Every finding on record at Ben Hur Health and Rehabilitation

Based on observation and interview, the facility failed to ensure medication administration error rate was less than 5 percent (%) when 2 errors were observed out of 28 medications observed for an error rate of 7.14% (Residents 61 and 47). Findings include:1. On 4/9/26 at 8:40 a.m., observed Registered Nurse (RN) 3 administer Vitamin B12 medication orally (swallow) to Resident 47. Reviewed the physician order with RN 3 for administration of the medication. The record indicated the medication was to be administered sublingually (under the tongue).On 4/9/26 at 8:45 a.m., during an interview, RN 3 indicated Resident 47 preferred to chew the medication. She indicated she would separate medications if they were designated to be administered by an alternate route, or if they were to be administered after clinical assessment. On 4/9/26 at 8:47 a.m., Licensed Practical Nurse (LPN) 4 spoke with Resident 47 and asked the resident if she wanted to chew the medication the resident indicated she did not know. On 4/9/26 at 8:55 a.m., during an interview Resident 47 indicated she did not know she had a medication that was to be given under her tongue and she did not know how she preferred it to be administered. On 4/9/26 at 11:30 a.m., the medical record of Resident 47 was reviewed. The resident was admitted to the facility on [DATE]. Diagnoses included, but not limited to, Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks).A physician order, dated 2/13/26, indicated to administer Flonase Allergy Relief spray, suspension, one spray each nostril once a day.Manufacture guidelines, prescribing information (FLONASE (fluticasone propionate) nasal spray Initial U.S. Approval: 1994) administration of medication indicated. Using your FLONASE nasal spray: Step 1. Blow your nose to clear your nostrils. Step 2. Close 1 nostril. Tilt your head forward slightly and, keeping the bottle upright, carefully insert the nasal applicator into the other nostril.A care plan, dated 1/31/25, indicated resident chooses to self-administer medication: topical creams, nasal sprays. Intervention included but not limited to provide education to resident on proper use of medication.A quarterly Minimum Data Set Assessment (MDS) dated [DATE] indicated the resident was mildly cognitively impaired.2. On 4/9/26 9:30 a.m., during a medication administration, Resident 61 requested RN 3 administered Flonase nasal medication. Observed RN 3 administer the medication. During administration to each nostril the nurse failed to hold opposite nostril closed when administering the nasal spray.On 4/9/26 at 9:35 a.m., during an interview RN 3 indicated she did not know if she should hold the opposite nasal closed when administering nasal medication.On 4/9/26 at 11:00 a.m., reviewed the medical record of Resident 61. The resident was admitted to the facility on [DATE]. Diagnoses included, but not limited to, cerebral infarction (CVA) stroke, congestive heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs), vitamin B12 deficiency anemia (a common blood disorder where you lack enough healthy red blood cells or hemoglobin to carry adequate oxygen to your body's tissues).A physician order, dated 5/12/25, indicated administer cyanocobalamin (vitamin B-12) tablet sublingual; 1,000 micrograms (mcg) once daily.A quarterly Minimum Data Set (MDS) assessment, dated 1/13/26, indicated the resident was cognitively intact.On 4/9/26 at 1:18 p.m., the Administrator provided a document titled, Medication administration (Medication Pass Procedure), dated 9/2012, and indicated it was the policy currently being used by the facility. The policy indicated, .Procedure steps: Standards for all medications.2. The 5 rights of medication performed: Right Resident, Right Medication, Right Dose, Right Route, Right time.410 IAC (Indiana Administrative Code) 16.2-3.1-37410 IAC (Indiana Administrative Code) 16.2-3.1-37(a)410 IAC (Indiana Administrative Code) 16.2-3.1-48(c)(1)

Based on observation, interview, and record review, the facility failed to ensure food thermometers were cleaned according to policy which had the potential to effect 9 of 9 residents who received a modified meal from the kitchen. Findings included: During a random kitchen observation on 11/30/23 at 11:40 a.m., food temperatures were checked by Dietary Cook 9. Cook 9 removed a packet from the box, removed the wipe from the packet, cleaned the thermometer, and plunged it into a full container of the soft and bite pizza (modified meal for residents requiring soft and bite size food). The box she retrieved the packet from was observed to be Sureprep Skin Protectant Wipes (a liquid film-forming dressing applied to skin to form a protective barrier to reduce friction). When asked what she cleaned the thermometer with, she indicated she had just cleaned the thermometer and showed the opened wipe package that she had placed in a bowl. The packet indicated it was a Sureprep skin protectant wipe. Cook 9 indicated probe wipes (thermometer sanitizing wipes). When asked to read the packaging, she picked up the box of Sureprep skin protectant wipes and indicated it said probe wipes. When asked to re-read it, she again indicated it to be probe wipe cleaner while she pointed at the words. When informed that the wipes she used to clean the thermometer were not probe cleaning wipes, the box did not indicate they were probe cleaning wipes, and the wipes used were a medical skin treatment, Cook 9 called for the Dietary Manager (DM) and asked him if the wipes she just used were the correct wipes. The DM indicated they were probe wipe cleaners and pulled packets out of his shirt pocket to compare. The packets he pulled from his pocket were observed to be Wipes Plus probe wipes. The DM was notified that the wipes Cook 9 had were not probe wipes but were a medical skin treatment. Cook 9 indicated she could not serve the soft and bite pizza after putting the thermometer in it without being cleaned with probe wipe cleaners. She notified the DM that the container of food needed to be thrown away. In an interview on 11/30/23 at 11:47 a.m., the DM indicated that the box of skin protectant wipes had been in the kitchen since the last dietary manager was there before him, and since he started. The wipes were stored in a drawer located at the cook's station. The DM checked the drawer and only Wipes Plus probe wipe cleaners were found to be in the drawer. The DM indicated that he gave the skin protectant wipes to the Executive Director (ED) to get rid of. On 11/30/23 at 2:45 p.m., the ED provided and identified a document as a current facility policy, titled, American Senior Communities Food Temperatures with a revised date of 6/23. The policy indicated, .5. Temperatures should be taken with a sanitized and calibrated thermometer On 11/30/23 at 2:57 p.m., the ED provided and identified a document as the current product description for the skin protectant wipes that had been used to clean the thermometer in the kitchen. The description included a picture of the box that indicated, Medline; skin protectant . Sureprep protective wipe . effective protection between adhesive and skin . helps tape and film adhesion; non-irritating On 11/30/23 at 3:00 p.m., the ED provided and identified a document as current facility material safety data sheet (SDS), titled, Safety Data Sheet Sureprep Skin Protectant Wipe with a revised date of 8/10/23. The SDS indicated, .Section 4. First-Aid Measures .ingestion: if swallowed, call a physician immediately. Rinse mouth and throat thoroughly with water 3.1-21(i)(3)

Based on observation, record review, and interview, the facility failed to obtain an order for oxygen delivery to a resident upon the resident's admission to the facility until 6 days later and failed to ensure a resident received the correct oxygen flow for 1 of 1 resident reviewed for respiratory care (Resident 245). Findings include: On 11/27/23 at 2:15 p.m., during observation of Resident 245, oxygen delivered by a concentrator (a medical device that separates nitrogen from the air around you so you can breathe up to 95% pure oxygen), at 3 liters (L) continually by nasal cannula (NC) (a medical device to provide supplemental oxygen therapy to people who have lower oxygen levels). The Resident indicated he had been on 4 to 5 liters and was to have 6 liters when he was up walking. He indicated it should be at least 5 L. Resident had some shortness of breath during the observation and interview. On 11/30/23 at 8:54 a.m., Resident tested positive for COVID-19 and was placed in droplet precautions (isolation requiring personal protective equipment). The resident was pale and shaky. Oxygen was being administered by a concentrator at 6 L per NC continually. During interview on 11/30/23 at 10:01 a.m., Licensed Practical Nurse (LPN) 4 indicated the liter flow should be set at 3 to 5 L, and the resident was receiving 5 L. She indicated she checked on the resident and verified it was set at 5 liters. LPN 4 indicated Certified Nurse Aides (CNA) were to tell the nurse to adjust liter flow since the CNA did not adjust the liter flow. During an interview on 12/1/23 at 12:57 p.m., Licensed Practical Nurse (LPN) 7 indicated she would call the physician at the time of admission and obtain an order for oxygen if a resident needed it and was aware the resident was on oxygen after being admitted . LPN 7 indicated Resident 245 did not have an order for oxygen at the time of admission. LPN 7 indicated the resident currently had an order for 3 to 5 liters to keep oxygen SATs (saturation level) (a percentage of how much oxygen your blood is carrying compared to the maximum it is capable of carrying), above 90%. On 12/1/23 at 1:15 p.m., a medical record review indicated Resident 245 had diagnoses of Atherosclerotic heart disease of native coronary artery (refers to heart weakening caused by reduced blood flow to your heart) without angina pectoris (chest pain), essential (primary) hypertension (high blood pressure), COPD (chronic obstructive pulmonary disease) (a group of diseases that cause airflow blockage and breathing-related problems), pneumonia (respiratory infection which affects the lungs), and respiratory failure with hypoxia (low levels of oxygen in your body tissues). Hospital discharge, dated 11/21/23, indicated an order of O2 (oxygen): at rest: 5L with activity: 6L with Oxymizer (an oxygen-conserving device that is designed to function optimally at lower flow rates, typically up to about 6 liters per minute). It was advised to continue use at ECF (extended care facility). Resident 245 had acute hypoxic respiratory failure secondary to left upper lobe pneumonia and sepsis and the treatment plan was to continue antibiotics, steroids, and the O2 order above. Oxygen order, dated 11/27/23 at 6:59 p.m., indicated Oxygen at 3 to 5 L per nasal cannula to keep O2 sats above 90%, every shift for diagnosis of chronic obstructive pulmonary disease. Staff were to monitor Oxygen sats every shift, dated 11/27/2023. A care plan, dated 11/28/23, indicated resident has a potential for impaired gas exchange related to COPD. Intervention dated, 11/28/23, administer oxygen as ordered, 3 to 5 Liters per nasal cannula. The medication administration record indicated an order for Oxygen at 3 to 5 L per nasal cannula to keep O2 sats above 90%. The record indicated the order was administered beginning 11/28/23. Nurse progress note dated, 11/21/23 at 5:02 pm indicated, Resident receives O2 at 5L at rest. Nurse progress note dated, 11/22/23 at 4:32 p.m., indicated Respiratory Assessment: Uses oxygen (device/LPM) 5L/NC, Bi-pap/C-pap, SOB on exertion. On 11/30/23the Executive Director (ED) provided an undated document, titled, Oxygen Therapy and Devices and indicated it was the policy currently being used by the facility. The policy indicated, .Purpose, Oxygen is a basic human need. Without it, we would not survive. The air that we breathe contains approximately 21% oxygen. For most people with healthy lungs, this is sufficient, but for some people with certain health conditions whose lung function is impaired, the amount of oxygen that is obtained through normal breathing is not enough. Therefore, they require supplemental amounts to maintain normal body function .Indications for oxygen use 1. Obstructive pulmonary disease, 2. Shortness of breath .Definition of Oxygen .1. Oxygen is a drug which must be ordered by the physician .Initiation of Oxygen .1. Verify physician order .7. Apply device to patient with appropriate liter flow ., 3.1-47(a)(6)

