Every finding on record at Elwood Health and Living

Based on observation, interview, and record review the facility failed to protect the residents' right to be free from misappropriation of property for 3 of 5 residents reviewed for drug diversion. (Residents B, C, and D) Findings include:During an interview, on 3/10/26 at 10:00 a.m., the DON and Administrator indicated they had been called early in the morning about an unusual occurrence with a shift-to-shift narcotic count. The count had been off by one pill from when the original count was done. LPN 13 indicated she thought she left a pill in a cup in the medication room. She went into the medication room and brought out a pill in a cup. The Administrator and DON had reviewed the camera footage and saw LPN 13 take a pill out of her bag that was in the medication room, place the pill in a med cup, then leave the medication room. During review of camera footage, on 3/10/26 at 12:22 p.m., the DON showed a clip of LPN 13 entering the medication room, getting into her personal backpack, and pulling out a plastic bag of pills. She removed a pill from the bag. She then opened a new sleeve of medication cups. As she went to a shelf unit in the medication room, one pill in a plastic medication cup was visible in her hand. She exited the medication room. Another video clip showed LPN 13 placing a sheet of paper on Medication Cart 1, along with several medication cups. She placed three medication cups on the top of the medication cart. She popped out a pill from a medication card into her hand then placed it into the medication cup. Another clip showed LPN 13 at the 300 hall medication carts. She placed six medication cups on Medication Cart 2. She opened the first drawer, then closed it. She opened the second drawer of the medication cart. She looked though the cards, then took the first medication cup and moved in the direction of Medication Cart 1's trash. She opened the third drawer of the medication cart and looked through the medication cards. Then, back to the second drawer. Next, she opened the narcotic drawer. She popped out a narcotic pill into her left hand and closed her fingers. Then, she looked in the second drawer, pulled a card out, and popped a pill into her right hand. She put the pill from her right hand into a medication cup. She continued to keep three fingers of her left hand closed with the pill contained in the hand. She pulled another card out and popped a pill into her left hand with her left hand. With her right hand, she removed one pill from the left hand and placed it in a medication cup on the cart. She moved her hands to her right pocket as if dropping something into her pocket and swung her body like she was stretching. She continued to look through the medication cards in the drawers, then leaned down and put her left hand on a card in the cart and pushed on the card. Her hand was closed when she withdrew her hand from the cart. She opened the narcotic drawer, while keeping her left hand closed, she pulled up a narcotic card and popped a pill into her left hand. She then placed one pill into the medication cup. She retrieved the narcotic log book, while keeping three fingers of her left hand closed. She passed the narcotic log book to her right hand. Then, she placed her left hand in her left pocket and pulled her hand out of her pocket. She passed the narcotic book back to her left hand. She opened the second drawer with her right hand and passed the narcotic log book back to her right hand. She put her left hand in her left pocket, then her right pocket, looking into her pockets. She placed the narcotic log book on the opened second drawer. Next, she flipped through the narcotic log book and looked at the medications in the narcotic drawer. She placed her right hand deeply into the narcotic drawer. Then she placed her left hand deeply into the drawer, moving the drawer with the exertion. Next, she pulled up a narcotic card and popped it into her left hand and placed a pill into a medication cup. Three fingers of her right hand remained closed as she held a pen while going through the medications. She popped another narcotic pill into her left hand and kept three fingers of her left hand closed. She did not put any medications in any cups after popping the most recent narcotic pill she had popped out. She closed the narcotic drawer, took something from her left hand and placed it into her right hand. Her right hand moved in the direction of her right pocket. Her hands were no longer partially closed. During an interview, on 3/12/26 at 10:23 a.m., LPN 5 indicated when she came in, on dayshift on 3/10/26, LPN 7 was waiting to get report. LPN 13 finished giving report to LPN 6, then went into the medication room. LPN 7 indicated the narcotic count was off. LPN 13 indicated Resident B's hydrocodone-acetaminophen (opioid pain medication) 10-325 mg narcotic card contained 50 tablets, but the log book indicated 51 tablets should have been left. LPN 13 went into the medication room to get the medication. She was in the medication room for longer than it would take to grab something off the counter. LPN 13 indicated she had double popped the medication. She had popped out the medication, then went to get the Resident B's roommate's intravenous (IV) medication supplies. She had left the medication in the medication room and had popped it out again. LPN 5 indicated she looked through the as needed (PRN) narcotics that were signed off for the shift LPN 13 worked. LPN 13 had given multiple PRN medications to residents who did not typically take PRN medication during the night. During an interview, on 3/12/26 at 11:14 a.m., the Administrator indicated she had completed the reportable to the State agency and had concluded LPN 13 had taken residents' medications and multiple activity supplies from the facility. The police were currently investigating the incident. A narcotic sign out sheet for Resident D, provided by the Administrator on 3/12/25 at 11:43 a.m., indicated that LPN 13 signed out an oxycodone-acetaminophen (opioid pain medication) for Resident B on 3/10/26 at 4:30 a.m. Resident routinely received the medication daily at 8:00 a.m. The facility's investigation of the incident, reviewed on 3/12/26 at 11:43 a.m., included, but was not limited to the following items:The report to the state agency indicated: On 3/10/26 during a shift-to-shift count, a discrepancy was noted. LPN 13 reported she forgot she had pulled a narcotic medication and went to the medication storage room. She returned with medication, and the narcotic count was correct. The staff were concerned with the medication coming from the medication room. An investigation was initiated. Camera footage was reviewed and appeared to show LPN 13 pull a pill from her personal backpack. The staffing agency from where LPN 13 was contracted was notified. LPN 13 will not be permitted to return to the facility. A follow-up on 3/12/26 indicated LPN 13 had taken multiple medications through her shift. Per the security camera footage, LPN 13 would pop out a medication and hold it in her hand and then drop the medication in her pocket. In addition to medication, she was observed on video in the activities room putting items such as lotion, jewelry, and games in a filing cabinet and later putting them in her backpack and exiting the building. Pain assessments and interviews were conducted by the facility with residents, on 3/10/26, which included Resident C and Resident D. Resident D denied experiencing any pain. She denied requesting or receiving any pain medication during the previous night. Resident C indicated LPN 13 entered his room to administer his 12:00 a.m. medication. He immediately recognized it did not look like his regular medication. LPN 13 argued for several minutes and said the medication was likely from a different manufacturer. He declined to take the medication. LPN 13 returned a few minutes later with the medication he recognized as his own, and he took the medication. At 4:00 a.m., he was woken up for his routine oxycodone and given a medication cup. He did not look at the medication prior to putting it in his mouth. The medicine began to immediately dissolve, so he spit it out and did not recognize it as his pain medication. He reported this to the oncoming nurse at 6:00 a.m. on 3/10/26. The day shift nurse was given a medication cup with a bright pink colored, disintegrating pill which was given to Unit Manager 4, then given to the DON. Statements were received from employees and included, but were not limited to the following:LPN 5's statement indicated she was at the desk when LPN 13 and LPN 7 counted the narcotics. LPN 13 went into the medication room, and LPN 7 indicated the count was off. Resident B's narcotic count record indicated she had 51 pills, but she had 50 pills. LPN 13 came out of the medication room and indicated she had double popped her narcotic. She said she had popped it out, and took the pill into the medication room while she was getting Resident B's roommate's IV supplies. Then, she popped it out again and gave it to Resident B. LPN 5 told LPN 13 she would have to fill out a medication error because at first, she thought LPN 13 gave Resident B two pills. Then, LPN 5 understood what LPN 13 meant. LPN 5 and LPN 7 verified the pill was the correct one. LPN 7 notified the DON. A Narcotic Shift to Shift Count Record for the 300 Hall, contained two lines of documentation. On 3/9 at 10:00 p.m., indicated LPN 25 signed as off going nurse and LPN 13 signed as oncoming nurse. On 3/10/26 at 6:00 a.m., the off going nurse box was not signed and LPN 7 signed to oncoming nurse box. During a phone interview, on 3/12/26 at 11:57 a.m., LPN 7 indicated LPN 13 gave report on 3/10/26 from night shift to day shift and did not indicate any PRN medications were given. When she counted the narcotics with LPN 13, Resident B was missing a hydrocodone-acetaminophen 10-325 mg pill. LPN 13 indicated she might have popped out an extra one for Resident B. The narcotic count was finished, then LPN 13 went into the medication room. While she was in the medication room, LPN 7 called LPN 5 over and told her that something was not right and a hydrocodone was missing. LPN 13 came out of the medication room with a hydrocodone in a medication cup. LPN 13 said she left it on the counter when she was gathering Resident B's roommate's IV medication supplies. LPN 13 took about two minutes to return from the medication room to get a medication cup that was supposedly on the counter. After LPN 13 brought the pill, LPN 5 and LPN 7 verified with LPN 13 the pill was a hydrocodone by its markings and appearance. The medication was destroyed. During a phone interview, on 3/12/26 at 12:07 p.m., LPN 24 indicated she counted narcotics with LPN 13 on 3/9/26 for evening to night shift. The narcotic count was correct at that time. During a phone interview, on 3/12/26 at 2:56 p.m., CNA 25 indicated she worked with LPN 13 on 3/9/26 from 6:00 p.m. to 10:00 p.m. LPN 13 turned off all the lights at the nurses' station and in the hallway at 9:30 p.m. The lights at the nurses' station were not normally turned off. Some sconces on the wall provided some light, but the area was quite dark. During a phone interview, on 3/12/26 at 3:00 p.m., CNA 26 indicated she worked with LPN 13 from 10 p.m. on 3/9/26 to 6:00 a.m. on 3/10/26. LPN 13 asked CNA 26 when CNA 26 first arrived for her shift about the activity room exit that led to the parking lot. LPN 13 had turned off all the lights but one and was sitting in the corner of the activity room. She repeatedly went in and out of the activity room, swearing the whole time. She was swearing because she had to do a medication pass and count narcotics on the Assisted Living area. In the morning, LPN 13 went to the locked medication room, down the hall, and then to the activity room. CNA 26 had seen LPN 13 sitting in her car in the front parking lot when she arrived for her shift at 10:00 p.m. Later that shift, she saw LPN 13's car sitting in the back parking lot when she emptied the trash. Resident B's clinical record was reviewed on 3/12/26 at 11:20 a.m. Diagnoses included hereditary and idiopathic neuropathy (damage to nerves outside the brain and spinal cord which often causes pain), spondylosis (age related degenerative condition of the spine which frequently causes neck and back pain), and other intervertebral disc displacement, lumbar region (slipped disc which often causes lower back pain). Resident B's orders included hydrocodone-acetaminophen every 6 hours for pain (10/3/2025). A quarterly Minimum Data Set (MDS) assessment, dated 2/5/26, indicated Resident B was cognitively intact. During an interview, on 3/12/26 at 3:44 p.m., Resident D indicated she had not received any pain medications in the past several nights, as she did not need any. Resident D's clinical record was reviewed on 3/12/26 at 11:32 a.m. Diagnoses included chronic pain and polyneuropathy (disorder affecting multiple nerves, causing numbness, tingling ( pin and needles), burning sensations, and intense sensitivity to touch). Resident D's orders included oxycodone-acetaminophen 5-325 mg PRN 2 times a day for pain (2/19/26) and oxycodone-acetaminophen 5-325 mg daily (2/19/26). A quarterly MDS assessment, dated 12/10/25, indicated the resident was severely cognitively impaired. A medication administration sheet for 3/2026 lacked documentation that a PRN oxycodone had been given on 3/10/26 at 4:30 a.m. During a phone interview, on 3/12/26 at 4:21 p.m., Resident C indicated LPN 13 brought in his medications on 3/9/26 evening. He had two pills due at that time. He looked at the medications and told LPN 13 they were not his medications. She told him they were from a different manufacturer. He told her they were not his medications, and he was not going to take them. She returned about five minutes later with the correct medications. Later, through the night, she gave him his scheduled medication. The light was off, and the room was dark. He turned on the light and looked at the medication. The pill was pink and resembled his medication, but it was more like a wafer than a rounded pill. He put the pill in his mouth then spit it into a container as it did not taste like his medication, and he gave it to the day shift nurse later that morning. When LPN 13 came in again, later, she told Resident C that the medication would not have hurt him, it was just a vitamin. Resident C's clinical record was reviewed on 3/12/26 at 11:26 a.m. Diagnoses included low back pain, lower back pain, and wedge compression fracture of the first lumbar vertebra. Resident C's orders included oxycodone 10 mg every 4 hours for pain (2/23/26) and pregabalin (anticonvulsant) 100 mg 3 times a day (2/12/26). An admission MDS assessment, dated 2/18/26, indicated the resident was cognitively intact. LPN 13 was not available for interview during the survey dates. A current facility policy, revised 4/2017 and titled Abuse, Neglect, and Exploitation, provided by the Administrator on 3/5/26 with the entrance conference paperwork, indicated the following: .The resident has the right to be free from mistreatment, neglect, and misappropriation of property. 'Misappropriation of Resident Property' means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's personal belongings or money without the resident's consent. This citation relates to Intake 2799652. 410 Indiana Administrative Code (IAC) 16.2-3.1-28(a)

Based on observation, record review, and interview, the facility failed to ensure it was free of a medication error rate of greater than 5 percent for 2 of 5 residents (Residents 22 and 27) observed during the medication pass. There were 29 opportunities for error observed with 2 medication errors, resulting in a medication error rate of 6.9 percent. Findings include: 1. During a medication administration observation, on 3/10/26 at 8:42 a.m., LPN 6 prepared Resident 27's medications. She knocked on the door and took the prepared pills into the resident's room along with an 8 ounce of cup of water mixed with 17 grams of polyethylene glycol 3350 (laxative). The resident drank about four ounces of the medicated water mix. LPN 6 left the remainder of the medicated water mix on the resident's table. During an interview, on 3/10/26 at 8:57 a.m., LPN 6 indicated she left the of polyethylene glycol 3350 water mix with the resident to sip on. She would go back and check on the resident later. Resident 27's clinical record was reviewed on 3/11/26 at 9:37 a.m. Diagnoses included constipation, unspecified. Current orders included polyethylene glycol 3350 give 17 grams daily for constipation (7/21/24). The orders lacked an order for self-administration of medications. A quarterly Minimum Data Set (MDS) assessment, dated 2/3/26, indicated the resident was severely cognitively impaired. 2. During a medication administration observation, on 3/10/26 at 8:57 a.m., LPN 6 prepared Resident 22's medications. She knocked on the door and took the prepared pills into the resident's room along with an 8 ounce of cup of water mixed with 17 grams of polyethylene glycol 3350 (laxative). The resident drank approximately 2 ounces of the medication water mix. LPN 6 left the remainder of the medicated water mix on the resident's table. During an interview, on 3/10/26 at 9:08 a.m., LPN 6 indicated she would check back with the resident later. Resident 22's clinical record was reviewed on 3/11/26 at 10:17 a.m. Diagnoses included constipation. Current orders included polyethylene glycol 3350 give 17 grams daily for constipation (9/20/23). The orders lacked an order for self-administration of medications. A quarterly MDS assessment, dated 12/11/25, indicated the resident was moderately cognitively impaired. A care plan, initiated 6/1/21, indicated the resident had a potential for constipation related to impaired mobility. Interventions included administer medications as ordered (revised 11/30/23). During an interview, on 3/10/26 at 3:55 p.m., LPN 8 indicated polyethylene glycol 3350 mixed with water was not to be left with the residents as it was considered a medication. The residents were to be observed taking their medications. During an interview, on 3/11/26 at 10:47 a.m., RN 9 indicated medications including the polyethylene glycol 3350 mixed in water could not be left unattended with residents. The nurse must observe the residents take their medications. During an interview, on 3/11/26 at 2:19 p.m., the DON indicated medications including polyethylene glycol 3350 mixed with water were not to be left in the residents' rooms to be taken without being observed. A current facility policy, reviewed 2/1/23, titled Medication Administration General Guidelines, provided by the Administrator on 3/11/26 at 3:10 p.m., indicated the following: . Licensed nurse/authorized personnel MUST stay with the resident to ensure medication(s) are completely ingested. 410 IAC (Indiana Administrative Code) 16.2-3.1-48(c)(1)

Based on observation, interview, and record review, the facility failed to provide adaptive tableware for 1 of 2 residents reviewed for assistive devices used during dining. (Resident 16) Finding includes:During a dining observation, on 3/6/26 at 12:43 p.m., Resident 16's meal was provided in the dining room on a white plate.During a dining observation, on 3/10/26 at 12:57 p.m., Resident 16's meal was provided in the dining room on a white plate. During an interview, on 3/10/26 at 1:30 p.m., LPN 5 indicated Resident 16 often fed himself but needed increased cuing and staff assistance during the lunch and supper meals. Resident 16 did not use specialty cups, plates, or utensils during meals.Resident 16's clinical record was reviewed on 3/10/26 at 3:45 p.m. Diagnoses included need for assistance for personal care, dysphagia at the oropharyngeal stage (difficulty initiating to swallow), lack of coordination, and dry eye syndrome.Current orders included regular diet with regular texture, thin liquids, and a red plate at meals (2/26/26).An annual Minimum Data Set (MDS) assessment, dated 2/6/26, indicated Resident 16 had severe cognitive impairment. He required supervision or touching assistance with eating. He had adequate vision and did not have corrective lenses.A current care plan, dated 12/16/24, indicated Resident 16 was at risk for a potential alteration of nutrition and/or weight status. Interventions included the following: serve diet as ordered (12/16/24) and red plate for meals related to vision issues (2/27/26).A nurses note, dated 2/26/26 at 11:04 a.m., indicated a discussion occurred regarding Resident 16's vision and decreased meal intakes. A red plate at meals was to be attempted to see if intakes improved.During an interview on 3/11/26 at 11:25 a.m., [NAME] 17 indicated specialty items for dining were relayed to the dietary staff verbally from the nursing staff and a form was completed by nursing and turned into dietary. A few residents received their meals on a red plate. She was unsure which residents received red plates on the 300 hall. The Dietary Manager arrived during the interview and indicated Resident 37, who resided on the 300 hall, received a red plate for meals. Neither [NAME] 17 nor the Dietary Manager indicated Resident 16 used a red plate.During an interview, on 3/11/26 at 11:37 a.m., the Dietary Manager indicated Resident 16 was to get a red plate for meals and not Resident 37. During an interview, on 3/11/26 at 1:42 p.m., CNA 19 indicated Resident 16's lunch meal was not served on a red plate today. She recalled she had picked up a standard white plate when she picked up Resident 16's lunch items from the dining room. She opened the food cart she was pushing and confirmed there were no red plates in the cart.During an interview, on 3/11/26 at 2:17 p.m., Unit Manager 4 indicated she was unaware that Resident 16 had not received his meals on a red plate. CNAs were not typically aware of who needed red plates. It was not on the assignment sheets. She had made the dietary department aware of Resident 16 needing a red plate on the day she entered the order. She had also given the dietary department a copy of the updated dietary order that listed the red plate.During an interview, on 3/11/26 at 2:20 p.m., Speech Therapist 20 indicated Resident 16's red plate was utilized due to the resident having visual problems. The red plate was less effective if staff fed him. The facility used dark tablecloths, and red plates were more effective with lighter backgrounds.During an interview, 3/11/26 at 2:36 p.m., the DON indicated Resident 16's dining and visual problems were identified by the occupational therapist and during a nutrition at-risk meeting. A verbal report of Resident 16's need for the red plate intervention occurred during an IDT type meeting. There was no documentation of this discussion. An order was in place for Resident 16 to have a red plate. The red plate intervention was care planned and was identified on Resident 16's meal ticket. Dietary staff did not have to serve Resident 16's meals on a red plate but it did help the resident. Resident 16's dietary order and care plan implied the resident may have a red plate and not that he had to actually have one. It relied on the preference of the dietary staff. The dietary staff was aware the nursing staff was assisting Resident 16 more often and they could determine if he needed the red plate or not.During an interview, on 3/11/26 at 2:42 p.m., the Nurse Consultant indicated a red plate was to be used for Resident 16, especially if the meal consisted of pale foods.A facility policy, revised 4/17, titled Assistive Devices, provided by the Administrator, on 3/12/26 at 9:40 a.m., included the following: .Assistive devices will be provided to residents who need them. Purpose: To encourage residents to feed themselves. To maintain quality of life at highest level possible.D. Adaptive equipment is made available at mealtime by Dining Services . 410 IAC (Indiana Administrative Code) 16.2-3.1-21(h)

Based on observation and staff interview, the facility failed to ensure medications were stored in a manner to prevent loose pills in the medication cart drawers for 2 of 3 medication carts reviewed out of 5 facility medication storage carts. (200 hall and 300 hall)Findings include: During a medication cart observation on 3/5/26 at 11:07 a.m., accompanied by RN 14, a blue oblong pill inscribed with A-17 was found loose in the second drawer on the left side of the 200-hallway medication cart. RN 14 indicated that the pill should be destroyed in a drug buster (a drug disposal system). The medication carts were cleaned out weekly. During a medication cart observation on 3/5/26 at 12:19 p.m., accompanied by LPN 5, the following loose pills/capsules were observed in the third drawer from the top of the 300 hallway medication cart: one peach colored capsule inscribed with 215, a pink round pill inscribed with 262, a white round pill inscribed with HP 23, a green oblong pill inscribed with E 45, a pink and orange pill inscribed with EP 102, a white round pill inscribed with L 150, and a pink oblong pill inscribed with 894. During an interview with the Director of Nursing (DON) on 3/12/26 at 10:50 a.m., she indicated the facility performed medication cart audits and it was unusual to have loose pills in the carts. Unit managers cleaned out the carts once a week. A current facility policy, titled Medication Cart Supplier and Maintenance, provided by the Administrator on 3/12/26 at 4:47 p.m., indicated the following: .To ensure that medication carts are maintained in the proper manner .21) Disposal of medications should be completed for medications that are without secure closure, outdated, contaminated and/or deteriorated. a) Disposal needs to be timely. b) Remove medications immediately from stock. c) Dispose of medications per medication disposal procedure .e) Document medication disposal 3.1-25(o)(s)

