fall interventions, thoroughly analyze each fall incident to determine the root cause of the fall and revise the resident's care plan to reflect new or changed interventions after each fall as needed for 3 of 5 residents reviewed for falls. (Residents 29, 48 & 49) The Immediate Jeopardy began on 10/2/2020 when the facility failed to ensure Resident 41's aggressive behaviors did not result in potential or actual harm towards others. The Administrator was notified of the Immediate Jeopardy at 2:34 P.M. on 7/23/2021. The Immediate Jeopardy was removed on 7/26/2021, but noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Finding includes: 1. During intial tour of the facility, on 7/19/2021 at 10:45 A.M., Resident 41 was observed to have feces on himself, the wall, the air conditioner, his bed, his recliner and his call light. The air conditioner was missing its cover, the outlet was missing from the wall, the outlet was broken for air conditioner, foot board was missing from his bed, leaving metal bars standing up in the air. On 7/19/21 at 11:05 A.M., Resident 41's call light was still covered in feces and stretched across the newly made bed. On 7/19/2021 at 11:53 A.M., Resident 41 was observed standing at the head of his bed bent over with his socks halfway off his feet. Feces was observed running down the air conditioner and a broken electric outlet laying on the ground. On 7/19/2021 at 12:32 P.M., the Administrator acknowledged Resident 41 needed assistance/care to help with his situation. She indicated the staff did not finish cleaning up Resident 41's room. A clinical record review was conducted, on 7/19/2021 at 3:54 P.M., and indicated Resident 41 was admitted on [DATE] and his diagnoses included, but were not limited to: Wernicke's [CONDITION(S)], [CONDITION(S)] with delusions and dementia with behavioral disturbance. A Nurses Note, dated 10/1/2020, indicated .resident entered nurses station, and upon attempt to redirect resident out of this area, resident physically attacked this nurse . slapping glasses off face, and punching this nurse . the aide arrived and attempted to talk resident down at which time resident picked up the chair from the nurses desk and threw it . both the aide and this nurse attempted to escort the resident back to his room . he began throwing everything he could get his hands on down the hallway A Nurses Note, dated 10/8/2020, indicated .Resident going in others rooms and not listening to redirection. Attempted to throw a tennis shoe at this writer. Call to 911 for police A Behavior Note, dated 11/13/2020, indicated .Most of shift resident walked up and down hall and at times went into other resident's rooms A Behavior Note, dated 11/15/2020, indicated .Resident is physically aggressive toward staff, throwing books, roaming into other residents' rooms and messing with their things. Resident refused to take evening medications and attempting to punch at nurse while attempting to give meds and redirect A Behavior Note, dated 12/6/2020, indicated .Res has past behavior of crawling under other res' [residents] beds. Res' roommate is currently on O2 [oxygen]. While doing rounds, observed roommate's O2 off, et [and] machine under bed unplugged. This res was the only person in room with roommate at the time. Res has history of destroying electronic devices, such as Tvs, VCRs, computers, phones, and radios. This res also pulls the curtains around his roommate on a constant basis, obstructing staff's view of dying roommate A Behavior Note, dated 12/10/2020, .Found in another res' room, going through their closet earlier this am. Became agitated et verbally aggressive towards staff, refusing to leave room. Did finally allow staff to show him his room, where he continued to push things off of his bed angrily A Behavior Note, dated 12/16/2020, indicated .Res was going in et out of other res' rooms, taking their belongings and refusing to give them back, becoming agitated towards staff when attempting to re-direct res towards his room A Behavior Note, dated 12/31/2020, indicated .Resident up all morning, wandering into others rooms, touching/taking belongings . when staff attempts to redirect, resident ignores staff or becomes physically aggressive A Behavior Note, dated 1/1/2021, indicated .Resident entered another resident's room and could not be re-directed verbally. Became combative and aggressive. Inside other resident's room resident forcefully closed door A Behavior Note, dated 1/5/2021, indicated .resident is wandering the halls and going in and out of resident rooms A Behavior Note, dated 1/14/2021, indicated .Resident came out of room upon this nurses arrivial . covered in feces, male aide attempted to take resident to his room to get cleaned up when resident began punching staff member . two more staff came to assist. Resident fighting staff the entire time . staff successful in cleaning resident up, then staff cleaned up resident room as he had trashed it and defecated in the laundry basket as well, . A Behavior Note, dated 1/25/2021, indicated .Res in et out of other res' rooms frequently this shift. While in rooms, res found to be going through other resident's belongings A Behavior Note, dated 3/8/2021, indicated .Res frequently in other res' rooms today. Noted res covered up another res' head while they were lying in bed. Also noted to be messing with the heater in another res' room A Behavior Note, dated 4/5/2021, indicated .Up in the hall and going into other resident's rooms. Tried to redirect and he started trying to hit the CNA [certified nurses assistant]. He had a cup of water in his hand and he tried to throw it on the CNA. I took the water and emptied it. He walked ahead of me and picked a bottle of body wash off the CNA cart and throw it at me A Behavior Note, dated 4/5/2021, indicated .Again in another resident's room. He was making the empty bed. We encourage him to go to his room and he refused. We pulled the curtain to do AM care but he pulled the blanket off the other resident's bed and started to put it on the empty bed A Behavior Note, dated 4/5/2021, indicated .Became physically aggressive with staff a few minutes ago as staff was attempting to assist res with changing clothing. Res picked up a metal car decoration et was going to throw it at CNA until staff was able to get object away from him. Is now ambulating around unit, attempting to exit locked doors. Unable to redirect A Behavior Note, dated 4/5/2021, indicated .Ambulating up et down hallway at a very rapid pace. Going into other res' rooms et refusing to leave, flipped one res off, attempting to strike staff whenever care is attempted, et also attempting to go out locked doors A Behavior Note, dated 4/9/2021, indicated .At approx 0820 this am, staff member was attempting to deliver res' breakfast tray. Res had room door blocked with his bed. Staff able to move bed to allow entrance. Res became very angry et aggressive, Punched CNA in the face with his fist, attempted to spit in staff's faces et kicked a hole in the wall of his room. Unable to calm res. Res had also torn covering on bed in room, as well as fully destroying the heater/ air conditioning unit A Behavior Note, dated 4/9/2021, indicated .Found res in another res' room, attempting to pull apart the call-light system and the remote to other res' bed. Was able to redirect res back into his room, where this nurse found that res had torn off the footboard of his bed, as well as ripped mattress cover on his bed even further than he had previously A Behavior Note, dated 4/27/2021, indicated .Patient was pulling on electrical cord of the bed and the control unit trying to pull them out of the bed. he pushed the bed and table out of the room (412) the tv cable end had been pulled off, on the unit by pulling on the cords he could cause himself or others to trip or possibly be electrocuted from a bear wire contact . A Nurses Note, dated 5/8/2021, Indicated .Res in constant motion today. In other res' rooms . and .Went into another res' room, grabbed their package of snacks et had most of them consumed before staff could remove them. Found in his room et other res' rooms tinkering with the the heaters/ AC units A Behavior Note, dated 5/12/2021, indicated .During the evening this resident went into multiple rooms and removed personal items of residents in each room A Behavior Note, dated 5/14/2021, indicated .Resident remains very restless and unable to stay still. He continues going in and out of rooms and taking items A Behavior Note, dated 5/14/2021, indicated .Res has been in other res' rooms numerous times this shift, despite numerous staff attempts to redirect. Early in shift found res pushing a bed out into hallway with another res lying on it A Behavior Note, dated 7/18/2021, indicated .Res has been in et out of other res' rooms most of day- taking other res' small belongings. Not always easily redirected. Raised his fist at CNA as she was redirecting him out of a res' room During an interview, on 7/26/2021 at 9:55 A.M., the Administrator indicated after reading the progress notes, she indicated Resident 41 was a harm to himself and other residents. She indicated he is now on 1:1 supervision. 2. A record review was conducted, on 07/21/21 at 12:53 P.M., for Resident 48. Diagnoses included, but were not limited to, fracture of one rib right side, extrapyramidal and movement disorder, chronic diastolic [CONDITION(S)], chronic pain syndrome, [CONDITION(S)], depressive disorder, disorders of bone density, [CONDITION(S)] and [CONDITION(S)] disorder. A Quarterly MDS (Minimum Data Set) assessment, dated 6/29/21, indicated Resident 48 was cognitively intact, had 1 fall and required extensive assist of 1 for transfers. A Progress Note, dated 8/1/2020 at 9:42 P.M., indicated Resident 48 slipped while being assisted out of bed and landed on her left arm. She complained of her left arm being a little sore, but no broken bones were noted or any new injuries. A Progress Note, dated 8/2/2020 at 1:10 P.M., indicated Resident 48 had swelling and purple bruising around knuckles to her left ring and pinky finger, denied pain and was able to move her fingers and there were no apparent injuries noted. No documented IDT (Interdisciplinary) team note related to the fall she had with updated interventions and or root cause analysis being completed. The current care plan at the time of the fall for Resident 48 did not indicate an intervention was implemented to prevent further falls. A Progress Notes, dated 9/4/2020 at 6:22 A.M., indicated Resident 48 slid from her bed on to the floor mat while attempting to transfer herself. She was educated on calling for assistance. An IDT (Interdisciplinary) team note, dated 9/4/2020 at 3:25 P.M., indicated Resident 48 was attempting to self transfer and slid to the floor from the bed and the care plan was reviewed and updated as need. The intervention of education was done and Resident 48 understood. The current care plan at the time of fall indicated an intervention, dated 9/4/20, for therapy to screen due to a fall. A Progress Note, dated 10/10/2020 at 7:19 A.M., indicated Resident 48 was found sitting on her buttocks beside her bed, no injures were noted. She was assisted back to bed with the assist of 3 staff. She was encouraged to call for assistance. An IDT team note, dated 10/12/2020 at 1:26 P.M., indicated Resident 48 was reaching for something on her bedside table and ended up on the floor. An intervention of therapy would screen and the care plan was reviewed and updated. The current care plan at the time of fall indicated there were no new interventions implemented to prevent further falls, the intervention for therapy to screen was in place on 9/4/20. A Progress Note, dated 11/11/2020 at 9:10 A.M., indicated Resident 48 was found lying on her stomach with a laceration above her right eye and small laceration below her right eye and was sent to the ER (emergency room ) for evaluation. A Progress Note, dated 11/11/2020 at 5:00 P.M., indicated Resident 48 returned from the ER with 3 sutures above her right eye and 2 sutures to below her right eye and purple bruising to right eye. A IDT team note, dated 11/12/2020 at 4:31 P.M., indicated Resident 48 was found laying on the floor after attempting to self transfer, and the care plan was updated the facility would continue to monitor and the intervention would be to educate her for calling for assistance and therapy to screen. The current care plan in place at the time of the fall indicated an intervention, dated 6/13/20, and revised 11/9/20, for a sign placed in her bathroom to remind her to use her call light before transferring by herself, and on 11/2/20 an intervention for a low bed, but no new intervention was found to be put into place after the fall on 11/11/20 to prevent further falls with injuries. A Progress Note, dated 12/6/2020 at 3:35 P.M., indicated Resident 48 was found sitting on the floor in front of the bed with regular socks on her feet, and indicated no obvious injuries. She was educated about the injuries that could occur if she continued to attempt to transfer herself and gripper socks were applied to her feet for safety. An IDT team note, dated 12/6/2020 at 4:37 P.M., indicated Resident 48 slid down to the floor. She was educated about attempting to transfer self and the injuries that could occur if she continued to transfer herself, and gripper socks were applied to her feet. The facility would continue to monitor. The current care plan at the time of the fall indicated there were no new interventions implemented to prevent further falls. A Progress Note, dated 12/12/2020 at 6:17 P.M., indicated Resident 48 was found kneeling on her wheelchair in her bathroom. She was educated on using her call light to get assistance with transfers. There were no ID team notes available for review for the fall on 12/12/20. The current care plan at the time of the fall indicated no new interventions implemented to prevent further falls. A Progress Note, dated 1/16/2021 at 6:50 A.M., indicated Resident was found sitting on the floor of her bathroom and no injuries were noted. A Progress Note, dated 1/16/2021 at 9:12 A.M., indicated Resident was found sitting on the floor in her bathroom with her wheelchair behind her in the bathroom doorway. She indicated she was in a hurry to go to the bathroom, she kept going and her wheelchair did not and she landed on the floor. There were no IDT team notes available related to falls on 1/16/21. The current care plan at the time of the fall indicated an intervention was initiated, on 1/11/21, and revised on 1/26/21, to educate resident on use of call light and importance of calling for assistance and an intervention, initiated 1/11/21, to place a sign in her room reminding her she needed help with transfers. There were no new interventions in place for the fall on 1/16/21 to prevent further falls. An intervention, dated 2/12/21, was documented on the care plan for therapy to provide a wiping extender for the resident to use related to the fall on 1/16/21. A Progress Note, dated 2/23/2021 at 5:30 A.M., indicated Resident 48 was found on the floor and had a large knot over her right eye. An IDT team note, dated 2/23/21, indicated the resident attempted to self transfer and sat on the floor, hitting her head on the bedside table. Her right eye is purple and measured 2 x 1 cm (centimeter) and indicated the care plan had been reviewed and updated for a toileting program. The current care plan at the time of the fall, indicated no toileting program intervention had been added as an intervention on the care plan. There were no new interventions in place for the fall on 2/23/21 to prevent further falls. A Progress Note, dated 3/2/21 at 1:45 A.M., indicated at 12:05 