Every finding on record at Bridgepointe Health Campus

Based on observation, interview, and record review, the facility failed to ensure residents that required assistance with incontinence care and feeding received assistance timely for 1 of 3 residents reviewed for Activities of Daily Living (ADLs). A newly admitted resident was found in bed, by a family member, saturated in urine, and without having had breakfast. (Resident B) Finding includes:During an observation on 4/30/26 at 11:25 A.M., Resident B was sitting in a wheelchair in the restorative dining room receiving assistance eating from a family member. During an interview on 4/30/26 at 12:15 P.M. Resident B's family member indicated Resident B had moved to the facility's skilled nursing unit the day prior and the past night was her first night on the skilled care unit. The family member arrived at approximately 9:45 A.M. to find the resident in bed saturated from her shoulders to her feet in urine. The family member indicated the resident had not yet been out of bed and appeared to have not received routine incontinence care. The resident had not received breakfast and indicated her breakfast and lunch were the same meal. During an interview on 4/30/26 at 12:35 P.M., LPN 4 indicated Resident B required assistance with feeding and ate in a restorative dining room. During an interview on 4/30/26 at 12:40 P.M., the Dietary Manager (DM) indicated Resident B did receive a breakfast tray to her room that morning, but the resident required assistance with feeding. Since the resident was not yet out of bed, the breakfast tray was brought back to the kitchen so it would not get cold. The CNA on the hall was asked if she could assist the resident with her breakfast and she indicated that she did not have time. During an interview on 4/30/26 at 1:15 P.M., CNA 6 indicated she assisted Resident B with incontinence care that morning after a family member notified staff the resident was wet. CNA 6 indicated the resident was wet from head to toe. CNA 6 indicated she had wanted to get the resident up earlier in the morning, but the resident required a lift and two staff members to assist, and a second staff member was busy at the time. CNA 6 indicated she did not receive any information from the night shift CNA in the morning report, and the facility did not always have enough staff to assist the residents during mealtimes.Resident B's clinical record was reviewed on 5/1/26 at 11:30 A.M. Resident B's diagnoses included, but were not limited to, hemiplegia and hemiparesis affecting left non-dominant side, dementia, anxiety, schizophrenia, and cerebral infarction. Resident B's care plan included but was not limited to, Resident is malnourished or at risk for malnutrition (initiated 4/30/26) with an intervention of, assist with meals as needed. Resident B's nurses progress notes included, but was not limited to:4/30/26 at 10:15 A.M. - Perineal/buttock/trunk/extremities assessed following incontinence episode. After incontinent episode skin cleansed and dried. Fresh linens placed to bed.During an interview on 5/1/26 at 12:40 P.M., CNA 6 indicated she checked in on Resident B around 6:30 A.M on 4/30/26 and the resident did not indicate she needed assistance. CNA 6 indicated she did not provide any assistance or incontinence care until after family arrived on 4/30/26 at approximately 9:45 A.M.On 5/1/26 at 10:56 A.M., the Facility Administrator supplied a facility policy titled Perineal Care for Incontinence, dated 12/16/14. The policy included, Overview . To provide incontinence care that will keep skin from being exposed to prolonged periods or urine and feces .On 5/1/26 at 10:59 A.M., the Facility Administrator supplied a facility policy titled Guidelines for Meal Service, dated 12/12/25. The policy included, .Staff will be available to assist with meal service and eating .This citation relates to Intakes 2995042 and 2729564.410 IAC (Indiana Administrative Code) 16.2-3.1-38(a)(3)

Based on observation, interview, and record review, the facility failed to provide assistance with oral/denture care for 2 of 3 residents reviewed for activities of daily living (ADLs). Residents did not receive assistance with ADL's (oral/denture care) according to the plan of care and resident needs. (Resident B, Resident C)Findings include:1. A record review on 12/15/25 at 11:00 A.M., Resident B's diagnoses included, but were not limited to, Parkinson's disease, dementia with behavioral disturbance, anxiety, muscle weakness, and need for assistance with personal care. Resident B's most recent quarterly MDS (Minimal Data Set) assessment, dated 8/29/2,5 indicated the resident had moderate cognitive impairment, required set up or clean-up assistance with oral hygiene, and required partial to moderate assistance with transfers. Resident B's care plan included, but was not limited to, pay attention to basic needs and provide ADL care as required. The resident has upper partial dentures (started 4/9/25). Resident B's nurse's progress notes included, but were not limited to: 11/9/2025 at 5:59 P.M., Resident's spouse noticed upon arrival that his partial temporary plate was not there. Staff and the resident's spouse searched the resident's room and did not find them. Spouse suspected the resident had swallowed a partial denture and requested that he go to the hospital. A change in physical condition event started 11/9/25 at 5:26 P.M. indicated Resident B was thought to have swallowed his partial denture at some point between the administration of intramuscular medication Haldol on 11/8/25 at approximately 6:00 P.M. and 11/9/25 at approximately 6:00 P.M. when the dentures were discovered to be missing. During an interview on 12/15/25 at 2:55 P.M., CNA 5 indicated Resident B required assistance with denture care.Resident B's record contained no documentation that denture care was provided during November 2025. 2. During an observation and interview on 12/15/25 2:40 P.M., Resident C was lying in bed. Resident C indicated she wore dentures, could remove them herself, and staff would soak them overnight. Resident C indicated her dentures were not removed and soaked every night; at times, they would be forgotten, and she wouldn't realize until she woke. A record review on 12/15/25 at 3:00 P.M., Resident C's diagnoses included, but were not limited to, dementia, dysphagia (difficulty swallowing), and anxiety. Resident C's most recent quarterly MDS (Minimum Data Set) assessment, dated 12/12/25, indicated the resident had no cognitive impairment, required assistance with oral hygiene, and had a broken or loosely fitting full or partial denture. Resident C's care plan included, but was not limited to, the resident having potential for mouth pain due to edentulous and has upper/ lower denture (last reviewed 9/25/25), offer and provide mouth care as needed (started 6/23/21). Resident C's record contained no documentation that oral/denture care was provided during a 30-day review period.During an interview on 12/15/25 at 2:15 P.M., LPN 3 indicated the CNAs should remove dentures nightly, place them in a denture cup, clean them, and assist the resident to re-insert them in the morning. CNAs should document oral care in the CNA charting. On 12/15/25 at 3:30 P.M., RN 7 provided a Standard Operating Procedure titled Oral Care, dated 12/16/24. The procedure included, Overview . To provide each resident with good oral hygiene . Providing care to dentures: .4. Rinse dentures in cool running water before brushing them . 6. Brush dentures on all surfaces . 9. Place dentures in a clean denture cup . Procedure to be performed with am and pm care .This citation is related to intake 2679150. 3.1-38(b)(1)

Based on interview and record review, the facility failed to ensure comprehensive care was provided for 1 of 3 residents reviewed for behavioral healthcare and monitoring. A resident's plan of care was not updated following an escalation of behaviors, was not monitored for antipsychotic drug use, and did not receive routine care following the administration of an antipsychotic medication. (Resident B)Finding includes:A record review on 12/15/25 at 11:00 A.M., indicated Resident B's diagnoses included, but were not limited to Parkinson's disease, dementia with behavioral disturbance, anxiety, muscle weakness, and need for assistance with personal care. Resident B's most recent quarterly MDS (Minimal Data Set) assessment, dated 8/29/25 indicated the resident had moderate cognitive impairment, did not have unwanted behaviors during a 7 day look back period, required set up or clean-up assistance with oral hygiene, and had complaints of difficulty or pain when swallowing. Resident B's care plan included but was not limited to, resident has impaired cognition with associated short term memory impairment and risk for confusion, disorientation, altered mood, impaired or reduced safety awareness due to dementia. Resident will remain safe and not injure self secondary to impaired decision making. Pay attention to basic needs and provide ADL care as required, resident has upper partial dentures (reviewed 10/8/25). Resident has impaired swallowing due to dysphagia (reviewed 10/8/25), Resident has impairment in functional status due to Parkinson's disease, dementia, dysphagia, and decreased mobility. Provide assistance as needed with self-care (reviewed 10/8/25). Resident demonstrates altered behaviors including hallucinations due to long-standing Parkinson's disease. Monitor resident mood, affect, and behaviors (reviewed 10/8/25). Resident B's physician orders through November 2025 included but were not limited to, Target behavior (Restlessness/anxiety). At the end of each shift, mark frequency and intensity of behavior three times a day (started 9/17/25), Target behavior (agitation). At the end of each shift, mark frequency and intensity of behavior three times a day (started 10/2/25). Haldol injection, 5 milligrams (mg) intramuscular one time (started and completed 11/1/25). Haloperidol lactate (Haldol) solution 5 mg / milliliter (mL) injection one time (started and completed 11/8/25).Resident B's nurses progress notes included, but were not limited to:11/1/25 at 2:50 P.M. - Resident yelling loudly and hitting at staff. Attempting to get out of chair despite three workers holding him. Unable to get oral medications down. Resident is spitting. Spouse at side and trying to console resident with no response. Physician called and orders received for injection sedation. Haldol 5 mg given.11/1/25 at 6:50 P.M. - Resident resting quietly post Haldol administration. Resident ate in dining room with wife and was cooperative. Resident sleeping now.11/2/25 5:40 A.M. - Resident rested in Geri-chair this entire shift. Resident has been very sedated post Haldol injection given on 11/01/25. Monitored closely this shift and will continue to monitor.11/3/25 at 5:50 A.M. - Resident awake most of night shift, sleeping occasionally for short periods of time. At times is very agitated and resistive of care or directions. Physically very strong with upper extremities and will grab staff very tightly. Resident grabbed this nurse's left wrist, and it was very difficult to get him to let go. Resident keeps leaning forward or attempting to stand, frequently setting off his chair alarm. Difficult to understand resident's speech at times. Did calm briefly when another staff turned on hymn music for resident and he sang along to the hymns. Currently up in wheelchair with staff taking turns monitoring resident.11/8/25 at 6:01 P.M. - Resident very agitated and attempted to hit wife, another resident, and staff. Unable to give oral medication, resident spits medications out. Nurse practitioner notified and received a one-time dose of Haldol 5 mg intramuscular injection for agitation. Resident's wife is here and aware of condition and new order.11/9/25 at 5:38 A.M. - Resident asleep in recliner this shift. Evening medications were not given as resident was asleep after Haldol injection. No further behaviors this shift. 11/9/25 at 12:07 P.M. Resident sitting up in his recliner. Resident declined to take his medication. Nurse educated resident on benefits and dangers of not taking medication, resident still declined. Call light and water within reach, will continue to monitor. 11/9/2025 5:59 P.M. - Wife noticed upon arrival that resident's partial temporary plate (denture) was not in place. Staff and resident's wife searched the resident's room and did not find them. Wife suspected he had swallowed partial denture and requested that he go to emergency room via ambulance.Resident B's November medication administration record (MAR)/ treatment administration record (TAR) indicated the resident was observed for agitation on 11/8/25 between 8:00 P.M. and 10:00 P.M., with no agitation documented. Resident B was observed for restlessness/anxiety on 11/8/25 between 8:00 and 10:00 P.M., with no behavior present. Resident B's hospital emergency department notes dated 119/25 at 8:10 P.M., included, patient apparently became argumentative and violent last evening. Nursing home staff did have to give him Haldol. They believe at some point during the altercation or when he was sedated with Haldol he swallowed the denture. He complains of neck pain on the right side when swallowing. A Computed Tomography (CT) scan of the chest, abdomen, and pelvis was performed with an impression that included a tiny somewhat linear radiodensity within the transverse duodenal segment. Finding is nonspecific on CT scan but could represent a swallowed dental hardware. A hospitalist history and physical note dated 11/9/25 at 8:16 P.M., included, patient presented to emergency department for a swallowed foreign body. Due to aggression and agitation last night, was medicated with Haldol around 7:00 P.M. last night. Tonight, at supper, facility staff noticed difficulty swallowing. Wife reported at that time that the patient's partial plate was missing and was unable to be found. Patient reporting pain in right side of throat. Resident B's record contained no documentation that the resident received oral/denture care the night of 11/8/25 or the morning of 11/9/25. During an interview on 12/15/25 at 2:55 P.M., CNA 5 indicated Resident B required assistance with denture care.During an interview on 12/15/25 at 2:15 P.M., LPN 3 indicated the CNA's should remove dentures nightly, place them in a denture cup, clean them, and assist the resident to re-insert them in the morning. CNA's should document oral care in the CNA charting. During an interview on 12/16/25 at 11:15 A.M., LPN 8 indicated that an escalation of behaviors should be documented and initiate an update to the resident's plan of care. An increase in behavior that requires a new order of Haldol injection should initiate an event that would require further observation and documentation. Nurses should document the monitoring for side effects for any antipsychotic medication. During an interview on 12/16/25 at 11:25 A.M., the Director of Nursing (DON) indicated an escalation of behavior should trigger an update to plan of care with updated interventions. Use of antipsychotic medications and monitoring should be included in the resident's plan of care. On 12/15/25 at 3:30 P.M., RN 7 provided a Standard Operating Procedure titled Oral Care, dated 12/16/24. The procedure included, Overview . To provide each resident with good oral hygiene . Providing care to dentures: .4. Rinse dentures in cool running water before brushing them . 6. Brush dentures on all surfaces . 9. Place dentures in clean denture cup . Procedure to be performed with am and pm care .On 12/16/25 at 1:15 P.M., RN 7 provided a facility policy titled, Guidelines for Mental Health Wellness Program, revised 12/16/25. The policy included, .7. New or exacerbated behaviors shall be brought to the daily stand up meeting and CCM (Chronic Care Management) for review and discussion . 10. The Mental Health Wellness/Behavior Management Program shall consist of: a. A care plan initiated or updated with realistic, effective interventions . c. Medication reviews for effectiveness, side effects, and reductions. 11. Interdisciplinary team findings shall be contained in the clinical record .This citation is related to intake 2679150. 3.1-37(a)

