Every finding on record at Envive of Evansville

Based on observation, interview, and record review, the facility failed to maintain a safe, sanitary, and homelike environment in resident spaces for 2 of 2 units observed. (Pathways 1, Pavilion ) Findings include: On 8/10/26 at 10:33 a.m., the Pathways 1 unit was observed to have a dark substance on multiple air vents and ceiling tiles by the vents, throughout the unit. 2. On 8/11/26 at 9:45 a.m., the following was observed on the Pavilion unit: Exit doors on the unit had dirt/debris build up around the door frame, threshold. Cove base was observed coming off on both sides of the double exit doors by the nurses station. Cobwebs were observed on the window sills in the dining room. Dirt build up around the pillars in the dining room, around cabinets/counters, walls. Floors were sticky in the dining room and throughout the unit. room [ROOM NUMBER], 702, 705, 707, 708, 709 had dirt build up in the bathroom around the wall trim, walls and trim marred/gouged in the resident living quarters. The same was observed on 8/12/26. On 8/13/26 at 10:03 a.m., the Maintenance Director indicated work orders were derived from employees, residents and are prioritized how it impacts residents. He indicated they were made aware by a staff member that they suspected mold/mildew on the Pathways 1 unit, testing was done with no mold found. He indicated he suspected the vents had not been cleaned in years, some had been wiped but not deep cleaned. He indicated after bringing it to their attention during the survey he was having his employees take each vent down to clean them, the dark substance was dust. On 8/13/26 at 1:33 p.m., the Administrator provided the current environmental policy with a revised date of 8/24. The policy included but was not limited to: Environmental surfaces will be cleaned and disinfected according to current CDC (Centers for Disease Control and Prevention) recommendations for disinfection of healthcare facilities and the OSHA (Occupational Safety and Health Administration) bloodborne pathogens standard .9. Housekeeping surfaces (e.g; floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled . This citation relates to Intake 3131154. 410 IAC (Indiana Administrative Code) 16.2-3.1-19(f)

Based on observation, interview, and record review, the facility failed to ensure the physician was notified and an order was in place for a dressing to a wound for 1 of 3 residents reviewed for wounds. A dressing was observed on a wound with no treatment order. (Resident D) Finding includes: On 8/10/26 at 10:00 a.m., Resident D was observed sitting in her room. A dressing was observed to her lower right leg, undated, no initials. The dressing had a visible dark substance that was coming through. Resident D indicated she thought it was a skin tear, she was unsure when it happened or how long the dressing had been on her leg. On 8/11/26 at 10:26 a.m., the dressing to Resident D's lower right leg was observed to be gone. The wound appeared to have a moist surface. Resident D indicated staff removed the dressing and told her it needed to be open to air to heal. She was unsure who removed it or when it was removed. On 8/11/26 at 11:01 a.m, Resident D's clinical record was reviewed. Diagnoses included but were not limited to localized edema, essential hypertension. A quarterly MInimum Data Set (MDS) assessment dated [DATE], indicated cognition moderately impaired. Care plans were reviewed and included but were not limited to:At risk for skin integrity r/t (related to) impaired mobility, edema, and occasional incontinence, initiated 10/25/23, revised 5/28/26. Interventions included but were not limited to:Follow facility protocols for treatment of injury, initiated 5/29/24.Observe skin with daily cares. Notify nurse of new or worsening areas, dated initiated 10/25/23. Weekly skin assessments dated 8/6/26 and 7/30/26, were reviewed and indicated no discolorations or impairments to the skin. The clinical record lacked documentation of the wound or physician orders for treatment. The following skin and wound progress note from the wound Nurse Practitioner was reviewed : 6/12/26 3:23 a.m., Date of Service: 6/12/26 Visit Type: HP (history and physical) SKIN AND WOUND NOTE .She was seen this date due to a VLU (Venous Leg Ulcer) to the right anterior lower leg. Facility acquired on 6/11/26 . Wound 7 Location: Right anterior lower leg, Primary Etiology: Venous Ulcer, Stage/Severity: Partial Thickness, Wound Status: New, Size: 5.6 cm (centimeter) x 3.7 cm x 0.1 cm . Physician's orders for June 2026 were reviewed and included but were not limited to:Treatment- Right anterior lower leg: cleanse with normal saline or wound cleanser, pat dry, apply mupirocin to wound bed, then xeroform, cover with dry dressing daily and PRN(as needed), one time a day for venous ulcer, order date 6/12/26. Discontinued on 6/26/26. On 8/12/26 at 1:49 p.m., the DON indicated if staff find a new skin impairment on a resident, a new skin concern should be put into risk management, the physician and family notified, initial treatment done, wound monitoring started. The DON indicated Resident D had told her she thought she had scraped her leg on her wheelchair. The DON indicated she thought the area looked scabbed over and did not need a treatment, she put in the clinical record to monitor it. On 8/13/26 at 3:42 p.m., the Administrator provided the current policy and procedure manual with a revised date of 8/24. The policy included but was not limited to: Purpose- The purpose of this procedure is to guide the prevention of abrasions, skin tears, and minor breaks in the skin. Preparation- 1. Obtain a physician's order as needed. Document physician notification in medical record. 2. Review the resident's care plan, current orders, and diagnoses to determine resident needs. 3. Check the treatment record .Documentation- Record the following information in the resident's medical record: 34. Complete in-house investigation of causation. 35. Generate Non-Pressure form. 36. Document physician and family notification, and resident education (if completed) in medical record .42. When an abrasion/skin tear/bruises is discovered, complete a Report of Incident/Accident. Reporting - 43. Notify the responsible family member. Physician notification may be routine (that is, non-immediate) if the abrasion is uncomplicated ot not associated with significant trauma .45. Report other information in accordance with facility policy/guidelines and professional standards of practice .This citation relates to Intake 3131154. 410 IAC (Indiana Administrative Code) 3.1-5(a)(1)

Based on interview and record review, the facility failed to ensure a resident who wore oxygen via nasal cannula had a physician's order for oxygen use for 1 of 3 resident's reviewed for death. (Resident B) Finding includes : On 8/10/26 at 11:38 a.m., Resident B's clinical record was reviewed. Diagnoses included but were not limited to, acute on chronic systolic (congestive) heart failure, chronic respiratory failure with hypoxia, unspecified asthma, uncomplicated, chronic pulmonary edema, chronic obstructive pulmonary disease, unspecified, obstructive sleep apnea. A Minimum Data Set (MDS) 5 day assessment was marked yes for oxygen use. Care plans were reviewed and included but were not limited to: The resident has asthma, initiated 6/17/26, revision 6/17/26. Interventions included but were not limited to: Give nebulizer treatments and oxygen therapy as ordered, initiated 6/17/26. The resident has COPD (Chronic Obstructive Pulmonary Disease), obstructive sleep apnea, and chronic pulmonary edema, initiated 6/17/26, revision 6/17/26. Interventions included but were not limited to: Oxygen as ordered, initiated 6/17/26. Progress notes were reviewed and included but were not limited the following: 6/16/26 10:40 p.m., Resident was asleep, woke up with a loud voice calling for CNA (Certified Nursing Assistant). Resident stated she could not breathe and exhibits SPO2( peripheral oxygen saturation) 95% on room air and forced respiratory rate of 25 which decreases with diversional activity. O2 (oxygen) 2 L (liter) was placed by nasal cannula with immediate calming effect. RR (respiration rate) decreased to 16. 6/17/26 4:00 a.m., Resident is removing gown, states she needs her O2 turned up. NO SOA (shortness of air) and SPO2 is 94% on room air. She is continually removing her O2 stating it is getting tangled up on her arm when her gown comes off. She in noncompliant and attention seeking. 6/17/26 at 6:08 a.m., Resident calling out stating she is falling out of bed, or she is not getting enough oxygen, or she needs a pain pill .She is removing her gown, her O2, and noncompliant with request. 6/17/26 at 3:40 p.m., .O2: O2 96% -6/17/26 15:39 (3:39 p.m.) )Method : Oxygen via Nasal Cannula . 6/17/26 at 11:39 p.m., O2 : O2 93% -6/17/26 23:41 (11:41) Method: Oxygen via Nasal Cannula . On 8/13/26 at 1:18 p.m., the Regional Nurse Consultant indicated a physician's order is needed for oxygen use for routine or PRN (as needed), Resident B's clinical record did not contain a physician's order for oxygen use. On 8/13/26 at 12:17 p.m, the Administrator provided the current policies and procedures manual for oxygen administration with a revised date of 8/24. The policy included but was not limited to: Purpose- The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation- 1. Verify that there is a physician's' order for this procedure. Review the physician's orders or facility protocol for oxygen administration .Equipment and Supplies- .5. No Smoking/Oxygen in Use signs; .33. Instruct the resident, his/her family, visitors and roommate (if any) of the oxygen safety precautions. Provide the resident with a written copy of the Oxygen Safety handout .Documentation- After completing the oxygen setup or adjustment, the following information should be recorded in the resident's record: .The rate of oxygen flow, route, and rationale. This citation relates to Intake 3152801. 410 IAC (Indiana Administrative Code) 3.1-47(a)(6)

Based on observation, interview, and record review, the facility failed to implement care plans for 3 of 7 residents reviewed for falls and 1 of 5 residents reviewed for weight loss. Care plan interventions were not implemented to prevent falls and for monitoring residents with weight loss. (Resident 6, Resident 67, Resident 92, and Resident 111) Findings include:1. On 3/9/26 at 10:50 A.M., Resident 92 was observed in the common room participating in activities. He was wearing white socks that did not have non-skid bottoms. On 3/12/26 at 11:00 A.M., Resident 92's clinical record was reviewed. Diagnoses included, but were not limited to, Parkinson's Disease, Alzheimer's Disease, and muscle weakness. The most current Quarterly Minimum Data Set (MDS) Assessment, dated 12/8/25, indicated Resident 92 had severe cognitive impairment, was dependent on staff for toileting, and did not have any falls since the prior assessment. A current risk for falls care plan, initiated 6/12/23, included, but were not limited to, the following interventions:Non-skid socks/footwear on at all times, initiated 6/27/23 and revised on 11/22/24.Non-skid mat at bedside, initiated 9/15/23. The most current fall risk assessment, dated 12/20/25, indicated Resident 92 was at high risk for falls. A care conference was completed on 3/5/26 with family in attendance. Care plans were reviewed. Physician orders included, but were not limited to:To have non-skid footwear/socks at all times every shift for safety, dated 6/27/23 On 3/13/26 at 9:52 A.M., Resident 92 was observed sitting on his bed in his room. He was wearing white socks that did not have non-skid bottoms. There was not a non-skid mat at his bedside. During an interview on 3/13/26 at 11:38 A.M., the Director of Nursing (DON) indicated that the non-skid mat was not in Resident 92's room and his socks were not non-skid. 2. On 3/10/26 at 2:45 P.M., Resident 111's clinical record was reviewed. Diagnoses included, but were not limited to, multiple sclerosis and dementia. The most current Quarterly MDS Assessment, dated 12/7/25, indicated Resident 111 had severe cognitive impairment, required substantial to maximal assistance of staff (staff does more than half of the effort) for toileting and transferring, and had one fall without injury since the prior assessment. A current risk for falls care plan, initiated on 11/11/24, included, but was not limited to, the following interventions:Non-skid mat in front of toilet, dated 9/12/25. A care conference was completed on 1/15/26. The care plan was reviewed. The most current fall risk assessment, dated 3/7/26, indicated Resident 111 was at high risk for falls. Physician orders included, but were not limited to:Non-skid mat in front of toilet every shift, dated 9/12/25. On 3/13/26 at 9:48 A.M., Resident 111's bathroom was observed. There was not a non-skid mat in front of the toilet. At that time Certified Nurse Aide (CNA) 5 indicated that there was not a non-skid mat in front of Resident 111's toilet and he was unsure if one was supposed to be there. During an interview on 3/13/26 at 11:38 A.M., the Director of Nursing (DON) indicated there was not a non-skid mat in front of Resident 111's toilet and there should have been. 3. On 3/11/26 at 11:45 A.M., Resident 6's clinical record was reviewed. Diagnosis included, but was not limited to, dementia. The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 12/13/25, indicated Resident 6 was severely cognitively impaired, was completely dependent on staff (staff do all of the work) for toileting, bathing, and transfers, had no or unknown to have weight loss since the previous MDS assessment, and was receiving hospice services. The current care plan included, but was not limited to:I am at risk for nutritional problems related to hypokalemia, hypothyroidism, depression, initiated 11/29/24Interventions included, but were not limited to: Obtain weight as ordered, initiated 12/6/24. Physician orders included, but were not limited to: Vital Signs to be done monthly. If weight is less than three pounds or greater than three pounds difference from previous months weight, resident must be reweighted. One time a day starting on the 1st and ending on the 1st every month for per facility protocol. Document all vitals. Start date 12/1/24. Resident 6's most recent recorded weight was 1/1/26 of 115.2 pounds; prior to that on 12/10/25 was 115.2 pounds. The electronic medication administration record (eMAR) indicated Resident 6 refused a weight on 2/1/26, but no attempts to reweigh were recorded. The eMAR indicated the physicians order to obtain a weight on 3/1/26 was not completed. During an observation on 3/13/26 at 9:49 A.M., Resident 6 was weighted; her weight was 98.8 pounds. During an interview on 3/16/26 at 11:18 A.M., the Director of Nursing indicated staff should try to obtain weight again at another time if a weight is refused. 4. On 3/11/26 at 1:54 P.M., Resident 67 was observed lying in bed with no non-skid mat at bedside. On 3/11/26 at 9:26 A.M., Resident 67's clinical record was reviewed. Diagnoses included, but were not limited to, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side and dysphagia, oropharyngeal phase. The Current Quarterly Minimum Data Set (MDS) Assessment, dated 2/21/26, indicated Resident 67 was cognitively intact. Resident 67 needed supervison for eating and transferring, partial to moderate assistance for hygiene, and substantial to maximum assistance for dressing. Resident 67 also had a history of falls. The current fall risk care plan related to hemiplegia dated 11/3/35. Interventions included, but were not limited to, the following: Nonskid mat at bedside every shift for fall intervention, dated 11/3/25 Current physician orders included, but were not limited to, Nonskid mat at bedside every shift for fall interventions dated 11/3/25. On 3/12/26 at 3:49 P.M., Resident 67 was observed sitting in a wheelchair with no non-skid mat at bedside. On 3/13/26 at 2:30 P.M., Resident 67 was observed sitting in a wheelchair with no non-skid mat at bedside. On 3/16/26 at 8:58 A.M., Resident 67 was observed lying in bed with no non-skid mat at bedside. During in interview on 3/16/26 at 8:55 A.M., the Assistant Director of Nursing (ADON) indicated that there should be a mat at the bedside and did not know why one was not present. On 3/16/26 at 11:12 A.M., the Administrator provided a current policy Falls and Falls Risk, Managing dated 8/2024. The policy indicated . The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls . 410 IAC (Indiana Administrative Code) 16.2-3.1-35(g)(2)

