Every finding on record at Brooke Knoll Village

Based on observations, interviews, and record review, the facility failed to ensure enhanced barrier precautions were implemented per facility policy and ensure appropriate professional standards for infection prevention were implemented for 3 of 27 residents reviewed for infection control (Residents 105, 77, and 1). Findings include:1. On 4/6/26 at 10:32 a.m., Resident 105 was initially observed. He was lying in bed with an intravenous (IV) pole at bedside which ran to a peripherally inserted central catheter (PICC). A Foley catheter (urinary catheter) drainage bag was also noted to the side of his bed with dark yellow urine in it. On 4/8/26 at 9:30 a.m., Resident 105 was observed through his open door. Licensed Practical Nurse (LPN) 14 and an unidentified Certified Nursing Aide (CNA) were in his room with him. The CNA indicated she was finishing getting Resident 105 cleaned up and bathed and had called the nurse in to put a treatment on his bottom. LPN 14 was observed as she applied a zinc cream to his coccyx area. She was not wearing a gown. The CNA indicated she had not worn a gown to provide his bed bath. On 4/8/26 at 10:14 a.m., LPN 14 returned to Resident 105's room with a new bag of antibiotic medicine. She indicated he was receiving the antibiotic for a urinary tract infection and had a foley catheter. LPN 14 did not perform hand hygiene before she donned gloves and began to set up the bag of antibiotics. She touched multiple surfaces which included, the pump, the IV pole, the bathroom door handle, and the residents blankets. She did not remove her glove or perform hand hygiene before she inserted the IV line into the PICC port. She began to remove her gloves, then indicated she forgot to flush the PICC. She kept her old gloves on, removed the PICC line and dropped it to the bed as she picked up and opened a flush syringe. Performed the flush and then re-inserted the PICC line back into the port without re-cleaning the PICC port. On 4/7/26 at 11:36 a.m., Resident 105's record was reviewed. The most recent Minimum Data Set (MDS) assessment was an admission assessment, dated 3/31/26, which indicated he had a Foley catheter and received an antibiotic. His record lacked a baseline or comprehensive care plan for enhanced barrier precautions, however there was a sign posted on the resident's closet door which indicated he required enhanced barrier precautions. 2. On 4/8/26 at 11:10 a.m. Certified Nursing Aide (CNA) 8 was observed while he provided incontinent care for Resident 77. CNA 8 was observed taking the catheter bag that was attached to Resident 77's suprapubic catheter (a hollow, flexible tube inserted into the bladder through a small abdominal incision, typically a few inches below the navel), switching it to a leg collection bag and then carrying the old collection bag to the resident's bathroom with only gloves on. After switching the collection bags CNA 8 used the same gloved hands to go through Resident 77's drawers and closet searching for supplies to finish incontinent care. CNA 8 then continued to use the same gloved hands to finish incontinent care for Resident 77. At no point during care did CNA 8 wear a gown or a mask. On 4/8/26 at 11:45 a.m. Resident 77's medical record was reviewed.He was a long-term care Resident who had a chronic suprapubic catheter. Resident 77's medical record showed an active order for Enhanced Barrier Precautions (EBP) related to his catheter. 3. During an observation, on 4/8/26 at 1:42 p.m., Licensed Practical Nurse (LPN) 13 provided wound care to Resident 1, while Qualified Medication Aide (QMA) 12 assisted with the resident's positioning. During the wound care the following was observed. LPN 13 applied an isolation gown and gloves. LPN 13 cleansed the resident's wound and used their gloved finger to apply zinc cream around the wound bed. After the zinc cream application, zinc cream remained on LPN 13's gloved finger. The gloves were not changed, and LPN 13 continued with the dressing change. LPN 13 used their metal scissors to cut the treatment and applied it to the wound bed. Zinc cream was left on the metal scissors from LPN 13's finger. LPN 13 placed a dressing over the resident's wound. With the same gloves, LPN 13 picked up the metal scissors, wiped off the visible soilage from the zinc cream with a paper towel, put them in their pocket, and indicated the scissors would be cleaned later. LPN 13 removed their gloves and washed their hands. After washing their hands, LPN 13 touched the front of the isolation gown and pulled it off. LPN 13 left the resident's room without washing their hands after touching the front of the isolation gown. Resident 1's record was reviewed on 4/9/26 at 10:29 a.m. A 5-day Minimum Data Set (MDS) assessment, dated 3/6/26, indicated the resident had a moderate cognitive impairment and a pressure ulcer (localized damage to the skin and underlying tissue related to prolonged pressure) that had been present upon admission to the facility. A physician's order, dated 3/30/26, indicated the resident required enhanced barrier precautions (EBP) related to a feeding tube (tube inserted into the stomach for artificial nutrition) and wound care. A physician's order, dated 4/1/26, indicated cleanse the coccyx (tailbone) wound with normal saline, pat dry, apply zinc oxide paste (barrier cream) around the wound, apply collagen sheet (wound dressing used to treat chronic, stalling, or acute wounds) to the wound bed, cover with a hydrocolloid dressing (gel-forming, waterproof dressing that creates a protective environment), may secure with gauze and tape if necessary, and change every other day. A care plan, initiated on 3/30/26, indicated the resident required EBP during high contact care activities that provide opportunities for the transfer of multi-drug resistant organisms (MDROs). High contact care activities included, but were not limited to, wound care. During an interview, on 4/9/26 at 11:25 a.m., the Infection Preventionist (IP) indicated personal protective equipment (PPE) for EBP should have been removed by pulling off the isolation gown and removing the gloves as the gown is removed. After PPE removal, handwashing should have been completed. If the isolation gown was touched after handwashing, then hands should have been washed again. During an interview, on 4/9/26 at 12:14 p.m., QMA 12 indicated PPE should have been removed by taking off the isolation gown, removing the gloves, and washing hands. The isolation gown should not have been left on during handwashing or touched after handwashing was completed. Re-usable equipment, including scissors, should have been sanitized between each resident with sani-cloths (sanitizing wipes). Equipment should have been cleaned before it was placed in a pocket. Normally, staff brought the sani-wipes in the resident's room with them. If gloves were visibly soiled they should have been changed. On 4/9/26 at 1:33 p.m., the Administrator provided a document titled, Enhanced Barrier Precautions, dated October 2019, and indicated it was the policy currently being used by the facility. The policy indicated, .Purpose: Enhanced Barrier precautions.expand the use of PPE beyond situations in which exposure to blood and body fluids is anticipated. These precautions entail the use of gown and gloves during 'high-contact' resident care activities that provide opportunities for transfer of multi-drug resistant organisms.to staff hands and clothing to address the continued risk of transmission from residents with MDRO colonization. On 4/9/26 at 1:33 p.m., the Administrator provided a document titled, Dressing-Clean Technique, dated October 2014, and indicated it was the policy currently being used by the facility. The policy indicated, .Purpose: A clean dressing technique is used to provide an appropriate environment conducive to wound healing. Policy: All dressings are performed by licensed personnel per physician's order using clean technique, unless another technique is specified by the physician. 410 IAC (Indiana Administrative Code) 16.2-3.1-18(b)

Based on record review and interview, the facility failed to accurately code a Minimum Data Set (MDS) (a standardized, comprehensive assessment of an adult's functional, medical, psychosocial, and cognitive status) for 1 of 6 residents reviewed for MDS accuracy (Resident 11).Findings include:On 4/7/26 at 2:26 p.m., a record review was completed for Resident 11. She had the following diagnoses which included, but were not limited to, unspecified dementia, hallucinations, depression, and anxiety disorder.On 4/9/26 at 1:34 p.m., a Preadmission Screening and Resident Review (PASRR) level II (used to identify the specialized needs of individuals with mental illness (MI), dated 8/9/24, intellectual or developmental disability ID/DD, or both (MI/ID/DD) was provided. Resident 11's, MDS assessment, dated 6/17/25, indicated the resident did not have a PASRR level II.During an interview on 4/9/26 at 2:00 p.m., the Corporate MDS Coordinator indicated Resident 11's MDS was inaccurate. She corrected the MDS and provided a copy of the attestation form on 4/9/26. On 4/10/26 at 12:26 p.m., the Director of Nursing (DON) indicated they did not have a policy for MDS and followed the Resident Assessment Instrument (RAI) manual.

Based on observation, interview and record review, the facility failed to ensure baseline care plans were implemented for 1 of 5 residents reviewed for baseline care plans (Residents 105).Findings include:On 4/6/26 at 10:32 a.m., Resident 105 was initially observed. He was lying in bed with an intravenous (IV) pole at bedside which ran to a peripherally inserted central catheter (PICC). A foley catheter drainage bag was also noted to the side of his bed with dark yellow urine in it. Resident 105 indicated he was very tired, cold, and his arm hurt.On 4/6/26 at 12:00 p.m., Resident 105 was observed. He was lying in bed and indicated he was cold, and still had a little pain, or aches over his whole body.On 4/8/26 at 9:25 a.m., Resident 105's door was closed. He was heard calling out from the closed door.During an interview on 4/8/26 at 9:38 a.m., Licensed Practical Nurse (LPN) 14 exited his room. LPN 14 indicated his calling out during turning and repositioning was normal for him, he had general pain and aches, and experienced discomfort when care, turning, and repositioning.On 4/8/26 at 9:55 a.m., Physical Therapist (PT) 15 entered Resident 105's room. He began to assist Resident 105 by putting socks on, but Resident 105 called out in pain. PT stopped and asked if he was ok. At that time, LPN 14 entered the resident's room to adjust his IV. PT 15 attempted to put the resident's socks on again, but moving his foot and leg, the resident cried out in pain. LPN 14 and PT 15 stopped what they were doing and asked where his pain was and what level his pain was. Resident 105 indicated he was aching all over and his pain was a 7, 8 or 9, and he asked for some Tylenol. LPN 14 left the room to go get medicine.On 4/8/26 at 10:14 a.m., LPN 14 returned to Resident 105's room with a new bag of antibiotic medicine. She indicated he was receiving the antibiotic for a urinary tract infection and did not have an order for as needed or scheduled pain medication, so she called the Nurse Practitioner (NP) and was waiting for a response.On 4/7/26 at 11:36 a.m., Resident 105's record was reviewed. The most recent Minimum Data Set (MDS) assessment was an admission assessment, dated 3/31/26, which indicated he had a foley catheter, a PICC, and was at risk for pain.The record lacked backline care plans to address his immediate needs for his PICC, Foley, and/or pain.During an interview on 4/9/26 at 9:00 a.m., the Director of Nursing (DON) indicated baseline care plans were completed by the Social Service Director and kept in her office.During an interview on 4/9/26 at 9:07 a.m., the Social Service Director indicated she did not do baseline care plans, that was the nursing department.During an interview on 4/9/26 at 9:53 a.m., the DON indicated she looked for Resident 105's baseline care plan but could not find one and that there needed to be a better process for the baseline care plans moving forward.On 4/8/26 at 2:16 p.m. the Administrator provided a copy of current facility policy titled, Care Plan Development and Review, dated 9/2017. The policy indicated, .This facility shall develop and implement a baseline care plan within 48 hours of a resident's admission that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care.

