Every finding on record at Bethel Manor

Based on observation, interview and record review, the facility failed to ensure residents privacy. Staff did not knock on resident doors before entering to deliver meal trays. (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER]) Finding includes: The following was observed during the delivery of meal trays at supper on 3/12/26:At 5:06 p.m., CNA 3 was observed to enter room [ROOM NUMBER] with a meal tray without knocking or announcing himself. At 5:07 p.m., CNA 2 was observed to enter room [ROOM NUMBER] with a meal tray without knocking or announcing herself. At 5:10 p.m., CNA 2 was observed to enter room [ROOM NUMBER] with a meal tray without knocking or announcing herself. At 5:11 p.m., CNA 3 was observed to enter room [ROOM NUMBER] and deliver a meal tray without knocking or announcing himself. At 5:12 p.m., CNA 2 was observed to enter room [ROOM NUMBER] and deliver a meal tray without knocking or announcing herself.At 5:13 p.m., CNA 3 was observed to enter room [ROOM NUMBER] and deliver a meal tray without knocking or announcing himself. On 3/16/26 at 11:37 a.m., CNA 4 indicated before going into a resident room, you should knock, announce yourself, let the resident know what department you are with, ask if you can come in room. On 3/16/26 at 11:44 a.m., the Assistant Administrator provided the current policy on promoting/maintaining resident dignity with a revision date of 2025. The policy indicated it was the practice of the facility to protect and promote resident rights and treat each resident with respect and dignity. This citation relates to Intake 2738912.410 IAC (Indiana Administrative Code) 16.2-3.1-3(a)

Based on observation, interview, and record review, the facility failed to store and prepare food under sanitary conditions during 3 of 3 kitchen observations. Food was not labeled correctly, expired food was not disposed of, hairnets were not worn properly, and staff placed their fingers in their mouth during food service. (Main Kitchen, Cottage Kitchen, Dietary [NAME] 9)Findings include: 1. On 8/19/25 at 8:55 A.M., the following was observed during the initial tour of the Main Kitchen:In large reach-in refrigerator:1 gallon jug of coleslaw, dated 7/2 with a best by date of 6/5/25.On the spice rack at the preparation table:2 bottles of chili pepper with no open date1 bottle of lemon pepper with no open date1 bottle of sage with no open date1 bottle of pepper with no open date1 bottle of nutmeg with no open date1 bottle of cinnamon with no open date1 bottle of ginger with no open date1 jar black pepper with no lid or openIn the dry storage area:bag of chips with no open date1 bag of sprinkles with no open date1 bottle of oregano with no open date1 bottle of white vinegar, best by date 11/3/22 and dated 6/63 jugs of salsa, best by date 1/25/25The following staff were observed in the Main Kitchen with improper hairnet placement:Dietary Aide 13 - hair at base of neck was not coveredDietary Aide 7 - hair on side of head by ears was not coveredDietary Manager - bangs on forehead was not covered 2. On 8/19/25 at 9:35 A.M., during the initial tour of the Cottage Kitchen the following was observed:In the dry storage:1 bag of stuffing with no open date1 container of garlic, best by date 6/2022 and open date 3/251 bottle of pepper with no open dateReach-in Refrigerator:1 container of turkey bacon with no open date3. On 8/19/25 at 12:05 P.M., during a random dining observation in the Cottage Kitchen, Dietary [NAME] 9 was observed wiping a drizzle of gravy off a resident's plate with her finger. She put the finger in her mouth and then served the resident the plate without washing her hands.During an interview on 8/19/25 at 9:30 A.M., the Dietary Manager indicated that she should date items when opened.During an interview on 8/22/25 at 9:00 A.M., the Dietary Manager indicated that hair nets should completely cover the hair. At that time, she indicated that no one should use bare fingers to wipe off food drizzles from resident plates. On 8/22/25 at 10:53 A.M., the Administrator provided a current Date Marking for Food Safety policy, dated 3/26/25, that indicated .the individual opening or preparing the food shall date mark the item at the time of opening .On 8/22/25 at 10:56 A.M., the Administrator provided a current Dietary Employee Personal Hygiene policy, dated 3/26/25, that indicated all dietary staff must wear hair restraints .hairnets .to prevent contact with food .3.1-21(i)(2)3.1-21(i)(3)

Based on record review and interview, the facility failed to develop a plan of care related to recurrent urinary tract infections (UTIs), or medication used to treat recurrent UTIs, for 1 of 1 resident reviewed for UTIs. (Resident 3) Finding includes:On 8/20/25 at 1:06 P.M., Resident 3's clinical record was reviewed. Resident 3 was admitted on [DATE]. Diagnoses included, but were not limited to, Alzheimer's disease. The most recent Significant Change Minimum Data Set (MDS) Assessment, dated 5/27/25, indicated Resident 3's cognition was too low to be assessed, and that Resident 3 was dependent on staff (staff does all of the work) for eating, toileting, bathing, and transfers. Physician orders included, but were not limited to: D-Mannose Oral Capsule 500 MG (milligrams) Give one capsule by mouth one time a day for UTI prevention, Start date 8/9/25 Laboratory results indicated Resident 3 had positive urinary tract infection cultures on 10/17/24, 7/24/25, 8/7/25. A nursing progress note, dated 8/20/25 at 12:56 P.M., indicated Resident 3 was admitted to the hospital for a urinary tract infection and encephalopathy. The clinical record, including care plan, progress notes, and assessments, lacked a plan of care related to Resident 3's recurrent urinary tract infections, monitoring, or the medication used to treat recurrent urinary tract infections. During an interview on 8/22/25 at 9:46 A.M., the Infection Preventionist Nurse indicated Resident 3 had frequent UTIs causing an ongoing decline in condition. On 8/22/25 at 10:56 A.M., the Administrator provided a policy titled Comprehensive Care Plans, dated 2/5/25, indicated The care plan must include services to maintain the Resident's highest practicable well-being .and individualized interventions. 3.1-35(a)

Based on interview and record review, the facility failed to ensure care plans were revised after a fall for 3 of 6 residents reviewed for falls. (Resident 7, Resident 54, Resident 3)Findings include:1. On 8/21/25 at 8:39 A.M., Resident 7's clinical record was reviewed. Diagnoses included, but were not limited to, dementia. The most current Annual Minimum Data Set (MDS) Assessment, dated 8/5/25, indicated Resident 7 was not assessed for cognitive impairment due to being rarely or never understood, was independent for transfers and required supervision of staff for toileting, and had no falls since the prior assessment. A care plan conference was completed on 7/29/25. Notes indicated to continue with the current plan of care. A current risk for falls care plan, revised on 6/25/25, indicated Resident 7 had a history of falls with multiple risk factors. A nursing progress note, dated 4/14/25 at 3:44 P.M., indicated Resident 7 sustained a witnessed fall while pacing the hallway faster than her usual pace. The clinical record lacked documentation to indicate that the Interdisciplinary Team (IDT) met to review that fall. The care plan was not updated with a new intervention following that fall. On 8/22/25 at 8:30 A.M., the Administrator provided a document that indicated the IDT requested a medication review in relation to the fall on 4/14/25. A psychiatric assessment, dated 4/18/25, indicated medications were reviewed and no changes were made.On 8/22/25 at 8:56 A.M., the Administrator indicated the root cause of the resident's fall was anxiety. Visits from the mental health provider were increased, but it was not put into the plan of care. 2. On 8/20/25 at 12:55 P.M., Resident 54's clinical record was reviewed. Diagnoses included, but were not limited to, Alzheimer's disease. The most current Annual Minimum Data Set (MDS) Assessment, dated 6/10/25, indicated Resident 54 was not assessed for cognitive impairment due to being rarely or never understood, was dependent on staff (staff does all of the work) for transfers and toileting, and had no falls since the prior assessment. A care plan conference was completed on 6/4/25. Notes indicated to continue with the current plan of care. A current risk for falls care plan, dated 7/8/22, indicated Resident 54 had a history of falls with multiple risk factors. A nursing progress note, dated 1/27/25, indicated that Resident 54 sustained an unwitnessed fall in his room. The resident was unable to voice why he fell. The clinical record lacked documentation to indicate that the Interdisciplinary Team (IDT) met to review that fall. The care plan was not updated with a new intervention following that fall. On 8/22/25 8:30 A.M., the Administrator provided a written statement that indicated no new intervention was initiated at the time of the fall on 1/27/25. 3. On 8/20/25 at 1:06 P.M., Resident 3's clinical record was reviewed. Resident 3 was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, Alzheimer's disease. The most recent Significant Change Minimum Data Set (MDS) Assessment, dated 5/27/25, indicated Resident 3's cognition was too low to be assessed, was dependent on staff (staff does all of the work) for eating, toileting, bathing, and transfers, and had no falls since the prior assessment. The care plan included, but was not limited to: Resident is a risk for falls characterized by history of falls/injury, multiple risk factors related to: impaired mobility, weakness, unsteadiness, polyneuropathy, use of psychotropic medications, cognitive status, use of assistive device. Date Initiated: 3/12/24 Revision on: 6/2/25 The clinical record indicated Resident 3 experienced falls on 1/28/25 and 7/3/25. The plan of care lacked new interventions added to the plan of care for the falls occurring on 1/28/25 and 7/3/25. On 8/22/25 at 8:56 A.M., the Administrator indicated that staff didn't always put interventions in the plan of care, but they should because it could be used as a tracking tool to make previously tried interventions easier to find. On 8/22/25 at 10:56 A.M., the Administrator provided a policy titled Care Plan Revisions Upon Status Change, dated 9/18/24, that indicated It is the policy of this facility to maintain a consistent process for reviewing and revising the care plan whenever a resident experiences a status change. Upon identification of a change in status .the care plan will be updated with new or modified interventions. 3.1-35(d)(2)(B)3.1-35(e)

Based on observation, interview, and record review, the facility failed to ensure food was correctly prepared during 1 of 1 observation of puree altered diet preparation. (Dietary [NAME] 9)Finding includes: On 8/19/25 at 12:07 P.M., Dietary [NAME] 9 was observed preparing one serving of pureed meat loaf. Dietary [NAME] 9 added the following ingredients to the blender:1 slice of meat loaf unknown amount of milk The recipe for Meatloaf Pureed Thick was reviewed. Ingredients for 20 servings included:5 pounds and 12 ounces meatloaf2 and 5/8 teaspoon beef base2 3/4 cup hot water1/3 cup and 2/3 teaspoon food thickener During an interview on 8/19/25 at 12:10 P.M., Dietary [NAME] 9 indicated she should follow the recipe instead of using milk. On 8/22/25 at 10:56 A.M., the Administrator provided a current Puree Recipe policy, dated 3/26/25, that indicated .all pureed items will be prepared using facility-approved, standardized recipes . 3.1-21(a)(3)

Based on observation, record review, and interview, the facility failed to ensure infection control practices and standards were performed during 2 of 2 random observations. Staff did not use Personal Protective Equipment (PPE) for a resident on Enhanced Barrier Protection (EBP) and did not clean blood pressure equipment between residents. (Resident 2, Resident 63, and Resident 64)Findings include: 1. On 8/19/25 at 11: 52 A.M., during a random observation of care for Resident 2, Certified Nursing Aide (CNA) 3 was observed transferring Resident 2 from the bed to a Broda chair without wearing a gown. An Enhanced Barrier Precaution (EBP) sign was observed on the resident's door. On 8/22/25 at 8:22 A.M., Resident 2's clinical record was reviewed. Diagnoses included, but were not limited to, Parkinson's Disease and unspecified protein-calorie malnutrition. The most current Significant Change Minimum Data Set (MDS) Assessment, dated 8/19/25, indicated Resident 2 was severely cognitively impaired. Resident 2 was dependent on staff for eating, transferring, hygiene, and dressing. The resident had a Percutaneous Endoscopic Gastrostomy Tube (PEG) for nutrition. Current physician orders included, but were not limited to:Enhanced Barrier Precautions due to PEG tube per facility protocol every day and night shift for PEG tube, dated 6/30/25 A care conference was conducted on 8/13/25 and the care plan was reviewed. The current care plan for skin impairment was revised on 8/13/25. Interventions included, but were not limited to:Enhanced Barrier Precautions in high contact activities, dated 8/6/25. During an interview on 8/20/25 at 9:46 A.M., CNA 3 indicated the equipment outside of Resident 2's room was for Transmission Based Precautions (TBP) and a gown should have been applied before entering the room. 2. During an observation on 8/22/25 at 7:16 A.M., Licensed Practical Nurse (LPN) 14 used a blood pressure cuff to obtain a blood pressure from Resident 63. LPN 14 then went to the medication room and gathered medications. LPN 14 then used the blood pressure cuff to obtain a blood pressure from Resident 64 without sanitizing the blood pressure cuff. During an interview on 8/22/25 at 9:10 A.M., the Infection Preventionist Nurse indicated shared medical equipment should be cleaned after each use. On 8/22/25 at 10:56 A.M., the Administrator provided a policy titled Cleaning and Disinfection of Resident-Care Equipment, dated 7/1/25, that indicated Multi-resident use items are cleaned and disinfected between each use. On 8/22/25 at 10:56 A.M., the Administrator provided a current Enhanced Barrier Precautions policy, dated 4/24/25, that indicated .EBP are implemented for residents who have a . indwelling device . gloves and gloves should be used when performing high-contact activities with residents . 3.1-18(b)(1)3.1-18(b)(2)

Based on observation, interview, and record review, the facility failed to ensure food was served in a sanitary manner in accordance with professional standards for food service safety for 2 of 2 observations of the kitchen. Floors and equipment were soiled. (Kitchen) On 3/4/25 at 9:30 a.m., the kitchen was observed to have the following: 1. The burners on the stove had grease and food build up. 2. Debris was observed on the floor under the two and three compartment sinks, under the racks that held the pots and pans, under stainless steel prep tables, in the dishwasher area, around the hot water heater, under the stove and steam table. 3. The hot water heater had dirt/dust on the top of heater and on the pipes. 4. Five food carts had debris on the surfaces. 5. The side of the steamer unit had debris. The same was observed on 3/5/25 at 11:05 a.m. On 3/5/25 at 11:07 a.m. Dietary Aide 2 indicated night staff are supposed to sweep and mop the floors, including under equipment, all staff have a schedule for what is supposed to be cleaned. On 3/5/25 at 12:01 p.m., the Dietary Manager provided the current policy food safety requirements with a revision date of February 2023. The policy included, but was not limited to: It is the policy of the facility to procure food from sources approved or considered satisfactory by federal, state and local authorities. Food will be stored, prepared, distributed and served in accordance with professional standards for food service safety . On 3/5/25 at 11:59 a.m., the Dietary Manger provided the current kitchen cleaning schedules. The schedule included, but was not limited to: .clean the 2 & 3 compartment sink areas .clean stove top area .clean both cooks tables including tops & underneath Clean all regular 3 tier carts . This citation relates to Complaint IN00453432. 3.1-21(i)(3) 3.1-21(i)(2)

