Every finding on record at Zionsville Meadows

Based on observation, interview, and record review, the facility failed to ensure a resident on dual antiplatelet therapy who had a fall from bed, landed on her face, and sustained a visible head injury was assessed for a change in condition and promptly sent to the hospital for 1 of 3 residents reviewed for accidents (Resident B). The immediate Jeapardy began on [DATE], at approximately 8:00 p.m., when Resident B with previous history of cerebrovascular accident (CVA, commonly called a stroke is a condition where blood flow to a part of the brain is blocked or a blood vessel bursts, causing brain cells to die from a lack of oxygen), subdural hemorrhage in December of 2025, and was taking two antiplatelets (drugs that stop blood cells from sticking together), rolled off her bed during peri-care. She hit the floor face first and sustained an immediately visible, swelling hematoma (collection of clotted or partially clotted blood that pools outside of blood vessels) to her right eyebrow. The resident was assessed and placed back into bed, before the on-call provider was contacted. At 10:30 p.m., Resident B's right eye was noted to be swollen shut, and staff had to lift the eyelid to visualize her pupil. The on-call physician and/or Nurse Practitioner (NP) were not notified of this change. Starting at 11:00 p.m. until 12:45 a.m., the neuro checks continued without assessment of the right eye since it was swollen shut. At approximately 12:45 a.m., the resident was unresponsive and 911 was called. Upon EMS arrival, Resident B was noted to be unresponsive and to have shallow snoring respiration with a score of 3 on the Glascow Coma Scale (GCS, the lowest possible score, indicating a deep, unresponsive coma or profound lack of consciousness). Hospital documentation indicated she had obvious trauma to the right side of her face, her eyelids were swollen, making it difficult to visualize the globe. Resident B was intubated upon arrival to the ER and imaging showed she had suffered intercerebral hemorrhaging (where a blood vessel bursts inside the brain tissue, causing bleeding that puts pressure on the brain) and bilateral subdural hematoma (a serious and life-threatening condition where blood collects between the surface of the brain and its outer protective lining usually caused by a head injury). Resident B died on [DATE]. The Director of Nursing (DON), Regional Nurse Consultant (RNC), and Executive Director (ED) were notified of the Immediate Jeopardy on [DATE] at 2:02 p.m. The immediate jeopardy was removed on [DATE], and the deficient practice corrected on [DATE], prior to the start of the survey and was therefore Past Noncompliance. Findings include:A confidential statement indicated Emergency Medical Staff (EMS) were concerned about the condition of Resident B upon their arrival and described, the resident as completely unresponsive, with obvious swelling to the right orbital [eye] area to the point where her eye was swollen shut and obvious deformities to the face. An Indiana Department of Health Facility Reported Incident report, submitted by the facility on [DATE], indicated Resident B rolled out of bed to the floor and was noted to have sustained a hematoma (a localized pool of mostly clotted blood that forms outside of blood vessels, usually caused by an injured or ruptured blood vessel) above the resident's right eye. She was later sent to the hospital upon a change in her condition. During an interview on [DATE] at 1:02 p.m., Resident B's family member indicated that he received a call on [DATE] around 8:18 p.m. and saw the facility's name on the caller I.D. but they immediately hung up. He received a second call a few moments later from an unknown number but answered it anyway and it was the nurse taking care of Resident B. The nurse indicated it was the first time she was taking care of Resident B and explained that the resident fell out of bed, and had a goose egg above her right eye and asked what the family wanted to do. The family member was taken aback, and indicated he wasn't a nurse, but thought they should put some ice on the area. The nurse indicated they had already put ice to the area but asked if he wanted her to be sent to the hospital. The family member indicated he wanted to see how she responded with the ice pack since it was already planned that he would be coming the next morning to proceed with her planned discharge back home. He did not receive another call until after 12:00 a.m., and was told that Resident B was unresponsive and they were sending her to the emergency room (ER) and they wanted to know where to send her. He told them her preferred hospital and rushed to meet her there. He was told shortly after his arrival to the hospital that there was likely nothing they could do, and she would not be going home. When he was able to see Resident B, he was shocked at the condition of her face and said the injuries were much worse than what had been told to him over the phone. During an interview on [DATE] at 10:20 a.m., the RNC indicated it was her expectation that nursing staff would call the on-call provider back for any worsening symptoms or an acute change of condition. During a follow up interview on [DATE] at 12:37 p.m., the family member clarified, if he had been given a more detailed description of Resident B's injuries, in combination with the risks associated with her current medication regimen, he would have had wanted her sent out immediately, but at the time of the initial call the resident's injuries had been minimally described/explained and it didn't seem like as big deal. He provided pictures of Resident B in the trauma unit of a local hospital. The pictures showed Resident B in a hospital bed receiving respiratory airway support, a cervical immobilization device was visible around her neck and tubing was inserted into her mouth. The photograph shows significant visible discoloration, swelling, and bruising involving the right periorbital area. The upper and lower right eyelid and surrounding tissue had extensive dark red/purple discoloration and the eye was swollen shut. A confidential interview during the survey indicated Resident B was not able to say much prior to her fall, but could answer yes or no, and small words. For example, when encouraged to eat, Resident B would respond okay. After the fall, Resident B only moaned and no longer answered questions with words. According to Open Resources for Nursing, Chapter 6 Neurological Assessment, Retrieved on [DATE] from https://www.ncbi.nlm.nih.gov/books/NBK593206/, Routine neurological exams performed by registered nurses during their daily clinical practice include assessing mental status and level of consciousness, pupillary response, motor strength, sensation, and gait. The Glasgow Coma Scale is also frequently used to objectively monitor level of consciousness in patients with neurological damage such as a head injury or cerebrovascular accident. Routine assessment of a patient's mental status by registered nurses includes evaluating their level of consciousness, as well as their overall appearance, general behavior, affect and mood, general speech, and cognitive performance. Level of consciousness refers to a patient's level of arousal and alertness. The Glasgow Coma Scale (GCS) is a standardized tool used to objectively assess and continually monitor a patient's level of consciousness when damage has occurred, such as after a head injury. The chapter indicated the following related to assessing pupils during a neurological (neuro) check, .Test bilateral pupils to ensure they are equally round and reactive to light.Pupils should be round and bilaterally equal in size. The diameter of the pupils usually ranges from two to five millimeters.Test pupillary reaction to light. Using a penlight, approach the patient from the side, and shine the penlight on one pupil. Observe the response of the lighted pupil, which is expected to quickly constrict. The pupil where you shine the light should constrict (direct reaction) and so should the other one (consensual reaction). Repeat by shining the light on the other pupil. Both pupils should react in the same manner to light.An unexpected finding is when one pupil is larger than the other or one pupil responds more slowly than the other to light, which is often referred to as a 'sluggish response.'. During an interview on [DATE] at 1:30 p.m., Licensed Practical Nurse (LPN) 8 indicated she was Resident B's nurse on the night of the accident but had not worked with her prior to the event and was not familiar with the resident. Around 8:00 p.m., she was notified by the aide, that Resident B rolled out of bed during peri-care (the act of cleaning the genital and anal areas of the body to maintain hygiene, prevent infection, and protect sensitive skin) and hit her face on the floor. LPN 8 entered the room and found Resident B face down on the floor. LPN 8 conducted an initial assessment of Resident B while she was on the floor but determined it was okay to get her up and back into bed because the resident was uncomfortable on the floor. Then she called the on-call provider. LPN 8 asked Resident B if she was in any pain, but the resident couldn't really talk. Her vital signs and neurological checks were all normal. LPN 8 indicated Resident B's eye was not swollen shut during her shift and Resident B had fallen asleep before she left. During a follow up interview on [DATE] at 2:50 p.m., with the Assistant Director of Nursing (ADON) present, LPN 8 indicated the oncoming nurse for the night shift was already in the building and aware of Resident B's fall. LPN 8 indicated she went into the room with the oncoming nurse for a bedside report around 11:00 p.m., at that time, Resident B's eye had swollen shut, so she had to physically lift the eye lid. Her pupil was not reactive at that time. During a follow up interview on [DATE] at 10:54 a.m., with the Regional Nurse Consultant (RNC) present, LPN 8 clarified her above statement and indicated, she did not give a bedside report to the oncoming nurse since that nurse was already aware of the situation. LPN 8 conducted her last neurological assessment at 10:30 p.m., and it was at that time, she noticed Resident B's eye was swollen shut and had to lift the eye lid and found that her pupil was reactive at that time. During an interview on [DATE] at 1:45 p.m., LPN 9 indicated she got report about the fall and was told to continue monitoring Resident B and applying ice to the affected eye. LPN 9 indicated on her first assessment Resident B's right eye was swollen shut, so she did not assess that pupil as a part of the neuro checks. LPN 9 did not know if that eye was open before and she did not see the neurological flow sheet until afterwards, therefore was unaware if the swollen shut eye was a change of condition or not and she was just monitoring the resident's neuro checks as best as she could. LPN 9 indicated she worked with Resident B once or twice before and knew she could verbalize some, but after the fall she couldn't really verbalize anything and just moaned. During an interview on [DATE] at 2:30 p.m., the Director of Nursing (DON) indicated, after the fall, the nurse determined it was safe to transfer the resident back to bed and continue to monitor her neuro checks for a change of condition or worsening symptoms. The DON indicated that the provider should be notified if nurses were unable to complete a neuro check due to swelling to determine if they should change their course of treatment. During an interview on [DATE] at 4:45 p.m., LPN 10 indicated she came to assist getting Resident B off the floor and back into bed. Resident B was on the floor when she entered the room, and she immediately noticed a large goose egg above her right eye and indicated to the other nurse, you need to send her out. Additional staff entered the room with the Hoyer (mechanical or powered patient transfer device) pad to get her back into bed and LPN 10 indicated she went back to her cart, and did not see if or when Resident B went out. During an interview on [DATE] at 11:00 a.m., Certified Nursing Aide (CNA) 11 indicated she had worked with Resident B over the previous week since her admission and had no trouble. She found the resident to be pleasant and compliant. She was paralyzed on her right side but could help herself with bed mobility using her left side. CNA 11 indicated everything had gone fine until she went to finalize tucking the resident's brief which caused Resident B to roll off the opposite side of the bed, away from the CNA. CNA 11 was unable to help break the fall. Because the bed was in a high position, she could not see how the resident fell, but heard a loud thunk. She ran around to the other side of the bed and called the resident's name. Resident B was making noise, so CNA 11 ran to get the nurse. When they turned her over, that's when they saw her eye. She indicated, it was big, red and swollen. CNA 11 indicated she had been a CNA for many years and when she saw the hematoma above her eye, she thought the resident would immediately be sent to the emergency room. During an interview on [DATE] at 12:15 p.m., with the on-call Nurse Practitioner and her supervising Medical Doctor (MD), the NP indicated she received a call from the facility on [DATE] at 8:18 p.m. She was told that Resident B fell out of bed and had a goose egg on her right eye but her neuro checks and vital signs were all within normal limits. The nurse told the NP, that Resident B's family did not want to send her to the hospital, so the NP told them to continue icing the affected area and to call back with any worsening symptoms or an acute change of condition. The MD indicated residents with history of head injuries and obvious head injury from a fall have a lower threshold (limit) for staying at the facility and it would be more likely that they would send them out to the hospital for evaluation. Residents with certain medications such as blood thinners and antiplatelets to help keep their blood thin, would also be more likely to be sent out due to increased risks of internal bleeding. The NP indicated she was only informed that Resident B received aspirin (antiplatelet medication that stops blood cells called platelets from sticking together to prevent harmful blood clots) and it was not clarified on the call that she also received Plavix (prescription antiplatelet medication used to prevent harmful blood clots). The NP indicated if she had known the resident was on dual antiplatelet therapy, it would have lowered her consideration threshold for sending Resident B to the hospital. The MD indicated it was the nurse's responsibility to educate the resident's family member on the severity of injury and the risks of keeping the resident at the facility, especially if the resident was on antiplatelet medications. If the on-call NP or doctor was told by the nurse that the family refused to send the resident to the hospital, they respect the family/resident's choice and will ask to monitor the resident and report any changes in condition. Neither the NP or the MD were aware if Resident B's family had been educated on Resident B's use of antiplatelet medications and the increased risks related to these medications with head injuries. On [DATE] at 10:00 a.m., Resident B's record was reviewed. She was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, hemiplegia (total or partial paralysis of one entire side of the body, affecting the face, arm, and leg) / hemiparesis (weakness or partial loss of voluntary movement on one entire side of the body, affecting the face, arm, and leg) following cerebral infarction (commonly known as an ischemic stroke, happens when a blocked blood vessel cuts off blood and oxygen to an area of the brain, causing tissue death) affecting her right dominant side, and aphasia (a language disorder caused by damage to the parts of the brain). Resident B's historical hospital summary, dated [DATE], revealed she had experienced a previous fall in [DATE]. On [DATE], she slipped and fell on ice which caused a subdural brain bleed. She had a first time seizure on [DATE] and was moved to the intensive care unit (ICU). She required brain surgery to drain fluid off on [DATE] but the procedure had to be repeated on [DATE] when the brain bleed worsened, until the bleeding was ultimately stopped by completing a blood vessel embolization on [DATE]. A hospital Discharge summary, dated [DATE], indicated Resident B was a high fall risk. An admission fall assessment, completed on [DATE], in the facility indicated Resident B was only a moderate risk for falls. The fall assessment indicated Resident B had no continence barriers, but the bowel and bladder assessments, dated [DATE], indicated Resident B was always incontinent of bowel and bladder, and completely dependent on staff for continence management. The fall assessment indicated Resident B did not use a diuretic medication, but she had a current physician's order for hydrochlorothiazide (a prescription diuretic used to treat high blood pressure and fluid buildup). Physician orders, dated [DATE], included, but were not limited to, medication orders for clopidogrel (Plavix) 75 milligrams (mg) orally once a day, aspirin delayed release 81 mg orally once a day, and acetaminophen (Tylenol, pain medication) 650 mg as needed (PRN) every 6 hours. Resident B's baseline care plan, initiated [DATE], included the fall intervention, Provide fall prevention interventions: (call light in reach, area free of clutter, room orientation, non-skid footwear when out of bed, other). This intervention was unchecked, and therefore not added to the CNAs point of care charting and was not checked to be included on the resident's profile. A nursing progress note, dated [DATE] at 10:07 p.m., indicated Resident B had a witnessed fall from bed during patient care. The staff had been providing care when Resident B rolled off the bed and hit her head on the floor. Her vital signs and neuro checks were within normal limits. A hematoma was visible above her right eye, she complained of pain, and was given Tylenol per the resident's orders. Resident B's neurological assessment document, dated [DATE] through [DATE] was reviewed and indicated the following: From 8:15 p.m., until 10:30 p.m., both pupils were documented as assessed and reactive. There was no documentation in the resident's record or on the neurological assessment document that LPN 8 had to physically lift the eye lid as indicated in her interviews. LPN 9 documented lines or dashes for the right pupil at 11:00 p.m. and 12:00 a.m. There was no documentation in the resident's record or on the neurological assessment document that LPN 9 was unable to visualize the right pupil due to Resident B's eye continuing to swell. The resident's record lacked documentation that LPN 8 or LPN 9 called the on-call provider back to notify them of the worsening symptoms associated with her fall. A nursing progress note, dated [DATE] at 1:00 a.m., indicated Resident B was no longer responding per her baseline. Her vital signs were recorded: blood pressure was 112/63, temperature was 98 degrees, respirations were 20, and oxygen saturation was 94 percent (%). The DON was notified, who advised the nurse to call the NP. The NP gave orders to send her out for further evaluation. An EMS Care Report, dated [DATE] at 12:52 a.m., indicated the chief complaint was traumatic, altered mental status with the primary symptom of head injury, and additional symptoms of abnormal breathing, altered mental status, face injury, and head injury. The Glasgow score was 3 with assessments of unresponsive, no eye movement, no verbal response, and no motor responses. On [DATE] at 1:09 a.m., bag valve mask ventilation (a manual rescue technique that delivers positive pressure air or oxygen to patients who are not breathing or are breathing inadequately) was started. The report indicated upon arrival at the facility EMS was informed that the resident fell at 8 p.m., 4 hours prior. The resident had fallen out of bed and landed on the right side of her face. When Nurses changed shift the nurse found the pt [patient] to be unresponsive. There was no report of the pts [patient's] condition immediately after the fall, but 911 was not called for the pt initially. The resident was lying in bed unresponsive to painful stimuli. The resident had snoring respirations and the airway was positioned with a jaw thrust maneuver and this opened the airway successfully. The right orbital area is noted to be very swollen with possible fractures and the eye is swollen shut. The left eye was reactive to light and no other trauma was noted to the rest of the head or face. The resident had a stroke a few weeks ago but at her baseline she was still able to talk and answer questions with a yes or no. She was now GCS 3 with no response and limbs were flaccid (soft, limp, or lacking firmness, stiffness, and normal vigor). A hospital Discharge summary, dated [DATE], indicated the resident presented to the ER as a trauma patient. She had fallen out of bed. Her GCS was 3 and was placed on a Non-rebreather (a medical device used in emergencies to deliver high concentrations of oxygen to patients who can still breathe on their own). On arrival the resident continued to be unresponsive and the decision was made to intubate (to place a flexible plastic tube through a person's mouth or nose and down into their windpipe to keep the airway open and help them breathe) for airway protection. She had a large hematoma to her right eye with surrounding edema (swelling). Computed Tomography (CT, a medical imaging test that creates a detailed cross sectional picture of the inside of the body) of the head resulted with devasting traumatic brain injury (TBI). This is a devasting head injury with unfortunately no intervention deemed appropriate. Resident was extubated with plans to admit to hospice with comfort care. Resident dead at 9:32 a.m. [DATE]. The corresponding CT scan, dated [DATE], indicated a subdural hemorrhage (a serious condition where blood collects between the protective layers covering the brain) overlying the right cerebral hemisphere (1 of 2 symmetrical halves of the brain), measuring 1.5 centimeters (cm) causing approximately 9 millimeter (mm) leftward midline shift (a medical condition where pressure inside the skull pushes the brain sideways from its normal center line). Additional subdural hematoma (blood collects between the surface of the brain and its outer protective lining usually caused by a head injury) overlying the left parietal region (a major region of the brain located near the top and back of the head, right beneath the crown of the skull) measuring 1.8 cm, and a 4mm subdural hematoma overlying the right parietal region. A 9 mm hemorrhage involving the right tentorium (a tent-like fold of the outer membrane covering the brain that separates the cerebrum from the cerebellum). Diffuse subarachnoid hemorrhage (bleeding spread widely across the fluid-filled space surrounding the brain). Resident B was admitted to hospice for intracerebral hemorrhage with a catastrophic traumatic brain injury. On [DATE] at 12:19 p.m., the Administrator provided a copy of current facility policy titled, Fall Management Policy, dated 8/2022. The policy indicated, It is the policy of American Senior Communities to ensure residents residing within the facility receive adequate supervision and or assistance to prevent injury related to falls. Any resident experiencing a fall will be assessed immediately by the charge nurse for possible injuries and necessary treatment will be provided. A neurological assessment will be initiated on all un-witnessed falls. A neurological assessment will be initiated on all residents with a suspected head injury based upon the fall. The physician will be contacted immediately, if there are injuries, and orders will be obtained. On [DATE] at 12:19 p.m., the Administrator provided a copy of current facility policy titled, Resident Change of Condition Policy, dated 11/2018. The policy indicated, It is the policy of this facility that all changes in resident condition will be communicated to the physician and family/responsible party, and that appropriate, timely, and effective intervention takes place. Life Threatening Change a. The licensed nurse will initiate appropriate first aide measures until emergency response personnel arrive on the scene. b. The licensed nurse will inform the attending physician, alternate physician, or Medical Director of resident status as soon as possible before, during, or after the change of condition occurs or when resident crisis has been managed, and document the notification. c. The licensed nurse will notify the family/responsible party of resident change of condition and document notification. d. All nursing actions, physician contacts, and resident assessment information will be documented in the medical record. e. The nursing supervisor (or licensed nurse) will notify the Director of Nursing Services or Executive Director, as appropriate. Acute Medical Change a. Any sudden or serious change in a resident's condition manifested by a marked change in physical or mental behavior will be communicated to the physician. b. If unable to contact the attending physician or alternate physician in a timely manner, notify the Medical Director for medical intervention. c. The responsible party will be notified that there has been a change in the resident's condition and what steps are being taken. d. All nursing actions/interventions will be documented in the medical record as soon as possible after resident needs have been met. The past noncompliance immediate jeopardy began on [DATE]. The immediate jeopardy was removed, and the deficient practice was corrected by [DATE] after the facility implemented a systemic plan that included the following actions: residents were audited for a change of condition; education was completed for nurses on changes in condition including: performing neurological exam, changes in neuro assessment, changes in mentation, changes of condition and timely notification to provider; and a monitoring process for staff's response to change of conditions was implemented. This citation relates to Intakes 3137140, 3174061, and 3174131. 410 IAC (Indiana Administrative Code) 16.2-3.1-37.

Based on interviews and record review, the facility failed to prevent a fall of a resident with right-sided paralysis when the resident was turned onto her left side and fell out of bed hitting her head on the ground resulting in actual harm when the resident sustained intercerebral hemorrhaging (where a blood vessel bursts inside the brain tissue, causing bleeding that puts pressure on the brain) and bilateral subdural hematoma (a serious and life-threatening condition where blood collects between the surface of the brain and its outer protective lining usually caused by a head injury) for 1 of 3 residents reviewed for accidents (Resident B). The deficient practice was corrected on 8/6/26, prior to the start of the survey, and was therefore past noncompliance. Findings include: During an interview on 8/27/26 at 11:00 a.m., Certified Nursing Aide (CNA) 11 indicated she had worked with Resident B before the accident but indicated the resident was new to the facility, and she had only worked with the resident a few times before. CNA 11 indicated on 7/29/26 at around 8:00 p.m. she went into Resident B's room to do her hourly rounds of check and changes. She indicated she checked Resident B's brief and saw that the Resident needed to be change, so she gathered some supplies and went back to change Resident B. CNA 11 indicated she raised the height of the bed as she was trained, to protect her back, and while she was providing care she talked the resident though what she was doing. The resident seemed a little more agitated than normal but tolerated the care well. Resident B was able to talk back to CNA 11 a little, but she indicated the resident had very delayed speech, so staff had to be patient with her. CNA 11 indicated she told Resident B she was going to help turn them onto their left side. The resident attempted to help the CNA with rolling but was not able to do much as the residents' right side was mostly paralyzed from a previous stroke. CNA 11 indicated she got the resident rolled over on their left side towards the window, wiped the resident up and as she was getting ready to tuck the new brief underneath the resident. Resident B turned a little more to the left and rolled out of bed onto the floor. CNA 11 indicated Resident B had an alternating pressure mattresses, so she wasn't sure if the mattress aired up too much on the opposite side the resident was rolled to and it pushed her too far over or if she had pushed the brief too far under Resident B causing her to turn a little more but the resident just rolled off and she was unable to stop them. CNA 11 indicated there were no side rails or mobility bars on Resident B's bed at the time the care was being provided. CNA 11 indicated when Resident B hit the floor it sounded more like a thunk and she immediately went to the other side of the bed and checked to make sure the resident was responsive by calling the resident's name and asking if they were ok. CNA 11 indicated Resident B moaned at the sound of their name, so she ran to get a nurse. Two nurses with CNA 11 went back into Resident B's room and evaluated the resident. At first they didn't see any injuries because of how the resident was laying. She indicated Resident B was lying on their stomach with the right side of their face against the ground. CNA 11 indicated once the nurses got the resident turned over to position them on the Hoyer pad (a sling used with a mechanical Hoyer lift used for residents who cannot bear any of their own weight), that's when they were able to see Resident B's right eye injury. CNA 11 indicated the residents' right eye was big, red and swollen. She indicated the nurses did contact the family to see if they wanted the resident to be sent to the hospital, but at that time they didn't want her to be sent out because they were planning to take Resident B home the next day. After the nurses got Resident B back in bed CNA 11 indicated she checked on the Resident every 30 minutes until her shift was over at 11:00 p.m. trying to keep them awake due to the injury to the resident's head. On 8/26/26 at 10:00 a.m., Resident B's record was reviewed. She was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, hemiplegia (total or partial paralysis of one entire side of the body, affecting the face, arm, and leg) / hemiparesis (weakness or partial loss of voluntary movement on one entire side of the body, affecting the face, arm, and leg) following cerebral infarction (commonly known as an ischemic stroke, happens when a blocked blood vessel cuts off blood and oxygen to an area of the brain, causing tissue death) affecting her right dominant side, and aphasia (a language disorder caused by damage to the parts of the brain). Resident B's historical hospital summary, dated 12/31/25, revealed she had experienced a previous fall in December 2025. On 12/4/25, she slipped and fell on ice which caused a subdural brain bleed. She had a first time seizure on 12/7/25 and was moved to the intensive care unit (ICU). She required brain surgery to drain fluid off on 12/12/25 but the procedure had to be repeated on 12/19/25 when the brain bleed worsened, until the bleeding was ultimately stopped by completing a blood vessel embolization on 12/24/25. A hospital Discharge summary, dated [DATE], indicated Resident B was a high fall risk. An admission fall assessment, completed on 7/23/26, in the facility indicated Resident B was only a moderate risk for falls. The fall assessment indicated Resident B had no continence barriers, but the bowel and bladder assessments, dated 7/23/26, indicated Resident B was always incontinent of bowel and bladder, and completely dependent on staff for continence management. The fall assessment indicated Resident B did not use a diuretic medication, but she had a current physician's order for hydrochlorothiazide (a prescription diuretic used to treat high blood pressure and fluid buildup). Resident B's baseline care plan, initiated 7/27/26, included the fall intervention, Provide fall prevention interventions: (call light in reach, area free of clutter, room orientation, non-skid footwear when out of bed, other). This intervention was unchecked, and therefore not added to the CNAs point of care charting and was not checked to be included on the resident's profile. A nursing progress note, dated 7/29/26 at 10:07 p.m., indicated Resident B had a witnessed fall from bed during patient care. The staff had been providing care when Resident B rolled off the bed and hit her head on the floor. Her vital signs and neuro checks were within normal limits. A hematoma was visible above her right eye, she complained of pain, and was given Tylenol per the resident's orders. Hospital records, dated 7/30/26 at 2:34 a.m., indicated when Resident B arrived to the emergency room (ER) with a Glasco Coma Scale (GCS) (a 3 to 15-point clinical tool used to measure a patient's level of consciousness and assess the severity of acute brain injury) (Score interpretation: 3-deeply unresponsive to 15-fully awake and oriented) score of 3, with snoring breaths and was intubated (a medical procedure where a flexible plastic tube is inserted through the mouth into the windpipe to keep the airway open and help a patient breathe.) upon arrival to the ER in order to preserve the resident's airway. The record indicated Resident B had obvious trauma to the right side of their face, and both eyelids were swollen shut. Imaging was done and revealed a devastating head injury with no intervention that could help. Resident B was placed on hospice and passed away at the hospital on 8/2/26. The medical record lacked documentation of a siderail assessment being completed for Resident B. On 8/27/26 at 12:30 p.m. the Regional Nurse Consultant (RNC) indicated the SPAN Pressure Guard APM 2 was the specific alternating pressure mattress that was being utilized by Resident B during their stay at the facility, and the instruction manual for that mattress was provided. The SPAN PressureGuard APM 2 owner's manual indicated, .Auto Firm Mode. Suspends cyclical inflation/deflation and sets system to the firmest inflation level for 20 minutes to facilitate user. activities of daily living (ADLs). During an interview on 8/28/26, CNA 11 indicated Resident B's mattress was different than the air mattresses she was used to. She indicated some air mattresses should be filled with air before providing care, but she indicated she did not need to do that for Resident B's mattress. During an interview on 8/28/26 at 12:35 p.m. The Director of Nursing (DON) indicated in her opinion best practice would have been for Resident B to be turned on to their affected side, the right side, for the majority of the incontinence care, allowing the resident to use their good side, the left side, to help with turning. The DON indicated it is not their policy that staff must use the auto firm setting when providing ADL care, but it was an option if they or the resident wanted to use it. A Fall Management Policy, dated 7/01 and last revised 8/2022, indicated, .It is the policy of American Senior Communities to ensure residents residing within the facility receive adequate supervision and or assistance to prevent injury related to falls. A 'Fall' refers to unintentionally coming to rest on the ground, floor, or other lower level . 1. Fall risk/ Fall prevention will be assessed upon admission or re-admission, quarterly and with significant change utilizing a formalized fall assessment tool. 2. All new admissions will be considered at fall risk based upon his/her new living arrangements and his/her reasons for being admitted into the nursing facility. a. All staff members will be notified of new admissions per facility specific policy. 3. A care plan will be developed at time of admission with specific care plan interventions to address each resident's fall risk factors. Care plan including interventions and fall risks will be reviewed at least quarterly. 4. All residents with a score greater than 0 are considered at risk for falls 5. Residents who are categorized as moderate to high risk should have fall interventions implemented based on resident specific risk factors. The deficient practice was corrected on 8/6/26, prior to the start of the survey, and was therefore past noncompliance. The deficient practice was after the facility implemented a systemic plan that included the following actions: residents were audited for falls; the process of utilizing two staff during care of residents on alternating air mattresses was implemented; education was completed for nurses on preventing falls; and a monitoring process for falls was implemented. 410 IAC (Indiana Administrative Code) 16.2-3.1-45(a) This citation relates to Intakes 3137140, 3174061, and 3174131.

Based on observation, interview, and record review, the facility failed to ensure a resident had orders for a wander guard device and failed to remove the device when it was determined to be unnecessary for 1 of 1 resident reviewed for wander guards (Resident 5). Findings include:On 1/20/26 at 11:45 a.m. Resident 5 was observed as she sat on her bed in her room watching tv. On her right ankle a wander guard device was observed and appeared to be applied and functioning properly. Resident 5 indicated when she first admitted to the facility, she was very confused and needed to be in the memory care unit. After a while she was better and decided along with the care team that moving out of the locked unit and onto a unit with peers on her cognitive level was best for her social well-being. Resident 5 pointed to the wander guard and indicated she wasn't sure why she still needed that device now that she was no longer as confused as she was. She indicated the staff had told her they would be taking it off, but they had not done it yet. Resident 5 indicated it didn't upset her, but it was bothersome and she didn't want it if she no longer needed it. On 1/23/26 at 10:00 a.m. Resident 5's medical record was reviewed. She was a long-term care resident whose diagnoses included, but were not limited to, dementia and brief psychotic disorder. Resident 5's most recent Brief Interview for Mental Status (BIMS) score from 11/10/25 was 12 out of 15 indicating she had moderate cognitive impairment. A progress note, dated 11/18/25 at 10:37a.m., indicated a wander guard device was placed on Resident 5 to improve safety during the transition from the locked memory care unit to the long-term care unit. The note indicated they would review the transition in a few weeks. An Interdisciplinary Team (IDT), dated 1/5/26 at 10:16 a.m., indicated since her transition to the long-term care unit Resident 5 had not displayed any exit-seeking behaviors and they determined a trial discontinuation of the wander guard was appropriate. An elopement assessment, dated 1/5/26, indicated Resident 5 was still at a high risk for elopement but they discontinued the wander guard device. The record lacked active or discontinued orders for the wander guard device to be placed and monitoring parameters for the device. During an interview on 1/28/26 at 12:30 p.m. the Director of Nursing (DON) indicated they planned to trial a disconsolation of the wander guard device on 1/5/26, but it got missed. She indicated they did however discontinue it on 1/20/26 after the surveyor observed Resident 5. The DON then presented an order for placement of the wander guard and an order to monitor the wander guard for appropriate functionality both with start dates of 11/18/25 and discontinue dates of 1/20/26. Both orders presented had creation dates of 1/28/26. During an interview on 1/28/26 at 2:08 p.m. the Regional Director of Clinical Services (RDCS) indicated they did not have a policy related to quality of care. 3.1-37

Based on observation, interview, and record review, the facility failed to ensure residents residing on the secured memory care unit, who were dependent on staff for dental care, received those services for 7 of 9 residents reviewed for Activities of Daily Living (ADL) assistance (Residents B, D, F, J, G, P, and H).Findings include:An anonymous concern during the survey indicated, a resident representative did not believe staff were brushing the residents' teeth.1. On 8/20/25 at 12:25 p.m., Resident B was observed sitting at a dining room table among her peers. The resident's natural bottom teeth were barely visible when she spoke, and unable to determine if the teeth looked recently brushed/cleaned. Resident B's clinical record was reviewed on 8/20/25 at 1:30 p.m. Diagnoses on Resident B's profile included dementia. A nursing progress note, dated 8/1/25 at 12:59 p.m., indicated Resident B was seen by the dental hygienist on 7/31/25. Continue with the current plan of care.A dentist's progress note, dated 8/18/25, indicated tissues were red and inflamed, had heavy plaque, and poor oral hygiene.A nursing progress note, dated 8/20/25 at 11:39 a.m., indicated Resident B was seen by the dentist on 8/18/25. The resident had gross decay and areas too large to restore teeth #9, #10, and #12. Continue with the current plan of care. 2. Resident D's clinical record was reviewed on 8/21/25 at 9:30 a.m. Diagnoses on Resident D's profile included dementia and psychotic disorder with delusions. A nursing progress note, dated 8/20/25 at 11:42 a.m., indicated Resident D was seen by the dentist on 8/18/25. Procedures performed included he scaled implants and polished. Continue with current plan of care. A dental exam report, dated 8/18/25, indicated the resident was edentulous with implants at #22 and #27. Area for implant retained the lower denture. Full upper and lower appliance. Tissues were red and inflamed, had heavy plaque, and poor oral hygiene. Oral hygiene instructions included, remove dentures nightly and soak. 3. On 8/20/25 at 11:45 a.m., random observation of residents included, a. Resident F, broken front natural teeth with dark discoloration. b. Resident J, build-up of plaque on the bottom front natural teeth. On 8/20/25 at 12:34 p.m., during the initial facility tour observations included,a. Resident G had no oral supplies in her room.b. Resident J had no oral supplies in his room.c. Resident P had a toothbrush and tube of toothpaste stored in a wash pan on a closet shelf, stored under clothing. d. Resident D had a toothbrush and tube of toothpaste in a wash pan on a closet shelf, stored under a blanket and 2 pillows, and among personal items to include a pair of [NAME] socks and a shoe insole. e. Resident H had a tube of toothpaste in a wash pan on a closet shelf, stored with a pair of socks. There was no toothbrush in his room. During an interview on 8/20/25 at 11:58 a.m., Licensed Practical Nurse 9 indicated she worked full time on the secured memory care unit. There were currently 21 residents residing in the unit, and they all received assistance with care from the staff. The residents' bathing supplies and toiletries were stored in the resident rooms. During an interview on 8/20/25 at 12:59 p.m., Certified Nursing Assistant (CNA) 10 indicated the residents were washed up daily in their rooms and received a shower in the shower room on assigned days. Oral care was provided daily as part of the resident's morning care.During the exit conference on 8/20/25 at 11:40 a.m., the DNS indicated there was a large quantity of bathing and oral supplies stored on the secured memory care unit. The supplies were within easy access to staff providing care to residents on the unit. There were shower/bathing sheets that documented the residents were receiving routine baths and oral care. The DON indicated she had observed supplies for bathing and oral care in the resident's rooms and believed they had been taking care of. On 8/21/25 at 9:45 a.m., the Executive Director provided an AM Care Nursing Skills Competency check list, dated 3/2023. The procedure steps indicated, .7. Assist resident with oral hygiene [including denture care if applicable] On 8/21/25 at 9:45 a.m., the Executive Director provided a HS/PM Care Nursing Skills Competency check list, dated 3/2023. The procedure steps indicated, .8. Assist resident with oral hygiene [including denture care if applicable] This citation relates to Intake 2588701.3.1-38(a)(3)

Based on observation, interview, and record review, the facility failed to ensure all aerosol disinfectant sprays and medications were secured in the resident rooms, for 3 random observations for potential accidents (Residents H, M, and N). Findings include:On 8/20/25 at 12:48 p.m., during the initial facility tour observations included, a. Resident H, residing on the secured memory care unit, had a large can of generic disinfectant spray. The disinfectant spray was visible from the hallway door sitting on the top shelf of an open closet. The can's caution label indicated, store preferably under lock. Hazardous if absorbed through the skin or inhaled. b. Resident M, who had a roommate, had a large can of Febreze spray, an odor eliminator. The spray can was sitting on top of a dresser, visible from the hallway. The can's caution label indicated, do not spray toward face, if eye contact occurred, rinse well with water and seek medical attention as needed. c. Resident N, had a bottle of selenium sulfide lotion 2.5 %, an antifungal medicated shampoo. The bottle with the top missing was observed sitting on top of a dresser, visible from the hallway. The resident's clinical record lacked documentation of an order for may keep medications at bedside. d. Resident N, who was in the hospital, had an opened bottle of Pepto Bismol liquid, a medication used to treat digestive ailments. The bottle was observed sitting on her bedside stand and had no prescription label with the resident's name or direction for use. The resident's clinical record lacked documentation of an order for Pepto Bismol or for an order for may keep medications at bedside. On 8/21/25 at 10:45 a.m., a second observation of the aerosol sprays in the resident rooms and medication at bedside with the Executive Director, who indicated the items had not been stored properly. On 8/21/25 at 9:45 a.m., the Executive Director provided a Safety - Cleaning Products policy, dated 8/17, and indicated the policy was the one currently being used by the facility. The policy indicated, All cleaning chemicals must be kept in locked storage rooms when not in use.Cleaning chemicals in remote locations, i.e. activity room, shower/spa rooms, nurse's stations, public areas, etc.should be in locked storage when not in use.On 8/21/25 at 11:35 a.m., the Director of Nursing Services (DNS) provided a Medication Storage and Expiration Policy, dated 11/2024, and indicated the policy was the one currently being used by the facility. The policy indicated, Medications including treatment items should be stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors.20. Facility should not provide medications without a Physician's order.21. Bedside medications should be stored in a locked compartment within the resident's room.This citation relates to Intake 2588701.3.1-45(a)(1)