Based on observations, record review, and interview, the facility failed to correctly administer insulin for 1 of 1 resident observed for insulin administration (Resident 63).Findings include:On 4/7/26 at 12:12 p.m., RN 6 was observed prepping a Humalog insulin pen to administer to Resident 63. The order was for 2 units based on her blood sugar of 153. RN 6 dialed in 2 units of insulin and held up the insulin pen to be seen. RN 6 was intervened due to not priming the insulin pen with 2 units of insulin prior to dialing in the 2 units to administer to the resident. The correction was made and the insulin was administered to Resident 63's left lower abdomen. The Director of Nursing (DON) was present throughout the procedure. On 4/8/26 at 2:08 p.m. during an interview with the DON, she indicated she went through the steps of administering insulin prior to being observed and he did everything correctly. She indicated RN 6 was nervous being observed. On 4/10/26 at 10:20 a.m., RN 6's insulin administration competency checklist was reviewed. On the checklist, item number 8 indicated to dial a dose of 2 units to prime the pen. He demonstrated competency with this task. On 4/10/26 at 10:22 a.m., a policy was requested and not received at the time of exit.410 IAC (Indiana Administrative Code) 16.2-3.1-37

Based on observations, interview, and record review, the facility failed to ensure activities of daily living (ADLs) nail care was provided for residents who were dependent on staff for person hygiene for 3 of 4 residents reviewed for nail care (Residents 51, 61, and 1).Findings include:1. On 4/6/26 at 10:54 a.m., Resident 51 was initially observed. He was lying in bed in a hospital gown, his hair was unbrushed and appeared greasy. His fingernails were long and had debris under them. He indicated his nails were long and jagged and wanted to get them cut down. On 4/7/26 at 9:45 a.m., Resident 51's nails were observed. They remained long, and had debris under them. He indicated no one had cut them yet, but maybe they would for his shower day. On 4/8/26 at 9:20 a.m., Resident 51's tube feeding pump was alarming. Licensed Practical Nurse, (LPN) 14 entered his room to check the pump. She observed his nails at that time and indicated they were jagged and needed to be cut, she would let the aide know. On 4/7/26 at 10:42 a.m., Resident 51's record was reviewed. The most recent Minimum Data Set (MDS) assessment was an admission assessment, dated 3/20/26, which indicated he was cognitively intact and requested maximum or total dependence on staff for all ADL care. Resident 51's point of care CNA documentation was reviewed and indicated nail care was provided each shift and checked off as completed. 2. During an observation, on 4/6/26 at 12:32 p.m., Resident 61 had an unshaved beard and mustache growth. At the same time, the resident indicated he wanted to be shaved and did not like having the beard and mustache growth. During an observation, on 4/8/26 at 9:36 a.m., Resident 61 had unshaved beard and mustache growth. At the same time, the resident indicated no one had offered to help him shave. During an observation, on 4/9/26 at 9:51 a.m., Resident 61 had unshaved beard and mustache growth. At the same time, the resident indicated a couple of days ago the staff helped him shower, but no one had offered to help him shave. He wanted to be shaved. Resident 61's record was reviewed on 4/8/26 at 2:28 p.m. Diagnoses on the resident's profile included, but were not limited to, need for assistance with personal care and hemiplegia (complete paralysis or severe dysfunction of one side of the body) and hemiparesis (partial weakness on one side of the body) following cerebral infarction (stroke caused by a blockage in an artery supplying the brain) affecting right dominant side. A 5-day Minimum Data Set (MDS) assessment, dated 2/14/26, indicated the resident was cognitively intact, had not rejected care during the look back period, had impairment on one side of upper and lower extremities, and required substantial/maximal staff assistance with showering and bathing. A care plan, initiated on 1/23/26, indicated the resident required long-term care due to being dependent on others for all ADLs. A care plan, initiated on 1/27/26, indicated the resident required one or two staff assistance with activities of daily living (ADLs). Interventions included, but were not limited to, provide assistance with ADLs as the resident required and showers/baths per schedule and more frequently as needed or requested. Point of care documentation in the electronic record, dated 3/1/26 to 4/8/26, indicated the resident received five showers and one complete bed bath during the timeframe. The bathing documentation did not specifically address shaving. Progress notes, dated 3/1/26 to 4/8/26, lacked documentation shaving was offered, provided, or refused. Shower sheets, dated March and April 2026, indicated the resident received a shower or bath on 3/1/26, 3/3/26, 3/4/26, 3/7/26, 3/11/26, 3/14/26, 3/21/26, 4/1/26, and 4/8/26. The resident refused a shower or bath on 3/28/26. The shower sheets lacked documentation shaving was offered, provided, or refused with the showers. On 4/9/26 at 1:33 p.m., the Administrator provided a document titled, Shaving Male, dated October 2014, and indicated it was the policy currently being used by the facility. The policy indicated, .Purpose: To remove facial hair and improve sense of well-being. Policy: Male residents may shave their own facial hair, if capable, or personnel will assist residents to shave with an electric or safety razor, as indicated or requested. 3. During an observation, on 4/6/26 at 10:59 a.m., Resident 1 had long fingernails on both hands with chipped nail polish and dark debris underneath them. During an observation, on 4/7/26 at 9:10 a.m., Resident 1 had long fingernails on both hands with chipped nail polish and dark debris underneath them. During an observation, on 4/8/26 at 9:38 a.m., Resident 1 had long fingernails on both hands with chipped nail polish and dark debris underneath them. Resident 1's record was reviewed on 4/9/26 at 10:29 a.m. Diagnoses on the resident's profile included, but were not limited to, multiple sclerosis (a disease that causes breakdown of the protective covering of nerves) unspecified and need for assistance with personal care. A 5-day Minimum Data Set (MDS) assessment, dated 3/6/26, indicated the resident had a moderate cognitive impairment, had not rejected care during the look back period, and was dependent on staff assistance for showering/bathing. A care plan, initiated on 6/20/25, indicated the resident required the assistance of two staff members with activities of daily living (ADLs). Interventions included, but were not limited to, nail care as needed. Progress notes, dated March and April 2026, lacked documentation fingernail care was offered, provided, or refused. Shower sheets, dated March and April 2026, indicated the resident received a shower or bath on 3/2/26, 3/16/26, 3/25/26, 3/30/36, 4/1/26, 4/6/26, and 4/8/26. Shower sheets lacked documentation fingernail care was offered, provided, or refused. During an interview, on 4/9/26 at 12:13 p.m., CNAs 10 and 11 indicated fingernail care and shaving should have been provided with showers and as needed. If a resident refused ADL care the nurse should have been notified and the refusals documented. During an interview, on 4/9/26 at 12:14 p.m., Qualified Medication Aide (QMA) 12 indicated fingernail care and shaving should have been provided with showers and as needed. If a resident refused ADLs the nurse should have been notified and the care reattempted at a later time. Refusals should have been documented. During an interview, on 4/9/26 at 12:50 p.m., the Director of Nursing (DON) indicated fingernail care and shaving should have been provided with showers and as needed. If ADL care was refused, it should have been documented. On 4/9/26 at 1:33 p.m., the Administrator provided a document titled, Fingernail Care, dated October 2014, and indicated it was the policy currently being used by the facility. The policy indicated, .Purpose: Cleanliness and good grooming contribute to the dignity and self-esteem of resident. Policy: Nails should be kept short, clean, and free of rough or jagged edges. Fingernail care is provided when assigned, if fingernails appear soiled or have jagged edges, and as indicated. 410 IAC (Indiana Administrative Code) 16.2-3.1-38(a)(3)(D) 410 IAC 16.2-3.1-38(a)(3)(E)

Based on observations and interviews, the facility failed to label over the counter medications and failed to date medications when opened for 3 of 5 medication carts reviewed and 1 of 1 medication room (Residents 103, 7, 24, and 18).Findings include: On 4/7/26 at 12:28 p.m. the 200 hall, 300 hall, and medication room were observed for medication storage.On the 200 Hall Medication Cart, Resident 103 had Tylenol 650 mg (milligrams), B12 1000 mcg (micrograms), and Vitamin D3 without a label to indicate her name, room number, or physician's name.On the 300 Hall Medication Cart, Resident 7 had azelastine 137 mcg (a nasal spray used for allergies) in the cart without a date to indicate when it was opened.In the Medication Room Refrigerator, Resident 24 had a bottle of lorazepam 2 mg/ml (milliliter) without a date to indicate when it was opened.Resident 18 had a bottle of lorazepam 3vmg/ml without a date to indicate when it was opened.A policy titled, Storing Drugs dated 7/2025 indicated, .Any outdated, contaminated, or deteriorated drugs, or those drugs that have containers that are cracked, soiled or without secure closures must be removed from stock and destroyed according to policy.410 IAC (Indiana Administrative Code) 16.2-3.1-25(j)410 IAC (Indiana Administrative Code) 16.2-3.1-25(m)410 IAC (Indiana Administrative Code) 16.2-3.1-25(n)

Based on record review and interview, the facility failed to ensure documentation in a resident's medical record was accurate for 1 of 18 resident records reviewed (Resident 4). Findings include:Resident 4's record was reviewed on 4/8/26 at 12:56 p.m. Census information indicated the resident was hospitalized from [DATE] to 2/22/26. A progress note from Licensed Practical Nurse (LPN) 14, dated 2/19/26 at 5:57 p.m., indicated, Medicare: Resident is A&O [alert and oriented] x4. VSS [vital signs stable]. C/o [complaints of] pain to lower/upper back specifically muscle spasms. Staff makes multiple attempts to reposition with pillows, mostly effective. Continues on scheduled lyrica [nerve pain medication], hydromorphone [pain medication], diazepam [medication for anxiety and muscle spasms], and oxycodone [pain medication], somewhat effective. No increased pain noted at this time. Dependent with all ADL's [activities of daily living], able to consume meals with set up and meds given po [by mouth] crushed.Staff continues to anticipate wants and needs. Resident continues on OT/PT [occupational therapy/physical therapy]. A progress note from LPN 14, dated 2/20/26 at 5:57 p.m., indicated, Medicare: Resident is A&O x4. VSS. C/o pain to lower/upper back specifically muscle spasms. Staff makes multiple attempts to reposition with pillows, mostly effective. Continues on scheduled lyrica, hydromorphone, diazepam, and oxycodone, somewhat effective. No increased pain noted at this time. Dependent with all ADL's, able to consume meals with set up and meds given po crushed.Staff continues to anticipate wants and needs. Resident continues on OT/PT. A progress note from LPN 14, dated 2/21/26 at 5:57 p.m., indicated, Medicare: Resident is A&O x4. VSS. C/o pain to lower/upper back specifically muscle spasms. Staff makes multiple attempts to reposition with pillows, mostly effective. Continues on scheduled lyrica, hydromorphone, diazepam, and oxycodone, somewhat effective. No increased pain noted at this time. Dependent with all ADL's, able to consume meals with set up and meds given po crushed.Staff continues to anticipate wants and needs. Resident continues on OT/PT, compliant with med admin [administration] and therapies. During an interview, on 4/8/26 at 1:15 p.m., LPN 14 indicated Medicare charting required a hands-on physical assessment of the resident. The charting should have included how alert and oriented the resident was, any complaints of pain, scheduled medications if the residents were in pain, how ADLs were completed, vital signs, and information about any resident specific care needs. If a resident was not in the facility, Medicare charting should not have been documented. An assessment was not able to be completed if a resident was not in the facility. During an interview, on 4/826 at 2:05 p.m., the Director of Nursing (DON) indicated Medicare charting was a progress note related to the resident's specific care needs. The nurses should have completed a hands-on physical assessment and charted it to complete the Medicare note. There should not have been Medicare notes documented if a resident was not in the facility. During an interview, on 4/9/26 at 10:03 a.m., the DON indicated she reviewed the resident's chart and saw the Medicare notes entered on the days the resident was hospitalized . The notes should not have been put in the resident's record. On 4/9/26 at 9:45 a.m., the Administrator provided a document titled, Medicare 'A' Nursing Documentation Use of Guidelines/Prompts, dated October 2014, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy: This facility shall document on skilled services rendered to a resident receiving Medicare Part A services on an, at least, daily basis. Background: When a resident's stay is covered by Medicare Part A, there is a specific condition or combination of conditions which make it necessary for the resident's care to be overseen by a licensed nurse. In an effort to affirm that the licensed nurse is monitoring the resident's medical status, response to treatment, etc., the charting guidelines/prompts have been developed. 410 IAC (Indiana Administrative Code) 16.2-3.1-50(a)(2)