Based on observation, interview, and record review, the facility failed to ensure Enhanced Barrier Precautions (EBP) were implemented for 3 of 3 residents reviewed for transmission based precautions, and failed to position fans to prevent cross contamination in the laundry processing area for 1 of 2 random observations of the laundry room. (Resident 57, Resident 60, Resident 17, and Laundry Room) Findings include: 1. On 7/23/24 at 7:57 A.M., a PPE (personal protective equipment) cart was observed outside of Resident 57's room. There was no sign observed indicating instructions for specific use of the PPE or to see the nurse before entering the room. On 7/23/24 at 8:00 A.M., Resident 57's clinical record was reviewed. The clinical record lacked orders, care plans, and progress notes related to transmission based precautions. On 7/23/24 at 8:15 A.M., Licensed Practical Nurse (LPN) 23 indicated that Resident 57 was on EBP because he had a feeding tube. 2. On 7/23/24 at 8:15 A.M., LPN 23 indicated Resident 60 was on EBP because he had an indwelling urinary catheter. At that time, she indicated they do not hang signs to indicate instructions for PPE use, but there is usually a flyer hanging in the nurse's station. She could not locate the flyer in the nurse's station. On 7/23/24 at 8:23 P.M., no PPE cart or sign was observed outside of Resident 60's room indicating transmission based precaution requirements. At that time, LPN 23 indicated Resident 60 had just gotten the catheter and the PPE cart hadn't been put out yet. On 7/23/24 at 8:34 A.M., Resident 60's clinical record was reviewed. Current physician orders included, but was not limited to: Foley Catheter for retention, dated 7/20/2024. The clinical record lacked orders, care plans, and progress notes related to transmission based precautions. 3. On 7/23/24 at 9:30 A.M., a PPE cart was observed outside of Resident 17's room. There was no sign observed indicating instructions for specific use of the PPE or to see the nurse before entering the room. LPN 25 indicated that residents who were on transmission based precautions had a bumblebee sticker on their nameplate. Staff got the indication for precautions and instructions for PPE use during report or had to look through the physician orders. On 7/23/24 at 9:36 A.M., Resident 17's clinical record was reviewed. Physician orders included, but was not limited to: Observe Enhanced Barrier Precautions - every shift for indwelling Foley catheter, dated 4/23/24 On 7/24/24 at 2:36 P.M., the Infection Preventionist indicated that residents who were on EBP had a bumblebee sticker on their nameplate which would signify to anyone who went into the room that they needed some form of PPE. She indicated either she or the admitting nurse was responsible for placing the signage and PPE carts outside of the room upon order. On 7/25/24 at 10:15 A.M., the Administrative Support indicated any resident who required EBP should have a physician's order and a care plan for it. 4. On 7/21/24 at 12:47 P.M., a fan was observed sitting on top of the small washing machine blowing from side of room where soiled linen was stored to the side of the room where clean linen was stored. On 7/25/24 at 11:32 A.M., the Environmental Services Manager indicated that laundry staff had a fan in the laundry processing area, but the fan was supposed to stay on the clean side of the room and not blow from dirty to clean. On 7/26/24 at 9:13 A.M., the Administrative Support provided an Enhanced Barrier Precautions Policy that indicated Clear signage will be posted on the door or wall outside of the resident room indicating the type of precautions, required personal protective equipment (PPE), and the high-contact resident care activities that require the use of gown and gloves . An order for enhanced barrier precautions will be obtained for residents with any of the following: wounds and/or indwelling medical devices (e.g., central line, urinary catheter, feeding tube .) . Make gowns and gloves available immediately outside of the resident's room. On 7/26/24 at 9:13 A.M., the Administrative Support provided an Infection Prevention and Control Program, revised 1/24/2024, that indicated Laundry and direct care staff shall handle, store, process, and transport linens to prevent spread of infection. On 7/26/24 at 9:13 A.M., the Administrative Support provided a Laundry policy, undated, that indicated Soiled laundry shall be kept separate from clean laundry at all times. 3.1-18(b)(1) 3.1-18(b)(2)

Based on interview and record review, the facility failed to ensure residents requiring assistance with Activities of Daily Living (ADLs) received adequate assistance with showering/bathing for 4 of 4 residents reviewed for dependent ADL care. (Resident 28, Resident 37, Resident 57, Resident 6) Findings include: On 7/23/24 at 3:10 P.M., multiple Resident's attending the Resident Council meeting voiced concern of not receiving routine showers and/or complete bed baths as scheduled. 1. On 7/23/24 at 10:12 A.M. Resident 28's clinical record was reviewed. Diagnoses included, but were not limited to, Alzheimer's Disease and polyosteoarthritis. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 5/8/24, indicated Resident 28 was severely cognitively impaired and required substantial assistance from staff for toileting, bathing, and transfers. A self-care deficit care plan, dated 3/26/18, indicated Resident 28 had need for assistance with personal care and should receive a shower twice weekly and partial bath all other days. The Point of Care (POC) (a Certified Nurse Aide documentation system) Tasks for showering indicated the Resident received showers on Tuesdays and Fridays. A record review from 5/1/24 through 7/26/24 indicated Resident 28 had only received 3 of 25 scheduled showers, with no documented refusals. 2. On 7/23/24 at 1:59 P.M., Resident 37's clinical record was reviewed. Diagnoses included, but were not limited to, Alzheimer's Disease and anxiety. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 6/4/24, indicated Resident 37 was severely cognitively impaired and required substantial assistance from staff for toileting and bathing. A self-care deficit care plan, dated 4/26/21, indicated Resident 37 had need for assistance with personal care and should receive a shower twice weekly and partial bath all other days. The Point of Care (POC) (a Certified Nurse Aide documentation system) Tasks for showering indicated the Resident received showers on Mondays and Thursdays. A record review from 5/1/24 through 7/26/24 indicated Resident 37 had only received 8 of 25 scheduled showers, with one documented refusal on 5/2/24. 3. On 7/24/24 at 8:53 A.M. Resident 57's clinical record was reviewed. Diagnoses included, but were not limited to, dysphagia and muscle weakness. The most recent Admission MDS (Minimum Data Set) Assessment, dated 6/17/24, indicated Resident 57 was moderately cognitively and was completely dependent on staff for toileting and showers. A self-care deficit care plan, dated 6/11/24, indicated Resident 57 required assistance with personal care and should receive a shower twice weekly and partial bath all other days. The Point of Care (POC) (a Certified Nurse Aide documentation system) Tasks for showering indicated the Resident received showers twice a week starting 6/10/24. A record review from 6/10/24 through 7/26/24 indicated Resident 57 had only received 3 showers in the past 7 weeks, with no documented refusals. 4. On 7/25/24 at 11:18 A.M., Resident 6's clinical record was reviewed. Diagnoses included, but were not limited to, diabetes and chronic kidney disease. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 4/23/24, indicated Resident 6 was severely cognitively impaired and required substantial assistance from staff for toileting and bathing. A self-care deficit care plan, dated 1/16/24, indicated Resident 6 required assistance with personal care and should receive a shower twice weekly and partial bath all other days. The Point of Care (POC) (a Certified Nurse Aide documentation system) Tasks for showering indicated the Resident should receive showers twice a week. A record review from 5/1/24 through 7/26/24 indicated the Resident 6 had only received twice weekly showers for 5 weeks during the 12 week period. During an interview on 7/25/24 at 1:51 P.M., the DON (Director of Nursing) indicated Resident's should receive at least two (2) showers each week, or a complete bed bath only if it is their personal preference, and should receive a partial bed bath each day, and staff should document showers given or refused in the POC tasks each day. On 7/25/24 at 1:30 P.M., a shower policy was request but was not provided. 3.1-38(a)(3)

Based on interview and record review, the facility failed to ensure residents with limited range of motion or mobility received services to maintain or improve mobility for 4 of 4 residents reviewed for restorative therapy. (Resident 6, Resident 28, Resident 52, Resident 55) Findings include: 1. On 7/23/24 at 10:12 A.M. Resident 28's clinical record was reviewed. Diagnoses included, but were not limited to, Alzheimer's Disease and polyosteoarthritis. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 5/8/24, indicated Resident 28 was severely cognitively impaired and required substantial assistance from staff for toileting, bathing, and transfers. Current care plans included, but were not limited to: Resident requires RNP (Restorative Nursing Program) of ROM (Range of Motion), Date initiated 11/2/22. Resident to perform BLE (bilateral lower extremities) exercises throughout all planes x 20 reps or on cubii pedaler on Level 1 for 15 minutes 3-4x/week, Date initiated: 11/9/23. Resident to perform BUE (bilateral upper extremities) strengthening exercises at 1-2 sets of 15 reps utilized light resistance thera-band (red) 3-4x/week, Date initiated: 11/9/23. Resident will perform BUE (bilateral upper extremities) strengthening exercises on arm bike x6-8 min with rest breaks as needed (2 sets) 3-4x/week, Date initiated 7/21/23. The Point of Care (POC) (a Certified Nurse Aide documentation system) Tasks for restorative nursing therapy was reviewed from 5/1/24 through 7/26/24 and indicated Resident 28 had only received 5 days of restorative nursing therapy during the 12 week period. 2. On 7/25/24 at 11:18 A.M., Resident 6's clinical record was reviewed. Diagnoses included, but were not limited to, diabetes and chronic kidney disease. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 4/23/24, indicated Resident 6 was severely cognitively impaired and required substantial assistance from staff for toileting and bathing. Current care plans included, but were not limited to: Resident requires RNP (Restorative Nursing Program) of ROM (Range of Motion) due to diabetes insipidus, impaired mobility, and to help resident remain at his highest level of physical functioning, Date initiated: 3/13/24. Resident will perform BUE strengthening exercises x 10 reps; BLE exercises x 10 reps (2 sets) seated 3-4x/week x 90 days. Resident will walk > (greater/more than) 200ft 3-4x/week Date initiated, 3/13/24. The Point of Care (POC) (a Certified Nurse Aide documentation system) Tasks for restorative nursing therapy was reviewed from 5/1/24 through 7/26/24 and indicated Resident 6 had only received 5 days of restorative nursing therapy during the 12 week period. 38770 3. On 7/23/24 at 11:42 A.M., Resident 52's clinical record was reviewed. Diagnosis included, but were not limited to, hemiplegia and hemiparesis following cerebral infarction affecting unspecified side. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 6/18/24, indicated no cognitive impairment, no behaviors, and no days of restorative. Resident 52 required supervision assistance of one staff with transfers. A current restorative nursing program care plan, dated 7/6/23, indicated an intervention but was not limited to, resident to walk up to 150-200 feet with staff 3-4 times per week, dated 5/17/24. In the last 30 days, Resident 52 had received restorative nursing that entailed resident walking up to 150-200 feet with staff on 7/21/24 for 10 minutes. On 6/27/24, Resident 52 refused. All other dates were not completed. On 7/24/24 at 9:50 A.M., the Director of Nursing (DON) indicated they had been trying to get a dedicated Certified Nurse Aide (CNA) for restorative nursing, but currently did not have one. She indicated whatever CNA was working was responsible for doing restorative nursing tasks with the residents. On 7/24/24 at 9:59 A.M., CNA 3 indicated restorative nursing range of motion exercises were performed with Resident 52 in the room with transfers. She indicated there was nothing in particular that needed to be done with the resident as far as which extremities and whatever was done was supposed to be documented in the clinical record. 46758 4. On 7/22/24 at 12:22 P.M., Resident 55 was observed sitting in wheelchair in dining room with wife. On 7/23/24 at 9:00 A.M., Resident 55 was observed sitting in wheelchair in room watching television. On 7/25/24 at 10:20 A.M., Resident 55 was observed sitting in wheelchair in room after morning care. On 7/25/24 at 2:17 P.M., Resident 55's clinical record was reviewed. Diagnoses included but were not limited to, Type 2 diabetes mellitus with diabetic neuropathy, unspecified and peripheral vascular disease, unspecified. The current Quarterly MDS (Minimum Data Set) assessment dated [DATE] indicated the resident was cognitively intact. The resident needed substantial help toileting and transferring. MDS indicated there was a restorative program. During the 7 days look back period 0 minutes were recorded daily for restorative care. The medical record lacked current physician orders for restorative care. The current care plan indicated the resident requires RNP (Restorative Nursing Program) related to impaired mobility due to diabetic neuropathy. Interventions included but were not limited to: Resident will perform active ROM (Range of motion) to BUE( Bilateral Upper Extremities) for strengthening seated or supine x(Times) 15 minutes 3-4x /week x 90 days and resident will walk 50-100 feet with FWW(Full Weight Bearing) and GB(Gait Belt), Min A-CGA (Minimum Activity -Comprehensive Geriatric Assessment 3-4x/week dated 4/15/24. On 7/25/24 at 1:55 P.M., LPN (Licensed Practical Nurse) 2 provided the CNA(Certified Nurse Aide) Tasks for Nursing Rehabilitation that was for Active ROM BUE for strengthening seated or supine x15 minutes 3-4x/week the only days from 6/26/240-7/22/24 that included Nursing Rehabilitation times were as follows: 6/30/24 at 2:40 P.M. for 15 minutes 7/1/24 at 9:29 P.M. for 5 minutes 7/8/23 at 6:29 P.M. for 15 minutes 7/9/24 at 3:15 P.M. for 15 minutes 7/21/24 at 6:29 P.M. for 4 Minutes 7/22/24 at 6:29 P.M. for 3 minutes During an interview on 7/25/24 at 1:50 P.M., LPN 2 indicated there was no restorative aide for the facility. On 7/26/24 at 8 A.M., Administrative Support provided an undated policy titled Restorative Nursing Program that indicated It is the policy of this facility to provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level. Restorative aides will implement the plan for a designated length of time, performing the activities, and documenting on the Restorative Aide Documentation Form. The Restorative Nurse, or designated licensed nurse, will provide oversight of the restorative aide activities, review the documentation at least weekly, and evaluate the effectiveness of the plan monthly. On 7/24/24 at 10:45 A.M., the DON provided a current Restorative Nursing Services policy, revised 7/2017, that indicated Residents will receive restorative nursing care as needed to help promote optimal safety and independence At that time, the Administrative Support indicated restorative nursing had not been done. On 7/26/24 at 8 A.M., Administrative Support provided an undated policy titled Restorative Nursing Program that indicated It is the policy of this facility to provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level. Restorative aides will implement the plan for a designated length of time, performing the activities, and documenting on the Restorative Aide Documentation Form. The Restorative Nurse, or designated licensed nurse, will provide oversight of the restorative aide activities, review the documentation at least weekly, and evaluate the effectiveness of the plan monthly. On 7/24/24 at 10:45 A.M., the DON provided a current Restorative Nursing Services policy, revised 7/2017, that indicated Residents will receive restorative nursing care as needed to help promote optimal safety and independence At that time, the Administrative Support indicated restorative nursing had not been done. 3.1-42(a)(1) 3.1-42(a)(2)