Based on observation, and interview, the facility failed to maintain a clean, safe, and sanitary environment on 1 of 4 hallways (Auguste's Cottage - a secured memory care unit) observed for cleanliness. Findings include:On 8/20/25 at 12:48 p.m., during the initial facility tour observations included:a. A PTAC heating and cooling unit in the memory care unit dining room, was observed in the wall under the dining room window. The plaster board base under the PTAC unit was chipped, pealing, and white debris was observed on the floor. b. A cove base strip of trim that had been installed where the wall met the floor, was pulled from the wall, exposing chipped paint to the wall. An approximate 3 foot of cove base, still attached to the wall on one end, was observed laying on the floor near dining room tables where residents walked to be seated for meals and activities. b. An electrical outlet with a missing face plate was observed in the hallway on the front side of the nurse's desk. The exposed outlet was observed to be approximately 1 foot from the floor, and within sight and reach of anyone ambulating by or seated in a wheelchair. On 8/20/25 at 12:56 p.m., observation of a supply storage area located in the back hallway of the secured memory care unit. Supplies were observed to be disorganized, some boxes on the floor versus pallets, and packages of oxygen tugging and boxes of bandages on the floor in the aisle. An environmental safety policy was not received during the survey process. This citation relates to Intake 2588701.3.1-19(f)(5)

Based on observations, interviews, and record review, the facility failed to ensure repeated grievances brought to the attention of the facility by the resident council were responded to for 7 of 12 months of resident council reviewed. Findings include: On 12/3/24 at 1:10 p.m., the Activity Director (AD) provided the Resident Council Minutes for review. On 12/3/24 at 1:15 p.m., the Resident Council Minutes were reviewed. Repeated concerns for the previous 12 months included, but were not limited to: food temperatures, availability and/or access to adequate amounts of linens, staff attitude and/or body language, and staff use of cell phones and ear buds. 1. Cold Food: a. Concerns related to cold food were discussed during the months of: January, February, June, July, September, October (two meetings), and November. b. Responses to concerns related to food temperatures were not found for the months of: February, June, July or September. 2. Quantity/quality and/or access to/availability of linens: a. Concerns related to linens were discussed during the months of: January, June, August (times two meetings), September, and October (two meetings). b. Responses to concerns related to linens were not found for the months of: August (for 8/26/24 meeting) or October (for the 10/14/24 meeting). 3. Staff attitude/body language and use of cell phones/ear buds: a. Concerns related to staff attitude and/or the use of phones were discussed during the months of: January, February, March, July, August, September, and October (two meetings). b. Responses to concerns related to staff attitude and/or the use of phones were not found for the months of: February, March, July, and August. On 12/4/24 at 12:08 p.m., a Resident Council meeting was conducted with 6 residents who regularly participated in Resident [NAME]. The residents indicated there were still ongoing concerns and complaints related to cold food, access to and the amount of linens available, and staff attitude. When responses were provided from previous meetings, they were often the same answers and over time if the issue was fixed for a couple of weeks, it would come back around again. Overall concerns were not resolved, and residents were often told, we'll look into it. The residents indicated they still had complaints about food, it was, cold, cold, cold. The residents indicated they still had complaints about access to linens but felt that it had been better the previous month. The residents indicated they still had concerns regarding staff attitudes and body language that made them feel, devalued. During an interview on 12/4/24 at 12:49 p.m., the AD indicated, it was sometimes a struggle to get resident council responses back from each department, and that sometimes the responses had not been accepted by Resident Council, especially if the concerns were repeated. Common or repeated issues were always related to food being too cold, staff use of their personal cell phone or ear buds, and trying to get enough linens. The AD indicated he had seen some staff on their phone or ear buds and had to stop them and remind them to remove the earbuds because the residents deserved undivided attention. The issues related to staff attitude and body language were often discussed as a cultural and language barrier between some residents and some staff who have immigrated from [NAME], but the AD did not know if that had been addressed with the nursing staff. On 12/4/24 at 1:22 p.m., an unidentified Dietary Aide was observed as she left the main dining room with a 4-wheeled rolling cart. The cart had two shelves and was not enclosed and uninsulated. There were 7 lunch trays stacked on the cart. On 12/4/24 at 1:24 p.m., a blue, insulated room tray cart was observed on the back hall. The cart did not have a door. An unidentified Certified Nursing Assistant (CNA) who assisted with meal delivery indicated, the cart had not had a door for a long time and maybe that was why residents complained about cold food. On 12/5/24 at 9:26 a.m., the blue insulated room tray cart was observed on the back hall as breakfast trays were delivered. The cart remained in disrepair as the door was missing. During an interview on 12/5/24 at 9:13 a.m., the Housekeeping (HK) Supervisor indicated linen supply was a constant complaint, and the HK department spent on average $1,000.00 a month on a linen budget. HK staff were to empty soiled laundry rooms and restock linen supply closets every 2 hours. On 12/5/24 at 9:15 a.m., the linen supply closet for the skilled long-term care halls was observed with the Housekeeping Supervisor (HKS). The shelves were not empty, but the linens were not stocked to the fullest (designated by brightly colored tape on the wall). There was only one stack of washcloths on the labeled shelf, with empty space for two additional stacks. The HKS indicated there was an ample supply at that time, and HK would come around soon to restock. On 12/5/24 at 9:20 a.m., the linen supply closet for the secured memory care unit was observed with the HKS. The shelves were not empty, but the linens were not stocked to the fullest. There were only 5 towels. The HKS opened two towels, which were thin, worn, and not larger than an average bathmat rug. The HKS indicated that HK staff would stock the closet again. The HKS indicated missing linen may have been misplaced, or nursing staff used many wash clothes to clean residents and probably threw them away. During an interview on 12/5/24 at 2:00 p.m., with the Dietary Manager (DM) and Clinical Regional Dietician (CRD) present, the DM indicated she was aware of continued resident complaints about cold food, and it had been an ongoing issue as long as she had worked at the facility. The CRD indicated a new heat on demand system had replaced an outdated pellet warmer, and staff were educated on how to use the system. On 12/6/24 at 12:45 p.m., the Regional Nurse Consultant (RNC) provided a copy of the current facility policy titled, Resident Council, revised 2/2020. The policy indicated, The facility will promote and support the residents' right to participate and organize resident council. The Council will be used to communicate concerns, give suggestions for future programming and events, and otherwise participate in and guide facility life . concerns or suggestions from the meeting will be addressed by the appropriate department. The Executive Director will review all minutes and concern to ensure thorough resolution of concerns . the facility responses to concerns/grievances will be reviewed by the Resident Council President and the resident council on their next meeting On 12/6/24 at 12:45 p.m., the RNC provided a copy of the current facility policy titled, Resident Concerns and Grievances, revised 9/2024. The policy indicated, .the Executive Director/Grievance Official shall review all complaints and agree with the actions taken towards resolution. Responses to resident, representative and/or family shall be made as soon as possible and preferably immediately. Actions taken to resolve the complaint shall be made within 72 hours from the time the concern/Grievance form was received unless there is a compelling reason for delay. Actions taken include contacting the resident, representative and/or family with an explanation of the steps the facility will take to resolve the complaint and to ensure their satisfaction . all concerns/grievances will be trended monthly by the Grievance Official or designee and reported in summary form to the QAPI committee 3.1-3(l) 3.1-3(m)

Based on interview and record review, the facility failed to ensure the Ombudsman received end-of-the month hospital discharges information for 4 of 4 hospitalization discharges (Resident 14) and the Ombudsman did not receive hospitalization discharges from October 26, 2023, until October 24, 2024, for 21 of 34 residents. The deficient practice was corrected on October 24, 2024, prior to the start of the survey, and was therefore past noncompliance. Findings include: On 12/6/24 at 9:53 a.m., Resident 14's record was reviewed. He was admitted on [DATE]. His diagnoses included, but were not limited to, chronic obstructive pulmonary disease (lung disease with constriction of airways and difficulty breathing), emphysema (chronic lung disease that damages the air sacs in the lungs), and dysphagia (difficulty swallowing). He had four recent hospitalization s: from 1/30 to 2/6/24 because his nephrostomy tube (a thin tube that drains urine from the kidney to a bag outside of the body) was pulled out, from 2/29 to 3/8/24 because his nephrostomy tube was pulled out, from 3/27 to 3/29/24 due to abdomen pain and tenderness, and from 8/27 to 9/3/24 due to low sodium levels. During an interview, on 12/5/24 at 2:52 p.m., the Regional Director of Clinicals (RDC) indicated she was unable to provide Resident 14's Ombudsman hospital discharge notifications because the facility did not send the end-of-the-month hospital discharge information to the Ombudsman. The facility found this deficiency in August 2024 and started the action plan in October 2024. During an interview, on 12/6/24 at 11:36 a.m., the Social Services Director (SSD) indicated the facility conducted an internal survey in September 2024 and did not find any Ombudsman notifications of hospital discharges. On October 24, 2024, all previously unsent hospital discharge notifications were sent to the Ombudsman. On 12/6/24 at 11:53 a.m., the SSD provided documentation of all total discharge and hospital discharges since October 26, 2023. The SSD indicated since October 26, 2023, there had been a total of 34 residents discharged from the facility with 21 residents having a hospital discharge. He indicated the Ombudsman had not notified of the hospital discharges at the end-of-the-month of their discharges. A current policy, titled, Emergency Transfer Notifications, dated 4/18, was provided by the Regional Director of Clinicals (RDC), on 12/6/24 at 10:50 a.m. A review of the policy indicated, .Purpose of Policy: Provide guidance regarding notification requirements to the ombudsman when an emergency transfer occurs to an acute care setting .The Census Activity Report will be faxed or mailed to the state Ombudsman each month The deficient practice was corrected by October 24, 2024, after the facility implemented a systemic plan that included the following actions: auditing all discharges of residents, education of staff, notification of the ombudsman, and a system to monitor compliance. 3.1-1(r)(6)(A)(iv)

Based on observation, interview, and record review, the facility failed to ensure food was hot when served to a resident for 1 of 1 test tray temperature checked and for 7 of 12 months of resident council minutes reviewed. Findings include: On 12/3/24 at 1:15 p.m., the Resident Council Minutes were reviewed. Repeated concerns for the previous 12 months included but were not limited to: cold food temperatures for hot foods. Concerns related to cold food were discussed during the months of: January, February, June, July, September, October (two meetings) and November. Responses to the concerns related to cold food temperatures were not found for the months of: February, June, July or September. Facility responses and interventions included repeated staff in-services, repeated assurance that plate warmers were being used, and assurance that test trays would be sampled by staff members. On 12/4/24 at 12:08 p.m., a Resident Council meeting was conducted with 6 residents who regularly participated in Resident Council. The residents agreed there was still ongoing concerns and complaints related to cold food. When responses were provided from previous meetings, they were often the same answers and over time if the issue was fixed for a couple of weeks, it would come back around again. The residents agreed, overall concerns were not resolved, and residents were often told, we'll look into it. The residents indicated they still had complaints about food, and it was, cold, cold, cold. During an interview, on 12/4/24 at 12:49 p.m., the Activity Director (AD) indicated, it was sometimes a struggle to get Resident Council responses back from each department. On 12/4/24 from 1:04 to 1:33 p.m., the 200 hall meal cart was observed to be left open while lunch trays were being delivered on the 200 hall. On 12/4/24 at 1:33 p.m., the Certified Dietary Manager (CDM) was present on the 200 hall to check the temperature of the last tray removed from the 200 hall meal cart for Resident 16. She indicated the tuna casserole was 123 degrees Fahrenheit (F), the green beans were 113 degrees F, and the applesauce should have been 34 - 35 degrees F, but the applesauce temperature was 57 degrees F. She indicated the hot foods should have been above 140 degrees F. On 12/4/24 at 1:38 p.m., the CDM indicated she needed to provide Resident 16 another lunch from the kitchen. During an interview on 12/5/24 at 2:00 p.m., with the Dietary Manager (DM) and Clinical Regional Dietician (CRD) present, the DM indicated she was aware of continued resident complaints about cold food, and it had been an ongoing issue as long as she had worked at the facility. The CRD indicated a new heat on demand system had replaced an outdated pellet warmer, and staff were educated on how to use the system. During a Quality Assurance Performance Improvement (QAPI) interview, the Executive Director (ED) indicated the QAPI team met every other month and consisted of many department heads, but not the dietary manager because she was new to the facility. A review of the employee records indicated the CDM started on 9/13/24. Regarding the cold food complaints from the residents, some of it was repetitive from certain residents. The ED indicated the kitchen got new carts to help with the food temperatures. The facility used Dynex hot plate bases that were heated to help with temperatures. The ED indicated she wanted to get residents out of their rooms and coming back to the dining room. She wanted to work with the Certified Nursing Aides (CNA) and the Social Services Director (SSD) to encourage residents to get out of their rooms. A current policy, titled, Food Temperatures, dated 6/23, was provided by the RNC, on 12/6/24 at 10:50 a.m. A review of the policy indicated, .All hot and cold food items will be served to the resident at a temperature that is considered palatable at the time the resident receives the food .Hot food will be held at or above 135 degrees F. If minimum temperature requirements are not maintained, food will need to be reheated to a minimum of 165 degrees F for 15 seconds before serving .Cold food will be held at or below 41 degrees F. If cold food temperature is not maintained, food item will need to be chilled to less than or equal to 41 degrees F before serving This citation relates to Complaint IN00444032. 3.1-21(a)(2)

Based on observation, interview, and record review, the facility failed to ensure drinks were covered while providing lunch trays on the 200 hall for 4 of 10 resident reviewed (Resident 6, 34, 40, and 135). Findings include: On 12/2/24 at 1:01 p.m., Certified Nursing Aide (CNA) 7 was observed carrying a lunch tray to Resident 40's room, the coffee cup was uncovered. On 12/4/24 at 1:06 p.m., CNA 7 was observed carrying a lunch tray to Resident 6's room, her coffee and orange drink were uncovered. On 12/4/24 at 1:06 p.m., the Activity Director was observed carrying a lunch tray to Resident 34's room, his orange drink was uncovered. The lunch tray was carried to the Assisted Dining room. On 12/4/24 at 1:06 p.m., CNA 7 was observed carrying a lunch tray to Resident 135's room, his orange drink was uncovered. A current policy, titled, Meal Service and Distribution, dated 4/24, was provided by the Regional Nursing Consultant (RNC), on 12/3/24 at 9:15 a.m. A review of the policy indicated, .Prepared food will be transported to other areas either covered or in covered container/enclosed carts. Food and beverage items should be covered when being taken a distance such as down a hall or to another unit 3.1-21(i)(2)

A. Based on observation, interview, and record review, the facility failed to ensure staff wore personal protective equipment (PPE) appropriately for 11 of 11 observations of PPE, and failed to ensure the facility had a thorough process for contact tracing of infections for 2 of 2 months of infection tracking reviewed. B. Based on observations, interview and record review, the facility failed to ensure appropriate infection prevention procedures for laundry/linen services were followed to prevent the potential for the spread of germs and infection for 1 of 1 observation of the laundry room. This deficient practice had the potential to affect 82 of 82 residents who received laundry services from the facility. C. Based on observation, interview, and record review, the facility failed to ensure staff cleaned a blood glucose glucometer properly for 1 of 1 observation of glucometer cleaning. Findings include: A1. On 12/2/24 at 10:24 a.m., a sign was noted on Resident 4's door indicating he was on enhanced barrier precautions (EBP). The sign indicated staff were to wear gowns and gloves when providing activities of daily living (ADL) care and specified personal protective equipment (PPE) was to be worn during care that involved changing briefs, dressing, transferring, and bathing/showering. During an interview, on 12/2/24 at 10:25 a.m., Certified Nursing Aide (CNA) 7 indicated she helped Resident 4 get up for the day which included assisting with dressing him. She indicated she did not wear a gown or gloves or PPE while assisting him because the resident had been there a long time and was not the resident under enhanced barrier precautions. The resident in isolation was his roommate, a new admission. During an interview, on 12/2/24 at 11:54 a.m., the Infection Preventionist (IP) indicated Resident 4 was on EBP and the staff should have worn gown and gloves when providing direct care because he had a feeding tube. A2. On 12/3/24 at 9:33 a.m., Housekeeper 23 was observed not wearing a mask while cleaning floor near the 200 hall where there were COVID-19 positive residents. On 12/3/24 at 11:11 a.m., Qualified Medication Aide (QMA) 6 was observed wearing a surgical mask. Before she entered Resident 25's COVID-19 positive room, she placed on N95 on top of her surgical mask. She exited wearing the same surgical mask. She subsequently went into Resident 33's COVID-19 positive room, still wearing her surgical mask and placed an N95 mask on top of it. During an interview on 12/3/24 at 11:30 a.m., the IP indicated the facility had a COVID-19 outbreak. Staff members who tested COVID-19 positive on 12/2/24 were the Executive Director (ED), Payroll Director (PD), Guest Relations (GR), and the facility Bus Driver (BD). She indicated she talked with the staff to figure out who they were around and would test those residents. All staff should be wearing surgical masks in the facility. For source control, she indicated the surgical mask must be removed before using an N95. During an interview, on 12/3/24 at 11:30 a.m., the Director of Nursing Services (DNS) indicated the facility's COVID-19 outbreak included 4 cases, two residents and two staff would be reported to the Health Department. Their source control was N95 masks, and they were available. On 12/3/24 at 11:35 a.m., Housekeeper 24 was observed not wearing a mask while cleaning the 200 hall shower room. On 12/3/24 at 11:50 a.m., Resident 22 was reported to be positive for COVID-19. On 12/3/24 at 12:00 p.m., Housekeeper 24 was observed in the hallway, near the Sunshine lunchroom, with a visible hole in his surgical mask. On 12/3/24 01:17 p.m., QMA 22 was observed with a beard. He put an N95 mask on top of a surgical mask before entering Resident 136's COVID-19 positive room to provide his lunch tray. QMA 22 indicated he did not know if it was acceptable to wear an N95 mask on top of a surgical mask, but he would ask the DNS. A Covid in-service was completed on 12/3/24 at 3:30 p.m. by the DNS. It included handwashing, PPE, double masking, COVID-19, alcohol-based hand rub, and donning and doffing of PPE. The in-service signature sheet showed 18 attendees, and included QMA 6 and QMA 22. The LTC (Long Term Care) Respiratory Surveillance Line List, dated 12/2024, was provided by the Executive Director (ED), on 12/4/24 at 1:59 p.m. A review indicated: a. Resident 81 was symptomatic on 11/26/24 and was tested on the same day. The testing result was COVID-19 positive. b. The ED was symptomatic on 11/27/24 and was tested on [DATE]. The testing result was COVID-19 positive. She returned to work on 12/2/24. c. Resident 57 was symptomatic on 11/29/24 and was tested on the same day. The testing result was COVID-19 positive. d. The Bus Driver (BD) was symptomatic on 12/2/24 and was tested on the same day. The testing result was COVID-19 positive. e. The Payroll Director (PD) was symptomatic on 12/2/24 and was tested on the same day. The testing result was COVID-19 positive. f. Receptionist 27 was symptomatic on 12/2/24 and was tested on the same day. The testing result was COVID-19 positive. g. Resident 238 was symptomatic on 12/2/24 and was tested on the same day. The testing result was COVID-19 positive. h. Resident 136 was symptomatic on 12/2/24 and was tested on the same day. The testing result was COVID-19 positive. i. Resident 54 was symptomatic on 12/2/24 and was tested on the same day. The testing result was COVID-19 positive. j. Resident 33 was symptomatic on 12/3/24 and was tested on the same day. The testing result was COVID-19 positive. k. Resident 12 was symptomatic on 12/3/24 and was tested on the same day. The testing result was COVID-19 positive. l. Resident 25 was symptomatic on 12/3/24 and was tested on the same day. The testing result was COVID-19 positive. m. CNA 28 was symptomatic on 12/4/24 and was tested on the same day. The testing result was COVID-19 positive. n. CNA 29 was symptomatic on 12/4/24 and was tested on the same day. The testing result was COVID-19 positive. On 12/4/24 at 10:30 a.m., the IP indicated Resident 45 and Resident 65's COVID-19 tests result were positive. On 12/4/24 at 1:04 p.m., Resident 22's door was observed with an isolation sign, it indicated to keep the door closed, to perform hand hygiene, wear a gown, N95 mask, eye protection, and disposable gloves before entering the room. QMA 22 put on a gown, face shield, and disposable gloves. He was observed already wearing a surgical mask. He did not wear an N95 mask. He entered Resident 22's COVID-19 positive room. He left the residents door open and after delivering his lunch tray, came out without his surgical mask. He gelled his hands and put on a new surgical mask. Her door hanger was observed with both N95 and surgical masks. On 12/4/24 at 1:09 p.m., Resident 12's door was observed with an isolation sign. QMA 22 was already wearing a surgical mask, he put on a gown, face shield, and disposable gloves. He did not wear an N95 mask. He left the resident door open and after delivering her lunch tray, came out without his surgical mask. He gelled his hands and put on a new surgical mask. Her door hanger was observed with both N95 and surgical masks. On 12/4/24 at 1:14 p.m., Resident 136's door was observed with an isolation sign. QMA 22 was already wearing a surgical mask, he put on a gown, face shield, and disposable gloves. He did not wear an N95 mask. He left the resident door open and after delivering his lunch tray, came out without his surgical mask. He gelled his hands and put on a new surgical mask. Her door hanger was observed with both N95 and surgical masks. On 12/4/24 at 1:19 p.m., Resident 54's door was observed with an isolation sign. QMA 22 was already wearing a surgical mask, he put on a gown, face shield, and disposable gloves. He did not wear an N95 mask. He left the resident door open and after delivering his lunch tray, came out without his surgical mask. He gelled his hands and put on a new surgical mask. His door hanger was observed with both N95 and surgical masks. On 12/4/24 at 1:25 p.m., Resident 81's door was observed with an isolation sign. QMA 22 was already wearing a surgical mask, he put on a gown, face shield, and disposable gloves. He did not wear an N95 mask. He left the resident door open and after delivering her lunch tray, came out without his surgical mask. He gelled his hands and put on an N95 mask. Her door hanger was observed with both N95 and surgical masks. During an interview, on 12/4/24 at 1:30 p.m., QMA indicated he did not know which mask to wear in a COVID-19 positive room, but he just put on an N95 mask because he needed to go into Resident 16's room to assist him with eating and his roommate, Resident 22, was COVID-19 positive During an interview, on 12/5/24 at 10:50 a.m., the IP indicated QMA 22 would have needed a good seal with his N95 mask for it to work properly and he would be unable to accomplish it with a beard. He should not have entered the COVID-19 positive room without a seal on his N95 mask. During an interview, on 12/4/24 at 2:53 p.m., the Regional Nurse Consultant (RNC) indicated QMA 22 would be tested for COVID-19. During an interview, on 12/5/24 at 10:30 a.m., the IP indicated she became IP certified on 2/24/24 and became the facility's IP person at that time. She had been using the facility's transmission-based precautions and the COVID-19 outbreak policy as resources to guide her through the current outbreak. During an interview, on 12/5/24 at 10:44 a.m., the IP indicated Resident 59 and Resident 64 were COVID-19 positive. Also, the Charge Nurse 30 from the 100 hall was Covid positive. She indicated she was aware of the breaks in the COVID-19 policy and procedure and had been rounding more. During an interview, on 12/5/24 at 10:56 a.m., the IP indicated since the COVID-19 outbreak started she was doing contact tracing and would provide documentation. She indicated she documented where she observed the COVID-19 residents. During the contact tracing interview, on 12/6/24 at 11:30 a.m., the IP provided the, Covid-19 Outbreak Investigation Contact Tracing Form, for COVID-19 positive residents. Four Covid positive residents were reviewed: a. Resident 81 tested positive on 11/26/24. The resident indicated a friend visited, no date or contact information was provided. No information if the friend was contacted. The section, Identify Close Contacts, and the Outbreak Testing Plan were observed blank. b. Resident 57 tested positive on 11/29/24. The section for the Outbreak Testing Plan was observed blank. c. Resident 238 tested positive on 12/2/24. The resident was in the therapy gym, but IP did not add other residents or staff who were also in the therapy gym to complete contact tracing. The section, Identify Close Contacts, and the Outbreak Testing Plan were observed blank. d. Resident 136 tested positive on 12/2/24. The resident was in the therapy gym and visited with family, but IP did not add other residents or staff who were also in the therapy gym or contact the family to complete contact tracing. The section, Identify Close Contacts, and the Outbreak Testing Plan were observed blank. During an interview, on 12/5/24 at 3:12 p.m., the IP indicated COVID-19 began in the facility at the end of November with Resident 81 as the first case and on 11/26/24 and Resident 57 on 11/29/24. She indicated there were signs on the doors, use of PPE, and we were trying to use dedicated staff for the 100 hall. The ED was symptomatic on 11/27/24 and tested positive on 11/29/24. During a review of the IP's tracking and trending, on 12/5/24 at 3:22 p.m., she indicated the COVID-19 positive cases were not tracked on the November color coded map. There was a cluster of urinary tract infections (UTI) noted on her November map. She did not follow-up with staff education regarding the UTIs or was aware of any further cluster of UTI near those resident rooms. She indicated she would compile the December infection information later. The analysis of infection was determined by looking at the color-coded map. During an interview, on 12/5/24 at 3:22 p.m., the Float IP indicated the facility did not graph infections to gather more information. The pharmacy provided an antibiotics analysis. A job description, titled, Infection Preventionist Position Description, dated 7/2020, was provided by the DNS, on 12/6/24 at 1:54 p.m. A review of the IP job description indicated, .The Infection Preventionist is responsible for assessing and educational needs of staff, coordinating programs based upon identified needs, and ensuring compliance with all State and Federal guidelines for infection prevention and control, in-service education A current procedure, titled, Personal Protective Equipment (PPE) Donning and Doffing, dated 7/2023, was provided by the Director of Nursing Services (DNS), on 12/3/24 at 3:30 p.m. A review of the policy indicated, .fit the mask to the face so it [sic] snug to face and below chin, if N-95 respirator A current policy, titled, Covid-19 Policy, dated 7/2023, was provided by the IP, on 12/3/24 at 11:46 a.m. A review of the policy indicated, .Routine Infection Prevention and Control Practice .residents and visitors will be offered education about the importance of receiving the Covid-19 vaccine .Staff to follow appropriate PPE use according to the Standard and Transmission Based Precautions policy .Source control option for HCP [health care providers] include: .A well-fitting facemask .When evaluating the need for source control, the Infection Preventionist will use multiple sources to make an informed decision when recommending source control including, but not limited to, respiratory virus transmission in the local community, respiratory virus transmission in the facility including staff date, local SARS-CoV-2 hospital admission data form the CDC COVID Data Tracker, and risk of current population served A current policy, titled, Standard and Transmission-Based Precautions (Isolation) Policy, dated 4/24/24, was provided by the RNC, on 12/2/24 at 4:01 p.m. A review of the policy indicated, .Personal Protective Equipment (PPE) refers to protective items or garments worn to minimize exposure to hazards that cause injuries and illnesses .Respirator includes a fit-tested NIOSH-approved N95 or higher-level respirator for healthcare personnel when indicated .Covid-19, which includes the use of N-95 respiratory .residents suspected or confirmed with Covid-19 should remain in their current location .Use of Personal Protective Equipment HCP should wear an N95 or higher-level respirator, eye protection (i.e. goggles or a face shield that cover the front and sides of the face), gloves, and gown when care for these resident 38768 B. On 12/5/24 at 9:30 a.m., the facility's laundry service and processing rooms were observed with the Housekeeping Supervisor (HKS) present. Upon initial observation on 12/5/24 at 9:30 a.m., the laundry room was dimly lit, paint was peeled/chipped away from the walls in various areas, the overhead vents had clumps of dark debris and dust stuck to the grates. There was an empty unidentified plastic bottle on the floor behind the washing machines. The remainder of the floors behind the washing machines were littered with dust, lint and other unidentified debris. The tubes which carried detergent/sanitizer and other laundry chemicals from their containers to the machines, were observed to have a film of and clumps of the chemicals that had spilled down. The metal wire-baskets in which the chemicals were stored were rusted and the paint had chipped/peeled off. The soiled linen closet was observed. There were 9 large plastic trash can barrels lined with clear plastic bags. Two lids had been secured in place, three lids were on top of the can, but not secured closed, and four barrels were open to air as the clear plastic bags were not tied shit, and there were no lids on top of the barrels. There was a door between the soiled linen closet, and the main washing/drying areas which remained open. There were no hand sanitizers/hand hygiene stations for entrance/exit of the laundry area or within the laundry area. During an interview on 12/5/24 at 9:33 a.m., with the HKS, HK/laundry Aides (HKA) 30 and 31 present, HKS 30 and 31 indicated, they knew there was a COVID-19 outbreak in the facility at that time. There was no special way they were supposed to collect and sanitize COVID-19 positive soiled linens from regular, everything was treated the same. HKA 31 indicated, when COVID-19 was first around, the facility had utilized a color-coded trash bag system, so that staff would know which clothes or linen came from the COVID-19 positive rooms, so it could be stored and washed separately. HKA 30 and 31 did not know what temperatures were required to sterilize the linen, they did not know if linen was sterilized with chemicals, heat, or a combination of both. On 12/5/24 at 9:38 a.m., HKA 31 was observed as she demonstrated the wash cycle procedure. Without performing hand hygiene or donning personal protective equipment (PPE) she put on a pair of translucent surgical gloves and entered the soiled side. She retrieved a barrel and rolled it to a washing machine. On top of the pile of clothes in the barrel was a soiled pair of green flannel pants. There was a large smeared and crusted blotchy stain. HKA 31 indicated it was poop that the CNAs were supposed to rinse off in the Hoppers which were located in the soiled utilities room. HKS 31 grabbed an armful of soiled clothes, which included the soiled flannel pants smeared with poop, and dumped the items into the washing machine. As she continued to grab armfuls of laundry, the items brushed against the bare skin of her forearms, as she wore a short-sleeved shirt. As the barrel became empty, HKA 31 needed to bend over, into the barrel to retrieve the rest of the items. Without PPE in place, the edge and side of the soiled barrel came into direct contact with the front of her scrub shirt. When all the items were in the machine, HKA 31 did not remove her gloves before she pressed a series of buttons to begin the wash cycle. When the machine started, HKA 31 removed her gloves, without performing hand hygiene, she went to the clean laundry area and resumed folding clean clothes. During an interview on 12/5/24 at 9:45 a.m., the HKS indicated, HKA 31 should have worn a yellow gown which was reusable and hung on the back of the laundry room door. The purpose of the gown was to protect the staff member from potential contamination while in contact with soiled items and help prevent the spread of infection. On 12/5/24 at 9:47 a.m., the soiled linen closet on Pine Hall (where the majority of COVID-19 positive residents resided) was observed with the HKS present. There was a large industrial plastic bin. The lid of the bin was left open and leaned backwards against the wall. Inside the bin there were several clear plastic bags of soiled laundry. Two of the bags were observed untied and open to the air. The HKS indicated the soiled linen in plastic bags should be tied and sealed up and the lid on the bin should remain closed. On 12/5/24 at 9:57 a.m., the Float Infection Preventionist, (F-IP) indicated, it was the policy of the facility that all soiled linen and laundry should be considered contaminated and standard Infection Prevention procedures should be in effect. During an interview on 12/5/24 at 10:29 a.m., with the Facility's Infection Preventionist (IP) and F-IP present. The F-IP indicated staff should wear a PPE gown and gloves when they handled soiled linens to prevent contaminated items from coming in contact with their person. After handling soiled items, staff were expected to perform hand hygiene. Soiled closets should be kept tidy, and the bins lids should be closed. During an interview on 12/6/24 at 12:02 p.m., the Corporate HK Consultant indicated all staff who assisted with laundry should follow standard precautions. Contaminated laundry should be securely contained from the source. Staff would then execute procedures to handle contaminated items in a manner that protected the employee and precluded the contamination of clean linen. On 12/5/24 at 10:10 a.m. the F-IP provided a copy of the current facility policy titled, Laundry/Linen, revised 12/2021. The policy indicated, .Purpose of the policy to ensure the proper care and handling of linen and laundry to prevent the spread of infection . all linen in use is contaminated. All linen, including that from a resident with a diagnosed infection is treated the same way except a resident who is under transmission-based precautions for C-Diff . soiled linen, carry away from body to prevent soiling uniform . containers in soiled linen room should be labeled, lined with will-fitted lids . keep soiled linen covered in container until ready to load in machine . before removing or touching clean laundry, perform hand hygiene 46414 C. On 12/4/24 at 12:52 p.m., RN 20 was observed cleaning a blood glucometer meter. She wiped the meter with a Chlorox Bleach Germicidal wipe and sat it on a paper towel to dry. She did not allow the meter to remain wet with contact from the wipe for at least 3 minutes. On 12/9/24 at 1:22 p.m., the Assistant Director of Nursing (ADNS) was interviewed. She indicated the glucometer needed to remain wet for 3 minutes. A skills competency procedure was provided by the Regional Nurse Consultant (RCS) on 12/4/24 at 1:10 p.m. It indicated, .Wipe entire external surface of the blood glucometer meter wipe (Clorox Bleach Germicidal Wipes) and allow the surface of the meter to remain wet for 3 minutes. When using Clorox Bleach Germicidal wipes in the individual packet, it is best to squeeze out excess solution into a trash container or plastic cup to be disposed of 3.1-18(b)(1)

Based on observation, interview, and record review, the facility failed to ensure a resident received requested and desired nail trimming and shaving for 1 of 9 residents reviewed for nail trimming and shaving (Resident 135). Findings include: On 12/6/24 at 9:46 a.m., Resident 135's record was reviewed. His diagnoses included, but were not limited to, mild cognitive impairment (difficulties with thinking, learning, remembering, and making decisions), glaucoma (eye disease causes blindness), and a history of myocardial infarction (heart attack). His care plan, dated 11/25/24, indicated he required assistance and/or monitoring for morning (AM) and afternoon (PM) care, nutrition, hydration, and elimination. The goal indicated he would have his activities of daily living (ADLs) needs met. An Approach indicated his PM care included bathing, dressing, hair combing, and oral care. His care plan, dated 12/5/24, indicated he required assistance with activities of daily living (ADL)s due to history of TIA (stroke), left sided weakness, glaucoma (eye disease that causes blindness), obesity, and impaired mobility. A nursing care approach indicated to assist with bathing as needed per resident preference. Another approach was to assist with dressing, grooming, and hygiene as needed. During an interview, on 12/3/24 at 9:47 a.m., Resident 135 indicated he only had two showers since he arrived at the facility, one last week and one this week. He indicated he had asked staff to cut his fingernails and toenails, he really needed his toenails cut, especially on his right foot. His right foot toenails were observed to be discolored and long to the end of his toes and just past his toes. During an interview, on 12/6/24 at 9:24 a.m., the Regional Nursing Consultant (RNC) indicated nail care was part of the resident receiving a shower. During an interview, on 12/6/24 at 10:02 a.m., Resident 135 indicated he wanted to be shaved and have his fingernails and toenails cut. He told Certified Nursing Aide (CNA) 25 during his shower and she did not do it. He was observed with fingernails to the ends of his fingers and had noticeably visible facial hair. During an interview, on 12/6/24 at 10:06 a.m., CNA 25 indicated she did not provide nail cutting when providing a shower, but she should have shaved him. During an interview, on 12/6/24 at 10:38 a.m., Registered Nurse (RN) 26 indicated during resident's showers the CNAs should look for any skin issues, bathe, shampoo, and trim their nails. Sometimes the nurses cut the residents' toenails. The CNAs did shave the residents during the shower. If there was a delay and they could not shave the resident during the shower, they should not wait until the next shower, but should do it the same day as the shower. If residents wanted to go to activities, ADL care should be done after that activity. On 12/6/24 at 10:56 a.m., the RDC provided Resident 135's shower sheets, dated 11/26, 11/29, and 12/3/24. The showers sheets dated 11/26 and 12/3/24 indicated Resident 135 was not shaved. The shower sheets for 11/26 and 11/29/24 indicated no nail care was provided. A current policy, titled, Resident Rights, dated 10/23, was provided by the RDC, on 12/2/24, after the entrance conference. A review of the policy indicated, .Respect and Dignity .The resident has the right to .reside and receive services in the facility with reasonable accommodation of resident needs and preferences .Self-Determination .A resident has the right to: .Make choices about aspects of his or her life in the facility that are significant such as schedules, including but not limited to sleeping, waking, eating, and bathing 3.1-38(a)(3)(d) 3.1-38(a)(3)(e)