Based on observation, interview, and record review, the facility failed to ensure proper storage of medication for 4 of 4 medication carts observed. Loose pills were observed in the medication cart drawers. (Short [NAME] Hall, Pavillion, Pathways, North East Hall)Findings include:1. On 3/9/26 at 8:44 A.M., the Short [NAME] Hall medication cart contained the following loose pills: 1 red circle pill with 11 marking1 yellow circle pill with 75 marking2. On 3/9/26 at 9:05 A.M., the Pavillion medication cart contained the following loose pills: 3 red circle pills with PH32 marking1 large white circle pill with no marking1 orange circle pill with 40 marking1/2 orange oval pill with u marking1 yellow circle pill with L marking1 red oval pill with 5 marking3 medium white circle pills with no marking2 blue circle pills with F5 marking2 green oval pills with V75 marking1 white circle pill with 337 marking1 white circle pill with H marking5 1/2 white oval pills with unidentifiable markings1 white circle pill with APO marking1 white circle pill with LL marking1 white circle pill with 77 marking1 white circle pill with U marking1/2 white circle pill with unidentifiable markings1 white oval pill with UU markingAt that time, Registered Nurse (RN) 3 indicated that pharmacy came to the facility once a month and cleaned out the cart, but she was unsure of the facility's policy in regards to who was supposed to clean the cart in between pharmacy visits.3. On 3/9/26 at 9:12 A.M., the Pathways medication cart contained the following loose pills:1 yellow oval pill with H126 marking1 red oval pill with H6 marking1 green oval pill with no markingsAt that time, Licensed Practical Nurse (LPN) 4 indicated that she cleaned the cart herself every time she passed medications, but was not sure of the facility's policy in regards to who was supposed to clean the carts.4. On 3/9/26 at 9:18 A.M., the North East Hall medication cart contained the following loose pills: 1 speckled brown circle pill with 85 marking1 large white circle pill with 54/22 markingOn 3/16/26 at 11:09 A.M., the Administrator provided a current Medication Storage in the Facility policy, dated 2020, that indicated Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier . (Name of Pharmacy) dispenses medications in containers that meet legal requirements, including requirements of good manufacturing practices where applicable. Medications are kept and stored in these containers . Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to the procedures for medication destruction, and reordered from the pharmacy, if a current order exits . Medication storage areas are kept clean, well lit, and free of clutter.410 IAC (Indiana Administrative Code) 16.2-3.1-25(j)

Based on interview, observation, and record review, the facility failed to ensure physician orders for oxygen administration were followed for 1 of 2 residents reviewed for respiratory care. (Resident 41) Finding includes:During an interview and observation on 3/10/26 at 9:45 A.M., Resident 41 indicated she wore oxygen continuously. The oxygen concentrator was set at four liters per minute of oxygen. On 3/10/26 at 2:34 P.M., Resident 41's clinical record was reviewed. Diagnoses included, but were not limited to, chronic respiratory failure with hypoxia. The most recent admission Minimum Data Set (MDS) Assessment, dated 1/7/26, indicated Resident 41 was cognitively intact, required substantial assistance from staff (staff do more than half of the work) for toileting and bathing, and was on oxygen. Physician orders included, but were not limited to:Oxygen at two to three liters per minute via nasal cannula continuously maintain saturation above 90% every shift related to chronic respiratory failure with hypoxia; Start date12/30/25. Change humidifier/bubbler monthly and as needed (PRN) for empty/compromised and one time a day every Sunday for routine oxygen; Start date 12/29/25. During an observation and interview on 3/13/26 at 10:02 A.M. residents' oxygen at 3.5 liters per minute; LPN 7 verified the oxygen concentrator was above three liters per minute and turned it down to three. The oxygen concentrator was out of reach of Resident 41 and did not have a humidification bottle on the concentrator. On 3/16/26 at 11:09 P.M., the Administrator provided a policy titled Oxygen Administration, dated 8/2024, that indicated Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration . Check the mask, tank, humidifying jar, etc., to be sure they are in good working order and are securely fastened. Be sure there is water in the humidifying jar and that the water level is high enough that the water bubbles as oxygen flows through. 410 IAC (Indiana Administrative Code) 16.2-3.1-47(a)(6)

Based on interview and record review, the facility failed to ensure a physician's assessment was completed within 30 days following admission for 2 of 2 residents reviewed for physician assessments following admission. (Resident 41 and Resident 32) Findings include: 1. During an interview on 3/10/26 at 9:45 A.M., Resident 41 indicated she had not seen a physician since admission. On 3/10/26 at 2:34 P.M., Resident 41's clinical record was reviewed. Resident 41 was admitted on [DATE]. Diagnosis included, but was not limited to, chronic respiratory failure with hypoxia. The most recent admission Minimum Data Set (MDS) Assessment, dated 1/7/26, indicated Resident 41 was cognitively intact, required substantial assistance from staff (staff do more than half of the work) for toileting and bathing, and was on oxygen. The clinical record lacked a physician assessment since admission. During an interview on 3/12/26 at 2:32 P.M., the Director of Nursing indicated Resident 41 was on the list to be seen by the physician on 2/11/26 but no assessment was completed in the medical record. 2. On 3/10/26 at 2:03 P.M., Resident 32's clinical record was reviewed. Resident 32 was admitted on [DATE]. Diagnosis included, but was not limited to, dementia. The most recent Quarterly MDS Assessment, dated 1/9/26, indicated Resident 32 was severely cognitively impaired and required partial assistance (staff do half of the work) for toileting and transfers. The clinical record indicated Resident 32 was assessed by the physician on 11/18/25. On 3/16/26 at 11:09 A.M., the Administrator provided a policy titled Physician Services, dated 8/2024, that indicated Supervising the medical care of residents includes (but is not limited to): participating in the resident's assessment and care planning; monitoring changes in resident's medical status; providing consultation or treatment when called by the facility; prescribing medications and therapy; ordering transfers to the hospital if necessary; conducting routine required visits; Physician visits, frequency of visits, emergency care of residents, etc., are provided in accordance with current OBRA regulations and facility policy. 410 IAC (Indiana Administrative Code) 16.2-3.1-22(c)(2)410 IAC 16.2-3.1-22(d)(1)

Based on interview, observation, and record review, the facility failed to ensure a resident's dental status monitored, family was notified of dental changes, and dental services were initiated for 1 of 1 residents reviewed for dental. (Resident 3) Finding includes: During an interview on 3/9/26 at 11:53 A.M., it was indicated a family member had visited the resident the previous week, and noticed her front tooth missing, and indicated staff were unaware when it had occurred. On 3/11/26 at 9:38 A.M., Resident 3's clinical record was reviewed. Diagnosis included, but was not limited to, dementia.The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 3/2/26, indicated Resident 3 was severely cognitively impaired, was dependent on staff (staff do all of the work) for toileting, bathing, and transfers, and required maximal assistance (staff do more than half of the work) for oral hygiene. Physician orders included, but were not limited to:Do not attempt to floss between resident's two front teeth, as these teeth have been fused per recent dental procedure every shift; Start date: 8/15/24 The current care plan included, but was not limited to:The resident has an ADL (activities of daily living) self-care performance deficit related to Alzheimer's; Date Initiated: 5/23/24Interventions included: Do not attempt to floss between resident's two front teeth, as these teeth have been fused per recent dental procedure; Date Initiated: 8/16/24. During an observation on 3/12/26 at 10:06 A.M., Resident 3's front right tooth was chipped/not fully intact, and the left front tooth was completely missing. During an interview on 3/12/26 at 10:06 A.M., the Social Services Assistant indicated Resident 3's right tooth had been broken for a long time and the left tooth recent fell out, but was unsure exactly when the left tooth fell out. The daily oral task indicated staff performed, or set Resident 3 up to perform herself, oral care twice each day. The clinical record, including progress notes, assessments and documents, lacked documentation related to Resident 3 losing her tooth or notification to the family or dentist about Resident 3 losing her tooth. Resident 3's record contained a photo taken by staff on 6/19/23; the resident had both front teeth in the photo. During an interview on 3/13/26 at 10:11 A.M., The Director of Nursing (DON) indicated she thought the resident's tooth fell out sometime within the past two weeks; she indicated she had called staff and was unable to determine when the tooth was first observed gone, and indicated she was unaware if staff had found the missing tooth in the facility. On 3/16/26 at 11:09 A.M., the Administrator provided a policy titled Dental Services, dated 8/24, that indicated Routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care All dental services provided are recorded in the resident's medical record. A copy of the resident's dental record is provided to any facility to which the resident is transferred.410 IAC (Indiana Administrative Code) 16.2-3.1-24(a)(2)410 IAC 16.2-3.1-5(a)(2)

Based on observation, interview, and record review, the facility failed to ensure documentation was accurate and complete for 2 of 5 residents reviewed for significant weight loss. Resident weights were not entered into the clinical record. (Resident 16 and Resident 75)Findings include:1. On 3/11/26 at 1:39 P.M., Resident 16's clinical record was reviewed. Diagnoses included, but were not limited to, Parkinson's disease.The most current admission Minimum Data Set (MDS) Assessment, dated 1/20/26, indicated Resident 16 was moderately cognitively impaired, required substantial to maximal assistance of staff (staff does more than half of the effort) for toileting and transferring, and had a weight loss of 5 percent (%) or more in the last month or loss of 10% or more in last six months.Current care plans included, but were not limited to:The resident has nutritional problem or potential nutritional problem related to Parkinson's disease, initiated 1/10/26.Physician orders included, but were not limited to:Weekly weights for four weeks, then monthly, and as needed one time a day every Monday for four weeks and one time a day starting on the 1st and ending on the 2nd of every month, dated 1/19/26.A weight summary for March 2026 indicated Resident 16 had the following weights:3/1/26 221 pounds (lbs.)3/2/26 211.9 lbs., a 9.1 lb. weight lossThe clinical record lacked documentation to indicate Resident 16 was re-weighed or that the 9.1 lb. weight loss in a day was followed up on.On 3/13/26 at 11:04 A.M., Certified Nurse Aide (CNA) 6 was observed to weigh Resident 16. He weighed 217.2 lbs.During an interview on 3/13/26 at 11:38 A.M., the Director of Nursing indicated that on 3/2/26 there was an issue with the scale in the Pavillion. Staff took Resident 16 to the therapy room to be re-weighed and his weight on that day was 220 lbs., but staff did not document the re-weigh in the resident's medical record.2. On 3/11/26 at 1:54 P.M., Resident 75's clinical record was reviewed. Diagnoses included, but were not limited to, protein-calorie malnutrition, dysphagia, and gastro-esophageal reflux disease (GERD).The most current Quarterly Minimum Data Set (MDS) Assessment, dated 1/23/26, indicated Resident 75 had severe cognitive impairment, was dependent on staff for toileting, required partial to moderate assistance of staff (staff does less than half of the effort) for eating, and had a weight loss of 5% or more in the last month or loss of 10% or more in last six months.A care conference was completed on 2/12/26 with family in attendance. Weight was down 22 pounds (lbs.) since December but did not trigger for significant weight loss. Staff would continue to monitor for further loss. The care plan was reviewed.Current care plans included, but were not limited to:The resident has nutritional problem or potential nutritional problem related to dementia and decline, dated 9/5/23.Physician orders included, but were not limited to:Weekly weight on Monday in the morning every Monday for weekly weight Clinically At Risk (CAR) review, dated 2/2/26 through 3/5/26.Weekly weight for Nutritionally At Risk (NAR) review one time a day every Monday, dated 3/9/26.The electronic Medication Administration Record (eMAR) for February and March 2026 was reviewed. There was not a weight documented on the following Mondays:2/16/26 - marked sleeping with no documentation of an attempt to try again at a different time2/23/263/2/26During an interview on 3/13/26 at 11:38 A.M., the Director of Nursing (DON) indicated that staff did weigh Resident 75 on 2/16, 2/23, and 3/2, but did not document it in the clinical record. Weights were recorded on an internal audit tool but never entered into the resident's clinical record.On 3/16/26 at 11:11 A.M., the Administrator provided a current Charting and Documentation policy, dated 8/2024, that indicated The following information is to be documented in the resident medical record: . Treatments or services performed . Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.On 3/16/26 at 11:11 A.M., the Administrator provided a current Weight and Measuring Resident policy, dated 8/2024, that indicated The following information should be recorded in the resident's medical record: . The height and weight of the resident . Report significant weight loss/weight gain to the nurse supervisor.410 IAC (Indiana Administrative Code) 16.2-3.1-50(a)(1)410 IAC (Indiana Administrative Code) 16.2-3.1-50(a)(2)

Based on interview and record review, the facility failed to ensure documentation was complete and accurate for 2 of 3 residents reviewed for falls (Resident M and Resident D) and 2 of 3 residents reviewed for dialysis (Resident B and Resident H). Findings include: 1. On 3/12/25 at 10:06 A.M., Resident M's clinical record was reviewed. Resident M was admitted on [DATE]. Diagnoses included, but were not limited to, cognitive communication deficit. The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 3/3/25, indicated Resident M was severely cognitively impaired, required substantial assistance from staff (staff do more than half of the work) for eating, toileting, bathing, and transfers, and had fallen since the most recent MDS Assessment (1/3/25). A Clinically at Risk Assessment, dated 3/11/25, indicated Resident M had fallen on 2/8/25, 2/25/25, 3/3/25, and 3/10/25. A Fall Risk Assessment, dated 2/26/25, indicated Resident M was alert and oriented x3 (to person, place, and time), and had no falls in the past 3 months. A Fall Risk Assessment, dated 3/11/25, indicated Resident M was alert and oriented x3, and had no falls in the past 3 months. During an interview on 3/13/25 at 11:37 A.M., the Director of Nursing (DON) indicated the fall on 3/3/25 was documented in error. 2. On 3/13/25 at 10:30 A.M., Resident B's clinical record was reviewed. Resident B was admitted on [DATE]. Diagnoses included, but were not limited to, renal failure and peripheral vascular disease. The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 1/16/25, indicated Resident B was cognitively intact and required substantial assistance from staff (staff does more than half of the work) for toileting, bathing, and transfers. Current physician orders included, but were not limited to: Do not obtain blood pressure in the left arm, dated 2/24/25 Pre-Dialysis assessment to be completed prior to dialysis one time a day every Monday, Wednesday, Friday, dated 10/9/24 Post-Dialysis assessment to be completed after to dialysis one time a day every Monday, Wednesday, Friday, dated 10/9/24 The following dates and times included blood pressures documented obtained from the left arm: 2/26/25 7:00 A.M. 2/26/25 3:40 P.M. 2/28/25 3:07 P.M. 3/3/25 5:27 P.M. 3/5/25 3:02 P.M. 3/5/25 3:04 P.M. 3/7/25 9:28 A.M. 3/7/25 2:06 P.M. The clinical record lacked a pre or post dialysis assessment completed on 3/10/25. 48147 3. On 3/12/25 at 11:53 A.M., Resident H's clinical record was reviewed. Diagnoses included, but were not limited to, end stage renal disease. The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 12/18/24, indicated Resident H was cognitively intact, required substantial to maximal assistance (staff does more than half) with toileting, and received dialysis. Physician orders included, but were not limited to: Complete Post Dialysis Assessment in (name of electronic charting system) one time a day every Monday, Wednesday, and Friday, dated 6/5/24 The clinical record lacked a Post Dialysis Assessment for 3/7/25. The March 2025 Medication Administration Record (MAR) indicated a Post Dialysis Assessment had not been completed on 3/7/25 and included a chart code of other/see progress notes. The clinical record lacked a progress note related to the Post Dialysis Assessment on 3/7/25. On 3/13/25 at 9:00 A.M., the Director of Nursing (DON) provided a (name of dialysis center) Pre Treatment/Post Treatment form, dated 3/7/25. The form indicated the Pre Treatment Assessment was to be completed by the facility nurse and the Post Treatment Assessment was to be completed by the dialysis nurse. Both assessments were signed by the Assistant Director of Nursing (ADON). The completed Post Treatment Assessment did not include the name of the nurse from the dialysis center that completed the assessment. On 3/13/25 at 10:15 A.M., the ADON indicated that it was her signature on both the Pre and Post Treatment Assessment forms, but she did not perform the Post Treatment Assessment herself. She indicated that she received the Post Assessment information by phone from the dialysis nurse. At that time, she indicated the Pre Treatment/Post Treatment form information was supposed to be entered into the Dialysis Assessment forms in (name of electronic charting system). On 3/13/25 at 1:47 P.M., the DON indicated that the clinical record lacked documentation to indicate the ADON received the Post Treatment Assessment information by phone on 3/7/25 and who performed the assessment. 4. On 3/12/25 at 12:08 P.M., Resident D's clinical record was reviewed. Diagnoses included, but were not limited to, cerebral infarction, repeated falls, and muscle wasting and atrophy. The most recent Admission Minimum Data Set (MDS) Assessment, dated 1/21/25, indicated Resident D was cognitively intact, required substantial to maximal assistance (staff does more than half) with toileting, sit to stand transferring, and lying to sitting bed mobility, had no falls prior to admission, and required the use of a walker and a wheelchair. A current care plan, initiated 1/10/25, indicated Resident D was at risk for falls due to cerebral infarction, neuropathy, and arthritis. A fall risk assessment, dated 2/9/25, resulted in a score of 9.0 indicating Resident D was a low fall risk (a high fall risk was a score of 10.0 or greater). The assessment indicated the resident had one to two falls in the past three months and required the use of assistive devices for mobility (wheelchair, walker, cane, furniture). A nursing progress note, dated 2/28/25, indicated Resident D had an unwitnessed fall while attempting to self-transfer from his wheelchair to the bed. A fall risk assessment, dated 2/28/25, resulted in a score of 2.0 indicating Resident D was a low fall risk. The assessment indicated the resident had no falls in the past three months and did not require the use of assistive devices for mobility. An Interdisciplinary Team (IDT) Note, dated 3/3/25 at 9:10 A.M., indicated the IDT met to review Resident D's fall on 3/2/25. The clinical record lacked documentation to indicate Resident D sustained a fall on 3/2/25. An IDT Note, dated 3/5/25 at 9:24 A.M., indicated Resident D had an unwitnessed fall on 3/4/25 while attempting to get out of bed. A nursing progress note, dated 3/5/25 at 9:51 A.M., indicated Resident D's resident representative was notified of the fall yesterday. The clinical record lacked documentation to indicate an initial falls note and assessment had been completed after the fall on 3/4/25. On 3/12/25 at 1:50 P.M., the Administrator indicated she was not sure if the resident fell on [DATE] or 3/4/25 and would need to check on the information. On 3/13/25 at 8:35 A.M., the Administrator indicated that the fall that occurred on 3/4/25 was documented in an incident report which was not part of the clinical record, and that the nurse who filled out the incident report forgot to take the action step to include the fall information in the clinical record. On 3/13/25 at 11:06 A.M., the Director of Nursing (DON) indicated Resident D did not fall on 3/2/25 and the date was documented wrong in the IDT note. On 3/13/25 at 1:47 P.M., the DON indicated that staff needed to be re-educated on documentation. She indicated documentation that Resident D's resident representative was notified of the fall that occurred on 3/4/25 the same day, but the information in the incident report was not carried over into the clinical record. At that time, she indicated the fall risk assessments for Resident D and Resident M were filled out incorrectly resulting in an inaccurate fall risk score. The DON indicated the nurse that took blood pressures for Resident B documented the location of the blood pressure in error and did not take the blood pressure in her left arm On 3/13/25 at 1:50 P.M., the Administrator provided a current Charting and Documentation policy, revised 8/2024, that indicated The following information is to be documented in the resident medical record .Treatments or services performed; .Events, incidents or accidents involving the resident; and Progress toward or changes in the care plan goals and objectives. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate . Documentation of procedures and treatments will include care-specific details, including: the name and title of the individuals(s) who provided the care. On 3/13/25 at 1:50 P.M., the Administrator provided a current End-Stage Renal Disease, Care of a Resident with policy, revised 8/2024, that indicated Education and training of staff includes, specifically .the type of assessment data that is to be gathered about the resident's condition on a daily or per shift basis . On 3/13/25 at 1:50 P.M., the Administrator provided a current Change in a Resident's Condition or Status policy, dated 8/2024, that indicated Our facility promptly notified the resident .and the resident representative of changes in the resident's medical/mental condition and/or status . The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. This citation relates to complaint IN00453363. 3.1-50(a)(2)

