Every finding on record at American Village

Based on interview and record review, the facility failed to protect the resident's right to be free from physical and mental abuse by another resident when one resident grabbed another resident's neck. Using the reasonable person concept, this action would likely lead to fear and distress for 1 of 2 residents reviewed for abuse. (Resident 127)Findings include: The clinical record for Resident 127 was reviewed on 3/17/26 at 3:07 p.m. The resident's diagnosis included, but was not limited to, Alzheimer's disease (progressive irreversible neurodegenerative disorder that causes the brain cells to die, the brain to shrink, and significant impairment of memory, thinking, and behavior). A Quarterly Minimum Data Set (MDS) Assessment, completed 2/26/26, indicated Resident 127 had severely impaired cognition. A Nursing Progress Note, dated 3/12/26 at 3:46 p.m., indicated Resident 127 was involved in an altercation with another resident (Resident 97). Resident 127 had no injuries noted and no signs and symptoms of distress. Resident 127 continued to participate in day-to-day activities. The clinical record for Resident 97 was reviewed on 3/17/26 at 3:07 p.m. The resident's diagnoses included, but were not limited to, dementia (a decline in mental ability including memory, thinking, reasoning, and behavior) and psychosis (loss of contact with reality, where an individual struggles to distinguish what was real from what was not). An Annual MDS Assessment, completed 2/5/26, indicated Resident 97 had severely impaired cognition. A care plan, created 8/23/24 and last reviewed on 3/13/26, indicated Resident 97 could become verbally/ physically aggressive, make threatening remarks to staff and other residents at times, knock over items in room, slam doors, throw things in the hallway, rip decorations off the walls, curse, charge at nurse and residents, hit walls, and not flip over tables in dining room. The goal was for the resident to not cause distress to others, and he would not cause harm to self or others. The interventions, created 8/28/24 and last reviewed on 3/13/25, were to address any immediate needs. Administer medications as ordered by the physician. Ensure safety, allow him time to cool off. Provide calm, unhurried and supportive approach. The physician and responsible party notified of behaviors. Remove from immediate area to further evaluate needs. A care plan, created 10/25/25 and last reviewed on 3/11/26, indicated Resident 97 had refused to have a Stop sign on his door, will accept stop sign on his door to detour other residents from coming inside his room without permission. The goal was that residents would not enter Resident 97's room without permission. The intervention, initiated 10/25/25, was to redirect other residents to activities and/or their rooms. A nursing progress note, dated 3/6/26 at 4:58 p.m., indicated Resident 97 became upset when another resident (Resident 127) went to his room. Resident 97 came to the dining room area yelling and made threats to hit other residents and staff. Resident 97 proceeded to flip over the dining table and chairs. Staff members attempted to calm Resident 97; however, he stated he would not listen to anyone. The Nurse Practitioner (NP) arrived and spoke with Resident 97 and he eventually calmed down. A physician's order for a one-time dose of clonazepam (a medication used to treat anxiety and panic disorder) was received and administered to Resident 97. The Director of Nursing (DON) was notified of situation. Resident 97 had calmed down and was lying in bed. A Nursing Progress Note, dated 3/12/26 at 2:50 p.m., indicated Resident 97 had displayed violent behaviors. 911 had been called and Resident 97's guardian had been notified. Resident 97 was calm and sitting in the hallway being monitored directly by staff until the emergency medical service arrived. The incident report, dated 3/12/26 at 2:39 p.m., indicated Resident 97 and Resident 127 had a disagreement resulting in Resident 97 being verbally aggressive and Resident 97 putting his hands toward the neck of Resident 127. As Resident 97 made contact with Resident 127 the staff immediately separated the residents. Resident 97 was placed on one-on-one care (one staff member to one resident direct observation) until the emergency medical services arrived and Resident 127 had no recollection of the event. No injuries were noted to either resident. An Acute Care Progress Note from Nurse Practitioner (NP) 20, dated 3/12/26, indicated Resident 97 was evaluated for an acute visit due to explosive and violent behaviors. The resident had become violent and extremely upset due to his family being out of the facility for the last few days. The staff were aware and were attempting to remedy the situation. The resident (Resident 97) in the meantime had choked another resident, told the social worker he was going to kill her and shoved another resident that approached his room. The patient was impossible to redirect. 911 was called due to no other options available acutely. The patient was put on 1 to 1 care as the facility waited for emergency services. During an interview on 3/20/2026 at 1:13 p.m., Certified Nursing Assistant (CNA) 21 indicated she had witnessed the incident between Resident 97 and 127 on 3/12/26. Resident 97 had been sitting in a chair in the hallway across from the nursing station. Resident 127 was in her wheelchair, talking out loud and propelling herself up the hallway, past Resident 97. Resident 97 had told Resident 127 to shut up. Resident 127 kept moving and talking to herself and then Resident 97 jumped out of his chair and put his hands around Resident 127's neck. CNA 21 had been sitting behind the nursing station and immediately went to Resident 127 and got Resident 97's hands from around Resident 127's neck. CNA 21 then removed Resident 127 from the area and told the nurse what had happened. During an interview on 3/23/26 at 2:58 p.m., Family Member (FM) 22 indicated that prior to Resident 127 having impaired cognition, Resident 127 would have been scared, upset, and distressed if another person had put their hands around her neck and attempted to choke her. On 3/20/26 at 2:24 p.m., the ED provided the Abuse Prohibition, Reporting, and Investigation policy, last revised June 2018, indicated . It is the policy.to provide each resident with an environment that is free from 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. Definitions/ Examples of Abuse: Willful used in the definition of abuse means the individual must have acted deliberately, not that the individual intended to inflict injury or harm.Physical abuse- a willful act against a resident by another resident, staff member, or other individual [s]. Examples may include but not limited to hitting, beating, slapping, punching, shoving, striking with an object, pulling, twisting, squeezing, pinching, scratching, tripping, biting, burning, and use of improper restraints. 410 IAC (Indiana Administrative Code) 16.3.1-27(a)(1)

Based on observation, interview and record review, the facility failed to assist residents with fingernail care and facial hair removal for 2 of 6 residents reviewed for Activities of Daily Living (Resident J and Resident K). Finding include:1.The clinical record for Resident K was reviewed on 3/18/25 at 9:00 a.m. The diagnoses for Resident K included, but were not limited to, stroke (blood flow to the brain was blocked or a vessel burst killing brain cells) and dementia (decline in mental function). An Activities of Daily Living (ADL) care plan, dated 10/25/25, indicated the staff was to assist hygiene and provide showers twice a week and partial bed baths all other days. A quarterly Minimum Data Set (MDS) Assessment, dated 2/4/26, indicated Resident K was moderately cognitively impaired. She was dependent on staff to provide hygiene care. An observation was made of Resident K with Resident K's Representative on 3/18/26 at 11:10 a.m. The resident's fingernails were observed long in length. Resident K had indicated she would like her nails to be trimmed, shaped and painted. The staff had never offered to trim her fingernails, only trimmed her toenails. Resident K's Representative indicated the resident's fingernails were very long and unkept. They needed to be trimmed. An observation was made of Resident K in bed on 3/23/26 at 11:18 a.m. The resident's fingernails were observed to be long in length. An observation was made of Resident K on 3/24/26 at 11:03 a.m. The resident's fingernails were long in length. The resident indicated she did want her fingernails trimmed and filed. The staff had not offered to trim them. She wanted to have her nails look groomed and nice. An interview was conducted with Certified Nursing Assistant (CNA) 7 on 3/24/26 at 11:05 a.m. She indicated nail care was provided when it was observed that the resident's nails are dirty and long in length she will ask if they would like nail care. The March 2026 shower reports for Resident K were provided by the DNS on 3/24/26 at 2:20 p.m. The resident had received a bed bath on 3/17/26. The shower report did not include documentation of nail care provided. An interview was conducted with the Director of Nursing Services (DNS) on 3/24/26 at 2:20 p.m. She indicated Resident K had been refusing her showers at times. The shower sheets did not include a place for staff to document nail care services that had been provided. 2. During an observation and interview with Resident J on 3/18/2026 12:21 p.m., Resident J indicated the facility they just wash me up. The resident had moderately long fingernails on both hands with a black substance underneath them. The resident had facial hair of a full mustache. The resident indicated she always shaved her facial hair with a razor at home and no staff had offered to shave her face. The resident indicated she would be willing to use the cream that takes off facial hair if that was what the facility used. During an observation on 3/19/26 at 2:35 p.m., Resident J was lying in bed dressed. The resident had moderately long fingernails on both hands with a black substance underneath them and had a full mustache. During an observation and interview with Resident J on 3/20/2026 at 1:11 p.m., Resident J had a full mustache and her fingernails on both hands were moderately long with black substance underneath them. The resident was eating a turkey sandwich with her bare hands. Resident J indicted the facility staff had not offered to clean her nails yet. Review of the clinical record of Resident J on 3/19/26 at 2:50 p.m., indicated the resident's diagnoses included, but were not limited to, weakness and repeated falls. The plan of care for Resident J, dated 12/17/26, indicated the resident required assistance with Activities of Daily Living (ADL). The interventions included, but were not limited to, offer a shower two times a week and assist with grooming as needed. The admission Minimum Data Set (MDS) for Resident J, dated 12/22/25, indicated the resident was moderately impaired for daily decision making. The resident had no behaviors of refusal of care. The resident required substantial from staff for showers and partial to moderate assistance from staff with personal hygiene. During an interview with Unit Manager 1 on 3/20/26 at 1:40 p.m., indicated it was the responsibility of the CNA's to clean and trim Resident J's fingernails and shave her facial hair. The Unit Manager indicated Resident J was scheduled to have showers on Wednesday and Saturday. The A.M. care policy provided by the Executive Director on 3/23/26 at 11:32 a.m., indicated the staff were to assist residents with washing their hands and shaving during morning care. This citation relates to Intake 2646777. 410 IAC (Indiana Administrative Code) 3.1-38(a)(3)(A)

Based on observation, interview, and record review, the facility failed to ensure residents' pain were assessed, monitored and addressed for 2 of 3 residents for pain management. (Resident C and Resident D) Findings include: 1.The clinical record for Resident C was reviewed on 3/17/25 at 10:00 a.m. The diagnoses for Resident C included, but were not limited to, pain, osteoarthritis (loss of cartilage causing rubbing of bone to bone at the joints), kidney disease (kidneys not filtering blood properly), and type 2 diabetes mellitus (pancreas does not make enough insulin) with diabetic neuropathy (damage of the nerves). A quarterly Minimum Data Set (MDS) Assessment, dated 3/19/26, indicated Resident C was moderately cognitively impaired. A pain care plan, dated 12/27/23, indicated the staff were to administer pain medications as ordered, assess and document the effectiveness of PRN medications, notify the medical provider if the pain was the relieved or had worsened and provided non pharmacological interventions for pain relief. A controlled substance record indicated 5-325 milligrams of hydrocodone (pain medication) was administered to Resident C on 3/17/26 at 12:00 p.m. An interview was conducted with Resident C on 3/17/26 at 11:28 a.m., the resident indicated the staff did not ask her the location of her pain or how bad her pain was. The pain medication she received did not work at times. A random observation was made of License Practical Nurse (LPN) 6 on 3/17/26 at 11:48 a.m. Resident C was observed sitting in her room and had requested a pain medication from LPN 6. LPN 6 indicated it would be just a minute. He then went to the medication cart and pulled a medication out of the narcotic box. After, he returned to Resident C's room, handed her the medication and then left the room. There was no observation of LPN 6 assessing Resident C's pain location or level of her pain before or after the pain medication was administered. An interview was conducted with LPN 6 on 3/19/26 at 12:26 p.m. He indicated he was supposed to assess and document the location and level of the resident's pain when giving a PRN pain medication. 2. The clinical record for Resident D was reviewed on 3/17/25 at 3:00 p.m. The diagnoses for Resident D included, but were not limited to, pain. A quarterly MDS assessment, dated 9/15/26, indicated Resident D was severely cognitively impaired. A pain care plan, revised 2/18/26, indicated on a start date of 8/28/18, the staff was to notify the medical provider if the resident's pain was not relieved or had worsened and staff were to assess for signs of pain the resident displayed related to being nonverbal. A physician's order, dated 11/27/24, indicated Resident D was to receive 1,000 milligrams of Acetaminophen three times a day. A progress note, dated 10/1/25 at 1:37 p.m., indicated Resident D had complaints of right leg pain. The medical provider had been notified. A physician's order, dated 10/1/25, indicated Resident D was to receive 50 milligrams of tramadol every 8 hours PRN for pain. A progress note, dated 10/7/25, indicated Resident D had bruising on right leg behind the knee and swollen foot. The resident had complaints of pain when she touched her foot. A progress note, dated 10/8/25, indicated, Resident D had a bruise to the right leg. The resident had faded scattered bruising from knee to ankle on the right lower leg and the foot was swollen. Upon the resident's foot being touched the resident yelled in pain. New orders were received by the Nurse Practitioner (NP) for an x-ray of the resident's right knee, right ankle, lower leg bones at that time. The October 2025 Medication Administration Record for Resident D indicated the resident had received the 50 milligrams of PRN tramadol on 10/9/25 at 12:31 p.m., and the pain medication was effective. A controlled substance record, dated 10/2/25, for 50 milligrams of tramadol indicated Resident D had received the 50 milligrams of tramadol on 10/2/25 at 1:00 p.m. and 10/9/25 at 12:00 p.m. The resident's clinical record lacked documentation Resident D's pain was assessed with location of pain, level of pain, or effectiveness after pain medications were administered. There was no documentation the resident's pain was monitored or addressed on 10/7/25 and 10/8/25. An interview was conducted with the Director of Nursing Services (DNS) on 3/24/26 at 12:00 p.m. She indicated pain assessments should be conducted with residents that receive scheduled pain medications. Resident D had received 1,000 milligrams of Acetaminophen three times a day. The staff should have conducted pain assessments every shift, and they were not. She was unable to provide information that the resident's pain was addressed on 10/7/25 and 10/8/25 other than the scheduled 1,000 milligrams of Acetaminophen had been administered three times those days. A pain policy was provided on 3/19/26 at 10:00 a.m. It indicated, .policy: It is the policy of American Senior Communities to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing, including pain management. Procedure: 1. Residents are assessed for pain upon admission, weekly, and during medication administration.7. Residents receiving routine pain medication should be assessed each shift by the charge nurse during rounds and/or medication pass.Documentation of administration of ordered PRN pain medication will be documented on the Electronic Medication Administration Record (EMAR). 9. Additional information including, but not limited to reasons for administration, and effectiveness of pain medication will be documented of the Electronic Medication Administration Record (EMAR). This citation is related to Intake 2733447. 410 IAC (Indiana Administrative Code) 16.2-3.1-37(a)