Based on the interview and record review, the facility failed to ensure care was provided by qualified staff for 2 of 4 residents reviewed for diabetic care and 2 of 3 residents reviewed for wound care. Qualified Medication Aides (QMAs) documented the administration of routine insulin injections without being certified to administer insulin, and QMAs documented the completion of ordered wound treatments. (Resident F, Resident G)Findings include: 1. During record review on 11/25/25 at 10:15 A.M., Resident F's diagnoses included but were not limited to type II diabetes and chronic venous hypertension with ulcer of the right lower extremity.Resident F's physician orders included, but were not limited to; insulin glargine insulin pen; 100 units per milliliter (ml), administer 20 units subcutaneous at bed time (started 6/14/25), cleanse area to right lower leg with wound cleanser, apply collagen Ag (silver) to wound bed, and wrap with Kerlix every three days (started 9/26/25 and discontinued 11/12/25), and Cleanse area to right lower leg with wound cleanser, apply Adaptic layer (non-adherent dressing), apply collagen Ag to wound bed, and wrap with Kerlix (started 11/12/25). Resident F's most recent wound assessment, dated 11/23/25, indicated the resident's right, lower leg wound measured 8-centimeter (cm) (length) x 2.5 cm (width) x 0.1 cm (depth) with a moderate amount of serosanguineous exudate (fluid or drainage) described as partial thickness: loss of epidermis and into but not through the dermis. Resident F's medication administration record (MAR) and Treatment administration record (TAR) from 11/1/23 to 11/25/25 indicated the order insulin glargine insulin pen; 100 units per milliliter (ml), administer 20 units subcutaneous at bedtime was documented as administered by QMA 2 on the following dates: 11/1/25, 11/10/25, 11/11/25, 11/17/25, 11/18/25, and 11/24/25. The order to apply collagen Ag (silver) to the wound bed and wrap with Kerlix every 3 days was documented as completed by QMA 2 on 11/10/25. The order: apply collagen Ag to wound bed and wrap with Kerlix was documented as completed by QMA 2 on 11/18/25. 2. During record review on 11/25/25 at 10:35 A.M., Resident G's diagnoses included but were not limited to: type II diabetes, peripheral vascular disease, and type II diabetes with foot ulcer.Resident G's physician orders included, but were not limited to; Humalog Junior KwikPen U-100 (insulin lispro) insulin pen, half-unit; 100 unit/ml administer per sliding scale (started 7/15/25), Lantus Solostar U-100 Insulin (insulin glargine) insulin pen; 100 unit/ml, administer 8 units at bedtime (started 7/15/25), and left anterior lower Leg: cleanse wound with normal saline, pat dry, apply Prisma to wound bed dampened with a few drops of saline. Cover with 2x2 gauze and secure with tape. Change dressing every other day (started 11/14/25). Resident G's recent wound observation of the anterior lower leg, dated 11/15/25, indicated the wound measured 5.5 cm x 1 cm x 0.1 cm with serosanguineous exudate and was described as full thickness: through dermis and down to subcutaneous tissue. During a review of Resident G's MAR and TAR from 11/1/25 to 11/24/25, the resident's order Humalog Junior KwikPen U-100 (insulin lispro) insulin pen, half-unit; 100 unit/ml administer per sliding scale was documented as administered by QMA 2 on 11/10/25. The order Lantus Solostar U-100 Insulin (insulin glargine) insulin pen; 100 units/ml, administer 8 units at bedtime was documented as administered by QMA 2 on 11/7/25, 11/10/25, 11/11/25, 11/16/25, and 11/18/25. The order left anterior lower leg: cleanse wound with normal saline, pat dry, apply Prisma to wound bed dampened with a few drops of saline. Cover with 2x2 gauze and secure with tape. Change dressing every other day was documented as completed by QMA 7 on 11/16/25. During a review of QMA 2's state licensure on 11/25/25 at 11:45 A.M., the license indicated that no secondary license to administer insulin had been obtained. During an interview on 11/25/25 at 10:45 A.M., LPN 8 indicated that QMAs who had not obtained the license for insulin administration could not administer insulin and that QMAs could not provide wound treatments for venous and arterial wounds. On 11/25/25 at 2:30 P.M., RN 5 supplied an undated facility policy titled, Non-Licensed Medication Administrator's Scope of Practice Guidelines by State. The policy included that a QMA may administer insulin only with a state certification. An Indiana-only Qualified Medication Aide Insulation facility policy, dated 12/16/24, included, To allow Indiana QMA's who are current on the QMA registry or have completed the QMA 100 (hour) training program, passed the state exam and successfully completed the Insulin Administration Education Module to administer insulin.The Indiana QMA scope of practice indicated, .The following tasks shall NOT be included in the QMA scope of practice: .(6) Administer a treatment that involves advanced skin conditions, including stage II, III, and IV decubitus ulcersThis citation relates to intakes 2604039 and 2639662. 3.1-14(j)

Based on observation, interview, and record review, the facility failed to provide prominent access to the most recent annual survey. Signage near the front business office window indicated the most recent survey results were available in a cabinet near an entrance doorway, however the most recent survey results were not found. Findings include: During an observation and record review on 10/14/25 at 1:30 P.M., signage that indicated the most recent IDOH survey results were contained in a cabinet near an entryway. A drawer in the cabinet contained two file folders with survey reports. A review of the IDOH survey reports indicated that the most recent survey available was dated June 2024. No other survey reports were found in the cabinet. During an interview on 10/14/25 at 1:35 P.M., LPN 4 indicated the facility's most recent annual survey was completed in August 2025. During an interview on 10/14/25 at 2:40 P.M., LPN 4 indicated the facility did not have a written policy regarding the availability of the most recent survey results, but indicated the facility followed the regulations regarding the posting of survey results. 3.1-3(b)(1)

Based on observation, interview, and record review, the facility failed to ensure food was prepared and distributed in sanitary conditions and in accordance with professional standards for food service safety during 3 of 3 kitchen observations. Air vents and overhead lighting above food preparation areas contained a build up of dust and debris. Finding includes: During an initial kitchen observation on 6/18/25 at 10:15 A.M., hanging overhead lights fixtures above food preparation tables contained a build up of dust and debris. A mounted air conditioning (AC) unit near the doorway to the main dining room doorway was not functioning, appeared to be missing a panel or vent cover, and vent covers at the bottom of the unit contained a thick build up of dark colored dust and debris. During a meal service observation on 6/20/25 at 11:00 A.M., the hanging overhead light fixtures above the food preparation area contained a build up of dust and debris. Kitchen staff utilized a food preparation table directly under the mounted AC unit to make side salads and fill condiment cups. The mounted AC unit contained a thick build up of dust and debris toward the bottom of unit. During an observation and interview on 6/20/25 at 1:55 P.M., an uncovered bowl of what appeared to be icing for a dessert was placed on a food preparation table directly under the mounted AC unit. The mounted AC unit contained a thick build up of dust and debris toward the bottom of the unit. The dietary manager (DM) indicated the AC unit had failed and was no longer in use and needed replaced. The DM indicated being aware of the build up of dust on the air conditioning and on the overhead lighting above the food preparation areas. The DM indicated routine clearing of the light fixtures was not completed by kitchen staff, and that their was a work order for the maintenance department to clean the light fixtures. During an interview on 6/20/25 at 2:25 P.M., the Facility Administrator indicated the kitchen staff would no longer be preparing food under the disrepair of the kitchen AC unit. On 6/25/25 at 9:20 A.M., the Facility Administrator supplied a facility policy titled, Ceilings Preventative Maintenance, dated 1/26/25. The policy indicated, It is [facility corporation] policy to inspect ceilings monthly. HVAC (Heating, Ventilation, and Air Conditioning) units should be checked quarterly for dust and grease build up . 3.1-21(i)(2) 3.1-21(i)(3)

Based on observation, interview, and record review, the facility failed to provide a safe and sanitary environment to prevent the development and transmission of communicable diseases and infections for 1 of 3 residents observed during toileting. Gloves were not changed between dirty and clean tasks, hands were washed for 12 seconds, and the resident was not offered to wash their hands after using the toilet. (Resident 39) Finding includes: On 6/20/25 at 10:44 A.M., Certified Nurse Aide (CNA) 7 was observed to assist Resident 39 to the toilet. Upon entrance to the bathroom, CNA 7 put on a pair of gloves, assisted the resident to pull her pants and brief down, and the resident sat on the toilet. CNA 7 took off the resident's pants and brief, touching the bottoms of the resident's shoes while lifting the feet to remove the items. Using the same gloved hands, CNA 7 then used wet wipes to clean the resident after a bowel movement. The resident then stood, and CNA 7 pulled up the clean brief and pants before assisting the resident out into the room and to her recliner. CNA 7 did not change her gloves during the observation. The resident was not offered to wash her hands before leaving the restroom. CNA 7 then touched the resident's blanket on her bed while asking the resident if she wanted it. CNA 7 then removed her gloves on the way back to the restroom, and washed her hands for 12 seconds beginning to end. On 6/23/25 at 2:11 P.M., the Infection Preventionist (IP) indicated hands should be washed for at least 20 seconds or as long as it takes to sing Happy Birthday twice. She indicated gloves should be changed from dirty to clean tasks, and staff should offer the resident to wash their hands after toileting. On 6/23/25 at 2:45 P.M., the Administrator provided a current Guideline for Handwashing/Hand Hygiene policy, dated 12/17/24, that indicated Residents shall be given the opportunity and assistance to wash their hands . Health Care Workers (HCW) shall use hand hygiene at times such as . Before/after having direct physical contact with residents . Residents shall be offered the opportunity to wash their hands . After toileting . Hand washing . Wash well for at least 20 seconds, using a rotary motion and friction On 6/23/25 at 2:48 P.M., the Administrator provided a current Perineal Care for Incontinence policy, dated 12/26/24, that indicated Pay particular attention to infection prevention and control techniques when performing pericare, to prevent introduction of contamination that may lead to a urinary tract infection 3.1-18(l)

Based on observation, interview, and record review, the facility failed to ensure follow up for a resident discharged from the hospital with a new catheter. The resident was not assessed for removal of the catheter and did not receive appropriate treatment and services to prevent urinary tract infections (UTIs) for 1 of 3 residents reviewed for UTIs. (Resident 16) Finding includes: During an interview on 6/19/25 at 10:28 A.M., Resident 16 indicated her catheter hurt sometimes to the point that she pulled it out and currently had a UTI. A catheter bag was observed hanging on the right side of the bed. On 6/23/25 at 2:11 P.M., Resident 16's clinical record was reviewed. Diagnoses included, but were not limited to, neuromuscular dysfunction of bladder and chronic pain. Resident 16 was admitted on [DATE]. The most recent quarterly Minimum Data Set (MDS) assessment, dated 4/25/25, indicated Resident 16's cognition was moderately impaired, dependent on staff for bed mobility, transfers, toileting, had an indwelling catheter, and had not had a UTI in the past 30 days. Physician Orders included, but were not limited to, the following: Change urinary catheter as needed, based on clinical indications, such as infection, obstruction, or when the closed system is compromised, ordered 3/3/25. Bactrim DS (antibiotic) 800-160 milligram (mg) tablet, give one orally daily on Monday, Wednesday, and Friday for prophylactic antibiotic, ordered 3/3/25. Macrobid (antibiotic) 100 mg capsule, give one orally twice daily for UTI for 7 days, ordered 3/31/25. Macrobid 100 mg capsule, give one orally twice daily for UTI for 7 days, ordered 6/17/25. A current urinary Catheter Care Plan, last revised 5/14/25, included an intervention to assist with catheter care and change urinary catheter per physician orders. A Skilled Nursing Assessment, dated 3/4/25, indicated the resident was continent and there was no catheter present. The Hospital Discharge Orders, dated 3/3/25, indicated a urinary catheter had been placed while inpatient because the resident wasn't urinating for an unknown reason and included an appointment scheduled on 3/19/25 with a Urologist (a medical specialist who diagnoses and treats conditions related to the urinary and reproductive systems) for follow up of catheter placement and prophylactic (preventative) antibiotic. A Progress Note, dated 3/21/25 at 2:07 P.M., indicated resident's son was questioning the urinary catheter being removed per the hospital discharge summary and follow up with her urologist to discuss removal. Son indicated he tried to contact their office to reschedule, and would need to try and reschedule that appointment. (It did not specify if son or facility were to reschedule appointment.) The clinical record lacked documentation that the resident followed up with a urologist. Resident 16 had the following UTIs since admission: UTI 1 On 3/26/25 at 1:36 P.M., blood was noted in the resident's catheter bag. An order was received to collect a urine specimen for a urinalysis (UA) and culture and sensitivity (C&S). The urine culture, resulted 3/29/25 at 9:39 A.M., indicated >100,000 Colony Forming Units per milliliter (CFU/ML) Staphylococcus epidermidis (bacteria). Macrobid 100 mg twice daily for seven days was ordered on 3/31/25 for a UTI. Bactrim DS was placed on hold for duration of Macrobid, then restarted. UTI 2 On 4/14/25 at 5:27 A.M., a new order was received to obtain a urine specimen for a UA and C&S for blood in the urine. The urine culture, resulted 4/17/25 at 8:08 A.M., indicated >100,000 CFU/ML Citrobacter freundii (bacteria) and >100,000 CFU/ML Pseudomonas fluorescens (bacteria). The clinical record lacked documentation of the physician reviewing the results. The resident remained on prophylactic Bactrim DS. UTI 3 On 6/17/25 at 1:45 P.M., a urine specimen was reported as collected 6/14/25 at 5:51 P.M., because resident had recently pulled out catheter with balloon intact because it was causing her pain. The urine culture, resulted 6/17/25 at 8:48 A.M., indicated > 100,000 CFU/ML Klebsiella oxytoca (Extended Spectrum Beta-Lactamase or ESBL organism). Macrobid 100 mg BID for 7 days for UTI. Bactrim DS was placed on hold for the duration of Macrobid. On 6/20/25 at 11:13 A.M., catheter and incontinence care for Resident 16 performed by Certified Nurse Aide (CNA) 22 and the Interim Director of Nursing (IDON) was observed. CNA 22 was wearing a gown and gloves and was on the left side of the resident with 2 basins of water on the bedside table. Resident was laying on her back in the bed. The IDON washed her hands with a three second lather and put on her gown and gloves. The CNA and IDON both unfastened the incontinence pad. CNA 22 had the resident touch the wash cloth after it was dipped in soapy water to feel the temperature, used that wash cloth to wipe the resident's left upper leg and groin area, and placed the soiled wash cloth on the right side foot of the bed on the mattress touching the resident's sheet and sock. CNA 22 repeated that process on the right side. The resident's skin on her groin was red and had pinpoint red bumps throughout. CNA 22 wiped the outside of the labia but did not open the resident's labia to cleanse the inside area. CNA 22 wiped the catheter tubing from just outside the labia as far as she could reach. The resident's groin was rinsed and wiped dry. The resident was rolled to her right side and CNA 22 opened the bedside dresser, grabbed a package of wipes, and wiped the resident's buttocks with a visible bowel movement. The resident's skin on her buttocks was red and had pinpoint red bumps throughout. Without changing gloves or performing hand hygiene, CNA 22 placed a new incontinence pad (touched the inside of the pad) and draw sheet under the resident. Once the incontinence pad was pulled through, they fastened the resident's incontinence pad. The soiled linens at the foot of the bed were placed into a trash bag. They pulled up the resident's pants, pulled the resident up in bed, put pillows under the feet, pulled up the sheet and blankets to cover the resident, adjusted the bed with the controller, and placed a call light by the resident (touched the part that the resident would use). The IDON washed her hands with a 15 second lather. CNA 22 removed her gloves and put on new ones without sanitizing her hands. She moved the bedside table over to the resident, gave the resident her television remote, grabbed a bag of chips and other resident items from the top of the bedside dresser, and placed them on the bedside table. CNA 22 removed her gloves and gown and washed her hands with an 11 second lather. Both staff exited the room without changing the resident's socks or blankets that were in direct contact with soiled wash cloths from the incontinence care. During an interview with the Infection Preventionist (IP) on 6/23/25 at 2:11 P.M., She indicated when washing their hands, staff should be lathering hands with soap for at least 20 seconds, should change their gloves and sanitize hands between dirty to clean tasks. They should not be touching resident items, etc with soiled gloves and the soiled wash cloths should be placed directly into a trash bag and not on the resident's bed. If the soiled cloths came into contact with the resident's socks and blankets, then they should have been changed. During an interview on 6/25/25 at 10:44 A.M., Regional Clinical Support 3 indicated urinary catheters were only changed as needed and not routinely. She indicated the resident's son traveled internationally for work. She indicated after an internal investigation the previous night, the resident had a history of bladder cancer but was released from oncology in 2023. She had not followed up with urology since then because she hadn't had any problems. She indicated the son canceled the 3/19/25 appointment and rescheduled it to 4/15/25 but did not communicate that to the facility. He then canceled the appointment on 4/15/25 without rescheduling. At the time Regional Clinical Support 3 contacted the urologist, the resident did not have any appointments scheduled for follow up. During an interview on 6/25/25 at 11:40 A.M., the Social Services Director (SSD) indicated they relied on family to communicate and nursing judgement for urgency and need of follow up appointments. On 6/23/25 at 2:45 P.M., the Administrator provided a current Urinary Catheter Care Policy, revised 5/11/16, that indicated . to perform the procedure . put on gloves . wash the resident's genitalia and perineum thoroughly . place soiled linen into designated container . remove gloves . wash and dry your hands thoroughly . put on clean gloves . with non dominant hand separate the labia of the female resident. Maintain the position of this hand throughout the procedure. Assess the urethral meatus. For a female: Use a wipe, wash cloth with periwash to cleanse the labia. Use on e area of the wipe or wash cloth for each downward, cleansing stroke,Use a clean wipe or washcloth with periwash to cleanse and rinse the catheter from insertion site to approximately four inches outward . On 6/25/25 at 11:55 A.M., Regional Clinical Support 6 provided a Standard Precautions Guideline Policy, dated 5/11/16, that indicated Standard precautions include . items in the resident's environment likely to have been contaminated with infectious fluids or other potentially infectious matter must be handled in a manner to prevent transmission of infectious agents . On 6/25/25 at 12:21 P.M., the SSD provided a Use of Indwelling Catheter Policy, dated 5/11/16, that indicated . A resident who enters the campus with an indwelling urinary catheter is assessed for removal of the catheter as soon as possible . Resident/Representative should be informed of the risks and benefits of indwelling catheter use . 3.1-41(a)(2)

