Every finding on record at Brown County Health and Living Community

Based on interview and record review, the facility failed to ensure the dialysis center provided a report or communication form after dialysis treatment and the Pre-Dialysis and Post-Dialysis Assessment Observation were completed after Resident 7's dialysis treatment and for 1 of 1 resident reviewed for dialysis. (Resident 7)Findings include:On 8/11/25 at 2:40 p.m., Resident 7 indicated he received dialysis early in the mornings on Monday, Wednesday, and Friday.On 8/13/25 at 10:28 a.m., Resident 7's clinical record was reviewed. The diagnoses included, but were not limited to, end stage renal disease and malnutrition.Resident 7's August 2025 Physician Orders indicated the following:-Complete the Post-Dialysis Assessment Observation after treatment on Monday, Wednesday, and Friday, initiated 11/27/24.-Complete the Pre-Dialysis Assessment Observation before treatment on Monday, Wednesday, and Friday, initiated 11/27/24.-Resident to receive dialysis on Monday, Wednesday, and Friday.A care plan, dated 12/2/24, indicated Resident 7 received dialysis for end stage renal disease. His interventions were to provide dialysis as ordered by the medical doctor (MD) and to observe the dialysis site daily for signs and symptoms of infection and bleeding. The August 2025 Treatment Administration Record (TAR) indicated Resident 7 received dialysis on 8/1/25, 8/4/25, 8/6/25, 8/8/25, 8/11/25, and 8/13/25. The August 2025 Medication Administration Record (MAR) indicated to complete the Pre-Dialysis Assessment Observation before treatment on Monday, Wednesday, and Friday, and to complete the Post-Dialysis Assessment Observation after treatment on Monday, Wednesday, and Friday. The MAR lacked documentation of monitoring the dialysis site daily for signs and symptoms of infection and/or bleeding.The clinical record lacked documentation of a Pre-Dialysis Assessment Observation dated 8/4/25.The clinical record lacked documentation of a Post-Dialysis Assessment Observation dated 8/1/25, 8/4/25, and 8/8/25.Resident 7's Progress notes lacked documentation of dialysis center being notified to request a communication form or monitoring the dialysis site daily for signs and symptoms of infection and/or bleeding. During an interview on 8/14/25 at 10:13 a.m., Licensed Practical Nurse (LPN) 1 indicated Resident 7 went to dialysis on Monday, Wednesday, and Friday. The Pre-Dialysis Assessment Observation would go with the resident to dialysis. The dialysis center did not always send a communication form back with the resident when he returned from dialysis. After Resident 7 returned from dialysis, the facility staff would complete a Post-Dialysis Assessment. During an interview on 8/14/25 at 2:47 p.m., the Director of Nursing (DON) indicated she needed to call the dialysis center to receive the August 2025 dialysis communication or the run report. The run reports were not in the clinical record. The dialysis center did not always send a communication form back with the resident when he returned from dialysis. During an interview on 8/15/25 at 10:15 a.m., the Director of Nursing indicated a Post-Dialysis Assessment should be completed when Resident 7 returned from dialysis. At that time, she provided Resident 7's August 2025 Post-Dialysis Assessment which lacked 8/1/25, 8/4/25, and 8/8/25.On 8/15/25 at 10:15 a.m., the Administrator provided the facility policy, Hemodialysis Policy, dated 6/4/19, and indicated it was the policy currently being used. A review of the policy indicated, .4. Complete a pre- and post- dialysis assessment . The policy lacked documentation of the dialysis center was needing to send a communication report to the facility after dialysis. 3.1-37(a)

Based on interview and record review, the facility failed to revise a care plan for a resident who fell and sustained an injury for 1 of 1 residents reviewed for accidents. (Resident 8) Findings include: During an interview on 8/30/23 at 10:30 A.M., Resident 8 indicated she had fallen in June while she was reaching for a snack. She was sent to the hospital where it was determined that she had broken her left hip. She did not recall meeting with staff regarding new interventions to her fall care plan. On 8/30/23 at 10:45 A.M., Resident 8's clinical record was reviewed. The diagnoses included, but were not limited to, fracture of unspecified part of neck of left femur, cerebral infarction, and type 2 diabetes. A progress note, dated 6/20/23 at 4:22 P.M., indicated, Resident fell in room trying to get donuts. Resident has laceration above left eyebrow and complaints of left hip pain. Did not move resident from floor. Left leg appeared shortened. Notified [name of physician] and sent resident to [name of hospital] for eval [evaluation] and treatment. A hospital history and physical document, dated 6/20/23, indicated the resident had fallen in her room and sustained a fracture of the neck of the left femur. A fall care plan with start date of 10/10/22, indicated the resident was at risk for falls. An intervention for fall risk with a start date of 6/21/23 indicated, Resident sent to ER [emergency room ) for follow up. The fall care plan included no further fall interventions after the resident's fall on 6/20/23. During an interview on 9/1/23 at 11:50 P.M., the Administrator indicated the fall care plan interventions had not been revised following the resident's fall. On 9/1/23 at 12:20 P.M., the Director of Nursing provided the Fall Prevention Policy and Procedures, dated 5/6/16, and indicated this was the current policy used by the facility. A review of the policy indicated, .it is the responsibility of the interdisciplinary team to document falls prevention, when a fall occurs, and interventions to avoid future falls . and .a member/designee of the interdisciplinary team will assist the team and update the care plan . 3.1-35(d)(2)(B)

Based on observation, interview, and record review, the facility failed to ensure the daily posted nurse staffing sheet had the name of the facility and the actual hours worked by staff for 5 of 5 days of daily posted nurse staffing reviewed. Finding includes: During an observation on 8/29/23 at 11:39 a.m., the daily posted nursing staff sheet lacked the name of the facility or the actual hours worked by staff. On 9/1/23 at 2:46 p.m., the Administrator provided the daily posted nursing staff sheet dated 8/28/23 through 9/1/23. The daily posted nursing staff sheet lacked documentation of the name of the facility or the actual hours worked by staff. During an interview on 9/5/23 at 9:58 a.m., the Corporate Nurse Consultant and Director of Nursing indicated the daily posted nursing lacked the name of the facility and the actual hours worked.

Based on interview and record review, the facility failed to protect the residents right to be free from misappropriation of property for 1 of 1 residents reviewed. A resident's narcotic pain medication and count sheet were unaccounted for. (Resident C, RN 1) Findings include: During an interview on 8/1/23 at 9:50 a.m., the Director of Nursing (DON) and Administrator (ADM) indicated the on 7/23/23, LPN 1 discovered a bottle of Resident C's liquid Dilaudid (a narcotic medication used for pain control) was missing from the medication cart along with the narcotic count sheet. Their investigation discovered RN 1 was working around that time who was administering a significant amount of as needed medication (PRN) and her statements were incriminating. RN 1 was put on suspension during the investigation and later resigned. The Dilaudid was delivered via a shipping partner from a hospice pharmacy while the resident was sent out to inpatient care. Once the resident returned to the facility, the Dilaudid was placed into the medication cart lock box. On 7/31/23 at 11:30 a.m., Resident C's clinical record was reviewed. The diagnoses included, but were not limited to, multiple sclerosis, dementia, chronic pharyngitis (pain or irritation in the throat that can occur with or without swallowing), low back pain, pain in the thoracic spine, chronic pain syndrome, and disease of the gallbladder. A progress note, dated 7/3/23, indicated the resident was having increased pain and had an overall decline in condition. The hospice company ordered lorazepam (an antianxiety medication) 0.5 milligrams twice a day and every 4 hours PRN. The resident's clonazepam (an antianxiety medication) was discontinued during this visit. Further evaluation by the hospice staff indicated he needed to be sent to inpatient hospice care. During an interview on 8/1/23 at 11:30 a.m., the Unit Manager indicated that the LPN 2 was the one who identified the missing bottle of Dilaudid because she normally worked that hall and wondered if the Dilaudid was discontinued because she could not locate the medication nor count sheet. During an interview on 8/1/23 at 12:00 p.m., the ADM and DON indicated the resident's hospice nurse ordered the medication, however, she did not have access to put orders into their electronic medical record. She would have had to tell the floor staff in regard to the medication order. During an interview on 8/1/23 at 12:30 p.m., LPN 2 indicated she received the Dilaudid package from the shipping partner. The medication was in a dark bottle with the resident's name on it. She further indicated she worked on 7/23/23 when the medication was discovered missing. She reached out to staff to see if the medication was discontinued in an attempt to locate the medication. The medication was never found. During an interview on 8/1/23 at 2:51 p.m., the hospice nurse indicated she ordered the liquid Dilaudid for the resident because he did not have optimal pain control. As the day went on, he had a change in condition and he was sent to the inpatient hospice center for pain control. She indicated she filled out an medication order sheet which was given to the floor nurse, but she could not remember who she gave the sheet to. She did not have access to enter medication orders electronically into the resident's chart. During an interview on 8/1/23 at 3:00 p.m., the ADM and DON indicated the facility would no longer allow hospice companies to order medication from a different pharmacy than the facility utilized. The medication nor count sheet were never located. On 8/1/23 at 3:10 p.m., the ADM provided the policy RESIDENT RIGHTS, revised on 1/16/20, and indicated it was the policy currently being used by the facility. A review of the policy indicated, . These rights include the resident's right to: . 3. Freedom from . misappropriation of property . The deficient practice was corrected on 7/25/23 after the facility implemented a systemic plan that included the following actions: in-service related to procedures for narcotic medication counts and ongoing monitoring. 3.1-28(a)