Based on observation, interview, and record review, the facility failed to timely updated the individualized plan of care for residents who displayed behaviors, document non-pharmacological interventions attempted prior to the administration of an as needed anti-anxiety medications, and to document effectiveness of interventions attempted to alleviate behaviors for 2 of 3 residents reviewed for dementia care (Resident 6 and Resident 97).Findings include: 1 The clinical record for Resident 97 was reviewed on 3/17/26 at 3:07 p.m. The resident's diagnoses included, but were not limited to, dementia (a decline in mental ability including memory, thinking, reasoning, and behavior) and psychosis (loss of contact with reality, where an individual struggles to distinguish what was real from what was not). A care plan, created 10/25/25 and last reviewed on 3/11/26, indicated Resident 97 had refused to have a Stop sign on his door, will accept stop sign on his door to detour other residents from coming inside his room without permission. The goal was that residents would not enter Resident 97's room without permission. The intervention, initiated 10/25/25, was to redirect other residents to activities and/or their rooms. A care plan, created 8/23/24 and last reviewed on 3/13/26, indicated Resident 97 could become verbally/ physically aggressive, make threatening remarks to staff and other residents at times, knock over items in room, slam doors, throw things in the hallway, rip decorations off the walls, curse, charge at nurse and residents, hit walls, flip over tables in dining room, etc. The goals were that Resident 97 would not experience lasting distress. He would not cause distress to others, and he would not cause harm to self or others. The interventions, created 8/28/24 and last reviewed on 3/13/25, were to address any immediate needs. Administer medications as ordered by the physician. Encourage preferred activities such as bingo, watching television, and games. Ensure safety, allow him time to cool off. Provide calm, unhurried and supportive approach. The physician and responsible party notified of behaviors. Remove from immediate area to further evaluate needs. An Annual MDS Assessment, completed 2/5/26, indicated Resident 97 had severely impaired cognition. A Behavioral Health Monthly Review, dated 2/4/26, indicated Resident 97 had a new/worsening behavior exhibited on 1/9/26. He was agitated with staff and threw a chair up against the wall. The Interdisiplinary Team (IDT) had reviewed the event. Care plans updated with effective interventions was marked as not applicable (N/A). Resident 97 was taking psychotropic (drugs that alter the brain chemistry to treat mental health conditions) medications. The targeted behavior for each medication was depression and agitation. A Behavioral Health Monthly Review, dated 2/13/26, indicated Resident 97 had a new/ worsening behavior of yelling and charging at a nurse on 1/9/26. The IDT team had reviewed the event. Care plan updated with effective interventions was marked as not applicable (N/A). Resident 97 was taking psychotropic medications. The targeted behavior for each medication was anxiety. A nursing progress note dated 3/6/26 at 4:58 p.m., indicated Resident 97 became upset when another resident went to his room. Resident 97 came to the dining room area yelling and made threats to hit other residents and staff. Resident 97 proceeded to flip over the dining table and chairs. Staff members attempted to calm Resident 97; however, he stated he would not listen to anyone. The Nurse Practitioner (NP) arrived and spoke with Resident 97 and he eventually calmed down. A physician's order for a one-time dose of clonazepam (a medication used to treat anxiety and panic disorder) was received and administered to Resident 97. The Director of Nursing (DON) was notified of situation. Resident 97 had calmed down and was lying in bed. A NP Acute Care Progress Note, dated 3/6/26, the residents interval history indicated the resident was evaluated that day for an acute visit due to anxiety and anger outburst. The resident had chronic anxiety and was on clonazepam daily. Another resident entered his room and he had become quite angry and was yelling out loudly. The resident was hard for staff to redirect. An additional dose of clonazepam was ordered that afternoon. An IDT Behavior Review Note, dated 3/11/26, indicated a resident had come into Resident 97's room and he became very upset, made threats, and flipping over a table and a chair. The immediate intervention was that the NP spoke with Resident 97 and staff gave resident space and time to calm down. The assessment of potential correlation to root cause was a dementia diagnosis and a resident came into Resident 97's room. The root cause of behavioral expression was that a resident came into Resident 97's room.There were no new interventions added to Resident 97's behavioral care plans. Resident 97's clinical record contained a nursing progress note, dated 3/12/26 at 2:50 p.m., that indicated he had displayed violent behaviors. 911 had been called and Resident 97's guardian had been notified. Resident 97 was calm and sitting in the hallway being monitored directly by staff until the emergency medical service arrived. An Acute Care Progress Note from Nurse Practitioner (NP) 20, dated 3/12/26, indicated the resident had an acute visit due to explosive and violent behaviors. The resident had become violent and extremely upset related to his family member being out of the facility for the last few days. The staff were aware and were attempting to remedy the situation. The resident had choked another resident, told the social worker he was going to kill her and shoved another resident that approached his room. The resident was impossible to redirect. 911 was called due to no other options available acutely. The resident was placed on one to one observation (one staff to one resident) until emergency services arrived. During an interview on 3/20/2026 at 1:13 p.m., Certified Nursing Assistant (CNA) 21 indicated she had witnessed the incident between Resident 97 and another resident on 3/12/26. Resident 97 had been sitting in a chair in the hallway across from the nursing station. The other resident was in her wheelchair, talking out loud and propelling herself in the hallway, past Resident 97. Resident 97 had told the other resident to shut up. The other resident had kept moving and talking to herself. Resident 97 jumped out of his chair and put his hands around the other resident's neck. CNA 21 had been sitting behind the nursing station and immediately went to the other resident and removed Resident 97's hands from around the other resident's neck. CNA 21 then removed the other resident from the area and told the nurse what had happened. During an interview on 3/20/26 at 1:18 p.m., Licensed Practical Nurse (LPN) 23 indicated she had been the nurse for Resident 97 on 3/12/26. Resident 97 had been calm and had come out of his room to sit in the hallway prior to the incident with the other resident. During an interview on 3/23/26 at 11:32 a.m., Social Services (SS) 24 indicated Resident 97 was calm most of the time. The staff used Soda, candy, chips, and tea to help calm him when he got upset. Those specific interventions had not been captured on the care plan. The behavioral incident, dated 1/9/26, had been related to Resident 97 believing his wallet was missing. Resident 97's wallet was found and he immediately calmed down. SS 24 had provided one-on-one (one staff to one resident) care for Resident 97 after the behavioral incident on 3/12/26. SS 24 had given Resident 97 some snacks and drinks and he had been calm while he was receiving one-on-one care. During an interview on 3/23/26 at 11:32 a.m., SS 25 indicated Resident 97's behavioral outbursts on 3/6/26 and 3/12/26 had both involved the same female resident on the unit. Resident 97 did not normally flip over tables or throw chairs. Resident 97 was normally easily redirected. During an interview on 3/23/26 at 11:32 a.m., the Director of Nursing Services (DNS) indicated Resident 97 was a creature of habit, using the example that Resident 97 received pancakes every morning for breakfast. If he received 2 pancakes instead of 3 pancakes, he would become upset. Resident 97 was usually very redirectable. Resident 97 did not know what to do when he was out of his normal routine. During the behavior incident on 3/6/26 the NP had ordered a one-time dose of clonazepam. During the behavioral incident on 3/12/26 the NP had been on the unit and Resident 97 was placed on one-on-one care until the emergency medical services had arrived. 2. The clinical record for Resident 6 was reviewed on 3/17/26 at 4:08 p.m. The resident's diagnosis included, but were not limited to, dementia with anxiety and depression. She was admitted to the facility on [DATE]. An admission MDS Assessment, completed 2/21/26, indicated Resident 6 had severely impaired cognition. She displayed the behavior of rejection of care four to six days during the seven day look back period. She had displayed the behavior of wandering daily during the seven day look back period. Her wandering had significantly intruded on the privacy or activities of others. A care plan, initiated on 2/27/26 and last reviewed on 3/11/26, indicated Resident 6 experienced the following behavior expressions and intrusive wandering. Refusal of care at times and wander into other residents' rooms at times. She had a diagnoses of dementia and major depression disorder with a treatment of psychoactive medications. The goals were for her not to experience lasting distress, not to cause others distress, and not to cause harm to herself or others. The interventions, initiated on 2/27/26 and last reviewed on 3/11/26, were to address any immediate needs, offer diet coke, Resident 6's favorite drink. Ensue safety. Allow Resident 6 time to cool off. Provide calm, unhurried, and supportive approach. Remove from the immediate area/ resident rooms to further evaluate needs. A Psychiatry Progress Note, dated 3/3/36, indicated Resident 6 had transitioned to the memory care unit. Staff reported Resident 6 remained anxious and restless. She had delusions involving needing to leave the facility to get care and take care of her cat. Resident 6 was unable to participate in activities due to her restlessness and inattentiveness. Resident 6 was receiving sertraline (anti-depressant medication) 50 milligrams (MG) daily. The dose had been adjusted on 2/24/26 to assist with her anxiety. The clinical record did not contain behavior progress notes or behavioral events from 3/3/26 to 3/6/26. A Nurse Practitioner (NP) Acute Care Progress Note, dated 3/6/26, indicated the chief complaint for the visit was aggressive behavior and insomnia. The interval history indicated Resident 6 was being seen due to aggressive behaviors and insomnia. Resident 6 had been aggressive with staff. The NP has discussed Resident 6 with the psychiatry provider who recommended lorazepam (anti-anxiety medication) as needed for seven days. The psychiatry provider would follow up with Resident 6 next week. A physician's order, dated 3/6/26, indicated Resident 6 was to receive lorazepam 0.25 mg every 12 hours as needed. The March 2026 Medication Administration Record (MAR) indicated Resident 6 had received lorazepam on 3/7/26 at 9:52 a.m. for anxiety which was effective. The Controlled Substances Record for Resident 6's lorazepam 0.25 mg indicated she had received a dose of lorazepam 0.25 mg on the following days and times: 3/7/26 at 8:00 a.m. and 8:00 p.m., 3/8/26 at 8:00 p.m. The clinical record did not indicate what non-pharmacological interventions had been attempted prior to administering the as needed lorazepam. A Behavioral Health Monthly Review, dated 3/7/26, indicated no new or worsening behaviors had been noted. An IDT review for the events and care plan updated with effective interventions were not applicable (N/A). A Nursing Progress Note, dated 3/08/2026 at 8:56 p.m., indicated Resident 6 was riding in wheelchair, going in and out of other resident rooms. She was being re-directed and she then attempted to get up from her wheelchair and ended up falling to the floor. Staff would continue with ongoing observation. A Nursing Progress Note, dated 3/10/2026 at 12:26 p.m., indicated a new physician's order had been received to increase sertraline to 100 mg daily, discontinue lorazepam 0.25 mg twice daily, and start lorazepam 0.5 mg twice daily as needed for 14 days. The March MAR indicated Resident 6 had received lorazepam 0.5 mg on the following days and times: 3/10/26 at 1:39 p.m. for behavioral issues which was effective, 3/10/26 at 7:23 p.m. for behavioral issues with was not effective, and 3/11/26 at 8:46 a.m. for agitation which was effective. The clinical record did not indicate what non-pharmacological interventions had been attempted prior to administration of the as needed lorazepam. An NP Follow-Up Progress Note, dated 3/11/26, indicated Resident 6 was being seen for frequent falls. She had fallen 3 times in 12 hours. She has had no apparent injuries. Nursing reported that Resident 6 was significantly anxious and frequently trying to get up from her wheelchair which was when the falls occurred. She had lorazepam available as needed, but nursing did not feel it had been effective. Resident 6 had labs drawn on 3/9/26 which were reviewed. The plan was to change lorazepam to 0.5 mg twice daily and to continue the 0.5 mg twice a day as needed. An IDT Psychotropic Medications New/ Change Order Review, dated 3/12/26, indicated Resident 6 had received a new or changed as needed lorazepam order. The clinical indication for medication use was anxiety. The list of non-pharmacological interventions attempted prior were to encourage activities of choice, encourage family involvement, encourage independence, encourage resident to verbalize fears and anxiety. The expected benefits from medication use was to decrease anxiety. A nursing progress note, dated 3/16/26 at 5:53 a.m., indicated Resident 6 appeared restless throughout the night. Staff attempted multiple times to redirect resident and assist her to her bed and wheelchair; however, redirections were difficult and largely unsuccessful. She became combative during care and resistive to assistance. Resident 6 remained in wheelchair at nursing station to ensure safety. On 3/18/26 at 9:30 a.m., Resident 6 was observed sitting in her wheelchair in the hallway on the dementia care unit with staff standing around her. She was holding a stuffed cat that meowed and purred. She was petting the cat and talking about the cat's name and how much she loved the cat and smiling when it meowed. A Behavior Communication Note, dated 3/18/26 at 12:33 p.m., indicated that at 12:00 p.m., Resident 6 was in the dining room and had punched a staff member in the cheek. The interventions attempted was to move her away from all other residents and she was put on one-on-one for monitoring and safety. The interventions were effective. A NP Acute Care Progress Note, dated 3/18/26, indicated Resident 6 was seen due to violent behavior. She had punched a staff member and another resident in the common area. She had been moved to a separate area and appeared to calm down. An additional dose of as needed lorazepam was given. During an interview on 3/19/2026 at 3:39 p.m., Activity Aide (AA) 26 indicated if residents displayed behaviors, she would tell the nurse so that the behavior could be documented. During an interview on 3/19/26 at 3:42 p.m., CNA 27 indicated when Resident 6 was agitated, CNA 27 would offer to rub her back, talk with her, and offer reassurance. CNA 27 informed the nurse of any behaviors so that they could be documented. During an interview on 3/20/2026 at 1:19 p.m., LPN 23 indicated Resident 6 had ups and downs. Resident 6 could be sweet and the next minute she doesn't want to be bothered. Resident 6 loved cats. The staff would use her stuffed cat to redirect her, and it helped. At times Resident 6 became overstimulated and when she was taken to a quiet place she would calm down. If Resident 6 was wandering, LPN 23 would ask her if she needed to go to the bathroom. Normally, after being taken to the bathroom, Resident 6 would calm down. The behavioral care plan had not been updated with the interventions of using Resident 6's stuffed cat to distract and/ or redirect her or to offer to take Resident 6 to the bathroom when she was wandering. During an interview on 3/23/25 at 2:34 p.m., LPN 23 indicated Resident 6 had not made physical contact with another resident since being on the dementia care unit. On 3/20/26 at 2:24 p.m., the Executive Director provided the Behavior Management Policy, last revised August 2022, that read .It is the policy of American Senior Communities 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 toward preventing, relieving and/or accommodating a resident's behavioral expressions.Care plans should 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.If the behavioral expression is new, worsening, or high risk, the nurse will record the behavior using the New/Worsening Behavior Event. New or worsening behaviors are reviewed by the IDT for assessment and preventative actions.The IDT review is a discussion with the team as to the behavioral expression, an evaluation of interventions, presentation of new interventions if applicable and an assessment of any underlying causes of the behavior [ie pain, environmental stressor, medical illnesses, etc]. The root cause and preventative interventions will be included in the resident's plan of care.If the behavioral expression is not new, worsening or high risk; the nurse will record the behavior in the progress notes using the Behavior Communication Note. The IDT will review progress notes the next business day to determine if immediate follow up action is required for the Behavior Communication. If the behavior requires an interdisciplinary response as described above, the IDT will complete the IDT Behavior Review. If not, the plan of care will be reviewed and updated if needed to include a description of the behavior and effective intervention. 410 IAC (Indiana Administrative Code) 16.3.1-37

Based on interview and record review, the facility failed to ensure a resident received the correct medications for 1 of 6 residents reviewed for unnecessary medications. (Resident 51)Findings include:The clinical record for Resident 51 was reviewed on 3/17/25 at 12:00 p.m. The diagnosis for Resident C included, but was not limited to, heart failure (heart cannot pump enough blood throughout the body). An interview was conducted with Resident 51 on 3/17/26 at 12:21 p.m. He indicated he had to monitor the staff with administration of his medications. The nurse had given him in error his roommates evening medications a couple of months ago. He was monitored by staff afterward, and there were no adverse effects from the error. A nursing progress note dated 1/11/26 at 8:25 p.m. indicated the nurse administered metoprolol 100 milligrams (mg) and metformin 500 mg scheduled for another resident (Resident D) to Resident C. New orders were received to monitor Resident C's Blood pressure and pulse every 4 hours overnight to watch for hypotension (low blood pressure). The resident continued sitting on the side of the bed conversating with roommate, no concerns or comments noted at that time and the nurse would continue to monitor. An interview was conducted with the DNS on 3/24/26 at 3:00 p.m. She indicated License Practical Nurse (LPN) 8 had received education after she administered the wrong medication to Resident 51.A medication administration procedure guide was provided by the Executive Director on 3/24/26 at 12:02 p.m. It indicated, .Procedures for all medications.2nd step. The 5 rights of medication performed: Right Resident, Right Medication, Right Dose, Right Route, Right Time. 410 IAC (Indiana Administrative Code) 16.2-3.1-48(c)(2)