Based on interview and record review, the facility failed to update the plan of care after a resident fell for 1 of 3 residents reviewed for falls. (Resident D) Finding includes: On 3/12/25 at 12:08 P.M., Resident D's clinical record was reviewed. Diagnoses included, but were not limited to, cerebral infarction, repeated falls, and muscle wasting and atrophy. The most recent Admission Minimum Data Set (MDS) Assessment, dated 1/21/25, indicated Resident D was cognitively intact, required substantial to maximal assistance (staff does more than half) with toileting, sit to stand transferring, and lying to sitting bed mobility, and had no falls prior to admission. A current care plan, initiated 1/10/25, indicated Resident D was at risk for falls due to cerebral infarction, neuropathy, and arthritis. Interventions included, but were not limited to: Anti-rollbacks to wheelchair Bed against the wall Bed in lowest position as resident allows Anticipate and meet the resident's needs Call light is within reach Ensure pathways are free of clutter Keep personal items within reach Therapy screen/eval/treat as indicated An initial fall note, dated 3/10/25 at 6:40 P.M., indicated the resident had an unwitnessed fall while attempting to self-toilet. The care plan was not updated with a new intervention after that fall. The clinical record lacked documentation to indicate the Interdisciplinary Team (IDT) met to review that fall. On 3/12/25 at 1:50 P.M., the Administrator indicated that after a resident fell , the IDT met the next clinical morning to review the fall and determine an appropriate intervention to prevent future falls. The care plan was updated after that meeting. At that time, the Administrator indicated she could not remember if the IDT had met to review Resident D's fall that occurred on 3/10/25 at 6:40 P.M. On 3/13/25 at 1:50 P.M., the Administrator provided a current Falls and Fall Risk, Managing policy, revised 8/2024, that indicated The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls . In conjunction with the attending physician, staff will identify and implement relevant interventions .to try to minimize serious consequences of falling . The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling . If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. This citation relates to complaint IN00453363. 3.1-35(d)(2)

Based on observation, interview, and record review, the facility failed to ensure interventions were in place to prevent falls for 1 of 3 residents reviewed for falls. (Resident D) Finding includes: On 3/12/25 at 12:08 P.M., Resident D's clinical record was reviewed. Diagnoses included, but were not limited to, cerebral infarction, repeated falls, and muscle wasting and atrophy. The most recent Admission Minimum Data Set (MDS) Assessment, dated 1/21/25, indicated Resident D was cognitively intact, required substantial to maximal assistance (staff does more than half) with toileting, sit to stand transferring, and lying to sitting bed mobility, and had no falls prior to admission. A current care plan, initiated 1/10/25, indicated Resident D was at risk for falls due to cerebral infarction, neuropathy, and arthritis. Interventions included, but were not limited to: Anti-rollbacks to wheelchair Bed against the wall Bed in lowest position as resident allows Anticipate and meet the resident's needs Call light is within reach Ensure pathways are free of clutter Keep personal items within reach Therapy screen/eval/treat as indicated A fall risk assessment, dated 2/9/25, indicated Resident D was at low risk for falls. The clinical record indicated Resident D fell five times between 2/28/25 and 3/10/25. Fall 1 On 2/28/25 at 3:15 P.M., Resident D had an unwitnessed fall while attempting to transfer from his wheelchair to his bed without assistance. Anti-rollbacks to wheelchair was added to his care plan. A fall risk assessment, dated 2/28/25, indicated the resident was at low risk for falls. Fall 2 On 3/3/25 at 9:30 A.M., Resident D had a witnessed fall while toileting. Medication review as indicated was added to the care plan. A fall risk assessment, dated 3/3/25, indicated the resident was at high risk for falls. Fall 3 On 3/4/25 at 12:15 P.M., Resident D had an unwitnessed fall while in bed. Bed in lowest position as resident allows was added to the care plan. A fall risk assessment, dated 3/4/25, indicated the resident was at high risk for falls. Fall 4 On 3/8/25 at 12:06 A.M., Resident D had a witnessed fall while attempting to get out of bed. Bed against wall was added to the care plan. A fall risk assessment, dated 3/9/25, indicated the resident was at high risk for falls. Fall 5 On 3/10/25 at 6:40 P.M., Resident D had an unwitnessed fall while attempting to self-transfer from his bed to the bathroom. The care plan was not updated with a new intervention. A fall risk assessment, dated 3/10/25, indicated the resident was at high risk for falls. On 3/13/25 at 10:00 A.M., Resident D was observed lying in a low to the ground bed. The bedside table was behind the resident's head and was raised high. The bedside table was observed to have the resident's drink and remote control on it. The resident's reacher was on his wheelchair on the opposite side of his room behind a curtain. On 3/13/25 at 1:47 P.M., the Director of Nursing (DON) indicated she observed Resident D in his room without his personal items in reach and staff were re-educated on following fall interventions at that time. On 3/13/25 at 1:50 P.M., the Administrator provided a current Falls and Fall Risk, Managing policy, revised 8/2024, that indicated The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls . In conjunction with the attending physician, staff will identify and implement relevant interventions .to try to minimize serious consequences of falling . The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling . If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. This citation relates to complaint IN00453363. 3.1-45(a)(2)

Based on observation, record review, and interview, the facility failed to ensure assistance at meals or assistance with bathing was provided for 7 of 8 residents reviewed for Activities of Daily Living (ADL) tasks. (Resident L, Resident S, Resident G, Resident U, Resident R, Resident N, and Resident T) Findings include: 1. During a continuous observation on 1/16/25 beginning at 12:08 P.M., a kitchen staff member was observed delivering trays to the dining room. Staff removed trays from the cart and placed them at the dining tables. Resident L was observed sitting in a recliner facing the dining area. Staff served all the residents at the dining tables, then collected trays as residents were done eating. At 12:41 P.M., Resident L called out to staff for help out of the recliner. At 12:47 P.M., staff transferred Resident L out of the recliner into a wheelchair and wheeled him to the dining table where Resident L ate alone. On 1/21/25 at 12:34 P.M., Resident L's clinical record was reviewed. Diagnoses included, but were not limited to, dementia. The most recent Annual Minimum Data Set (MDS) Assessment, dated 12/23/24, indicated Resident L was moderately cognitively impaired and required substantial assistance from staff (staff does more than half of the work) for toileting, bathing, and mobility. Meal intake for Resident L was not documented for lunch or dinner on 1/16/24. 2. During an interview on 1/21/25 at 10:54 A.M., Resident S indicated showers were not being given according to the plan of care. On 1/22/25 at 9:15 A.M., Resident S's clinical record was reviewed. Diagnoses included, but were not limited to, chronic ulcers and congestive heart failure. The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 1/9/25, indicated Resident S required substantial assistance (staff does more than half of the work) from staff for bathing. The Point of Care (POC) (a Certified Nurse Aide documentation system) Tasks for showering indicated that bathing/showers were to be given on Monday and Thursday dayshift, before breakfast, Offer full or partial bed bath on non-shower days. Resident S's clinical record lacked showers provided on the following preferred days in December 2024 and January 2025: 12/2/24 12/12/24 1/13/25 1/20/25 On 12/19/24 at 12:03 P.M. and 1/9/25 at 5:51 P.M., shower refusals were documented but did not follow resident preference of time of day offered. 3. On 1/22/25 at 1:55 P.M., Resident G's clinical record was reviewed. Diagnoses included, but were not limited to, dementia. The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 12/24/24, indicated Resident G was severely cognitively impaired and required substantial assistance (staff does more than half of the work) for bathing and transferring. The Point of Care (POC) (a Certified Nurse Aide documentation system) Tasks for showering task indicated that Bathing (prefers showers) schedule: Tuesday and Friday night shift. Resident G's clinical record lacked showers provided on the following preferred days in December 2024 and January 2025: 1/3/25 1/10/25 1/17/25 1/21/25 48147 4. On 1/21/25 at 2:04 P.M., Resident U indicated she did not receive showers twice a week. On 1/22/25 at 2:03 P.M., Resident U's clinical record was reviewed. Diagnoses included, but were not limited to, atrial fibrillation. The most current Quarterly Minimum Data Set (MDS) Assessment, dated 12/27/24, indicated Resident U was cognitively intact, required supervision of staff for bathing, and had no rejection of care during the 7-day look back period. A preferences care plan, dated 6/20/23, indicated the resident preferred showers every other day at night time. The Point of Care (POC) (a Certified Nurse Aide documentation system) Tasks for showering indicated Resident U received showers on Wednesdays and Saturdays on night shift. Resident U did not receive or refuse a shower on the following days in December 2024 and January 2025: 12/4/24 12/7/24 12/14/24 12/25/24 1/11/25 5. On 1/21/25 at 2:04 P.M., Resident R indicated he did not receive showers twice a week. On 1/22/25 at 2:10 P.M., Resident R's clinical record was reviewed. Diagnoses included, but were not limited to, pulmonary fibrosis. The most current Significant Change Minimum Data Set (MDS) Assessment, dated 1/11/25, indicated Resident R was cognitively intact, required substantial to maximal assistance of staff (staff does more than half) for bathing, and had no rejection of care during the 7-day look back period. A choices care plan, revised 1/4/24, indicated the resident preferred showers on Tuesdays and Fridays during the day. The Point of Care (POC) (a Certified Nurse Aide documentation system) Tasks for showering indicated Resident R received showers on Tuesdays and Fridays before bed. Resident R did not receive or refuse a shower on the following days in December 2024 and January 2025: 12/6/24 12/13/24 12/17/24 12/20/24 12/27/24 12/31/24 1/3/25 1/7/25 1/10/25 1/14/25 1/17/25 6. On 1/21/25 at 2:04 P.M., Resident N indicated she did not receive showers twice a week. On 1/22/25 at 2:18 P.M., Resident N's clinical record was reviewed. Diagnoses included, but were not limited to, chronic pain syndrome. The most current Quarterly Minimum Data Set (MDS) Assessment, dated 12/19/24, indicated Resident N was cognitively intact, required substantial to maximal assistance of staff (staff does more than half) for bathing, and had no rejection of care during the 7-day look back period. An Activities of Daily Living (ADL) care plan, dated 8/6/23, indicated the resident required physical assistance of one with bathing due to chronic pain. The Point of Care (POC) (a Certified Nurse Aide documentation system) Tasks for showering indicated Resident N received showers on Mondays and Fridays on day shift. Resident N did not receive or refuse a shower on the following days in December 2024 and January 2025: 12/6/24 12/13/24 12/20/24 12/23/24 1/6/25 50827 7. In an anonymous interview, it was indicated that Resident T had not been getting his showers and smelled like he hadn't showered and was living on the streets. Staff had indicated they didn't brush Resident T's teeth because he was care planned to brush his own teeth even though Resident T was right-arm dominant and that arm had been broken and was in a sling. On 1/21/25 at 1:39 P.M., Resident T's clinical record was reviewed. Diagnoses included, but were not limited to, Alzheimer's disease with late onset, fracture of distal end of femur, fracture of fibula, and tibial plateau fracture (right side). The most recent Significant Change Minimum Data Set (MDS) Assessment, dated 7/29/24, indicated Resident T had mild to moderate cognitive impairment, exhibited behaviors that included other behaviors not directed towards anyone that had worsened since the previous assessment, and required substantial to maximal assistance (staff does more than half) with oral hygiene and showering. A current Activities of Daily Living (ALD) care plan, dated 2/25/22, included the following interventions: The resident requires extensive assist by one staff with bathing/showering. The resident can be independent but occasionally does require extensive assist by one staff for personal hygiene and oral care. The Point of Care (POC) (a Certified Nurse Aide documentation system) Tasks for showering indicated Resident T received showers on Tuesdays and Fridays. Resident T did not receive or refuse a shower on the following days in June and July 2024: 6/11/24 7/12/24 7/19/24 A nursing progress note, dated 7/24/24 at 6:45 P.M., indicated the Registered Nurse (RN) noted Resident T to have poor oral hygiene, could not change his clothing on his own, and that he was in need of someone to help in doing hygiene such as brushing teeth, bathing, and changing clothes. On 1/22/25 at 2:39 P.M., the Director of Nursing (DON) indicated that all showers were charted in POC Tasks. Shower sheets were used but were not part of the clinical record. During an interview with the Administrator on 1/27/25 at 12:31 P.M., she indicated there was no written policy related to the timing of showers, but residents were expected to receive showers twice weekly. On 1/27/25 at 12:31 P.M., the Administrator provided a policy titled Assistance with Meals, dated 8/2024, that indicated Facility staff will serve resident trays and will help residents who require assistance with eating. Residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity. This citation relates to Complaint IN00448749. 3.1-38(a)(2)(A) 3.1-38(a)(2)(D) 3.1-38(a)(3) 3.1-38(b)(1) 3.1-38(b)(2)