Based on interview and record review, the facility failed to provide supervision to prevent resident to resident behaviors for 1 of 3 residents reviewed. This resulted in a resident sustaining a fracture following a resident to resident altercation. (Resident B, Resident C) Findings include: On 12/21/22 at 11:00 a.m., Resident B's clinical record was reviewed. The diagnoses included, but were not limited to, bipolar disorder, Alzheimer's disease, and restlessness and agitation. The Quarterly MDS (Minimum Data Set) assessment, dated 11/22/22, indicated the resident was not cognitively intact. The resident's care plan indicated, PROBLEM: Problem Start Date: 10/13/22 .edited 12/20/22 . Resident displays behavior of wandering/pacing, ongoing agitation .GOAL: Long Term Goal Target date: 2/22/23 .edited 12/09/22 .Resident will not cause or sustain injuries while wandering qd [every day] thru next review . The resident's care plan indicated, PROBLEM: Problem Start Date: 10/11/22 .edited 12/14/22 .Resident displays behavior of physical aggression, difficult to redirect .GOAL: Long Term Goal Target Date: 2/22/23 .edited 12/9/22 .Resident will not display physically abusive/aggressive behavior towards staff/visitors/residents qd [every day] thru the next review . A nursing progress note, dated 10/4/22 at 7:37 p.m. indicated, Resident approached a male resident in the dining area, began caressing his face and rubbing his shoulders . A nursing progress note, dated 10/6/22 at 11:44 a.m. indicated, .Resident was in the dining room with other residents .resident then walked over to another resident and poured her chocolate milk on the other residents head. Resident then went over to the other drinks that were poured for the other residents and threw them all on the floor. Resident then began to leave dining room .went in and out of other residents rooms and poured their waters on their bedding. Resident attempted to pull another resident out of her recliner. Resident then walked into another residents room and started yelling at her .Resident then left residents room and went into a male residents room and laid in his bed (male resident was in recliner at this time) . A nursing progress note, dated 10/9/22 at 7:34 p.m. indicated, Resident became agitated while in the dining room, grabbed wet floor sign and .tried to swing the sign in the direction of oncoming resident, staff intervened to keep [Resident B] from hitting resident with wet floor sign .Resident grabbed nurses hand tightly refusing to let go . A nursing progress note, dated 10/12/22 at 9:15 a.m. indicated, Resident wandering the unit. Resident seems to be agitated and pacing the unit. Resident went into another residents room and through [threw] breakfast tray onto the floor .Resident continues to get agitated. Unable to redirect with staff . A nursing progress note, dated 10/12/22 at 4:03 p.m. indicated, Resident noted to be wandering in and out of residents rooms. Agitation seems to be increasing .nothing has distracted her from wandering in other residents rooms. PRN [as needed] Haldol 2mg [milligrams] tab was administered at this time . A nursing progress note, dated 10/13/22 at 9:15 a.m. indicated, Resident has been noted to be pacing the unit this am [morning]. Banging on exit door from unit. Resident beginning to wander in and out of residents rooms .could not direct resident to a meaningful activity. PRN [as needed] Haldol 2mg [milligrams] PO [by mouth] administered at this time . A nursing progress note, dated 10/13/22 at 4:55 p.m. indicated, Resident noted to be pacing halls/other residents rooms. Unable to redirect. PRN [as needed] Haldol PO [by mouth] administered . A nursing progress note, dated 11/19/22 at 12:35 p.m. indicated, Resident attempted to enter a female resident's room, when the female resident told her to leave her room, resident smacked female resident in the face with the back of her hand. Resident escorted out of room and one on one supervision initiated . A nursing progress note, dated 11/19/22 at 11:44 p.m. indicated, Resident has been one on one all this shift tonight due to altercation today with other residents. She does not listen and wants to go wherever she wants to go. All you can do is follow her and make sure she is not harming any of the residents. A nursing progress note, dated 11/26/22 at 1:39 p.m. indicated, Displaying some aggressive behaviors in the common area this afternoon, throwing items. Not easily redirected. Very easily annoyed . A nursing progress note, dated 11/29/22 at 4:45 p.m. indicated, CNA [Certified Nurse Aide] witnessed resident having an altercation with another resident . A Social Services progress note, dated 11/30/22 at 9:24 a.m. indicated, Resident involved in altercation with another resident. Order obtained to refer to inpatient psych [psychiatric]for EVAL/TX [evaluation and treatment] . A nursing progress note, dated 11/30/22 at 4:25 p.m. indicated, [Name of] transportation here at this time to transport resident to facility, paperwork sent with resident . A nursing note, dated 12/12/22 at 6:52 p.m. indicated, Resident returned to facility this date. Shortly after return, resident began wandering in and out of residents' rooms. Unable to direct. Other residents becoming very agitated r/t [related to] resident's behavior. Resident was placed on 15-minute checks immediately upon returning to facility r/t [related to] previous incident. Resident unable to sit calmly. Wandering the unit .grabbing at papers and ripping them up, tearing down Christmas decorations on the walls and tree. Resident has been placed on 1:1 r/t [related to] residents uncertain behavior outbursts. On 12/20/22 at 11:45 a.m., Resident C's clinical record was reviewed. The diagnoses included, but were not limited to, dementia, weakness, and cognitive communication deficit. The Quarterly MDS assessment, dated 11/3/22, indicated the resident was not cognitively intact. A nursing progress note, dated 11/29/22 at 4:45 p.m. indicated, QMA [Qualified Medication Aide] notified nurse of fall, nurse assessed resident c/o [complaint of] left sided pain and left wrist pain . A nursing progress note, dated 11/30/22 at 10:15 a.m. indicated, IDT [Interdisciplinary Team] fall review: Resident sustained fall on 11/29/22 while up ad lib [up and about as the resident desires] .was involved in an altercation with other resident on facility dementia unit. At this time, resident is at hospital for treatment . A History and Physical Final Report from the hospital, dated 11/29/22 at 11:41 p.m. indicated, .presents from said living facility after witnessed fall 2011-29-22 [11/29/22] and was brought to the emergency department and has sustained a left aceta [NAME] [sic] fracture [a break in the socket portion of the ball and socket hip joint], left inferior pubic ramus fracture [a break in a bone of the lower left pubis bone in the pelvic region], right superior pubic ramus fracture [a break in a bone of the upper right pubis bone in the pelvic region], and small retropubic hematoma [bruising in the space behind the pubic area] . During an interview on 12/20/22 at 12:10 p.m., Qualified Medication Aide 1 indicated Resident B was unpredictable in her behaviors and frequently required one to one staff supervision. The resident could be pleasant one moment and then become aggressive with no provocation. During an interview on 12/20/22 at 12:30 p.m., the Corporate Nurse Consultant and acting Director of Nursing indicated Resident B was unpredictable in her behaviors and could be verbally aggressive without provocation. Following the altercation between Resident B and Resident C on 11/29/22, the resident was sent to an in-patient psychiatric care facility for evaluation and treatment The resident returned and was currently on 1:1 supervision for safety due to her erratic behaviors. The resident became agitated at being redirected to wear a mask as was required due to high county transmission rate. Following incidents of aggression, the resident was placed on 1:1 supervision for several days until the resident appeared stable and not aggressive. At that point, the resident was placed on 15 minute checks. During an interview Certified Nurse Aide 1 indicated on 11/29/22 around 4:45 p.m., she observed Resident B and Resident C in the hallway next to the dining area on the closed dementia unit. They were waving their arms at each other. Resident B then pushed Resident C to the floor, where Resident C grabbed her left hip and complaining of pain. Resident B had disruptive and aggressive behaviors prior to that incident, and after those behaviors she was placed on 1:1 supervision until her agitation decreased. After 1:1 supervision periods Resident B would be pleasant and not aggressive. Resident B was difficult to redirect and would have unpredictable aggressive behaviors. This Federal tag relates to Complaint IN00395819. 3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure residents were transferred per plan of care with the right amount of assistance for 2 of 6 residents reviewed for accidents. One resident sustained a fractured right shoulder (Resident 98) and another resident sustained injury to an existing wound requiring invasive wound vacuum therapy. (Resident 26) The Immediate Jeopardy began on 6/7/22 when the facility failed to ensure a resident was safely transferred by qualified staff which resulted in the resident experiencing immediate pain and was sent to the hospital where it was discovered the resident sustained right shoulder fracture (Resident 98). On 7/17/22 a resident sustained a fall which resulted in profuse bleeding from an existing wound. The resident then required wound vacuum treatment to heal the opened wound. The Administrator and Director of Nursing were notified of the Immediate Jeopardy on 7/22/22 at 2:00 p.m. The Immediate Jeopardy was removed on 7/23/22 at 4:40 p.m., but noncompliance remained at the lower scope and severity level of isolated, no actual harm but potential for more than minimal harm that is not Immediate Jeopardy. Findings include: 1. During an interview on 7/19/22 at 11:30 A.M., Resident 98 indicated in the early evening of 6/7/22, Certified Nursing Aide (CNA) 1 and CNA 2 were attempting to reposition her in the bed but could not locate the handled pull sheet that was used to reposition her. They attempted to pull her up in bed by getting behind her as she layed in bed, putting their arms under her shoulders, and pulling her up toward the head of the bed. There was a pop in her right shoulder and immediate pain. She was sent to the hospital where she was told she had a fracture in her shoulder area. Her movement was restricted and she had pain in her shoulder and right arm and had to go back to the doctor at some point to see if a sling was all she needed for her fracture. During an interview on 7/21/22 at 11:15 A.M., CNA 1 indicated on the evening of 6/7/22 she and CNA 2 were attempting to reposition the resident higher in the bed. The resident was usually moved in bed by a pull sheet with handles due to her larger size and [CONDITION(S)], but they were unable to access the handles on the pull sheet. They pulled the resident up in the bed by reaching under her arms and pulling her. There was a popping sound from her right shoulder and they reported the incident to the nurse. During an interview on 7/22/22 at 10:15 A.M., Licensed Practical Nurse 1 indicated on 6/7/22 CNA 1 and CNA 2 reported to her they were attempting to reposition Resident 98 in her bed and were not able to access the slip sheet handles, so they pulled her by the arms and there was a pop in the resident's right shoulder. The resident required a slip sheet with handles for bed mobility due to her larger size and [CONDITION(S)]. On 7/20/22 at 11:10 A.M., Resident 98's clinical record was reviewed. The diagnoses included, but were not limited to, morbid severe obesity, anxiety disorder, and [CONDITION(S)] (a medical condition in which the bones become fragile and brittle) with current pathological fracture, unspecified site. The Annual MDS (Minimum Data Set) assessment, dated 3/25/22, indicated the resident was cognitively intact and required extensive assistance of 2 people for bed mobility. A nursing progress note, dated 6/7/22 at 5:14 P.M., indicated, Aides were repositioning resident when her right shoulder popped really loudly and resident was not able to move extremity .pain rated as an eight. DON [Director of Nursing] and NP [Nurse Practitioner] on call notified. Resident sent to [hospital name] for eval [evaluation] and treatment . A Nurse Practitioner's progress note, dated 6/16/22 at 9:59 P.M., indicated, .the patient reported that facility staff were trying to move her up in the bed by picking her up by the shoulders when she heard a loud pop and felt immediate pain in the right shoulder .active medical problems .fracture of humerus: upper end of left humerus, subsequent encounter for fracture with routine healing .past medical history .fracture of upper end of left humerus, subsequent encounter for fracture with routine healing . A radiology record, dated 6/7/22 at 5:29 P.M., indicated, .severely comminuted (a fracture that produces multiple bone splinters) displaced fracture of the right humeral neck in the right humeral head . An Inpatient Discharge Summary, dated 6/14/22 at 11:51 A.M., indicated, .severe comminuted displaced fracture of the right proximal humerus .non-operative treatment recommended at this time with pain control and sling .follow-up . On 7/22/22 at 11:00 A.M., the care plans were reviewed. A care plan, with a start date of 4/19/21 and edit date of 7/21/22 indicated, .requires assistance for bed mobility .assist resident in proper transfer, bed mobility . 2. On 7/18/22 at 3:00 P.M., Resident 26's clinical record was reviewed. The diagnoses included, but were not limited to: [CONDITION(S)] (tissue swelling caused by an accumulation of protein-rich fluid that's usually drained through the body's lymphatic system), postmastectomy [CONDITION(S)] syndrome (a problem that may occur after cancer surgery when lymph nodes are removed), dyspnea ([CONDITION(S)]), difficulty in walking, weakness, [CONDITION(S)] (swelling), pain, anxiety disorder, postviral fatigue syndrome (a disease characterized by profound fatigue, sleep abnormalities, pain, and other symptoms that are made worse by exertion.), and [CONDITION(S)] [CONDITION(S)] (a condition when a rapid, erratic heart rate begins suddenly and then stops on its own). A Quarterly MDS assessment, dated 5/2/22, indicated the resident had moderately impaired cognition and required the extensive assistance of 2 staff members with transfers. A fall event, dated 7/18/22 at 1:57 A.M., indicated the resident sustained a fall while being transferred from her wheelchair. The CNA (Certified Nurse Aide) informed the nurse the resident slipped off of the bed during transfer. The nurse observed the resident sitting on the floor beside her bed. The resident complained of pain to her right arm. Bleeding was observed from an existing wound on her right breast during the assessment. The RN and CNA assisted the resident back into bed and the nurse changed the dressing. The Progress Notes indicated the following: -On 7/18/22 at 2:03 A.M., CNA informed the nurse the resident had slipped off of the bed during transfer. Nurse observed resident sitting on the floor beside her bed. Resident was able to move legs and left arm without discomfort, but did state that her right arm was sore. Bleeding was observed from an existing wound on the right breast during an assessment. The nurse and CNA assisted patient onto the bed. The nurse changed the dressing. -On 7/18/22 at 6:47 A.M., RN 1 monitored the residents vitals and weight. -On 7/18/22 at 6:49 A.M., RN 1 gave medication and no adverse side effects were noted. -On 7/18/22 at 12:35 P.M., RN 2 indicated the resident did not have any pain or discomfort. -On 7/18/22 at 2:09 P.M., the DON (Director of Nursing) indicated the resident fell to the floor while being transferred from wheelchair to the bed by a CNA. The resident landed with only the top half of her body on the bed during initial transfer and the CNA attempted to better position the resident in the bed causing resident to fall to the floor. IDT (interdisciplinary team) recommended to educate staff to use slide board during transfers. -On 7/18/22 at 2:09 P.M., the DON indicated a scab to the right upper chest wound dislodged during the fall and the area continued to bleed. A pressure dressing in place was saturated four times. A new order was received to send the resident to the emergency room for evaluation and treatment. During an interview on 7/20/22 at 11:00 A.M., Resident 26 indicated she sustained a fall, on 7/17/22, which resulted in an injury to an existing upper chest wound. During an observation, at that time, the resident pulled down the neck of her blouse to reveal a pressure dressing in place to her right auxiliary (armpit) region. She had [CONDITION(S)] to her right arm and was observed with a compression wrap on her right arm. She indicated the wound profusely bled and the facility sent her to the emergency department for treatment. The wound opening had immediately caused her a significant amount of pain and bleeding. She requested RN 1 to put a pillow underneath her armpit before she was pulled up off of the floor, however, the staff did not put anything to prevent her wound from further injury. On 7/22/22 at 10:50 A.M., Resident 26's clinical record was reviewed. The progress notes included, but were not limited to: -On 7/18/22 at 3:05 P.M., the resident was sent out of the facility by ambulance and transported to the hospital. -On 7/18/22 at 11:48 P.M., the resident arrived back to the facility. -On 7/22/22 at 12:38 P.M., the wound doctor assessed the resident and ordered a wound VAC(Vacuum-assisted closure of a wound is a type of therapy. The vacuum pump pulls fluid and infection from the wound. This helps pull the edges of the wound together. It also helps the wound heal by promoting the growth of new tissue.) for the right chest wound. -On 7/22/22 at 12:55 P.M., the resident continued to be upset about the fall incident and was worse when her emergency contact was in the facility. A hospital health and physical, dated 7/18/22 at 4:15 P.M., indicated the resident presented to the emergency department with an open right armpit wound secondary to injury that occurred last night. The patient fell from her bed onto the floor after having her right arm pulled with significant force. Nursing home nurses attempted to pack the wound and control the bleeding temporarily, though she had continued bleeding profusely throughout the day. The patient had a chronic right auxiliary wound that required a wound VAC which was removed 4 weeks ago. The scab was busted open in the fall and had been bleeding profusely. The wound was repacked at the hospital before the resident discharged back to the facility. The resident's current July, 2022, physician's orders indicated on 7/18/22, the resident was ordered a sliding board with the assistance of 2 staff members with transferring. On 7/19/22, the resident was ordered an [MEDICATION(S)] and [MEDICATION(S)] (antibiotic medications) for her upper chest wound. On 7/25/22, the resident was ordered a wound VAC to her right chest. An ADL (activities of daily living) care plan, dated 1/24/22 and current through 10/20/22, included an intervention for the resident to be transferred with a gaitbelt and a sliding board with the assistance of 2 staff members. This intervention was not implemented until after Resident 26's fall on 7/17/22. Weekly wound assessment dated [DATE] at 12:23 P.M., indicated the resident's right chest wound size measured 0.6 centimeters in length, by 0.4 centimeters in width, by 0.1 centimeters in depth. The wound's health status was improving. Weekly wound assessment dated [DATE] at 8:50 P.M., indicated the resident's right chest wound size measured 2.7 centimeters in length, by 2 centimeters in width, by 2.4 centimeters in depth. The wound's health status was declining. During an interview on 7/21/22 at 4:03 P.M., CNA 3 indicated she did not get a report sheet, nor report, when she got to the facility; only her assignment for her evening shift. She had an hour left in her shift when the resident asked for help getting out of her wheelchair and into her bed for the night. The CNA asked the resident how she transferred and the resident told her that she could stand and pivot. The resident instructed the aide to count to 3, pulled up on her pants, and slid her from her wheelchair to her bed. The CNA attempted to self transfer the resident and when she counted to 3, the resident did not fully stand, so her bottom came back down into the wheelchair. Together they attempted to get her transferred a second time, and this was when the resident ended up with half of her bottom in the bed and half on the wheelchair seat. The resident began to slide down, so she assisted her to the floor. The CNA went to get RN 1 for help, and upon entry, the RN indicated they could not use the full body dependent mechanical lift since it did not go all the way to the floor. RN 1 indicated they needed to manually lift the resident up off of the floor by pulling underneath the resident's shoulders. At that time, the resident requested the RN place a pillow under her arm due to her wound. No pillow was provided. CNA 3 immediately saw blood on the resident's shirt and it was obvious it was coming from a bandage which she was not aware of the resident having a wound. The aide obtained a clean gown, cleaned her up, and made sure the resident was not hurting. During an interview on 7/22/22 at 10:30 A.M., RN 1 indicated she was working the night when the resident had the fall. CNA 3 came and told her the resident had fallen. When she came into the room, the resident was sitting on her bottom and facing the foot of the bed. RN 1 did not know the full body dependent mechanical lift went all the way down to the ground, so she told the aide to put her foot in front of the resident's feet for traction, lift up under her arms, and push up on her bottom. The RN stood on the resident's right side and the CNA was on the left. Since the bed was in low position, they just slid her over to her bed. The resident initially complained of pain in her right arm while on floor, but did not complain of pain until later in the shift until it was discovered she was bleeding. The nurse repacked the wound, and then a few hours later, the wound was still bleeding. During an interview on 7/22/22 at 10:45 A.M., the resident indicated the wound doctor had assessed her wound and she would need a wound VAC. She indicated she was frustrated she needed to have the wound VAC and the treatment would set her progress back a couple of months. During an interview on 7/22/22 at 10:54 A.M., the resident's wound doctor indicated the resident required a wound VAC due to the fall incident. During an interview on 7/22/22 at 1:37 P.M., the Director of Nursing indicated the wound doctor ordered a wound VAC for the resident which should arrive on Monday, 7/25/22. The facility would utilize wet-to-dry dressing changes until the wound VAC arrived. She indicated therapy ordered the slide board. The facility did not have a policy in regard to resident transfers. During an interview on 7/25/22 at 12:26 P.M., Resident 26 was observed with wound VAC in place on her right chest. The resident indicated she was very depressed with the wound VAC. She demonstrated she could not raise her right arm above her shoulders and the presence of the wound VAC set her progress back at least two months, which was very frustrating to her. The Immediate Jeopardy, that began on 6/7/22, was removed on 7/23/22 when the facility educated and trained staff on the proper assistance levels for resident transfers, ensured policies and procedures were followed, and ensured monitoring was in place, but the noncompliance remained at the lower scope and severity of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy because a systemic plan of correction had not been developed and implemented to prevent recurrence. 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure a urinary drainage bag attached to a Foley catheter F/C (flexible tube which passed through the urethra and into the bladder to drain urine) was positioned off the floor for 1 of 1 resident reviewed during a random observation. (Resident 64) Finding includes: On 7/19/2022 at 3:40 p.m., Resident 64 was observed to be awake in bed. A urinary drainage bag attached to a F/C was observed having touched the floor. On 7/20/2022 at 11:21 a.m., Resident 64 was observed to be up in a wheelchair rolling around on the unit. A urinary drainage bag attached to a F/C was observed having dragged the floor. On 7/20/2022 at 3:28 p.m., Resident 64 was observed to be in bed asleep. A urinary drainage bag attached to a F/C was observed having touched the floor. Resident 64's clinical record was reviewed on 7/22/2022 at 11:00 a.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician orders, dated 6/22/2022 through 7/22/2022, for Resident 64 indicated . May have Foley catheter #20 fr [french]/30 ml [milliliter] secondary to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, initiated on 6/29/2022, and current through 9/30/2022, for Resident 64 indicated: . PROBLEM: Resident has an indwelling urinary catheter . GOAL: Resident will not have complications from indwelling catheter through next review . APPROACH: Do not allow tubing or any part of the drainage system to touch the floor . A review of a urine culture collected on 7/18/2022 and 7/20/2022, indicated Resident 64 had a urinary tract infection. During an interview on 7/21/2022 at 11:59 a.m., Unit Manager 1 indicated the urinary drainage bag should be positioned off the floor. On 7/23/2022 at 2:35 p.m., the Clinical Specialist provided the facility's policy,Catheterizing the Urinary Bladder with an Indwelling Catheter Skills Validations, undated, and indicated it was the policy currently being used by the facility. A review of the policy indicated, . 18. Position the drainage bag below the level of the bladder at the side of the bed. No tubing must touch the floor . 3.1-41(a)(2)