Based on observations, interviews and record review, the facility failed to prevent the potential for accidents by ensuring bed rail/mobility devices were appropriately monitored/adjusted to reduce the risk of entrapment for 2 of 5 residents reviewed for accidents (Residents 67 and 32), and failed to ensure fall interventions were in place for 1 of 5 residents reviewed for accidents, (Resident 27). Findings include: 1. On 12/2/24 at 10:26 a.m., Resident 67 was observed in her room on the secured memory care unit. She was seated in a regular wheelchair; her bed was neatly made. Bilateral side rails observed installed to the frame of her bed. There was a large gap between the edge of the mattress and the side rail. On 12/2/24 at 3:35 p.m., Resident 67's bed frame and side rails were observed with the Maintenance Director. He measured the gap between the edge of the mattress to the rail. The Maintenance Director indicated without measuring, he could tell the gap was too large and failed visual inspection. After measuring, he indicated the gap was 5 inches wide and needed to be adjusted to meet the bed zone requirements. The Maintenance Director indicated it was important to ensure there was not too large of a gap to prevent the potential for entrapment. On 12/2/24 at 3:45 p.m., the Maintenance Director provided a copy of the current procedure for bed rail safety checks. The Maintenance Director indicated the problem area on Resident 67's bed was zone 3, between rail and mattress which should not measure greater than 4 and 3/4 inches. On 12/3/24 at 11:51 a.m., Resident 67's medical record was reviewed. She was a long-term care resident who resided on the secured memory care unit with diagnoses which included, but were not limited to, dementia (a degenerative brain disease which affects memory and cognitive function), glaucoma (a progressive eye disease which causes vision loss), muscle weakness, and anxiety. She had a current physician's order, dated 9/11/23, for two half side rails to enhance her bed mobility. A care plan, dated 9/12/23, indicated Resident 67 required assistance with activities of daily living (ADLs) which included bed mobility and an intervention for this plan of care included, but was not limited to, bilateral half side rails. The care plan lacked implementation and/or revision to include routine ongoing assessments and/or monitoring of the side rails for safety and appropriateness. A Bed Rail Notification, observation was created on 8/7/24 at 7:32 p.m. The notification was not signed by the resident and/or their representative to acknowledge the potential hazards of the use of side rails as stated on the notification; I have been informed and understand the potential hazards that may occur with the use of bed rail (s) as follows: Potential hazards may include: decreased independence with getting in and out of bed, potential for bruising, potential for skin tears, potential for entrapment causing serious injury or death, and increased distance of falling if resident climbs over bed rails with possibility of greater injury. The record lacked any ongoing assessments and/or monitoring of the side rails for safety. 2. On 12/4/24 at 9:26 a.m., Resident 32 was observed. He was reclined in his bed and a large gap was observed from the edge of his mattress to the bilateral mobility bars. On 12/4/24 at 2: 47 p.m., Resident 32 remained in bed. He indicated the mobility bars were too far away for him to reach by himself, but he used them to hold on to when he was turned in bed to get cleaned up or for bed baths. On 12/5/24 at 9:25 a.m., Resident 32's bed frame was observed with the Maintenance Director who measured the gap. The Administrator (ADM) was also present at that time. The Maintenance Director indicated the gap on the right side of the bed was 5 and a half inches, and the gap on the left side was 4 and one quarter inches. The Maintenance Director indicated he was aware Resident 32 had the mobility bars installed on his bed, but it appeared that nursing had switched his mattress and not notified the Maintenance Director to come and inspect them and/or adjust to the appropriate measurement. The Maintenance Director indicated the gap on the right side was too wide, and he would adjust the bars immediately. On 12/5/24 at 1:52 p.m., Resident 32' medical record was reviewed. He was a long-term care resident with a diagnosis which included but was not limited to Parkinson's disease (a chronic, progressive brain disorder that affects the nervous system and causes movement problems). His record lacked documentation of the mobility bars initial and/or ongoing assessments for safety and appropriateness. On 12/3/24 at 9:30 a.m., the Regional Nurse Consultant, (RNC) provided a copy of current facility policy titled, Restraints: Bed Rail Safety Check, updated 8/2021. The policy indicated, Purpose: to ensure bed rails utilized in the facility are safely and appropriately secured to the bed. A bed rail safety check will be completed on all beds that have any type of rail. The bed rail safety check will be completed upon initiation or change of any bed rail, mattress and or bed frame, and at least annually thereafter. The bed rail safety check form will be completed with each safety check and will be maintained at the facility for [AGE] years 51296 3. On 12/2/24 at 10:00 a.m., Resident 27 was observed sitting on the side of the bed. The Resident's face was bruised from underneath both eyes to her hairline and on her bilateral knees and shins. Her bed was in a low position with a regular mattress on the frame, her oxygen concentrator was by the bedside approximately 1 foot from the Resident. A call before you fall sign was not observed in her room. The resident indicated she had recently become very off balance and that she had fallen out of bed twice and hit her face on the oxygen concentrator next to her bed causing the bruising to her face. On 12/3/24 at 11:02 a.m., Resident 27 was observed sitting on the side of her bed, with her oxygen concentrator pushed up against the right side of the bedframe. There was a normal mattress on the bed frame. A call before you fall sign was not observed in the room. On 12/4/24 at 1:50 p.m., The Director of Nursing Services (DNS) and the Assistant Director of Nursing services (ADNS) were observed talking to Resident 27 in her room. After the DNS and ADNS left the room, the Resident was observed sitting on the side of the bed with her call light and glasses on the floor partially under the bed. There was a normal mattress on the bed frame, the bed was approximately 1 to 2 feet away from the wall. and there was no A call before you fall sign was not observed in the room. On 12/05/24 2:15 p.m., Resident 27 was observed lying in bed with her eyes closed. The resident was lying on the edge of the right side of the bed, her oxygen concentrator was approximately 6 inches from the right side of the bed and her call light was on the floor. Qualified Medication Aide (QMA) 6 was asked to check on Resident 27. QMA 6 was observed pulling Resident 27 over to the middle of the bed, QMA 6 asked the Resident if she needed anything else and then left the room. The Residents call light remained on the floor and her oxygen concentrator was not moved away from the side of the bed. On 12/04/24 at 10:10 a.m., Resident 27s medical record was reviewed. She was a long-term care resident whose diagnoses included, but were not limited to, end stage renal disease, dependance on renal dialysis, generalized muscle weakness, and unsteadiness on her feet. A nursing progress note, dated 10/27/24 at 4:13 a.m., indicated an unknown CNA found Resident 27 lying on the floor next to her bed, and the Resident indicated that she had hit her head on the oxygen concentrator. An IDT progress note, dated 10/27/24 at 4:20 a.m., indicated that the cause of the fall was poor bed boundaries, weakness, unsteady gait, and unaware of physical limitations. The note also indicated that the intervention put in place was a call before you fall sign in the resident's room. A nursing progress note, dated 11/21/24 at 6:54 a.m., indicated that Resident 27 was found lying beside the bed and that the Resident indicated that she fell asleep sitting on the side of the bed. An IDT progress note, dated 11/21/24 at 6:26 a.m., indicated that the cause of the fall was poor bed boundaries and weakness. The note also indicated that the interventions put in place were nonskid strips next to the bed and a scoop mattress. A physician order, dated 11/21/24, indicated for a scoop mattress to be placed on her bed. A care plan, initiated on 7/17/24, indicated that she was at risk for falls. Interventions for this plan of care included but were not limited to: scoop mattress to the Residents bed and call before you fall sign in the Residents room. During an interview on 12/05/24 at 2:50 p.m., The DNS and ADNS indicated that resident call lights should always be placed within reach of the resident. They indicated that in order to change out mattresses, the nurse who received the order for a new mattress should contact maintenance and then they would change the beds out. They indicated that they did not know why her mattress wasn't changed but agreed that Resident 27 should have a scoop mattress on her bed. They indicated that oxygen concentrators should be placed far enough away from the bed so that resident could not fall onto them. 3.1-45(a)(1)

Based on observation, interview, and record review, the facility failed to adequately manage, supervise, monitor, and initiate interventions for a dementia resident with a known history of aggressive behaviors for 1 of 3 dementia residents reviewed for incidents (Residents L, K, N). Findings include: An Indiana State Department of Health Survey Report System report, dated 4/30/24 at 10:45 a.m., indicated Resident L made contact with Resident K. Resident L had a skin tear on his left hand and Resident K had a skin tear on her left forearm. Root cause was to be determined regarding resident engagement. A 5/3/24 follow -up indicated Resident L's care plan was updated with a new intervention of a sign on his door to redirect other residents from entering his room. 1. Resident L's record was reviewed on 5/15/24 at 2:45 p.m. Diagnoses on Resident L's profile included, but were not limited to, Alzheimer's disease, and dementia with severe mood disturbance (verbal and physical aggression and wandering) and psychotic disturbance (can become aggressive at times and have trouble regulating emotions). A hospital discharge summary, dated 3/11/24, indicated Resident L had recently completed a 14 day in-patient stay at a psychiatric hospital for psychosis and agitation. The day after his return to the facility, he had an aggressive episode with a female resident who was sitting near the nurse's station and grabbed her left arm and was yelling at her. Resident L was sent back to the in-patient psychiatric hospital for an additional 12 day stay, and the family was told to seek alternate placement. A Memory Care Initial Admissions Guidelines Checklist, dated 3/7/24, indicated the resident had a diagnosis of an irreversible form of Alzheimer's or dementia and met guidelines to be placed on the secured unit. The assessment did not document the resident having just been discharged from 2 back to back in-house psychiatric stays for physical aggression against his peers at his last facility. On 5/16/24 at 11:25 a.m., Resident L was observed being brought out of his room in a wheelchair (wc) propelled by Certified Nursing Aide (CNA) 10. The resident was placed at a table with another male peer, he was not observed to engage with others. On 5/17/24 at 9:37 a.m., Resident L was observed propelling himself in a wc with his feet into the activity/dining room among 5 peers. A physician's order, dated 3/11/24, indicated the resident resided on a secured unit, and his activity level was to be up as he wanted with assistance and use of a walker. The resident record lacked documentation a person centered care plan was initiated upon admission for a history of aggressive behaviors towards others, root cause of aggressive behaviors, or interventions initiated to assist staff in caring for the resident. A physician's progress note, dated 03/20/24 at 12:44 a.m., indicated Resident L was seen for his initial history and physical. The patient was status post hospitalization for increased agitation and aggressive episodes. He had medication adjustments completed with improvement in his behaviors. He was unable to return to his assisted living apartment due to requiring more supervision. A progress notes, dated 4/10/24 at 1:03 p.m., indicated the resident continued to attempt to stand independently. When staff attempted to assist the resident to either sit down or ambulate with his walker, he declined to use the walker even though he was unsteady standing. Resident L became agitated at times and hit a staff member during unsuccessful attempts at redirection. A care plan dated 4/11/24 indicated Resident L became aggressive with staff when trying to redirect to activity. The goal was for him to not become agitated. Approaches included administering medications as needed, redirect resident to activity of choice, assess resident for unmet needs, and labs will be drawn. A progress notes, dated 4/15/24 at 10:07 p.m., the resident had an agitated afternoon. He refuses to sit on several occasions and attempted to hit staff sometimes. A behavior review note, dated 4/16/24 at 1:36 p.m., indicated the resident refused to be redirected, to stay in his wheelchair, and continued to wander throughout the memory care unit. A behavior review note, dated 5/1/24 at 3:41 p.m., indicated 2 female residents (Residents K and L) entered the resident's room. Resident L became agitated and used part of his wheelchair to make contact with Resident K's left lower arm. A progress notes, dated 5/9/24 at 10:32 a.m., Resident L was passing through the dining room at the end of breakfast. He passed very close to Resident K and grabbed her by her left arm and held on. She yelled out from the contact and Resident L responded by yelling as well. The nurse came from behind the care station and a CNA came out of another resident's room. A therapist was also nearby and helped. Staff needed additional attempts to have Resident L release his grip on Resident K's arm when staff separated them. Resident K was taken to her room to finish her breakfast. Resident L was placed on one on one (1:1) supervison with staff after the event. He continued to move about the hallways in his wheelchair. A progress notes, dated 5/09/24 at 11:09 a.m., indicated Resident L grabbed Resident K by the arm during breakfast time and threatened to harm her. He was moving around in his wheelchair, he then became aggressive towards Resident K thinking her chair was in his way, so he grabbed her by the left elbow area. The staff rushed there to separate them, Resident L was removed from the area and redirected. A progress notes, dated 5/14/24 at 2:43 p.m., indicated Resident L was observed to be agitated shortly after getting up that morning. He was wheeling his wc down the hallway, using the handrail to pull himself along, and when he came close to Resident N banged his wheelchair into hers instead of going around her. Resident N who was positioned half in her doorway and half out, was upset at this action and raised her voice at Resident L. He did not change direction, so staff immediately helped him move around stationary Resident N. Several times the day staff had to provide additional redirects for Resident L as he was easily agitated by others who would not move for him. An admission Minimum Data Set (MDS) assessment, completed 3/18/24, assessed Resident L as having the ability to sometimes make himself understood and to sometimes understand others. A Brief Interview for Mental Status (BIMS) score 4/15 indicated severe cognitive impairment. The resident had signs and symptoms of delirium to include evidence of an acute change in mental status from the resident's baseline, inattention, and disorganized thinking. The resident had no behavior to include physical or verbal symptoms towards others, rejection of care, or wandering. Mobility devices included a wheelchair and a walker. Partial assistance was needed for transfers, mobility, and ambulation. A care plan, dated 5/2/24, indicated Resident L experienced physical aggression, he made contact with another resident, and had a diagnosis of dementia with behaviors. The goal was for the resident not to experience lasting distress, not cause distress to others, and not cause harm to self or others. Approaches included the resident was to have a sign on his doorway to redirect others from entering his room, and staff were to assure the sign was in place as much as possible. Provide activities of interest, a psychiatric consultation, notify the NP/MD (nurse practitioner, physician), address any immediate needs (hunger, thirst, pain, boredom, loneliness, tiredness, etc.), and remove from immediate area to further evaluate needs. During an interview on 5/16/24 at 11:04 a.m., the Executive Director (ED) and Director of Nursing (DON) indicated the MDS Coordinator had completed the pre-admission assessment for Resident L to be admitted into the secured memory care unit, but she had made her determination by completing a review of the resident's prior records. There was no written information to show to others. The ED indicated Resident L liked to move down the hallway multiple times daily pulling himself with the railing, and Resident N liked to sit in the doorway of her room. On 5/14/24 Resident N was sitting in her doorway and in Resident L's way and he banged his wc wheel into her wc wheel. Resident N yelled at Resident L but there had not been any physical contact. The DON indicated Resident L had been admitted from an in-house psych unit, but she would have to look at his chart to determine what was put into place upon his admission. The ED and DON indicated there were currently 19 residents residing on the secured memory care unit, the resident record had been no care plan put into place upon Resident L's admission to protect other residents on the unit from Resident L's history of physical aggression. During an interview on 5/16/24 at 12:30 p.m., Licensed Practical Nurse (LPN) 8 indicated Resident L would make laps around the secured unit in his wc by pulling himself using the handrail. Recently he got upset and bumped into Resident N as he was pulling himself along and she was sitting in the doorway of her room with her legs out into the hallway. LPN 8 indicated, she did not think Resident L had anything against Resident N, she was just in his way. During an interview on 5/16/24 at 12:32 p.m., CNA 7 indicated Resident L could be easily diverted unless he was already mad when they got to him, then she would push him in his wc around the unit several times until he calmed. During an interview on 5/17/24 at 9:47 a.m., LPN 14 indicated, Resident L required total care with ADLs, except he could transfer with assistance and feed himself. The resident would propel himself in a wc with his feet, and he liked to propel himself in the hallways by grabbing the railing. Resident L displayed behaviors when he was agitated like when staff repeatedly encouraged him to sit down and not fall. To help calm the resident, the staff either let him roll around in the hallway, used conversation to divert him, give him a snack or drink, or put him at a table with things for him to handle and rummage through, it did not take a lot to distract and calm him. LPN 14 indicated in her opinion it was mostly about how others approached him. 2. An Indiana State Department of Health Survey Report System report, dated 5/12/24 at 6:32 p.m., indicated the nurse noted swelling and pain of Resident K's left arm. The NP ordered a stat (as soon as possible) x-ray and x-ray results indicated a fracture of the left ulnar shaft (the longer of the two bones in the forearm - helps to move the arm, wrist, and hand). Resident K was sent to the ER (emergency room ) per the NP's orders. Root cause to be determined. A follow-up dated 5/16/24 indicated investigation continues. On 5/16/24 at 11:20 a.m., Resident K was observed seated in the dining room at a table with another female peer, her wc was positioned in the aisle with other residents passing in the narrow space behind her. Resident L was observed being propelled out of his room in a wc by an CNA 10, they passed behind Resident K on the way to seating him with a table between the two residents. Resident K and L's rooms were observed to be side by side within 6 feet of the dining room. On 5/16/24 at 11:25 a.m., Resident K was observed in the dining room at 1 of 5 tables within 15 feet of the doorway to her room. A white hard cast was observed on her left arm from below the elbow to mid fingers and around the thumb. A skin tear and purple discoloration were observed above and below her left elbow. Resident K pointed to the cast and indicated, it's swelled up and hurts in there. Resident K's record was reviewed on 5/16/24 at 2:00 p.m. Diagnoses on Resident K's profile included, but were not limited to, 4/1/24 unspecified dementia without behavior disturbance. Diagnoses added after identification of the ulna fracture included 5/13/24 other specified disorders of bone density and structure, unspecified site (osteopathies [disease of the bone] or chondropathy [disease or disorder that affects the cartilage in the body]), 5/14/24 unspecified fracture of lower end of left ulna, and 5/15/24 pain. A progress notes, dated 4/30/24 at 5:10 p.m., Resident K was walking in the hallway with Resident M this morning and followed her into Resident L's room. Resident L became agitated with them in his room and exhibited a physical behavior toward Resident K by using part of his wc and made contact to her left arm causing a skin tear. Staff did not witness the event. An initial wound review, dated 5/01/24 at 12:15 p.m., indicated Resident K had a skin tear on her left forearm that measured 6.0 centimeters (cm) x (by) 2.0 cm, with bruising surround the area measuring 4 cm x 4 cm, caused from physical contact with a wc arm. The resident's care plan was updated for intrusive wandering. A progress notes, dated 5/09/24 at 12:05 p.m., indicated Resident K was grabbed by Resident L who became aggressive thinking this resident's wheelchair was in his way. No new skin areas noted, previous bruises remain and skin tear with steri strips intact to left lower arm. Complaint of pain and slight discomfort to dressing sight, Tylenol given with positive effect at this time. A progress notes, dated 5/09/24 at 12:35 p.m., indicated Resident K was seated at a table eating her breakfast when Resident L tried to pass by her in his wheelchair. He grabbed her left arm and tried to move behind her. Resident K yelled at him to let go and he then yelled back at her but did not release his grip. Staff immediately came to separate residents and needed extra time to redirect male resident to let go. Resident K was taken to her room to finish breakfast and to be checked by the nurse, and Resident L left the dining room in his wheelchair and moved down the hallway. An intervention was added that Resident K would be seated on the window side of the table where there was no pass-through for wheelchairs. A progress notes, dated 5/12/24 at 1:31 p.m., indicated Resident K's left arm had swelling especially to the wrist and forearm. The NP gave new orders to x-ray the arm stat. A radiology results notification, dated 5/12/24 at 9:15 p.m., indicated the left forearm had soft tissue swelling, and an acute left distal ulnar shaft fracture (on the pinky side of the arm and above the wrist). A physician's order, dated 5/15/24, give acetaminophen tablet (analgesic) 500 milligrams (mg) 2 tablets (1000 mg) by mouth three times daily for pain. A progress notes, dated 5/12/24 at 10:49 p.m., indicated the resident was observed with a clean dressing on her left forearm. There was swelling of the fingers and left hand, and the resident complained of pain in the left hand which worsens with movement. An X-ray done on the left hand showed the presence of a fracture at this level. The resident was referred to the hospital for better care, and left by ambulance at 10:35 p.m. A progress notes, dated 5/13/24 at 3:32 a.m., indicated the resident returned to the facility from the hospital with a splint on her left arm for comfort. No new orders given. Resident was to follow up with an orthopedic clinic within 3-5 days. A progress notes, dated 5/13/24 at 3:06 p.m., the resident's splint and sling were intact, the dressing was changed, and the steri-strips were intact. Limited range of motion, and increased assistance was required with ADL's (activities of daily living - i.e. bathing, dressing, eating, toilet use). A progress notes, dated 5/15/24 at 2:17 p.m., indicated the resident returned from her orthopedic appointment with a cast to the left forearm. The radiology report indicated the resident had an acute left distal ulnar shaft fracture. A progress notes by the NP 15, dated 5/15/24, indicated Resident K was seen for evaluation and management of her left ulnar fracture and pain. She had complaints of increased pain, swelling and decreased range of motion to her left wrist over the weekend. An x-ray was completed that showed an acute left distal ulnar shaft fracture with mild displacement. She was sent to the ER for evaluation. She had a brace and sling placed with orders to follow up with orthopedics, scheduled for today. She was at high risk for fracture due to her advanced age and osteopenia. She was observed up in a wc, she did endorse discomfort with her left wrist. She was not currently on any scheduled pain relief. New orders were given to start Tylenol 1000 mg by mouth three times daily. An orthopedic MD history and physical, signed off 5/16/24, indicated this was a [AGE] year old patient who was in a group home. Another patient from the group home grabbed her hair and twisted the arm. Apparently, he was very aggressive. The patient after that started to have pain in the left upper extremity. Also, she had skin wounds in the proximal aspect of the forearm with a cut that was more superficial. She had basically a fracture of the distal 3rd of the ulna. There were some concerns of a possible fracture in the elbow. Procedure: A left fiberglass short arm cast with regular padding was applied and appropriately molded to maintain satisfactory alignment. The skin laceration that she had was glued with a wound glue to protect the area. An annual MDS review assessment completed on 3/13/24, assessed the resident as having the ability to make herself understand and to understand others. A BIMS score of 6/13 indicated severe cognitive impairment. No falls since prior assessment 12/15/23. During an interview on 5/16/24 at 11:00 a.m., the ED indicated Resident K was [AGE] years old with brittle bones. Staff had not reported a fall until the day before when the resident attempted to toilet independently and staff assisted her off the bathroom floor. The ED indicated she had no idea how Resident K obtained the ulnar fracture, the pain and swelling had not manifested until over the weekend. During an interview on 5/16/24 at 12:00 p.m., CNA 7 indicated the first encounter between Residents K and L happened on 5/1/24 when another resident entered Resident L's room thinking it was her room and Resident K followed her into the room. There was yelling but no physical contact among the residents. On 5/9/24 she was working but not within sight of resident's K and L when she heard yelling. She circled around the dining area to where she could see them and observed a therapist attempting to get Resident L's hands off of Resident K, he was holding tightly with both hands on her left forearm, one hand at the wrist and one hand below the elbow. CNA 7 indicated it took her and the therapist to pry Resident L's hands loose, and when they got his hands off her arm, there were red marks on Resident K's arm. CNA 7 indicated, staff attempted to keep an eye on Resident L when he was out of his room and used a lot of diversion as needed when he encountered other residents, he could get upset quickly when he perceived others to be in his way or bothering his things in his room. During an interview on 5/16/24 at 3:40 p.m., Occupational Therapist (OT) 11 indicated, on 5/9/24 she was in the memory care unit dining room during breakfast working, when she was alerted to a situation between Residents K and L. OT 11 indicated, she was the only staff member in the dining room at the time, so she got up and immediately went to the residents to see what was happening. OT 11 observed Resident L was holding Resident K's left lower forearm. Both residents were screaming at each other non-sensicle verbiage but there was no real conversation happening between them. OT 11 indicated she got behind Resident K and tried to get Resident L to let go but he would not. The whole situation happened so fast, and OT 11 was focused on keeping Resident K's arm as straight as possible, so it was stabilized, as Resident K was attempting to get her arm away, and both residents were pulling in opposite directions. Soon after a CNA and a nurse approach, came around on her other side facing Resident L, and staff finally got Resident L to let go, and the residents were separated. During a phone interview on 5/16/24 at 5:15 p.m., Resident K's attending physician indicated he had not yet seen the final notes from the orthopedic specialist finalized that date. He indicated, NP 15 had seen Resident K on 5/9/24 soon after the altercation with the male resident, and at that time the resident had no obvious injury. However, that did not rule out an injury as anyone with dementia dependent on the day might not comprehend there was pain or an injury. A few days later when Resident K had symptoms of decreased mobility, pain, and edema in the left arm, x-rays were ordered with a return diagnosis of an ulna fracture. The attending physician indicated, it was hard to tell how the fracture happened, but if the final report from the orthopedic specialist documented a spiral fracture, he could not rule out the resident's injury was related to the altercation with the male resident. On 5/17/24 at 11:02 a.m., the Executive Director provided a policy, titled, Behavior Management & Monitoring Program, dated 8/22. The policy indicated, It is the policy of [facility name] to provide behavior interventions for residents with problematic or distressing behaviors. Interventions provided are both individualized and non-pharmacological and part of a supportive physical and psychosocial environment that is directed towards preventing, relieving, and/or accommodating a resident's behavioral expressions. Procedure: 1. Care plans shall be initiated for any behavioral expression that is problematic or distressing to the resident, other resident, or caregivers. Care plan interventions should include individualized and non-pharmacological interventions which address both proactive and responsive interventions. 2. Care plans should be initiated when a resident is receiving psychotropic medication used to treat either mood or behavior. The care plan should clearly identify the specific mood, thought process or behavioral expression which the prescriber has identified as the indication for use of the psychotropic medication .7. Direct care staff will be educated as to the interventions for residents reviewed by the IDT [interdisciplinary team] On 5/17/24 at 11:02 a.m., the Executive Director provided a document, titled, Resident Rights, dated 11/15. The policy indicated, a facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident, and all residents shall be free from mental and physical abuse. The resident has a right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and support for daily living safety. 3.1-37(a)

Based on observation, record review, and interview, the facility failed to ensure that kitchen equipment was free from disrepair, ensure appropriate low temperature dishwasher chemical sanitization levels, and failed to ensure food was stored at appropriate temperatures for 2 of 2 days of kitchen observation. This issue had the potential to affect 64 of 66 residents who resided in the facility and received dietary services from the kitchen. Findings include: 1. On 10/19/23 at 10:15 a.m., the Dietary Manager (DM) sent a rack of bowls through the dishwashing machine. One bowl was left right side up to collect water during the cycle. When the cycle was completed, the DM tested for chemical sanitization levels using Hydrion QT 40 chemical test strips. He dipped the test strip into the bowl that had filled during the cycle, read the result to be zero parts per million (ppm). He repeated the chemical sanitization testing process a second time, he read the result was still zero ppm. At 10/19/23 at 10:17 a.m., the DM refilled a jug above the dishwashing machine with a yellow substance labeled Eco-San, he indicated it was the sanitizing solution that went into the dishwashing machine. He indicated it was not empty, he filled it up to be sure that was not the problem. On 10/19/23 at 10:18 a.m., the DM repeated the chemical sanitization testing process for a third time, he read results to be zero ppm and indicated it was supposed to be above 50 ppm and less than 200 ppm. On 10/19/23 at 10:20 a.m., the DM repeated the chemical sanitization testing process for a fourth time, he read result to be zero ppm. He indicated he would try different strips. On 10/19/23 at 10:21 a.m., the DM repeated the chemical sanitization testing process for a fifth time, with new strips, he read the result to be zero ppm. He indicated he was going to drain and refill the dishwashing machine. On 10/19/23 at 10:24 a.m., the DM used the chemical test strips to check the chemical levels in the quaternary (sanitizing solution) buckets that were near dish machine and read the result to be 150 ppm. He indicated the test strips were working. On 10/19/23 at 10:27 a.m., the DM repeated the chemical sanitization testing process for a sixth time after the machine had refilled. He read the results at 10 ppm. On 10/19/23 at 10:29 a.m., the DM repeated the chemical sanitization process for a seventh time. He read the results to be 100 ppm and that it was supposed to be between 50 ppm -100 ppm. He indicated staff tested and recorded the results daily after breakfast. On 10/24/23 at 9:00 a.m., the ED provided a document titled, Product Specification Document, Eco-San, undated, and indicated this was the user guide currently being used by the facility. The document indicated . liquid chlorine sanitizer and destainer specifically formulated for use in low temperature chemical warewashing machines .tableware sanitizer and destainer for mechanical spray warewashing machines. For sanitizing tableware in low temperature warewashing machines, inject Eco-San into the final rinse water at a concentration of 100 ppm available chlorine. Do not exceed 200 ppm. To ensure that available chlorine concentration does not fall below 50 ppm, periodically test the rinse solution with a suitable test kit and adjust the dispensing rate accordingly 2. On 10/19/23 at 10:09 a.m., hotbox (used to heat up food) observed with DM to be on and in use with cooked mashed potatoes and puree burgers inside. The temperature gauge on the outside was not functioning, no thermometer was located on the inside. DM indicated a thermometer was normally inside the hotbox, he did not know how long it had been broken. He removed a thermometer from inside another oven and placed it inside the hotbox. On 10/23/23 at 10:26 a.m., second observation of the hotbox with the DM, the hotbox external temperature gauge was not functioning, no internal thermometer located inside. On 10/24/23 at 9:06 a.m., the Executive Director (ED) indicated she had the hotbox removed from the kitchen and she did not know why they used it in the first place. On 10/24/23 at 10:10 a.m., the DM indicated they got rid of the hotbox because the thermometer did not work, there was not a plan to replace it. On 10/25/23 at 12:02 p.m., the ED indicated no one had reported the hotbox as being in disrepair prior to it being removed. On 10/24/23 at 9:00 a.m., the ED provided a policy dated 3/23 of unknown year titled, Kitchen Safety Guidelines, indicated the policy was the one currently being used by the facility. The policy indicated, . 2. All employees will report defective equipment, unsafe conditions, acts, or safety hazards to the supervisor and/or the maintenance department . 12. The maintenance department is responsible for routine inspections and repair of fans, vents, and equipment . 3.1-21(i)(3)

Based on observation, interview, and record review, the facility failed to ensure a resident did not have tangled and matted hair (tangled into a dense mass) for 1 of 4 residents reviewed for activities of daily living (ADL) care (Resident 47). Findings include: On 10/19/23 at 12:10 p.m., Resident 47 was observed in her bed with her hair not brushed. Her hair was severely tangled and standing up on its ends. She was unwilling to show the back of her hair at this time. Her lunch had just arrived, and she was agitated with questioning. On 10/19/23 at 8:45 p.m., a family interview was completed. Her daughter indicated Resident 47's hair had not been brushed in weeks. It was so tangled now that she could not brush it out. The resident's preference was to have her hair brushed into a bun on top of her head with a head band at her hairline. Her hair had been extremely tangled for several weeks. Her daughter indicated she wanted Resident 47 to have clean and detangled hair. On 10/20/23 at 2:35 p.m., Resident 47 indicated the staff didn't brush her hair. Her hair was observed to be severely tangled in its ends, but the top layer of her hair had been lightly smoothed out and a purple decorative comb (used to hold hair back) had been pressed into the tangles. On 10/23/23 at 2:31 p.m., Resident 47 indicated her hair was matted and she could not comb it. Some of the staff had taken advantage of the fact that sometimes she did not know what was going on. A very large mat of hair was observed on the back of the resident's head encompassing all of the hair on the back of her head. The front and both sides of her hair was further smoothed over the tangles with the purple comb in it. On 10/23/23 at 3:13 p.m., the Director of Nursing Services (DNS) indicated she was not aware of the large mat on the back of Resident 47's head. She indicated the nursing staff should have been aware of this issue since they did weekly skin checks. Her shower sheets were requested at this time, but not received by the end of the survey. On 10/24/23 at 9:51 a.m., Resident 47's record was reviewed. Her diagnoses included, but were not limited to, Alzheimer's disease (brain disorder with memory loss), chronic obstructive pulmonary disease (COPD), and heart failure. A behavioral care plan, dated 9/22/23, indicated she sometimes refused to have ADLs completed such as showers and hair brushing. The interventions were to assess the resident for unmet needs, provided an alternate caregiver, and re-approach at a later time. An ADL care plan, dated 10/13/23, indicated she required assistance with ADLs. The interventions included to assist with bathing as needed per resident preference and assist with dressing, grooming, and hygiene. A cognitive care plan, dated 10/13/23, indicated she exhibited cognitive impairment with a Brief Interview for Mental Status (BIMS) score fluctuations. The interventions were to give resident choices throughout the day regarding decisions as able, provide resident with prompts and cues as needed, and provide simple instructions and repeat as needed. On 10/24/23 at 10:34 a.m., the Executive Director (ED) indicated the facility staff were able to get the large mat out of Resident 47's hair last night. They had to use a lot of de-tangler. On 10/24/23 at 12:01 p.m., Registered Nurse (RN) 14 indicated she sometimes worked with Resident 47. She did not refuse care all the time, but sometimes she refused care. If the staff talked with her a lot, it would help with her cooperation. If she refused care, she could call another RN and talk with her about it. She was unaware whether Resident 47 took showers or bed baths. On 10/24/23 at 12:05 p.m., RN 13 indicated she usually worked on Resident 47's hall and the resident sometimes refused ADL care. If she refused, she would talk to her a couple of times and call her daughter to try to get cooperation. Resident 47 would usually get a bed bath but would sometimes scream with it. Her plan was to give the resident a scheduled pain pill (Tylenol or Tramadol) prior to the bed bath to prevent screaming. She was aware of the large mat on the back of her head from lying in bed but did not document it anywhere in her medical chart. It should have been possible to prevent the large mat on the back of her head if the Certified Nursing Aides (CNA) had been brushing her hair. On 10/24/23 at 12:14 p.m., CNA 15 indicated Resident 47 refused everything and started screaming. She refused to wake-up in the morning when sleeping, refused to eat, and refused bed bath and showers. When she got her up, the resident allowed her to wash her face and arm pits. Then, she said the resident allowed bed baths twice a week but refused her to touch her hair. She was aware of large mat on back of her head and reported to the nurse. She refused care to everyone on staff and was asked to leave her alone. If she called the nurse, the resident still refused. She agreed with changing her disposable brief and washing her face. CNA 15 indicated she did not know how the facility could prevent her hair from matting, but she never tried to use detangler on her hair. On 10/24/23 at 12:24 p.m., Resident 47 was observed in bed with her eyes closed. Her visible hair was pulled back into fabric blue (shower-like) cap. The rest of her hair was unobserved due to her sleeping. CNA 15 indicated Resident 47 usually slept during the day. On 10/25/23 at 11:26 a.m., the DNS indicated Resident 47's care plan indicated she doesn't allow staff to brush her hair. The intervention to re-approach the resident was not always accessible. The facility had a shower cap shampoo available and a silk cap to help prevent issues with her hair. The facility had been trying to brush her hair. On 10/25/23 at 11:26 a.m., the DNS indicated the facility would provide documentation of the resident's preferences for her grooming. This document was not provided. A current document titled, AM Care, dated 2/2010, was provided by the Regional Nurse Consultant (RNC), on 10/25/23 at 12:23 p.m. A review of the procedure indicated to, .comb and style resident's hair per preference 3.1-38(b)(3)

