Every finding on record at Envive of Liberty

Based on interview and record review the facility failed to complete neurological assessments after two residents fell and hit their head resulting in Resident B sustaining a subdural hematoma (collection of blood that forms between the dura mater (the outer layer of the brain's protective membranes) and the brain itself) and requiring hospitalization for 2 of 3 residents reviewed for accidents (Residents B and D). Findings include:1. Review of the clinical record of Resident B on 11/6/25 at 11:02 a.m., indicated the resident's diagnoses included, but were not limited to sick sinus syndrome, syncope and collapse, hypertensive heart disease, diabetes, anemia, anxiety, coronary artery disease, cerebral vascular accident (CVA) and hypertension. The clinical record for Resident B indicated the resident was admitted to the facility on [DATE] from the local hospital. The local hospital note for Resident B indicated the resident was in the hospital from [DATE] to 10/22/25. The resident was riding his 3 wheeled electric bike and had a syncopal (fainting) episode. The resident had on a helmet. Neurological assessments were completed with no abnormal findings. The CT (Computed Tomography) scan of Resident B's head, completed on 10/17/25 indicated no acute intracranial findings, generalized atrophy and mild left maxillary sinus disease, no fractures, the ventricles were normal, no midline shift. The CT of the Resident B's spine indicated no acute fractures or dislocations. The CT of Resident B's chest indicated no pneumothorax or fractures. The resident had a pacemaker successful placed on 10/20/25. The baseline functional status assessment for Resident B, dated 10/22/25 at 12:51 p.m., indicated the resident was cognitively intact for daily decision making. The resident required substantial/maximal assistance for showering. The (late entry) progress note for Resident B, dated 10/22/25 at 8:58 p.m., indicated the resident had a fall in the shower room around 8:20 p.m. CNA 1 reported the resident slipped and fell. Emergency Medical Technician (EMT) was called to assist the resident off the floor because the resident had a pacemaker put in on 10/21/25. LPN 2 left the shower room and called 911. The resident was talkative, no apparent injuries. The EMT got behind the resident and put his arms around the residents waist and lifted him up into the shower chair. The resident moved eyes, followed all commands. The resident's blood pressure was 118/68, pulse was 87 and oxygen saturation was between 93 % and 94%. LPN 2 went back into the shower room after completing some task and took the resident's vital signs, his blood pressure was 118/64, pulse 84 and oxygen saturation was 93%. LPN 2 looked at the back of his head and neck as she was passing the resident and no injuries were noted. LPN 2 gently took her left hand and felt up his neck and behind his head. The (late entry) progress note for Resident B, dated 10/22/25 at 8:58 p.m., indicated LPN took another resident's blood sugar at 9:00 p.m. and done a treatment. LPN 2 checked on residents around 9:15 p.m., to 9:20 p.m., LPN 2 went into Resident B's room and asked how he was doing and he did not respond. The resident was breathing rapidly. LPN 2 yelled for the CNA to call 911, but the CNA said she could not because she did not know what to say. LPN 2 walked rapidly to the front of the building and called 911. LPN 2 went back to Resident B's room and did a sternal rub with no response. The resident's oxygen saturation was 94%, was not able to get a blood pressure cuff on the resident because his arm was jerking. EMT's arrived. LPN 2 gave Resident B Tylenol at 4:30 p.m., for a bad head ache but accidently documented it was for back pain. The EMS (Emergency Medical Service) report for Resident B, dated 10/22/25 at 9:57 p.m., indicated the unit was dispatched to the facility for an immediate urgency, Resident B was found unconscious . This indicated there was 1 hour and 37 minutes from the time Resident B fell and from the time he was found unresponsive. The local hospital note for Resident B, dated 10/22/25 at 10:37 p.m., indicated the resident had a subdural hematoma. The resident's CT scan findings were there was a large right holohemispheric (affecting the entire hemisphere of the brain) acute subdural hematoma. There was a 26 millimeter (mm) right to left midline shift. The impression was a large holohemispheric acute subdural hematoma measuring 26 mm in thickness with 26 mm right to left midline shift and uncal herniation. The resident was placed on a ventilator (life support machine that helps the patient breathe). Resident B was transported via helicopter to a major medical hospital. During an interview with CNA 1, on 11/5/25 at 11:20 a.m., indicated she was assisting Resident