Based on observation, interview, and record review, the facility failed to ensure gloves were doffed and hand hygiene was performed timely during incontinent care and that a resident's urinary catheter tubing was not dragging on the floor for 2 of 3 residents reviewed for activities of daily living (Resident 54 and Resident 102).Findings include:1 The clinical record for Resident 102 was reviewed on 3/24/26 at 2:10 p.m. The resident's diagnosis included, but was not limited to, dementia (mental decline). On 3/24/26 at 2:10 p.m., Certified Nursing Assistant (CNA) 29 was observed performing incontinent care for Resident 102. CNA 29 performed hand hygiene (HH), donned gloves, and removed Resident 102's pants and opened his brief. Resident 102 had been incontinent of stool. CNA 29 assisted Resident 102 to turn to his side and performed incontinent care. CNA 29 did not doff soiled gloves or perform hand hygiene. CNA 29 then put a clean incontinent brief on Resident 102, assisted Resident 102 out of his shirt and to put a gown on him. CNA 29 then doffed his gloves and performed hand hygiene. During an interview on 3/24/26 at 2:28 p.m., CNA 29 indicated he normally changed his gloves and performed hand hygiene after doing incontinent care and prior to assisting a resident to dress in clean items. 2. The clinical record for Resident 54 was reviewed on 3/18/26 at 2:10 p.m. The resident's diagnosis included, but was not limited to, obstructive and reflux uropathy (a condition where urine flow was blocked or flows backward). A current care plan, last reviewed on 3/19/26, indicated Resident 54 required an indwelling urinary catheter related obstructive uropathy. The goal was for her to have her catheter care managed appropriately as evidenced by not exhibiting signs of urinary tract infections or urethral trauma (damage to the tube that carries urine from the bladder). The interventions included, but was not limited to, staff were to not allow the catheter tubing or any part of the drainage system to touch the floor. On 3/24/26 at 2:30 p.m., Resident 54 was observed in the common area around nurses station. Two nursing staff were standing by her. Resident 54 was wheeling back and forth, talking out loud and her catheter tubing was dragging on the floor. Resident 54 ran over her catheter tubing with her wheelchair. Resident 54 then wheeled herself behind the nurses station. Nursing staff were present in the nursing station. Resident 54's catheter tubing continued to drag on the floor. On 3/24/26 at 3:10 p.m., Resident 54 was observed in her wheelchair, rolling herself in the hallway with her catheter tubing dragging on the floor. Two nursing staff were at the medication cart in the hallway. Resident 54 requested for someone to help her up the hallway. The nursing staff came to talk with Resident 54 and attempted to assist her up the hallway. Resident 54's catheter tubing continued to be on the floor. During an interview on 3/24/26 at 3:15 p.m., the Assistant Director of Nursing indicated that Resident 54's catheter tubing should not be on the floor. 410 IAC (Indiana Administrative Code) 16.3.1-18(l)

Based on observation, interview, and record review, the facility failed to timely have the interdisciplinary team (IDT) determine and document self-administration of medications and treatments were clinically appropriate for 2 of 2 randomly observed residents. (Resident 10 and Resident 20) Findings include: 1. The clinical record for Resident 10 was reviewed on 7/1/25 at 11:51 a.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease. The Quarterly 5/12/25 Minimum Data Set (MDS) assessment indicated Resident 10 was cognitively intact. A physician's order, dated 3/11/25, indicated the resident was to receive 10 micrograms of vitamin D3 once a day. A physician's order, dated 3/13/25, indicated the resident was to receive 60 milligrams of Cymbalta once a day. A physician's order, dated 3/11/25, indicated the resident was to receive 100 milligrams of Neurontin three times a day. A physician's order, dated 3/11/25, indicated the resident was to receive 30 milliliters of lactulose three times a day. A physician's order, dated 3/11/25, indicated the resident was to receive 5 milligrams of pilocarpine once a day. A physician's order, dated 3/11/25, indicated the resident was to receive 100 milligrams of thiamine daily. An observation was conducted of Resident 10 on 7/1/25 at 11:51 a.m. The resident was observed in bed with one medication cup of liquid medication and one medication cup of pill medications on the bedside table. There was no nurse present in the room at that time. She indicated it was her morning medications, and she had not taken them yet. An interview was conducted with Registered Nurse (RN) 1 on 7/1/25 at 11:55 a.m. She indicated she was Resident 10's nurse that morning. At that time, RN 1 was observed walking into the resident's room and speaking with Resident 10 about the medication left at the bedside. After, she left the room and reported the resident had now taken her medications. 2. The clinical record for Resident 20 was reviewed on 7/1/25 at 11:50 a.m. The diagnoses included, but were not limited to, dementia. The Quarterly 4/24/25 MDS assessment indicated Resident 20 was cognitively intact. A physician's order, dated 12/16/24, indicated the resident was to receive 500 milligrams of ascorbic acid daily. A physician's order, dated 6/5/24, indicated the resident was to receive 500 micrograms of vitamin B-12 daily. A physician's order, dated 10/20/22, indicated the resident was to receive 2.5 milligrams of Eliquis twice a day. A physician's order, dated 11/20/24, indicated the resident was to receive 20 milligrams of omeprazole once a day. A physician's order, dated 12/27/23, indicated the resident was to receive 50 micrograms of vitamin D3 once a day. An observation was conducted of Resident 20 on 7/1/25 at 11:58 a.m. The resident was observed sitting on the side of the bed. The bedside table had one medication cup of medications. There was no nurse present in the room at that time. He indicated he believed one of the pill medications in the cup was his Eliquis medication and another pill was B-12 medication. The other pills in the cup; he was unsure what they were. An interview was conducted with RN 1 on 7/1/25 at 12:00 p.m. She indicated Resident 20 refused to let her remove the pill medications from his room when she delivered them that morning. RN 1 at that time, walked into the resident's room and spoke to the resident about taking the medications. During that time, she had stated to the resident, I don't have time to stand here all day. An interview was conducted with the Director of Nursing (DON) on 7/1/25 at 12:23 p.m. She indicated Resident 10 does have a self-medication assessment in the clinical record that she was able to self-medicate lotion. It does not indicate she was able to self-administer pill medications. Resident 20 does not have a self-administration assessment that had been conducted indicating he was able to self-administer his medications. A self-administration of medications policy was provided by the DON on 7/1/25 at 1:56 p.m. It indicated, .Policy. It is the policy of this facility to respect the wishes of alert, competent residents to self-administer prescribed medications as allowable under state regulations. The facility will provide instruction for all residents choosing to and capable of self-administration .If a resident desires to participate in self-administration, the Interdisciplinary Team will assess the competence of the resident to participate by completing the Self-Administration of Medication Assessment observation. A physician order will be obtained specifying the resident's ability to self-administer medications and, if necessary, listing which medications will be included in the self-administration plan .Storage of self-administered medications will comply with state and federal regulations. All bedside medications will be maintained in a secured location in the resident's room. The resident will be assessed for continued self-administration of medications quarterly and with any significant change of condition . 3.1-11(a)

Based on observation, interview, and record review, the facility failed to remove discontinued resident medications, refrigerate a medication requiring refrigeration, and label open medications in 2 of 3 medication carts observed (Residents 22, 49, 60, 75, 76, 105). Findings include: 1. An observation was conducted of the 200-hall medication cart, on [DATE] at 9:55 a.m., with Licensed Practical Nurse (LPN) 4. The medication cart contained an insulin degludec pen (type of long-acting insulin for diabetes) for Resident 60 that was opened with no open date label. Another insulin degludec pen for Resident 60, delivered on [DATE], was unopened/unused and not being refrigerated per manufacturer instructions. A bottle of lactulose (liquid medication for constipation) for Resident 49 was open, but did not have an open date label. A bottle of liquid guaifenesin dextromethorphan (medication for cough/upper respiratory symptoms) for Resident 105 was open with no open date label. This medication was discontinued, on [DATE], but not removed from the cart. A bottle of lactulose for Resident 75 was open with no open date label. An interview was conducted with LPN 4 on [DATE] at 10:05 a.m. He indicated he was not sure if opened medications needed an open date label, and did not know why the medications were not labeled. The unopened insulin pen should be refrigerated, but he did not know why it was not refrigerated. 2. An observation was conducted of the 400-hall medication cart, on [DATE] at 10:10 a.m., with LPN 2. A bottle of nitroglycerin pills (used as needed for chest pain) for Resident 22 was open with no open date label. It was delivered to the facility on [DATE]. Another bottle of nitroglycerin pills for the same resident also was open with no open date label. This bottle was delivered to the facility on [DATE]. A bottle of liquid ibuprofen (used as needed for pain) for Resident 76 was open with no open date label. It was delivered to the facility on [DATE]. An interview was conducted with LPN 2 on [DATE] at 10:15 a.m. She indicated she was not sure why the medications did not have an open date label, and she was not sure if they needed that label. On [DATE] at 10:20 a.m., the Director of Nursing (DON) provided the current facility policy titled, Medication Storage and Expiration Policy, dated ,d+[DATE]. It indicated, .Facility staff should record the date opened on the primary medication container (vial, bottle, inhaler) .Facility should destroy and reorder medications with soiled, illegible, worn, makeshift, incomplete, damaged, or missing labels or cautionary instructions .Medications should be stored in accordance with manufacturers' recommendations .Facility should ensure that medications are stored at their appropriate temperatures according to the United States Pharmacopeia guidelines for temperature ranges .Medications that are expired, discontinued, or belong to hospitalized patients should be stored separately, away from use, until destroyed or returned to the provider. 3XXX,d+[DATE](j) 3XXX,d+[DATE](m) 3XXX,d+[DATE](o)

Based on observation, interview, and record review, the facility failed to ensure appropriate social services follow-up, related to a previous allegation of abuse of a resident by a family member, for 1 of 1 resident reviewed for dementia care. (Resident 62) Findings include: The clinical record for Resident 62 was reviewed on 2/18/25 at 10:55 a.m. The diagnoses included, but were not limited to, dementia, depression, and cognitive communication deficit. An Admission Minimum Data Set (MDS) assessment, dated 12/11/24, indicated Resident 62 was severely cognitively impaired. An incident report, dated 10/31/24, indicated Resident 62's husband was overheard by staff raising his voice at the resident while assisting her with activities of daily living (ADL) care on the attached Assisted Living (AL) unit of the facility. A Nursing Progress Note, dated 11/2/24, indicated Resident 62's husband had been overheard yelling at the resident. Once staff entered the resident's room the resident's husband began yelling at facility staff to leave the room. Facility staff stayed in the resident's room to ensure safety. The resident was tearful and indicated multiple times that she was scared and attempted to move away from her husband and towards staff, but the resident's husband prevented her from doing so. Facility staff asked the resident's spouse to leave the facility, and he refused. At the advisement of the Director of Nursing (DON), the facility staff called the police, upon their arrival the resident's spouse was escorted out of the facility. On 11/6/24, a follow-up note was provided to the original incident report indicating Resident 62's husband had supervised visitations. On 12/4/24, Resident 62 was discharged from the attached AL unit and admitted to the Skilled Nursing Facility (SNF) due to progression of dementia. A hospice Master of Social Work (MSW) Visit Note, dated 12/6/24, indicated Resident 62 was experiencing fluctuating emotions, staff reported she had been crying all morning and yelling out. MSW encouraged husband to coordinate care needs with facility to reduce stress and the facility Registered Nurse (RN) was notified. A Psychiatry Progress Note, dated 1/7/25, indicated staff had reported increased anxiety, irritability, and agitation when Resident 62's husband visited. Included in the progress note; the plan was to continue lorazepam (antianxiety medication) 0.5 milligrams (mg) as ordered. On 2/18/25 at 11:39 a.m., Resident 62 was observed in her wheelchair tearful and grimacing while her husband was wheeling her into her room. During this time, the resident's husband was not actively being supervised by facility staff. During an interview on 2/21/25 at 1:36 p.m., the Social Services Director (SSD) of the AL unit, indicated facility staff noticed Resident 62's husband exhibit aggressive behavior toward the resident. He was forceful while changing her, would get mad at her, and be rough with her. The resident would cry a lot. Initially, Resident 62 would walk a lot and smile a lot, but when her husband came around, she would become tearful and withdraw. We even talked to the children, and they indicated he had always acted in this manner towards the resident. There was a meeting once the incident occurred, and we asked the resident's husband to please just let staff provide ADL care. We scheduled times for him to come in and initiated supervised visits in open areas. During an interview on 2/21/25 at 1:41 p.m., the Memory Care Support Specialist (MCSS) of the SNF, indicated Resident 62's husband was aggressive towards herself and staff, and liked to delegate where the resident was and who was involved with her care. Resident 62 gets tearful during the day, by herself, not just when the spouse was here. The MCSS then indicated that we (the SNF), don't provide one on one supervision here. We have never provided that overall. She did not know they were providing that (supervised visits) in the AL. During an interview on 2/21/25 at 2:04 p.m., the DON indicated Resident 62's husband and daughter share joint power of attorney. When the resident's husband visits, we try to keep the door open and keep an eye on him. He has been told several times not to provide ADL care and keep doors open; he is not compliant. They also try to keep an eye on him while he is feeding the resident because he tries to force feed her. During an interview on 2/21/25 at 2:31 p.m., hospice staff 1 indicated she was informed that Resident 62's door had to remain open and visits with the resident's husband had to be in an open area and supervised. During an interview on 2/24/25 at 9:44 a.m., hospice staff 2 indicated she had heard through the rest of the team and facility staff, that Resident 62's husband was possibly going to be banned from the facility. I saw Resident 62 for the first time on the secured memory care unit at the SNF part of the facility. I had been in contact with her daughter prior to the initial visit. I knew there had been some allegations of long-time abuse. I was under the impression that the resident's husband was not going to be there, however when I arrived, he was there. There were not any staff around and the door was open. Later, the staff walking down the hall saw me in the resident's room. On 2/21/25 at 3:24 p.m., the DON provided the Visitation Policy, dated 11/2016, revised 10/2022, which indicated, .Procedure: 4. Visitors must not behave in a way that imposes on the rights of other residents (i.e. using loud, abusive language; intimidating staff or other residents; appearing under the influence of drugs or alcohol, etc.) If a visitor is found to behave in a manner that imposes on the rights of other residents, the visitor will be asked to leave the facility .6. The facility may either deny or provide supervised visitation for a visitor who is suspected of abuse until an investigation into the allegation is completed. If the visitor is found to be abusing, exploiting or coercing a resident, visitation may be denied, limited or supervised as determined by the Executive Director On 2/24/25 at 10:52 a.m., the DON provided the Social Services Policy, dated 8/1998, revised 11/2016, which indicated, .It is the policy to provide medically-related social services to attain or maintain each resident's highest practicable physical, mental, and psychosocial well-being of each resident including provision of mental health services as ordered by the attending physician . 3.1-34(a)(1) 3.1-34(a)(2)

Based on interview and record review, the facility failed to accurately complete a Minimum Data Set (MDS) assessment for 1 of 1 resident reviewed for dental services, 1 of 1 resident reviewed for Preadmission Screening and Resident Review, and 1 of 1 resident reviewed for skin conditions (Resident 22, Resident 49, and Resident 329). Findings include: 1. The clinical record for Resident 329 was reviewed on 02/21/25 at 9:59 a.m. The diagnoses included, but were not limited to, gangrene and pain. Resident 329 was admitted on [DATE]. A wound progress note, dated 2/11/25, indicated the resident did have arterial insufficiency on bilateral feet. Areas noted to have arterial insufficiency are the top and bottom of all toes, bottom of both feet, and top of both feet. The Admission MDS assessment, completed on 2/12/25, indicated Resident 329 did not have arterial ulcers present. During an interview on 2/25/25 at 11:15 a.m., the Minimum Data Set Coordinator (MDSC) indicated she was not aware of the arterial insufficiency ulcers, and they should have been included on the Admission MDS assessment. 40287 2. The clinical record for Resident 22 was reviewed on 2/18/25 at 3:10 p.m. The diagnoses included, but were not limited to, Parkinson's disease. A Nurse Practitioner Progress Note, dated 10/23/24, indicated Resident 22 was being seen due to two broken teeth that were causing her to have issues with eating. A Significant Change Minimum Data Set assessment, completed 11/27/24, indicated she was severely cognitively impaired and had no dental issues. A care plan, last reviewed 12/2/24, indicated she was at risk for caries (cavities) or missing teeth. The goal was for her to be free from mouth pain, red or bleeding gums, and oral lesions. The approaches included, but were not limited to, dental consult as indicated, observe and document red/bleeding gums, lesions, loose teeth, and symptoms of pain, and notify physician as needed. During an interview on 2/21/25 at 11:53 a.m., the Minimum Data Set Coordinator (MDSC) indicated she would check on the dental coding of the MDS. 3. The clinical record for Resident 49 was reviewed on 2/19/25 at 11:27 a.m. The diagnoses included, but were not limited to, anxiety disorder and post-traumatic stress disorder. On 2/20/25 at 10:50 a.m., the Executive Director provided Resident 49's Notice of Preadmission Screening and Resident Review (PASAR) Level II outcome, dated July 6, 2021, which indicated Resident 49 was approved for long term care without specialized services. Based on his diagnoses, treatment history, symptoms and services needed, he had met the PASRR criteria. A Significant Change MDS assessment, dated 11/25/24, did not indicate Resident 49 had been evaluated for a PASRR Level II Assessment and was determined to have a mental illness. During an interview on 2/20/25 at 3:01 p.m., the MDSC indicated Resident 49's PASRR Level II assessment should have been captured on the MDS Assessment. The facility used the Resident Assessment Instrument Manual as the policy for completing the MDS assessment.