Based on observation, interview, and record review, the facility failed to ensure a resident who admitted to the facility for rehabilitation with a history of falls, received timely fall follow up to prevent falls for 1 of 4 resident reviewed for falls (Resident 38). Findings include: On 10/19/23 at 10:22 a.m., Resident 38 was observed as she laid in bed. A protective medical boot was observed on her right foot. When asked what happened, Resident 38 indicated she had broken her ankle when she fell in her bathroom. It had been her 4th fall in a span of 5 days. She indicated she had just started falling more and more as her legs would get weak and give out, which was what happened that day. She had gone to the bathroom with the assistance of an aide. As she started to back up toward the toilet, she felt her legs get weak, but because her walker was in front of her, and the aide was on the other side of the walker, there was no way the aide could have reached her or assisted her to the floor in a different position. Her legs buckled and the weight of her body collapsing onto her ankle was what caused it to break. Resident 38 indicated she was upset about the fall and her fracture because it had caused her to lose all the progress she had made. She was not longer able to get out of bed by herself, she was no longer able to use the bathroom by herself, and all her transfers had to be completed with a Hoyer lift. She felt embarrassed that she could no longer use the bathroom and had to mess herself in a brief, and now relied to wait on staff to come clean her up. She was afraid this would lead to bed sores, and she became tearful as she indicated, now I'm afraid I'll never walk again. On 10/24/23 at 2:28 p.m., Resident 38's medical record was reviewed. She admitted to the facility with diagnoses which included, but were not limited to, idiopathic peripheral autonomic neuropathy (damage of the peripheral nerves where cause cannot be determined and there are often symptoms that affect the feet) lack of coordination, muscle weakness, unsteadiness on feet and abnormalities of gait/mobility. The most recent comprehensive assessment, as an admission Minimum Data Set (MDS) assessment dated [DATE]. The MDS indicated Resident 38 was cognitively intact and required limited to extensive assistance of at least one staff member for her Activities of Daily Living, (ADLs). Specially, she required extensive assistance to transfer and use the toilet. Resident 38 received physical therapy (PT) rehabilitation services between 2/28/23 to 5/4/23 and her corresponding PT discharge summary indicated the following: a. At the beginning/baseline of therapy on 2/28/23, she required 70% moderate assistance for sit-to-stand from varied surfaces. Upon discharge she had reached her goal and was only required stand by assistance. b. She was discharged from therapy and placed on a restorative nursing ambulation program in order to maintain her ability to walk up to 200 feet with her front-wheeled-walker and stand by assistance. A nursing progress note dated 3/31/23 at 6:00 a.m., indicated, Resident 38 was heard screaming for help. Staff entered the room to find her sitting on the floor. She indicated she bent over to pick something up off the floor and lost her balance. She required the use of a Hoyer lift to transfer back into bed. At the time of the fall, was reminded to use her call light for assistance. An Interdisciplinary Team (IDT) progress note dated 3/31/23 indicated a Reacher was provided for Resident 38 to use to pick items up off the floor. A nursing progress note dated 4/11/23 at 9:05 p.m., indicated, Resident 38 sustained a second fall as she ambulated back from the restroom. She called for help, and upon assessment she complained of feeling lightheaded, dizzy and had heart palpation. She was pale, diaphoresis (sweating) and had periods of shortness of breath. The NP was notified and gave a new order for a STAT (immediate) lab to include a BMP and CBC (which were received an unremarkable). The record lacked documentation of an IDT fall follow up, and no root cause intervention was placed. Resident 38's Medicare charting/progress notes from the time of her admission to the time of her discharge on 5/4/23 indicated, she required extensive assistance with her ADLs and transfers. A quarterly MDS assessment, dated 5/30/23, indicated, her ADL self-performance abilities had improved to only require limited assistance for transfers (even though her Medicare charting indicated extensive assistance). A nursing progress note dated 8/5/23 at 9:26 p.m., indicated, Resident 38 experienced a 3rd unwitnessed fall. She was found in her room sitting on her buttocks with her back on the side of her bed. She indicated she tried to sit down on her recliner, but she fell short and tried to sit on the bed instead to prevent a fall, but was unable to, and fell to the floor. She required the assistance of three staff members and the Hoyer lift to get her back into her recliner. She complained of bearable soreness in her left leg. At the time of the fall, she was reminded to ask staff and use her call light for assistance. An Interdisciplinary Team (IDT) progress note, dated 8/7/23 at 3:07 p.m., indicated, Occupational Therapy (OT) was referred to ask for an evaluation for transfers. The record lacked documentation that a therapy referral had been placed. A NP progress note, dated 8/9/23 at 1:41 p.m., indicated, the resident was reviewed for recent labs. The evaluation did not include a review of her 8/7 fall. A nursing progress note dated 9/19/23 at 12:38 a.m., indicated, Resident 38 had an unwitnessed fall, (4th in total) She was found sitting on the floor and indicated she went to the bathroom but lost her balance as she went back to her chair. She indicated she hit the back of her head but had no bumps or pain. She was transferred back to her recliner with a Hoyer lift. The intervention put in place at the time of her fall was to remind her to call staff for assistance. An IDT progress note, dated 9/19/23 at 10:54 a.m., indicated the root cause analysis of her fall had been weakness during ambulation which resulted in a fall, so the IDT placed a referral to PT for evaluation. A nursing progress note, dated 9/20/23 4:04 p.m., indicated, Resident 38 had an unwitnessed fall, (5th in total). She was found sitting on the floor of her bathroom with both legs stretched out in front of her. She denied hitting her head and did not complain of any pain at that time. It took 5 staff members and a Hoyer lift to get her up and back into her recliner. The interventions put in place at the time of the fall was to remind Resident 38 to ask staff for help. An IDT progress note dated 9/21/23 at 3:29 p.m., indicated, the root cause determination of her fall had been weakness and the follow up intervention was to review her medications and place an OT referral. Although she was seen by the NP that same day and some medication adjustments had been ordered, the record lacked documentation that a PT and/or OT eval could be conducted before she sustained another fall on 9/22/23, (her 6th in total). A PT referral had been placed on 9/19/23, she was not evaluated until 9/28/23 after her return from the hospital on 9/22/23 with a fractured tibia. A nursing progress note dated 9/22/23 at 2:44 a.m., indicated, Resident 38 followed instructions to ask staff for assistance and put her call light on to go to the bathroom. She became weak in the knees and was lowered to the floor. When the nurse arrived, she observed Resident 38 to be on her knees holding onto the grab bar. The mechanical lift was unable to be fitted into the bathroom to assist her up, and 911 was called for assistance to get her up and out of the bathroom. She complained of pain in her ankles and requested the EMTs take her to the hospital. A corresponding hospital discharge summary, dated 9/22/23 indicated, Resident 38 returned from the hospital. She was diagnosed with another UTI and had sustained a right malleolar (ankle) fracture. During an interview on 10/25/23 at 9:58 a.m., the Director of Therapy Services (DTS) indicated, in her review of the Resident 38th therapy referrals, no referral had been placed after the 8/5/23 fall. She also indicated that a PT referral should have been requested instead of an OT referral, but there had been no follow up to clarify and/or complete the referral at that time. During an interview on 10/25/23 at 12:28 p.m., PT Assistant (PTA) 18 indicated, typically a new therapy referral would be followed up by the next business day but was variable due to the case load and/or situation. During an interview on 10/25/23 at 2:06 p.m., the DTS indicated, referral follow up should be completed within 7-10 days after the referral but depended on the situation and case load. The DTS indicated, at the time the referral had been placed she was on persona leave. During an interview on 10/25/23 at 3:15 p.m., the Director of Nursing Services (DNS) indicated, ideally if the nursing department made a referral to therapy, she would expect them to be seen within 1-2 days but would defer to the therapy department depending on their schedules. On 10/25/23 at 12:15 p.m., the Regional Nurse Consultant (RNC) provided a copy of current facility policy titled, Fall Management Policy, revised 8/2022. The policy indicated, It is the policy of American Senior Communities to ensure residents residing within the facility receive adequate supervision and or assistance to prevent injury related to falls . Post Fall . 5. A fall event will be initiated as soon as the resident has been assessed and cared for. The report must be completed in full in order to identify possible root causes of the fall and provide immediate interventions. 6. All falls will be discussed by the interdisciplinary team at the 1st IDT meeting after the fall to determine root cause and other possible interventions to prevent future falls On 10/25/23 at 12:15 p.m., the RNC provided a copy of current facility policy titled, Nursing Referrals to Therapy, dated 5/2018 (with no revision date). The policy indicated, To ensure there is standardized communication to the therapy department when a screen is being requested. When a change in resident functional status is noted a member of the nursing team will open up and complete a Nursing Referral to Therapy Observation, in Matrix EMR for therapy communication. The Director of Therapy/Designee will run the Matrix Observation Report daily to identify any new referrals from nursing to therapy 3.1-45 3.1-37

Based on observation, interview, and record review, the facility failed to ensure a dialysis resident's strict fluid restrictions were followed, STAT labs were completed as ordered, dialysis care plans and assessments were for the correct site, and transportation to dialysis was not missed for 1 of 1 resident reviewed for dialysis (Resident 44). Finding include: On 10/23/23 at 9:00 a.m., Resident 44 was observed with his eyes closed and appeared to be asleep. There was a plastic kitchen cup beside him on the bed which was observed to have water in it. On 10/23/23 at 11:07 a.m., Resident 44 was not in his room, as it was his scheduled Dialysis day. On 10/24/23 at 9:16 a.m., Resident 44 was observed in the activity lounge. He held a plastic cup full of water and drank it as staff walked by. During an interview on 10/24/23 at 9:38 a.m., Resident 44 indicated he was on Dialysis and went every Monday, Wednesday, and Friday. His access site was on his left forearm and he pulled up the sleeve to show that it was active, and no concerns were noted at that time. He indicated he used to have a port for access in his chest, but that had been closed off for a long time. Resident 44 indicated because his kidneys were so bad, he was also on a strict fluid restriction and was only allowed three cups a day. It was hard to manage the fluid restriction because he found himself to always feel thirsty. He also went out a lot to different activities and moved through the facility on his own and that often made him even more thirsty. Staff remind him when he could not have more water, but did not offer any other options like gum, or mints, or suckers, or something else just to satisfy his craving. If he did have too much water or fluid overload, his symptoms made him feel short of breath, and feeling like he couldn't breathe made him anxious. One night her remembered he was going up and down the halls looking for help when he started to feel off. He could not find anyone, and he was afraid he was going to die, so he called 911 himself and had to go to the hospital. During an interview on 10/24/23 at 11:36 a.m., the Director of Nursing Services, (DNS) indicated Resident 44 was very non-compliant with his fluid restriction, so much so that at one point he was taken off the restriction, but after his last hospitalization he was put back on. When he had too much to drink his symptoms were shortness of breath, that would often make him feel anxious. She indicated he did also have some mental illness and would often refuse to use supplemental oxygen. He was alert and oriented, and able to make his needs know, especially when he's had too much to drink, he could tell by his symptoms. During an interview on 10/24/23 at 12:58 p.m., Qualified Medication Aid (QMA) 19 indicated, sometimes Resident 44 was really good about his fluid restriction and went to dialysis faithfully. Sometimes he would ask for more water or sneak water without letting staff know. QMA 19 indicated he usually asked for more water in the evenings when he was alone and board in his room. She indicated sometimes he would keep the cup of water from the morning medication pass and refill it at the water stations throughout the day. Staff would remind him not to, but that was all they could do. During an interview on 10/24/23 at 1:00 p.m., the Activity Director (AD) indicated Resident 44 was very active in the activity program and liked to go on outings and go to group activities. The AD and his staff were aware of his fluid restriction, and they should remind him not to drink too much if he asked, but that was hard to do sometimes since many of the activities included snacks and drinks. During an interview on 10/25/23 at 9:36 a.m., with the DNS and Regional Nurse Consultant (RNC) present, the DNS indicated although Resident 44 was alert and oriented and could make his needs and wants known, he had a mental illness and often was not able to understand that by drinking too much water, it could be harmful. When asked what some other options for someone of a fluid restriction were because just reminding him not to drink too much, the RNS indicated maybe he could have some sugar free mints, because he was also a diabetic. On 10/25/23 at 10:00 a.m., Resident 44's room was observed (he was out to Dialysis at that time). There were three plastic cups thrown away in the trashcan at the foot of his bed. There was an empty plastic kitchen cup beside his recliner on the bed. On 10/25/23 at 10:01 a.m., Resident 44's room was observed with QMA 19. She indicated it could potentially be a problem to throw his medication water cups away in his room because he could pick them out and use them. She suggested maybe the nursing staff should take the medication water cups out of the room when they passed meds instead of throwing them away in his room. During an interview on 10/25/23 at 10:03 a.m., Certified Nursing Assistant (CAN) 20 indicated sometimes Resident 44 was noncompliant with his fluid restriction but when he had too much to drink he was able to tell them. When asked what staff should do when he was found to be drinking more than he should, she indicated the only thing they could do was just to remind him not to drink too much. During an interview on 10/25/23 at 10:05 a.m., Infection Preventionist (IP) 9 indicated Resident 44 sometimes sneaked cups of water or other beverages when he knew he shouldn't have them. Staff were not supposed to keep water at his bedside, and she was unaware that his medication pass cups were being left in his room. On 10/23/23 at 9:05 a.m., Resident 44's medical record was reviewed. He was a long-term care resident with diagnoses which included, but were not limited to, end stage renal disease, chronic obstructive pulmonary disease (COPD), schizophrenia, unspecified anxiety, and type II diabetes. He had a physician's order for his Dialysis access site on his left forearm, but he also still had an active order for an access site on his right upper chest. He had a physician's order for a 1500 ml (milliliter) fluid restriction. A nursing progress note, dated 3/14/23 at 6:58 p.m., indicated, Resident 44 was very anxious. He was given a nebulizer treatment for shortness of breath, but it had not been effective. Supplemental oxygen was offered, but he did not wear it, and his oxygen saturations ranged between 75%-95%. Although the note indicated, resident placed on MD list to be assessed in the a.m. the record lacked documentation the physician had been notified of his change of condition at that time. A Dialysis Run Log dated 3/15/23 indicated, Resident 44 complained of Shortness of breath when he laid down and had swelling in his lower legs at 4+ pitting edema. Both his ankles and lower legs were noted to with 4 to 6 millimeters (mm) indent noticeably deep, lasts more than 1 minute, extremity swollen. A Nurse Practitioner (NP) progress note dated 3/15/23 indicated, Resident 44 had been seen that day for follow up for his hypoxia, and .resident is being seen today for complaints of increased anxiousness. Per reports of the facility's staff, residents sats ranged between 75-95% . Upon physical assessment, he was noted to have trace edema to his right lower extremity, and 2+ edema to his left lower extremity. A STAT (immediately or as soon as possible) lab order was placed on 3/15/23 at 11:56 a.m. The record lacked documentation of nursing follow up to obtain the STAT labs. The lab was not collected until 3/16/23 at 1:10 p.m., (approximately 26 hours after the order was placed). An Event note, dated 3/15/23 at 11:59 a.m., indicated Resident 44 was placed on a 15000 ml fluid restriction, labs were ordered and he was to have a repeat Dialysis session the following day. An NP visit and treatment note, dated 3/15/23, indicated, .per the nursing staff, patient was having shortness of breath last night with increase restlessness- saturation maintained after patient was placed on 2 liters of oxygen. Spoke with nephrologist and nursing while he was in the dialysis- patient has fluid overload and needs extra Dialysis- scheduled for dialysis tomorrow morning at 6:00 a.m. An NP visit and treatment note, dated 3/16/23, indicated, .he missed dialysis this morning at 6:00 a.m. related to transportation issue- as per the nursing transportation was arranged for 5:30 a.m., but no one showed up to take the patient to dialysis . Plan: .chest x-ray completed that showed moderate CHF [congestive heart failure] with small bilateral pleural effusion- results communicated with nephrologist- 'OK' to monitor patient today since he is doing ok with saturation and will see him in the dialysis tomorrow. Spoke with dialysis nurse and requested longer dialysis tomorrow if possible and check schedule for any chair on Saturday if any chair is available in case patient needs additional days of dialysis . consider sending patient to the hospital for increase shortness of breath and saturation not maintained at 4-6 liters A nursing progress note, dated 3/16/23 at 10:37 p.m., indicated, Resident 44 removed his oxygen tubing and started yelling and screaming, nurse! Nurse! oxygen saturation between 78-88% without oxygen. The nurse replaced his oxygen nasal cannula and saturation up to 95%, medications and breathing treatments given as ordered and Resident was encouraged to take deep breaths and relax. The note lacked documentation of physician notification. A nursing progress note, dated 3/17/23 at 5:22 p.m., indicated, Resident 44's Dialysis center contacted the facility and informed the nurse he had been transferred to the hospital from dialysis due to fluid overload. The corresponding Hospital admission report dated, 3/17/23 at 7:33 p.m., indicated, .presented to the ED [emergency department] yesterday with fluid overload. He started out the week at 15 kg [kilograms] over his DW [dry weight] and despite best efforts by hemodialysis center he remains 5-6 kg over his dry weight. The nursing home is unable to provide him transportation for extra treatments, and yesterday after dialysis he was still requiring 4L of 02 to maintain 02 sats 88-90% It was decided he would probably not make it through the weekend without additional dialysis, so he was brought to the ED for further Eval Resident 44 had a comprehensive care plan initiated on 4/4/19 and indicated, he was at risk for fluid imbalance due to: Dialysis, his need for assistance with food/fluid and was on a fluid restriction. Despite staff education and encouragement for resident to follow potassium restricted diet as well as decrease fluid intake to prevent fluid overload; resident continues to eat foods outside his diet order and drink fluids throughout the day without always consulting with staff . Interventions for this plan of care included, to record intakes, provide labs as scheduled, document and notify MD of signs and symptoms of fluid volume deficit . and to administer medications. On 3/23/23, after he returned from the hospital, a new intervention was added to for his fluid restriction to have no water at bedside. A nursing progress note, dated 6/13/23 at 2:40 p.m., indicated, Resident 44 came to the nurses' station and reported not feeling well. His vital signs were taken and his blood pressure was high. The NP gave a new order to give him hydralazine (a blood pressure medication). A nursing progress note, dated 6/17/23 at 9:59 p.m., indicated, Resident 44 came to the nurses' station around 8 p.m., and was noted to be anxious, was shouting and verbalized I'm feeling horrible and terrible! He was given a dose of hydralazine at 8:11 p.m., and encouraged to relax and was offered a snack. Resident came in again and verbalized he felt better but still felt anxious. NP on call spoke with the Resident via phone and ordered a one time dose of Pepto-Bismol and hydroxyzine 25 mg. A nursing progress note, dated 6/18/23 at 3:56 a.m., indicated Resident 44 continued to complain that he did not feel well between 2:00-3:00 a.m. He acted restless, felt hot and was on edge. His blood pressure was 179/90 and his as needed hydralazine was given, but resident after 10 minutes he started to yell out and asked to be sent to hospital. The NP ordered the as needed blood pressure medication and to give him Tylenol for general comfort. A nursing progress note, dated 6/19/23 at 2:40 a.m., indicated, Resident 44 continued to complain of feeling that something is wrong. He was anxious, restless and could not settle down. The Nurse encouraged oxygen, but Resident 44 called 911 and went to the hospital. The corresponding hospital summary, dated 6/19/23, indicated, .presented today from his nursing facility with complaints of shortness of breath that began last night. He reports drinking too much fluid this weekend and began to have dyspnea yesterday evening for which he was placed on 3L of oxygen at his facility. He does not typically use oxygen at home. He reports minimal improvement with oxygen and called EMS at 1:30 a.m. Upon arrival to the ER he complaint of continued shortness of breath despite utilization of 3L oxygen and saturation level found to be 88% . Upon interview today patient is laying comfortably in bed and anxiously asks about when he will receive dialysis. He was scheduled to undergo dialysis today as an outpatient at 10:00 a.m. but reports being unable to wait due to continued shortness of breath. Chest x-ray obtained shows findings indicative of volume overload/congestive heart failure with pulmonary edema . patient also found to have blood pressure 222/101 during interview but denied chest pain, headaches, nausea or vomiting Upon his return from the hospital, an intervention was added to his comprehensive care plan, noted above, on 7/25/23 to encourage resident to be compliant with fluid restriction. On 10/24/23 at 3:30 p.m., the DON provided a copy of current facility policy titled, Labs and Diagnostics, dated 11/2017. The policy indicated, It is the policy of American Senior Communities to provide or obtain laboratory and diagnostic services to meet the needs of its residents. The facility is responsible for the quality and timeliness of the services . the facility must have contracts in place if they are utilizing vendors to provide radiology and laboratory services The corresponding vendor contract, Exhibit B, Statement of Work, was provided by the RNC on 10/25/23 at 2:45 p.m. The contract indicated, .C. Vendor provides STAT (life threatening situation) services 24 hours per day, 365 days per year. Laboratory STAT testing will be reported within four (4) hours . Vendor shall respond to an ASC Location's request for STAT services within 30 minutes On 10/25/23 at 12:15 p.m., the RNC provided a copy of current facility policy titled, Resident Change of Condition Policy, revised, 11/2018. The policy indicated, It is the policy of this facility that all changes in resident condition will be communicated to the physician and family/responsible party, and that appropriate, timely, and effective intervention takes place . Acute Medical Change: a. any sudden or serious change in a resident's condition manifested by a marked change in physical or mental behavior will be communicated to the physician . During an interview on 10/25/23 at 12:15 p.m., the RNC indicated there was not a policy which addressed fluid restrictions, only a policy for hydration management. The policy was provided at this time. It was titled, Hydration Management, revised 11/2017. The policy indicated, .fresh water or other preferred beverages will be passed to all residents, unless medically contraindicated but did not address fluid restriction and/or alternative methods/interventions/approaches for residents who required a fluid restriction. On 10/25/23 at 12:15 p.m., the RNC provided a copy of current facility policy titled, IDT Comprehensive Care Plan Policy, revised, 8/2023. The policy indicated, It is the policy of this facility that each resident will have an interdisciplinary comprehensive person-centered care plan developed and implemented based on Resident Assessment Instrument (RAI) process. The Care plan must include measurable goals and resident specific interventions based on resident needs and preferences to promote the resident's highest level of functioning including medical, nursing, mental and psychosocial well-being 3.1-37

Based on observation, interview, and record review, the facility failed to ensure extended-release medications were not crushed to prevent significant medication errors for 1 of 2 residents reviewed who had gastric tubes (tube inserted in stomach to receive nutrition and medication) in place (Resident 6). Findings include: The record for Resident 6 was reviewed on 10/23/23 at 9:45 a.m., diagnoses included, but were not limited to, dysphagia following cerebral infarction (difficulty swallowing following a stroke), gastrostomy status (tube inserted in stomach to receive nutrition and medication), hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (partial paralysis), aphasia (inability to swallow), and hypertensive (high blood pressure) heart disease with heart failure. Progress note, dated 8/17/2023 at 11:38 a.m., indicated resident now NPO (nothing by mouth) with gastrostomy. Tube feeding and water flushes only for nutrition. Physician order, dated 8/12/23, indicated to administer Metoprolol succinate (beta-blocker that treats high blood pressure) 25 milligram (mg) extended release (ER), one tablet daily through gastric tube. Physician order, dated 8/12/23, indicated staff may crush appropriate medications and administer per G-tube (gastric tube). Special instructions indicated to dissolve each crushed medication in at least 10 milliliter (ml) to 30 ml of water. Physician order, dated 10/23/23, indicated to administer Metoprolol tartrate (beta-blocker that treats high blood pressure) 25 mg tablet, one tablet daily through the gastric tube. The record lacked documentation of new progress notes after 10/20/23. On 10/23/23 at 3:15 p.m., in an interview with the Director of Nursing Services (DNS), she indicated Resident 6 did not take anything by mouth and received everything through his G-tube. On 10/25/23 at 10:32 a.m., Registered Nurse (RN) 13 indicated Resident 6 received all his medications through his g-tube and that all his medications that were pill form were crushed and dissolved before given through the g-tube. The MAR was observed with RN 13 for the medications Resident 6 received that morning. Medications included, but was not limited to, Metoprolol tartrate (treats blood pressure and irregular heartbeats). The medications Resident 6 located inside the medication cart were observed with RN 15, and she read the label as Metoprolol tartrate 25 mg. This was observed to be regular release and scored. She indicated it was ordered on 10/23/23 and that he was not receiving any medications that were not supposed to be crushed. She looked up the order history, prior to the change on 10/23/23, Resident 6 was receiving Metoprolol succinate 25 mg ER. RN 13 indicated that Metoprolol ER was able to be crushed and was not sure why the order was changed. On 10/25/23 at 12:32 p.m., received medication administration record (MAR) for last thirty days from Regional Nurse Consultant (RNC) indicating Metoprolol succinate tablet, extended release 24-hour tablet, was ordered to be administered via gastric tube once daily, started on 8/12/23 and was discontinued on 10/23/23. It had been given every day on the thirty-day report between 9/25/23-10/23/23. The MAR indicated that a new order for Metoprolol tartrate tablet 25 mg, was to be administered via gastric tube, order began 10/23/23. On 10/25/23 at 2:28 p.m., in an interview with the RNC, she indicated the medication Metoprolol succinate 25 mg ER was changed to regular release medication because ER medications were not to be crushed. She indicated they also discontinued the omega 3 (supplement) as well because it was gel capsule and they had to puncture it and squeeze out the contents to administer it. On 10/23/23 at 10:00 a.m., the DNS provided a list from the facility pharmacy titled, Common Oral Dosage Forms That Should Not Be Crushed, and deemed it as current. The list of do not crush medications included, .metoprolol succinate .Reason, extended release 3.1-48(c)(2)

Based on observation and interview, the facility failed to date eye drops, remove expired eye drops for 2 of 2 residents observed to receive eye drops (Residents 59 and 39), and failed to label and date the insulin for 1 of 1 resident observed with insulin during medication administration (Resident 218). Findings include: On [DATE] at 10:18 a.m., during the medication storage observation, Resident 59 had a bottle of latanoprost (an eye drop used to treat glaucoma). The bottle was opened and lacked a date indicating when it was opened. Resident 59 had a bottle of ofloxacin 0.3% (antibiotic) on the medication cart. The bottle was dated opened on [DATE]. The manufacturer's directions indicated, .You should expect that the eye drops will be stable long enough to finish your treatment. For example, if you're using an antibiotic eye drop like ofloxacin the duration is usually 14 days or less. So, the bottle should be stable for at least 14 days Resident 39 had a bottle of latanoprost 0.05% on the medication cart. It lacked a date the bottle was opened. It was sent from the pharmacy on [DATE]. Resident 218 had a Lantus insulin pen on the cart. His name was on the pen. The pen lacked directions for use and lacked a date it was opened. A policy titled, LTC (Long Term Care) Facility's Pharmacy Services and Procedures Manual, indicated, .Facility staff should enter the date opened on the label of medications with shortened expiration dates (e.g., insulins, irrigation solutions, etc.) 3XXX,d+[DATE](j) 3XXX,d+[DATE](m) 3XXX,d+[DATE](n)

Based on observation, record review, and interview, the facility failed to identify wounds, and complete skin assessments for 1 of 3 residents resulting in the resident developing a stage 3 pressure ulcer (a pressure ulcer which involved epidermis, dermis, and subcutaneous tissue and was a full thickness loss) to the sacrum before being identified which worsened to a stage 4 pressure ulcer (an ulcer which involved epidermis, subcutaneous tissue, bone and other supportive tissue including full thickness skin loss with extensive destruction of underlying tissue and structures) with [CONDITION(S)] (infection to the bone) requiring hospitalization and surgical debridement and upon arriving to the hospital the resident was found to have Deep Tissue Injuries (a pressure-related injury to sub-cutaneous tissue under intact skin, as a result of prolonged compression of bony prominences on underlying soft tissue, particularly muscle) to the bilateral heels for 1 of 3 residents reviewed for pressure ulcers (Resident B). The immediate jeopardy began on 5/19/22 when the facility failed to complete weekly skin assessments for Resident B, the resident developed a stage 3 pressure ulcer to the sacrum before being identified which worsened to a stage 4 pressure with [CONDITION(S)] requiring hospitalization and surgical debridement. Upon arrival to the hospital, the resident was found to have Deep Tissue Injuries to the bilateral heels. The Executive Director (ED) was notified of the immediate jeopardy at 2:45 p.m., on 7/1/22. The immediate jeopardy was removed on 7/1/22, 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: A confidential interview conducted during the course of the survey indicated Resident B had admitted to the facility a few months ago with no wounds or skin breakdown. The resident had since been admitted to the hospital with a deep wound on her bottom, wounds on both heels, and had been placed on hospice care related to her wounds. The surgeon caring for the resident indicated if Resident B's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident B's record was reviewed on 6/30/22 at 11:05 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An Admission Observation for Resident B, dated 4/22/22, indicated no alterations in skin, warm, dry, and skin turgor normal. A Braden Scale for Predicting Pressure Sore Risk, dated 4/22/22, with a scale score of 16, indicated the resident was at risk for skin breakdown. An admission MDS (Minimum Data Set) assessment, completed 4/29/22, assessed the resident as requiring extensive assistance of 2 or more persons physical assist for bed mobility, transfers, and toileting. Extensive assistance of 1 person physical assist for dressing, and personal hygiene. The resident was always incontinent of bladder and bowel and was at risk of developing pressure ulcers/injuries. The resident had no current unhealed pressure ulcers/injuries. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident record lacked documentation to indicate any weekly skin assessment had been completed. Physician/NP Progress Notes scanned into Resident B's EMR (electronic medical record) indicated the resident was visited by the physician on 4/27/22 for a new admission encounter and initial exam. Documentation indicated the resident's skin was normal, warm, dry and fragile. NP (Nurse Practitioner) visit notes on 4/29/22 and 5/18/22 were for abnormal lab values and follow up for resident anxiety, there was no documentation related to the skin's condition. The resident record lacked documentation of the physician or NP had visited or examined the resident from 5/19/22 - 6/15/22. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A nursing progress note, dated 5/19/22 at 6:23 a.m., indicated Resident B had a wound on the sacrum (triangular bone just below the lumbar vertebrae) measuring 1.8 cm (centimeters) by (x) 2.0 cm. A wound management assessment for Resident B, dated 5/20/22 at 11:53 a.m., indicated first observation of wound on 5/19/22 at 11:50 a.m. A wound to the sacrum, not present upon admission, measured 2.0 cm (centimeters) L (length) x 1.8 cm W (width) x 0.1 cm D (depth) stage III pressure ulcer (a pressure ulcer which involved epidermis, dermis, and subcutaneous tissue and was a full thickness loss). Light exudate serosanguineous (pale red to pink, thin and watery). The wound had 95% granulation tissue, 5% covered in slough (necrotic tissue which needs to be removed from the wound for healing to take place), tissue edges/margins rolled under/thickened, no odor, wound was stable. A Weekly Wound Review Note, dated 5/25/22 at 3:01 p.m., indicated Resident B had a stage III pressure ulcer to the sacrum, and the wound had worsened. Contributing factors included incontinence and increased moisture between bilateral buttocks. A wound management assessment for Resident B, dated 5/25/22, indicated sacral wound measured 0.7 cm L x 1.5 cm W x 0.2 cm D, light serous (clear, amber, thin and watery) exudate, no odor, unstageable (slough and/or eschar), 75% covered in slough margins well defined, and wound declining. A Weekly Wound Review Note, dated 6/1/22 at 2:51 p.m., indicated Resident B had a pressure injury to the sacrum, and the wound had worsened. Contributing factors included poor offloading, incontinence, and moisture. A wound management assessment for Resident B, dated 6/1/22 at 2:44 p.m., indicated sacral wound measured 2.3 cm L x 2.2 cm W x 0.2 cm D, light seropurulent (yellow or tan, cloudy and thick), no odor, Stage III, 20% granulation, 80% slough, wound edges macerated/soft and well defined, wound healing status declining, (wound company) assessed wound via telehealth. The resident record lacked documentation the wound company had assessed the resident. A Weekly Wound Review Note, dated 6/8/22 at 12:50 p.m., indicated Resident B had a pressure area to the sacrum, and the wound had worsened. Contributing factors included poor offloading, incontinence, and moisture. Resident was currently being treated with an antibiotic, mighty shakes at lunch and dinner meals, Active Liquid protein 30 ml (milliliters) twice daily between meals, and a magic cup at lunch. Resident also received a dietary supplement twice daily between meals to help increase overall calorie/protein intake. A wound management assessment for Resident B, dated 6/8/22 at 1:14 p.m., indicated sacral wound measured 7 cm L x 7.2 cm W x 2.5 cm D, moderate exudate serosanguineous (pale red to pink, thin and watery), wound odor present described as malodor (very unpleasant smell), Unstageable - 100% Slough and/or Eschar, wound healing status declining. Comments: wound has declined this week. New orders received for sacral X-ray, labs (CBC, CMP), out of bed 1-2 hours per day, requesting foley catheter, and OT (occupational therapy) referral for positioning. Shower Report sheets, dated 4/26, 4/29, 5/3, 5/6, 5/10, 5/13, and 5/17, indicated no documentation of skin/wound concerns. Shower report sheets, dated 5/20, 5/24, 5/27, 6/3, 6/7, 6/10, and 6/14/22, had the sacral area circled and dressing or treatment written on the sheet. A shower sheet report had blanks at the top to fill in the resident name, date and time of shower. Check boxes were available to indicate if the resident refused a shower, had a complete bed bath and if bed linens were changed. The form indicated to circle problem areas (on outline of a body) and check all boxes as needed to include bruise, open area, rash, redness, skin tear, or blister. Directions on the bottom below charge nurse signature indicated, all skin problems must be assessed, and documented by the charge nurse. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] a. On 5/22/22, Santyl ([MEDICATION(S)] agent) ointment 250 unit/gram, cleanse sacrum with normal saline, pat dry, apply Santyl to wound, cover with foam dressing daily. b. On 5/26/22, Active Liquid Protein 30 ml twice daily. c. On 5/27/22, Santyl ([MEDICATION(S)] agent) ointment 250 unit/gram, cleanse sacrum with normal saline, pat dry, apply Santyl to wound, place calcium alginate (highly absorbent) dressing, then cover with foam dressing daily and as needed for soilage. d. On 6/1/22, Dakin's Solution (antiseptic wound cleanser), 0.25% sodium hypochlorite, cleanse sacral wound with normal saline, pat dry, apply Dakin's moistened gauze to wound bed, cover with foam dressing daily and as needed. e. On 6/1/22, [MEDICATION(S)] (antibiotic) 100 mg give 1 tablet every 12 hours for 10 days for wound healing. f. On 6/2/22, Pre-[MEDICATION(S)] level (helps the doctor determine if getting enough nutrients, namely protein in the diet) for worsening wound. g. On 6/8/22, Dakin's Solution (antiseptic wound cleanser), 0.25% sodium hypochlorite, cleanse sacral wound with normal saline, pat dry, apply Dakin's moistened gauze to wound bed, cover with foam dressing twice daily and as needed. h. On 6/8/22, x-ray order to the sacrum/coccyx open wound. i. On 6/9/22, Tylenol 1000 mg three times daily for pain. j. On 6/13/22, up ad lib in a Broda (tilt-in-space) chair. k. On 6/14/22, equagel (gel filled double thick pad) cushion in wheelchair. l. On 6/14/22, an appointment with the local hospital wound center scheduled for 6/22/22 at 9:30 a.m., with transportation by ambulance. A care plan, dated 4/23/22, indicated Resident B was at risk for further skin breakdown due to very moist skin, resident was bed fast, had slightly limited mobility, probable inadequate nutritional intake, and problem with friction and shear. The goal was for the resident to be free from further skin breakdown. Approaches included: the resident was to turn and reposition at least every 2 hours, provide assistance as needed, house barrier cream at bedside to be used as needed, incontinent care as needed using peri wash and moisture barrier, and pressure reducing/redistributing mattress on the bed. On 5/19/22 interventions of a low air loss specialty mattress set to the resident's comfort was added, and on 6/13/22 an equagel cushion in the wheelchair at all times was added. A care plan, dated 5/21/22, indicated Resident B had impaired skin integrity and had acquired a pressure ulcer to the sacrum. The goal was for the resident to be free from signs of complications. Approaches included treatment as ordered, Assess for pain and treat as ordered and notify the physician of unrelieved/worsening pain, Assess the wound weekly/document measurements and description, Encourage resident to eat at least 75% of meals, Incontinence care as needed, Labs as needed, Notify physician of worsening or no change in wound or for signs of infection, Observe for signs of infection: redness, pain, drainage, malodorous drainage, fever, increase in size/depth of wound, Pressure reducing/redistribution cushion in chair and mattress on bed, RD (registered dietician) to assess routinely, supplements as ordered, turn and reposition every 2 hours, and wound healing vitamins as ordered. On 5/25/22 a documentation of a sacrum wound was added. A late entry progress note by the DON (Director of Nursing), dated 6/17/22 at 12:06 p.m., indicated on 6/15/22 at 2:01 p.m., Resident B was visited during wound rounds, wound noted with worsening/decline. The DON reached out to (a wound company) which advised the resident to be sent to the hospital for evaluation. Dressing completed to sacrum prior to emergency services pick up. A local hospital ED (Emergency Department) Note, dated 6/15/22, indicated Resident B's present illness included, but was not limited to, sacral decubitus ulcer which had been treated at the nursing home for some time. There was a large deep sacral ulcer which appeared to go down to the muscle and possibly to the bone. There was surrounding [CONDITION(S)] (redness) possibly secondary [CONDITION(S)] (bacterial skin infection). There was a strong odor to the wound. A local hospital hospitalist note, dated 6/15/22, indicated skin concerns to the left heel, and a sacral wound measuring 7.0 centimeters (cm) by (x) 10 cm, malodorous and with surrounding [CONDITION(S)]. A local hospital general surgery consult note, dated 6/15/22, indicated the transferred to the hospital for wound care of a sacral decubitus ulcer. The resident also had bilateral heel decubitus ulcers. The sacral wound was foul smelling, tunneled to the bone, and was a stage 4 pressure ulcer (an ulcer which involved epidermis, subcutaneous tissue, bone and other supportive tissue including full thickness skin loss with extensive destruction of underlying tissue and structures) with [CONDITION(S)] (infection to the bone). Bilateral heel deep tissue injures (DTI) (a pressure-related injury to sub-cutaneous tissue under intact skin, as a result of prolonged compression of bony prominences on underlying soft tissue, particularly muscle) were noted. The sacral wound was very odorous with unhealthy tissue in wound bed and edges. A local hospital's, Admission Assessment, dated 6/15/22 at 7:59 p.m., indicated Resident B's pain assessment was 10 out of 10. The measurements and staging of the sacrum ulcer and bilateral heels were as follows: a. Right heel pressure ulcer stage 1, skin unbroken and red, measured 2.0 cm length (L) x 1.5 cm width (W) x 0.1 cm depth (D), (per definition provided on the hospital assessment page. A Stage 2 (skin broken, superficial skin loss involving epidermis alone or also dermis. Partial loss of skin layers). b. Left heel DTI measured 4.0 cm L x 6.1 cm W x 0.1 cm D. c. Sacrum Stage IV (per definition on the admission assessment provided indicated a stage IV pressure ulcer involved epidermis, subcutaneous tissue, bone and other supportive tissue including full thickness skin loss with extensive destruction of underlying tissue and structures). The sacrum wound measured 6.5 cm L x 10.2 cm W x 3.3 cm D, with tunneling present at 2 o'clock measuring 4 cm and at 7 o'clock measuring 3 cm, and the wound had moderate foul smelling brown drainage. A local hospital wound clinic inpatient wound assessment, dated 6/16/22 at 4:14 p.m., indicated, a. Right heel pressure ulcer stage 1, general appearance blister, measured 2.0 cm L x 1.5 cm W x 0.1 cm D. b. Left Heel pressure ulcer deep tissue injury. General appearance blister, bruise and ecchymosis (bruise caused by blood leaking from broken blood vessels into the tissues of the skin or mucous membranes). Sub-tissue exposure. 4 cm L x 6.1 cm W x 0.1 cm D. c. Sacrum stage IV pressure ulcer with moderate amount of brown foul smelling drainage. General appearance eschar/slough, with bone exposure. 6.5 cm L x 10.2 cm W x 3.2 cm D with tunneling of 4 cm at 0200 and 3 cm at 0700. A hospital operative report, dated 6/17/22, indicated unstageable sacral decubitus ulcer, procedures performed: debridement of 70 square cm (10.85 square inches) of sacral decubitus, ulcer down to bone level with 210 ml of necrotic tissue removal, bone biopsy. A tissue culture was obtained of the deep soft tissues. A bone biopsy then ensued at the midline level of the sacrum. One piece of bone was taken with the rongeur for a wound culture. Another two specimens were taken for permanent pathology to evaluation for [CONDITION(S)] presence. Bone wax was placed in the larger biopsy site. A microbiology final results for wounds, collected on 6/17/22, indicated bone gram stain-anaerobic culture, proteus mirabilis (gram-negative bacterium which was well known for its ability to robustly swarm across surfaces in a striking [NAME]-eye pattern). A diagnostic report, sample collected 6/17/22 at 12:27 p.m., indicated Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Negative for malignancy. B. Sacral bone biopsy: acute [CONDITION(S)]. A local hospital discharge summary, discharge date [DATE], indicated discharge diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During hospitalization , the patient underwent decubitus ulcer of sacral area debridement of bone and also biopsy of the bone. The patient was to be followed by hospice. Narrative summary in brief indicated, patient with history of [CONDITION(S)] dementia, and debility was sent from the emergency department from ECF (extended care facility) for worsening sacral wound. Wound had worsened appearance and had a foul odor. The patient was brought into the hospital for decubitus ulcer of sacral area. She underwent debridement of sacral wound per general surgery, and had a wound vacuum placed. She grew out bacteria Proteus mirabilis. IV (intravenous) medications recommended for 6 to 8 weeks. Given the extensive nature of the wound, the resident was felt to be a poor candidate for healing, placed on hospice and discharged to a SNF (skilled nursing facility.) During an interview, on 6/30/22 at 5:20 p.m., the Director of Nursing (DON) indicated Resident B's record lacked documentation nurses had completed weekly skin assessments as the nurses had failed to complete the assessments. Documentation from the wound company visit was also unavailable on the chart, he would call and request copies. During an interview, on 7/1/22 at 9:40 a.m., RN (Registered Nurse) 9 indicated he had been the nurse in charge of Resident B's care. The resident had developed a sore on her sacral area which required a treatment. Initially the resident had not complained of pain but later in her stay was having pain in the area. The resident sometimes got wet due to incontinence and had to be monitored often due to the size of the wound. To his knowledge the resident had only a sore on her bottom. Protocol was for all residents to have skin checks weekly, and in cases like Resident B the checks could be more often. CNAs (Certified Nursing Assistants) helped to monitor skin during care and bathing and would report concerns to the nurse. The nurse was to document skin problem in the progress notes, and report to the physician. The EMR prompted the nurse to document on wounds. During an interview, on 7/1/22 at 10:30 a.m., the DON provided a copy of a wound company report, dated 6/8/22, which indicated the resident had a sacrum wound due to pressure, some grimacing, initially seen on 6/1/22. This date the wound was larger and with new blisters to peri wound. The wound measured 7.0 cm L x 7.2 cm W x 2.5 cm D. There was a small amount serosanguineous drainage and foul odor after cleaning. There was a large (67 - 100%) amount of necrotic tissue within the wound bed including adherent slough. Wound progress was worsening. During an interview, on 7/1/22 at 9:49 a.m., the MDS Coordinator indicated, during the morning meeting with the IDT (interdisciplinary team), the ED (Executive Director) had a check list which prompted him to inquire about all new wounds, and the DON or MDS Coordinator would report all new wounds, type, and stage. With any new wound, the charge nurse would open a skin event (new concern) in the EMR. Every morning the DON monitored all newly opened events in the EMR, and if a wound was observed it wound be added to wound management tracking in the EMR, which then prompting the IDT to monitor and track. Resident B had no wounds upon admission on 4/22/22. There was a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation of Resident B's medical record with the MDS Coordinator, she indicated the resident record lacked documentation the resident had Weekly Skin Observations completed. The Certified Nursing Assistants (CNAs) completed shower sheets and if they saw a skin issue it would be documented on the shower sheet, and then the nurse was to be informed. She was not sure why the resident ended up with a wound, it happened so quickly. To her knowledge the resident had only a wound on her sacrum. Preventative interventions were to check and change every 2 hours, barrier cream with each episode of incontinence, and turn and reposition every 2 hours, although these were standard precautions and not documented for compliance. The MDS Coordinator indicated, she could not find weekly skin sheets completed for this resident in the EMR, which must have been the reason she had received skin assessment and pressure wound training that am. During an interview, on 7/1/22 at 12:10 p.m., the DON indicated when Resident B first arrived, she was more motivated with therapy, alert with confusion due to dementia, would move around in bed, and was incontinent of bowel and bladder. The resident was ordered [MEDICATION(S)] and staff provided standard precautions of turning and toileting every 2 hours. Resident B was dependent on staff for ADL's (activities of daily living) to include transfers. On 4/29/22, an order was written for weekly skin assessments, but the nurses responsible for the resident did not document a completed weekly skin assessment during the resident's stay. On 5/19/22, a nurse or a CNA found the sacral wound, and the nurse documented the wound. The wound initially was documented as a stage III due to having approximately 5% slough but was probably more a stage II due to size and depth. The resident then was ordered a low air loss mattress, and a treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident B had a poor appetite but was drinking supplements and active protein. Resident did not complaint of pain. The DON had set up an appointment for the (local hospital) wound center for 6/22/22. Residents had their skin monitored weekly when the aides gave them a bath or shower and when the nurse completed and documented the weekly skin sheet. After a resident was identified as having a wound they were added to the list for the DON and team to see, assess and documented head to toe assessments during the weekly skin sweeps. Upon discharge to the hospital, the DON had assessed the resident and changed the sacral wound dressing. The DON indicated the resident had no other wounds, only the sacral wound. On 7/1/22 at 12:04 p.m., the ED provided a Skin Management Program policy, revised 5/22, and indicated the policy was the one currently being used by the facility. The policy indicated, Purpose: To promote the prevention of pressure ulcers/injury development; promote the healing of existing pressure ulcers/injuries and prevent development of additional pressure injury .1. All residents will be assessed at admission .3. Interventions to prevent wounds from developing and/or promote healing will be initiated based upon the individual's risk factors .6. Any skin alterations noted by direct care givers during daily care and/or shower days must be reported to the licensed nurse for further assessment, to include but not limited to bruises, open areas, redness, skin tears, blisters, and rashes. The licensed nurse is responsible for assessing all skin alterations by the direct caregivers on the shift report. 7. Facility skin sweeps [head to toe assessments] are conducted monthly to assess all residents' current skin conditions and to ensure appropriate preventative measures are in place The immediate jeopardy that began on 5/19/22 was removed on 7/1/22 when the facility assessed all residents for risk of pressure ulcer development, and if at risk, interventions were implemented and residents with current pressure ulcers were reviewed for appropriate care and treatment, and care plans updated. Nursing staff were in-serviced on pressure ulcer care. The noncompliance remained at the lower scope and severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy because of the facility's need for continued monitoring. This Federal tag relates to Complaint IN 707. 3.1-40(a)(1) 3.1-40(a)(2)