Based on observations, interviews, and record review, the facility failed to ensure tube feedings were administered per physician orders for a resident with known weight loss and who received all their nutrition by Gastric Tube (G tube) for 1 of 1 residents reviewed for tube feeding (Resident B). Findings include:On 2/2/26 at 10:34 a.m. Resident B's room was observed. The resident was not in the room at that time. Next to Resident B's bed there was a pole with a feeding pump set up but it was not running. The formula bag that was hanging was 1000 milliliters (ml) IsoSourse (a brand of high calorie formula used to supplement nutrition) 1.5 k/cal (kilocalorie, which is a unit of energy used to measure the energy content of food and beverages) with 2/2/26 at 2:15 a.m. written on the bag along with initials of Licensed Practical Nurse (LPN) 3. There was approximately 800 ml left in the bag. On 2/2/26 at 11:00 a.m. Resident B's medical record was reviewed. He was a long-term care resident whose diagnoses included, but were not limited to, traumatic brain injury and dysphagia (difficulty swallowing). Resident B had an active gastrostomy tube (G-tube, a medical device inserted through the abdomen directly into the stomach to provide nutrition, fluids, and medication for individuals unable to eat enough by mouth) feeding order, dated 1/29/26, for Glucerna (a brand of high calorie formula used to supplement nutrition) 1.5 k/cal to be set at a rate of 75 ml per hour for 20 hours per day starting at 4:00 p.m. and ending at 12:00 p.m. the following day. The order lacked special instruction that a substitute brand of tube feeding formula could be used for the ordered formula. On 2/2/26 at 1:45 p.m. Resident B was observed as they were sitting in their Broda chair (a specialized, highly adjustable medical wheelchair designed for individuals with mobility challenges) in their room. The G tube tubing appeared to be connected to the resident, but the pump appeared to be turned off. There was approximately 100 ml less in the bag than there was during the previous observation. During an interview on 2/2/26 at 1:50 p.m. the Unit Manager (UM) indicated the tube feeding was not running at this time because it was past noon when the resident's tube feed was ordered to stop. During an interview on 2/2/26 at 2:30 p.m. the Director of Nursing (DON) indicated the only reason IsoSource would have been used instead of Glucerna would be if Glucerna was not available. She indicated for staff to substitute formulas it needed to be approved by the Nurse Practitioner (NP). The DON indicated she wasn't sure why there was 400 ml more than should have been in the tube feeding bag, but she thought what must have happened was the nurse on night shift opened and spiked the new bag of formula in anticipation of the bag that had been running finishing. She indicated they would have dated and timed the bag for when they opened and spiked the bag not necessarily when the bag was started. During an interview on 2/2/26 at 2:50 p.m. LPN 3 indicated she was the nurse who started the tube feeding on night shift. She indicated the time that was written on the bag was the time the tube feeding was started. On 2/2/26 at 4:30 p.m. a copy of a Dietician quarterly assessment note, dated 1/19/26, indicated nursing staff could substitute IsoSource for Glucerna if it was not available. The note indicated it was recorded on 2/2/26 at 2:50 p.m. This citation relates to Intake 2731013. 3.1-44(a)(2)

Based on observations and interviews, the facility failed to prevent the potential for infection when they failed to change a used suction canister for over a week for 1 of 3 residents reviewed for infection control practices (Resident B). Findings include:On 2/2/26 at 10:34 a.m. Resident B's room was observed. There was a suction canister that was approximately half full of yellow tinged liquid with a layer of yellow sediment that had settled to the bottom. The canister was dated 1/13/26On 2/2/26 at 11:05 a.m. the Executive Director (ED) indicated the canister had been changed on 2/2/26.On 2/2/26 at 4:30 p.m. a copy of a current facility document titled, Supply Change Out, dated 6/2024 was provided. That document indicated Suction Canisters/Tubing should be changed weekly and as needed.This citation relates to Intake 2731013.3.1-18(b)

Based on observations and interviews, the facility failed to ensure controlled substances were appropriately stored in a medication cart for 1 of 2 narcotic count observations. Findings include:On 8/14/25 at 10:43 a.m. the medication cart on 500 hall was observed for a narcotic count with Qualified Medication Aide (QMA) 7.Resident B had a bottle of Tramadol 50 milligrams (mg) tablets with an order to take 1/2 a tablet twice daily. QMA 7 took the contents out of the bottle. There were three pill crush sleeves stapled together with 20 half tablets in each of the sleeves, one pill crusher sleeve that was stapled with 20 half tablets in it and 1 pill crusher sleeve open with 14 half tablets in it. QMA 7 indicated the three sleeves that were stapled together were from another full bottle of the same prescription, and the other two were from the current bottle. The QMA indicated sometimes the nurse who received the bottle would pre count the pills to make counting easier. They would put 20 pills each into a pill crusher sleeve and then staple them shut.During an interview on 8/14/25 at 12:00 p.m. the Executive Director (ED) indicated that the practice of pre counting pills and storing multiple bottles of pills in one bottle was not best standard practice and he would expect the nursing staff to follow the facilities policy on medication storage.On 8/14/25 at 12:15 p.m. the ED provided a copy of a current facility policy titled, Storing Drugs, dated 7/2025. This policy indicated, . each drug must be kept and stored in the labeled dispensing container. Drugs may not be transferred from one container to another.3.1-25 (j)3.1-25 (m) 3.1-25 (n)

Based on observations, interviews and record reviews, the facility failed to ensure residents had the right to privacy and dignity when staff failed to knock and announce themselves before entering the residents' room for 3 of 3 residents reviewed for dignity (Resident 25, 34, and 46), and for 1 of 1 resident council meeting (Residents 9, 20, 48, 11, and 43). Findings include: 1. During an interview on 3/24/25 at 10:25 a.m. with Resident 25, an unknown staff member opened the door without knocking and entered the room. The staff member indicated she was looking for Resident 25's roommate and then left abruptly. Resident 25 indicated a lot of staff members did not knock before they entered the room or the bathroom. Staff would often make demeaning comments about the smell when she had a bowl movement. Resident 25 indicated when staff did not knock before coming into the room or bathroom it made her feel disrespected and undignified. 38768 2. During a random observation on 3/26/25 at 8:51 a.m., Certified Nursing Aide (CNA) 12 and another unidentified CNA rolled a hoyer lift to Resident 34's closed door. They opened the door and entered without knocking or identifying who they were and rolled the hoyer lift into the room. 3. On 3/26/25 at 1:00 p.m., a Resident Council Meeting was held with Residents 9, 20, 48, 11, and 43. They indicated, staff did not always knock and announce themselves before they entered the residents' rooms. Especially if the call light was already on, they would just walk into the rooms and say, what do you need now? The residents indicated when this happened, they did not feel like they were treated with respect or given privacy in their rooms. 4. On 3/26/25 at 1:54 p.m., CNA 14 was explaining how staff could tell if a resident was on enhanced barrier precautions (EBP) and as an example she indicated to Resident 46's room and walked in without knocking, or announcing herself to the resident who was in bed. On 3/27/25 at 10:50 a.m. the Regulatory Consultant provided a copy of current facility policy title, Residents Rights, reviewed January 2025. The policy indicated, This facility shall treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life . always knock and request permission before entering the room. The person entering should call out his/her name and wait slightly for the resident to respond to the individual prior to entering the room 3.1-3(p)

Based on observation and interview, the facility failed to date medications when opened and label over the counter medications for 3 of 6 medication carts reviewed (Residents 34, 47, 5, 64, 49, 11, 44, and 59). Findings include: 1. Resident 34 had an insulin pen lispro in the cart dated [DATE]. It expired 28 days after opening. 2. Resident 47 had latanoprost eye drops in the medication cart with no date to indicate when they were open for 2 of 2 bottles observed. 3. Resident 5 had a bottle of nasal deep-sea spray in the cart with no date to indicate when it was opened. 4. Resident 64 had a bottle of Tylenol in the medication cart, and it lacked a label. 5. Resident 49 had an insulin pen lantus in the medication cart dated [DATE]. It expired 28 days after opening. 6. Resident 11 had a bottle of Tylenol in the medication cart with no label on the bottle. She had a nasal spray, nanogel, in the cart with no date to indicate when it was opened. 7. Resident 44 had a bottle of fish oil with no label on the bottle. 8. Resident 59 had fluticasone nasal spray in the medication cart. It lacked a date to indicate when it was opened. On [DATE] at 10:20 a.m., the Nurse Consultant indicated they attempted to manage medication storage, but it was a difficult task. She indicated the carts were correct now. A policy titled, Medication Expiration was provided by the Regulatory Consultant on [DATE] at 1:35 p.m. It indicated, .Opthalmic, otic, and nasal preparations will expire per the manufacturer expiration date unless otherwise noted on manufacturer packaging, e.g. refrigerate, discard any unused solution after 14 days. Multiple dose injections, such as insulin will expire 28 days after opening unless otherwise noted by manufacturer. Facility staff shall date the label of any multi-use vial when the vial is first accessed and access the vial in a dedicated medication preparation area 3XXX,d+[DATE](j) 3XXX,d+[DATE](m) 3XXX,d+[DATE](n)

A. Based on observations, interviews, and record reviews, the facility failed to ensure appropriate infection control measures were used during the administration of a nasal spray for a resident for 1 of 1 observation of a nasal spray administration (Resident 13). B. Based on observations, interviews, and record reviews, the facility failed to ensure consistent and effective infection control practices related to enhanced barrier precautions (EBP) to ensure staff and visitors were aware of who required EBP and that personal protective equipment (PPE) was readily accessible for 6 of 6 residents reviewed for EBP (Residents 44, 34, 41, 71, 15, and 46). Findings include: A. During a medication administration observation on 3/27/25 at 8:30 a.m., Licensed Practical Nurse (LPN) 13 was observed as she prepared a nasal spray for Resident 6. LPN 13 set and administered the resident's oral medications, then returned to the cart to prepare the resident's nasal spray. LPN 13 proceeded to administer the residents nasal spray without performing hand hygiene or donning gloves. After administering the nasal spray, LPN 13 left Resident 6's room and did not perform hand hygiene. On 3/27/25 at 1:21 p.m. the Regulatory Consultant, provided a copy of a current facility policy titled Nasal Drops/Spray Instillation reviewed January 2025. The policy indicated, . 1. Perform necessary initial steps . 5. Perform necessary final steps .procedure #1: initial steps . 9. Wear gloves as indicated by standard precautions .Procedure #2: final steps . 1. Remove gloves if applicable and wash your hands . B1. On 3/26/25 at 1:50 p.m. Residents 44, 34, and 41's rooms were observed for Enhanced Barrier Precautions (EBP) and Personal Protective Equipment (PPE). Resident 44, who required EPB related to her feeding tube, had a small EBP sign on her closet door and two packages of almost empty yellow isolation gowns stuffed into different corners of her closet, intermixed with the resident's personal clothing and items. Resident 34, who required EBP related to a below the knee amputation (BKA) and dialysis, had a small EBP sign on his closet door and one thin package of blue isolation gowns on the top shelf of his closet. Resident 41, who required EBP related to a pressure ulcer wound, had a small EBP sign on his closet door, but did not have any PPE in or around his closet. 38768 B2. On 3/24/25 at 10:45 a.m., Unit Manager 10 indicated she was preparing to complete the dressing changes for Resident 71 who had wounds on both of his feet. Resident 71's room had no indication via signage and/or available PPE that he required EBP as an extra precaution against the potential for infection related to his wounds. On 3/26/25 at 10:47 a.m., Certified Nursing Aide (CNA) 14 exited Resident 15's room with a trash bag. She indicated she had just changed the resident's brief for the morning, but had not donned any PPE because she only changed her brief and did not get near the resident's wound on her foot. On 3/26/25 at 1:43 p.m., Residents 15, 71 and 46 rooms were observed for EBP and PPE. Resident 15, who required EBP for a wound on her left foot had an EBP sign on her closet door, but there was no PPE in the closet, or elsewhere in her room. Resident 71, who required EBP for wound to both of his feet, had no indication of his requirement for EBP. There was no sign and no PPE. Resident 46, who required EBP for her use of a foley catheter, had a sign on her closet door. During an interview on 3/26/25 at 1:54 p.m., CNA 14 indicated staff should know if a resident required EPB because there should be a sign on the closet door and the PPE was stocked in each resident's closet. CNA 14 entered Resident 46's room (without knocking) and pointed to the EBP sign on her closet door and indicated, there should be PPE in the closet, but when she opened the closet to check, there was no PPE. On 3/25/25 at 1:35 p.m., the Regulatory Consultant provided a copy of current facility policy titled, Enhanced Barrier Precautions (EBP), reviewed January 2025. The policy indicated, .use of EBP is also indicated for residents with chronic wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO . procedure: post signage within the resident room . make PPE, including gowns and gloves available within the resident room