Based on observation, interview, and record review, the facility failed to ensure staff donned personal protective equipment (PPE) prior to a wound dressing for 1 of 1 random observation. (Resident 5) Findings included: The clinical record for Resident 5 was reviewed on 2/18/25 at 1:29 p.m. The diagnoses included, but were not limited to, Alzheimer's disease. A care plan, dated 2/3/25, indicated Resident 5 had pressure ulcer on her sacrum. A physician order, dated 2/3/25, indicated the staff was to cleanse sacrum with wound cleanser, apply collagen powder, and cover with bordered gauze once a day. An observation was made of Resident 5's room on 2/21/25 at 11:30 a.m. Licensed Practical Nurse (LPN) 21 was observed leaving the resident's room with a treatment cart. She indicated she had provided a wound treatment to Resident 5. At that time, an observation was made of the resident's room with the Director of Nursing (DON). The DON had indicated the Enhanced Barrier Precaution signage was placed on the closet doors of Resident 5's room. The trash can in the resident's room did not contain discarded PPE. An interview was conducted with LPN 21 with the DON on 2/21/25 at 2:57 p.m. LPN 21 indicated she had donned gloves only to provide the wound treatment to Resident 5. She was unaware Resident 5 was on Enhanced Barrier Precautions. An Enhanced Barrier Precautions policy was provided by the DON on 2/21/25 at 10:39 a.m. It indicated, Enhanced Barrier Precautions (EBP): An intervention designed to reduce the transmission of resistant organisms that employs targeted use of gown and glove use during high contact resident care activities .Enhanced barrier precautions are used for: Resident(s) with chronic wounds and/or indwelling medical devices, regardless of their MDRO [Multidrug-Resistant Organisms] status .Wounds generally include: Chronic wounds, not shorter-lasting wounds, such as skin breaks or skin tears covered with a adhesive bandage (e.g., Band-Aid) or similar dressing. Examples of chronic wounds include, but are not limited to, pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers .Use of Personal Protective Equipment - gown and gloves: During high-contact resident care activities .wound care: any skin opening requiring a dressing . 3.1-18(b)(2)

Based on observation, interview, and record review the facility failed to develop a person-centered care plan timely for refusal to change clothes for 1 of 9 residents reviewed for activities of daily living (ADL) care. (Resident 19) Findings include: The clinical record for Resident 19 was reviewed on 2/18/25 10:30 a.m. The diagnoses included, but were not limited to, dementia, mild intellectual disabilities, and need for assistance with personal care. A Quarterly Minimum Data Set (MDS) assessment, dated 12/10/24, indicated the resident was cognitively impaired and required supervision and setup assistance during dressing. On 2/18/25 at 12:19 p.m., Resident 19 was observed sitting in the dining room for lunch wearing a green shirt and khaki pants with suspenders On 2/19/25 at 11:05 a.m., Resident 19 was observed in his room wearing the same clothing as the day prior, a green shirt and khaki pants with suspenders. On 2/20/25 at 1:59 p.m., Resident 19 was observed in the activities room with other residents, wearing the same clothing previously worn on 2/18/25 and 2/19/25. During an interview on 2/20/25 at 2:01 p.m., Certified Nurse Aide (CNA) 7 indicated Resident 19 sometimes refused to change his clothing. The clinical record was reviewed on 2/20/25 at 2:19 p.m. and did not contain a care plan for Resident 19's refusal to change clothing. During an interview with the Director of Nursing (DON) on 2/24/25 at 3:00 p.m., she indicated a lot of times the resident refused to change his clothing because he had some favorite clothing to wear and becomes fixated on those items. On 2/25/25 at 10:04 a.m., the DON provided a Comprehensive Care Plan Policy, dated 1/2010 and revised on 8/2023, it indicated the following, .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 . 3.1-35(b)(1) 3.1-35(b)(2)

Based on interview and record review, the facility failed to ensure lidocaine patches were administered as ordered for 1 of 1 resident reviewed for pain, and to obtain weights three times weekly and inform the physician of weight changes, as ordered by the physician, for 1 of 1 resident reviewed for edema (Resident 3 and Resident 63). Findings include: 1. The clinical record for Resident 63 was reviewed on 2/18/25 at 12:29 p.m. The diagnoses for Resident 63 included, but were not limited to, pain and neuropathy. A physician order, dated 1/29/25, indicated Resident 63 was to receive lidocaine patches twice a day. The staff were to apply the patches to both feet on day and evening shift. The February 2025 Treatment Administration Record (TAR) indicated the following days and shifts the resident did not receive the lidocaine patches, due to not being available: 2/10/25 - day and evening shift, 2/12/25 - day shift, 2/13/25 - day and evening shift, 2/16/25 - evening shift, 2/17/25 - day and evening shift, 2/18/25 - day and evening shift, 2/19/25 - day shift, 2/20/25 - day shift, and 2/21/25 - day shift. A nursing progress note, dated 2/17/25, indicated pharmacy was notified regarding lidocaine patch availability. The pharmacy reported the order needed clarification by the medical provider prior to sending a supply. The resident cannot wear lidocaine patches all the time. The order needed to state a timeframe the resident will not be wearing the lidocaine patches. An interview was conducted with the Director of Nursing on 2/24/25 at 3:00 p.m. She indicated the nursing staff should have received clarification of the order sooner. 40287 2. The clinical record for Resident 3 was reviewed on 2/19/25 at 11:14 a.m. The diagnoses included, but were not limited to, congestive heart failure and diabetes. A physician's order, dated 1/29/25, indicated she was to have her weight done once a day on Monday, Wednesday, and Friday. The physician was to be notified of a weight gain of three pounds. The February 2025 Medication Administration Record (MAR) did not contain documentation that a weight had been obtained on Wednesday 2/5/25, Friday 2/7/25, and Monday 2/10/25. A weight of 184 pounds was recorded on 2/12/25 and a weight of 189.2 pounds was recorded on 2/14/25. The MAR did not include documentation of the physician being notified of the 5.2 pound weight gain. During an interview on 2/20/25 at 3:08 p.m., Unit Manager 3 indicated Resident 3 should have weights obtained and the physician should be notified of a weight gain of three pounds or more per the physician's order. On 2/20/25 at 3:40 p.m., the Executive Director provided the Resident Weight Monitoring policy, last reviewed September 2024, which indicated, .It is the policy of this facility to weigh residents no less that monthly or per physician order . 3.1-37(a)

Based on observation, interview, and record review, the facility failed to apply splints, as care-planned, for 1 of 1 resident reviewed for limited range of motion (ROM) (Resident 40). Findings include: The clinical record for Resident 40 was reviewed on 2/18/25 at 1:05 p.m. The diagnoses included, but were not limited to, Alzheimer's disease, multiple sclerosis, osteoarthritis, and chronic pain. A Quarterly Minimum Data Set (MDS) assessment, dated 1/22/25, indicated Resident 40 was cognitively impaired. A care plan, last reviewed 1/23/25, indicated Resident 40 was on the Passive Range of Motion (PROM) program, she was able to tolerate wearing left hand resting splint/brace for four hours, apply in the morning. She has a diagnosis of multiple sclerosis (MS) which contributes to her risk of contractures and need for assistance with daily care. The goal was to reduce the risk of contractures. On 2/18/25 at 3:06 p.m., Resident 40 was observed sitting in her wheelchair in the activities room, with no splint or brace in place. On 2/19/25 at 10:25 a.m., Resident 40 was observed without a splint or brace in place on her left hand while sitting in her wheelchair in the activities room. On 2/20/25 at 10:32 a.m., Resident 40 was observed sitting in her wheelchair without a splint or brace on her left hand. During an interview on 2/20/25 at 2:08 p.m. with Certified Nurse Aide (CNA) 6, she indicated she did not know why Resident 40 did not have her splint or brace on and she should wear her brace. During an observation of Resident 40's room on 2/20/25 at 2:10 p.m., CNA 6 was unable to locate Resident 40's splint or brace and indicated it may be in the laundry. During an interview with the Director of Nursing (DON) on 2/24/25 at 1:45 p.m., she indicated Resident 40 should have her splint or brace on as care planned. On 2/25/25 at 10:04 a.m., the DON provided a Comprehensive Care Plan Policy, dated 1/2010 and revised on 8/2023, it indicated the following, .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 . 3.1-42(a)(2)

Based on observation, interview, and record review, the facility failed to timely develop a person-centered behavior management care plan with individualized interventions and document approaches to care for a resident with dementia who exhibited behaviors for 1 of 1 resident reviewed for behaviors. (Resident 62) Findings include: The clinical record for Resident 62 was reviewed on 2/18/25 at 10:55 a.m. The diagnoses included, but were not limited to, dementia, depression, and cognitive communication deficit. An Admission Minimum Data Set (MDS) assessment, dated 12/11/24, indicated Resident 62 was severely cognitively impaired. A hospice Master of Social Work (MSW) Visit Note, dated 12/06/24, indicated Resident 62 was experiencing fluctuating emotions, staff reported she had been crying all morning and yelling out. MSW encouraged husband to coordinate care needs with facility to reduce stress and the facility Registered Nurse (RN) was notified. The clinical record did not contain documentation from facility staff of the noted behaviors from the MSW or interventions initiated on 12/06/24. An Acute Care Progress Note, dated 12/12/24, indicated, .Due to progression in dementia with increasing behaviors - agitation, restlessness, wandering, going into other residents' rooms, it was decided to transfer patient to the nursing memory care unit for more assistance . A physician order for scheduled lorazepam (antianxiety medication) 0.5 milligrams (mg) oral tablet every four hours was started, on 12/22/24, as well as an order for as needed lorazepam 0.5 mg oral tablet every two hours with the same start date. A hospice RN Recertification Note, dated 12/26/24, indicated the hospice MSW was to coordinate with the facility and hospice team to encourage proper supervision and assessment of behaviors. A Psychiatry Progress Note, dated 1/07/25, indicated staff had reported increased anxiety, irritability, and agitation when Resident 62's husband visited. Included in the progress note plan was to continue lorazepam 0.5 mg as ordered. Non-pharmacological interventions were not included in the plan. The clinical record for Resident 62 did not include a care plan for monitoring behavior when the resident's husband was present in the facility. On 1/17/25 at 3:56 p.m., during a care plan meeting, Resident 62's husband indicated he had concerns the resident was too drowsy at times and too anxious at other times, hospice nurse indicated a change in administration times for lorazepam might help. A physician order for as needed lorazepam 0.5 mg oral tablet every hour was placed on 1/21/25. A Psychiatry Progress Note, dated 1/28/25, indicated staff endorsed concerns for lethargy, per hospice, addition of lorazepam 0.5 mg oral tablet every hour was indicated following spouse concerns for increasing anxiety. Facility reports patient often appeared agitated or anxious when husband was visiting but otherwise calm with no behavioral concerns in his absence. A decrease in frequency of administration of as needed lorazepam 0.5 mg was ordered. A nursing progress note, dated 2/02/25 at 9:29 p.m., by Licensed Practical Nurse (LPN) 22, indicated the resident was yelling and crying while visiting with her husband. The resident took her oral medications and let staff perform activities of daily living (ADLs). There was no documentation to indicate non-pharmacological interventions were used in the clinical record. A Psychiatry Progress Note, dated 2/04/25, indicated Resident 62 was seen at the request of the facility for increasing behaviors. Staff indicated an increase in anxiety, agitation, and distressful yelling out since dose reduction. Dosage of lorazepam 0.5 mg was increased in frequency from every six hours to every five hours. The progress note plan indicated to monitor and hold for sedation. The clinical record for Resident 62 did not include an order for behavior monitoring or any daily documentation of behavior monitoring. A nursing progress note, dated 2/13/25 at 3:17 p.m., by LPN 23, indicated Resident 62 had increased agitation and anxiety during this shift. Hospice nurse was here and recommended to give as needed morphine and as needed lorazepam. LPN 23 indicated a voicemail was left to the Hospice nurse and had notified her that the resident had not changed behavior since she left. There was no documentation to indicate non-pharmacological interventions were used in the clinical record. On 2/15/25 at 8:17 p.m., Registered Nurse (RN) 26 indicated in a progress note that Resident 62 was attempting to get out of wheelchair and bed throughout shift. Resident sitting in common area with staff at that time. On 2/18/25 at 11:39 a.m., Resident 62 was observed sitting in her wheelchair grimacing and exhibiting tearfulness while alongside her husband. A Psychiatry Progress Note, dated 2/18/25, indicated the facility reported persistent and slightly worsening anxiety, tearfulness, restlessness, pacing, and distressful yelling out. The resident's order for lorazepam 0.5 mg (scheduled and as needed) was discontinued and was changed to clonazepam 0.25 mg oral half-tablet twice a day starting on 2/18/25. During an interview on 2/21/25 at 1:41 p.m., the Memory Care Support Specialist (MCSS) indicated Resident 62 gets tearful during the day, anything can set her off, it just depends. For the most part, she can be consoled or redirected. She has a fake cat we give her; she likes music, the main thing she likes is holding onto someone. During an interview on 2/21/25 at 2:04 p.m., the Director of Nursing (DON) indicated Resident 62 would become tearful all throughout the day and would try to grab onto whoever was near her to hold onto them, she really liked touch. During an interview on 2/21/25 at 2:09 p.m., Registered Nurse (RN) 25 indicated Resident 62 had moments of tearfulness throughout the day. The DON provided the resident's care plans on 2/21/25 at 2:33 p.m. A care plan for mood and behaviors related to a diagnosis of dementia was not included. A Behavior Management Policy, dated 7/1/22, revised 8/22, was provided by the DON on 2/25/25 at 10:14 a.m. The policy indicated the following, .Policy: It is the policy of [name of corporation] 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 toward preventing, relieving, and/or accommodating a resident's behavioral expressions . Procedure: 1. Care plans should 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 . 3.1-37(a)

Based on observation, interview, and record review, the facility failed to provide sufficient nursing staff with appropriate competencies or skill sets to ensure ADL (Activities of Daily Living) care was provided in accordance with the plan of care for 8 of 12 residents reviewed for ADL care (Residents B, H, J, K, M, R, S, and SS) and physician orders were effectively provided in accordance with the plan of care for 7 of 14 reviewed for medication administration and treatments (Residents' B, H, T, 40, 44, 83 and 118) Findings include: During this recertification and complaint survey, 1/3/24 to 1/10/24, two deficiencies were cited at a pattern level - F677 E and F684 E. 1. Activities of Daily Living (ADLs): Eight residents out of 12 reviewed in total were not provided ADL care related to incontinence, eating, getting residents out of bed, and nail care. Cross reference F677. 2. Quality of Care: Seven residents did not have medications administered as ordered, follow physician orders for elevation of bilateral lower extremities, and apply pressure relief boots as ordered by the physician. Cross reference F684. An anonymous interview was conducted with a Family Member. They indicated there were issues in the facility due to understaffing. The workload was unrealistic. They were in the facility on a routine basis. In the dining room, they witnessed how residents were and were not being fed. They didn't think the staff understand the needs of the patients. The facility needed oversight, supervision, and communication. Staff set trays in front of residents and they're just left there. The food wouldn't be cut up as needed, not considering the resident's needs. They saw a lot of untouched trays being returned to the kitchen. In this place, poor dispositions are often. Staff are easily irritated. They were in halls when trays were cleared from rooms, and there were trays with no evidence of staff having attempted to feed the residents, residents who have no ability to say yes or no. They'd seen staff feed residents too much and too fast. Residents couldn't finish one bite before being served another, if the resident was fed at all. Staff were constantly on their phones, when they were supposed to be feeding residents. They rarely saw staff take the consideration to microwave a plate. They tried to assist other residents with eating, but the staff didn't want them to, but it's hard for me to watch people not eat or drink. Some time ago, they were not in the facility for 3 consecutive days, and in that time frame, their family member, who was dependent on staff for changing their brief, had developed inflamed skin, bloody even. They were upset that I couldn't be gone for 3 days. There were times staff put 2 briefs on their family member. Staff refer to residents as feeds and I don't appreciate that The aides run the show. I don't think they have sensitivity training. During an interview on 1/04/24 at 11:25 a.m., Resident 85 indicated that he watched residents with dementia sit in the activity area for hours in the same position. He had smelled very strong urine smells when he has stopped to talk with them and could tell they had been incontinent and not been changed. During an interview on 1/06/23 2:30 p.m., the DON (Director of Nursing) indicated that when there are 2 CNAs on the hall and a resident needs fed and another resident who is a mechanical lift needs changed, how should that be prioritized. On 1/9/24 at 12:53 p.m., the Administrator provided a list of 22 residents who required verbal cues, as needed, with eating. During an interview on 1/10/24 at 10:27 a.m., Unit Manager 23 indicated that there were 5 residents who resided on the 200 hallway that needed a mechanical lift for transfers. Two staff members were required to assist residents when the mechanical lift was used. During an interview on 1/10/24 at 10:33 a.m., CNA (Certified Nursing Assistant) 50 indicated there were 3 residents who resided on the 100 hallway that required assistance of a mechanical lift for transfers. During an interview on 1/1024 at 10:35 a.m., LPN (Licensed Practical Nurse) 51 indicated there were 9 residents residing on the 400 hallway that required assistance of a mechanical lift for transfers. The 400 hallway was normally staffed with 2 CNAs and a split assignment for a CNA, where the aide cared for residents on both the 200 and 400 hallways, on the day and evening shifts. During an interview on 1/10/23 at 1:18 p.m., the Staffing Coordinator indicated the number of licensed nurses and certified nursing assistants scheduled to provide direct care for the residents each day was determined by the facility census. The corporation decided the staffing ratio. He was unsure what type of information they used to decide how many staff should be scheduled, other than the census. Sometimes staff had complained that there were not enough staff to care for the residents on the weekends. A Resident Rights policy was provided by the ED on 1/9/24 at 9:01 a.m. It indicated .Planning and implementing care .You have the right to be informed, and participate in, your treatment. This includes the right to .Receive the services and/or items included in the plan of care .The right to reside and receive services in the facility with reasonable accommodations of your needs and preferences except when to do so would endanger the health or safety of you or your residents . 3.1-17(a)