Based on interview and record review, the facility failed to ensure a resident's legal guardian was immediately notified of a fall with injuries when the resident, who was unable to make decisions for herself, was refusing to go to the emergency room which resulted in actual harm when emergency medical treatment was delayed for the multiple areas of bleeding in the brain, a subdural hematoma (a type of bleed that occurs within the skull of head but outside the actual brain tissue), and arm fracture for 1 of 5 residents reviewed for falls (Resident B). Findings include: During a confidential interview during the survey, the interviewee indicated Resident B had been a long-time dependent user of anticoagulant medication. Unfortunately, the resident did not manage her medication regimen well on her own and had other medical complications [MEDICAL RECORD OR PHYSICIAN ORDER] . She started making very poor decisions for herself and was eventually admitted to the facility and assigned a legal guardian to make decisions for her. She was very sensitive to anticoagulant medications, and her regimen needed to be monitored very closely. On the morning of the fall, Resident B's guardian was not notified of the fall until 7:40 a.m. The facility staff indicated they had not notified the guardian earlier because they didn't want to wake you. It was the facility's policy not to send residents to the ER if they refused to go, and Resident B kept refusing to go to the ER. Resident B had significant bruising on one side of her head which had begun to swell. At the hospital, they were informed Resident B had broken her arm in several places and had multiple brain bleeds as well as a subdural hematoma. The hospital had to drill bur holes into Resident B's head to relieve the pressure on her brain. She was in the hospital for 30 days and almost died . The guardian should have been notified of the fall when it happened, they would have demanded that Resident B be sent to the hospital immediately. During an interview on [DATE] at 3:52 p.m., a Social Worker from a local hospital indicated Resident B had been treated at the hospital for severe head injuries after a fall at the facility. The resident had been on an anticoagulant (blood thinning medication) which complicated her treatment and recovery. At one point she was close to dying because of her injuries, the subdural hematoma had been very life threatening. On [DATE] at 9:15 a.m., Resident B's medical record was reviewed. She had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident B's Face Sheet indicated, the resident was not responsible for herself and listed the guardian as the emergency contact. She had a comprehensive care plan initiated [DATE] and revised [DATE]. The care plan indicated, Resident B had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions for this care plan included but were not limited to, emphasize to the resident her acting guardian should assist in making decisions on her behalf. Resident B had a comprehensive care plan initiated [DATE] and revised [DATE]. The care plan indicated she had cognitive impairments with interventions that included but were not limited to, provide simple instructions, and repeat as needed. Resident B had a comprehensive care plan initiated [DATE] and revised [DATE]. The care plan indicated she was at risk for falls with interventions that included but were not limited to, offer a night light, non-skid footwear, transfer pole next to her bed and call before you fall sign. Resident B had a comprehensive care plan initiated [DATE] and revised [DATE]. The care plan indicated she used an anticoagulant medication with interventions that included but were not limited to, document abnormal findings and notify the physician. A Fall Event, dated [DATE] at 2:59 a.m., indicated Resident B had an unwitnessed fall in her room. The event document indicated the physician had been notified at 3:07 a.m. and the guardian had been notified at 9:26 a.m. A corresponding Nursing Progress Note, dated [DATE] at 3:15 a.m., indicated Resident B was found on her floor near her bed. She had returned from the bathroom and fell while she tried to transfer from her wheelchair to the bed. The room was noted to be poorly lit, and the wheelchair was not near the transfer pole. The note indicated Resident B had a right temporal (the side of the head next to the eyes) hematoma and complained of dizziness. She was given an ice pack and refused to go to the ER. The nurse left a message with the on-call physician was awaited a return call. A Physician Communication Tool, dated [DATE] at 7:22 a.m., indicated, the physician was notified of the fall at 7:26 a.m., and the guardian was notified of the fall at 7:26 a.m. A Nursing Progress Note, dated [DATE] at 5:03 a.m., indicated the nurse spoke with on-call NP (nurse practitioner), and no new order was given at that time. The NP advised the nurse to continue ice packs and call back if cognitive changes occurred. A Nursing Progress Note, dated [DATE] at 7:27 a.m., indicated Resident B was sent to the ER for further evaluation after her fall which resulted in a right temporal hematoma. Resident B started to complain of a headache and dizziness that was not controlled with pain management. Resident B had refused two times before allowing nurse to send her out to the hospital. A Nursing Progress Note, dated [DATE] at 10:25 a.m., indicated Resident B had been admitted to a local hospital to the Neurological Intensive Care Unit with a subdural hematoma and multiple areas of bleeding in her brain. During an interview on [DATE] at 1:56 p.m., Licensed Practical Nurse (LPN) 28 indicated she had been the nurse working the night Resident B fell . She had been at the nurse's station when Resident B's call light alarmed. She immediately went to check on the resident and found her sitting on the floor. The resident indicated she was Ok. LPN 28 called for help, and a CNA (Certified Nursing Assistant) came to sit with the resident so she could get supplies for an assessment. LPN 28 got her supplies and called for another nurse, LPN 32 for assistance. LPN 28 and 32 completed an initial assessment which was all normal and helped transfer Resident B back into her bed. LPN 28 asked the resident if she wanted to go to the hospital, and Resident B declined. LPN 28 indicated she sat with the resident for the first 30 minutes before calling the doctor. When she called the first time, she did not speak with the doctor, but left a message and was told if she did not hear back in 30 minutes, to call again. She did not get a call back, so after ,d+[DATE] minutes called back to the doctor. At that time, LPN 28 spoke with the on-call doctor and told them what happened. The on-call doctor asked about anticoagulant medication and what was the resident's last results of the Prothrombin time and International Normalized Ratio (a blood test used to determine therapeutic levels of blood thinning medications and referred to as PT/INR). The on-call doctor advised the nurse to continue to monitor the resident and if her symptoms worsened, they could send her to the ER. Several hours later, around 6:00 a.m., when LPN 28 began her medication pass and checked on Resident B, her condition had worsened. Resident B was complaining of a headache and was dizzy. A neurological assessment (neuro check, an examination of hearing, speech, vision, coordination, and balance) was completed, which indicated the resident's status had deteriorated. LPN 28 called 911 to send the resident to the hospital. LPN 28 indicated she notified the guardian of Resident B's fall around 5:00 a.m. She had waited to contact the guardian, because she's funny about people calling her at night and was out of town. LPN 28 indicated by the time they sent Resident B out, the hematoma on the resident's head was quite big and bruises had developed which was concerning because the resident used anticoagulants. During an interview on [DATE] at 2:13 p.m., the Director of Nursing (DON) indicated Resident B had a guardian because her brief interview for mental status (BIMS) scores fluctuated up and down. Some days she was cognitive aware, and other days she was not. The guardian was very involved in her care, especially her anticoagulant medication regimen. Anticoagulant medication increased the risk for uncontrolled bleeding, and subdural hematomas which was what happened with Resident B. At the time, the nurse was following instructions provided by the on-call doctor, but in hindsight Resident B should have been sent out to the hospital sooner. On [DATE] at 3:00 p.m., the DON provided a copy of a fall investigation completed after Resident B's fall. The fall investigation documentation included a written statement from LPN 28, dated [DATE], which indicated the Resident activated her call light around 2:30 a.m. She was observed on the floor sitting on buttocks near her bed. The bedroom was completely dark, and her wheelchair was close to the foot of the bed. She was fully dressed but her night pants were below her knees, and she was not wearing any non-skid socks. Resident B stated she had returned from the restroom and tried self-transfer from the wheelchair to her bed but lost her balance and fell . She was unable to state if she hit her head, but a hematoma was observed on her right temple. Neuro checks were initiated, and Resident B complained of a headache during the assessment. The resident was given an ice pack and offered to be sent out to ER, but she denied. LPN 28 contacted the on-call medical service and spoke with a NP and explained what happened. The NP gave no new orders and agreed to continue ice packs every 20 minutes as tolerated and continue to monitor for worsened condition. LPN 28 continued neuro assessments, and during medication pass administered Tylenol. When LPN 28 returned for a follow up, the medication was not effective. LPN 28 received a phone call from the NP and received the order to send her to the ER. A lab Result document, dated [DATE], indicated Resident B had the following Prothrombin time and International Normalized Ratio (PT/INR) lab results prior to the fall: On [DATE]: PT of 21.4, INR of 2.1 On [DATE]: PT of 26.2, INR of 2.5 On [DATE]: PT of 26.4, INR of 2.6 On [DATE]: PT of 19.4, INR of 1.9 Normal ranges for PT were 9.6 to 12.2 and INR were 0.9 to 1.1. Aggressive anticoagulant ranges for patients requiring medication for INR was 2.5 to 3.5. On [DATE] at 3:00 p.m., the DON provided a copy of the current facility policy titled, Fall Management Program, dated ,d+[DATE], and most recently revised ,d+[DATE]. The policy indicated, .the physician will be notified immediately, if there are injuries, and orders will be obtained . the family will be notified immediately by the charge nurse of falls with injury This Federal tag relates to Complaint IN 572. 3.,d+[DATE](a)

Based on interview and record review, the facility failed to ensure physician's orders were followed for dressing changes, medication, a special procedure, wound care, assessment and collaboration with the hospital wound clinic for 3 of 3 residents reviewed for wounds (Residents B, C, D). This resulted in Residents B and C being hospitalized for [REDACTED]. Findings include, 1.On 12/03/20 at 11:00 a.m., the medical records were reviewed for Resident B. The [DIAGNOSES REDACTED]. The most recent admission, after a hospital visit, was on 9/20/20. On 10/23/20 at 9:57 a.m., a nurse progress note, created by the Unit Manager/ Wound Care Nurse indicated, Transport arrived to transport pt (patient) to [MEDICAL TREATMENT] appt, pt states that he wants to go to the ED (emergency department) rt (related to) his foot wound, states that the dressing hasn't been changed since Sunday, writer reminded pt that wound care assessment was completed on Weds (Wednesday) and dressing completed, then pt states that it smells foul, upon assessment, no change in odor, pt states that he just 'want to have Wound Care look at my foot at the (Name of Hospital) and that will be the only way that it gets done today,' which is accurate rt (related to) (Name of Hospital) scheduling, transport aware of pt request, dressing on foot dated for yesterday, pt aware, will cont. to monitor. A second nurse progress note documented after the note, dated 10/23/20 at 9:57 a.m., indicated on 10/23/20 at 9:30 a.m. the resident's dressing was changed. Completed dressing on right foot per order - dressing that was removed was noted to be very saturated with yellow and dark brown drainage. Black skin from the wound also noted to be on the dressing that was removed. Odor from wound was very foul and resident made statement that dressing has not been changed and he wanted to go to ER. ADON (Assistant Director of Nursing) made aware. will cont. to f/u (follow up). On 10/25/20 at 11:11 a.m., a progress note indicated, SS (Social Service) from (Name of Hospital) called facility and spoke with writer regarding getting his (Resident B) medical records faxed over. This nurse faxed them 3 times as requested. A confidential interview, during the survey dates from 12/3 -12/4/20, indicated, Resident B was admitted to the hospital from the ER. The interviewee indicated the facility was not changing the resident's wound dressing as scheduled. The resident noticed his wounds had developed an odor and asked to be sent to the hospital. The facility had refused his requests until 10/23/20 when he told the nurse, who had changed his dressing on the weekend (Licensed Practical Nurse 17), about his concerns. The interviewee indicated during a conversation with LPN 17, LPN 17 indicated she had changed Resident B's dressings on the previous weekend. LPN 17 indicated it did not appear the resident's dressings had been changed as ordered and his wounds were deteriorated based on her observation from the previous Sunday when she had last changed the dressings. A review of Resident B's physician orders indicated, [MEDICAL TREATMENT] treatment days were Monday, Wednesday, and Friday, at 11:00 a.m. A treatment order, dated 9/10/20, indicated, clean left heel and/or foot with normal saline, pat dry, and apply [MEDICATION NAME] (a type of iodine liquid) moistened gauze to the wound beds. Then cover with an ABD (a thick bandage) pad, and secure with kerlix (rolled gauze). Treatment was ordered to be done once a day between 7 a.m. -11:00 a.m. and as needed for soilage/dislodgement. Wound Management Detail Reports for left lateral foot ulcer indicated the following: On 9/24/20 at 1:06 p.m., wound measurements were 3 centimeters (cm) by (x) 1.9 cm with partial thickness loss of epidermis (top layer of skin) and into but not through the dermis (deeper skin tissue). Necrotic (dead) tissue was observed. There was no odor. It was calloused, and firm with surrounding tissue pink and normal. On 10/1/20 at 2:37 p.m., the wound measured 3.5 cm x 2.5 cm, had necrotic tissue, and was dry and thin. Wound healing status was classified as declining. On 10/7/20 at 7:40 a.m., measurements were 3 cm x 2 cm with necrotic tissue, 100% eschar (black tissue) and surrounding skin scaling. IDT (Intradisciplinary Team) note indicated the wound was stable and to continue current treatment per wound orders from the hospital's wound center. On 10/14/20 at 8:04 a.m., measurements were 3 cm x 2 cm with necrotic and serosanguinous (pale red to pink, thin watery) drainage. On 10/21/20 at 7:43 a.m., documented 10/22/20 at 7:45 a.m., the wound measured 3.5 cm x 2.25 cm. There was serous drainage (clear, amber, thin, and watery), foul odor present, and eschar tissue. Wound healing status was listed as declining. The area was noted to be slightly larger than last assessment. The resident indicated, transportation hit his foot on stretcher during transfer more than once this week. wound care center aware. A Wound Management Detail Report for left heel indicated the following: On 9/24/20 at 1:06 p.m., the left heel wound measurements were 7.5 cm x 9 cm with light exudate (fluid), and [MEDICAL CONDITION] (yellow/ tan, cloudy thick) drainage. There was partial thickness loss of epidermis and into but not through dermis with surrounding skin [DIAGNOSES REDACTED] (redness), blanchable and pink/normal. The wound was stable. On 10/1/20 at 2:37 p.m., the wound measured 8 cm x 9 cm with light exudate, and serosanguineous drainage. The wound had necrotic tissue and was dry and thin. Wound healing status was classified as declining. On 10/7/20 at 7:40 a.m., the wound measured 8 cm x 9 cm with necrotic tissue. On 10/14/20 at 8:04 a.m., Left heel, Measurements 8cm x 8.5 cm, serosanguinous drainage, necrotic tissue. IDT assessed areas to left heel. Area remained stable. There were no changes in orders from (Name of Hospital) wound clinic. On 10/21/20 at 7:43 a.m., wound measured 8.5 cm x 8.5 cm. with serosanguinous drainage, and a foul odor related to drainage/eschar, necrotic tissue. The wound was declining, and the area was noted to be slightly larger than the last assessment. A review of Resident B's Treatment Administration Record (TAR) for the last 6 weeks before transfer to the hospital on [DATE] was requested. The facility provided treatment records for October. No treatment documents for September were provided. The October TAR indicated, to cleanse the L (left) heel/LL (left lateral) foot with NS (normal saline solution), pat dry, apply [MEDICATION NAME] moistened gauze to wound beds, cover with an ABD (thick dressing/bandage), and secure with kerlix (gauze wrap). The order was to be completed once a day with a start date of 9/10/20 and end date of 11/04/20 (DC date). The October TAR indicated the following dates a treatment was not completed: On 10/05/20 at 11:16 a.m. the record indicated, Not administered: Resident unavailable, [MEDICAL TREATMENT]. On 10/12/20 at 11:18 a.m. the record indicated, Not Administered: Resident unavailable, LOA (leave of absence) for [MEDICAL TREATMENT]. On 10/14/20 at 7:41 a.m. the record indicated, Not Administered, LOA early for [MEDICAL TREATMENT] and was with PT (physical therapy) first thing this morning prior to LOA. On 10/16/20 at 10:40 a.m. the record indicated, Not Administered: Resident unavailable. On 10/19/20 at 11:03 a.m. the record indicated, Not Administered: Resident unavailable. Resident LOA for [MEDICAL TREATMENT]. On 10/22/20 there was no initial for the treatment. The space for documentation was blank. The record indicated from 10/25/20 through 10/31/20 the resident was LOA to the hospital. A review of the physician's progress notes for September and October did not discuss any collaboration with the hospital wound care clinic, or recommendations related to his left foot wounds. Each physician progress notes [REDACTED]. Skin warm, dry and appropriate color. No visible [MEDICAL CONDITION]. See nursing notes for additional skin detail. The resident's history listed osteo[DIAGNOSES REDACTED] of the right lower extremity, post right BKA 9/4/20. The facility provided copies of nurse notes for all refusals of care by Resident B. There were no refusals for dressing changes. There was no documentation in the TAR, or nurse notes of treatment refusals. During an interview on 12/4/20 at 1:36 p.m., the Consultant Director of Nursing (DON) indicated if a treatment had been done, it should have been documented on the treatment administration record (TAR). There was not a policy for documenting treatments; it was a company expectation. The facility did not have any records of Resident B's wound care treatments or notes from the hospital wound center. In response to how nursing staff would know what wound treatments were done and how to provide further care, related to the wound care clinic's recommendations, the Consultant DON indicated she was unsure. During an interview, on 12/4/20 at 2:00 p.m. the Administrator indicated she did not know what had happened to Resident B. He had not returned to the facility after having gone out to the hospital. During an interview, on 12/4/20 at 2:54 p.m., the Wound Care Nurse indicated Resident B had [MEDICAL TREATMENT] three times a week, Monday, Wednesday, and Friday. If a resident went out for [MEDICAL TREATMENT] their dressing changes needed to be scheduled for a time when they were available, he should have had them done in the evening upon return from [MEDICAL TREATMENT]. A daily dressing still needed to be done, not omitted. He was seen at the wound clinic at the hospital. There should have been correspondence between visits. If the clinic didn't send notes, then medical records should have sent a request for the notes to be sent to the facility. When the resident returned from a hospital stay orders for treatment were entered into the physician's order set based on the hospital discharge orders sent upon return. During an interview, on 12/07/20 at 11:55 a.m., Resident B's sister indicated, she had not been able to see Resident B at the facility because of Covid-19 restrictions. He told her on the phone his left leg was worsening and the facility wasn't changing his dressing like they were supposed to. She tried to see through the window, during window visits, but it had a boot on it or was covered every time. One time he sent her a picture to her phone, and it looked awful. He had already lost one leg and was worried about losing the other. She was worried too but was unable to do much because she could not come into the facility. She received a call from the emergency room physician at the hospital when he was admitted on [DATE]. They said his leg and foot was in such bad condition they couldn't save it. His left leg was amputated just below the knee on 10/28/20. The family sent the resident to another facility when he was discharged because the resident did not want to return to the facility after the way they cared for him. The resident said they would not change his bandages and tend to his foot even when he would ask them to. 2. On 12/4/20 at 9:30 a.m., the medical record for Resident C was reviewed. The medical [DIAGNOSES REDACTED]. Resident C was admitted to the facility on [DATE] for rehab after a stay at a LTAC (long term acute care) hospital following debridement (surgical cleaning) of her leg wounds. On 11/18/2020 at 11:41 a.m. an IDT (Interdisciplinary Team) note indicated, assessed multiple wounds today, pt (patient) tolerated assessment well, stage 3 (full thickness skin loss) below L (left) breast healed, stage 3 below R (right) breast improving- cont (continue) current tx (treatment), stage 3 to sacrum improving- cont current tx, surgical incisions to LLE (left lower extremity) improving- L ankle area resurfaced- cont current tx, surgical incisions to RLE (right lower extremity) improving- vac cont with dressing changed today by wound nurse, pt aware of improvement at this time, wound MD present for assessment, will cont to monitor. A review of Resident C's current physician orders, as of discharge on 11/23/20 included but were not limited to: Cleanse LLE (left lower leg), apply puracol (wound treatment medication) to wound bed, cover and secure, and use ace wrap to keep in place daily and as needed for soilage. Wound vac (a suction device for wound treatment) to BLE (bilateral lower extremities) at -175 mmhg (degree of suction). Order to change foam dressing weekly by the Wound Nurse on Wednesdays. Cleanse area below pannus (abdominal folds) and apply barrier cream every shift. Cleanse area below left and right breasts, pat dry, apply [MEDICATION NAME] (soothing barrier cream). Cleanse sacrum, pat dry, apply skin prep to area surrounding wound, apply [MEDICATION NAME] (medicated ointment made of honey product) to wound bed, and cover with a foam dressing. A review of Resident C's Treatment Administration Records indicated the following exceptions in care: On 11/15/20 on the 3 p.m. to 11 p.m. shift, at 9:15 p.m., a treatment to apply calmeseptine to the resident's breast was documented as not done. The resident was eating. There were no repeat attempts documented. On 11/15/20 on the 3 p.m. to 11 p.m. shift, at 9:15 p.m., the resident's sacral treatment was documented as not done. The resident was eating. There were no repeat attempts documented. On 1/17/20 on the 3 p.m. to 11 p.m. shift, at 10:34 p.m., the resident's sacral treatment was documented as refused, no additional attempts are documented. On 11/20/20 on the 11p.m. to 7 a.m. shift an assessment for pain was not initialed, and not completed. On 11/20/20 on the 11 p.m. to 7 a.m. shift a wound treatment, to LLE was not initialed, and not completed. On 11/20/20 on the 11 p.m. to 7 a.m. shift a treatment order to assess the resident for change in wound, such as worsening, or signs of infection, was not initialed as completed. On 11/20/20 on the 11 p.m. to 7 a.m. shift an assessment to observe for signs of infection, redness, pain, drainage, malodorous drainage, fever increase in size, depth of wound, was not initialed as completed. On 11/20/20 on the 11 p.m. to 7 a.m. shift, an order to turn and reposition every 2 hours, was not initialed as completed. A Shower Report for Resident C indicated on 11/13/20 open areas with redness were observed on bilateral lower legs, sacrum, and breast area. The same areas were documented on 11/16/20 and 11/20/20. On 11/22/20 at 10:49 p.m. a nurse's note indicated, Resident is alert/orient, able to voice needs .Resident states that her BLE are causing her pain. Resident attempted to remove dressings to legs .Resident turned off wound vac several times .Resident given prn (as needed) pain medication .Unit Manager made aware On 11/23/20 at 1:34 a.m., a nurse's note indicated, .Resident refused treatment to LLE stating, 'My legs are hurting too bad I'm in pain.' Resident continues to have episodes of yelling et crying out in a loud tone, 'Oh Lord Help Me Please, Oh Lord' .Is currently in bed yelling out in pain with call light within reach, denies wanting to go to ED (emergency department), will continue to monitor. On 11/23/20 at 6:17 a.m., a nurse's note indicated, PRN for pain admin. To manage pain; in-effective, resident continues to yell et cry out in pain to bilat. Legs pain level 10/10. Resident has not been asleep all night shift et yelling and crying out has been continuous the entire shift. Resident continues to refuse treatment to LE's as ordered. Dressing has drainage on it and a new one needs to be reinforced, attempted x3; each time resident refuses and continues to yell out. Will continue to monitor. On 11/23/2020 at 08:12 a.m., a nurse's note indicated, Pt yelling out, inconsolable, incoherent babbling this morning, combative with care, notable change in mental status, MD (medical doctor) notified, ordered to send pt out to hospital at this time, notified ambulance service and pt transported to (Name of Hospital) ER for eval. Family aware. On 11/23/2020 at 1:34 p.m., a nurse's note indicated, This nurse arrived on shift this a.m. and resident was yelling out Lord help me repeatedly. Resident not answering questions when staff asks. Resident is alert but has altered mental status. Did Complete IV (intravenous) atb (antibiotic) this a.m via RUE (right upper extremity) midline (intravenous line). No noted ss (signs and symptoms) of infection/infiltration at midline site - dressing CDI (clean dry and intact). MD contacted and resident sent out to ER. This nurse notified resident's daughter. Report called into (Name of Hospital) ER. A confidential interviewee indicated Resident C had been a patient at (Name of Hospital) from 10/29/20 to 11/9/20. At that time the resident had been admitted , from the facility with multiple metabolic derangements which included [MEDICAL CONDITION] and [DIAGNOSES REDACTED] and bacteremia. She had returned to the hospital on [DATE]. Upon arrival to the hospital she was in extreme distress and pain. She had extreme confusion, and agitation. Her wounds appeared uncared for, with wounds noted in skin folds/creases that appeared poorly managed. Patient was anxious and screaming which was not usual behavior for the resident. The hospital physician reported significant wound worsening from the time the resident was discharged on [DATE] and 11/23/20. Resident C was admitted to the ICU and was sedated and intubated. Wounds were cleaned, measured, and dressed. The patient had 10 wounds identified on her bilateral legs, and additional wounds beneath her right and left breasts, multiple areas denuded. A groin fold was red, open and weeping, related to moisture, from hip to hip. She had a stage III (full thickness tissue loss) on her sacrum. Additional areas included incontinence related, severe moisture acquired areas to buttocks with serosanguineous drainage. Another wound was on her upper back, just below the armpit which was red and non-blanchable (did not turn white with pressure). During an interview, on 12/4/20 at 2:54 p.m. the Wound Nurse indicated Resident C had been seen in the wound clinic at (Name of Hospital) whenever she had been an inpatient there. The resident had not returned for any clinic visits, that she was aware of, the orders for her wound vac settings were taken from her admission orders [REDACTED]. During an interview, on 12/4/20 at 1:36 p.m., the Consultant Director of Nursing indicated if a treatment had been completed, it should be documented on the treatment administration record. The facility did not have any record of Resident C's hospital wound care notes. 3. On 12/4/20 at 1:00 p.m., the medical record was reviewed for Resident D. The [DIAGNOSES REDACTED]. Resident D was admitted on [DATE], for rehabilitation. A review of the Treatment Administration Record (TAR) indicated the following exceptions in care: On 11/1/20, a treatment order to cleanse Left inner ankle, pat dry, paint with [MEDICATION NAME], cover with foam, once per day, indicated not done. On 11/4/20 an assessment order to observe for signs of infection, redness, pain, drainage, malodorous drainage, fever, increase in size/depth of wound, every shift. Was blank, no initial, indicated not done, on 3 p.m. shift. On 11/9/20 an assessment order to observe for signs of infection, redness, pain, drainage, malodorous drainage, fever, increase in size/depth of wound, every shift. Was blank, no initial, indicated not done, on 3 p.m. shift. On 11/18/20 a treatment order to change foam dressing to wound vac weekly (wound nurse only), once a day on Wednesday indicated not done. On 11/20/20 a treatment order to cleanse right ankle, apply calcium aliginate (wound treatment) cover with ABD (padded dressing) and secure with kerlix (roll gauze), once a day on Monday, Wednesday, and Friday was blank, no initial, indicated not done. On 11/25/20 an assessment order to notify the MD of change in wound such as worsening or signs of infection, every shift was blank, no initial, indicated not done. On 11/25/20 at 2:34 p.m., a nurse's note indicated, resident a/o (alert and oriented) x2, able to make needs known. Asst of 1 w/ bed mobility. Vitals and neuros wnl (within normal limits) this shift. No c/o or concerns related to fall. Appetite fair this shift. Resident c/o L ankle pain; L ankle wound assessed peri wound red and swollen. Yellow discharge noted at site. Dr.& family notified, new order for wound consult. Pain meds provided; Wound care provided to L ankle per order. Res currently in room watching television, call light and fresh water within reach. On 11/30/20 at 12:06 p.m., a nurse's note indicated, Resident back from wound care appt @ (at) (Name of Hospital). Per staff that accompanied resident, scheduled procedure canceled d/t (due to) Blood thinner (Eliquis) not held previous days prior to today. A.M med admin prior to leaving et this nurse was not made aware of such orders nor this appointment. Resident changed room from another unit days prior. Procedure rescheduled for next month. Wound dressing change completed before returning back to facility. Tx remains intact, no bleeding or drainage noted at this time. Will continue to monitor. On 12/4/20 at 1:36 p.m., an interview the Consultant Director of Nursing (DON) indicated if a treatment had been done, it should have been documented on the treatment administration record. when asked how nursing staff would know what wound treatments were done, and how to provide further communicate care, the consultant DON indicated, she did not know. On 12/4/20 at 2:00 p.m., the Consultant DON provided a current policy, titled Resident Refusal of Medications, Treatments, dated 8/98. This policy indicated, .Return to the resident within the allowed time frame of the order and attempt to offer the medication or treatment a second time .documenting the refusal on the back or documenting the refusal in the EMAR (electronic medication administration record) On 12/4/20 at 2:00 p.m., the Consultant DON provided a current policy, titled, Skin Management Program, dated 7/20. This policy indicated, It is the policy of (Name of Company) to ensure that each resident receives care, consistent with professional standards of practice .and receives treatment and services consistent with standards of practice, to promote healing, preventing infection This Federal tag relates to Complaints IN 974 and IN 609. 3.1-37(a) 3.1-37(b)