A.Based on observation, interview, and record review, the facility failed to utilize infection prevention and control strategies related to handling of a urinary drainage bag for 1 of 2 residents reviewed for indwelling catheters. (Resident 65)B. Based on observation, record review, and interview, the facility failed to ensure enhanced barrier precautions (EBP) were implemented during perineal care and wound care for a resident with a feeding tube for 1 of 3 residents reviewed for wound care. (Resident 56) Finding includes:A.During an observation, on 3/6/26 at 10:45 a.m., Resident 65's indwelling urinary catheter drainage bag hung under his wheelchair. The bag touched the floor. The bag drug on the floor as Resident 65 self-propelled his wheelchair in the hallway. During an observation, on 3/6/26 at 12:13 p.m., Resident 65's urinary catheter drainage bag drug on the floor as Resident 65 self-propelled his wheelchair in the hallway. During an observation, on 3/9/26 at 10:45 a.m., Resident 65's urinary catheter drainage bag drug on the floor as Resident 65 self-propelled his wheelchair in the hallway. During an observation, 3/9/26 at 4:16 p.m., Resident 65 sat in his wheelchair in room. The urinary catheter drainage bag hung under his wheelchair. The bag was dated 3/1 and rested on the floor. Resident 65's clinical record was reviewed on 3/9/26 at 9:46 a.m. Diagnoses included obstructive and reflux uropathy (urine flow is blocked or flows backward into the kidneys) and dementia. Current physician orders included urinary drainage bag changed weekly on Wednesdays (10/22/25). A Minimum Data Set (MDS) assessment, dated 1/23/26, indicated Resident 65 had moderate cognitive impairment. He used a wheelchair for mobility. He was dependent on staff assistance for toileting and personal hygiene and for chair/bed to chair transfers. He had an indwelling catheter. A current care plan, revised on 1/27/26, indicated Resident 65 had a catheter due to urinary retention. Interventions included the following: catheter care as ordered (10/20/25), change urinary catheter as ordered by medical doctor (10/20/25), keep catheter tubing and bag below level of bladder (10/20/2025) and notify medical doctor if problems occur with catheter (10/20/2025). The electronic treatment administration record (ETAR) indicated Resident 65's urinary drainage bag was changed on 3/4/26. During an observation, on 3/10/26 at 4:33 p.m., Resident 65 sat in his wheelchair in his room. The urinary catheter drainage bag hung under his wheelchair. The bag was dated 3/1 and rested on the floor. During an interview, on 3/10/26 at 4:46 p.m., CNA 21 confirmed Resident 65's catheter drainage bag was resting on the floor under his wheelchair. CNA 21indicated a catheter bag should never touch the floor because of infection control issues. She put on a pair of gloves, lifted the privacy cover on the front of the bag and did a visual inspection of the urine. The bag contained approximately 200 milliliters of urine. She did not empty the urine from the drainage bag. She unhooked the bag from under the wheelchair and hung the bag on the right arm rest of the wheelchair. During an interview, on 3/10/26 at 4:53 p.m., LPN 5 indicated a urinary catheter drainage bag was not to touch the floor and it was an infection control issue. The urinary drainage bag was to be secured so it would not slide down and touch the floor. Facility staff were aware the catheter bag was not to touch the floor. Urinary drainage bags were changed by night shift nurse, weekly, on Wednesdays. The ETAR indicated the bag was changed on 3/4/26. LPN 5 confirmed the urinary drainage bag was dated 3/1/26. During an interview, on 3/10/26 at 5:10 p.m., the DON indicated a catheter drainage bag was not to touch the floor, ever, and touching the floor was an infection control issue. During a catheter care observation, on 3/11/26 at 2:47 p.m., CNA 19 confirmed Resident 65's urinary catheter drainage bag was resting on the floor under Resident 65's wheelchair. CNA 19 indicated the catheter bag was not to touch the floor. The bag may get snagged and leak and it was an infection control issue. A facility policy, revised 7/27/21, titled Foley Catheter Policy, found on conference table on 3/11/26 at 8:45 a.m., included the following: . 4. The use of an indwelling urinary catheter will be in accordance with physician orders. 8. Indwelling catheters (urethral or suprapubic) will be utilized in accordance with current standards of practice, with interventions to prevent complications to the extent possible. Possible complications include but are not limited to urinary tract infection. 9. The plan of care will address the use of an indwelling urinary catheter, including strategies to prevent complications. B. Resident 56's clinical record was reviewed on 3/9/26 at 3:10 p.m. Diagnoses included dysphagia, oropharyngeal phase, central cord syndrome at C3 level of cervical spinal cord and C4 level of cervical spinal cord, and personal assistance with personal care. Current orders included enhanced barrier precautions – don appropriate PPE (personal protective equipment) when caring for feeding tube every shift. A quarterly Minimum Data Set (MDS) assessment, dated 2/4/26, indicated the resident was dependent on staff for all activities of daily living. A current care plan, revised 4/18/25, indicated the resident required enhanced barrier precautions related to his feeding tube. Interventions included the following: Continue to provide education to staff as needed (4/18/25) and EBP signage on the door to assist staff in identifying need for PPE (4/18/25). During a wound care and perineal care observation, on 3/10/26 at 1:11 p.m., LPN 8 and CNA 11 sanitized their hands and applied gloves upon entering the resident's room to perform perineal and wound care. They removed the resident's brief and performed incontinence care. They rolled the resident back and forth on the bed with his body touching their arms. After the incontinence care was performed, LPN 8 performed wound care after washing her hands and applying new gloves. LPN 8 and CNA 11 did not wear gowns during these activities. During an interview, on 3/10/26 at 1:34 p.m., LPN 8 indicated she did not need to wear a gown during the wound or incontinence care for EBP because the EBP was specific to feeding tube care. During an observation, on 3/10/26 at 1:36 p.m., a sign on the resident's door indicated he was on EBP which indicated the following: EVERYONE MUST: Clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Wear gloves and a gown for the following High-Contact Resident Care Activities. Dressing Bathing/Showering Transferring Changing Linens Providing Hygiene Changing briefs or assisting with toileting Device care or use: central line, urinary catheter, feeding tube, tracheostomy Wound Care: any skin opening requiring a dressing. During an interview, on 3/11/26 at 10:51 p.m., CNA 11 indicated she had not worn a gown during Resident 56's perineal care yesterday, but she found out yesterday she was supposed to wear gowns with all residents on EBP when providing high contact care. During an interview, on 3/11/26 at 2:19 p.m., the DON indicated she would expect the staff to apply PPE to perform high contact care on residents on EBP. A current facility policy, dated 4/2/24, titled Enhanced Barrier Precautions, provided by the Administrator on 3/11/26 at 3:10 p.m., indicated the following: . Enhanced Barrier Precautions (EBP) will be in place during high contact care activities for resident with the following conditions: . All Resident's with indwelling medical devices which includes but is not limited to catheter, central lines, feeding tubes, tracheostomy tubes.Residents for whom EBP are indicated, EBP is employed when performing the following high contact resident care activities; Dressing, Bathing/Showering, Transferring, providing hygiene, changing linens, changing briefs/incontinent care/toileting, Device care or use: Central line, urinary catheter, feeding tube, tracheostomy, ventilator, Wound care other than skin tears or simple breaks in the skin. 410 IAC (Indiana Administrative Code) 16.1-3.1-18(a)

Based on interview and record review, the facility failed to ensure the narcotic shift to shift count was completed for 4 of 5 medication carts reviewed. Findings include::During a medication cart observation, on 3/5/26 at 11:07 a.m., the 200-hall back medication cart Narcotic Shift to Shift Count Record was missing signatures on 3/2/26 at 6 p.m. for the oncoming nurse, on 3/3/26 at 6 a.m. for the off going nurse, on 3/3/26 at 10 p.m. for the oncoming nurse, on 3/4/26 at 6 a.m. for the off going nurse, and on 3/5/26 at 9 a.m. for the oncoming nurse. The 200-hall front medication cart was missing signatures on 2/15/26 at 6 a.m. for the oncoming nurse, on 2/15/26 at 2 p.m. for the oncoming nurse, on 2/15/26 at 6 p.m. for the off going nurse, 2/15/26 at 6 p.m., for the oncoming nurse, 2/15/26 at 10 p.m. for the off going nurse, on 2/26/26 at 6 a.m. for the oncoming nurse, on 3/3/26 at 6 a.m. for the off going nurse, 3/3/26 at 10 p.m. for the oncoming nurse, and on 3/3/26 at no time listed for the off going nurse. During the observation, RN 14 indicated the Narcotic Shift to Shift Count Record was missing signatures and should be signed with each oncoming and off going nurse. During a medication cart observation, on 3/5/25 at 12:19 p.m., the 300-hall back medication cart Narcotic Shift to Shift Count Record was missing signatures on 2/20/26 at 6 a.m. for the oncoming nurse, on 2/20/26 at 6 p.m. for the off going nurse, on 2/20/26 at 10 p.m. for the off going nurse and the oncoming nurse, on 2/21/26 at 6 a.m. for the off going nurse, on 2/24/26 at 6 a.m. for the off going nurse, on 2/27/26 at 6 a.m. for the off going nurse, on 2/27/26 at 6 p.m. for the oncoming nurse, and on 2/28/26 at 6 a.m. for the oncoming nurse. During the observation, LPN 5 indicated the Narcotic Shift to Shift Count Record was missing signatures and should be signed every shift. During a medication cart observation, on 3/5/26 at 1:03 p.m., the 100-hall medication cart Narcotic Shift to Shift Count Record was missing signatures on 1/28/26 at 6 a.m. for the oncoming nurse, on 1/28/26 at 6 p.m. for the off going nurse., on 3/1/26 at 6 a.m. for the oncoming nurse, on 3/1/26 at 2 p.m. for the off going nurse, on 3/2/26 at 10 p.m. for the off going nurse, and on 3/5/26 at 6 a.m. for the off going nurse. During the observation, RN 9 indicated the Narcotic Shift to Shift Count Record was missing signatures and should be signed every shift upon arriving and leaving with the other nurse. During an interview, on 3/12/26 at 10:48 a.m., the DON indicated the narcotics should be counted and the shift-to-shift count should be signed every shift. Sometimes the nurses and QMAs will sign on but then do not sign off. Since the QMAs worked eight-hour shifts and the nurses worked 12-hour shifts, it can be confusing. But they should still be signing the Narcotic Shift to Shift Count Record. A current facility policy, reviewed 2/1/23, titled Medication Administration General Guidelines, provided by the Administrator on 3/11/26 at 3:10 p.m., indicated the following: Policy: Preparation or administration of medication(s) or biologicals completed in accordance with physician's orders; manufacturer's specifications (not recommendations); accepted professional standards and principles that apply to professionals providing service. The accepted professional standards and principals include the various practice regulations in each State, and current commonly accepted health standards established by national organizations, boards and councils. Do Not report off shift without ensuring documentation is complete. 410 IAC (Indiana Administrative Code) 16.2-3.1-25(e)(3)

Based on observation, interview, and record review, the facility failed to provide supervision and develop and implement interventions to prevent recurrent falls for 2 of 4 residents reviewed for accidents (Resident 7 and Resident 6). Findings include: 1.During an observation, on 3/5/26 at 3:03 p.m., Resident 7 walked up and down the unit's hallway. Resident 7's clinical record was reviewed on 3/9/26 at 9:36 a.m. Diagnoses included difficulty walking, low back pain, unspecified dementia, severe, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, other intervertebral disc degeneration, lumbar region without mention of lumbar back pain or lower extremity pain, restless leg syndrome (RLS), and hypertension. Current orders included donepezil (for dementia) 10 mg daily at bedtime (8/9/23), memantine extended release (for dementia) 28 mg daily (7/5/23), acetaminophen 1000 mg daily for pain (2/6/26), activity level: up ad lib (6/8/21), apply gripper socks at bedtime to prevent falls at bedtime for fall prevention (12/19/23), fall mat at bedside at night - put out of walk way during waking hours every shift (2/4/25), mattress on the floor with another mattress beside the mattress while in bed, stack mattress while resident out of bed every shift to help prevent falls (2/9/26), and may use weighted blanket while in bed every shift (2/7/26). A quarterly Minimum Data Set (MDS) assessment, dated 12/23/25, indicated the resident was severely cognitively impaired. He had no functional range of motion impairments to his extremities and utilized no mobility devices. He required supervision/touching staff assistance with rolling in bed, dressing his lower body, donning and doffing footwear, and moving from sitting to lying position. He required partial/moderate assistance with moving from lying to sitting, moving from sitting to standing, chair to bed and bed to chair transfers, toilet transfers, and tub/shower transfers. He walked 150 feet independently. A care plan, initiated 6/7/21, indicated the resident was at risk for falls due to abnormalities of gait, dementia, potential side effects from medications, and syncope. He was currently up ad lib. Interventions included the following: gripper socks as ordered (9/6/24), keep call light within reach (6/8/21), and keep walkways free of clutter (6/8/21). A care plan, initiated 6/8/21 and last revised 2/24/26, indicated the resident had falls with multiple dates listed including, but not limited to 1/5/26, 1/7/26, 1/9/26, 1/11/26, 1/15/26, 2/1/26, 2/4/26, 2/5/26, 2/8/26, 2/10/26, and 2/23/26. Interventions included the following: increase rounding when resident not in line of staff view (1/6/26), request medication review, possible restless leg syndrome and change in brexpiprazole times from morning to bedtime (1/6/26), medication review requested by physician (1/12/26), medications reviewed per pharmacy, restless leg syndrome (1/13/26), staff to assist resident to lay down when found ambulating with eyes closed (1/19/26), monitor resident more closely and assist to chair with attempts to sit down (1/27/26), frequent and routine rounds to prevent resident from physical discomfort which may increase restlessness or need to wander (2/1/26), pool noodle bolster under sheet to right side of bed (2/1/26), have physician review meds and ask for acetaminophen at bedtime (2/5/26), weighted blanket in bed to help with RLS, mattress on floor (2/8/26), keep wheelchairs in room or if in hallway have wheels locked (2/11/26), and refer to physical and occupational therapy (2/24/26). A progress note, dated 1/3/26 at 1:14 p.m., indicated the resident was walking around with his eyes closed and bumped his head on the wall and frames hanging by the doors. The staff attempted to lay the resident down. The resident was restless and attempted to get up. The staff assisted the resident up, and he continued to pace. The resident's representative sat with the resident. A progress note, dated 1/5/26 at 3:40 a.m., indicated the resident was found on the floor. He had an unwitnessed fall. He was on the floor sitting up leaning against his bed when staff arrived in the room. The bed was lowered all the way to the floor. His fall mat and bed alarm were in place. He wore his nonskid footwear. The immediate intervention was to meet the resident's needs and continue to monitor. A progress note, dated 1/5/26 at 2:00 p.m., indicated the resident ambulated in the hallway, dining room, and lounge with his eyes closed. He ran into things. He was unable to sit still. He was toileted then assisted to the lounge to listen to music. The resident's representative sat with him and indicated she had to push a chair under him several times to prevent him from falling. The resident was assisted to bed but only lay in bed for several minutes before he crawled out. A progress note, dated 1/5/25 at 6:02 p.m., indicated the resident had an unwitnessed fall. He was found in the music room by the outside door with his bottom on the floor and his head and back against the wall. The immediate intervention was to increase rounding while resident was not in sight. A progress note, dated 1/6/26 at 8:38 a.m., indicated the IDT (interdisciplinary team) met to review the fall that occurred on 1/5/26 at 3:40 a.m. The resident was found sitting upright on the floor mat beside the bed. The unit manager indicated the resident continued to often be restless when he was in bed. He moved his legs frequently and caused the bedsheets to tangle which caused him to end up on the floor mat bedside the bed. The immediate intervention was to meet the resident's needs and assist him back to bed. IDT recommended his medications be reviewed and to consider a medication for his RLS as well to change his brexpiprazole from morning to bedtime. A progress note, dated 1/6/26 at 12:46 p.m., indicated the IDT met to review the fall that occurred on 1/5/26 at approximately 4:30 p.m. when resident was sitting in the music room and was found sitting on the floor in front of the outside door. It was thought the resident got up as he usually did and tried to sit back down, missed the chair, and landed on the floor. No injuries were noted. He was assisted by two staff members to his feet. The resident was progressively declining and having increased falls. He walked with his eyes closed, and his gait had become less stable. He walked into walls and furniture and continued to keep going. Immediate and future intervention was to increase rounding on resident when he was not in the line of vision of the staff. A progress note, dated 1/9/26 at 11:01 a.m., indicated the resident grabbed the side railing and squatted up and down. He was unable to stand all the way up, and the staff member lowered the resident to the floor. The resident smelled of bowel movement. He was assisted to the restroom and had a bowel movement. It appeared the resident tried to have a bowel movement and experienced a vasovagal response. He was cleaned up, taken to his room, and assisted to bed. The physician and the resident's representative were notified. A progress note, dated 1/12/26 at 12:54 a.m., indicated the resident had an unwitnessed fall and was found on the floor. He was found sitting up with his back against the bed. The resident was given a drink and checked for incontinence. A light was left on in the room. A progress note, dated 1/12/26 at 12:53 p.m., indicated the IDT met to review the fall that occurred on 1/9/26 at approximately 11:00 a.m. The staff witnessed the resident holding on to the sideral of his bed and squatting up and down. The resident could not get to a standing position, so the resident was lowered to the floor. The nurse found the resident cool and clammy. He was taken to the bathroom as he smelled like bowel movement. He was incontinent of a large bowel movement. The immediate intervention was to provide incontinence care and assist him to bed. IDT believed the resident had a vasovagal response. A progress note, dated 1/13/26 at 1:12 p.m., indicated the IDT met to review the fall that occurred on 1/12/26 at approximately 12:33 a.m. When staff heard the bed alarm sounding, they went into the room. The resident sat on his bottom on the bedside mat. No injuries were noted. He was assisted back to bed after he was toileted. He recently started medication to treat his RLS. The order was clarified per pharmacy recommendation. The IDT believed once the RLS medication became effective, the need to move constantly would improve. A progress note, dated 1/15/26 at 7:06 p.m., indicated the resident was found on the floor with a chair on top of him. The resident was assisted to bed and given incontinence care. No injuries were noted. A progress note, dated 1/19/26 at 10:18 a.m., indicated the IDT met to review the fall that occurred on 1/15/26 at approximately 6:00 p.m. The resident had ambulated with his eyes closed and went into a room where he attempted to sit in a chair and missed the chair which caused him to fall. A new intervention was for the staff to assist the resident to bed when he ambulated with his eyes closed. No injuries were noted. A progress note, dated 2/1/26 at 4:30 a.m., indicated the resident was found kneeling on both knees on the fall mat beside his bed. He wore non-slip socks. No injuries were noted. He was repositioned to a more comfortable position. A progress note, dated 2/2/26 at 12:08 p.m., indicated the IDT met to review the fall on 2/1/26. The resident was found with his knees resting on the foam mat beside his bed. The resident had a history of throwing his legs off the side of the bed while he was asleep. The IDT recommended a pool noodle bolster under the sheet on the right side of the bed to prevent the resident from kicking his legs off the bed. A progress note, dated 2/4/26 at 10:55 p.m., indicated the resident had an unwitnessed fall. His knees were slightly reddened. A progress note, dated 2/5/26 at 11:41 p.m., indicated the resident had an unwitnessed fall. He was found with his knees on the fall mat, and his top half of his body was on the bed in a kneeling position. A progress note, dated 2/6/26 at 8:45 a.m., indicated the IDT reviewed the fall on 2/5/26 at 11:41 p.m. He was found with his knees on the fall mat and upper body in bed. The resident had RLS and liked to dangle his legs off the bed. IDT recommended a weighted blanket to see if it would help with the RLS. A progress note, dated 2/9/26 at 10:20 a.m., indicated the IDT reviewed the resident's change of plane on 2/8/26. The resident was found on his knees beside the bed on his mat. No injuries were noted. The physician recommended a mattress on the floor and to have acetaminophen at bedtime. A progress note, dated 2/10/26 at 5:18 p.m., indicated the resident was on the floor in the hallway on his right side with a wheelchair on top of him. No injuries were noted. Wheelchairs were removed from the hallway. A progress note, dated 2/11/26 at 4:35 p.m., indicated the IDT reviewed the fall on 2/10/26. Resident ambulated in the hallway with his shoes on. He attempted to move the wheelchair and sit down. The wheelchair moved, and he fell onto his right side. The wheelchair was found on top of him. He did not exhibit any injuries. A new intervention was to keep all wheelchairs in rooms or locked if they were in the hallway. A progress note, dated 2/23/26 at 5:30 p.m., indicated the resident fell. He was found on his back with his head by another resident's wheelchair. A progress note, dated 2/24/26 at 10:41 a.m., indicated the IDT reviewed the resident's fall on 2/23/26. He was observed sitting with his legs crossed. He attempted to stand up with his legs crossed which caused him to fall. He hit his head on a nearby wheelchair. The resident had been leaning forward more when walking. The IDT recommended getting an order for a physical and occupational therapy evaluation. During an observation, on 3/9/26 at 10:35 a.m., the resident lay on his low bed facing the wall. A mattress was beside his bed. The bed did not have a pool noodle on it or under the sheets. During an observation, on 3/9/26 at 11:40 a.m., the resident walked down the hall with his head bent down and his hands in his pockets. During an observation, on 3/10/26 at 8:38 a.m., the resident lay in his bed with his eyes closed. He was propped on his right side with the use of two pillows. A pool noodle was not utilized on the bed for a bolster. A mattress was beside the low bed. During an observation, on 3/10/26 at 11:02 a.m., the resident sat in a chair in the dining room with his eyes tracking the movement of staff and other residents. During an observation, on 3/10/26 at 11:03 a.m., the floor mattress in the resident's room was propped up against the resident's bed at an angle. During an observation, on 3/10/26 at 11:06 a.m., two wheelchairs were in the hallway. One was located along the wall near the doorway of the resident's room and was not locked. Another one was located against the wall across from the dining room and was not locked. During an interview, on 3/10/26 at 11:57 a.m., CNA 10 indicated the resident's mattress was usually put up against the wall and then put the mattress behind the headboard of the bed against the wall. She did not understand the order for stacking the mattress. She indicated the wheelchairs were to be locked in the hallway as she locked the wheelchair near the resident's doorway to his room. The resident used to have a pool noodle, but she did not think they used it anymore. She found the pool noodle on the chest of drawers behind pictures. He did not use the pool noodle during the day, but she thought he did during the evening. To keep the resident from falling, she toileted him frequently, walked with him, gave him interactive books, and played music (as he loved music). During an observation, on 3/10/26 at 3:52 p.m., the resident walked out of the lounge area and mumbled something incoherently. He walked up to a two wheeled walker located against the wall in the hallway and lifted it sideways. During an interview, on 3/10/26 at 4:26 p.m., RN 9 indicated she did not know what the mattress order meant, but she did make sure the bed was lowered to the floor, and the floor mattress was placed behind the bed up against the wall to prevent a resident from tripping over the mattress. She did not know about the pool noodle. She had not used it. CNAs could access the interventions on the electronic medical record. Most of the resident's falls were at night. She rounded more frequently than every two hours. During the day, he was toileted often. He sometimes fell asleep while walking, so she tried to assist him to sit down or lie down. Wheelchairs in the hallways should be on one side and locked. During an interview, on 3/10/26 at 4:35 p.m., CNA 12 indicated she checked the Kardex on the electronic medical record for any updates and interventions. To prevent falls for the resident, she made sure he had on gripper socks, his bed was lowered to the floor, had his bed alarm on, put the mattress beside his bed when he was in bed in case he rolled out of bed, put the mattress behind the bed when the resident was up so no one would trip on it, and put shoes on him when he was up. She did not use the pool noodle. During an interview, on 3/12/26 at 11:09 a.m., the DON indicated the resident previously had a different bed and was rolling out of it at night. He liked to lay on the bed with his knees on the floor. He was marked for falls because of the change of plane. A couple of his falls were because he needed to have a bowel movement. He squatted down and then fell. The staff should be following the care planned interventions. She did not know why the nurse had put in an order to stack mattress, as it should have been mattress on the floor. 2.During an observation on 3/6/26 at 11:54 a.m., Resident 6 was propelling himself to the dining room.During an observation on 3/9/26 at 10:46 a.m., Resident 6 was sitting in a wheelchair across from the nurse's station, eating a snack.During an observation on 3/9/26 at 3:27 p.m., Resident 6 was asleep in his wheelchair in the dining room.Resident 6's clinical record was reviewed on 3/9/26 at 10:44 a.m. Diagnoses included hemiplegia (paralysis) following cerebral infarction (stroke) affecting left non-dominant side, dysphasia, displaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing, fracture of superior rim of right pubis, subsequent encounter of fracture with routine healing, muscle weakness, difficulty in walking, unsteadiness on feet, other lack of coordination, and need for assistance with personal care. A comprehensive Minimum Data Set (MDS) assessment, dated 9/3/25, indicated the resident was cognitively intact, impaired on the left side of both his upper and lower extremities, used a wheelchair to ambulate, required substantial to maximal assistance for bed mobility (rolling left to right and sit to stand),bed to chair transfers, and shower and toilet transfers. He was able to ambulate independently. A current care plan, initiated on 7/9/25 and revised on 10/15/25, indicated Resident 6 had an Activity of Daily Living (ADL) self-care performance deficit and required supervision for toileting, bed mobility, transfers, and set-up and clean-up assistance for eating/drinking related to weakness from a stroke. Interventions included assisting the resident during bathing, one to two staff to reposition and turn the resident in bed, one staff to assist with dressing, encourage the resident to use call light for assistance, one staff to assist with toileting, and one staff to assist with all transfers. A current care plan, initiated on 7/10/25 and revised on 1/15/26, indicated Resident 6 was at risk for falls related to weakness, impaired balance, and hemiparesis. Interventions included anticipating and meeting the resident's needs (7/9/25), ensure the call light was within reach and encourage the resident to use if for assistance as needed, offering the resident activities to promote exercise, physical activity for strengthening and improved mobility, PT (physical therapy) to evaluate and treat as ordered as needed, re-educate the resident on the importance of using the call light (7/24/25), review information on past falls and attempt to determine cause of falls, record possible root causes, alter or remove any potential causes if possible, and weight bearing as tolerated (8/31/25). A current care plan, initiated 7/14/25, indicated Resident 6 had hemiparesis related to a stroke. Interventions included giving medications as ordered, monitoring for side-effects and effectiveness of medications, obtaining and monitoring labs and diagnostics, providing alternative comfort measures as needed, and physical therapy, occupational therapy, and speech therapy to evaluate and treat as ordered. A progress note, dated 7/18/25 at 11:40 p.m., indicated Resident 6 turned on his call light and was found on the floor. He got up to use the restroom without assistance. He was not wearing non-skid socks and said he got tripped up on a blanket on the floor. The immediate intervention was to advise him to ask for help before transferring. Non-skid socks were placed on his feet, and the clutter was removed from the floor. An occurrence note, dated 8/5/25 at 11:20 p.m., indicated Resident 6 was found on the floor beside his bed, knees drawn up and resting against his recliner. Resident 6 did not complain of pain or discomfort and was not injured. Resident 6 stated he was sitting on the edge of the bed and just slid off onto the floor. He was not trying to self-transfer. He was assisted back to bed, and the call light was left within his reach. The root cause(s) of the occurrence was determined to be the resident was sitting on the edge of the bed, self-transferring, gait imbalance, ambulating without assistance, and poor lighting. A progress note, dated 8/6/25 at 11:57 a.m., indicated the interdisciplinary team (IDT) met to review falls that occurred on 8/3/25 and 8/5/25. In both incidents, the resident was in bed prior to the falls. Staff found Resident 6 sitting on the floor next to his bed. Resident 6 said he slid off the edge of the bed. He was not injured in either incident. The care plan was reviewed and updated as needed. An occurrence note, dated 8/9/25 at 6:55 p.m., indicated staff heard a loud crash and went to Resident 6's room to investigate. He was found lying on the floor on his right side, legs bent, and head towards the recliner. Resident 6 stated he was ambulating with his walker, lost his balance, and fell. He had been ambulating around his room and up and down the hallway all day. Staff returned Resident 6 to his bed and gave him the call light. He was re-educated about using the call light to get help when ambulating. The fall care plan indicated the resident was provided education after the fall on 8/9/25. A Fall Follow-Up note, dated 8/19/25 at 12:25 p.m., indicated the IDT met to review a fall from 8/16/25 where the resident stated he slid out of bed. He was found wearing a pressure-relieving boot on his right foot and he was alert and oriented. The resident was known to be non-compliant with safety. He complained of right hip pain and had a scratch on his right temple. He was assisted back to bed, a mobile x-ray was ordered, and the x-ray results indicated multiple fractures of the pelvis.The clinical record lacked indication of updated interventions to mitigate the risk of subsequent falls following the resident's pelvic fracture on 8/16/26. An IDT progress note, dated 8/21/25 at 7:55 a.m., indicated the team met to discuss Resident 6's recent decline in condition. The resident sustained a fall which resulted in pelvic fractures, causing an overall decline in the resident's condition. A Fall Follow-Up note, dated 9/3/25 at 8:16 a.m., indicated the IDT met to review a fall occurring on 8/27/25 at approximately 12:35 p.m. Resident 6 was found sitting on the foot pedals of his wheelchair in his room. The call light had been pulled out of the wall. The resident stated he was trying to put the call light back in the wall. The resident tended to be impulsive and had no safety awareness. The immediate intervention was to place a pressure alarm in the seat of the wheelchair to alert staff when Resident 6 attempted to self-transfer. The pressure alarm was not added to the care plan until 9/4/26.An occurrence note, dated 9/1/25 at 10:30 p.m., indicated Resident 6 was found sitting on his buttocks on the floor in front of his bed with his back against the bed frame and his legs crossed in front of him. There were no visible signs of injury or pain. The note had a pre-populated area regarding the use of a personal alarm, which was marked not applicable. The resident stated he was trying to get up to get his walker, realized he would not be able to get to the walker, and sat down on the floor. To prevent the recurrence of the fall, the call light and walker were left within reach of the resident. He was assisted back to bed and re-educated on safety and fall precautions. The root cause(s) of the occurrence were listed as ambulating without assistance, gait imbalance, needs unmet, and refusal to allow staff to assist with care.A care plan intervention was added for the resident's bed to be placed in the lowest position when the resident was in bed (9/4/25).A progress note, dated 9/8/25 at 7:32 a.m., indicated the IDT met to review a fall that occurred on 9/7/25 at approximately 1:19 a.m. A CNA entered the resident's room and found him lying on the floor next to his bed. He was assessed for injury with no findings. Resident 6 indicated he was reaching for something on his bedside table. The bed was not in the lowest position. Re-education was provided to staff regarding following care plan interventions. The fall care plan was updated to say staff were re-educated to follow fall prevention interventions (9/8/25). An occurrence note, dated 9/16/25 at 2:50 a.m., indicated Resident 6 was found sitting on the floor of his room with his legs bent in front of him, leaning against his bed. No injuries were identified. The personal alarm was in place but did not sound when the resident slid out of bed. Resident 6 stated he was sitting on the side of the bed and fell when the bed rolled out from under him. The immediate interventions were to move the bed, reset the bed alarm, and check the call light. The resident was given a drink and a snack. The root cause(s) of the fall were determined to be the brakes on the bed were not locked, the personal alarm was not sounding, and the resident was sitting on the side of the bed.A current care plan, initiated on 9/22/25 and revised 10/15/25, indicated Resident 6 had a history of self-transferring and lack of safety awareness. Interventions included making sure the call light was within reach and reminding the resident to use the call light to ask for assistance. An occurrence note, dated 10/9/26 (with a correction date of 10/10/25) at 6:36 a.m., indicated Resident 6 fell out of his wheelchair and hit his head while falling. He sustained a small bump on the head. No other injuries were noted. He was sent to the ER for a CT (radiology study) scan of his head. Immediate interventions were to help Resident 6 to his bed. He was encouraged to use the call light. The personal alarm was moved from the wheelchair to the bed and placed under the resident. Root cause(s) of the fall were determined to be the resident was drowsy, refused assistance, and was unsteady. The clinical record lacked an individualized fall prevention intervention following 10/10/25.An IDT fall follow-up note, dated 11/3/25 at 11:35 a.m., indicated the team met to review a fall that occurred on 11/1/25 at 4:50 p.m. Resident 6 was found lying on the floor with his knees next to the bed. No injuries were notes. Resident 6 stated he was not trying to get up. He was just sitting and probably slid off the bed. The nurse noted that the resident had only one non-skid sock in place. The nurse had failed to re-apply the resident's non-skid sock after completing a skin treatment. The IDT determined the nurse required re-education to ensure non-skid socks were in place prior to leaving the room.A quarterly MDS assessment, dated 11/18/25, indicated the resident was severely cognitively impaired, impaired on the left side of both his upper and lower extremities, used a walker and a wheelchair to ambulate, required substantial to maximal assistance for bed mobility, and was dependent for all transfers. An IDT fall follow-up note, dated 11/25/25 at 12:38 p.m., indicated Resident 6 fell on [DATE] at approximately 11:15 a.m. The resident was found sitting on the floor in front of his wheelchair near the entrance to the bathroom. He was assessed for injury and a scrape to his back was noted. The personal alarm did not sound. The CNA reported the alarm was malfunctioning. Resident 6 was assisted up to his wheelchair, then taken to the restroom.A quarterly MDS assessment, dated 12/30/25, indicated the resident was severely cognitively impaired, was impaired on the left side of both his upper and lower extremities, used a walker and wheelchair for ambulation, required substantial/maximal assistance for bed mobility (rolling left to right and sit to stand), and substantial/maximal assistance for tub/shower and toilet transfers. An occurrence note, dated 1/3/26 at 1:40 a.m., indicated a CNA found Resident 6 on the floor of his room, lying on his right side with his feet towards the bed and his head resting on his arm. The bed alarm was in place and working properly. Resident 6 stated he wanted to get up and walk over there. The bed was placed in low position, and the resident was reminded to use the call light for assistance. During an interview with the Director of Nursing (DON) and the Regional Nurse Consultant (RNC) on 3/11/26 at 1:58 p.m., the DON indicated it was her responsibility to update care plans. Some of the fall interventions for Resident 6 were resolved and were no longer applicable. Resident 6's cognition fluctuated and some days he was more capable of following fall interventions. Personal alarms were supposed to be checked every shift. When the battery was low, the alarm would start to beep. Sometimes, when staff replaced the batteries, they forgot to turn the alarm back on. The RNC indicated Resident 6 was often non-compliant with many things. The wheels on all beds should be locked in place. It was possible someone may have moved the bed and forgot to engage the locks. The bed controller, which raises and lowers the height of the bed and the head of the bed, was needed for staff when providing care. She thought Resident 6 might be responsible for raising the bed above the lowest position. She felt it was the resident's right to move the position of the bed if he wanted. A current facility policy, titled Fall Policy and Procedure, provided by the Administrator on 3/12/26 at 4:47 p.m., indicated the following: .7) All falls, regardless of injury, will be reviewed the following morning, during normal business hours, by the Interdisciplinary Team to determine if fall process was followed and an appropriate intervention was put in place. The care plan will be updated, and the CNA Care Guide will be reviewed to ensure new interventions are in place 410 IAC (Indiana Administrative Code) 16.2-3.1-45(a)(2)