A.M., Resident 48 was found laying on the floor on her back in her room. The resident indicated she was trying to go to the bathroom. Staff were educated to assist Resident 48 to the bathroom every 2 hours. A IDT team note, dated 3/2/2021 at 10:11 A.M., indicated Resident 48 had gotten up to the bathroom without assistance and fell from wheelchair during self transfer. She was educated on the importance to call for assistance and an intervention for the pharmacist to review meds for side effect and the careplan had been reviewed and updated. The current care plan at the time of the fall indicated interventions, dated 3/2/21, for the pharmacist to review medications for side effects and review the genetic test results by the psychiatric NP (Nurse Practitioner). A Progress Note, dated 4/16/21 at 3:30 P.M., indicated Resident 48 attempted to transfer herself from toilet to wheelchair and lost her balance and fell to the floor on her right side and hit the right side of her forehead on toilet paper holder sustaining a laceration above right eye 3.0cm x 0.8 cm. She was sent to the ER for evaluation. A Progress Note, dated 4/16/21 at 11:16 P.M., indicated she returned to the facility with stitches to her right forehead. An IDT team note, dated 4/19/2021 at 9:21 A.M., indicated Resident 48 transferred herself and was unstable and fell and it had been reported the resident had been using her call light frequently throughout the day, but did not use for going to the bathroom. The intervention would be to send a UA (urinalysis) for an evaluation for a UTI (urinary tract infection) and the care plan was reviewed and updated. There was no documentation available to review related to a urinalysis being obtained. The current care plan at the time of the fall indicated there were no new interventions implemented to prevent further falls. A Progress Note, dated 5/6/21 at 3:15 P.M., indicated Resident 48 had been found sitting on the bathroom floor, she indicated she was brushing her teeth and was trying to sit back in her wheelchair when she sat on the floor. She denied any injuries at the time, but complained of right rib pain. A order was to get x-rays 3 views with chest. The chest x-ray was obtained, on 5/6/21, and indicated no fractures were present. A Progress Note, dated 5/8/21 at 7:00 A.M., indicated Resident 48 complained of severe right sided pain and was guarding her right side. The nurses assessment indicated no bruising, redness or swelling was noted to the resident's right side. The resident was sent to the ER for an evaluation. A Progress Note, dated 5/8/21 at 10:30 A.M., indicated Resident 48 had returned from the ER with a diagnoses of 11th right rib fracture. An IDT team note, dated 5/10/2021 at 9:27 A.M., indicated regarding a fall on 5/6/21 Resident 48 was up by herself at the bathroom sink and she went to sit down in the wheelchair and missed the seat, the wheelchair was unlocked and rolled back and hit her right side upon the fall. Resident 48 had been educated at the time of the fall on how to lock her wheelchair and to call for assistance with transfers and activities of daily living. It was indicated the care plan was reviewed and updated. The current care plan at the time of the fall indicated there were no new interventions implemented to prevent further falls. A Progress Note, dated 5/10/21 at 9:30 P.M., indicated Resident 48 complained of extreme pain in her right ribs and requested to go to the hospital and she was sent to the ER for an evaluation. A Progress Note, dated 5/11/21 at 3:32 A.M., indicated Resident 48 returned to the facility. A Progress Note, dated 5/17/21 at 6:25 P.M., indicated Resident 48 had complained of being short of breath and had been noted to have been very pale with extreme labored breathing. Oxygen had been applied per nasal cannula at 2 liters per minute due to her oxygen saturation was at 78% (percent) and the nurse increased her oxygen to 3 liters per minute and her oxygen saturation went to 87% (normal oxygen saturation is 95-100% for healthy adults). The resident was sent to the ER for evaluation. A hospital History & Physical, dated 5/17/21, indicated she was being admitted to the hospital with a right rib fracture and a large probable right hemothorax (an accumulation of blood between the linings of the lung and the chest wall) A Progress Note, dated 5/25/21 at 2:06 P.M., indicated Resident 48 returned from the hospital at approximately 12:00 P.M. and indicated she had been in the hospital for hemothorax from a fall. A Progress Note, dated 5/25/2021 at 1:30 P.M., indicated the nurse was called to Resident 48's room and she had been found laying on the floor on her left side with a large hematoma above her left eyebrow, she complained of her head hurting and was holding her head and was sent to the hospital for an evaluation. An IDT team note, dated 5/26/21 at 12:05 P.M., indicated Resident 48 had been readmitted from the hospital, on 5/25/21 at 12;05 P.M., and by 1:30 P.M., she had fallen and was experiencing shortness of breath and was sent to the ER for evaluation and was readmitted to the hospital. She had poor safety awareness and refuses to call for assist to transfer, but will put on call light for staff to sit with her and indicated the care plan had been updated. The current care plan at the time of the fall indicated there were no interventions implemented to prevent further falls. A hospital History & Physicial, dated 5/25/21, indicated Resident 48 had been discharged at 11:00 A.M., on 5/25/21 and returned back to the facility where she had fallen and returned back to the hospital. She was found to have a hemothorax and underwent a chest tube placement and was found to have a right 10th rib fracture. A Progress Note, dated 6/3/21 at 12:12 P.M., indicated Resident 48 had been readmitted to the hospital. A Progress Note, dated 6/15/21 at 4:40 P.M., indicated Resident 48 was found on the floor next to her wheelchair, lying on her right side and her gripper socks were intact. She indicated she was trying to get back in bed. She had been educated on using her call light. An IDT team note, dated 6/16/2021 at 11:09 A.M., indicated Resident 48 had a fall from her wheelchair during a self transfer. She had been educated on calling for assistance and therapy would assess wheelchair cushion for positioning, and indicated the care plan was reviewed and updated. The current care plan at the time of the fall indicated there were no new interventions implemented to prevent further falls. A care plan, dated 3/21/2018 revised 4/19/2021, indicated Resident 48 was at risk for falls and has experienced a recent fall due to poor balance, ankle issues, [CONDITION(S)] and the use of [CONDITION(S)] medications, she required the use of a walker and wheelchair, she transferred herself even with knowledge of requiring assist and did not use her call light for assist, and used the call light to gain attention from staff. The goal, dated 3/21/18 and revised 2/7/20, indicated Resident 48 risk for falls and or minimal injuries would be decreased. Resident 48's interventions were to educate her on the use of call light and importance of calling for assistance (revised 1/26/21); to place a sign in her room reminding her she needs help with transfers (revised 2/4/21); Sign placed in residents bathroom to remind her to use the call light before trying to transfer off the toilet by herself (revised 11/9/2020); Therapy will provide a wiping extender for resident to use related to fall on 1/16/21 (dated 2/12/21); Pharmacist to review meds for side effects (dated 3/2/21); Review of genetic test results by psychiatric NP (dated 3/2/21); Social services to follow up with psych services (revised 11/9/2020); Will review genetic results with psych services due to actual fall on 2/28/21 (dated 2/28/21 and revised 3/3/21); anticipate her needs (dated 3/21/2018); Assess her falls risk at least quarterly and when declines in her condition are observed (Date 03/21/2018); Assess her pain management plan of care and provide her with interventions that will effectively maintain my pain at an acceptable level (Date 03/21/2018); Ensure that the walkway paths are clear in her room (Date 03/21/2018); Ensure that there is adequate lighting in her personal space (Date 03/21/2018); Make sure her glasses are clean daily (Date 03/21/2018); Make sure that all of her personal items that she may want to use are within her reach and at her level (Date 03/21/2018); Provide her with a low bed (Date 11/02/2020); Review her medications and discontinue any unnecessary meds that may contribute to her falls risk (Date 03/21/2018). There were no root cause analysis documentation available for review for Resident 48's falls. A Fall Risk Evaluation, dated 6/15/21, indicated Resident 48 fall score was 17 representing being high risk for falls. No other Fall Risk Evaluations were provided for review. During an interview on, 7/22/21 at 11:47 A.M., the DON indicated they had IDT meetings to discuss her falls and the MDS nurse is responsible for updating the care plan after a fall, but the facility has not had a MDS person. She indicated the residents care plan should have been updated after each fall to prevent further fall and injuries. During an interview, on 7/26/21 at 11:29 A.M., RN3 indicated the nurse completes a fall report and completes a risk management report for falls and pain management and puts an intervention on the risk management form for each fall, but the DON (Director of Nursing) is who updates the care plan with the intervention. She indicated the Floor nurse doesn't participate in IDT meetings, but management may come around and get input from them. During an interview, on 7/27/21 at 9:40 A.M., the ED (Executive Director) indicated the DON had indicated everything about the fall is discussed in the IDT meetings and there should be a root cause analysis completed. 3. On 7/23/21 at 11:04 A.M., the record for Resident 29 was reviewed. Diagnoses included, but were not limited to, [CONDITION(S)], dementia with behavioral disturbance, muscle weakness, repeated falls and lower leg contractures. An annual MDS assessment, dated 6/15/21, indicated Resident 29 had a BIMS score of 10-moderately impaired cognition. He required extensive assistance from 2 staff members for transfers and bed mobility, was non-ambulatory, and had limited range of motion to all extremities. He required limited assistance of 1 staff member for locomotion in his wheelchair both on and off the unit. A Care Area Assessment for falls, indicated the resident had a fall resulting in a hematoma and bruising and required extensive to total assist with transfers. Fall Risk Assessments, dated 11/24/20, 2/20/21, 6/2/21 and 7/18/21, indicated the resident was at high risk for falls. A Care Plan, initiated on 9/9/20 and revised on 9/24/20, indicated the resident was at risk for falls and had experienced a recent fall due to [CONDITION(S)] diagnosis. The goal, revised on 6/25/21, was for the resident to exhibit safe practices to prevent falls through the next review. Interventions and dates initiated were: 2/21/21-fall mat to floor beside bed; 11/9/20-Sign placed in resident's room to remind him to call for help before transferring; 9/24/20-Anticipate his needs; 9/24/20-Assess fall risk at least quarterly and when declines in condition are observed; 9/24/20-Assess pain management plan of care and provide interventions that effectively maintain pain at acceptable levels; 9/24/20-Encourage him to avoid sudden changes in position; 9/24/20-Ensure the walkway paths are clear in his room; 9/24/20-Ensure that there is adequate lighting in his personal space; 9/24/20-Restorative program for strengthening; 9/24/20-Make sure personal items are within reach; and 9/24/20-Provide resident with a low bed. A Care Plan, initiated on 9/9/20 and revised on 9/24/20, indicated the resident required assistance with activities of daily living due to [CONDITION(S)] diagnosis and poor mobility. The goals, updated on 6/25/21, were for the resident to feed himself all 3 meals and to be appropriately dressed and groomed daily. Interventions included, but were not limited to, 11/9/20-complete bed mobility with one person assist; 11/9/20-complete transfers with one person assist; 11/9/20-complete walking tasks with one person assist using walker; and 11/9/20-perform locomotion with one person assist using the walker. The care plan did not indicate Resident 29's current functional status per the MDS assessment completed on 6/15/21. A Resident Care sheet, dated 7/23/21, indicated the resident was independent with eating, resided on the memory care unit, had no safety protocols, transferred with assistance of 1 staff member, had behaviors which were not specified, and used a wheelchair. An Occupational Therapy Evaluation and Plan of Treatment form indicated the resident had received therapy services to increase his activity tolerance and safety with transfers from 6/14/21-7/13/21. A Physical Therapy Evaluation and Plan of Treatment form indicated he had received physical therapy to improve his functional mobility to decrease his fall risk from 6/9/21-7/6/21. On 7/23/21 at 11:36 A.M., Resident 29 was observed wearing a hospital gown and lying in his bed with the head of the bed elevated. There was no floor mat to his bed. He had contractures to both hands and extensive bruising to the right side of his forehead and around and below his right eye. He indicated he had fallen recently and injured the same side of his head as when he'd fallen previously. He indicated both falls occurred from his wheelchair and the falls needed to stop; he had tried to get up by himself and probably shouldn't have. On 7/24/21 at 11:50 A.M., The resident was observed wearing a hospital gown and lying in his bed with the head of the bed elevated and an overbed table placed in front of him. There was no floor mat next to his bed. He indicated he was uncomfortable and needed someone to reposition him before eating lunch. A Nursing Note, dated 6/2/21 at 2:06 p.m., indicated Resident 29 was found face down on the floor of his room, under his roommates bed. He indicated he had fallen out of his wheelchair. The NP (Nurse Practitioner) was notified and staff were to continue to assess him. Nurse Practitioner Notes indicated the following: 6/2/21 at 2:20 p.m., resident was assessed after a fall that occurred on this day. He was found by nursing staff in his room, lying face down under his roommate's bed after activities returned him to his room. The resident indicated he had fallen out of his chair when he tried to reach for the call light. Nursing staff reported the roommates call light was not on the floor and that no items were on the floor for him to try and pick up. There were multiple areas of trauma-a large hematoma to the right side of his forehead, redness to