B with a shower on 10/22/25 and he slipped and fell backwards and hit his head on the wall and on the floor. CNA 2 indicated she did report to LPN 2 that he had hit his head on the wall and the floor. The resident went unresponsive later that evening in his bed. During an interview, on 11/5/25 at 12:20 p.m., the Director of Nursing indicated neurological assessments were not completed after Resident B fell because LPN 2 did not feel that he hit his head. The DON indicated neurological assessments should have been conducted if the facility policy says they should have been. During an interview with LPN 2, on 11/5/25 at 12:55 p.m., she indicated she did not complete neurological assessments on Resident B after he fell and hit his head twice because the resident said he was fine and she waved her hand at him and he looked at her hand and she looked at the back of his head and did not see any swelling. LPN 2 indicated she was unsure how long it was from the time he fell to the time he was found unresponsive, but thought it was approximately 20 minutes. 2. The clinical record for Resident D was reviewed on 11/5/25 at 1:00 P.M. The diagnoses included, but were not limited to, unsteadiness on feet, muscle weakness, cognitive communication deficit, and dementia. A Quarterly Minimum Data Set (MDS) assessment, dated 8/29/25, indicated Resident D was moderately to highly cognitively impaired and used a wheelchair for ambulation. A nurses note, dated 10/27/25 at 8:58 A.M., indicated Resident D had an un-witnessed fall by the nurse's station. Resident D was found laying on the floor with left arm in wheelchair. Resident D stated they had hit their head. Orders received from on call provider to send Resident D to the ER (Emergency Room) for head CT (Computed Tomography) and evaluation. A Fall Risk Evaluation note, dated 10/27/25 at 8:20 P.M., indicated Resident D had a fall, and was at high risk for falls. Immediate intervention was to send to the ER for evaluation. The nurses notes indicated resident D left the facility at 8:55 pm and returned from the hospital on [DATE] at 1:12am with no new orders. A Change in Condition Evaluation, dated 10/27/25 at 9:33 P.M., indicated a neurological assessment was relevant to the change in condition being reported and no changes were observed. No neurological assessments were completed or documented in Resident D's EHR (Electronic Health Record). A plan of care for Resident D, dated 9/30/25, indicated Resident D was at risk for falls due to impaired cognition/safety awareness and unsteadiness on feet. The interventions included, but were not limited to, prevent injuries due to falling. During an interview, on 11/6/25 at 1:53 P.M., the Director of Nursing indicated neurological checks were not completed after Resident D's fall and hitting her head because the assessment of Resident D included no findings and they only do neurological checks as ordered by the provider and no neurological checks were ordered post fall. A Neurological Assessment policy was provided by the DON on 11/5/25 at 12:50 P.M. It indicated,.General Guidelines: 1. Routine neurological assessment is conducted to evaluate the resident for small changes over time that may be indicative of neurological injury.2. Routine neurological exams include assessing: a. mental status and level of consciousness; b. pupillary response; c. motor strength; d. sensation; and e. gait. Nursing standards for neurological checks after a head injury involve a comprehensive assessment of the patient's consciousness, pupillary response, motor function, and vital signs, with a frequency that depends on the injury's severity. Initially, checks are performed very frequently (e.g., every 15 to 30 minutes for a Glasgow Coma Scale (GCS) less than 15 or for the first few hours), with the frequency gradually decreasing as the patient stabilizes and their condition improves. Key components include monitoring the Glasgow Coma Scale, pupillary size and reaction, motor strength, and vital signs while also checking for signs of Cerebrospinal fluid (CSF) leakage or other injury. Core components of neurological checks: Glasgow Coma Scale (GCS): A standardized score from 3 to 15 to assess the level of consciousness based on eye-opening, verbal response, and motor response. Pupillary response: Assess the size, equality, and reaction to light of the pupils. Motor function: Evaluate for motor strength, symmetry, and any specific deficits like pronator drift. Vital signs: Monitor blood pressure, heart rate, respiratory rate, and oxygen saturation, as changes can indicate a worsening condition. Neurological symptoms: Ask about and monitor for symptoms such as headache, nausea, dizziness, vision changes, or numbness. Signs of CSF leakage: Inspect the nose and ears for clear, watery fluid, which can indicate