Based on observation, interview, and record review, the facility failed to ensure dishwasher temperatures and chemicals were within range and logs were completed for 1 of 2 kitchens observed. (Cottage kitchen) Findings include: 1. On 7/21/24 at 10:14 A.M. during an initial kitchen tour of the Cottage, Dietary Aide 40 indicated the dishwasher was a high temperature dishwasher, but she was unsure what the temperature was supposed to be when the machine was running. She indicated there was water on the floor when she came in that morning so she was not certain if the machine was functioning properly and would call maintenance to look at it. At that time, Dietary Aide 40 provided the dishwasher temperature logs for June and July. Sixty-Four of 90 opportunities for wash and rinse temperature testing were not filled out in June. Fifty-one of 61 opportunities for wash and rinse temperature testing were not filled out in July. Dietary Aide 40 indicated she was supposed to fill out the temperature logs at the end of her shift. On 7/22/24 at 9:45 A.M., Dietary Aide [NAME] 10 indicated the dishwash temperature should get to 120 degrees Fahrenheit (F). She indicated that sometimes she had to run the cycle several times to get the temperature up to where it needed to be. At that time, she ran a dishwasher cycle. The dishwasher thermometer read 113 F. She ran the cycle again and the thermometer read 115 F. She ran the cycle five more times with the thermometer reading 116 F each time. At that time, she indicated she wasn't sure why it wasn't reaching 120 F and would let maintenance know. On 7/22/24 at 12:45 P.M., the Administrative Support provided the instruction manual for the Dishwasher, undated, that indicated Recommended temp 140 degrees F . required minimum temp 120 degrees F . follow the directions precisely that are on the litmus paper vial and test the water on the surface of the bottle of the glasses. Concentration should be 50 p.p.m. (parts per million) minimum to 100 p.p.m. maximum. If concentration is incorrect contact your chemical supplier . low heat during operation likely cause low incoming water temperature (below 140 degrees F). On 7/22/24 at 2:20 P.M., [NAME] 10 indicated there were chemicals hooked up to the dishwasher. The chemicals were dated 6/14. She indicated she tested the dishwasher chemicals with a test strip once a day if she remembered, but did not log the results anywhere. At that time, a dishwasher cycle was observed. [NAME] 10 used a test strip to test for p.p.m. of hypochlorite. The test strip read 0 p.p.m. On 7/23/24 at 7:42 A.M., a sign on the cottage dishwasher indicated Out of Order! Use 3 compartment sinks to wash and sanitize dishes! Thank you!. On 7/23/24 at 11:05 A.M., the Dietary Manager indicated that the Cottage dishwasher was a low temperature dishwasher. Staff should be recording the wash temperature and the sanitizing solution readings twice a day. She indicated the dishwasher log used in the Cottage was not the right form. She further indicated the dishwasher worked on and off and had told staff multiple times that if the wash temperature was not at or over 120 F or the chemicals were not reading to not use the dishwasher, but staff wouldn't listen. 2. On 7/21/24 at 10:14 A.M., Dietary Aide 40 provided the Cottage Equipment Temperature logs for June and July. The temperature logs indicated the following: The pantry refrigerator, pantry freezer, pantry freezer, kitchen refrigerator, and kitchen freezer temperatures were missing 13 times during the morning shift and 29 times during the evening shift in June, and 16 times during the morning shift and 20 times during the evening shift in July. At that time, Dietary Aide 40 indicated she was supposed to fill out the temperature logs at the end of her shift. On 7/26/24 at 9:13 A.M., the Administrative Support provided a Dishwasher Temperature policy, undated, that indicated For low temperature dishwashers (chemical sanitization): the wash temperature shall be 120 degrees F. The sanitizing solution shall be 50 ppm (parts per million) hypochlorite (chlorine) on dish surface in final rinse . Chemical solutions shall be maintained at the correct concentration, based on periodic testing, at least once per shift, and for the effective contact time according to manufacturer's guidelines. Results of concentration checks shall be recorded. Water temperatures shall be measured and recorded prior to each meal and/or after the dishwasher has been emptied or re-filled for cleaning purposes. On 7/26/24 at 9:13 A.M., the Administrative Support provided a Monitoring of Cooler/Freezer Temperature policy, undated, that indicated Logs for recording temperatures for each refrigerator or freezer will be posted in a visible location outside the freezer or refrigerator unit. Temperatures will be checked and logged at least twice per day by designated personnel. 3.1-21(i)(2) 3.1-21(i)(3)

Based on record review and interview, the facility failed to ensure person-centered care plans were developed and implemented for 2 of 5 residents reviewed for unnecessary medications and behaviors. (Resident 37, Resident 49) Finding includes: 1. On 7/23/24 at 1:59 P.M., Resident 37's clinical record was reviewed. Diagnoses included, but were not limited to, Alzheimer's Disease and anxiety. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 6/4/24, indicated Resident 37 was severely cognitively impaired, required substantial assistance from staff for toileting and bathing, and was receiving antianxiety, antidepressant, diuretic, antiplatelet, and hypoglycemic medications. Current physician orders included, but were not limited to: Lexapro (antidepressant medication) 10 mg (milligram) Give 1 tablet by mouth at bedtime, start date 12/8/23. Ativan (antianxiety medication) 0.5 mg (Lorazepam) Give 1 tablet by mouth one time a day, start date 4/12/24. Lasix (diuretic medication) 20 mg Give 1 tablet by mouth one time a day, start date 1/27/23. Aspirin (antiplatelet medication) 81 mg Give by mouth one time a day, start date 2/9/22. Metformin (hypoglycemic medication) 1000 mg Give by mouth two times a day, start date 2/24/23. Invokana (hypoglycemic medication) 100 mg Give 1 tablet by mouth one time a day, start date 1/24/24. Januvia (hypoglycemic medication) 100 mg Give by mouth one time a day, start date 1/24/24. Current care plans included, but were not limited to: Resident is at risk for altered blood sugars and resulting physical complications related to diabetes, Observe for hypo-/hyperglycemic reactions. Date Initiated: 4/26/21. The clinical record lacked care plans related to monitoring of antianxiety, antidepressant, diuretic, and antiplatelet medications. 50827 2. On 7/21/24 at 11:10 A.M., Resident 49's clinical record was reviewed. Diagnosis included, but was not limited to, Alzheimer's Disease with late onset. The MDS (Minimum Data Set) assessment dated [DATE] indicated resident was not cognitively intact, required use of wheelchair, required partial/moderate assistance with eating, substantial/maximal assistance with toileting, substantial or maximal assistance with bathing, and substantial or maximal assistance with bed mobility. Care plan initiated on 6/28/24 had the following interventions: get resident's attention before beginning to speak to resident, provide reassurance and patience when communicating with resident. Care plan initiated on 7/8/24 included the following: allow resident time to respond to directions or requests (due to dementia more time is required to absorb instructions), approach the resident slowly and from the front, be cognizant of not invading resident's personal space, be sure you have the residents attention before speaking or touching, if strategies are not working, leave resident and reapproach at later time and/or different staff. On 7/21/24 at 12:46 P.M. CNA 84 performed incontinence care on Resident 49. Care plan was not implemented at that time. Resident 49 resisted this care, cried out for CNA to stop and attempted to push CNA 84 away repeatedly. CNA continued providing incontinence care. Resident 49 told CNA 84 she did not want to get out of bed. After CNA 84 performed incontinence care, transferred Resident to wheelchair while resident continued to yell out and push CNA away. On 7/25/24 at 1:02 P.M. QMA 8 indicated that if Resident 49 exhibited behaviors/resisted care, staff would have stopped what they were doing to prioritize safety. Staff would have been expected to give resident space, time, and reapproach at another time. QMA 8 indicated there would have been 2 staff members caring for Resident 49. One staff member to have kept Resident calm while the other performed care. During an interview on 7/25/24 at 1:51 P.M. the DON (Director of Nursing) indicated care plans should be updated any time there are new orders or new issues with the resident. On 7/26/24 at 8:00 A.M. Administrative Support provided a undated policy titled Comprehensive Care Plans that indicated It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. 3.1-35(a)

Based on observation, record review and interview, the facility failed to ensure residents that were self administering medications were assessed for capability to self administer medications for 2 of 2 residents observed with medications at bedside (Resident 49, Resident 23) Finding include: 1. On 7/21/24 at 10:16 A.M., Desitin was observed be to be on Resident 49's bedside table with Resident's name and physician noted on the label. On 7/21/24 11:10 A.M., Resident 49's clinical record reviewed. Diagnosis included, but not limited to, Alzheimer's disease with late onset. The MDS (Minimum Data Set) assessment dated [DATE] indicated that Resident 49 is severely cognitively impaired, required substantial/maximal assistance with toileting, substantial or maximal assistance with bathing, and substantial or maximal assistance with bed mobility. The clinical record lacked any self-administration of medication assessment or care plans. Physician orders included but were not limited to Desitin External Paste 40 % Zinc Oxide Topical, as needed, dated 6/28/24. QMA 8 indicated during interview on 7/25/24 at 11:20 A.M., that if medication was found at bedside it would be put away immediately and the nurse would have been notified. Also that Desitin in not a medication allowed to be kept at bedside. 48147 2. On 7/24/24 at 12:02 P.M., a medicine cup with one pill in it was observed sitting on Resident 23's bedside table. On 7/25/24 at 10:57 A.M., Resident 23's clinical record was reviewed. Diagnosis included, but was not limited to, cerebral infarction with some residual weakness on the right side. The most current Annual Minimum Data Set (MDS) Assessment, dated 7/9/24, indicated Resident 23 was cognitively intact and required setup assistance for eating. The clinical record lacked an order, care plans, and assessment for self administration of medications. On 7/25/24 at 1:53 P.M., the Administrative Support indicated medications were not to be left at beside. On 7/26/24 at 8:00 A.M., the Administrative Support indicated Resident 23 did not have a self administration of medication assessment. On 7/26/24 at 8:00 A.M., the Administrative Support provided a Resident Self-Administration of Medication policy, undated, that indicated The results of the interdisciplinary team assessment are recorded on the Medication Self-Administration Assessment Form, which is placed in the resident's medical record. 3.1-11(a)

Based on observation, interview, and record review, the facility failed to ensure resident privacy for 2 of 2 random observations. Resident information was left visible on a computer screen during medication administration. (Resident 13, Resident 16) Finding includes: 1. On 7/24/24 at 10:00 A.M., Licensed Practical Nurse (LPN) 5 was observed gathering medications at a medication cart. When LPN 5 walked away from the medication cart and down the hall, the computer screen was left up with Resident 13's information visible (picture, name, date of birth, and medication list). LPN 5 came back to the cart at 10:04 A.M., and promptly left the cart again to enter a resident's room. At 10:06 A.M., Resident 3 was observed walking by the medication cart. LPN 5 returned to the cart at 10:06 A.M. 2. On 7/24/24 at 11:17 A.M., the medication cart was observed sitting between the nurses station and elevator with the computer screen open and Resident 16's information visible. LPN 5 was observed at that time in the Dining Room with a resident. At 11:19 A.M., Certified Nurse Aide (CNA) 3 was observed pushing a resident past the medication cart on the way to the Dining Room, then LPN 5 was observed to come back to the medication cart. On 7/24/24 at 3:04 P.M., LPN 7 indicated when leaving the medication cart, staff should hide and/or lock the computer screen to ensure resident privacy. On 7/26/24 at 8:00 A.M., a current non-dated Confidentiality of Personal and Medical Records policy was provided that indicated This facility honors the resident's right to secure and confidential personal and medical records 3.1-3(o)

Based on observations, interview, and record review the facility failed to protect the resident's rights to be free from physical abuse for 1 of 1 residents reviewed. Resident 36 was hit by CNA(Certified Nurse Aide) while receiving care resulting in laceration above the left eye. (Resident 36) Findings include: On 7/22/24 at 10:28 A.M., Resident 36 was observed in a chair smiling. On 7/22/24 at 1:21 P.M., Resident 36's clinical record was reviewed. Diagnoses included, but were not limited to, ALZHEIMER'S DISEASE and Dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance. The current Annual MDS (Minimum Data Set) assessment dated [DATE] indicated Resident 36 was severely cognitively impaired. The resident was dependent on transfer, toileting, and dressing. Current physician orders included, but were not limited to: Lexapro Tablet 10 MG (Milligrams) (Escitalopram Oxalate)(Antidepressant medication). Give 1 tablet by mouth one time a day for depression/anxiety related to adjustment disorder with mixed anxiety and depressed mood dated 9/9/22. Seroquel oral tablet 50 MG (Quetiapine Fumarate)(Antipsychotic medication) Give 1 tablet by mouth two times a day related to ALZHEIMER'S DISEASE and Dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance dated 8/8/23. The current care plan indicated the resident may exhibit verbal/physical behaviors with care r/t (Related to) the inability to comprehend the need for care r/t cognitive status. Interventions included, but were not related to: Allow resident time to respond to directions or requests d/t (due to) dementia more time is required to absorb instructions. Be cognizant of invading resident's personal space. Approach the resident slowly and from the front. Be sure to have the resident's attention before speaking or touching. Those interventions were dated 7/11/22. A nursing progress note dated 7/5/24 at 9:30 P.M., indicated QMA (Qualified Medicine Aide) 4 working unit heard resident yelling from hallway. Upon entering room QMA 4 observed a resident with a skin tear above left eyebrow. QMA 4 assisted resident to safe position. CNA (Certified Nurse Aid) 6 reported to QMA 4 on unit resident was being combative, hitting and scratching him. CNA 6 also reported he was defending himself when the resident obtained a skin tear 3 cm x 0.5 cm above left eyebrow. QMA called on call management. Head to toe assessment completed. Cleaned left eye with normal saline and applied steri strips. Resident denies pain. No change in ROM. No change in LOC. Neurological assessments x 72 hours initiated. Administrator notified, DON, POA (Power of Attorney) , PCP (Primary Care Physician) . The progress note was recorded by an RN in the facility at the time. A Social Service Progress note done on 7/8/24 at 9:20 A.M., indicated there was a Psychosocial Assessment completed and the resident was not having s/s (signs or symptoms) of sadness, anxiety, or fear. The resident voiced no concerns, and none noted in body language or overall mood. A Psychiatric Nurse Practitioner dated 7/8/24 at 12:22 P.M., indicated there was a new order to discontinue Melatonin (sleep aid) and to notify Nurse Practitioner of issues with insomnia. On 7/10/24 at 4:45 P.M., the Social Service Progress Note indicated there was another Psychosocial Assessment completed and the resident was not exhibiting s/s of sadness, fear, or anxiety. The resident was up doing normal routine and was not voicing concerns or observed via body language On 7/11/24 at 12:28 P.M., the Social Service Progress Note indicated there was another Psychosocial Assessment completed and the resident was not exhibiting s/s of sadness, fear, or anxiety. The resident was up doing normal routine and was not voicing concerns or observed via body language. Reviewed at the time of the medical record review, an Indiana Department of Health Form was dated 7/5/24 at 1:33 P.M. The form indicated on 7/5/24, the resident was involved in an altercation with CNA (Certified Nurse Aide) 6 while receiving care. QMA ( Qualified Medicine Aide) 4 heard the resident yelling and being combative with CNA 6. CNA 6 indicated in the report the resident was combative and scratching CNA 6. The on-call nurse manager, DON (Director of Nursing), Administrator, physician, and family made aware. Follow up dated 7/8/24 indicated the scratch was 0.3 cm (Centimeters) x (By)) 0.5 cm was cleaned with saline and stertripes. Resident Assessment completed there was no loss of consciousness or range of motion. A Psychological Assessment was completed with no s/s of fear, anxiety, or sadness. The nurse practitioner saw the resident on 7/8/24 and was to continue present orders, clean wound, keep dry and clean and monitor for signs and symptoms of infection, were to continue present orders and monitor for behaviors. CNA 6 indicated in a written statement dated 7/5/24 he is changing urine-soaked socks. The resident was kicking in response to the care and protesting not wanting clothes changed. CNA 6 calmly spoke with the resident, but resident got more aggressive and tried to scratch CNA 6 while turning and fastening the brief. CNA 6, again, tried to calmly talk to the resident while the resident was physically assaulting him and yelling. CNA 6 indicated he has had post-traumatic stress from childhood abuse of a parent and allowed his anger to take over. During an interview on 7/22/24 at 3:05 P.M., the wife indicated that she was told the resident was hit by CNA that was apparently witnessed. During an interview on 7/23/24 at 2:31 P.M., the Human Resources Director indicated she was told that CNA 6 reacted to the situation with the resident that swung at him. There were no complaints against the CNA and was popular with staff and residents liked him. She indicated there were no indications that CNA 6 was angry. During an interview on 7/23/24 at 7:10 PM., QMA 4 indicated she did not really witness the incident but was in the hallway outside the resident's door. QMA 4 heard the resident say, don't hit me. QMA 4 then went into the room and CNA 6 was trying to tell QMA 4 what happened, and the resident was saying you're lying. QMA 4 also noted CNA 6 was trying to clean the gash above the resident's left eye not knowing how big it was. QMA 4 indicated CNA 6 had asked if QMA 4 was going to report this and she said she had to because she was not going to lose her license. She stated CNA 6 was angry with himself about the situation and was apologizing to her and the resident. She immediately came to the nurse on call and (Director of Nursing) who came to assess the resident. They in turn called the family, who did not come to the facility. During an interview on 7/24/2 at 8:41 A.M., the Nurse Manager on Call indicated QMA 4 had called her and indicated there was an incident with Resident 36 and CNA 6. CNA 6 was doing care and QMA 4 had walked into the room and the resident had blood above his left eyebrow. QMA 4 indicated she had asked what had happened and CNA 6 had admitted that he had struck the resident 1 time, but the resident had been resistive to care with the resident had been scratching and hitting him. There was a skin tear. QMA 4 had CNA 6 leave the room and she immediately called her. She called the Administrator and the DON, she then called said that they had made a 3-way call with QMA 4 where she indicated that the resident had been scratching CNA 6 chest and reaching for face while the resident was also trying to hit CNA 6. They then spoke with CNA 6, and he was crying about the incident . CNA 6 was remorseful. He never indicated anything about PTSD (Post Traumatic Stress Disorder) or having flash back. The conversation was only a few minutes. The nurse on call indicated the resident and CNA 6 had never had a problem. The DON said that the wife and family actually preferred CNA 6 to take care of the resident. They feel that this incident was an isolated incident and he had never had a problem like this before. On 7/26/24 at 8:00 A.M., the Administrator Support Person provided a current policy Abuse, Neglect, and Exploitation Policy dated 3/31/23. The policy indicated .it is the policy of the facility to provide protections for the health, welfare, and rights of each resident by developing written policies and procedures that prohibit abuse .the facility will have written procedures to assist staff in identifying the different types of abuse mental/verbal abuse, sexual abuse, physical abuse .This include staff to resident abuse and certain resident to resident altercations . Possible indicators of abuse include, but are not limited to: resident, staff, or family report of abuse and physical marks .on a resident's body . 3.1-27(a)(1)