Based on observation, interview and record review, the facility failed to ensure staff provided care services in a manner that promoted privacy, respect, and dignity, and to provide an environment where residents were able to express grievances without fear of reprisal for 11 of 12 residents reviewed for dignity. (Residents' B, C, D, S, T, SS, 45, 69, 80, 85 and an Anonymous Resident) Findings include: 1. During a Resident Council meeting on 1/3/24 at 2:05 p.m., Resident 85 indicated that the staff treat you like s*** after they are talked to by the management staff about your complaint. The staff that were complained about comes back and treat you badly after you complain about care that was provided. Residents are scared to complain. Resident 69 and Resident 45 indicated agreement to Resident 85's comments. Resident 80 indicated some of the staff were disrespectful, especially on the weekends. The weekend staff appeared not to care what residents needed. 2. An anonymous interview was conducted with a Family Member. They indicated there were issues in the facility due to understaffing. The workload was unrealistic. They were in the facility on a routine basis. In the dining room, they witnessed how residents were and were not being fed. They didn't think the staff understand the needs of the patients. The facility needed oversight, supervision, and communication. Staff set trays in front of residents and they're just left there. The food wouldn't be cut up as needed, not considering the resident's needs. They saw a lot of untouched trays being returned to the kitchen. In this place, poor dispositions are often. Staff are easily irritated. They were in halls when trays were cleared from rooms, and there were trays with no evidence of staff having attempted to feed the residents, residents who have no ability to say yes or no. They'd seen staff feed residents too much and too fast. Residents couldn't finish one bite before being served another, if the resident was fed at all. Staff were constantly on their phones, when they were supposed to be feeding residents. They rarely saw staff take the consideration to microwave a plate. They tried to assist other residents with eating, but the staff didn't want them to, but it's hard for me to watch people not eat or drink. Some time ago, they were not in the facility for 3 consecutive days, and in that time frame, their family member, who was dependent on staff for changing their brief, had developed inflamed skin, bloody even. They were upset that I couldn't be gone for 3 days. There were times staff put 2 briefs on their family member. Staff refer to residents as feeds and I don't appreciate that The aides run the show. I don't think they have sensitivity training. 3. During an interview on 1/04/24 at 9:50 a.m., Resident T indicated that he was hesitant to say anything about how staff treated him because he was worried that the staff wound find out and treat him badly. During the interview, CNA (Certified Nursing Assistant) 21 was observed entering through the closed door without knocking. Resident T indicated that some staff would knock before entering and some would not. 4. During an interview on 1/04/24 at 2:39 p.m., Resident 69 indicated he felt disrespected, because the staff did not answer his call lights timely and provide the care he needed. 34850 5. During an Anonymous Resident Interview, they indicated some nurses bark orders and are disrespectful bullies. They had asked a nurse one time, why was she was so angry? The nurse in a hateful tone responded, I am not angry! Anonymous Resident Interview did not feel comfortable with revealing the nurse's name in fear of retaliation. 6. An interview was conducted with Resident C on 1/04/24 at 10:16 a.m. He indicated some nurses and Certified Nursing Assistants (CNA) staff are unfriendly and rude. 7. An interview was conducted with Resident D on 1/4/24 at 10:26 a.m. She indicated CNA staff are disrespectful. She turned on her call light last evening, CNA 51 came into her room turned off her call light; stated he would be back and then left the room. He never came back to assist with changing her. It happens all the time. 8. During an interview with Resident B's Representative 5 on 1/4/24 at 10:55 a.m., She indicated the nursing staff are rude and disrespectful. The evening shift nurse, License Practical Nurse (LPN) 50 always has an attitude when asking questions about the resident's care. 9. The clinical record for Resident SS was reviewed on 1/5/24 at 9:00 a.m. The diagnosis for Resident SS included, but was not limited to, fracture of left femur. The resident was admitted to the facility on [DATE]. A nutrition care plan dated 1/4/23 indicated Resident SS was to be assisted with feeding. An Activities of Daily Living (ADL)s care plan dated 1/1/24 indicated Resident SS requires assistance with eating, bed mobility, and transfers. The interventions in place for the resident's plan of care was to assist with placement of dentures, hearing aids and eating. A random observation was made of Resident SS and Resident SS's Representative on 1/5/24 at 9:05 a.m. Resident SS was observed lying in bed with a gown on with no dentures or hearing aids in. The resident's breakfast tray was sitting on a bedside table untouched. Resident SS indicated she did want to eat breakfast. Resident SS's Representative indicated she was very upset with the care that was provided in the facility. The resident was admitted to the facility a week ago, and the experience has been on going with long delays to receive care services. She had been asking for assistance with getting Resident SS up in a chair prior to meal delivery for the past 40 minutes, so she can eat her breakfast when it arrived. The physician had stated yesterday, the resident needed to be up in a chair for meals. The staff has ignored her request. She felt like she was begging staff to get her up. The meal now has arrived approximately 5 minutes ago, and the resident was still not up in a chair to eat. An observation was made of Resident SS on 1/5/24 at 9:22 a.m., Certified Nursing Aide (CNA) 7 was observed entering Resident SS's room without knocking or introducing herself. CNA 7 had a flat affect facial expression and was not communicating to anyone. She walked over to Resident SS's uneaten breakfast tray, picked it up and turned around to walk out of the room. There was no explanation on why she was removing the tray. Resident SS's roommate, Resident 21 had stated to CNA 7 as she was walking to the door, don't take her tray she has not eaten yet. CNA 7 responded in an unfriendly tone she was heating it up, and then continued to walk out of the room. At 9:25 a.m., CNA 7 returned to the resident's room with Resident SS's breakfast tray. As she was assisting the resident with her meal, Resident SS's Representative had spoken to CNA 7 about the resident needing to be up in a chair for meals and requested CNA 7 to introduce herself to Resident SS. CNA 7 with a flat affect facial expression in a harsh tone stated her name to the resident. During that time, CNA 7 had indicated to Resident SS's Representative if she was told to get Resident SS up prior to meals she would have done so at 7:00 a.m. An interview was conducted with Director of Nursing on 1/8/24 at 4:11 p.m. She indicated she had spoken to Resident SS's Representative about the incident with breakfast on 1/5/24, and it was addressed. 41129 10. A random interview with Resident 45 was conducted on 1/6/24 at 1:26 p.m. Resident 45 indicated that morning she was lying in bed while working on a crossword puzzle and had fallen asleep with her pen in her hand, when she was suddenly awakened by CNA (Certified Nursing Assistant) 33 snatching the pen out of her hand and saying, I need that pen. CNA 33 used her pen then returned it to Resident 45's bedside table. Resident 45 indicated, since she was awake at that point, she returned to working on the crossword puzzle and again had fallen asleep with the pen in her hand. While Resident 45 was asleep, CNA 33 returned to her room again and snatched the pen out of her hand and startled her awake again saying she needed to use Resident 45's pen. CNA 33 then used Resident 45's pen to date the water cup. Resident 45 indicated; she thought CNA 33's behavior was extremely rude. Resident 45's Quarterly MDS (Minimum Data Set) completed on 12/7/23 indicated, Resident 45 was cognitively intact. An interview with DON (Director of Nursing) conducted on 1/6/24 at 1:51 p.m. indicated, CNA 33 should not have taken a pen out of a resident's hand while they were sleeping and stated, it was rude. An interview was conducted with the Executive Director (ED) on 1/9/24 at 8:58 a.m. She indicated the facility provides continuous education to the staff related to customer service and resident rights training. She expects the staff to be respectful and provide good care to the residents. A Resident Rights policy was provided by the ED on 1/9/24 at 9:01 a.m. It indicated .Resident rights. You have the right to a dignified existence, self-determination, and communication with and access to the persons and services inside and outside the facility .Planning and implementing care .You have the right to be informed, and participate in, your treatment. This includes the right to .Receive the services and/or items included in the plan of care Be informed in advance, of the care to be furnished and the type of care giver or professional that will furnish care .Respect and Dignity. You have a right to be treated with respect and dignity, including .The right to reside and receive services in the facility with reasonable accommodations of your needs and preferences except when to do so would endanger the health or safety of you or your residents .Grievances. You have the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment, the behavior of staff and of other residents; and other concerns regarding your facility stay . 3.1-3(t)