Based on interview and record review, the facility failed to ensure a resident was invited to their care plan meeting (Resident 60) and care plans were developed (Residents 2, 52, and 14) for 4 of 21 residents reviewed for care planning. Findings include: 1. During an interview, on 8/25/22 at 2:19 p.m., Resident 60 indicated she had not been invited to or attended a care plan meeting. Resident 60's record was reviewed on 8/31/22 at 2:25 p.m. A quarterly Minimum Data Set (MDS) assessment, dated 7/16/22, indicated the resident was cognitively intact. Census information indicated the resident was admitted to the facility on [DATE]. A care plan summary observation, dated 8/18/21, indicated a care plan meeting was held with the Dementia Care Director and Social Services Director (SSD) in attendance. The resident's representative had not responded to the care plan meeting invitation. The summary lacked documentation the resident was invited or declined attending the meeting. A progress note, dated 11/11/21, indicated a care plan was scheduled for the following day by phone. The note lacked documentation of who the care plan was scheduled with. The electronic record lacked documentation the care plan meeting was held the following day. A care plan summary observation, dated 4/20/22, indicated a care plan meeting was held with the Dementia Care Director and SSD in attendance. The summary lacked documentation the resident or resident's representative were invited or declined attending the meeting. An undated care plan invitation post card indicated the resident's representative was mailed an invitation to a care plan on 4/27/22. The electronic record lacked documentation of a response to this invitation, or a care plan meeting was held on this date. An undated care plan invitation post card indicated the resident's representative was mailed an invitation to a care plan on 7/7/22. The electronic record lacked documentation of a response to this invitation, or a care plan meeting was held on this date. During an interview, on 9/1/22 at 9:36 a.m., the Executive Director (ED) indicated if residents were alert enough to attend a care plan meeting and had an interest in attending, they would have been invited. She was unsure if Resident 60 attended her care plan meetings. The invitations and responses should have been documented in the progress notes. Care plan meetings were documented with the care plan summary observations. During an interview, on 9/1/22 at 10:15 a.m., the ED indicated she was unable to find any additional documentation regarding Resident 60's care plan meetings. 2. Resident 2's record was reviewed on 8/29/22 at 2:35 p.m. An admission Minimum Data Set (MDS) assessment, dated 5/4/22, indicated the resident had a severe cognitive impairment and had not demonstrated behaviors during the assessment period. Census information indicated the resident was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A progress note, dated 5/1/22, indicated the resident repeatedly hit the wall and table and screamed for help. When staff attempted to provide assistance, the resident stated he either wanted to go back to bed or back in his wheelchair. A progress note, dated 5/3/22, indicated the resident was confused, and banged on the wall while yelling for help. A progress note, dated 5/24/22, indicated while a certified nursing assistant (CNA) provided care to the resident and the resident used his urinal, the resident told the CNA he wanted to kiss her breast. The resident was reminded this was inappropriate, and the resident responded he just had to say it. An interdisciplinary team (IDT) note, dated 5/24/22, indicated the resident's behavior was reviewed with a root cause of impaired vision and low cognitive level caused resident to mistake caregivers for his wife at times. Staff was to introduce themselves by name and title before providing care. A new or worsening behavior event, dated 5/24/22, indicated the resident made inappropriate comments to staff. A progress note, dated 6/12/22, indicated the resident was in the dining room at dinner time and stated he was in jail. The resident was going around to other residents telling them the facility did nothing but trapped them there. Resident continuously stated he had to go to the bathroom, and repeatedly attempted to open the cabinets and oven. Progress notes, dated 6/14/22, indicated the resident was in the dining room talking with other residents, became loud, asking other residents why he was here, and stated he did not do anything. The resident asked other residents to push him around in his wheelchair and take him to the curb so he could drive or call a cab to go home. During this time, the resident took another resident's hand, made contact with her, and told her she was a good person. A new or worsening behavior event, dated 6/14/22, indicated the resident told other residents he was being kept in jail. A progress note, dated 6/24/22, indicated the CNA assisted the resident to bed from the restroom. Upon his return to bed, the resident slapped the CNA multiple times. A new or worsening behavior event, dated 6/24/22, indicated the resident had a physical altercation with staff. A progress note, dated 6/25/22, indicated the resident was combative with staff during care, dumped supper tray onto the floor, and blamed staff for the tray falling. A progress note, dated 6/26/22, indicated the resident was combative at times with care and was difficult to redirect. A progress note, dated 6/29/22, indicated the resident yelled out wanting to know why he was being held here, staff was stupid, and wanted to call the police. A new or worsening behavior event, dated 6/29/22, indicated the resident yelled at staff and called them stupid. He requested to go to the bathroom without remembering he had just gone and argued with his roommate that he was able to get up on his own. A physician communication event, dated 6/29/22, indicated the resident was more argumentative with staff, thought he was in jail, and called staff stupid. A progress note, dated 6/30/22, indicated the resident became agitated and verbally aggressive towards staff when offered the urinal. A new order event, dated 7/1/22, indicated a psychiatric evaluation was to be completed. A progress note, dated 7/3/22, indicated the resident presented with extreme agitation and anxiety, yelled at staff and other residents, and attempted to coerce other residents to assist with his needs as well as those of other residents. A new order event, dated 7/12/22, indicated [MEDICATION(S)] (an antidepressant) 25 milligrams (mg) by mouth daily at bedtime. A hot charting event, dated 7/20/22, indicated the resident was monitored for psychosocial distress due to resident to resident contact. A new or worsening behavior event, dated 7/30/22, indicated the resident had a new behavior. A progress note, dated 8/2/22, indicated the resident exposed his penis, and yelled out that he wanted to go home and asked why the staff was keeping him here. When campus peers approached him, he attempted to kiss their hands, puckered his lips, and blew kisses in the air at campus peers. A new or worsening behavior event, dated 8/2/22, indicated the resident attempted to kiss other residents' hands and yelled out about why he was being kept in the facility. A progress note, dated 8/3/22, indicated the resident was in the dining room, attempted to pull down pants in front of other residents. The resident was assisted to the bathroom but did not void. He was returned to the dining room and attempted to take off all of his clothes twice. Resident yelled out he could not be kept there. The physician was notified, and [MEDICATION(S)] was ordered for inappropriate sexual behaviors. A new order event, dated 8/3/22, indicated resident was to be sent to an inpatient psychiatric unit for evaluation and treatment. A new order event, dated 8/3/22, indicated [MEDICATION(S)] sprinkles (a mood stabilizer) 250 mg by mouth twice daily for inappropriate sexual behaviors. A care plan, dated 8/4/22, indicated the resident had a behavioral expression of indecent exposure in the common area. A progress note, dated 8/5/22, indicated the resident's wife was updated regarding inpatient psychiatric referrals. The resident's wife wanted to consider hospice (specialized care for the terminally ill) services for the resident. She talked to the physician who said if the resident was denied to inpatient psychiatric facilities, a hospice referral would be made. A new order event, dated 8/8/22, indicated hospice to evaluate and treat. A care, initiated 8/9/22, indicated the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, initiated 8/9/22, indicated per the resident's wife, the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had a contributing diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A new order event, dated 8/10/22, indicated the resident was admitted to hospice services, and included, but was not limited to orders for [MEDICATION(S)] increased to 50 mg by mouth daily at bedtime, and [MEDICATION(S)] (an antianxiety) 0.5 mg by mouth every 4 hours as needed (PRN) for 14 days, continue psychiatric services as ordered. A care plan, initiated 8/15/22, indicated the resident was at risk for anxiety. The care plan lacked documentation of any specific behaviors the resident exhibited. A new order event, dated 8/17/22, indicated give [MEDICATION(S)] 0.5 mg, 1 tablet, by mouth at bedtime for anxiety. A new order event, dated 8/23/22, indicated start [MEDICATION(S)] (an antidepressant) 5 mg by mouth daily for 7 days, then increased to 10 mg by mouth daily. A care plan, initiated 8/26/22, indicated the resident was at risk for adverse side effects related to use of [CONDITION(S)] medication, antidepressant and antianxiety. The electronic records lacked documentation a care plan was developed for [CONDITION(S)] medication usage prior to 8/26/22. Two printed care plans were provided by the Executive Director (ED) on 8/31/22 at 10:49 a.m. The care plans indicated the resident had expressed delusions of alcohol be consumed by visitors and believed campus peers were responsible for his chair rolling into objects with a problem start date of 6/26/22, and the resident was at risk for verbal sexual remarks towards staff during care with a problem start date of 5/25/22. Both care plans indicated they were last reviewed and revised on 8/31/22. At the same time, the ED reviewed the resident's care plans from the record review and indicated those care plans were not included. There should have been behavior care plans put in place when new and worsening behaviors were noted. During an interview, on 8/31/22 at 11:00 a.m., the ED indicated upon further review, the care plans for behavior monitoring provided on paper were initiated yesterday and should have been initiated on the dates indicated in the care plans. Care plans should have been developed for behaviors. 3. Resident 52's record was reviewed on 8/26/22 at 2:14 p.m. A quarterly Minimum Data Set (MDS) assessment, dated 7/1/22, indicated the resident was cognitively intact and reported occasional mild pain. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Current care plans lacked a care plan for migraines. During an interview, on 8/29/22 at 1:25 p.m., the Director of Nursing (DNS) indicated there should have been a care plan in place for migraines. 4. Resident 14's record was reviewed on 8/26/22 at 2:17 p.m. An active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly Minimum Data Set (MDS) assessment, dated 5/20/22, indicated the resident was cognitively intact, did not have any behavioral disturbances during the assessment period, and had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident 14's care plans lacked documentation a dementia care plan had been created for the resident. During an interview, on 8/29/22 at 10:57 a.m., the Social Services Director (SSD) indicated Resident 14 should have a dementia care plan, since the resident had a dementia diagnosis. On 08/29/22 at 11:35 a.m., the Executive Director indicated, Resident 14 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . At the same time, the ED provided and identified a document as a current facility policy titled, IDT Comprehensive Care Plan Policy, dated 10/2019. The policy indicated, .Policy: It is the policy of this facility that each resident will have a comprehensive person-centered care plan developed based on comprehensive assessment. The care plan will 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 needs .Procedure: .Resident, resident's representative, or others as designated by resident will be invited to care plan review .The care plan review may be conducted face to face, via phone conference, video conference, or through written communication per resident and/or representative preference .Care plan problems, goals, and interventions will be updated based on changes in resident assessment/condition, resident preferences or family input 3.1-35(b)(1) 3.1-35(d)(2)(B)

Based on interview, record review, and observation, the facility failed to ensure the temperature and palatability of food served for 7 of 7 residents reviewed for concerns with food temperatures, and for 1 of 1 test tray reviewed for temperature and palatability. Findings include: During an interview, on 8/26/22 at 10:42 a.m , Resident 26 indicated the food was nothing to write home about. I eat breakfast in my room and the food is cold, especially the scrambled eggs and oatmeal. During an interview, on 8/25/22 at 11:49 a.m., Resident 14 indicated he ate meals in his room and the food was cold. During an interview, on 8/26/22 at 10:26 a.m., Resident 69 indicated that sometimes food was not hot enough. The resident ate in the dining room. During an interview, on 08/25/22 11:30 a.m., Resident 4 indicated that hot food was cold during all three meals. During an interview, on 8/25/22 at 2:37 p.m., Resident 52 indicated that food was not always hot. During an interview, on 8/26/22 at10:12 a.m., Resident 58 indicated he ate in his room. Food often was cold, especially the meat. During an interview, on 8/25/22 at 2:48 p.m., Resident 73 indicated she ate meals in her room and the food was cold. During lunch on 8/30/22 at 11:37 a.m., Dietary Manager obtained the following food temperatures: Tuna Noodle Casserole - 153 degrees Fahrenheit (F) Pureed Tuna Noodle Casserole - 160 F Vegetable Salad - 36 F Green Beans - 170 F Fruit - 36 F Pureed fruit - 30 F Milk - 36 F On 8/30/22 at 12:41 p.m. the test tray food temperatures were: Tuna Noodle Casserole - 111 F Vegetable Salad - 52 F During an interview on 8/30/22 at 12:45 p.m., the Dietary manager indicated that the Tuna Noodle Casserole should be 150 F and vegetable salad should be below 41 F. On 8/30/22 at 12:41 p.m., the Executive Director (ED) provided and identified a document as a current facility policy titled, Food Temperatures, dated 06/21. The policy indicated that .Hot foods will leave the kitchen at or above 135 and cold foods at or below 41 3.1-21(a)(2)

Based on interview and record review, the facility failed to ensure a resident was provided a quarterly statement for their personal funds account for 1 of 1 residents reviewed for personal funds (Resident 60). Findings include: During an interview, on 8/25/22 at 2:17 p.m., Resident 60 indicated she had not received a quarterly statement for her personal funds account. She had asked for one. Resident 60's record was reviewed on 8/31/22 at 2:25 p.m. A quarterly Minimum Data Set (MDS) assessment, dated 7/16/22, indicated the resident was cognitively intact. Census information indicated the resident was admitted to the facility on [DATE] and resided on the Cottage (memory care unit). A care plan, initiated 4/18/22, indicated the resident's cognitive level was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . The reason for placement was the resident's dementia allowed for testing well on assessments but presented with safety needs that required a secure setting. A letter, dated 7/13/22, indicated the resident's responsible party was mailed two copies of the account ledger sheet and requested a signed copy be returned. The letter lacked documentation the signed copy was returned to the facility. The electronic record lacked documentation the resident was provided a quarterly statement for her personal funds account. During an interview, on 9/1/22 at 10:40 a.m., the Executive Director (ED) indicated if a resident resided on the Cottage, they were not provided with their personal funds account quarterly statement. It was mailed to their resident representative instead. If a resident requested a statement, they would have provided it. During an interview, on 9/1/22 at 11:51 a.m., Resident 60 indicated she wanted to receive her personal funds account statement quarterly. If the statement was sent to her family, it was most likely sent to her son. Her son would not have paid much attention to what the facility sent him or communicated those things with her very much. She had not been offered a statement. On 9/1/22 at 1:14 p.m., the ED provided a document titled, QUARTERLY STATEMENTS, and indicated it was the policy currently being used by the facility. The policy indicated, .POLICY: Federal regulations require that each quarter the Resident or his/her Responsible Party be provided with quarterly accounting of the Resident Trust Account .PROCEDURE: .For residents in the facility who can handle their own finances, give two copies of the quarterly statement to the Social Services Director. The Social Services Director will get both statements signed by the resident leaving one copy with the resident and returning the other signed copy to the Business Office .For residents who are unable to manage their own finances, send two copies of the quarterly statement along with a letter on letterhead to the responsible party 3.1-6(g)