Based on observation, interview, and record review, the facility failed to ensure adequate supervision and implementation of the plan of care for 1 of 1 residents reviewed for falls with major injury. A resident's fall interventions were not in place at the time of fall. (Resident 2) Finding includes: On 6/18/25 at 11:05 A.M., Resident 2 was out of her room, the bathroom door was open, and a call don't fall sign was not observed in the resident's room or bathroom. On 6/23/25 at 11:18 A.M., Resident 2 was out of her room, the bathroom door was open, and a call don't fall sign was not observed in the resident's room or bathroom. On 6/20/25 at 10:22 A.M., Resident 2's clinical record was reviewed. Diagnosis included, but was not limited to, dementia. The most recent annual Minimum Data Set (MDS) assessment, dated 2/24/25, indicated Resident 2's cognition was severely impaired, had 1 fall with no injury, and was a partial to moderate assist (resident performs over half the effort) for bed mobility and showering, and substantial to maximum assist (staff performs over half the effort) for transfers and toileting. Physician's Orders included, but were not limited to, the following: transfer with 1 assist, ordered 8/6/24. call light attendant (bed alarm) to bed and check placement, ordered 2/11/25. call don't fall sign, ordered 12/24/24. bed in lowest position, ordered 2/10/25. The Risk to Fall Care Plan, last revised 4/9/25 included, but was not limited to, the following interventions: Call light batteries replaced, initiated 3/25/25. Bed in lowest position, initiated 2/10/25. Call light attendant to bed, initiated 2/10/25. Call don't fall sign, initiated 12/23/25. Fall Risk Assessments from 11/25/24 to present indicated the resident was at high risk for falls. The clinical record lacked documentation of the call light attendant batteries being monitored by staff to make sure they were working. Progress notes were reviewed and indicated Resident 2 had the following 3 falls: Fall 1 On 12/23/24 at 7:20 A.M., a Certified Nurse Aide (CNA) found the resident seated on the floor in her room. The progress note (at that time) indicated resident had right hand/finger pain rated a 5 out of 10 on the pain scale, with painful Range of Motion (ROM). The following day after the fall, the resident reported edema and pain to right hand fingers. Resident was noted to have a new onset of increased edema and pain to right hand fingers. An x-ray was ordered of the right hand and showed an acute oblique coronal fracture through the diaphysis and distal metaphysis of the proximal phalanx of the middle finger, with approximately 3.4 millimeter(mm) cortical step-off at the dorsal ulnar fracture margin (a recent broken bone in the middle finger, specifically in the shaft and lower portion of the bone closest to the palm. The fracture line was angled and also ran through the bone from front to back. The broken pieces were displaced, with a noticeable offset of about 3.4 mm). At that time, the care plan was updated to include a call don't fall sign. Fall 2 On 2/8/25 at 2:30 P.M., a CNA found the resident on the floor in her room beside the bed. No injury was noted on the post fall assessment. New interventions were to put bed in lowest position and add a call light attendant to her bed. Fall 3 On 3/23/25 at 1:23 P.M. a CNA found the resident on the floor in her room beside her bed. The Post Fall Assessment, dated 3/24/25, indicated new measures to be taken were to put bed in lowest position and rearrange room. The Interdisciplinary Team (IDT) Note, dated 3/25/25, indicated The call light attendant was not attached at the time of the fall and did not ring to alert staff that she was in need of help. No injury was noted. The new intervention was to replace the call light attendant batteries. During an interview on 6/25/25 at 10:02 A.M., Regional Consultant 3 indicated the call light attendant batteries were replaced after the fall but the reason for the fall was impulsiveness and room clutter, so after that, they rearranged her room as the new intervention. During an interview on 6/25/25 at 10:13 A.M., Regional Consultant 6 indicated the call don't fall sign should have been in the resident's room or bathroom. At that time, she had another staff member go look for the sign and it was on the back of the bathroom door that was open during observations and not visible. On 6/24/25 at 8:00 A.M., Regional Consultant 3 provided a Fall Management Program Policy, dated 5/31/17, that indicated [facility company] strives to maintain a hazard free environment, mitigate fall risk factors, and implement preventative measures 3.1-45(a)

Based on interview and record review, the facility failed to ensure physician orders were obtained and implemented following readmission for 1 of 3 residents reviewed for wound care. A resident readmitted to the facility with a new pressure wound without treatment orders and treatment order was not obtained for 2 days following readmission. (Resident F) Finding includes: During record review on 3/202/4 at 1:35 P.M., Resident F's diagnoses included, but was not limited to, heart disease, anemia, weakness, and dysphagia. Resident F's admission minimum data set (MDS) assessment dated [DATE], indicated the resident had no cognitive impairment, and had no unhealed pressure wounds. Resident F's nurse's progress notes included, but were not limited to: 2/28/25 at 8:44 A.M. - Resident stated he is very weak and clammy. Orders were received to send to emergency department and emergency medical services (EMS) was notified. Report was called to (hospital) emergency department. 3/4/25 at 7:00 P.M. - Resident returned from hospital via ambulance service. An admission observation and data collection, dated 3/4/25 at 7:02 P.M., included a skin observation that indicated the resident had skin impairment that was unable to be observed to due to a dressing that was clean and intact. A note indicated the wound care nurse would evaluate the impairment. A Braden scale assessment indicated the resident was at risk for pressure and included, Resident will not develop a pressure ulcer, or if a pressure ulcer present it will not worsen. An intervention included, provide routine skin care per current order. Resident F's wound assessments indicated the resident had a pressure ulcer to the sacrum identified on 3/4/25 at 10:16 P.M. Resident F's physician orders included, but were not limited to, cleanse wound to sacrum with wound cleanser or normal saline, apply skin prep to peri-wound, apply Santyl (ointment to remove dead tissue from wounds) to wound bed, cover with island foam dressing, and change daily (received 3/6/25). Resident F's treatment administration record (TAR) for the month of March, 2025 indicated the order, cleanse wound to sacrum with wound cleanser or normal saline, apply skin prep to peri-wound, apply Santyl to wound bed, cover with island foam dressing, and change daily was not started until 3/7/25. During an interview on 3/20/25 at 2:40 P.M., RN 4 indicated she documented the first observation of Resident F's sacral wound after readmitting from the hospital on 3/4/25. RN 4 indicated a (unordered) treatment was applied to the wound and the physician was not notified of the wound at that time. During an interview on 3/20/25 at 3:20 P.M., LPN 6 indicated if a new wound is observed on a resident, the physician should be notified to obtain an order for treatment and the order should be entered into the resident record at that time. On 3/20/25 at 4:40 P.M., RN 7 supplied a facility policy titled, Guidelines for Physician Services, dated 12/17/24. The policy included, 1. The resident's attending physician shall participate in the resident's assessment . and provide consultation or treatment as required by resident condition . when consulted/called by the campus. 2. The resident's attending physician is responsible for prescribing new therapy . to ensure that the resident receives quality care and medical treatments . This citation relates to complaint IN00454560. 3.1-30(a)

Based on observation, interview, and record review, the facility failed to ensure infection control practices were maintained during 1 of 2 observations of care. Staff failed to complete hand hygiene after removing their gloves during care, a resident's oxygen tubing and nasal cannula were allowed to fall to the floor and were repeatedly stepped on during care, and a resident's catheter drainage bag was not kept below the resident's bladder, was clipped to the side of a waste bin, and was resting on the floor. (Resident D) Finding includes: During an observation on 1/3/24 at 10:15 A.M., CNA 4 and CNA 5 were performing incontinence care for Resident D. Resident D was receiving supplemental oxygen via nasal cannula with oxygen tubing extending from the resident to the oxygen concentrator located on the floor near the resident's bed. While providing care, staff removed Resident D's supplemental oxygen and allowed the nasal cannula and tubing to fall to the floor next to the resident's bed. Throughout the incontinence care, CNA 5 stood on and stepped on the resident's oxygen tubing. Resident D also had a urinary catheter with a catheter drainage bag clipped to the side of his bed. CNA 4 provided catheter care and perineal care to Resident D, then assisted the resident to turn towards CNA 5 to remove a small amount of BM (bowel movement) from the resident's buttocks. Following care, both CNA 4 and CNA 5 removed their gloves and did not perform hand hygiene. CNA 4 briefly exited the resident's room to retrieve a Hoyer lift from the hallway just outside Resident D's room. CNA 4 proceeded to lift Resident D from his bed while the catheter drainage bag was given to Resident D to hold during the transfer to his recliner. While hanging in the Hoyer lift, Resident D's hands were in front of his face and holding on to the drainage bag, positioned above the resident's bladder. As CNA 4 lowered Resident D into his recliner, CNA 5 placed her hand on Resident D's forehead. Staff then clipped Resident D's catheter drainage bag to the side of a waste bin located next to the recliner. Staff then reinserted the resident's nasal cannula without cleaning the cannula or wiping the tubing. During an interview on 1/3/24 at 11:00 A.M., QMA 8 indicated that resident's nasal cannula and oxygen tubing should be wrapped up and placed in bag on a table or night stand when not in use. QMA 8 indicated catheter drainage bags should stay below the level of the bladder and should not be resting on the floor, and that staff should perform hand hygiene prior to donning gloves and after removing gloves. On 1/3/24 at 2:05 P.M., the DON (Director of Nursing) supplied a facility policy titled, Hand Hygiene, dated 1/18/23. The policy included, Purpose: Effective hand hygiene reduces the incidence of healthcare-associated infections . 3. Handwashing may also be used for routinely decontaminating hands in the following clinical situations: .After removing gloves . The DON also provided a policy titled Urinary Catheter Care, dated 12/31/22. The policy included, To prevent infection of the resident's urinary tract . 4. The urinary drainage bag should be held or positioned lower than the bladder to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder . 11. Be sure the catheter tubing and drainage bag are kept off the floor. 3.1-18(b) 3.1-18(l)

Based on record review and interview, the facility failed to ensure physician orders were obtained and implemented following admission for 1 of 3 diabetic resident's reviewed. A resident with a diagnoses of type II diabetes did not have a physician's order to monitor their blood sugar levels for 7 days following their admission to the facility. (Resident F) Finding includes: During record review on 1/2/24 at 11:15 A.M., Resident F's diagnoses included, but was not limited to, type II diabetes mellitus with diabetic chronic kidney disease and type II diabetes mellitus with hyperglycemia. Resident F's admission MDS (minimum data set) dated, 11/29/23, indicated that the resident had diabetes mellitus and did not receive insulin. Resident F's physician orders included, but were not limited to, Trulicity Pen Injector 1.5 mg (milligrams) per ml (milliliter) for diabetes mellitus type II once a day on Mondays (started 11/22/23 on admission) Accucheck 4 times daily (started 11/29/23). A hospital discharge summary, dated 11/22/23, provided discharge medications which included glucose blood test strips with instructions to test 4 times daily before meals and at bedtime. Resident F's blood sugar levels were not documented from the admitted [DATE] thru 11/29/23, nor was an order obtained for monitoring the resident's blood sugar until 11/29/23. During an interview on 1/3/24 at 1:05 P.M., LPN 10 indicated that any resident with a diagnosis of type II diabetes should have a physician's order to monitor their blood sugar levels routinely. On 1/3/24 at 2:15 P.M., the DON (Director of Nursing) supplied a facility policy titled, Glucometer SOP (Standard Operating Procedure), dated 12/31/22. The policy included, .1. Blood glucose monitoring shall be completed for the resident per the physician's order . This citation relates to complaint IN00423574. 3.1-30(a)