Based on observation, interview and record reveiw, the facility failed to ensure residents with dementia and aggressive behaviors received appropriate resdient specific programming and ongoing interventions which resulted in multiple injuries, harm to self and harm to others, includeing fear and psychosocial harm to the reasonable person, for 3 of 5 residents reviewed for dementia care. (Resident 41, 21 & 28) The Immediate Jeopardy began on 10/2/2020 when the facility failed to ensure Resident 41 was not provided with specific programming to assist with his dementia. The Administrator was notified of the Immediate Jeopardy at 2:36 P.M. on 7/23/2021. The Immediate Jeopardy was removed on 7/26/2021, but noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Finding includes: 1. During intial tour of the facility, on 7/19/2021 at 10:45 A.M., Resident 41 was observed to have feces on himself, the wall, the air conditioner, his bed, his recliner and his call light. The air conditioner was missing its cover, the outlet was missing from the wall, the outlet was broken for air conditioner, foot board was missing from his bed, leaving metal bars standing up in the air. On 7/19/21 at 11:05 A.M., Resident 41's call light was still covered in feces and stretched across the newly made bed. On 7/19/2021 at 11:53 A.M., Resident 41 was observed standing at the head of his bed bent over with his socks halfway off his feet. Feces was observed running down the air conditioner and a broken electric outlet laying on the ground. On 7/19/2021 at 12:32 P.M., the Administrator acknowledged Resident 41 needed assistance/care to help with his situation. She indicated the staff did not finish cleaning up Resident 41's room. A clinical record review was conducted, on 7/19/2021 at 3:54 P.M., and indicated Resident 41 was admitted on [DATE] and his diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Nurses Note, dated 10/1/2020, indicated .resident entered nurses station, and upon attempt to redirect resident out of this area, resident physically attacked this nurse . slapping glasses of face, and punching this nurse . the aide arrived and attempted to talk resident down at which time resident picked up the chair from the nurses desk and threw it . both the aide and this nurse attempted to escort the resident back to his room . he began throwing everything he could get his hands on down the hallway .other staff members arrived to this unit and helped to ensure the safety of all other residents on the unit A Nurses Note, dated 10/2/2020, indicated .CNA [certified nurses assistant] went into residents room to do a check. Reported to nurse that his BM was spread all over his room. This writer went to room and observed that resident had smeared feces all over his room. All over the walls, bed side table, inside of his box of cookies that family had brought in, all over the floor and bedding that he had previously laid on the floor A Nurses Note, dated 10/26/2020, indicated .Res very restless et exit seeking at present. Up by nurses' station, attempting to open locked unit doors, et to open locked linen room door. Frequently pacing back et forth, opening ice cart, looking inside, then closing lid again. Observed by staff to be studying fire alarm, et at one point, removing face plate. Staff able to replace before res pulled fire alarm. Not able to be redirected. Also standing at med cart, touching et moving objects. Frequently telling staff bye and I've got to be going A Behavior Note, dated 11/13/2020, indicated .Most of shift resident walked up and down hall and at times went into other resident's rooms. Much redirection, but most of time did very little to get resident to do a different activity A Behavior Note, dated 12/5/2020, .Res noted to have urinated x2 [twice] in inappropriate places, such as corner in his room, et [and] in unit dining room. Bathroom door in res' room left open et res shown bathroom several times this am A Behavior Note, dated 12/6/2020, indicated .Res has past behavior of crawling under other res' beds. Res' roommate is currently on O2 [oxygen]. While doing rounds, observed roommate's O2 off, et machine under bed unplugged. This res was the only person in room with roommate at the time. Res has history of destroying electronic devices, such as Tvs, VCRs, computers, phones, and radios. This res also pulls the curtains around his roommate on a constant basis, obstructing staff's view of dying roommate A Behavior Note, dated 12/16/2020, indicated .Res was going in et out of other res' rooms, taking their belongings and refusing to give them back, becoming agitated towards staff when attempting to re-direct res towards his room A Behavior Note, dated 12/17/2020, indicated .Observed urinating into a dresser drawer this am. Was found in an empty room, attempting to pull call-light out of wall, then slamming doors on closets. Redirected into his room, where he only stayed a few seconds, then went back into previous room where behavior continued A Nurses Note, dated 12/27/2020, indicated .writer was in the middle of mid day med pass when he saw resident pushing very aggressively on the ice bucket almost trying to break it, the ledge finally gave in and the resident fell down hitting his nose on the way down. resident then jumped up and down, had a unsteady gait. writer rushed over to help resident . writer called for a cna to get a wheel chair while helping the resident stand up straight. resident assisted back into the wheel chair and pushed back to his room for further assessment. when helped in the bed writer notice that the resident then became unresponsive to his name and was laying there hyperventilating with his eyes close vs assed Bp [blood pressure] 137/73 pulse 103 o2 [oxygen level] was between 78-83% and temp [temperature] was 98. Resident was repositioned and oxygen initiated and 911 was called A Behavior Note, dated 12/31/2020, indicated .Resident up all morning, wandering into others rooms, touching/taking belongings . when staff attempts to redirect, resident ignores staff or becomes physically aggressive. Resident sleeping at this time, however, has not slept per night shift nurse for the last 2 nights A Behavior Note, dated 1/1/2021, indicated .Resident entered another resident's room and could not be re-directed verbally. Became combative and aggressive. Inside other resident's room resident forcefully closed door An Incident Note, dated 1/11/2021, indicated .This nurse called to resident room per therapy, noted small laceration and raised area to back of head, L of center . resident was crawling around on the floor and bumped his head on the bed, as evidenced by the blood A Behavior Note, dated 1/14/2021, indicated .Resident came out of room upon this nurses arrivial . covered in feces, male aide attempted to take resident to his room to get cleaned up when resident began punching staff member . two more staff came to assist. Resident fighting staff the entire time A Behavior Note, dated 2/12/2021, indicated .Resident noted to be in his room, standing up and having a bowel movement all over the floor . when staff attempted to provide care, resident began to swing with closed fists A Behavior Note, dated 3/8/2021, indicated .Res frequently in other res' [resident] rooms today. Noted res covered up another res' head while they were lying in bed. Also noted to be messing with the heater in another res' room A Behavior Note, dated 3/31/2021, indicated .res attempting to place small balls of bm under his pillow this am. Allowed CNA to clean him et change his clothing. Staff also found a brief that was heavily soiled with urine in res' bedside table A Behavior Note, dated 4/5/2021, indicated .Up in the hall and going into other resident's rooms. Tried to redirect and he started trying to hit the CNA. He had a cup of water in his hand and he tried to throw it on the CNA. I took the water and emptied it. He walked ahead of me and picked a bottle of body wash off the CNA cart and throw it at me A Behavior Note, dated 4/5/2021, indicated .Again in another resident's room. He was making the empty bed. We encourage him to go to his room and he refused. We pulled the curtain to do AM care but he pulled the blanket off the other resident's bed and started to put it on the empty bed. The CNA and I took an arm each and pulled him down the hall and put him in his room and closed the door. The male CNA opened the door and ask this resident [NAME] he was doing. He yelled back Get out A Behavior Note, dated 4/9/2021, indicated .At approx 0820 [8:20 A.M.] this am, staff member was attempting to deliver res' breakfast tray. Res had room door blocked with his bed. Staff able to move bed to allow entrance. Res became very angry et aggressive, Punched CNA in the face with his fist, attempted to spit in staff's faces et kicked a hole in the wall of his room. Unable to calm res. Res had also torn covering on bed in room, as well as fully destroying the heater/ air conditioning unit and .At present, res found standing up in his room completely naked, took 2 staff members to get res dressed, as res was being combative A Behavior Note, dated 4/9/2021, indicated .Found res in another res' room, attempting to pull apart the call-light system and the remote to other res' bed. Was able to redirect res back into his room, where this nurse found that res had torn off the footboard of his bed, as well as ripped mattress cover on his bed even further than he had previously A Behavior Note, dated 4/27/2021, indicated .Patient was pulling on electrical cord of the bed and the control unit trying to pull them out of the bed. he pushed the bed and table out of the room the tv cable end had been pulled off, on the unit by pulling on the cords he could cause himself or others to trip or possibly be electrocuted from a bare wire contact A Behavior Note, dated 5/12/2021, indicated .During the evening this resident went into multiple rooms and removed personal items of residents in each room. I redirected over and over and returned the items he removed. I gave him a PBJ sandwich and he ate all the sandwich. After about 2200 [10:00 P.M.] we put this resident in his room and stationed a CNA in front of his door. CNA redirected this resident multiple times and did not allow him to leave his room. At this point he has not tried to open his door for about 15mins A Behavior Note, dated 5/14/2021, indicated .Resident remains very restless and unable to stay still. He continues going in and out of rooms and taking items. When this resident is placed in his room with a CNA at the door, he pulls apart anything and everything A Behavior Note, dated 5/14/2021, indicated .Res has been in other res' rooms numerous times this shift, despite numerous staff attempts to redirect. Early in shift found res pushing a bed out into hallway with another res lying on it. Was easily redirected at that time. Continued to attempt to push other beds into hallway, pushed his bed out several times. Observed tinkering with heater in his room numerous times. Has broken cover off of unit. Unable to be redirected. Told staff member to Kiss my a-- when taking dirty dishes out of his room. Continues to ambulate up et down hallway at present A Nurses Note, dated 5/25/2021, indicated .Resident up this am in his room, tearing things up as he does, and this nurse noted swelling and discoloration to R [right] hand this am while giving resident his medications. NP advised, received new orders for XR [x-ray] of R hand . ordered and awaiting tech A Nurse Practitioner Note, dated 5/25/2021, indicated .Nursing staff report right hand bruising to resident. There is no known source of injury and no witnessed falls/injury. Nurse reports noticing swelling and bruising this morning that was not there previously. Staff also report that resident often fixes or works on furniture around the unit. He has a history of [CONDITION(S)] and dementia, is a poor historian and .[CONDITION(S)] present to right wrist and hand measuring 16cm in length, bruising covering this area is present. [CONDITION(S)] and bruising wrap around to radial/ulnar wrist areas with 6cm in diameter from wrist into forearm. Pain response is illicited with palpation to radial area. Pain response is strong and present with right wrist extension and flexion. Mild pain response to adduction and abduction of right wrist. It is hard for resident to make a fist with right hand A Nurses Note, dated 5/25/2021, indicated .XR positive for FX [fracture] to R distal radius [bone in the arm] A Nurses Note, dated 6/2/2021, indicated .Found face down in front of his chair. Noted large lump on right forehead and right eye bruised . and .911 called A Behavior Note, dated 6/6/2021, indicated .Upon entering unit this am , noted res to be in his room with air conditioning/heating unit cover lying on floor, entire unit taken out of wall et lying on the floor, insulation removed from unit, et large hole in place where unit was removed from. Res in his room continuing to tinker with his clothing, his belongings, et the furniture in the room A Nurses Note, dated 6/10/2021, indicated .Told physician that res has had an altered gate today. His reply was We can't fix his dementia A behavior Note, dated 7/10/2021, indicated .Last evening I noted this resident chewing and chewing. I ask him what was in his mouth and was able to remove the item. He was chewing on 2 pieces of rubber that he had pilled off the inside of his shoes A Behavior Note, dated 7/18/2021, indicated .Res has been in et out of other res' rooms most of day- taking other res' small belongings. Not always easily redirected. Raised his fist at CNA as she was redirecting him out of a res' room A review of Resident 41's medical record indicated there were no individualized or nonpharmacological interventions to assist him with his dementia. During an interview, on 7/22/21 at 11:49 A.M., the DON indicated anyone can stub their toe, get stitches to their head or break their wrist. During an interview, on 7/23/2021 at 11:06 A.M., the Administrator indicated there wasn't any programing for the residents in the dementia unit and that there were no individualized interventions for this resident, related to his dementia. 2. On 7/19/2021 at 12:19 P.M., Employee 19 served Resident 21 her lunch. Resident 21's bed sheets were observed with brown/yellow circles dried and wet yellow circles. A soiled brief was observed lying on the opposite bed in her room, also observed to be wet. Five flies were observed crawling around on Resident 21's pillow. Resident 21 was observed sitting in her chair with a strong odor and her pants were observed to be wet. Employee 19 did not mention the wetness or clean anything, only served her her meal tray. During an interview, on 7/19/2021 at 12:32 P.M., the Administrator acknowledged the situation Resident 21 was left in and began assisting her to get cleaned up and change her linens. A clinical record review was completed, on 7/19/2021 at 2:35 P.M., and indicated Resident 21's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Social Service Note, dated 1/15/2021, indicated Resident .had an accident, and her room smells like uring. I asked [Resident 21's name] if I could help her get on some clean clothes, she said f--- you and f--- no. A behavior Note, dated 1/23/2021, indicated .During morning ADL [activities of daily living] resident became combative with care and hit door with left hand resulting in bruising and decreased ROM [range of motion]. Nurse applied ice pack and finished ADL resident did not have socks and shoes which nurse applied to feet DON [Director of Nursing] updated on behavior N.O. for STAT order 2 view to left wrist A Nurses Note, dated 1/23/2021, indicated .nurse stayed with resident during xray of wrist - visible fracture of distal radius A Nurses Note, dated 1/23/2021, indicated .IMPRESSION: Acute fracture of the distal radius A Nurses Note, dated 1/24/2021, indicated .Left wrist and hand still swollen and bruised ice applied fingertips warm and moveable A Nurses Note, dated 1/26/2021, indicated .Lt [left] wrist remains edematous. Res [Resident] guarding limb very closely A Nurses Note, dated 1/28/2021, indicated .resident has not eaten a meal for at least the last 48 hrs [hours] . different alternative meals/snacks have been offered, and resident continues to refuse . DON notified . will continue to monitor A Social Services Note, dated 1/28/2021, indicated .Attempted to do interview with [Resident 21's name] she refused. Nurse did say she has refused to eat for the past two days, did try to offer snacks and she still said no. She has had some behaviors with cussing at