Based on record review and interview, the facility failed to ensure pain assessments were completed for residents who were administered pain medication for 2 of 5 residents reviewed for unnecessary medication (Residents 64 and 52). Findings include: 1. Resident 64's record was reviewed on 8/29/22 at 11:47 a.m. The record indicated the resident had been admitted to the facility on [DATE]. The profile indicated the resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An annual Minimum Data Set (MDS) assessment, dated 1/3/22, indicated the resident had no cognitive deficit and reported occasional mild pain. A quarterly MDS assessment, dated 6/23/22, indicated the resident had cognitive deficit, reported frequent mild pain, and received an opiod (substances that act on opiod receptors to produce [MEDICATION(S)]-like effects) pain medications. A care plan, dated 4/23/21, indicated the resident was at risk for pain related to diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included, but were not limited to, administer medications as ordered. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the July 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The record lacked documentation of assessment of the location and the severity of the pain. Review of the August 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Both administrations lacked documentation of assessment of the location and the severity of the pain. 2. Resident 52's record was reviewed on 8/26/22 at 2:14 p.m. A quarterly Minimum Data Set (MDS) assessment, dated 7/1/22, indicated the resident was cognitively intact and reported occasional mild pain. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The administration lacked documentation of the resident's pain. A MAR, dated August 2022, indicated the resident received Excedrin-Migraine 250-250-65 mg by mouth 4 times during the month. The administrations lacked documentation of a severity of the resident's pain. During an interview, on 8/29/22 at 1:25 p.m., the Director of Nursing Services (DNS) indicated when a PRN pain medication was administered they should have documented non-pharmacological interventions attempted, pain scale for severity, location of pain, and the effectiveness of the administration about an hour after administration. During an interview, on 8/29/22 at 1:40 p.m., the DNS indicated the pain severity should have been documented in the progress notes because the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/29/22 at 1:39 p.m., the DNS provided a document titled, Pain Management, and indicated it was the policy currently being used by the facility. The policy indicated, .POLICY: It is the policy .to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well being, including pain management. Procedure: 1. Residents are assessed for pain .during medication administration as outlined below. 2. The following will be used when assessing pain .IDT Pain Interview or PAINAD (Pain Assessment in Advanced Dementia Scale). Ongoing nursing assessments can also be documented in matrix progress notes or matrix vitals. 3. Interviewable Resident-Pain medications will be prescribed and given based upon the intensity of the pain as follows using the verbal descriptive, numerical scale (1-10) or Wong-Baker FACES Scale .4. Non-Interviewable Resident-Pain medications will be prescribed and given based upon nursing assessment of the following: NON-VERBAL SOUNDS .VOCAL COMPLAINTS OF PAIN .FACIAL EXPRESSIONS .PROTECTIVE BODY MOVEMENTS OR POSTURES .Wong-Baker FACES Scale 3.1-48(a)(3)

Based on record review and interview, the facility failed to ensure residents were re-evaluated for the need of a Preadmission Screening and Resident Review (PASRR) (a screening to ensure nursing home placement is appropriate) Level II (an assessment that ensures residents with mental illness and intellectual disabilities receive the services they need) assessments with changes in diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Resident 38's record was reviewed on 8/26/22 at 2:06 p.m. A significant change Minimum Data Set (MDS) assessment, dated 9/10/21, indicated the resident was not considered by the state Preadmission Screening and Resident Review (PASRR) (a screening to ensure nursing home placement is appropriate) process to have a serious mental illness and had a severe cognitive impairment. Census information indicated the resident was admitted to the facility on [DATE]. A Level I PASRR, dated 3/26/19, indicated no Level II (an assessment that ensures residents with mental illness and intellectual disabilities receive the services they need) assessment was required related to no serious mental illness diagnosed . A diagnosis, dated 8/16/21, indicated [CONDITION(S)] (a mental disorder characterized by a disconnection from reality) with delusions (fixed, false beliefs) due to known physiological condition. The electronic record lacked documentation the resident was referred for a Level II PASRR after the addition of the diagnosis. During an interview, on 8/31/22 at 11:24 a.m., the Executive Director (ED) indicated she reviewed the resident's PASRR, and it was not re-submitted for a Level II when the [CONDITION(S)] diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/31/22 at 11:24 a.m., the ED provided a document titled, PAS Paperwork, and indicated it was the policy currently being used by the facility. The policy indicated, .Pre-Admission Screening (PAS) is a requirement for Nursing Facilities in the State of Indiana .PAS paperwork is used to .2. Assure persons with major mental illness continue recommended treatment in the nursing facility .Maintaining PreAdmission Forms after Admission: Level I Screen. The nursing facility is responsible for submitting a Level I screen for any resident who: .Requires an updated Level I screen because of a change in medication, diagnoses, etc 3.1-16(d)(1)

Based on record review and interview, the facility failed to address pharmacy recommendations in a timely manner for 2 of 5 residents reviewed for unnecessary medications (Resident 64 and 14). Findings include: 1. Resident 64's record was reviewed on 8/29/22 at 11:47 a.m. The profile indicated the resident's diagnoses included, but were not limited to [CONDITION(S)] ([CONDITION(S)]-a group of lung diseases that block airflow and make it difficult to breathe), constipation, and chronic pain. An annual Minimum Data Set (MDS) assessment, dated 1/3/22, indicated the resident had no cognitive deficit and reported occasional mild pain. A quarterly MDS assessment, dated 6/23/22, indicated the resident had cognitive deficit, reported frequent mild pain and received an opiod (substances that act on opiod receptors to produce [MEDICATION(S)]-like effects) pain medications. A care plan, dated 4/23/21, indicated the resident was at risk for pain related to diagnoses which included, but were not limited to [CONDITION(S)], and constipation. Interventions included, but were not limited to, administer medications as ordered. A pharmacy recommendation, dated 9/16/21, indicated to consider discontinuing (DC) the following as needed (PRN) medications which had not been used for 60 days: Tylenol (acetaminophen) suppository (rectally inserted medication used to treat mild to moderate pain and fever), [MEDICATION(S)] suppository (rectally inserted medication used to relieve constipation), and duonebs (aerosol medication used to treat and prevent symptoms (wheezing and shortness of breath) caused by ongoing lung disease). A pharmacy recommendation, dated 11/15/21, indicated to consider discontinuing the following PRN medications which had not been used for 60 days: Tylenol (acetaminophen) suppository, [MEDICATION(S)] suppository, and duonebs. Review of a discontinued medication order, indicated acetaminophen suppository 650 milligrams (mg) give rectally for fever, every 4 hours, PRN, had not been discontinued until 1/13/22. Review of a discontinued medication order, indicated [MEDICATION(S)] suppository 10 mg give 1 suppository rectally, one time daily, PRN for constipation, had not been discontinued until 1/13/22. Review of a discontinued medication order, indicated [MEDICATION(S)] (a medication that opens the airways)-[MEDICATION(S)] (a medication that decreases inflammation in the lungs) solution (duonebs), for nebulization (a drug delivery device used to administer medication in the form of a mist inhaled into the lungs) 0.5 mg-3 mg, give one vial every 6 hours PRN for wheezing/shortness of breath (SOB) had not been discontinued until 1/5/22. During an interview, on 8/29/22 at 2:20 p.m., the Executive Director (ED) indicated the previous Director of Nursing (DON) had left the position in the fall of 2021. The Assistant Director of Nursing (ADON) was promoted into the DON position shortly after. The concerns with the timeliness of the pharmacy recommendations was not discovered until December. 2. Resident 14's record was reviewed on 8/26/22 at 2:17 p.m. Diagnoses included, but were not limited to heart failure, nonvalvular [CONDITION(S)] (irregular heartbeat rhythm) (AFib), end stage renal disease (kidney failure), and unspecified dementia without behavioral disturbance (mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems). A quarterly Minimum Data Set (MDS) assessment, dated 5/20/22, indicated the resident was cognitively intact, received an anticoagulant (blood thinner) medication, and received [CONDITION(S)] (procedure to remove waste products and excess fluid from the blood when the kidneys stopped working properly). A care plan, initiated on 10/23/19, indicated the resident was at risk for abnormal/excessive bleeding due to use of an anticoagulant medication. Interventions on the care plan included, but were not limited to, administer medication as ordered and to observe for adverse effects of medication, such as blurred vision, nausea, decreased appetite, headache, joint pain, and shortness of breath. A pharmacy recommendation, dated 9/16/21, indicated Resident 14 received [MEDICATION(S)] ([MEDICATION(S)]) (medication used to prevent serious blood clots from forming due to an irregular heartbeat) 2.5 milligrams (mg) twice daily for the prevention of systemic emboli (blood clot) due to AFib and to please to increase the dose of [MEDICATION(S)] to 5 mg twice daily. The drug manufacturer recommended dose when used in AFib in a [CONDITION(S)] patient is 5 mg twice daily. The Director of Nursing Services (DNS) signed and documented on the recommendation the doctor's office was called on 12/30/21 at 2:45 p.m. and a new order was received on 1/7/22 to increase the [MEDICATION(S)] to 5 mg twice daily. A pharmacy recommendation, dated 11/15/21, indicated Resident 14 received [MEDICATION(S)] ([MEDICATION(S)]) (medication used to prevent serious blood clots from forming due to an irregular heartbeat) 2.5 milligrams (mg) twice daily for the prevention of systemic emboli (blood clot) due to AFib and to please to increase the dose of [MEDICATION(S)] to 5 mg twice daily. The drug manufacturer recommended dose when used in AFib in a [CONDITION(S)] patient is 5 mg twice daily. The physician and the DNS agreed with the recommendation and signed the recommendation on 1/3/22. A current August 2022 physician's orders indicated Resident 14 received [MEDICATION(S)] 5 milligram (mg) tablet twice a day for the diagnosis of [CONDITION(S)] AFib (episodes of AFib that occurred occasionally and usually stopped spontaneously) with a start date of 4/16/22. During an interview, on 8/29/22 at 9:33 a.m., the Executive Director (ED) indicated the previous DNS had left the facility in the fall of 2021 and the Assistant Director of Nursing (ADNS) had taken over the DNS position and started reviewing the pharmacy recommendations in December 2021. The facility and doctor should have addressed and signed the pharmacy recommendations within 30 days of receiving the recommendations. On 8/29/22 at 9:35 a.m., the ED provided and identified a document as a current facility policy, titled Medication Regimen Reviews and Pharmacy Recommendations, dated 10/2018, which indicated, .Purpose: It is the policy of ASC that the facility maintains the resident's highest practicable level of physical, mental, and psychosocial well-being and prevents or minimizes adverse consequences related to medication therapy to the extent possible by providing oversight by a licensed Pharmacist, Attending Physician, Medical Director, and Director of Nursing .The Consultant Pharmacist recommendations will be reviewed by the Director of Nursing and the Attending Physician will be notified promptly of any recommendations needing immediate attention .Pharmacy recommendations should be reviewed with follow up by the physician within 30 days of the facility receiving .Once reviewed by the Physician the pharmacy recommendations will be filed in the resident's medical record 3.1-25(j)