Based on observation, interview, and record review, the facility failed to ensure residents received necessary care and services upon admission for 1 of 3 residents reviewed for skin impairment. A resident who was admitted with skin impairment did not have treatment orders put in place upon admission. (Resident 101) Finding includes: On 9/4/24 at 11:09 A.M., Resident 101's clinical record was reviewed. Diagnoses included, but were not limited to, unspecified intracapsular fracture of right femur, subsequent encounter for closed fracture with routine healing, chronic kidney disease, stage 4, (severe), type 2 diabetes mellitus without complications. An Admission MDS (Minimum Data Set) Assessment, dated 9/3/24, was still in progress and indicated Resident 101's cognition was moderately impaired. Care plans included, but were not limited to: Resident has actual impairment to skin integrity AEB (as evidenced by) diabetic ulcer to left 2nd toe and diabetic ulcer to left heel, and shearing to sacrum r/t (related to) diabetes mellitus, and impaired mobility, date initiated 8/27/24, revision 9/4/24. Interventions included but were not limited to: Alert MD (medical doctor) if wound worsens or does not show any improvement within a 14 day period. Treatments per order. Weekly skin assessment of site to include full measurements, drainage, odor, wound bed assessment, surrounding tissue assessments, pain/discomfort at site, date initiated 8/27/24 Resident has actual skin impairment to skin integrity AEB skin tear to back of right hand w/sutures, skin tear to right and left forearm, blister to 3rd toe r/t previous fall, dog bite, and impaired mobility, date initiated 8/27/24. Interventions included but were not limited to: Alert MD if wound worsens or does not show improvement within a 14 day period. Treatments per order. Weekly skin assessment of site to include full measurements, drainage, odor, wound bed assessment, surrounding tissue assessments, pain/discomfort at site, date initiated 8/27/24 Resident is at risk for infection r/t open lesion 2/2 to MASD (Moisture Associated Skin Damage) and right hip fracture secondary to in house MDRO (multi-drug resistant organisms) AEB surgical incision to right hip and other skin issues, date initiated 8/28/24, revision 9/4/24. Interventions included but were not limited to: Treatments as per MD order, evaluate surgical incision for signs/symptoms of infection weekly with skin assessment and as needed, date initiated 8/28/24. Resident has a potential for further impaired skin integrity r/t generalized weakness, impaired mobility, DMII (diabetes mellitus type 2), s/p (status post) right femur fracture, date initiated 8/27/24. Interventions included but were not limited to: Treatments per order. Weekly skin assessment by licensed nurse, notify physician of any new areas of concern, date initiated 8/27/24. Resident has actual impairment to skin AEB open lesion to gluteal cleft 2/2 to MASD r/t impaired mobility, incontinence, right femur fracture, date initiated 9/4/24 Interventions included but were not limited to: Alert MD if wound worsens or does not show any improvement within a 14 day period. Treatments as ordered. date initiated 8/27/24. Weekly skin assessments of site to include full measurements, drainage, odor, wound bed assessments, surrounding tissue assessment, pain/discomfort at site, date initiated 9/4/24. A nursing admission skin assessment dated [DATE] indicated the following skin impairments: Right trochanter (hip) surgical incision, incision covered with Aquacell (sic) - c, d, i Right hand (back) skin tear with sutures 4.3 cm (centimeters) x 1.2 cm Left heel diabetic ulcer 3 cm x 3 cm left toe(s) 2nd toe diabetic ulcer 2.6 cm x 1.2 cm Left toe(s) 3rd toe blister 1 cm x 1 cm Sacrum shearing 1.5 cm x 1 cm Other (specify) left forearm skin tear 3.7 x 2 cm Other (specify) right forearm skin tear 0.2 cm x 0.2 cm Other (specify) scattered bruising to bilateral arms and multiple locations unable to measure August 2024 orders were reviewed and included, but were not limited to: Leave Aquacel dressing on right hip surgical incision until follow up appointment on 8/30/24. May shower, call [name] with any questions every shift for right hip surgical incision until 8/30/24, order date 8/27/24. Weekly VS (vital signs), nursing summary, and skin assessment per schedule- document VS in wt/vitals tab in resident chart, order date 8/27/24. No skin treatment orders were in place on the August 2024 physician orders. A daily skilled nurses note dated 8/29/24 indicated skin conditions - surgical wound. A daily skilled nurses note dated 9/2/24 indicated skin conditions- skin intact/no skin issues. A skin and wound evaluation, effective date 9/4/242 at 12:07 P.M., included, but was not limited to: Type: Moisture Associated Skin Damage (MASD) In-house acquired New Wound measurements: Area- 7.3 cm2 (centimeters squared) Length- 3.9 cm Width - 3.2 cm Practitioner notified Progress notes were reviewed and included, but were not limited to: 9/3/24 at 7:33 P.M., indicated, res (resident) c/o (complains of) soreness to her bottom, upon assessment noted 3cmx1cm open area to inner buttocks. wound bed bright pink, no drainage, perimeter wound edges intact, normal. 9/4/24 at 10:43 A.M., indicated, [name] office called at this time new orders for calmoseptine to inner buttock q (every) shift till healed. 9/4/24 at 12:19 P.M., Skin assessment completed areas are as follows right trochanter incision with 16 staples intact measuring 8.5 cm right back of hand skin tear with sutures 4.3 cm x 1.2 cm left heel diabetic ulcer 3cm x 3cm resident has stated has had for years left 2nd toe diabetic ulcer 2.6cm x 1.2 cm resident stated has had for years sacrum MASD 3cm x 1cm left forearm skin tear 0.2cm x 0.2 cm scattered bruising to bilateral arms. 9/4/24 at 1:21 P.M., Call placed to [name] office for clarification orders to when to remove sutures to top of right hand. Will address with MD and return call with further orders. 9/4/24 at 1:46 P.M., Staples removed from right hip. No redness or s/s (signs and symptoms) of infection noted. Edges well approximated. Resident tolerated procedure well. 9/4/24 at 2:07 P.M., New order from [name] ok to remove sutures to top of right hand today and apply steri strips after removing. Resident aware of new order. TAR (Treatment Administration Record) updated. A summary of Resident 101's physician's visit dated 9/2/24 was reviewed and included, but was not limited to: Skin: Inspection and palpation: no rash or jaundice and good skin turgor; abrasions on forearms from scratching. Nails: abnormal (clubbing). On 9/5/24 at 9:45 A.M., Resident 101 indicated she did not remember if treatments were done to her skin areas before she came to the facility at the hospital or before she went to the hospital. She was unsure what areas she had. She indicated she had dry skin. On 9/4/24 at 1:50 P.M., the Administrator provided a typed piece of paper indicating it was an explanation of why treatment orders were not put in place upon Resident 101's admission. The paper indicated: The resident was admitted to our facility with longstanding skin impairments, which she reports had been present for several years. Prior to admission resident reported, both her physician and the hospital had assessed these impairments and did not initiate any treatment. At the time of admission, no active treatment orders were prescribed for these conditions, as they were not being actively treated at the hospital or prior to hospitalization . Upon admission, we thoroughly assessed and measured the skin impairments and immediately included them in the care plans on 8/27/24. One of our key interventions was to monitor the conditions closely and notify the physician if they worsened or did not show improvement. Since admission, the resident has been evaluated by both her nurse practitioner and physician, and no new treatment orders or recommendations were made. Follow-up assessment and measurements are being performed today as we do them every week and are due to be done this week. When we observed changes in the sacral shearing, we acted in accordance with our care plan by notifying the MD. On 9/5/24 at 9:55 A.M., LPN (Licensed Practical Nurse) 14 was observed to do the treatment to Resident 101's inner buttocks. LPN 14 removed Resident 101's socks and indicated there were no skin areas to the right foot. The left heel appeared to be dry. The second toe on the left foot appeared it may have betadine on it. She was unaware of any treatments except to the coccyx area. On 9/5/24 at 11:30 A.M., the Administrator indicated he was not sure why the skin and wound assessment dated [DATE] indicated the MASD area was documented as new and in-house acquired. It was not new and was present on admission. The nurse may have charted it that way because it increased in size. On 9/5/24 at 11:21 A.M., the Administrator provided the current wound management policy with a reference date of 2019. The policy included but was not limited to: .Policy explanation and compliance guidelines: 1. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type, of dressing, and frequency of dressing change. 2. In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in the absence of the treatment nurse . 3.1-30(a)