a basilar skull fracture. Frequency of checks The frequency of neurological checks is guided by the initial severity of the injury and any changes in the patient's condition. Severe injury (GCS < 15): Perform neurological observations every 30 minutes until the GCS reaches 15. Mild injury (GCS 15 or higher): Perform observations every 30 minutes for the first two hours. Perform hourly observations for the next four hours. Perform every two hours thereafter. If deterioration occurs: Immediately revert to checks every 30 minutes and restart the protocol. Nursing responsibilities Frequent reassessment: Continue to monitor the patient's condition closely and adjust the frequency of checks based on clinical judgment and the patient's stability. Communication: Report any deterioration or new findings immediately to the physician or nurse practitioner. Documentation: Document all findings accurately and thoroughly in the patient's chart. Care plan management: Update the care plan to reflect the patient's changing status and any interventions being performed. https://www.ncbi.nlm.nih.gov/books/NBK593206/ (chapter 6) and www.aacnnursing.org This citation relates to intake 2654128 3.1-37

Based on observation, interview, and record review, the facility failed to ensure a safe environment in the shower room (wet/slick floor) with two residents suffering a fall in the shower room (Resident B and C). This deficiency resulted in Resident B acquiring a large right acute subdural hematoma with left midline shift and uncal herniation. Findings include: 1. Review of the clinical record of Resident B on [DATE] at 11:02 a.m., indicated the resident's diagnoses included, but were not limited to sick sinus syndrome, syncope and collapse, hypertensive heart disease, diabetes, anemia, anxiety, coronary artery disease, cerebral vascular accident (CVA) and hypertension. The clinical record for Resident B indicated the resident was admitted to the facility on [DATE] from the local hospital. The baseline functional status assessment for Resident B, dated [DATE] at 12:51 p.m., indicated the resident was cognitively intact for daily decision making. The resident required substantial/maximal assistance for showering. The plan of care for Resident B, dated [DATE], indicated the resident was at risk for fall related injury due to recent pacemaker placement and non weight bearing left arm. The (late entry) progress note for Resident B, dated [DATE] at 8:58 p.m., indicated the resident had a fall in the shower room around 8:20 p.m. CNA 1 reported the resident slipped and fell. Emergency Medical Technician (EMT) was called to assist the resident off the floor because the resident had a pacemaker put in on [DATE]. LPN 2 left the shower room and called 911. The resident was talkative, no apparent injuries. The EMT got behind the resident and put his arms around the residents waist and lifted him up into the shower chair. The resident moved his eyes and followed all commands. The resident's blood pressure was 118/68, pulse was 87 and oxygen saturation was between 93 % and 94%. LPN 2 went back into the shower room after completing some task and took the resident's vital signs, his blood pressure was 118/64, pulse 84 and oxygen saturation was 93%. LPN 2 looked at the back of the resident's head and neck as she was passing the resident and no injuries were noted. LPN 2 gently took her left hand and felt up his neck and behind his head. The (late entry) progress note for Resident B, dated [DATE] at 8:58 p.m., indicated LPN took another resident's blood sugar at 9:00 p.m. and done a treatment. LPN 2 checked on residents around 9:15 p.m., to 9:20 p.m., LPN 2 went into Resident B's room and asked how he was doing and he did not respond. The resident was breathing rapidly. LPN 2 yelled for the CNA to call 911, but the CNA said she could not because she did not know what to say. LPN 2 walked rapidly to the front of the building and called 911. LPN 2 went back to Resident B's room and did a sternal rub with no response. The resident's oxygen saturation was 94%, was not able to get a blood pressure cuff on the resident because his arm was jerking. EMT's arrived. LPN 2 gave Resident B Tylenol at 4:30 p.m., for a bad head ache but accidently documented it was for back pain. The local hospital note for Resident B, dated [DATE] at 10:37 p.m., indicated the resident had a subdural hematoma. The resident's CT scan findings included, but were not limited to, a large right holohemispheric (affecting the entire hemisphere of the brain) acute subdural hematoma. There was a 26 millimeter (mm) right to left midline shift. The impression was a large holohemispheric acute subdural hematoma measuring 26 mm in thickness with 26 mm right to left midline shift and uncal herniation (a life-threatening neurological