A. Based on observation, interview, and record review, the facility failed to ensure a resident was transported appropriately by staff resulting in harm when a resident obtained a spiral fracture of the lateral malleolus when transfered down a ramp in a shower chair without foot pedals for 1 of 1 residents reviewed for accidents (Resident 58). B. Based on observation, interview, and record review, the facility failed to ensure hot water temperatures were maintained within a safe range for 4 of 13 residents reviewed for hot water temperatures (Residents 15, 56, 14, and 49). Findings include: A. During an interview, on 7/6/21 at 2:10 p.m., Resident 58 indicated she was being pushed by staff in her chair, down the facility ramp, when her foot went under the chair, and she broke her ankle. She went to the hospital for the fracture. Resident 58's record was reviewed on 7/8/21 at 2:43 p.m. Diagnoses on the resident's profile included, but were not limited to, other [CONDITION(S)] (a congenital disorder of movement, muscle tone, or posture), pain in right ankle and joints of right foot, and displaced (out of alignment) fracture of lateral (outer) malleolus (the bone on each side of the ankle) of right fibula (the smaller of two bones in the calf area) subsequent encounter for closed (no puncture through the skin) fracture with routine healing. A significant change Minimum Data Set (MDS) assessment, dated 9/30/20, indicated the resident was cognitively intact, required total assistance of two staff members for transfers, extensive assistance of one staff member for personal hygiene, and extensive assistance of one staff member for locomotion throughout the facility. A progress note, dated 9/30/20 at 8:30 p.m., indicated the resident was in her wheelchair and being transferred back to her room when her right foot went under the wheelchair while going down a ramp in the hallway. The resident screamed out, and her right ankle and foot were noted with swelling, and right big toe turned dark in color. The resident was unable to move her leg or foot without pain. The Nurse Practitioner (NP) was notified and ordered to send the resident to the hospital for x-ray of the foot and ankle. The staff was educated that anytime a resident was transferred in the wheelchair, foot pedals were to be in place. A progress note, dated 9/30/20 at 11:26 p.m., indicated the emergency room (ER) nurse indicated the resident had a spiral fracture (complete fractures of long bones that result from a rotational force applied to the bone, spiral fractures are usually the result of high energy trauma) to the right leg. An x-ray report of the right ankle, dated 9/30/20, indicated a [NAME] type B (a type of fracture above the tibiofibular ligaments) spiral fracture of the lateral malleolus with mild lateral displacement. A progress note, dated 10/1/20 at 1:43 a.m., indicated the resident returned to the facility with her right lower leg in a splint. A progress note, dated 10/2/20 at 2:17 p.m., indicated the resident was seen by the orthopedic (a doctor who specializes in the musculoskeletal system) doctor yesterday, and the plan was conservative care to the fracture of the right lower extremity (RLE). A fracture boot was in place to the RLE. During an interview, on 7/9/21 at 2:13 p.m., the Director of Nursing Services (DNS) indicated the resident had fractured her right ankle, and based on her investigation, the resident was being transferred in a shower chair back to her room after a shower. Her foot got caught and was run over. Foot pedals were not in place because it was a shower chair. It was not best practice to transport residents in a shower chair but was not specifically against their facility policy. On 7/9/21 at 1:38 p.m., the Executive Director (ED) provided a document titled, Resident Rights, and indicated it was the policy currently being used by the facility. The policy indicated, .POLICY: .All staff members recognize the rights of residents at all times and residents assume their responsibilities to enable personal dignity, well- being, and proper delivery of care B. During an observation on 7/6/21 at 11:30 a.m., Resident 15's and Resident 56's shared bathroom sink water temperature was too warm to hold hands under the water for more than a few seconds without hurting the skin. The Maintenance Supervisor checked the water temperature, on 7/6/21 at 11:38 a.m., and indicated the water temperature was too warm at 142 degrees Fahrenheit (F) per the facility's thermometer and should be between 100 to 120 degrees F. During an observation with the Maintenance Supervisor, on 7/6/21 at 11:40 a.m., the Maintenance Supervisor checked the water temperature with the facility's thermometer of Resident 14's bathroom sink water and indicated the water temperature was too warm at 144 degrees F. During an observation with the Maintenance Supervisor, on 7/6/21 at 11:42 a.m., the Maintenance Supervisor checked the water temperature with the facility's thermometer of Resident 49's bathroom sink water and indicated the water temperature was too warm at 142 degrees F. The Maintenance Supervisor indicated he checked random residents' bathrooms water temperatures routinely, kept a temperature log, and had not had any logged water temperatures in the facility more than 120 degrees F. 1. Resident 15's record was reviewed on 7/8/21 at 10:09 a.m. Diagnosis included but was not limited to dementia (chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) with behavioral disturbances. An annual Minimum Data Set (MDS) assessment, dated 6/29/21, indicated Resident 15 was severely impaired and required limited assistance of one staff for toileting and supervision assistance of one staff for personal hygiene. During an interview on 7/8/21 at 9:38 a.m., Licensed Practical Nurse (LPN) 40 indicated the resident took herself to the bathroom. During an interview on 7/8/21 at 9:44 a.m., Certified Nursing Aide (CNA) 41 indicated Resident 15 was independent with toileting and the resident was currently in the bathroom. 2. Resident 56's record was reviewed on 7/8/21 at 2:38 p.m. Diagnosis included but was not limited to dementia with behavioral disturbances. A quarterly MDS assessment, dated 5/26/21, indicated Resident 56 was severely impaired and required limited assistance of one staff for toileting and personal hygiene. 3. Resident 14's record was reviewed on 7/7/21 at 2:33 p.m. Diagnosis included but was not limited to dementia with behavioral disturbances. A quarterly MDS assessment, dated 6/21/21, indicated Resident 14 was severely impaired and required extensive assistance of one staff for toileting and personal hygiene. During an interview on 7/8/21 at 9:34 a.m., LPN 40 indicated Resident 14 was not supposed to go to the bathroom by herself and staff try to toilet her at least every 2 hours. But she caught the resident that morning attempting to go to the bathroom by herself. On 7/8/21 at 9:52 a.m., Resident 14 was observed in the bathroom. A family member was observed sitting at bedside in the recliner. 4. Resident 49's record was reviewed on 7/8/21 at 10:42 a.m. Diagnosis included but was not limited to dementia. An annual MDS assessment, dated 5/20/21, indicated Resident 49 was severely impaired and required limited assistance of one staff for toileting and personal hygiene. During an interview on 7/8/21 at 9:40 a.m., LPN 40 indicated the resident did take himself to the bathroom. The resident did not need assistance for toileting. Staff at times changed his brief, but he took himself to the bathroom. During an interview with the Executive Director on 7/7/21 at 9:34 a.m., she indicated the facility did not have a policy regarding water temperatures but followed the State guidelines for safe water temperatures of 100 to 120 degrees Fahrenheit; there had been no reported [CONDITION(S)] or scalding's as a result of water temperatures. The Medicare State Operation Manual, Rev. 133, dated 2/6/15, was referenced for safe water temperatures for bathing and indicated 100 degrees F was a safe temperature. On Page 338 of the manual indicated the time required for 3rd degree [CONDITION(S)] from water temperatures of 124 degrees F was 3 minutes, 127 degrees F was 1 minute, 133 degrees F was 15 seconds, and 140 degrees F was 5 seconds. 3.1-45(a)(1) 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to follow CDC guidance during a pandemic and ensure infection control practices for COVID-19 were implemented to prevent the potential for spread of the virus for droplet isolation precautions for a resident (Resident 13) exhibiting signs and symptoms of a cough and congestion, failed to separate Resident 13's roommate (Resident 28) from continued potential exposure to her symptomatic roommate, failed to ensure staff wore appropriate personal protective equipment (PPE) while in droplet isolation rooms, failed to ensure staff sanitized their hands after doffing PPE, and failed to ensure unvaccinated staff wore medical goggles during resident care for 4 of 4 random observations of transmission based precautions and resident care (Residents 13, 28, 219, and 59). Findings include: 1. On 7/8/21 at 9:31 a.m., Residents 13 and 28 were observed in their shared room watching television. Resident 13 was observed lying in her bed and Resident 28 was observed seated a few feet away in her wheelchair. No isolation precautions were observed for these residents' room at that time and the privacy curtain was completely open. On 7/8/21 at 1:59 p.m., Resident 13 was observed in her room alone with contact/droplet isolation precautions sign on the door and an isolation PPE cart outside of the door. Licensed Practical Nurse (LPN) 12, on 7/8/21 at 2:01 p.m., indicated Resident 13 was in droplet isolation for a respiratory infection. The Infection Preventionist (IP) was coming to Resident 13's room to perform a rapid Covid-19 test. Resident 13's roommate did not need to be in isolation, because she was not symptomatic. The roommate was in the main dining room in an activity with other residents playing bingo. On 7/8/21 at 3:02 p.m., IP indicated Resident 13 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The results of the chest x-ray showed infiltrates on the lung. The afternoon of 7/8/21, Resident 13 was placed into contact/droplet isolation precautions for pneumonia. She was tested for Covid-19 on 7/6/21 and again on 7/8/21, with the results negative for both tests. On 7/9/21 at 10:04 a.m., LPN 12 indicated Resident 13 and her roommate, Resident 28, were both in contact/droplet isolation precautions due to Resident 13 having a respiratory infection and the roommate being exposed to Resident 13. On 7/12/21 at 10:28 a.m., Resident 13 and Resident 28 were observed in their contact/droplet isolation room with the privacy curtain completely open. Resident 13 was observed lying in bed with her eyes closed and Resident 28 was observed seated in her wheelchair receiving activities of daily living (adl) care from Registered Nurse (RN) 20. RN 20 was observed wearing a gown, gloves, goggles, and a surgical mask while she was caring for the isolation residents. The clinical education coordinator, on 7/12/21 at 10:38 a.m., observed RN 20 in the isolation room performing resident care and indicated RN 20 should have worn an N-95 face mask in the contact/droplet isolation room. The clinical education coordinator asked RN 20 to come to the isolation room door and handed RN 20 an N-95 face mask from the PPE cart. RN 20 doffed the surgical mask and donned the N-95 mask without sanitizing her hands before or after donning the N-95 mask. On 7/12/21 at 10:50 a.m., RN 20 doffed her gown, gloves and N-95 mask, exited the room and placed a surgical mask on without sanitizing her hands. RN 20 indicated she should have had an N95 mask on for the contact/droplet isolation room and should have sanitized her hands prior to donning the surgical mask. Resident 13's record was reviewed on 7/8/21 at 1:32 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Special instructions, if the resident has any of these symptoms, place resident in droplet plus precautions, notify physician, and obtain orders for Covid-19 testing. A nurse's progress note, dated 7/2/21 at 2:04 p.m., indicated the nurse practitioner (NP) had seen Resident 13 and ordered [MEDICATION(S)] (cough and cold medication used to thin [MEDICATION(S)]/drainage) for seven days due to resident's complaints of nasal congestion draining into her throat. A nurse's progress note, dated 7/6/21 at 1:32 p.m., indicated new order received to obtain chest x-ray for cough. A nurse's progress note, dated 7/6/21 at 11:18 p.m., indicated chest x-ray scheduled with mobile/portable x-ray for 7/7/21. A nurse's progress note, dated 7/7/21 at 1:25 p.m., indicated mobile x-ray completed and awaiting results. A radiology report, dated 7/7/21 at 12:24 p.m., indicated Resident 13 had mild increased right basilar hazy opacities (congestion in the right lung). A nurse's progress note, dated 7/8/21 at 3:42 p.m., indicated per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, initiated on 7/8/21, indicated Resident 13 placed into droplet plus isolation (used to prevent the spread of pathogens that are passed through respiratory secretions) due to an active infectious disease respiratory infection with the goal of resident's isolation will reduce the spread of the infectious agent and minimize the transmission of the infection. Interventions on the care plan included but not limited to, follow facility's infection control policies/procedures when cleaning/disinfecting room, handling soiled and/or contaminated linen, disinfecting equipment, etc.; have adequate PPE available for staff and visitors; teach resident to cough into tissue for droplet isolation precautions; practice good handwashing; and use principles of infection control and universal/standard precautions. The record lacked documentation Resident 13 had been tested for other respiratory conditions to rule out respiratory syncytial virus (RSV)/influenza. 2. Resident 28's record was reviewed on 7/9/21 at 11:19 a.m. Census record indicated Resident 28 had resided in the same room with Resident 13 since 5/3/21. A care plan, initiated on 7/8/21, indicated Resident 28 had need for isolation related to potential exposure to possible respiratory infection of roommate with the long-term goal of Resident 28's isolation will reduce the spread of the infectious agent and minimize the transmission of the infection. Interventions on the care plan included but were not limited to, droplet isolation precautions, follow facility's infection control policies/procedures when cleaning/disinfecting room, handling soiled and/or contaminated linen, disinfecting equipment, etc.; and utilize guidelines for Transmission-Based Precautions. On 7/12/21 at 11:45 a.m., the Executive Director (ED) indicated two dietary staff at the facility had tested positive for Covid-19 on 7/6/21 and 7/8/21. Resident 13 was fully vaccinated for COVID-19 and her roommate, Resident 28, had received her first dose of the COVID-19 vaccination and was scheduled to receive her second dose of the COVID-19 vaccination on 7/14/21. The facility followed CDC guidance for infection control and she provided and identified a document as a current facility policy, titled Standard and Transmission-Based Precautions (Isolation) Policy, updated March 2021, which indicated, .Policy: The facility shall utilize the appropriate transmission-based precaution based on the means of transmission and the infectious agent or organism involved .Purpose: To implement appropriate transmission-based precautions to prevent the transmission of infection .Personal Protective Equipment (PPE): refers to the protective items or garments worn to minimize exposure to hazards that cause injuries and illnesses .Standard Precautions: Refers to infection prevention practices that apply to all residents, regardless of suspected or confirmed diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .after removing personal protective equipment (e.g. gloves, gown, facemask) .Transmission-Based Precautions: refers to the actions (precautions) implemented, in addition to standard precautions, that are based upon the means of transmission (airborne, contact, and droplet) to prevent or control infection .In addition to Standard Precautions, Transmission-Based Precautions should be used for resident(s) with documented or suspected infection(s) or colonization with highly transmissible or epidemiological pathogen(s) for which additional precautions are needed to prevent the spread of the infection(s) .Droplet Plus Precautions: is used to designate transmission-based precautions beyond droplet precautions for residents with unknown COVID-19 status under 14-day observation, COVID-19 suspected or positive residents, and the use of N-95 or approved KN95 mask .Resident placement: .Private room should be utilized if possible .If residents are co-horted and COVID status is unknown privacy curtains will remain closed and co-horted residents will have their beds at least 6 feet apart. They will have a dedicated bathroom, bedside commode, or bedpan .Use of Personal Protective Equipment .HCP should wear an N95, approved KN95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or face shield that covers the front and sides of the face), gloves, and gown when caring for these residents .Isolation cart must remain outside of room .PPE must be appropriately doffed and discarded in trash prior to leaving the room .Hand hygiene should be performed before donning and after doffing PPE The CDC guidance for COVID LTC Facility Infection Control Guidance Standard Operating Procedure, updated on 6/22/21 in the Indiana Department of Health Newsletter 6/25/21 page 7 #3, indicated, . If despite negative testing there remains clinical uncertainty around a resident's COVID-19 status and they are symptomatic, the symptomatic resident should be placed in TBP (may shelter in place if they do not have a roommate during testing) and moved to the yellow zone if symptomatic and remain negative for testing 3. During a random observation, on 7/8/21 at 9:50 a.m., Resident 219's room was observed to have an isolation cart outside of the room and a sign that indicated contact/droplet precautions. Registered Nurse (RN) 20 was observed with a surgical mask on assisting Resident 219 at this time. RN 20 indicated Resident 219 was on isolation due to being a new admission. 4. During a Hoyer lift (an assistive device used by staff to transfer residents) transfer observation, on 7/12/21 at 10:31 a.m., Certified Nursing Assistant (CNA) 21 was observed providing direct care to Resident 59. CNA 21 was observed to be wearing goggles that left gaps around all sides. During a review of employee records, on 7/13/21 at 2:00 p.m., CNA 21 lacked documentation she had been vaccinated or received education for vaccinations of COVID-19. On 7/13/21 at 1:28 p.m. the Executive Director (ED) provided a facility document that indicated the facility's current positivity rate for COVID-19, from 6/29/21 through 7/5/21, was 14.49%. At this time, the ED indicated the facility required the staff to wear eye protection when they were six feet from a resident and when direct care was provided. The Indiana Department of Health Guidance, updated 3/31/21, and titled, Long-term Care Eye Protection Use of Face shields or protective eyewear/goggles, included but was not limited to, Eye Protection: To align with updated Centers for Disease Control and Prevention (CDC) updated guidance on potential transmission by aerosol transmission, Indiana Department of Health (IDOH) recommends the use of eye protection as a standard safety measure to protect long-term care (LTC) healthcare personnel (HCP) who provide essential direct care within 6 feet of the resident in all levels of care in all long-term care and assisted living. This eye protection should be used according to these guidelines: Examples include: .During moderate to high community transmission eye protection should be worn by HCP who provide essential direct care within 6 feet for any resident regardless of COVID status in all levels of care in LTC settings. If the county positivity rates are < 5% with low community transmission and the facility is not in outbreak testing, then eye protection will not be required when providing essential direct care within 6 feet to residents who are not in transmission-based precautions (TBP) for COVID-19 or quarantined for COVID positive exposures. This would include residents in the general population (green zones) who are not suspected to have COVID-19. If the county positivity rates increase to moderate or high substantial community transmission then eye protection should be used for all residents within 6 feet when delivering essential direct care, regardless of COVID 19 status. All LTC facilities care providers (nurses, CNAs, QMAs, hospice, EMS, healthcare providers, environmental services and support staff) who provide direct care within 6 feet of the resident are impacted. HCP who provide care for residents confirmed or suspected to have COVID-19 are required to wear eye protection already as part of Droplet-Contact TBP - this practice has already been in place across the state. It is now recommended to wear eye protection when providing direct care within 6 feet of the resident regardless of COVID-19 status when there is moderate to substantial (high) community transmission On 4/16/21 at 12:01 p.m., the DON provided a document, undated, and titled, The Basics of Eye Protection for COVID-19 and indicated it was the policy currently being used by the facility. The policy indicated, .Why wear eye protection during the COVID-19 pandemic? Eye protection, such as face shields and goggles, protect your eyes from splashes, sprays, and infectious droplets. your eyes are a potential portal of entry for COVID-19. What counts as eye protection? Eyewear must protect the eyes from all sides so fluids do not enter. Most face shields and goggles count as eye protection 3.1-18(b)(1) 3.1-18(b)(2)