Based on interview and record review, the facility failed to ensure an allegation of physical abuse was reported to the State Agency for 1 of 1 residents reviewed for abuse. (Resident 5)Resident 5's clinical record was reviewed on 3/10/26 at 8:59 a.m. Diagnoses included hemiplegia and hemiparesis (paralysis) following a cerebral infarction affecting the right dominant side.A progress note, dated 2/15/26 at 3:11 p.m., indicated Resident 5 called for the nurse to come to her room. The resident stated someone was really rough when changing her and her wrist got slammed on the wall. The nurse asked the resident what time it happened and Resident 5 stated it happened overnight. The aides were not paying attention and were in a rush. The resident's wrist was assessed and no redness or swelling were noted. The resident continued to complain of pain in the right wrist.A progress note, dated 2/15/26 at 3:14 p.m., indicated a new order for a right wrist x-ray.An acute care note, dated 2/16/26 at 3:55 p.m., indicated Resident 5 was seen for an acute visit for wrist pain. The resident reported the previous day that when nursing staff was providing care, they were really rough when changing her and her wrist got slammed against the wall. During the visit, the resident described how when she was turned, her arm fell off the bed and was bent backward. An x-ray of the wrist was ordered and results were pending.A follow-up note, dated 2/18/26 at 4:49 p.m., indicated Resident 5 was seen for a follow-up visit after a traumatic incident a few days prior. The right wrist x-ray, performed on 2/18/26, indicated a complete compression fracture of the lunate bone and partial compression fracture of the scaphoid bone (both bones found in the wrist). A previous x-ray of the right wrist from 11/2022 had a similar abnormal appearance of the lunate bone which suggested a lunate fracture. A CT scan of the wrist would be helpful for further characterization. The findings of the 2/18/26 x-ray of the right wrist were not acute fracture findings. Resident 5 reported diminishing pain in her wrist, describing it as sore. Recommendations were made for rest, ice, and elevation.During an observation and interview on 3/10/26 at 4:36 p.m., Resident 5 indicated she was doing just fine. When asked about her right wrist, she said it was fine. She did not remember her wrist getting hurt.A written and unsigned statement, provided by the DON on 3/11/26 at 3:20 p.m., indicated the following: CNA 23 and I (CNA 22) went into Resident 5's room at about (not legible) on 2/15/26 to get her dressed. We moved the bed away from the wall and I stood on one side. CNA 23 was on the other side, and we continued to get her dressed. She complained of right wrist pain and had CNA 23 put her brace on before CNA 23 went to get her a cup of coffee.A written statement by CNA 23, provided by the DON on 3/11/26 at 3:20 p.m., indicated the following: Aides (CNA 23 and CNA 22) entered resident's room between 4:00 and 4:30 a.m. to get resident dressed for the day. (We) gathered clothes and supplies and got started. CNA 22 pulled the bed away from the wall to stand on each side. I was on the side closest to the door. We got Resident 5 dressed and she asked for (her) brace to be put on. I ever so gently put brace on for resident, then went and made her a cup of coffee. Resident 5 complained of right wrist pain at the beginning of the shift. Stated someone was too rough. Signed and dated by CNA 23 on 2/15/26.During an interview with the DON and Regional Nurse Consultant (RNC) on 3/11/26 at 10:21 a.m., the DON remembered the incident was on a weekend but did not remember the details. When she interviewed Resident 5, the resident said nobody hurt her. The DON did not report the incident to the State Agency. The RNC indicated Resident 5 was not a reliable witness. During an interview with CNA 22 on 3/11/26 at 10:30 a.m., she indicated she knew nothing about the wrist until a nurse contacted her. The nurse asked CNA 22 to write out a statement about care provided to Resident 5 on the night of the incident. The nurse told CNA 22 about the resident's wrist hurting the day after CNA 22 and CNA 23 provided care. CNA 22 described how they moved the bed away from the wall and did not see anything unusual. Resident 5 said her wrist was hurting and CNA 23 put the brace onto Resident 5's right wrist. CNA 22 did not notice any redness or swelling of the right wrist.An interview with CNA 23 was attempted on 3/11/26 at 10:30. The voice mailbox was full, and no message could be left. Two more calls were attempted at 10:40 a.m. and 10:50 a.m. CNA 23 was not available for an interview.A current facility policy titled Reporting of Reasonable Suspicion of a Crime, Reporting, Investigate/Prevent/Correct Alleged Violations, provided by the RNC on 3/11/26 at 10:15 a.m., indicated the following: .It is the policy of this facility .to report any reasonable suspicion of crimes committed against a resident of this facility.The purpose of this policy is to ensure reporting of crimes occurring in federally funded long term care facilities is in accordance with the Social Security Act.11) Final report of the results of all investigations to the administrator or his/her designated representative and to other officials in accordance with State law, including to the State Survey Agency within five working days of the incident and if the alleged violation is verified appropriate corrective action must be taken.12) Facility has conducted a thorough investigation, have prevented further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress and all results of thorough investigation has been reported within five working days.410 IAC (Indiana Administrative Code) 16.2 - 3.1-28(c)

Based on observation, interview, and record review, the facility failed to provide accommodations to support a resident's ability to reposition in bed for comfort and safety and to have access to physician ordered respiratory supplies according to their plan of care 1 of 5 residents reviewed for accommodation of needs. (Resident 62) Findings include:During an observation, on 3/5/26 at 11:50 a.m., a sign hung on Resident 62's wall. The sign indicated Resident 62 was to only receive nectar thickened liquids when she was in an upright position, no straws, small sips were to be taken, the head of the bed was to be elevated to 90 degrees, and the resident was to be kept up for 30 minutes after meals. Resident 62 was lying on her back in her bed. The head of the bed was not elevated. A white foam cup, dated 3/5/26, with a lid and straw, sat on a bedside table that was positioned across the mid-section of Resident 62. A continuous pressure airway machine (CPAP, a machine to help breathing) sat on a nightstand at the head of the bed. No CPAP mask was present. Resident 62 indicated she preferred to wear the CPAP at times, per her discretion, but was unable to do so due to no mask being available. She was unable to recall the last time a mask was present in her room. Resident 62 was unable to elevate the head of her bed due to not having a handheld bed control remote. The bed was controlled by staff by the controls that were located on the footboard of the bed. She drank her fluids while lying flat.During an observation, on 3/6/26 at 10:40 a.m., the head of Resident 62's bed was elevated less than 30 degrees in the bed with controls at the footboard. A CPAP mask was not present.During an observation, on 3/9/26 at 11:02 a.m., a nurse entered Resident 62's room and elevated the residents head of the bed with the controls at the footboard, administered the resident's medication, and then lowered the head of the bed prior to her departing the room. During an observation, on 3/9/26 at 4:13 p.m., a CPAP mask was not present in Resident 62's room.During an observation, 3/10/26 at 9:43 p.m., a CPAP mask was not present in Resident 62's room.Resident 62's clinical record was reviewed on 3/11/26 at 11:16 a.m. Diagnoses included dysphagia at the oropharyngeal stage (difficulty initiating to swallow), chronic obstructive pulmonary disease (COPD, incurable lung disease), gastro-esophageal reflux (GERD, backflow of stomach acid into the esophagus), obstructive sleep apnea (sleep disorder), and hemiplegia and hemiparesis following a cerebral infarctions (paralysis and weakness after a stroke).Current physician orders included BIPAP (Bilevel Positive Airway Pressure, a machine to help breathing) on while sleeping, head of bed elevated per resident preference to prevent shortness of breath while lying flat related to COPD, and reduced carbohydrate diet, mechanically soft with ground meat texture, and nectar thick liquid consistency.A quarterly Minimum Data Set (MDS) assessment, dated 2/5/26, indicated Resident 62's cognitive status was intact. Resident 62 had no impairment to functional range of motion in her upper and lower extremities. She required set up or clean up assistance for eating and was dependent on staff for rolling left and right. She received a mechanically altered diet which required a change in the texture of food or liquids. She received oxygen therapy.A current care plan, dated 8/12/24, indicated Resident 62 had COPD, received oxygen and nebulizer treatments, and the residents head of bed was to be elevated to alleviate shortness of breath while lying flat. Interventions included the following: BIPAP as ordered (2/17/25) and head of bed to be elevated or out of bed upright in a chair during episodes of difficulty breathing (8/12/24).A current care plan, revised 2/6/26, indicated Residents 62 had an activity of daily living performance deficit related to a stroke, seizures, and impaired mobility. Interventions included the following: Resident 62 was dependent for bed mobility and required the assistance of two staff members (2/6/26) and the resident was able to feed self (8/12/24).A current care plan, dated 8/12/24, indicated Resident 62 was at risk for a potential alteration of nutrition and/or weight status related to her having a diagnosis of diabetes, COPD, anemia, anxiety, GERD, and schizophrenia. She needed a therapeutic diet. Interventions included the following: encourage the resident to consume fluids (8/12/24), monitor for signs and symptoms of dysphasia and swallowing/chewing problems (8/12/24), serve diet as ordered, mech soft ground meat and nectar thickened liquids (3/26/25).During an observation, on 2/11/26 at 1:42 p.m., no CPAP mask was present in Resident 62's room.During an interview, on 3/11/26 at 1:43 p.m., CNA 15 indicated Resident 62 was alert and voiced her wants and needs. She had a bed remote in her room and used it to control the bed. The resident attached it to the call light so she could reach both at the same time. The resident received thickened liquids. The resident laid on her back most of the time per her request and preference.During an interview, on 3/11/26 at 1:47 p.m., Resident 62 indicated she was unsure why she never had a handheld bed remote. She was aware she was to sit up with liquids but was unable to do so without a bed remote and she often took drinks of her fluids while lying flat. She wanted a bed remote so she could use it accordingly. During an interview, on 3/11/26 at 1:51 p.m., LPN 6 indicated Resident 62 was alert and oriented and able to voice needs and wants. Resident 62 used to wear her CPAP and had a mask in her room previously, but she began to refuse to wear it, so the electronic treatment administration record was marked as refused. Resident 62's bed was controlled by the buttons on the foot board. The resident would be able to use bed remote if one was available to her. If Resident 62 wanted the head of the bed elevated to drink her liquids, the resident used the call light and staff elevated the head of the bed for her.During an interview, on 3/11/26 at 1:53 p.m., Unit Manager 4 indicated Resident 62 did not want to use her CPAP most of the time. She was unsure when a CPAP mask was last in the resident's room. She was not sure about the bed not having a handheld bed remote. A lack of having a bed remote prevented and restricted Resident 62 from independent movement and position changes. Resident 62 was on thickened liquids due to a failed swallow study (an exam to evaluate safety of swallowing). The resident would often take a drink and lay right back down.During an interview, on 3/11/26 at 1:55 p.m., CNA 16 indicated she always used the buttons on the footboard to control Resident 62's bed. She had never observed a handheld bed remote on Resident 62's bed.During an interview, on 3/11/26 at 2:17 p.m., Unit Manager 4 confirmed Resident 62 did not have a bed remote in her room. She had not been aware previously that the bed did not contain a handheld remote.During an interview, on 3/11/26 at 2:40 p.m., the DON indicated there was not a known reason why Resident 62 did not have a handheld bed remote. Resident 62's positioning was restricted due to not having a bed remote. She did not know the facility had any beds without a handheld bed remote.During an interview, on 3/11/26 at 2:40 p.m., the Nurse Consultant indicated Resident 62 was to have a handheld bed remote and not having one could put the resident at risk for complications. She was unaware the facility had any beds without a handheld bed remote. The facility did not have a policy pertaining to bed remotes or accommodation of needs.A facility policy, dated 10/17, titled COMPREHENSIVE CARE PLANS, provided by the Administrator, on 3/12/26 at 4:44 p.m., included the following: Policy: The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident's rights and that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment.The facility must establish, document, and implement the care and services to be provided to each resident to assist in attaining or maintaining his or her highest practicable quality of life. 410 IAC (Indiana Administrative Code) 16.2 - 3.1-3(v)(1)

Based on interview and record review, the facility failed to provide supervision for a cognitively impaired resident residing on the secured unit resulting in the resident (Resident B) leaving the secured unit twice without supervision.Findings include:Resident B's clinical record was reviewed on 10/27/25 at 10:59 a.m. Diagnoses included anxiety, depression, vascular dementia with behaviors, and stage 3 chronic kidney disease. The resident was admitted to the facility on [DATE].A current quarterly MDS (Minimum Data Set) assessment, dated 8/30/25, indicated the resident had no current behaviors and was able to ambulate independently and was severely cognitively impaired.A care plan related to elopement risk, dated 3/22/21, indicated the resident demonstrated exit seeking behaviors. Interventions included escorting the resident outside and use of distractions. A care plan related to exit seeking behaviors, dated 6/8/21, indicated the resident may shake and push/fidget with doors in an attempt to leave the facility.An elopement risk assessment dated [DATE], indicated the resident was at risk for elopement.A facility reported incident, dated 7/22/25, indicated the resident was found wandering unsupervised outside of the secured courtyard fence. During an interview on 10/27/25 at 11:43 a.m., the Memory Care Coordinator indicated residents were observed and the doors on the unit were secure. The Memory care Coordinator indicated she reminded staff to make sure doors were closed tight. She reminded visitors and staff to make sure no one followed them off the unit. On 7/22/25, the residents were having an activity in the courtyard. They were located near the entrance door. Resident B was ambulating around the secured area, then went back inside the facility. The Memory Care Coordinator was not sure how the resident was able to leave the secured courtyard without being noticed. The resident was found on the side of the building right before the driveway (parking lot), unsupervised. A CNA was on break and saw her. It was not known how long she was out there unsupervised. During an interview on 10/27/25 at 1:10 p.m., the Administrator indicated she watched security video for 7/22/25 and saw Resident B exit the building and less than 3 minutes later, she was seen being brought back into the facility by CNA 3. During an interview on 10/27/25 at 1:22 p.m., CNA 3 indicated, on 7/22/25, she saw the resident around lunch time. CNA 3 was not sure of the time but remembered it was in the afternoon. CNA 3 had exited the facility through a side door and observed the resident in the parking lot. She asked the resident what they were doing and the resident said, I got out. CNA 3 was able to redirect the resident back into the facility without difficulty. CNA 3 indicated the resident did not have a lot of exit seeking behaviors but when she did, she is bad. The residents would go to every single door and try to open them. No further information was provided prior to exit from the facility. This citation is related to intake 2646064.3.1-45 (a)(2)

Based on observation and interview, the facility failed to provide a safe and comfortable environment for 3 of 4 residents reviewed for homelike environment. (Resident C, Resident D and Resident 42) Findings include: Resident D's clinical record was reviewed on 2/12/25 at 10:38 a.m. Diagnoses included type 2 diabetes mellitus, chronic kidney disease, muscle weakness, and abnormality of gait and mobility. During an interview, on 2/12/25 at 12:09 p.m., Resident D indicated maintenance would be replacing her countertop. She used the countertop to help herself balance during transfers. They had not fixed the countertop at that time, as they had to order a new one. During a room observation, on 2/12/25 at 12:17 p.m., room [ROOM NUMBER]'s bathroom countertop was pulling away from the wall. It had a small gap between the backsplash and the wall. The countertop moved downward when pressure was placed on top of it. During an interview, on 2/12/25 at 1:17 p.m., Resident D indicated she went to get up from the toilet, twisted her knee wrong and was able to lower herself down to the floor. She used the loose countertop to get herself off the floor. She always transferred on her own. An Interdisciplinary Team (IDT) progress note, dated 2/10/24 at 1:29 p.m., indicated Resident D reported she attempted a self-transfer from the toilet to her wheelchair, lost her balance, and fell to one knee. The resident reported she was able to get herself back into her wheelchair and was not injured. Her bathroom was assessed and non-skid strips were in front of the toilet, there was a grab bar on the right-hand side of toilet, and a toilet seat riser. Her countertop was beginning to deteriorate and was loose when pressure was applied to the top of the counter. Resident D reported that she used the countertop to balance herself during transfers and felt that movement may have contributed to her fall. A maintenance request was put in for her countertop to be replaced. During an interview, on 2/12/25 at 1:22 p.m., the Maintenance Supervisor indicated he had Resident D's bathroom countertop in his office since Monday, it was just a matter of getting the time to install it. The countertop needed the hole cut out for the sink to drop in. He felt it was late last week when he was notified that her bathroom countertop was loose. He was unable to restructure/brace the existing countertop due to ADA guidelines. 2. During an interview, on 2/11/25 at 10:32 a.m., Resident C indicated she had paint missing from her walls where she and her roommate's bed were rubbing up against the wall, causing it to scrape into the drywall. She had complained to the maintenance department regarding wanting her room fixed and repainted. It had been like that for the last four months. During an observation, at the time as the interview, Resident C's room had numerous areas just above the bed, where the bed frame had scrapped into the drywall causing small holes and paint to be missing. During an interview, on 2/12/25 at 1:22 p.m., the Maintenance Supervisor indicated Resident C had asked previously when her walls would be fixed. He spoke with Resident C weekly regarding painting her walls. He wasn't able to put a timeframe on when it would be fixed, as he has other issue that need fixed with a higher level of severity. A random observation of the 300 hall, on 2/12/25 at 11:09 a.m., indicated the following: room [ROOM NUMBER] had missing paint and gouges of missing drywall, above the resident's bed. A large area, approximately the size of an index cared, of missing paint and the top layer of drywall was missing around the door frame of the soiled utility room. 3. During an observation, on 2/17/25 at 1:56 p.m., Resident 42's window sill behind her bed's headboard had a hole approximately the size of an index card and approximately one inch deep. It was covered with plastic and paper tape that was peeling off. During an interview, on 2/17/25 at 1:58 p.m., QMA 11 indicated the area had been there since January 2025. She had not reported it to maintenance, and she was unsure if anyone else had reported it. During an interview, on 2/17/25 at 1:59 p.m., LPN 12 indicated the area in Resident 42's window sill had been there for at least a month. She was uncertain if it had been reported to maintenance. During an interview, on 2/17/25 at 2:04 p.m., the Maintenance Supervisor indicated he was just notified on Friday regarding the residents window sill. He thought he had a board to fix it but needed to get a bigger board. During an interview, on 2/17/25 at 2:23 p.m., the Administrator indicated they did not have a facility policy regarding environment. This citation relates to Complaints IN00449079, IN00449973, and IN00452205. 3.1-19(e)