Based on observation, interview, and record review, the facility failed to ensure meals were served at a palatable temperature for 1 of 1 trays tested for temperature. (North Hall) Finding includes: On 1/17/25 at 10:46 A.M., Resident 118 indicated the food tasted bad and was cold. On 1/21/25 at 10:13 A.M., Resident 35 indicated the food temperature was never what it was supposed to be. Her hot foods were not hot and her cold foods were not cold. On 1/21/25 at 10:53 A.M., Resident S indicated the food was cold when she got it and hot plates were sometimes not used to keep it warm while delivering it to residents. On 1/23/24 at 12:45 P.M. a test tray was obtained. Food temperatures from that meal were: Cheeseburger 100.6 F (Fahrenheit) Sweet potato fries 87 F The food tasted lukewarm and the cheeseburger was observed to be pink in the middle of the meat. On 1/23/24 at 12:50 P.M., the Dietary Supervisor indicated that the burgers used were precooked. On 1/27/25 at 12:31 P.M., the Administrator provided a Food Temperatures policy, dated 2021, that indicated foods sent to the units for distribution (such as meals, snacks, nourishments, oral supplements) will be transported and delivered to unit storage areas to maintain temperatures at or below 41 degrees F for cold foods and at or above 135 degrees F for hot foods. 3.1-21(a)(2)

Based on observation, interview, and record review, the facility failed to provide a safe and sanitary environment during 7 random observations. Odor was present in the facility and puddles of fluid and debris were on the floor. (West Hall, East Hall, 500-hall, Pavilion Dining Room) Findings include: 1. On 1/16/25 at 9:23 A.M., an unattended rolling cart of trash sitting in front of East Hall nurses station had an odor consistent with bowel movement. 2. On 1/16/25 at 9:32 A.M., the 500-hall had a strong putrid smell. 3. On 1/16/25 at 9:35 A.M., the [NAME] Hall was noted to have an odor consistent with bowel movement. 4. On 1/16/25 at 12:37 P.M., the Pavilion dining room floor had a large puddle of fluid and dirty debris observed along the dining room floors. 48057 5. On 1/21/25 at 8:00 A.M., the East Hall was noted to have an odor consistent with urine. 6. On 1/23/25 at 8:10 A.M., the East Hall was noted to have an odor consistent with urine. 7. On 1/23/25 at 10:41 A.M., the [NAME] Hall was noted to have an odor consistent with bowel movement. During an interview on 1/24/25 at 9:19 A.M., the Housekeeping Supervisor indicated that managing odors was a part of the housekeeping staff's daily cleaning tasks. All housekeepers have odor eliminating supplies on their cart and odors were taken care of as soon as they were noticed. On 1/27/25 at 12:31 P.M., the Administrator provided a current Homelike Environment policy, effective 8/2024, that indicated The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include .pleasant, neutral scents. 3.1-19(f)

Based on interview and record review, the facility failed to ensure SNF-ABN (Skilled Nursing Facility-Advanced Beneficiary Notice) Forms were provided following the end of Medicare skilled services for 1 of 2 residents who discharged from Medicare services and remained in the facility. (Resident Z) Finding includes: On 1/17/25 at 9:45 A.M., the SNF (Skilled Nursing Facility) Beneficiary Protection Notification Review Forms were reviewed. The form indicated Resident Z received Medicare Part A Skilled Services starting 12/4/24. The form indicated the last covered day of Part A services was 1/14/25 and the resident remained in the facility. The form indicated Resident Z did not receive a SNF-ABN (Skilled Nursing Facility-Advanced Beneficiary Notice) Form because she was scheduled to be discharged home on 1/15/25 following the last covered day, but family failed to pick up the resident who remained in the facility. At that time, the Administrator indicated a SNF-ABN had not been issued to the resident. During an interview on 1/21/25 at 12:41 P.M., the Administrator indicated Resident Z was still in the facility and would be responsible for the fees associated with room and board for her stay in the facility between 1/14/25 and whenever she was discharged . On 1/23/25 at 9:30 A.M., Resident Z's clinical record was reviewed. The census indicated Resident Z was admitted on [DATE] with Medicare as the payer source. On 1/15/25 the payer source was changed to private pay. On 1/22/25 the resident was discharged from the facility. On 1/27/25 at 12:31 P.M., the Administrator provided a Notice of Medicare Non-Coverage (NOMNC) policy, revised 10/1/23, that did not address the SNF-ABN form requirements. During an interview on 1/27/25 at 2:47 P.M., the Administrator indicated that the facility did not have a policy that addressed SNF-ABN forms and expected the facility to follow federal regulations for form requirements and distribution. 3.1-4(f)(2)

Based on interview and record review, the facility failed to ensure a resident's discharge was documented in the clinical record for 1 of 3 residents reviewed for discharge. (Resident 60) Finding includes: On 1/23/25 at 12:24 P.M., Resident 60's clinical record was reviewed. Resident 60 was admitted on [DATE]. Diagnoses included, but were not limited to, Parkinson's Disease. The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 11/5/24, indicated Resident 60 was moderately cognitively impaired, required substantial assistance from staff (staff does more than half of the work) for toileting and transfers, and was dependent on staff for bathing. A nutrition note created on 1/17/25 at 2:09 P.M., indicated Resident 60 was discharged with return not anticipated. The clinical record, including progress notes, assessments, and documents, lacked information regarding planning of a discharge, documents sent during discharge, where Resident 60 was discharged to, or when discharge occurred. During an interview on 1/23/25 at 2:58 P.M., the Admissions Director indicated Resident 60 left the faciity on [DATE] after a planned discharge and went to another long term care facility, but was unable to find any documentation of discharge planning. On 1/23/25 at 2:35 P.M., the Administrator provided a document titled Summary of Episode Note, created on 1/17/25, and indicated nursing staff should make a progress note when a resident leaves the facility stating when they left, where they went, and what was sent with the resident. On 1/27/25 at 12:31 P.M., the Administrator provided a policy titled Discharge Summary and Plan, dated 8/2024, that indicated When a resident's discharge is anticipated, a discharge summary and post-discharge plan is developed to assist the resident with discharge. Every resident is evaluated for his or her discharge needs and has an individualized post-discharge plan. A member of the interdisciplinary team reviews the final post-discharge plan with the resident and family at least 24 hours before discharge takes place. A copy of the following is provided to the resident and receiving facility and a copy will be filed in the resident's medical records: an evaluation of the resident's discharge needs, the post-discharge plan, and the discharge summary. 3.1-12(a)(6)(A) 3.1-12(a)(6)(B)

Based on interview and record review, the facility failed to ensure social services were provided to meet a resident's mental and psychosocial needs for 1 of 1 residents reviewed for Preadmission Screening and Resident Review (PASARR). (Resident 61) Finding includes: On 1/22/25 at 2:14 P.M., Resident 61's clinical record was reviewed. Diagnoses included, but were not limited to, Wernicke's encephalopathy, alcohol use disorder, non-Alzheimer's dementia, seizures, anxiety, depression, and an unspecified psychiatric disorder. The resident was admitted to the facility on [DATE]. The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 12/20/24, indicated the resident was cognitively intact, required supervision for all mobility tasks, and received antipsychotics, antianxiety medication, antidepressants, and anticonvulsants during the 7-day look back period. Physician orders included, but were not limited to: olanzapine (an antipsychotic medication) oral tablet 10 milligrams (mg) - 1 tablet at bedtime, dated 11/21/23. Valium (an antianxiety medication) oral tablet 2 mg - 1 tablet by mouth twice daily, dated 6/3/24. Wellbutrin XL (an antidepressant) oral tablet Extended Release 24 Hour - give 150 mg by mouth one time a day, dated 1/21/24. thiamine (vitamin given to alcoholics to prevent Wernecke's encephalopathy) HCl oral tablet - give 100 mg by mouth one time a day, dated 1/21/24. Target behaviors: psychosis, delusions, hallucinations- to be monitored and charted on at the end of each shift, dated 10/13/24. Observe closely for significant side effects from antipsychotic medication use such as sedation, drowsiness, dry mouth, constipation, blurred vision, abnormal tremors/facial/tongue movements, weight gain, edema, postural hypotension, sweating, loss of appetite, urinary retention. Notify provider if observed and document in progress notes, dated 10/13/24. May utilize (name of mental health facility) for counseling services, dated 9/29/24. Target behaviors: depression- tearfulness, withdrawn, agitation, excessive crying, or social isolation. To be monitored and documented at the end of each shift, dated 8/9/24. Target behaviors: anxiety- self-reported nervousness, restlessness, sleeplessness, etc. To be monitored and documented at the end of each shift, dated 6/24/24. Resident may reside on secured memory care unit, dated 6/6/24. Antianxiety medication- monitor for drowsiness, slurred speech, dizziness, nausea, aggressive/impulse behavior. Monitor and document at the end of each shift, dated 6/4/24. Current care plans included, but were not limited to: Resident resides on secured memory care unit. She has a diagnoses of dementia, Wernicke's Encephalopathy, alcohol induced persisting amnestic disorder, and other signs involving cognitive function and awareness. She has a history of exit seeking and wanting to leave to go home. Date Initiated: 1/24/24 Resident is at risk for ineffective coping due to unexpected loss of loved one (sister and spouse). Date Initiated: 2/1/24. Interventions included: Psych services as needed. Date Initiated: 2/1/24. On 1/23/25 at 9:00 A.M., the Administrator provided a copy of a PASARR completed for Resident 61 in April 2023, 8 months prior to the resident's admission to the facility. During an interview on 1/27/25 at 9:52 A.M., the Administrator indicated that Resident 61's diagnoses were updated after the previous PASARR was completed and the Admissions Director should have reviewed the PASARR on admission to make sure it was current and updated. On 1/27/25 at 12:31 P.M., the Administrator provided an Admissions Criteria policy, dated 8/2024, that indicated All new admissions and readmissions are screened for mental disorders (MD), intellectual disorders (ID), or related disorders (RD) per the Medicaid Pre-Admission Screening and Resident Review process. 3.1-34(a)

Based on interview and record review, the facility failed to ensure the development and completion of a baseline care plan within forty-eight (48) hours of admission for use of respiratory equipment, tracheostomy, and Enhanced Barrier Precautions (EBP) for 1 of 1 residents reviewed for respiratory care. (Resident 277) Finding includes: On 1/21/25 at 11:21 A.M., Resident 277's clinical record was reviewed. Resident 277 was admitted on [DATE]. Diagnoses included, but were not limited to, chronic respiratory failure with hypoxia and tracheostomy. The Admission Minimum Data Set (MDS) Assessment was in progress. Current physician orders included, but were not limited to, the following: Change oxygen tubing monthly and as needed (PRN), one time a day every four weeks on Sunday for Oxygen (O2) use and as needed for soiled or compromised, dated 1/15/25. Change humidifier/bubbler monthly and as needed (PRN), as needed for empty/compromised and change one time a day every four weeks on Sunday for routine oxygen, dated 1/15/25. Resident requires the use of Enhanced Barrier Precautions (EBP) related to the medical device (Tracheostomy & Peg Tube) to reduce the risk of transmission of Multiple Drug-Resistant Organisms (MDROs) every shift for Isolation Precautions. Use Personal Protective Equipment (PPE) precautions when providing prolonged direct resident care, dated 1/14/25. The clinical record lacked a base line care plan for the tracheostomy, oxygen use, and EBP protocol. During an interview on 1/23/25 at 11:35 A.M., the Assistant Director of Nursing (ADON) indicated that a baseline care plan was based on the initial assessment that the admitting nurse completed. The initial assessment included, but was not limited to, physical assessment of the resident and oxygen use with a baseline care plan initiated within 48 hours of admission. On 1/27/25 at 12:31 P.M., the Administrator provided a current Care Plans, Baseline policy, revised 8/2024, that indicated A baseline care plan to meet the resident's immediate health and safety needs is developed within forty-eight (48) hours of admission. The baseline care plan includes instructions to provide effective, person-center care for the resident to meet professional standards of practice and must include the minimum healthcare information to properly care for the resident . 3.1-30(a)

Based on record review and interview, the facility failed to ensure care plans were updated after a fall for 1 of 6 residents reviewed for falls. (Resident 8) Finding includes: On 1/21/25 at 3:19 P.M., Resident 8's clinical record was reviewed. Diagnoses included, but were not limited to, chronic pain syndrome, spinal stenosis lumbosacral region, and age-related physical disability. The most current Quarterly Minimum Data Set (MDS) Assessment, dated 12/13/24, indicated the resident was mildly cognitively impaired, required substantial to maximal help (staff does more than half) with dressing, required partial to moderate assistance of staff (staff does less than half) with transferring, and had one fall with injury since the prior assessment. Current physician orders included, but were not limited to: 1/4 side rails for mobility positioning every day and night shift to aide with bed mobility related to morbid (severe) obesity, dated 11/20/20. A current falls care plan, dated 12/12/17, indicated that Resident 8 was at risk for falls related to potential side effects of medications (cardiac, opioid, psychological etc.). Interventions included, but were not limited to, the following: Medication review, labs, and orthostatic blood pressures, initiated on 1/20/25. Pain management, initiated 12/2/24. There should be a safe environment with even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; Side rails as ordered, handrails on walls, personal items within reach initiated on 12/17/17 and revised on 8/2/23. An Interdisciplinary Team (IDT) note, dated 12/2/24 at 9:50 A.M., indicated that Resident 8 had an unwitnessed fall with injury on 11/27/24 at 9:45 P.M. The intervention for that fall was to provide an environmental assessment. The clinical record lacked documentation to indicate the new intervention was added to the plan of care. During an interview on 1/23/25 at 3:15 P.M., the Administrator indicated there should be a new intervention after each fall and the care plan was not updated with a new intervention after the resident fell on [DATE]. On 1/27/25 at 12:31 P.M., the Administrator provided a current Comprehensive Care plans policy, revised 8/2024, that indicated comprehensive assessments are utilized in developing person-centered care plans .a significant change is a major decline or improvement in a resident's status that will not normally resolve itself without intervention by staff . 3.1-35(d)(2)