Based on observation, record review, and interview, the facility failed to ensure Foley catheters (a tube inserted into the bladder to drain urine) were maintained off of the floor for residents with a history of urinary tract infections (UTI) for 2 of 2 residents reviewed for catheters (Residents 54 and 40). Findings include: 1. On 7/6/21 at 11:03 a.m., Resident 54 was observed sitting up in her wheelchair, with Foley catheter (a tube inserted into the bladder to drain urine) tubing resting on the floor. Resident 54's record was reviewed on 7/7/21 at 2:09 p.m. A quarterly Minimum Data Set (MDS) assessment, dated 5/25/21, indicated the resident was cognitively intact and had an indwelling catheter. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission indwelling catheter assessment, dated 4/15/21, indicated the resident was newly admitted to the facility and had a urinary catheter. The resident had acute urinary retention or bladder outlet obstruction and the catheter was medically necessary. Census information indicated the resident was hospitalized from 5/8/21 to 5/13/21. A progress note, dated 5/8/21, indicated the resident complained of nausea and vomiting, and refused breakfast. [CONDITION(S)] was notified and instructed to send her to her regular appointment. A progress note, dated 5/13/21, indicated the resident returned to the facility via stretcher, and ate dinner at the hospital. An infection control event, dated 5/14/21, indicated the resident had a urine culture on 5/8/21, and had a UTI. The resident returned from a hospital stay with an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A suspected UTI event, dated 6/29/21, indicated the resident had acute pain around the catheter site and mental status change, warranted a urinalysis and culture. A care plan, goal target dated 8/28/21, indicated the resident had an indwelling catheter due to obstructive [CONDITION(S)]. Interventions included, but were not limited to, do not allow tubing or any part of the drainage system to touch the floor. During an interview, on 7/9/21 at 9:48 a.m., the Director of Nursing Services (DNS) indicated Foley catheter tubing should not have been on the floor. 2. During a random observation, on 7/6/21 at 11:43 a.m., Resident 40 was observed sitting in his wheelchair outside the dining room. His indwelling urinary catheter (generally referred to as a Foley catheter, is a closed sterile system with a catheter and retention balloon that is inserted either through the urethra to allow for bladder drainage) tubing was touching the floor. Resident 40's record was reviewed on 7/7/21 at 2:55 p.m. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A significant change Minimum Data Set (MDS) assessment, dated 5/12/21, indicated the resident had an indwelling Foley catheter. A care plan, dated 3/4/21, indicated the resident required an indwelling urinary catheter and was at risk for UTI's. Interventions included, but were not limited to, do not allow tubing or any part of the drainage system to touch the floor. An event report, dated 6/1/21, indicated the resident had contracted a UTI. A corresponding order for [MEDICATION(S)] (an antibiotic medication which is a combination of two antibiotics: [MEDICATION(S)] and [MEDICATION(S)], and is used to treat a wide variety of bacterial infections), 800-160 milligrams (mg), by mouth, every 12 hours times 10 days. On 7/8/21 at 2:42 p.m., the Director of Nursing Services (DNS) provided an undated document, titled, Ben [NAME] Health & Rehab Catheter Maintenance, and indicated it was the policy currently being used by the facility. The policy indicated, Standard of Practice is for catheter tubing not to touch the floor for the purpose of prevention of contamination. 3.1-41(a)(2)

Based on observation, record review, and interview, the facility failed to ensure interventions were implemented as care planned, infection control standards were maintained during a dressing change for a resident who developed a pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) for 1 of 1 residents reviewed for pressure ulcers (Resident 54). Findings include: On 7/6/21 at 11:07 a.m., Resident 54 was observed up in her wheelchair with non-skid socks on. Her heels were resting directly on the wheelchair foot rests. No pressure relieving boots were observed. At the same time, the resident indicated she wore pressure relieving boots, but not when she went to [CONDITION(S)] (process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally). She was going to be leaving for [CONDITION(S)] later that day. On 7/8/21 at 10:09 a.m., Licensed Practical Nurse (LPN) 9 was observed completing a dressing change to Resident 54's right heel. LPN 9 placed a plastic bag with a tube of Santyl (an enzyme that helps break up and remove dead tissue), a box of gloves, and a roll of trash bags directly on the resident's bed. LPN 9 removed the old dressing, cleansed the wound, applied Santyl to the wound bed, and covered with a dressing. After the treatment was completed, the box of gloves was moved from the resident's bed to the bathroom and the Santyl was returned to the treatment cart. Resident 54's record was reviewed on 7/7/21 at 2:09 p.m. Census information indicated the resident was admitted to the facility on [DATE]. An admission nursing assessment, dated 4/14/21, indicated the resident had no alterations in skin integrity. A Braden (a tool to assess the risk of pressure ulcer development) assessment, dated 4/14/21, indicated a score of 19, not at risk for pressure ulcer development. A baseline care plan, initiated 4/15/21, indicated the resident was at risk for pressure ulcer development. Interventions included but were not limited to turn and reposition at least every two hours but lacked documentation of any specific pressure relieving techniques for the resident's heels. A comprehensive admission Minimum Data Set (MDS) assessment, dated 4/20/21, indicated the resident was cognitively intact, required extensive assistance of one staff member for dressing, was at risk for pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) development, and had no pressure ulcers. The assessment lacked documentation the resident exhibited any behaviors, including rejection of care. A progress note, dated 4/23/21, indicated a wound to the right heel was noted, measured two centimeters (cm) by two cm, with necrotic tissue. New treatment orders received, and Prevalon (pressure relieving) boots to bilateral lower extremities (BLE) when in bed. A wound management detail report, dated 4/23/21, indicated the resident had an unstageable pressure ulcer to the right heel, measured two cm in length by two cm in width. A Braden assessment, dated 5/13/21, indicated a score of 18, at risk for pressure ulcer development. A wound management detail report, dated 5/13/21, indicated the resident had an unstageable pressure ulcer to the right heel, and 45 percent of the wound bed was slough (soft, dead tissue). The wound had declined during the resident's recent hospitalization . A Braden assessment, dated 5/18/21, indicated a score of 16, at risk for pressure ulcer development. A quarterly MDS assessment, dated 5/25/21, indicated the resident was cognitively intact, required extensive assistance of one staff member for dressing, was at risk for pressure ulcer development, and had one unstageable (an ulcer that has full thickness tissue loss but was either covered by extensive necrotic tissue or by an eschar) pressure ulcer not present upon admission. The assessment lacked documentation the resident exhibited any behaviors, including rejection of care. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An interdisciplinary team (IDT) wound review, dated 6/23/21, indicated the resident had a pressure ulcer to the right heel and wore pressure relieving boots to [CONDITION(S)]. A care plan, goal target dated 8/28/21, indicated the resident had impaired skin integrity, pressure ulcer to the right heel. Interventions included, but were not limited to, resident to wear pressure relieving boots to [CONDITION(S)], resident to wear Prevalon boots at all times to BLE, remove for hygiene and transfers, and supplements as ordered. A care plan, goal target dated 8/28/21, indicated the resident required hemodialysis. Interventions included, but were not limited to, [CONDITION(S)] on Tuesday, Thursday, and Saturday. Current care plans lacked documentation the resident refused medications or care. During an interview, on 7/8/21 at 1:25 p.m., Licensed Practical Nurse (LPN) 12 indicated she thought the resident usually wore the pressure relieving boots to [CONDITION(S)]. The resident was not normally non-compliant with care. During an interview, on 7/9/21 at 9:48 a.m., the Director of Nursing Services (DNS) indicated the resident's pressure relieving boots should have been worn at all times, removed for hygiene and transfers. They should have been worn to [CONDITION(S)]. During a dressing change, supplies should have been placed on a clean surface, not on the resident's bed without a barrier. On 7/9/21 at 1:43 p.m., the ED provided a document titled, SKIN MANAGEMENT PROGRAM, and indicated it was the policy currently being used by the facility. The policy indicated, .PROCEDURE FOR WOUND PREVENTION: 1. All residents will be assessed at admission using a skin risk (Braden) assessment to determine risk for pressure ulcer/injury with initiation of care plan .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 ( .offloading heels .) PROCEDURES FOR ALTERATIONS IN SKIN INTEGRITY-PRESSURE .6. A plan of care will be initiated to include resident specific risk factors and contributing factors with appropriate interventions implemented .WHEN A RESIDENT DECLINES TREATMENTS OR INTERVENTIONS: For a resident who declines treatment the IDT or designee must discuss with the resident and/or resident representative, the resident's condition, treatment options, expected outcomes, and consequences of refusing treatment. The facility is expected to address the resident concerns and offer relevant alternatives if the resident has declined the specific treatments On 7/9/21 at 1:58 p.m., the ED provided a document titled, Dressing Change (Incision or Wound), and indicated it was the policy currently being used by the facility. The policy indicated, .Procedure Steps: .5. Set up clean .field to ensure easy access to supplies during procedure 3.1-40(a)(2)

Based on observation, record review, and interview, the facility failed to ensure nail care was provided to a resident who required assistance (Resident 62) and resident was provided assistance with shaving (Resident 5) for 2 of 3 residents reviewed for activities of daily living (ADL's). Findings include: 1. On 7/7/21 at 10:20 a.m., Resident 1 was observed in her room sitting in her chair. The resident had no socks or shoes on at this time and her toenails were observed long, jagged, and untrimmed on bilateral feet. On 7/7/21 at 9:47 a.m., Resident 1's bilateral feet were observed by Licensed Practical Nurse (LPN) 6. The resident's toenails on bilateral feet were observed to be long, jagged, and untrimmed. The third toe was observed to lay over the top of the second toe and when separated by LPN 6 the second toe was observed to have an open raw area that was pink in color. At this time, LPN 6 indicated the resident's toenails needed to be trimmed and should be trimmed by nursing staff. She was unsure when the last time they had been trimmed. There was no treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1's record was reviewed on 7/7/21 at 2:14 p.m. A quarterly Minimum Data Set (MDS) assessment, dated 6/11/21, indicated the resident had a severe cognitive impairment and required limited assistance of 1 for personal hygiene and was total dependent for bathing. A diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the resident's medical record, dated 6/1/21 through 7/7/21, lacked documentation nail care had been provided. A care plan, initiated 3/12/21, indicated the resident required assistance with ADLs related to dementia. Interventions included, but were not limited to, assist with bathing as needed per resident preference. Offer showers two times per week and partial bath in between. Assist with dressing/grooming/hygiene as needed and encourage resident to do as much for self as possible. During an interview, on 7/9/21 at 3:05 p.m., the Director of Nursing Services (DNS) indicated nail care should be provided as needed on shower days and did not believe it would be documented anywhere. 2. During the initial pool observation, on 7/5/21 at 10:39 a.m., Resident 5 was observed asleep in his bed. He was observed with long stubble facial hair. During a random observation, on 7/6/21 at 9:57 a.m., the resident was observed asleep in his bed. He was observed with long stubble facial hair. During a random observation, on 7/7/21 at 10:34 a.m., the resident was observed awake in his bed. He was observed with long stubble facial hair. At the same time, he indicated no one had offered to shave him in quite sometime and he did not wish to grow a beard. Resident 5's record was reviewed on 7/8/21 at 11:44 a.m. The profile indicated the resident received hospice services for diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An annual Minimum Data Set ( MDS) assessment, dated 12/31/20, indicated the resident had no cognitive deficit and required extensive assist of 1 with personal hygiene. A quarterly MDS assessment, dated 6/18/21, indicated the resident had moderate cognitive deficits and required extensive assist of 1 with personal hygiene. A care plan, dated 4/12/20, indicated the resident required assistance with his Activities of Daily Living (ADLs). Interventions included, but were not limited to assist the resident with dressing/grooming/hygiene as needed. A care plan, dated 4/16/20, indicated the resident required hospice related to [CONDITION(S)]. Interventions included, but were not limited to hospice aide visits 2 times per week to provide ADL care. During an interview, on 7/8/21 at 2:21 p.m., [NAME] [NAME], Certified Nursing Assistant (CNA) indicated he primarily worked on the evening shift. The day shift CNA's resident would have had the responsibility to shave the resident. He also knew the resident was on hospice services. He was not sure if the hospice aide would be responsible for shaving the resident. On 7/9/21 at 1:38 p.m., the Executive Director (ED) provided a document titled, Nursing, and indicated it was the policy currently being used by the facility. The policy indicated, .Components/Guidelines: 1. General Resident Care: a. Bathe or assist to bathe resident at least 2 times per week or per state regulations .j. administers treatments as ordered according to professional standards 3.1-38(a)(3)