Based on observation, interview and record review, the facility failed to ensure the resident had the right to chose when he received routine lab draws that honored his preference not to be woken up too early for 1 of 1 residents reviewed for choices. Findings include: During an interview on 3/24/25 at 2:11 p.m., Resident 47 indicated, he was doing ok except he was tired of being woken up too early to keep getting blood draws. He indicated last time he woke up around 2:00 a.m. with a needle in his arm, it had startled him and made him mad. When they came that early to get his blood, they turned on the lights, jostle him in bed, stuck him and drew the blood, then he had a hard time falling back asleep. Resident 47 indicated he did not understand why he had to keep getting so much lab work done, and he wished they would do it later in the day. During a follow up interview on 3/27/25 at 8:48 a.m., Resident 47 indicated he did not understand, why they keep getting me up so D--- early for all this blood work. He couldn't go back to sleep then felt grumpy throughout the day. He indicated he told everyone and named three staff members. I know I've told them, but nothing gets done about it. During an interview on 3/27/25 at 8:50 a.m., Certified Nursing Aide (CNA) 12 indicated Resident 47 did not like it when labs came in super early. CNA 12 tried to remind the resident, it was only once a week or so, and not every day, and encouraged him to take naps throughout the day. CNA 12 did notice a difference in Resident 47's attitude on the morning he was woken up too early. Resident 47 would be a little more grumpy than usual and short-tempered. During an interview on 3/27/25 at 9:00 a.m., Qualified Medication Aide (QMA) 11 indicated Residnet 47 hated it when labs came early for his bloodwork. QMA 11 worked night shift sometimes and indicated labs usually came around 3:00-4:00 in the morning for fasting blood draws. He usually had a hard time falling back asleep and would be grumpy later in the day. During an interview on 3/27/25 at 10:47 a.m., the Activity Director (AD) indicated she knew Resident 47 was not an early morning person. She knew he preferred to sleep in, and would often deliver his Daily Chronicle or other activities later in the morning after he had a chance to get up and eat breakfast. During an interview on 3/27/25 at 11:04 a.m., the Director of Nursing indicated, labs usually came early in the morning around 3:00-4:00 a.m., but resident's had the right to refuse, and the nurses at the facility could draw the labs later if needed. On 3/26/25 at 1:58 p.m., Resident 47 electronic and hard/paper charts were reviewed. He was a long-term care resident with diagnoses which included, but were not limited to, a history of a kidney transplant and insomnia. He had a standing lab order, dated 8/1/24, which indicated, the above patient [Resident 47] had a kidney transplant . and will be coming to your lab routinely for the following labs. This is a standing lab order. Expiration date of the order should be the maximum allowed time interval by your company policy. Resident 47 was instructed to receive monthly lab work, which included, but was not limited to a Prograf draw (Tacrolimus/Prograf is an immunosuppressant medication used along with other medications to prevent rejection in people who have received a liver, lung, or heart transplants) the order specified that the Prograf must be 24 hr trough level, (Trough is the lowest level of a drug in a patient's body and blood should be drawn immediately before the next dose to assess drug concentrations during the trough phase). Resident 47 had a current physician's order for tacrolimus capsule; 0.5 milligrams (mg) administer 1 tablet every morning scheduled from 6:30 a.m. - 10:30 a.m. Resident 47's comprehensive care plans were reviewed and lacked implementation or revision to include goals/interventions for his routine recurring lab orders. Resident 47's labs were reviewed and revealed the following: On 11/4/24 at 3:14 a.m., blood was collected for his routine labs which included a draw for his Tacrolimus level. The medication was scheduled to be given the previous day as early as 6:30 a.m., so the lab would have been drawn too early. On 12/3/24 at 3:56 a.m., blood was collected for his routine labs which included a draw for his Tacrolimus level. The medication was scheduled to be given the previous day as early as 6:30 a.m., so the lab would have been drawn too early. On 12/5/24 at 2:41 a.m., blood was collected for his routine labs. On 1/7/25 at 3:56 a.m., blood was collected for his routine labs which included a draw for his Tacrolimus level. The medication was scheduled to be given the previous day as early as 6:30 a.m., so the lab would have been drawn too early. On 2/5/25 at 3:14 a.m., blood was collected for his routine labs which included a draw for his Tacrolimus level. The medication was scheduled to be given the previous day as early as 6:30 a.m., so the lab would have been drawn too early. In March 2025, Resident 47 had 5 early labs as follows: a. On 3/3/25 at 4:09 a.m. blood was collected for his routine labs which included a draw for his Tacrolimus level. The medication was scheduled to be given the previous day as early as 6:30 a.m., so the lab would have been drawn too early. b. On 3/5/25 at 3:21 a.m., he had a draw for magnesium. c. On 3/10/25 at 4:16 a.m., he had a draw for magnesium. d. On 3/14/25 at 4:21 a.m., he had blood work drawn for routine labs and a vitamin D level. e. On 3/24/25 at 3:34 a.m., he had a draw for magnesium. During an interview on 3/27/25 11:07 a.m., the Social Service Director (SSD) indicated she was not aware that Resident 47 did not like getting his labs draw too early, but she was told by nursing to make a new care plan that morning. The SSD reviewed his care plans and indicated he did not have one to address his routine labs, and she would add one. On 3/27/25 at 10:50 a.m., the Regulatory Consultant provided a copy of current facility policy titled, Laboratory Orders, Timely Draws, reviewed January 2025. The policy indicated, Laboratory testing shall be conducted in a timely manner per physician's orders. The facility shall ensure that physician's orders requesting laboratory services to be rendered are followed as specified in the order On 3/27/25 at 10:50 a.m., the Regulatory Consultant provided a copy of current facility policy titled, Resident Choice/Self-Determination, reviewed January 2025. The policy indicated, This facility shall promote and facilitate resident self-determination through support of resident choice. The resident has the right to and this facility shall promote and facilitate self-determination through support of resident choice, including but not limited to . a right to make choices about aspects of his or her life in the facility that are significant to the resident . the resident/representative shall be interviewed following admission in an effort to identify resident choice/self-determination . the resident/representative shall be encouraged to notify staff should a resident's choice change, in an effort the facility may support and accommodate said change, communicating the same to applicable caregivers 3.1-3(u)

Based on record review and interviews, the facility failed to initiate a new PASARR (Preadmission Screening and Resident Review)screening after a new mental health diagnosis was added to the diagnosis listing for 1 of 1 resident reviewed for PASARR (Resident 3). Findings include: On 3/27/25 at 8:56 a.m., a record review was completed for Resident 3. She had the following diagnoses which included but were not limited to bi-polar , dementia, essential hypertension, chronic kidney disease, and major depressive disorder. Resident 3 had a level I (A Level 1 Screening involves completion of an evaluation to determine if an individual has, or is suspected of having, a PASRR condition, i.e., serious mental illness (SMI), intellectual disability (ID), developmental disability (DD), or related condition (RC) completed on 1/24/25. The diagnosis listed on her level I was major depression. On 4/15/24, Resident 3 had a new diagnosis of bi-polar added. Resident 3's record lacked documentation that a new PASRR screening was completed to determine if a level II was required. During an interview on 3/27/25 at 10:21 a.m., the Social Services and Activities Consultant indicated that Resident 3 had a diagnosis of dementia so it may not have triggered a level II. A policy titled, PASARR Level II Referral provided by the Regulatory Consultant on 3/27/25 at 1:01 p.m. It indicated, .The facility shall notify the state mental health authority or state intellectual disability authority, as applicable, promptly after a significant change in the mental or physical condition of a resident who has a mental disorder or intellectual disability for resident review .

Based on record review and interview, the facility failed to ensure a comprehensive discharge plan was in place and implemented for 1 of 2 closed record reviewed (Resident 80). Findings include: On 3/26/25 at 8:46 a.m., Resident 80's closed record was reviewed. She had been a short-term resident who completed a rehabilitation stay from 12/17/24 - 12/29/24 for aftercare following a joint replacement surgery. Resident 80 had a comprehensive care plan, dated 12/18/24, which indicated her desire to discharge home, but her goal was TBD (to be determined). Interventions for this plan of care were not person centered and adaptive equipment needed was left blank as well as home services needed was left blank. A Discharge summary, dated [DATE], was reviewed. The recapitulation of the resident's stay was left blank. A summary at the time of her discharge was left blank. Her discharge plan of care indicated, discharge hom and proceed with home health for nursing, physical and occupational therapy and home health aide. The Discharge summary lacked specification of which home health agency, physical therapy and/or occupation therapy contract service she might need, and did not include any contact information for any service. A copy of her Home Discharge Instructions form dated 12/29/24 was reviewed. The instructions lacked documentation for the following areas: a. A list of medications with instructions b. Dietary specifications c. Activity specifications d. Therapy specifications e. Referral documentation. The Discharge instructions for social services indicated, seek assistance as needed . but did not specify who, or provide contact information. The record lacked documentation of reconciliation for all her medications at the time of her discharge. During an interview on 3/27/25 at 11:00 a.m., the Regional Nurse Consultant, (RNC) indicated she could not locate any documentation of Resident 80's medication reconciliation for the time of her discharge and reviewed the above Discharge summary and Home Instruction forms. She indicated the forms were minimally documented and should have included more information and details. On 3/27/25 at 8:15 a.m. the Regulatory Consultant provided a copy of current facility policy titled, Discharge Planning, reviewed January 2025. The policy indicated, The facility shall develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care and the reduction of factors leading to preventable readmissions . The discharge planning process shall begin on admission and involve identifying each resident's discharge goals and needs, developing and implementing interventions to address the, and continuously evaluate them throughout the residents stay to ensure a successful discharge . the discharge care plan is part of the comprehensive care plan and must: . be re-evaluated regularly and updated when the resident's needs or goals change . discharge planning must include: documentation of referral to local contact agencies . documentation of the response to referrals . the facility shall documents any referrals to local contact agencies or other appropriate entities made for this purpose . this facility shall update the resident comprehensive care plan and discharge plan, as appropriate, in response to information received from referrals to local contact agencies or other appropriate entities . 3.1-36(a)

Based on observation, record review, and interview, the facility failed to prevent the potential for accidents related to medications at bedside for 2 of 4 residents reviewed for accidents (Residents 60 and 33). Findings include: 1. On 3/26/25 at 1:30 p.m., a record review was completed for Resident 60. He had the following diagnoses which included but not limited to hypertension, arthritis, weakness, and anxiety. On 3/24/25 at 10:12 a.m., Resident 60 was sitting in his wheelchair with his back at the door. Behind him on a table was a cup of pills. The color of the pills was white, orange, and red. There were approximately 8 pills in the cup. On 3/25/25 at 1:58 p.m., the Regulatory Consultant indicated the Qualified Medication Assistant (QMA) was instructed not to leave Resident 60's medications at bedside unattended. On 3/27/25 at 10:21 a.m., the Director of Nursing (DON) indicated he was now allowed to have his medication at bedside. 51296 2. During a medication pass on 3/27/25 at 8:20 a.m. Resident 33 indicated to Licensed Practical Nurse (LPN) 13, there was a pill on the floor next to her bed that was there from night shift. LPN 13 walked over to where the Resident said the pill was picked up an unidentified, oblong shaped, tan pill off the ground next to the resident's bed. LPN 13 immediately disposed of the pill in the sharps container and continued with medication pass. A policy titled, Medications, Self-Administration was provided by the Regulatory Consultant on 3/25/25 at 1:35 p.m., It indicated, .Always observe the resident taking their medication(s). Never permit medication to remain in the resident's room. Residents may not self-administer medications unless specifically authorized in writing by the attending physician, and then only in accordance with facility procedures for self-administration 3.1-45(a)