Based on interview and record review, the facility failed to ensure a resident's clinical record was complete with a completed against medical advice form for 1 of 1 resident reviewed for discharge. (Resident B) Finding include: On 7/20/22 at 2:46 p.m., Resident B's closed clinical record was reviewed. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) assessment, dated 6/22/22, indicated Resident B had severe cognitive impairment and no active discharge plan. Resident B's progress notes, dated 7/3/22 at 2:15 p.m., indicated he left against medical advice with son. Resident B's medication were not sent with him. The clinical record lacked any documentation of against medical advice form or any discharge instructions given to Resident B or his son. During an interview on 7/21/22 at 11:08 a.m., the Administrator indicated on 7/3/22 at 2:11 p.m., Resident B left with his family against medical advice. Resident B's son indicated he told the Qualified Medication Aide (QMA) 1 he was discharging Resident B home. QMA 1 did not inform any nurse on duty Resident B was discharging with son. Resident B's against medical advice form was mailed to Resident B's son. During an interview on 7/22/22 at 12:10 p.m., Registered Nurse 2 indicated she was working 6:00 a.m. through 6:00 p.m. on 7/3/22. QMA 1 would report to her, and she did not report Resident B was discharging home with his son against medical advice. On 7/23/22 at 1:46 p.m., the Clinical Specialist indicated they did not have a policy for residents discharging the facility against medical advice. This Federal tag relates to Complaint IN 902. 3.1-50(a)(1)