Based on observation, interview, and record review, the facility failed to store and serve food in accordance with professional standards for food service safety for 3 of 3 kitchen observations. Findings include: The Main Dining room and Kitchen tour began on [DATE] at 8:55 A.M. The following was observed in the main dining room as follows: 1. The juice machine had a sticky substance dripping from the spouts; the area behind spouts was sticky. On [DATE], the juice machine was still sticky with juice dripping from one of the dispensers. 2. The coffee machine had brown debris all over the bottom portion of the machine. 3. The Coke machine levers were sticky. The following was observed in the kitchen on [DATE] at 9:00 A.M.: 4. Five ice cream containers in a small portable freezer had an expiration date of [DATE], all were open to air. Follow up observations on [DATE] all the ice cream containers had Saran Wrap on the top to cover them except the strawberry, which was open to air, and orange sherbet that was partially covered. The ice cream containers all had expiration dates of [DATE] and [DATE] . The name on the new labels was the kitchen manager's name. On [DATE] 12:11 PM Four of the containers of ice cream in small freezer were uncovered. One newly-opened container of vanilla ice cream was uncovered. 5. The floor throughout the kitchen was observed to have debris. 6. In the walk-in freezer, a bag of frozen onion rings was open to air, a partial bag of chicken was not dated. 7. In the dry food storage area, a bag of dry pasta was open and not dated; a box of sprinkles expired [DATE]. Dry spices had no observable manufacturer-provided expiration or use-by dates. One side of each container was covered by a large label that covered the whole side and had a delivery date printed on it. The lemon pepper had a delivery date of [DATE], thyme delivered [DATE], cumin [DATE], onion powder label is torn off, rosemary [DATE], nutmeg open to air, delivered [DATE]. When the lemon pepper container was shaken, the contents did not move - it was stuck together and stuck to the sides of the container. On [DATE], all the spices had new labels with new expiration dates; a large bin of oatmeal was about half full, dated [DATE]; on [DATE] the new label listed expiration as [DATE]. On [DATE] at 10:30 A.M. during an interview with the kitchen manager and the facility administrator, the kitchen manager indicated that after 6 months the spices lose their potency. He indicated that if the spices appeared fine, they continued to use them because he stated that spices didn't really go bad. A gallon-sized clear food storage bag that contained crushed Oreos was open to air. 8. In the refrigerator there was a cracked brown egg in the back and another cracked brown egg on the side of the shelf. 9. During an interview with kitchen staff in the kitchen at that time, they stated there was no thermometer in the refrigerator; the staff produced a daily log that documented the temperature in the refrigerator that morning was 36 degrees. 10. During observation in the kitchen on [DATE] at 9:00 A.M., employees working in the food preparation area were not wearing hairnets, or not wearing them properly. A woman in an orange shirt had no hairnet, one woman had a hairnet wrapped around only her ponytail with the rest of her hair uncovered, a dark-haired woman had lots of loose hair sticking out of her hairnet around her face. The men working in the kitchen lacked hair nets and proper beard covers, wearing only surgical masks on their faces. 11. During observation in the kitchen on [DATE] at 12:15 P.M., the temperature of the food on the serving line steam table was not measured prior to serving. On [DATE] at 12:30 P.M. during an interview with the assistant kitchen manager and the facility administrator, the assistant kitchen manager indicated the temperature of the food was measured before staff put it on the serving line steam table. He produced a daily log of food temperatures. The log contained dates but not times indicating when the food temperature was measured, so there was no way to tell when the temperature of the food was taken nor how much time lapsed between taking the temperature and serving the food. On [DATE] at 2:15 P.M. the assistant kitchen manager provided the hair restraint policy dated [DATE], which indicates that all dining service employees are required to wear hair restraints as required by the 2009 Federal Food Code; hair restraints ,d+[DATE].11 Effectiveness. This federal policy requires that Except as provided in paragraph B of this section, food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles. (B) This section does not apply to food employees such as counter staff who only serve beverages and wrapped or packaged foods, hostesses, and wait staff if they present a minimal risk of contaminating exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles. On [DATE] at 12:54 P.M. the facility administrator provide the hot and cold temperature holding guidelines dated [DATE]. The guidelines indicated that hot food on the steam table should be at least 135 degrees Fahrenheit . The guidelines indicated that cold foods should be 40 degrees or less when the temperature is taken in the kitchen at the time of service. The guidelines indicated that thermometers should be in all refrigerators, freezers, and storage areas. 3.,d+[DATE](i)(2) 3.,d+[DATE](i)(3)

Based on interview and record review, the facility failed to ensure care plan conferences were completed. A quarterly scheduled care conference were not completed for 3 of 3 residents reviewed for care planning (Resident 19, 35, 11) and for 1 of 1 residents (Resident 45 ) reviewed for dementia care. Findings include: 1. On 11/29/22 at 2:07 P.M., Resident 45's clinical record was reviewed. Resident 45 was admitted to the facility on [DATE]. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent quarterly MDS (Minimum Data Set) assessment, dated 11/10/22, indicated Resident 45 was severely cognitively impaired. Resident 45's clinical record lacked any documentation of care plan conferences after 7/21/22. During an interview on 12/1/22 at 3:23 P.M., the Regional Consultant indicated resident 45's last care plan conference was 7/21/22. 2. During an interview on 11/29/22 at 11:38 A.M., Resident 35 indicated they had not been to nor been invited to any care plan conferences. On 11/29/22 at 3:00 P.M., Resident 35's clinical record was reviewed. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 35 was admitted to the facility on [DATE]. The most recent quarterly MDS assessment, dated 8/23/22, indicated Resident 35 was cognitively intact. The most recent care plan conference was documented on 7/5/22. During an interview on 12/2/22 at 2:00 P.M., the Social Services Director indicated that care plan conferences should be done quarterly and Resident 35's last care plan conference was 7/5/22. 3. The medical record for Resident 11 was reviewed on 11/30/22 at 12:53 P.M. The diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 11 was admitted to the facility on [DATE]. The quarterly MDS (Minimum Data Set) assessment, completed on 10/28/22, assessed Resident 11 as cognitively intact. During an interview on 11/28/22 at 11:32 A.M., Resident 11 indicated she did not get invited to care plan conferences. She indicated her daughter was in charge of her care. On 11/30/22 at 12:53 P.M., Resident 11's clinical record was reviewed. The latest care plan conference was documented on 6/21/22. 4. During an interview with Resident 19 on 11/29/22 at 9:07 A.M., the resident indicated she had not participated in any care plan conferences. The clinical record was reviewed on 11/30/22 at 2:43 P.M., the resident was admitted [DATE]. The facility identified care conferences as Resident First conferences. Two conferences were documented, dated 2/17/22 and 7/18/22. The records indicated that the resident and/or resident representative were invited to attend. Boxes were checked off to indicate the Social Service Director (SSD), Life Enrichment Director (LED) (activities), MDS coordinator, and resident/representative were in attendance. During an interview with SSD on 12/1/22 2:00 P.M., the SSD indicated that care conferences are supposed to be conducted quarterly. The policy was reviewed on 12/2/22 at 10:15 A.M., the facility policy indicated that care conferences are to be conducted at least quarterly and upon significant change in status. 3.1-35(c)(2)(C) 3.1-35(d)(2)(B)

Based on observation, interview and record review, the facility failed to ensure residents' medical records reflected accurate documentation of current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A resident's medical record indicated he consumed meals prior to the scheduled meal time and a resident's TAR (Treatment Administration Record) indicated his oxygen was set at 3 LPM (liters per minute) but was observed to receive 2 LPM. (Resident 56, Resident 59) Findings include: 1. On 12/1/22 at 8:48 A.M., Resident 56 was observed sleeping in his bed with his plate appearing untouched in front of him on the bedside table. On 12/2/22 at 11:00 A.M., Resident 56's clinical record was reviewed. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent quarterly MDS (Minimum Data Set) Assessment, dated 9/15/22, indicated Resident 56 was 67 inches tall and weighed 145.6 lbs (pounds), severely cognitively impaired, an extensive assist of 1 (one) staff for eating, and had a weight loss of 5% or more in last month or loss of 10% or more in 6 months and was not on a physician prescribed wt loss regimen. Current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Day shift to document intake and output for breakfast, lunch, and A.M. snack, initiated 12/14/21 and evening shift to document intake and output for dinner, P.M. snack, and bedtime snack, initiated 12/14/21. Mechanical soft diet, initiated 8/22/22. A current weight loss care plan, revised 9/28/22, included, but were not limited to, the following interventions: Monitor and record intake of food, initiated 12/15/21 and document and report refusal of meals/liquids, initiated 12/15/21. Resident 56's recorded weights included, but were not limited to, the following: 5/15/2022 9:50 A.M., 176.6 lbs 11/22/22 8:59 A.M., 145.6 lbs (weight loss of 17.55%) A meal time list, provided by the Administrator on 11/28/22, indicated the following times for skilled resident meals: Breakfast 7 A.M.-9 A.M. (open) Lunch 12:00 P.M. Dinner 5:00 P.M. From 10/1/22 to 12/2/22, the following meal consumption's were timestamped win the medical record before they were provided: 10/3/22 2:57 P.M. Dinner 76-100% 10/3/22 4:00 P.M. Dinner 76-100% (duplicate) 10/4/22 3:39 P.M. Dinner 76-100% 10/5/22 8:21 A.M. Lunch 76-100% 10/5/22 3:39 P.M. Dinner 76-100% 10/7/22 11:04 A.M. Lunch 76-100% 10/7/22 3:56 P.M. Dinner 76-100% 10/8/22 9:44 A.M. Lunch 76-100% 10/8/22 3:24 P.M. Dinner 76-100% 10/9/22 10:42 A.M. Lunch 51-75% 10/9/22 3:18 P.M. Dinner 76-100% 10/13/22 10:01 A.M. Lunch 76-100% 10/14/22 3:12 P.M. Dinner 76-100% 10/15/22 9:19 A.M. Lunch 76-100% 10/16/22 9:09 A.M. Lunch 76-100% 10/17/22 10:43 A.M. Lunch 51-75% 10/19/22 10:26 A.M. Lunch 51-75% 10/20/22 9:12 A.M. Lunch 76-100% 10/21/22 10:56 A.M. Lunch 76-100% 10/23/22 10:48 A.M. Lunch 51-75% 10/23/22 3:59 P.M. Dinner 76-100% 10/25/22 8:57 A.M. Lunch 51-75% 10/26/22 9:40 A.M. Lunch 76-100% 10/27/22 10:49 A.M. Lunch 76-100% 10/30/22 10:46 A.M. Lunch 26-50% 10/31/22 9:29 A.M. Lunch 76-100% 11/2/22 10:19 A.M. Lunch 76-100% 11/4/22 9:16 A.M. Lunch 51-75% 11/6/22 8:26 A.M. Lunch 76-100% 11/6/22 4:40 P.M. Dinner 76-100% 11/10/22 8:42 A.M. Lunch 76-100% 11/10/22 3:29 P.M. Dinner 76-100% 11/11/22 9:21 A.M. Lunch 76-100% 11/11/22 3:35 P.M. Dinner 76-100% 11/12/22 8:39 A.M. Lunch 76-100% 11/13/22 7:25 A.M. Lunch 76-100% 11/14/22 8:17 A.M. Lunch 76-100% 11/15/22 11:07 A.M. Lunch 51-75% 11/16/22 10:33 A.M. Lunch 76-100% 11/17/22 9:18 A.M. Lunch 76-100% 11/18/22 9:26 A.M. Lunch 76-100% 11/19/22 10:30 A.M. Lunch 26-50% 11/22/22 8:26 A.M. Lunch 76-100% 11/23/22 8:54 A.M. Lunch 76-100% 11/24/22 8:05 A.M. Lunch 76-100% 11/24/22 4:27 P.M. Dinner 76-100% 11/26/22 9:16 A.M. Lunch None 11/27/22 10:24 A.M. Lunch 76-100% 11/28/22 9:10 A.M. Lunch 76-100% 12/2/22 8:19 A.M. Lunch 76-100% The following days, the medical record lacked documentation of meal consumption: 10/1/22 Dinner 10/13/22 Dinner 10/27/22 Dinner 11/15/22 Dinner 11/16/22 Dinner 11/18/22 Dinner 11/19/22 Dinner 11/20/22 Dinner 11/23/22 Dinner 11/25/22 Dinner 11/26/22 Dinner 11/29/22 Dinner 12/1/22 Breakfast 12/1/22 Lunch During an interview on 12/2/22 at 9:40 A.M.,QMA (Qualified Medication Aide) 4 indicated if the resident refused a meal, it should be documented as a refusal. She further indicated meals are usually served between 7:00 A.M.-9:00 A.M. for breakfast, 12:00 P.M.-1:30 P.M. for lunch, and 5:00 P.M.-6:00 P.M. for dinner. During an interview on 12/2/22 at 10:16 A.M., CNA (Certified Nurse Aide) 5 indicated meal consumption documentation should be done after the resident eats. During an interview on 12/2/22 at 10:22 A.M., CNA 6 indicated lunch was served generally between 12:45 P.M. and 1:00 P.M. and they have until the end of their work shift to document consumption of meals. During an interview on 12/2/22 at 2:05 P.M., the Regional Consultant indicated if it's not documented in the record at all, the staff may not have been able to document meal consumption before leaving the facility. During an interview on 12/5/22 at 9:57 A.M., the Regional Consultant indicated sometimes aides document meals at the same time and if they don't go back and modify the time, it shows the time it was documented. She further indicated training would be given to staff regarding documenting in the residents' medical record. A current Nursing ADL (Activities of Daily Living) Documentation Guidelines policy, reviewed 12/1/21, provided by the DON (Director of Nursing) on 12/5/22 at 10:22 A.M., lacked info related to documentation of meal consumption, but did indicate ADL services will be conducted and documented by the CNA each shift at the point of care or as reasonably possible after care 2. On 11/28/22 at 12:12 P.M., Resident 59 was out of his room, but the dial on his oxygen machine was set at 2 LPM. On 11/28/22 at 2:20 P.M., Resident 59 was observed laying in his bed with nasal cannula in place and the oxygen dial set at 2 LPM. On 11/29/22 at 9:32 A.M., Resident 59 was observed laying in his bed with nasal cannula in place and the oxygen dial set at 2 LPM. On 11/30/22 at 9:33 A.M., Resident 59 was observed laying in his bed with nasal cannula in place and the oxygen dial set at 2 LPM. At that time, the resident indicated he doesn't change the setting on the machine. On 12/1/22 at 2:33 P.M., Resident 59 was observed laying in his bed with nasal cannula in place and the oxygen dial set at 2 LPM. On 11/29/22 at 2:08 P.M., Resident 59's clinical record was reviewed. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent admission MDS Assessment, dated 10/31/22, indicated Resident 59 was cognitively intact and an extensive assist of 2 (two) staff for bed mobility and transfers. Current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Oxygen at 3 LPM per nasal cannula continuously three times a day (7:00 A.M.-2:00 P.M., 3:00 P.M.-10:00 P.M., 11:00 P.M.-6:00 A.M.) initiated 10/27/22 and discontinued 11/29/22. Oxygen at 3 LPM per nasal cannula continuously twice a day (6:00 A.M.-6:00 P.M., 6:00 P.M.-6:00 A.M.), initiated 11/29/22. A current ADL's care plan, initiated 10/27/22, included, but was not limited to, the following intervention: Oxygen at 3 LPM continuous, initiated 10/27/22. A current activity intolerance care plan, initiated 11/3/22, included, but was not limited to, the following intervention: Oxygen as ordered by physician, initiated 11/3/22. A current potential for cardiovascular distress care plan, initiated 11/3/22, included, but was not limited to, the following intervention: Administer oxygen per order, initiated 11/3/22. During observation of resident receiving oxygen at 2 LPM on 11/28/22, 11/29/22, 11/30/22, and 12/1/22 the clinical record contained documentation that the resident was receiving 3 LPM of oxygen. During an interview on 12/1/22 at 2:35 P.M., RN (Registered Nurse) 2 indicated nursing staff were to set the oxygen machine to the proper LPM and Resident 59 doesn't adjust it. She further indicated the LPM was checked multiple times daily. At that time, RN 2 went into Resident 59's room and indicated the dial on the oxygen machine was on 2 LPM and it should have been at 3 LPM. A current Administration of Oxygen policy, reviewed 12/1/21, provided by the DON (Director of Nursing) on 12/5/22 at 10:22 A.M., lacked information about documenting the level of oxygen the resident receives in the TAR, but indicated guidelines to properly administer oxygen . verify physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is administered On 12/5/22 at 10:45 A.M., the Regional Consultant indicated it was their policy to follow doctor orders as written. 3.1-50(a)(2)