Based on observation, interview and record review, the facility failed to ensure residents with significant past trauma and/or post-traumic stress disorder (PTSD) received personalized care to address and avoid triggers for 2 of 2 residents reviewed for trauma informed care (Residents 25 and 65). Findings include: 1. During an interview on 3/24/25 at 10:25 a.m., Resident 25 indicated she regularly stayed up late at night because she couldn't shut her mind off and had trouble going to sleep and staying asleep. On 3/25/25 at 1:35 p.m., Resident 25's medical record was reviewed. She was a long-term care resident whose diagnoses included, but were not limited to Multiple Sclerosis (a chronic, autoimmune disease that affects the brain and spinal cord) and Major Depressive Disorder. A progress note, dated 1/1/2025 at 4:52 a.m., indicated Resident 25 was up in her wheelchair awake. When the nurse asked the resident if she had slept any throughout the night the Resident indicated she had not because she had too much on her mind to sleep. A mood and behavior communication memo, dated 10/17/24, indicated between 10:00 p.m. and 6:00 a.m., Resident 25 was up in her wheelchair sleeping. The nurse asked the Resident to get in bed because she was sliding out of her wheelchair. The Resident agreed but at 2:00 a.m. when the nurse checked on the resident she had gotten back up out of bed and into her wheelchair. The resident was redirected four times to rest in bed. A psychology note, dated 11/7/24, indicated Resident 25 had a significant history of trauma which included but was not limited to, her father committing suicide in their backyard while she was home when the resident was [AGE] years old and the resident's father being an alcoholic and physically abusive to her and her mother. The note also indicated Resident 25 had experienced depression and PTSD her entire adult life and was facing current life challenges as she had to sell her home, had to have her cats adopted because she was unable to live on her own, and her long-time roommate was moving away with family. A trauma questionnaire, dated 10/7/23, indicated when asked, have you ever had a close friend or family member murdered or killed by a drunk driver, substance abuse or suicide the answer was no. The record lacked documentation that a new trauma-informed questionnaire/interview had been conducted after the Psych provider identified evidence of her past trauma. Resident 25's comprehensive care plans were reviewed and lacked documentation of implementation and/or revision of her plan of care to address her mental health and past trauma experiences. During an interview on 3/27/25 at 3:21 p.m., the Social Services Director (SSD) indicated she did the initial trauma questionnaire upon a resident's admission and was unaware that Resident 25 had past trauma. The SSD indicated that the Psychology group didn't usually talk or debrief with her after they talked to the Resident, she usually just read through the notes but she indicated she easily could have missed that information. The SSD indicated the notes from the psychology group should have prompted her to do a new trauma questionnaire for trauma informed care. 38768 2. During an initial interview on 3/24/25 at 10:36 a.m., Resident 65 indicated she had severe PTSD related to her history. She shared openly, but became tearful as she explained she had been sexually assaulted so severely that her jaw was broken and she lost her ability to play the flute and lost a musical scholarship. She had to change her major to art and theatre, which she enjoyed, but felt a great loss that she could never play the flute again. Resident 65 also spent time as an Emergency Medical Technician (EMT) and experienced PTSD related to some horrible things she responded to. Resident 65 indicated she found ways to cope by learning new instruments, arts and crafts. Resident 65 indicated the best thing she could do when she felt triggered or overwhelmed was to talk with other people because it felt like she was in control and could help someone else. Resident 65 indicated she absolutely did not like to leave her room, and it made her anxious when she was asked to go and do things because she did not want to upset anyone by saying no, but she preferred to stay in her room. Resident 65 indicated she did not like to have male caregivers and it made her angry that she was told she refused showers because she didn't want to take them with a male caregiver. She did not want to be labeled as refusing care, just because she preferred only female staff. On 3/26/25 at 11:19 a.m., Resident 65's electronic medical record was reviewed. She was a long-term care resident who had diagnoses which included, but were not limited to, PTSD, anxiety and psychosis with hallucinations. The electronic record Resident Profile lacked documentation of her PTSD triggers and/or interventions. A copy of Resident 65's current Certified Nursing Aide (CNA) assignment sheet was provided by Licensed Practical Nurse (LPN) 13. The assignment sheet lacked documentation of her PTSD triggers and/or interventions. During an interview on 3/26/25 at 10:20 a.m., CNAs 14 and 15 indicated they worked with Resident 65 on a regular basis. They knew she had PTSD because she was pretty open about her past and shared with her female caregivers but did not like male caregivers. The CNAs did not know what her triggers were, or if she had other specific interventions other than just trying to talk to her and calm her down. The CNAs used their assignment sheets, but those mostly only indicated the resident's activities of daily living (ADL) requirements, like diet orders, side rails, transfer assistance etc. Information related to her mental illness would need to come from the nurse because the CNAs did not have time to go through folders of care plans. On 3/26/25 at 11:19 a.m., Resident 65's paper/hard chart was reviewed. She had a Pre-Admission Screen and Record Review (PASARR) level II dated 8/9/25 effective indefinitely which indicated she was considered to have a major mental illness. She had a physician's note from her long-standing psychiatric provider which indicated any attempt at gradual dose reductions (GDRs) for her psychiatric medications would likely cause instability and was contraindicated related to her history. Resident 65 had a .long-standing diagnosis of psychotic disorder and psychosis with hallucinations which is effectively managed [by her psychiatric medications]. Resident 65's folder of comprehensive care plans was reviewed. There were over 75 individual pages of care plans, and 14 pages related to mood/behavior/psychiatric disorder etc . Care plans titled Mood and Behavior 1. Delusions revised 1/20/25, which indicated, .may exhibit any or all of the following mood and behavior challenges: (LIST) but none were listed. Interventions included, encourage activities of interest such as: (LIST), but none were listed. 2. Psychosis revised 1/20/25. Interventions included, encourage activities of interest such as: (LIST), but none were listed. 3. PTSD, revised 1/25/25, indicated, .may exhibit any or all of the following mood and behavior challenges: recent events, past events, sex abuse, verbal abuse. Interventions: listen to music, games on phone, play musical instruments. Additional care plans related to behaviors: 4. Rejection of care revised 1/20/25, bathing and showers were circled, but lacked revision to include her preference for female caregivers. 5. Non-Adherence revised 1/20/25, which indicated, the resident is non-adherent with: . but was left blank. 6. Verbal Behavior Symptoms Directed Towards Others, the list for interventions was left blank. 7. False Allegations Against Staff, revised 1/20/25 which had check marks over care or lack of care, abuse, neglect etc. Interventions were not individualized. 8. Manipulative Behavior, revised 1/20/25, which indicated she voiced different stories and would tell her niece she showered when she had not. There were no individualized interventions listed. Additional care plans related to her mental health conditions: 9. Hallucinations, revised 1/20/25 which indicated, The resident has hallucinations as evidence by: previous nursing notes. There were no individualized interventions. 10. Health Conditions, revised 1/2/25 which indicated she had PTSD disorder, she was easily startled, had anxiety and difficulty sleeping. There were no individualized interventions. 11. Abuse, revised 1/20/25 which indicated, she had a history of sexual, physical, mental and verbal abuse and has PTSD with potential triggers: loud noises, loud voices, crowds and male caregivers. Interventions included, but were not limited to, avoid triggers. 12. Mental Health Services, revised 1/20/25 which indicated, Outside Provider, but did not specify who the provider was or how often she was seen. 13. Anxiety, revised 12/24/25 which indicated she had fatigue, irritability and racing thoughts. Interventions included, watching TV, playing on phone and talking to family. 14. Fear and Anxiety- Potential For, revised 1/20/25, which indicated, she had anxiety due to past sexual, verbal, mental and physical abuse. Triggers: noises, loud voices, crowds, male caregivers. Interventions included, but were not limited to, avoid triggers. Resident 65 had a Trauma Questionnaire, dated 8/23/24 which indicated she had experienced verbal, mental and physical abuse and had attempted suicide in the past. A De-Escelation Preference Interview, dated 8/24/24, indicated Resident 65 had the following triggers: being touched, being isolated, feeling rushed, preferences not being honored, unresolved pain, door remaining open, loud noises, yelling, crowded places, specific scents such as bleach, pesticides and perfumes Resident 65's care plan did not include and/or were not revised to include documentation related to her suicide attempt in the past and/or being sensitive and/or triggered by certain scents. During an interview on 3/27/25 at 11:14 a.m., the Social Service Director, (SSD) indicated staff should have access to the care plan folders and could see that trying to flip through so many pages with different issues and interventions could be cumbersome. The SSD indicated the CNA assignment sheet would be the best place to put her triggers and interventions for Residents with PTSD and be updated as needed. The SSD indicated a lot of the times she was too busy to pick though each page of the care plans to find one to revise, so she would quickly print and date a new one to stick it in the folder. During an interview on 3/27/25 at 11:23 a.m. the Regional Nurse Consultant, (RNC) reviewed the 14 pages of care plans for Resident 65 and indicated they should be condensed down, and/or updated interventions that were most helpful could be added to the CNA assignments sheets for easier access to direct care staff. On 3/27/25 at 10:50 a.m. the Regulatory Consultant provided a copy of current facility policy titled, Trauma Informed and Culturally Competent Care, revised January 2025. The policy indicated, A trauma-informed, culturally competent approach to care acknowledges that caregivers have a complete picture of a resident's life situation - past and present - in order to provide effective healthcare services with a healing approach On 3/27/25 at 10:50 a.m. the Regulatory Consultant provided a copy of current facility policy titled, Care Plan development and Review, revised January 2025. The policy indicated, .the facility shall develop and implement a comprehensive person-centered care plan for each resident . care plans shall be re-written as needed to maintain an up-to-date legible document . care plan interventions specific to direct care personnel will be included on the direct caregiver's assignment sheet, or similar tool in use

Based on record review and interview, the facility failed to follow up with pharmacy recommendations in a timely manner for 1 of 5 residents reviewed (Resident 69). Findings include: On 3/26/25 at 1:02 p.m., a record review was completed for Resident 69. He had the following diagnoses which included but were not limited to encounter for palliative care, hypertension, sleep apnea, and pain. He had a pharmacy recommendation on 2/5/25 for a reduction in the amount of aspirin he was receiving. The physician did not respond until 2/12/24, 7 days later. Resident 69 had a pharmacy recommendation on 2/5/25 for a reduction gabapentin and the current dosage. The physician did not respond until 2/12/25. On 3/26/25 at 1:32 p.m., the Regulatory Consultant indicated the facility's policy indicated they have 3 days to get pharmacy recommendations completed. On 3/27/25 at 10:09 a.m., The Director of Nursing (DON) indicated they send the recommendation to the physician and if there was no response in 3 days, she sent it again. She flagged the recommendations and when the physician responded, she pulled them back down in her binder. On 3/26/25 at 12:20 p.m., the Regulatory Consultant provided a policy titled, Pharmacy Recommendations and Regimen Review. It indicated, DON or designee, shall be responsible to monitor attending physician review/response. Recommendations of an emergent nature shall be communicated by the pharmacist immediately to the DON with a request for immediate attending physician review/response. For recommendations of a non-emergent nature, should response not received in three (3) physician office business days, DON or designee shall be responsible to ensure the attending physician is again contacted and response received and documented 3.1-25(i)