Based on observation, interview and record review, the facility failed to ensure timely assistance was provided with eating, nail care, incontinent care, residents getting out of bed, and ensure residents that need assistance with incontinence was provided 1 incontinent brief at a time for 8 of 12 residents reviewed for Activities of Daily Living. (Residents' B, H, J, K, M, R, S and SS) Findings include: 1. The clinical record for Resident SS was reviewed on 1/5/24 at 9:00 a.m. The diagnosis for Resident SS included, but was not limited to, fracture of left femur. The resident was admitted to the facility on [DATE]. A nutrition care plan dated 1/4/23 indicated Resident SS was to be assisted with feeding. An Activities of Daily Living (ADL)s care plan dated 1/1/24 indicated Resident SS requires assistance with eating, bed mobility, and transfers. The interventions in place for the resident's plan of care was to assist with placement of dentures, hearing aides and eating. A random observation was made of Resident SS and Resident SS's Representative on 1/5/24 at 9:05 a.m. Resident SS was observed lying in bed with gown on with no dentures or hearing aides in. The resident's breakfast tray was sitting on a bedside table untouched. Resident SS indicated she did want to eat breakfast. Resident SS's Representative indicated she was very upset with the care that was provided in the facility. The resident was admitted to the facility a week ago, and the experience has been on going with long delays to receive care services. She had been asking for assistance with getting Resident SS up in a chair prior to meal delivery for the past 40 minutes, so she can eat her breakfast when it arrived. The physician had stated yesterday, the resident needed to be up in a chair for meals. The staff has ignored her request. She felt like she was begging staff to get her up. The meal now has arrived approximately 5 minutes ago, and the resident was still not up in a chair to eat. Resident SS's Representative was observed holding the resident's oatmeal bowl and indicated the resident's food was now getting cold. At 9:13 a.m., Qualified Medication Aide (QMA) 2 entered the resident's room. She indicated she did not know Resident SS. At that time, QMA 2 was observed asking Resident SS's Representative how does the resident take her medications. She was unaware of the route. Resident SS's Representative responded to QMA 2; the resident takes her medications crushed in applesauce. QMA 2 then left the room. An observation was made of Resident SS on 1/5/24 at 9:22 a.m., Certified Nursing Aide (CNA) 7 was observed entering Resident SS's room and removed the resident's uneaten breakfast tray. She indicated she was heating up the breakfast tray. At 9:25 a.m., CNA 7 returned to the resident's room with the breakfast tray and assisted the resident with her breakfast meal while the resident was in bed. CNA 7 had indicated to Resident SS's Representative if she was told to get Resident SS up prior to meals she would have done so at 7:00 a.m. An interview was conducted with Director of Nursing on 1/8/24 at 4:11 p.m. She indicated she had spoken to Resident SS's Representative about the incident, and it was addressed. 2. The clinical record for Resident B was reviewed on 1/4/24 at 10:00 a.m. The diagnosis for Resident B included, but was not limited to, epilepsy. The quarterly 12/3/23 Minimum Data Set (MDS) assessment indicated Resident B was severely cognitively impaired. A care plan dated 8/20/23 indicated Resident requires assistance with Activities of Daily Living (ADL)s including bed mobility, transfers, eating and toileting .Approach .Assist with toileting and/or incontinent care as needed . An interview was conducted with Resident B's Representative 5 on 1/4/24 at 10:55 a.m. She indicated during visits, the resident sits up in her chair and/or in bed for long periods of time without being changed or repositioned. She has observed at times, the resident to be soaked with urine. An observation was made of Resident B in her room with Resident B's Representatives 3 and 4 on 1/6/24 at 1:35 p.m. The resident was observed wearing a jogging suit and sitting in her broda chair by her bed. Resident B's Representative 3 indicated she had been visiting the resident since 11:30 a.m., that day. The staff had not come into the room to provide incontinent care during her visit. She had asked the staff approximately 5 minutes ago to change her due to not knowing how long it had been since she had received incontinent care. NA 8 reported to them she needed to go get some help from the resident's assigned CNA, (CNA 9) to change the resident. At that time, they were currently waiting for assistance. An observation was made of incontinent care to Resident B with Nurse Aide (NA) 8 and Certified Nursing Assistant (CNA) 9 on 1/6/24 at 2:00 p.m. The resident was observed being transferred by hoyer from the broda chair to the resident's bed by NA 8 and CNA 9. After the transfer, urine odor was present coming from the broda chair. CNA 9 indicated at that time, the cloth pad in the broda chair was wet with urine. CNA 9 then removed the resident's jogging pants, and the pants were observed to be wet with urine. After the removal of the soiled brief, a skin tear area was observed an inch in length and red in color on the left side under the resident's abdomen fold. CNA 9 at that time requested NA 8 to leave the room and report to the nurse to come and observe the skin area on the resident. CNA 9 indicated that was the first time she had observed the skin area on the resident. As of Friday, 1/5/24, the resident did not have the skin area. The last time she had provided incontinent care to Resident B was at 12:00 p.m., that day. An interview was conducted with CNA 9 on 1/6/24 at 2:20 p.m. She indicated incontinent care was to be provided to the residents every 2 hours and double briefing the residents was not allowed to be utilized. 40287 3. The clinical record for Resident R was reviewed on 1/4/23 at 2:30 p.m. The Resident's diagnosis included, but were not limited to, chronic kidney disease and heart failure. A care plan, initiated 2/12/2020, indicated Resident R needed assistance with ADL (Acts of Daily Living) care, including transfers and toilet use. The goal was for him to improve current functional status. The interventions included, but were not limited to, assist of at least one staff with toileting and/ or incontinent care as needed, initiated 2/12/2020, and to use a Hoyer lift (mechanical lift) for all transfers with assistance of two staff members. A care plan, initiated 3/2/2020, indicated that Resident R required assistance with toileting. The goal was for him to be free from adverse effects of incontinence. The interventions included, but were not limited to, assist with incontinent care and/ or toileting as needed, initiated 3/2/202, and check every 2 hours for incontinence, initiated 3/2/23. A bladder assessment, dated 12/16/22, indicated he was always incontinent of urine. He was aware of his need to void, but unable to hold his urine. A bowel assessment, dated 12/16/22, indicated he was always incontinent of bowel. He was aware of his need to defecate, but unable to delay defecation. An Annual MDS (Minimum Data Set) Assessment, completed 11/15/23, indicated he was moderately cognitively impaired, was able to make himself understood and to understand what was said to him, needed maximum assistance with toileting, and was dependent on staff for transfers from his chair to his bed. On 1/5/23 from 9:33 a.m. until 10:13 a.m., Resident R was observed laying in his bed and indicated he needed to be changed. CNA (Certified Nursing Assistant) 6 walked in to Resident R's room and turned off his call light. CNA 6 indicated Resident R had been asking a couple of times to be changed in the last 10 minutes and that she was not his CNA. During that time, CNA 7, who was Resident R's aide, walked in the Resident R's room and CNA 6 reported to her the resident had been asking to be changed for a while. CNA 7 stated Resident R was about to get up and walked out of room. Incontinent care had not been provided to Resident R and the call light remained off at that time. Resident R was observed to continue to lay in his bed. At 10:02 a.m., two CNAs walked by his room. At 10:05 a.m., CNA 6 walked by his room. At 10:13 a.m., CNA 7 went to Resident R's room with linen in her hand. CNA 7 indicated she was Resident R's assigned CNA and had been in the dining room assisting another resident to eat. CNA 7 was unaware that Resident R was in need of incontinent care. On 1/6/23 from 12:49 p.m. until 1:40 p.m., Resident R was observed sitting in his wheelchair in his room. At 12:49 p.m., Resident R had his call light on and indicated he had a bowel movement and needed changed. CNA 7 entered his room with his lunch tray and turned off his call light. CNA 7 indicated to Resident R that he would be changed after his meal and sat the lunch tray in front of him on the bedside table. At 12:52 p.m., Resident R turned on his call light. CNA 24 answered his call light and came back to the hallway. Resident R continued to sit in his wheelchair with his meal tray in front of him. At 1:06 p.m., Resident R put his call light back on and indicated that he had not been changed. At 1:13 p.m., CNA 24 was observed going into Resident R's room with the mechanical lift and linens. CNA 24 indicated that she was going to change Resident R and lay him down. CNA 24 exited the room and returned with CNA 7, and then assisted Resident R into bed for incontinence care using the mechanical lift. CNA 24 then provided incontinent care for Resident R. CNA 24 removed Resident R's sweat pants and undid 2 briefs. CNA 24 indicated that Resident R was wearing 2 incontinent briefs. CNA 24 was unsure why Resident R had 2 incontinent briefs on and that putting 2 briefs on a resident was not normal practice. The incontinent brief closest to Resident R's skin was observed to be wet and the 2nd brief was dry. Resident R had been incontinent of bowel and was cleansed. During a confidential interview, they indicated aides were using double briefs and bed pads to avoid changing residents as often. During an interview on 1/06/24 at 1:13 p.m., CNA 24 indicated that she and CNA 7 were the two CNAs assigned to the hallway for the first shift. During an interview on 1/06/23 2:30 p.m., the DON (Director of Nursing) indicated that when there are 2 CNAs on the hall and a resident needs fed and another resident who is a Hoyer lift needs changed, how should that be prioritized. During an interview on 1/08/24 at 4:11 p.m., the DON indicated there was no excuse for double briefing. 4. The clinical record for Resident S was reviewed on 1/5/23 at 9:49 a.m. The Resident's diagnosis included, but were not limited to, absence of right eye and dementia. A care plan, last reviewed 1/5/24, indicated Resident S needed assistance with ADL care including eating. The goal was for her to improve current functional status. The interventions included, but were not limited to, provide assist of one with eating and drinking as needed, initiated 7/12/21. During an interview on 1/5/23 at 9:49 a.m., Resident 45 indicated that Resident S was blind and needed help with eating because she would pour milk all over herself. The staff were not assisting her. Resident 45 and another resident would help her to eat. On 01/09/24 at 1:31 p.m., Resident S was observed sitting at a table in the main dining room with her meal in front of her. There were nursing staff present in the dining room. A male resident gave Resident S her spoon so that she could eat her fruit and salad. The male resident then unwrapped her cookie, and Resident S ate the cookie. He then took her corn bread out of the wrap and put it where she could reach it. 41129 5. On 1/6/24 at 1:37 p.m., an observation of Resident M found her lying in bed with her head all the way down and the upper trunk of her body angled/turned to the right facing the wall. Resident M's lunch which included, but not limited to, a large sausage/bratwurst and a regular plastic cup containing an orange liquid were sitting on a tray on her bedside table uncovered. The bedside table was not within reach of the resident and the meal appeared to be untouched as the silverware was still wrapped in the napkin. A nurse had walked past during the observation and was asked if someone had assisted the resident with her lunch. Within a few moments, CNA (Certified Nursing Assistant) 28 arrived, entered Resident M's room, and began to unwrap the silverware when ADM (Administrator) walked up to the resident's doorway. Unsure of how long Resident M's food had been sitting there, it was requested to obtain a thermometer from the kitchen and take the temperature of her food. ADM then went to the kitchen and came back with a thermometer and handed it to CNA 28, who then took the temperature of the sausage/bratwurst and found it to be 84.4 degrees. An interview with ADM immediately after obtaining the food temperature indicated, Resident M's food was too cold for her to eat and needed to be warmed up. The clinical record for Resident M was reviewed on 1/9/24 at 10:39 a.m. Resident M's diagnoses included, but not limited to, dementia, dysphagia (difficulty with swallowing foods or liquids), cognitive communication deficit, and anxiety disorder. Resident M's quarterly MDS (Minimum Data Set) completed on 12/19/23 indicated, she required substantial/maximal assistance for eating. Resident M's care plan dated 8/25/20 indicated, she required assistance with ADLs including, but not limited to, eating and was at risk for altered nutritional status related to her progression of dementia, increased age, depression, anxiety and difficulty self-feeding. Interventions included, but not limited to, provide the assistance of one person with eating and drinking as needed and to use of a Kennedy cup (a spill-proof drinking cup) at meals. A Feeding a Resident skills competency procedure was provided on 1/9/24 at 12:33 p.m. It indicated, Procedure Steps .2. Provide privacy and explain procedure. 3. Perform hand hygiene .6. Place resident in a comfortable position. 7. Check meal care for name and diet, confirm correct food, condiments, and utensils. 8. Set tray on over the bed table and describe food . 36942 6. The clinical record of Resident J was reviewed on 1/9/24 at 2:55 p.m. The diagnoses included, but were not limited to, frontotemporal neurocognitive disorder, Alzheimer's disease, dementia, malnutrition, and muscle weakness. An annual minimum data set (MDS) assessment, dated 11/27/23, indicated severe cognitive impairment, set up assistance and/or clean up assistance with eating, partial to moderate assistance with rolling from left to right, substantial/maximal assistance with sit to lying, and substantial/maximal assistance with lying to sitting. A nutritional status care plan, dated 7/9/21 and revised on 2/16/23, indicated the following, .at risk for altered nutritional status r/t [related to] progression of Alzheimer's dementia .feeds self slowly; she would benefit with assistance at meals however does not like staff to assist .Approach .Offer substitute if 50% or less of any meal is consumed An activities of daily living (ADLs) care plan, revised 1/9/23, indicated the following, .Resident requires assistance with ADLs including bed mobility, transfers, eating and toileting related to: Dementia .Approach .Up to Dining room for all meals .Assist of one with eating and drinking as needed An observation conducted of Resident J, on 1/8/24 at 2:00 p.m., lying in bed with her head of bed elevated and consuming lunch. She was leaning to the right and the bedside table was elevated to the level of her face. She was reaching over the bedside table to reach for the food on her tray. Only bites of her lunch were consumed at the time of observation. She was noted with long nails on 3 out of 5 digits to her left hand and all 5 digits to her right hand. Resident J indicated she didn't mind having longer nails but not that long. An observation conducted of Resident J, on 1/9/24 at 9:30 a.m., lying in bed with her breakfast tray on her bedside table. The bedside table was to the height of her face and Resident J was having difficulty trying to reach the cups on her tray. A cup that contained orange juice was consumed but no food was consumed at the time of observation. Resident J attempted to reach upwards towards her tray for the silverware but was unable to reach such so, she moved her hands back on the bed. Her fingernails remained long. An observation conducted of Resident J, on 1/9/24 at 11:36 a.m., with her breakfast tray still located on the bedside table that she was still attempting to consume. There was oatmeal in 2 cups that were not consumed along with eggs and sausage that were scattered on her tray, located off of the plate. Resident J appeared with slouched posture and the bedside table was to the level of her face. She was attempting to reach up towards the tray for the food with her hands. An observation conducted of Resident J, on 1/9/24 at 1:05 p.m., still with a slouched posture in bed with her lunch tray in front of her. She had not eaten anything but was attempting to reach with her arm to the tray. The bedside table was to the level of her face to where she needed to raise her arms to reach for the food on the tray, located on the bedside table. An observation conducted of Resident J, on 1/9/24 at 1:40 p.m., still with a slouched posture. She was reaching upwards for her meal tray on the bedside table. She retried a piece of the side salad and was eating it with her hands. Her nails remain long. An observation conducted of Resident J, on 1/10/24 at 10:05 a.m., slouched in bed with her head facing downwards on the right side of her bed. The head of the bed was elevated but the bedside table remains at the height to her face. Resident J would have to reach upwards for her food. She only consumed a few bites of her breakfast. A document titled Fingernail Care, review date of 09/2023, was provided by the Director of Nursing (DON) on 1/10/24 at 11:08 a.m. The document indicated to clean under the nails and clip fingernails straight across and file in a curve. 7. The clinical record for Resident K was reviewed on 1/9/24 at 2:30 p.m. The diagnoses included, but were not limited to, Alzheimer's disease, dementia, major depressive disorder, malnutrition, abnormal weight loss, and congestive heart failure. A quarterly MDS assessment, dated 10/26/23, noted severe cognitive impairment, set up or clean-up assistance with eating, substantial/maximal assistance with roll left and right, sit to lying, and lying to sitting. An ADL care plan, dated 10/28/21, indicated Resident K required assistance with ADLs including bed mobility, transfers, eating and toileting. The approach listed, but were not limited to, out of bed to chair with meals, assist of one with bed mobility, transfers, and eating as needed. An observation of Resident K, on 1/9/24 at 1:15 p.m., lying in bed with the head of the bed elevated but her bedside table was to the level of her face. Resident K was having to reach for food. The side salad and bowl of fruit were still covered with clear plastic. An observation conducted of Resident K, on 1/9/24 at 1:42 p.m., lying in bed with the head of the bed elevated but the bedside table was to the level of her face. The salad and bowl of fruit were still covered with clear plastic. She had eaten a couple of bites of the cornbread. 8. The clinical record for Resident H was reviewed on 1/8/24 at 2:11 p.m. The diagnoses included, but were not limited to, hemiplegia and hemiparesis, anxiety disorder, dysphagia, abnormal posture, and muscle weakness. A significant change MDS assessment, dated 11/22/23, indicated severe cognitive impairment, impairment on one side for upper extremity, impairment on both sides for lower extremity, substantial/maximal assistance with eating, dependent for roll left and right, and dependent for chair/bed to chair transfer. A diet order was noted for regular, honey thick/moderately thick liquids, pureed consistency. Special instructions were to have regular bread, magic cup at lunch and dinner, resident must be in main dining room for lunch and dinner and fed by staff. Another diet order, dated 1/9/24, indicated the following, .Regular, Thick/Moderately Thick, Pureed .Special Instructions: WITH REGULAR BREAD. Magic Cup at Lunch and Dinner An observation of Resident H, on 1/8/24 at 1:55 p.m., lying in bed with her head of bed elevated but the bedside table was to the height of her face. She had a spoon to her right hand and was attempting to scoop food onto but was unsuccessful. Resident H commented on how she can feed herself at times and other times she cannot. She had a Magic Cup on her tray, and it was not opened. An observation of Resident H, on 1/9/24 at 1:05 p.m., lying in bed, leaning to the right. The head of the bed was elevated but Resident H was slouched downwards with her head at the height of the bedside table where her lunch tray was. A Magic Cup was on the lunch tray but not opened. Another observation of Resident H, on 1/9/24 at 1:40 p.m., lying in bed with her right hand on the meal tray with nothing being eaten. The Magic Cup remained unopened. Resident H was still slouched downwards with her head at the height of the bedside table. Another observation of Resident H, on 1/9/24 at 2:07 p.m., laying in bed with her head elevated by the width of a standard pillow. There was no staff in the room and Resident still had not eaten anything off of the lunch tray. Therapy Staff 35 came into the room and asked if Resident H needed help to being raised in the bed. Resident H indicated yes. Therapy Staff 35 indicated they would like for Resident H to be up in the dining room and proceeded to explain the risk of choking to resident related to her leaning over and not sitting up straight in the bed. Therapy Staff 35 indicated it has been a hit or miss if Resident H was up for meals. The call light was pressed, and another staff member assisted Therapy Staff 35 on pulling Resident H up in her bed. Resident H indicated she felt better after being repositioned and nodded her head yes to it being easier to eat. An interview conducted with the DON, on 1/10/24 at 2:40 p.m., indicated the diet order for Resident H was an old order. A document titled Feeding a Resident, review date of 09/2023, was provided by the DON on 1/10/24 at 11:08 a.m. The document indicated the following, .6. Place resident in a comfortable position .8. Set tray on over the bed table and describe food .11. Food should be in bite sized pieces or with the spoon half full .12. Allow resident time to chew food and swallow A Resident Rights policy was provided by the ED on 1/9/24 at 9:01 a.m. It indicated .Resident rights. You have the right to a dignified existence, self-determination, and communication with and access to the persons and services inside and outside the facility .Planning and implementing care .You have the right to be informed, and participate in, your treatment. This includes the right to: .Receive the services and/or items included in the plan of care Be informed in advance, of the care to be furnished and the type of care giver or professional that will furnish care .Respect and Dignity. You have a right to be treated with respect and dignity, including: .The right to reside and receive services in the facility with reasonable accommodations of your needs and preferences except when to do so would endanger the health or safety of you or your residents . This citation relates to complaint IN00422553 and IN00420608. 3.1-38(a)(2)(A) 3.1-38(a)(2)(C) 3.1-38(a)(2)(D) 3.1-38(a)(3)(E)