Based on observation, interview, and record review, the facility failed to ensure adequate supervision was provided to Resident C, an aggressive resident, to protect Resident B, a cognitively impaired resident, from being pushed to the floor for 1 of 3 residents reviewed for accidents. This deficient practice resulted in Resident B falling and requiring hospitalization for surgical repair of a right femur fracture. (Resident B, Resident C) Finding includes: On 5/13/24 at 9:33 a.m., during interview, Resident B indicated a man got mad, pushed, and threw her, reached down, and grabbed her hair. Resident B indicated it happened in [name of city]. On 5/13/24 at 10:01 a.m., Resident B's clinical record was reviewed. Diagnoses included, but were not limited to, fracture of unspecified part of neck of right femur, anxiety disorder, vascular dementia, unspecified severity, without behavioral disturbance. A Quarterly MDS (Minimum Data Set) assessment dated [DATE], indicated Resident B's cognition was moderately impaired, ROM (range of motion) no impairment upper or lower, bed mobility independent, 1 (one) person assist, transfer independent set up help only, toilet independent set up, sit to lying supervision or touching assistance, sit to stand supervision or touching assistance, walk 10 feet supervision or touching assistance, mobility device, walker. The 5/14/24 MDS was still in progress. A care plan for surgical wound to right hip, dated 5/9/24, included, but was not limited to interventions of, treatments as ordered, notify provider of worsening or s/sx (signs and symptoms) of infection. A care plan for risk for emotional and/or physical distress r/t (related to) history of sexual assault, dated 9/12/23, included, but was not limited to interventions of, allow me to express my concerns, fears, feelings, and expectations. Progress notes included, but were not limited to: 4/21/24 at 11:33 p.m., Called to room by CNA, resident was sitting on floor in front of bathroom door, resident stated that resident in [Resident C room] came in her room and attacked her, resident was then checked for injuries, resident had large raised area noted to the top of her head and stated that her right hip was hurting, notified NP (nurse practitioner) with findings, received order to transfer resident to [name of hospital] for eval, resident was transferred via [name of ambulance service], DON, RP (representative), and NP notified. A state reportable incident form was reviewed and indicated on 4/21/24 at 11:35 p.m., Resident C made contact with Resident B causing her to fall to the floor sustaining a reddened area to her head. An orthopedic surgery discharge summary with a discharge date of [DATE], included, but was not limited to: .Closed fracture of neck of right femur, initial encounter .Open treatment of right displaced femoral neck fracture with right hip hemiarthroplasty. A progress note dated 5/8/24 at 3:51 p.m., indicated: Resident came to facility around 1400 (2:00 p.m.) via wheelchair, accompanied by driver. Escorted to room and oriented to room with instructions on how to use call lights and bed controls. VS (vital signs) checked and recorded. Assessed operative site with 7-8 stitches draining scant amount of yellowish fluids. No distress noted. Current Physician orders for May 2024 included but were not limited to: OT (occupational therapy) 5x/week for 8 weeks. Tx will consist of self-care training, therapeutic exercises, neuromuscular re-education, therapeutic activities, and group activities, order date 5/10/24. A follow up to the state reportable dated 4/21/24, added on 5/13/24, indicated: Let this serve as follow up to incident # 439. [Resident C] entered [Resident B] room while she was sleeping. She got up and confronted the resident. [Resident C] pushed [Resident B] down resulting in hitting her head and a fractured hip. Residents separated and diversional activities provided for [Resident C]. [Resident B] was sent to ER for evaluation of injury. [Resident C] became increasingly agitated and was sent to ER for evaluation. No change in mood or behavior for [Resident B's] roommate and no signs of psychosocial distress with other residents. On 5/13/24 at 12:50 p.m., Resident C's clinical record was reviewed. Diagnoses included but were not limited to Alzheimer's disease with early onset, unspecified dementia, moderate, with agitation. An Admission MDS (Minimum Data Set) assessment dated [DATE], indicated Resident C's cognition was severely impaired, physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually): behavior of this type occurred 1 to 3 days during the assessment period. Care plans were included but were not limited to: Resident refuses care/is non- compliant with care r/t: adjustment to nursing home, dementia, dated initiated 4/9/24. The resident is/has potential to be physically aggressive as evidenced striking out/hitting, getting angry, and being aggressive with staff and other r/t dementia, He gets agitated when staff try to provide care, tends to be more aggressive with male staff, date initiated 4/22/24. A psych progress note dated 4/8/24 included but was not limited to: Chief Complaint/Reason for this Visit Follow up for dementia. HPI Relating to this Visit Patient seen for follow up for previous reports of agitation and adjustment to facility. Staff states patient is often combative with staff when trying to provide care. He does slightly better with female staff than male staff. He is quiet and does not say much according to staff. He is calm on assessment playing balloon ball during a group activity and says he is doing ok. Current Risk Factors - Danger to self or others Patient is NOT currently a danger to self/others. Aggression: Physical, Verbal during care. Progress notes included, but were not limited to: 4/13/24 at 3:20 p.m., Resident noted with the room coming behind a CNA in the resident's room while CNA was straightened up the bed and grabbed ahold of CNA's ponytail pulling back on her head and notified this writer. Resident was also throwing things around the room as well. 4/21/24 at 4:40 a.m., Behavior note: Resident has frequent episodes of anger and frustration. Verbally threatens to hit staff trying to assist him, often refuses care with ADL's (activities of daily living). Resident was able to be redirected this morning and did assist in changing clothes. 4/21/24 10:37 p.m., Incident note: Called to Unit by CNA, noticed resident very angry and attempting to attack resident B, received order to transfer resident to ER for eval and treatment. 4/21/24 at 11:25 p.m., Behavior note: Called to room by CNA, noted resident in violent, agitated state, resident was reported to have walked into room [Resident B] and attacked occupant of that bed, resident also attacked staff and myself included, resident 1 was separated from resident 2 to ensure safety, received order to transfer resident to [name of hospital] for Psychiatric eval, carried out order as noted, resident transferred via [name of ambulance service] The record lacked documentation of any previous outbursts towards other residents. On 5/14/24 at 11:10 p.m., LPN 1 indicated Resident C had not been observed with aggressive behaviors towards another resident before the night of 4/21/24, only staff. On 5/14/24 at 1:06 p.m., the Administrator indicated written statements were not done by the involved staff, she had handwritten notes of the statements that were taken by phone by herself and the Assistant Director of Nursing. On 5/14/24 at 1:30 p.m., the handwritten statements were reviewed and included the following: 4/21/23(sic) Sunday 2332 (11:32 p.m.) [RN1]. RN charge called and reported that [Resident C] attacked [Resident B]. He went in room; staff heard her yelling and ran to room. Found her on floor by the bathroom. She stated he came in her room & He pushed her down. She had open area to top of head and c/o hip pain. Staff was able to get him out of room, but he continued to try to come back in door. 2 staff stayed at out on unit to watch and try to redirect him. While nurses attended to her. Another staff called 911 to transport. Staff informed to immediately notify [Administrator] and both families. Phone call [RN 1] 4/21 around Midnight (11:45pm) [Resident C] went in [Resident B's] room. Clarified which [resident name]. She said he pushed her down and is now very agitated and aggressive with staff. Asked if other residents were around- she said no. Roommate asleep. Asked if [Resident B] was ok- she reported that she has a red spot/bleeding Where she hit her head. Stated they were sending her out. She said staff was with [Resident B] & she came to help. Asked if [Resident C] was still agitated. She said yes- He kept trying to hit staff who were nearby. Reported that [staff name] had blood on his scrubs. (From [Resident B] laceration) Discussed 911 for [Resident C] as well. [RN1] called back (11:57 pm) when 911 arrived. Police wanted to know the end goal with [Resident C]. Notified them we wanted evaluation for inpatient psych due to escalated behaviors. [RN1] passed message. Police had no further questions. [RN1] said no other residents were up or around & police were handling [Resident C]. EMS taking [Resident B]. Reported no staff injuries. On 5/14/24 at 11:28 a.m., the Administrator provided the current policy for unmanageable residents with a revision date of April 2010. The policy included but was not limited to: Each resident will be provided with a safe place of residence . This citation relates to Complaint IN00433087 and IN00434508. 3.1-45(a)(1)

Based on observation, interview, and record review, the facility failed to ensure adequate supervision and assistive devices to each resident to prevent accidents for 4 of 8 residents reviewed for falls. Care plans were not updated following each fall, and the clinical record lacked information related to falls resulting in a hip fracture. This deficient practice led to a fall with a fracture requiring hospitalization . (Resident P, Resident Y, Resident F, Resident T) Findings include: 1. On 12/1/23 at 1:31 P.M., Resident P's clinical record was reviewed. admitted was 8/31/23. Diagnoses included, but were not limited to, Alzheimer's disease, dementia, and anxiety. The most recent quarterly MDS (Minimum Data Set) Assessment, dated 10/4/23, indicated a severe cognitive impairment and 1 fall with injury since the previous assessment on 9/8/23. A current risk for falls care plan, initiated 9/12/23, included, but was not limited to, the following interventions: Motion sensor in place for safety, dated 11/20/23. Evaluate fall risk on admission and as needed, dated 9/12/23. A current fall with major injury - left intertrochanteric femur fracture care plan was dated 9/29/23. Resident P's clinical record lacked a baseline care plan for falls. Falls risk assessments were completed on the following dates: 8/31/23 9/3/23 9/11/23 9/29/23 10/3/23 11/16/23 All falls risk assessments indicated high fall risk. Progress notes indicated the following falls since admission: Fall 1 9/11/23 at 2:35 P.M. Fall was not witnessed. Resident found siting on the floor of another resident's room in between a chair and bedside table. Resident was wearing a non-skid sock. Neurological checks completed. A risk for falls care plan was initiated the following day, on 9/12/23. No Interdisciplinary Team (IDT) note was completed. Fall 2 9/13/23 at 4:15 P.M. Fall was not witnessed. Resident was found on the floor in the dining room on her back. Neurological checks were completed. The falls care plan was not updated with a new intervention following the fall. No IDT note was completed. Fall 3 9/14/23 at 7:15 P.M. A Certified Nurse Aide (CNA) indicated to a nurse that this resident and another had been arguing, Resident P struck the other resident on the left cheek causing that resident to push her walker into Resident P, knocking her down to the floor and causing a skin tear to the right elbow around 2-3cm (centimeters) long. Earlier in the day, the following progress note was entered at 5:00 P.M.: [Resident] would not stay in the wheelchair this evening. she would propel herself around the unit then get up and start walking and refuse to sit back in the wheelchair. would try to redirect her back to a chair when she was found up walking for safety. Following the fall, the falls care plan was not updated with a new intervention. No IDT note was completed. Fall 4 9/18/23 at 6:45 P.M. as this nurse was getting report from day shift nurse, CNA from day shift reported that she saw resident up out of wheelchair and fell against the dining room table and chair. Resident observed laying on her left side with her legs stretched outin [sic] front of her. Resident stated she hit her head on the chair and fell to the floor. Neurological checks were initiated, then stopped on 9/19/23 at 4:30 A.M. On 9/19/23, the falls care plan was updated with an intervention to anticipate needs. No IDT note was completed. Fall 5 9/20/23 at 2:45 A.M. Resident fell in between her and roommate's bed and landed on the floor. The nurse on duty observed the incident. The resident could not stand or walk alone and complained of both right and left leg pain. No bruises or fracture seen upon inspection. The DON (Director of Nursing) was notified via text message, and the Nurse Practitioner (NP) was notified via binder. An IDT note dated 9/20/23 at 9:55 A.M. indicated a new fall intervention to offer more assistance with ADLs (activities of daily living) related to current COVID diagnosis and increased weakness. On 9/20/23 at 3:55 P.M. While staff was changing and turning the resident, the resident was holding her left leg grimacing in pain. A left hip x-ray was ordered and showed a left hip fracture. The resident was sent to the hospital for surgery and returned 9/26/23. A fall with major injury care plan was initiated 9/29/23. Fall 6 10/3/23 at 10:55 A.M. Fall was unwitnessed. Resident was observed sitting on the floor facing the bed. The resident's brief was full of urine and the room was slightly lit. Resident indicated at that time to the nurse Thank God . I don't know how long I'm gonna call for help. The resident indicated she did not hit her head and complained of lower back pain. An x-ray at that time showed no new fractures. Neurological checks were completed. The falls care plan was updated on 10/4/23 to include staff assist with toileting. No IDT note was completed. Fall 7 11/3/23 at 1:34 A.M. Fall was unwitnessed. Resident was attempting to self toilet and fell in room. An IDT note dated 11/3/23 at 9:51 A.M. indicated resident had a motion sensor that was sounding and would initiate every two hour toileting as a new intervention. Neurological checks completed and falls care plan updated with the new intervention. Fall 8 11/9/23 at 6:25 P.M. Fall was unwitnessed. A sensor alarm was sounding and resident was found lying on the floor with her head partially under the bed and legs bent. Resident complained of right elbow and right leg and hip pain. An x-ray at that time showed a fracture of the right hip. Neurological checks were not completed, and the falls care plan was not updated with a new intervention. No IDT note was completed. Fall 9 11/19/23 at 12:00 P.M. The resident was lowered to the floor when the nurse coming down the hall heard the alarm going off and found the resident coming out of bed. Neurological checks were not completed, and an IDT note was not documented. The falls care plan was updated with new interventions. On 12/4/23 at 10:42 A.M., Resident P was observed sitting in a wheelchair across from the nurse's station. An alarm was not observed. At that time, CNA 6 indicated Resident P did not have an alarm to the wheelchair or bed, and was unaware of any alarm that the resident currently had. 2. On 11/30/23 at 10:45 A.M., Resident Y's door was closed. On 12/4/23 at 10:43 A.M., Resident Y's door was observed closed. Resident Y was lying in bed with the call light hanging down from the head of the bed tangled in other cords, out of the resident's reach. On 11/29/23 at 1:48 P.M., Resident Y's clinical record was reviewed. Diagnoses included, but were not limited to, history of falling and muscle weakness. The most recent quarterly MDS Assessment, dated 9/28/23, indicated a severe cognitive impairment. Resident Y required extensive assistance of one staff with bed mobility, transfers, and toileting. A current risk for falls care plan initiated 8/19/22 included, but was not limited to, the following interventions: Call light within reach, dated 8/2/23. Encourage resident to have door open for safety, dated 11/16/23. A current risk for falls/injury care plan was dated 10/6/23. Falls risk assessments from 7/2023 through 12/2023 were completed on the following dates: 7/22/23 7/23/23 10/25/23 11/4/23 11/27/23 All falls risk assessments indicated a high fall risk. Progress notes indicated the following falls since 7/2023: Fall 1 7/22/23 at 4:30 P.M. Fall was unwitnessed. Resident indicated she was trying to pick up a piece of paper off the floor and fell . Resident was found lying on the right side in front of the recliner. A falls care plan was not observed to be in place at that time, nor was one initiated. Neurological checks were completed. No IDT note was completed. Fall 2 10/3/23 at 11:45 A.M. Fall was unwitnessed. Resident was found on the floor in front of the wheelchair. The resident indicated she slid out of it. Dycem was applied to the wheelchair cushion and the care plan updated. Neurological checks were completed. 10/4/23 at 12:20 P.M. Resident indicated she did not feel well. Speech was slurred and trunk control very weak. Eyes were pinpoint and not reactive. Resident was sent to the hospital and diagnosed with subacute lacunar infarction (a type of stroke) and dysmetria (poor coordination). Returned to the facility 10/6/23. Fall 3 11/4/23 at 12:15 A.M. Fall was unwitnessed. Resident was attempting to self toilet and fell in the bathroom. Neurological checks were initiated, but not completed from 11/4/23 at 8:45 A.M. till 4:45 P.M., then again from 11/5/23 at 8:45 A.M. till 4:45 P.M. The falls care plan was updated to toilet every 2 hours. Fall 4 11/15/23 at 10:45 A.M. Fall was unwitnessed. Resident was found on the floor in front of the wheelchair with legs out in front of her. Neurological checks were initiated, but not completed on 11/17/23 from 8:15 A.M. through 4:15 P.M. The falls care plan was updated to include encourage resident to have door open for safety. Fall 5 11/27/23 at 6:16 P.M. Fall was unwitnessed. Resident was found sitting on buttocks in the middle of her room on the floor. She was attempting to change pants. Neurological checks were not completed. The risk for falls care plan was updated for occupational therapy to expand therapy to include additional ADLs. A neurological assessment flow sheet was provided and indicated neurological checks were initiated on 11/3/23 at 9:00 P.M. Resident Y's clinical record did not indicate a reason for the checks. 3. On 11/30/23 at 10:50 A.M., Resident F was observed lying in bed. A call light was observed draped over the headboard, out of reach. At that time, Physical Therapy Assistant (PTA) 10 measured the bed height at 20 inches and indicated she thought the resident's bed should be locked at 20 inches. On 11/29/23 at 1:21 P.M., Resident F's clinical record was reviewed. admitted was 10/3/23. Diagnoses included, but were not limited to, Alzheimer's disease, hemiplegia/hemiparesis, anxiety, and depression. The most recent admission MDS Assessment, dated 10/11/23, indicated a severe cognitive impairment, 1 fall since admission with injury, and a fracture related fall in the 6 months prior to admission. A current risk for falls care plan initiated 10/3/23 included, but were not limited to, the following interventions: Therapy to evaluate bed height. Locked at 19.5 inches, dated 10/12/23. Call light within reach, dated 10/3/23. A falls risk assessment, dated 10/7/23, indicated a high risk for falls. Progress notes indicated the following falls since admission: Fall 1 10/10/23 at 1:35 P.M. Resident attempted to ambulate without assistance in the dining room. When resident stepped forward, her sweater caught in the locking handle of the wheelchair causing her to trip over the foot pedals. Dycem was placed in the wheelchair seat. At the time of the fall, the falls care plan had one intervention to make sure call light was within reach. Following the fall, a new intervention to only utilize foot pedals while transporting was added. No IDT note was completed. Fall 2 10/11/23 at 4:45 P.M. Fall was unwitnessed. Resident was found lying on the floor with legs stretched towards the bathroom door. Bleeding was observed coming from the back of her head. Neurological checks were initiated but not completed on 10/12/23 at 12:30 P.M., 10/12/23 at 2:30 P.M., and 10/13/23 at 2:30 P.M. An IDT note dated 10/12/23 indicated for therapy to evaluate for appropriate bed height. The falls care plan was updated. On 11/30/23 at 1:58 P.M., a neurological assessment flow sheet was provided that indicated neurological checks had been initiated for Resident F on 10/19/23 at 12:30 P.M. and ended 10/21/23 at 2:15 P.M. The form lacked 9 checks on 10/19/23 from 12:45 P.M through 6:15 P.M. At that time, a 15-minute monitoring form was provided as well that indicated Resident F had begun 15-minute checks on 10/20/23 at 11:00 P.M. and ended 10/22/23 at 10:45 P.M. The reason for the precaution was not indicated, but the word corridor was circled. Resident F's clinical record lacked a reason or any other indication for the neurological checks or 15-minute checks. The most recent update to the falls care plan was dated 10/12/23. On 12/4/23 at 11:04 A.M., the Administrator indicated after a fall, the clinical team would review the resident's care plan interventions and update as needed. On 12/5/23 at 12:00 P.M., LPN 4 indicated Resident F was not capable of using a call light due to a diagnosis of dementia, and was an inappropriate intervention for a falls care plan. 48147 4. On 11/30/23 at 10:19 A.M., Resident T's clinical record was reviewed. Resident T was admitted on [DATE]. Diagnoses included, but were not limited to, dementia and muscle weakness. The most recent quarterly MDS Assessment, dated 11/2/23, indicated Resident T had severe cognitive impairment, required extensive assistance of 2 or more staff for bed mobility, transfers, and toileting, and has had one fall with major injury since the prior assessment (8/22/23). A fall risk assessment, dated 8/20/23, indicated Resident T was a high risk for falls with a score of 14.0. The instructions on the Fall Risk Assessment form indicated If the total score is 10 or greater the resident should be considered AT HIGH RISK for potential falls. A prevention protocol should be initiated IMMEDIATELY and documented on the care plan. Progress notes indicated that Resident T sustained an unwitnessed fall on 10/16/23 at 5:53 P.M. while walking without her walker in another resident's room. This fall resulted in a left wrist fracture. An orthopedic note, dated 10/17/23, indicated L (left) wrist films show a 3 part intra-articular distal radial Fx (fracture), minimal shortening, loss of volar tilt. The fracture is in an acceptable position; therefore, surgical intervention is not required. Cast application x (times) 4 weeks with repeat x-rays in 4 weeks. The patient may use the extremity for most activities as comfort allows in the cast. A falls care plan, initiated 10/17/23, indicated Resident T was at risk for falls/injury due to: Gait/balance problems, Hx (history) falls - Fall with major injury fx of left distal radial metaphysis and subtle fx of ulnar styloid. The clinical record lacked a falls care plan prior to 10/17/23. On 12/1/23 at 10:15 A.M., the Assistant Director of Nursing (ADON) indicated she would expect there to be a care plan for fall if a resident were to be identified as a high falls risk on a falls risk assessment. On 12/4/23 at 8:44 A.M., a current Fall Program Guidelines policy, dated 12/2022, indicated the resident will be assessed for fall risk upon admission and quarterly. Interventions will be implemented if resident is determined to be at risk. Should a fall occur .the Interdisciplinary Team (IDT) should determine root cause and evaluate to ensure appropriate interventions are implemented . The resident care plan should be revised to reflect any new or change in interventions. This citation relates to complaint IN00418710. 3.1-45(a)