Based on interview and record review, the facility failed to ensure a care plan meeting was conducted for 1 of 4 residents reviewed for care plans (Resident 67). Findings include: During an interview, on 7/7/21 at 10:13 a.m., Resident 67 indicated he did not think he had been invited to a care plan meeting. Resident 67's record was reviewed on 7/9/21 at 2:28 p.m. An admission Minimum Data Set (MDS) assessment, dated 6/21/21, indicated the resident was cognitively intact. Census information indicated the resident was admitted to the facility on [DATE]. The observation section of the clinical record, dated 6/21/21 to 7/9/21, lacked documentation of a care plan meeting. Progress notes, dated 6/21/21 to 7/9/21, lacked documentation of a care plan meeting. During an interview, on 7/9/21 at 2:56 p.m., the Social Services Director (SSD) indicated she was unable to find any documentation a care plan meeting had been completed. She thought they had a meeting, but it was not documented. The initial care plan meeting should have been completed within 48 hours from admission. On 7/9/21 at 1:42 p.m., the Executive Director (ED) provided a document titled, IDT Comprehensive Care Plan Policy, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy: It is the policy of this facility that each resident will have a comprehensive person-centered care plan developed based on comprehensive assessment .Procedure: .Resident, resident's representative, or others as designated by the resident will be invited to care plan review On 7/9/21 at 3:13 p.m., the SSD provided a document titled, IDT Baseline Care Plan, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy: It is the policy of this facility that each resident will have an interdisciplinary baseline care plan developed within 48 hours of admission. The baseline care plan will be developed in collaboration with the resident, family, and/or representative and direct care staff to incorporate findings based on the admission assessment, observations, interviews, and resident preferences .Procedure: .A summary of the Baseline Care Plan will be provided to and reviewed with the resident and/or representative during the Road to Recovery, or other scheduled IDT meeting following admission to the facility 3.1-35(e)

Based on interview and record review, the facility failed to ensure the resident received a copy of their baseline care plan at admission for 1 of 4 residents reviewed for care plans (Resident 67). Findings include: During an interview, on 7/7/21 at 10:13 a.m., Resident 67 indicated he did not think he received a copy of his baseline care plan upon admission to the facility. Resident 67's record was reviewed on 7/9/21 at 2:28 p.m. An admission Minimum Data Set (MDS) assessment, dated 6/21/21, indicated the resident was cognitively intact. Census information indicated the resident was admitted to the facility on [DATE]. The observation section of the clinical record, dated 6/21/21 to 7/9/21, lacked documentation the resident was provided a copy of the baseline care plan at admission. Progress notes, dated 6/21/21 to 7/9/21, lacked documentation the resident was provided a copy of the baseline care plan at admission. During an interview, on 7/9/21 at 2:56 p.m., the Social Services Director (SSD) indicated she was unable to find any documentation the resident was provided a copy of the baseline care plan at admission. The initial care plan meeting should have been completed within 48 hours from admission, and a copy of the baseline care plan should have been provided at that time. On 7/9/21 at 3:13 p.m., the SSD provided a document titled, IDT Baseline Care Plan, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy: It is the policy of this facility that each resident will have an interdisciplinary baseline care plan developed within 48 hours of admission. The baseline care plan will be developed in collaboration with the resident, family, and/or representative and direct care staff to incorporate findings based on the admission assessment, observations, interviews, and resident preferences .Procedure: .A summary of the Baseline Care Plan will be provided to and reviewed with the resident and/or representative during the Road to Recovery, or other scheduled IDT meeting following admission to the facility

Based on observation, record review, and interview, the facility failed to ensure residents were provided privacy, in order to maintain their dignity during care for 2 of 24 residents reviewed for dignity (Residents 54 and 58). Findings include: 1. During a dressing change observation, on 7/8/21 at 10:09 a.m., Licensed Practical Nurse (LPN) 9 removed the dressing to Resident 54's right heel, cleansed the wound, and applied a new dressing. The resident's room door and privacy curtain remained open. The dressing change was readily visible to anyone in the hallway. Resident 54's record was reviewed on 7/7/21 at 2:09 p.m. A quarterly Minimum Data Set (MDS) assessment, dated 5/25/21, indicated the resident was cognitively intact. During an interview, on 7/9/21 at 9:48 a.m., the Director of Nursing (DNS) indicated privacy should have been provided during a dressing change. On 7/9/21 at 1:58 p.m., the Executive Director (ED) provided a document titled, Dressing Change (Incision or Wound), and indicated it was the policy currently being used by the facility. The policy indicated, .Procedure Steps: .2. Provide privacy and explain procedure 2. During a medication administration observation, on 7/9/21 at 11:28 a.m., Licensed Practical Nurse (LPN) 12 performed an accu-check (blood sugar check) and administered [MEDICATION(S)] (insulin) five units (u) subcutaneous (SQ) (an injection into the fatty layer beneath the skin and above the muscle) to Resident 58. The resident was in her room with Resident 59, her roommate. The resident's room door and privacy curtain remained open. The accu-check and [MEDICATION(S)] administration were readily visible to the resident's roommate and anyone in the hallway. Resident 58's record was reviewed on 7/8/21 at 2:43 p.m. A quarterly Minimum Data Set (MDS) assessment, dated 6/1/21, indicated the resident was cognitively intact. During an interview, on 7/9/21 at 12:06 p.m., the Director of Nursing Services (DNS) indicated privacy should have been provided for insulin administration, but she was not sure about accu-checks. On 7/9/21 at 1:38 p.m., the Executive Director (ED) provided a document titled, Resident Rights, and indicated it was the policy currently being used by the facility. The policy indicated, .POLICY: .All staff members recognize the rights of residents at all times and residents assume their responsibilities to enable personal dignity 3.1-3(a)

Based on interview and record review, the facility failed to ensure a pharmacy recommendation was addressed in a timely manner for 1 of 5 residents reviewed for unnecessary medications (Resident 13). Finding includes: On 7/8/21 at 9:05 a.m., the Director of Nursing Services (DNS) provided Resident 13's pharmacy consultation report, dated 4/23/21 and indicated the pharmacy recommendation for 4/23/21 was not completed until 7/8/21. DNS indicated the pharmacy recommendation was not addressed because rinsing the mouth with water after usage of the inhaler medication was a routine nursing measure. Today, 7/8/21, she had added to Resident 13's physician's [MEDICATION(S)] inhaler order for the resident to rinse with water after use and do not swallow. The pharmacy recommendation should have been addressed in a timely manner. Resident 13's record was reviewed on 7/8/21 at 9:31 a.m., diagnosis included, but was not limited to, [CONDITION(S)] (chronic [CONDITION(S)] lung disease that causes obstructed airflow from the lungs). The pharmacy consultation report, dated 4/23/21, indicated Resident 13 received a medication containing an inhaled corticosteroid, [MEDICATION(S)] and to update the order to include the directions to rinse mouth with water after use; do not swallow with rationale for the recommendation to reduce the risk of thrush, the mouth should be rinsed after the administration of the corticosteroid inhaler. The DNS signed the pharmacy consultation report on 7/8/21. A physician's order, dated 7/8/21, indicated [MEDICATION(S)] (fluticasone furoate-vilanterol) for [CONDITION(S)] 100-25 mcg (microgram)/dose blister with device, once a day, one puff, inhalation. Rinse mouth with water after use. Do not swallow. On 7/12/21 at 11:44 a.m., the Executive Director indicated the IDT (Interdisciplinary Team) with the pharmacist and our mental health services staff reviewed all pharmacy recommendations monthly. The pharmacy recommendation should have been addressed within the month. The facility has now added to the residents' inhaler treatment order to rinse mouth with water after use. 3.1-25(j)

Based on record review and interview, the facility failed to ensure blood pressure medications were held per parameters as ordered by the physician for 1 of 5 residents reviewed for unnecessary medications (Resident 58). Findings include: Resident 58's record was reviewed on 7/8/21 at 2:43 p.m. A quarterly Minimum Data Set (MDS) assessment, dated 6/1/21, indicated the resident was cognitively intact. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A MAR, dated July 2021, indicated the resident's blood pressure was 100/66 on 7/1/21, 100/62 on 7/3/21, and 100/67 on 7/5/21, at the time of the [MEDICATION(S)] administration. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, goal target dated 9/16/21, indicated the resident had ineffective tissue perfusion related to hypertension. Interventions included, but were not limited to administer medications as ordered and monitor vital signs. During an interview, on 7/9/21 at 9:48 a.m., the Director of Nursing Services (DNS) indicated medications should have been administered as ordered by the physician and held according to the parameters. On 7/9/21 at 1:58 p.m., the Executive Director (ED) provided a document titled, General Dose Preparation and Medication Administration, and indicated it was the policy currently being used by the facility. The policy indicated, .Procedure: .4. Prior to administration of medication, Facility staff should take all measures required by Facility policy and Applicable Law, including, but not limited to the following: 4.1: Facility staff should: 4.1.1 Verify each time a medication is administered that it is the correct medication, at the correct dose .4.1.5 If necessary, obtain vital signs 3.1-48(a)(3)

Based on interview, and record review, the facility failed to ensure behaviors were monitored, interventions were implemented, and a rationale was provided when an as needed anti-anxiety medication was administered for 1 of 5 residents reviewed for unnecessary medications (Resident 1). Findings include: Resident 1's record was reviewed on 7/7/21 at 2:14 p.m. A quarterly Minimum Data Set (MDS) assessment, dated 6/11/21, indicated the resident had a severe cognitive impairment. Diagnoses on the resident's profile included, but were not limited to, dementia a group of thinking and social symptoms that interferes with daily functioning) with behavioral disturbance and anxiety (intense, excessive, and persistent worry and fear about everyday situations). A physician's order, initiated 5/24/21 and discontinued 6/7/21, indicated lorazepam (anti-anxiety) 0.5 milligrams (mg) administer one tablet by mouth as needed three times daily for anxiety. A physician's order, initiated 6/7/21 and discontinued 6/21/21, indicated 0.5 mg administer one tablet by mouth as needed three times daily for anxiety. A physician's order, initiated 6/21/21 and discontinued 7/6/21, indicated 0.5 mg administer one tablet by mouth as needed three times daily for anxiety. A physician's order, initiated 6/7/21, indicated the resident had diagnoses of anxiety and dementia with behavioral disturbance. The resident had behaviors of exit seeking, packing, and carrying belongings throughout facility. Intervention 1: Offer the resident an activity of choice, such as coloring or folding laundry, intervention 2: offer the resident a glass of lemonade and sit down to talk, intervention 3: asses for signs and symptoms of pain and offer pain medication if needed, intervention 4: attempt to involve resident in an activity away from exit door, intervention 5: if the resident insists on exiting, allow the resident to exit with staff and then walk back with her. A Medication Administration Record (MAR), dated June 2021, indicated lorazepam 0.5 mg, give 1 tablet by mouth as needed three times daily for anxiety. The MAR indicated the medication had been administered on the following dates: On 7/1/21 at 6:11 p.m., 7/2/21 at 2:59 p.m., 7/3/21 at 12:48 p.m. and 5:50 p.m., 7/4/21 at 1:46 p.m., 7/5/21 at 10:51 a.m., 7/13/21 at 7:08 p.m., 7/17/21 at 10:36 a.m., and 7/20/21 at 4:36 p.m. The MAR lacked documentation the resident had behaviors and lacked nonpharmacological interventions had been attempted prior to the administration of an as needed anti-anxiety medication on these dates. The MAR indicated on 7/18/21 the resident had one behavior of anxiety. Interventions attempted included offering the resident an activity of choice, assessment of pain, and attempted to involve the resident in an activity away from the exit door. The interventions attempted indicated they were effective. The MAR indicated, on 7/18/21 at 11:10 a.m., an as needed lorazepam was administered to the resident. A MAR, dated July 2021, indicated on 7/1/21 at 2:50 p.m. lorazepam 0.5 mg 1 tablet was administered to Resident 1. The MAR indicated the resident had no behaviors due to diagnosis of dementia and lacked documentation nonpharmacological interventions had been attempted prior to the administration of an as needed anti-anxiety medication on 7/1/21. A care plan, initiated 6/7/21, indicated the resident had diagnoses of anxiety and dementia with behavioral disturbance. The resident had behaviors of exit seeking, packing, and carrying belongings throughout facility and the resident had taken a fire extinguisher and broke the door frame trying to get out. The resident had physician orders for antipsychotic and antianxiety medications. Interventions included, but were not limited to, intervention 1: Offer the resident an activity of choice, such as coloring or folding laundry, intervention 2: offer the resident a glass of lemonade and sit down to talk, intervention 3: asses for signs and symptoms of pain and offer pain medication if needed, intervention 4: attempt to involve resident in an activity away from exit door, intervention 5: if the resident insists on exiting, allow the resident to exit with staff and then walk back with her. During an interview, on 7/8/21 at 1:37 p.m., Corporate Consultant 3 indicated an as needed anti-anxiety medication should only be administered if nonpharmacological interventions had been attempted and were not effective. The interventions should have been completed first and documented in the resident's medical record if they were effective or not. During an interview, on 7/9/21 at 11:49 a.m., Licensed Practical Nurse (LPN) 27 indicated the resident had behaviors when she became anxious and indicated she was typically able to redirect the resident with interventions that were effective, and it was harder to redirect the resident during the evening hours. On 7/9/21 at 1:38 p.m., the Executive Director (ED) provided a document titled, [CONDITION(S)] Management Policy, and indicated it was the policy currently being used by the facility. The policy indicated, .Procedure: .6. All residents who are taking antipsychotic, anxiolytic, are required to have a behavior monitoring program in place identifying targeted behavioral symptoms being monitored as well as personalized nonpharmacological interventions .7. The residents who are on behavior program will be reviewed monthly for quantification of behaviors and evaluation of interventions .11. PRN orders for [CONDITION(S)] drugs are limited to 14 days unless it is deemed appropriate to use longer by the physician or prescribing practitioner 3.1-48(b)(1) 3.1-48(b)(2)