Based on observation, interview, and record review, the facility failed to maintain water temperatures at a comfortable level for 4 of 7 residents reviewed for comfortable water temperatures on the 300 Hall. (Residents C, D, E, F) Findings include: On 2/10/25 at 11:28 a.m., the following was observed: The hot water in room [ROOM NUMBER]'s bathroom sink reached a temperature of 96.8 degrees Fahrenheit (F) after it ran for five minutes. The hot water in room [ROOM NUMBER]'s bathroom sink reached a temperature of 100 degrees F after it ran for three minutes. During an interview, on 2/10/25 at 2:20 p.m., Resident E indicated the water from her bathroom sink was always cold, even after letting the water run for a while. It had been like that for the last 3-4 months. During an interview, on 2/11/25 at 10:32 a.m., Resident C indicated the water from her bathroom sink was cold all the time. During an observation, on 2/11/25 at 10:35 a.m., the hot water in Resident C's bathroom sink was turned on, and after letting the water run for three minutes, the water was lukewarm to touch. During an interview, on 2/11/25 at 10:59 a.m., Nurse Assistant 5 indicated some residents had complained of cold water in their bathrooms. Some rooms only had lukewarm even after running the water for a while. During an interview, on 2/11/25 at 11:03 a.m., the CNA Coordinator indicated residents had been complaining of cold water in their bathroom sinks. Further down the 300 hall you went, the colder the water was. She had to turn the water on and walk away for a while, so the water had time to warm up. She had waited over 20 minutes to get hot water in some of the resident rooms. Maintenance had been notified regarding the water being cold. During an interview, on 2/11/25 at 11:07 a.m., CNA 7 indicated the bathroom sink water in room [ROOM NUMBER] only ever got lukewarm. You needed to let the water run a while before it would get warm. Maintenance had been notified regarding the cold water down the 300 hall. During an interview, on 2/12/25 at 1:22 p.m., the Maintenance Supervisor indicated residents had complained about lack of hot water toward the end of 300 hall. He had performed temperature checks and the water did get above 100 degrees F. The other day, room [ROOM NUMBER] took eight minutes to get hot water. He told staff members, in order to get hot water, they needed to let the water run a while. Weekly water temperature audit logs were obtained from the Maintenance Supervisor on 2/12/25 at 2:25 p.m., and indicated the following: 2/11/25: room [ROOM NUMBER] was 118 degrees F room [ROOM NUMBER] was 115 degrees F room [ROOM NUMBER] was 111 degrees F room [ROOM NUMBER] was 109 degrees F The water temperature audit logs did not indicate how long the water had run to reach those temperatures. 2/4/25: room [ROOM NUMBER] was 114 degrees F room [ROOM NUMBER] was 116 degrees F room [ROOM NUMBER] was 109 degrees F The water temperature audit logs did not indicate how long the water had run to reach those temperatures. 1/23/25: room [ROOM NUMBER] was 116 degrees F room [ROOM NUMBER] was 117 degrees F room [ROOM NUMBER] was 114 degrees F The water temperature audit logs did not indicate how long the water had run to reach those temperatures. During an observation, on 2/13/25 beginning at 2:57 p.m. and ending at 3:28 p.m., accompanied by the Maintenance Supervisor, the following hot water temperatures were obtained: The hot water in room [ROOM NUMBER]'s bathroom sink reached 97.8 degrees F after the water ran for 15 minutes. The hot water in room [ROOM NUMBER]'s bathroom sink reached 97.7 degrees F after the water ran for 6 minutes. Upon returning to room [ROOM NUMBER], the hot water in the bathroom sink reached over 100 degrees after four minutes. Upon returning to room [ROOM NUMBER], with the water still running, the water reached 100 degrees F after running for over seven minutes. During an interview, on 2/13/25 at 2:59 p.m., the Maintenance Supervisor indicated he had a plumber in the building earlier that morning to discuss adding a recirculating pump to the end of 300 hall to help with hot water circulation. During an interview, on 2/17/25 at 2:23 p.m., the Administrator indicated they did not have a facility policy regarding environment and hot water. This citation relates to Complaints IN00449079, IN00449973, and IN00452205. 3.1-19(f)(5)

Based on observation, interview, and record review, the facility failed to ensure staff implemented transmission based precautions for 2 of 8 residents reviewed for infection control. (Residents D and Resident 62) Findings include: Resident 62's clinical record was reviewed on 2/10/25 at 1:38 p.m. Diagnoses included osteomyelitis of vertebra, thoracic region, cerebral infarction, COVID-19, depression, and cognitive communication deficit. Physician orders, dated 2/5/25 at 2:00 p.m., indicated transmission based (droplet) precautions were to be observed for 9 days for COVID-19. All services were to be received in his room. On 2/10/25 at 10:47 a.m., a sign on Resident 62's door indicated the resident was on droplet precautions. The Certified Occupational Therapy Assistant (COTA) exited the room wearing a surgical mask and glasses. The COTA indicated she would remove personal protective equipment (PPE) when exiting a room. She would replace the N-95 mask with a surgical mask. Her personal glasses were not covered by protective eyewear because she was not able to see well with goggles over her glasses. Resident D's clinical record was reviewed on 2/10/25 at 2:18 p.m. Diagnoses included hypothyroidism, anxiety, chronic combined systolic and diastolic heart failure, and bipolar disorder. Physician orders, dated 2/3/25 at 10:00 p.m., indicated droplet precautions were to observed for 10 days. The resident tested positive for COVID-19. All services were to be received in her room. On 2/11/25 at 10:40 a.m., an Activities Assistant was observed entering Resident D's room. A sign on the door indicated the resident was on droplet precautions. The Activities Assistant donned a gown and a surgical mask. She did not don gloves or protective eyewear. During an interview, at the time of the observation, the Activities Assistant indicated staff should don gloves, a gown, an N-95 mask, and protective eyewear. She forgot to wear the goggles. During an interview with Nurse Assistant 5, on 2/11/25 at 10:59 a.m., she indicated staff should wear a gown, mask, and protective eyewear when entering the room of a resident diagnosed with COVID-19. During an interview with the Certified Nursing Assistant Coordinator, on 2/11/25 at 11:03 a.m., she indicated staff should wear protective eyewear, a mask, an N-95 mask, gloves, and gown when entering the room of a resident diagnosed with COVID-19. Even if staff wore glasses, they should put protective eyewear over the glasses. During an interview with CNA 7, on 2/11/25 at 11:07 a.m., she indicated staff should wear gloves, a gown, an N-95 mask, and protective eyewear when entering the room of a resident diagnosed with COVID-19. Staff wearing glasses should also don protective eyewear over them. During an interview with LPN 10 on 2/11/25 at 1:34 p.m., she indicated staff should wear a gown, an N-95 mask, protective eyewear, and gloves when entering the room of a resident diagnosed with COVID-19. Goggles should be worn over eyeglasses. A current 7/5/21 facility policy, titled Transmission Based Precautions Infection Control, provided by the Administrator on 2/17/25 at 4:35 p.m., indicated the following: .It is the policy of (the facility) to take appropriate precautions to prevent transmission of infectious agents. Transmission based precautions are for resident's who are known or suspected to be infected or colonized with infectious agents, including certain epidemiologically important pathogens, which require additional control measures to effectively prevent transmission. These precautions are to be used in adjunct with standard precautions .Droplet Precautions .a) Intended to prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions (respiratory droplets that are generated by a resident who is coughing, sneezing, talking, or singing) .d) Healthcare personnel must wear a mask (surgical, N-95, approved KN95, or respirator when appropriate) 3.1-18(a)

Based on observation, interview, and record review, the facility failed to ensure an antipsychotic medication was not initiated without indication for 1 of 5 residents reviewed for unnecessary medications. (Resident 15) Findings include: Resident 15's clinical record was reviewed on 2/17/25 at 9:32 a.m. Diagnoses included generalized anxiety disorder, alcohol dependence (in remission), hypertension, sedative, hypnotic, or anxiolytic dependence (uncomplicated), cognitive communication deficit, and unspecified dementia (unspecified severity - with other behavioral disturbance). A quarterly MDS, dated [DATE], indicated the resident had active diagnoses of anxiety, depression, and a psychotic disorder (other than schizophrenia). Current orders included buspirone (anti-anxiety) 5 mg tablet give 1 tablet by mouth three times a day, tramadol (opiate pain reliever) 50 mg tablet give 1 tablet by mouth every 8 hours as needed, quetiapine fumarate (anti-psychotic) 25 mg give 1 tablet by mouth at bedtime, and behavior assessment to be performed every shift due to psychotropic medications. A current, 3/20/22, care plan indicated the resident had a diagnosis of insomnia. She had daytime tiredness, irritability, depression and/or anxiety. Interventions included gradual dose reductions (GDRs) as ordered, medications as ordered, observe for signs and symptoms of adverse reactions to medications and notify they physician of any concerns, provide a relaxing environment for the resident, and psych services as ordered. A current, 3/30/22, care plan indicated a diagnosis of generalized anxiety disorder, described as persistent worrying or anxiety about a number of areas that were out of proportion to the impact of the events, restlessness, fatigue, crying, verbal behaviors, difficulty concentrating, irritability, multiple health complaints, and tearfulness. The resident worried about her husband and daughter when unable to reach them by phone. Interventions included medications as ordered, the nurse(s) were to assess health complaints, observe and document resident for signs and symptoms of increased anxiety, offer medications for health complaints when available, provide a calm, relaxing environment for resident, and provide reflective listening and reassurance to the resident. A current, 3/30/22, care plan indicated a diagnosis of major depressive disorder, described as feelings of sadness, tearfulness, emptiness or hopelessness, fatigue, lack of energy, loss of appetite or overeating, loss of interest, and lack of concentration. Interventions included allowing the resident time to voice feelings and frustration, GDRs as ordered, medications as ordered, observe the resident for signs and symptoms of increased depression (and document), and observe for signs and symptoms of adverse reactions to medications as listed on the behavior/intervention monthly flow record. A current, 3/30/22, care plan indicated the resident had the potential for increased signs and symptoms of depression related to her diagnoses of depression, alcohol dependence, and depression assessment indicators. Interventions included allowing the resident to vent her feelings, using good listening techniques, encourage family and social interactions, encourage involvement in daily needs and concerns, monitor for signs and symptoms of depression, provide a caring and structured environment and routine, and use supportive words and reassurance during contact with the resident. A current, 3/30/22, care plan indicated the resident had a history of making negative statements, i.e., stating she wished to disappear, wanted to harm herself (but then stated she just wanted God to kill her), wished she were dead, and wanted to die because her stomach hurt. She indicated she was Catholic and would never harm herself. She often had those ideations during times of pain or when requesting more pain medications. Interventions included assessing the resident for pain, assisting the resident to call her family members, medications as ordered for depression, observe any changes in mood, appetite, change in sleep patterns, or any increased verbalizations of being depressed or blue, and provide reflective listening and reassurance to the resident. A current, 3/30/22, care plan indicated the resident exhibited anxious verbalizations, i.e., yelling out continuously, even with redirection, and crying out loudly that she was dying. Interventions included introducing the resident to peers with similar interests, offer a small conversation to help calm and reassure the resident, and offer a back rub or repositioning. A current, 9/28/22, care plan indicated the resident had impaired cognitive function or impaired thought processes related to a dementia diagnosis. The resident needed supervision with all decision making. Interventions included keeping her routine consistent and provide consistent care givers as much as possible, in order to decrease confusion. A current, 9/28/22, care plan indicated the resident had a diagnosis of alcohol and sedative/hypnotic/anxiolytic dependence. Interventions included offering validation, empathy, and listening techniques, identifying triggers that led to urges of alcohol use, observe and report to the physician any changes in mood (withdrawal) or urges to use alcohol. A current, 7/17/23, care plan indicated the resident had a diagnosis of psychosis. She took antipsychotic medications related to the following behaviors - pain, constipation, multiple health conditions, money, yelling out, statements that she was dying because her stomach hurt, uncontrollable sobbing, calling 911 frequently, and verbal aggression towards the staff and her roommate. Interventions included GDRs as ordered, medications as ordered, observe for signs and symptoms of adverse reactions to medications as listed on the behavior/intervention monthly flow record, observe for side effects of medications and notify physician of any concerns, and psych services as ordered. A behavior note, dated 4/13/24 at 5:24 p.m., indicated the resident had been walking around the building with her roommate. During resident care, she told the nurse she needed her pain pill. The nurse explained it was not yet time for the pill. The nurse offered acetaminophen instead. The resident argued that it was time for her pain pill. The nurse tried to explain why the pain pill could not be given but the resident continued to argue with the nurse. The behavior assessment indicated the resident was irritated. A behavior note, dated 5/10/24 at 10:21 a.m., indicated the resident refused to get out of bed. A nursing progress note, dated 12/1/24 at 11:49 a.m., indicated the resident requested pain medication. She wanted to go to the emergency room to get some good meds. The resident yelled that she wanted to die. She had no plans to hurt herself. She was placed on 15 minute checks at that time. A social service progress note, dated 1/14/25 at 9:11 a.m., indicated the resident was on buspirone two times and day for anxiety and quetiapine 25 mg once daily at bedtime for depression. The resident had no behaviors since 5/10/24. A physician's progress note, dated 1/29/25 at 2:36 p.m., indicated the resident was seen to follow up on hip pain. The resident had complained of pain in her right hip and threatened to call 911. She wanted to go to the hospital. The pain radiated from her right hip into her leg. The pain medication was not helping. The resident was repositioned at that time. A nursing progress note, dated 2/5/25 at 2:36 p.m., indicated the resident was upset because her pain medication was not helping her pain. The nurse practitioner discontinued her narcotic pain medication at that time and started the resident on acetaminophen (Tylenol) 1000 mg, three times a day and tramadol 50 mg, three times a day as needed. A behavior progress note, dated 2/11/25 at 9:40 a.m., indicated the resident refused to go to a doctor's appointment. She had been sick all night and did not want to go to the appointment. Her behavior was described as upset and anxious. A physician's progress note, dated 2/11/25 at 3:43 p.m., indicated the resident was not feeling well and stated she was a ball of nerves. She denied having concerns about anything in particular. She refused to go to an outside doctor's appointment that day and denied having any pain. The resident's buspirone was increased to three times a day. During an interview with CNA 14, on 2/17/25 at 11:19 a.m., she indicated Resident 15 would often have her call light going off every few minutes, complaining of pain. Even when told she was not due for a medication, she would continue to ask the nurse for pain medication. She would follow the nurse around, sometimes into other resident's rooms. During an interview with the Activities Assistant (AA), on 2/17/25 at 11:22 a.m., she indicated the resident cried sometimes because she was lonely or did not feel well. No hallucinations or delusions were observed by the AA. The resident often complained of pain. During an interview with QMA 15, on 2/17/25 at 11:24 a.m., she indicated the resident had good and bad days. Interventions were implemented but did not always work. When interventions were unsuccessful, the staff would document the behavior. Most often, the behavior was related to pain. The resident had never said anything about hearing voices or seeing things that were not there. During an interview with the Director of Nursing (DON), on 2/17/25 at 4:42 p.m., she indicated most of Resident 15's behaviors were complaints of pain. She would sometimes say she felt like she was losing her mind. The resident had a long history of addiction. A summary of the black box warning for quetiapine, retrieved from https://www.nami.org/about-mental-illness/treatments/mental-health-medications/types-of-medication/quetiapine-seroquel/ on 2/18/25 at 12:08 p.m., indicated the following: .Increased Mortality in Elderly Patients with Dementia Related Psychosis - When used for dementia related psychosis in elderly patients, both first generation (typical) and second generation (atypical) antipsychotics are associated with an increased risk of mortality A current facility policy, with a revision date of 10/2022, and titled Psychotropic Medication Policy, was provided by the Administrator on 2/17/25 at 1:30 p.m. The policy indicated the following: .Behavioral interventions are individualized, non-pharmacological approaches to care that are provided as part of a supportive physical and psychosocial environment, directed toward understanding, preventing, relieving, and/or accommodating a resident's distress or loss of abilities, as well as maintaining or improving a resident's mental, physical or psychosocial well-being .Expressions or indications of distress refers to a person's attempt to communicate unmet needs, discomfort, or thoughts that he or she may not be able to articulate. The expressions may present as crying, apathy, or withdrawal, or as verbal or physical actions such as pacing, cursing, hitting, kicking, pushing, scratching, tearing things, or grabbing others .Medication Management: .The facility will ensure to the extent possible that the following are met regarding medication management .Selection of medications(s) based on assessing relative benefits and risks to the individual resident .Evaluation of a resident's physical, behavioral, mental, and psychosocial signs and symptoms, to identify the underlying cause(s), including adverse consequences of medications .The facility will ensure each resident's clinical record contains the following: 1) Indication and clinical need for medication .Additionally, the facility will ensure when administering psychotropic medication, the following is met: Giving psychotropic medications only when necessary to treat a specific diagnosed and documented condition .Residents must not receive any medications which are not clinically indicated to treat a specific condition. The medical record must show documentation of the diagnosed condition for which a psychotropic medication is prescribed .Facility shall not use these types of brain altering medications .unless there is documented clinical indication for the use .The facility will use extreme caution in utilizing antipsychotic medications in the elderly. The following will be considered prior to initiation of antipsychotic medication: Behavioral symptoms present a danger to the resident or others 3.1-48(a)(4)