Based on interview, and record review, the facility failed to ensure a resident was provided medication as ordered, notification of medication change to family, and notification of medication ordered between specialty physicians and primary physicians, resulting in loss of blood flow to right lower leg, and ischemia due to clots in the lower extremities for 1 of 3 residents (Resident D) reviewed for quality of care. Findings include: The clinical record was reviewed for Resident D on [DATE] at 6:51 A.M. Diagnoses included, but were not limited to, presence of cardiac pacemaker, atrial flutter, atrial fibrillation, and long term use of anticoagulants. A significant change Minimum Data Set (MDS) assessment, dated [DATE], indicated Resident D was severely cognitively impaired and required extensive assistance of two for mobility, transfers, dressing, and toileting. A care plan, dated [DATE] through [DATE], included, but was not limited to, interventions as follows: I would like staff to continue to keep me and my family updated on my care, and I have a pacemaker; Give all cardiac meds as ordered by the physician, observe side effects and report adverse reactions to physician. On [DATE] at 12:15 P.M., a progress note indicated family was in the facility and gave concern for bruising noted. The progress note indicated family was told the Nurse Practitioner would see the resident the following day, and the family would be updated afterwards. A Nurse Practitioner (NP) progress note, dated [DATE] at 10:24 A.M., indicated resident D was seen for new areas of bruising. The NP gave orders to discontinue the resident's anticoagulant medication and check complete blood count (CBC) and levels. On [DATE] at 11:19 A.M., labs were resulted and sent to the facility; the hemoglobin and platelet levels were both noted in normal range. On [DATE] 1:08 P.M., a progress noted Resident D had returned from a cardiologist appointment, and orders were given to continue Eliquis. The clinical record and care conference dated [DATE] lacked notification to family regarding the discontinuation of Eliquis (anticoagulant). During a review of physician orders, the record indicated Eliquis was discontinued on [DATE] and lacked any further Eliquis orders past that date. A Nurse Practitioner note, dated [DATE], indicated Resident D was seen for right great toe pain. An order was given for Keflex (antibiotic) and Miconazole cream (antifungual cream) to feet for 14 days. A NP note, dated [DATE] at 1:26 P.M., indicated an X-ray for the right foot was ordered and resulted normal findings. A hydrocodone (pain medication) order was renewed. A NP note, dated [DATE] at 8:45 A.M., indicated Resident D was seen for swelling and redness in the right foot. No new orders given. A NP note, dated [DATE] at 11:49 A.M., indicated Resident D was seen for increased pain in the right foot and purple tinged toes. An order was given to check venous and arterial blood flow. A radiology report, dated [DATE] at 2:36 P.M., indicated an ultrasound of the right lower extremity was performed. Clinical information noted included pain and swelling, purple in color of the 1st, 2nd, and 3rd toes, open non-healing wound of the right great toe, and breakdown of skin and weeping. Findings of the right lower arterial ultrasound included no flow detected below the right common femoral artery, and clot within the distal superficial femoral artery and popliteal artery. The resident was then transferred from the facility to the hospital for evaluation. A hospital progress note, dated [DATE] at 9:47 P.M., indicated Resident D was seen in the emergency room and was referred for a vascular surgery consult. During the vascular surgery consult, a confirmation of occlusion of Resident D's right superficial femoral and popliteal arteries was indicated. The plan of care stated the physician explained to Resident D's family acute limb ischemia required emergency intervention but would not be a good surgical candidate and this may be an end of life situation. Resident D was admitted on hospice services on [DATE] and expired on [DATE]. During an interview on [DATE] at 10:40 A.M., the Nurse Practitioner indicated that heart related medication orders given by Cardiology supersede orders given by facility nurse practitioners, and indicated the orders given on [DATE] by Resident D's cardiology that the resident should continue on Eliquis were not given to the NP by the facility. The NP stated that communication between the facility, such as when a resident receives orders from an outside physician, would be logged in the NP communication binders located at the nurse's station. During an interview on [DATE] at 12:03 P.M., a copy of the NP communication log from [DATE] was requested. The Administrator stated the facility does not keep these logs longer than one month in medical records and was unable to provide a copy of the NP communication log or verify if the facility NP or physician was made aware of the medication notification. On [DATE] at 9:30 A.M., the Administrator provided a current copy of the policy and procedure labeled Resident Change of Condition, dated ,d+[DATE]. The policy indicated all changes will be communicated to the physician and family/responsible party. This Federal tag relates to Complaint IN00411714. 3XXX,d+[DATE](a)