Based on record review, interview, and observation, the facility failed to ensure staff utilized resident-specific transfer requirements, failed to report a fall, and failed to assess the resident after the fall resulting in harm when a resident sustained [REDACTED]. The facility failed to ensure staff utilized resident-specific transfer requirements not resulting in harm for 1 of 4 residents reviewed for accidents (Resident C), and failed to ensure appropriate fall interventions were implemented and post-fall neurological assessments were completed for 1 of 4 residents reviewed for accidents (Resident D). Findings include: 1. A facility reported incident, received on 1/22/20 with an incident date of 1/20/20, indicated staff received an x-ray report that indicated Resident B had possible fractures to the left distal lateral condyle and right distal femur and had been transferred to the hospital. An investigation for the cause of the fractures was initiated. Resident B's record was reviewed on 1/23/20 at 9:55 a.m. The [DIAGNOSES REDACTED]. A Fall Risk Assessment, dated 6/10/19, indicated the resident was high risk for falls. A significant change Minimum Data Set (MDS) assessment, dated 11/1/19, indicated the resident had severe cognitive deficit and was totally dependent of 2 or more (+) persons with transfers. A care plan, dated 6/10/19, indicated the resident was at risk for falls due to dementia and weakness. Interventions included, but were not limited to, use a mechanical lift (used to move those who are unable to stand on their own or whose weight makes it unsafe to move or lift them manually) for transfer and sit the resident in a Broda chair (seating which provides tilt-in-space comfortable chairs for long-term and complex care environments). A progress note, dated 1/14/20 at 5:40 p.m., indicated a Certified Nursing Assistant (CNA) had reported that the resident had complained of pain with repositioning. The Registered Nurse (RN) immediately assessed the resident. When the RN attempted to assess left lower extremity, the resident yelled out, and the RN stopped the assessment. The Unit Manager (UM) was notified and she came to do assessment, no abnormality was discovered. A progress note, dated 1/16/20 at 1:21 p.m., indicated the resident was yelling out in pain with care. The resident slapped the CNA while the CNA was attempting to assist resident to change due to an episode of incontinence. When CNA asked resident what made her slap her resident told CNA that her legs were hurting. Nurse Practitioner (NP) was notified of residents increased pain. New orders were received to increase Tylenol 650 milligrams (mg) to every 6 hours and to add Bonfire to hips/thighs three times daily. A progress note, dated 1/17/20 at 1:20 p.m., indicated the NP was this morning and saw the resident. The resident yelled out in pain when the NP was touching her legs and when staff attempted to reposition the resident. A new order was received for x-ray of lower extremities. A progress note, dated 1/17/20 at 6:40 p.m., indicated Mobilex (portable-ray unit) on unit to x-ray the resident's bilateral lower extremities. The technician required staff assistance to complete the procedure. A progress note, dated 1/18/20 at 2:25 p.m., indicated a call had been placed to NP to report positive x-ray results. New orders were received to send resident to the emergency room (ER). The resident continued to yell out in pain when moved. An ambulance was notified. The resident left the facility via gurney and report was called to ER. A progress note, dated 1/18/20 at 9:02 p.m., indicated the facility received a call from the nurse at the hospital. The resident had been admitted to the hospital. A progress note, dated 1/20/20 at 2:32 p.m., indicated the resident had been admitted back to facility. Hospital discharge [DIAGNOSES REDACTED]. Family did not want surgery, as they believed it will only make it worse. A care plans, dated 1/21/20, indicated the resident had a femoral fracture. Interventions included, but were not limited to, turn and reposition with two nursing staff and provide support bilateral lower legs. During an interview, on 1/23/20 at 9:37 a.m., the Executive Director (ED) indicated she had received notification from the hospital, of the resident's fractures on 1/20/20, and the facility had initiated an internal investigation immediately. During their investigation, it was discovered that CNA 4 indicated on 1/12/20, she had attempted to transfer the resident from her bed to her chair by herself. She was unable to transfer the resident and had lowered the resident gently to the ground onto her bottom. The CNA requested help from her nurse, Qualified Medication Aide (QMA) 5. The ED indicated they had not been able to determine that any post-fall assessment of the resident had been completed by a nurse. CNA 4 and QMA 5, were immediately suspended, pending results of the facility's investigation. The resident had no complaint of pain in her legs until several days after the fall. The resident exhibited no change in her function and had no apparent bruising. The Nurse Practitioner (NP) came to the facility and saw the resident for routine visit several days later. At the visit, the NP noted the resident complained of pain in her legs and an order for [REDACTED]. During an interview, on 1/23/20 at 1:57 p.m., Licensed Practical Nurse (LPN) 8 indicated she had been working on another unit at the time of the resident's incident. No one came and got her to assess the resident. The first time she had heard about the incident was when the ED and the Director of Nursing Services (DNS) came to question her. During an interview, on 1/23/20 at 2:13 p.m., CNA 9 indicated Resident B was always a 2 person mechanical lift transfer. During an interview, on 1/23/20 at 2:21 p.m., CNA 7 indicated Resident B was a 2 person mechanical lift transfer. During an interview, on 1/24/20 at 9:23 a.m., CNA 4 indicated she had gone in to get the resident up for dinner. She had been an employee for 2 months and had not taken care of Resident B before. She had not picked up an assignment sheet prior to beginning her shift, and was not aware that the resident was a 2 person mechanical lift. When she picked Resident B up the resident slid on the side of the bed, so the CNA lowered her gently to the floor. The CNA went and got QMA 5. QMA 5 had looked the resident over and then went and got another unknown staff member. All of them lifted the resident into her chair. The resident did not complain of any pain during the transfer process. After she was in her chair and in the dining room the resident did complain of some butt pain. The resident never complained of any leg pain that she could recall. The CNA indicated at no time did QMA 5 ever attempt to get the nurse and was unable to state if he ever told the nurse of the incident. Multiple attempts were made to contact QMA 5. There was no answer on any of the attempts and the phone message indicated the individual's mailbox was full. During an observation, on 1/23/20 at 2:54 p.m., the resident was observed lying in her bed. She and her roommate were talking. The resident denied any pain in her legs. 2. During a random observation, on 1/23/20 at 9:29 a.m., Resident C was observed in her wheelchair (w/c) in the dining area next to the nurse's station. At this time, the resident indicated she had steri-strips (sterile pieces of medical tape used to close wounds and help the edges grow back together) to her left arm from an injury she received when she hit the arm rest of her w/c. She could not remember what caused her to hit her arm or where she was at when it happened. Resident C's record was reviewed on 1/22/20 at 2:10 p.m. A care plan, initiated on 1/7/20 and revised on 1/20/20, indicated the resident required assistance with activities of daily living (ADL's) for transfers. Interventions included, but were not limited to, transfer resident with two person assistance. A care plan, initiated on 1/7/20 and revised on 1/20/20, indicated the resident was at risk for falls due to [MEDICAL CONDITION] of legs. Interventions included, but were not limited to, assist times two for transfers. A progress note, dated 1/18/20 at 4:21 p.m., indicated the resident had an assisted fall in the bathroom. An immediate intervention indicated 2 assist until therapy re-evaluated transfers. A point of care history indicated the resident was a one person physical assist with transfers, and a one person physical assist for toileting for the following dates and times: 1/19/20 at 3:18 a.m., 1/19/20 at 6:58 a.m., 1/19/20 at 9:42 p.m., 1/20/20 at 9:13 a.m., 1/21/20 at 12:45 a.m., 1/21/20 at 12:46 a.m., 1/21/20 at 8:41 a.m., and 1/21/20 at 8:42 a.m. A progress note, dated 1/21/20 at 11:46 a.m., indicated the resident was being transferred from the toilet to wheelchair (w/c) and her knee gave out and caused her to hit her left upper arm on the arm rest of her w/c. Resident obtained 3 skin tears to the left upper arm above the elbow. First skin tear measured 4 centimeters (cm) by (x) 0.1 cm, second skin tear measured 5.5 cm x 0.1 cm, and the third skin tear measured 2 cm x 0.1 cm. Steri-strips were applied and arm was wrapped with kerlix for protection. A point of care history indicated the resident was a one person physical assist with transfers, and/or a one person physical assist for toileting for the following dates and times: 1/22/20 at 1:04 a.m., 1/22/20 at 7:18 a.m., 1/22/20 at 7:19 a.m., and 1/22/20 at 9:51 a.m. A care plan, initiated 1/22/20, indicated the resident had three skin tears on her left upper arm, just above the elbow. Interventions included, but were not limited to, treatment as ordered, steri-strips until healed. During an interview, on 1/23/20 at 9:43 a.m., Registered Nurse (RN) 19 indicated she had investigated what happened on 1/21/20 when Resident C hit her arm. During her investigation she found a Certified Nursing Assistant (CNA) had toileted the resident with one assist and the resident should have been a two person assist with transfers and toileting. When she interviewed the CNA, the CNA indicated she was not aware the resident was a two person assist with transfers and toileting, so she educated the CNA at that time. 3. During a random observation, on 1/21/20 at 1:45 p.m., Resident D was observed in his room sitting up on the edge of his bed. A bed side table was positioned next to the bed, the resident was observed to move the bedside table away from the bed. At this time, the resident indicated he had fallen about a week prior and still had discomfort to his left side and back area. During an observation, on 1/23/20 at 9:34 a.m., Resident D was observed sitting up on the edge of his bed. A bed side table was positioned next to the bed, the resident was observed to move the bedside table away from the bed. During an observation, on 1/24/20 at 1:32 p.m., with the Director of Nursing Services (DNS). The DNS was observed to move Resident D's bedside table, and at this time indicated the bedside table wheels were locked. The intervention for the locked wheels was put in place to prevent the table from moving when the resident leaned on it. Resident D's record was reviewed, on 1/23/20 at 2:30 p.m. [DIAGNOSES REDACTED]. A fall risk assessment, dated 11/11/19, indicated the resident was a moderate fall risk. A progress note, dated 1/12/20, indicated the resident had an unwitnessed fall in his room. Prior to the fall the resident was sitting on the side of his bed eating lunch. Resident indicated he had laid his head on over bed table and the table rolled away. Neurological (neuro) checks were indicated at this time. The resident had two skin tears to left hand, skin tear between 3rd and 4th knuckle and 4th and 5th knuckle, and an abrasion to the left side of back. Immediate intervention was to remove the bedside table out of the way. An interdisciplinary (IDT) note, dated 1/13/20, indicated the resident had a fall on 1/12/20. The immediate intervention was to move bedside table out of the way, new intervention was a bedside table with wheels that locked was provided to the resident. A post fall neurological assessment, dated 1/12/20 to 1/15/20, indicated neuro checks should have been checked every 15 minutes times 1 hour, every 30 minutes times 2 hours, every 1 hour times 4 hours, and every 8 hours times 72 hours. The assessment lacked documentation neuro checks had been checked on 1/12/20 at 6:00 p.m., 1/12/20 at 7:00 p.m., and 1/15/20 from 6:00 a.m. to 2:00 p.m. A Certified Nursing Assistant (CNA) assignment sheet, lacked documentation Resident D had an intervention for a bedside table that locked. A care plan, revised 1/13/20, indicated the resident was at risk for falls due to end stage [MEDICAL CONDITION]. Interventions included, but were not limited to, ensure wheels are locked on bedside table. During an interview, on 1/24/20 at 10:29 a.m., CNA 20 indicated Resident D transferred himself with a rolling walker. The resident always had his bedside table next to his bed. She was unaware of any recent falls and any interventions in place for the bedside table. If a resident had a fall and a new intervention was put in place it would be documented on the resident's profile and the CNA assignment sheet would be updated to reflect the new intervention. At that time, she reviewed her CNA assignment sheet and indicated it lacked documentation of any interventions for the bedside table. On 1/24/20 at 11:55 a.m., the floating DNS provided a document, revised 11/2017, and titled, Fall Management Program, and indicated it was the policy currently being used by the facility. The policy indicated, Policy: It is the policy of (name of company) to ensure residents residing within the facility receive adequate supervision and or assistance to prevent injury related to falls .Procedure: Fall risk .6. The resident specific care requirements will be communicated to the assigned caregiver utilizing resident profile or CNA assignment sheet. 7. The interdisciplinary team will discuss new residents on the 1st business day after admission in the clinical meeting. Fall risk will be discussed at this time, including appropriate interventions. Post fall: 1. Any resident experiencing a fall will be assessed immediately by the charge nurse for possible injuries and necessary treatment will be provided. A neurological assessment will be intimated on all un-witnessed falls .2. If the resident experienced an injury from the fall, contact facility DNS/ED per facility policy .5. A fall event will be indicated as soon as the resident has been assessed and cared for. The report must be completed in full in order to identify possible root causes of the fall and provide immediate interventions. 