Based on observation, interview, and record review, the facility failed to ensure residents received necessary care and services upon admission for 1 of 3 residents reviewed for skin impairment. A resident who was admitted with skin impairment did not have treatment orders put in place upon admission. (Resident 101) Finding includes: On 9/4/24 at 11:09 A.M., Resident 101's clinical record was reviewed. Diagnoses included, but were not limited to, unspecified intracapsular fracture of right femur, subsequent encounter for closed fracture with routine healing, chronic kidney disease, stage 4, (severe), type 2 diabetes mellitus without complications. An admission MDS (Minimum Data Set) Assessment, dated 9/3/24, was still in progress and indicated Resident 101's cognition was moderately impaired. Care plans included, but were not limited to: Resident has actual impairment to skin integrity AEB (as evidenced by) diabetic ulcer to left 2nd toe and diabetic ulcer to left heel, and shearing to sacrum r/t (related to) diabetes mellitus, and impaired mobility, date initiated 8/27/24, revision 9/4/24. Interventions included but were not limited to: Alert MD (medical doctor) if wound worsens or does not show any improvement within a 14 day period. Treatments per order. Weekly skin assessment of site to include full measurements, drainage, odor, wound bed assessment, surrounding tissue assessments, pain/discomfort at site, date initiated 8/27/24 Resident has actual skin impairment to skin integrity AEB skin tear to back of right hand w/sutures, skin tear to right and left forearm, blister to 3rd toe r/t previous fall, dog bite, and impaired mobility, date initiated 8/27/24. Interventions included but were not limited to: Alert MD if wound worsens or does not show improvement within a 14 day period. Treatments per order. Weekly skin assessment of site to include full measurements, drainage, odor, wound bed assessment, surrounding tissue assessments, pain/discomfort at site, date initiated 8/27/24 Resident is at risk for infection r/t open lesion 2/2 to MASD (Moisture Associated Skin Damage) and right hip fracture secondary to in house MDRO (multi-drug resistant organisms) AEB surgical incision to right hip and other skin issues, date initiated 8/28/24, revision 9/4/24. Interventions included but were not limited to: Treatments as per MD order, evaluate surgical incision for signs/symptoms of infection weekly with skin assessment and as needed, date initiated 8/28/24. Resident has a potential for further impaired skin integrity r/t generalized weakness, impaired mobility, DMII (diabetes mellitus type 2), s/p (status post) right femur fracture, date initiated 8/27/24. Interventions included but were not limited to: Treatments per order. Weekly skin assessment by licensed nurse, notify physician of any new areas of concern, date initiated 8/27/24. Resident has actual impairment to skin AEB open lesion to gluteal cleft 2/2 to MASD r/t impaired mobility, incontinence, right femur fracture, date initiated 9/4/24 Interventions included but were not limited to: Alert MD if wound worsens or does not show any improvement within a 14 day period. Treatments as ordered. date initiated 8/27/24. Weekly skin assessments of site to include full measurements, drainage, odor, wound bed assessments, surrounding tissue assessment, pain/discomfort at site, date initiated 9/4/24. A nursing admission skin assessment dated [DATE] indicated the following skin impairments: Right trochanter (hip) surgical incision, incision covered with Aquacell (sic) - c, d, i Right hand (back) skin tear with sutures 4.3 cm (centimeters) x 1.2 cm Left heel diabetic ulcer 3 cm x 3 cm left toe(s) 2nd toe diabetic ulcer 2.6 cm x 1.2 cm Left toe(s) 3rd toe blister 1 cm x 1 cm Sacrum shearing 1.5 cm x 1 cm Other (specify) left forearm skin tear 3.7 x 2 cm Other (specify) right forearm skin tear 0.2 cm x 0.2 cm Other (specify) scattered bruising to bilateral arms and multiple locations unable to measure August 2024 orders were reviewed and included, but were not limited to: Leave Aquacel dressing on right hip surgical incision until follow up appointment on 8/30/24. May shower, call [name] with any questions every shift for right hip surgical incision until 8/30/24, order date 8/27/24. Weekly VS (vital signs), nursing summary, and skin assessment per schedule- document VS in wt/vitals tab in resident chart, order date 8/27/24. No skin treatment orders were in place on the August 2024 physician orders. A daily skilled nurses note dated 8/29/24 indicated skin conditions - surgical wound. A daily skilled nurses note dated 9/2/24 indicated skin conditions- skin intact/no skin issues. A skin and wound evaluation, effective date 9/4/242 at 12:07 P.M., included, but was not limited to: Type: Moisture Associated Skin Damage (MASD) In-house acquired New Wound measurements: Area- 7.3 cm2 (centimeters squared) Length- 3.9 cm Width - 3.2 cm Practitioner notified Progress notes were reviewed and included, but were not limited to: 9/3/24 at 7:33 P.M., indicated, res (resident) c/o (complains of) soreness to her bottom, upon assessment noted 3cmx1cm open area to inner buttocks. wound bed bright pink, no drainage, perimeter wound edges intact, normal. 9/4/24 at 10:43 A.M., indicated, [name] office called at this time new orders for calmoseptine to inner buttock q (every) shift till healed. 9/4/24 at 12:19 P.M., Skin assessment completed areas are as follows right trochanter incision with 16 staples intact measuring 8.5 cm right back of hand skin tear with sutures 4.3 cm x 1.2 cm left heel diabetic ulcer 3cm x 3cm resident has stated has had for years left 2nd toe diabetic ulcer 2.6cm x 1.2 cm resident stated has had for years sacrum MASD 3cm x 1cm left forearm skin tear 0.2cm x 0.2 cm scattered bruising to bilateral arms. 9/4/24 at 1:21 P.M., Call placed to [name] office for clarification orders to when to remove sutures to top of right hand. Will address with MD and return call with further orders. 9/4/24 at 1:46 P.M., Staples removed from right hip. No redness or s/s (signs and symptoms) of infection noted. Edges well approximated. Resident tolerated procedure well. 9/4/24 at 2:07 P.M., New order from [name] ok to remove sutures to top of right hand today and apply steri strips after removing. Resident aware of new order. TAR (Treatment Administration Record) updated. A summary of Resident 101's physician's visit dated 9/2/24 was reviewed and included, but was not limited to: Skin: Inspection and palpation: no rash or jaundice and good skin turgor; abrasions on forearms from scratching. Nails: abnormal (clubbing). On 9/5/24 at 9:45 A.M., Resident 101 indicated she did not remember if treatments were done to her skin areas before she came to the facility at the hospital or before she went to the hospital. She was unsure what areas she had. She indicated she had dry skin. On 9/4/24 at 1:50 P.M., the Administrator provided a typed piece of paper indicating it was an explanation of why treatment orders were not put in place upon Resident 101's admission. The paper indicated: The resident was admitted to our facility with longstanding skin impairments, which she reports had been present for several years. Prior to admission resident reported, both her physician and the hospital had assessed these impairments and did not initiate any treatment. At the time of admission, no active treatment orders were prescribed for these conditions, as they were not being actively treated at the hospital or prior to hospitalization. Upon admission, we thoroughly assessed and measured the skin impairments and immediately included them in the care plans on 8/27/24. One of our key interventions was to monitor the conditions closely and notify the physician if they worsened or did not show improvement. Since admission, the resident has been evaluated by both her nurse practitioner and physician, and no new treatment orders or recommendations were made. Follow-up assessment and measurements are being performed today as we do them every week and are due to be done this week. When we observed changes in the sacral shearing, we acted in accordance with our care plan by notifying the MD. On 9/5/24 at 9:55 A.M., LPN (Licensed Practical Nurse) 14 was observed to do the treatment to Resident 101's inner buttocks. LPN 14 removed Resident 101's socks and indicated there were no skin areas to the right foot. The left heel appeared to be dry. The second toe on the left foot appeared it may have betadine on it. She was unaware of any treatments except to the coccyx area. On 9/5/24 at 11:30 A.M., the Administrator indicated he was not sure why the skin and wound assessment dated [DATE] indicated the MASD area was documented as new and in-house acquired. It was not new and was present on admission. The nurse may have charted it that way because it increased in size. On 9/5/24 at 11:21 A.M., the Administrator provided the current wound management policy with a reference date of 2019. The policy included but was not limited to: .Policy explanation and compliance guidelines: 1. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type, of dressing, and frequency of dressing change. 2. In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in the absence of the treatment nurse . 3.1-30(a)

Based on interview and record review the facility failed to ensure residents were free of any significant medication errors for 1 of 5 residents reviewed for unnecessary medications. A resident was given the wrong medication resulting in rebound congestion when the medication was discontinued. (Resident 56) Finding includes: On 7/23/24 at 9:23 A.M., Resident 56's clinical record was reviewed. Diagnosis included, but were not limited to, anxiety, depression, and psychotic disorder. The most recent Admission MDS (Minimum Data Set) Assessment, dated 5/6/24, indicated no cognitive impairment and no behaviors. Resident 56 required supervision with bed mobility, eating, transfers, and toileting. Physician orders included, but were not limited to: Nasal spray nasal solution 0.05% (Oxymetazoline HCl) 2 sprays in both nostrils two times a day for allergies, dated 6/3/24 through 7/1/24. (medication if used more than 3 days may cause rebound congestion) Saline nasal solution 0.65% (Saline) 2 sprays in both nostrils four times a day for nasal congestion for 5 days, dated 7/3/24. A Nurse Practitioner (NP) visit note, dated 6/3/24, indicated the resident complained of nasal congestion. The NP sent an order through triage to begin nasal saline 2 sprays in each nostril at bedtime for nasal congestion. Nursing progress notes included, but were not limited to, the following: 7/1/24 at 5:56 A.M. Triage called to discontinue the nasal spray (Oxymetazoline HCl) and to report if the resident had any rebound nasal congestion in the following 3-5 days. 7/3/24 at 2:26 A.M. The resident was very upset the nasal spray had been discontinued due to a lot of rebound symptoms. 7/3/24 at 4:28 P.M. A new order for saline nasal spray 2 sprays each nostril four times a day for 5 days was received from the NP. On 7/24/24 at 9:37 A.M., the DON indicated when the NP was in the facility, she would put any new orders through triage to be entered into the resident's record. She indicated she could not remember the conversation, but would look in the communication history to see what was communicated about the resident taking the Oxymetazoline HCl nasal spray for over 3 days. At that time, a triage communication form was reviewed for Resident 56 from 6/3/24 that indicated the NP ordered nasal saline two sprays each nostril at bedtime for nasal congestion. On 7/24/24 at 10:30 A.M., the NP indicated she did not order the Oxymetazoline HCl nasal spray for Resident 56 and instead wanted the resident to have nasal saline spray. She indicated she was unaware how the order was put in for Oxymetazoline HCl, but when it was noticed, it was discontinued. On 7/26/24 at 8:00 A.M., a current non-dated Medication Orders policy was provided that indicated When recording orders for medication, specify the type, route, dosage, frequency and strength of the medication ordered 3.1-48(a)

Based on observation, interview, and record review, the facility failed to ensure prevention of pressure ulcers for 2 of 3 residents reviewed for pressure injury. Interventions were not followed, and wound assessments were not completed as ordered. (Resident 54, Resident 55) Findings include: 1. On 7/21/24 at 12:42 P.M., Resident 54 was observed lying in bed on her back. When the resident was rolled to the left side, there was no dressing observed covering the pressure area on her sacrum. At that time, the area was observed slightly open in the middle revealing subcutaneous tissue, and the area surrounding the pressure injury was observed a dark pink color indicative of a deeper wound under the skin. No drainage was observed. Granulation tissue (healing connective tissue in the wound bed) was observed in the middle of the wound. At that time, Licensed Practical Nurse (LPN) 21 did not indicate anything about a missing dressing. On 7/22/24 at 1:24 P.M., Resident 54 was observed lying on her back with the head of the bed raised and knees elevated. On 7/2/24 at 8:14 A.M., Resident 54 was observed lying on her back with the head of the bed raised. On 7/22/24 at 1:00 P.M., Resident 54's clinical record was reviewed. Resident 54 was admitted [DATE]. Diagnosis included, but were not limited to, Alzheimer's disease, anxiety, and Stage 3 pressure ulcer. The most recent Significant Change MDS (Minimum Data Set) Assessment, dated 5/5/24, indicated total dependence for bed mobility and toileting, and one Stage 3 pressure ulcer. Cognition level could not be assessed. Current physician orders included, but were not limited to: Cleanse pressure injury to sacrum with normal saline, apply Medihoney to wound bed, and cover with bordered foam dressing every night shift for wound care, dated 7/17/24. A current care care plan for impaired skin integrity indicated as of 4/5/24, the area on the sacrum was a Stage 3. Interventions included, but were not limited to: treatments per order, dated 3/11/24 and weekly assessment of site to include full measurements, drainage, odor, wound bed assessment, surrounding tissue assessment, and pain/discomfort at site, dated 3/11/24. A current potential for further impaired skin integrity, dated 10/4/23, included but was not limited to, an intervention for weekly skin assessments by a licensed nurse, also dated 10/4/23. Progress notes included, but were not limited to: 3/4/24 at 9:43 P.M. Weekly assessment revealed an abrasion to coccyx measuring 1 cm (centimeter) x 0.1 cm with barrier cream applied. A fax was sent to the doctor regarding treatment for the area. 3/11/24 at 6:12 P.M., a Physician's Order note indicated to cleanse pressure injury to sacrum with normal saline, apply Hydrogel to wound bed and cover with bordered foam dressing. The order was received from triage. 4/8/24 at 2:54 P.M., a Dietary note from the Registered Dietician (RD) indicated they were notified of the resident having a Stage 3 pressure injury to the sacrum. 4/9/24 at 10:44 A.M., an MDS Quarterly Assessment Note indicated resident had a Stage 3 pressure injury to the medial sacrum related to impaired mobility and incontinence, and treatment to the area was completed daily per licensed nursing staff. 4/9/24 at 1:31 P.M. a Social Services note indicated resident was severely impaired with decision making and that resident would be at risk for skin breakdown and poor nutrition without staff intervention as the resident would not request routine care and did not make decisions related to care needs. A Braden Scale for predicting pressure sore risk was completed on the following dates: 10/4/23 1/5/24 4/5/24 4/30/24 All assessments indicated a high risk for pressure. Weekly skin assessments prior to the development on the sacrum were completed with the exception of the following dates: No assessment between 11/7/23 and 11/21/23 No assessment between 12/12/23 and 12/26/23 A skin assessment on 3/4/24 indicated the coccyx had an abrasion measuring 1 cm x 0.1 cm. A skin assessment on 3/11/24 indicated a pressure area was present to the sacrum. Wound assessments were started on 3/11/24, and included the following information: 3/11/24 unstageable pressure to sacrum, measuring 1.4 cm x 0.8 cm. 3/19/24 unstageable pressure to sacrum, measuring 1.2 cm x 0.6 cm. (completed 8 days after the previous assessment) 3/28/24 Stage 3 pressure to sacrum, measuring 1.0 cm x 0.5 cm. (completed 9 days after the previous assessment) 4/5/24 Stage 3 pressure to sacrum, measuring 0.9 cm x 0.5 cm. (completed 8 days after the previous assessment) 4/16/24 Stage 3 pressure to sacrum, measuring 0.8 cm x 0.3 cm. (completed 11 days after the previous assessment) 4/30/24 Stage 3 pressure to sacrum, measuring 0.6 cm x 0.2 cm. (resident was in the hospital from 4/18/24 through 4/30/24) 5/10/24 Stage 2 pressure to sacrum, measuring 0.6 cm x 0.3 cm. (completed 10 days after the previous assessment) 5/17/24 Unstageable pressure to sacrum, measuring 3.2 cm x 1.3 cm. 5/23/24 Unstageable pressure to sacrum, measuring 3.2 cm x 1.1 cm. 5/31/24 Unstageable pressure to sacrum, measuring 2.3 cm x 0.8 cm. (completed 8 days after the previous assessment) 6/7/24 Unstageable pressure to sacrum, measuring 1.6 cm x 0.8 cm. 6/11/24 Unstageable pressure to sacrum, measuring 1.4 cm x 0.7 cm. 6/20/24 Unstageable pressure to sacrum, measuring 1.7 cm x 0.8 cm. (completed 9 days after the previous assessment) 6/28/24 Stage 3 pressure to sacrum, measuring 2.9 cm x 0.6 cm. (completed 8 days after the previous assessment) 7/9/24 Stage 3 pressure to sacrum, measuring 1.7 cm x 1.0 cm. (completed 11 days after the previous assessment) 7/17/24 Stage 3 pressure to sacrum, measuring 3.7 cm x 0.4 cm. (completed 8 days after the previous assessment) On 7/23/24 at 10:45 A.M., LPN 5 indicated wound assessments were completed weekly, but had not been completed when she was on vacation from 6/28/24 through 7/6/24. She indicated she followed the National Pressure Ulcer Advisory Panel for staging pressure ulcers and that Resident 54's sacral pressure was a Stage 3 that began with yellow and slough granulation. She indicated once a pressure was staged a 3, it was always a 3, and could not be labeled anything lower. She indicated Resident 54's pressure had gotten worse at the hospital, but was currently getting better. She indicated the area should be kept covered at all times, and if staff needed assistance with the dressing, they could ask her for help. (The National Pressure Ulcer Advisory Panel indicates that full thickness loss of skin, in which adipose tissue is visible in the ulcer, meets the definition of a Stage 3 pressure injury. Granulation tissue and epibole (rolled wound edges] are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss, this becomes an Unstageable Pressure Injury) On 7/23/24 at 1:32 P.M., LPN 5 was observed to change Resident 54's sacral dressing. The old dressing was removed, and the wound was observed with two open areas. No drainage was observed, and the surrounding area was a dark pink. LPN 5 indicated areas were measuring 0.4 cm x 0.3 cm each. LPN 5 emptied a vial of normal saline onto gauze, then indicated she was unsure if the order was for normal saline or wound cleanser, then sprayed wound cleanser on a gauze and used that to wipe the area. Medihoney was applied to a bordered dressing, and placed on the wound. 46758 2. On 7/25/24 at 2:17 P.M., Resident 55's clinical record was reviewed. Diagnoses included but were not limited to, Type 2 diabetes mellitus with diabetic neuropathy, unspecified and peripheral vascular disease, unspecified, and pressure ulcer of left heel, unstageable The current Quarterly MDS (Minimum Data Set) assessment dated ,d+[DATE] indicated the resident was cognitively intact. The resident needed substantial help toileting and transferring. During the 7 day look back period the resident had an unstageable pressure ulcer. Current physician orders included, but were not limited to: Heel lift boots on when in bed every shift for pressure relief to pressure ulcer of left heel, unstageable dated 1/9/24. Betadine swab to the left heel every shift for wound care related to pressure ulcer of left heel unstageable dated 1/22/24. Weekly vital signs, nursing summary, and skin assessment per schedule dated 3/22/24. Current care plan indicated the resident has an actual impairment to skin integrity related to as evidenced by deep tissue injury to left medial heel related to type 2 diabetes and peripheral vascular disease area turned to unstageable 3/8/24. Interventions included but were not to: Weekly assessment of site to include full measurements, drainage, odor, wound bed assessment, surrounding tissue assessment, pain/discomfort at site dated 1/23/2024. The record lacked weekly regular skin and wound assessments. During an interview on 7/25/24 at 10:09 A.M., the Administrative Support Person indicated there should be weekly skin assessments done and the wound person had not been doing them. On 7/25/24 at 8:00 A.M., the Administrative Support Person provided a current, nondated policy Pressure Injury Prevention and Management The policy indicated .the facility is committed to the prevention of avoidable pressure injuries and the promotion of healing or existing pressure injuries .licensed nurses will conduct, .weekly skin assessment .findings will be documented in the medical records . On 7/26/24 at 8:00 A.M., a current non-dated Pressure Injury Surveillance policy was provided and indicated A system of surveillance is utilized for preventing, identifying, reporting, and investigating any new or worsened pressure injuries in the facility On 7/26/24 at 8:00 A.M., a current non-dated Wound Dressing policy was provided and indicated to change dressings as directed by the physician or wound nurse. 3.1-40(a) 3.1-40(a)(2)