Based on interview and record review, the facility failed to provide supervision to prevent falls for 1 of 3 residents reviewed for falls. (Resident B) Findings include: On 1/31/22 at 1:15 p.m., Resident B's clinical record was reviewed. The diagnoses included, but were not limited to, status post (s/p) fracture of left hip, dementia, and Alzheimer's disease. The Admission MDS (Minimum Data Set) assessment, dated 12/3/21, indicated Resident B had severe cognitive impairment. On 12/5/21 at 10:30 p.m., Resident B was found on her mattress beside the bed, the intervention was to start a tolieting schedule. On 12/9/21 at 5:00 p.m., Resident B was found sitting in front of her broda chair in the common area, the intervention was to provide tylenol to assist with anxiety. On 12/19/21 at 12:30 p.m., Resident B was noted to have a fall, (no description given), the intervention was for the resident to be referred to Occupational Therapy (OT) for wheelchair positioning. On 12/31/21 at 11:30 p.m., Resident B fell next to the broda chair, the intervention was to remove the broda chair and use a standard wheelchair for correct positioning. On 1/4/22 at 12:50 p.m., Resident B had a fall (no description given), the intervention was to increase activities during daytime hours. On 1/13/22 at 12:40 p.m., Resident B had a fall (no description given), the intervention to place anti-roll backs to wheelchair. On 1/19/22, Resident B was found to be positive for COVID-19 and placed in isolation. During the isolation period, (no date given), at 3:24 a.m., the resident was noted to be on the floor of her restroom. No injury was noted and the intervention was to put in place a soft touch call light in the event Resident B attempted to use the call light. On 1/24/22 at 3:30 a.m., Resident B was found on the bathroom floor, the intervention was to replace the call light with a soft touch call light. A care plan, created on 12/6/21, indicated Resident B was at risk for falling and fall related injuries related to decreased mobility, weakness, and a history of falls. On 1/31/22 at 3:30 p.m., the Administrator provided the facility's fall prevention policy and procedure, dated May 2016. The Administrator indicated the policy was the one currently being used by the facility. A review of the policy indicated the purpose of the policy was to provide residents with the best practices and evidence based approaches to prevent falls and protect residents who are at risk of falling. This Federal tag relates to Complaint IN 589. 3.1-45(a)(2)