6. All falls will be discussed by the interdisciplinary team at the 1st IDT meeting after the fall to determine root cause and other possible interventions to prevent future falls. The fall event will reviewed by the team, IDT note will be written, and the care plan will be reviewed and updated This Federal tag relates to Complaint IN 737 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure a gait belt was used during a transfer resulting in a fall with a fracture (Resident 105), failed to ensure adequate safety procedure during personal care resulting in a fall (Resident 78) for 2 of 3 residents reviewed for falls, and failed to ensure hot water temperatures were maintained within safe range (Residents 99, 79, 311, 78, 35, 29, 13, 85, 93, 69, 27, 105, 72, 86, and 32), for 15 of 24 residents reviewed for accidents. Findings include: 1. During an interview, on 1/17/18 at 9:37 a.m., Resident 105 indicated she fell and broke her right upper arm on 1/6/18. A CNA (Certified Nurse Aide) lifted her without a gait belt, she slipped and fell on her right side. She was taken to the hospital and had a surgical repair on her arm. Resident 105's record was reviewed on 1/22/18 at 1:13 p.m. The [DIAGNOSES REDACTED]. The resident's admission fall assessment, dated 1/6/17, indicated a history of one or more falls within a previous 6 months prior to admission and determined the resident was a moderate fall risk. The admission MDS (Minimum Data Set) assessment, dated 1/13/17, indicated the resident had no cognitive deficit, was an extensive assist of 2 plus physical assist with transfers, extensive assist of 1 plus physical assist with walking in her room and corridor, and with locomotion on and off the unit. The resident had falls within 2 to 6 months prior to admission, a fall with a fracture within 6 months prior to admission, had 1 fall since admission to the facility, and had no major injury. The annual MDS assessment, dated 12/28/17, indicated the resident had no cognitive deficit, was an extensive assist of 2 plus physical assist with transfers, extensive assist of 1 plus physical assist with walking in her room and corridor, and with locomotion on and off the unit. The resident had falls since admission with one fall with a non-major injury. A care plan, dated 1/9/17, revised on 1/10/18, indicated the resident was at risk for falls. Interventions included, but were not limited to, when walking resident she should have a gait belt on her and staff should walk behind her not in front of her. A care plan, dated 1/10/18, indicated the resident had a fractured right humerus with ORIF (Open Reduction Internal Fixation). Interventions included, but were not limited to, use assist of 2 with gait belt with all transfers. A progress note, dated 1/6/18 at 2:00 a.m., indicated a nurse had been called to the resident's room. The nurse noted the resident had a right shoulder deformity. The resident indicated a CNA was getting her ready for bed earlier in the evening and she had fallen onto her right side. The CNA had picked her up and continued to get her ready for bed. A second progress note, dated 1/6/18 at 2:00 a.m., indicated CNA 14 indicated she had gone to assist the resident to the bathroom. When she attempted to assist the resident to her feet, she screamed and complained of pain at 10 of 10 pain in her right shoulder. She reported the finding to the nurse. The nurse assessed the resident and determined the resident should have been sent to the hospital out for an evaluation. A progress note, dated 1/6/18 at 5:05 a.m., indicated the hospital called the facility and to inform them the resident had [DIAGNOSES REDACTED]. During an interview, on 1/22/18 at 3:15 p.m., the Administrator indicated CNA 20, who was with the resident at the time of the fall, had been suspended pending the investigation. The result of the investigation determined the CNA did not use a gait belt when she transferred the resident. Nor did the CNA report the fall to the nurse. Upon completion of the investigation, the CNA was terminated. An all staff inservice was completed on 1/16/18, and staff were re-educated on using gait belts. During an interview, on 1/23/18 at 9:44 a.m., COTA (Certified Occupational Therapy Assistant) 10 indicated the facility had no formal gait policy. They used the gait belt skills validation as their policy. She had provided the gait belt skills validation training on 1/16/18. All staff had to show competency in the gait belt validation at the completion of the training. On 1/23/18 at 9:46 a.m., COTA 10, provided a document, dated 2/2010, titled, Gait Belt-Application, and indicated it was the policy currently used by the facility. The policy indicated, Procedure Steps: .5. Place the belt over the resident's clothing and around the waist .7. Tighten the buckle until snug .9. Secure the belt through buckle .11. Proceed with transfer 2. Resident 78's record was reviewed on 1/23/18 at 9:53 a.m. A care plan, start date 1/14/15 and revised on 1/9/18, indicated the resident was at risk for falls and would not sit still and would stand independently. Fall risk assessment score was 21, which indicated she was at high risk for falls. Goals included, but was not limited to, resident fall risk factors will be reduced in an attempt to avoid significant fall related injury. A quarterly Minimum Data Set (MDS) set, dated 11/20/17, indicated the resident was an extensive assist of one for personal hygiene. A review of a fall event, dated 12/31/17, indicated the resident had a fall in the resident's room. The report indicated at 8:49 p.m., the Certified Nurse Aide (CNA) had put the resident to bed and reached for items just out of her reach. The resident rolled from the bed to the fall mat and bumped her head on the bed frame. A review of progress notes, dated 1/2/18, indicated the resident had a witnessed fall. The resident was laying in bed while care was provided by a CNA. The CNA turned to reach for items. At this time the resident rolled from bed onto mat and landed on her right side and hit her head on bed rail. Resident had bump on the right side her of forehead. Route cause was CNA leaving the resident too close to the edge of bed when getting items. The interventions were education of staff to move resident to center of bed when leaving bedside, and bed frame pushed in below mattress. During an interview on 1/23/18 at 3:50 p.m., the Administrator indicated the interdisciplinary team conducted an investigation and found that the resident was left close to the edge of bed and the CNA turned to get items to provide care and the resident rolled out of bed. The staff must ensure resident safety when care was provided. An inservice was provided to the CNA and the bed frame was pushed in to go under the mattress. On 1/23/18 at 4:04 p.m., the Administrator provided a document titled, Fall Management Program, and indicated it was the policy currently being used by the facility. The policy indicated, It is the policy of American Senior Communities to ensure residents residing within the facility receive adequate supervision and or assistance to prevent injury related falls . Fall risk: . 4. All residents with a score greater than 0 are considered at risk for falls 3a. During an observation the Maintenance Director checked the water temperature on 1/16/18 at 2:33 p.m. Residents' 78, 35, 99, and 13 shared bathroom had a hot water temperature of 131.3 degrees Farenheit (F) per the facility's thermometer. a. Resident 78's record was reviewed on 1/22/18 at 2:20 p.m. A quarterly Minimum Data Set (MDS) assessment, dated 11/30/17, indicated Resident 78 had a severe cognitive impairment. [DIAGNOSES REDACTED]. b. Resident 35's record was reviewed on 1/22/18 at 2:32 p.m. A quarterly MDS assessment, dated 10/24/17, indicated Resident 35 was cognitively intact. [DIAGNOSES REDACTED]. c. Resident 99's record was reviewed on 1/17/18 at 2:02 p.m. A significant change MDS assessment, dated 12/18/17, indicated Resident 99 was severely cognitively impaired. [DIAGNOSES REDACTED]. A nurse's note, dated 10/22/17, indicated Resident 99 transferred herself into the bathroom and washed her hands after using the toilet. A nurse's note, dated 12/18/17, indicated Resident 99 had taken herself to the bathroom. During an interview on 1/16/18 at 2:51 p.m., CNA 3 indicated Resident 99 was sometimes able to take herself to the bathroom. d. Resident 13's record was reviewed on 1/22/18 at 2:44 p.m. A quarterly MDS assessment, dated 12/28/17, indicated Resident 13 was severely cognitively impaired. [DIAGNOSES REDACTED]. 3b. During an observation the Maintenance Director checked the water temperature on 1/16/18 at 2:35 p.m. Residents' 29, 85, 311, and 27 shared bathroom had a hot water temperature of 131.5 degrees F per the facility's thermometer. a. Resident 29's record was reviewed on 1/22/18 at 2:53 p.m. A quarterly Minimum Data Set (MDS) assessment, dated 10/11/17, indicated Resident 29 had a moderate cognitive impairment. [DIAGNOSES REDACTED]. b. Resident 85's record was reviewed on 1/22/18 at 3:04 p.m. A 14 day MDS assessment, dated 12/20/17, indicated Resident 85 had a moderate cognitive impairment. [DIAGNOSES REDACTED]. c. Resident 311's record was reviewed on 1/22/18 at 10:31 a.m. Resident 311 was admitted on [DATE], and an MDS assessment had not yet been completed. [DIAGNOSES REDACTED]. During an interview on 1/22/18 at 1:55 p.m., the Social Services Director (SSD) indicated Resident 311 was intellectually disabled. d. Resident 27's record was reviewed on 1/22/18 at 3:30 p.m. A quarterly MDS assessment, dated 10/9/17, indicated Resident 27 was cognitively intact. [DIAGNOSES REDACTED]. During an interview on 1/16/18 at 2:51 p.m., CNA 3 indicated Resident 27 was able to take himself to the bathroom. During an interview on 1/19/18 at 11:01 a.m., Resident 27 indicated he was able to take himself to the bathroom. 3c. During an observation the Maintenance Director checked the water temperature on 1/16/18 at 2:37 p.m. Residents' 93, 69, and 105 shared bathroom had a hot water temperature of 128 degrees F per the facility's thermometer. a. Resident 93's record was reviewed on 1/22/18 at 3:14 p.m. A 14 day Minimum Data Set (MDS) assessment, dated 1/13/18, indicated Resident 93 had a severe cognitive impairment. [DIAGNOSES REDACTED]. unspecified, and [MEDICAL CONDITION] with late onset. During an interview on 1/16/18 at 2:51 p.m., Certified Nursing Assistant (CNA) 3 indicated Resident 93 was independent and was able to take herself to the bathroom. b. Resident 69's record was reviewed on 1/22/18 at 3:21 p.m. A quarterly MDS assessment, dated 11/22/17, indicated Resident 69 was cognitively intact. [DIAGNOSES REDACTED]. c. Resident 105's record was reviewed on 1/22/18 at 1:13 p.m. An annual MDS assessment, dated 12/28/17, indicated Resident 105 was cognitively intact. Resident 105 required extensive assistance for activities of daily living (ADL's). [DIAGNOSES REDACTED]. 3d. During an observation the Maintenance Director checked the water temperature on 1/16/18 at 2:43 p.m. Resident 79's sink in her room had a hot water temperature of 123.3 degrees F per the facility's thermometer. Resident 79's record was reviewed on 1/19/18 at 11:13 a.m. A quarterly Minimum Data Set (MDS) assessment, dated 11/30/17, indicated Resident 79 was severely cognitively impaired. [DIAGNOSES REDACTED]. During an interview on 1/16/18 at 2:36 p.m., the Maintenance Director indicated water temperatures were checked daily in 2 different locations. During an interview on 1/16 at 2:39 p.m., the Maintenance Director indicated hot water temperatures should have been between 100 degrees F and 120 degrees F. The water in the shared bathroom was way too hot and he would adjust the water temperature. A document titled, Water Temperatures, was provided by the Administrator on 1/16/18 at 3:29 p.m. The document did not indicate any temperatures outside the parameters of 100 degrees F and 120 degrees F. During an interview on 1/22/18 at 3:40 p.m., the Administrator indicated there was no facility policy for hot water temperatures. The water should not have been hotter than 120 degrees F. 3e. During an observation on 1/16/18 at 2:00 p.m. Resident 32's bathroom sink was too hot to hold hands under the water for more than a few seconds without burning the skin. The Maintenance Supervisor (MS) checked the water temperature 1/16/18 at 2:45 p.m. and indicated the temperature was too warm at 122.1 degrees Fahrenheit (F) per the facility's thermometer and should be between 100 to 120 degrees Fahrenheit. Resident 32's record was reviewed on 1/18/18 at 2:47 p.m. [DIAGNOSES REDACTED].) A Minimum Data Set (MDS) assessment, dated 10/18/17, indicated Resident 32 was cognitively intact and required assistance of two persons for transfers and required one person for bathing/showering. 3f. During an observation with the MS on 1/16/18 at 2:48 p.m., the water temperature in Resident 72's and Resident 86's shared bathroom was 124.3 degrees Fahrenheit per the facility's thermometer. The MS indicated the hot water in room [ROOM NUMBER] was too warm and he checked random resident bathrooms water temperatures daily, kept a temperature log, and had not had any water temperatures in the facility more than 120 degrees Fahrenheit. Resident 72's record was reviewed on 1/18/18 at 3:00 p.m. [DIAGNOSES REDACTED]. A MDS assessment, dated 11/22/17, indicated Resident 72 was moderately impaired and required supervision for bathing/showering. Resident 86's record was reviewed on 1/18/18 at 3:25 p.m. [DIAGNOSES REDACTED]. A MDS assessment, dated 1/13/18, indicated Resident 86 was cognitively intact and required supervision for bathing/showering. During an interview with the Administrator on 1/16/18 at 3:12 p.m., she indicated the facility did not have a policy regarding water temperatures, but followed the State guidelines for safe water temperatures of 100 to 120 degrees Fahrenheit; there had been no [MEDICAL CONDITION] scalding's as a result of water temperatures. The Medicare State Operation Manual, Rev. 133, (02-06-15) was referenced for safe water temperatures for bathing and indicated 100 degrees F was a safe temperature. Page 338 of the manual indicated the time required for 3rd [MEDICAL CONDITION] water temperatures of 124 degrees F was 3 minutes, 127 degrees F was 1 minute, 133 degrees F was 15 seconds, and 140 degrees F was 5 seconds. 3.1-45(a)(1) 3.1-45(a)(2)