staff, and refusing care A Nurses Note, dated 2/11/2021, indicated .Resident scheduled for outpatient surgery for [MEDICAL RECORD OR PHYSICIAN ORDER] A Behavior Note, dated 2/19/2021, indicated .Res has flooded her bathroom x2 today by flushing small plastic cups down her toilet. Flooded her bathroom et [and] part of her room A Behavior Note, dated 3/22/2021, indicated .Physically aggressive towards CNA [Certified Nurses Assistant] this am while attempting to get res ready for Dr's [Doctor] appt [appointment]. Attempted to hit with her splinted hand. A Behavior Note, dated 3/24/2021, indicated .This nurse over-heard res yelling, F--- you b----. Upon entering room, observed this res holding up her middle finger and angrily shaking it at her roommate. Roommate removed from room. Went back into room to talk with this res, res threw her water cup et tv remote across the room, while continuing to yell f------ b---- A Behavior Note, dated 3/30/2021, indicated .Res very residtant to care this am. Physically aggressive towerds CNA, also cursed, flipped off staff et threw soiled brief at CNA. Res refused to allow CNA to assist her with dressing, et was found standing in her doorway wearing just a bra et cursing at staff A Behavior Note, dated 5/10/2021, indicated .resident continues to stand in doorway of her room and scream at staff as they walk past. she occasionally is slamming her door. one of her chairs in room is broken and was removed for safety to which she continued to scream at staff, f--- you, you w----. continual screameing even with staff giving resident her space A Behavior Note, dated 5/10/2021, indicated .resident still upset and slamming the door to her room at times, continues with agitation A Behavior Note, dated 5/10/2021, indicated .resident refusing PO [by mouth] meds at this time. will nto take any snacks or fluids from staff either. continues to yell at times and slammed the door on staff A Behavior Note, dated 5/10/2021, indicated .resident is in room with all clothing off and is refusing to get dddressed. door and curtain closed for privacy. different staff have gone into room to attempt care and resident becomes very aggressive with staff A Social Services Note, dated 5/14/2021, indicated .Called [local psychiatric hospital] to get an update on [Resident 21's name]. The nurse on duty [nurses name] said that she was very pleasant the past few days but this morning she threw a cup at another resident and said f--- you. [nurses name] said she redirected [Resident 21's name] and tried to ask her what happen and what made her throw the drink and she said [Resident 21's name] jsut looked at her A Nurse Practitioner Note, dated 6/2/2021, indicated .[Resident 21's name] has been readmitted to [facilities name] after being transferred to [a psychiatric hospital] on 5/11/2021 after numerous episodes of aggressive behavior, screaming profanities at staff and residents, throwing items, and becoming physical with staff A Nurse Practitioner Note, dated 6/3/2021, indicated .[Resident 21's name] was assessed today after nurse reported new thumb swelling and bruising. [Resident 21's name] has significant neurologic and mental health history and is not able to report how thumb was injured and .Obtain xray of right thumb A Nurse Practitioner Note, dated 6/9/2021, indicated .[Resident 21's name] was seen today for f/u [follow up] s/p right thumb fracture. She reports thumb is not painful. She denies any numbness or tingling to right thumb, hand and wrist. X-ray showed acute nondisplaced fracture of distal phalanx on thumb A Behavior Note, dated 6/20/2021, indicated . Resient was screaming at the top of her lungs, throwing things, swinging to hit staff, threw her urine soiled pants at staff and refused to allow staff to clean her up, change her brief, or make her bed. Resident refused meds and care during the evening and night shift as well. This tantrum topped any that writter had seen her throw. She would not reason with writer either A Behavior Note, dated 6/29/2021, .Accompanied housekeeper into res' room. Found at least 40 used cups in res' bedside table. Also found a bag full of used briefs containing urine et faces in res' closet A Behavior Note, dated 7/26/2021, indicated .Resistant to care. 2 staff assisted with getting res to change out of soiled clothing, et to change res' bed linen. Res very angry with staff, threw water et all other liquids from her bedside table across the room A Behavior Note, dated 7/19/2021, indicated .resident soaked from being incontinent. gave her a total bed bath and did peri care. clothing changed. resident had refuesed care from 3 different staff members previous to my coming in to offer care. bed linen was soaked with juice. mattress cleaned and new linen placed on bed. resident did refuse to shower, that is why a bed bath was given. refused to brush hair and teeth multiple times. empty gatorade bottles, cups and silverware removed from room. they were found in bottom of her closet A Behavior Note, dated 7/19/2021, indicated .resident physiccally and verbally combative with care, yells profanities and threatens to spit on and hit staff when staff tries to provide care A Behavior Note, dated 7/15/2021, indicated .resident needed cahgned and staff was changing her, she was screaming, swearing, and hit the CNA but did not cause injury. she called them names B---- and was angry, residents room smelled very bad like uring and needed cleaned. Resident wold benefit from a monthly antipsychotic injection as she is so labile and refuses meds [medications] often During an interview, on 7/23/2021 at 3:02 P.M., the DON indicated she did not have an individualized care plan documented to address Resident 21's dementia needs. 3. On 7/24/21 at 12:43 P.M., the clinical record for Resident 28 was reviewed. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was admitted to the facility's memory care unit following hospitalization . A hospital note, dated 6/2/21, indicated the resident had been hospitalized for evaluation of weakness, possible dehydration, and altered mental status and was found to have a urinary tract infection. She had a long history of mental disorder and aggressive behavior. A few weeks ago, she fell and broke her hip. After hip repair, she was discharged to a nursing home. She lasted about a week in the nursing home but would not follow staff directions, refused to eat, and refused to take medication. She was discharged home . She continues to refuse to eat or drink. She is not taking medications . she came back to the hospital for psychiatric evaluation. An admission MDS assessment, dated 6/12/21, indicated a BIMS score of 2-severely impaired cognition. Resident 28 had multiple mood indicators which occurred over 12-14 days of the assessment which were: little interest or pleasure in doing things; feeling down, depressed or hopeless; feeling tired or little energy; and trouble concentrating on things. She had no behaviors. The resident required extensive assistance from 2 staff members for bed mobility and transfers; extensive assistance from 1 staff member for dressing, toileting, and personal hygiene; and supervision from 1 staff for eating. She was incontinent of bowel and bladder and had a total of 5 pressure ulcers. A Psychosocial Care Area Assessment (CAA) triggered due to resident having multiple mood symptoms. She recently moved into the facility with a dx of ID/DD and altered mental state. MD/NP to assess for psych (psychological) services. Will encourage her to participate in activities of choice. On 7/24/21 at 11:56 A.M., Resident 28 was observed in her room with the door open. She was lying in bed on her right side facing the wall and was covered with a sheet up to her chin. There was a sign outside her room on the wall that indicated she was in contact precautions and staff were to don a gown and gloves prior to entering her room. -At 12:53 P.M., the resident was observed still lying on her right side, towards the wall. Her sheet had slipped down below her shoulders to her waist and a large dried brown stain was observed on the bottom sheet. Her feet were uncovered by the sheet and her left heel had a large black necrotic ulcer that had separated at the edges of the wound and was red in color. A staff member was observed to go in the room and ask the resident if she wanted to eat. There was no tray observed in the room. The resident was heard to say no and the staff member left the room. -At 1:09 P.M., CNA 29 was observed in resident's room with clean linens and gown. The CNA asked the resident if she wanted to get up or allow the aid to change her bed sheets because she had spilled coffee on the bottom sheet. Resident 28 stated no. The CNA got all her supplies ready and placed on the bedside table while she continued to talk to the resident and tried to engage her in conversation but the resident said nothing. CNA 29 indicated the resident had lain on her right side, in the same position, all day since she had arrived for her shift, and she wasn't sure what to do. Her shift was getting ready to end and she indicated she needed to get the resident cleaned up and off her right side because she had a sore on her hip. The CNA indicated she had asked the resident throughout the day if she could help her get cleaned up but each time the resident had refused. The resident's TV was on which was located on the bedside stand across the room from the resident's bed. Behind the TV, sat the residents lunch plate with a cover over it, an uncovered bowl of chocolate pudding and a full glass of uncovered red juice. The cover on the plate was lifted off and the food appeared to be untouched and was a congealed mass of green vegetable, unidentified meat and gravy. The CNA indicated another staff member had come in and asked the resident if she wanted to eat and the resident had said no. CNA 29 started to change the resident's bedding while calmly speaking to her and telling her what she was doing but the resident continued to say no and I don't want to move. She had the soiled linen rolled under the resident and new bedding on when she told the resident she needed to remove her brief. The brief was dry, and the resident had not voided all shift. The aid kept explaining to Resident 28 that she would need to help her turn over and go over a large bump. LPN 27 then entered the room to assist the CNA to complete care to the resident who was gripping the right side of the bed frame and stated, leave me alone and why do you have to do that. After much coaxing, the CNA and LPN were able to roll the resident over and finish making her bed. Care Plans indicated the following: -Actual behaviors related to refuses ADL care, changing of wound treatments, refuses meals at times (initiated 6/15/21) and exhibits behaviors of anger/yelling/cursing at staff when trying to give care, change wound dressing, giving incontinent care. When meals are brought, will refuse meal, and yell I want my mother or will state I want my mom's food (initiated 6/22/21). Interventions, dated 6/15/21, were: approach in a quiet calm manner; ask another staff member to assist; introduce self and tasks needing attention; explain task before beginning; play music to resident's liking; return at later time when refusing, yelling, or physically aggressive; and IDT to review behavior management program quarterly and as needed. -Makes racial comments to staff when non-white staff try to give care (initiated 6/22/21). The goal was for the resident to be accepting of care at least once daily. Interventions, all dated 6/22/21, were to approach at later time; ask other staff to assist as needed; introduce self and explain task before beginning; and notify doctor and family of behavior. A Resident Care Sheet, dated 7/23/21, indicated Resident 28 was on a regular, diabetic diet and required cueing when eating; was an elopement risk; was incontinent and required 1-2 staff members to assist with transfers and bed mobility; and she had unspecified behaviors. Behavior and Nurse notes indicated the following: 6/5/21 at 2:31 p.m., very resistant to care this a.m . incontinent of bladder and bowel and resisting care from CNA . During care, resident cursed, screamed, and resisted allowing clothes to be changed. Continues to refuse all food and fluids offered. Yells out frequently . Spoke with brother and wife this a.m . resident has IQ of an 8 year old. fell at home 3 weeks ago and had to have hip surgery. Ever since fall, resident has refused to eat or drink . personality has changed . is now mean, verbally and physically aggressive towards care givers . Resident has small stuffed lion that she likes to hold during care. 6/6/21 at 1:35 p.m., .Yells and screams out, resistant to care, refuses all food and fluid offered. Different staff have attempted care, explained everything before doing any tasks. Symptoms interfere with ADL's and care. -At 2:52 p.m., [family members] came to window for window visit. Resident refused to look at them or speak to them, just continued to scream 'I wanna go home!' over and over. Continues to refuse all food and fluids offered. Verbally aggressive towards staff. 6/8/21 at 3:31 p.m., Resident verbally combative with CNA this shift, swatting at her while she is trying to change her, calling her names such as 'N-----' and 'Blackie' . Resident asked not to speak to staff that way, and the verbal assaults just kept coming out of resident's mouth . 6/9/21 at 3:23 p.m., therapy in with resident this am, they reported to this nurse that resident was physically and verbally combative with them, resident also stated 'I won't be happy until I kill somebody with my gun' . resident resists care. 6/13/21 at 4:31 p.m., Resident combative with care requiring 3 staff to change resident, attempts to hit, bite staff. Yelled all shift for her mother, refused fluids and food, attempted to redirect resident in calming, reassuring manner, all attempts failed. 6/14/21 at 2:13 p.m., Refused all food and fluids, multivitamin, and have temperature taken. Refused to allow staff to change her clothing or line [TRUNCATED]