Based on interview and record review, the facility failed to prevent staff to resident abuse for 1 of 1 resident reviewed for abuse in a sample of 3. (Resident D). The isolated event, with no actual harm, but had the potential for more than minimal harm began on 6/27/2020, when CNA (Certified Nursing Assistant) 3 responded to a cognitively impaired and combative resident by having gotten on Resident D's bed and forcefully placed his knee on the resident's chest and face. The deficient practice was corrected on 6/28/2020, prior to the start of the survey and was therefore Past Noncompliance. Findings include. On 10/5/2020 at 3:15 p.m., the Administrator provided an Initial Incident Report Form, dated 6/28/2020, regarding Resident D. The report indicated on 6/27/2020 at 11:45 p.m., CNA 4 and CNA 5 were attempting to assist Resident D with changing clothes and linens when Resident D became agitated. CNA 5 then requested CNA 3 to assist with Resident D. CNA 3 approached Resident D's bed on the left side, at which time Resident D hit CNA 3 in his genitals. CNA 3 then jumped up on Resident D's bed and placed his knee on Resident D's face and chest. CNA's present pulled CNA 3 off of Resident D and removed him from the room and reported the incident to their unit manager. On 10/5/2020 at 3:15 p.m., the Administrator provided a Follow-Up report, dated 6/28/2020, which indicated on 6/27/2020 at approximately 11:45 p.m. Resident D became combative during care and CNA 3 was witnessed jumping onto Resident D's bed, and placing their knee on Resident D's chest and face after Resident D kicked them in the genitals. CNA 3 was immediately removed from the resident's room. Administrator was notified immediately. CNA 3 was suspended immediately and removed from the schedule. A written statement sent via e-mail by CNA 3, dated 6/29/2020 at 10:05 a.m., indicated, I was assigned to D hall from 2:00 p.m. to 6:00 a.m. As I was working a CNA . requested my assistance with a difficult patient on the dementia unit. As I made my way with both CNA's admitted they were unable to get the patient changed due to him being combative. As I was preparing to assist to help putting my gloves on and the patient immediately began to berate the CNA's as we entered, he verbally assaulted me an 'a--h---' then with feces and his hand physically assaulted me with a fist to my crotch. I simply restrained the patient physically so the aides were able to change . A written statement by CNA 5, dated 6/28/2020 at 12:15 a.m., indicated CNA's 3, 4, and 5, went into Resident D's room to change the resident. CNA 3 walked up to Resident D's bed and Resident D hit CNA 3. I saw CNA 3's knee on Resident D. Myself and CNA 4 removed CNA 3's knee from Resident D's face. A written statement by CNA 4, dated 6/28/2020 at 12:15 a.m., indicated, they had asked CNA 3 to come and assist with Resident D. CNA 3 came up to the bed and Resident D hit CNA 3 in his private parts. CNA 3 then jumped up and put their knee on his chest. A written statement by LPN (Licensed Practical Nurse) 2, dated 6/27/2020 (no time given), indicated CNA 4 and 5 told her CNA 3 was attempting to provide care and Resident D punched CNA 3 in his private parts and CNA 3 forcefully placed his knee on Resident D's chest and face to hold him down. CNA 3 was asked to leave the room and I notified on the on call manager, the DON. The DON advised me to escort CNA 3 from the building. A interview with the ADON (Assistant Director of Nursing) on 10/6/2020 at 1:30 p.m., indicated having reviewed the statements given by the staff, all written statements were exactly what each staff member had told her. An incident narrative completed by a Patrolman of the Nashville Police Department, created date 07/07/2020 at 10:32 a.m., indicated, On June 29th I, (Patrolman) of the Nashville Police Department received witnessed statements regarding a battery incident. The incident involved a Certified Nursing Assistant (CNA) and a resident at Brown County Health and Living. There are a total of witness statements that summarizes what had occurred there on June 27, 2020. According to all of the statements provided, the CNA who is in question is (Name CNA 3 and DOB (date of birth)). The victim (Name Resident D), who is a resident of Brown County Health and Living. (Name Resident D) was receiving care from (Name CNA 3) when (Name Resident D) punched (Name CNA 3) in the groin area. Which then (Name CNA 3) then forcefully placed his knee on (Name Resident D's) chest and face to hold him down. At which point the other two CNA's (Name CNA 4 and DOB) and (Name CNA 5 and DOB) who was also in the room told (Name CNA 3) to stop and leave the room. After, the incident occurred the manager and administrator were notified. When all the administrators was made aware of the situation (Name CNA 3's) employment was terminated. The clinical record of Resident D was reviewed on 10/05/2020 at 2:00 p.m. [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment, dated 7/28/2020, indicated the resident had severe impairment and required extensive assistance from staff for activities of daily living care. On 10/05/2020 at 11:00 a.m., the Administrator provided the current facility policy on Abuse, Neglect, and Misappropriation Prohibition and Prevention Policy, revised date 6/4/2020. A review of the policy indicated, Physical abuse is defined as hitting, slapping, pinching kicking, etc. it also includes controlling behavior through corporal punishment. Review, on 10/5/2020 at 11:00 a.m., of CNA 3's facility's employee discipline form, dated 6/27/2020, indicated CNA 3 was suspended immediately following an incident on 6/27/2020 and would remain suspended until investigation was completed. Staff member (CNA 3) was advised not to be on the premises during their suspension. Review, on 10/5/2020 at 11:00 a.m., of the follow up employee discipline form for CNA 3, dated 6/29/2020, indicated CNA 3's employment was terminated due to violation of resident rights/abuse during personal care. The Past Noncompliance isolated event, with no actual harm, but had the potential for more than minimal harm began on 6/27/2020. The deficient practice was removed and corrected by 6/28/2020, after the facility implemented a systemic plan the included the following actions: Termination of employment for CNA 3. Re-education to all staff regarding dementia care and responding to difficult situations, re-education to all staff on abuse, re-education to all staff on residents' rights. Monitoring of staff through the facility's Quality Assurance and Performance improvement Program to ensure compliance of residents' right to be free from abuse. This Federal tag relates to Complaint IN 458. 3.1-27(b)

Based on interview and record review, the facility failed to ensure a care plan intervention was implemented for a resident who refused repositioning care for 1 of 3 residents reviewed for pressure ulcer care plans. (Resident B) Findings include: Resident B's clinical record was reviewed on 8/17/2020 at 2:00 p.m. [DIAGNOSES REDACTED]. A current care plan, initiated on 6/20/2020, for Resident B indicated: PROBLEM: . Resident resists care . T&R (turning and repositioning) . lowering head of bed to provide care . GOAL: (Resident name) will have his right to refuse honored QD (every day) . APPROACH: Explain the disease process and consequences of refusal . Review of Nursing Progress Notes for Resident B indicated the following: - 6/9/2020 at 3:09 p.m. non-compliance with turning/repositioning . - 6/9/2020 at 4:42 a.m. Skin assessment completed: pressure ulcer noted per left inner buttock; L (length) 1.5 cm, W (width) 1 cm (centimeter) ; D (depth) 0.2 cm; skin surrounding site is red with purplish areas; foam gauze dressing applied; unable to reposition off left buttock due to increased pain per LLE (left lower extremity) and left hip . -6/13/2020 at 2:22 a.m. discomfort noted with positioning. Doesn't like to turn. Doesn't want staff to lower his head so that he can be turned . -6/14/2020 at 2:13 p.m. discomfort noted with positioning. Doesn't like to turn. Doesn't want staff to lower his head so that he can be turned . The clinical record for Resident B lacked documentation of education being provided, for the refusal of turning and repositioning to relive pressure off the sacral region, as indicated in the care plan approach. A resident progress note provided by administrative staff, dated 7/2/2020 at 11:17 a.m. (4 weeks after on-set of pressure ulcer), indicated Wound to coccyx/sacral area continues to decline . Resident continues to refuse to be repositioned off of area despite staff encouragement and patient education The note lacked documentation of encouragement and patient education that had been provided. Interview, on 8/18/2020 at 3:20 p.m., the Director of Nursing (DON) indicated there was no additional documentation in the clinical record to indicate Resident B was educated on the consequences of refusing to turn and reposition to relieve pressure off of the sacral region. On 8/18/2020 at 3:30 p.m., the DON indicated the facility did not have a policy on following care plans. They follow the RAI Manual. The Resident Assessment Instrument (RAI) Manual, effective October, 2019, indicated, . e. Implementation . putting that course of action (specific interventions derived through interdisciplinary individualized care planning into motion by staff knowledgeable about the resident's care goals and approaches; carrying out the (how) and (when) of resident care. This Federal tag relates to Complaint IN 486. 3.1-35(g)(2)

Based on observation, interview, and record review, the facility failed to ensure the safe transfer of a resident resulting in a fall with [MEDICAL CONDITION] (Resident 43) and the facility failed to implement a care plan interventions for a resident with a history of falls (Resident 37) for 2 of 5 residents reviewed for accidents. Findings include: 1. On 10/23/19 at 10:00 [NAME]M., Resident 43's clinical record was reviewed. [DIAGNOSES REDACTED]. The Minimum Data Set assessment (MDS) quarterly review, dated 6/6/19, indicated the resident required extensive assistance of two people for transfers from bed to wheelchair. The Physical Therapy Plan of Care Evaluation, dated 6/4/19, indicated the resident required maximum assistance of 2 people for transfers from bed to chair. On 10/25/19 at 12:40 P.M., the Director of Nursing provided the resident's care plan and indicated this was the current care plan for Resident 43 used by facility staff. A review of the care plan indicated a problem start date of 12/2/19, edited date of 8/21/19, which indicated, .impaired mobility transfers with VC (vocal cues) and assist of one surface to surface ., and an approach start date of 12/2/19, edited date of 4/15/16, which indicated, .Transfer training transfer surface to surface with VC and extensive assist of one . Interview, on 10/25/19 at 2:53 P.M., the Director of Nursing indicated the care plan had not been updated to include the correct number of people (two) required to transfer the resident from surface to surface. A review of the resident's nursing progress notes indicated the following: -7/27/19, 4:30 P.M., .Aide was getting resident up for supper and was not able to complete transfer to wheelchair. Resident was slowly lowered to the floor. ROM (range of motion) was within normal limits. No complaints of pain or discomfort at this time . -7/28/19, 5:35 P.M., .During routine patient care res (resident) expressed pain to right hip area. Guarding when RLE (right lower extremity) manipulated or touched Spoke with on-call NP (nurse practitioner) who gave order for right hip and pelvis x-ray . -7/28/19, 10:22 [NAME]M., .resident x-ray returned resident has a relatively acute minimally displaced supracondylar [MEDICAL CONDITION] right femur. NP (nurse practitioner) and family notified . -7/28/19, 10:56 [NAME]M., .Resident sent to IU (Indiana University) hospital for eval and treatment of [REDACTED]. -7/28/19, 10:01 P.M., .Resident returned from IU (Indiana University) Health Resident to resume all meds and orders. Resident to wear knee immobilizer for transfer for the next 4-6 weeks . Interview, on 10/24/19 at 12:35 P.M., Certified Nursing Aide (CNA) 2 indicated on 7/27/19, around 4:30 P.M., she was transferring the resident by herself from her bed to her wheelchair and could not get the resident all the way to the chair. She lowered the resident to the floor and called for another staff member to assist her. Interview, on 10/25/19 at 2:53 P.M., the Director of Nursing indicated the number of staff required to transfer a resident from bed to wheelchair was determined by the Physical Therapy evaluation. 2. On 10/21/19 at 10:25 a.m., Resident 37 was resting in her recliner. Her rolling walker was at the bedside. No bright colored tape was observed on the walker handles. On 10/23/19 at 10:00 a.m., Resident 37 was observed to be resting in bed. Her recliner was observed not to have Dycem (non slip product) in the seat of the recliner. On 10/24/19 at 3:22 p.m., Resident 37 was observed to be resting in bed. Her recliner was observed not to have Dycem in the seat of the recliner. Her rolling walker was observed not to have bright colored tape on the walker handles. On 10/24/19 at 3:30 p.m., Resident 37's clinical record was reviewed. [DIAGNOSES REDACTED]. An Interdisciplinary Team (IDT) Note, dated 9/4/19 at 9:45 a.m., indicated Resident 37 was noted to be ambulating in the hallway without the use of her walker. The nurse went to get Resident 37's walker. Resident 37 decided to sit and then lay on the ground. The intervention was to apply bright colored tape to the rolling walker handles to encourage, to remind, and to use her rolling walker during ambulation and transfers. A care plan, initiated on 4/17/18, and current through 10/12/19, for Resident 37 indicated: PROBLEM: .Resident at risk for falling and fall related injuries related to WEAKNESS, UNSTEADY BALANCE DEMENTIA, USE OF ANTIDEPRESSANT (medication to treat depression) AND ANXIOLYTIC (medication to treat anxiety) .GOAL: Will minimize risk for injuries RELATED TO FALLS DAILY THRU NEXT REVIEW .APPROACH: .bright colored tape to walker handles .Dycem to recliner . On 10/24/19 at 10:01 a.m., Licensed Practical Nurse (LPN) 1 indicated some of Resident 37's fall interventions were to remind her to use her rolling walker. LPN 1 did not indicated fall interventions of Dycem in recliner or bright colored tape to rolling walker. On 10/25/19 at 10:20 a.m., the Unit Manager (UM) indicated some of Resident 37's fall interventions were to use bright colored tape to her walker handles and to have Dycem in the seat of her recliner. On 10/25/19 at 10:28 a.m., Resident 37's rolling walker and recliner were observed with UM. The UM could not locate Dycem in recliner or in any drawer in Resident 37's room The UM indicated the rolling walker had no bright colored tape to the handles. On 10/25/19 at 1:15 p.m., the Director of Nursing (DON) provided the facility's policy, Fall Prevention Policy and Procedure, undated, and indicated it was the policy currently being used by the facility. A review of the policy indicated, .Care plans are a vital part of the nursing process and serve as an individualized pathway used by all care givers . 3.1-45(a)(2)