Based on observation, interview, and record review, the facility failed to prevent sexual abuse between residents for 2 of 3 residents reviewed for sexual abuse when a resident (Resident D) inappropriately touched another resident's (Resident E) genitals resulting in psychosocial harm to Resident [NAME] who continued to exhibit tearfulness and anger for 12 days after the abuse. (Residents D and E) Findings include: 1. A report, titled Indiana State Department of Health Survey Report System, and dated 6/16/19 at 7:01 p.m. with a follow up added on 6/24/19, indicated Resident D intrusively wandered into Resident E's room. Resident [NAME] indicated Resident D had inappropriately touched him (Resident E) in the groin area. The residents were immediately separated for their safety, staff assured their needs were met, and a police report was filed. On 6/26/19 at 5:31 a.m., a stop sign barrier was observed hanging next to the open door of Resident E's room. The sign was not across the doorway blocking the entry. On 6/26/19 at 5:57 a.m., a stop sign barrier was observed hanging next to the open door of Resident E's room. The sign was not across the doorway blocking the entry. Resident [NAME] was observed sitting in a recliner in front of the television with his eyes closed. On 6/26/19 at 6:25 a.m., the stop sign barrier was observed hanging across Resident E's open doorway. A 1 to 1 observation form was lying on a bedside table next to a chair across from the door. Certified Nurse Aide (CNA) 15 came down the hallway and sat in the chair across from Resident E's door. CNA 15 indicated Resident [NAME] was on 1 to 1 supervision but was unsure the reason for the supervision. There was another resident on the unit ,Resident D, on 1 to 1 supervision too, but she did not know the reason for his supervision either. During an interview on 6/26/19 at 6:33 a.m., CNA 16 indicated Resident [NAME] was on 1 to 1 supervision for his protection. Resident [NAME] was blind and unaware of his environment. On 6/26/19 at 11:02 a.m., Resident E's room door was observed to be closed with the stop mesh sign with Velcro over the doorway. During an observation and interview on 6/26/19 at 11:14 a.m., Resident [NAME] was observed being propelled into his room by Occupational Therapist 23 and assisted into his recliner with a stand up lift. Resident [NAME] was alert and talkative and indicated, around Father's Day, he was sitting in his recliner early in the morning, and a man came into his room, reached under his clothes, and grabbed his genitalia. Resident [NAME] yelled and a staff member came and removed the other resident from his room. He indicated, due to being blind, he kept a bright light on the wall on all the time. Before this incident, early mornings he had seen shadows of someone walking into his room, but when he would yell who is there the person would quickly leave. He did not know who the man was who groped him, but had heard through the grapevine that staff knew. The resident tearfully repeatedly indicated he was not wired that way and did not appreciate being touched in such as manner. For the money he and others paid to live at the facility, they should not have to worry about being touched or treated that way. If he could see better, the incident would have ended in a physical way as he was not wired that way and did not appreciate it. On 6/26/19 at 2:52 p.m., Resident [NAME] was observed in his recliner with a staff member for 1 to 1 supervision. Resident [NAME] was talkative and pleasant. A motion detector was observed to activate a chime when you walked into Resident E's room entrance before the bathroom door. a. Resident E's record was reviewed on 6/27/19 at 12:26 p.m. [DIAGNOSES REDACTED]. A Care plan, with a start date of 3/23/19 and last reviewed/revised on 6/21/19 at 12:02 a.m., indicated Resident is legally blind in bilateral eyes .GOAL .Resident will not experience negative consequences of [MEDICAL CONDITION] as evidenced by: remaining physically safe, and participating in social and self-care activities The quarterly Minimum Data Set (MDS) assessment, dated 6/19/19, indicated Resident E's cognition was moderately impaired. The resident had no [MEDICAL CONDITION], no behaviors, and no wandering. He was able to make himself understood and understood others. A progress note, dated 6/16/19 at 5:45 p.m., indicated the nursing supervisor was notified by the charge nurse that Resident [NAME] had alleged an unknown male resident had entered his room and groped him. The nursing assistant indicated she had observed a male resident from a different unit self-propelling out of Resident E's room, and Resident [NAME] was yelling at the male resident to get out and stay out. She assisted in moving the male, Resident D, from Resident E's room. Resident [NAME] was upset and yelled at Resident D for being in his room. When Resident [NAME] was interviewed by the writer, he indicated a male resident, unknown to him, had entered his room and groped his privates. A progress note, dated 6/16/19 at 6:50 p.m. and recorded as late entry on 6/17/19 at 1:39 a.m., indicated Resident [NAME] was interviewed in his room with his family member present. He indicated He came into the room and just sat here and I'm blind so I couldn't see details of what he was doing, then I felt him grab my package .I told him to get the hell out of my room .I don't know who he is because I am legally blind and couldn't see him .I kept yelling at him to get out of my room, and he was leaving but someone came and took him all the way out. A progress note, dated 6/17/19 at 7:41 p.m. and recorded as late entry on 6/18/19 at 7:41 a.m., indicated Resident [NAME] had elevated blood pressure. A progress note, dated 6/18/19 at 2:49 a.m., indicated Resident [NAME] had talked to this nurse about the incident that occurred earlier. He has been anxious and has repetitively used his call light. He has made statements reflecting a want or a need to 'get out of here'. He has asked several times to call his . (family member) to come pick him up stating that he doesn't have keys to the bus or he would drive himself. States that he doesn't want to stay if that man is here. His call light remains in his hand and we will continue to monitor. A progress note, dated 6/18/19 at 1:49 p.m., indicated Worker completed face to face interview with resident in his room today. He was upset at the time of this visit. He informed me that the staff will not tell him who did the thing to him. He stated that if he finds out who did this to him that he would want to cause harm to him. The resident does not have the ability to cause harm. This resident stated that he is not built 'that way'. This worker offered counseling again as was offered yesterday. He stated he cannot use counseling because he will deal with this himself for now. He later stated that if he needs help he will ask. He wanted to know if it is being taken care. I told him the situation is being taken care of. He stated 'good' A social service note, dated 6/19/19 at 3:25 p.m., indicated During psycho-social followed up resident show signs of tear fullness. No agitation. No others signs of distress, writer assured resident staff is here for emotional support if needed. Staff will continue to monitor as needed. Resident remains 1 on 1 for peace of mind. A care plan, with a start date of 6/18/19 and last reviewed/revised on 6/20/19 at 11:27 p.m., indicated Resident is at risk for psychosocial distress due to incident with peer who touched him inappropriate. Interventions included, but were not limited to, Extender was add to call light .Door alarm chimes to alert resident when people enter room .Provide 1:1 staff b. Resident D's record was reviewed on 6/27/19 at 9:40 a.m. [DIAGNOSES REDACTED]. The quarterly MDS assessment, dated 6/12/19, indicated Resident D was severely cognitively impaired. The resident had no [MEDICAL CONDITION], no behaviors, and no wandering. He was able to make himself understood and understood others. The resident required an extensive assist of two staff members for transfers and bed mobility. The resident required an extensive assist of one staff member for locomotion. On 6/27/19 at 11:48 a.m., the Executive Director (ED) provided a report, titled Progress Note from a medical consultant and dated 6/11/17. The progress note indicated Resident D was seen for inappropriate sexual behavior, but the resident had not had any recent witnessed inappropriate behavior and had increased sedation after the Depo-[MEDICATION NAME] (female hormone used to lower testosterone and decrease sex drive) injections. The Director of Nursing had requested to discontinue the Depo-[MEDICATION NAME] injections. A care plan, with a start date of 9/24/18, indicated Resident D had a history of [REDACTED]. Interventions included, but were not limited to, .Redirect resident to common areas as needed, Refer to NP (Nurse Practitioner) for medication review, Refer to psych services as needed, Provide 15 minute checks as needed A progress note, dated 6/5/19 at 4:53 p.m., indicated Nurse informed that resident found in another resident's room with arm outstretched towards that resident. Residents were not making contact and both residents denied that anything had happened. Resident placed on 15 minute checks. A progress note, dated 6/6/19 at 10:58 a.m., indicated No distress noted due to wandering into peer room. Resident has had medication changes in the last 30 days, NP (Nurse Practitioner) to assess A progress note, dated 6/6/19 at 11:00 a.m., indicated Resident has recently shown increase in alertness, mood, and ambulation. Resident can be intrusive towards others at times. GDR (Gradual Dose Reduction) may be root cause. A progress note, dated 6/11/19 at 11:13 p.m., indicated Resident D was found on the 100 hall in another resident's room picking up a dirty tray to attempt to take to the dining room. Earlier in the shift the resident had a couple of episodes of attempting to enter peers' rooms Resident got agitated with nurse when nurse would not let him into peer's room to use telephone to call his brother A care plan, with a start date of 6/11/19 and last reviewed/revised 6/21/19 at 1:17 p.m., indicated Resident has episodes of intrusive wandering, may enter peers' rooms without permission. Interventions included, but were not limited to, 1 to 1 supervision (with a start date of 6/17/19), and redirect and protect the privacy of other residents. A progress note, dated 6/16/19 at 7:00 p.m. recorded as Late Entry on 6/17/19 at 1:50 a.m., indicated Resident D was placed on 1 to 1 observations for a wandering incident. A progress note, dated 6/16/19 at 9:43 p.m., indicated Resident D was alert and oriented with clear speech and able to make some needs known. He was able to stand and pivot with assistance, able to ambulate with wheel chair, and able to propel wheel chair on own. Resident D had wandered into another resident's room and was removed from the room. A staff member had stayed with the resident until he went to sleep and then another staff member was in his room while he slept. A progress note, dated 6/17/19 at 6:02 p.m., indicated Resident D did not recall what had happened or who was involved. He was upset because he thought something was being said about him and he thought something bad happened but he did not know what. A care plan, with a start date of 6/17/19 and last reviewed/revised on 6/25/19 at 2:52 p.m., indicated Resident D had touched a peer inappropriately in a sexual way. The goal for the care plan was for the resident to not touch peers inappropriately. Interventions included, but were not limited to, a medication review, 1 to 1 supervision, and psychiatric services. A progress note, dated 6/18/19 at 1:39 p.m., indicated Resident D's family was called to inform him of the resident's continued behavior and attempts to inappropriately touch other male residents. Resident remained on 1 to 1 supervision and they were attempting to send the resident out to the psychiatric hospital to adjust his medications so these behaviors would not continue. Resident D may not be safe with the continued behaviors because if he grabs a male resident inappropriately, he may get hurt and it's not acceptable for him to continue to grab the male residents in a sexual manor (sic). A social services progress note, dated 6/18/19 at 2:31 p.m., indicated the Director of Nursing Services (DNS) had attempted to get a referral to a psychiatric hospital but was denied. A social services progress note, dated 6/18/19 at 3:00 p.m., indicated the Social Services Director (SSD) had made multiple attempts to refer Resident D to several different psychiatric and behavioral facilities but all denied the resident due to his age and because he was on Medicaid. SSD was able to get a referral to one facility and the DNS to a different facility. Requested information was faxed to both facilities. A progress noted, dated 6/18/19 at 10:07 p.m., indicated Resident D continued on 1 to 1 supervision and had been administered a Depo-[MEDICATION NAME] injection. During an interview on 6/26/19 at 11:45 a.m., Licensed Practical Nurse (LPN) 19 indicated Resident D had a GDR of [MEDICATION NAME] (medication used for depression and anxiety disorders) and had been decreased from 20 milligrams (mg) to 10 mg on 5/19/19. Resident D became more alert and talkative. He did well with the reduction for the first few weeks, but the last few weeks he had had more behaviors. Resident D had always had poor impulse control, was hyperactive, ambulated all over the place, and wandered into other residents' rooms. On 6/16/19 a 1 to 1 supervision was started and the resident had a sitter. On 6/18/19 his [MEDICATION NAME] was increased back to 20 mg which had made the resident more sedated, and the Nurse Practitioner had re-ordered the Depo-[MEDICATION NAME] monthly. During a review of the resident's medical record with LPN 19, she indicated the resident had a history of [REDACTED]. He had a [DIAGNOSES REDACTED]. Resident D had been in the facility for 3 years. During his first year in the facility he had been on Depo-[MEDICATION NAME] monthly, and the medication had been discontinued at some point. During an interview on 6/27/19 at 10:05 a.m., the Regional Consultant and the ED indicated Resident [NAME] had shown some social distress from the incident with Resident D. The ED indicated Resident [NAME] was probably also embarrassed due to personnel. Resident [NAME] was a very proud man and it's been an emotional situation. After the incident the mesh stop sign was placed on the doorway. A meeting was held with the family, and they ordered a doorway chime. The resident had expressed anger, so a 1 to 1 staff sitter was added to protect other residents. If Resident [NAME] was approached and didn't know who it was he might swing out to protect himself. During an interview on 6/27/19 at 10:21 a.m., the Regional Consultant and the ED indicated to their knowledge Resident D had been on Depo-[MEDICATION NAME] in the past but had not been displaying sexual behaviors. After the incident with Resident E, Resident D was put on 1 to 1 direct supervision. They were looking for psychiatric placement for Resident D but had been unsuccessful due to his age and payment source. During an interview on 6/27/19 at 12:50 p.m., the Regional Consultant and the ED indicated Resident E's extender on his call light was provided by the family after the incident to allow the resident access to his call light without it being stretched. Adding the extender made the call light cord double the length, the family did not like the cord being pulled tight from the wall to the resident's recliner. The Regional Consultant indicated he thought the resident had the call light at the time of the incident. On 6/27/19 at 2:40 p.m., the ED provided a current policy, titled Abuse Prohibition, Reporting, and Investigation, and revised (MONTH) (YEAR). The policy indicated It is the policy of (company name) to provide each resident with an environment that is free of abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to verbal abuse, sexual abuse, physical abuse, mental abuse, corporal punishment, and involuntary seclusion .(Company name) will not permit residents to be subjected to abuse by anyone including employees, home office staff, other residents This Federal tag relates to Complaint IN 666. 3.1-27(a)(1)

Based on interview, and record review, the facility failed to prevent a male resident (Resident B) with a known history of sexual aggression, from persuading a cognitively impaired female resident (Resident C) into performing an act of oral sex and touching Resident B's genitalia on 3/20/19, and then a second incident on 3/26/19 where Resident B touched another female resident's (Resident D) breasts for 3 of 4 residents reviewed for abuse. The immediate jeopardy began on 3/20/19, when staff failed to prevent Resident B from sexually abusing Resident C by persuading her to perform and act of oral sex, and touch his penis, and the facility further failed to prevent Resident B from sexually abusing a second resident (Resident D) on 3/26/19 when he escorted her into an empty room, and touched her breasts. The Executive Director (ED), Director of Nursing Services (DNS), and Regional Director of Clinical Services were notified of the immediate jeopardy at 2:30 p.m. on 4/12/19. The immediate jeopardy was removed on 4/14/19, 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. On 4/10/19 at 11:35 a.m., the Executive Director (ED) provided a report, titled, Indiana State Department of Health Survey Report System, dated 3/20/19. The reports indicated, On 3/20/19 at 1:30 a.m., Residents observed in male resident's room. Male's clothing was off from the waist down. Female fully clothed at end of bed. Female resident observed making contact with male resident's genitalia with hands .Both placed on 15 minute checks x (times) 72 hours for safety. Male resident placed on 1:1 (one on one) observation . Follow up added 3/26/19 indicated, Male resident was relocated off of the secured unit . Record review was completed for Resident B, on 4/10/19 at 2:57 p.m. The record indicated, the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of a quarterly Minimum Data Set (MDS) assessment, dated 2/6/19, indicated Resident B had the ability to make himself understood and to understand others. BIMS score of 5 indicated severe cognitive impairment. No signs or symptoms of [MEDICAL CONDITION], behaviors, rejection of care, or wandering. A form titled, Progress Note, written by the Nurse Practitioner and dated 10/31/18, indicated the resident was seen on that date for reports of inappropriate sexual behavior. Nursing staff had reported the patient was making inappropriate verbal comments of a sexual nature towards them. These incidents had been increasing in frequently over the past several weeks. On one occasion, staff were assisting the patient with hygiene for incontinence and patient thrust his penis at caregivers face and made comments about his genitalia. A form titled, Progress Note, written by the Nurse Practitioner and dated 3/20/19, indicated, the resident was observed on that date to have a female resident in his room, patient was naked from the waist down and was instructing the female to suck his penis per female resident's report. Patient has had other incidents of [MEDICAL CONDITION]. Review of Resident B's physician's orders [REDACTED].>On 3/21/19 Depo-[MEDICATION NAME] (birth control shot, when administered in males lowers testosterone levels, lowering sexual drive) 150 mg/ml (milligrams per milliliter) one a day on 4th Friday of the month, for dementia with behaviors. The order was discontinued on 3/22/19. Review of Resident B's Progress Notes, dated 3/20/19 - 3/21/19, indicated, On 3/20/19 at 11:49 a.m., (late entry on 3/21/19 at 11:50 a.m.) LPN 12 indicated, Resident B was moving to a room on the nursing LTC (long term care) from secured unit. The family was called, but unable to leave a message. On 3/20/19 at 3:52 p.m., (late entry on 3/21/19 at 11:01 a.m.) LPN 14 indicated, Resident B moved into a healthcare room. The resident was able to ambulate throughout facility, and a wanderguard was placed on the left ankle due to discharge from the secured unit. On 3/20/19 at 4:04 p.m., Social Service Director (SS) indicated, she had attempted to contact family in regards to peer incident that occurred early morning on 3/20/19. The POA (power of attorney) did not answer and voicemail box was full. Writer would attempt to contact again tomorrow morning. Resident B had no exit seeking behavior and would be transferred to a health care unit for more appropriate placement. Wander guard placement due to new surroundings. Resident continues with 15 minute wellness checks for 72 hours. On 3/20/19 at 4:55 p.m., (late entry on 3/21/19 at 11:55 a.m.) LPN 12 indicated, the Nurse Practitioner (NP) spoke to the POA regarding Depo-[MEDICATION NAME] injections, and the daughter refused. On 3/21/19 at 8:52 a.m., Social Service Director indicated, the POA was notified of the new order for medication and informed of incident with female peer (Resident C), per NP notification. Writer contacted POA this morning for follow up on NP conversation, and a message left notifying of room move. Resident B remained on 15 wellness checks. Review of a tab, titled, Events, dated 3/20/19 - 3/21/19: On 3/20/19 a document, titled, IDT Behavior Review, indicated, Resident B was found with a female peer in the bedroom half clothed. Root cause was documented as, the resident had a girlfriend and was sexually active prior to admission. The residents had been conversing in the hallway and Resident B invited Resident C to his bedroom. On 3/20/19 a documented, titled, New/Worsening Behavior Communication Event, indicated, Resident B exhibited inappropriate sexual behavior, family was not notified of the behavior. Review of Resident B's Care Plans, to include but were not limited to: 1. 3/21/19 Problem: (Resident B has history of sexual behavior with female peers. Goal: Staff will monitor resident for increased sexual behavior. Approach: Provide depo shot as ordered by physician. 2. 3/27/19 Problem: Resident attempts to assist peers to and from requested areas. Goal: Resident will allow for staff to assist peers. Approach: Redirect as needed to ensure he does not assist peers. Direct resident to selected common area after meals. Provide resident with 15 (sic) as needed. Record review was completed on Resident C, on 4/11/19 at 10:50 a.m. The record indicated, the resident was admitted on [DATE], with [DIAGNOSES REDACTED]. Review of Progress Notes for Resident C, dated 3/20/19 - 4/11/19, indicated: On 3/20/19 at 4:08 p.m., the Social Service Director indicated, she had spoken to Resident C in regards to an incident with a male peer (Resident B), and the resident indicated she remembered the time she spent with the peer. On 3/20/19 at 4:12 p.m., the Social Service Director indicated, she had spoken with Resident C's brother who is the Guardian, in regards to the peer incident. The POA stated, the resident had a history of [REDACTED]. Review of a quarterly Minimum Data Set (MDS) assessment, dated 2/19/19, indicated, Resident C had the ability to make herself understood and to understand others. Her Brief Interview for Mental Status (BIMS) score of 6 indicated severe cognitive impairment. The resident consistently had signs and symptoms of [MEDICAL CONDITION] present to include inattention, and disorganized thinking. Review of Resident C's Care Plans, to include, but were not limited to: 1. Resident is at risk for adverse side effects due to antipsychotic medication use due to [DIAGNOSES REDACTED]. Problem: Resident refuse to wear clothing .3. Problem: Resident has habit of clapping her hands together, on her legs, blowing kisses, or rubbing arms. (MONTH) make unintentional contact with others .4. Resident resides on a memory care unit related to [DIAGNOSES REDACTED].e. can become physically aggressive towards staff and peers due to [DIAGNOSES REDACTED]. During an interview with Resident C on 4/12/19 at 1:45 p.m., she indicated Resident B used to be her friend, but they were not friends anymore. Resident C went to his room to visit, and Resident B asked her to touch him, then made her perform oral sex, he used his hand to push her head really hard onto his penis. She didn't like it, and it made her feel gross. During an interview on 4/15/19 at 2:10 p.m., CNA 17 indicated she was working the night of 3/20/19 when the incident occurred. After the incident Resident C came to the desk and was slapping the counter and being anxious and yelled for mouthwash. During an interview on 4/15/19 at 3:30 p.m., CNA 18 indicated on 3/20/19 she was the one that found Resident C in Resident B's room sitting on the edge of the bed holding Resident B's penis. Resident C indicated, we're having sex. CNA 18 removed Resident C from the room and helped her wash up. 2. On 4/10/19 at 11:35 a.m., the Executive Director (ED) provided a report, titled, Indiana State Department of Health Survey Report System, 3/26/19 at 3:44 p.m. The report indicated, (Resident B) pushed (Resident D) down the hallway from the dining room after lunch. (Resident D) stated that (Resident B) pushed her into his room and touched her shoulder/breast area .Residents both placed on 1:1 care. Psychosocial distress will be monitored in both residents . Follow up added 4/1/19 indicated, Male resident was transferred to a behavior facility A review of Resident B's Progress Notes, dated 3/21/19 - 3/29/19, indicated, On 3/27/19 (late entry on 4/1/19 at 11:59am), the Director of Nursing Services (DNS) documented, Spoke to sister (Power of Attorney) at length about the event that occurred this week. Told sister that we had reached out to other facilities to find a better fitting facility for his needs. She mentioned that she was having surgery on Thursday and to leave a voicemail with where he is transferring to. She was understanding of the event and transfer. On 3/27/19 at 1:39 p.m., Social Service Director documented, IDT spoke with resident in regards to recent incident of assisting female peer to wrong bedroom. Resident was helping female peer in her wheelchair and entered wrong bedroom. Female then came to nurse station stating he had touched her chest and rubbed her shoulders. Resident has [DIAGNOSES REDACTED]. A review of a tab, titled, Events, dated 3/22/19 - 3/29/19: On 3/26/19 a documented, titled, New/Worsening Behavior Communication Event, indicated, Resident B assisted a female (Resident D) peer to the wrong bedroom. On 3/29/19 a documented, titled, Discharge to Other Facility, indicated, resident was discharged due to behaviors. On 4/10/19 at 3:11pm the DNS provided documented, untitled, dated 3/26/19, and indicated it was a statement provided by Certified Nursing Assistant (CNA) 16. The statement indicated, the aide was walking towards the hall and noticed Resident B and Resident D coming out of a room, he was not sure what room. I asked what were they doing and (Resident B) hurried up and said nothing and walked away. (Resident D) the proceeded and started wheeling herself my way. She then stated, that man pushed me passed my room and into another room and put his hands in my shirt from behind A Progress note, dated 3/29/19 at 2:00 p.m., indicated, Staff helped resident gather belongings. Paperwork completed, meds (medications) gathered for residents transfer. Facility transferring resident to (facility name) at this time A record review was completed for Resident D, on 4/12/19 at 10:26am. The record indicated, the resident was admitted on [DATE], with [DIAGNOSES REDACTED]. A review of admission MDS assessment, dated 3/6/19, indicated, Resident D was able to make herself understood and to understand others. BIMS score of 14 indicated she was cognitively intact. No signs or symptoms of behaviors, [MEDICAL CONDITION], rejection of care or wandering. She required an extensive assist of 1 for locomotion on the unit, and total dependence of 1 for locomotion off the unit. A review of Resident D's Progress Notes, dated 3/26/19 - 4/12/19: On 3/26/2019 at 2:41 p.m., (Recorded as Late Entry on 03/27/2019 02:44 PM), the Social Service Director indicated, she had spoken with Resident D in regards to an incident with male peer (Resident B). Resident D stated that Resident B had inappropriately touched her. No evidence had been found and local authorities had been contacted per resident and family request. Resident provided 1:1 for safety and comfort. Resident was showing limited signs or symptoms of distress depending on which staff members were present. On 3/26/2019 at 4:12 p.m., LPN 19 indicated, Resident D came to the nurse's station after lunch and was emotional. She stated another resident, who she was unable to identify, had pushed her to her room and touched her breast. Resident had changed her statement multiple times. She denied any injury. A head to toe assessment was completed with no noted findings. On 3/26/2019 at 11:41 p.m., (Recorded as Late Entry on 03/27/2019 12:41 AM) 20 Registered Nurse (RN) indicated, Resident D was in an irritable mood which she attributed to an incident where she was touched inappropriately by another resident. Resident D complained she did not feel safe. On 3/27/2019 at 9:24 a.m., the Social Service Director indicated, she had spoken to Resident D that morning about previous alleged incident with a male peer. Resident D stated she recalled the incident, although her account of the event had varied with each interview. Resident continued to be unable to state the name of the male peer or recall any features other than he was wearing an orange sweatshirt. On 3/27/2019 at 2:45 p.m., the Social Service Director indicated, she had spoken with Resident D that morning in regards to incident, resident asked why writer was so concerned about her night. Resident D then explained that she slept terribly due to incident with male peer. Resident stated, That man wanted to touch me, I know it. On 3/28/2019 at 2:13 p.m., the Social Service Director indicated, Resident D continued to show some agitation due to recent alleged event with male peer. Resident also stated she was upset due to argument with her daughter about the alleged incident. Review of Resident D's Care Plans, to include, but were not limited to: 1. 3/27/2019 Problem: Resident has a history of making false allegations/accusations about staff and peer. Will attention seek despite all needs being met. Goal: Resident will receive medications, care, and support she needs in a timely and professionally manner without complaining, refusing, or making false allegations. Call local authorities as requested by resident or resident family to provide investigation. Provide 1:1 staff member as required during accusations or distress due to delusional thoughts. Provide multiple IDT members for various interview to ensure accusation is consistent. 2 staff members at all times during care and med pass .2. Problem: Resident is at risk for changes in mood due to [DIAGNOSES REDACTED]. Goal: Resident will experience limited changes in mood through review date. Approach: Administer all medications as ordered by physician, Monitor for changes in mood including but not limited to: increased agitation, verbal or physical aggression, Refer to NP for medication review as needed . During an interview with the Social Service Director, on 4/11/19 at 11:18 a.m., she indicated, Resident B's Power of Attorney (POA) wanted to transfer him out of the secured memory care unit in January, but the resident did not want to move after a day trial on the long term care unit. She indicated, after an incident with a female peer on 1/18/19, the IDT suggested medications be tried first and the POA refused. After the second episode on 3/20/2019, when Resident B was still in memory care, again medication were suggested and the POA declined again. The SS Director then had a discussion with Resident B and his POA regarding a transfer off the secured memory care unit for the safety of cognitively impaired female residents on the unit, and Resident B was transferred to the Pine Hallway, on the long term care unit. On 3/27/19 a 3rd episode occurred with another female peer (Resident D). Resident D was persistent in requesting to have police involvement as she didn't feel safe, so the police were contacted and came to the facility. At that time, the IDT decided Resident B's needs would better be met in an all-male or behavioral facility. Resident B was transferred to a behavioral facility on 3/29/19 due to sexual expression towards female peers. On 4/11/19 at 12:48 p.m., the DNS indicated, the resident's POA called and wanted to trial in the health center around end of (MONTH) or mid-March. The trial was for one day and Resident B did not like it out on the long term care unit, so he was moved back into the memory care unit. The resident had always had sexual tendencies, and the doctor wanted to trail the depo shot. An order was gotten in February, but the POA did not want the medication intervention so the order was discontinued. On 3/20/19 after a reportable sexual incident with Resident C from memory care, the doctor tried to order the depo shot again, and the POA refused again. There was talk of moving Resident B to the health care side to a more visual room where he could be monitored better around the ladies. On 4/11/19 at 12:48 p.m., the DNS indicated, on 3/27/19 Resident D went to the nurse's station and reported Resident B had touched her left breast, although Resident B said he had no recollection. Resident D identified the male resident as having an orange shirt. When the cameras were monitored, the video showed Residents B and D were in the room together for one min, then Resident D came back out by herself. When staff went to interview Resident B he was asleep on the bed. Resident D indicated she felt unsafe in the facility, and the police came and talked with her. Resident D had a history of [REDACTED]. On 4/11/19 at 12:58 p.m., the DNS indicated due to previous behaviors interventions were attempted for Resident B which included a new order for Depo-[MEDICATION NAME] shots which the POA refused, 15 minute checks for 72 hours, redirection in common areas, and public activities. Between the incidents on 3/20/19 and 3/26/19 Resident B was being observed with sexual behaviors towards female peers, there was a new order for Depo-[MEDICATION NAME] shots which the POA refused again, Resident B was moved to the 200 hallway where there was more foot traffic and staff, he was given a wanderguard, and staff offered involvement in activities. When the POA was notified, she indicated, he had always been a ladies' man. On 4/11/19 at 2:48 p.m., the DNS indicated, the Resident B had not been seen by psych services as he had no psych diagnosis. There was also no documentation of 15 minute checks, just progress notes indicating the checks were taking place. On 4/12/19 at 9:54 a.m., the DNS indicated, there was no care plan for Resident B regarding sexual behaviors upon admission, although the staff and POA had discussed his history with women. A care plan was not initiated after an incident on 1/18/19 when the resident was observed having an escalation in aggressive sexual behaviors. A care plan was finally initiated 3/27/19 after the 3rd incident. During an interview on 4/12/19 at 11:20 a.m., LPN 12 indicated, from the very beginning, since Resident B's admission 8/30/18, he had exhibited sexually inappropriate behaviors on a frequent basis. He had a girlfriend who he spoke on the phone with almost daily, and the conversations were often sexually explicit so Resident B had to be reminded to keep his conversations PG (an American film rating of Parental Guidance Suggested for some material may not be suitable for children) in front of other residents. He was very interested in women, he was a man, and talked about sexual things. On 4/12/19 at 11:45 a.m., the DNS indicated, Resident D's care plan for false accusations was initiated on 3/27/19 after the incident, although there was no investigation. The resident had not had any incidents of false allegations while she was a resident in this facility, the care plan was written with information from past history at another facility. During an interview with Resident D on 4/12/19 at 12:00 p.m., she indicated a man pushed her in her wheelchair past her room, and into another room down the hall. He was standing behind her, and he reached around and put his hands under her shirt, and grabbed her breasts. It made her mad, and she felt creeped out. She was angry and she hated the man, and screamed for help. During an interview with Resident D's family member on 4/12/19 at 12:05 p.m., she indicated her mother had been sexually abused by another resident. When she came in to see her mother the day after the abuse occurred, her mother was inconsolable, crying, and angry. She was so concerned for her mother's safety, she took off work to look for another facility for an immediate transfer. On 4/12/19 at 12:41 p.m., the Director of Nursing Services (DNS) indicated, Residents B, C, and D had no documentation of having been assessed for sexual consent, or care plans regarding sexual consent. On 4/12/19 at 11:40 a.m., the Executive Director (ED) provided a policy, titled, Abuse Prohibition, Reporting and Investigation, dated (MONTH) (YEAR). The policy indicated, It is the policy of (company name) to provide each resident with an environment that is free from abuse .This includes but is not limited to verbal abuse, sexual abuse, physical abuse, mental abuse .(Company name) will not permit residents to be subjected to abuse by anyone, including employees, home office staff, other residents .Supervisory personnel are responsible to monitor, through observation and counseling as needed, staff/resident interactions, and the provision of care and services to residents The immediate jeopardy that began on 3/20/19 was removed on 4/14/19 when the facility interviewed all residents to assess for potential abuse from residents or staff, head to toe assessments were completed on any residents unable to complete interview regarding abuse, staff were in-serviced on the abuse policy, and management and staff were in-serviced on abuse reporting and investigation The noncompliance remained at the lower scope and severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy because of the facility's need for continued monitoring. This Federal tag relates to Complaints IN 292, IN 709, and IN 486. 3.1-27(a)(1)

Based on interview, and record review, the facility failed to conduct a thorough investigation of the sexual abuse by a male resident (Resident B) with a known history of sexual aggression to a cognitively impaired female resident (Resident C) on 3/20/19, resulting in a subsequent allegation of sexual abuse by the same male resident (Resident B) to another female resident (Resident D) on 3/26/19 for 3 of 4 residents reviewed for abuse. The immediate jeopardy began on 3/20/19 when staff failed to conduct a thorough investigation when Resident B sexually abused Resident C. A subsequent allegation of abuse, when Resident B was alleged to sexually abuse Resident D was also not investigated. The Executive Director (ED), Director of Nursing Services (DNS), and Regional Director of Clinical Services were notified of the immediate jeopardy at 2:30 p.m. on 4/12/19. The immediate jeopardy was removed on 4/14/19, 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. On 4/10/19 at 11:35 a.m., the Executive Director (ED) provided a report, titled, Indiana State Department of Health Survey Report System, dated 3/20/19. The reports indicated, On 3/20/19 at 1:30 a.m., Residents observed in male resident's room. Male's clothing was off from the waist down. Female fully clothed at end of bed. Female resident observed making contact with male resident's genitalia with hands .Both placed on 15 minute checks x (times) 72 hours for safety. Male resident placed on 1:1 (one on one) observation . Follow up added 3/26/19 indicated, Male resident was relocated off of the secured unit A record review was completed for Resident B, on 4/10/19 at 2:57 p.m. The record indicated, the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. A review of a quarterly Minimum Data Set (MDS) assessment, dated 2/6/19 indicated, Resident B had the ability to make himself understood and to understand others. BIMS score of 5 indicated severe cognitive impairment. No signs or symptoms of [MEDICAL CONDITION], behaviors, rejection of care, or wandering. A form titled, Progress Note, written by the Nurse Practitioner and dated 3/20/19, indicated, the resident was observed on that date to have a female resident in his room, patient was naked from the waist down and was instructing the female to suck his penis per female residents report. Patient has had other incidents of [MEDICAL CONDITION]. On 4/10/19 at 3:11 p.m., the DNS provided 4 written statements and indicated that was the complete investigation for the abuse on 3/20/18. The DNS indicated an untitled document with no signature to indicate the author, dated 3/20/19, was one of the written statements. The statement indicated, the writer spoke with resident in regards to peer to peer sexual incident that occurred 3/20/19 around 1:30 a.m. Resident states he (Resident B) does not recall the incident. He states he does remember (Resident C) being in his bedroom, but denies anything occurring. A record review was completed on Resident C, on 4/11/19 at 10:50 a.m. The record indicated, the resident was admitted on [DATE], with [DIAGNOSES REDACTED]. A review of a quarterly Minimum Data Set (MDS) assessment, dated 2/19/19, indicated, Resident C had the ability to make herself understood and to understand others. Her Brief Interview for Mental Status (BIMS) score of 6 indicated severe cognitive impairment. On 4/10/19 at 3:11 p.m., the Director of Nursing Services (DNS) provided 4 written statements and indicated that was the complete investigation for the abuse on 3/20/18. The DNS indicated an untitled document, dated 3/20/19, was a statement provided by the Social Service (SS) Director. The statement indicated, SS spoke with Resident C about the sexual incident with a male peer. Resident stated she was talked into going into peer's bedroom. Resident stated she was asked to do oral sex, she did not want to do it, but did .Resident states she feels betrayed. During an interview with Resident C on 4/12/19 at 1:45 p.m., she indicated Resident B used to be her friend, but they were not friends anymore. Resident C went to his room to visit, and Resident B asked her to touch him, then made her perform oral sex, he used his hand to push her head really hard onto his penis. She didn't like it, and it made her feel gross. 2. On 4/10/19 at 11:35 a.m., the Executive Director (ED) provided a report, titled, Indiana State Department of Health Survey Report System, 3/26/19 at 3:44 p.m. The report indicated, (Resident B) pushed (Resident D) down the hallway from the dining room after lunch. (Resident D) stated that (Resident B) pushed her into his room and touched her shoulder/breast area .Residents both placed on 1:1 care. Psychosocial distress will be monitored in both residents . Follow up added 4/1/19 indicated, Male resident was transferred to a behavior facility . Record review was completed for Resident D, on 4/12/19 at 10:26am. The record indicated, the resident was admitted on [DATE], with [DIAGNOSES REDACTED]. Review of admission Minimum Data Set (MDS) assessment, dated 3/6/19, indicated, Resident D was able to make herself understood and to understand others. BIMS score of 14 indicated she was cognitively intact. No signs or symptoms of behaviors, [MEDICAL CONDITION], rejection of care or wandering. During an interview with Resident D on 4/12/19 at 12:00 p.m., she indicated a man pushed her in her wheelchair past her room, and into another room down the hall. He was standing behind her, and he reached around and put his hands under her shirt, and grabbed her breasts. It made her mad, and she felt creeped out. She was angry and she hated the man, and screamed for help. During an interview with Resident D's family member on 4/12/19 at 12:05 p.m., she indicated her mother had been sexually abused by another resident. When she came in to see her mother the day after the abuse occurred, her mother was inconsolable, crying, and angry. She was so concerned for her mother's safety, she took off work to look for another facility for an immediate transfer, but had been unable to find a bed. On 4/12/19 at 9:55 a.m., the Regional Consultant indicated, there was no investigative documentation at this time regarding the sexual encounters or abuse allegations with Resident B for 3/20/19 or 3/27/19 to indicate the residents were assessed after the incidents, the physician, administrator, charge nurse, or family members had been notified, documentation that an administrative investigation had been completed, or that preventative interventions were initiated to protect female residents from persistent aggressive sexual behaviors. On 4/12/19 at 11:40 a.m., the ED provided a policy, titled, Abuse Prohibition, Reporting and Investigation, dated (MONTH) (YEAR). The policy indicated, It is the policy of (company name) to provide each resident with an environment that is free from abuse .Supervisory personnel are responsible to monitor, through observation and counseling as needed, staff/resident interactions, and the provision of care and services to residents .The Executive Director is the designated individual responsible for coordinating all efforts in the investigation of abuse allegations, and for assuring that all policies and procedures are followed .The Interdisciplinary Team will assess the situation and make recommendations for further interventions .The Executive Director/Designee will analyze the occurrence to determine root cause and when changes are needed to prevent further occurrence .Based on the root cause, ED/Designee will determine how care provisions will be changed. The care plan will be updated accordingly The immediate jeopardy that began on 3/20/19 was removed on 4/14/19 when the facility interviewed all residents to assess for potential abuse from residents or staff, investigations were completed for the two incidents of abuse from Resident B, staff were in-serviced on the abuse policy and procedure, and management and staff were in-serviced on abuse reporting and investigation. The noncompliance remained at the lower scope and severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy because of the facility's need for continued monitoring This Federal tag relates to Complaints IN 292, IN 709, and IN 486. 3.1-28(d)