Based on observation, interview and record review, the facility failed to ensure a resident with cognitive deficits, who was at risk for elopement and resided on a locked dementia unit, did not exit the building unattended and without the knowledge of staff, resulting in an elopement for 2 of 3 residents reviewed for elopements. (Resident B and Resident D) The Immediate Jeopardy began, on 8/27/19 at 6:00 [NAME]M., when Resident B was last observed in his room by Certified Nurses Aide (CNA) 2 and was found by the local police department blocks away, just off a major highway and taken to a local emergency room for an evaluation at 8:26 [NAME]M. The Administrator and the Director of Nursing (DON) were notified of the Immediate Jeopardy on 9/3/19 at 4:10 P.M. The Immediate Jeopardy was removed on 9/4/19, but noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Findings include: 1. During the initial tour, on 9/3/19 at 9:38 [NAME]M., Resident B was observed in his room, on the secure dementia unit. CNA 3 was sitting directly outside the resident's door, facing the resident's bed. She indicated the resident was currently being observed, one on one (1:1). She indicated she was watching him for another staff member who took a break, and the 1:1 observations were due to the resident going out and/or breaking the window and the police brought him back to the unit. During an interview, on 9/3/19 at 10:15 [NAME]M., CNA 5 indicated Resident B was on 1:1 observations to make sure he did not get out of the building. During an interview, on 9/3/19 at 10:22 [NAME]M., LPN (Licensed Practical Nurse) 6 indicated she worked the day Resident B went missing. She had gotten out of nurses report around 7:45 [NAME]M., and as she was going down the hallway she noticed Resident B was not in his room, so she checked the activity/TV room and he was not there. She next checked the dining area and there was no sign of the resident, so she asked another staff member if she had seen him and together they observed each room and area as they went down the hallway twice. After not finding him anywhere they called a Silver Alert. She indicated she had seen a screen lying outside on the ground in the Activity room and in the resident's room but was still not sure which window he left from. LPN 6 indicated the police brought Resident B back to the facility on [DATE] around 11:00 [NAME]M. During an interview, on 9/3/19 at 10:32 [NAME]M., the Maintenance Director indicated Resident B went out the window in his room. The screw placed in the sill of the window, to prevent it from opening, had been pulled out and was lying on the floor in Resident B's room, and the window screen was lying on the ground outside of the room in the grass. He indicated he had checked all the windows on the dementia unit to make sure the screws were securely in place, to prevent the window from opening. He indicated he had also placed a screw in Resident B's window opening latch to ensure the resident could not open his window. He indicated he had been checking the windows and screws on the dementia unit daily but had no documentation to provide for review. Incident #177, dated 8/27/19, indicated staff entered Resident B's room to get him for breakfast, however the resident was not in his bed. Staff did a quick search of the unit and could not locate Resident B's whereabouts. It was determined the resident left via a window. A full search of the facility was conducted and the resident was not located in the facility. The police had found the resident and had taken him to the local ER for an evaluation. The resident was returned to the facility that same day. During an interview, on 9/3/19 at 10:57 [NAME]M., the Administrator indicated upon Resident B's return, he was placed on 15 minute checks for 72 hours, an elopement risk assessment was completed and all windows in the facility were observed to ensure a mechanism was in place to prevent further exits through an open window. She indicated the resident was still on 1:1 observations with staff documentation every 15 minutes due to some of his statements. During an interview, on 9/3/19 at 9:49 [NAME]M., CNA 4 indicated she was unsure why Resident B was receiving 1:1 observations. A typed statement from CNA 2, untitled and undated, provided by the Administrator indicated CNA 2 had last seen the resident in his bed around 6:00 [NAME]M., as she had been in the room to assist his roommate. The form indicated the CNA did not recall the window being open at the time. On 9/3/19 at 11:10 [NAME]M., a review of the clinical record for Resident B was conducted. The record indicated the resident was admitted on [DATE]. The resident's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment, dated 6/11/19 indicated the resident's assessment showed moderate dementia, was independent with transfers and ambulation on the unit, but required the assistance of 1 person when walking off the unit. An Elopement Risk Assessment, dated 6/7/19, indicated the resident had a score of 15. The assessment indicated .a score of 5 or more is considered to be at risk for elopement The assessment indicated the resident ambulated independently, was having difficulties accepting facility placement, wandered aimlessly and expressed a desire to locate a family member. A Progress Note, dated 8/27/19 at 7:46 [NAME]M., indicated .Last evening he (Resident B) was very upset as he wanted to go out to smoke. He stated another resident will give him a smoke. I informed him I would ask about getting him smokes. He was OK after that An emergency room (ER) Report, dated 8/27/19, indicated Resident B presented to the ER with confusion. The police reported he was found wandering the streets with an unsteady gait. The resident claimed he lived with his daughter and was going to meet her. He did not know his address. He became agitated in the ER when the staff kept him in his ER room. The resident's primary physician confirmed the gentleman was a resident, who had escaped last night, from a locked dementia unit. The resident was agreeable to return to the nursing home and was discharged back to the nursing home. During an interview, on 9/3/19 at 12:20 P.M., the Administrator indicated she had spoken to the police department and there was no police report. She indicated the police reported to her the resident was found a few blocks north of the facility, walking along the highway (State Road 19 - a extremely busy 4 lane highway with a middle turning lane). Resident B had to cross a busy 4 lane road to get to where he was found. The facility was located on busy highway with the St.[NAME]River just outside the resident's window. During an interview, on 9/3/19 at 2:20 P.M., the Social Service Director indicated the resident had no behaviors of exit seeking since his admission. She indicated the night before his elopement he had requested to a nurse he wanted to go outside to smoke but was denied. On 9/4/19 at 9:20 [NAME]M., Resident B was sitting in the activity/TV area. He indicated at this time his .name was inmate . because he couldn't get out of the facility. He indicated he had gotten out of the building the other day, through his window and walked down the highway. 2. On 9/3/19 at 12:45 P.M., an interview was conducted with Resident D and his POA (Power of Attorney). The POA indicated he was concerned about the safety of the unit because the window in Resident D's room was able to be opened. Resident D also resided on the locked dementia unit and the window in his room was observed at this time. The window had a screw in the sill but the window pane was loose and able to be maneuvered over the screw and be opened completely. The Administrator and DON were brought to observe the window that was able to be opened and the Administrator indicated she would contact the Maintenance Director to secure the window in this room and check the other rooms again on the dementia unit. On 9/3/19 at 2:32 P.M., a review of the clinical record for Resident D was conducted. The record indicated the resident was admitted on [DATE], and [DIAGNOSES REDACTED]. An elopement risk assessment, dated 8/31/19, indicated Resident D scored 8. The assessment indicated .a score of 5 or more is considered to be at risk for elopement A progress note, dated 9/2/19 at 5:13 P.M., indicated .Resident called this nurse to room and stated I heard someone outside my door .saying they were going to pop my left eye out and that's my good eye. resident reassured nothing like that was going to happen to him on this unit The initial care plan, dated 8/30/19 indicated the resident had impaired cognitive function/dementia related to new [MEDICAL CONDITION] in left eye and delusional thoughts that someone was going to hurt him. The interventions included but were not limited to: keep residents routine consistent, try to provide consistent care givers and engage resident in simple, structured activities that avoid overly demanding tasks. During an interview, on 9/3/19 at 2:52 P.M., LPN (Licensed Practical Nurse) 6 indicated Resident D was not in the elopement binder kept at the nurses station, but he was at risk for an elopement. She indicated he had just been admitted over the weekend. A form titled Window checks, indicated every shift for 72 hours, for all rooms on the secure unit, the activity room and dining room were to be checked and staff had checked Resident D's window in his room on 8/27, 8/28 and 8/29 with no concerns. A Performance Improvement Tool, indicated Resident D's room had a secure window on 8/27, 8/28, and 8/30/19. No documentation indicating the tool was used on 9/1/19. On 9/3/19 at 11:13 [NAME]M., the Director of Nursing (DON) provided a policy titled Elopements Policy and Procedure, dated 11/28/17 and indicated the policy was the one currently used by the facility. The policy indicated .It is the policy of this facility to assess all residents upon admission to the facility and quarterly for their risk of elopement. Residents who are assessed as being high risk for elopement will have a plan of care that identifies the risk and appropriate interventions. A picture of the resident with relocation information shall be placed in the Elopement Risk Book kept at the nurses station On 9/4/19 at 11:01 [NAME]M., the Director of Nursing (DON) provided a policy titled Elopement Prevention Policy and Procedure, dated 11/28/17 and indicated the policy was the one currently used by the facility. The policy indicated .New Resident Monitoring: Facility shall monitor new Residents as needed as a good practice to evaluate and address Resident's patterns of activity and capabilities .Windows and Doors: Windows and doors must be routinely checked and maintain in manner consistent with preventing attempts at elopement .Supervision: Supervision must be adequate to meet the Resident's individual needs Interventions: Reasonable interventions must be implemented to prevent elopement as a foreseeable risk The Immediate Jeopardy that began on 8/27/19 was removed on 9/4/19 when the facility secured all windows in the locked dementia unit, reassessed all residents for elopement risk, and inserviced all staff related to elopement procedures, but the noncompliance remains at the lower scope and severity level of isolated, no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy because of the need for continued monitoring and inservicing. This Federal tag relates to complaint IN 108. 3.1-45(a)(1) 3.1-45(a)(2)

Based on observation, interview and record review, the facility failed to turn and re-position the resident, monitor and implement interventions, which resulted in the reoccurrence of severe excoriation and subsequent bleeding for 1 of 6 residents reviewed for skin integrity. (Resident 18) Finding includes: During an observation, on 06/14/2019 at 10:20 A.M., Resident 18's skin from the back of both thighs up to and including the shoulders, were dark red with purple shading. One small spot on the residents upper back along with several small spots along the gluteal fold were observed to be bleeding During an interview, on 6/14/2019 at 10:20 A.M., CNA (Certified Nurses Aide) 48 indicated the discoloration on Resident 18's skin recurs. On 06/14/2019 at 10:09 A.M., 11:14 A.M., 12:30 P.M., 2:58 P.M. and 4:19 P.M., Resident 18 was observed lying on his back covered with a sheet, blanket and sheep's wool under his legs and feet with the head of bed elevated. A clinical record review was completed, on 06/14/2019 at 1:30 P.M., and indicated Resident 18's [DIAGNOSES REDACTED]. A weekly skin assessment, dated 06/10/2019 indicated Resident 18 had no alteration in skin integrity. A skin assessment, dated 06/14/2019 at 5:00 P.M., indicated .Red excoriation into gluteal cleft, Red excoriation into gluteal cleft, Redness: 4.0 cm X 2.0cm X 0,Red excoriation from below neck down to sacrum and .Resident found to have red ecchymotic rash from below neck down to sacrum(entirety of back). Buttocks also very reddened into gluteal cleft & folds. Gluteal cleft noted to have some oozing of blood and .Rash has been recurrent A wound care specialist evaluation, dated 02/05/2018, indicated Resident 18 had a previous [DIAGNOSES REDACTED]. During an interview, on 06/14/19 at 11:14 A.M., LPN (Licensed Practical Nurse) 2 indicated that she was unaware of skin irritation to Resident 18's back with bleeding. During an interview, on 06/14/19 02:03 P.M., the DON(director of nursing) indicated she was unaware that the moisture [MEDICAL CONDITION] on Resident 18's back had reoccurred and there was not a care plan for MASD (Moisture Associated Skin [MEDICAL CONDITION]). During an interview, on 06/14/2019 at 3:05 P.M., the Administrator indicated she would expect a care plan for the moisture [MEDICAL CONDITION] to be in place, as it recurs and they should have interventions in place to prevent the resulting fungal infection, along with the weekly skin assessments which are meant to monitor/prevent altered skin integrity. A policy was requested but one was not provided. 3.1-37(a)

Based in record review, observation and interview, the facility failed to ensure that pressure ulcers were assessed weekly and that treatments were completed as ordered by a physician resulting in the worsening and infection of an unstageable pressure ulcer for 2 of 3 residents reviewed for pressure ulcers. (Resident 4 & 11) Findings include: During an observation, on 6/13/19 at 9:55 A.M., Resident 4 was observed laying in bed eating breakfast siting up. There was no air-loss mattress in place currently. The clinical record for Resident 4 was reviewed on 6/14/19 at 9:33 A.M. [DIAGNOSES REDACTED]. A quarterly MDS (Minimum Data Set) assessment, dated 5/29/19, indicated Resident 4 had a BIMS (Brief Interview Mental Status) score of 12, mild cognitive impairment and had an unstageable pressure ulcer. A progress note, dated 1/2/19 at 7:25 A.M., indicated the nurse was called into Resident 4's room and resident was noted to have a 4 cm (centimeter) x 3.5 cm unstageable open area to right heel. The physician was notified and [MEDICATION NAME] was ordered twice daily and off-loading device to right foot at all time to right foot. A pressure ulcer wound sheet, dated 1/8/19, indicated unstageable pressure ulcer to right heel began on 1/3/19 and was 4.0 cm x 3.5 cm x 0.1 cm and had scant amount serous/serosanguinous exudate. The treatment was calcium alginate and optic foam and pressure relieving device was cushion to wheelchair and pressure reducing mattress. A care plan for actual pressure ulcer to right heel, created 1/9/19, did not contain any intervention to off load right foot, however it included apply treatment as ordered, assess pressure ulcer location, stage, size and surrounding tissue, Braden scales quarterly, observe skin and report any further breakdown and report signs of [MEDICAL CONDITION]. A pressure ulcer sound Sheet, dated 1/15/19, indicated unstageable pressure ulcer to right heel measured 4 cm x 3.5 cm x 0.1 cm. The treatment was cover right heel with [MEDICATION NAME] and wrap with kerlix, change daily. The pressure relieving interventions were pressure reducing cushion on wheelchair and pressure reducing mattress on bed. The TAR (Treatment Administration Record), dated 1/1/19 to 1/31/19, indicated an order for [REDACTED]. There was no documented treatment completed on 1/4/19, 1/8/19, 1/18/19, 1/21/19 and 1/25/19. A pressure ulcer wound sheet, dated 2/12/19, indicated unstageable pressure ulcer to right heel measured 4.5 cm x 3.5 cm x unknown depth and began on 1/8/19 was covered with 100% necrotic tissue and surrounding tissue was [MEDICAL CONDITION] The treatment was Datkin's solution twice daily. The pressure reducing intervention was a blue boot. A pressure ulcer wound sheet, dated 2/26/19, indicated unstageable pressure ulcer to right heel measured 3.8 cm x 2.8 cm x 0.2 cm began on 1/8/19. The treatment was Datkin's 1/2 strength solution to right heel twice daily and wrap with kerlix. There was slow improvement noted to wound. The pressure reducing intervention was pressure reducing cushion to wheelchair, low air loss mattress to bed, and offloading foot. The TAR, dated 2/1/19 - 2/28/19, indicated on order for cleanse right heel, cover with [MEDICATION NAME] and wrap with kerlix with start date of 1/24/19 to 2/6/19, cleanse right heel twice a day with normal saline, start Datkin's 1/2 strength solution soaked gauze to right heel twice