Based on observation, interview, and record review, the failed to identify and respond to an assessed weight loss and failed to implement interventions for a dependent resident with weight loss which resulted in additional severe weight loss for 1 of 4 residents reviewed for weight loss. (Resident 85) Findings include: Meal times for the assisted dining room, provided by the Administrator, on (MONTH) 20, 2019, indicated meal service for lunch was at 12:00 p.m. and for dinner was at 5:30 p.m. On 10/24/19 at 12:11 p.m., Resident 85 was seated in the assisted dining room for lunch. At 12:30 p.m., the resident was observed to scoop small amounts of rice onto a fork and take small bites. The resident was observed to poke the chicken a few times and then set the fork down without eating. From service time, 12:15 to 12:55 p.m., staff were observed to not assist nor cue Resident 85 with food intake. Less than 10 percent of the meal had been eaten. At 12:55 p.m. (40 minutes after meal service), CNA 1 was observed to cut up the resident's chicken and offer a bite to eat. The resident took multiple bites of food when CNA 1 brought the food to her mouth. On 10/24/19 at 5:25 p.m., Resident 85 was seated in the assisted dining room for dinner. At 5:45 p.m., RN 1 was observed to cut up the resident's hamburger and hand the resident one half of the sandwich. The resident held the sandwich for some time and took one bite, after being cued by staff. At 6:16 p.m. (46 minutes after meal service), RN 2 sat down with the resident and began to assist her with food intake. The resident took multiple bites of food when RN 2 brought the food to her mouth. Interview, on 10/24/19 at 6:21 p.m., RN 1 indicated the resident has had an overall decline, she did look at her plate for long periods of time, and she will feed herself. However, she loves sweets so she'll (RN 1) offer the sweets first. RN 1 did not indicate a need for staff to cue and/or assist Resident 85 with food intake during meals. On 10/25/19 at 12:17 p.m., Resident 85 was seated in the assisted dining room. From 12:25 p.m. to 1:16 p.m. (49 minutes after food service), the resident was observed to stare at her food without eating. Less than 10 percent of the meal had been eaten. At 1:16 p.m., RN 1 was observed to sit next to Resident 85 and offer her bites of food. The resident took multiple bites of food when RN 1 brought the food to her mouth. Interview, at that time, RN 1 indicated the resident did ok when staff fed her. On 10/23/19 at 12:04 p.m., Resident 85's clinical record was reviewed. [DIAGNOSES REDACTED]. A care plan, initiated on 2/18/19 and current through 1/14/20, for Resident 85 indicated: PROBLEM: . Resident is at nutritional risk related to: DX (diagnoses) dysphagia, [MEDICAL CONDITIONS],[MEDICAL CONDITION](hypertension), h/o (history of) weight decline, receives therapeutic diet, sig (significant) weight gain noted. GOAL: Resident will intake 76% or more of meals and weight will remain within 5# (pounds) of 125# . APPROACH: . MED PASS PER ORDER . Resident 85's weights indicated the following: -On 4/3/19 the resident weighed 132.9 pounds. -On 5/2/19 the resident weighed 134 pounds. -On 6/11/19 the resident weighed 134.6 pounds. -On 7/8/18 the resident weighed 134.6 pounds. -On 8/5/19 the resident weighed 135 pounds. -On 9/18/19 the resident weighed 126.6 pounds. This was an assessed 8.4 #, 6.2% weight loss from (MONTH) 5, 2019. The clinical record lacked documentation that indicated staff had identified and implemented interventions in regard to the assessed weight loss, to prevent further weight loss. -On 10/10/19 the resident weighed 108.4 pounds. This was an assessed 18.43% severe weight loss in 6 months and 14.38% severe weight loss in one month. Resident 85's quarterly MDS (Minimum Data Set) assessment, dated 10/14/19, indicated the resident was severely cognitively impaired and required extensive assistance of one staff member with eating. Section K indicated, . Weight loss . Loss of 5% of more in the last month or loss of 10% or more in the last 6 months . No . Interview, on 10/25/19 at 2:53 p.m., the MDS Coordinator indicated Resident 85's MDS assessment was coded incorrectly, should have been coded, yes. Resident 85's Nutritional Assessment Short Form, dated 10/15/19 at 7:12 a.m., indicated, No, for weight loss of 5% in last month and 10% in last 6 months. The assessment did not identify the assessed severe weight loss. Forty-three days after an assessed 6.2% weight loss and seven days after the assessed severe weight loss Resident 85's progress note, dated 10/17/19 at 11:32 a.m., indicated, Nutrition: CBW (current body weight) 108.4# (pounds), which shows an 18# (14.4%) wt loss in 22 days. Res is now w/ a decline in condition . Current nutrition interventions: fortified foods w/ (with) meals, Medpass (nutritional supplement) 120 ml BID (twice a day) . Currently, res (resident) refuses Medpass nearly 100% of the time. Recommend to d/c (discontinue) Medpass d/t (due to) refusals. Continue w/ fortified foods, and add Magic Cups (nutritional supplement) BID between meals for extra kcal (calories) r/t (related to) wt loss and extra protein r/t wound. Res is w/ a decline however, and is (number of years old), so is at greater risk for wt loss. Will monitor. The care plan, dated 2/18/19 to 1/14/19, lacked updated approaches following the assessed weight loss, the discontinuation of Med Pass and addition of the Magic Cup supplement. The care plan lacked interventions in regard for staff to provide cueing and/or meal assistance to ensure food intake. Resident 85's, October, 2019, MAR (Medication Administration Record) indicated the following: -On 3/22/17 the resident was ordered Med Pass between meals. The resident refused the supplement 23 times between 10/1/19 to 10/18/19. The clinical record lacked documentation of communication with a physician or dietary staff in regard to refusals. The Med Pass was discontinued on 10/18/19 (18 days after the Med Pass was started). The clinical record lacked documentation of assessment as to why the Med Pass had been refused. -On 10/18/19 the resident was ordered Magic Cup BID (2 times a day) between meals. The resident refused the supplement 11 times from 10/19/15 to 10/25/19. The clinical record lacked documentation of communication with a physician or dietary staff in regard to refusals. The clinical record lacked documentation of assessment to determine why the Magic Cup had been refused. The clinical record lacked documentation for assessment of, or implementation of, other nutritional supplements after the discontinuation of the Med Pass and Magic cup. Resident 85's dietary profile report, non-dated and identified as current by the Assistant Regional Dietary Consult, indicated no assessment was completed in regard to the resident's dietary preferences. Interview, on 10/25/19 at 1:25 p.m., the Assistant Regional Dietary Consultant indicated the facility had not assessed Resident 85's likes and/or dislikes related to food preferences, which would have been documented on the dietary profile report. Interview, on 10/25/19 at 12:46 p.m., the Director of Nursing indicated Resident 85 should have been immediately re-weighed with that great of a weight loss and she should have been notified of the resident's weight loss. If she had been notified the resident would have been placed on weekly weights. On 10/25/19 at 1:15 p.m., the Director of Nursing provided the facility's policy, Weight Management Policy, undated, and indicated it was the policy currently being used by the facility. A review of the policy indicated, . Re-weigh policy: If the resident weighs 100 lbs (pounds) or less and there is a weight change from the previous weight of +/- 3 lbs. then he/she will be re-weighed . Significant weight change is defined as: 5% loss/gain in 30 days . Significant weight loss/gain protocol . IDT will meet weekly on residents with significant weight changes to evaluate the current interventions and make changes as necessary to stabilize the resident and attain the care plan goal . weekly weight monitoring . Initiate or update care plan . 3.1-46(a)(1)