Based on interview and record review, the facility failed to ensure a resident's wheelchair wheels were engaged into the facility van wheelchair-locks properly for 1 of 3 residents reviewed for accidents (Resident B). The deficient practice was corrected on 2/22/24, prior to the start of the survey, and was therefore Past Noncompliance. Finding includes: A confidential interview during the survey indicated on 2/20/24 Resident B was being transported in the facility van while seated in her wheelchair. Resident B's wheelchair was not strapped into the van properly. The wheelchair and resident tipped over and the resident hit her head. During an interview, on 3/8/24 at 2:00 p.m., the Corporate Consultant (CC) indicated Resident B had an accident while riding in the facility van. The van made a sudden stop that caused the resident and the wheelchair to tip backwards. The resident her hit head on the wall/floor of the van. A facility nurse went to the van and assessed the resident. The resident had a bump on the back of her head. The resident went to the hospital. The facility spoke with the van manufacturer about the van's automatic wheelchair locks, and they suggested getting upgraded hand crank straps to hold the wheelchair better in place. The facility van has been out of commission since the incident. The facility had another van which had hand crank straps to hold the wheelchairs in place during transports that the facility had been utilizing. Resident B's record was reviewed on 3/8/24 at 2:30 p.m. The resident was admitted to the facility on [DATE] with the diagnoses that included, but were not limited to, type 2 diabetes mellitus with diabetic chronic kidney disease (high blood sugar with kidney damage) and dependence on renal dialysis (procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly). An admission Minimum Data Set (MDS) assessment, dated 2/15/24, indicated the resident was cognitively intact, required supervision or touching assistance for transfers, and received dialysis while a resident at the facility. An Accident and Incident Report and Investigation, dated 2/20/24 at 8:40 a.m., indicated the Administrator (ADM) had contacted a nurse to come assess Resident B, who had fallen while riding in the facility van with noted hematoma (bump) to the forehead. Resident B denied pain and indicated she was sitting in her wheelchair in the van when the driver hit the brakes and the wheelchair flipped backwards causing the resident to fall into the back of the van. The resident's family arrived and requested Resident B be sent to the emergency room for further evaluation. A hospital record, dated 2/20/24 at 9:50 a.m., indicated the resident was being transported in the facility van. The wheelchair wheels were not engaged in the van properly. The van made a sudden stop which caused the wheelchair to tip backwards and the resident hit her head on wall/floor of van. The resident required assistance to stand and endorsed constant frontal headache since incident. Noticed head swelling but not bleeding. An x-ray of the resident's head and neck showed low force trauma to the head without signs of active bleeding and no abnormalities. The resident was discharged from the hospital and returned to the facility the same day as the incident. The transportation driver's statement, dated 2/20/24, indicated, that morning, during transport of Resident B, the driver began merging into traffic, had to tap the van brakes, and he observed Resident B begin to tip in her wheelchair. Upon stopping the van, the driver immediately opened the back hatch to view the resident. Resident B was attempting to rise by herself, and the driver assisted the resident by bringing the wheelchair into the upright position to prevent any injury, as the resident was demanding to get up and attempting to rise by herself. The driver contacted the ADM about the incident. The ADM had a nurse come to the site to assess the resident within 15 minutes. The resident's family arrived and requested the resident be sent to the hospital for evaluation. The ADM and driver confirmed the wheelchair brakes were applied and the back two wheelchair wheel restraints were locked into place, but the front two wheelchair wheel restraints were not attached. The van was inspected by the automobile dealership with results of the wheel restraints and vehicle securement system were working properly. The ADM's statement, dated 2/20/24, indicated she had received a call from the transportation driver indicating while transporting Resident B he had tapped his brakes and saw the resident tip in her wheelchair. The ADM had a nurse go to the scene and assess the resident. The resident was sent to the emergency room via 911, and the ADM immediately took the vehicle out of service. The wheelchair was assessed with no concerns. No obvious signs of equipment damage in the van. The vehicle was taken to the dealership for inspection. The dealership advised that no malfunctions of equipment were noted and that there was a potential that if the resident was too close at the time she was secured that the latch would not secure. Dealership advised that the facility could upgrade to self-securement system, but this incident was possibly the result of user error and not ensuring the securement device clicked prior to moving the vehicle. Upon return of the van, on 2/22/24, the ADM provided education to transportation drivers, to confirm a secure click, when securing residents' wheelchairs wheels properly in the facility van with a return demonstration from the transportation drivers. A confidential interview during the survey indicated, on 2/20/24, the interviewee was waiting for Resident B at the dialysis center and had called Resident B to see where she was. Resident B answered the phone, explained the van incident, and they went to the scene of the van incident to see the resident. The transportation driver, the ADM, and a nurse were at the scene. They observed swelling on Resident B's head and a knot on the front of the resident's forehead, and requested the resident be sent to the hospital emergency room for examination. The hospital staff indicated the resident did not have any active bleeding from the incident and the resident returned to the facility. On 3/8/24 at 3:35 p.m., the Corporate Consultant provided and identified a document as a current facility policy, titled Accident and Incident Reporting, dated 10/2014. The policy indicated, .Purpose: To document all accidents and incidents occurring to residents, employees and visitors .Policy: An Accident/Incident Report form is to be completed for all incidents involving residents, employees and visitors. A written description of circumstances surrounding the incident is to be completed and submitted to the nursing supervisor as soon as possible during the tour of duty in which the incident occurred. The report form should be initiated as soon as possible following the incident, after appropriate assessment and necessary emergency intervention is completed .Procedure: 1. Resident: Complete assessment and provide necessary emergency care .Notify physician, family and nursing supervisor .4. In All Cases: Generate Accident/Incident Report Form .Provide an accurate, written description of the circumstances surrounding the accident/incident The Past Noncompliance deficiency began on 2/20/24 and was removed and corrected by 2/22/24, after the facility implemented a systemic plan that included the following actions: the facility van was out of commission since the incident, the van was inspected by the dealership, and the facility staff in-serviced the transportation drivers to ensure the van's wheelchair wheels locks were fully engaged into the wheelchair restraint locks before transporting a resident. This citation relates to Complaint IN00428895. 3.1-45(a)(1)

Based on record review and interview, the facility failed to identify, assess, and treat a pressure wound on a resident's right heel prior to discharge, resulting in harm when the resident had to have a surgical intervention and debridement for 1 of 4 residents reviewed for wounds (Resident C). Findings include: On 4/28/21 at 10:00 a.m., Resident C's daughter indicated she had taken the resident to her (the daughter's) home upon discharge, 2/21/21. Resident C had a cardiology appointment in the morning on 2/22/21. The resident had complained of pain in her heel. The physician looked at it and sent her to the wound center for immediate evaluation. The resident had not been able to see her own heel due to her recent right leg and hip surgery she was unable to bend or cross her leg. The resident had since required a surgical intervention and debridement of the blackened area on her heel. She had gone to live at an assisted living facility on 2/22/21 after the doctor's appointments. Her heel wound was now cared for at the assisted living. She was receiving dressing changes and treatment there. On 4/29/21 at 4:00 p.m., Resident C's daughter provided a copy of the resident's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This document indicated Resident C was seen at the wound center for an unstageable pressure ulcer of the right heel. Measurements were 3.5 centimeters (cm) x 3 cm x 0.1 cm. The problem/location indicated [CONDITION(S)] (swelling) right lower leg, with measurements at the calf of 28.5 cm, 20 cm at the ankle, and 21.5 cm around the foot. Return to clinic 3/8/21. Photos of the right heel with a large area of black tissue were provided. There were orders for a treatment with Santyl (debriding ointment) and daily dressing change for two weeks. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Return to clinic on 3/29/21. Physician to see patient on 3/22/21 at facility. On 4/29/21 at 9:30 a.m., the closed medical record for Resident C was reviewed. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was admitted to the facility on [DATE] for a rehabilitation stay. An admission Minimum Data Set (MDS) assessment, dated 1/28/21, indicated Resident C was cognitively intact with a Brief Interview Mental Status (BIMS) score of 15/15. She was at risk for skin breakdown but had no pressure or unhealed pressure (injury to the tissue from prolonged pressure over a boney prominence). A Braden Scale for Predicting Pressure Ulcer Risk, dated 1/25/21, 2/1/21, 2/8/21, and 2/15/21 indicated Resident C's risk score was 19/23 which indicated she was at low risk for pressure injury. An admission skin/wound assessment, dated 1/25/21, indicated Resident C admitted with a surgical incision on her right hip and bruises of the left forearm and right chin. No other skin irregularities were noted. A care plan, dated 1/25/21, titled, Skin Condition, indicated the resident would be free from skin breakdown through next review. No review date was listed. Interventions included but was not limited to monitor skin for signs and symptoms of skin breakdown. A care plan, dated 1/25/21, indicated the resident was at risk for development of pressure ulcers related to general ORIF right femur, [CONDITION(S)], and decreased mobility. The goal indicated the resident would be free from pressure ulcers through the next review. No review date was listed. Interventions included but were not limited to head to toe skin assessment at least weekly by a licensed nurse, staff observe skin condition while providing care, and notify nurse of any skin concerns. A care plan, dated 1/26/21, indicated the resident was at risk for the development of pressure ulcers related to bilateral TED hose (compression socks). The goal indicated the resident would be free from pressure ulcers through the next review. No review date was listed. The interventions included but were not limited to head to toe skin assessment at least weekly by a licensed nurse, staff to observe skin while providing care, and check skin upon removal of TED hose per order. A review of the resident's daily Treatment Administration Record (TAR), for January and February, indicated TED hose to bilateral lower extremities (BLE) as tolerated. On at 8 a.m., off at 8 p.m. The boxes for on and off were initialed each day, from admitted to discharge date . 8 p.m. daily, skin assessment under BLE TED Hose upon removal. The boxes were initialed for each evening. A third TAR entry indicated skin assessment upon removal of abduction pillow (an A shaped pillow used between the legs after hip surgery), every morning. A box for the 6 a.m. to 2 p.m. shift was initialed each day of the resident's stay. An occupational therapy note, on 2/9/21, indicated, She completed training for donning/doffing [on and off] socks using reacher and sock aid. Her sock aid was too narrow d/t [due to] min swelling in Rt foot, therefore pt [patient] was given larger sock aid; nursing notified of swelling. An occupational therapy note, on 2/17/21, indicated, She has significant swelling noted in RLE [right lower extremity] and minimal seeping. Nursing notified and acknowledged, stating she was put on [MEDICATION(S)] [a diuretic] this AM. A shower sheet, dated 2/20/21, indicated Resident C had a scratch on her back. No other alterations in skin were noted. A weekly skin assessment, dated 2/21/21, and signed by the Assistant Director of Nursing (ADON) indicated, no new skin alteration. On 2/18/21 a Nurse Practitioner (NP) progress note, created by NP 14, indicated, Resident sitting in chair. RLE with [CONDITION(S)] to ankle and lower leg, mild [CONDITION(S)] (redness). Report spasms are decreased and denies current pain. No other c/o [complaints]. No acute distress noted. On 2/19/21 a discharge summary note created by NP 14, indicated, .Physical exam .skin: warm, dry, and appropriate color. No visible [CONDITION(S)]. See nursing notes for skin details Resident C was discharged from the facility on 2/21/21. On 4/30/21 at 9:15 a.m., during an interview the Regional Consultant (RC) indicated he was familiar with Resident C and was aware of Resident C's pressure area on her heel. He had been made aware of it the day after discharge when the resident's daughter had called the facility. She had sent photos to the previous Administrator. He did not believe the resident had any skin problems when she left the facility, at discharge on 2/21/21. She went to her daughter's home that night. Maybe it was a deep tissue injury that developed over night. The pressure was found the next day at the doctor's office. She had to have developed the pressure over night at her daughter's house. They had interviewed the staff about it. No one had recalled seeing any problems with Resident C's skin on her foot or heel. She did have [CONDITION(S)] in that leg, from the surgery. The staff would have seen it when taking her TED hose off and on. She had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . He had also spoke with the Administrator (ADM) at the resident's Assisted Living (AL). The Administrator at the AL indicated the resident was admitted there after the doctor's appointment on 2/22/21 and was being treated there. The wound was present on her admission assessment paperwork at the AL. On 4/30/21 at 11:39 a.m., during a telephone interview, Resident C indicated she had had some pain in her heel during her stay at the facility. She usually told the evening shift nurse about it because it hurt at night. She had a lot of swelling in her foot and leg. She never wore TED hose at the facility because there was too much swelling, and staff could not get them on. She just wore non-skid socks. Staff did not take the TED hose off and look at her feet daily. She never wore shoes. She thought she might have rubbed her heels on the sheets of the bed, trying to push herself up, when she slid down. It was painful. She got showers in a chair in the open shower. Staff never looked at the bottoms of her feet. She saw Nurse Practitioner (NP) 14 a couple days before she was discharged , but NP 14 never looked at her feet either. On 4/30/21 at 12:07 p.m., during a telephone interview, NP 14 indicated she had seen Resident C on 2/19/21 at the facility. If the resident was not complaining of the heel hurting, she would not have looked at it. Often residents were fully dressed sitting in a chair when she saw them, and they were examined. If the heel was found to be black the day after discharge, whether a deep tissue injury or pressure ulcer, it was possible it had already been red and just starting as a pressure area and missed by staff. Or due to the location of the area on the back of the heel, staff might just have not seen it. On 4/29/21 at 4:28 p.m., the RC provided a current undated policy titled, Pressure Ulcer Prevention and Nursing Intervention. This policy indicated, .Common causes of impaired skin integrity is friction which involves rubbing heels or elbows toward bed linen and moving the patient up in bed without use of a lift sheet On 4/29/21 at 4:28 p.m., the RC provided a current undated policy titled, Skin Management Program. This policy indicated, The facility will assess/identify the presence of risk factors that may contribute to the development of pressure ulcers and other skin alterations in an effort to prevent skin breakdown and/or further deterioration limited by the individual's recognized pathology and pre-existing co-morbid conditions .Residents who wear a device such as splint, brace, immobilizer, etc. will have his/her skin assessed daily by a licensed nurse due to greater risk of skin breakdown This Federal tag relates to Complaint IN 320. 3.1-40(a)(1)