daily and wrap with kerlix with start date of 2/7/19 - 2/17/19, Catkin's 1/2 strength solution to right heel twice daily with start date of 2/18/19 to 2/26/19 and Dakins 1/2 strength wrapped with kerlix twice daily with start date of 2/27/19 to 3/7/19. There was no documentation of treatment completion for 2/6/19, 2/12/19 (evening), 2/15/19 (evening), 2/20/19 (day/evening), 2/23/19 (evening), 2/24/19 (evening) and 2/26/19 (evening). A progress note from visiting wound nurse, dated 3/5/19, indicated concerns with [DIAGNOSES REDACTED] to right heel, low grade temp and confusion for Resident 4. Wound measured 5.0 cm x 5.5 cm x 0 depth with 100% necrotic tissue. A wound culture was ordered and [MEDICATION NAME] was ordered for wound infection. A wound culture result, dated 3/5/19, indicated the wound was positive for proteus mirabilis (bacteria found in water and soil) and [MEDICATION NAME] raffinosus (bacteria with unknown origin but is found in the oropharnx of domestic cats). A pressure ulcer wound sheet, dated 3/5/19, indicated unstageable pressure ulcer to right heel measured 5 cm x 5.2 cm x 0.2 cm and began on 1/3/19. The treatment was [MEDICATION NAME] and wrap with kerlix daily. The pressure reducing intervention was low air loss mattress, cushion pad to wheelchair and off loading heel. The TAR, dated 3/1/19 - 3/31/19, indicated an order for [REDACTED]. There was no documented treatments completed on 3/1/19 (day) and 3/2/19 (day). A pressure ulcer wound sheet, dated 4/2/19, indicated stage 3 pressure ulcer to right heel measured 7 cm x 5.0 cm x 0.5 cm and began on 3/10/19 with foul purulent drainage. The physician and family with notified on 4/10/19. A pressure ulcer wound sheet, dated 5/7/19, indicated unstageable pressure ulcer to right heel measured 6.0 cm x 6.5 cm x unknown due to necrotic tissue with moderate purulent drainage. A progress note from outside wound nurse, dated 5/8/19, indicated nursing reported tissue hanging from wound and odor present to wound. New order for [MEDICATION NAME] and calcium alginate for moderate drainage. The wound was debrided with dermal curette. A pressure ulcer wound sheet, dated 6/4/19, indicated unstageable pressure ulcer to right heel measured 6.0 cm x 6.5 cm x 0.2 cm, with purulent drainage. During an observation, on 6/14/19 at 11:30 A.M., RN 5 removed the dressing to the large unstageable pressure ulcer noted to the back of Resident 4's right heel. The wound present with yellow slough noted to lower portion of wound and beefy red granulation tissue to upper portion of wound. A foul odor was present when the dressing was removed. During an interview, on 6/14/19 at 11:30 A.M., RN 5 indicated the wound measured 5.5 cm x 4.0 cm x 0.1 cm with 40% white/yellow slough and 60% beefy red tissue that was noted to bleed easily. She indicated the wound edges were reddened and there was light pink/yellow exudate noted. During an interview, on 6/14/19 at 2:00 P.M., the ED (Executive Director) indicated she was not aware of the need for an air mattress and ensured the facility would get one for the resident. During an interview, on 6/17/19 at 5:05 P.M., the Corporate Nurse indicated the wound to right heel began on 1/2/19 and that documentation should be correct on all wound sheets. She indicated treatments should have been as ordered. 2. During an interview, on 6/13/19 at 12:00 P.M., LPN 1 indicated that Resident 11 had fallen in (MONTH) which resulted in a left [MEDICAL CONDITION] and Resident 11 later developed a pressure ulcer to left heel. During an observation, on 6/13/19 at 1:00 P.M., Resident 11 was noted to be sleeping in bed with no device present to elevate heels. During an observation, on 6/17/19 at 1:22 P.M., Resident 11 presented with an unstageable pressure ulcer to left heel. Bilateral heels were reddened surrounding tissue. The was no device in place to elevate the heels from the bed. During an interview, on 6/17/19 at 1:23 P.M., the QMA (Qualified Medication aide) 4 indicated there were no orders present to elevate heels and she was not aware of stage 1 to right heel and unstageable to left heel. During an interview, on 6/17/19 at 1:34 P.M., the RN (Registered Nurse) 5 indicated the unstageable pressure wound to left heel measured 0.7 cm x 1.0 cm. She indicated the wound nurse had healed the wound out one month ago. She indicated there no order for boots currently ordered and no orders to float heels, those were discontinued when the wound was healed out. The clinical record for Resident 11 was reviewed on 6/14/19 at 12:16 P.M. The [DIAGNOSES REDACTED]. A quarterly MDS (Minimum Data Set) assessment, dated 3/13/19, indicated Resident 11 had BIMS (Brief Interview of Mental Status) score of 9, moderate cognitive impairment, had impairment to one side of lower extremity and required extensive assist with ADLs (activities of daily living). A hospital nurse's transfer/discharge assessment form, dated 1/15/19, indicated no open areas to bilateral heels. A nurse's transfer/discharge condition assessment form, dated 2/27/19, indicated Resident 11 had one old wound to left heel. A care plan, dated 2/27/19, indicated Resident 11 returned from hospital with a Stage 4 to right heel and blister left heel. The TAR, dated 2/1/19 - 2/28/19, did not contain any orders for wound care or elevating bilateral heels. There were no wound assessments available for the left heel wound. A physician order, dated 3/5/19 at 4:33 P.M., indicated an order for [REDACTED]. A physician order, dated 3/20/19 at 3:48 P.M., indicated an order for [REDACTED]. A pressure ulcer wound assessment, dated 3/27/19, indicated Resident 11 had a Stage 1 to right heel that measured 2.5 cm x 2.0 cm. A composite report pressure wound skin evaluation report, dated 3/30/19, indicated Resident 11 had pressure ulcer to left heel that measured 2.5 cm x 2.0 cm. A pressure ulcer wound assessment sheet, dated 4/3/19, indicated the left heel had healing scabs and was a stage 1 that measured 3 cm x 3.8 cm. A pressure ulcer wound assessment sheet, dated 4/17/19, indicated area to left heel was close to being resolved and was a Stage 1 that measured 3 cm x 3.8 cm, with start date of 4/16/18. A pressure ulcer wound assessment sheet, dated 4/17/19, indicated bilateral heels with stage 1 pressure ulcers that started on 3/10/19 and measured 0.5 cm x 0.5 cm. The physician was notified on 4/30/19 and the wound assessment was signed on 4/30/19. A Nurse's Transfer/Discharge Condition Assessment Form, dated 4/29/19, indicated Resident 11 bilateral heel breakdown. The Order Summary Report, dated 6/17/19, indicated an order to encourage resident to off load heels while in bed, however there were no orders to treatment or assessment of left heel wound. During an interview, on 6/17/19 at 3:00 P.M., the DON (Director of Nursing) indicated the wound had been healed out by the wound nurse and that the wound nurse had been following the wound since readmission from hospital on [DATE]. During an interview, on 6/17/18 at 4:00 P.M., the Wound Nurse Practitioner indicated she was unaware of wound to Resident 11 heel until today when she was requested to come evaluate the wound. She indicated the interventions to elevate heels should remain in place for residents who were at risk for pressure ulcer development. On 6/17/19 at 4:00 P.M., the DON provided the Weekly Skin Check policy, dated 11/2011, and indicated this was the policy currently be used by the facility. The policy indicate the all areas of the resident's skin should be inspected by his of her nurse and documented at least weekly, if skin impairment was identified the nurse should complete the weekly skin assessment form indicating any new areas of abnormality and obtain treatment order from attending physician immediately, the nurse should complete the Pressure or Non-pressure form weekly to track the area of skin impairment identified. On 6/17/19 at 4:00 P.M., the DON provided the Prevention of Pressure Ulcers policy, dated 10/2010, and indicated this was the policy currently being used by the facility. The policy indicated the risk factor for immobility was when in bed, every attempt should be made to float heels (keep heels of the bed) by placing a pillow from the knee to ankle and with other devices as recommended by therapist and prescribed by a physician. On 6/17/19 at 4:00 P.M., a policy on the treatment of [REDACTED]. 3.1-40(a) 3.1-40(b)

Based on record review and interviews, the facility failed to ensure interventions were implemented to provide a safe transfer for 1 of 1 residents which resulted in the resident being lowered to the floor and incurring a femur fracture. This deficiency affected 1 of 1 residents in a sample of 3 reviewed for accidents and falls. (Resident "C") Finding includes: The closed record of Resident "C" was reviewed on 08/14/13 at 9:30 a.m. Resident "C" was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the resident's quarterly MDS (Minimum Data Set: a tool used to facilitate resident care), dated 04/26/13, indicated Resident "C" was totally dependent with the assist of 2 for transfers, locomotion, and toileting. The resident was cognitively intact. Review of "Nurses Notes" indicated: "05/28/13 6:00 a.m. Pt c/o (complain/of)pain in his legs...." "06/09/13 2:30 p.m. Resident A& O (alert and oriented) X (times) 3 (person/place/time), able to make needs known, c/o (L) (left) leg pain. Writer assessed area and observed pt (L) leg c (with) pitting 3 edema...writer obtain P.O. (phone order) for (L) leg e-ray: pain swelling." "06/09/13 9:00 p.m. ...(L) leg & ft (foot) remain swollen." "06/10/13 6:50 p.m. X-ray done of (L) knee/LLE (Left Lower Extremity)." "06/11/13 6:00 a.m. X-ray results obtained of LLE...ADON (Assistant Director of Nursing) notified." "06/11/13 11:30 a.m. (Physician's name) c order to see resident to (sic) (ACF: Acute Care Facility name) r/t (related/to) (L) femur...." "06/11/13 12 N (12:00 p.m.)...Up in w/c (wheelchair) c Hoyer (mechanical apparatus to facilitate safe transfers) and assist X 2...(company name) here to transport res (resident) to ER via stretcher." Review of a radiology report, dated 06/10/13, indicated: "EXAM: LEFT KNEE. FINDINGS: Limited examination of left knee reveals suspicious transverse impacted supracondylar fracture of the distal femur...IMPRESSION: SUSPICIOUS TRANSVERSE IMPACTED SUPRACONDYLAR FRACTURE OF THE DISTAL FEMUR WITH NO SIGNIFICANT DISPLACEMENT. CLINICAL CORRELATION AND FOLLOW-UP EXAMINATION IS SUGGESTED." Review of information indicated Resident "C" had surgery on his (L) femur on 06/13/13, and was readmitted to the facility on [DATE]. The Administrator was interviewed on 08/14/13 at 10: 30 a.m. The Administrator indicated being unaware of any problems until staff reported the X-ray results of a fracture, and initiated an investigation. The Administrator provided information which included, but was not limited to, record information and the CNA worksheet (a tool to facilitate CNA care), dated 06/03/13. The CNA worksheet indicated Resident "C" was to be transferred utilizing a Hoyer. The Administrator indicated Resident "C" had been transferred without a Hoyer on an unknown date, in late May or early June, and then lowered to the floor. The Administrator indicated staff should have initiated a fall circumstance/investigation. CNA #5 was interviewed on 08/14/13 at 1:00 p.m. CNA #5 indicated on an unknown date of being called from her assigned unit, Unit "2," to Unit "1" to assist CNA #4. CNA #5 indicated assisting CNA #4 transfer Resident "C" from a chair to a shower chair. CNA #5 indicated Resident "C" was unable to stand and was assisted to the floor, bearing weight on both knees. CNA #5 indicated she had not previously transferred Resident "C" and after the occurrence, became aware the resident was a Hoyer transfer. LPN #3 was interviewed on 08/14/13 at 1:10 p.m. LPN #3 indicated she was called from her unit, Unit "2," to Unit "1" to assist transfer of Resident "C" from the floor to a chair. LPN #3 indicated the Unit "1" Nurse, LPN #2, was on lunch break at the time. LPN #3 indicated Resident "C" should have been transferred by the Hoyer and reported to LPN #2 the incident for follow-up. Review of a Policy & Procedure, titled, "Fall Prevention and Assessment: 09/2012", provided on 08/14/13 at 10:30 a.m., indicated: "Assessment and Recognition...1. When a fall has occurred, the nurse shall assess and document/report the following:... b. Recent injury,... c. Musculoskeletal function, observing for change in normal range of motion, weight bearing, etc.... f. Pain... g. Precipitating factors, details on how fall occurred...." Review of a Policy & Procedure, provided at the time, titled, "Using a Mechanical Lift: 06/2011," indicated: "Purpose: The purpose of this procedure is to help lift residents using a manual lifting device. Preparation: 1. Review the resident's care plan to assess for any special needs of resident... General Guidelines: Two (2) nursing assistants will be required to perform the procedure...." 3.1-45(a)(2)

Based on observation, interview and record review, the facility failed to clean and disinfect the blood glucose machine (device used to check blood sugar) used for multiple residents. This affected 2 of 8 residents who used the blood glucose machine (Resident #32 and #72) The facility also failed to have an effective system to prevent the spread of blood borne pathogens from the use of the blood glucose machine potentially affecting 8 of 8 residents in the facility who had their sugars tested in the facility. (Resident #100, #32, #65, #52, #16, #11, #72, and #15). This immediate jeopardy that began on 4-19-13 at 7:51 a.m. when RN #1 was observed to obtain a blood sugar test from Resident #32 without cleaning the blood glucose machine before or after use. The Administer and Director of Nursing (DON) were notified of the immediate jeopardy on 4-19-13 at 3:17 p.m. Findings included: On 4-19-13 at 7:51 a.m., RN #1 was observed getting a blood glucose machine (a device to check blood sugar) from her cart. RN #1 did not clean the blood glucose machine prior to obtaining a blood sugar reading on Resident #32. RN #1 was observed to clean the resident's finger with alcohol, prick the finger and obtain a drop of blood for use with the blood glucose machine. RN #1 then put the blood glucose machine back into the medication cart without cleaning it. A small drop on blood was observed on the front of the blood glucose machine. RN #1 indicated she was finished doing her blood sugars for the morning. On 4-19-13 at 9:45 a.m., RN #1 was asked if the blood glucose machine was cleaned and she indicated she had not clean it. She pulled the blood glucose machine out of the medication cart and the drop of blood was observed to still be on the blood glucose machine. The RN #1 then cleaned the blood glucose machine with a Clorox Disinfecting Wipe. On 4-19-13 at 10:50 a.m., a policy titled "Infection Control-Blood Glucose Machine," provided by the DON and deemed as current, indicated on #3 "...Be sure to clean and disinfect the blood glucose machine environmental surface with Clorox-Wipes before and after testing the resident's blood." On 4-19-13 at 11:16 a.m., LPN #2 was observed with a blood glucose machine on her cart and indicated she was gathering her materials to obtain an blood sugar reading on Resident # 72. LPN #2 obtained a blood sugar on the resident and returned the blood glucose machine to the cart without cleaning it. When interviewed regarding the protocol for cleaning the blood glucose machine for the facility, LPN #2 indicated she did not cleanse the machine before or after use on the resident as the policy directed. On 4-19-13 at 12:50 p.m., the DON indicated there were no residents in the facility with a [DIAGNOSES REDACTED].#100, #32, #65, #52, #16, #11, #72, and #15). She further indicated there had not been any in-services in regards to cleaning and disinfecting the blood glucose machine for the nurses. On 4-19-13 at 12:52 P.M., review of the clinical record for #36 indicated a [DIAGNOSES REDACTED]. On 4-19-13 at 1:20 p.m.,review of the label for the Clorox Disinfecting Wipes revealed the Clorox wipes used by the facility were not effective in disinfecting blood borne pathogens. During a phone interview, a representative from Clorox confirmed the Clorox Disinfecting Wipes were not effective in killing a blood borne disease (a disease that can be spread through contamination by blood) such as human Immunodeficiency virus (HIV) or Hepatitis virus. The immediate jeopardy, that began on 04/19/13 at 7:51 a.m., was removed, on 4-20-13 at 12:30 p.m., when the facility was noted to have obtained an effective disinfectant, updated their policy and procedure for cleaning blood glucose machine and updated their system for cleaning the blood glucose machines, and inserviced the nursing staff regarding the updated policy and procedures for cleaning the blood glucose machines, and observation confirmed nursing staff were following the correct procedures for cleaning blood glucose machines. The immediate jeopardy was removed, but noncompliance remained at the lower scope and severity level of pattern, no actual harm with potential for more than minimal harm that is not immediate jeopardy. 3.1-18(a)