Based on interview and record review, the facility failed to accurately code a Quarterly Minimum Data Set (MDS) assessment for a resident with significant weight loss for 1 of 28 residents reviewed for MDS accuracy. (Resident 85) Findings include: On 10/23/19 at 12:04 p.m., Resident 85's clinical record was reviewed. [DIAGNOSES REDACTED]. A review of Resident 85's weights indicated the following: On 4/3/19 the resident weighed 132.9 pounds. On 9/18/19 the resident weighed 126.6 pounds. On 10/10/19 the resident weighed 108.4 pounds. This is an assessed 18.43% weight loss in 6 months and 14.38% weight loss in one month. A review of Resident 85's Quarterly MDS assessment, dated 10/14/19, indicated, . Weight loss . Loss of 5% of more in the last month or loss of 10% or more in the last 6 months . No . Interview, on 10/25/19 at 2:53 p.m., the MDS Coordinator indicated Resident 85's MDS assessment was coded incorrectly, should have been coded yes, and she would do a modification to correct the weight loss discrepancy. 3.1-31(d)

Based on record review and interview, the facility failed to update the care plan to include the number of people required to transfer a resident from bed to wheelchair for a resident at risk for falls for 1 of 2 residents reviewed for care revision. (Resident 43) Findings include: On 10/23/19 at 10:00 [NAME]M., Resident 43's clinical record was reviewed. [DIAGNOSES REDACTED]. The Physical Therapy Plan of Care Evaluation, dated 6/4/19, indicated the resident required maximum assistance of 2 people for transfers from bed to chair. The Minimum Data Set assessment (MDS) quarterly review, dated 6/6/19, indicated the resident required extensive assistance of two people for transfers from bed to wheelchair. On 10/25/19 at 12:40 P.M., the Director of Nursing provided the resident's care plan and indicated this was the current care plan for Resident 43 used by facility staff. A review of the care plan indicated a problem start date of 12/2/19, edited date of 8/21/19 which indicated, .impaired mobility transfers with VC (vocal cues) and assist of one surface to surface ., and an approach start date of 12/2/19, edited date of 4/15/16 which indicated, .Transfer training transfer surface to surface with VC and extensive assist of one . Interview, on 10/25/19 at 2:53 P.M., the Director of Nursing indicated the care plan had not been updated to include the correct number of people (two) required to transfer the resident from surface to surface. 3.1-35(d)(2)(B)

Based on interview and record review, the facility failed to ensure a resident was free from abuse for 1 of 1 resident reviewed for abuse (Resident B). Findings include: Resident B's clinical record was reviewed on 1/8/19 at 11:00 a.m. [DIAGNOSES REDACTED]. The Admission Minimum Data Set assessment, completed on 12/10/2018, indicated Resident B was not interviewable and was severely cognitively impaired. A review of Resident B's progress notes indicated the following: Nurses note, on 12/19/18 at 2:21 p.m., CNA (certified nursing assistant) was walking past another residents room and saw (Resident B's name) laying in other resident's bed and other resident was hitting (Resident B's name) in the face saying give me money. Staff immediately intervened and separated the residents removing (Resident B's name) from the room . Redness noted to left side of face, left chest, and left ABD (abdomen). Physician note, on 12/19/18 at 2:37 p.m., This is a brief note. Another resident found him in his bed and hit him twice once on the face and the other on his L (left) ribs. He has some swelling of L infraorbit (below the eye) and [DIAGNOSES REDACTED] (redness) over L ribs. Nurse is applying ice. The other resident will be sent out for psych (psychological) evaluation . Checking orbit (eye) and rib xrays. Nursing note, 12/20/19 at 12:17 a.m., (Radiology company name) radiology tech (technician) here to obtain xrays of res' (resident's) facial, orbital (eye) and left rib areas following the earlier altercation with another res. Noted some swelling to left side of face. Res continues to wander throughout unit, in and out of other res rooms. Easily redirected although brief . Nursing note, 12/24/18 at 7:42 a.m., No reports of any distress r/t (related to) event, continues to wander. Resident C's clinical record was reviewed on 1/8/19 at 11:30 a.m. [DIAGNOSES REDACTED]. The Annual Minimum Data Set assessment, completed on 12/10/2018, indicated Resident C was not interviewable and was severely cognitively impaired. A review of Resident C's progress notes indicated the following: Nursing note, 12/19/18 at 2:38 p.m., As CNA was walking pass residents room saw (Resident C's name) leaned over his bed and she entered his room she found another resident in his bed and witnessed (Resident C's name) hit the other resident and was telling him to give his money back. CNA immediately intervened separating residents and removing other resident from (Resident C's name) room. Staff member stayed with (Resident C's name) for 1:1 (one-on-one) care. Social Services notes, 12/19/18 at 3:05 p.m., Writer was informed that (Resident C's name) physically assaulted another resident. Writer called (name) at VA (veterans administration), she states to send to VA ER (emergency room ) for eval/tx (evaluation/treatment) . Met with (Resident C's name) and explained to him that he needed to go to VA ER for evaluation and he stated, 'ok by me' . 1:1 at this time . A review of Resident C's care plans indicated the following: A care plan, initiated on 9/16/2018 and current through 3/10/19, for Resident C indicated, Category: Behavioral Symptoms. #9 Resident displays socially inappropriate behavior of CURSING . A care plan, initiated on 9/16/2018 and current through 3/10/19, for Resident C indicated, Category: Behavioral Symptoms. #9B Resident displays behavior of being verbally abusive/aggressive WITH STAFF . A care plan, initiated on 9/16/2018 and current through 3/10/19, for Resident C indicated, Category: Behavioral Symptoms. #9C Resident behavior of INTRUSIVE wandering (INTO OTHER ROOMS) AND EXIT SEEKING . A care plan, initiated on 9/16/2018 and current through 3/10/19, for Resident C indicated, Category: Behavioral Symptoms. #9E Resident displays behavior of physical abuse/aggression TOWARDS STAFF WITH REDIRECTION . During an interview, on 1/8/19 at 12:56 p.m., CNA 1 indicated Resident B was laying in Resident C's bed and Resident C was witnessed to punch Resident B in the face one time, however, she heard what sounded like another hit before she entered the room. She indicated Resident B's constantly wandered in and out of residents' rooms, but he is easily redirected. Resident C liked to stick to his routine and was very protective of his space. During an interview, on 1/8/19 at 2:38 p.m., LPN 1 indicated she was called into Resident C's room and observed Resident B in Resident C's bed, and Resident C said something about Resident B stealing from him. She removed Resident B from the room and assessed him to have redness and swelling to the left side of his face. On 1/8/19 at 3:30 p.m., the Director of Nursing provided the facility policy, Abuse policy, updated August, (YEAR), and indicated it was the policy currently being used. A review of the policy indicated, It is the policy of (Corporation Name) to provide each resident with an environment that is free from verbal . physical, and mental abuse . d. physical abuse is define as hitting, slapping . On 1/8/19 at 3:30 p.m., the Administrator provided the facility policy, Resident Rights, dated 11/28/16, and indicated it was the policy currently being used. A review of the policy indicated, (a) Resident rights . (1) . The facility must protect and promote the rights of the residents . Resident behavior and facility practices . (b) Abuse. The resident has the right to be free from . physical, and mental abuse . This Federal tag relates to Complaint IN 298. 3.1-27(a)(1)

Based on observation, interview, and record review, the facility failed to ensure 1 of 1 medication cart was locked while unattended for 1 of 1 random observation. This had the potential to effect 25 of 25 cognitively impaired residents who reside on the secure dementia unit of 105 residents who reside in the facility. Findings include: On 10/24/18, from 10:45 A.M. until 11:15 A.M., the medication cart in the hallway, across from rooms [ROOM NUMBERS], on the secure dementia unit, was observed to be unlocked and unattended. No fewer than 10 residents were sitting in the adjacent dining and activity area. One resident was observed to walk to the cart and stand by it. Inside the cart were medications for 25 residents residents who reside on the secure dementia unit. During an interview, on 10/24/18 at 11:16 A,M,, Licensed Practical Nurse 1 indicated the medication cart was not locked and should have been locked while unattended. Facility census, provided by facility staff, dated 10/24/18, indicated 25 cognitively impaired residents resided on the dementia unit. On 10/30/18 at 2:10 P.M., the Director of Nursing provided the policy, Security of Medication Cart, revised date (MONTH) 2007, and indicated this was the current policy used by the facility. A review of the policy indicated, when the medication cart is not being used, it must be locked . 3.1-45(a)(1)