Based on observation, interview, and record review, the facility failed to ensure a resident received necessary respiratory care and services in accordance with professional standards of practice. The facility failed to follow physician oxygenation orders, date oxygen tubing, and clean the oxygen filter on 1 of 1 residents reviewed for respiratory care. (Resident 59) Finding includes: On 11/28/22 at 12:12 P.M., Resident 59 was out of his room, but the dial on his oxygen machine was set at 2 LPM (liters per minute). The tubing attached to the machine was not dated. On 11/28/22 at 2:20 P.M., Resident 59 was observed laying in bed with nasal cannula in place and the oxygen dial set at 2 LPM. The oxygen tubing was not dated and the machine's filter was observed to have a white layer of dust covering it. On 11/29/22 at 9:32 A.M., Resident 59 was observed laying in bed with nasal cannula in place and the oxygen dial set at 2 LPM. The oxygen tubing was not dated. On 11/30/22 at 9:33 A.M., Resident 59 was observed laying in bed with nasal cannula in place and the oxygen dial set at 2 LPM. The oxygen tubing was not dated. At that time, the resident indicated he doesn't change the setting on the machine. On 11/30/22 at 10:00 A.M., Resident 59's oxygen tubing was observed on the floor after incontinence care. CNA (certified nurse aide) 3 asked him to put the tubing back into his nose and resident did. On 11/30/22 at 8:53 A.M., Resident 59's oxygen tubing was observed on the floor while resident was out of his room. On 12/01/22 at 10:32 A.M., the oxygen machine was observed to have a white layer of dust over the filter. A sticker on the side of the machine and on top indicated it was serviced 6/1/22. The dial was set at 2 LPM and resident was laying in his bed with the nasal cannula in place. At that time, Resident 59 indicated he hasn't seen anyone clean or change the filter. There was no date on oxygen tubing. On 12/1/22 at 2:33 P.M., Resident 59 was observed laying in his bed with nasal cannula in place and the oxygen dial set at 2 LPM. There was no date on oxygen tubing. On 11/29/22 at 2:08 P.M., Resident 59's clinical record was reviewed. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent admission MDS Assessment, dated 10/31/22, indicated Resident 59 was cognitively intact and an extensive assist of 2 (two) staff for bed mobility and transfers. Current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Oxygen at 3 LPM per nasal cannula continuously three times a day (7:00 A.M.-2:00 P.M., 3:00 P.M.-10:00 P.M., 11:00 P.M.-6:00 A.M.) initiated 10/27/22 and discontinued 11/29/22. Oxygen at 3 LPM per nasal cannula continuously twice a day (6:00 A.M.-6:00 P.M., 6:00 P.M.-6:00 A.M.), initiated 11/29/22. Change oxygen tubing once a day on the first of the month, initiated 10/27/22. Clean external concentrator filter once a day on Sunday every two weeks, initiated 10/27/22. A current ADL's care plan, initiated 10/27/22, included, but was not limited to, the following intervention: Oxygen at 3 LPM continuous, initiated 10/27/22. A current activity intolerance care plan, initiated 11/3/22, included, but was not limited to, the following intervention: Oxygen as ordered by physician, initiated 11/3/22. A current potential for cardiovascular distress care plan, initiated 11/3/22, included, but was not limited to, the following intervention: Administer oxygen per order, initiated 11/3/22. A progress note, dated 11/9/22, indicated chest X-Ray results came back showing pneumonia in right lung and possible left base infiltrate. A new order was received for [MEDICATION(S)] 100 mg bid (twice a day) for 1 week (7 days). On 11/28/22, documentation in the TAR indicated the resident was on 3 LPM of oxygen at 7:00 A.M.-2:00 P.M., 3:00 P.M.-10:00 P.M., and 11:00 P.M.-6:00 A.M when observed to receive 2 LPM. The following days, documentation in the TAR indicated the resident was on 3 LPM of oxygen at 6:00 A.M.-6:00 P.M. and 6:00 P.M.-6:00 A.M when observed to receive 2 LPM.: 11/29/22 11/30/22 12/1/22 During an interview on 12/1/22 at 2:35 P.M., RN (Registered Nurse) 2 indicated nursing staff were to set the oxygen machine to the proper LPM and Resident 59 doesn't adjust it. She further indicated the LPM is checked multiple times daily. At this time, RN 2 went into Resident 59's room and indicated the dial on the oxygen machine was on 2 LPM and it should have been at 3 LPM. On 12/2/22 at 10:51 A.M.,RN 2 indicated filters should be cleaned on night shift every 2 (two) weeks and tubing is supposed to be dated when changed. At that time, RN 2 also indicated-if oxygen tubing was observed on the floor, it should be tossed and a new one should be given to the resident. A current Administration of Oxygen policy, reviewed 12/1/21, provided by the DON (Director of Nursing) on 12/5/22 at 10:22 A.M., lacked information about documenting the level of oxygen the resident receives in the TAR, but indicated guidelines to properly administer oxygen . verify physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . date the tubing for the date it was initiated . adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is administered On 12/5/22 at 10:45 A.M., the Regional Consultant indicated it was their policy to follow doctor orders as written. 3.1-47(a)(6)

Based on record review and interview the facility failed to provide the Centers for Medicare and Medicaid Services (CMS) form (SNF) Advanced Beneficiary Notice (ABN) to 1 of 3 residents reviewed for liability notice. (Resident 16) Findings include: On 12/1/22 at 10:00 A.M., the SNF/ABN form for Resident 16 was received from SSD. Medicare Part A Skilled Services started on 6/16/22 and last day of Part A service was 7/12/2022. The facility initiated the discharge from Medicare Part A Services when benefit days were not exhausted due to her level of function. On 12/2/22 at 11:58 A.M., Resident 16's clinical record was reviewed. Resident 16 was admitted on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Physical therapy discharged resident from their service due to the resident's achievement of the highest function obtainable. A care conference was completed on 7/12/22 with resident and family present. There was no documentation of an ABN given to the family. During an interview on 12/5/22 at 9:25 A.M., the Infection Preventionist (IP) indicated that no ABN had been given to the family or resident at the care conference. On 12/5/22 at 9:47 A.M., a current (NOMNC Completion SOP) policy, dated 6/22/21 was provided, and indicated In order to streamline communication for completion .SNF/ABN, this SOP outlines the expectations for completion. When would we issue .If the resident has Medicare days remaining and is staying on campus .social services will issue the SNF/ABN form . 3.1-4(f)(2)

Based on interview and record review, the facility failed to completely assess and document the appearance of a pressure ulcer, for 1 of 3 residents reviewed with pressure ulcers. (Resident B) Findings include: The closed clinical record of Resident B was reviewed on 5/24/21 at 11:25 A.M. The resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurses Notes included the following notations: 4/14/21 at 11:52 A.M.: Res [resident] noted to have pressure area to coccyx. Surrounding area pink in color. Area cleaned with iodine swab, covered with foam dressing. NP [nurse practitioner] notified A Skin Integrity Event, dated 4/14/21, indicated, Location: coccyx, Length: 4 cm [centimeters], Width 5 cm, Present on admission? No Nurses Notes continued: 4/14/21 at 9:36 P.M.: Noted area on buttocks worse from this nurse seeing at 1:30 pm today Documentation that the physician was notified of the worsening pressure ulcer was not found. A Skilled Documentation note, dated 4/15/21 at 2:35 A.M., indicated, Skin Integrity: Skin Color Pale .Warm . Documentation of the pressure area was lacking. A Nurses Note, dated 4/15/21 at 10:30 A.M., indicated: [Recorded as Late Entry on 04/16/2021 02:32 PM] .Resident wound assessed, resident noted with staged pressure injury to coccyx .Unable to measure due to decline in assessment. Noted redness with minimal drainage. Preventative dressing changed, cleansed .Resident sent to ER Documentation of further characteristics of the wound was not found in the clinical record. A hospital history and physical, dated 4/15/21 at 4:09 P.M., indicated, Sacral wound on bottom with serosanginous [sic] [watery, bloody] discharge A hospital wound assessment, dated 4/16/21 at 9:00 A.M., indicated: Wound # 1: Location: unstageable pressure injury coccyx, Dimensions: 2.5 x 3.5 x .6 cm, Wound Bed: 100% [NAME] [sic] eschar .Peri-Wound Skin: Red blanchable, excoriated On 5/25/21 at 11:50 A.M., LPN 1 was interviewed. LPN 1 indicated she was the nurse who identified the pressure area on Resident B. She indicated the resident had a small area that was open, and was not black, but more of a purplish color. She indicated the measurement of 4 cm x 5 cm was not the open area, it was the open area with the surrounding redness. On 5/25/21 at 2:05 P.M., during an interview with the Director of Nursing (DON), she indicated if a pressure area is identified, the nurse assesses the wound and opens an event. On 5/25/21 at 2:30 P.M., during an interview with the Director of Nursing (DON), she indicated when a pressure area is identified, the nurse assesses the wound and opens an event. Then typically either she or the Assistant Director of Nursing would do a further assessment, since not all of the nurses were wound care certified. The DON indicated she was unable to do a more thorough assessment on 4/15/21, because she was attempting to transfer the resident to the hospital. On 5/25/21 at 2:10 P.M., the DON provided the current facility policy Pressure/Stasis/Diabetic Wound Condition Guidelines, dated 5/23/18. The policy included: 1. Appropriate skin Event is completed by a RN/LPN in EHR [electronic health record] .2. Document description of wound using: a) Length .b) Width .c) Depth - deepest area of wound bed d) Exudates [drainage] e) Color f) Odor g) Wound margins h) Surrounding tissue i) Tunneling .3. Document objective information about pain This Federal tag relates to Complaint IN 048. 3.1-40(a)(2)

Based on observation, interview, and record review, the facility failed to ensure proper food storage and food sanitation practices were maintained during 2 of 2 kitchen observations and 1 of 2 Resident Refrigerator observations. Hand hygiene was not performed, frozen foods were left open to air, foods were not labeled or dated, and food items were mislabeled. Findings include: 1. During an initial kitchen observation on 2/24/20 at 10:00 A.M., a standing freezer contained the following: 1 bag of waffles in a package labeled as sliced bread. 1 bag of chicken tenders open to air. 1 bag of pork fritters open to air. 1 bag of breaded fish unlabeled and undated. 1 bag of chicken patties unlabeled and undated. A walk in freezer contained the following: 2 bags of breaded meat product unlabeled and undated. 1 bag of ribs labeled as frozen leftovers. 1 bag of frozen muffins labeled as frozen leftovers. 2 wrapped pies labeled as frozen leftovers. 2. During a second observation on 2/27/20 at 9:15 A.M., a standing freezer contained the following: 1 bag of chicken open to air 1 bag of breaded catfish open to air 1 bag of waffles labeled frozen leftovers. 3. On 2/24/20 at 12:03 P.M., Dietary 3 was observed behind the serving line with gloves on her hands. Dietary 3 dropped her pen on the floor, picked it up, placed it in her coat pocket, obtained the thermometer from the tomatoes, wiped the thermometer off with a towel, and began serving food to the dining room. No hand hygiene or glove change was observed. 4. On 2/28/20 at 10:18 A.M., the 400 Hall Medication Room was observed. In the resident refrigerator the following was observed:a. One bowl of uncovered and unlabeled food. b. One bowl of unlabeled food. c. Two containers of applesauce, opened, with no open date. During an interview on 2/27/20 at 9:20 A.M., the Dietary Manager (DM) indicated food should not be stored open to air and should be labeled and dated. The DM indicated the frozen leftover label is often used when labeling frozen leftovers. On 2/27/20 at 10:30 A.M., the DON (Director of Nursing) supplied an undated facility policy titled, Storage. The policy included, Food and supplies shall be properly stored to keep foods safe and preserve flavor, nutritive value, and appearance . All foods in the freezer are wrapped in moisture proof wrapping or placed in suitable containers to prevent freezer burn. Items are labeled and dated. 3.1-21(i)(2) 3.1-21(i)(3)

Based on observation, interview, and record review, the facility failed to ensure dignity was maintained for a resident who was addressed by a nickname instead of her given name for 1 of 2 residents reviewed for dignity. (Resident 59) Findings include: The clinical record for Resident 59 was reviewed on 2/24/20 at 10:40 A.M. The record indicated Resident 59's [DIAGNOSES REDACTED]. The Quarterly MDS (Minimum Data Set) assessment dated [DATE] indicated Resident 59 experienced cognitive impairment. The assessment further indicated Resident 59 required the assistance of two staff for transfers, toileting, and bed mobility. The medical record lacked a plan of care for addressing which name Resident 59 preferred. During an observation on 2/24/20 at 10:07 A.M., CNA 1 walked into Resident 59's room and addressed Resident 59 by saying, Hi, (resident's name) potato, then continued walking into the resident's bathroom where CNA 1 dropped off a package of wipes. During an interview on 2/24/20 at 10:10 A.M., Resident 59 said, That's a nickname they gave me. I told them my name is (name), not (name) potato. During an interview on 2/27/19 at 11:00 A.M., LPN 10 indicated that whenever a resident preferred to be called something other than their given name, such preferences were documented on their face sheet and care plan. Otherwise, staff were supposed to call residents by their given name, not by a nickname. During an interview on 03/02/20 at 11:23 A.M., the Administrator indicated it was the facility's policy that residents should be addressed by their given names unless the care plan indicated otherwise. 3.1-3(t)