Based on observation, record review and interviews, the facility failed to ensure interventions were implemented timely to prevent pressure ulcer development for a resident at risk for 1 of 2 residents reviewed for pressure ulcers. This resulted in the resident developing an unstageable pressure ulcer. (Resident #76) Finding includes: The pressure ulcer for Resident #76 was observed, on 04/24/13 at 9:45 A.M. The resident was observed lying in his bed. The resident was noted to be thin, had a gastrostomy tube feeding running, was dressed in a hospital gown and was noted to be lying on his left side on an alternating air mattress. The resident was noted to have a large, butterfly shaped open area that extended to both the right and left side of his upper buttocks and lower coccyx area. There was visible tunneling noted up into the coccyx area on the right side of his ulcer. The wound bed was noted to be beefy red with moist serosanginous exudate. LPN #10, who was performing the dressing change on the wound for Resident #76, indicated the wound had developed at the facility. She was noted to clean the wound with normal saline, then lightly pack and cover the wound with gauze dampened with normal saline, and then the gauze was covered with a [MEDICATION NAME] dressing. The clinical record for Resident #76 was reviewed on 04/24/13 at 9:20 A.M. Resident #76 was admitted to the facility on [DATE], from an acute care facility with diagnoses, including but not limited to, recent traumatic amputation of bilateral legs, lack of coordination, symbolic dysfunction,[MEDICAL CONDITION](hypertension), [MEDICAL CONDITION] [MEDICAL CONDITIONS], urinary obstruction, and [MEDICAL CONDITION]. The resident's weight on admission was 112 pounds. The Admission nursing assessment, completed on 03/01/13, indicated the resident had scrotal [MEDICAL CONDITION] and bilateral surgical incisions on his leg stumps. There were no pressure ulcers or other impaired skin issues identified. The initial skin risk assessment, completed on 03/01/13, indicated the resident was at high risk for impaired skin issues. The assessment indicated the resident was totally incontinent of his bladder and bowels, and required 2 person staff assistance for transfers. The initial Nutrition Assessment form, completed on 03/02/13, by the FSS (Food Service Supervisor), Employee #11, indicated the resident's caloric needs were figured using the resident's height after his bilateral amputations. The total caloric needs were estimated to be 1028 calories per day and his estimated fluid needs were 1530 cc of fluid per day. The initial care plan related to impaired skin, initiated on 03/01/13, indicated the resident had an alteration in skin integrity related to the surgical incision on his right and left stump. The interventions on the plan, on 03/01/13, were "skin issues will be measured weekly noting size, color, drainage (sic) and odor," and "resident on pressure reduction mattress." On 03/04/13, "shearing right and left buttocks" was added to the problem list on the care plan and "wedge cushion to assist with TAP (turning and repositioning)" was added. Nursing notes and Weekly Wound Documentation Records, dated 03/04/13, indicated a 5.9 by .9 cm nonpressure shearing wound was noted on the resident's left buttocks. The physician was notified and no orders were received regarding the wound. The Wound record indicated the wound was cleansed with wound cleanser and a house barrier cream was applied. On 03/08/13, the resident's weight was down to 108 pounds, a 4 pounds weight loss in one week. The resident then refused to be weighed so arm circumference measurement ensued from 03/20/13 - 03/29/13. The initial care plan regarding nutritional needs, initiated on 03/08/13, indicated the problem of the resident refusing to eat at least one of the meals on three different days. The interventions were to encourage his family members to bring in favorite food items from home or restaurants, explain the importance of eating, offer alternatives, invite him to food-related activities, monitor/document circumstances surrounding mealtimes/refusals to eat. Attempt to determine cause, praise all of his progress or efforts, weights according to facility policy, inform doctor and family of weight loss according to policy. There was an additional nutritional care plan, initiated on 03/11/13, regarding the resident's significant weight loss and poor appetite. The interventions indicated the following: "feeding tube placement. Resident will receive majority of nutrition at this time from peg tube (with an initiation date of 03/22/13), encourage him to partake of food related events in facility, receive a regular diet per physician order, be on the skin and nutrition at risk program per facility policy." Review of the March 2013, Food Consumption record for Resident #76 indicated he was refusing and/or taking just bites of most of his meals. Nursing notes, dated 03/06/13, indicated the physician was notified of the resident's poor appetite due to the family's concern. There were no new orders received at the time. In addition, nursing notes indicated the resident had been having loose stools. The resident also was documented to have a temperature of 99.9 degrees on 03/08/13. On 03/09/13, the resident's blood pressure was noted to be low and the physician was notified of the low blood pressure and the resident's poor appetite. The physician order [REDACTED]. On 03/10/12, the physician ordered the laboratory test, [MEDICATION NAME] and [MEDICATION NAME], to be done due to the residents new wounds. The lab test results, completed on 03/12/13 for Resident #76, indicated the resident's [MEDICATION NAME] level was low at 3.0 g/dl. The normal range for an [MEDICATION NAME] level was 3.5 - 5.2 g/dl. The resident's [MEDICATION NAME] level was low at 6.1 mg/dl. The normal [MEDICATION NAME] level was 20 - 40 mg/dl. The next weekly Wound Documentation flow record, completed on 03/11/13, indicated the resident was now assessed to have an unstageable 12 by 8 centimeter wound on his coccyx/buttock area. The wound was assessed to have a small amount of purulent drainage and was covered with both slough and necrotic tissue. A low air loss mattress was implemented and a [MEDICATION NAME] foam treatments, and oral antibiotics were ordered. Also on 03/11/13, an order was received for the resident to see a physician for pressure ulcer treatment. The specialist ordered an antibiotic and a new treatment for [REDACTED]. Physician orders, dated 03/15/13, indicated an order for [REDACTED]. On 03/18/13, the Consultant Dietician, Employee #16, recommended the resident receive a regular diet and med pass supplement 120 cc three times a day until the gastrostomy tube was placed. Once the gastrostomy feeding tube was placed he recommended [MEDICATION NAME] 60 ml (milliliters) per hour continuously with 120 cc water flush q (every) 4 hours, and an iron tablet be started due to the wound and the resident's low hemoglobin. The resident's low hemoglobin level of 9.9 had been present on admission to the facility on [DATE]. The dietician did not reassess the resident's total nutritional needs on the 03/18/13 handwritten note of recommendations. On 03/19/13, Prostat was ordered to be given twice a day for a protein supplement. On 03/22/13, an iron supplement, which was recommended by the dietician on 03/18/13, was ordered. On 03/29/13, the resident's weight was obtained and noted to be 95.8 pounds. On 03/29/13, the Registered Dietician documented a progress note and recommended a vitamin, zinc supplement, Vitamin C supplement, and Prostat for additional protein be started due to the resident's wound. The dietician still did not indicate how many calories, fluids, and protein the recommended [MEDICATION NAME] was to provide, nor did he evaluate the caloric and nutritional needs of the resident. He did document recent laboratory test results and the resident's current condition on the progress note. On 04/12/13, the resident's tube feeding was increased from [MEDICATION NAME] 60 ml/hr to [MEDICATION NAME] 75 ml/hr due to the resident's wound and weight loss. Interview with the CDM (Certified Dietary Manager), on 04/24/13 at 11:15 A.M. indicated the Dietician visited the facility about every 2 weeks and often came in the early mornings and left before conversing with the CDM regarding any specific resident concerns or facility dietary needs. She indicated 03/29/13 was the first time the dietician assessed Resident #76's nutritional needs, after the gtube was placed. She indicated when the resident was first admitted , the family was trying to bring in fresh fruits and fast foods to try and get the resident to eat. 3.1- 40(a)(1)

Based on observation, record review and interviews, the facility failed to ensure interventions were implemented timely to ensure nutritional parameters were maintained 1 of 4 residents reviewed for nutrition. This resulted in a significant weight loss and development of an unstageable pressure ulcer. (Resident #76) Finding includes: The clinical record for Resident #76 was reviewed on 04/24/13 at 9:20 A.M. Resident #76 was admitted to the facility on [DATE], from an acute care facility with diagnoses, including but not limited to, recent traumatic amputation of bilateral legs, lack of coordination, symbolic dysfunction, hypertension, [MEDICAL CONDITIONS], urinary obstruction, and [MEDICAL CONDITION]. The resident's weight on admission was 112 pounds. The Admission nursing assessment, completed on 03/01/13, indicated the resident had scrotal [MEDICAL CONDITION] and bilateral surgical incisions on his leg stumps. There were no pressure ulcers or other impaired skin issues identified. The initial skin risk assessment, completed on 03/01/13, indicated the resident was at high risk for impaired skin issues. The assessment indicated the resident was totally incontinent of his bladder and bowels, and required 2 person staff assistance for transfers. The initial Nutrition Assessment form, completed on 03/02/13 by the FSS, Employee #11, indicated the resident's caloric needs were figured using the resident's height after his bilateral amputations. The total caloric needs were estimated to be 1028 calories per day and his estimated fluid needs were 1530 cc (cubic centimeters) of fluid per day. The resident's estimated protein needs were 51 grams per day. On 03/04/13, the resident developed a shearing wound to his buttocks/coccyx area. On 03/08/13, the resident's weight was down to 108 pounds, a 4 pounds weight loss in one week. The resident then refused to be weighed so arm circumference measurement ensued from 03/20/13 - 03/29/13. The initial care plan regarding nutritional needs, initiated on 03/08/13, indicated the problem of the resident refusing to eat at least one of the meals on three different days. The interventions were to encourage his family members to bring in favorite food items from home or restaurants, explain the importance of eating, offer alternatives, invite him to food-related activities, monitor/document circumstances surrounding mealtimes/refusals to eat. Attempt to determine cause, praise all of his progress or efforts, weights according to facility policy, inform doctor and family of weight loss according to policy. There was an additional nutritional care plan, initiated on 03/11/13, regarding the resident's significant weight loss and poor appetite. The interventions indicated the following: "feeding tube placement. Resident will receive majority of nutrition at this time from peg tube (with an initiation date of 03/22/13), encourage him to partake of food related events in facility, receive a regular diet per physician order, be on the skin and nutrition at risk program per facility policy." Review of the March 2013, Food Consumption record for Resident #76 indicated he was refusing and/or taking just bites of most of his meals. Nursing notes, dated 03/06/13, indicated the physician was notified of the resident's poor appetite due to the family's concern. There were no new orders received at the time. In addition, nursing notes indicated the resident had been having loose stools. The resident also was documented to have a temperature of 99.9 degrees Fahrenheit, on 03/08/13. On 03/09/13, the resident's blood pressure was noted to be low and the physician was notified of the low blood pressure and the resident's poor appetite. The physician order [REDACTED]. On 03/10/12, the physician ordered the laboratory test, [MEDICATION NAME] and [MEDICATION NAME], to be done due to the residents new wounds. The lab test results, completed on 03/12/13, for Resident #76, indicated the resident's [MEDICATION NAME] level was low at 3.0 g/dl. The normal range for an [MEDICATION NAME] level was 3.5 - 5.2 g/dl. The resident's [MEDICATION NAME] level was low at 6.1 mg/dl. The normal [MEDICATION NAME] level was 20 - 40 mg/dl. The resident was not reassessed regarding his nutritional needs despite the development of a large shearing pressure ulcer, continued weight loss, loose stools and elevated temperature, or low [MEDICATION NAME] and [MEDICATION NAME] levels. Physician orders, dated 03/15/13, indicated an order for [REDACTED]. On 03/18/13, the Consultant Dietician, Employee #16, recommended the resident receive a regular diet and med pass supplement 120 cc three times a day until the gastrostomy tube was placed. Once the gastrostomy feeding tube was placed he recommended [MEDICATION NAME] 60 ml (milliliters) per hour continuously with 120 cc water flush q 4 hours, and an iron tablet be started due to the wound and the resident's low hemoglobin. The resident's low hemoglobin level of 9.9 had been present on admission to the facility on [DATE]. The dietician did not reassess the resident's total nutritional needs on the 03/18/13, handwritten note of recommendations. On 03/19/13, Prostat was ordered to be given twice a day for a protein supplement. On 03/22/13, the iron supplement, which was recommended by the dietician on 03/18/13, was ordered. On 03/29/13, the resident's weight was obtained and noted to be 95.8 pounds. On 03/29/13, the Registered Dietician documented a progress note and recommended a vitamin, zinc supplement, Vitamin C supplement, and Prostat for additional protein be started due to the resident's wound. The dietician still did not indicate how many calories, fluids, and protein the recommended [MEDICATION NAME] was to provide, nor did he evaluate the caloric and nutritional needs of the resident. He did document recent laboratory test results and the resident's current condition on the progress note. On 04/12/13, the resident's tube feeding was increased from [MEDICATION NAME] 60 ml/hr to [MEDICATION NAME] 75 ml/hr due to the resident's wound and weight loss. Interview with the CDM (Certified Dietary Manager), on 04/24/13 at 11:15 A.M., indicated the Dietician visited the facility about every 2 weeks and often came in the early mornings and left before conversing with the CDM regarding any specific resident concerns or facility dietary needs. She indicated 03/29/13, was the first time the dietician assessed Resident #76's nutritional needs, after the gtube was placed. She indicated when the resident was first admitted , the family was trying to bring in fresh fruits and fast foods to try and get the resident to eat. Interview with the CDM, on 04/24/13 at 4:20 P.M., indicated there was no facility policy regarding completing nutritional assessments and implementing interventions. She indicated she just utilized the forms and completed them herself when a resident was admitted . 3.1-46(a)(1)