Based on observation, interview, and record review, the facility failed to ensure residents with dementia did not receive anti-psychotic medications without indication and individualized interventions for behavior expressions were implemented for 2 of 5 residents reviewed for dementia care (Resident 33 and Resident 61). Findings include: 1. During an observation, on 2/10/25 at 3:50 p.m., Resident 33 walked with a shuffling gait in the activity/dining area with his hands in his pockets. He was encouraged by a staff member to participate in an activity and was assisted to sit in a chair. On 2/12/25 at 10:09 a.m., Resident 33 shuffled up and down the hall with his hands in his pockets. On 2/12/25 at 12:40 a.m., Resident 33 talked nonsensically to his tablemate while sitting at a dining table. He moved food around on his plate, then poured water on it. He put small pieces of his pie in his water glass with his fork, then he ate small bites of the pie from his water glass. On 2/14/25 at 3:39 p.m., Resident 33 was lying in bed with his eyes closed. Resident 33's clinical record was reviewed on 2/13/25 at 2:03 p.m. Diagnoses included personal history of other mental and behavioral disorders, anxiety disorder, unspecified, primary insomnia, unspecified symptoms and signs involving cognitive functions and awareness, depression, unspecified, unspecified dementia, unspecified severity, with anxiety, and unspecified dementia, unspecified severity, with psychotic disturbance. A physician's order for quetiapine fumarate 12.5 mg daily was started on 7/13/21 and was discontinued on 8/31/24. Current physician's orders included venlafaxine (antidepressant) 75 milligrams (mg) daily (started 12/17/24), melatonin (sleep aid) 3 mg daily at bedtime (started 3/25/21), and quetiapine fumarate (antipsychotic) 25 mg daily (started 9/18/24). A quarterly Minimum Data Set (MDS) assessment, dated 9/12/24, indicated the resident was severely cognitively impaired. The resident did not experience hallucinations or delusions during the assessment period. The resident did not exhibit behavioral symptoms during the assessment period. The resident did not reject care or wander during the assessment period. An annual MDS assessment, dated 1/23/25, indicated the resident was severely cognitively impaired. The resident did not experience hallucinations or delusions during the assessment period. The resident did not exhibit behavioral symptoms during the assessment period. The resident did not reject care or wander during the assessment period. A current care plan, initiated on 3/30/21 and revised on 1/19/23, indicated the resident had impaired cognitive function and/or thought processes related to diagnoses of dementia and physical behaviors related to not understanding a situation or his peers' behavior who have dementia. He believed what he saw on television. Interventions included the following: Keeping the resident's routine consistent and try to provide consistent caregivers as much as possible to decrease confusion (3/30/21) and providing a homelike environment (3/30/21). A current care plan, initiated on 4/20/21 and revised on 11/27/22, indicated the resident refused care at times. The resident picked at his food and declined to eat very much. Interventions included the following: Attempting to use a different staff member if the resident was uncomfortable with the current staff (4/20/21), educating the resident on the importance of care the staff were trying to provide (7/27/21), reapproaching the resident at a later time (4/20/21), and allowing the resident to assist with his care, by soaping up the wash cloth and handing it to him (10/15/24). A current care plan, created on 6/17/21 and revised on 5/2/24, indicated the resident may urinate/defecate in inappropriate places at times (trash can, dining room floor, dresser drawer). The resident stuck things in his pocket (i.e. butter knife) as if he is carrying a comb. He had a history of carrying a brush in his pocket. Interventions included the following: Assisting the resident with toileting before bed (11/25/24), assessing the resident for pain (initiated 6/17/21 and revised on 4/14/22), encouraging the resident to toilet frequently (initiated 6/17/21 and revised on 4/14/22), observing the resident meal tray after meals for all utensils (3/6/24), providing one on one reassurance and assistance (initiated 4/13/22 and revised on 6/28/22), and showing the resident the bathroom (initiated 6/17/21 and revised 4/14/22). A current care plan, created on 3/10/22 and revised on 1/23/23, indicated the resident may be verbally aggressive and may threaten to smack staff, cause harm to someone, talk about guns, and threaten to punch a peer. Interventions included the following: Assessing the resident for an unmet need (3/10/22), assessing the resident for pain (3/10/22), ensuring the resident is safe and ceasing interaction (3/10/22), redirecting the resident with conversation and activities he enjoys (3/10/22), and using a different caregiver if possible (3/10/22). A current care plan, created 12/26/22 and revised on 1/24/25, indicated the resident had threatened to hit staff and peers when he got agitated. He would raise his hand and shake it. He had not hit any peers. Interventions included the following: Allowing the resident to wash his own private parts assisting with putting soap on wash cloth and handing it to the resident and explaining what to do (7/3/24), allowing the resident to be up out of bed a bit before providing care when possible (1/10/25), assessing resident for a need that might be contributing to his behavior (12/26/22), redirecting the resident with activities such as listening to music he prefers like Elvis and Buddy [NAME] (11/21/24), intervening to make sure the resident and his peers are safe (12/26/22), walking away if resident is being physically aggressive with staff (11/8/23), and walking away from the resident and reapproaching after several minutes (6/10/24). A current care plan, created and initiated on 9/17/24, indicated the resident walked up and down the hallway and hits the rails, the wall, and the nurse's cart. Interventions included the following: assess the resident for pain when he is hitting things (9/17/24), distract the resident with snack such as cookies and chocolate milk and cokes (initiated 9/17/24 and revised 1/23/25), the resident likes to listen to music and dance to the music this will redirect him at times (9/17/24), and try to distract the resident with activities of his choice when he is walking up and down the hall hitting things (9/17/24). A current care plan, created and initiated 10/1/24, indicated the resident had a diagnosis of unspecified psychosis and took an antipsychotic medication for behaviors related to this condition. Interventions included the following: Giving medication as ordered from physician (10/1/24), the resident enjoys Buddy [NAME] and Elvis Presley's music. Playing music for resident while being redirected from behaviors. (initiated 10/1/24 and revised 1/24/25), notifying the physician if the resident is having increased behaviors (10/1/24), and redirecting the resident from behaviors by engaging him in activities of his choice. He enjoys ball toss and listening and dancing to music (10/1/24). A current care plan, created 10/23/24 and revised 2/13/25, indicated the resident may take other residents' food and drinks in the dining room and will sometimes swat at staff. Interventions included the following: Moving the resident to another table (10/23/24), giving the resident's drinks to him in a clear cup (10/23/24), and offering to refill the drink if the resident drinks all of his drink (initiated 10/23/24 and revised 1/2/25). A current care plan, created and initiated on 11/26/24, indicated the resident receives psych services. Interventions included the following: Acting as a liaison between the facility, the resident, the psych personnel, and the family (11/26/24), encouraging the resident to express his feelings to the psych personnel (11/26/24), and introducing the resident to the psych personnel (11/26/24). A current care plan, created 1/23/23 and revised on 1/23/23, indicated the resident had a decline in mental status related to dementia. Interventions included the following: Allowing the resident to voice his concerns and reassure him (2/7/25), assisting the resident with tasks as needed (1/23/23), and redirecting the resident as appropriate (1/23/23). A current care plan, created 12/17/24 and revised 12/17/24, indicated the resident had depression and received an antidepressant. Interventions included the following: Allowing the resident to express his feelings and provide emotional support as needed (12/17/24), giving medications as ordered (gradual dose reduction as appropriate) (12/17/24), and notifying the physician if the depression worsened or did not get better (12/17/24). A current care plan, created 1/23/23 and revised on 5/2/24, indicated the resident walked about the unit and sometimes into other residents' rooms. He sometimes wandered and whistled because he forgot where his room was located related to his dementia. Interventions included the following: Allowing the resident to wander in a safe and unobtrusive way (1/23/23), encouraging the resident to participate or remain with the group providing him with structure (1/23/23), and engaging the resident in a functional appropriate exercise and activities. Keep the resident occupied in meaningful time pursuits (1/23/25). A progress note, dated 8/17/24 at 4:01 a.m., indicated Resident 33 was assisted to the bathroom. The resident started to get agitated and started to push staff while staff were providing bowel incontinence care. A Behavior Note, dated 8/19/24 at 8:57 p.m., indicated the resident growled, cussed, hit, pushed, and grabbed during a shower. Interventions attempted included played music, talked with the resident, approached the resident by different staff, and redirected the resident. The interventions were not successful. A Social Service Note, dated 8/20/24 at 1:37 p.m., indicated the resident had several behaviors that quarter including urinating and defecating in an inappropriate place and hitting staff during care. The resident had not experienced hallucinations or delusions during that quarter. A Behavior Note, dated 8/20/24 at 7:22 p.m., indicated the resident hit, kicked, pushed, grabbed, made loud disruptive noises, threatened others, and used foul language during personal care. Interventions included talked to the resident and finished his care. A Behavior Note, dated 8/23/24 at 7:18 p.m., indicated the resident was found lying in a female resident's bed watching television. He was redirected to the dining area for breakfast. A Behavior Note, dated 8/23/24 at 7:39 a.m., indicated the resident attempted to punch the CNA twice when the CNA tried to redirect the resident from urinating in the hall. The resident was redirected and encouraged to allow care. A Behavior Note, dated 8/23/24 at 12:27 p.m., indicated the resident punched the wall, the medication carts, and the handrails. The resident was redirected. A Behavior Note, dated 8/25/24 at 10:02 a.m., indicated the resident urinated on the doors, the walls, and the bedside tables. He defecated in peers' closets, cussed, and tried to hit staff during care. The need to use the bathroom and perineal care triggered the behaviors. Interventions included talking with the resident which was unsuccessful and providing care and leaving the resident alone was successful. A Behavior Note, dated 8/25/24 at 5:00 p.m., indicated the resident paced the hall, pushed bedside tables and wheelchairs down the hallway, hit the walls as he paced the hall. He yelled and threatened staff. The resident was given snacks and toileted. The staff walked with him. The interventions were unsuccessful. A Behavior Note, dated 8/26/24 at 8:44 a.m., indicated the resident pulled back his fist towards the CNA who was providing his care. The provision of care triggered the behavior. The CNA disengaged with the resident and offered care at a later time. The resident was redirected. A Behavior Note, dated 8/26/24 at 3:53 p.m., indicated the resident was found in a female resident's bed eating candy he found in the room. The resident became agitated with attempts to redirect. The resident was redirected and offered a different snack. A Behavior Note, dated 8/26/24 at 4:30 p.m., indicated the resident was aggressive and combative with care. He hit the CNA during care. He was redirected, and staff disengaged when he became aggressive. A Nurses Note, dated 8/30/24 at 5:56 p.m., indicated the resident urinated on the floor in the hall. The resident drew his fist when the staff attempted to redirect. A Behavior Note, dated 8/31/24 at 6:26 a.m., indicated the resident threatened staff, pulled back his fist at staff, and cursed at staff. The staff talked to the resident to intervene. A Behavior Note, dated 9/1/24 at 5:14 a.m., indicated the resident went into other residents' rooms. The resident became aggressive and held his fist up when the CNA attempted to redirect him. A Behavior Note, dated 9/3/24 at 12:17 p.m., indicated the resident wandered into other residents' rooms and urinated in trash cans and on different items in peers' rooms. The resident urinated in his closet, in the office, and in the lounge. Interventions included toileted the resident before and after meals and toileted the resident when he wandered. The interventions were not successful. A Behavior Note, dated 9/3/24 at 2:49 p.m., indicated the resident pushed hard on the exit door. He shook the door and told the staff he was trying to fix it. The staff talked with the resident and gave him a snack and coke. A Behavior Note, dated 9/4/24 at 9:39 a.m., indicated the resident threatened to kill the staff and swung at the staff. The staff were cleaning urine out of his closet which triggered the behavior. The staff talked with the resident and was unsuccessful at stopping the behavior. The cease of interaction with the resident was successful. A Behavior Note, dated 9/4/24 at 9:50 a.m., indicated the resident tried to hit staff with a lotion bottle. The CNA attempted to toilet the resident, and the resident picked up a lotion bottle and attempted to hit her with it. He told her to shut up and get out of there. The resident exited the shower room. The ceasing of interaction with the resident was a successful intervention. A Behavior Note, dated 9/6/24 at 11:08 a.m., indicated the resident paced throughout the hall and into other residents' rooms. He pushed on the exit doors repeatedly. He hit his fist against the wall, the handrails, and the medication carts while he walked in the hall. He refused care. The resident was redirected and reapproached after refusals of care. He participated in an exercise activity on the unit. He was offered snacks and drinks. He was encouraged with toileting. A Behavior Note, dated 9/8/24 at 5:53 p.m., indicated the resident threatened to hit and kill staff. The resident was digging in the trash, and a staff member told him to not do that and tried to redirect the resident. The resident then tried to swing at the staff member and told her he was going to kill her. Talking with the resident was unsuccessful for changing the behavior. Redirecting the resident was somewhat successful for changing the behavior. A Behavior Note, dated 9/9/24 at 9:56 a.m., indicated the resident attempted to kick the staff member and threatened to kill the staff member when a bladder scan on the resident was attempted. The intervention was to disengage with the resident. A Behavior Note, dated 9/9/24 at 5:27 p.m., indicated the resident pulled on the handrails in the hall. The resident was redirected with ice cream, drinks of choice and meal intake encouragement. A Behavior Note, dated 9/11/24 at 6:33 p.m., indicated the resident walked around with his drink. He was about to tilt and dump his drink on another resident when the CNA attempted to help him straighten his cup, the resident pulled away from the CNA and dropped the cup on the floor. When the CNA started to pick up the cup, the resident pushed the CNA out of the way. The staff attempted to talk to the resident to explain they were trying to help, this was unsuccessful to deescalate the behavior. The resident was left alone and walked away, which was a successful intervention to deescalate the behavior. A Social Service Note, dated 9/12/24 at 8:30 a.m., indicated the resident had several behaviors since the last assessment. He had hit, cursed, and threatened staff. He urinated in inappropriate places and took other residents' belongings. He had no hallucinations or delusions. A Behavior Note, dated 9/16/24 at 12:12 p.m., indicated the resident hit the nursing staff during care. He kicked the CNA while his wet pants were changed. He threatened to kill the staff. He was redirected and reassured while care was provided. A Behavior Note, dated 9/16/24 at 6:24 p.m., indicated the resident paced in and out of rooms. He removed papers from the wall and hit carts and the handrails. When the resident was questioned, he verbalized he was in pain. The resident was redirected. Activities and meal intake was encouraged. The resident was assisted to bed. A Physician's Progress Note, dated 9/17/24 at 2:04 p.m., indicated the resident was being seen for an acute visit due to ongoing behaviors. The nursing staff had reported concerns about the safety of the staff, the resident, and the other residents. The resident was on lorazepam 0.5 mg twice a day and buspirone 10 mg twice a day. Buspirone was recently increased on 8/27/24. There had been an ongoing concern the behaviors could be due to pain. The nursing staff reported the resident occasionally admitted to lower extremity pain. The resident took scheduled acetaminophen twice a day since last year. He also had an order for acetaminophen as needed which was not taken very often. Assessment/Plan - For unspecified dementia, unspecified severity, with other behavioral disturbance the resident was having significant anxiety, agitation, and aggression. The resident had an increase in buspirone with not much changes. The resident did seem to have components of delusions and paranoia. It was difficult to assess for hallucinations. The physician suspected the changes were related to psychosis related to the progression of dementia. He started a trial of quetiapine. He also suspected a component of traumatic brain injury with apparent cognitive fluctuations and thought the quetiapine would help that component. Quetiapine 25 mg daily was ordered. A Nurses Note, dated 9/17/24 at 2:24 p.m., indicated a new order for quetiapine 25 mg daily was received. The physician requested a psychological evaluation. A Behavior Note, dated 9/18/24 at 7:39 p.m., indicated the resident grabbed the staff and squeezed their hands hard. He cursed and hit the walls. The staff redirected and talked to the resident. A Behavior Note, dated 9/22/24 at 1:44 p.m., indicated the resident raised his fist behind another resident's back. The aide intervened. The resident then tried to go into another resident's room. The aide tried to get him to come out of the room, and the resident doubled his fist and told the aide he was going to kill the aide. The resident acted like his abdomen was bothering him. Interventions included distraction and one on one. A Nurses Note, dated 9/23/24 at 9:00 a.m., indicated the recent verbalizations and nursing assessments indicated the resident was in pain. The nurse practitioner ordered tramadol 25 mg twice a day. A Behavior Note, dated 9/23/24 at 3:14 p.m., indicated the resident raised his hand toward another resident when another resident touched him to get his attention. He was redirected. A Behavior Note, dated 9/23/24 at 5:24 p.m., indicated the resident hit the walls and medication carts. He paced. He was redirected, offered food and fluids, and medication. A General Progress Note, dated 9/24/24 at 6:40 p.m., indicated the resident went into another resident's room. He had a bowel movement on the floor and stepped in it. He got feces all over the room. He urinated on the floor by the bed and the other resident's shoes by the bed. He tore the toilet paper holder off the wall. He then put his hand inside the ice chest and got a piece of ice. A Behavior Note, dated 9/25/24 at 10:42 a.m., indicated the resident tried to karate chop the staff during care when his clothes were being changed. A Behavior Note, dated 9/26/24 at 7:21 a.m., indicated the resident started to squeeze the CNAs hands, hit and kick them while they changed his brief. A Nurses Note, dated 9/30/24 at 12:20 p.m., indicated the resident's buspirone was to be gradually reduced from 10 mg bid to 5 mg bid for 7 days, then to 5 mg daily for 7 days, then to 5 mg every other day for 7 days, then discontinue. A Behavior Note, dated 10/4/24 at 12:47 p.m., indicated the resident poured chocolate milk on another resident. Then, he attempted to pour milk on other residents as the staff intervened. The resident was trying to get himself between the dining chairs and the window. Other residents were seated in those chairs, eating lunch. The resident was redirected. A General Progress Note, dated 10/4/24 at 7:30 p.m., indicated the resident urinated in the corner by the double doors and walked into other residents' rooms. When the staff attempted to redirect the resident he tried to hit them. A Behavior Note, dated 10/5/24 at 12:22 p.m., indicated the resident was physically and verbally aggressive during care. Ceasing of the interaction with the resident was successful to deescalate the behavior. A General Progress Note, dated 10/8/24 at 6:30 p.m., indicated the resident looked like he was going to urinate in the hallway, and the staff member took him to toilet him. The resident hit the staff member on the shoulder during the care A Behavior Note, dated 10/9/24 at 12:36 p.m., indicated the resident wandered into other residents' rooms, destroyed the other residents' items and threw them in the trash. He banged his head on the bathroom door. He punched and hit the staff member while the staff member tried to redirect the resident out of the other residents' rooms. The staff member ceased interaction with the resident, and the resident calmed down. A Social Service Note, dated 10/9/24 at 3:40 p.m., indicated the resident was seen by the physician regarding the increased behaviors. He received a new order to increase the tramadol to three times a day. A General Progress Note, dated 10/16/24 at 6:30 p.m., indicated the resident urinated in the hall by the double doors. The aide attempted to assist him to the bathroom, and he began urinating on the floor. A General Progress Note, dated 10/18/24 at 5:53 p.m., indicated the resident tried to hit and kick the staff and called them names during toileting and changing of his clothes A Behavior Note, dated 10/18/24 at 6:19 p.m., indicated the resident got into another resident's bed. He yelled and threatened the staff when they tried to get him out of the bed. The staff talked to the resident. The behavior stopped when the staff got the resident to his own bed. A Social Service Note, dated 11/21/24 at 1:19 p.m., indicated the resident had several behaviors in the past quarter. He cursed at staff, hit staff during care, hit the walls as he walked down the wall, hit a peer when he stepped on his foot, threw milk in a peer's face, got into other residents' beds, and urinated in inappropriate places. He experienced no hallucinations or delusions during the quarter. A Social Service Note, dated 1/23/25 at 12:41 p.m., indicated the resident had multiple behaviors during the quarter. He hit the walls and medication carts, urinated in the hallways, bent the staff's fingers back, wandered in and out of other residents' rooms, and was combative with care. He had no delusions or hallucinations in the quarter. During an interview, on 2/14/25 at 9:22 a.m., QMA 11 indicated the resident had mentioned a fire the other day which was new. She did not know what he meant. Usually, he just became agitated during care. He generally just walked back and forth a lot. They met his needs the best they could. They gave him snacks and tried to redirect him. During an interview, on 2/14/25 at 2:14 p.m., CNA 16 indicated his psychosis was shown in his behaviors. Most of his aggression was with his care or also when the staff redirected him. He did not like showers. He tried to lie in other residents' beds. When assisting him with toileting, the staff did care in pairs (they use two people at least). The resident would occasionally walk by a wall and punch it. When the staff talked throughout his care telling him each step of the way, that seemed to help with his agitation. During an interview, on 2/14/25 at 3:51 p.m., the Unit Manager indicated the resident's dementia had progressed significantly in the last six to eight months and had become more violent. His psychotic behaviors are throwing milk at others, mostly the staff. Everyday he changed. The staff were having him sleep in and wake up naturally and that seemed to help some. She assisted with his care, and sometimes he was fine then other times he swatted at her. When the resident was admitted he took quetiapine. The medication had been reduced then discontinued a few years ago. All of sudden recently, it seemed like his dementia had gotten worse and his agitation had gotten worse. During an interview, on 2/14/25 at 4:24 p.m., the Social Services Director (SSD) indicated the resident had started on quetiapine because he had a lot of behaviors like aggression towards staff, especially during care. He had been on quetiapine when he was admitted . The facility had tried other medications, but they were not helping control his aggressive behaviors towards others. During an interview, on 2/17/25 at 4:31 p.m., the DON indicated the medical director had ordered the quetiapine for the resident. She knew the resident had increased aggression. 2. During an observation, on 2/10/25 at 10:44 a.m., Resident 61 ambulated in the hall wearing his coat and carrying a drink. During an observation, on 2/12/25 at 8:33 a.m., Resident 61 stood in the doorway of his room. He had a pull-up brief on his right hand, wore his coat, and was looking around. His speech was nonsensical. During an observation, on 2/13/25 at 3:54 p.m., Resident 61 ambulated in the hall with his hands in his pockets. He walked by the entrance doors with no attempt to leave. During an observation, on 2/14/25 at 11:34 a.m., Resident 61 was ambulating in his room. His roommate told the resident that he was not going to see well with those glasses because they were his (the roommate's). During an observation, on 2/14/25 at 3:21 p.m., Resident 61 was standing up in his room, looking at the bed. Resident 61's clinical record was reviewed on 2/13/25 at 2:45 p.m. Diagnoses included anxiety disorder, unspecified, cerebral infarction, unspecified, dementia in other diseases classified elsewhere, unspecified severity, with anxiety, delusional disorders, unspecified psychosis not due to a substance or known physiological condition and hallucinations, unspecified. Current physician's orders included ciprofloxacin (antibiotic) 500 milligrams (mg) twice a day for urinary tract infection (UTI) for 7 days (started 2/11/25), lorazepam (antianxiety) 1 mg at bedtime daily (started 11/26/24), quetiapine fumarate (antipsychotic) 12.5 mg twice a day (started 2/4/25), and quetiapine fumarate 12.5 mg every 24 hours as needed for hallucinations, delusions, and paranoia until 2/18/25 (started 2/12/25). An admission 8/9/24 Minimum Data Set (MDS) indicated the resident was cognitively intact. He had no delusions, hallucinations, behaviors, wandering, or rejection of care during the assessment period. A significant change 12/2/24 MDS indicated the resident was moderately cognitively impaired. He had no delusions, hallucinations, behaviors, wandering, or rejection of care during the assessment period. The resident's behavior status was the same as the prior assessment. A quarterly 12/28/24 MDS assessment indicated the resident was cognitively intact. He had no delusions, hallucinations, behaviors, wandering, or rejection of care during the assessment period. A current care plan, initiated 8/7/24, indicated the resident had impaired cognitive function or impaired thought processes related to dementia. Interventions included discussing concerns about confusion (8/7/24), disease process and nursing home placement (8/7/24), needing supervision with all decision-making (8/7/24), and keeping routine consistent with consistent caregivers as much as possible in order to decrease confusion (8/7/24). A current care plan, initiated 8/7/24 and revised on 1/21/25 indicated the resident had a diagnosis of delusional disorder, hallucinations, and psychosis. The resident took an anti-psychotic medication for those diagnoses. At home the resident would see things in the yard that weren't there. He often at the facility talked about things and saw things that did not make sense or were not present. Interventions included allowing adequate time to voice feelings and frustrations (8/7/24), never arguing with the resident about delusions/hallucinations (8/7/24), and providing psychological services as ordered (8/7/24). A current care plan, initiated 8/7/24, indicated the resident had a diagnosis of anxiety disorder and took an anti-anxiety medication for increased anxiety, pacing, fidgeting, and voicing increased anxiety/shakiness. Interventions included allowing adequate time to voice feelings and frustrations (8/7/24), reducing the medication as ordered (8/7/24), and observing and reporting increased signs and symptoms of anxiety to the physician (such as fidgety, wandering, statements of feeling anxious, shaking, shortness of breath, and change in appetite/sleep) (8/7/24). A current care plan, initiated 1/8/25, indicated the resident used psychotropic medications related to hallucinations and delusions. The goals were to remain free of drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction or cognitive/behavioral impairment through the review date and to reduce the use of psychoactive medications through the review date (both initiated 1/8/25). Interventions included consulting with pharmacy, considering by physician of dosage reduction when clinically appropriate and observing and recording of target behavior symptoms (pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others) and document per facility protocol (1/8/25). A current care plan, initiated 1/21/25, indicated the resident frequently packed his belongings and asked when/where he was supposed to be going to. He rummaged through his roommate's belongings at times. Interventions included offering the resident the activity of conversation to redirect him from behavior (he enjoys talking about his past work as a policeman/mayor, he enjoys going outside when the weather is nice) (1/21/25), offering the resident a snack or drink (he likes suckers) (1/21/25), and offering the resident to call his son (1/21/25). A current care plan, initiated 1/21/25, indicated the resident wandered in the hallways with no concrete destination. Interventions included assessing the resident for basic needs, assessing the resident for pain, offering the resident an activity to occupy time, and offering to call the resident's son (1/21/25). A Nurses Note, dated 11/23/24 at 4:14 p.m., indicated the resident was in his room packing his bags and packing his roommate's items with his belongings. The resident was agreeable to putting the roommate's belonging back after the staff talked with the resident. A Behavior Not[TRUNCATED]

Based on observation, interview, and record review, the facility failed to limit medication access to authorized personnel for 1 of 2 residents reviewed for medication storage. (Resident B) Findings include: On 9/18/24 at 10:50 a.m., Resident B was observed in her room. During the observation, the DON indicated the resident did not keep any medications in the room. The DON asked the resident if she had any medications in the room and the resident responded that she did not. The DON and the Administrator indicated there was one instance when the resident's family had brought in an injectable migraine medication, Imitrex (trade name of the medication), also known as sumatriptan succinate (generic name of the medication). The facility provided the sumatriptan succinate, but both the resident and family insisted the generic version of the medication did not work. The Administrator indicated Resident B's family had been informed they were not permitted to inject the resident with the medication, nor bring the medication into the facility from an outside source. The facility had the medication on hand and the supply should come from the facility's medication cart. Resident B's clinical record was reviewed on 9/18/24 at 11:15 a.m. The resident had diagnoses, including but not limited to, Amyotrophic Lateral Sclerosis (ALS or Lou GehrigsDisease, a fatal neurological disorder), dysphagia (difficulty swallowing), depression, anxiety, and severe migraines. A behavior note, dated 9/4/24 at 4:03 a.m., indicated a nurse had located a syringe of Imitrex in the bottom drawer of a small white dresser in the resident's room. The resident became agitated when she had to help the nurse locate the key for a lock-box where the medication was stored. During an interview with LPN 3 on 9/18/24 at 12:18 p.m., she indicated Resident B kept Imitrex in the bottom drawer of her dresser, next to the mini-fridge. It was in a lock-box. The nurse had a key for the lock-box on a keyring stored in the front 200 Hall medication cart. The key was kept in that cart because it contained other medications for Resident B. During an interview with Resident B's family member on 9/18/24 at 1:06 p.m., she indicated the generic brand of the medication did not work for the resident. She had brought in the Imitrex for the last few months because the medication had to be kept in the resident's room. The DON had agreed to put the medication under lock and key. The lock-box was provided by the facility. The mother did not keep a key and was not concerned about the lock-box being stolen from the resident's room. She would pick up the medication from the pharmacy, take it to the facility, and place it in the lock-box. She would access a key, hidden in the room on a shelf near the resident's perfumes, open the box, place the medication in the box, lock it, and return the key to it's hiding place. All the nurses knew where to find the hidden key. During an observation on 9/18/24 at 1:23 p.m., accompanied by the DON and Administrator, Resident B indicated there was a key to a lock-box in her room. The key was where the resident's family had indicated. The DON found the key and assured the resident the lock-box would not be taken from her. She took the key from the resident's room. After retrieving the key and leaving the room, the DON indicated she was never aware of either the lock-box or the key in the resident's room. She did not understand why a key in the room would be necessary since the nurse's had a key on the medication cart keyring. The lock-box could belong to the facility, but she had no information or documentation to indicate it had been provided to the resident or the resident's mother. A current facility policy, dated 5/22/22, and titled Medication and Biological Storage Requirements, provided by the Administrator on 9/19/24 at 10:33 a.m., indicated the following: .In accordance with state and federal laws, and manufacturer or supplier recommendations, the facility must store all medications and biologicals in compartments or storage rooms under proper temperature controls and permit only authorized personnel to have access to the keys .2) The facility is required to secure all medications in a locked storage area and to limit access to only authorized or licensed personnel consistent with state or federal requirements and professional standards of practice This citation relates to Complaint IN00442861. 3.1-25(m)

Based on observation, interview, and record review, the facility failed to properly administer medications as ordered by the physician. There were 26 opportunities with 2 errors, resulting in a 7.69% medication administration error rate. These errors involved 2 of 6 residents observed for medication administration. (Residents 31 and 50) Findings include: 1. During an observation of medication administration for Resident 31, on [DATE] at 11:24 a.m., QMA 5 prepared the following medication to administer: Insulin Aspart (to treat diabetes), 2 units. The insulin vial was dated [DATE] for the opened date. QMA 5 administered the 2 units of insulin for Resident 31 in the lower left quadrant of her abdomen. 2. During an observation of medication administration for Resident 50, on [DATE] at 11:26 a.m., QMA 5 prepared the following medication to administer: NovoLOG (Insulin Aspart), 1 unit, the insulin vial was dated [DATE] for the opened date. QMA 5 administered the 1 unit of insulin for Resident 50 in her left forearm. During an interview, at the time of observation, QMA 5 indicated the dates on the insulin vials were [DATE] and [DATE], and most insulin expired 28 days after opening. Resident 31's clinical record was reviewed on [DATE] at 12:05 p.m., current physician's orders for the resident included: Insulin Aspart Injection Solution (Insulin Aspart), Inject as per sliding scale: if 150 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 unit; 301 - 350 = 8 units; 351 - 400 = 10 units, subcutaneously before meals and at bedtime for Diabetes. Call MD for Blood Sugar less than 60 or above 400. Resident 50's clinical record was reviewed on [DATE] at 12:05 p.m., current physician's orders for the resident included: NovoLOG Injection Solution 100 UNIT/ML (milliliter) (Insulin Aspart), Inject as per sliding scale: if 151 - 200 = 1 unit; 201 - 250 = 2 units; 251 - 300 = 3 units; 301 - 350 = 4 units; 351 - 400 = 5 units; 401 - 450 = 6 units, subcutaneously before meals for diabetes. During an interview, on [DATE] at 3:36 p.m., the DON indicated the Product Expiration Dates guidelines were kept on the medication carts and QMA 5 should not have given NovoLOG or Aspart insulin with an opened date greater than 28 days from day of administration. A current facility document, revised [DATE], titled, Product Expiration Dates, provided by the Corporate Nurse Consultant, on [DATE] at 3:19 p.m., indicated the following: .Insulin vials at room temperature expiration date is 28 days A current facility policy, approved [DATE], titled, Insulin Preparation and Administration, provided by the Corporate Nurse Consultant, on [DATE] at 3:19 p.m., indicated the following: .Procedure .7) Insulin Vial Procedure .b. Check insulin vial to ensure correct type and check expiration date 3XXX,d+[DATE](c)(1)