emergency where the innermost part of the temporal lobe, is squeezed through the tentorial notch due to increased intracranial pressure). The resident was placed on a ventilator (life support machine that helps the patient breathe). Resident B was transported via helicopter to a major medical hospital. The progress note for Resident B, dated [DATE] at 12:58 p.m., indicated the writer placed a call to Major medical hospital and spoke with on the medical surgical intensive care unit nurse. The nurse reported that the resident was currently intubated, sedated, and medically stable at this time. The resident had sustained a severe neurological insult deemed non-operable. The hospital social worker was in the process of identifying the resident's next of kin and was planning to facilitate a goals-of-care discussion with them. The progress note for Resident B, dated [DATE] at 12:00 p.m., indicated the resident was pronounced deceased on [DATE] at the Major medical hospital. During an observation and interview with CNA 1 on [DATE] at 11:20 a.m., she indicated she was assisting Resident B with a shower on [DATE] and he slipped and fell backwards and hit his head on the wall and on the floor. CNA 1 indicated the resident's whole body smacked the floor. CNA 1 indicated she did report to LPN 2 that he had hit his head on the wall and the floor. The resident went unresponsive later that evening in his bed. Observation of the shower room, the floor was a smooth flat surface with no ridges. There was non skid strips on the shower floor, CNA 1 indicated the non skid strips were not in place of [DATE] when Resident B fell. CNA 2 indicated there was not a bath mat in place or a towel on the shower floor when Resident B fell. CNA 2 indicated the shower floor was slippery when it wet and she herself had slipped on it before when giving showers. During an interview with the Maintenance Director on [DATE] at 10:58 a.m., he indicated the shower floors were a fiber glass acrylic material. 2. The clinical record for Resident C was reviewed on [DATE] at 11:47 A.M. The diagnoses included, but were not limited to, respiratory failure, chronic pain syndrome, and major depressive disorder. A Quarterly Minimum Data Set (MDS) assessment, dated [DATE], indicated Resident C was cognitively intact, required substantial/maximal assist with ability to bathe self, and had limited range of motion to bilateral lower extremities. A nurses note, dated [DATE] at 8:00 P.M., indicated Resident C had a fall in the shower room while transferring. Shower room floor was wet and resident slipped and was lowered to floor by CNA (Certified Nursing Assistant). During an interview with Resident C on [DATE] at 1:52 P.M., the resident indicated he did fall in the shower room on [DATE]. The resident was sitting on the shower commode in front of the sink when the CNA (Certified Nursing Assistant) who Resident C indicated he did not know the name of, but she was an agency CNA who does not normally work in the facility, had him stand up to wipe his back off. Resident C indicated as soon as he stood up, his feet slid right out from underneath him and he fell and hit his bottom on the floor. The shower room floor was wet and very slippery. The CNAs will usually place a towel down on the shower floor because of how slippery it gets when wet. The resident usually would wear his non-skid socks in the shower because of how slippery the floors always were and did not want to fall, but he just forgot to wear them that day. The CNA was also unaware how the other CNAs would usually place a towel on the floor in anticipation of the floor becoming so slippery. Resident C indicated there were no non-skid grippers on the shower room floor. A Fall Risk Evaluation note, dated [DATE] at 8:41 P.M., indicated Resident C was a low fall risk. Immediate interventions included, but were not limited to, make sure shower room floor is dry before transferring. An Assessing Falls and Their Causes policy was provided by the Director of Nursing (DON) on [DATE] at 12:50 P.M. It indicated,.Steps in the Procedure- After the Fall:.10. If a resident has just fallen, or is found on the floor without a witness to the event, evaluate for possible injuries to the head, neck, spine, and extremities.15. Observe for delayed complications of a fall for approximately forty-eight (48) hours after an observed or suspected fall, and will document findings in the medical record. A Fall Risk Assessment policy was provided by the DON on [DATE] at 10:55 A.M. It indicated,.8. The staff will seek to identify environmental factors that may contribute to falling, such as lighting and room layout.9. 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. This citation relates to intake 2654128 3.1-45(a)