Based on observation, interview, and record review, the facility failed to ensure adequate supervision and assistance to prevent accidents for 3 of 3 residents reviewed for falls. Interventions were not updated following falls. (Resident 52, Resident 28, Resident 11 Findings include: 1. On 7/21/24 at 9:43 A.M., Resident 52 indicated she had fallen about a month ago when she lost her footing. At that time, Resident 52 was sitting in a recliner with her walker in front of her. On 7/23/24 at 11:42 A.M., Resident 52's clinical record was reviewed. Diagnosis included, but were not limited to, hemiplegia and hemiparesis following cerebral infarction affecting unspecified side. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 6/18/24, indicated no cognitive impairment, and no behaviors. Resident 52 required supervision assistance of one staff with transfers. Current physician orders included, but were not limited to: Up with walker and staff assist and non skid shoes, dated 1/4/24. A current risk for falls care plan, dated 6/13/23, indicated the following interventions: 1/4 side rails in bed for mobility enablers, dated 6/13/23. Call light within reach, dated 6/13/23. Ensure environment is free of clutter, dated 6/13/23. Have commonly used articles within easy reach, dated 6/13/23. Non skid footwear at all times, dated 3/20/24. Non skid strips in front of the toilet, dated 12/29/23. Reminder sign to call for assistance in room, dated 7/15/24. Shoes with backs when ambulating, dated 8/24/23. Roho cushion with Dycem underneath in resident's recliner, dated 8/18/23. Independent with transfers, initiated 6/13/23 and revised 12/20/23. Resident 52 experienced the following falls since 12/18/23: Fall 1 12/18/23 at 12:05 A.M. Fall was not witnessed. Resident was found lying on the floor on her back, with a walker near her feet. A hematoma measuring 5cm (centimeters) x5cm was observed on the back of her head. An ice pack was applied to the hematoma, and neuro checks were initiated. The resident indicated she was trying to pull back the curtain and lost her balance. The immediate intervention put into place was for the resident to call for assistance. A post fall evaluation, dated 12/20/23, indicated the resident was attempting to self toilet at the time of the fall. An Interdisciplinary Team (IDT) note, dated 12/28/23, indicated Resident 52 was diagnosed with RSV (Respiratory Syncytial Virus) and pneumonia at the time of the fall, and physical therapy was to evaluate for weakness related to the diagnosis. The falls care plan intervention for mobility was updated 12/20/23 to indicate independent with transfers. Fall 2 12/29/23 at 3:44 A.M. Fall was unwitnessed. Resident was found on the bathroom floor sitting upright with feet extended out and back facing the toilet. The resident indicated she had just used the bathroom, and when she went to grab her walker it slid causing her to lose her balance. The falls care plan was updated the same day to include non skid strips in front of the toilet. Fall 3 3/19/24 at 5:10 A.M. Fall was unwitnessed. Resident was attempting to self toilet, resulting in a fall and skin tear to the right forearm. A post fall evaluation, dated 3/19/24 at 2:54 P.M., indicated the resident was wearing non-skid shoes/socks at the time of the fall. The falls care plan was updated 3/20/24 to include non skid footwear at all times. Fall 4 5/21/24 at 6:45 P.M. Fall was unwitnessed. Resident fell in her room sneaking water. Resident was at the sink attempting to get extra water at mealtime. The falls care plan was not updated with a new intervention following fall. Fall 5 6/27/24 at 8:00 A.M. Fall was unwitnessed. Resident was found sitting on the floor to the right of the commode attempting to self toilet. The resident indicated she slid herself down to the floor. The falls care plan was not updated with a new intervention following fall. Fall 6 7/14/24 at 7:00 P.M. Fall was unwitnessed. Resident was attempting to self toilet when her legs got weak. The falls care plan was not updated with a new intervention following fall. On 7/24/24 at 9:52 A.M. the Director of Nursing (DON) indicated therapy had deemed Resident 52 not safe to be up independently and the resident and family were aware, but the resident continued to get up without asking for assistance. The DON indicated Resident 52's falls were from her wanting to be independent. She further indicated all falls were discussed the following morning during a meeting, and new interventions were added to the care plan. On 7/24/24 at 2:55 P.M., Certified Nurse Aide (CNA) 32 indicated Resident 52 should be assisted by staff to get up and with transfers by one staff. She indicated the resident required moderate assistance and supervision with mobility. 48057 2. On 7/23/24 at 10:12 A.M. Resident 28's clinical record was reviewed. Diagnoses included, but were not limited to, Alzheimer's Disease and polyosteoarthritis. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 5/8/24, indicated Resident 28 was severely cognitively impaired and required substantial assistance from staff for toileting, bathing, and transfers. Current physician orders included, but were not limited to: Fall reduction measures: Non-skid strips to side of bed, personal night light, raised toilet seat. 4/17/23. Sensor alarm to wheelchair; check placement, function every shift for decreased safety awareness 12/13/22 Care plans included, but were not limited to: Resident is at high risk for falls characterized by history of falls, impaired vision, dementia, osteoarthritis, other abnormalities of gait and mobility, and medication usage. Resident frequently forgets or refuses to use call light or ask for staff assistance. Date Initiated: 03/26/2018. Substantial/maximal assist, [NAME] transfer aide for all transfers, Date initiated 3/29/18. Resident to wear non-skid shoes or gripper socks at all times, Date initiated: 11/20/18. Raised toilet seat, Date initiated 4/17/23. Visual aid call before you fall placed on bathroom door and wall in resident's room, Date initiated 12/7/23. Anti-rollbacks to wheelchair, Date initiated 1/3/24. Staff education on fall prevention, Date initiated 2/19/24. Non-skid strips to floor in front of toilet, Date initiated: 4/9/24. The clinical record indicated Resident 28 had 10 falls in the past 12 months. The following indicates the time each fall occurred, how it occurred, and the intervention put in place by the IDT (interdisciplinary team) according to the Fall Event Notes provided by the DON (Director of Nursing) on 7/26/24 at 8:00 A.M. Fall #1 9/7/23 at 1:35 P.M.; A CNA (Certified Nurse Aide) was assisting Resident 28 to the bathroom when Resident 28 began to fall, the CNA lowered resident 28 to the floor. The intervention put in place was for Two (2) staff members to assist with transfers from wheelchair to commode and transfers to bed. Fall #2 10/20/23 at 9:49 P.M.; Staff was transferring Resident 28 to bed when Resident was assisted to floor. The intervention put in place was for staff to use [NAME] transfer aid (device to assist with pivot transfers) and two (2) staff during transfers. Fall #3 11/14/23 at 11:45 A.M.; A CNA was transferring Resident 28 from the right side of the bed to the shower chair when the bed began to roll and Resident was lowered to the floor. The intervention put in place was for maintenance to fix the locks on the bed. Fall #4 12/6/23 at 3:58 P.M.; Resident 28 was attempting to toilet herself after activity and fell in the bathroom. The intervention put in place was a 'Call Don't Fall' sign placed in the Residents room. Fall #5 12/29/23 at 2:55 P.M.; Resident 28 was found by staff in bathroom floor. The intervention put in place was staff education on checking Resident's wheelchair alarm while up in chair. Fall #6 2/14/24 at 4:15 P.M.; Resident 28 was brought back to room by staff and instructed to reposition self in wheelchair, resulting in sliding out of wheelchair. Intervention put in place was staff education to prevent falls. Fall #7 2/21/24 at 12:41 P.M.; Resident 28 was in activities when she slid out of her wheelchair. Intervention put in place was educate staff on proper positioning in wheelchair. Fall #8 3/10/24 at 7:04 P.M.; Resident 28 Resident was found sitting in floor of bathroom. Intervention put in place was educate staff regarding toileting resident after meals. Fall #9 4/8/24 at 2:00 P.M.; Staff found Resident 28 sitting in bathroom floor. Intervention put in place was non-skid strips in front of toilet in bathroom. Fall #10 4/29/24 at 1:50 P.M.; A CNA attempted to transfer Resident 28 from the toilet to the wheelchair, resulting in Resident to slide into floor. Intervention put in place was for Resident to see physical therapy three (3) times a week for eight (8) weeks and occupational therapy three (3) times as week for four (4) weeks. During an interview on 7/25/24 at 9:24 A.M., the DON (Director of Nursing) indicated Resident 28 should be transferred with assistance from two staff members. During an interview on 7/26/24 at 10:58 A.M., the DON indicated she was unable to provide the staff education as fall interventions on 12/29/23, 2/14/24, 2/21/24, 3/10/24 because the education did not exist. 46758 3. On 7/23/24 at 11:35 A.M., Resident 11's clinical record was reviewed. Diagnoses included, but were not limited to, muscle weakness, generalized and idiopathic epilepsy and epileptic syndromes, not intractable, without status epilepticus, bilateral secondary osteoarthritis of knee. The current Quarterly MDS (Minimum Data Set) assessment dated [DATE]. The resident is mildly cognitively impaired and needs limited assist of 1 for transfer, toileting, and bed mobility. MDS indicated the resident had a history of falls within the last 3 months. Current physician orders included, but were not limited to: Activity level: up in wheelchair with assist from staff; turn transfer with 2 assist to be used for all transfers dated 7/2/24. Resident should not wear gripper socks with shoes. Nurses/ QMA (Qualified Medicine Aide) to check every shift for pressure relief dated 1/23/24. The current care plan indicated Resident is at risk for falls r/t (related to) seizure disorder, abnormality of gait,mild cognitive impairment, and potential to become easily frustrated and/or overstimulated and may set herself on the floor as a result. Resident has reported falls that have not been witnessed or have been questionable if they were behavioral in nature r/t anxiety and attention seeking. Interventions included, but were not limited to, resident is often resistive to any intervention or offer of extra help and Transfers: [NAME] transfer aide with 2 assists for all transfers. Progress notes included but were not limited to: On 7/24/24 8:55 P.M., a Nurse's note indicated a CNA was assisting Resident 11 from commode back to the wheelchair and reported resident fell forward on to knees bumping head on floor. The wheel chair was located outside of the bathroom near the sink. The fall occurred in front of the wheelchair. When asked what happened, the resident indicated my legs gave out. Resident was assisted up from floor to bed and was reminded to call for assistance from the staff. On 7/24/2024 at 9:11 P.M., at post fall evaluation indicated that the fall was witnessed and occurred when a CNA (Certified Nurse Aide) was assisting resident from the bathroom to the w/c (Wheelchair)The resident did not require a visit to the ER (emergency room ) or hospitalization . A contributing factor was noted to be loss of balance and weakness. On 7/24/24 at 7/24/2024 at 9:07 P.M., the Fall Rise Evaluation indicated: the resident had a history of falls in the past 3 months, there was no loss of consciousness. The resident had 1-2 predisposing factors. Fall Risk Score: 13.0 On 6/27/24 at 8:00 P.M., Resident 11's roommate reported that resident had fallen from her recliner. The resident was found sitting on her left hip leaning against recliner with wet clothing due to incontinence episode. Neurochecks began and were within normal limits. MD, family, and DON made aware. Intervention added was to have the resident transfer with 2 assists. On 7/26/24 at 8:00 A.M., a current non-dated Fall Prevention Program policy was provided and indicated Each resident's risk factors and environmental hazards will be evaluated when developing the resident's comprehensive plan of care [and] the plan of care will be revised as needed . When any resident experiences a fall, the facility will . Review the resident's care plan and update as indicated 3.1-45(a) 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to provide supervision to prevent falls, resulting in hip fractures; utilized alarms for supervision; and failed to correctly place an alarm, for 3 of 3 residents reviewed for falls (Residents B, C, D). Findings include: 1. On 3/7/22 at 9:20 A.M., during the initial tour, the Director of Nursing (DON) indicated Resident C had recently fallen. The resident had sustained a fractured hip. Resident C was observed lying in bed at that time, with his eyes closed. The clinical record of Resident C was reviewed on 3/7/22 at 1:35 P.M. Diagnoses included, but were not limited to, unspecified dementia with behavioral disturbance. A care plan, initially dated 6/17/21 and updated 2/23/22, indicated the following: Resident is at risk for falls characterized by history of falls/ injury, multiple risk factors related to: impaired balance, poor coordination, generalized weakness, dementia, polyarthritis, [CONDITION(S)] drug use, s/p [status post] right femur fracture. The interventions included: Call light within reach Date Initiated: 06/17/2021, Sensor alarm to bed, check placement and functioning every shift, Date Initiated: 06/17/2021 Sensor alarm to bedside chair, check placement and functioning Date Initiated: 11/16/2021. A quarterly Minimum Data Set (MDS) assessment, dated 12/7/21, indicated Resident C had a severe memory problem, and required extensive assistance of two or more staff to transfer and walk. A test for balance during transfers and walking indicated, Not steady, only able to stabilize with human assistance. The resident had fallen 2 or more times since the previous assessment. Nurses notes included the following notations: 12/16/2021 at 8:18 A.M.: Interdisciplinary Team [IDT] . note for root cause analysis/review of risk factors R/T [related to] event on 12/15/2021 @ 1430 [2:30 P.M.]. Roommate reported to staff that resident slid out of bed. Resident was on the floor, right side of bed, sitting on his buttocks. Resident assessed, no C/O [complaints of] discomfort . To standing position with assist of three staff. Resident was toileted and then to W/C [wheelchair]. BIMS [brief interview of mental status] score 03 [low], fall risk score is 25 [high risk]. DX [diagnoses] include Dementia .Medications reviewed .Received therapy services recently and presented with balance deficits, decreased safety awareness, poor judgement, and gross motor deficits. Care Plan reviewed. Adding perimeter/concave mattress D/T [due to] sliding from bed. 1/25/22 at 10:18 P.M.: .Mobility/Transfers/ Walking: Patient uses a mechanical lifts to stand. Patient is wheelchair and bed bound. Patient to receive physical therapy. Patient is a X2 dependent assist with activity .Cognitive assessment: Patient is oriented to self. Patient is forgetful and pleasantly confused usually .Safety Awareness: Patient has poor safety awareness. Patient has a bed/chair alarm equipped for when he tries to get up on his own. Patient call light within reach, patient has non-skid socks, and bed is in lowest position. 1/27/22 at 12:18 A.M.: .Mobility/Transfers/ Walking: Resident utilizes a mechanical lift with transfers. needs assistance with bed mobility. Uses wheelchair. does not walk. 2 person extensive assist with care . Alert and oriented to self only. confused and forgetful . Safety Awareness: Resident has poor safety awareness. Bed alarm in place and functioning. 1/27/22 at 5:17 P.M.: Heard resident's alarm sounding, by the time got to the room he was laying on the floor in front of the dresser with legs outstretched in front of him. When asked resident what he was trying to do when he fell and resident states, ' I was going over my girlfriends house' .Assessed resident for injuries and none noted .Resident sitting up in wheelchair with sensor pad alarm in place . Safety Interventions in Current Use (alarms, etc): Resident already has sensor pad alarms in bed and in wheelchair. Describe Resident care post-fall: Resident placed on observation and neurological assessments per facility's protocol . Immediate Intervention put into place: [left blank] 1/28/22 at 8:04 A.M.: IDT note for root cause analysis/review of risk factors R/T incident on 022 @ approximately 1715 [5:15 P.M.]. Staff responded to resident's W/C alarm sounding. Resident was sitting on the floor with his legs extended outward .Sensor alarms in place. Resident is confused, has BIMS score of 03, indicating severe cognitive impairment .Care Plan reviewed, goal remains appropriate and interventions in place for fall prevention. 2/1/22 at 11:41 P.M.: .Resident is able to take a few steps with extensive assist of 2 with walker .alert to self. pleasantly confused. short term and long term memory deficit .Safety Awareness: Poor safety awareness. bed alarm and chair alarm in place and functioning. 2/2/22 at 12:00 P.M.: Heard alarm sounding from resident's room. Resident lying on the floor in the doorway of his room on his right side. When asked resident what he was doing when he fell , he states ' I was trying to get something to eat.' Resident assessment .Was able to move resident to his back to be able to assess him better. Resident did tolerate being moved to his back well. Assessed resident for injuries and no outward injuries could be seen at this time. Resident did however complain of some right hip/leg pain. No lengthening or shortening of the extremities noted at this time. No outward deformities of the hips noted at this time. Resident able to move all extremities without limitations. Able to assist resident to a standing position and he was able to bear weight. Assisted resident to bed at this time. Resident placed on observation and neurological assessments. Bed in lowest position with sensor pad alarm in place and functioning properly at this time. Safety Interventions in Current Use (alarms, etc): [left blank] . Immediate Intervention put into place: [left blank] 2/2/22 at 12:30 P.M.: Received new order to obtain x ray of right hip/pelvis due complaints of pain post fall 2/2/22 at 11:33 P.M.: Received radiology report stating resident has a right acute hip intertrochanteric fracture. Faxed results to [name of physician]. The resident was transferred to the hospital on 2/3/22 at 1:34 A.M. with the diagnosis of right hip fracture. 2. The closed clinical record of Resident B was reviewed on 3/7/22 at 12:00 P.M. Diagnoses included, but were not limited to, [CONDITION(S)] and [CONDITION(S)] [weakness and paralysis on one side] following cerebral infarction affecting right dominant side, and fracture right femur. A care plan, initially dated 12/29/21 and updated 2/8/22, indicated: Resident is at risk for falls characterized by history of falls/ injury, multiple risk factors related to: impaired balance, poor coordination, unsteady gait, generalized weakness, ataxia [abnormal, uncoordinated movements] from stroke, [CONDITION(S)]. The interventions included: Call light within reach Date Initiated: 12/29/2021, Transfers: extensive assist of 1-2, Date Initiated: 12/29/2021. A Fall Risk Assessment, dated 12/28/21, indicated the resident had multiple falls in the previous 6 months, exhibited a loss of balance while standing, required hands-on assistance to move from place to place, used shuffling steps, had changes in gait pattern when walking through doorways, had a lurching, swaying, or slapping gait, and had a decrease in muscle coordination. The assessment indicated Resident B was at a high risk for falls. An admission MDS assessment, dated 1/4/22, indicated Resident B had moderately impaired memory, required extensive assistance of one staff for transfers, and extensive assistance of two or more staff for toilet use. A test for balance during transitions and walking indicated, Not steady, only able to stabilize with human assistance. The resident had fallen in the 1 month prior to admission. Nurses notes included the following notations: 12/28/21 at 6:08 P.M.: Resident has arrived to facility via W/C at this time. Resident oriented to facility and to her room. Assessment preformed at this time. Bed alarm has been placed in functioning order at this time per resident family request. States that resident can be impulsive and will get up on her own without ringing the call light. 12/29/21 at 3:30 A.M.: Resident was frequently up and down setting off alarm this shift. Resident attempted to get out of bed on own with unsteady gait. Educated resident to ring call light for assistance before getting out of bed resident verbalized understanding yet would set alarm off again attempted to get out of bed unassisted. Resident very anxious wanting to get up out of bed and use bedside commode several times an hour and unable to void. Resident does have hx of [CONDITION(S)]. Resident bed alarm intact functioning properly. Call light within reach. 1/25/22 at 2:36 P.M.: .Cognitive assessment: Alert et oriented x 3 with periods of forgetfulness . Safety Awareness: Sensor pad alarms to bed et chair d/t [due to] poor safety awareness. Non skid footwear on at all times. Call light et fluids in easy reach. Rolling walker within reach. 2/4/22 at 10:40 A.M.: .Mobility/Transfers/ Walking: one assist with amb.[ambulation] independent with bed mobility and one assist with transfers. uses walker .alert and oriented occ confusion and forgetfulness .Safety Awareness: alarm in place and functioning. 2/4/22 at 12:22 P.M.: .Description of event: alarm sounding, res [resident] standing at foot of bed, left hand bleeding, slide down to knees, witnessed by CNA attempting to reach res .middle finger 1 cm [centimeter] skin tear .bruise to left middle finger knuckle, 'hit my hand on the bed' .Safety Interventions in Current Use (alarms, etc): bed and chair alarm, slipper socks, walker with SBA [stand-by assist] .Immediate Intervention put into place: staff to offer and assist to toilet every 2 to three hours 2/6/22 at 3:48 P.M.: Resident needs limited assist of one with mobility and ambulation .Toileting/ Continence: Has been continent of bowel and bladder, up to the bathroom with assist of one. Cognitive assessment: Alert with intermittent confusion noted .Safety Awareness: Sensor pad alarms are in place and functioning properly. Has not made any attempts to get up on own, she has been using call light consistently for help this shift. 2/7/22 at 8:30 A.M.: Description of event: CNA had just took resident to the bathroom and was in the actual room making resident's bed when CNA heard resident fall. When nurse entered resident's bathroom, noted resident laying on the floor in between the doorway of the bathroom and the adjoining room on her left side. Resident was trying to get herself to a sitting position to try and get herself up before staff was able to get her up. Resident stated that her legs just gave out on her when she stood up to try and walk then went down to the floor. Resident assessment . Now when assisted to a standing position, she did complain of some left hip pain. Assisted resident back to bed at this time . Sensor pad alarm in place and functioning with bed in lowest position at this time. Call light within reach .Safety Interventions in Current Use (alarms, etc): Sensor pad alarms in place to bed and chair with bed in lowest position. Describe Resident care post-fall: Placed on observation and on neurological assessments per facility protocol. Immediate Intervention put into place: Call placed to doctor and obtained order to get an x ray of left hip/pelvis 2/7/22 at 12:00 P.M.: Received a call from [radiology service] regarding x ray results of left hip/pelvis and there is a fracture noted. Results faxed over to triage at this time and did call them as well to notify of fracture. To call the facility back with further orders. The resident was transferred to the hospital on 2/7/22 at 1:41 P.M. with a diagnosis of a left hip fracture. 3. On 3/7/22 at 9:30 A.M., during the initial tour, the DON indicated Resident D had recently fallen. Resident D was sitting in a wheelchair in her room. An alarm box was observed on the wheelchair. The clinical record of Resident D was reviewed on 3/7/22 at 2:10 P.M. Diagnoses included, but were not limited to, fractured right femur and dementia. An admission Fall Risk Assessment, dated 1/18/22, indicated Resident D was at a high risk for falls. A care plan, initially dated 1/18/22 and updated 2/8/22, indicated: Resident is at risk for falls characterized by history of falls/ injury, multiple risk factors related to: impaired balance, poor coordination, unsteady gait, use of [CONDITION(S)] medications, generalized weakness, s/p right femur fracture. The interventions included: Call light within reach Date Initiated: 01/18/2022, Have commonly used articles within easy reach, Date Initiated: 01/18/2022, Transfers: extensive assist of 2 Date Initiated: 01/18/2022. There were no interventions dated after 1/18/22. Nurses notes included the following notations: 1/20/22 at 11:20 A.M.: .Mobility/Transfers/ Walking: Requires constant cueing for sequencing et [and] safety . Decreased functional mobility with significant assistance x 2 assist. Cognitive assessment: Alert to self et family only. Has Dx of Dementia. Confused per norm baseline for resident .Safety Awareness: Decreased safety awareness d/t Dx of Dementia. Non skid footwear at all times. Bed in lowest position when occupied. Call light et fluids within easy reach. Earlier in shift, resident was sitting on front edge of her W/C, as if she were going to stand up. Reinforced the fact that she must ask for assist at this time, until therapy deems it okay for her to be up ad lib. She voiced understanding. Stated she didn't want anything, she just 'didn't know was going on'. 1/21/22 at 2:38 P.M.: Resident has been working with therapy services to build strength and endurance .Resident is a 2 staff assist with all transfers, bed mobility, and mobility within the room with gait belt use. Resident has significant pain to her right hip which effects [sic] her mobility and transfers. Resident does require cueing . Resident is alert to self. Resident has diagnosis of Dementia. Confusion has been her baseline while stay here at facility .Safety Awareness: Resident has confusion and tends to get up on her own to take self to the restroom. Resident is checked every 2 hours if not more frequently. Resident is frequently reminded of the use of call light. 1/22/22 at 9:53 P.M.: Description of event: RN in nursing office heard loud noise and resident across the hall asking if [Resident D] was ok. RN and CNA immediately responded to noise and she was on floor on left side. Bed alarm not sounding; upon investigation, alarm was attached to side rail of bed but alarm pad was located in chair under bed pads .Safety Interventions in Current Use (alarms, etc): Gripping socks were on to bilateral feet during fall. Alarm was placed appropriately under resident behind in bed and turned on; is functional . Resident assisted to standing position with RN and CNA. Able to bear weight and take steps to bed with limited assist of 2. Denies pain or discomfort .Immediate Intervention put into place: Bed alarm placed in appropriate setting. Educated staff on double checking function and placement of bed alarms upon start of shift On 3/7/22 at 3:00 P.M., during an interview with the Unit Manager, she indicated that the facility did not use paper CNA assignment sheets. The residents who were fall risks, and/or required alarms, was communicated through shift report. On 3/7/22 at 3:10 P.M., CNA 1 was interviewed. She indicated she knew which residents had alarms by a CNA binder, kept at the desk. She indicated that changes were also communicated through shift report. At that time, the Unit Manager was questioned where that CNA binder would be located. She was unable to find one for the South unit. She questioned CNA 1 where the CNA binder would be located, and neither could find it. The Unit Manager indicated each unit would have their own book. The Unit Manager then went to the North Unit, and found a CNA binder. The binder had communications from at least September 2021. Information for Resident C did not include the use of an alarm. The Unit Manager indicated at that time that the binder would need to be updated. On 3/7/22 at 3:20 P.M., LPN 1 was interviewed regarding the use of resident alarms. She indicated that if she did not know, she could always call the MDS Coordinator. LPN 1 thought the CNA staff knew which residents had alarms by the use of their hand held computers used for their charting. LPN 1 questioned CNA 1 at that time, and CNA 1 searched for Resident D in the computer. There was no indication that Resident D utilized an alarm. On 3/7/22 at 3:25 P.M., the DON provided a current list of residents, and indicated those residents who utilized alarms. Out of the current census of 43 residents residing in the main part of the facility, 10 residents utilized some sort of alarm. 6 of those residents had more than 1 alarm. On 3/8/22 at 9:17 A.M., the Administrator in Training (AIT) provided the current facility policy, Fall Risk Assessment, dated November 2017. The policy included, It is the policy of this facility to provide an environment that is free from accident hazards over which the facility has control, and provides supervision and assistive devices to each resident to prevent avoidable accidents .An 'At Risk for Falls' care plan will include interventions, including adequate supervision, consistent with a resident's needs, goals, and current standards of practice in order to reduce the risk of an accident. Monitor the effectiveness of the care plan interventions, and modify the interventions as necessary, in accordance with current standards of practice. At that time, the AIT provided an additional current facility policy, Fall Prevention Program, dated November 2017. The policy included, Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls .Each resident's risk factors and environmental hazards will be evaluated when developing the resident's comprehensive plan of care. Interventions will be monitored for effectiveness. The plan of care will be revised as needed This Federal tag relates to Complaint IN 805.