Based on observation, interview, and record review, the facility failed to provide incontinence care in a hygienic manner for 1 of 3 residents reviewed for urinary tract infections (UTIs) (Resident 115). Finding includes: During a perineal care (washing of the genitals and rectal areas) observation, on 4/18/24 at 10:57 a.m., Resident 115 was laying on her back in the bed. CNA 9 washed under the resident's abdomen and thigh creases. Using the same washcloth, the CNA next washed Resident 115's labia from back to front. The CNA repeated the same steps, in the same order, with another washcloth to rinse the same areas. Resident 115's record was reviewed on 4/21/24 at 8:32 a.m. Diagnoses included type 2 diabetes mellitus and need for assistance for personal care. The current physician orders included a urinalysis with culture and sensitivity (urine testing for infection) to be collected via in and out catheter for dysuria and altered mental status (4/18/24) and nitrofurantoin (antibiotic) 100 mg two times a day for five days for UTI (4/21/24). An admission, 4/11/24, Minimum Data Set (MDS) assessment indicated the resident was dependent on the staff for toileting hygiene, showering/bathing, and personal hygiene. She required substantial/maximal assistance to roll left and right, move from sitting to lying position, and lying to sitting position. The resident was frequently incontinent of bowel and bladder. A care plan, initiated 3/22/24, indicated the resident may be incontinent of urine. Interventions included check and change as needed (3/22/24) and provide perineal care after incontinence episode (3/22/24). A nurses note, dated 4/17/24 at 11:33 a.m., indicated a urinary specimen for a U/A C&S was collected. During an interview, on 4/18/24 at 11:12 a.m., CNA 9 indicated she had washed the resident from back to front, and should have washed the resident from front to back, when performing incontinence care. She thought because she was standing towards the resident's head she got mixed up. During an interview, on 4/18/24 at 11:17 a.m., RN 8 indicated she had noticed during the incontinence care the resident had been wiped from back to front, and should have been wiped from front to back. During an interview, on 4/19/24 at 2:36 p.m., the DON indicated CNA 9 had told her she had performed perineal care incorrectly. The CNA should have washed, rinsed, and dried the resident's perineal area from front to back. A nurses note, dated 4/20/24 at 2:50 p.m., indicated the facility had received the urine culture results and was awaiting a return call from the physician. A nurses note, dated 4/21/24 at 1:55 p.m., indicated the physician had ordered an antibiotic for the urinary culture results. A care plan, initiated 4/21/24, indicated the resident was on antibiotic therapy for UTI. A current facility policy, revised on 4/1/19, provided by the DON on 4/19/24 at 3:14 p.m., titled Peri care Policy, indicated . 8. For female residents, separate the labia., a. Wash with soapy washcloth, from front to back, using the clean area of the washcloth with each stroke. b. Rinse area, moving from front to back, using the clean area of the washcloth for each stroke. c. Dry area moving from front to back, using a blotting motion with the towel 3.1-41(a)(2)

Based on observation, interview, and record review, the facility failed to provide adequate supervision and implement resident-specific interventions to prevent a fall resulting in a fracture for 1 of 5 residents reviewed for falls. (Resident 22) Finding includes: During an observation, on 4/15/24 at 11:18 a.m., Resident 22 was lying in bed in a low position with a mat on the floor. During an observation, on 4/17/24 at 9:55 a.m., the resident was lying in a low bed, with the head of the bed up and a mat on the floor next to the bed. During an observation, on 4/18/24 at 2:57 p.m., the resident was lying in a low bed, with the head of the bed up and a mat on the floor next to the bed. Resident 22's record was reviewed on 4/18/24 at 9:04 a.m. Diagnoses included unsteadiness on feet, muscle weakness, repeated falls, unspecified abnormalities of gait and mobility, history of falling, chronic pain, generalized anxiety disorder, and dementia. Physician orders included, but were not limited to, alprazolam 0.5 mg (anti-anxiety) three times a day for anxiety (12/12/23), duloxetine 60 mg (anti-depressant) two times a day for chronic pain syndrome (12/6/23), gabapentin 300 mg (nerve medication) two times a day for chronic pain syndrome (12/6/23), furosemide 20 mg (water pill) daily for edema (swelling) (12/13/23), and quetiapine fumarate 25 mg (anti-psychotic) daily at bedtime for delusional disorders (initiated 1/30/24 and discontinued 3/21/24). A 12/12/24, admission, Minimum Data Set (MDS) assessment indicated Resident 22 was moderately cognitively impaired. The resident required substantial/maximal assistance with toileting hygiene, showering/bathing, putting on/taking off footwear, and personal hygiene. The resident required partial/moderate assistance with upper and lower body dressing. The resident required partial/moderate assistance to roll left to right, move from sitting to standing, move from lying to sitting on the side of the bed, chair to bed and bed to chair transfers and toilet transfers. The resident was frequently incontinent of bowel and bladder. A 3/13/24, quarterly, MDS assessment indicated Resident 22 was moderately cognitively impaired. The resident required substantial/maximal assistance with toileting hygiene, showering/bathing, and upper and lower body dressing. The resident was dependent on staff for putting on/taking off footwear and personal hygiene. The resident required substantial/maximal assistance to roll left and right, move from lying to sitting on the side of bed, move from sitting to standing, chair to bed and bed to chair transfers, and transfers to the toilet. The resident was frequently incontinent of bowel and bladder. She had one fall with no injury and one fall with major injury since the prior assessment. A current fall care plan, initiated on 12/6/23 and revised on 12/11/23, indicated the resident was at risk for falls related to muscle weakness, history of falls and impaired mobility. Interventions included anticipate and meet the resident's needs (12/6/23), be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed (12/6/23), and fall mat to bedside when in bed per family request (3/28/24). A nurses note, dated 12/20/23 at 1:57 p.m., indicated the resident had been increasingly lethargic throughout the shift and was unable to concentrate once awakened. Hospice discontinued a hydrocodone (opiate pain medication) order and started tramadol 50 mg (opiate pain medication) twice a day. A nurses note, dated 1/17/24 at 6:35 p.m., indicated the resident's roommate called staff to the room. According to the roommate the resident slid out of bed from a seated position on the side of the bed. The resident was found on the floor with her back against the bedside. She indicated she was going to the bathroom. X-rays for the left shoulder and both hips were ordered. A nurses note, dated 1/18/24 at 2:00 a.m., indicated the X-ray results were received with no obvious or acutely displaced fractures. An Interdisciplinary Team (IDT) note, dated 1/19/24 at 1:48 p.m., indicated the 1/17/24 fall was reviewed. The resident had been sitting on the side of her bed when she attempted to stand and slid to the floor. She was found sitting upright next to the bed. The resident had also recently been diagnosed with COVID-19 and had been slightly weaker than baseline. An intervention was initiated to have the staff complete more frequent rounding on the resident. A current care plan, initiated 1/21/24, indicated the resident had a fall on 1/17/24. The intervention was more frequent rounding (1/21/24). A nurses note, dated 2/15/24 at 6:20 a.m., indicated a housekeeper witnessed Resident 22 fall while trying to get up on her own. The resident lost her balance and fell backward. The nurse found Resident 22 on the floor, beside the bed, with her head under the bed. The resident's bed was found soaked, and she was in a puddle of urine. The resident indicated she was getting up to go to the bathroom. Staff were educated on needing to take the resident to the toilet frequently. The resident was known to hold urine until taken to the toilet and could not always let needs be known. A nurses note, dated 2/15/24 at 3:41 p.m., indicated X-ray results had been received and concluded there was an acute appearing acromion (shoulder) fracture to the left side. An IDT note, dated 2/22/24 at 9:04 a.m., indicated the fall on 2/15/24 was reviewed. Staff present at the time of fall reported Resident 22 was heavily incontinent of urine at the time, and the resident had reported she was attempting to go to the bathroom. The IDT spoke with the staff who worked prior to the fall. The staff indicated they were under the impression that the resident used her call light, and would ask for assistance with bathroom needs, as this was her normal previously when she resided in another part of the building. Staff indicated they did not know the resident would attempt to toilet herself. A facility investigation of the 2/15/24 fall, provided by the Administrator on 4/18/24 at 2:42 p.m., indicated staff had assisted the resident's roommate at 5:00 a.m. The resident was asleep at the time. Staff indicated they had not returned to the room to check on Resident 22, as staff was waiting for the resident to turn on her call light. The staff were educated on how some residents do not use call lights to get assistance for their needs and intentional rounding should be performed every two hours. A CNA assignment sheet, provided by LPN 10 on 4/19/24 at 10:19 a.m., indicated the resident required assistance of 1 to 2 persons and frequent rounding. During an interview, on 4/19/24 at 10:12 a.m., CNA 9 indicated she was uncertain what frequent rounding meant. She checked on the resident every two hours to see if she needed to go to the bathroom. During an interview, on 4/19/24 at 10:36 a.m., CNA 7 indicated she did not know what frequent rounding meant on the CNA assignment sheet. During an interview, on 4/19/24 at 11:06 a.m., CNA 11 indicated she was not sure what frequent rounding meant. She looked at the CNA assignment sheet and indicated it meant to check on the resident frequently. She was not sure if there was an exact time frame, but she tried to look at the resident when she walked up and down the hall. First thing in the morning and if the resident seemed agitated, she would offer to take her to the bathroom. During an interview, on 4/19/24 at 2:23 p.m., the DON indicated the definition of frequent rounding meant more frequently than every two hours. When the staff walked down the hall, they should be looking specifically at the residents who fall. A current policy, revised on 7/22/21, provided by the DON on 4/19/24 at 3:11 p.m., titled Fall policy and procedure, indicated .All falls, regardless of injury, will be reviewed the following morning, during normal business hours by the Interdisciplinary Team (IDT) to determine if the fall process was followed and an appropriate intervention was put in place 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to identify a pressure injury and implement interventions to promote healing (Resident 115) and failed to implement an ordered treatment (Resident 24) for pressure injury for 2 of 4 residents reviewed for pressure injuries. (Residents 115 and 24) Findings include: During an interview, on 4/16/24 at 9:30 a.m., Resident 115 sat in a wheelchair in her room and indicated she had painful sores on her bottom. During an interview, on 4/17/24 at 10:05 a.m., the resident sat in a wheelchair in her room, crying. She indicated she wanted to go back to bed because her bottom was sore, and she hurt all over. During an observation, on 4/17/24 at 2:22 p.m., the resident sat in a wheelchair in her room. During a wound observation, on 4/18/24 at 10:57 a.m., a ladybug-sized wound, with a depth slightly greater than a pencil tip, was present to Resident 115's inner left gluteal area. The wound bed had a small amount of yellow tissue and the edges were rolled. Resident 115's record was reviewed on 4/19/24 at 11:32 a.m. Diagnoses included type 2 diabetes mellitus, muscle weakness (generalized), need for assistance with personal care, other abnormalities of gait and mobility, and depression. The current physician orders included, but were not limited to, clean open area to left inner gluteal with normal saline. Pat dry. Apply house barrier cream to periwound (area around the wound). Apply antimicrobial wound gel to wound bed and cover with foam dressing. Change every other day and as needed for open area to left gluteal. Change for soilage/displacement (4/18/24). An admission, 4/11/24, Minimum Data Set (MDS) assessment indicated Resident 115 was cognitively intact and dependent on staff for toileting hygiene, showering/bathing, upper and lower body dressing, putting on footwear, and personal hygiene. She required substantial/maximal assistance to roll left and right, moving from sitting to lying position, and from lying to sitting position. The resident was at risk for a pressure injury and did not have unhealed pressure injuries. A current care plan, initiated 3/22/24 and revised 4/18/24, indicated the resident had a potential for impairment to the skin integrity related to impaired mobility, incontinence and admitted with moisture-associated skin damage (MASD). On 4/18/24, the resident had a stage 3 pressure injury (full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer) to the left inner gluteal area. Interventions included daily skin checks with care and report new areas to nurse (3/27/24). A consultant wound assessment and plan note, dated 4/10/24, indicated the resident was admitted back from the hospital with MASD from occasional incontinence. Wound care was ordered as follows: Cleanse wound with normal saline or sterile water. Apply zinc and antifungal powder to wound bed and cover with clean dry foam dressing every day and as needed. A nurses note, dated 4/10/24 at 2:45 p.m., indicated the resident was seen by the wound consultant and a new order was received for treatment to MASD area on bilateral buttocks. A nurses note, dated 4/16/24 at 1:44 p.m., indicated a skin sweep was completed. Treatment continued to the MASD are on bilateral buttocks. A nurses note, dated 4/18/24 at 9:25 a.m., indicated a new wound was identified during morning care. The wound measured 1.0 cm (centimeter) long by 0.8 cm wide by 0.3 cm deep. The wound bed was pink/red. The center of the wound had a slightly yellow discoloration with scant amount of serous (clear to yellow) fluid. The wound margins had epibole (rolled wound edges). During an interview, on 4/18/24 at 10:57 a.m., RN 6 indicated the area was new to Resident 115's buttock and had appeared overnight. The resident had MASD prior to having the wound. During an interview, on 4/18/24 at 11:17 a.m., RN 6 indicated she did Resident 115's treatment to the left gluteal area the prior day and did not see the complete area. She had applied barrier cream to the wound, but had not completely wiped off the old barrier cream, so she was unable to see the wound bed. During an interview, on 4/19/24 at 10:36 a.m., CNA 7 indicated the sore on Resident 115's buttock was worse today than the last time she saw it a couple of weeks ago. The resident was turned onto her sides if she was comfortable with it, but was not always comfortable with rolling on her sides. During an interview, on 4/19/24 at 11:53 a.m., LPN 8 indicated when the resident was first admitted , she had wounds on her bottom. When the resident came back from the hospital, she had an open area on her buttock. During an interview, on 4/19/24 at 2:32 p.m., the DON indicated she had asked about the resident's open area on 4/15/24. The staff had told her it was closed. The rolled edges to the wound would indicate the area had been there longer than overnight. 48384 During an observation on 4/17/24 at 8:52 a.m., Resident 24 was laying on his back in his bed. His knees were slightly bent, falling outwards, and his feet were rolled out, resting on his ankles. The resident was observed in the same position on the following dates and times: 4/17/24 at 9:54 a.m., 4/17/24 at 10:54 a.m., 4/18/24 at 9:00 a.m., and 4/18/24 at 10:02 a.m. Resident 24's clinical record was reviewed on 4/17/24 at 8:45 a.m. Diagnoses included, but were not limited to, type 2 diabetes mellitus, congestive heart failure, non-Alzheimer's dementia, and coronary artery disease. A quarterly Minimum Data Set (MDS) assessment, dated 2/11/24, indicated Resident 24 was severely cognitively impaired was dependent on staff for toileting, dressing, transferring, rolling left to right, and showering/bathing. The resident was at risk for developing pressure ulcers. A current physician's order, dated 2/6/24 at 2:00 p.m., indicated preventative skin assessments to be performed every evening shift. A current physician's order, dated 4/10/24, at 8:00 a.m., indicated a foam dressing was to be applied to the left ankle daily until healed. A progress note, dated 1/11/24 at 5:56 p.m., indicated a new wound alert for a reddened area on the left ankle. No measurements were documented. The wound received immediate treatment of a foam dressing application. A progress note, dated 4/2/24 at 8:25 p.m., indicated a stage 1 pressure wound (Intact skin with a localized area of non-blanchable redness) to the left ankle. The wound was measured as 1 cm length x 1 cm width and pink in color. During an interview with RN 6 on 4/18/24 at 10:07 a.m., she indicated there was no wound on the resident's left ankle. During an observation, on 4/18/24 at 11:07 a.m., the DON checked for a dressing on the resident's left ankle. There was a dressing present, dated 4/11/24. The DON indicated the order for the foam dressing had been put into the clinical record incorrectly. This resulted in the dressing not being changed since the order had been put in on 4/10/24. She did not know how the wound and/or dressing were missed during daily preventative skin assessments. A current, undated facility policy, provided by the DON on 4/19/24 at 3:11 p.m , titled Wound Care Program, indicated .Nursing staff will employ preventative measures to successfully manage skin integrity of those resident who are identified to be at risk .When a wound/rash is found, if identified by non-licensed personnel, the resident's nurse will be notified immediately. This nurse is responsible to do a wound/skin interruption assessment on the affected area, chart this, notify the MD/NP, get treatment orders, and notify the family .Charting Parameters for any wound will include: . 2. Wound dimensions: Length x Width x Depth .6. The condition of the wound margins .10. If the wound is a pressure injury, or has a pressure injury component, it must be staged according to the current National Pressure Ulcer Advisory Panel (NPUAP) guidelines Weekly follow ups by the wound nurse and or designee (primary care nurse) should be completed on any open wounds . 3.1-40(a)(1) 3.1-40(a)(2)

Based on observation, interview and record review, the facility failed to provide interventions to alleviate constipation for 2 of 3 residents reviewed for bowel monitoring (Residents C and B). This deficient practice resulted in Resident C being transferred to the hospital for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Findings include: 1. Resident C's closed record was reviewed on 8/5/21 at 10:29 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She had physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A 5/26/21, quarterly, Minimum Data Set (MDS) assessment indicated she was severely cognitively impaired, was totally dependent for transfers and toileting, and was totally incontinent of bladder and bowel. Review of the resident's June 2021 bowel movement documentation indicated she had an extra large loose/diarrhea stool on 6/30/21, after not having a bowel movement since 6/26/21. Review of the resident's June 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's July 2021 bowel movement documentation indicated she did not have a bowel movement from July 1 through July 6, 2021. Review of a 7/6/21 progress note indicated she had two episodes of vomiting and again twice later in the morning; her emesis was brown and runny. Her bowel sounds were active. She had refused breakfast. She had not had a bowel movement since 6/30/21. The medical provider was notified and orders received for [MEDICATION(S)] tablets and an enema. Review of a 7/6/21 progress note indicated the enema was not effective. Her bowel sounds were hypoactive to her right upper and lower quadrants. An order was received to transfer her to the emergency department for evaluation and treatment. Review of the resident's July 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . She received two tablets of oral [MEDICATION(S)] 5 mg on 7/6/21 at 1:16 p.m. and an enema at the same time. Review of a 7/6/21 emergency department note indicated she had been transferred for constipation and had not experienced any vomiting. Upon arrival at the hospital, she had a large, loose bowel movement. An abdominal X-ray report, dated 7/6/21, indicated she had a significant amount of stool in her right colon, which could be contributing to a small bowel obstruction. A CT (computed tomography) scan was recommended. Review of an abdominal CT scan report, dated 7/6/21, indicated a small bowel obstruction, probably from an adhesion (scar tissue). During an interview, on 8/5/21 at 2:06 p.m., with the DON, Administrator, Medical Records Nurse, and Infection Preventionist, the DON indicated residents were to receive a [MEDICATION(S)] if they had not had a bowel movement in three days. The Medical Records Nurse indicated she generated a list three times weekly on Mondays, Wednesdays, and Fridays of residents who needed interventions for constipation. The DON confirmed Resident C had not had an intervention attempted for constipation between July 1 and July 5, 2021. 2. On 8/5/21 at 9:00 a.m., Resident B was in bed resting with his eyes closed. Review of Resident B's clinical record was completed 8/5/21 at 9:40 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He had current orders for, but not limited to, [MEDICATION(S)] (antibiotic) 500 mg intravenously every 6 hours for 10 days, [MEDICATION(S)] (antibiotic) twice daily for 10 days, oxygen at 3 liters per minute, and polyethylene [MEDICATION(S)] 17 grams daily in liquids. Review of the resident's July and August 2021 bowel movement documentation indicated he did not have a bowel movement from 7/31/21 through 8/2/21. Review of an 8/1/21 progress note indicated he had been offered prune juice due to not having had a bowel movement. There were no further interventions attempted through 8/3/21 when the resident had a medium bowel movement. The resident did not have orders for laxatives for acute use. During an interview, on 8/5/21 at 1:29 p.m., CNA 9 indicated bowel movements were documented every shift. CNAs were able to see the previous two shifts' documentation. The nurses monitored bowel movements for constipation and would give prune juice and medications as needed. During an interview, on 8/5/21 at 1:35 p.m., LPN 14 indicated third shift developed the list of residents who had not had a bowel movement in the day prior. The first day without a bowel movement, residents received prune juice. The second day, they usually received [MEDICATION(S)] tablets and on the third day, they received either a [MEDICATION(S)] suppository or an enema. During an interview, QMA 7 indicated if a resident required a [MEDICATION(S)] to be administered, it would show on the medication administration record. During an interview, on 8/5/21 at 1:59 p.m., LPN 18 indicated the Medical Records nurse would develop the list of residents who had not had a bowel movement recently. The nurse who administered the [MEDICATION(S)] or prune or apple juice should have monitored for results. During an interview, on 8/5/21 at 2:00 p.m., the DON indicated the facility did not have a policy for treating constipation. During an interview, on 8/5/21 at 3:09 p.m., the DON indicated the facility had no further information on any additional interventions for constipation for Resident B. No further information was provided by the facility prior to exit. This Federal tag relates to Compliant IN 119. 3.1-37(a)