Based on observation, interview, and record review, the facility failed to ensure care was provided, in that, a dependent resident admitted without a pressure ulcer on the right heel, developed a pressure ulcer on the right heel (Resident #78) and/or a dependent resident admitted without a pressure ulcer on the left posterior thigh developed a Stage 2 pressure ulcer on the left posterior thigh (Resident #116) for 2 of 3 residents who met the criteria for review of pressure ulcers. This deficient practice resulted in Resident #78 experiencing an Unstageable pressure ulcer on the right heel. Findings include: 1. On 5/6/15 at 12:30 P.M., Resident #78 was observed sitting in a wheelchair in the dining room with shoes on. The right heel was observed, at that time, to be in contact with the surface of the wheel chair foot pedal. On 5/6/15 at 2:00 P.M., Resident #78 was observed lying in bed with socks on. The right heel was observed, at that time, to be in contact with the surface of the bed. The clinical record of Resident #78 was reviewed on 5/7/15 at 9:00 A.M. The clinical record indicated Resident #78 was admitted to the facility on [DATE] with no skin impairment to the right heel and [DIAGNOSES REDACTED]. On 5/7/15 at 10:00 A.M., Resident #78 was observed sitting in a wheel chair in the Physical Therapy Room with shoes on. The right heel was observed, at that time, to be in contact with the surface of the floor. On 5/7/15 at 12:20 P.M., Resident #78 was observed sitting in a wheel chair in the dining room with shoes on. The right heel was observed, at that time, to be in contact with the surface of the wheel chair foot pedal. On 5/8/15 at 1:30 P.M., Resident #78 was observed lying in bed with socks on. The right heel was observed, at that time, to be in contact with the surface of the bed. The Admission MDS (Minimum Data Set) assessment dated [DATE] indicated Resident #78 was at risk for the development of a pressure ulcer, experienced mild cognitive impairment, had functional limitation to the lower extremities on one side, and required the extensive assistance of two staff for bed mobility. The Admission physician's orders [REDACTED]. The Nursing Admission assessment dated [DATE] indicated Resident #78 was at risk for the development of a pressure ulcer and had no skin impairment to the right heel upon admission to the facility. A Care Plan dated 4/3/15 indicated, .I have potential for alteration in skin integrity.related to decreased mobility and diabetes.provide me assistance as I need it for bed mobility. The care plan lacked documentation related to providing pressure relief to the heels of Resident #116. An Assessment Review and Considerations plan dated 4/2/15 indicated Resident #78 was at risk for skin breakdown related to mobility impairment. A PT (Physical Therapy) progress note dated 4/2/15 at 7:00 P.M. indicated, .Pt (patient) demonstrates dec (decreased) ROM (range of motion), strength.r/t (related to) right hip fx (fracture). An OT (Occupational Therapy) Daily Treatment note dated 4/7/15 indicated, .participated in bed mobility.rolling side to side with max (maximum) A (assist) & (and) 75% verbal cues. The Physician's Telephone Orders from 4/1/15 through 4/10/15 were reviewed and lacked any pressure relief interventions for the right heel. A Nurse's note dated 4/11/15 at 5:00 A.M. indicated, .while completing routine bed checks noted resident has a 2 cm (centimeter) X 1 cm dk (dark) purple unstageable area to rt (right) heel. A Pressure.Ulcer assessment dated [DATE] indicated Resident #116 experienced a pressure wound to the right heel. The assessment further indicated, .Stage E (un-stageable.non-removable dressing, slough/eschar, suspected deep tissue injury in evolution).dk (dark) purple.length.2 (two centimeters).width.1 (one centimeter}. During an interview on 5/12/15 at 2:15 P.M., the DON (Director of Nursing) indicated Resident #78 was admitted without skin impairment to the right heel, but experienced an unstageable wound after admission to the facility. The DON then indicated, no documentation could be provided to indicate complete pressure relief was provided to the right heel of Resident #78 between 4/1/15 through 4/10/15. The Policy and Procedure for Pressure Prevention provided by WCN (Wound Care Nurse) #1 on 5/8/15 at 10:15 A.M. indicated, .care plan interventions shall be implemented based on risk factors identified in the nursing assessments. Interventions may include, .elevate heels off the bed. 2. During an interview on 5/6/15 at 2:30 P.M., Resident #116 indicated staff assistance was required for bed mobility. During an interview on 5/7/2015 at 9:32 A.M., LPN #5 indicated Resident #116 experienced a blister on the left posterior thigh after admission to the facility. LPN #5 then indicated the blister was related to the rubbing of an immobilizer against the left posterior thigh. During an interview on 5/7/15 at 2:00 P.M., WCN (Wound Care Nurse) #1 indicated Resident #116 experienced a Stage 1 pressure ulcer to the left posterior thigh after admission to the facility. WCN #1 then indicated, the root cause of the pressure ulcer was related to the use of an immobilizer on the left lower extremity. The clinical record of Resident #116 was reviewed on 5/8/15 at 10:00 A.M. The record indicated Resident #116 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Nursing assessment dated [DATE] indicated Resident #116 experienced no cognitive impairment, was at risk for the development of pressure ulcers, required the extensive assistance of two staff for bed mobility, and/or experienced no skin impairment to the left posterior thigh. A Care Plan for Skin dated 4/17/15 indicated, .I have potential for alteration in my skin integrity related to decreased mobility.provide me with assistance as I need it for bed mobility.use a draw sheet for turning and repositioning me to decrease the probability of my getting shear or friction injuries. A Care Plan for Skin dated 4/28/15 indicated, .I have a pressure ulcer as evidence (sic) by my skin breakdown. I have (sic) stage 1 on my.upper thigh.This occurred related to my decreased mobility and immobilizer left leg. The Admission physician's orders [REDACTED].1/2 (half) positioning (bars) up X (times) 2 to aid in turning and repositioning.NWB (non-weight bearing) to (L) (left ) leg.immobilizer to (L) leg may be removed for skin care.turn/reposition q (every) 2 (hours) et (and) prn (as needed). A Nurse's note dated 4/28/15 at 9:00 A.M. indicated, .noticed a pressure area to the back of residents (sic) (L) thigh where the immobilizer presses onto the back of the thigh. A Pressure.Ulcer assessment dated [DATE] indicated Resident #116 experienced a Stage 1 pressure area to the back of (L) thigh.Length 1 (one centimeter) width 0.5 (half a centimeter). A Pressure.Ulcer assessment dated [DATE] indicated wound was assessed as, .Stage 2 (Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister.).L (length) 0.3 X W (width) 0.2.color: red. During an observation of care on 5/8/15 at 11:01 A.M., Resident #116 was observed lying in bed in supine (lying on the back) position with an immobilizer on the left leg. CNA #10 indicated, at that time, she was preparing to reposition Resident #116 to lay on the right side. CNA #10 was then observed to grasp an incontinence pad underneath Resident #116, pull the resident across the surface of the bed, and reposition Resident #116 to lay on the right side. CNA #10 indicated, at that time, Resident #116 required the assistance of one person to reposition in bed. RN #5 was then observed to enter the room and indicated, she was preparing to change the dressing to the left posterior thigh of Resident #116. The wound was observed to be a red, shallow, and open ulcer. RN #5 was then observed to measure the ulcer and indicated, at that time, the ulcer measured 0.8 cm (centimeters) length X 0.2 cm width X unknown depth and met the criteria for a Stage 2 pressure ulcer. During an interview on 5/13/15 at 10:00 A.M., the DON (Director of Nursing) indicated a dependent resident should be repositioned by lifting the resident off the surface of the bed. The DON further indicated, at that time, it was not facility practice to pull a resident across the surface of the bed with an incontinence pad during the repositioning procedure. The Policy and Procedure for Pressure Prevention provided by WCN #1 on 5/8/15 at 10:15 A.M. indicated, .care plan interventions shall be implemented based on risk factors identified in the nursing assessments. Interventions may include, .lift, do not slide resident. 3.1-40(a)(1) 3.1-40(a)(2)

Based on interview and record review, the facility failed to ensure a resident at risk for skin breakdown, with [DIAGNOSES REDACTED]. Resident C Findings include: 1. The closed clinical record of Resident C was reviewed on 12/3/14 at 1:45 P.M. [DIAGNOSES REDACTED]. A hospital transfer sheet, dated 10/10/14, included, "Pressure Areas: Lt (left) Buttocks - Foam, Bilateral feet foam dressings." An anatomical drawing had 2 "X" marks documented on the front ankle areas. A Nursing Admission Assessment, dated 10/10/14 at 4:00 P.M., indicated the resident was dependent upon the assist of 1 for transfers, wheelchair, bathing, dressing, and bed mobility. The assessment indicated the resident had a history of [REDACTED]." An anatomical drawing had the "front" bilateral feet marked with an "x." A notation indicated, "long term (old stasis)." A "Skin Impairment Assessment," unsigned, indicated: "Date: 10/10/14, Present on admission? Y (yes), Type: Excoriation, Location: (Right) foot, Length 6.0 (centimeters), Width 3.4, Depth (none). Color Red, Tx (treatment): Foam, Paper tape... Family notified:...Who: Admit." The Anatomical drawing had an "x" drawn on the resident's left front foot. An additional "Skin Impairment Assessment," unsigned, indicated: "Date: 10/10/14, Present on admission? Y (yes), Type: Excoriation, Location: (Left) foot, Length 2.5 (centimeters), Width 2.5, Depth (none). Color Red, Tx (treatment): Foam, Paper tape... Family notified:...Who: Admit." The Anatomical drawing had an "x" drawn on the resident's right front foot. physician's orders [REDACTED]." A Skilled Charting Evaluation, dated 10/11/14 at 4:00 A.M., indicated, "Other Observations, Needs, and Concerns...1. Wound (left) buttock (with) dsg (dressing) change, 2. Pressure Relieving Mattress, 3. [MEDICAL CONDITION] when sleeping, 4. [MEDICATION NAME] to thighs (every) shift." The care of the bilateral feet was not documented. The Skilled Charting Evaluation, dated 10/12, 10/13, and 10/14, did not address the condition or care of the resident's bilateral feet. An "Assessment Review and Considerations," dated 10/14/14, indicated, "Skin breakdown risk potential: Urinary ret (retention)/ (left) buttocks abcess/ DM (diabetes mellitus)/[MEDICAL CONDITION]." Documentation did not include the resident's bilateral feet condition. A Skilled Charting Evaluation, dated 10/15/15, did not include documentation of the resident's bilateral feet. A Physical Therapy Progress & Discharge Summary, dated 10/15/15, included, "Summary of Skilled Services...included strengthening in BLE (bilateral lower extremities), gait and balance training...Precautions, high fall risk...." Documentation regarding dressings to the resident's feet was not found in the physical therapy documentation. Discharge Instructions, dated 10/15/14, listed the resident's oral medications that he was to receive, his insulin, and his breathing treatments. The "Activity level," "Precautions," "Follow up appointments," "Discharge needs/arrangements," and "Comments/special instructions" were left blank. Documentation regarding dressing changes to the resident's buttock or bilateral feet was not listed. The resident's Medication Administration Record [REDACTED]. A notation, which indicated, "Cleanse areas to (bilateral) feet (with) NS, apply foam et secure (with) tape..." was initialed as completed on 10/13/14. No documentation describing the bilateral feet condition at that time was found in the clinical record. On 12/4/14 at 8:15 A.M., during an interview with a family member of Resident C, she indicated she took the resident home on 10/15/14. She indicated she got the resident ready for a shower on the morning of 10/16/14, took off his socks, and "couldn't believe it." She indicated his right heel "looked awful." She indicated the heel was "fiery red," had "2 pieces of skin, with an opening all away across the heel." She indicated the resident did not have any dressing on his heel or on the top of his foot. The family member indicated she took the resident to the physician the next day, and he indicated "there was no way that happened in just one or two days." She indicated she took pictures of the resident's heel, and took them to the facility. She indicated the resident had to go to the wound clinic, and "just had that leg amputated last week." On 12/4/14 at 10:40 A.M., a physician's progress note was obtained from the physician. The note, dated 10/17/14, 2 days after discharge from the facility, indicated, "History: (Resident C) presents here for what he describes as a right heel sore...He has diabetes. He has severe diabetic [MEDICAL CONDITION] Exam: We examined his right heel. The entire aspect of his heel has a large skin sloughing, it is red, has a clear-cut pressure sore on it. Hospital procedure culture was obtained...This gentleman is probably going to end up back in the hospital again...We started him on broad spectrum antibiotics. We are going to get wound care clinic to start seeing him ASAP. We are going to get pressure pads for his heels. Unfortunately, this is already fairly advanced and this is the first time I have seen it but we will just have to see how we go here." On 12/4/14 at 10:50 A.M., during an interview with the Director of Nursing (DON), she indicated the resident did not have pressure areas on his heels when he left the facility. She indicated the facility "charts by exception," and would not have documented if "nothing was seen." On 12/4/14 at 11:15 A.M., during an interview with the Physical Therapist, he indicated he saw Resident C every day, and he did not recall ever seeing a dressing on either of his feet. On 12/4/14 at 12:40 P.M., during an interview with LPN # 1, she indicated she was the staff member who admitted Resident C on 10/10/14. She indicated the resident had areas on both of his feet or ankles, "like he scraped them." She indicated she thought the areas had "almost cleared up." She indicated she could not remember if the resident had any areas on his heels. She did not respond when it was mentioned that it did not appear as if she filled out the skin assessment sheets on the resident's bilateral feet, but that another staff member had documented on those assessment sheets. She indicated she did not often work on that particular hall, and did not recall further information. On 12/4/14 at 12:45 P.M., during an interview with LPN # 2, she indicated she was the staff member who discharged Resident C on 10/15/14. She indicated she "barely remembered" Resident C. She indicated she knew the resident had no concerns with his catheter and had dressings to his buttocks, but was unsure about dressings to his feet. She indicated she thought his feet areas may have been healed. On 12/4/14 at 4:00 P.M., during an interview with the DON and Corporate Nurse, they indicated, "Therapy would not have known the dressings were on his feet if his socks were on." They indicated the resident had areas on the top of his feet, but not on the heels. They could not provide additional documentation regarding assessment of the resident's heels. 2. According to Lippincott's Pocket Manual of Nursing Practice, 2nd edition 2003: DIABETES TYPE 2 Assess feet and legs for skin temperature, sensation, soft tissue injuries, corns, calluses, dryness, hammer toe or bunion deformity, hair distribution, pulses, deep tendon reflexes. Maintain skin integrity by protecting feet from break-down. Use of heel protectors, special mattresses, foot cradles for patients on bed rest. Avoidance of drying agents to skin. Application of skin moisturizers to maintain suppleness and prevent cracking fissures. 3. On 12/4/14 at 11:45 A.M., the DON provided the current facility policy on "Pressure Prevention Guidelines," undated. The policy included: "Purpose: To maintain good skin integrity and avoid development of pressure ulcers. Procedure: Care plan interventions shall be implemented based on risk factors identified in the nursing assessment. Interventions may include but not be limited to: Inspect the skin daily during care for signs of breakdown or changes to the skin, Elevate heels off the bed- avoid use of 'heel protectors,' Utilize skin protection such as lamb's wool, Assess [DIAGNOSES REDACTED]." This Federal tag relates to Complaint IN 358. 3.1-37(a)