Based on observation, interview, and record review, the facility failed to ensure an assistive device was in safe functioning condition resulting in a Hoyer sling breaking during a transfer for 1 of 10 residents requiring Hoyer lifts for transfers resulting in the resident having multiple fractures and lacerations (Resident G). The immediate jeopardy began on [DATE] during a Hoyer lift transfer 4 of 6 loops broke off a Hoyer sling that was approximately in use for 12 months, resulting in the resident falling. The resident sustained [REDACTED]. After the fall with injuries the resident had a decline in her quality of life, pain, and died a week later. The Administrator, Director of Nursing, Regional Director, and the Registered Nurse Consultant were notified of the immediate jeopardy on [DATE] at 3:50 p.m. The immediate jeopardy was removed and the deficient practice corrected on [DATE], prior to the start of the survey and was therefore Past Noncompliance. Findings include: On [DATE] at 11:47 a.m., the Registered Nurse (RN) Consultant (RNC) provided a copy of a Hoyer (transfer equipment) sling accident investigation. A facility document, titled, Accident and Incident Report, dated [DATE], was not signed. It indicated on [DATE] at 4:00 p.m., Resident G was being transferred by a Hoyer lift and 4 of the 6 straps broke at the head of the sling, resulting in the resident, hitting the floor. The fall caused skin tears, lacerations (deep cut or tear in skin), and a hematoma (solid swelling of clotted blood within the tissues). Neuro checks were initiated because the resident hit her head. Resident G complained of pain to her right leg and back of head. A dressing was applied to her right leg, pressure was applied to the back of her head, then a dressing. Resident G was sent to the hospital at 4:40 p.m. Measurements of open injuries were: Right leg 25 cm (centimeter) (9.8 inches) long, 1 cm (0.4 inches) wide and 3 cm (1.2 inches) deep, left shoulder skin tear was 7 cm (2.8 inches) long, 9 cm (3.5 inches) wide and 1 cm (0.4 cm) deep. A progress note, dated [DATE] at 4:00 p.m., was written by the Assistant Director of Nursing (ADON). It indicated, CNA called nursing staff to Resident's room. Resident noted to be lying flat on back on floor parallel to bed. CNAs x (times) 2 at bedside with Resident. At this time, Resident a & o (alert and oriented) at baseline. Resident did not c/o (complain of) pain at this time, however, later stated that her RLE (right lower extremity) hurt a little. Head to toe assessment completed. Laceration noted to ant (anterior - front) RLE, skin tear (L) (left) elbow, skin tear (L) scapula (back of shoulder), hematoma noted to (L) back of head. Pupils' reactive bilat (both eyes). VSS (vital signs stable) .Son, (name) was notified at 4:15 p.m. per (name of Licensed Practical Nurse 11). Resident sent to ER (emergency room ) for evaluation per son request. EMS (Emergency Medical Services) transported at 4:40 p.m. Hospice notified. NP (Nurse Practitioner) notified. (Name of Hospice doctor) notified per hospice. A statement, with no title, dated [DATE], was written by CNA 12. It indicated, On [DATE], I was assigned to (name of Resident G). I and another aid had transferred the resident to her recliner via Hoyer earlier that day per request. I was making my rounds at 4pm, and noticed that (Resident G) was sleeping in her recliner. I had gone in and asked (Resident G) if she would like to lie down in her bed. (Resident G) responded with Yes. I asked (CNA 13) to assist me with putting (Resident G) to bed as she is a transfer via Hoyer. I retrieved the Hoyer lift and inspected the lift and Hoyer pad prior to use. I insured (sic) the bed wheels were locked and pathway was clear from her chair to the bed. (CNA 13) and I attached the Hoyer sling straps to the Hoyer lift hooks, calling out the color of the sling straps to (CNA13) to ensure we were using the same colors. After all the straps were connected, we both pulled to test the straps to ensure they were hooked properly. I instructed the resident to cross her arms across her chest. I used the box on the Hoyer lift to raise the resident from her recliner chair. Once suspended in the air (CNA 13) steadied the resident as I guided her over to the bed with Hoyer lift. As I was pushing the Hoyer I guided the Hoyer lift legs under the bed and (CNA 13) went around to other side of the bed to assist the resident onto the bed. I was pushing the Hoyer lift legs further under the bed when the (sic) (Resident G) fell to the floor. Neither (CNA 13) nor I heard any sounds from the Hoyer lift or Hoyer pad before the fall. When I looked at the lift there were four straps that broke off completely from the Hoyer pad. Upon observation, the resident's head was on part of the legs of the Hoyer lift and part of the resident body was under the bed. I immediately screamed for help and (CNA 13) exited the room to get the nurse. I remained with the resident until the nurse arrived. (sic) (ADON, LPN 14, LPN 11, LPN 19), all entered the room. A statement, with no title, dated [DATE], was written by CNA 13. It indicated, Around 4:00 p.m., (CNA 12), and I went into (Resident G)'s room to put her to bed (sic) we made sure that the Hoyer lift was properly inspected before use. We checked the sling for any tears, or loose ends. (CNA12) made sure that the brakes were locked, and the legs of the Hoyer were opened. We double checked tall hooks, and chains before hooking them up to the Hoyer. (CNA 12) then went to lift her up from the chair. (Resident G) was no more the (sic) 3 inches from the chair. I checked the area around the bed making sure that nothing would interfere with the transfer. As we went to put her in bed the Hoyer sling had broken causing (Resident G) to fall on the floor. Nothing was done out of the ordinary. We did what we would always do while using a lift. I went and got help immediately, and (CNA 12) stayed with her until help arrived. I also stayed with her to assit (sic) with her care until help arrived. This was unfortunate but we did everything we could to make sure she was safe. A statement, with no title, was dated [DATE], was signed by LPN 14 and the ADON. It indicated, At approximately 4pm, ADON and (LPN 14) were called to come assist in room (room number of Resident G). Upon entering room, resident noted to lying flat on back on floor parallel to bed. C.N.A.s (name of CNA 13) and (name of CNA 12) were noted to be next to resident. At this time, resident was alert and oriented to baseline. Resident did not complain of any pain at this, however, later stated that her right lower extremity 'hurt a little.' Complete head to toe completed by (LPN 14) and ADON. Resident noted to have laceration to anterior (front) right lower extremity, skin tear to left upper arm at elbow, and skin tear to left scapula. Resident also noted to have hematoma to back of head. Pupil's reactive and noted normal in size. Laceration and skin tears dressed per unit managers (name of LPN 11) and (name of LPN 14). Vitals signs and neuro status monitored until arrival of EMS and noted to be within normal limits for resident. A statement, with no title, was dated [DATE], was signed by the ADON. It indicated, .The loops of the front four straps (yellow and green) noted to still be attached to opposite sides of mechanical lift parallel to one another. Loops noted to be detached from straps back 4 loops and strap, remained intact and on hook and appropriately affixed to Hoyer hooks. No tethering, fraying, rips, tears, holes noted on any of the back loops/straps, and loops/straps noted to be in good condition. No tethering, fraying, rips, tears, holes noted on any of the front 4 straps or detached loops. Pad had no rips, stains, discolorations noted. Max (maximum) wt (weight) for mech. (mechanical) lift noted to be 600 lbs (pounds), and max wt for lift pad used by Resident at time of incident noted to be 450 lbs. Resident most recent wt was 231 lbs. In addition, all mech lifts assessed for use s (without) abnormal findings. All mech lift pads assessed by ADON and unit mangers and noted to be in good condition. No pads discarded due to potential for malfunction. However, all transfers using Hoyer/slings suspended at this time. A statement, with no title, was dated [DATE], was signed by LPN 14. It indicated, On Friday, [DATE], I assessed the Hoyer sling that was being used to transfer (Resident G) post fall. There was no visible wear and tear or fraying noted anywhere on sling. Straps appeared to have cleanly detached from the body of the Hoyer pad. A progress note, dated [DATE], was written by Resident G's Hospice physician (Hospice MD). It indicated, Unfortunate event! Four straps on Hoyer lift tore at same time during transfer. She fell to floor and suffered multiple injuries. Fx'd (fractured) C6, C7 (cervical spine or neck fractures), (L) (left) rib fxs (fractures), severe laceration to post (back of) scalp and (R) (right) tib-fib (low leg area). Fx'd (L) elbow and T ([MEDICATION NAME] or upper chest) spine. Transferred to hospital for eval (evaluation). Now back for ongoing hospice care. Has been in significant pain and MSO4 ([MEDICATION NAME]) has been adjusted. Here to review orders and speak c (with) family. A facility document, titled, Post Fall Investigation, with no date or signature, indicated Resident G fell in her room, the fall was witnessed. She was a Hoyer transfer with an assist of 2 staff members. The resident was being assisted to bed to be changed, she had been up for 6 hours. This was not the resident's first fall. The medical factors for consideration were incontinence, cardiac [MEDICAL CONDITION] (irregular heart beat), and [MEDICAL CONDITION] ([MEDICAL CONDITION] - stroke). The resident medications were listed as diuretics, cardiovascular meds (medications), and narcotic [MEDICATION NAME] (controlled substance pain reliever). A statement, with no title or date, was signed by the RN Consultant. It indicated, .At 4:15 pm, I determined it was necessary to evaluate the maintenance and care of the Hoyer slings, including the laundering process. I instructed that all Hoyer slings be discontinued from use permanently and replaced at the facility's expense. Given my understanding that new slings may not arrive until Monday, I began contacting sister facilities to obtain new, unused Hoyer slings. A statement, with no title, had a type-written signature for LPN 15. It indicated, On Saturday (MONTH) 27th at 1 am, the RN Consultant brought new Hoyer pads into the facility. The Hoyer pads were packaged and brand new. A progress note from the Nurse Practitioner (NP), dated [DATE], with no date, indicated Resident G was currently under hospice care. Her medical history was significant for [MEDICAL CONDITION] (irregular beats of the upper portion of the heart), depression, [MEDICAL CONDITION] (joint inflammation), [MEDICAL CONDITIONS] (under functioning [MEDICAL CONDITION]), [MEDICAL CONDITION] (too much fat in the blood), and altered mental status. Resident G had an accidental fall on [DATE], 4 straps on the Hoyer lift were torn at the same time during transfer, she fell to the floor, and suffered multiple fractures. Per facility's investigation, no cause can be found for the malfunction of the Hoyer sling, so they reported the incident to the FDA (Federal Drug Administration) and the manufacturer under the Safe Medical device Act (to report patient incidents involving a medical device to the manufacturer and to the FDA if a device caused or contributed to a serious injury). Resident G was able to open eyes to verbal command, her pupils were non-reactive, had labored breathing, staples to her leg and sutures to her scalp. On [DATE] at 3:00 p.m., (Name of) Hospital records were provided by the hospital. They indicated the laceration to her scalp was difficult to visualize, she had multiple c-spine (neck) fractures, and the physician did not want to move her. Therefore, 6 or 7 staples were applied to control the bleeding so that a C-collar (neck stabilizing device) could be applied. The right leg laceration need 13 sutures (stitches), the subcutaneous tissues was visible and side wound edges were brought together as much as was possible. The overall assessment for Resident G was C6 and C7 cervical (neck) fractures, fracture of the [MEDICATION NAME] (chest) spine, left rib fractures, left elbow fracture, laceration of the leg and scalp. Resident was discharged to hospice care. On [DATE] at 9:23 a.m., the RN Consultant indicated the (name of) medical supplier did not have a life span for the sling. It depended on the use of the sling. During an observation of the damaged sling with the RN Consultant on [DATE] at 9:34 a.m., one of the hard creases on the left hip or mid-body area of the Hoyer sling strap used for Resident G was pulled side to side and it easily tore. The RN Consultant indicated the integrity of the hard creases were stiff and more easily compromised. The soft pieces were flexible and strong. There was a difference between the old sling, used on Resident G, and the new sling. On the old sling, there were points that were compromised, but it had been assessed prior to use and was considered good for the day. On [DATE] at 9:50 a.m., the RN Consultant indicated the sling used for Resident G was a prior resident's sling. He purchased it a week before she discharged from the facility. Her name was written in Sharpie on the sling. She discharged on [DATE]. On [DATE] at 11:54 a.m., Resident G was observed in her bed with her eyes closed. Her breathing had a gurgling sound. On [DATE] at 11:55 a.m., Resident G's son indicated, prior to his mother's fall, she played cards, ate her meals, watched TV, used her cell phone and called the family. She had good days and bad days, but her mind was sharp. On [DATE] at 12:33 p.m., the Hospice Nurse indicated Resident G's blood pressure was ,[DATE], oxygen saturation was ,[DATE]% while on 4 L oxygen per nasal cannula, and heart rate was 68. On [DATE] at 3:16 p.m., the RN Consultant indicated after Resident G's fall the facility was dating the slings when they came in and would pull them after 6 months. On [DATE] at 3:58 p.m., LPN 18 indicated her assessment of Resident G was lethargic and largely unresponsive. She had rhonchi (rattling, continuous low-pitched breath sound) in her lungs and periods of apnea (no breathing) and her breathing was quite slow. The resident was in decline. She indicated prior to the fall, Resident G would be up in the mornings, eat her meals and had a sense of humor, she made short jokes. She really enjoyed her family. This was a tragedy, and was a significant difference after the fall. She had a lot more quality of life and her life was being cut short because of the fall. During an interview, on [DATE] at 4:50 p.m., the Hospice Physician indicated he believed the fall had Resident G in decline with a decreased quality of life and a shortened life. As far as the Hoyer accident, You better believe this will accelerate the end of her life. She was bed ridden .but she played cards, she could communicate. This unfortunate event did her in. Her difficulties were head injury, pain with breathing because of broken ribs, and fractures in her neck and [MEDICATION NAME] for pain, these combined caused breathing issues and apnea. After lying in bed for 6 days, she could have had pneumonia because of the thick, yellow secretions from her lungs. Her prognosis was very poor. On [DATE] at 8:35 a.m., the RN Consultant indicated Resident G died on this date On [DATE] at 10:54 a.m., the RN Consultant indicated the sling given to Resident G, used to be from another resident who no longer resided at the facility. For sizing of the slings the CNAs did not go by shoulder circumference, they went by the resident's weight. During an interview an anonymous family member indicated, Resident G did not like the type of Hoyer sling used at the time of the accident. There were two types of slings; one sling was larger, and fit flat behind both legs of a resident, like a swing-seat. The second type was U-shaped, and crossed between the resident's legs. Resident G did not like the U-shaped type of sling because it crossed between her legs, and made her uncomfortable and had given her skin tears, and rug-burn type abrasions on her thighs. The family, and Resident G, had previously brought these concerns to the facility's attention several times. This family member indicated it was Resident G's preference to be up at certain times a day, but in order to do that, she required the use of the Hoyer lift. At times, when the family came to visit, Resident G was not up, because there were no Hoyer slings available. This family member indicated Resident G had been given a Hoyer sling, which previously belonged to another resident who no longer lived at the facility, and was at least a year old. During an interview with the Administrator (ADM) on [DATE] at 9:30 a.m., he indicated the housekeeping staff was really good about communicating what the facility needed, like the Hoyer slings for example. Some residents prefer a certain type of sling, and supply orders for new slings were placed in January, (MONTH) and April, because the Hoyer slings were considered in good working condition for ,[DATE] months, unless damaged was noted beforehand. During an interview on [DATE] at 10:20 a.m., QMA 24 indicated, prior to Resident G's fall, there was no way to tell how old a Hoyer sling was. She would just visually inspect it, test it with tension by pulling on the straps to make sure it was strong. To determine the correct size of sling for a resident, she would just guess by using a smaller sling for a small resident and a larger sling for a large resident. During an interview on [DATE] at 10:28 a.m., QMA 25, indicated, prior to Resident G's fall, there was no way to tell the age of a Hoyer sling unless there was a name or date on the tag, but she was able to tell a new sling from and old one, because new slings were brighter, and softer, where as an older sling might look faded. In order to use the correct size sling, she would use a small sling for a small resident and a large sling for a large residents. During an interview on [DATE] at 10:34 a.m., CNA 26, indicated, prior to Resident G's fall, she tried to use new Hoyer slings or pads she could tell they were new by looking for discoloration, or fraying by visual inspections. In order to use the correct size sling for a resident she would check the color code, because some slings had different colors which meant to use for smaller or larger residents. During an interview on [DATE] at 10:40 a.m., CNA 27 indicated, prior to Resident G's fall, he did not know how to determine the age of a Hoyer sling except to look for signs of wear and tear, or holes in the pad. He would use longer pads for big residents and shorter pads for small residents, the size was important because if he used a pad which was too small, the resident could roll out. During an interview on [DATE] at 10:45 a.m., CNA 28 indicated, prior to Resident G's fall, she would always try to use new Hoyer slings, because they were strongest. During an interview on [DATE] at 11:51 a.m., a Product Support Specialist for (name of medical equipment supplier) indicated it was recommended to replace Hoyer slings every 6 months, and if the facility had questions related to their medical equipment, she would refer them to their website to review training material such as: training videos, best practice guidelines, and downloadable instructions. On [DATE] at 12:30 p.m., (name of medical equipment supplier)'s website was reviewed: A catalogue titled, Strong Hold, Soft Touch. Safe Patient Handling Slings, Comfort and Confidence for Patients and Staff, dated (YEAR), indicated, . Sizing Tool 1. Choose your preferred sling style. 2. Weigh the patient to determine the needed capacity. 3. Measure the patient for a proper fit using the chart below. General Transfer Slings Measure the patient's shoulder circumference .reusable sling should be replaced every 6 months An undated, downloadable document titled, Safe Patient Handling Program, indicated, .maintenance personal are responsible for inspecting the patient lifting equipment, slings, and batteries each month . The U-shaped sling, More About This Item tab, on the Product Order web-page indicated, .Sling maintenance best practices .Reusable slings should be replaced every six months During an interview on [DATE] at 1:08 p.m., with the Director of Nursing present, QMA 30 observed the (medical equipment suppliers) Product Order Page and indicated, that was the website she used to order the Hoyer lift slings. During an interview, on [DATE] at 10:22 a.m., the RN Consultant indicated they did not have a policy or procedure for Hoyer slings. They were inspected prior to use. They deferred to the manufacturer's guideline located on the tag of the Hoyer sling. Those instructions advised, to inspect the sling before each use for any rips, tears, frayed or bleached areas, which are unsafe and could result in injury, to not exceed max weight specified, and to see the owner's manual for operation of lift. An owner's manual, titled, (Name of medical supplier) Battery Operated Patient Lift, indicated for the sling, always check if the sling was suitable for the particular patient, and was of the correct size and capacity, never use a sling which was frayed or damaged, and always fit the sling according to the instructions provided. A policy, titled, Mechanical Lift, was provided with the RN Consultant's initial investigation on [DATE] at 11:47 a.m. A review of the policy indicate, .A mechanical lift is to be utilized for residents who are too heavy to be moved by one person, or who are disabled to the point of inability to assist with transfers. Two (2) personnel members must be present when a mechanical lift is utilized .to assist back to bed: inspect the mechanical lift before use. Make certain bed wheels are locked prior to transfer. Perform necessary initial steps .Roll lift to resident's chair and widen base to its widest point. Attach the sling to the straps or chains. Position resident's arms over their chest or in their lap .press the appropriate control if the lift is hydraulic, raising ,[DATE] inches from chair. Confirm sling is secure prior to proceeding. Once confirmed sling is safely attached .press the appropriate control if the lift if hydraulic, until the resident's body clears the chair. NOTE: Make certain to support resident's head, neck and feet. Roll lift away from the chair and back to the bed. Center resident over the bed. Lower resident onto bed. Unhook sling and remove from beneath resident by turning resident from side to side The past noncompliance immediate jeopardy began on [DATE]. The immediate jeopardy was removed and the deficient practice corrected by [DATE] after the facility implemented a systemic plan that included the following actions: The facility discontinued the use of the Hoyer lifts until all Hoyer slings in the building were replaced with new slings, created a system to monitor the age of the slings, re-educated staff on checking the condition of slings prior to use, and staff did skill check-offs of the Hoyer lifts for proper use. This Federal tag relates to Complaint IN 341. 3XXX,[DATE](a)(2)