Based on observation, record review, and interview, the facility failed to provide adequate supervision to prevent falls for 2 of 7 residents reviewed (Residents 256 and 6), and failed to implement personalized interventions to prevent falls for 1 of 7 residents reviewed (Resident 49). This deficient practice resulted in Resident 256 and Resident 49 each sustaining a [CONDITION(S)]. Findings include: 1. During an interview, on 4/19/21 at 12:34 p.m., Resident 256 indicated she had fallen and broken her left hip a couple weeks ago. Resident 256's clinical record was reviewed on 4/20/21 at 12:57 p.m. Diagnoses included, but were not limited to, non-displaced intertrochanteric fracture of left femur and Alzheimer's disease. Physician orders included, but were not limited to, the following: Requip (nonergot [MEDICATION(S)] agonist), 0.25 mg (milligram), one tablet three times a day related to [CONDITION(S)], order date 5/1/19. [MEDICATION(S)] (hormonal supplement), 3.0 mg, two tablets at bedtime related to [CONDITION(S)], order date 10/14/19. [MEDICATION(S)] (antipsychotic), 2.5 mg, one tablet once a day related to [CONDITION(S)] disorder, order date 3/1/21. A progress note, dated 12/23/20 at 11:15 p.m., indicated the resident had been found on the floor in her room. The resident had indicated she was going to the bathroom and slid out of her walker without injury. A Morse Fall Risk Assessment, dated 12/23/20 at 11:22 p.m., indicated her fall risk score was 100. The assessment form indicated a score of 45 or greater required high risk fall prevention interventions be implemented. A progress note, dated 12/24/20 at 4:35 a.m., indicated the resident had been educated to ask for help when getting up. An IDT (Interdisciplinary Team) Fall Follow Up progress note, dated 12/28/20 at 1:52 p.m., indicated the IDT had met to review the fall that had occurred on 12/25/20. The resident was ambulating with her walker without requesting assistance from staff. She had been educated multiple times regarding ambulation and transfers without assistance, lacked safety awareness and often over estimated her abilities. The resident was not injured in the incident. Staff re-enforced reasoning for call light use at the time of the incident. The MD and family had been made aware. A 1/23/21 quarterly MDS (Minimum Data Set) assessment indicated she had severe cognitive impairment, required extensive assistance with bed mobility, transfers, locomotion on and off the unit, dressing, toilet use, and personal hygiene, and limited assistance to walk in room. A progress note, dated 3/14/21 at 6:32 p.m., indicated the resident had fallen from the wheelchair to the floor in the hallway . The resident complained of back pain, discoloration was noted to her back and her right hand. A Morse Fall Risk Assessment, dated 3/14/21 at 6:51 p.m., indicated her fall risk score was 90. An IDT Fall Follow Up progress note, dated 3/15/21 at 9:40 a.m., indicated the resident had been propelling herself to her room after a meal, was pulling herself along with the use of the handrail, was not positioned all the way back in her wheelchair seat and slid out of the wheelchair when she pulled on the handrail. The resident was educated to sit back on wheelchair seat during locomotion. A current fall care plan, with a revised date of 11/6/19, indicated she was at risk for falls related to weakness, impaired mobility, incontinence, and potential medication side effects. Interventions included, but were not limited to, provide re-education as needed to ask for assistance as needed for transfers, date initiated was 5/4/20. The resident was provided with education to not try to propel herself while on a rollator, date initiated was 12/28/20. A current care plan, with a revised date of 11/13/20, indicated the resident had a history of self transferring. Interventions included, but were not limited to, educate the resident on the importance of using call light for assistance, initiated on 4/17/19 and revised on 11/13/20. A progress note, dated 4/8/21 at 3:40 p.m., indicated the resident had been found lying on the floor, on her left side. She was nonresponsive and not reacting to verbal or physical stimulation. Staff continued to call out her name, performed sternal rubs and the resident had begun to respond. Redness and swelling had been noted to her left eyebrow and she complained of pain, on the left side of her head, an 8 on the 0/10 pain scale. Her left lower extremity had been noted to have external rotation and the resident rated pain to the leg at a 10 on the 0/10 pain scale. The Nurse Practitioner was notified and gave order to send the resident to the emergency room . 911 was called. An Occurrence/Description of unwitnessed fall progress note, dated 4/8/21 at 4:48 p.m., indicated the resident had been sent to the emergency room for further treatment. The resident had indicated she was trying to pick something up and blacked out. Intervention to prevent recurrence was to remind the resident to call for assistance when needing to get items off the floor. An IDT Fall Follow Up progress note, dated 4/9/21 at 2:17 a.m., indicated the resident had been admitted to an out of town hospital with a left [CONDITION(S)]. 2. During an interview, on 4/20/21 at 9:05 a.m., Resident 49 indicated she had fallen in March while being assisted by CNA 30; she had broken her hip and needed surgery. Resident 49's clinical record was reviewed on 4/20/21 at 11:20 a.m. Diagnoses included, but were not limited to, heart failure, dementia, right upper arm muscle wasting, conversion disorder with seizures or convulsions, fracture of neck of right femur, and chronic kidney disease stage 3. A 3/18/21 annual Minimum Data Set (MDS) assessment indicated she was cognitively intact, required extensive assistance for transfers and toileting, and supervision when walking in her room. A 4/5/21 significant change MDS assessment indicated she was cognitively intact, required extensive assistance for transfers, toileting, and when walking in her room. She had a current 1/11/20 care plan problem of risk for falls. Interventions included, but were not limited to, encourage to position self in middle of bed to prevent rolling out (5/4/18), orthostatic blood pressure as ordered (12/16/20), and walker and/or wheelchair use (11/16/18). A 12/2/20 fall risk assessment indicated she was at high risk for falls due to overestimating or forgetting her limits, a weak gait, and a history of falling. A progress note, dated 12/2/20 at 4:43 p.m., indicated she was lowered to the floor in front of the commode with her legs straight out. She had no apparent injury. The nursing assistant had gone into the room to help her pull up her pants. She had taken herself to the bathroom, and pulled her call light. The nursing assistant pulled up her pants, and stepped out of the way to let her move her walker around. The resident then lost her balance. The nursing assistant grabbed underneath her arm and helped lower her to the floor. The immediate action taken to prevent occurrence was to educate the resident and staff to utilize a gait belt when resident was needing to ambulate. The root cause was adjusting the walker in preparation to ambulate from restroom to bed. A 12/3/21 Interdisciplinary Team (IDT) review note of the 12/2/20 fall indicated the resident was in her bathroom and lost her balance. She had not had any recent falls. The IDT felt the resident was likely tired due to having ambulated more than normal as she had an appointment outside of the facility the same day. She was to be screened by therapy due to fall. An order for physical therapy was received on 12/8/20. There were no new fall prevention interventions added to her care plan. A progress note, dated 12/14/20 at 4:16 p.m., indicated the resident had been found in her room, laying on her back; she stated she had hit her head and her right hip on the floor. She had been ambulating to the bathroom when she lost her balance and fell . She had no injuries. A statement was attached to the incident report. To prevent further falls, the resident was re-educated to use her call light. The root cause was a gait imbalance which was unsteady and weak. A 12/14/20 progress note indicated a 4x4 (unit of measure not documented) bruise to her left elbow. Review of a 12/14/20 fall investigation note indicated a (unidentified) aide was in the resident's room at the time of the fall, but was unable to stop her from falling. She had a bruise to her left elbow. The investigation note referred to a written statement by the aide. There was no written statement attached to the investigation note provided by the facility. A 12/15/20 fall risk assessment indicated she remained at high risk for falls. A 12/16/20 IDT review note of the 12/14/20 fall indicated she had lost her balance and fell . The fall was witnessed. A new intervention was ordered for orthostatic blood pressures to be completed daily for three days. The nurse practitioner was to be notified of the results. Her care plan was reviewed and updated as needed. Review of the resident's December 2020 medication administration record indicated a 12/16/20 physician's order for orthostatic blood pressure assessment daily for three days. The measurements were taken only on 12/18/20 and were as follows: 84/48 while laying down, 112/64 while sitting, and 107/67 while standing. There were no other orthostatic measurements in the clinical record. The 12/19/20 measurement was not done and indicated to see the progress notes. There were no progress note in the record dated 12/19/20. There was no record of the nurse practitioner being notified of the 12/18/20 orthostatic blood pressures, nor of the other two day's measurements not being completed. A 3/17/21 fall risk assessment indicated she remained at high risk for falls. A progress note, dated 3/24/21 at 10:12 a.m., indicated the resident was found laying on the floor on her right side. She stated her legs went out as she had been going to the bathroom. There was not any bruising noted to the right side of her body at the time. Her right hip was assessed and did not present with rotation or shortening. Statements were given for the risk management review. To prevent recurrence, she was re-educated on waiting for assistance. The root cause of the fall was weakness, self - transferring, being unable to walk without an assistive device, needing to use the restroom, and staff being unable to assist the resident to the floor. Review of a 3/24/21 fall investigation note indicated she complained of right hip pain and would not put weight on the leg. CNA 50 had answered the resident's call light and the resident told her she had to go the bathroom. When the CNA turned to turn off the call light, the resident stood up and fell over onto her right side. A progress note, dated 3/24/21 at 6:45 p.m., indicated the resident was having uncontrolled pain, her right leg was rotated outward and shorter than the left leg. An X-ray showed a right [CONDITION(S)]. She was to be sent to the emergency department the following morning for surgery. A 3/24/21 progress note indicated a right hip x-ray showed a right intertrochanteric fracture with moderate angulation and displacement. A 3/25/21 IDT review note of the 3/24/21 fall indicated the resident had stood abruptly, with her walker in reach, but she had not used it for support. She immediately fell to the right, and the CNA was unable to reach the resident before she fell . No physical abnormalities were visualized - no shortening in length, no internal or external rotation, no pain voiced but when she was assisted up to bed, she voiced complaints of pain and could not bear weight on the right leg. The resident had stated to the CNA I wish i [sic] would have waited for you to help me . Review of a 3/25/21 hospital history and physical note indicated the resident was to be admitted directly for open reduction and pinning of right [CONDITION(S)]. A 3/30/21 progress note indicated she readmitted to the facility. A 4/2/21 fall risk assessment indicated she remained at high risk for falls. There were no new fall prevention interventions added to her care plan. During an interview, on 4/21/21 at 1:47 p.m., CNA 51 indicated Resident 49 hadn't needed much help before her last fall, but needed a lot of assistance of two, sometimes three, staff to transfer. She could bear weight, but not very well. During an interview, on 4/22/21 at 2:24 p.m., the DON indicated she was not able to locate a new fall prevention intervention following the resident's fall in March. The orthostatic blood pressures were not completed for two of the days ordered. Staff should use gait belts when assisting residents to transfer or walk. She was not able to locate the written statement from the resident's December fall investigation. 3. On 4/23/21 at 1:52 p.m., Resident 6 was observed resting in bed with her shoes on the floor by the bed in the path where the resident placed her feet to stand if she exited the bed. The other side of the bed was against the resident's wall. The shoes created a trip hazard. Her rollator was located 3 feet from the bedside and not within reach. During an interview at the time of observation, on 4/23/21 at 1:56 p.m., the Memory Care Unit Coordinator indicated Resident 6's rollator was not within reach of the resident when she was in bed. She moved the shoes under the bed and placed the walker next to the bed within reach of the resident. During an interview, on 4/21/21 at 10:10 a.m., Certified Nurse's Aid 33 (CNA 33) indicated the CNA assignment sheet provided information on how much assistance each resident required and it was used as a reference each shift. Review of an assignment sheet, provided by CNA 33 on 4/21/21 at 10:11 a.m., indicated Resident 6 required 1 person assistance for transfers, her rollator at bedside when in bed, and non-skid footwear on at all times. During an interview, on 4/21/21 at 2:30 p.m., CNA 35 indicated Resident 6 was a fall risk, required staff assistance for transfers and non-skid footwear on at all times. She indicated she worked a variety of shifts and Resident 6 did not have any specific frequency checks on night or day shift. Resident 6's clinical record was reviewed on 4/21/21 at 4:05 p.m. Diagnoses included, but were not limited to, unspecified dementia with behavioral disturbances, unsteadiness on feet, muscle weakness, cognitive communication deficit, [CONDITION(S)], major depressive disorder, and panic disorder. Medications included, but were not limited to, [MEDICATION(S)] (depression) 25 milligrams (mg) daily at bedtime, and [MEDICATION(S)] (panic disorder) 10 mg daily at bedtime. A nursing comprehensive admission assessment indicated Resident 6 was at high risk for falls with a history of falls. A nurse's noted, dated 1/11/21 at 12:50 a.m., indicated the resident fell on to her face as she leaned forward on the edge of the bed. The resident was not wearing non-skid footwear. This fall resulted in a 0.5 centimeter x 0.5 centimeter reddened area to the bridge of the nose. The resident was trying to get up to go home. Non-skid socks were applied after the fall. Another nurse's note, dated 1/11/21 at 8:45 p.m., indicated the resident was found on the floor next to her bed on her left backside and was wearing house slippers. Review of a nurse's note, dated 1/19/21 at 1:19 a.m., indicated the resident was found sitting on the floor with her legs stretched out in front of her with bare feet. The nurse's note indicated Resident 6 said she was getting up to check on her kids. The clinical record lacked a new fall intervention. Non-skid socks were applied after the fall. A nurse's noted, dated 1/20/21 at 2:23 a.m., indicated the resident was found on the floor sitting against the side of the bed with regular socks on the resident's feet. The resident was unsure why she tried to get out of bed. Blue grip socks were applied after the fall. A quarterly Minimum Data Set (MDS) assessment, dated 4/16/21, indicated the resident's cognitive status was severely impaired. She required 1 person assistance for bed mobility, transfers, and supervision for ambulation. Mobility devices included a walker and wheelchair. The MDS indicated Resident 6 had a history of falls on admission with 2 or more falls since admission. A current care plan for activities of daily living self-performance deficit, dated 1/7/21, indicated the resident required 1-2 person staff assistance for bed mobility, transfers, and toileting related to dementia and weakness. A current care plan for falls, dated 1/7/21, indicated the resident was at risk for falls. Interventions included but were not limited to, non-skid footwear dated 1/7/21, provide activities of daily living (ADL) assistance as needed dated 1/7/21, keep personal items within reach dated 1/7/21, encourage resident to wear non-skid socks when in bed dated 1/20/21, and keep rollator at bedside dated 2/9/21. A current care plan for impaired cognitive function, dated 1/12/21, indicated the resident was easily confused. Interventions included, but were not limited to, supervision was needed with all decision making. During an interview, on 4/23/21 at 9:47 a.m., the Director of Nursing (DON) indicated the floor nurse was expected to add an immediate fall intervention, appropriate to the situation after a resident fall in addition to the current fall interventions. Review of a current policy, titled Fall Program/Policy, undated and provided by the DON on 4/22/21 at 11:59 a.m., indicated Prevention/Intervention .* Interventions to prevent changes in plane should be initiated based on risk assessment and documented in the plan of care as well as the resident care/need sheet (assignment sheet) .Post-Fall Event .* A review will occur after the resident is stabilized to determine the cause of the incident if possible, and to implement an immediate intervention to prevent a further change in plane. * Each fall is reviewed by the interdisciplinary Team (IDT) in the morning meeting. The IDT will determine further screenings or other interventions needed for the resident. This IDT meeting/outcome will be documented in the resident's medical record in the Progress Note function .Fall Quality Monitoring Procedures .* Does the care plan reflect resident's current status as it relates to falls? Are individual interventions specific to the resident? 3.1-45(a)(2)

Based on interview and record review, the facility failed to use a shower bed correctly and failed to have two staff members assist with bathing in accordance with the resident assessment and plan of care for 1 of 3 residents reviewed for accidents (Resident B). This deficient practice resulted in Resident B sustaining a fall resulting in lacerations, sutures, skin tears and pain. Findings include: The clinical record for Resident B was reviewed on 1/7/21 at 9:09 a.m. [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) assessment, dated 6/16/20, indicated the resident was moderately cognitively impaired. She required extensive two-person assistance for transfers, hygiene, bed mobility, dressing and toileting. The most recent quarterly Minimum Data Set (MDS) assessment, dated 10/24/20, indicated the resident was moderately cognitively impaired. She required extensive two-person assistance for transfers, hygiene, bed mobility, dressing and toileting. A current health care plan, initiated 8/3/18 and revised 7/1/19, indicated the resident was unable to complete her late loss Activities of Daily Living (ADLs) related to a stroke with [MEDICAL CONDITION], weakness and impaired mobility. Interventions included, but were not limited to, extensive assistance with two staff dependent for bathing and showering needs. A fall risk assessment, dated 6/15/20, indicated the resident scored 45, which indicated the resident was a high fall risk. A fall risk assessment, dated 10/23/20, indicated the resident scored 70, which indicated the resident was a high fall risk. A progress note, dated 8/28/20 at 6:45 p.m., indicated the resident rolled off the shower bed onto the floor. The note indicated the resident was found lying on her right side on the shower room floor in a pool of blood. Pressure was applied to her head and 911 was called. She had a gash to her left leg and 2 skin tears on her right lower arm and hand and a laceration to her head. The resident returned to the facility on [DATE] at 12:57 a.m. She had bruising and swelling noted to her left eye and a great amount of swelling around her eye and across her nose. A readmission assessment, dated 8/29/20 at 12:57 a.m., indicated the resident had the following injuries: a. A laceration to her left shin with sutures. The laceration measured 8.5 cm x 3.0 cm x 0.1 cm. b. A laceration to her forehead with sutures. The wound was unable to be measured on return due to the amount of dried blood. c. A small laceration under her left nare with a suture. d. Abrasion to the right hand and posterior right wrist. The abrasion measured 1.5 cm x 0.5 cm. e. A skin tear to left posterior shin area. No measurement were noted. Resident B received [MEDICATION NAME] 5-325 mg([MEDICATION NAME] and [MEDICATION NAME], to treat severe pain) on 8/29/20, twice on 8/30/20 and again on 8/31/20. The resident complained of leg pain and pain all over. Review of the September Medication Administration Record [REDACTED]. A new order for [MEDICATION NAME] 5-325 mg, dated 9/1/20, indicated a give 1 tablet as needed for pain 4 times daily. The resident received the medication on 9/3/20, 9/14/20 and 9/17/20. An Interdisciplinary Team (IDT) note, dated 8/31/20 at 9:58 a.m., indicated the resident was being assisted with shower using a shower gurney. The aide assisted the resident in turning to the side so she could bathe the resident's bottom and back. The rail on shower bed broke off and resident rolled from the gurney to floor. The resident obtained a laceration to her leg, head, and below the nose. The resident was sent to emergency room for evaluation and treatment. The resident returned to facility with sutures to lacerations. No fractures or major head injury was noted in the incident. The shower gurney was removed from facility and was no longer in use. IDT will schedule training for staff with shower equipment and safety measures to be used. The physician and son were notified of situation and care plans were reviewed and updated as needed. A statement completed by CNA 1 on 8/28/20, indicated she took the resident to the shower room at approximately 6:00 p.m. Another CNA helped transfer her with the mechanical lift onto the shower bed. After she showered the resident, she was dressing her and asked her to turn onto her side. Resident B grabbed the rail and turned. She had pulled up her pants and as she was putting her shirt on, the rail fell down and the pin fell out. The resident rolled over on her left side and fell . Review of the investigation report initiated 8/28/20, indicated on 8/31/20 the Administrator spoke to CNA 1 who said the shower rail was down and she had to look for the pin that went through the rail. Although two pins were required, she only found one. The pin was located on top of the linen cart. CNA 1 inserted the pin thinking that one pin would hold the rail. The pin did not have the safety clasp that would have secured it to the rail. During an interview on 1/7/21 at 11:08 a.m., the Director of Nursing (DON) indicated when they interviewed the aides, they did say they were both present when the resident was transferred to the shower bed via mechanical lift, but other aide left and only one CNA was present during the shower. They no longer have any shower beds, but only have a reclining shower chair. She thought they had a discussion about how many staff should have been present during the shower, but knew from their statements only one was present. The aide only used 1 pin and should have used 2. She was not sure if the aide put the one pin at the top or the bottom of the shower bed. On 1/7/21 at 11:18 a.m., the Administrator and DON indicated they completed an inservice for all aides. They do not know when the pins had been changed out. They also started a Performance Improvement Plan (PIP) and removed all the shower beds. She indicated they always transfer with 2 staff persons, but once she was in the shower chair, she would only be a one person assist. They felt like the care plan is just not clear enough. Review of a facility policy, dated 12/2017, titled,Free of Accident hazards/supervision/devices was provided by the DON on 1/7/21 at 1:00 p.m. The policy indicated the following: Policy: The facility must ensure that- The resident environment remains as free of accident hazards as is possible. Each resident receives adequate supervision, services, and assistance devices to prevent accidents. This Federal tag relates to Complaint IN 193. 3.1-45(a)(1) 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent a fall and failed to ensure interventions were addressed to prevent further falls for 1 of 4 residents reviewed for falls (Resident 45). This deficient practice resulted in a resident sustaining a [MEDICAL CONDITION]. Findings include: Review of Resident 45's clinical record was completed on 4/5/18 at 1:12 p.m. [DIAGNOSES REDACTED]. She had current MEDICATION ORDERS FOR [REDACTED]. She had a 3/28/18 physician's orders [REDACTED]. A 2/27/18, quarterly, Minimum Data Set (MDS) assessment indicated she was severely cognitively impaired, ambulated with supervision, and required extensive assistance for ADLs. A 3/28/18, significant change/5-day Medicare, MDS assessment indicated she was severely cognitively impaired, required extensive assistance for bed mobility and transfers, did not ambulate, and was dependent for locomotion. She had current careplan problems including, but not limited to, the following: Risk for falls, revised 4/4/18. Interventions included, but were not limited to, keep call light in reach, follow fall protocol, non-skid footwear, personal items in reach, to be kept in sight of nurse when unsteady, use a wheelchair when unsteady, observe self-transfers and help as needed, and toilet resident more frequently. Right [MEDICAL CONDITION] related to fall, revised 4/4/18. Interventions included, but were not limited to, anticipate needs and answer call light promptly, and observe for self-transferring or movement around facility and offer help as needed. Unable to independently complete her late loss ADLs, revised 4/4/18. An intervention for transfers included, but was not limited to, extensive assistance of one staff member. The mechanical lift, low bed, and fall mat were not indicated on the resident's careplans. Review of Progress Notes and Fall Reports indicated the following: On 11/30/17 at 11:00 p.m., she was found on floor in the middle of the 200 Hall. She had no injuries, indicated she was going to South Carolina and was found barefooted. She was placed at the nurses' station for observation. On 12/7/18 at 10:50 a.m., she had a witnessed fall with no injury. There were no new interventions added. On 12/8/17 at 2 p.m., she was found on the floor, crawling, and had climbed into her wheelchair. She had previously been laying in bed. An immediate intervention was indicated to attempt to walk her more and turn on her TV. On 12/8/17 at 2:11 p.m., she was found hanging onto the bathroom door and fell on to her buttocks before staff could reach her. She was to be toileted more often. On 1/13/18 at 2:48 p.m., she was found crawling on the floor. There were no new interventions added. On 2/24/18 at 3:50 p.m., she had an unwitnessed change in plane, when she was found with her walker overturned, resulting in a purple bruise to her left buttock, measuring 2 centimeters (cm) long x 1.7 cm wide. She was confused per her usual and her right knee continued to be weak. There were no new interventions added. On 2/25/18, she came out of her room, pushing her wheelchair, and was unsteady. She was assisted to her wheelchair. On 3/18/18 at 8:45 a.m., she was was found sitting on the floor in the lounge area, where she had been sleeping on the sofa. She complained of right thigh pain and was sent to the emergency room for evaluation. She was admitted to the hospital with [REDACTED]. She was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was receiving antibiotic injections for the UTI. No new fall interventions were added to her fall careplan. On 3/25/18, she was diagnosed with [REDACTED]. A 4/3/18 Activity Note indicated she was trying to get out of her chair throughout a small group activity at 4:18 p.m. On 4/3/18 at 8:57 p.m., she was found sitting on the floor next to her bed. She did not have any new injuries. The note indicated she was to utilize a low bed with a fall mat. On 4/5/18 at 1:08 p.m., Resident 45 was observed in bed asleep, with the bed low and a fall mat on the floor. On 4/6/18 at 7:57 a.m., she was observed seated in her wheelchair in the front lounge area with two other residents. Her legs were extended in front of her on the foot pedals of the wheelchair. On 4/6/18 at 8:01 a.m., she remained in her wheelchair in the lounge, but she had scooted to the edge of the seat and had her feet on the floor, in between the leg rests. She was attempting to propel the wheelchair forward with her feet, while pulling on the sofa arm with her hand, and had caught one of the leg rests on the back of another resident's wheelchair. She continued to to attempt to propel forward, causing her to scoot forward to the edge of the wheelchair seat. Upon being notified, the SSD approached the resident and asked if she was trying to get to the sofa; she stood by the resident until a CNA approached at 8:03 a.m. On 4/9/18 at 11:58 a.m., she was seated in her wheelchair near the 200 Hall nurses station. She was asleep. During an interview, on 4/6/18 at 8:35 a.m., CNA 31 indicated resident care interventions were in the charts at the desk and they had CNA assignment sheets, but they did not list many specifics. During an interview, on 4/6/18 at 8:40 a.m., CNA 32 indicated Resident 45 required a mechanical lift for transfers and had a low bed with a fall mat. The CNA assignment sheets had resident care interventions listed on them. Review of a current CNA sheet, provided by CNA 33 on 4/6/18 at 8:38 a.m., indicated Resident 45 used a walker and a wheelchair and her safety device was a walker. She had no special instructions for transfers- UP AD LIB. Review of an updated CNA sheet, provided by the DON on 4/9/18 at 10:15 a.m., indicated she required a mechanical lift and two staff persons, used a wheelchair, and had a floor mat for safety. During an interview, on 4/9/18 at 2:40 p.m., the DON indicated Resident 45 had normally stayed in the lounge area to watch TV and sleep on the couch. She was found to have a UTI at the hospital and may have been weak at the time of the fall when she fractured her hip. She would crawl on the floor when she was first admitted and would sit on the floor and scoot herself, although there was no indication in clinical record as to her having had behaviors of putting herself on the floor or scooting. Her bed was kept in a low position with a mat in place prior to the fall due to her behaviors. She had never had an actual fall prior to her [MEDICAL CONDITION] and the facility would not have known to supervise her. She had started physical therapy in December. Interdisciplinary notes indicated interventions were in place, such as a mat and low bed. She could currently ambulate with a walker and assistance and propelled her wheelchair with her feet, although she had the foot pedals. She would try to propel the wheelchair with her arms as well. On 4/9/18 at 3:07 p.m., the ADON indicated her care plans had not been updated. At 3:18 p.m., the ADON indicated she could not locate a careplan about her crawling on the floor. She did not need the fall mat outside of her room, as it was not in place for her fall risk. 3.1-45(a)

Based on record review, and interview, the facility failed to ensure the staff identified abuse and failed to immediately notify facility Administration, resulting in a delay in the investigation of an incident for 1 of 3 residents reviewed for abuse. (Resident B and LPN 3) The immediate jeopardy began on 9/27/2017 when facility staff failed to report suspicions of abuse. The facility staff failed to report suspicions of sexual abuse to the appropriate management to facilitate a timely investigation and reporting of said suspicions. The Administrator was notified of the immediate jeopardy on 9/29/2017 at 12:28 p.m. Findings include: Resident B's record was reviewed on 9/29/2017 at 12:49 p.m. Current [DIAGNOSES REDACTED]. Review of a current admission Brief Interview for Mental Status dated 9/28/2017 indicated Resident B was cognitively impaired with a score of 4 out of 15. During an interview on 9/29/2017 at 12:36 a.m., LPN 3 indicated she became suspicious of CNA 4's interaction with Resident B. LPN 3 indicated CNA 4 made inappropriate comments during resident care on the evening of 9/27/2017 at approximately 9:15 p.m. LPN 3 did not report the suspicions to the Administrator per facility policy. LPN 3 waited until after she gave the third shift nurse her report then called the Director of Nursing at approximately 10:30 p.m. CNA 4 remained in the facility and continued to provide care until clocking out at 10:00 p.m., 1 hour and 45 minutes after LPN 3 acknowledged the suspicion. During an interview on 9/29/2017 at 12:42 p.m., Resident B's husband indicated he had been notified by the facility his wife had been sent to the emergency room for evaluation of possible sexual abuse. He indicated the hospital told him they would do testing for sexual assault but it could take up to 2 weeks for the results to come back. During an interview on 9/30/2017 at 11:43 a.m., the Director of Nursing indicated on 9/29/2017 at 2:10 p.m., LPN 3 changed her previous statement related to the time line of the incident. LPN 3 indicated CNA 5 informed her of the leaking [DEVICE] at approximately 8:30 p.m. on 9/27/2017. The Director of Nursing indicated LPN 3 went to the resident's room then left to retrieve supplies. The alleged misconduct was acknowledged by LPN 3 at approximately 8:45 p.m., 1 one and 45 minutes before contacting the Director of Nursing with the allegation of abuse. Review of the progress note, dated 9/27/2017 at 9:15 p.m., indicated LPN 3 was notified the resident's [DEVICE] was leaking and observed the alleged inappropriate interaction between CNA 4 and Resident B. Review of a progress note, dated 9/27/2017 at 10:30 p.m., indicated the following: : Off going nurse gave in report that an awkward situation occurred while she and CNA were providing care. Off going nurse notified DON at 2230 (10:30 p.m.). Was instructed to start immediate investigation. Entered resident's room to find res (resident) dozing off. Res awakened easily and alert to name. Vitals taken bp (blood pressure) 156/74, p (pulse) 99, r (respirations) 20, t (temperature) 98.6, O2 sats 96% RA (room air). This nurse spoke with res asking if she felt safe. Res shook head no. Asked res, Do you feel like CNA was inappropriate when care was provided? Res shook head yes. Reassured res that she was safe now. Head to toe assessment completed, with no immediate skin issues. Continued investigation. Call light in reach. In a confidential interview with another resident on 9/27/2017 at 1:45 p.m., she indicated CNA 4 always rubbed more than necessary during incontinent care. A review of this resident's most recent MDS indicated they had a BIMS score of 15 out of 15, indicating the resident was interviewable. Review of a progress note, dated 9/28/2017 at 2:17 a.m., indicated the Administrator was notified at 10:44 p.m. 9/27/2017, 1 hour and 30 minutes after the employee acknowledged the suspicion of abuse. The resident was sent to the emergency room at 1:24 a.m. 9/28/2017. The resident was not admitted to the hospital and returned to the facility. Review of a current policy, dated 11/2016, titled Abuse, Neglect and Exploitation was provided by the Administrator on 9/29/2017 at 9:30 a.m. The policy indicated the following: Abuse, Neglect and Exploitation Policy: It is the policy of the Community Health Network that each resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, exploitation and involuntary seclusion. The resident has the right to be free from mistreatment, neglect and misappropriation of property. Residents must not be subject to abuse by anyone, including, but not limited to; facility staff, other residents consultants or volunteers, staff of other agencies serving the resident, family members, legal guardians, friends or other individuals. Compliance Guidelines: 1. The Abuse Coordinator in the facility is the Director of Nursing, Administrator, or facility appointed designee. Report allegations or suspected abuse, neglect or exploitation immediately to: Administrator . V. Investigation of Alleged Abuse, Neglect and Exploitation When suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur, an investigation is immediately warranted. VII. Response and Reporting of Abuse, Neglect and Exploitation Anyone in the facility can report suspected abuse to the abuse agency hotline. When abuse, neglect or exploitation is suspected, the Licensed Nurse should: Respond to the needs of the resident and protect them from further incident (document) Notify the Director of Nursing and Administrator (document) . The Immediate Jeopardy that began on 9/27/2017 was removed on 9/30/2017 when the facility reeducated staff regarding abuse and following the abuse policy, but the non-compliance remained at no actual harm, but potential for minimal harm because system monitoring had not been completed. This Federal tag relates to Complaint IN 921. 3.1-28(a)