Based on observation, interview and record review, the facility failed to ensure 2 of 3 residents reviewed for hydration needs in a sample of 3 was provided fluids and/or interventions to maintain proper hydration. This resulted in the residents blood urea nitrogen, creatinine and sodium levels becoming critical and the need to transfer the resident to an acute care center. (Resident A and B) Findings include: 1. During an interview on 4/18/13 at 10:00 A.M., Resident B ' s son indicated his father was not offered fluids during the 4 days he stayed with his father. During an interview on 4/19/13 at 10:15 A.M., Resident B ' s wife indicated she asked the nurse on duty when he stopped eating and drinking is he could have an IV (intravenous fluids). The nurse ' s indicated they do not do those things here. She further indicated when he went to the hospital on [DATE], she was told by the doctors that he was severely dehydrated and malnourished. The closed clinical record for resident "B" was reviewed on 4/18/13 at 8:48 A.M. The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]." Review of a blood chemistry laboratory test, completed on 1/29/13, indicated the residents BUN (blood urea nitrogen) level was elevated at 32 mg/dl. The normal range for a BUN was 8-23 mg/dl. The residents creatinine level was elevated at 1.76 mg/dl. The normal range for a blood creatinine level was 0.7-1.50 mg/dl. The residents sodium level was elevated at 149 mEq/L. The normal range for a sodium blood level was 134-145 mEq/L. The residents chloride level was slightly elevated at 109 mEq/L. The normal range for a chloride blood level was 96-108 mEq/L. The resident's potassium level was within the normal range. Review of the admission nursing assessment, dated 1/24/13, indicated nutrition: total dependence, swallowing problem, thickened liquids (type) honey. Dehydration risk assessment: score of 17, a score or 10 or more places the resident at risk for dehydration. Braden pressure ulcer risk assessment: score 13, a score of 13-14 represents moderate risk. A nurse note, dated 2/10/13 at 3:30 P.M., indicated the following: " Resting in bed with eyes closed. Opens eyes when name called. Skin feels warm to touch. LCTA (lungs clear to auscultation). (physician's name) called R/T (related to) increased temp (temperature) with n.o. (new orders) rec'd (received) for UA (urinalysis) with C&S (culture and sensitivity). (daughter's name) called and notified of order rec'd. T (temperature) 99.5." A nurse note, dated 2/13/13 at 9:00 A.M., indicated the following: "n.o. obtained [MEDICATION NAME] mg (milligrams) QD (daily) X (for) 10 days, Dx (diagnosis) UTI (urinary tract infection)." A nurse note, dated 2/13/13 at 1:00 P.M., indicated the following: "vs (vital signs) T (temperature) 99.1, p (pulse) 62, R (respirations) 18, Bp (blood pressure) 152/90, biox 90% on RA (room air). Res (resident) skin w/d (warm and dry) to touch BS (blood sugar) elevated. Md (medical doctor) aware. No s/s (signs and symptoms) of [MEDICAL CONDITION]. Res continues to decline, family aware. Md aware." A nurse note, dated 2/14/13, untimed, indicated the following: "Res continues to decline. Md, family aware. T 99.8. Fed by family took 100 cc (cubic centimeters) of flds (fluids)." A nurse note, dated 2/14/13 at 1545 (3:45 P.M.), indicated " Biox 88%. Applied O2 (oxygen) @ (at) 2L (liters)/min (minute) per NC (nasal cannula). Doctor, pharmacy, and POA (power of attorney) notified." A nurse note, dated 2/16/13 at 9:00 A.M., indicated "Attempted to feed resident breakfast, pockets food, coughing c (with) moist/coarse lung sounds...Updated resident's wife; verbalized understanding but continues to question why doctor did not start IV (intravenous), explained to her that resident is able to take fluids in, skin is moist/warm." A nurse note, dated 2/16/13 at 1910 (7:10 P.M.), indicated "Son observed by staff attempting to force res to swallow thickened liquids. Res coughing/choking. Son states to res "you've just got a cold Dad, you need to drink this." A nurse note, dated 2/16/13 at 2015 (8:15 P.M.), Son has decided to send res to ER (emergency room ) c (with) the intention of res receiving an IV. Res wife agrees c (with) transfer. Md notified and order received for transfer to ER." Review of the hospital admission history and physical assessment, dated 02/16/13, indicated the resident presented to the emergency room with a BUN of 102 mg/dl, a creatinine level of 4.03 mg/dl and a sodium level of 175mEq/L. The resident was diagnosed with [REDACTED].o. (oral) intake, severe [MEDICAL CONDITION] and [MEDICAL CONDITION]. Review of the hospital consultation, dated 02/22/13, indicated the resident was found to be profoundly dehydrated with severe [MEDICAL CONDITION] and acute [MEDICAL CONDITION]. Review of the food consumption sheets for resident "B", from 01/25/13 -02/16/13, indicated the resident's meal fluid intake was below the 2610 ml (milliliters) requirement assessed by the facility's dietary manager on 01/25/13. Review of the dietician nutritional services progress note, dated 02/02/13, indicated estimated daily needs 1.8-2.1 liters (1800-2100 ml) fluid. Review of the five day scheduled assessment MDS (minimum data set) assessment for Resident "B", completed on 01/31/13, indicated the resident was moderately cognitively impaired, required extensive assistance for eating, total dependence for toileting needs, and was incontinent of both bowel and bladder. An initial care plan for dehydration risk, dated 01/24/13, indicated the plan to address hydration needs was to determine likes and dislikes, labs as ordered, assist as needed and encourage fluids. Review of the dietician Care Plan, dated 02/04/13, indicated "... alteration in nutrition with potential for alteration in hydration. Approaches: regular diet with pureed consistency, honey thickened liquids, extensive to total assistance with eating and dysphasia therapy...." Review of the specific fluid intake amounts for Resident "B", from 01/25/13-02/16/13, indicated the resident's daily fluid intake averaged approximately 950 cc (cubic centimeters) per day. However, from 02/12/13 five days prior to his transfer to the acute care facility on 02/16/13 indicated the following total cc's of fluid per day: 02/12/13- 720 cc's, 02/13/13- 600 cc's, 02/14/13- 900 cc's, 02/15/13-60 cc's plus sips, 02/16/13 sips. There was no plan to address the resident's chronic less than required intake of fluids from 01/25/13-02/16/13. Review of the current "Hydration & Snack Carts," policy dated 7/2012, indicated "To ensure that residents will be offered fluids between meals...Documentation of fluid and snack consumption will be completed...Identify resident and explain need for adequate fluid intake...Explain benefits of the procedure to the resident...Encourage family and friends to assist resident with fluid intake when possible...." 2. The clinical record of Resident #A was reviewed on 4-24-13 at 10:16 a.m. The resident's [DIAGNOSES REDACTED]. Review of the "Nutrition Assessment Form" dated 12-25-12, completed by the dietary manager, indicated the resident required 1890 ml (milliliters) of fluids per day. A "Nutritional Services Progress Note"completed by the dietician dated 1-7-13, indicated the resident had a potential for alteration in nutrition/hydration with a goal that Resident #A would have no signs or symptoms of dehydration. The estimated daily needs fluids was 1.6-2.0 liters(1600-2000 ml) of fluid and 1200-1600 calories a day. The report also indicated the resident was able to feed himself after receiving some setup assistance and direction. Review of the "Food Consumption" form for February, March and April indicated the resident wasn't receiving the estimated 1.6 to 2.0 liters (1600 to 2000 ml) of fluid per day as recommended by the dietician. Fluid intake recorded at meal times for February, March and April were: 2-1-13 the recorded fluid intake was 1580 ml. 2-15-13 the recorded fluid intake was 1380 ml. 2-28-13 the recorded fluid intake was 1320 ml. 3-10-13 the recorded fluid intake was 1320 ml. 3-20-13 the recorded fluid intake was 1080 ml. 3-30-13 the recorded fluid intake was 1560 ml. 4-10-13 the recorded fluid intake was 1100 ml. 4-30-13 the recorded fluid intake was 1200 ml. During an interview on 4-24-13 at 11:10 a.m., CNA #6 indicated the resident was sometimes able to feed himself. The staff help to get him started then they let him try. CNA stated,"Sometimes he feeds himself and sometimes he don't." CNA #6 also indicated the staff refilled water pitchers at the beginning of each shift and water was offered to the resident when he was in his room. She also indicated she was not aware of documenting fluids given between meals. On 4-24-13 at 11:05 a.m., an observation of resident's water pitcher indicated it was empty and had the lid on it with no straw. The water pitcher was located on a drawer behind a chair. During an interview on 4-24-13 at 3:30 p.m., CNA's # 7 and #3 indicated they pass fresh water at the beginning of their shift and offer resident's water throughout their shift. They were not aware they should document fluids given to resident's between meals. During an observation on 4-24-13 at 3:35 p.m., resident's water pitcher indicated it was empty. Resident #A was observed wandering up and down the hallway. On 4-24-13 at 3:40 p.m. a review of a Careplan dated 4-1-13 for nutrition indicated, resident was slightly above his IBW (ideal body weight) at this time. Interventions included but were not limited to: make changes when necessary on tray card, receives regular diet, on skin and nutrition program per facility policy, and monitor weight and labs. Another Careplan for constipation was reviewed and did not include an intervention to offer fluids to resident. This Federal tag relates to Complaint #IN 085. 3.1-35(b)(1)

Based on record review and interviews, the facility failed to ensure the prevention of frequent falls that resulted in a laceration to the resident's mouth and a fractured wrist. This deficiency affected 1 of 6 residents reviewed for falls in a sample of 15 (Resident X). Finding include: Resident X's record was reviewed on 2/27/12 at 10:00 a.m. Resident X's [DIAGNOSES REDACTED]. The Fall Risk assessment dated [DATE] indicated Resident X was at high risk for falls. Review of the significant change Minimum Data Set Assessment ((MDS) dated [DATE], indicated Resident X had short term and long term memory loss and had decision making impairment. The MDS also had indicated the resident was independent for ambulation with minimal setup. A review of Resident X 's Fall Reports indicated the following: the post fall investigation dated 9/19/11 indicated the resident was ambulating in the hallway slightly leaning to the side when she tripped over her foot and fell to the floor. The new intervention that was put in place after the resident had fallen was to offer stand by assist when resident is ambulating until right sided leaning improved. The post fall investigation dated 11/10/11 indicated the resident was coming out of another resident's room when she slipped and fell to the floor. The resident was not wearing her shoes and had socks on her feet. The new intervention put into place immediately after the resident had fallen the resident was assisted in putting her shoes on. The resident was also instructed to wear her shoes during ambulation. The post fall investigation dated 11/17/11 indicated the resident was found in the dining room laying down on the floor. The post fall investigation form further indicated in the column for footwear shoes were check marked as present on her feet. The intervention put immediately in place after the fall was ice was placed on the resident's forehead and steri-strips were placed to a laceration on the nasal bridges and to closely monitor the resident. The care plan was updated with the interventions indicated the resident was to wear her shoes while she ambulated and she had removed her shoes prior to this fall. The Nurses Notes dated 1/18/12 at 10:00 a.m. indicated the nurse had heard a 'thump' coming from the hall and found the resident on the floor. The post fall investigation dated 1/8/12 indicated the resident had non skid foot wear on her feet and she was sent to the local hospital emergency room for a laceration to the upper lip . The Interdisciplinary Team Progress Notes dated 1/8/12 at 10:00 a.m. indicated the resident was guarding her left hand. The resident had returned from the hospital with a splint to her left hand and with a [DIAGNOSES REDACTED]. The Rehabilitation Screen dated 11/10/11 indicated the resident was not appropriate for skilled therapy intervention at this time. In the comments section of the Rehab Screen indicated "Cognitive status is @ (at) risk for fall level. Recommend (eligible word) shoes and provide supervision during walking. The physician's orders [REDACTED].. The Plan Of Treatment form for physical therapy dated 12/11/11 through 12/17/11 indicated the resident was seen for a [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. On 2/27/12 at 1:00 p.m. the Director of Nursing Services (DNS) was interviewed in regard to the intervention after the 11/10/11 fall. The DNS indicated the resident was good at taking her shoes off of her feet. The DNS also indicated the intervention should not had been to remind the resident to leave her shoes on but to instruct the staff to make sure the resident had her shoes on her feet. On 2/28/12 at 9:00 a.m. the Care Planning policy dated 10/2010 was received from the DNS and reviewed and indicated "7 The Care Planning/Interdisciplinary Team is responsible for the periodic review and updating of care plans: When there has been a significant change in the resident's condition; When the desired outcome is not met...." On 2/28/12 at 9:15 a.m. CNA #3 was interviewed in regard to Resident X taking her shoes off her feet and she indicated the resident "would never takes shoes off and had regular socks on". On 2/28/12 at 9:30 a.m. the DNS was interviewed in regard to after the 9/19/11 fall the Care Plan was not updated with new interventions. The DNS indicated the care plan should had been updated with new interventions. The DNS also indicated she inserviced staff in regard to the resident fall and her taking her shoes off her feet. This federal tag is related to Complaint # IN 761 3.1-41(a)(2)