Based on record review and interview, the facility failed to ensure services were provided to prevent falls for 1 of 4 residents reviewed. A resident who required one assist for transfers and ambulation had a fall in the bathroom while the call light was going off and the resident was unattended. The resident complained of back pain and a x-ray results showed a compression fracture. (Resident F) Findings include: During a record review on 1/24/18 at 3:12 p.m., Resident F's [DIAGNOSES REDACTED]. An order, dated 12/18/17, indicated Resident F activity level as, activity as tolerated, up with assist x (times) 1 (one) every day and night shift. The Physical Therapy Evaluation and Plan of treatment for [REDACTED]. The PT evaluation also indicated Resident F is a fall risk. The Occupational Therapy Evaluation and Plan of treatment for [REDACTED]., increase functional activity tolerance, provision of strengthening and facilitate sitting tolerance and postural control. The Admission MDS (Minimum Data Set), dated 12/25/17, indicated Resident F had a BIMS (Brief Interview for Mental Status) of 06, which indicated severe impairment. The MDS indicated Resident F required the following: Limited assistance with 1 assist for bed mobility Limited assistance with 1 assist for transfers Limited assistance with 1 assist for ambulation in room/corridor Limited assistance with 1 assist for toilet use The MDS, dated [DATE], indicated Resident F is not steady, only able to stabilize with staff assistance - with walking, moving from seated to standing position, turning around and facing the opposite direction while walking, moving on and off toilet, and surface to surface transfer. The MDS indicated Resident F had a fall prior to admission. A progress note, dated 1/3/18 at 2:00 a.m., indicated Resident F put the bathroom call light on and the nurse found Resident F lying on the floor with legs straight out. A progress note, dated 1/4/18 at 10:06 a.m., indicated Resident F had been having increased pain to lower back since fall yesterday. An order was received for pain medication and an X-ray. A progress note, dated 1/4/18 at 4:26 p.m., indicated Resident F's X-ray results showed a compression fracture of unknown age and left pleural effusion. A care plan, dated 1/5/18, indicated Resident F was at risk for falls r/t (related to) gait/balance problems. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. A care plan, dated 1/5/18, indicated Resident F had limited physical mobility r/t weakness, debility, requires limited to extensive assistance assist with bed mobility, transfers, and toileting and requires set up for meals. A progress note from Nurse Practitioner 1, dated 1/9/18, indicated Resident F had a fall on 1/3/18 late evening and was unwitnessed and there is minimal documentation available. Staff did report though on 1/4/18. During an interview on 1/25/18 at 2:00 p.m., LPN 2 indicated when a resident is admitted for a fall, they assess the resident and orientate to their room and needs. LPN 2 indicated resident is then monitored routinely with hourly rounds and no alarms are used at this point. LPN 2 indicated Resident F's non-compliance with using the walker and call light were due to dementia with behaviors. LPN 2 indicated care plans should be in place within 48 hours of admission to the facility. LPN 2 indicated if staff had reported Resident F's non-compliance with using the walker and call light, the facility would have initiated a care plan for non-compliance. LPN 2 indicated initial fall risk interventions for Resident F should have been to make Resident F more accessible in a public place to be observed, activities to calm the resident, and a medication review. LPN 2 indicated a last resort intervention would be to initiate an alarm system. A policy titled, Fall - Clinical Protocol, dated September 2012, was provided by the DON on 1/25/18 at 1:19 p.m. The policy indicated, The staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling. A policy titled, Fall Risk Assessment, dated December 2007, was provided by the DON on 1/25/18 at 1:19 p.m. The policy indicated, The staff and Attending Physician will collaborate to identify and address modifiable fall risk factors and interventions to try to minimize the consequences of risk factors that are not modifiable. A policy titled, Falls and Fall Risk, Managing, dated December 2007, was provided by the DON on 1/25/18 at 1:19 p.m. The policy indicated, The staff, with the input of the Attending Physician, will identify appropriate interventions to reduce the risk of falls. The policy indicated, In conjunction with the Attending Physician, staff will identify and implement relevant interventions (e.g., hip padding or treatment of [REDACTED]. This Federal tag relates to complaint IN 275 and IN 753. 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to provide supervision to prevent falls, used alarms in place of supervision, and utilized the incorrect alarm, resulting in a fall that resulted in a cervical (neck) fracture and head laceration, for 2 of 3 residents reviewed for falls, in a sample of 17. Residents A and C Findings include: 1. On 2/3/16 at 11:00 A.M., the Administrative Assistant provided the current CNA assignment sheets. The assignment sheets indicated the North, South, and East halls shared 1 nursing station. The North hall had 29 residents, and 9 of those residents had some type of an alarm, to notify staff of a resident attempting to rise without assistance. The South hall had 24 residents; 14 residents had alarms. The East hall had 27 residents; 18 residents had alarms. 2. The closed clinical record of Resident A was reviewed on 2/3/16 at 3:45 P.M. [DIAGNOSES REDACTED]. Progress Notes included the following notations: 7/14/15 at 5:33 P.M.: Housekeeping/laundry aide called this nurse to room, found res (resident) lying on back, head against closet door in corner of room. Res states 'my head is bleeding' noted 3 cm (centimeters) by 3 cm lump on lt (left) side of head .noted rt (right) elbow bleeding .no alarm sounding .talked with unit CNA's (sic), states res was in recliner and alarm is on, found bed alarm had been turned on not floor mat alarm 7/20/15 at 4:24 P.M.: Resident had unwitnessed fall at 1045 (10:45 A.M.) .nurse noted resident to be lying on her left side near closet in her room. Wheelchair was next to resident with alarm sounding. Resident was alert but unable to state what had happened .Skin tear noted to left elbow area .Resident c/o (complained of) left arm pain at that time .Brakes to wheelchair were not engaged .Resident educated and reminded of the importance of asking staff for help to get up and using call light when needing to get up. 7/24/15 at 2:42 P.M.: Restorative Program Note. Restorative staff attempted to walk resident .able to walk short distance with max encouragement and constant ineffective cues for safety .unable to follow verbal and visual cues. Her posture is poor and she would not lift her head which negatively effected (sic) her balance. She was confused .She had little to no motivation to participate A Minimum Data Set (MDS) assessment, dated 8/19/15, indicated Resident A scored a 3 out of 15 for cognition, with 15 indicating no memory impairment. The MDS assessment indicated Resident A required extensive assistance of one person for transfer and did not ambulate. A test for balance while moving from seated to standing position and surface-to-surface transfer, indicated, Not steady, only able to stabilize with staff assistance. The MDS assessment indicated the resident had fallen since the prior assessment. Progress Notes continued: 9/22/15 at 9:45 A.M.: At 0720 (7:20 A.M.) Res yelling out for help, found res sitting on floor mat alarm next to foot of bed, incontinent of bladder. No alarms sounding. Required 2 extensive assist to get res up to wheelchair .Res had bed alarm, chair alarm, tab alarm when in w/c, and floor mat alarm 9/25/15 at 5:11 A.M.: This nurse was called to the residents (sic) room by CNA (name). Bed alarm and floor alarms were sounding, resident was sitting in the floor with her back against the bed .stated she was 'trying to get up' but when asked why she did not know 9/29/15 at 7:05 A.M.: IDT Note: Review of fall that occurred on 9/22/15 .Alarms were not sounding .Intervention: Perimeter Mattress for tactile boundaries .Resident did have another fall the evening of 9/24/15. An MDS assessment, dated 11/19/15, indicated Resident A scored a 4 out of 15 for cognition. The MDS assessment indicated Resident A required extensive assistance of two+ staff for transfer and did not ambulate. A test for balance while moving from seated to standing position and surface-to-surface transfer, indicated, Not steady, only able to stabilize with staff assistance. The MDS assessment indicated the resident had not fallen since the prior assessment. Progress Notes continued: 12/3/15 at 6:15 P.M.: This nurse heard w/c alarm sounding in resident's room; entered room to find resident on floor in front of recliner on left side, under bedside table; sensor pad & clip string alarms sounding .noted blood coming from forehead; resident assisted to recliner w (with) 3 assist. 12/3/15 at 7:20 P.M.: Called to resident's room at 1815 (6:15 P.M.) by CNA stating that resident had fallen. CNA stated that resident was in wheelchair with alarm on. Bedside table was in front of her with supper tray. CNA stated that she had fed her supper, left room to assist another resident when she heard alarm sounding and went back to her room where resident was laying on the floor .Laceration to forehead cleansed with NS (normal saline). Edges not well approximated. 2.3 cm x 3 cm in size .new order received to send to (name of hospital) for evaluation and treatment 12/3/15 at 9:00 P.M.: Called (name of hospital). Received report that resident has fractured c-spine A hospital Trauma Admission Note, dated 12/3/15, indicated, (Resident A) .reportedly fell forward out of her chair hitting her head and face on the ground. She was found on the floor by personnel at her nursing home .She is confused .She is complaining of pain in her head and neck .Impression: Fall with C1-2 (neck) fxs (fractures) and forehead laceration A Care Plan, dated 9/25/14 and revised 12/17/15, indicated, The resident is at risk for falls/injury r/t (related to) decreased mobility, impaired cognition secondary to Senile Dementia, occasional bladder incontinence, psychotropic med use, history of falls. Interventions included: Anti-roll backs to w/c. Perimeter mattress to the bed. Floor sensor to alert staff for attempts to self transfer. Bed and chair sensors as ordered. Change batteries monthly. Dycem to w/c 3. The clinical record of Resident C was reviewed on 2/3/16 at 2:00 P.M. [DIAGNOSES REDACTED]. A Progress Note, dated 8/1/15 at 1:46 P.M., indicated, This nurse was notified resident was witnessed on the floor, on her knees. This nurse wentastraight (sic) to room, but resident was in recliner .The alarm was in place but not going off. It was not on. Alarm turned on at that time and moved out of resident sight as she has a history of turning off alarms .Encouraged to use call light for needs and transfers and to keep shoes on .The resident could not verbalize what she was doing on the floor. A Social Service Note, dated 8/4/15 at 4:17 P.M., indicated, Resident was found on the floor on her knees on 8/1/15. No injuries notified. Resident encouraged to use her call light for her needs and transfers. A Social Service Note, dated 8/5/15 at 3:29 P.M., indicated: OT (occupational therapy) picked up resident for shoulder pain following her fall. An Incident Note, dated 8/7/15 at 12:56 P.M., indicated: IDT (interdisciplinary team) Note: Review of fall that occurred on 8/1/15 .Alarm check (sic) and was on but not sounding, resident has reported history of turning alarms off. Alarm box positioned out of resident's reach. No shoes were noted to resident's feet .Encouraged resident to use call light for assistance .IDT Intervention: Alarming floor pad. A Minimum Data Set (MDS) assessment, dated 8/11/15, indicated Resident C scored a 11 out of 15 for cognition, with 15 indicating no memory impairment. The MDS assessment indicated Resident C required limited assistance of one person for transfer and walking in the room and corridor. A test for balance while moving from seated to standing position, walking, turning around, and surface-to-surface transfer, indicated, Not steady, only able to stabilize with staff assistance. The MDS assessment indicated the resident had fallen since the prior assessment. Progress Notes included the following notations: 8/12/15 at 1:16 P.M.: QMA notified this nurse that this res (resident) was kneeling on the floor and no alarm sounding .w/c (wheelchair) laying on its back with no alarm sounding .res began rubbing back of head .did note red area on rt. (right) side mid back .Asked if res hit head, res states 'yes' started neuro checks .checked alarm and placed back in alarm on position. 8/23/15 at 5:21 P.M.: CNA called out to nurse from Residents (sic) bathroom. Observed sitting up on bathroom floor with w/c behind her .chair alarm on and functioning but turned off. Resident has history of turning off alsrms (sic) 8/25/15 at 10:45 A.M.: .On 8/24/15 resident was very tearful .difficult to understand her. She kept saying 'weak' and 'wheelchair.' Resident was eventually able to say that she was upset that she's getting weaker and has been having falls lately. Resident was easily redirectable with 1:1 (one on one). 9/9/15 at 4:02 P.M.: Late entry, (Resident C) fell against her chair and slid to the floor. No injury noted. Staff member, (Resident C), CNA was in the room with the resident getting her clothes out of the closet 9/17/15 at 2:13 P.M.: IDT Note: Review of fall that occurred on 9/9/15 .to room to assist resident, staff back was turned, getting clothes out of closet. Staff was unable to get to resident before sliding to floor. Resident states that she slid out of the chair .Alert and oriented x 2 with confusion .Bed, W/C, and floor sensors; anti-rollbacks. Intervention; Requested orders for Dycem to chair. 10/4/15 at 12:11 P.M.: CNA (name) called for nurse. When this nurse got to room, resident observed on floor, leaning up against recliner, with wheelchair in front of her. Alarms were not sounding as the resident turned her chair alarm off .The resident was assisted up into recliner, alarm placed, turned on and functioning .Reminded resident that she is not to turn alarm off and needs to call for assistance when she needs to transfer. She did not verbalize understanding after repeating this multiple times 10/6/15 at 3:12 A.M.: Received new orders from triage for residents (sic) bed alarm to be discontinued and to add motion sensor and check function every shift 10/11/15 at 1:09 A.M.: CNA reported to this nurse she observed resident sitting on her bathroom floor with no injuries alarm was not sounding, resident had turned alarm off .CNA moved wheelchair alarm box to bottom of chair where resident is unable to reach and turn off herself. 10/18/15 at 9:15 A.M.: Nurse witneesed (sic) Residentn (sic) attempting to transfer self from recliner to her w/c, alarm sounding and unable to reach Resident, did call out a warning. Resident fell to the floor near recliner landing on her right knee .instructd (sic) to use call light for help with any ttansfers (sic) .Resident noted to have bruise on right knee (faint) 2 cm (centimeters) L (length) x 2 cm W (width) and bruise below right knee 3 cm L x 2 cm W, legs elevated and ice applied to right knee. 10/26/15 at 2:30 P.M.: Resident sitting on the floor next to her w/c, w/c was next to reclining chair that Resident had been sitting on prior to incident .Resident instructed to use call light prior to getting out of w/c or recliner, and reminded not to turn alarms off, since none of her alarms were on at time of fall, although present 11/5/15 at 12:25 P.M.: IDT Note: Review of fall that occurred on 10/26/15 .Intervention: Speak with family about placing resident on a new program here at the facility, 'Forget me not' program .Any staff member passing room is to look in room to see if assistance is needed as indicated by the 'Forget Me Not' Flower at doorway .Continue with care plan in place for fall prevention. An MDS assessment, dated 11/11/15, indicated Resident C scored a 11 out of 15 for cognition. The MDS assessment indicated Resident C required extensive assistance of one person for transfer, and limited assistance of one for walking in the room and corridor. A test for balance while moving from seated to standing position, walking, turning around, and surface-to-surface transfer, indicated, Not steady, only able to stabilize with staff assistance. The MDS assessment indicated the resident had not fallen since the prior assessment. Progress Notes continued: 12/31/15 at 1:09 P.M.: This nurse notified by another staff member that resident was on the floor .found on the floor next to w/c with w/c on its side 1/13/16 at 3:32 P.M.: IDT Note: Review of fall that occurred on 12/31/15 .(Resident C) sustained a witnessed fall by roommates' (sic) daughter .(Resident C) did not hit her head .(Resident C) is unable to give a verbal description of what occurred due to garbled speech per her usual .Orders were received for w/c assessment .Placed a work order for maintenance to arm rest that was broken and inflated (Resident C's) seat cushion 1/16/16 at 6:21 A.M.: Resident FOF (found on floor) at 0545 (5:45 A.M.). Abrasion to back noted 1/18/16 at 3:43 A.M.: Resident continues on follow up after unwitnessed fall, alert to self and staff with some confusion. Continues to get up to take self to restroom. Motion sensor alarm and bathroom alarm, present and functioning 1/26/16 at 8:14 A.M.: IDT Note: Review of fall that occurred on 1/16/16 at 0456 (4:56 A.M.) .observed by the nurse sitting on the floor in her room. Lights were off .states she was on her way to the bathroom and slipped, she was not wearing appropriate footwear .Life Safety Measures: Anti-roll backs; Non-skid mat in front of bed and recliner; Forget Me Not Program; Dycem to w/c and recliner; Motion sensor .Staff Intervention: Non-skid shoes placed on (Resident C) at time of fall. IDT Intervention: Requesting routine pain management and stool softeners and labs A Care Plan, initially dated 8/11/15 and updated 11/16/15, indicated, Focus: (Resident C) as impaired cognition r/t (related to) Dementia .Interventions: Cue, reorient and supervise as needed .Present just one thought, idea, question or command at a time An additional Care Plan, initially dated 5/19/15 and revised 11/16/15, indicated, Focus: The resident is at risk for falls r/t Psychoactive drug use, Gait/balance problems, Incontinence .Interventions: Anti-roll backs to w/c. Motion sensor when in bed and front of the recliner. Dycem to chair and recliner .possible move closer to Nurse's station if family agrees and room available. 'Forget Me Not' Program .Be sure the resident's call light is within reach and encourage the resident to use if for assistance .Ensure that the resident us wearing appropriate non-skid foot wear when ambulating or mobilizing in w/c (5/19/15) .The resident uses w/c electronic alarms to alert staff of unsafe movements. Ensure the device is in place and functioning properly every shift, change batteries monthly. On 2/4/16 at 11:44 A.M., Resident C was observed sitting in her wheelchair in her room alone. A motion sensor alarm was observed in the room. No alarms were present on the resident's wheelchair. At that time, RN # 2 was interviewed, and indicated the resident no longer had alarms on her wheelchair. On 2/4/16 at 2:30 P.M., during an interview with the Director of Nursing (DON) and Administrator, the DON indicated the facility had recently implemented the Forget Me Not program to assist in reducing the number of falls. On 2/4/16 at 3:15 P.M., the Director of Nursing provided the current facility policy Fall Prevention Program, revised October 2015. The policy included: The fall prevention program emphasizes assessment, identification, and intervention of resident falls while utilizing the least restrictive method possible to keep the resident safe. The program identifies the factors that place residents at risk for falls, promotes proactive healthcare practices for resident care planning and identifies the main components of an effective fall prevention program .Fall prevention interventions/strategies may include the following: .Staff education to increase awareness and teach precautions .Use of bed and chair alarms, when other interventions are not sufficient This Federal tag relates to Complaint IN 122 and Complaint IN 472. 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure a resident with multiple fractures received adequate pain management, and instead frequently received medication for anxiety, for 1 of 5 residents reviewed for pain management, in a sample of 6. Resident D Findings include: 1. On 11/28/12 at 10:00 A.M., during the initial tour, RN # 1 indicated Resident D was receiving therapy, and had a gastrostomy tube. On 11/28/12 at 2:15 P.M., Resident D was observed lying in bed with her eyes closed. The clinical record of Resident D was reviewed on 11/28/12 at 2:35 P.M. The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Daily Skilled Nurse's Note, dated 10/15/12 at 11:50 A.M., indicated, "...admitted to facility...Transferred to bed (with) assist x 3..." The note indicated the resident was alert, had difficulty in speaking, had no altered mood or behavior, and did not exhibit pain. An admission assessment, dated 10/15/12 and untimed, included: "...Resident verbally expresses pain: Yes. Resident is on pain medication: Y (yes). Resident shows evidence of pain: Yes...Intensity Scale: (left blank)...Describe origin/causes of pain - movement, repositioning...Pain Expression, Sounds of distress, Pain Relief...Tylenol...Pain is increased by movement...." A physician's orders [REDACTED]." Nurses notes, dated 10/16/12 at 2:45 A.M., indicated: "(Two) Tylenol... given for s/s (signs and symptoms) pain - moaning, facial grimace...." A Physical Therapy plan of care, dated 10/16/12, indicated: "Medical history...serious fall at son's home 10/07/12...Pt (patient) fell down approximately 7 stairs resulting in a skull fracture, C6 fracture, L1 compression fracture, ribs 1-6 fractured, left clavicle fracture, and pelvic fracture...Reported quality of life: Unable to respond. Observed signs of pain. Pain: Patient unable to report, but observed signs & symptoms of pain...Other clinical observations/ Assessments: Patient without complaints of pain at rest but cries out with pain at times during mobility activities especially rolling. Patient very difficult to understand at times and very apprehensive during mobility activities...Patient demonstrates decreased cognition and difficulty processing verbal cues at times...." A physician's orders [REDACTED]. Give 2 caplets (1000 mg)...every 6 hours as needed for pain." A physician's orders [REDACTED]." A "Pain Assessment/Non-Interviewable Resident," dated 10/22/12, indicated: "Is the resident currently on routine pain medications? No...is the resident currently exhibiting non-verbal signs of pain (Yes)...Non-verbal sounds (crying, whining, gasping, moaning, or groaning), Facial expressions (grimaces, winces...), Location of resident's current pain: (Right) side of Body D/T (due to) multiple fx (fractures). Has resident experienced pain in the last 5 days? No...Current medication used to relieve pain: Tylenol 500 mg (2) tabs Q (every) 6 hrs (hours) PRN (as needed)...If chronic, how long have you had the pain? 10/7/12. Identify conditions that may contribute to pain or discomfort: Post fall resulting in multiple fx." A Minimum Data Set (MDS) assessment, dated 10/22/12, indicated the resident scored a 3 out of 15 for cognition, with 15 indicating no memory impairment. The MDS assessment indicated the resident required total dependence on two + staff for bed mobility and transfer, and did not ambulate. The MDS assessment indicated the resident was not on a scheduled pain medication regimen, received PRN pain medications and non-medication interventions, and was unable to answer a pain presence interview. A Staff Assessment for Pain indicated the resident had indicators of pain including Non-verbal sounds, Facial expressions, and Protective body movements or postures "(e.g., bracing, guarding...or holding a body part during movement)." The MDS assessment indicated the resident had indicators of pain or possible pain observed daily. A Care Area Assessment (CAA) Summary, dated 10/22/12, indicated, "Resident has s/s of pain AEB (as evidenced by) facial grimacing and moaning...Speech is unclear at times so resident does not always verbally convey presence of pain. Receives ES (extra strength) Tylenol PRN per MD order...Contributing factors to pain include recent fall with multiple fractures...Proceed with care plan." A Care Plan, dated 10/29/12, indicated: "Problem, Pain Related to recent fall (with) C-6 facet fx, 1-6 (left) rib fx, pelvis fx, L1 comp. (compression) fx as evidenced by: facial grimace, moaning, restlessness. Interventions, Assess for nonverbal signs of pain i.e.... irritability, restlessness, anxiety, withdrawal...Administer pain med as ordered. Discuss with resident the need to request pain mediations before pain becomes severe...Evaluate resident's response to pain...Notify physician of any change in level or frequency of pain...." A physician's orders [REDACTED]." A Pain Assessment, dated 11/12/12, indicated: "Is resident currently on routine pain medications? No. ...is the resident currently exhibiting non-verbal signs of pain? (Yes)...Non-verbal sounds...Facial expressions...Location of resident's current pain: Resident unable to state...Current medications used to relieve pain: [MEDICATION NAME] 50 mg (one) Q 4 hrs PRN. Is the pain chronic or new? D/T (due to) fx...." A Care Plan Conference Summary, dated 11/12/12, indicated, "...Resident having a lot of anxiety affecting progress (with) therapy...now seems to be having a hard time progressing...Discussed anxiety/pain she has been exhibiting." A Physical Therapy Updated Plan of Care, dated 11/13/12, included: "...Reported quality of Life: Unable to respond. Observed signs of pain...Patient has not met any additional STGs (short term goals) this week due to increased anxiety and complaints of increased pain...Nursing working with medication management to increase alertness while decreasing anxiety...Patient demonstrates...guardedness with movement...." A Nurses Note, dated 11/14/12 at 3:00 A.M., indicated, "...(Increased) restlessness, crying, states 'I don't know' when asked what's wrong. Gave 0.25 mg [MEDICATION NAME] per peg. 0400 (4:00 A.M.) (No) further s/s anxiety/restlessness but face grimace et (and) cried out 'ow, ow' during brief change, gave (one) 50 mg [MEDICATION NAME] per peg for s/s pain...." A Nurses Note, dated 11/14/12 at 5:00 P.M., indicated, "Yelling out (and) tearful. Facial grimace, restless; legs off mattress...Calling out for Mommy. Reassurance given not effective. [MEDICATION NAME] 50 mg (one) per peg tube...." A Nurses Note, dated 11/15/12 at 12:00 A.M., indicated, "...(Increased) restlessness, calling out 'Help' (and) for 'Mama,' gave (one) [MEDICATION NAME] per peg...0100 (1:00 A.M.) Resident less restless but moaned (with) facial grimace during bed check, gave (one) 50 mg [MEDICATION NAME] per peg for pain...." A Nurses Note, dated 11/15/12 at 7:40 A.M., indicated, "Tylenol given @ this time D/T (due to) resident moaning (and) yelling out in bed...." A Nurses Note, dated 11/15/12 at 12:30 P.M., indicated, "Resident very anxious (and) restless. Yelling out...Attempted to redirect (without) success. Denies pain or discomfort...(Name of physician) (notified) of (increased) anxiety...Awaiting return call." A Nurses Note, dated 11/15/12 at 1:10 P.M., indicated, "New orders received from (name of physician) as follows: 1) [MEDICATION NAME] 0.5 mg via peg tube Q 4 hours PRN anxiety. 2) DC (discontinue) [MEDICATION NAME]." A different pain medication was not ordered. Nurses Notes included the following notations: 11/15/12 at 9:35 P.M.: "Repositioned (with) assist for restlessness. Anxious (and) tearful - yelling out. Reassures (without) relief. [MEDICATION NAME] 0.25 mg (two) tabs per peg for anxiety...." 11/16/12 at 1:50 A.M.: "PRN [MEDICATION NAME] 0.25 mg given via peg for restlessness/anxiety...." 11/16/12 at 7:00 A.M.: "...Resident (increased) anxiety (and) agitation, crying out 'Don't hurt me (and) I'm scared.' Attempted staying 1-1 (with) resident, talking, rubbing arms...Resident would calm for short time then cry out again. 0900 (9:00 A.M.) [MEDICATION NAME] given, and staff stayed (with) resident...." 11/17/12 at 8:30 A.M.: "Resident yelling out, nurse (checked) brief, was dry, shook head no when asked if needed rest room or in pain. 0900 Increased restlessness, yelling out, [MEDICATION NAME] 0.25 mg given for c/o (complaints of) restlessness and (increased) agitation." 11/17/12 at 4:30 P.M.: "Agitated yelling out @ times. [MEDICATION NAME] 0.5 mg (sic) given per peg tube." 11/18/12 at 7:00 A.M.: "...resident calling out, restless, facial grimacing...Tylenol 500 mg (2) and [MEDICATION NAME] 0.25 mg (2) given...." 11/18/12 at 7:45 P.M.: "Agitated, yelling out criscros (sic) in bed. [MEDICATION NAME] 0.5 mg given via peg tube." 11/18/12 at 4:00 P.M.: "Agitated, yelling out sideways in bed. [MEDICATION NAME] 0.5 mg given per peg tube...Repositioned will monitor." 11/18/12 at 11:00 P.M.: "(Increased) restlessness, calling out, this nurse comforted patient, cried out/facial grimace during brief change, repositioned. 2330 (11:30 P.M.) Continues to moan/cry out, (increased) restlessness, s/s pain, gave (1) [MEDICATION NAME] 0.5 mg et (2) Tylenol 500 mg...." 11/19/12 at 7:30 A.M.: "(Increased) restlessness, tearful, crying, denies pain, gave 0.5 mg [MEDICATION NAME] per peg." 11/19/12 at 4:15 P.M.: "Yelling out, restless, crying. Calling out for 'mommy.' [MEDICATION NAME] 0.5 mg given...2100...Continue restless at times. Repositioned (with) 1 assist...Reassurance given." 11/20/12 at 2:45 A.M.: "(Increased) crying, yelling, despite staff 1 on 1 comforting, gave 0.5 mg [MEDICATION NAME] for anxiety...." 11/20/12 at 6:00 A.M.: "Continues to yell out, crying, inconsolable, fax sent to MD." 11/20/12 at 10:00 A.M.: "Res. (up) in w/c (wheelchair). Alert et yelling out. Facial grimacing et inconsolable. PRN [MEDICATION NAME] 0.5 mg (1) given...." 11/20/12 at 6:00 P.M.: "Res (resident) in bed hollering out et anxious. Repositioned et brief changed...." 11/20/12 at 9:00 P.M.: "Restless et yelling out. PRN [MEDICATION NAME] 0.5 given...." A Physical Therapy Progress Report, dated 11/20/12, indicated: "...Pain: Patient unable to report, but observed signs & symptoms of pain, Pain location/description: unable to localize or verbalize pain...." Nurses Notes continued: 11/21/12 at 12:00 A.M.: "Crying, yelling out...provided reassurance by staff, repositioned, resident calmed down slightly. 0100 (1:00 A.M.) (Increased) restlessness, crying, yelling out, gave (1) [MEDICATION NAME] 0.5 mg per peg...." 11/21/12 at 9:40 A.M.: "Rec'd (received) n.o. (new order) from (physician) to (increase) [MEDICATION NAME] to 1 mg po Q 4 (hours) PRN anxiety et start [MEDICATION NAME] 25 mg (an antipsychotic medication) po BID (twice daily) for atypical [MEDICAL CONDITION]..1220 Res has (increased) restlessness et anxiety, crying out loudly et yelling. Administered [MEDICATION NAME] 1 mg as per PRN order for anxiety." 11/21/12 at 6:45 P.M.: "Resident crying out thrashing covers and agitated, [MEDICATION NAME] 1.0 mg given...." 11/22/12 at 1:00 A.M.: "Yelling out, crying, unable to redirect, gave 1.0 mg [MEDICATION NAME] per PEG for (increased) anxiety/restlessness...." 11/22/12 at 11:40 A.M.: "Resident anxious. Staff attempted to console et redirect resident - anxiety continues. PRN [MEDICATION NAME] given...." 11/22/12 at 4:00 P.M.: "...Resident is yelling out and restless. Attempt to comfort with talk and holding resident's hand. 1700 (5:00 P.M.) Res. continues to yell and cry out. Threw covers off. [MEDICATION NAME] given per orders...." 11/23/12 at 12:30 A.M.: "Restless, crying, (Temperature) 100.0...gave (2) Tylenol 500 mg for pain/fever, gave 1.0 mg [MEDICATION NAME] for restlessness, crying...." 11/23/12 at 2:15 P.M.: "[MEDICATION NAME] .5 mg given per peg tube for restlessness, yelling out - tearful. Reposition (illegible) (and) reassurance (without) effectiveness prior to [MEDICATION NAME] given...." 11/24/12 at 2:30 P.M.: "Restless, yelling out; Repositioned. Checked for incontinence. Not effective. [MEDICATION NAME] 1 mg per peg tube given...." 11/24/12 at 8:30 P.M.: "Resident agitated and crying out gave [MEDICATION NAME] 1.0 mg...." 11/25/12 at 12:30 A.M.: "Crying, yelling out, (increased) anxiety, T 99.7, gave 1.0 mg [MEDICATION NAME] et 1000 mg Tylenol per peg...0430 (4:30 A.M.) Yelling, (increased) restlessness, anxiety, gave 1.0 mg [MEDICATION NAME] per peg." 11/26/12 at 3:00 P.M.: "Res. lying in bed, restless and crying out, social worker visits attemp (sic) to comfort res. 1530 (3:30 P.M.) Res continues crying and yelling out states 'she is scared.' [MEDICATION NAME] 1.0 mg given...." 11/26/12 at 7:00 P.M.: "Res begins crying and yelling out. Repositioned q 2 hrs...1930 (7:30 P.M.) Continues to cry and have (increased) anxiety. Gave [MEDICATION NAME] 1.0 mg...." 11/27/12 (untimed): "Res moaning...Unable to get resident comfortable. PRN [MEDICATION NAME] provided per order to help resident calm down...." 11/27/12 at 5:15 P.M.: "Res in bed crying out anxious et tearful. PRN [MEDICATION NAME] given after this staff was unable to comfort res. Sat (with) res., reassured her, massaged back...." A Speech Therapy Progress Report, dated 11/27/12, included: "...Pain: Patient unable to report, but observed signs & symptoms of pain...." A care plan note, dated 11/28/12, indicated, "Resident's medical condition continues to decline impacting ability to participate in therapy. Plan to discharge from therapy considering palliative care...." The resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The resident received [MEDICATION NAME] 0.25 mg 23 times, [MEDICATION NAME] .5 mg 13 times, and [MEDICATION NAME] 1.0 mg on 17 different occasions from 11/1/12 through 11/29/12. The MAR indicated [REDACTED]'s pain. On 11/29/12 at 11:15 A.M., during interview with the Director of Nursing (DON), she indicated she did not know why the physician did not order a different medication after he discontinued the [MEDICATION NAME] on 11/15/12, and did not know why the staff did not administer the PRN Tylenol more often instead of the [MEDICATION NAME]. The DON indicated the resident did have a head injury, and the staff did not want her "too sedated." 2. On 11/29/12 at 12:50 P.M., the Director of Nursing provided the current facility policy on "Pain Management," revised 8/12. The policy included: "...Effective and aggressive pain management is to be provided for all residents....Pain management is the responsibility of physicians, nurses and other health care professionals providing direct care to the resident...All residents will be screened and assessed for pain upon admission to the facility...Residents will be re-evaluated quarterly for pain issues. Residents who are identified as having more severe pain issues, or who are admitted for pain management may receive more frequent assessments." This federal tag relates to Complaint IN 983. 3.1-37(a)