Based on interview and record review, the facility failed to prevent staff to resident sexual abuse for 1 of 3 residents reviewed for abuse. (Resident B and CNA 4) The immediate jeopardy began on 9/27/2017 when facility staff failed to prevent and report suspicions of abuse. The facility staff failed to report suspicions of sexual abuse to the appropriate management to facilitate a timely investigation and reporting of said suspicions. The Administrator was notified of the immediate jeopardy on 9/29/2017 at 12:28 p.m. Findings include: Resident B's record was reviewed on 9/29/2017 at 12:49 p.m. Current [DIAGNOSES REDACTED]. Review of a current admission Brief Interview for Mental Status dated 9/28/2017 indicated Resident B was cognitively impaired with a score of 4 out of 15. During the initial tour LPN 2 indicated Resident B was alert and oriented, but hard to understand. During an interview on 9/29/2017 at 12:36 a.m., LPN 3 indicated she became suspicious of CNA 4's interaction with Resident B. LPN 3 indicated CNA 4 made inappropriate comments during resident care on the evening of 9/27/2017 at approximately 9:15 p.m During an interview on 9/29/2017 at 12:42 p.m., Resident B's husband indicated he had been notified by the facility his wife had been sent to the emergency room for evaluation of possible sexual abuse. He indicated the hospital told him they would do testing for sexual assault but it could take up to 2 weeks for the results to come back. Review of a written statement from LPN 3 indicated the following: .While I was in the residents (sic) room, I explained to her what I was doing. At this time, (CNA 4) stated, 'Well I found out that (Resident B) is ticklish.' I replied, 'Oh (Resident B) I am too! Where at? Your knees? Your neck?' (CNA 4) then says, 'No actually some place you would not expect.' I then say, 'Oh I bet its your butt cheeks cause that is my tickle spot!' (CNA 4) replied, 'Nope but around the front she is.' At that point I did not reply, (CNA 4) left the room after saying that. I looked at (Resident B) and asked her if she was ok and if she had a nice bath She replied,'yes'. I finished fixing the [DEVICE], cleaned up the area, made sure that (Resident B) was comfortable and the call light was in reach. Review of the progress note, dated 9/27/2017 at 9:15 p.m. indicated LPN 3 was notified the resident's [DEVICE] was leaking and the observed the inappropriate interaction between CNA 4 and Resident B. Review of a progress note, dated 9/27/2017 at 10:30 p.m., indicated the following: : Off going nurse gave in report that an awkward situation occurred while she and CNA were providing care. Off going nurse notified DON at 2230 (10:30 p.m.). Was instructed to start immediate investigation. Entered resident's room to find res (resident) dozing off. Res awakened easily and alert to name. Vitals taken bp (blood pressure) 156/74, p (pulse) 99, r (respirations) 20, t (temperature) 98.6, O2 sats 96% RA (room air). This nurse spoke with res asking if she felt safe. Res shook head no. Asked res, Do you feel like CNA was inappropriate when care was provided? Res shook head yes. Reassured res that she was safe now. Head to toe assessment completed, with no immediate skin issues. Continued investigation. Call light in reach. Review of a progress note, dated 9/27 (YEAR) at 10:45 p.m., indicated the resident was interviewed by staff. The interview questions and answers are as follows: Resident was .asked if she recalled the CNA (young man) who cleaned her up this evening. Res (Resident) told her 'yes'. Resident was asked if she felt safe. The resident responded no. Resident was asked if she felt the young man had touched her inappropriately. The resident responded yes. Resident B responded yes when asked if she felt the staff member had been inappropriate; In a confidential interview with a resident on 9/27/2017 at 1:45 p.m., she indicated CNA 4 always rubbed more than necessary during incontinent care. A review of this resident's most recent MDS indicated the resident had a BIMS score of 15 out of 15. this indicated the resident was interviewable. Review of a progress note, dated 9/28/2017 at 2:17 a.m., indicated the Administrator was notified at 10:44 p.m. 9/27/2017, 2 hour and 14 minutes after the employee acknowledged the suspicion of abuse. The resident was sent to the emergency room at 1:24 a.m. 9/28/2017. The resident was not admitted to the hospital and returned to the facility. Review of a current policy dated 11/2016, titled Abuse, Neglect and Exploitation was provided by the Administrator on 9/29/2017 at 9:30 a.m. The policy indicated the following: Abuse, Neglect and Exploitation Policy: It is the policy of the Community Health Network that each resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, exploitation and involuntary seclusion. The resident has the right to be free from mistreatment, neglect and misappropriation of property. Residents must not be subject to abuse by anyone, including, but not limited to; facility staff, other residents consultants or volunteers, staff of other agencies serving the resident, family members, legal guardians, friends or other individuals. The Immediate Jeopardy that began on 9/27/2017 was removed on 9/30/2017 when the facility reeducated staff regarding abuse and following the abuse policy, but the non-compliance remained at no actual harm, but potential for minimal harm because system monitoring had not been completed. This Federal tag relates to Complaint IN 921. 3.1-27(a)(1)

Based on record review and interview, the facility failed to ensure interventions identified in the resident's plan of care were in place to help prevent falls for 1 of 3 residents reviewed who met the criteria for accidents. This deficient practice allowed the resident to have a resulting arm fracture. (Resident B) Findings include: The clinical record for Resident B was reviewed on 7/16/15 at 9:15 a.m. [DIAGNOSES REDACTED]. The most recent Quarterly Minimum Data Set (MDS) assessment, dated 4/2/15, indicated Resident B was severely cognitively impaired. Resident B received the following Activities of Daily Living (ADL) assistance; transfer-extensive assist with one person assist, dressing, bathing, hygiene and toileting Resident B was occasionally incontinent of bowel and bladder. During a review of the fall reports for the past three months provided by the Administrator on 7/16/15 at 9:40 a.m., Resident B had three reported falls within the past three months. A plan of care, dated 1/9/13, indicated Resident B was a high risk for falls related to Unaware of safety needs and impaired mobility. Interventions for this problem included, but were not limited to, Anticipate and meet the resident's needs. A plan of care, dated 6/10/14, indicated Resident B had a history of [REDACTED]. A plan of care, dated 1/24/13, indicated Resident B has an ADL (Activities of Daily Living) Self Care Performance deficit related to dementia and impaired mobility. Interventions for this problem included, but were not limited to, TOILET USE: The resident requires 1 staff limited assistance to use toilet. TRANSFER: The resident requires 1 staff limited assist with transfers. Review of the nursing notes, dated 7/6/15 at 1:47 p.m., indicated Resident B was found on the floor in her bathroom. Resident B had been left on the commode and instructed to use the call light when she was finished. Resident B complained of pain in her left shoulder. Post fall an x-ray of the left shoulder was ordered. Review of the radiology report, dated 7/6/15, indicated suspected recent fracture of the left humeral neck. During an interview on 7/16/15 at 1:10 p.m., Housekeeper #2 indicated she was in Resident B's room cleaning at the time of the fall. I was cleaning her room and the bathroom door was open and I saw (Resident B's name) sitting on the potty and she said she was done. I told her I'd go get somebody to help her and I left. I got maybe five steps out of her room and I heard (Resident B's name) hollering. She got up herself. She didn't want to wait for help. I didn't see her fall but I heard her. Housekeeper #2 indicated she noticed the call light was on at the time. During an interview on 7/16/15 at 1:20 p.m., LPN #1 indicated she had taken Resident B to the toilet after lunch on 7/6/15. She indicated she left the resident in the bathroom and instructed her to use the call light when she was done. I walked her into the bathroom and gave her the call light. She stated she would pull the light when she was finished and I left the room. During an interview on 7/16/15 at 1:00 p.m., QMA #3 (Qualified Medication Aide) indicated she was in the hallway when a housekeeper came out of Resident B's room and said she had fallen. When I came into the room she was on the bathroom floor on her left side. I called for the nurse. They started doing their thing, you know, vitals and stuff. They asked her if she hurt anywhere and she said her left arm. During an interview on 7/16/15 at 4:00 p.m., the Administrator indicated Resident B should not have been left alone in the bathroom. No further information was provided. This federal tag relates to Complaint IN 474. 3.1-45(a)(2)

Based on observation, interview and record review, the facility failed to ensure a resident was not given the wrong medication resulting in a drug overdose and hospitalization for 1 of 1 resident reviewed for a significant medication errors. (Resident #54) Findings include: During a 5/12/15, 3:18 p.m., interview, Resident #54's family member indicated Resident #54 had been given the wrong person's medication sometime in the winter months. She indicated, as a result of receiving the wrong medication, Resident #54 had been hospitalized for [REDACTED]. An 11/22/14, "Medication Error Report" indicated Resident #54 was given the wrong resident's medication due to the employee went into the wrong room. Resident #54 was given 3 blood pressure medications that she did not normally receive and a narcotic for pain ([MEDICATION NAME]) that she would not normally take. Resident #54 was sent to the emergency room (ER) due to a decreased blood pressure. Resident #54's clinical record was reviewed on 5/13/15 at 9:00 a.m. Resident #54's current [DIAGNOSES REDACTED]. Resident #54 had an 11/22/14, 8:30 a.m., Nursing Note which indicated the QMA (qualified medication aide) inadvertently gave the resident another resident's medication. The resident was given 3 blood pressure/hypertensive medications which she did not normally receive and a narcotic pain medication. The Nursing Note, which was written by LPN #8, indicated "I told QMA to hold her [MEDICAL CONDITION](hypertensive) medications and give other medications as ordered." Nursing personal would monitor the resident. Vital signs were: B/P 114/71 (blood pressure), HR- 63 (heart rate), R- 12 (respirations) and O2 sat - 91% (oxygen saturation). Resident #54's routine vital signs for October through November 2015 were: B/P 131/67 to 155/84 Pulse/Heart Rate 61-79 Respiratory Rate 18-20 O2 sats 94-99% on room air. Resident #54 had an 11/22/14, 10:00 a.m., (1 and 1/2 hours after the error was first documented) Nursing Note which indicated the resident was asleep and her vital signs were B/P- 103/63, HR-63, R - 14, O2 sat 96%. Resident #54 had an 11/22/14, 11:30 a.m., (1 and 1/2 hours between documented vital signs) Nursing Note which indicated the resident's vital signs were B/P- 99/62, HR-66, R-18, O2 sat 93%. Resident #54 had an 11/22/14, 1:42 p.m., Nursing Note which indicated at approximately 12:55 p.m. the nurse checked on the resident and her vital signs were B/P-87/56, HR-58, R-9, O2 sat at 89% on room air. The DON, family and doctor were contacted and the resident was sent to the ER. Resident #54 had an 11/12/4, 1:15 p.m., physician's orders [REDACTED]. Resident #54 had an 11/22/14 hospital report which indicated: " resp rate (respiration rate) down to 9 at nursing home. Was given [MEDICATION NAME] (anti-narcotic) in ER.... [MEDICAL CONDITION]: note urine output down this am ... Lab results: CREAT 1.98* BUN 22 (no range given)... ASSESSMENT: 1. Accidental overdose, initial encounter 2. Narcotic-induced respiratory depression ... 5. [MEDICAL CONDITION] ...NYHA (New York Heart Association) class III, chronic systolic 6. Respiratory depression 7. [MEDICAL CONDITION] 8. other specified hypertension." Resident #54 had an 11/22/14, "Hospital Admission History and Physical" which indicated: "accidental overdose. Pt (patient) was in per (ambulance name) from parkview nursing home. Pt was given a different person's medication this morning at 0930 (9:30 a.m.). Pt was given potassium 10 mEq, [MEDICATION NAME] 150 mg ( acid reducer), [MEDICATION NAME] 10 mg (heart medication), [MEDICATION NAME] 10 mg (blood pressure medication), [MEDICATION NAME] 100 mg (stool softener), Duloxetine 60 mg (anti-depressant) , [MEDICATION NAME] tab (eye vitamin), [MEDICATION NAME] 40 mg (hypertensive), multi- vitamin, [MEDICATION NAME] 7 mg (Alzheimer's medication), [MEDICATION NAME] 40 mg (acid reducer), and [MEDICATION NAME] 30 mg (narcotic pain medication). Pt's BP and RR (respiratory rate) low. Pt LOC (level of consciences) decreased." Resident #54 had the following laboratory results during her hospitalization : 11/22/14 Admission labs: AST/SGOT (liver function)-147 H (range 14-36); ALT/SGPT (liver function)- 98 H (R 9-52), alkaline [MEDICATION NAME] (liver functions)-193 H (R 38-126); Creatinine ( urinary function) 1.98* ( no range given); BUN (urinary function) 22 (no range given). 11/24/14 labs: BUN -16, Creatinine-88, 11/25/14 labs: AST/SGOT-27, ALT/SGOT - 67, alkaline [MEDICATION NAME]- 133 H. All laboratory levels improved with treatment. Resident #54 had an 11/25/14, Hospital Discharge summary, which indicated the resident had received new [DIAGNOSES REDACTED]. "Hospital course: her first 48 hours here were very sedated. She was given [MEDICATION NAME] in ER and sat and resp returned to normal. She required low dose [MEDICATION NAME] for her hypertension, and we were then able to successfully wean this. Initial urine flow was minimal, but improved with hydration." During a 5/13/15, 1:33 p.m. interview with LPN #8 and the DON, both indicated the QMA accidentally gave Resident #54 the wrong medication. She then contacted LPN #8. LPN #8 contacted the DON. The DON made the call to hold all hypertensive medications and administer the rest of Resident #54's morning medications. Both indicated the physician had not been involved in discussion to administer the routine morning medications. Resident #54 was observed in her room in bed on 5/11/15 at 2:09 p.m. She did not turn towards the speaker or make any form of recognition when called by name. On 5/12/14 at 7:59 a.m., Resident #54 was in a broda chair in her room. She was awake. She did not speak when called by name. A current, undated, facility policy, which was provided by the Administrator on 5/15/15 at 1:10 p.m., indicated the following: "The medication error will be reported to the attending physician or physician on call for the attending physician as well as the party responsible for the resident." 3.1-25(b)(9)

Based on observation, interview and record review, the facility failed to prevent the development of a pressure area due to lack of incontinent services resulting in the re-opening of a pressure area for 1 of 2 residents reviewed for pressure area prevention and treatment. This deficit practice resulted in Resident #33's healed pressure area re-opening to a stage 2 pressure area on 5/15/15. (Resident #33) Findings include: 1. On 5/15/15 at 9:54 a.m., Resident #33 was observed lying in bed. She was lying on her right side, curled up, and her face in the mattress. Resident #33 was moaning and crying. The resident's gown was wet from her hips to the middle of her back with a dark ring around the wet area on her gown. Resident #33 had two saturated incontinent pads under her. The white sheet under the two incontinent pads had an oval shaped, wet, yellow area with a dried, dark outer ring. During an interview with CNA #3 on 5/15/15 at 10:07 a.m., she indicated the wet area on the white sheet was approximately 20 inches long by 12 inches wide, yellow stained, wet with dry edges. CNA #3 indicated the two incontinent pads under Resident #33 were wet, along with the resident's gown. She indicated the resident's gown was wet up to her mid back with a dried ring around the wet area. During an interview with CNA #9 on 5/15/15 at 10:15 a.m., she indicated the last time she had checked on Resident #33 was at 6:30 a.m., 30 minutes after the start of her shift. She indicated she was not aware the resident was on a turn schedule or on hourly checks. CNA #9 indicated there was three CNA's currently working on the hall. CNA # 9 indicated she was assigned to provide care for Resident #33 on 5/15/15. During an observation of incontinence care for Resident #33 on 5/15/15 at 10:07 a.m., a reddened area was observed on the coccyx/left buttock. The area was sheared with loose white skin attached. The Wound Nurse was observed measuring the area to the coccyx/left buttock on 5/15/15 at 10:25 a.m. She indicated the wound was located on the coccyx and was a Stage 2 pressure area. The Wound Nurse indicated the measurements were 4.9 centimeters length by 4.0 centimeters width by 0.1 centimeters depth with a reddened and sheared area. The surrounding area was 4.1 centimeters length by 3.6 centimeters width. It had a red center with yellow slough around the open part of the wound. During an interview with the Wound Nurse on 5/15/15 at 3:20 p.m., she indicated Resident #33's wound to her coccyx had been a healed stage 2 and now had reopened to the proximal area of the healed wound. She indicated the wound looked worse on 5/15/15 than it had on 5/12/15. She indicated the wound looked to be closed, pink with fragile skin around the healed prior stage 2 wound of the coccyx on 5/12/15. The Wound Nurse indicated the wound looked to have fresh shearing on 5/15/15. During an interview with the Hospice Nurse on 5/18/15 at 1:45 p.m., she indicated when she saw the resident the middle of last week, the area to the resident's coccyx was not open but approximately 1 centimeter length by 1 centimeter width with no depth. It looked like a rug burn, no loose skin, it was reddened. A review of the "Wound Nurse Assessment", dated 5/15/15, with an onset date of 5/15/15, indicated "...Reddened area measures 4.9 x 4.0 x 0.1 surrounding open area 4.1 x 3.6 Area stage 2 with red center and yellow slough around open part of wound. Skin very fragile and pink...." Resident #33's clinical record was reviewed on 5/13/15 at 12:57 p.m. Resident #33's current [DIAGNOSES REDACTED]. Resident #33 had a current, 4/6/15, significant change, Minimum Data Set assessment (MDS) which indicated: the resident was severely cognitively impaired and rarely or never made independent decisions. Resident #33 was totally dependent on staff assistance for mobility both on and off the unit, total dependence on staff for toilet use, hygiene and extensive assist with bed mobility. Resident #33 had a current 4/6/15, care plan problem/need regarding "impaired thought processes related to dementia/Alzheimer's." Approaches to this problem included but were not limited to, "needs cues with all decision making and communicate with resident and her family regarding resident's capabilities and needs." Resident #33 had a current 4/6/15, care plan problem/need regarding "activities of daily living self care deficit related to confusion, pain and impaired mobility." Approaches to this problem included but were not limited to, "...Check resident hourly to ensure needs are met...and ...resident requires mechanical aid as needed for transfers per 2 staff." Resident #33 had a current 4/6/15, care plan problem/need regarding "skin breakdown r/t (related to) occasional B&B (bowel and bladder) incontinence..." Approaches to this problem included but were not limited to, "Cleanse skin and dry after each incontinent episode...." A current undated facility policy titled "Perineal Care Policy/Procedure " provided by the Administrator on 5/18/15 at 8:45 a.m. indicated the following: "1. Perineal care will be provided as needed...to residents between bathing to prevent irritation, infection and skin breakdown, and to promote resident comfort and dignity. 2. Direct-care staff will be responsible for determining when a resident is in need of... perineal care, and will be responsible to provide perineal care to the resident...." A current undated facility policy titled "Pressure Ulcer Prevention and Treatment Policy/Procedure" provided by the Administrator on 5/18/15 at 8:45 a.m. indicated the following: "1. Prevention ...c. Pressure ulcer risk factors and interventions are as follows: i. Potential risk factors: moisture, friction and shearing, immobility, bowel and bladder incontinence, poor nutrition, decreased mental awareness, medications, co-morbid or terminal disease processes. ii. Potential interventions relative to risk factors: protective barriers, routine skin checks, routine toileting, repositioning... 3. Staging of Pressure Ulcers ...Stage II: A partial thickness loss of skin layers that present clinically as an abrasion, blister, or shallow crater...." 3.1-40(a)(2)

Based on observation, record review and interview, the facility failed to provide services to promote healing of a pressure sore for 1 of 3 residents who met the criteria for pressure ulcers (Resident #5). This deficient practice resulted in the worsening of a pressure sore for Resident #5 in size and depth. Findings include: The clinical review for Resident #5 was reviewed on 9/26/13 at 2:22 p.m. Resident #5 had [DIAGNOSES REDACTED]. A physician's orders [REDACTED]." The Recapitulation of Physician orders [REDACTED]." A care plan problem for Resident #5 indicated, "...has the potential for skin breakdown related to impaired mobility, bowel incontinence." Interventions related to the care plan problem indicated, "Resident to have low air loss mattress on bed, initiated 7/26/13, Identify/document potential causative factors and eliminate/resolve where possible, initiated 5/14/13." The review of the weekly skin documentation, dated 8/15/13, indicated a Stage III (Stage III; "Full thickness tissue loss. Subcutaneous fat maybe visible but bone, tendon or muscle is not exposed. Slough maybe present but does not obscure the depth of tissue loss. May include undermining and tunneling.") pressure ulcer to the left gluteal and sacrum with an onset date of 8/2/13. The length was 0.1 centimeters by 0.1 centimeters width and no depth noted. The description indicated a "superficial open, no drainage, no odor, scant eschar to coccyx area and closure pinpoint scant redness." The weekly skin documentation, dated 8/22/13, indicated a Stage III pressure ulcer to the left gluteal and sacrum with an onset date of 8/2/13. The length was 0.5 centimeters by 0.2 centimeters width and no depth noted. The wound progress description indicated "... left gluteal shearing." Treatment included "...flotation mattress. Wedge Roho cushion to wheelchair." The weekly skin documentation, dated 9/17/13, indicated a Stage III pressure ulcer to the left gluteal and sacrum with an onset date of 8/2/13. The length was 0.7 centimeters by 1.7 centimeters width and no depth noted. The description indicated a "open [MEDICATION NAME] shearing..." The weekly skin documentation, dated 9/25/13, indicated a Stage III pressure ulcer to the left gluteal and sacrum with conflicting onset dates of 8/8/13 and 8/2/13. The length was 1 centimeter by 2.2 centimeters width and 0.1 centimeters depth. The wound progress description indicated "depth present not improved..." Treatment included "Flotation mattress in use on bed, Roho cushion in place to wheelchair and reclined (sic)..." During an interview with LPN #4 on 9/27/13 at 8:48 a.m., LPN #4 stated the measurement at that time of the pressure ulcer to the left upper gluteal was 3.0 centimeters long by 3.5 centimeters in width and 0.1 centimeters in depth." During a wound treatment observation on 9/27/13 at 8:48 a.m., wound measurements with LPN #4 were consistent with the documentation of 9/25/13. This measurement indicated that the pressure ulcer had increased in size of first measurement of 8/15/13, which was 0.1centimeters in length by 0.1 centimeters in width and no depth noted. There was an increase in size of 2.9 centimeters in length, 3.4 centimeters in width and 0.1 centimeters in depth. During an interview with the Wound Nurse on 9/26/13 at 2:02 p.m., the nurse stated "...Resident is almost dead weight with her [DIAGNOSES REDACTED]. Interventions in place include a special flotation bed, special wedge Roho for her wheelchair and she can use the Roho in her recliner..." During an observation of Resident #5 on 9/26/13 at 3:32 p.m., Resident #5 was sitting in her recliner with no Roho cushion under her. Roho was visible in resident's empty wheelchair. During an interview with the DoN (Director of Nursing) on 9/26/13 at 4:27 p.m., indicated after a check of Resident #5's bed that "it's just a regular mattress not a low air flow mattress." During observation and interview with Resident #5 on 9/27/13 at 8:42 a.m., the new air flow mattress had been applied to her bed. The resident stated, "I slept really good last night on my new mattress. Before I had places that hurt all night long. On the previous mattress there would be spots on my bottom that would burn and hurt when in bed. I would have to scoot and move around throughout the night because my bottom hurt. "I have never put the cushion from my wheelchair into my recliner because I was never told I could do that or I would have. I try to lay down for two hours after lunch and reposition myself throughout the night." An interview with the DoN, on 9/27/13 at 9:20 a.m., indicated the DON did not know why it had been a couple months and no one noticed the order for the low air loss mattress. During an interview with the DoN on 9/30/13 at 8:52 a.m., the DoN indicated there was no wound committee in place. Staff were aware of wounds but did not meet regularly. A wound nurse did wound rounds weekly. A current undated facility policy titled "Decubitus Ulcer - Treatment," provided by the Assistant Director of Nursing on 9/30/13 at 12:30 p.m., indicated the following: "treatment of [REDACTED]. Since there is marked diversity in the treatment of [REDACTED]. ...2. The nurse is responsible for carrying out the treatment of [REDACTED]." 3.1-40(a)(2)