Based on observation, interview, and record review, the facility failed to keep the Foley catheter (flexible tube which passed through the urethra and into the bladder to drain urine) drainage bag from touching the floor for 1 of 1 resident reviewed for urinary catheter (Resident 50). Findings include: On 10/25/18 at 1:51 p.m., Resident 50 was observed to be resting in a low bed with the Foley catheter drainage bag resting on the floor. At that time, Resident 50 indicated he was not feeling well, and he was being treated for [REDACTED]. On 10/26/18 at 10:39 a.m., Resident 50 was observed to be resting in a low bed with the Foley catheter drainage bag resting on the the floor. On 10/29/18 at 1:37 p.m., Resident 50's clinical record was reviewed. The [DIAGNOSES REDACTED]. Resident 50's Physician Order, dated 9/30/18-10/30/18, indicated the following: -tamsulosin (medication to treat [MEDICAL CONDITION]) 0.4 milligrams (mg) capsule by mouth once a day (start date 8/22/18). -[MEDICATION NAME] chloride (medication to treat overactive bladder) 5 mg tablet (1/2 tablet) by mouth twice a day (start date 10/10/18). -Change urinary catheter and drainage bag every 2 weeks (start date 8/20/18). -May have Foley catheter 18 fringe (FR) with a 30 cubic centimeter (CC) bulb secondary to [DIAGNOSES REDACTED]. -Foley catheter flush with 120 milliliter (ML) of sterile water every shift (start date 10/9/18). Resident 50's Urine Culture Reports indicated the following: -On 7/25/18, moderate amount of bacteria in the urine which indicated Resident 50 had an UTI. -On 9/3/18, many amount of bacteria in the urine which indicated Resident 50 had an UTI. -On 9/24/18, moderate amount of bacteria in the urine which indicated Resident 50 had an UTI. -On 10/19/18, few amount of bacteria in the urine which indicated Resident 50 had an UTI. Resident 50's Change in Condition Event Reports indicated the following: -On 7/31/18 at 1:27 p.m., Resident 50 had an UTI and the intervention was [MEDICATION NAME] (antibiotic) 500 mg twice a day times 10 days. -On 9/7/18 at 11:53 a.m., Resident 50 had an UTI with urinating frequently and more urgently. The intervention was Keflex (antibiotic) 500 mg twice a day for 10 days. -On 9/27/18 at 1:25 a.m., Resident 50 had an UTI with painful urination. The interventions were catheter care, fluids, and [MEDICATION NAME] (antibiotic) 500 twice a day for 10 days. -On 10/21/18 at 4:48 p.m., Resident 50 had an UTI with increased confusion and new or worsening behavioral symptoms. The intervention was [MEDICATION NAME] (antibiotic) 875 mg by mouth twice a day for 7 days. A care plan, initiated on 7/1/18 and current through target date of 11/28/18, for Resident 50 indicated: PROBLEM: Resident has an indwelling urinary catheter r/t (related to) [MEDICAL CONDITION] bladder .GOAL .Resident will not have complications from catheter through next review .APPROACH .Do not allow tubing or any part of the drainage system to touch the floor .Keep catheter bag below level of the bladder and off the floor . During an interview, on 10/30/18 at 1:28 p.m., Certified Nursing Assistant (CNA) 1 indicated Resident 50 had an UTI. Resident 50 required assistance with the Foley catheter care such as moving the Foley catheter drainage bag from the wheelchair to the bed and from the bed to the wheelchair. CNA 1 indicated the Foley catheter drainage bag should not touch the floor while in a low bed. During an interview, on 10/30/18 at 2:30 p.m., the Director of Nursing (DON) indicated Resident 50 was prone to urinary tract infections due to his [DIAGNOSES REDACTED]. Resident 50 has had numerous admissions to the facility because of urinary tract infections. On 10/30/18 at 3:35 p.m., the DON provided the facility's policy, Catheter Care, Urinary, undated, and indicated it was the policy currently being used by the facility. A review of the policy indicated, The purpose of this procedure is to prevent infection of the resident's urinary tract .11. Be sure the catheter tubing and drainage bag are kept off the floor . 3.1-41(a)(2)

Based on observation, interview, and record review, the facility failed to ensure staff maintained transfer devices in a clean and sanitary condition for 2 of 2 random observations. Findings include: On 10/25/18 at 10:15 a.m., the sit-to-stand (helps patient go from a sit to stand position) lifts on the D and E hall were observed to have leg straps which were covered in a mixture of dirt, hair, and dust. There was 1 lift unit observed on the D hall and 1 lift unit observed on the E hall. On 10/26/18 at 2:25 p.m., the sit-to-stand lifts on the D and E hall were observed to have leg straps which were covered in a mixture of fuzz, hair, and dust. On 10/30/18 at 1:20 p.m., the sit-to-stand lifts on the D and E hall were observed to have leg straps which were covered in a mixture of fuzz, hair, and dust. On 10/30/18 at 1:30 p.m., the Director of Nursing indicated the night shift nursing staff is responsible for cleaning the transfer devices and she did not deny they were dirty. On 9/28/18 at 2:30 p.m., the Director of Nursing provided the facility's Admission Packet which included Resident Rights, undated, and indicated it was the policy currently being used. A review of the policy indicated, (i) Safe environment. The resident has a right to a safe, clean, comfortable and homelike environment . 3.1-19(f)(5)

Based on observation, interview, and record review, the facility failed to provide a clean drinking system for 1 of 40 residents reviewed for clean care equipment (Resident 7) and the facility failed to ensure staff repaired damaged walls, repaired a dented baseboard heater, removed unused window treatment hardware, and provided an odor free environment for residents' rooms observed during environmental observation. (Resident 12, Resident 19, Resident 25, Resident 27, Resident 34, Resident 36, Resident 40, Resident 41, Resident 49, Resident 80, Resident 81, Resident 91 Resident 97, Resident 98, Resident 117, and Resident 126). Findings include: 1.) On 10/02/2017 at 11:23 a.m., Resident 7's [MEDICATION NAME] tubing (oral suctioning tool) was observed to be hooked up to a beverage mug and was very dirty with brown substances and bite marks on the end. On 10/03/2017 at 10:24 a.m., Resident 7's [MEDICATION NAME] tubing was observed to be hooked up to a beverage mug and was dirty with a brown substance and bite marks on the end. On 10/03/2017 at 3:38 p.m., Resident 7's [MEDICATION NAME] tubing was observed to be hooked up to a beverage mug and was dirty with a brown substance and bite marks on the end. During an interview on 10/04/2017 at 11:08 a.m., CNA 1 indicated the [MEDICATION NAME] is changed every night on night shift and as needed. During an interview on 10/04/2017 at 12:08 p.m., Resident 7 indicated the staff does not change the [MEDICATION NAME] tubing every night. On 10/4/17 at 11:45 a.m., Resident 7's clinical record was reviewed. [DIAGNOSES REDACTED]. A review of Resident 7's annual Minimum Data Set (MDS) assessment dated [DATE], indicated a Brief Interview for Mental Status (BIMS) total score of 12 with total score of 8 to 12 being moderately cognitively impaired. The record lacked documentation the [MEDICATION NAME] tubing was changed and/or cleaned. On 10/4/17 at 11:45 a.m., the DON (Director of Nursing) provided the Cleaning and Disinfection of Equipment Policy, dated 2/11/16, and indicated the policy was the one currently being used by the facility. The policy indicated, Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to to current CDC (Centers for Disease Control) recommendations for disinfection and the OSHA (Occupational Safety and Health Administration) Bloodborne Pathogens Standard .b. Semi-critical items consist of items that may come in contact with mucous membranes or non-intact skin (e.g., respiratory therapy equipment). Such devices should be free from all microorganisms, although small numbers of bacterial spores are permissible . On 10/3/17 at 11:00 a.m., the Admission Director provided the facility policy, Resident Rights, effective 11/28/16, and indicated it was the policy currently being used. The policy indicated, (i) Safe environment. The resident has a right to a safe, clean, comfortable and homelike environment . 2a.) On 10/4/17 during room observations from 10:30 A.M. to 11:00 A.M., the rooms of Resident 126, Resident 12, Resident 34, Resident 117, Resident 40, Resident 80, Resident 36, Resident 25, Resident 41, and Resident 49 were observed to have unused metal window treatment hardware above the windows. On 10/4/17 during room observations from 11:00 A.M. to 11:30 A.M., the unused metal window treatment hardware in the aforementioned residents' rooms was still in place. b.) On 9/28/17, during room observations from 10:30 A.M. to 11:00 A.M., the rooms of Resident 19, Resident 27, and Resident 41 were observed to have wall damage above the wall air conditioning units. c.) On 9/28/17, during room observations from 10:30 A.M. to 11:00 A.M., the rooms of Resident 25, Resident 97, Resident 41, Resident 81, and Resident 98 were observed to have damaged walls next to the exam glove box holders. d.) On 9/28/17 at 10:30 A.M., the baseboard heater in Resident 12's room was observed to be dented with approximately 3 inches of metal protruding from the heater. Resident 12 was observed to be ambulatory with a walker and sat in his chair next to the baseboard heater. On 10/4/17 during an environmental tour from 11:00 A.M. to 11:30 A.M., the facility Administrator indicated the damage in the residents' rooms had been noted and repairs were forthcoming. She presented a room audit and maintenance plan book, dated 8/21/17, and indicated repairs would be made. On 10/4/17 at 2:30 P.M., the facility Administrator indicated the damaged baseboard heater in Resident 12's room had been repaired. On 10/3/17 at 11:00 a.m., the Admission Director provided the facility policy, Resident Rights, effective 11/28/16, and indicated it was the policy currently being used. The policy indicated, (i) Safe environment. The resident has a right to a safe, clean, comfortable and homelike environment . 3.) On 10/2/17 at 11:43 a.m., Resident 91's room was observed with a noticeable stale urine odor upon entering. On 10/2/17 at 2:55 p.m., Resident 91's room was observed with a noticeable stale urine odor. On 10/3/17 at 10:55 a.m., Resident 91's room was observe with a noticeable stale urine odor. On 10/3/17 at 2:45 p.m., Resident 91's room was observed with a noticeable stale urine odor. During an interview on 10/3/17 3:49 p.m., LPN 1 did not deny the urine odor was present in Resident 91's room. She indicated she believed the odor was coming from the roommate's bed and was then observed to ask a Certified Nursing Assistant to change the bed. On 10/3/17 at 11:00 a.m., the Admission Director provided the facility policy, Resident Rights, effective 11/28/16, and indicated it was the policy currently being used. The policy indicated, (i) Safe environment. The resident has a right to a safe, clean, comfortable and homelike environment . 3.1-19(f)