Based on record review and interview, the facility failed to ensure their policy and procedure of two staff members for mechanical lift transfers was followed resulting in a resident having fallen from the lift during the transfer and sustained a scalp laceration which required sutures for closure for 1 of 3 residents reviewed for accidents. (Resident B). Findings include: The record for Resident B was reviewed on 3/29/17 at 1:00 p.m. Resident B's [DIAGNOSES REDACTED]. A Care Plan, dated 12/13/16 and last reviewed on 3/15/17, indicated Resident B required assistance to transfer from one surface to another, and had a potential for falls and significant injury lacking staff assistance. Assistance needed: two. A Care Plan, dated 12/13/16, indicated the resident had multiple risk factors for falls. Interventions included, but were not limited to, Hoyer (mechanical lift) (symbol for with) 2 staff to be used for all transfers. The CNA assignment sheet, dated 3/17/16 and identified as in use 3/17/17 by the DON (Director of Nursing), indicated Resident B required maximum assist for ADLs (Activities of Daily Living), Hoyer for transfers. A Nursing Note, on 3/17/17 at 10:00 p.m., indicated the nurse had been called to the resident's room at 8:00 p.m. The resident was noted to be on the floor on her right side with her head on the leg of the Hoyer. It was noted she was bleeding. Staff called 911 and the resident was transported to the emergency room . A Nursing Note, 3/18/17 at 12:30 a.m., indicated the resident returned from the emergency room and had sutures to the center right hairline area. The hospital emergency room report, dated 3/17/17, indicated the resident had presented at the Emergency Department after having a fall, was in a Hoyer lift and fell forward, sustaining a laceration to the right side of the forehead. Description: Laceration: 2.5 cm (centimeters) in length. Scalp: right frontal Skin closure: 4 sutures. During an interview on 3/29/17 at 10:15 a.m., the DON indicated the CNA was going to transfer the resident to bed for the night, and was going to wait for another CNA, however, a family member was present who had indicated they would help. The CNA then started to raise the lift, and there was a pop and the resident slid out of the lift sling. The DON indicated the policy was for 2 staff members to be present for lift transfers and the CNA did not follow the policy. During an interview with CNA 1 on 3/30/17 at 10:20 a.m., she indicated the family member said they would help, but she should have declined and gotten a licensed or certified staff member to assist. CNA 1 indicated as she was raising the sling on the lift and the resident was elevated off the wheel chair, there was a snap and the resident seemed to drop a little and then fell forward and landed on the floor with her body on the floor and her head on the leg of the lift. The CNA sent the family member immediately to get the nurse. A current facility policy, dated 10/2014, titled Mechanical Lift was provided by the DON on 3/29/17 at 2:00 p.m. The policy indicated: Purpose: A mechanical lift enables nursing personnel to lift and transfer a resident to and from bed as safely and as easily as possible. Policy: A mechanical lift is to be utilized for residents who are too heavy to be moved by one person, or who are disabled to the point of inability to assist with transfers. Two (2) personnel members must (in bold letters) be present when a mechanical lift is utilized This Federal tag relates to Complaint IN 097. 3.1-45(a)(2)