Based on observation, record review, and interview, the facility failed to ensure residents who readmitted with no pressure ulcers, did not develop pressure related injury for 1 of 1 residents reviewed. This deficient practice resulted in Resident 52 developing an unstageable (full thickness tissue loss with base covered by eschar (black, tan, brown dead tissue) pressure injury to the left heel. (Resident 52) Findings include: On 2/20/18 at 9:15 a.m., Resident 52 was observed sitting in the common area with a blue boot to her left heel. On 2/20/18 at 9:56 a.m., the record for Resident 52 was reviewed. The record indicated, but was not limited to, Resident 52 readmitted to facility on 12/17/17 with a surgical site to the left hip. Progress note, dated 12/31/17 at 7:52 a.m., indicated a 2 cm (centimeter) x (by) 2 cm dark purple area on left heel. Denies any discomfort . Fax sent to triage. Physicians orders as follows: 1/1/18 skin prep to both heels every shift for prevention of skin breakdown. 1/3/18 float heels in bed, nurse to check every evening and night shift for pressure relief. A nutritional progress note, dated 1/30/18, episodic, indicated, but not limited to, pressure injury of the left heel, no open, discolored, . Braden 12 (tool to predict pressure ulcer risk) receiving some protein supplementation as well as a very high calorie supplement twice daily also. The Care Plans were reviewed and indicated, but were not limited to, Actual impaired skin integrity r/t (related to): impaired mobility, pain second to recent L (left) hip Fx ( fracture) AEB (as evidenced by) unstageable pressure injury to left heel, dated 1/2/18, revision date 2/20/18. Interventions included, but were not limited to, blue boot on left foot at all times when in bed, dated 1/16/18. Float heels when in bed, dated 1/2/18. Reposition resident q (every) two hours for pressure relief, dated 1/2/18. Treatments per order, dated 1/2/18. Weekly skin assessment by licensed nurse; notify physician of any new area of concern, dated 1/2/18. A progress note, dated 2/20/18 at 9:19 a.m., per the ADON indicated an unstageable pressure injury to the left heel, measured 3 cm (centimeter) x (by) 3 cm and showed no change this week. On 2/21/18 at 9:26 a.m., the ADON (Assistant Director of Nursing) was observed to sanitize her hands, apply gloves, and apply skin prep to Resident 52's left heel. The heel had an oblong brown area and dry with scaling edges, appearing as a large scab. The ADON was further observed to remove her gloves and wash her hands thoroughly. She then applied a blue boot, covered Resident 52, and sanitized her hands. Resident 52 denied pain or discomfort during observation. On 2/22/18 at 8:42 a.m., the ADON provided the Weekly Pressure Ulcer Assessment. The Assessment indicated, but was not limited to: Initial date, 12/31/17 and site/location L (left) heel. The area was listed as deep tissue injury. The area measured 2.0 x 2.0, with no depth, dark purple, surrounding skin color: pink, signature per the ADON. Weekly measurements continued to current, listed on 2/19/18 as Unstg. (sic) (unstageable), DTI (deep tissue injury) in origin 3.0 x 3.0, stable eschar, color: marked as black, dark purple, surrounding skin marked as normal skin. On 2/22/18 at 8:45 a.m., the ADON indicated, upon review of the record, the intervention to elevate the heels was not implemented until after the pressure injury occurred. On 2/22/18 at 9:08 at a.m., CNA 4 indicated if she noticed a red or purple area on a resident's heel, she would notify the nurse and elevate until evaluated. On 2/22/18 at 11:56 a.m., the ADON provided the current facility policy, Pressure Ulcer Prevention Guidelines, dated (YEAR). The Policy indicated, but was not limited to: it is the policy of this facility to implement evidence-based interventions for all residents who are assessed at risk or who have a pressure ulcer present. The Policy further indicted, in the absence of prevention orders, the licensed nurse will utilize nursing judgement in accordance with pressure ulcer prevention guidelines to provide care, and will notify physician to obtain orders. 3.1-40(a)(1)