Based on interview and record review the facility failed to notify a resident's physician and emergency contact/resident representative when a resident fell and hit his head for 1 of 3 residents reviewed for accidents (Resident B). Finding include:Review of the clinical record of Resident B on 11/6/25 at 11:02 a.m., indicated the resident's diagnoses included, but were not limited to sick sinus syndrome, syncope and collapse, hypertensive heart disease, diabetes, anemia, anxiety, coronary artery disease, cerebral vascular accident (CVA) and hypertension. The progress note for Resident B, dated 10/22/25 at 8:58 p.m., indicated the resident fell in the shower room around 8:20 p.m., the Emergency Medical technician (EMT) was called to assist the resident off the floor because the resident had a pacemaker placed on 10/21/25. The Director of Nursing (DON) was notified. There was no documentation of the physician or the resident's representative being notified. During an interview with CNA 1, on 11/5/25 at 11:20 a.m., she indicated she was assisting Resident B with a shower on 10/22/25 when he fell. CNA 1 indicated the resident slipped and hit his head on the wall and hit his head on the floor. CNA 1 indicated she reported to LPN 2 who was the nurse on duty that the resident hit his head when he fell. During an interview with LPN 2, on 11/5/25 at 12:55 p.m., she indicated she was the nurse caring for Resident B on 10/22/25 when he fell in the shower. LPN 2 indicated she did not know why she did not call the physician or the resident's representative when the resident fell and hit his head. LPN 2 indicated she was so scared and had another emergency down the other hallway with another resident. During an interview with Resident B's Emergency Contact 1, on 11/5/25 at 1:15 p.m., she indicated she was not notified when Resident B fell in the shower and hit his head. The assessing for falls and their causes policy provided by the DON on 11/5/25 at 12:50 p.m., indicated after a resident fall the attending physician and family would be notified in an appropriate time frame. The accidents and incidents reporting policy provided by the DON on 11/6/25 at 10:55 a.m., indicated the it would be documented the date and time the attending physician and family member was notified of the accident. This citation relates to Intake 2654128. 3.1-5(a)(1)

Based on observation, interview, and record review, the facility failed to maintain holding temperatures for pureed food for 4 of 4 residents receiving pureed foods. (Resident 10, 17, 23, and 29) Findings include: A tour of the kitchen was conducted, on 9/19/25 at 11:30 a.m., with [NAME] 2. During an observation of the pureed food temperatures being obtained, it was noted that pureed taco meat was recorded with a holding temperature of 90 degrees Fahrenheit, and pureed green beans had a holding temperature of 100 degrees Fahrenheit. During an observation of the steam table with [NAME] 2, four containers of pureed taco meat and four containers of pureed green beans were stacked to the right side of the steam table. During an interview with [NAME] 2, they indicated food temperatures were obtained one time after being cookedand before they were placed on the steam table. Food temperatures were obtained, on 9/19/25 at 11:00 a.m., before the food was placed on the steam table. [NAME] 2 indicated the taco meat was 171 degrees Fahrenheit, and the green beans were 160 degrees Fahrenheit. [NAME] 2 indicated they held pureed foods on the side of the steam table in prepared containers. [NAME] 2 also indicated other staff place prepared containers of pureed food into the microwave and will heat them up one to two minutes before the food was served. During an interview with the Administrator on 9/23/25 at 10:19 a.m., they indicated pureed food should be put into a metal container and held on the steam table. The Administrator indicated pureed food should be served directly out of the pan on the steam table and not in bowls to sit for holding. They indicated the holding temperatures should have been 135 degrees Fahrenheit and above. A Food Temperatures policy was provided by the Director of Nursing (DON) on 9/19/25 at 1:15 p.m. It indicated .1. Hot foods that are potentially hazardous will be held for service at or above 135 degrees Fahrenheit .2. All hot and cold food items will be served to the resident at a temperature that is considered palatable at the time the resident receives the food .8. Temperatures should be monitored throughout meal service to ensure adequate holding temperatures are maintained . 3.1-21(a)(2)