Based on interview and record review, the facility failed to administer medications as ordered for 1 of 5 residents reviewed for unnecessary medications and 4 of 5 randomly reviewed residents' for medications administrations; ensure physician orders were followed regarding elevation of bilateral lower extremities (BLE) for 1 of 1 resident reviewed for pressure ulcers, and to timely update and administer a physician's order for a wound treatment and to apply podus (pressure relief) boots as ordered by a physician for 1 of 3 residents reviewed for urinary catheters.(Residents' B, H, T, 40, 44, 83 and 118,) Findings include: 1. The clinical record for Resident B was reviewed on 1/4/24 at 10:00 a.m. The diagnosis for Resident B included, but was not limited to, epilepsy. A care plan dated 8/19/23 for the resident indicated the resident was risk for injury related to seizure activity; has potential for seizure activity. The intervention included but was not limited to, the staff was to administer medications as ordered. A physician order dated 8/18/23 indicated Resident B was to receive 15 milliliters of Brivact for seizures twice a day. The December 2023 Medication Administration Record (MAR) indicated the 15 milliliters of Brivact was not administered the day or evening dosages on 12/31/23 due to the medication was not available. The January 2024 MAR indicated the 15 milliliters of Brivact was not administered on the followings days due to the medications was not available: 1/1/24 - day and evening dosages, and 1/2/24 - day and evening dosages An interview was conducted with the Director of Nursing on 1/9/24 at 12:10 p.m. She indicated Resident B had ran out of her Brivact medications. The pharmacy shipment summary for Resident B's Brivact medication was provided by the Director of Nursing on 1/9/24 at 12:17 p.m. It indicated the medication was filled and shipped on 1/2/24. The facility received the medication on 1/3/24 at 4:29 a.m. 40287 2. The clinical record for Resident T was reviewed on 1/4/23 at 9:49 a.m. The Resident's diagnosis included, but were not limited to, obstructive uropathy and diabetes. A care plan, initiated 9/19/23, indicated Resident T had an abrasion to his right lateral (outer) foot. The goal was the abrasion would heal without complications. The approaches included, but were not limited to, protective clothing, initiated 9/19/23, and to provide treatment as ordered, initiated 9/19/23. A physician's order, dated 9/26/23, indicated he was to have a podus boot to right foot, on while in bed as tolerated. A Significant Change in Status MDS (Minimum Data Set) Assessment, completed 11/17/23, indicated Resident T was able to make himself understood and to understand what was said to him. He was cognitively intact and received ointment or medication to his feet. A physician's order, dated 12/20/23, indicated to cleanse right lateral foot would with normal saline, apply Santyl (wound care ointment) and cover with a bordered gauze daily. A wound care visit report, dated 1/2/23, indicated the wound on Resident T's right lateral foot was open and had a foul odor after cleansing. The plan was to treat the right foot wound by cleansing with normal saline, to apply Santyl followed with calcium alginate (absorbent wound dressing) and cover with foam. On 1/4/23 at 9:49 a.m., Resident T was observed laying in his bed. He was not wearing a podus boot on his right foot and his right foot was touching the foot board. On 1/8/23 at 10:31 a.m., Resident T was observed laying in his bed. He did not have a podus boot on and the dressing on his right lateral foot was coming off. During an interview on 1/08/24 at 10:35 a.m., LPN (Licensed Practical Nurse) 22 indicated that she was going to change Resident T's dressing because she had noticed it was coming off. On 1/08/24 at 10:50 a.m., LPN 22 was observed changing Resident T's right foot dressing. LPN 22 indicated the current treatment order was to cleanse the wound and apply Santyl covered with a bordered gauze dressing. LPN 22 removed the old dressing, cleansed the wound with normal saline and applied Santyl to the wound. She then covered the wound with a bordered gauze dressing. She did not apply the podus boot to Resident T's right foot. LPN 22 indicated that the CNA (Certified Nursing Assistant) would apply the podus boot after she provided care. The January 2024 TAR (Treatment Administration Record) indicated Resident T had received Santyl covered with a bordered dressing on the following days: 1/1, 1/2, 1/3, 1/4, 1/5, and 1/8/23. The treatment was not initialed as having been completed on 1/6/23 and 1/7/23. On 1/08/24 at 3:05 p.m., Resident T was observed laying in bed. His left foot was touching the foot board of the bed. His right foot was laying on the mattress. A green podus boot was located on the top a bedside table by the window in the room. Resident T indicated that the nursing staff had not put the podus boot on his foot in a long time. He had not refused to have the boot put on his right foot. During an interview on 1/08/24 at 3:30 p.m., the ADON (Assistant Director of Nursing) indicated that the treatment order for Resident T's right foot should have been updated on 1/2/24 and his podus should be applied as ordered. 41129 3. The clinical record for Resident 40 was reviewed on 1/10/24 at 11:58 a.m. Resident 40's diagnoses included, but not limited to, major depressive disorder, anxiety disorder and chronic pain. A physician's order dated 2/19/22 indicated, to give Resident 40 one 5 mg(milligrams) tablet of Eliquis (an anticoagulant) by mouth twice a day. A physician's order dated 12/5/23 indicated, to give Resident 40 one Ensure Plus carton three times a day at 8 a.m., 2 p.m. and 8 p.m. Resident 40's December 2023 MAR (medication administration record) received on 1/10/24 at 12 p.m. from DON (Director of Nursing) indicated, on 12/31/23, Resident 40 did not receive his Eliquis, which was scheduled to be given between 4 p.m. and 8 p.m., nor his Ensure Plus (dietary supplement), which was scheduled to be given at 8 p.m. 4. The clinical record for resident 44 was reviewed on 1/10/24 at 1:27 p.m. Resident 44's diagnoses included, but not limited to, malignant neoplasm of bladder (bladder cancer), chronic obstructive pulmonary disease (COPD), anemia, emphysema, congestive heart failure (CHF) and hypertension. A physician's order dated 10/30/23 indicated to give Resident 44 one 20 mg tablet of atorvastatin (medication for high cholesterol) at bedtime. A physician's order dated 11/1/23 indicated to administer 400 mg of magnesium oxide by mouth twice a day to Resident 44. A physician's order dated 11/9/23 indicated to administer 5 mg of Marinol (a man-made form of cannabis used to treat loss of appetite) twice daily by mouth to Resident 44. A physician's order dated 10/31/23 indicated, to administer melatonin 3 mg at bedtime for insomnia to Resident 44. A physician's order dated 12/19/23 indicated, to administer olanzapine 2.5 mg at bedtime to Resident 44 for mood/behavior. Resident 44's December 2023 MAR received on 1/10/24 at 12 p.m. from DON indicated, on 12/31/23, Resident 44 did not receive the following medications: atorvastatin, magnesium oxide, olanzapine, or melatonin (all were to be administered between 7 p.m. and 11 p.m.); and Marinol (was to be administered between 4 p.m. and 11 p.m.). Resident 44's Controlled Substance Record for his Marinol 5 mg tablets provided by DON on 1/10/24 at 1:22 p.m. indicated, he was to receive one tablet 1 hour prior to dinner daily. The first administration on this record was noted to be 1/2/24 and the last administration was on 1/10/24. The remaining quantity after the last administration recorded was 13 tablets. DON had not provided any other Controlled Substance Records for the Marinol. A medication storage observation completed on 1/9/24 at 3:06 p.m. with ADON (Assistant Director of Nursing) indicated, Resident 44's Marinol tablets were located inside a metal, lock box in the 100/200/300/400 hallway's medication room fridge. There were 15 tablets left in the pill bottle. The count on the controlled substance record and the physical number of pill of Marinol did not match. 5. An interview with Resident 83 conducted on 1/4/24 at 11:40 a.m. indicated, he did not receive all his medications at times. He added, last weekend there was a QMA (Qualified Medication Assistant) on and she was not able to give him his insulin and was told the nurse was on a different hallway. He did not receive his insulin that night. The clinical record for Resident 83 was reviewed on 1/10/24 at 11:44 a.m. Resident 83's diagnoses included, but not limited to, right leg AKA (above knee amputation), type II diabetes, congestive heart failure (CHF), neuropathy (weakness, numbness, and pain from nerve damage), muscle spasms, pain, and insomnia. Resident 83's clinical record contained physician orders for the following medications: gabapentin 300 mg, three times a day for nerve pain (dated 8/11/22); hydrocodone-acetaminophen 5-325 mg (Norco) twice a day for pain (dated 9/21/23); Lantus Solostar 5 units at bedtime for diabetes (dated 9/7/23); melatonin 3 mg tablet at bedtime for insomnia (dated 2/25/21); metformin 500 mg tablet twice a day for type II diabetes (dated 7/25/23); methocarbamol 500 mg tablet every 12 hours for muscle spasm (dated 8/9/23); nortriptyline 50 mg at bedtime to be given with melatonin and Norco for pain (dated 3/17/22). Resident 83's December 2023 MAR received on 1/10/24 at 12 p.m. from DON indicated, he was not administered the following medications: -blood sugar check at 10 p.m. on 12/31/23 -lantus at 8 p.m. on 12/2/23 and 12/31/23 -Norco at 11 p.m. on 12/11/23; at 10 a.m. on 12/14/23; and 12/31/23 at 11 p.m. -melatonin on 12/11/23 and 12/31/23 at 11 p.m. -metformin on 12/31/23 due between 7 p.m. and 11 p.m. -methocarbamol on 12/31/23 at 8 p.m. -nortriptyline on 12/11/23 and 12/31/23 at 11 p.m. -lasix on 12/31/23 at 8 p.m. Resident 83's Controlled Substance Record for his Norco (hydrocodone) 5-325 mg tablets was received on 1/10/24 at 1:22 p.m. from DON indicated, the only administration of Norco on 12/31/23 was at 10 a.m. 6. The clinical record for Resident 118 was reviewed on 1/10/24 at 11:53 a.m. Resident 83's diagnoses included, but not limited to, type II diabetes, cirrhosis of the liver, and myocardial infarction (heart attack). The clinical record for Resident 118 contained physician medication orders for Baclofen 10 mg tablet three times a day for muscle spasms dated 12/14/23 and hydrocodone-acetaminophen 10-325 mg tablets every 6 hours for pain. Resident 118's December 2023 MAR received on 1/10/24 at 12 p.m. from DON indicated, on 12/31/23, he was not administered his Baclofen tablet at 8 p.m. nor his hydrocodone-acetaminophen 10-325 tablet at 6 p.m. yet, he received other evening/night medications. Resident 118's Controlled Substance Record for his hydrocodone-acetaminophen 10-325 mg tablets was provided by DON on 1/10/24 at 1:22 p.m. It indicated, on 12/31/23 at 6 p.m. the tablet count was decreased by one tablet but did not contain a signature. A staffing schedule for 12/31/23 provided by DON on 1/3/23 at 2:12 p.m. indicated, LPN (Licensed Practical Nurse) 26 was the nurse on duty that evening and night shift for Residents 40, 44, 83 and 118. An interview with LPN 26 was conducted on 1/10/24 at 3:19 p.m. indicated, she was typically agency staff at the facility and each facility uses different types of medication charting systems. She stated, there are some residents that may or may not take their medications. She indicated, when going back into the electronic medication charting system to sign off medications sometimes they fell -off and she could no longer see the medication in the system to chart on it. She stated, she is still trying to acclimate to their system .'it sometimes kicks the med out and I can't find where it went. When asked if she asked any other nurses to assist her, she indicated, on the weekends there was not as many managers available and lots of times there's a lot of agency staff working and they don't know the system well either. When asked if she informed the DON of issues she indicated, this issue is not something she thinks could be explained to her by talking it out on the phone, but rather by showing her. An interview with DON and ED (Executive Director) conducted on 1/10/24 at 3:27 p.m. indicated, LPN 26 had not informed either of them of her issues with using the EMAR system. A Medication Administration procedure received on 1/10/24 at 2 p.m. from DON indicated, 1. Medications administered within 60 minutes before and/or after time ordered .12. Refusal of medication document as appropriate .19. Medication administration will be recorded on the MAR/EMAR [sic, electronic medication administration record] or TAR [sic, treatment administration record]after given .33. Administration and inventory of controlled substances were documented according to facility policy . 36942 7. The clinical record for Resident H was reviewed on 1/8/24 at 2:11 p.m. The diagnoses included, but were not limited to, hemiplegia and hemiparesis (Hemiplegia is paralysis of one side of the body. Hemiparesis is weakness of one side of the body), chronic obstructive pulmonary disease, peripheral vascular disease, chronic kidney disease, anxiety disorder, dysphagia (difficulty in swallowing food or liquid), and muscle weakness. A significant change minimum data set (MDS) assessment, dated 11/22/23, indicated severe cognitive impairment, impairment on one side for upper extremity, impairment on both sides for lower extremity, dependent to roll left and right, and dependent on chair/bed to chair transfer. A care plan for skin, dated 1/4/24, indicated Resident H had a pressure area to the right buttock. A physician order, dated 12/4/19, noted to elevate both lower extremities WIB (while in bed) for pressure relief/prevention. An observation conducted of Resident H, on 1/8/24 at 10:28 a.m., lying in bed with the head of bed elevated. The bilateral lower extremities were elevated, but only to her knees to where her lower legs were in a downward position. An observation conducted of Resident H, on 1/8/24 at 1:55 p.m., with her bilateral lower extremities in the same position. An observation conducted of Resident H, on 1/9/24 at 9:28 a.m., with her lying in bed and bilateral lower extremities were not elevated or floated. An observation conducted, on 1/9/24 at 11:35 a.m., of Resident H lying in bed with bilateral lower extremities not elevated or floated. An observation conducted, on 1/9/24 at 1:05 p.m., of Resident H lying in bed with bilateral lower extremities not elevated or floated. A policy titled SKIN MANAGEMENT PROGRAM, revised 5/22, was provided by the Director of Nursing (DON), on 1/10/24 at 11:08 a.m. The policy indicated the following, .PROCEDURE FOR WOUND PREVENTION .3. Interventions to prevent wounds from developing and/or promote healing will be initiated based upon the individual's risk factors to include but not limited to the following .Redistribute pressure (such as repositioning, protecting and/or offloading heels, etc.) 3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure medications stored in the facility's medication carts were not expired and/or had current orders for their use and/or were labeled with an opened date; a medication lock box was permanently affixed for narcotics in the medication fridge; and a medication cart remained locked during medication administration for 3 of 6 medication carts and 1 of 2 medication rooms reviewed within the facility. (Facility) Findings include: A review of the facility's medication storage rooms and medication carts was conducted on [DATE]. The following was observed: 1. On the 100 hallway with LPN (Licensed Practical Nurse) 26 at 2:37 p.m., the medication cart contained an albuterol sulfate inhaler for Resident 19 with an expiration date of [DATE]. 2. a. On the Auguste's Cottage hallway with LPN 30 at 2:48 p.m., the medication cart contained a bottle of Zyprexa (an anti-psychotic medication) labeled for Resident 103. The clinical record for Resident 103 was reviewed for current physician's orders on [DATE] at 9:28 a.m. Resident 103 did not have a current order for Zyprexa. Resident 103's physician's order for Zyprexa was discontinued on [DATE]. b. An opened vial of haloperidol lactate (an anti-psychotic medication) labeled for Resident G did not have an opened date on the vial. The clinical record for Resident G was reviewed for current physician's orders on [DATE] at 9:38 a.m. Resident G did not have a current order for haloperidol lactate. Resident G's physician's order for haloperidol lactate was discontinued on [DATE]. c. An opened bottle of Ofloxacin (an antibiotic) eye solution labeled for Resident 30 did not have an opened date on the bottle. The clinical record for Resident 30 was reviewed for current physician's orders on [DATE] at 9:38 a.m. Resident 30 did not have a current order for Ofloxacin. Resident 30's physician's order for Ofloxacin was discontinued on [DATE]. c. An opened bottle of brimonidine tartrate (used to treat glaucoma or high pressure in eyes) eye drops did not have a resident label affixed nor did it contain an opened date. d. An opened bottle of dorzolamide-timolol (used to treat glaucoma or high pressure in eyes) eye drops labeled for Resident 24 did not have an opened date on the bottle. e. An opened bottle of valproic acid (an anti-convulsant) labeled for Resident 49 did not have an opened date on the bottle. 3. The [DATE]/400 hallway medication room's fridge contained a metal lock box which was not permanently affixed. 4. On the 700 hallway with UM (Unit Manager) 27 at 3:42 p.m., the medication cart contained an opened bottle of Milk of Magnesia without an opened date. 5. During a medication administration observation conducted on [DATE] at 9:44 a.m., it was observed that LPN 31 when administering a medication to Resident 45 had left her medication cart unlocked and unsupervised. Resident 45 had stopped LPN 31 in the 400 hallway to request a prn (as needed) pain medication. As the resident went back to her room, LPN 31 wheeled the medication cart down the hallway and parked it across the hallway and slightly to over from Resident 45's room. LPN 31 prepped the medication, entered Resident 45's room and administered the medication but, LPN 31 had left her medication cart unlocked when she entered the resident's room. LPN 31 had her back to the resident's doorway and was out of sight of the medication cart. While she was in the resident's room, an unknown visitor was in the hallway. An interview with LPN 31 immediately following the observation indicated, she thought she had locked the cart. A Storage and Expiration Dating of Medications, Biologicals policy received on [DATE] at 4:05 p.m. from DON (Director of Nursing) indicated, Procedure .General Storage Procedures .3.1.1 Store all drugs and biologicals in locked compartments, including the storage of Schedule II-V medications in separately locked, permanently affixed compartments permitting only authorized personnel to have access .4. Facility should ensure that medication and biologicals that: (1) have an expired date on the label; (2) have been retained longer than recommended by manufacturer or supplier guidelines; or (3) have been contaminated or deteriorated, are stored separate from other medications until destroyed or returned to the pharmacy or supplier .5. Once any medication or biological package is opened .Facility staff should record the date opened on the primary medication container (vial, bottle, inhaler) when the medication has a shortened expiration date once opened .If a multi-dose vial of an injectable medication has been opened or accessed .the vial should be dated and discarded within 28 days . 3XXX,d+[DATE](n) 3XXX,d+[DATE](o)