A. Based on observation, interview, and record review, the facility failed to ensure a resident received adequate supervision and/or interventions were properly implemented and/or provided for 1 of 2 residents who met the criteria for review of falls. This deficient practice resulted in the resident experiencing a hip fracture. (Resident #98). B. Based on observation, interview, and record review, the facility failed to ensure a resident with a chest restraint/positioning device was positioned appropriately to prevent risk of injury from a chest restraint/device for 1 of 1 resident reviewed for a restraint/device in the stage 2 sample. (Resident #77) Findings include: A. Resident #98 was observed on 4/1/14 at 12:30 P.M., sitting in a wheelchair at the dining room table. The clinical record for Resident #98 was reviewed on 4/3/14 at 10:00 A.M. The clinical record indicated Resident #98 was admitted to the facility on [DATE] at 11:00 A.M., with [DIAGNOSES REDACTED]. The care plans include, but were not limited to, the following: Potential for Falls care plan was initiated 9/19/13, and interventions included pad alarm at all times, assist of one with transfers. Fall Circumstance and Assessment included in the chart indicated, Resident #98 fell on the following days. Fall # 1 occurred on 9/9/13 at 8:30 P.M., Resident #98 fell while transferring self in room with no injuries. A pad alarm was placed. Fall #2 occurred on 9/13/13 at 2:40 P.M. Resident #98 slid out of her recliner, resulting in no injuries. The facility placed dycem (a non slip surface) in the recliner and resident 's personal items were to be placed within reach. Fall #3 occurred on 10/11/13 at 7:50 P.M., Resident #98 was transferring self and w/c (wheelchair) rolled out from under her, the fall resulted in no injuries. The facility referred Resident #98 to Occupational Therapy (OT) for positioning. Fall #4 occurred on 10/15/13 at 5:40 A.M., Resident #98 was found on floor in bathroom, the fall resulted in no injuries. A toileting schedule was started as an intervention. Fall #5 occurred on 11/23/14 at 2:30 A.M., indicating Resident #98 was observed sitting on the floor in her room. A pressure alarm was placed on her bed as an intervention. A Nurse's note dated 12/22/13(sic) (correct date 11/22/13) at 2:30 P.M., indicated Resident #98's alarms were removed in response to a family request. A Nurse's note dated 11/23/14 at 2:30 A.M., indicated Resident #98 was observed sitting on the floor in her room. The intervention was to reinstate the pad alarm while in bed. A Nurse's note dated 11/23/13 at 4:10 A.M., indicated Resident #98 voiced complaints of right hip pain. "New order received to send res (resident) to GSH ER (local hospital)..." A Nurse's note dated 11/23/13 at 9:15 A.M., indicated Resident #98 was admitted to a local hospital with a [DIAGNOSES REDACTED]. The Director of Nursing (DON) was interviewed on 4/4/14 at 10:30 A.M., regarding Resident #98's history of falls. She indicated Resident #98 had been admitted to the facility on [DATE] for therapy after repair of a left hip fractured. She also indicated the resident's alarms were discontinued on 11/22/13 at the request of her family. That was in preparation for Resident #98 to be discharged to the assisted living unit of the facility. During an interview on 4/4/14 at 10:30 A.M., the DON indicated no interventions had been implemented when the alarms were removed. The DON confirmed no additional intervention had been implemented to ensure the resident's safety in response to the alarms being discontinued. A Physical Therapy note dated 11/20/13 indicated, Resident #98 had continued to show decreased safety awareness and she continued to be a high fall risk while being up ad lib (up at liberty) when in room. Physical Therapy Assistant #1 was interviewed on 4/4/14 at 1:25 P.M., she indicated she had been part of the team that had worked with Resident #98 during her initial admission. She further indicated, at that time, Resident #98 was a high risk for falls on 11/23/13 when Resident #98 experienced a fall that resulted in a fracture of the right hip. B. On 3/31/14 at 2:52 P.M., Resident #77 was observed sitting in his w/c leaning forward and to his right side wearing a vest chest restraint. He was feeding himself a snack. The right strap of vest restraint was against the resident's neck. LPN #6 was made aware of Resident #77's leaning position and position of the restraint strap. LPN #6 then explained to Resident #77 he needed to be repositioned. LPN #6 and LPN #7 then repositioned Resident #77 in his w/c so the vest strap was not against his neck. Resident #77's clinical record was reviewed on 4/3/14 at 8:53 A.M. He had been admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. His current Minimum Data Set Assessment (MDS ) dated 2/20/14, indicated bed mobility and transfers required extensive assistance of 2 or more staff. April 2014 physician orders [REDACTED]./Paralysis Agitans).10/29/13/ positioning vest is to be worn one hour after meals r/t poor trunk control (postural instability d/t Parkinson's W/Paralysis Agitans...)" A manufacturer's instruction sheet was included in the resident's treatment record for the Butterfly Chest Harness (chest vest restraint). The instruction sheet included, but was not limited to, "... THIS IS NOT A SAFETY DEVICE. IT IS TO BE USED ONLY FOR POSITIONING. IT MUST BE USED IN CONJUNCTION WITH A METAL SEAT BELT!" His current care plan included, but was not limited to, "...3/10/13 I use a positioning vest as a restraint to my W/C at all meals & as needed due to poor trunk control (postural instability), & gait instability due to a Parkinson with paralysis agitans. Remove vest 1 hour after meals as needed..." "... Assess for and notify my physician of any restraint associated problems. Benefits for this includes reduction of falls, provide feeling of security, & maintain body positioning. Remove & perform skin assessment every shift. Evaluate for reduction quarterly & as needed. Please review my interventions in 90 days to determine if changes are needed..." On 4/2/14 at 10:51 A.M., Resident #77 was observed sitting in his wheelchair in the TV area of the nursing station. He was wearing a chest vest device. A bed pillow was positioned under his right arm and across his lap. He was leaning forward and to the right side. The right strap of the vest was laying against his neck. CNA #8 came over to the resident asking him to toilet. She was made aware the resident was leaning to the right and the strap of the device was against the resident's neck. She indicated in regard to the resident's leaning position that it happens and staff then reposition the resident. On 4/2/14 at 3:00 P.M., Resident #77 was observed sitting in the TV area of the nurses station. He was wearing his vest device and was leaning forward and to his right side. On 4/3/14 at 8:30 A.M., observed resident sitting in w/c in restorative dining room feeding self breakfast. No positioning vest on just a seat belt. The Resident was leaning forward and to his right side. On 4/3/14 at 9:20 A.M., Resident #77 was observed wearing his positioning vest and the resident was leaning to his right side with his head on his right arm which was on a pillow. The strap of the vest was observed, at that time, to be against his neck. LPN #6 was made aware of his position. She indicated his vest device was difficult to adjust and required frequent adjustment. On 4/3/14 at 11:45 A.M., Occupational Therapy (OT) Staff #1 indicated Resident #77 had utilized the vest positioning device since September 2013. OT #1 further indicated at that time Resident# 77 had been discharged from therapy on 9/20/13 and nursing staff had been instructed on interventions to correct positioning problems. OT staff #1 then indicated he had noticed the resident leaning. He indicated he had ordered a device last week to be applied to the right arm of the resident's wheelchair to correct the positioning of the resident. He indicated the new device had not arrived. On 4/3/14 at 11:50 A.M., the Director of Nursing (DON) indicated the facility did not have an order for [REDACTED]. Resident #77 had been observed wearing a seat belt with his chest vest device thru out the survey . The DON and OT therapist were made aware at that time of the risk related to the res leaning forward and to the right in his w/c with the vest strap on the right side up against his neck. The DON and OT Therapist #1 agreed that the vest restraint strap against the resident's neck could be a potential hazard. On 4/7/14 at 11:45 A.M., a "Physical Restraint Information and Consent" form dated 11/4/13, was reviewed. The documentation indicated the positioning vest was a risk not limited to, "... Increased risk of strangulation, or death..." 3.1-45(a)(2)