Based on interview and record review, the facility failed to ensure falls were investigated and documented thoroughly for 3 of 3 residents reviewed for falls. (Residents E, G and H) Findings include: 1. The clinical record of Resident E was reviewed on 1-23-25 at 2:52 p.m. Her diagnoses included, but were not limited to, Alzheimer's disease, dementia, anxiety, chronic pain, spinal stenosis, and general muscle weakness. Her most recent Minimum Data Set (MDS) assessment, dated 11-18-24, indicated she was severely cognitively impaired, used a wheelchair for mobility, and was dependent for walking, toileting, and bed mobility. It indicated she had falls within the last six months, but no fractures. The Director of Nursing (DON) provided a fall log, indicating Resident E had a fall without injury on 10-12-24 at 3:55 p.m. During an interview with the DON on 1-23-25 at 3:16 p.m., she indicated Resident E had a diagnosis of dementia and did have a history of falls. I will have to look in her old chart and the old records for her information. She is the only person with a fall listed for 10-12-24. A progress note, dated 10-12-24 at 3:55 p.m., indicated Resident was getting up from w/c [wheelchair] & [sign for and] went down onto her knees. Assisted up to w/c after assessment completed. No additional assessments or documentation of the fall and/or follow-up were located in clinical record until 10-15-24. The DON provided a copy of a document entitled Initial 3-Day Post Fall Interdisciplinary Review, dated 10-12-24, as Day One, which indicated Resident E was getting up from w/c & went down on knees. Day two documented as 10-15-24, and Day three as 10-16-24. The DON indicated documentation of Resident E's fall did not get conducted timely related to we were having documentation issues at the time. During an interview with the DON on 1-24-25 at 2:55 p.m., she indicated the date of Resident E's fall would have been under previous ownership and with a different electronic health record (EHR) system, and the previous management/owners were not providing access to the EHR at the present time. They have told us that we will have to gain access through a third party for those records, and the current facility ownership does not know when that might take place. 2. The clinical record of Resident G was reviewed on 1-24-25 at 10:42 a.m. Her diagnoses included, but were not limited to, hyponatremia (low serum sodium level), general muscle weakness, unspecified protein-calorie malnutrition, unsteadiness on feet, and diabetes. Her most recent MDS assessment, dated 11-15-24, indicated she was cognitively intact, used a wheelchair for mobility, and required moderate assistance with transfers, walking, toileting, bathing and hygiene, and was independent with bed mobility. It indicated she had no falls since her last MDS assessment. During an interview with Licensed Practical Nurse (LPN) 7 on 1-22-25 at 11:55 a.m., she indicated Resident G had a recent fall without injuries and was recently diagnosed with hyponatremia with associated cognitive decline. A review of Resident G's unwitnessed fall, dated 1-21-25 at 1:12 p.m., indicated Resident G fell out of wheel chair while self transferring, and was found by staff lying on the floor in front of her wheelchair. It indicated the resident was assessed and appeared to have no injuries, had no pain, and was alert and oriented to person, place, time, and situation. It indicated the physician, the DON, and family were notified of the fall within minutes of the fall. A review of the nursing progress notes indicated no documentation as to why Resident G was later sent out to the hospital on the same date. An associated progress note, dated 1-21-25 at 11:12 p.m., indicated the resident was admitted to an area hospital with a diagnosis of hyponatremia. A progress note, dated 1-23-25 at 11:14 p.m., referred to placement of geri-sleeves (used for skin protection). No progress notes were located as to the resident returning to the facility from the hospital. A care plan entry for falls/fall risk, dated 1-21-25, indicated the resident had been sent to the emergency room for evaluation and change of condition. A re-admission nursing assessment was conducted, on 1-22-25, which indicated Resident G was alert and oriented to person, place, situation, had no current skin issues, was a known fall risk, was at risk for skin breakdown, was incontinent of bowel and bladder, and denied pain. In an interview with Resident G on 1-23-25 at 10:35 a.m., she indicated she had returned late last evening from a stay at an area hospital but was unsure of the reason for her hospitalization . She did recall a fall with no injury from her wheelchair several days prior. 