Based on observation, interview, and record review, the facility failed to provide adequate supervision to a resident who fell using a merry walker, resulting in a hospital emergency room visit requiring staples to the back of her head, to utilize a mechanical lift to transfer 2 residents, and to transfer a resident with a mechanical lift using 2 people, for 4 of 6 residents reviewed for accidents. (Residents L, M, N, and R) Findings include: 1. The clinical record for Resident M was reviewed on 5/2/18 at 10:00 a.m. The [DIAGNOSES REDACTED]. She was admitted to the facility on [DATE]. The 9/27/17 fall care plan indicated she was at risk for falls due to unsteady gait, dementia, forgets to use walker, does not ask for assist with transfers, one or more falls within the previous 6 months, age greater than 70, incontinence, on 2 or more high fall risk medications, and impulsive. The fall care plan did not reference Resident M's wandering. The 3/22/18 behavior care plan read, Resident intrusively wanders in and out of other resident's rooms. Resident is able to open doors when closed and does not comprehend stop signs. Resident has severe cognitive impairment d/t dementia. Interventions were to offer Resident M your hand and guide to communal areas; Walk with resident if she is unable to stop and be redirected; Give her clothes to fold; Play gospel/Motown/ R&B/soul music from the 50's and 60's. The 11/10/17 PT (Physical Therapy) - Therapist Progress & Discharge Summary read, Patient/Caregiver Training since Last Report - Staff education on how to set up pt (patient) in merry walker (walker ambulation device that surrounds patient with tubular frame and has wheels and a seat.) Summary of Skilled Services Provided since S[NAME] (start of care) - Tx (treatment) has been focused on assessing pt 's ability to use the merry walker safely and keeping pt mobile/ambulatory to prevent falls .Precautions - High fall risk, no safety awareness. The fall events indicated Resident M fell on the following dates and times: 9/27/17 at 12:20 p.m., 9/27/17 at 1:45 p.m., 11/29/17 at 5:00 a.m., 12/13/17 at 4:20 p.m., 12/14/17 at 10:08 a.m., 12/19/17 at 12:34 p.m., 1/14/18 at 8:49 a.m., 1/19/18 at 6:59 p.m., and 4/6/18 at 8:14 p.m. The 12/14/17, 12/19/17, 1/19/18, and 4/6/18 falls all occurred in her merry walker. The 1/19/18 unwitnessed fall event indicated Resident M was ambulating in the hallways prior to the fall. It read, Resident or witness statement of how fall occurred - CNA (Certified Nursing Assistant) found res (resident) in shower stall. Res intrusive wanders into rooms. Appears res entered bathroom (symbol for and) attempted to walk into shower (symbol for and) possibly tripped on lip of shower. The location of the fall was another resident's bathroom. Injuries noted were redness to right side of abdomen and across right side of lower back. The 4/6/18 unwitnessed fall event indicated Resident M was walking in her merry walker prior to the fall. The location of the fall was another resident's room. It read, Resident or witness statement of how fall occurred - Loud noise heard and upon investigation writer found resident on floor with merriwalker (sic) tipped over and legs tangled in meriwalker (sic) strap. The 4/6/18 nurses note, written by LPN #12, read, Loud noise heard by writer. Upon investigation resident found in another resident's room near door on floor. Merriwalker (sic) tipped over and resident's legs tangled in merriwalker (sic) strap. Writer helped to free resident's legs. Bleeding noted from raised area to R (right) mid (middle) head. Unable to determine length or depth of injury d/t (due to) resident's braids. ROM (range of motion) to upper and lower extremities intact. Neuros (neurological checks) initiated. MD office notified. Order to send resident to ER (emergency room ). Report called to (name of hospital.) The 4/7/18 nurses note read, res walking in merry walker all shift w/o (without) complications. Res has 5 staples on back of head The 4/6/18 hospital emergency room records read, Your [DIAGNOSES REDACTED]. The 4/19/18 Physical Therapy Therapist Discharge Summary, completed by PT #13, read, Analysis of Functional Outcome/Clinical Impression - Demo (Demonstrates) good safety in merry walker with set up assist and staff supervision to keep pt (patient) from going into rooms Patient/Caregiver Training since Last Report - Staff education on how to keep pt from going into rooms unsupervised, pt is stable and safe in merry walker hallway and clutter free. Summary of Skilled Services Provided since S[NAME] (Start of Care) - Tx (Treatment) has been focused on frequent assessment and training in using the merry walker to decrease pt's fall risk .Precautions - No safety awareness. Fall risk. An interview was conducted with PT #13 on 5/2/18 at 12:50 p.m. He indicated, so far, Resident M had been safe in her merry walker, so long as it was with staff supervision. If she's not in the chair, she can't take a break anytime. If she's in the hallway, she's fine. The problem with being in a room happens if she gets stuck, like on a fall mat or in the bathroom. She knows how to maneuver herself in it. She's fine in it, as long as she's out in the hallway and not in rooms. Staff can easily redirect her from going into rooms. She's easy to work with I knew about her 4/6/18 fall. I re-educated staff on keeping her from being in rooms unsupervised I did tell them about not leaving her unsupervised. Based on my observation of her, I noticed when she gets stuck in the merry walker, she doesn't know how to get out of it. An observation was made on 5/2/18 at 12:33 p.m. Resident M entered the doorway, just past the threshold of another resident's room. There were no staff in the area of Resident M to redirect her. Resident M turned around and left the room on her own, with no redirection from staff. An observation was made on 5/3/18 at 10:28 a.m. Resident M was walking out of another Resident's room and closed the door behind her. There were no staff with her at this time. An interview was conducted with CNA #14 on 5/2/18 at 2:25 p.m. She indicated she worked on the Memory Care Unit where Resident M resided everyday, evening shifts. I remember the fall on 4/6/18. I was in another room. When I came out of the room, the nurse told me she fell in another resident's room. I did not hear her fall. She was walking around in her merry walker in the hallway. I just saw her like 15 minutes before she fell . She wanders everywhere. It was typical for her to go in other residents' rooms. She's been doing that since she got there. She would go in with her merry walker as well. We were supposed to keep an eye on her, try to redirect her. I did have to redirect her from going in other residents' rooms. It worked sometimes. Sometimes she would get upset, and it would be hard to redirect her. I'd encourage her to go another way, offer her a snack. She likes to hold hands, so sometimes that worked. I never offered to have her fold clothes. Someone did tell me about folding clothes, but if you gave her clothes she would stuff it in her shirt or in her pants. Music didn't work as an intervention. I didn't try that. I don't know of any other time she fell in a resident's room. If it did happen, I was off that day. I never heard anything like that Sometimes the front wheel would get stuck or she'd get stuck in the belt. I'd try to twist her around, so she wouldn't be stuck. An interview was conducted with LPN #12 on 5/2/18 at 3:22 p.m. She indicated she worked at the facility since approximately July, (YEAR), and worked on the Memory Care Unit sporadically, but for a couple of months, it was every other weekend. I was working on 4/6/18, when Resident M fell . It was after dinner a little bit. She was in her merry walker and I heard a noise. I was at the nurses station. I got up and she was in a room on the floor, with her legs tangled up in the merry walker. She was a little past the doorway. It was not her room. I did not see her go into the room, and there were no other staff in the hallway at the time. Staff were on the floor, just in other rooms. It was common for her to go into other residents' rooms. I wasn't told of any interventions to prevent her from going into rooms, besides redirecting her, when we saw it. We'd say come on, let's go this way and she would. It was easy to redirect her. She'd been going into other residents' rooms since I'd worked back there. I think the first time I worked back there was in (MONTH) or November, (YEAR). I know some people back there do have clothes to fold, but I can't say her specifically. Music as an intervention, I don't remember her for that I held her hand and walked with her. You could sit and talk to her. I had heard of her falling before, but not in another resident's room. In this situation I had no idea she was going into the room, so I couldn't redirect her. I couldn't see her. An interview was conducted with the DON (Director of Nursing) on 5/3/18 at 2:50 p.m. She indicated Resident M's 4/6/18 was a concern for her. The Intrusive Wandering Guideline policy was provided by the MCF (Memory Care Facilitator) on 5/3/18 at 12:00 p.m. It read, To protect the well being of all residents, we need to identify those who engage in intrusive wandering, develop an individualized care plan that strives to prevent and to intervene with such expressions, and ensure that team members then execute that plan accordingly .Care planning .An initial care plan will be developed and then reviewed by the IDT, resident, and representative, if applicable, at least quarterly and at significant change Interventions may include, but are not limited to: .Providing 1:1 supervision if wandering becomes difficult to redirect or becomes intractable .team members will regularly observe the resident and care team members to ensure efficacy of the care plan interventions and to ensure interventions are being offered accordingly. 2. The clinical record for Resident N was reviewed on 4/30/18 at 11:15 a.m. The [DIAGNOSES REDACTED]. The 6/1/17 ADL (activities of daily living) care plan for Resident N indicated she required assistance of 2 for transfers with the stand up lift. The 2/3/18 Fall Event for Resident N indicated prior to the fall, she was sitting in her wheel chair. After the fall, she was on her knees, with her arms in the stand up sling. The resident was in pain. It read, CNA (Certified Nursing Assistant) stated that resident removed legs from lift and slid down CNA educated on proper use of stand-up lift (all straps to be utilized at all times.) The 2/3/18, 11:19 p.m. nurses note, written by LPN (Licensed Practical Nurse) #12, read, Writer walked into res (resident's) room and found resident on knees on the floor with arms still in stand up lift in the sling. CNA stated that resident had removed legs from stand up lift while in standing position. Res did not hit head. No injuries noted. Res was assisted into w/c (wheel chair) by staff of three and into bed with stand up lift. The 2/5/18, 10:52 a.m. nurses note read, IDT Interdisciplinary Team) Fall Review Witnessed fall on 2/3 (2/3/18) at approx. (approximately) 8:13 p.m. Nurse walked into res room and found resident on knees on the floor with arms still in stand up lift in the sling. CNA's stated that resident had removed legs from stand up lift while in standing position. Immediate intervention was staff x (times) 3 assisted res to bed. Nurse educated staff on proper use of stand of lift. IDT recommends placing staff back through training to ensure they can safely operate the stand up lift. An interview was conducted with LPN #12 on 5/3/18 at 2:37 p.m. She stated, I was across the hall. I went over there, because I heard the stand up lift beeping and (name of Resident N) was up in the lift with her arms up, but her knees were down, because her legs hadn't been strapped in (Name of CNA #15) was the only one in there transferring her, so it was just me and (name of CNA #15) who helped her back in her wheel chair. There should be 2 people assisting with the stand up lift transfers. (Name of Resident N) was not screaming or crying or anything, but she said help me get up. She did look a little distressed. Her legs were not strapped in at all. I talked to (name of CNA #15) about it and the proper way to transfer with a stand up lift and how there should be 2 people. 3. The clinical record for Resident R was reviewed on 5/1/18 at 10:00 a.m. The [DIAGNOSES REDACTED]. A quarterly MDS (Minimum Data Set) assessment dated [DATE], indicated Resident R's BIMS (brief interview for mental status) assessment score was a 15 out of 15. Resident R was cognitively intact. It also indicated he required extensive assistance of two staff members for transfers and tolieting. A care plan dated, 8/1/2017, for Resident R indicated, Resident needs assistance with ADLS (activities of daily living) including bed mobility, transfers, eating and toilet use related to: onset cerebellar ataxia, weakness, impaired mobility, incontinence, pain, [MEDICAL CONDITIONS] /SOB (shortness of breath), [MEDICAL CONDITIONS] .Approach Assist at least two with transfers, stand up lift to motorized w/c as needed . An interview was conducted with Resident R at 4/26/18 at 11:31 a.m. He reported during a transfer with a stand up lift on 4/20/18, Certified Nursing Assistant (CNA) 6 did not have assistance with the transfer. He stated he had trouble grabbing onto the bars due to the handles of the lift did not include the black rubber grips. He stated the stand up lifts he was transferred with in the past, did include black grip handles which make it easier to grab onto the bars of the lift. He indicated he does not have the strength to hold onto the bars without the grips. Resident R reported he did not fall, but it did cause discomfort to his left shoulder. A nurse practitioner progress note dated 4/30/18, indicated Resident R had concerns of injury to his left shoulder when using the stand up lift on 4/20/18. Resident R requesting an x-ray to his left shoulder. A chest x-ray dated 4/30/18, on Resident R's left shoulder indicated no fracture or dislocation. An internal Resident Event Investigation report dated 4/20/18, indicated, .Physician notification 4/20/18 .Brief Description of Incident/Event Res (Resident R) stated by being transferred by CNA (6) he hurt his arm L (left) shoulder because she used the incorrect lift .Witness Statement of Incident/Event (name of person) CNA 6 stated she has had Resident R all week on her assignment and used the stand up lift to transfer him. She wasn't aware of any concerns from Resident R. Resident Statement of Incident/Event. Resident stated that new aide (CNA 6) used the wrong stand up lift to transfer him to the restroom . An interview was conducted with CNA 2 and CNA 3 on 5/3/18 at 10:16 a.m. They both reported residents who use the mechanical lifts for transfers which include stand up lifts and hoyer lifts should have 2 staff members present. An interview was conducted with the Director of Nursing (DON) on 5/3/18 11:05 a.m. The incident was addressed the same day of the transfer with Resident R. She had spoken to Resident R and his concern was the type of stand up lift that was used during the transfer by CNA 6. She reported the physician was made aware and no new orders were ordered at that time. An interview was conducted with CNA 6 on 5/3/18 at 3:13 p.m. She reported she had transferred Resident R using a stand up lift on 4/20/18. CNA 6 indicated Resident R was an easy transfer and had used the same stand up lift before with no complaints. CNA 6 reported she had transferred Resident R on 4/20/18, with no other staff present. She stated there were times when she does transfer residents that use mechanical lifts by herself. A care plan policy was provided by the Administer on 5/3/18 at 2:35 p. m. It indicated, Mechanical lift .Procedure Steps: Note: Two (2) staff is required at all times when using a mechanical lift . 4. The clinical record for Resident L was reviewed on 5/1/18 at 9:40 a.m. The [DIAGNOSES REDACTED]. A Significant Change Minimum Data Set (MDS), dated [DATE], noted a Brief Interview for Mental Status (BIMS) score of 12 indicating Resident L was cognitively intact. The MDS further indicated Resident L was extensive assistance with 2 staff person for transfers. A physician order, dated 2/8/17, indicated the following, .stand up lift x2 assist with transfers A care plan for falls, revised 2/19/18, indicated the following, .Fall risk related to: dx (diagnoses) [MEDICAL CONDITIONS], Parksinson's (sic), Contracture of RUE (right upper extremity), Muscle wasting and atrophy, Anxiety, [MEDICAL CONDITION], Requires some assistance with Mobility .Approach .He is x1 assist with ADL's (activities of daily living), and x2 (times 2 staff assist) standup lift for transfers A Nurse Practitioner (NP) note, dated 3/13/18, indicated the following, .Pt (patient) reported to therapy new LT (left) shoulder pain, pt (patient) reported he slipped on stand up lift a few days ago, pt (patient) reports he did not have socks on at the time A left shoulder x-ray for Resident L, dated 3/14/18, indicated a [MEDICAL CONDITION] humerus. An incident from the Indiana State Department of Health Survey Report System, dated 3/14/18, indicated the following, .(name of Resident L) .On 3/13/18 resident reported to the NP (Nurse Practitioner) that he was having pain in his left shoulder. X-ray ordered. Resident reported that he slipped in the stand up lift, but did not fall .Type of Injury .fx (fracture) to humerus The investigative file was reviewed for the above incident. The following statement indicated the following, .When he (Resident L) returned to the facility he informed me that he would like to be layed down. I pulled his broda chair next to his bed and pulled it up to a fully seted (sic)(seated) position raped (sic)(wrapped) a gat (sic)(gait) belt around him and transford (sic) (transferred) him to he bed asked if he had any discomfort (sic) and proceeded to change him The statement was signed by Certified Nurse Aide (CNA) 18. An interview conducted with CNA 18, on 5/2/18 at 3:05 p.m., indicated the stand up lift batteries were dead on 3/12/18. He proceeded to have himself, and another staff member, utilize a gait belt to transfer Resident L from his broda chair to his bed. CNA 18 indicated he knew Resident L was a stand up lift transfer and sometimes would require the use of a Hoyer (type of mechanical lift) when he was weak from going to [MEDICAL TREATMENT]. An interview conducted with the Director of Nursing Services (DNS), on 5/4/18 at 8:24 a.m., indicated if a resident is weak, sick, or comment they do not like the mechanical lift, we should communicate it to therapy or management to determine if the mechanical lift is deemed safe or if we can use another route to transfer a resident. Physical Therapy notes, dated 1/19/18, indicated Resident L remained a maximum assistance with transfers and had the inability to maintain a standing balance. A policy titled Fall Management Program, revised 11/2017, was provided by the Administrator on 5/3/18 at 2:35 p.m. The policy indicated the following, .Procedure .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 .6. The resident specific care requirements will be communicated to the assigned caregiver utilizing resident profile or CNA assignment sheet 3.1-45(a)(2)