Based on observation, record review, and interview, the facility failed to prevent a medication error resulting in the hospitalization for 1 of 5 residents reviewed for medication errors (Residents C). Findings include: A record review for Resident C was completed on 4/10/18 at 11:25 a.m. The record indicated, the resident was admitted with [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set (MDS) assessment, dated 2/7/18, indicated, Resident C had a Brief Interview for Mental Status (BIMS) score of 10 indicating moderate cognitive impairment, required extensive assistance of 2 staff for bed mobility and transfers, did not walk, and required supervision for eating. Resident Progress notes for Resident C, dated 3/25/18 at 11:30 p.m., indicated, This late entry is in relation to medications (meds) administered to resident. The medications were intended for roommate that included medications for pain and blood pressure (BP). Writer (Licensed Practical Nurse 13) had the meds for roommate, then stepped out to computer to record a vital of roommate while staff completed care. When writer returned to room she noted that resident had ingested meds .The Nurse Practitioner (NP) from Optum said to monitor the BP and encourage fluids she stated that the meds took a while to absorb in the body so she should be fine . Resident Progress notes for Resident C, dated 3/26/18 at 1:27 p.m., indicated, This writer placed a follow up call to next of kin (name of relative). Made aware of the following medications received on 3/25/18 on evening shift: [MEDICATION NAME] ([MEDICAL CONDITION]), [MEDICATION NAME] (antipsychotic), [MEDICATION NAME] (muscle relaxant), [MEDICATION NAME] (sedative and antihypertensive drug), [MEDICATION NAME] (lowers cholesterol and triglycerides), Senna (laxative), Tacfidera (treatment for [REDACTED]. Aware of orders from physician to monitor blood pressure and encourage fluids . Resident Progress notes for Resident C, dated 3/26/18 at 1:40 p.m., indicated, Resident C was brought back from dining room unconscious/unresponsive, taken to room and put back to bed, vital signs taken, mouth clear, diaphoretic (sweating), blood pressure check 138mg, oxygen saturation 88% initiated oxygen at 3L (liters)/minute, still not responding, call 911 and taken to the emergency room (ER) for evaluation. Called granddaughter and informed incident. On 4/12/18 at 11:32 a.m., the MDS nurse provided document, titled, Documentation Administration History: 3/25/18 - 3/25/18. The administration record indicated, Licensed Practical Nurse (LPN) 13 administered medications to Resident C on 3/25/18 between the hours of 5:00 p.m. - 10:00 p.m. Resident C was administered medications to include: Carvedilol (anti-hypertensive), [MEDICATION NAME] (diuretic), [MEDICATION NAME] (nerve pain and anticonvulsant), Latanoprost Eye Drops (treats [MEDICAL CONDITION]), [MEDICATION NAME] (anti-diabetic), Namzaric (treats moderate to severe [MEDICAL CONDITION]), [MEDICATION NAME] (narcotic pain medication), [MEDICATION NAME] (treats gastro-[MEDICAL CONDITION] reflux), and [MEDICATION NAME] (lowers cholesterol and triglycerides). On 4/12/18 at 2:20 p.m., the ADM provided a document titled, Optum Nurse Practitioner Call Log, dated 3/25/18 - 3/26/18. The log indicated LPN 13 notified the NP of the following: on 3/25/18 at 23:07, the patient took roommates meds by mistake. Patient already took her own medication at 8pm and in addition she also took roommates meds, patient has cognitive problems and took meds by mistake. Patient took Texadera 240mg (milligrams), [MEDICATION NAME], Fenobifrate, Simethacone, [MEDICATION NAME], Senna, and Vitamin C. NP response indicated, monitor neurological checks and blood pressure x 72 hours, encourage fluids, and call if any decreased blood pressure or difficulty in arousal. On 4/12/18 at 10:20am, the ADM provided a report titled, Indiana State Department of Health Survey Report System, dated 3/27/18. The report indicated, .3/27/18 during evening medication administration on 3/25/18, resident ingested roommates room medications. Nurse notified MD with order received to obtain blood pressure x 72 hours and encourage PO (by mouth) fluids. Prior to lunch meal service, VS (vital signs) WNL (within normal limits) with BP 130/74, resident alert per her usual. In the afternoon of 3/26/18 approximately 1:30PM, after having consumed lunch nurse noted resident unresponsive in dining room. Resident brought back to her room for assessment. Upon transferring her to bed could visualize food in oral cavity which was cleared. Resident responding with fluctuating level of alertness. Activated call to 911 and resident sent to ER (emergency room ) for evaluation. admitted to hospital with UTI (urinary tract infection) and in stable condition .Type of preventative measures added-3/27/18 blood pressure monitored and fluids encouraged .Follow up added-3/30/18 resident remains in hospital and is doing well. Discharge plans unknown at this time .Reeducation with skills validation with nurses/QMA's (Qualified Medication Aides) on medication administration. Roommate's name was not indicated in the report. Administrator provided name of roommate for review. On 4/12/18 at 11:32 a.m., the ADM provided document titled, Medication/Treatment Error Report, dated 3/28/18. The report indicated, LPN 13 had prepared medications for (roommates name) and set the medication on the bedside table while she went to retrieve something in the hallway, and when she returned to the room, the bedside table was on Resident C's side of the room, and she had taken the following medications: [REDACTED]. On 4/12/18 at 1:15 p.m., the ADM provided a document for Resident C titled, History and Physical (H&P), dated 3/26/18. The ADM indicated, this was the H&P completed at the hospital. The document indicated, .Chief Complaint: Accidental Overdose .Presenting Symptoms Details: .presented to the ED (emergency department) this afternoon after accidentally ingesting another resident's medications. Per documentation and report from family, the patient ingested 5-6 different medications which may have included [MEDICATION NAME] and a beta blocker (used to reduce high blood pressure). She was paced transcutaneously (through the skin) and given 0.5mg [MEDICATION NAME] (treated heart rhythm problems) for HR's (heart rates) in the 50's with systolic BP's in the 80's and 90's .The EKG (electrocardiography used for recording electrical activity of the heart over a period of time) showed sinus [MEDICAL CONDITION] (slow heart rate) .admitted to our care for care for her resolving accidental overdose .I will put her on telemetry. We will hold her beta-blocker . On 4/12/18 at 10:48 a.m., the MDS nurse provided binders titled, Plan of Correction for State and an untitled binder she indicated contained staff competency forms. Document for education of LPN 13 was not observed. Review of In-Service binder for (YEAR) was completed on 4/12/18 at 9:35 a.m. In-service education dated 3/6/18 included to following training: a. Remember the 5 Rights? They've grown up! They're now 7!!! Rights of medication administration. Right patient, right medication, right dose, right route, right time, right documentation, and right to refuse. b. Nebulizer Treatment (Small Volume Nebulizer-SVN-Medicated Aerosol Therapy) .Post Test c. Glucose Meter Cleaning & Testing d. Dressing Change e. Medication Pass Procedure f. Mechanical Lift g. Gait Belt-Application h. Perineal Care i. Feeding a Resident j. Enteral Tube-Medication Administration k. Enteral Nutrition-Gastrostomy or Jejunostomy Tube l. Hand Hygiene m. Good Documentation: Electronic Protection A review of Relias (electronic in-service program) Monthly In-Services (YEAR), was completed on 4/12/18 at 9:50 a.m. The report indicated, there were no nursing in-services scheduled for nursing skills, and there had been no documentation indicating LPN 13 completed any on-line in-service training in (MONTH) or (MONTH) (YEAR). A review of State Reportable incidents dated (MONTH) and (MONTH) (YEAR), and (MONTH) 12-April 8, (YEAR) was completed on 4/12/18 at 9:40 a.m. The review indicated, there was 1 medication error reported during the time frame. On 4/12/18 at 1:28 p.m., the ADM indicated, LPN 13 went to give Resident Q her pills mixed in pudding, she sat them on what she thought was Resident Q's over the bed table as the resident was being put to bed by hoyer lift. The bedside table had been moved out of the way. LPN 13 stepped out of the room to document something and when she returned to the room, the aides had moved the over bed table next to Resident C as it was her over the bed table. Resident C had taken the medication that had been sitting on the over the bed table, belonging to Resident Q, and indicated she thought they were her pills. LPN 13 notified the NP, received orders to check VS and report any out of line, and to give plenty of fluids which was done throughout the night. The next morning Resident C was up eating breakfast and her VS were good. She then ate most of her lunch. The Director of Nursing Services (DNS) received a call telling her Resident C was unresponsive in dining room, she was taken to her room, and put into bed. The ADM walking into the resident's room and observed her responding to sternal rubs, and had been told before she arrived kale had been removed from Resident C's mouth. Oxygen had been applied and Resident C was responding slowly. Staff notified the physician and Resident C was sent to the ER. Staff reported to Emergency Medical Technicians (EMT's) and the hospital regarding the kale, and that the resident had been responding after the kale was removed from the mouth. On 4/12/18 at 11:32 a.m., the ADM provided a policy titled, Medication Pass Procedure, dated 12/06. The policy indicated, .6. Perform the 5 rights of medication, Right Resident, Right Medication, Right Dose, Right Route, Right Time. 7. Observed taking medications-not left at bedside . On 4/12/18 at 11:32 a.m., the ADM provided a policy titled, Medication Errors, dated 2/2015. The policy indicated, Policy: It is the policy of this provider to ensure residents residing in the facility are free of medication errors and the facility maintains a medication error rate of less than 5%. Procedure: When a suspected medication error is identified, the nurse will immediately assess the condition of the affected resident and notify the physician of the event. The responsible party/family will be notified of the error. The DNS will be notified of the error, resident condition .Documentation in the medical record will include physicians/family notification, type of error, and assessment of resident . This federal finding relates to Complaint IN 136. 3.1-4(c)(2)

Based interview and record review, the facility failed to prevent the administration of non-prescribed medications to a resident which resulted in the resident becoming unresponsive and requiring a transfer of care to the hospital intensive care unit for 1 of 5 residents reviewed for unnecessary medication use (Resident 30). Findings include: On 4/10/17 at 11:56 a.m., Resident 30 indicated a nurse had given him someone else's [MEDICATION NAME] medicine a couple of months ago. I woke up in an ambulance and was told I had an overdose! During an interview on 4/11/17 at 11:11 a.m., the DNS (Director of Nursing Services), indicated on 11/21/17 RN (Registered Nurse) 15 had prepared medications for another resident and realized the medications were not due yet; labeled the medications and placed them in the medication cart. The nurse then began preparing Resident 30's medications. While preparing the medications, RN 15 assisted another resident and went back to the medication cart and grabbed the wrong medications that were intended for the other resident. Resident 30 received MSO4 ([MEDICATION NAME] sulfate) (extended release pain medication) 60 mg (milligrams), [MEDICATION NAME] [MEDICATION]) 400 mg, [MEDICATION NAME] (pain medication) 600 mg, metroprolol (blood pressure medication) 25 mg about 5:00 p.m., which were not prescribed/ordered for him. The MD (medical doctor) and family were notified and 15 minute checks were initiated. Resident 30 was found unresponsive on 11/21/16 at 9:58 p.m. He was sent to the emergency room . The record for Resident 30 was reviewed on 4/11/17 at 11:23 a.m. The Quarterly MDS (Minimum Data Set) Assessment, dated 2/22/17, indicated, Active [DIAGNOSES REDACTED]. Resident 30's BIMS (Brief Mental Status) indicated a score of 14 (cognitively intact). An ineffective tissue perfusion care plan, originally dated 4/27/16 and updated 3/23/17, indicated a goal for Resident 30 would be to maintain adequate tissue perfusion, as evidenced by blood pressure within normal limits for resident, no change in mental status, no complaints of dizziness/lightheadedness/[MEDICAL CONDITION], no [MEDICAL CONDITION]; with a nursing approach to administer medications as ordered. A Physician telephone order, noted by RN 15, on 11/21/16 at 5:20 p.m., indicated, 1) Hold all evening meds with the exception of bactrium (ointment). 2) Continue to monitor resident .with a care plan updated upon the same form, dated 11/21/16 at 5:30 p.m., Problem: Risk for low BP (blood pressure) and low O2 (oxygen) sat; Goal: ensure resident safety; Intervention: follow above orders per MD (medical doctor). A DNS Progress note, dated 11/21/16 at 5:33 p.m., indicated, Charge nurse notified this writer that resident received [MEDICATION NAME] 400 mg (milligrams), [MEDICATION NAME] (pain medication) 600 mg, Metroprolol (blood pressure medication) 25 mg, and MSO4 ([MEDICATION NAME] sulfate) (extended release pain medication), this day around 5:00 p.m. No adverse reactions noted at this time. Respirations are even and labored. Resident is alert per usual. Vitals are WNL (within normal limits). Provider made aware of the above. Made aware of allergy list. Provider wants administer antibiotic therapy as ordered and monitor to at this time. Notification to next of kin. RN 15 wrote a progress note, dated 11/21/16 at 9:58 p.m., indicated, The writer of this note went to assess the resident and found the resident unresponsive. The writer of this note called emergency medical services immediately, sat resident up to 90 degrees, and noted pulse. The writer of this note stayed with resident until EMS (emergency medical services) arrived. Resident was sent to the ED (emergency department). Family notified. On call NP 17 (nurse practitioner) notified of resident worsening condition. DNS notified. The progress note, dated 11/21/16 at 11:19 p.m., written by RN 15, indicated, The writer of this note called ED to give report, Nurse in ED reported to the writer of this note that the resident is in stable condition, resident is responding to staff, and resident is on a [MEDICATION NAME] (opioid reversal) drip, resident will be admitted to ICU (intensive care unit). An ED record document, dated 11/21/16 at 2235 (10:35 p.m.), indicated, HPI (history of present illness) = 88 y.o. (year old), male, reported @ 1700 (5:00 p.m.) accidentally was given someone else's 60 mg [MEDICATION NAME] and 25 mg [MEDICATION NAME], was found to be confused/low blood pressure .gave total of 6 mg [MEDICATION NAME], more awake . A hospital admission summary document, dated 11/22/16, indicated, .In the ER (emergency room ) he was given a total of 8 mg of [MEDICATION NAME]. He was still unarousable. He did become eventually more awake in the ED. He vomited in the ED. He was started on a [MEDICATION NAME] drip in the ED and was transferred to the ICU. Patient was continued on a [MEDICATION NAME] drip for several hours until he woke up. Patient's blood pressure was also slightly low but that resolved after [MEDICATION NAME] got out of his system A facility DNS progress note, dated 11/22/16 at 8:12 a.m., indicated, Resident remains admitted the hospital in ICU. Nurse this a.m. reports he is stable. Call placed to (son) to discuss condition. This writer inquired of a time for IDT (interdisciplinary team) to meet with family to review findings. Son would like to speak with other siblings and will return call with a good time to meet. Son thanked this writer for call and plan to be in touch. Will continue to inquire of condition. The DNS provided a signed (by RN 15, DNS, and ADNS) interview document, dated 11/22/16, which indicated, .I (RN 15) prepared medication for resident in room (room number). I then realized the meds weren't due until 7-10 p.m. and noted one medication was a narcotic so I did not want to destroy; I labeled the medication cup with (room number) and put it in the cart. I then began to prepare medication for resident (Resident 30). I observed a resident attempting to stand who is a fall risk, I stopped what I was doing and responded to resident and in the mean time labeled that cup with (Resident 30's room number). After I addressed the fall risk, I erroneously grabbed the cup labeled (room number) and gave it to (Resident 30's room number). I immediately assessed resident in room (Resident 30's room number) and then made notification to supervisor, provider and next of kin. Provider gave an order to hold all evening shift medication with the exception of Bactrim and continue to monitor resident. I monitored him closely and assessed. At approximately 9:52 p.m., I observed him with a change in level of consciousness and decreased respirations. I initiated a call to 911 and remained with resident until EMS arrived On 4/11/17 at 11:35 a.m., the DNS provided and identified as current, Medication Pass Procedure, dated 06/2016, indicated, .Identified resident prior to administering 3.1-25(b)(9)

A. Based on observation, interview, and record review, the facility failed to ensure pain medication was administered to manage pain prior to incontinence and wound care to a resident resulting in verbal and non-verbal expressions of pain during the procedures for 1 of 3 residents reviewed for pain management (Resident #110). B. Based on record review and interview, the facility failed to ensure communication between the facility and [MEDICAL TREATMENT] provider for 1 of 1 residents reviewed for [MEDICAL TREATMENT] (Resident #14). Findings include: A1. During an observation of wound care on 1/26/2016 at 9:54 a.m., the Assistant Director of Nursing (ADON) Resident #110's removed Resident #110's multipodus boots was positioned sitting up, with multipodus boots (pressure relieving boots) and wound dressings from the bilateral heels as he sat up in his wheel chair. The resident moaned and made facial grimaces during the wound care. The ADON indicated Resident #110 experienced pain during his dressing changes. During an observation of incontinence and wound care on 1/27/2016 at 12:01 p.m., with Certified Nursing Assistant (CNA) #61, CNA #62, and Registered Nurse (RN) #63 present, Resident #110 was transferred by a hoyer lift to his bed to receive incontinence care. The resident moaned and stated, Ouch, ouch, during care and made facial grimaces when staff provided the care. One hour after care was initiated, the resident was transferred from his bed via Hoyer (mechanical lift) lift to his wheelchair and was given [MEDICATION NAME] (narcotic pain medication) 0.25 ml (milliliters) for pain relief. Resident 110's record was reviewed on 1/25/2016 at 12:00 p.m. Resident #110 had [DIAGNOSES REDACTED]. A pain care plan, dated 11/3/2015, and identified by the Administrator as current on 1/28/2016 at 12:23 p.m., indicated Resident #110 had pain related to [MEDICAL CONDITIONS] reflux disease, gout, and [MEDICAL CONDITION]. Strength; able to describe pain characteristics and efficacy of interventions. Potential for pain related to wounds. A goal indicated resident will be free from adverse effects of pain. Interventions indicated staff would administer medications as ordered, assist with positioning to comfort, document effectiveness of prn medications, notify the doctor if pain is unrelieved and/or worsening, observe for non verbal signs of pain: changes in breathing, vocalizations, mood/behavior changes, eyes change expression, sad/worried face, crying, teeth clenched, change in posture, and to offer non pharmacological interventions such as a quiet environment, rest, shower, back rub, and reposition. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A Minimum Data Set assessment (MDS) tool, dated 12/28/2015, indicated Resident #110 had exhibited vocal complaints of pain (ouch, that hurt, stop) to staff for 1 to 2 days within the past 5 days. The record indicated Resident #110 was cognitively intact with with a Brief Interview for Mental Status (BIMS) score of 9 out of 15. Resident #110 required extensive assistance of 2 staff members with bed mobility and transfers, and extensive assistance of 1 staff member with toileting. A wound consult report, dated 1/26/2016, indicated, Resident #110's ulcers persisted for a litany of reasons. Chief among them are: .2. Muscle pain/stiffness, resulting in difficulty repositioning resident without significant discomfort Resident 110's Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. The record lacked indication he had been administered the routine [MEDICATION NAME] pain medication after 1/27/2016. The record lacked indication Resident #110 had received the ordered as needed [MEDICATION NAME] narcotic pain medication on 1/27/2016 prior to his observed incontinence care at 12:01 p.m. During an interview on 1/26/2016 at 11:39 a.m., the Wound Physician indicated Resident #110 had muscle pain and had exhibited discomfort and pain with repositioning. During an interview on 1/26/2016 at 1:05 p.m., RN #60 indicated she had not administered Resident #110's as needed dose of [MEDICATION NAME] prior to Resident #110's incontinence care and had not yet administered his routine [MEDICATION NAME] pain medication scheduled for 2 p.m. During an interview on 1/27/2016 at 3:29 p.m., Resident #110 indicated his buttocks was very sore. He indicated it hurts when the staff reposition him while in bed. During an interview on 1/28/2016 at 10:54 a.m., with the Director of Nursing (DON), Administrator, and the ADON, the DON indicated if a resident was experiencing pain during care, she expected her staff to halt the care provided, assess pain, and provide pain relieving interventions and/or pain medication immediately before continuing care. She indicated she expected her staff to assess and document uncontrolled pain for the interdisciplinary team to review. A policy titled, Pain Management, dated 2/2015 and identified as current by the DON on 1/28/2016 at 11:13 a.m., indicated, Policy: It is the policy of (name of facility corporation) to provide the necessary care and services to attain or maintain the highest practical physical, mental, and psychosocial well being, including pain management. It is the responsibility of the facility to ensure that each resident is assessed for pain, and the efficacy of pain medication, while keeping the resident as comfortable and pain free as possible .the pain management program will be determined based upon staff observation of non-verbal signs of pain as follows: non-verbal sounds (crying, whining, gasping, moaning, or groaning) .vocal complaints of pain (that hurts, ouch, stop) .residents receiving routine pain medication should be assessed each shift by the charge nurse during rounds and/or medication pass .the licensed nurse will monitor the efficacy of the [MEDICATION NAME] and keep the physician informed of any indicators of drug or dosage change as it relates to the resident's pain management B. Resident #14's record was reviewed on 1/26/16 at 10:58 a.m. The admission Minimum Data Set (MDS) assessment, dated 12/8/15, indicated Resident #14 received [MEDICAL TREATMENT]. The care plans, dated 12/14/15 and 12/22/15, stated Resident #14 was, receiving [MEDICAL TREATMENT]. The nursing progress notes, dated from 12/15/15 to 1/26/16 were reviewed. Vitals were documented post [MEDICAL TREATMENT] on [MEDICAL TREATMENT] dates, but the record lacked documentation of communication with the [MEDICAL TREATMENT] center. The physician order [REDACTED].#14 had a [DIAGNOSES REDACTED]. During an interview on 1/26/16 at 2:09 p.m., Registered Nurse (RN) #60 indicated they did not have a [MEDICAL TREATMENT] communication binder and the forms sent back and forth to communicate with [MEDICAL TREATMENT] should be in the resident's chart under the [MEDICAL TREATMENT] tab. No forms were filed under the [MEDICAL TREATMENT] tab in Resident #14's chart. RN #60 indicated she was not Resident #14's nurse and there may have been another process for [MEDICAL TREATMENT] communication for that resident. During an interview on 1/26/16 at 2:18 p.m., RN #35 indicated there was no communication form or binder that was sent with or sent back with Resident #14 from the [MEDICAL TREATMENT] center. She indicated they did not call the [MEDICAL TREATMENT] center for a report or have report called to them from the [MEDICAL TREATMENT] center. During an interview on 1/26/16 at 3:18 p.m., the Assistant Director of Nursing (ADON) indicated she was unaware Resident #14 did not have a communication form being sent with him or returned with him when he went to [MEDICAL TREATMENT]. On 1/20/16 at 1:30 p.m., the Administrator provided the current [MEDICAL TREATMENT] contract with the requested entrance conference material. The contract titled, SNF Outpatient [MEDICAL TREATMENT] Services Agreement, dated 8/14/08, stated, .The Nursing Facility shall provide for the interchange of information useful or necessary for the care of the [MEDICAL CONDITION] Residents, including a Registered Nurse as a contact person at the Nursing Facility whose responsibilities include oversight of provision of Services to the [MEDICAL CONDITION] Residents .Both parties shall ensure that there is documented evidence of collaboration of care and communication between the Nursing Facility and [MEDICAL CONDITION] [MEDICAL TREATMENT] Unit. On 1/20/16 at 1:30 p.m., the Administrator provided the current [MEDICAL TREATMENT] policy with the requested entrance conference material. The policy titled, [MEDICAL TREATMENT] Care, dated 1/2015, stated, .The nurse in charge at the time of transfer to [MEDICAL TREATMENT] will provide the resident with all appropriate paperwork as required by the [MEDICAL TREATMENT] Unit .The nurse in charge at time of return will review paperwork for new orders and/or paperwork accompanying the resident. 3.1-37(a)

Based on observation, interview, and record review, the facility failed to identify and assess stage 2 pressure ulcers (partial thickness skin loss) on a resident ' s right and left buttocks and failed to implement interventions to prevent pressure ulcers from developing or deteriorating resulting in a resident developing a stage 3 pressure ulcer (full thickness skin loss) to the left heel and an unstageable pressure ulcer (depth of tissue damage is not able to be determined due to presence of nonviable tissue) to the right heel, and to prevent another resident who was admitted without pressure ulcers from developing an unstageable pressure ulcer that healed and recurred as a stage 3 pressure ulcer on the right hip for 2 of 3 residents reviewed for pressure ulcers (Residents #110 and #192). Findings include: 1. Resident #110 was observed on the following dates and times for pressure prevention interventions and wound care: a. 1/22/2016 at 2:57 p.m.- up in wheel chair with multipodus boots to bilateral feet on his wheelchair foot pedal. His low air loss mattress was set to level 5. b. 1/25/2016 at 9:46 a.m.- up in wheel chair with multipodus boots to bilateral feet on his wheelchair foot pedal. Roho cushion was placed in his wheelchair seat. His low air loss mattress was set to level 6. c. 1/25/2016 at 12:49 p.m.- up in new tilt wheel chair provided by therapy, with multipodus boots to his bilateral feet placed on the wheel chair foot pedal. A roho cushion was not observed in Resident #110's wheel chair. d. 1/25/2016 at 4:16 p.m.- up in tilt wheel chair in his room. A roho cushion was not observed in Resident #110's wheel chair. His low air loss mattress was set to level 6. e. 1/26/2016 at 9:54 a.m., with the Assistant Director of Nursing (ADON) present, Resident #110's wounds to his heels were observed. The left heel wound was observed as a stage 3 pressure ulcer, with a beefy red wound bed that contained white slough to the upper and outer edges, minimal serosanginous (containing both blood and serum) drainage, and without odor. The right heel wound was observed as an unstageable pressure ulcer with a wound bed containing 75% eschar. The lower edge of the wound contained beefy red tissue. The wound was without drainage, slough, or odor. The ADON indicated Resident #110 did not have any additional pressure ulcers. f. 1/26/2016 at 3:49 p.m.- up in tilt wheel chair with multipodus boots to bilateral feet placed on foot pedal. A roho cushion was not observed to wheel chair. g. 1/27/2016 from 12:01 p.m. to 12:58 p.m., with Certified Nursing Assistant (CNA) #61, CNA #62, and Registered Nurse (RN) #63 present, Resident #110 was observed to receive incontinence care. Resident #110 was transferred into bed by a Hoyer (mechanical lift) lift and placed on his back in bed. His bilateral heel wounds were wrapped with Kerlix (gauze bandage) and no drainage was observed through the dressings after his multipodus boots were removed from his bilateral feet in bed. A heel up device was placed directly under Resident #110's heels after he was placed in bed on his back. An open area was observed as a stage 2 pressure ulcer to both Resident #110's right and left buttock. RN #63 indicated he was unaware of the pressure ulcers before the incontinence care and could not provide documentation of the pressure ulcers. The stage 2 pressure ulcer to the right buttock measured 0.8 cm x 0.4 cm x less than 0.1 cm, with 100% granulation (new connective tissue) and a pink wound bed without drainage or odor. The stage 2 pressure ulcer to the left buttock measured 0.4 cm x 0.7 cm x less than 0.1 cm with 100% granulation and a pink wound bed without drainage or odor. [MEDICATION NAME] (barrier ointment) and a foam dressing was placed on both stage 2 pressure ulcers by RN #63. Resident #110 was then transferred by hoyer lift back into his tilt wheel chair with a Roho cushion placed in the wheel chair seat. Brown drainage was observed through both Kerlix dressings to his heel wounds as his multipodus boots were placed to his bilateral feet and placed on the foot pedal of the wheel chair foot pedal. CNA #61 indicated Resident #110 had the open areas to his buttocks during his morning incontinence care. She indicated he had the open areas for some time, couldn't give the exact date, and that she had notified her charge nurse. h. 1/27/2016 at 2:12 p.m.- up in tilt wheel chair with Roho cushion to seat and multipodus boots to bilateral feet placed on wheel chair foot pedal. i. 1/28/2016 at 10:16 p.m.- up in tilt wheel chair asleep with Roho cushion to chair and multipodus boots to bilateral feet placed on the wheel chair foot pedal. Resident #110's record was reviewed on 1/22/2016 at 12:20 p.m. A Pressure Wound Skin Evaluation Report, dated 1/19/16, indicated Resident #110 had an unstageable pressure ulcer with necrotic/eschar tissue to the right heel with measurements of 5.5 cm (centimeters) x 6 cm x 0.1 cm. The report indicated Resident #110 also had an unstageable pressure ulcer with necrotic/eschar (dry, dark scab or falling away of dead skin) tissue to the left heel with measurements of 4 cm x 2.3 cm x 0.1 cm. The record indicated Resident #110 had [DIAGNOSES REDACTED]. The record indicated Resident #110 had developed a stage 3 pressure ulcer to his left buttocks within 30 days of admission to the facility that had a current status of healed. The record lacked indication protein levels and/or [MEDICATION NAME] levels had been obtained since the resident's admission. The record lacked indication Resident #110 refused interventions to prevent or promote healing of pressure ulcers. A care plan, dated 11/3/2015, indicated Resident #110 was at risk for skin breakdown due to requiring assistance with bed mobility, his [DIAGNOSES REDACTED]. The care plan goal, dated 2/7/2016, indicated the resident would be free from skin breakdown. Interventions inlcuded: a pressure reducing mattress on bed- low air loss mattress at setting of 5, dated 12/3/2015; assess and document skin condition weekly and as needed and notify physician of abnormal findings, dated 11/3/2015; encourage resident to eat at least 75% of meals; house barrier cream at bedside to use as needed; incontinent care as needed using peri wash and moisture barrier; pressure reducing/redistribution cushion in chair/wheelchair, preventative treatments as ordered, and turn and reposition resident at least every two hours. A physician's orders [REDACTED]. An Admission Minimum Data Set assessment (MDS) tool, dated 11/7/2015, indicated Resident #110 was at risk for developing pressure ulcers and the resident was admitted without pressure ulcers. Skin and ulcer treatments included: pressure reducing device for chair, pressure reducing device for bed, application of non-surgical dressings, applications of ointments/medications. Resident #110 required extensive assistance of 2 staff for bed mobility, transfers, dressing and toileting. He required extensive assistance of one person for locomotion and was totally dependent upon staff for bathing. He was always incontinent of both bowel and bladder. He was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 13 out of 15. A physician's orders [REDACTED]. A care plan, dated 11/19/2015, indicated Resident #110 has unstageable pressure wounds to his bilateral heels with wound healing not anticipated related to his [DIAGNOSES REDACTED]. The care plan goal, with a target date of 1/9/2016, indicated his wound would heal without complications. Current interventions included: float heels when in bed, prevalon boots as ordered, treatment as ordered, assess wound weekly documenting measurements and description, notify physician of worsening or no change in wound or signs of infection, and observe for signs of infection. A physician's orders [REDACTED].#110 was to wear multipodus boots to his bilateral feet at all times. A physician's orders [REDACTED].#110 was to utilize low air loss mattress at setting #5. Check every shift. A physician's orders [REDACTED].Clarification: multipodus boots to bilateral feet at all times when not in bed. Float heels; heel up cushion at ALL times when in bed An MDS, dated [DATE], indicated Resident #110 was at risk for the development of pressure ulcers. The record indicated he has 2 unstageable pressure ulcers and had 1 stage 3 pressure ulcer on his prior assessment that has a current status of healed. Skin and ulcer treatments included: pressure reducing device for chair, pressure reducing device for bed, pressure ulcer care, applications of ointments/meds, application of dressings to feet. The record indicated Resident #110 was cognitively intact with with a BIMS score of 9 out of 15. Resident #110 required extensive assistance of 2 staff members with bed mobility and transfers, and extensive assistance of 1 staff member with toileting. A review of Resident #110's Medication Administration Review (MAR), dated 1/1/2016 to 1/31/2016, indicated Resident #110 to utilize LAL (low air loss) mattress with setting #5 and nursing to check every shift. The record indicated the nursing staff documented Resident #110's mattress was at setting 5 on 1/25/2016 from 11 to 7 p.m., 7 a.m. to 3 p.m., and 3 p.m. to 11 p.m. Resident #110's Wound Consult reports were reviewed on 1/26/2016 at 12:30 p.m. The records indicated Resident #110 was first assessed by the wound physician on 11/24/2015, with the bilateral heel wounds first observed on 11/18/2015. The left heel was a stage 3 pressure ulcer with measurements of 1 cm x 1.2 cm x 0.1 cm. The right heel was a necrotic tissue unstageable pressure ulcer with measurements of 3 cm x 9 cm x 0.1 cm. The 11/24/2015 wound report indicated, .continue to float at all times to reduce the risk of further pressure injury .elevate BLE (bilateral lower extremities) at rest to promote venous return The 12/1/2015 wound report indicated both heels were unstageable pressure ulcers, with the left heel measurements of 4.2 cm x 4.2 cm x 0.1 cm, and right heel measurements of 4.5 cm x 4.8 cm x 0.1 cm. The report also indicated Resident #110 had developed a stage 3 pressure ulcer to his left buttock on 11/24/2015 with measurements of 0.9 cm x 0.6 cm x 0.1 cm. The 12/1/2015 wound report indicated, .offloading education provided; should remove rigid boots in bed to float heels with heel up device and use boots when not in bed, to avoid pressure to open areas .upgrade to LAL mattress but should also use wedge or pillow beneath hip in bed to avoid direct pressure to buttock The 12/22/2015 wound report indicated Resident #110's stage 3 pressure ulcer to his left buttock had received a status as resolved. The left heel remained an unstageable pressure ulcer with measurements of 4 cm x 1.7 cm x 0.1 cm. The right heel remained an unstageable pressure ulcer with measurements of 4.4 cm x 5.8 cm x 0.1 cm. The 12/22/2015 wound report indicated, Buttock resolved; continue preventive offloading .be sure to continue to offload consistently to avoid new pressure injury (use heels-up device while in bed to float, and multipodus boots when up in w/c (wheel chair)). The 1/26/2016 wound report indicated the left heel was an unstageable pressure ulcer with measurements of 4.2 cm x 1.2 cm x 0.1 cm. The right heel was an unstageable pressure ulcer with measurements of 4 cm x 5.5 cm x 0.1 cm. The 1/26/2016 wound report indicated, .Be sure to float heels at ALL times to avoid ongoing pressure .continue to take measures to avoid infection in wounds and to redistribute pressure to avoid further tissue compromise. Resident #110's Weekly Summary reports were reviewed on 1/27/2015 at 11:45 a.m. The record lacked documentation of an acquired Stage 2 pressure ulcer to the right and left buttocks before the observation of incontinence care on 1/27/2015 at 12:01 p.m. Resident #110's Shower Reports were reviewed on 1/28/2015 at 9:00 a.m. The record lacked documentation that an open area had been observed by nursing staff on the right or left buttock from 12/23/2015 to 1/23/2016. During an interview on 1/25/2016 at 12:02 p.m., the Director of Nursing indicated all residents were reviewed by the interdisciplinary team upon admission for the risk of skin breakdown, based on mobility and history of pressure ulcers, and interventions are placed into the care plan. She indicated to measure the efficacy of the interventions, the facility staff would have to continually monitor that interventions were in place to ensure pressure ulcer prevention; if skin breakdown occurred, weekly measurements would be assessed; and current interventions would need to be reassessed if not working. She indicated Resident #110 had a history of [REDACTED]. During an interview on 1/25/2016 at 1:27 p.m., CNA #61 indicated she would fill out a Shower Sheet if a new open area appeared on the resident and report it to her charge nurse. She indicated Resident #110 is compliant with laying down throughout the day. She indicated he received a new tilt wheel chair that therapy provided. She indicated Resident #110 had an open area to his buttocks She indicated Resident #110 did not have a heel up device or an order to float his heels before he developed pressure ulcers to his heels During an interview on 1/25/2016 at 2:51 p.m., the DON indicated she expected her staff to offload Resident #110's heels prior to his pressure ulcer development to his bilateral heels. She indicated this intervention was not included in his care plan prior to the development of his bilateral heel wounds. She indicated she expected her staff to turn and reposition Resident #110 every two hours, utilize a wheel chair cushion, and was on a pressure reducation mattress, not a low air loss mattress, before 12/3/2015. She indicated she expected her staff to continually monitor the interventions were in place for Resident #110 and indicated she believed his pressure ulcers to his bilateral heels were unavoidable and would not heal. She indicated he did not have a pressure ulcer to his buttocks. During an interview on 1/25/2016 at 3:49 p.m., the ADON indicated that she was unaware if Resident #110's Roho cushion could be placed in his new tilt wheel chair. She indicated Resident #110 was at one time wearing the multipodus boots at all times and staff were expected to off-load heels with pillows while he was in bed. During an interview on 1/25/16 at 4:30 p.m., the Rehab Manager indicated the Roho cushion can be placed in Resident #110's tilt wheel chair to reduce pressure. During an interview on 1/26/2016 at 11:39 a.m., the Wound Physician indicated the most important intervention to decrease pressure to the heels is to ensure the heels are always off-loading. He indicated any amount of time the heels are not offloaded can increase the risk of pressure. He indicated a low air loss mattress and repositioning is most important for the pressure ulcer prevention and treatment of [REDACTED]. He indicated the multipodus boots should only be worn when resident is up in wheelchair to decrease pressure due to the rigidity of boots creating a possibility of contributing to pressure development and increase if the resident is laying on his back in bed. He indicated Resident #110's healed stage 3 pressure ulcer to his left buttock had been avoidable. He indicated with the resident's history of pressure ulcers to his heels, palliative care plan, vascular status, and discomfort and pain with repositioning, the pressure ulcers to the bilateral heels were unavoidable. During an interview on 1/27/2016 at 11:21 a.m., CNA #61 indicated she transfers Resident #110 into his wheel chair before breakfast and he generally stays up in his wheel chair through lunch. She indicated he is able to tell her when he would like to lay down in bed. During an interview on 1/27/2016 at 12:58 p.m., CNA #61 indicated Resident #110's heels should not be placed directly on the heel up device. She indicated the heels should off load. During an interview on 1/27/2016 at 3:29 p.m., Resident #110 indicated he had not been laid down into bed since before breakfast. He indicated his buttocks was very sore. He indicated he can tell the staff he'd like to lay down when they ask. He indicated they had asked him once that day if he would like to lay down in bed. He indicated it hurts when the staff reposition him in bed. During an interview on 1/28/2016 at 10:55 a.m, the DON indicated that if a new open area is found on the skin, she expected her staff to notify management, the physician and family immediately. She indicated Resident #110's new open areas to the left and right buttocks had not been documented in the weekly skin assessments and she expected her nursing staff to do a skin assessment weekly. 2. On 1/26/16 from 9:35 a.m. to 10:31 a.m., Resident #192 was observed in the activity area sitting in her wheelchair on a pressure relieving cushion. She was observed to be sitting in the center of the wheelchair and was not observed to be leaning to either side. Staff was not observed to reposition her or address her position in her wheelchair during observation. On 1/26/16 from 10:31 a.m. to 11:01 a.m., Resident #192 was sitting in her wheelchair on a pressure reducing cushion with her left leg crossed over the right knee and leaning slightly to her right side. Staff was not observed to reposition her or address her position in her wheelchair during observation. On 1/26/16 at 1:31 p.m., Resident #192 was sitting in the dining area in wheelchair on the pressure reducing cushion with her left leg crossed over the right knee and was leaning slightly to her right side. On 1/26/16 at 1:58 p.m., Resident #192's right hip wound was observed with Unit Manager (UM) #30 and Certified Nursing Assistant (CNA) #31. Resident #192 was sitting in the center of her wheelchair on a pressure reducing cushion. CNA #31 and UM #30 assisted the Resident #192 to her feet, lowered her pants and pulled back the dressing from her right hip. The open area on her right hip was approximately the size and depth of a tip of a pen, and red in color with a dark spot at the bottom of the wound. A small amount of brown drainage was observed on the dressing. CNA #31 replaced the dressing, and assisted UM #30 to transfer Resident #192 into her bed. Resident #192 was positioned on her back onto her foam mattress with a pillow under her head only. During the observation, Resident #192 spoke in her native language and only said, Yes, when UM #30 touched her bed and asked if she'd like to lie down. UM #30 indicated throughout the observation she was unable to understand Resident #192 and wished she could communicate with her. On 1/26/16 at 3:07 p.m., Resident #192 was lying on her foam mattress on her back. No pillow was observed under her right hip. On 1/26/16 at 4:46 p.m., and 1/27/16 at 9:12 a.m., Resident #192 was sitting in the center of her wheelchair on a pressure reducing cushion in the activity area. On 1/27/16 at 10:39 a.m., Resident #192 was lying on her foam mattress on her left side. No pillow was observed behind her back or under her hip. On 1/22/16 at 10:55 a.m., Resident #192's record was reviewed. The nursing progress note, dated 9/12/15 at 12:43 p.m., indicated Resident #192 was admitted at 4 p.m. and did not have skin issues on admission. The care plan, dated 9/14/15, stated Resident #192 was, .at risk for skin breakdown due to: requires extensive assist from staff for bed mobility. Incontinent of bowel and bladder. The care plan included the following interventions: Assess and document skin condition weekly and as needed. Notify MD of abnormal findings, encourage resident to eat at least 75% of meals, house barrier at bedside-use as needed, incontinent care as needed using peri wash and moisture barrier .pressure reducing/redistribution cushion in heelchair (sp), pressure reducing/redistribution mattress on bed, turn and reposition at least every 2 hours. The care plan, dated 9/14/15, indicated Resident #192 was at risk self-care deficit due to cognitive deficits and physical decline. The interventions included, but were not limited to the following: .assist resident with eating as needed, assist with transfers of one to two staff. The care plan, dated 9/14/15, stated Resident #192 had, .potential for unrelieved pain d/t (due to)communication impairment; dx ([DIAGNOSES REDACTED]. The care plan interventions included, but were not limited to the following: .assist with position to comfort .observe for nonverbal signs of pain. The care plan, dated 9/14/15, indicated Resident #192 was incontinent of bladder and bowel. The care plan interventions included, but were not limited to the following: .assess and document skin condition weekly and as needed, assist with elimination, assist with incontinent care as needed. The shower reports, dated 9/15/15 and 9/18/15, indicated Resident #192 had no areas of skin impairment. The admission Minimum Data Set (MDS) assessment, dated 9/18/15, indicated Resident #192 had a brief interview of mental status (BIMS) score of 0 out of 15 and was severely cognitively impaired. The MDS indicated Resident #192 required extensive assistance of two people for bed mobility, transfer, dressing, toileting, personal hygiene, and bathing. The MDS indicated Resident #192 was at risk for pressure ulcers and was frequently incontinent of bladder and bowel. The shower report, dated 9/22/15, indicated Resident #192 had a complete bed bath and had a red area on her right hip. The form titled, ASC New Skin Event, dated 9/22/15, indicated Resident #192 had a new pressure ulcer to her right hip that was not present on admission. The form indicated the pressure area measured 3 centimeters (cm) in length by 2 cm in width, and stated the wound was, dark brown with yellow around it. The form titled, ASC Pressure Wound Skin Evaluation, dated 9/22/15, indicated Resident #192 had an unstageable (full thickness skin or tissue loss) on her right hip and measured 1.6 cm in length by 1 cm in width by 0.1 cm in depth. The form indicated the wound was 60% slough (yellow [MEDICATION NAME] tissue that consists of [MEDICATION NAME], pus, and proteinaceous material). The nursing progress note, dated 9/22/15 at 5:37 a.m., indicated Resident # 192 had a new open area on her right hip measuring 3 cm in length by 2 cm in width. The note stated the wound had, a dark brown center with yellow area surrounding, and no drainage. The note stated, .Area cleansed and covered with foam dressing. Resident positioned by staff on L (left) side to alleviate pressure to area but noted returning /favoring lying on the R (right) side. Wound Care Specialists of Indiana (WCS) progress note, dated 9/22/15, stated Resident #192 had, necrotic tissue (unstageable) pressure ulcer, to her right hip. The note noted the wound measured 1.6 centimeters (cm) in length by 1 cm in width by 0.1 cm in depth. The following treatment was ordered, Cleanse wound bed with NS (normal saline); pat dry. Apply skin prep or barrier cream to wound edges and santyl (ointment) to open area. Cover with foam and secure. Change daily and PRN (as needed). The progress note stated the plan of treatment would be, .santyl to enzymatically debride, obtain cushion for w/c (wheelchair). The shower reports, dated 9/25/15 to 10/20/15, indicated Resident #192 had skin impairment to her right hip. The WCS progress note, dated 9/29/15, indicated the Resident #192's wound had changed from an unstageable to a stage 3 (full thickness tissue loss where bone, tendon or muscle is not exposed) pressure ulcer and measured 1.5 cm in length by 1 cm in width by 0.4 cm in depth. The note indicated the treatment was to remain the same. The significant change in status MDS, dated [DATE], indicated Resident #192 was severely cognitively impaired, and required extensive assistance of two people for bed mobility, transfer, dressing, toileting, personal hygiene, and bathing. The MDS indicated Resident #192 was at risk of developing pressure ulcers, and had one stage 3 pressure ulcer (full thickness tissue loss) that measured 1.5 cm in length by 1 cm in width by 0.1 cm in depth. The WCS progress note, dated 10/6/15, indicated Resident #192 had a stage 3 pressure ulcer on her right hip that measured 1.5 cm in length by 1 cm in width by 0.1 cm in depth. The note indicated the wound treatment was to remain the same and staff was to continue to encourage Resident #192 to stay off her right side despite poor compliance. The physician telephone order, dated 10/6/15 at 2:00 p.m., ordered, Encourage wedge cushion while in bed to promote resident to lie on L (left) .side. The treatment record for October 2015, had staff initials for each of the three shifts from 10/8/15 to 10/26/15 indicating the wedge pillow was placed while Resident #192 was in bed. The record lacked documentation that the resident refused the wedge pillow. The WCS progress note, dated 10/13/15, indicated Resident #192 had a stage 3 to the right hip measuring 0.6 cm in length by 0.6 cm in width by 0.1 cm in depth. The treatment was changed to the following, Cleanse wound bed with NS (normal saline). Pat dry. Apply skin prep or barrier cream to periwound. Apply foam dressing to wound bed and change every 3 days and PRN (as needed), soiled. The WCS progress note, dated 10/20/15, indicated Resident #192 had a stage 3 to the right hip with measurements of 1.4 cm in length by 0.9 cm in width by 0.1 cm in depth. The note stated, When wedge or pillow is used resident removes and lies on right side regardless. The note indicated the treatment was to remain the same. The shower reports, dated from 10/23/15 to 10/30/15, indicated Resident #192 did not have skin impairment. The WCS progress note, dated 10/27/15, indicated Resident #192 had a stage 3 pressure ulcer on the right hip. The wound measured 0.4 cm in length by 0.6 cm in width by 0.1 cm in depth. The note stated Resident #192, .Continues to lie preferentially on ulcerated side; continue to attempt to discourage and/or bolster with wedge or pillow/s (sp) to reduce risk of ongoing pressure injury. The physician telephone order, dated 10/27/15, ordered the wedge cushion to be discontinued because the resident was refusing to use it. The WCS progress note, dated 11/3/15, stated, .right hip stage 3 pressure ulcer .resolved .no drainage. Wound margin is attached to base .wound bed 76-100% [MEDICATION NAME] .scabbed. The shower reports, dated from 11/3/15 to 12/27/15, indicated Resident #192 did not have skin impairment. The quarterly MDS, dated [DATE], indicated Resident #192 was severely cognitively impaired, was always incontinent of bladder and bowel, and required extensive assistance of two for bed mobility, transfer, dressing, toileting, personal hygiene, and bathing. The MDS indicated Resident #192 was at risk for pressure ulcers, but did not currently have a pressure ulcer. The nurse practitioner progress note, dated 12/15/16, stated Resident #192, .has had refusal of care/resistance to care but not unusual .this is her baseline. The progress note indicated a urinalysis was ordered due to her behaviors. The physician order [REDACTED].House barrier cream to peri cream every shift and as needed .Daily vit (vitamin) to promote skin integrity. The shower report, dated 1/5/16, indicated Resident #192 had redness on her right hip. The form titled, ASC Pressure Wound Skin Evaluation Report, dated 1/6/16, indicated Resident #192 had a stage 3 pressure ulcer on her right hip, and it was originally found on 1/5/16. The note indicated the wound measured 1.5 cm in length by 1 cm in width by 0.1 cm in depth, and had a small amount of serosanguineous (blood and liquid part of blood) drainage. The physician order, dated 1/6/16, ordered the following wound treatment, Cleanse right hip wound with NS (normal saline) pat dry. Apply thick layer [MEDICATION NAME] (skin protectant)cream. Cover with foam dressing change daily and prn (as needed). The care plan, dated 1/7/16, stated Resident #192 had, pressure wound to right hip (previous wound re-opened). Care plan interventions included, but were not limited to: Assess for pain .Assess wound weekly documenting measurements and description .incontinent care as needed and with peri wash and moisture barrier .observe for signs of infection .pressure reducing/redistribution cushion in chair .treatment as ordered .turn and reposition every 2 hours .wound healing vitamins as ordered. The shower reports, dated 1/8/16 to 1/15/16, indicated Resident #192 did not have skin impairment. The form titled, ASC Pressure Wound Skin Evaluation Report, dated 1/12/16, indicated Resident #192 had an unstageable pressure ulcer to the right hip. The wound measured 1.7 cm in length by 1.5 cm in width by 0.1 cm in depth. The note indicated the wound had a small amount of serosanguineous drainage. The physician order, dated 1/12/16, ordered the following treatment, cleanse right hip with NS (normal saline), pat dry. Apply santyl (ointment) cover with foam and secure. Change daily. The WCS progress note, dated 1/12/16, indicated this was the first visit from the wound specialist and the wound measured 1.7 cm in length by 1.5 cm in width by 0.1 cm in depth. The note stated, Santyl to enzymatically debride; area likely unavoidable due to resident refusal to lie off ulcerated side. Continue to encourage redistribution of pressure. The WCS progress note, dated 1/19/16, indicated Resident #192 had an unstageable pressure ulcer to the right hip that measured 1.1 cm in length by 1.3 cm in width by 0.1 cm in depth. The note indicated wound had a small amount of serosanguineous drainage, and the treatment was to remain the same. The WCS progress note, dated 1/26/16, indicated Resident #192's wound had changed from an unstageable to a stage 3 pressure ulcer. The wound measured 0.8 cm in length by 0.5 cm in width, by 0.5 cm in depth. The note indicated wound had a small amount of serosanguineous drainage. The note stated, increased depth is a result of enzymatic activity of Santyl and reduction in slough filling ulcer bed. Cont (continue) Santyl to debride remaining slough; add hydrogel gauze to maintain moisture and fill dead space now that wound has appreciable depth. The physician order, dated 1/26/16, ordered, clarification . cleanse right hip ulcer with ns (normal saline), pat dry, apply [MEDICATION NAME] (lotion) to surrounding skin and santyl to wound base, pack lightly with puffed hydrogel-moistened gauze and secure. As of 1/26/16 at 4:22 p.m., the profile section of the computerized chart for Resident #192 indicated staff was to turn and reposition her every 2 hours and as needed while in bed and in chair, and she was to have, incontinent care as needed using peri wash and moisture barrier. During an interview on 1/26/16 at 10:49 a.m., Certified Nursing Assistant (CNA) #32 indicated she took care of Resident #192. She indicated was unaware if Resident #192 needed to be repositioned while up in her wheelchair or while in bed. She indicated she was unaware if there was a sp