Based on observation, interview, and record review, the facility failed to ensure residents were free from falls, in that alarms were used in place of supervision, and alarms that were used were not audible enough for staff to respond promptly or did not sound at all for 3 of 3 residents reviewed with history of falls in the sample of 5. This resulted in a resident fall with sutures to the head (Resident B), and a resident fall resulting in an increase in a subdural hematoma (Resident C). Resident B, C, and A Findings include: 1. On 4/2/12 at 9:40 A.M., during the initial tour, LPN # 1 indicated Resident B had fallen recently and was not interviewable. Resident B was observed lying in a low bed at that time. On 4/2/12 at 12:00 P.M., Resident B was observed sitting in a wheelchair in his room. A seat belt was observed around the resident. An alarm box was attached to the back of his chair. A cord was observed dangling from the back of his chair. QMA # 1 indicated she did not know why the cord was at the back of the chair. LPN # 1 indicated the cord "was probably from his old seat belt alarm." LPN # 1 indicated the resident's seat belt had been changed because the resident was able to disable the alarm on the previous seatbelt. The clinical record of Resident B was reviewed on 4/3/12 at 9:50 A.M. [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment, dated 11/29/11, indicated the resident scored an 8 out of 15 for cognition, with 15 indicating no memory impairment. The MDS assessment indicated the resident required extensive assistance of two + staff for transfer and extensive assistance of one staff for ambulation. A test for balance indicated the resident was "Not steady, only able to stabilize with human assistance" when moving from a seated to standing position, walking, and surface-to-surface transfer. Progress Notes included the following notations: 1/23/12 at 9:20 P.M.: "This nurse was doing evening shift med (medication) pass when residents (sic) alarming seat belt was sounding. This nurse immediately went into residents room and saw resident starting to slide out of chair. This nurse summoned for help from other evening shift nurse, (name) to assist resident up and back into chair. Resident was unable to provide any assistance to staff when trying to lift resident up and back in chair, resident is fully dependant on staff at this time...This nurse and other nurse decided to lower resident to the floor...Then resident lifted from floor back to w/c (wheelchair) with extensive assists (sic) of 2...resident replied 'I was trying to get ready for bed and that is why I took off this belt...' Nursing Intervention initiated: Staff will ask resident @ the hour of 7:00 p.m. (and q (every) 30 minutes until resident ready for bed) if resident is ready for bed to eliminate resident from undoing seat belt and attempting to get ready for bed without assistance...." A Fall Risk Assessment, dated 1/23/12 at 9:25 P.M., indicated: "Reason for Assessment Request, Recent Falls. Intermittant (sic) ocnfusion (sic). History of Falls within last six months, Multiple falls...Chairbound (requires restraints &/or assist with elimination)...Gait Analysis, Unable to independently come to a standing position, Requires hands-on assistance to move from place to place." 1/24/12 at 1:21 P.M.: "Res (resident) up in wheel chair with extensive assist with transferring...Alarming seat belt in use and res is attempting to remove at this time, confusional (sic) and explained to res he (sic) seat belt is for his safety, he does not understand the past episode of falling at this time.' 1/27/12 at 3:01 P.M.: "Res observed laying on back with head to south of room. Res stated he slid off the edge of the bed...Res assisted to the bed with extensive assist x 2 staff...." Documentation that an alarm sounded or did not sound was lacking in the clinical record. 2/1/12 at 2:15 P.M.: "Review of falls from 1/27/12 and 1/24/12. (Resident B) attempted to put himself to bed and fell of edge of bed - no injury. POC (plan of care) updated for staff to assist resident to bed when he appears tired." 2/22/12 at 9:40 P.M.: "This nurse passing evening shift medications when a loud thump was heard down the hallway. This nurse ran to (room number) where resident was lying on floor with a puddle of blood present around head, self release belt was undone. When asked, resident stated 'I was getting up out of this chair and I hit the floor.' Resident did not know why he was attempting to get out of chair when asked...Laceration to front of head measuring 4.4 cm (centimeters) x 1.3 cm <0.1 cm in depth. Laceration to (right) side of head above ear measuring 1.5 cm x 1 cm < 0.1 cm depth. MD notified...Resident transported to (name of hospital) ER...." A hospital emergency record, dated 2/22/12, indicated, "...Apparently, he was sitting in his wheelchair at (name of facility) when he fell forward and hit his head on the ground...He had a 4 cm horizontal laceration over his forehead...His wound was sutured with multiple...sutures...." The resident returned to the facility on [DATE] at 10:45 P.M. Progress Notes, dated 2/27/12 at 3:42 P.M., indicated, "Sutures to forehead removed as ordered...counted 14 in total when all where (sic) completely removed...." A care plan, initially dated 3/8/10 and most recently revised 3/6/12, indicated a focus of "Risk for falls related to: impaired mobility, pain, seizures, diabetes, use of psychotropic meds, neuro deficit r/t (related to) CVA, resistance to safety interventions." Interventions included: "Call light within reach and encourage resident to ask for assistance, Sensor alarm to bed and bedside chair at all times; check q (every) shift for placement and functioning. Ensure seatbelt is in place when in w/c. Staff to assist in preparing bed for resident after supper. Assist resident to bed at HS (bedtime) when he appears sleepy...." On 4/3/12 at 10:35 A.M., during interview with the Administrator and the Director of Nursing (DON), the DON indicated Resident B "figured out how to disarm the alarming seatbelt." The DON indicated the resident had been observed with the seatbelt unhooked, but with the alarm not sounding. The DON indicated staff and maintenance had checked the seatbelt for functioning, and it would always alarm for them. The DON indicated after the resident fell on [DATE], the facility put another type of seatbelt on him. 2. On 4/2/12 at 9:40 A.M., during the initial tour, LPN # 1 indicated Resident A had been admitted recently with a cervical fracture, and had fallen recently. LPN # 1 indicated Resident A was not interviewable. On 4/2/12 at 10:10 A.M., Resident A was observed lying in bed with a cervical collar on. An alarm box was observed on the bed frame. The clinical record of Resident A was reviewed on 4/2/12 at 10:30 A.M. [DIAGNOSES REDACTED]. A Nursing Admission Assessment, dated 3/14/12 at 12:43 P.M., indicated Resident A had a "Fall from bed with C2 fracture." An Admission Care Plan, dated 3/14/12, indicated a problem of "Falls/Safety Risk/Elopement Risk." The interventions indicated: "Keep call bell in reach. Enc. (encourage) use of call light. Assess resident's footwear for proper fit and non-skid soles." Progress Notes included the following notations: 3/14/12 at 6:52 P.M.: "Resident alert and orient (sic) to self. Very confused...Resident attempted to transfer without assist multiple times. Attempt to redirect effective...." A physician's orders [REDACTED]. Check placement (and) function every shift...." Progress Notes continued: 3/23/12 at 9:36 A.M.: "Alert to self and surroundings. Confused to time, place and situation...Scattered bruising in various stages of healing r/t (related to) fall prior to admission to facility. Miami J collar in place. Resident does remove collar per self and is replaced by staff...." 3/23/12 at 2:10 P.M.: "Resident A & O (alert and oriented) to name only at this time...Resident remains extensive assist x 1 for transferring from bed to standing position...Unsteady when ambulating with walker...pleasantly confused...." 3/26/12 at 1:59 A.M.: "Resident is alert and oriented to person. Resident is very HOH (hard of hearing) and communication is limited...Resident ambulates to restroom with the assistance of one and a walker. Resident is an assist of 1 for transferring...." 3/26/12 at 8:00 A.M.: "0710 (7:10 a.m.) - Two nurses where (sic) in adjoining room and heard a commotion in the adjoining bathroom. They opened the door and resident was laying on her back with her head against the south door of the bathroom. Alarm was sounding...Cervical collar not in place and placed per this nurse. No change in LOC (level of consciousness) as resident is confused to time, place, and situation...0722 (7:22 a.m.) (Name of physician) returned call - Order rec'd (received) to send to (name of hospital) ER for eval (evaluation) and treatment...." The resident returned to the facility the same date at 11:41 A.M,. with no new orders. Progress Notes continued: 3/26/12 at 4:47 P.M.: "Pressure sensitive alarm placed next to bed and by reclining chair to alert staff of unassisted transfer/ambulation." 3/28/12 at 2:10 P.M.: "...Reviewed fall which occurred 3/26/12...Per report of unit nurse alarm sounded but was not very loud and staff was unable to reach res. before she reached bathroom and fell . Alarming floor mat placed by bed and recliner to alert staff to unsafe independent transfer or ambulation... Res. had dementia and is unable to comprehend need for collar or to remember to call for assist...." On 4/3/12 at 12:15 P.M., during interview with the DON, she indicated Resident A had an alarm while in bed on 3/26/12. A nurse was in an adjoining room helping a resident, and another nurse was at the desk, and by the time they heard the alarm, "it was too late." The DON indicated the investigation showed the alarm was not very loud. 3. The closed clinical record of Resident C was reviewed on 4/2/12 at 2:45 P.M. [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment, dated 5/21/11, indicated the resident scored an 8 out of 15 for cognition, with 15 indicating no memory impairment, transferred with limited assist of 1, ambulated with supervision of 1, and had no falls since 2/15/11. Progress Notes included the following notations: 7/12/11 at 1:30 P.M.: "QMA passed resident's room and noticed him on floor on (right) side, laceration to right side of head and noticed large amount of bleeding under head; also noted s/t (skin tear) to right elbow, blood noted to nares, ears clear and large hematomia (sic) below right eye...." The resident was transferred to the hospital on [DATE] at 1:50 P.M. A hospital transfer record, dated 7/12/11, indicated, "Primary Diagnosis: [REDACTED]." Progress Notes continued: 7/13/11 at 5:05 P.M.: "Resident (sic) returned via stretcher at this time...resident very confused, does not know where he is, resident taken to bathroom, alarms secured to bed and chair in room." 7/13/11 at 7:45 P.M.: "Heard bed alarm sounding and upon entering room noted resident coming from bathroom with skin tear to right elbow...Escorted resident back to bed and alarm functioning and in place...." 7/13/11 at 8:25 P.M.: "Alarm sounding in resident's room, cna (sic) immediately went to res. bed, resident lying on the floor on left side, resident attempted to get up per self, water spilled on floor...resident very anxious, confused, and disoriented, resident has been most of this shift, resident contnued (sic) on 15 minute safety checks as nursing measure. Resident transferred back to bed with assist of 2 after assessed...." The resident was transferred to the emergency roiagnom on [DATE] at 9:15 P.M. A Progress Note, dated 7/14/11 at 4:18 A.M., indicated, "Call placed to (name of hospital)...stated res was admitted with Dx (diagnosis) of Subdural hematoma, skull Fx (fracture) and facial fractures, and low potassium." A Hospital History and Physical, dated 7/14/11, indicated, "...The patient was actually admitted to the trauma center over the last 24 hours with a fall at his nursing home...He, at that time, showed a small subdural hematoma which was stable...He was approved to return back to his skilled nursing facility. He was found on the floor of his room after his bed alarm had gone off this evening...CT scan of the head showed a significant increase in his right subdural hematoma and trauma admission was indicated...." On 4/3/12 at 12:15 P.M., during interview with the DON, she indicated when Resident C returned from the hospital on [DATE], he was "very, very confused." The DON indicated the staff did put alarms on him upon his return. 4. On 4/3/12 at 11:50 A.M., the Director of Nursing provided CNA assignment sheets for the upper level of the facility. The assignment sheets indicated that 38 residents currently resided on the upper level, and 11 of the residents had some type of alarm used for fall prevention. On 4/3/12 at 12:15 P.M., the Director of Nursing provided the current facility policy on "Falls Management," revised November 2009. The policy included: "The facility recognized that falls are a common source of serious injury amount the elderly...It is our intention to reduce the risk of falling through a comprehensive, interdisciplinary process of assessment, care plan development and ongoing plan review for effectiveness. Residents with a fall episode will receive prompt attention and their needs and plan of care will be reviewed as appropriate...If a Fall Occurs...Identify and implement any new intervention specific to the resident to reduce the risk for falls to recur and communicate to family and staff...." This federal tag relates to Complaint IN 614. 3.1-45(a)(2)