Based on interview and record review, the facility failed to ensure adequate supervision and/or interventions were properly implemented and/or provided to 4 of 8 residents reviewed for falls. Five residents were reviewed in Stage 2 for falls with 3 falls resulting in fractures, Resident #80, #54 and #41. The extended survey of 3 additional residents reviewed, indicated one added concern of Resident #33 for facility noncompliance to ensure the resident had adequate supervision to prevent falls. This resulted in substandard quality of care. Resident # 80, Resident # 54, Resident #41, Resident # 33 Findings include: 1. The clinical record of Resident # 80 was reviewed on 2/11/13 at 2 P.M. Resident #80 had been admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. An MDS (minimum data set assessment) dated 8/13/12, indicated the following for the resident: cognition score of 11, which indicated moderately impaired cognition; bed mobility and transfer skills indicated the resident required extensive assistance (resident involved in activity, staff provided weight bearing support) for these tasks. An MDS dated [DATE], indicated the resident's total cognition score was a 10, which indicated moderately impaired cognition. Bed mobility and transfer skills remained the same as the 8/13/12 assessment. On 2/12/13 at 10:07 A.M., the ADON (Assistant Director of Nursing) was interviewed. She indicated from 4/21/12 to 2/4/13, the resident had 10 falls. She indicated the fall on 1/21/13 resulted in a fractured hip. On 2/13/13 at 1 P.M., the DON (Director of Nursing) was interviewed. She indicated prior to the first fall, the resident had a patient protector alarm at all times (PPA) (this alarm has a tab which is attached by a string with one end to the resident and the other end attached to the alarm box), self releasing alarmed seat belt in the wheelchair (wc) and bed in the lowest position. At that time, the DON provided copies of the Fall Circumstance, Assessment and Intervention (FCAI) form for each fall. The DON also provided her summary of each of the resident's falls. The information provided included, but was not limited to, the following information for each fall: Fall #1 on 4/21/12 at 9:50 P.M.: Resident was found on floor in her room; prior to fall had been in bed; "Safety equipment in place and functioning at time of incident? No"; "Pressure pad alarm functioning when res (resident) placed into bed. Alarm not sounding when res found on floor, alarm on. New alarm box installed." The DON's summary indicated the following: "Alarm in place, alarm connected an (sic) on, alarm functioning correctly but not sounding..." The intervention added in place after this fall was the bed against the wall and mat to the floor. The PPA at all times and self release alarming seatbelt (SRASB) and bed in lowest position continued. Fall #2 on 7/3/12 at 9 P.M.: Resident found on floor in her bedroom; Resident hit her head, ice was applied; was transferring herself from her wheelchair at time of fall; Wheel chair alarms were sounding. The intervention added after the fall was "re education" to the resident and a room monitor at all times (a auditory type monitor), which was placed in the room. "Safety equipment in place and functioning, yes." Upon interview at that time, the DON indicated staff did not respond to the alarm in time to prevent the resident from falling. The SRASB and PPA (at all times) and bed in lowest position also continued. Fall #3 on 7/13/12 at 9:45 P.M.: Resident found on her knees beside her bed, on the mat, praying. The current interventions included, but not limited to, the following: PPA, SRASB. The DON indicated at that time, the current interventions prevented injury. She also indicated the intervention added to the CNA assignment was to offer the resident time to pray. The FCAI form indicated the prevention update was to "re-educate res to ask for help before she gets up to pray." This form also indicated the safety equipment was in place and functioning at time of the incident. This form also indicated the "alarm sounding..." The bed in lowest position, SRASB, room monitor and PPA (at all times) continued. Fall #4 on 8/3/12 at 11:15 P.M.: the resident was found on the floor on mat at bedside, reaching for water on nightstand. She rolled out of bed in lowest position. PPA on and functioning. The DON indicated the new intervention added was to provide water on a stool by the bed and begin 1 hour bedchecks at night as a nursing measure. The prior prevention interventions continued. Fall #5 on 9/4/12 at 4:05 P.M.: Resident found on the floor in her room. Fall resulted in an abrasion to her left forearm. Resident was transferring herself from her wheelchair. The DON indicated the resident had returned to her room from the beauty shop without the alarms connected (SRASB and PPA). She indicated the alarms were in place but not reapplied after being in the beauty shop. The new intervention in place after this fall, was to educate the beautician to ensure alarms were connected/notify staff when resident returned to room. The DON indicated at that time, the resident's hourly bed checks at night were discontinued on 9/5/12 because the resident was sleeping through the night. Fall #6 on 9/14/12 at 2:20 P.M.: That was a witnessed fall. The resident was at the nurses station in her wheelchair. The resident attempted to transfer herself. Alarms in place but not on/sounding. SRASB and PPA. The new intervention in place after the fall was to add 1 hour bed checks when resident in bed and put the alarm boxes in bags out of the resident's reach. The DON indicated at that time, the staff had been counseled. The DON indicated from their investigation, they were not sure if the resident disconnected the alarms or if the staff failed to connect the alarms. The DON indicated that during her investigation, staff had informed her that they would find the alarm cords unplugged and then they would reconnect them. At that time, the DON provided a copy of the following document: "Follow up and Re education" form. That form was dated 9/14/12 to "All CRCA's (certified registered care assistants) from nsg (nursing). That form indicated the following concern: "(resident's name) seatbelt alarm was not found on. Res (resident) was found standing up in the hallway, then she slid down the wall. No injury noted. It is everybody's job to make sure the alarms are on." Fall #7 on 9/28/12 at 10:25 P.M.: The FCAI form indicated the following: found on floor in room, climbed out of bed, safety equipment in place and functioning at time of incident? "yes." The DON indicated at that time the following: "The resident was in bed with PPA, bed in lowest position, call light in reach, mat beside bed, hourly bed checks, pressure pad alarm in bed (had been placed by staff as a nursing measure). Res found on floor mat bedside bed, stated she thought it was time to get up. Res holding pt (patient) protector in hand and bed pad alarm cord disconnected at box. Boxes in mesh bags, secured to bed frame. Res states she disconnected the alarm. Alarms did not sound." The new intervention added was an alarming floor mat. Fall #8 on 10/9/12 at 9 P.M., the resident had been in her wc at the nurses station. The FCAI indicated the following: "This was an unwitnessed fall." "Pt (patient) removed all alarms and slid down to floor, seat belt still intact...safety equipment was in place and functioning at time of incident "Yes...Pt keeps taking all alarm devices off and ambulating...Root cause: impulsive...zyprexia increased to 7.5 mg po (per os) at hs (bedtime)..." The DON indicated at that time, the resident removed the seatbelt (which was alarmed) and attempted to ambulate. She indicated the alarms were in place, SRASB, PPA and the resident had taken off the SRASB and then reconnected it behind her. The DON indicated the resident had also removed the clip alarm. The new intervention added was a pressure pad alarm at all times. The form "Interact" was dated 10/9/12 and indicated the following: "(resident name) slid down chair, took of (sic) alarms and slid under seatbelt..." A note on the DON's documentation of her summary of the resident's falls, she indicated on 11/27/12 the pressure pad alarm to the chair was discontinued due to the SRASB and PPA. Fall #9 on 1/21/13 at 11:30 P.M., the resident was found on the floor in her room. The FCAI form indicated the resident's safety equipment was not in place and functioning at the time of the incident. The DON's summary of the incident indicated the following: "...Found on floor with SRASB not sounding, buckled in wc. Pt. protector removed with gown. Sent to ER for tx (treatment) and eval (evaluation). The DON's summary also indicated the resident returned to the facility on [DATE] with the following information: seat belt/self release to wc when up (clip type belt), wanderguard, bed against wall and 1 hour checks on day and evening shift with 20 minute checks from 10 P.M. - 6 A.M. and pressure pad alarm at all times. Upon interview at that time, the DON indicated this fall resulted in the resident fracturing her right hip. A Restraint/Enabler Circumstance, Assessment and Intervention form was dated 1/29/13. That form indicated the resident was unable to release the seatbelt. The DON indicated upon interview at that time, the resident was unable to consistently release the seat belt on command. Fall #10 on 2/4/13 at 9:15 P.M., the FCAI form indicated the following for the resident: she was in her wheelchair in her bathroom and was found on the floor. She had an abrasion to her right lower leg. She was undressing herself while in the wheelchair; patient unbuckled her seat belt; the safety equipment was in place and functioning at the time of the incident. The DON's written summary indicated the resident's alarms were sounding, and the resident had unclipped the seat belt. The new intervention was they changed the type of seatbelt to a Velcro alarming seat belt and also added a PPA at all times. At that time, 1 P.M. on 2/12/13, the DON also indicated the 9/14/12 when she was in bed until 10/30/12, when this was changed to hourly bed checks around the clock. The DON indicated the hourly bed checks were then changed on 11/21/12 to hourly bed checks on the day and evening shift and every 20 minute checks on the night shift (10 P.M. - 6 A.M.). She indicated the resident was currently on every 20 minute checks at night and hourly checks during the day and evening shift. On 2/12/13 at 4 P.M., the DON provided a current copy of the facility policy and procedure titled "Falls Management Program Guidelines." That form was dated as revised 3/08. That form included but was not limited to the following: "Purpose:...strives to maintain a hazard free environment, mitigate fall risk factors and implement preventative measures...recognizes even the most vigilant efforts may not prevent all falls and injuries. In those cases, intensive efforts will be directed toward minimizing or preventing injury. Definition: A fall is considered to be: "an unintentionally coming to rest on the ground, floor or other lower level...A fall without injury is still a fall...Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred...Procedure: The fall risk assessment is included as part of the Admission and Monthly Nursing Assessment and Review and Circumstance forms: Identified risk factors should be evaluated for the contribution they nay have to the resident's likelihood of falling...Should the resident experience a fall the attending nurse shall complete the "Fall Circumstance and Reassessment Form. The form includes an investigation of the circumstances surrounding the fall to determine the cause of the episode, a reassessment to identify possible contributing factors, interventions to reduce risk of repeat episode and a review by the IDT (Interdisciplinary Team) to evaluate thoroughness of the investigation and appropriateness of the interventions..." 2. Resident #54's clinical record was reviewed on 2/8/13 at 10:00 A.M. A nursing admission assessment dated 7/3/12, indicated Resident #54 had been admitted to the facility on [DATE]. The assessment indicated on admission the resident had a left humerus fracture , short term memory deficits, and rambling /irrevelant conversation. Other [DIAGNOSES REDACTED]. A Minimum Data Assessment Assessment ((MDS) dated [DATE] (admission), indicated a cognitive score of 15 ( 13-15 cognition intact). An MDS dated [DATE] (14 day MDS) indicated a cognitive score of 14, a MDS of 8/28/12 (PPS unscheduled MDS), a cognitive score of 13, and a MDS dated [DATE] (significant change MDS), indicated a cognitive score of 11 ( moderate cognitive impairment). On 2/11/13 at 9:58 A.M., the Director of Nursing (DON) had been interviewed, she indicated Resident #54, had a physician's orders [REDACTED]. Fall #1: a fall circumstance, assessment and intervention documentation dated 8/29/12, indicated a fall had occurred in the resident's room at 8:15 P.M. That form indicated the resident had thought it was time to get up and the alarm had sounded. Documentation indicated the resident had left hip pain and was sent to the emergency room for evaluation. On 2/11/13 at 9:58 A.M., the DON had been interviewed, she indicated the resident had returned to the facility on [DATE], after hospitalization for a left hip fracture. She indicated on return on 9/2/12, she had a patient protector alarm and the assistance of 2 staff had been needed for transfers. She indicated on 9/7/12, the patient protector alarm had been changed to a pressure pad alarm. Fall #2: a fall circumstance, assessment and intervention documentation indicated a fall had occurred on 9/23/12 at 1:00 P.M. in the resident's room. The documentation indicated the resident had been transferred with a gait belt and a side rail used by the resident during the transfer had not locked.The side rail fell causing the resident to loose balance. No injury documented. On 2/11/13 at 9:58 A.M., the DON had been interviewed, she indicated there had been only one staff transferring Resident #54, during the 9/23/12 fall. She indicated there should have been 2 staff for this resident transfer. She indicated the CNA involved had been counseled. On 2/12/13 at 1:47 P.M., an Employee Counseling Record dated 9/23/12, had been reviewed. The counseling record indicated the resident fell and the CNA had not used a gait belt and had not transferred the resident with the assistance of 2 staff. Fall #3: a fall circumstance, assessment intervention form dated 10/27/12 at 11:00 A.M., indicated a fall had occurred in Resident #54's room. The documentation indicated the resident's alarm had sounded at the time of the fall. No injury had been documented. The immediate intervention documented had been to place the bed in the lowest position. On 2/11/12 at 9:58 A.M., the DON had been interviewed, she indicated the resident had been in bed and the alarm had been functioning. She indicated staff had been unable to assist resident before she fell . She indicated the Interdisciplinary Team review (IDT) of 10/29/12, indicated the resident had been climbing over and around the side rail attempting to transfer. She indicated the resident had been utilizing the side rail for positioning in bed and to sit up. Fall #4: documentation of a fall circumstance, assessment and intervention on 11/25/12 at 6:30 A.M., indicated a fall had occurred while the resident had been trying to toilet herself. No injury had been documented. That documentation indicated that safety equipment had not been in place and functioning at the time of the fall. Immediate intervention had been to keep the resident wheelchair out of sight. That documentation also indicated a urinalysis had been obtained and the resident had been given the antibiotic, Macrobid. Fall #5: a fall circumstance assessment intervention dated 12/6/12 at 7:30 P.M., indicated a CNA "... entered the bathroom and res.(resident) fell to floor, unable to catch her..." "...Had been toileted @ 7 pm per CNA; Res stated she felt like she had to urinate again..." Documentation indicated the alarm had sounded and there had been no injuries. Immediate interventions had been to toilet before bed and re-enforce the use of call light. On 2/11/13 at 9:58 A.M., the DON had been interviewed regarding the 12/6/12 fall, she indicated the alarm had been sounding at the time of the fall. She also indicated the resident had been still receiving the antibiotic, Macrobid for a urinary tract infection. Fall #6: a fall circumstance, assessment and intervention dated 12/26/12 at 10:15 A.M., indicated the resident had been found on the floor in the doorway to her resident room. No injuries had been documented. Documentation indicated the resident's alarm had not been plugged in and the alarm cord was out of the alarm box. The immediate intervention had been to re- educate staff. On 2/11/12 at 9:58 A.M., the DON had been interviewed, she indicated after the 12/26/12 fall, the alarm had been changed to a cord security alarm box. Fall #7: a fall circumstance, assessment and intervention form dated 12/30/12 at 9:45 A.M., indicated a fall had occurred at the bedside when the resident had attempted to stand from her wheelchair. The documentation indicated the pressure pad alarm had sounded. No injuries had been documented. The immediate intervention had been to add a patient protector alarm at all times. On 2/11/13 at 9:58 A.M., the DON had been interviewed, she indicated the pressure pad alarm had sounded. She indicated a patient protector alarm (clip alarm) had been added with the pressure pad alarm after this fall. Fall #8: a fall circumstance, assessment and intervention form dated 1/14/13, indicated a fall had occurred at 6:00 P.M., in the resident's room. Documentation indicated there resident had slid out of her wheelchair onto the floor. No injures had been documented. The immediate intervention had been to add dicem (non slip fabric) to her wheelchair. On 2/11/13 during 9:58 A.M., the DON had been interviewed, she indicated the alarm had sounded before the 1/14/13 fall. She indicated dicem had been added to the resident's wheelchair after the 1/14/13 fall. Fall #9: another fall had been documented on the fall circumstance, assessment and intervention form dated 1/19/13. The fall had occurred at 8:40 P.M., in the resident's room. No injuries had been documented. The documentation indicated an immediate intervention had been to place her bed in a low position. On 2/11/13 at 9:58 A.M., the DON had been interviewed, she indicated the new intervention had been from placing a regular bed to the lowest position to an actual low bed on the floor. She indicated both alarms (patient protector and pressure pad) had sounded before the 1/19/13 fall. Fall #10: a fall circumstance, assessment and intervention dated 2/4/13, indicated a fall had occurred in Resident #54's room at 3:40 P.M. No injuries had been documented. The immediate intervention had been to lay the resident down after lunch and an occupational therapy evaluation. On 2/11/13 at 9:58 A.M., the DON had been interviewed regarding the 2/4/13 fall. She indicated the resident had been trying to transfer herself back to bed. The DON indicated the alarms had been functioning properly at the time of the fall. Fall #11: a fall had been documented on 2/6/13 on a fall circumstance, assessment and intervention form. The documentation indicated the fall had occurred in the resident's room at 7:50 P.M. No injuries had been documented. Documentation indicated the resident had crawled out of bed onto her knees. The alarm had sounded. The immediate intervention had been to implement a mat beside the bed when the resident was in her bed. On 2/11/13 at 10:53 A.M., the DON was interviewed regarding Resident #54's falls from 8/29/12 through 2/6/13. The DON was made aware of the lack of supervision and assistance needed in regard to alarms functioning and that staff had frequently been unable to assist the resident before she fell . The DON indicated, at that time, the alarms were effective in alerting staff. 3. On 2/12/13 at 2:45 P.M., Resident # 41's clinical record was reviewed. Her clinical record indicated she had been admitted to the facility on [DATE], after a left hip fracture. Other [DIAGNOSES REDACTED]. An Admission nursing note 12/1/12 at 3:00 P.M., indicated, "... alert c (with) confusion..." A Minimum Data Set Assessment ((MDS) dated [DATE] (admission MDS), indicated a moderate cognitive impairment with a score of 11. A skilled nursing assessment and data collection form dated 12/20/12 , indicated signs and symptoms of dementia, forgetful with confabulations. Fall #1: a fall circumstance assessment, and intervention form dated 12/26/12, indicated at 4:45 P.M., on this date the resident had been found found on the floor. Documentation indicated the resident had been reaching for a box of candy on her bedside table and slid out of her wheelchair. No injuries had been documented. The immediate intervention had been to encourage the resident to ask for assistance and re-educate the resident. On 2/12/13 at 3:25 P.M., the Director of Nursing (DON) was interviewed regarding the 12/26/12 fall. She indicated the resident had slid from her wheelchair when reaching for chocolate on her bedside table. Fall #2: a fall circumstance, assessment and intervention form dated 1/10/13, indicated a fall had occurred in the resident's room on 1/10/13 at 6:30 A.M. No injuries had been documented. Documentation indicated the resident had not used her call light and her wheelchair had not been locked at the time of the fall. The immediate interventions had included : bed and chair alarm and to teach the resident wheelchair safety. On 2/12/13 at 3:25 P.M., during interview with the DON, she indicated a pressure pad alarm had been added to the resident's chair and bed at all times after the 1/10/13 fall. Fall #3: a fall circumstance, assessment and intervention form dated 1/13/13, indicated a fall had occurred in the resident's room at 6:30 A.M. The documentation indicated the resident's pressure pad alarm had been in place and functioning. No injuries had been documented. Immediate interventions initiated had been to: teach wheelchair safety, diversional activities, bed in low position, staff to check and assist resident every A.M., at 6:15 A.M., with transfer. An Interdisciplinary Team (IDT)review dated 1/14/13, indicated the interventions that had been initiated included labs of a CBC and a Chem 14. Documentation indicated the resident had been started on Cipro (an antibiotic) to treat an urinary tract infection (UTI). On 2/12/13 at 3:25 P.M., during interview with the DON, she indicated the resident's pressure pad alarm had been functioning at the time of the 1/13/13 fall. She indicated lab work had been done and the resident had been started on Cipro for a UTI. She indicated also that staff were to start assisting the resident up in am at 6:15 A.M. On 2/12/13 at 3:35 P.M., during interview with the DON, she was made aware of the re-education intervention of the resident to ask for assistance as inappropriate in regard to the 12/26/12 fall due to the resident's documented confusion. The DON also had been made aware of the staff not assisting and/ or providing adequate supervision to prevent the fall in regard to the alarm functioning before the 1/13/13 fall. The DON did not provide further information at that time. 4. The Clinical Record for Resident # 33 was reviewed on 2/12/13 at 1:00 P.M. Resident #33's admitted to the Transitional Care Unit was 10/26/13. [DIAGNOSES REDACTED]. Resident # 33's Minimum Data Set assessment dated [DATE], indicated a cognitive score of 7, which indicated a severe cognition impairment. Nursing notes for Resident #33 were reviewed on 2/12/13 at 1:00 P.M. The review indicated the following: On 9/27/12 at 9:00 A.M., the "Resident was noted to be sitting on the floor in front of the wheelchair. When asked what happened, resident unable to answer. Assessment done and no injuries noted. Resident alert et (and) WNL (with in normal limits) per V/S (vital signs) 132/64, 74, 18, 97.. Family notified. alarm functional and sounding." Nursing note dated 10/27/12 at 12:45 P.M., indicated Dycem foam would be placed in the wheelchair seat. Fall # 1: on Fall Circumstance, Assessment, and Interview Form was reviewed on 2/12/13 at 1:00 P.M. The review indicated Resident #33 fell on [DATE] at 9 A. M., in the Resident's room. The fall was not witnessed. The Resident was unable to tell the nursing staff what happened. When nursing staff responded to the sound of a pressure pad alarm, Resident #33 was found in a sitting position on the floor directly in front of wheelchair. The physician was notified. Placing Dycem foam in the seat of Resident #33's wheelchair was the follow-up intervention to that fall. The intervention was reviewed by the Interdiscilipnary Team (IDT) team on 10/29/12, and the Intervention was deemed by the IDT team to be appropriate. On 2/12/13 at 1:00 P.M., the following Skilled Nursing Assessment and Data Collection forms were reviewed and they indicated: Nurse's notes/comments dated 10/27/12, at 5:30 P.M., " Requires constant supervision r/t patient's desire to be up walking and rummaging . Will not follow redirection, does not benefit from divisional activities, does not watch TV, does not choose to sit in wheelchair, straight chair, or couch. Monitored 1:1 by this RN and CNA. Wanders into other patients' rooms and picks things up. Monitored 1:1 and sometimes 2:1 for safety. Unsteady on feet. Chair pressure pad of no value." Nursing notes/comments dated 10/30/12, at 6 P.M., "Resident #33 requires 1:1 supervision of staff. Does not use call light to alert staff of needs. Would go to other residents' rooms without 1:1. Lacks basic safety awareness. Will get up from unlocked wheelchair and then sit down in unlocked wheelchair. Unable to appreciate the risk of falls related to Dementia. Does not benefit from education related to dementia and impulsiveness." Nursing notes/comments dated 11/2/12, 3-11 shift, "Resident #33 requires 1:1 assist/observation related to safety. Does not follow instruction, roams and rummages. Gait and ambulation unsteady. Does not comprehend need for alarms and safety protocol. Family is here throughout day to provide care. Patient is generally pleasant with increased confusion." Nursing notes/comments dated 11/4/12, 11-7 shift, "Up at night to toilet, does not use call light and needs assistance to toilet, will sit on shower chair or trash can to toilet, must reorient to commode. Is usually pleasant and cooperative when redirected." Fall # 2: Circumstance, Assessment, and Interview Form was reviewed on 2/12/13 at 1:00 P.M. The review indicated that Resident # 33's, 2nd fall was in the dining room, on 11/8/12 at 8:15 AM. Resident #33 was sitting in a wheelchair at the dining room table and got up to return to room. Resident #33 caught foot on front wheel and fell forward, falling to the floor. An alarm sounded. Interventions implemented after fall were as follows: 1.) Self releasing alarm seat belt installed in wheelchair. 2.) Pressure pad alarm discontinued in wheelchair, and 3.) Continue pressure pad alarm in Resident #33's bed. On 2/12/13 at 1:00 P.M., Resident #33's Care Plan for falls dated 10/29/12 was reviewed. The Care Plan for Resident #33 indicated that the Resident was "at risk for fall/injury related to a history of falls, potential for falls,disease process, functional problems, decreased safety awareness and poor cognition." Interventions were as follows: 1.) Remind resident to reinforce safety awareness. 2.) Lock brakes on bed, wheelchair before transferring. 3.) Educate/remind resident to request assistance prior to ambulation. 4.) Pressure pad alarm at all times. Do not leave unattended if alarm off. 5.) Check functioning et placement of alarm every shift and prn. Care Plan was updated 10/30/12. New intervention as follows: 1.) Up adlib in room when family present because Resident has signed self determination of care form. Care Plan updated 11/8/12. New intervention as follows: 1.) Pressure pad alarm while in bed. 2.) Self release alarm seat belt to W/C when up. 3.) Check twice a day that resident can release the self releasing seat belt.. A radiology report from the hospital Dated 11/8/12 was reviewed on 2/12/13 at 1:00 P.M. The report read as follows: "New right superior/inferior pubis bone fractures." During an interview with the Director of Nursing (DON) on 2/12/13 at 4:00 P.M., the DON indicated that on 11/8/12 at 8:30 A.M., Resident # 33 was in the dining room sitting at the dining room table (in her wheelchair with a functioning alarm) for breakfast. When Resident # 33 stood up from her wheelchair and took a step forward, the alarm sounded, but the CNA was delivering a food tray to the table next to where Resident #33 was sitting. The DON indicated that as soon as the CNA set the food down on the adjacent table, the CNA then immediately turned to get Resident # 33, recognizing that Resident #33 already was in the process of falling. The DON indicated that the CNA could not reach Resident #33 in time to prevent the fall. Resident #33 was subsequently sent by ambulance to the ER where she was determined to have a pelvic fracture. 3.1-45(a)(2)