Based on record review and interview, the facility failed to ensure 1 of 3 residents having medication errors did not experience signs or symptoms of distress resulting in hospitalization in a sample of 6 residents reviewed for medication administration (Residents B, C, D). Findings include: 1. The record for Resident B was reviewed on 9/28/15 at 11:00 a.m. [DIAGNOSES REDACTED]. A Nurse Practitioner (NP) note, dated 4/7/15, indicated she had been informed by the facility nurse that she had accidentally given Resident B another resident's medication, which included the drugs [MEDICATION NAME], and [MEDICATION NAME], and that Resident B normally only took PRN (as needed) Tylenol. The note indicated about 11:40 a.m. she was notified Resident B's O2 (oxygen) saturation had dropped to 78% (normal is greater than 90%). Oxygen was placed on the resident and he was given 0.4 mg (milligrams) of [MEDICATION NAME] (antidote, opiod antagonist) intramuscularly. The resident had minimal response to this, so 30 minutes later the NP started an IV and administered another 0.4 mg of [MEDICATION NAME]. The resident opened his eyes to deep sternal rub but only briefly and his pupils remained pinpoint. The resident was then transferred to the emergency department via 911 and the NP called report to the hospital. The NP note also indicated Resident B was stable at the time of transfer and she had discussed this with the physician. A Nursing Note, dated 4/7/15 at 2:56 p.m. indicated the resident had been alert at the time of the medication error, the NP had been informed and had assessed him at that time. He was placed on 15 minute checks and vital signs every 30 minutes. When his O2 saturation dropped the NP was informed again and he was placed on oxygen by mask at 5 liters/minute. He had become lethargic as the morning progressed, and remained lethargic after oxygen and [MEDICATION NAME] were provided. The resident was transported to the hospital about 12:30 p.m. The emergency department history, 4/7/15, indicated he had been given another resident's medication at the nursing facility, which included [MEDICATION NAME] (opiod [MEDICATION NAME]) 200 mg, [MEDICATION NAME] (anticonvulsant) 100 mg, and [MEDICATION NAME] (corticosteroid) 2 mg. The resident was lethargic on arrival in the emergency department. [MEDICATION NAME] was administered and he opened his eyes and smiled. The emergency department plan indicated he was being admitted to the intensive care unit (ICU) and monitor his respiratory and mental status closely. The note indicated Overall, critically ill and his condition can deteriorate further. He was admitted to the ICU, had a [MEDICATION NAME] drip, and his somnolence resolved. Hospital records indicated on 4/8/15 he was transferred to the Medicine floor and therapy was started. The resident was discharged back to the facility on [DATE]. The hospital discharge summary on 4/14/15 indicated he was alert and oriented to self, not location or time, but pleasant and cooperative, following commands. The resident was breathing comfortably on room air. 2. The record for Resident C was reviewed on 9/29/15 at 10:30 a.m. Her [DIAGNOSES REDACTED]. A Medication Error Report, dated 8/11/15 at 2:30 p.m. indicated Resident C had received a wrong medication. A physician's orders [REDACTED]. A pharmacy dosage recommendation, dated 8/6/15, indicated her serum creatinine had increased to 2.0 mg on 8/6/15. The recommendation was to hold the [MEDICATION NAME] doses until more laboratory work was done on 8/7/15. A physician's orders [REDACTED]. The physician was notified of the medication error on 8/11/15 and ordered another laboratory test. No signs or symptoms of distress or side effects were noted in the Nursing Progress Notes on 8/11/15, 8/12/15 or 8/13/15. The creatinine level that had been drawn on 8/10/15 was 1.6 (normal 0.6 to 1.3), on 8/12/15 the level was 1.7, and the next one was 8/19/15 and that result was 1.0. 3. The record for Resident D was reviewed on 9/28/15 at 10:55 a.m. Her [DIAGNOSES REDACTED]. A health care plan, dated 12/16/14, indicated a problem was pain. Interventions included, but were not limited to, administer medications as ordered. A physician's orders [REDACTED]. A Medication Error Report, dated 9/19/15, indicated Resident D had not received the [MEDICATION NAME] at bedtime during the month of September, 2015, to that date. The Narcotic sign out sheet does not show any [MEDICATION NAME] being signed out until 1 as needed dose was signed out on 9/15/15. The September, 2015, MAR (Medication Administration Record) indicated no [MEDICATION NAME] had been administered. The Nursing Notes from September 1, 2015, through September 19, 2015, do not indicate the resident had any complaints of pain or discomfort except on 9/15/15 when she had complained of groin pain after having a procedure. During an interview with the DNS (Director of Nursing Services) on 9/29/15 at 12:05 p.m., she indicated there were 5 nurses involved in missing the [MEDICATION NAME] doses for Resident D, and they all had indicated they had missed the order. On 9/29/15 at 2:30 p.m., the DNS indicated the nurse administering the [MEDICATION NAME] hadn't looked at the MAR to see it was discontinued before she administered it. On 9/29/15 at 12:25 p.m., the DNS indicated her expectation was the nursing staff would look at the MAR for order changes before giving medication as well as reading the MAR during medication set up, and they were to follow the 5 Rights. A current facility policy, dated 11/02 and last revised 1/6/15, titled Medication Errors was provided by the DNS on 9/29/15 at 10:00 a.m. The policy indicated: It is the policy of this provider to ensure residents residing in the facility are free of medication errors . A form, titled Medication Pass Procedure dated 2/2010, was provided by the DNS on 9/29/15 at 10:00 a.m. and identified as the medication policy. It indicated: .2. Medications checked 3 times to verify order with label 6. Identified resident prior to administering 17. Medication administration will be recorded on the MAR .after given This federal tag relates to Complaint IN 446. 3.1-48(c)(2)

Based on observation, interview, and record review, the facility failed to provide dental services to meet a resident's needs related to impacted teeth resulting in pain and infection for 1 of 3 residents with dental problems in a sample of 3. (Resident #C). Findings include: On 12/7/11 at 10:35 A.M., with Unit Manager (UM) #1, Resident # C was observed lying in bed. The inside of the resident's mouth was observed. There were teeth extractions with sutures on the left lower side of the mouth. The resident indicated the area was "sore." Resident # C's clinical record was reviewed on 12/7/11 at 9:50 A.M. The record indicated the resident was admitted with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) quarterly assessment dated [DATE] indicated the resident was cognitively intact, had occasional moderate pain, and had mouth or facial pain, discomfort or difficulty with chewing. Nurses' notes indicated: 8/29/11 at 12:27 P.M. "Has been seen per outside dentist and they were unable to complete due to inability to transfer to their chairs. Has been placed on facility dental list per SS (social services)..." 8/31/11 at 8:37 A.M. "Resident has been having a tooth ache. Faxed consent to (company name) this morning to be placed on list for next visit..." A dental schedule for the facility dentist indicated the resident had been scheduled to see a dentist on 10/12/11 (one month and thirteen days after complaining of a tooth ache). Nurses' notes indicated: 9/28/11 at 9:32 A.M. "Resident requested to see dentist. SSD (social services director) had resident sign consent form, faxed to dentist and added to list to be seen next visit." 10/7/11 at 3:02 P.M. "...To see dentist this next week for complaints of tooth ache unable to be seen when went out to dentist.." 10/13/11 at 4:57 P.M. "Writer spoke with oral surgeon regarding making apt (appointment) for tooth extraction. Order noted to start antibiotic for impacted tooth. States lower jaw/tooth pain." A "Dental Treatment Plan" dated 10/12/11 indicated "Pt (patient) was scheduled for the initial oral exam (examination), but it was an emergency exam. Pt complained of pain, PA & T (x-rays) taken, infection observable swelling, will refer to an OS (oral surgeon) to take a pano (panoramic) radiograph to determine which teeth need to be removed...Antibiotics Rx (treatment) per MD approval..." A physician's orders [REDACTED]..re: impacted tooth." Nurses' notes indicated: 10/14/11 at 3:13 A.M. "Resident c/o (complained of) tooth pain. Administered two pain pill (sic) as ordered prn (as needed)..." 10/15/11 at 3:26 A.M. "Resident continuously c/o of toothache impaction..." The resident complained of tooth pain and was given pain medication on 10/16/11, 10/17/11, 10/18/11, and 10/19/11. 10/20/11 at 2:42 P.M. "...Dentist to review history and med. (medication) sheets then apt (appointment) will be set. Tylenol gr (grains) x (ten) x 1 given for complaints of tooth pain..." 10/21/11 at 12:03 A.M. "...Resident did c/o severe tooth pain which was relieved with pain medication..." 11/7/11 at 3:40 P.M. "Dentist called per writer to check on apt (appointment) and writer informed that Md (physician) has not evaluated Res (resident) history in order to get earlier apt...Apt for res. requested 2nd opinion (sic) this Friday." 11/14/11 at 5:04 P.M. "Dentist office called to confirm with apt. this Wed. (Wednesday) and order noted to start antibiotic for impacted tooth Keflex 500 mg, 1 cap tid x 7 days..." The resident was seen on 11/16/11 by an oral surgeon and had three teeth extracted with recommendation of having additional extractions in the future. Interview on 12/7/11 at 10:37 A.M. with Unit Manager #1 indicated residents with dental concerns other than routine examinations should be "seen right away." She indicated for referrals to outside (other than facility) dentists the Social Services Director contacted the outside dentist and made appointments. She indicated staff should accompany residents to appointments to assist with transfers in the dental office. Interview on 12/17/11 at 11:50 A.M. with the Social Services Director indicated social services contacted the providers for appointments and could usually "get them in 1-2 days." He indicated "few providers will accept Medicaid." He indicated November 16, 2011 was the "next available appointment" and "the pain was being managed by nursing staff." He indicated there was no documentation related to dates attempts were made to obtain dental appointments. He stated "I just made a phone call." Interview on 12/7/11 at 11:45 A.M. with the Administrator indicated residents with urgent dental concerns should be seen "within 7 days I would think." Review on 12/7/11 at 12:00 P.M. of a facility policy and procedure dated 1/06, provided by the Director of Nursing, identified as current, and titled "Dental Services" indicated "...The facility maintains an outside resource to provide dental services to meet the needs of each resident..." This federal tag relates to complaint IN 359. 3.1-24(a)(2) 3.1-24(b)

A. Based on record review and interview, the facility failed to ensure that the Therapy Department Manager provided training related to the application of moist hot packs, and failed to visually supervise, 1 of 1 therapy employees who was identified as a "new graduate" as a Certified Occupational Therapy Assistant (COTA). This deficient practice impacted 1 of 1 residents who sustained trauma identified as a full thickness burn from a moist hot pack which the untrained COTA had applied incorrectly; in a sample of 26 residents reviewed. (Resident # 21) B. Based on record review and interview, the facility failed to ensure that there was sufficient staffing on the Cottage 2 secured Alzheimer's unit to supervise residents at an evening meal. This deficient practice impacted 1 of 1 residents who received scratches and a laceration during a physical altercation with another resident on the unit, for 1 of 6 residents reviewed in a sample of 26 residents. (Resident #171). C. Based on observation and interview, the facility failed to keep sharp equipment and hazardous creams and lotions in a safe and secure manner, on 1 of 2 locked/secured Alzheimer's units. This deficiency had the potential to impact 22 residents residing on this unit. Findings include: A.1. Pre-survey information related to incidents/accidents, which had been reported by the facility to the Long Term Care Division, Indiana State Department of Health since the last annual on 5/21/10, was reviewed on 6/27/11. One incident submitted by the facility on 9/01/10 indicated "Resident (Resident #21) noted to have open area to mid back right side from trauma. Resident states therapy has been applying moist heat every morning. Resident denies pain to area. Resident alert and oriented X 3 (person, place and time).... Area to mid (R) back measuring 10.3 X 3.6 X 0 CM. Wound bed noted to be 50% dermis and 50% epithelial tissue with scattered fluid filled blisters.... Employee suspended pending outcome of investigation." The clinical record for Resident #21 was reviewed on 7/05/11. [DIAGNOSES REDACTED]. A "Nurse's Notes" progress note, dated 8/31/10 at 5:30 A.M., indicated "Open area noted to right side of back. No pain noted from site. Resident stated that heat has been applied to his back from therapy in the mornings. Site looks like a blister that had busted. Area was cleaned with NS (normal saline). Telfa applied and covered with Coverall. M.D. was notified along with wound team." An I.D.T. (Interdisciplinary Team) progress note on 8/31/10 indicated "Weekly skin note: Resident is being reviewed in I.D.T. for open area to coccyx and mid right back.... Mid back right side trauma partial thickness wound measures 10.3 X 3.6 X 0 cm. (centimeter).... Resident states he received moist heat therapy the previous day in therapy." On 7/5/11, the Executive Director provided the documentation of the facility's investigation of the reported incident. The documentation included a paper titled "Interview 8/31," "Employee Communication Form," "Performance Improvement Plan," "Therapy Department Orientation," "Cold Pack/Ice Pack Competency Checklist," and "Moist Hot Pack Competency Checklist." The "Interview" paper indicated that Therapy Assistant #7 did not have training on the application of moist heat packs, was "never supervised with heat," and had "not read therapy policy manual." The interview also indicated "they" ran out of towels so used 2 bath blankets on each side of the moist hot pack plus the cover, and that the Therapy Assistant "did not do visual check on the skin, but did ask the resident and he said he was fine." The "Interview" paper indicated the Therapy Manager "stayed with the resident during the treatment and asked if it was too warm, but did not visually check the skin." The hot moist pack treatment lasted 15 minutes. The "Employee Communication Form," dated 9/1/10, indicated "Manager did not ensure new staff orientation completed on at least 2 new employees. One incident resulted in harm to resident." The "Therapy Department Orientation" form, a "Cold Pack/Ice Pack Competency Checklist," and a "Moist Hot Pack Competency Checklist" for Therapy Assistant #7 was dated as completed on 9/1/10. A Policy/Procedure titled "Moist Hot Packs Competency," dated as revised on 12/09, included, but was not limited to, the following information: "POLICY: All clinicians who perform the hot moist pack modality will complete a skills validation checklist within 90 days of their hire date.... PROCEDURE: 1. Upon hiring, or as determined by the Rehab Services Manager or supervising therapist, each clinician that is going to perform moist hot packs will be assigned to another clinician whose skills have been validated to complete his/her skills validation checklist.... 2. The observing clinician will observe the clinician who is being tested perform the specific procedure.... 13. At five minutes after the initial application of the hot pack, the patient's skin should be checked for redness or blanching to touch, in which case, more towels should be added.... 15. Hot moist packs must be checked every 5 minutes for the duration of the treatment...." In an interview on 7/5/11 at 4:00 P.M., the Executive Director indicated there were no therapy records on Resident # 21 regarding moist hot pack application. In an interview on 7/6/11 at 11:05 A.M., the Assistant Rehabilitation Manager #9 and Rehabilitation Manager #10 indicated therapy progress notes on moist hot pack application were normally kept in a resident's record. However, no records existed for the hot pack application done in August, 2010 for Resident #21. They indicated the orientation policy and procedure had changed since the incident, and required new employees to have skills checked off by the Rehabilitation Manager by the third day of employment. The Rehab Manager included visually observing a new employee demonstrate the skills. A therapy-specific orientation had also been implemented following the incident. B.1. The closed clinical record of Resident #171 was reviewed on 7/6/11 at 10:30 A.M. [DIAGNOSES REDACTED]. A quarterly minimum data set assessment, dated 12/23/10, indicated Resident #171 had severely impaired decision making skills. A Plan of Care, dated 11/6/10, indicated "Res (Resident) will get into peers rooms if he is not taken to his room & assisted to his bed. Risk for harm." Interventions: " 1. Assist res to his room after each meal or event. 2. Gently redirect from peers room when redirected." A Plan of Care, dated 11/6/10, indicated "Resident is at risk for falls d/t (due to) debility, poor safety awareness..." Interventions included, but were not limited to, chair alarm to alert staff of attempts to transfer unassisted and offer to place res in recliner (after) meals if attempting to self transfer...." A Treatment Administration Record, dated for the month of January 2011, indicated "Chair alarm sensor to wheelchair and recliner at all times while in recliner or wheelchair..." A nursing note, dated 1/4/11 at 7:10 P.M., indicated "Resident was found on floor in another Resident's room....Resident (#171) had been in another resident's bed. The other Resident involved stated he hit the resident in the face (with) his fist et (and) shoe....Neither resident knew how (name of Resident #171) got on the floor....The other resident was put on 1:1 supervision...." During an interview with the unit manager, LPN #5, on 7/6/11 at 12:15 P.M., indicated staffing for evening shift was 2 CNAs and 1 LPN. Dinner was late that evening and no staff member was in the dining room. CNA #13 was assisting to toilet a Resident, CNA #12 was assisting a new Resident and LPN #12 was escorting a Resident upstairs to visit with their spouse. CNA #13 was on her way back to the dining room heard an alarm, going off, in Resident #170's room and found Resident #171 on the floor with Resident #170 standing over Resident #171 with a shoe in his hand. Resident #171 had left the dining room, while it was unattended by staff, and entered Resident #170's room and got into Resident #170's bed. No staff member heard Resident #171's wheelchair alarm sound when he transferred himself to Resident #170's bed. C.1. During the environmental tour on 6/29/11 at 2:00 P.M. with the Maintenance Manager and the Housekeeping Supervisor, in the kitchenette area in the drawers which were not locked and in the drawers were disposable razors and a nose hair trimmer. The shower room for the unit was found to be unlocked and in an unlocked cabinet there was found to be the following items; one bottle of deodorant, one .85 ounce tube of toothpaste, one 5 ounce tube of Provon perineal skin creme, one 1/8 ounce Calmoseptine packet, and one bottle of Quat disinfectant with a small approximately 1 ounce of liquid in it. At 2:05 P.M. in a hallway off of resident rooms which was not in visible site of nursing station or staff, a dresser was found unlocked with the following items in it; two 1/8 ounce packets of Calmoseptine ointment, one 5 ounce tube of Provon perineal skin creme. The warning label on the Calmoseptine indicated to keep out of reach of children and avoid contact with eyes. The warning for the Quat disinfectant indicated harmful if swallowed, avoid contact with eyes and keep out of reach of children. The warning for the Provon creme indicated to avoid contact with eyes. In an interview with the Housekeeping Supervisor and the Maintenance Manager immediately following the tour, the Maintenance Manager indicated the bathroom door should have been shut and locked and they do not secure the lock on the cabinet in the bathroom due to having a lock on the door. He also indicated the nose hair trimmers and disposable razors don't belong in the kitchenette area, he stated he would be sure to secure items. The housekeeping supervisor indicated the barrier creams and razors should not be kept in the unlocked dresser in the hallway by residents rooms. 3.1-45(a)(1)

Based on record review and interviews, the facility failed to monitor and provide professional medical services to assure residents receiving anticoagulation medication received care to assure the medication level remained therapeutic and safe. This deficient practice resulted in lack of laboratory monitoring of the anticoagulant blood level for 1 of 6 residents sampled for anticoagulation therapy management between 3/17/2011 and 4/15/11. The resident was then hospitalized with extensive bruising, internal bleeding, [MEDICAL CONDITION] "probably secondary to acute blood loss," and [MEDICATION NAME] toxicity. This deficient practice impacted 1 of 6 residents reviewed for management of anticoagulation therapy in the sample of 6. (Resident F) This deficient practice resulted in immediate jeopardy of past non-compliance. The immediate jeopardy of past non-compliance was identified on 5/19/2011 at 4:30 p.m., and began on 3/17/2011. The Administrator and the Director of Nursing were notified of the immediate jeopardy of past non-compliance on 5/19/2011 at 4:45 p.m. The immediate jeopardy was removed and corrected on 4/21/2011 at 5 p.m., when the facility implemented a new system of monitoring anticoagulation medications and ensuring laboratory values were ordered. Findings include: The closed clinical record of Resident F was reviewed on 5/18/2011 at 4:30 p.m. It indicated she was admitted to this facility from a hospital on [DATE]. Her [DIAGNOSES REDACTED]. She'd had a pacemaker implanted on 3/11/11. She was admitted for strengthening to return to her home where she lived independently. She had been on [MEDICATION NAME], an anticoagulation medication, for about one year. Review of the nursing notes throughout her admission of 3/12 through 4/18/11 indicated she was cognitively intact and acted as her own person legally. She required assistance for ambulation due to difficulties from chronic lower leg [MEDICAL CONDITION] (swelling). She was receiving occupational and physical therapy in anticipation of her return home. Further review indicated Resident F had been admitted with [MEDICATION NAME] (a medication that slows clotting time) 5 mg (milligrams) daily. Her first PT ([MEDICATION NAME] time) and INR (International Normalized Ratio) at the facility was on 3/14/11. These are blood tests that measure the time it takes the blood sample to clot The PT had been 12.3 seconds (normal 9.9- 13.3) and the INR was 1.1 ratio (normal 0.9-1.1). Her [MEDICATION NAME] dosage was increased to 6 mg. daily. The next labs were dated 3/15/11. The PT was 13.5 seconds and the INR was 1.2 ratio. The [MEDICATION NAME] dose was increased to 7 mg. daily on 3/15/11. On 3/17/11, the PT measured 21.2 seconds and the INR was 1.9 ratio. The nurse practitioner initialed the lab result to signal she had read it, but there were no new [MEDICATION NAME] orders and no orders for further lab testing. Evidence was lacking of any facility attempts to obtain an order for [REDACTED]. A nursing note on Friday, 4/15/11 at 10:30 a.m., indicated, "Res (resident) came to nurses station c (with) c/o (complaints of) nausea, dark stools, purple discolorations to bilateral inner forearms and L upper arms. (sic) MD notified. MD will assess resident today." The Nurse Practitioner wrote a progress note on 4/15/11, which indicated she ordered a stat (to be done immediately) PT/ INR. The 4/15/11 PT measured the level at > (greater than)140 seconds; normal was 9.9-13.3 seconds. The INR measured >10.0 with normal defined as 0.9-1.1 ratio. The [MEDICATION NAME] was also discontinued on 4/15/11. Another PT/INR was done on 4/16/11 with exactly the same readings. The nurse practitioner ordered an injection of Vitamin K and another PT/INR on 4/17/11. The 4/17/11 PT/INR was again the exact same. Another dose of Vitamin K was ordered with more labs on 4/18/11. On Monday, 4/18/11, the PT reading was 202 and the INR was at 10. Her hemoglobin reading was at 5.2; with a normal range of 11.2 - 15.7 She was sent to the emergency room . Review of the 4/18/11 emergency room documentation was done on 5/19/11 at 1:30 p.m. It indicated Resident F was "...covered with bruises all over." The initial [DIAGNOSES REDACTED]. She was admitted into the intensive care unit. Resident F was discharged from the hospital to another nursing home on 4/26/11. Her discharge summary listed the following discharge Diagnoses: [REDACTED]. 2. subcutaneous bleeding, left flank, bilateral arms secondary to [MEDICATION NAME] toxicity 3. hematoma right hip secondary to [MEDICATION NAME] toxicity 4. upper GI (gastrointestinal) bleeding secondary to [MEDICATION NAME] toxicity 5. [MEDICATION NAME] toxicity questionably secondary to drug interaction, probably [MEDICATION NAME] plus [MEDICATION NAME] 6. Liver dysfunction questionably secondary to statin versus shock liver secondary to #1, resolving 7. non-ST [MEDICAL CONDITION] infarction secondary to #1 8. acute [MEDICAL CONDITION], prerenal, resolved 9. [MEDICAL CONDITION] 10. [MEDICAL CONDITION] left upper extremity probably related to recent pacemaker placement 11. difficulty walking, multifactorial 12. [MEDICAL CONDITION], chronic 13. diabetes mellitus on insulin 14. hypertension, controlled without medications Interview with the Unit Manager of Resident F's stay on 5/19/11 at 3:30 p.m. indicated she assumed her duties in late April 2011. She had been in orientation starting 4/4/11. Interview with the Director of Nursing on 5/18/11 at 6 p.m., indicated she had reviewed Resident F's record and concluded the resident's plan of care had been followed. She indicated there was no physician's order for a PT/INR between 3/17/11 and 4/15/11. She indicated there had not been a facility protocol to cue the nursing staff to request an order for [REDACTED]. Further, each resident on [MEDICATION NAME] had a tracking form in the Medication Administration Record, [REDACTED]. An immediate jeopardy of past non compliance was identified on 5/19/2011 at 4:30 p.m. The immediate jeopardy of past non-compliance began on 3/17/11 when the nurse practitioner failed to write an order for [REDACTED]. This federal tag relates to complaint number IN 148. 3.1-48(a)(3)