Based on observation, record review and interview, the facility failed to provide pain assessment and management, for 2 of 7 sampled residents reviewed for pain, in the total sample of 29, in that a resident experienced pain during Activities of Daily Living without intervention, and a resident was made to wait over an hour for requested pain medication, resulting in pain rated at a 10 (most severe) and refusal of therapy due to pain. (#114, #185) Findings include: 1. Resident #114 was observed during a bed bath and incontinence care, provided by CNA #1 on 2/14/11 at 10:30 a.m. The resident was observed to require total assistance for the bath and was observed to have upper and lower extremity contractures. Whenever the resident was turned, repositioned, and/or arms and legs stretched to provide the bath, the resident would moan and grimace. On 2/14/11 at 11:55 a.m., LPN #3 was interviewed. She indicated the resident had [MEDICATION NAME] (pain medication) that could be given to her in the mornings prior to her morning care. CNA #1 was also interviewed with the nurse and indicated, "She was better this morning, usually she's louder." On 2/16/11 at 9:30 a.m., LPN #3 was interviewed. She indicated it seemed the pain medication had helped the resident, when given in the early morning 2/15/11, and they had given it again that morning and had faxed the physician about getting something routine for pain management with Activities of Daily Living. She indicated when she had cared for the resident, providing medications through a gastrostomy tube, the resident had not shown signs of pain. "I guess the CNAs will need to be more vigilant in telling us if they are having pain with care," she stated. Resident #114's clinical record was reviewed on 2/9/11 at 2:45 p.m. The most recent quarterly Minimum Data Set Assessment, dated 1/14/11, failed to identify any pain issues. There was no indication an assessment for pain had been completed when the resident was receiving care involving turning and repositioning, or having a bath. There was no care plan for pain management. The policy and procedure for Pain Management, dated as reviewed February, 2010, was provided by the Director of Nurses on 2/15/11 at 12:50 p.m. The policy and procedure indicated the following: "Residents who are unable to self-report (pain) due to age, level of consciousness, cognitive issues or other factors will be evaluated using behavioral or neurological responses. Behavioral responses include: altered body position, moaning, sighing, grimacing, crying, restlessness, muscle twitching, decreased activity, wincing, irritability, abnormal gait, failure to move an extremity, etc....Health care professionals should recognize that pain may not be accompanied by objective symptoms and complete the pain assessment form accordingly." "Patients who cannot self-report should have interventions based on assessment findings." "In the event a resident has a treatment which may cause pain, medication to be given should be administered 30-45 minutes prior to beginning the procedure." 2. Resident #185 was observed to receive his morning medication on 2/14/11. At 7:55 a.m., LPN #5 prepared the resident's medication. At 8:00 a.m., he received his medicine while in his room. At 8:15 a.m., LPN #5 indicated the resident wanted a pain pill; the LPN stated, "I'll just wait til after breakfast." At 8:35 a.m., LPN #5 prepared another resident's medications, while standing outside Resident #185's room. The resident stated from his room, "I need something for pain." LPN #5 stated, "I'll be with you, you will be next." From the time of 8:35 a.m. to 9:10 a.m., the therapy transporter was observed to approach Resident #185 four times for therapy; he was heard to instruct her that he was waiting on his pain medicine. The therapy transporter informed the nurse of the resident's need for pain medication, after the first interaction with the resident. The nurse informed the therapy transporter he (resident #185) would be next. At 9:10 a.m., the resident was overheard telling the therapy transporter, "I don't understand, having pain and suffering, and want something for it." At 9:10 a.m., LPN #5 questioned the resident regarding rating his pain, he stated "10" (ten) the worst in his hip and foot. He requested the strongest pain pill he had ordered. At 9:15 a.m., [MEDICATION NAME] 50 mg (milligrams) one tablet was given by LPN #5. The physician's orders [REDACTED]." The last dose was recorded on 2/14/11 at 0045 (12:45 a.m.) for feet and toe pain. The resident's Minimum Data Set (MDS) assessment, dated 12/17/10, listed the following as the pain assessment: receives prn (as needed) pain medication, non medicated interventions for pain used, pain or hurting in last 5 days, frequently, hard to sleep at noc(night) due to pain, have limited day to day activity due to pain, moderate pain. 3.1-37(a)