3. The clinical record of Resident H was reviewed on 1-24-25 at 2:10 p.m. Her diagnoses included, but were not limited to, unspecified convulsions, anxiety, depression, unsteadiness on feet, nontraumatic subarachnoid hemorrhage, history of a traumatic brain injury, transient ischemic attacks [mini strokes], and cerebral infarction, CVA (cardiovascular attacks or stroke), high blood pressure, cognitive communication deficit, dementia, and a history of falls. Her most recent MDS assessment, dated 12-28-24, indicated she was severely cognitively impaired, required substantial assistance with toileting, bathing and hygiene, and required moderate assistance with bed mobility, transfers, and walking, and used a wheelchair for mobility. It indicated she was usually incontinent of bowel and bladder, received routinely scheduled pain medication and denied pain, and had two falls since her prior MDS assessment. A Fall Investigation document, dated 12-31-24 at 7:40 a.m., indicated Resident H was found on the floor of the lounge area by facility staff. It indicated she had a wheelchair alarm in place. An assessment by the licensed nurse indicated she sustained a hematoma to the right forehead to which an ice pack was applied, active range of motion to her upper and lower extremities was performed, she was alert to her name, and able to answer questions appropriately. Resident H was assisted to stand with the assistance of two people and returned to her wheelchair. Her blood pressure was elevated. Her physician was notified of the fall and made aware of being on aspirin therapy, with no change in cognition, with no verbal or non-verbal signs of pain. Resident H was able to indicate she had fallen out of the wheelchair and struck her head. Neurological checks were initiated and were within normal range. The documented history included multiple falls and unsteady gait. It indicated the family was notified and it indicated she was sent to a local emergency room for further evaluation. No further documentation was in Resident H's clinical record until 1-12-25. During an interview with the DON on 1-24-25 at 2:55 p.m., she indicated Resident H returned to the facility on the same date as when she was sent out, 12-31-24, but she could not locate additional information in regard to this. Yes, there should have been a readmission assessment conducted, but I cannot find it. Once again, that would have been under the previous ownership and with the other [EHR] system, and they are not giving us access to it at the present time. They have told us that we will have to gain access through a third party for those records, and the current facility ownership does not know when that might take place. The DON indicated Resident H had another fall, on 1-12-25, and was sent out to the emergency room for further evaluation and returned from the hospital on 1-14-25. She was unable to locate any handwritten or electronic records for a readmission assessment. This citation relates to Complaint IN00445202. 3.1-45(a)(1) 3.1-45(a)(2)

Based on interview and record review, the facility failed to protect the resident's right to be free from verbal abuse by a staff member for 1 of 3 residents reviewed for verbal abuse. (Resident B) Findings include: The facility completed an incident report and sent it to the Indiana Department of Health (IDOH) Long Term Care division, on 9-25-24, related to Resident B and Certified Nurse Aide (CNA) 4. In a written witness statement, dated 9-25-24, Registered Nurse (RN) 5, indicated on the same date at 5:15 p.m., he and another resident's family member, overheard [name of CNA 4] using inappropriate language and speaking in a raised tone towards the resident. The resident was heard using a racial slur directed at the staff member. In response, [name of CNA 4] stated 'You will not call me that, do you f-----g understand?' and added, 'You cannot attempt to get out of bed on your own; I already had to help your a-- off the floor once today.' This writer intervened by removing [name of CNA 4] from the room and escorting her to the break room to collect her belongings, followed by an escort to the time clock. In a documented staff interview, conducted on 9-26-24, by the Regional HFA (health facility administrator) with CNA 4, it indicated CNA 4 indicated she had been overwhelmed since the beginning of her shift on 9-25-24. Near the beginning of her shift, she found Resident B half in and out of bed and admitted to increasing her tone to get the resident's attention to not try to get up alone. She stated [name of Resident B] started calling her derogatory names and she stated 'I said, you can't talk to me like that, do you f-----g understand?' Employee stated the words just slipped out and she knew it was wrong and apologized to the resident. Employee stated she was stressed and did not ask for help and aware that she should have. Writer explained that Resident did not feel that she was intentional with her words and felt she was having a bad day. [Name of RN 5] stated he did not feel she was intentional but having a bad day. Employee will be paid for time off and job reinstated. Employee did receive written 1st warning. Employee received Stress/Burnout education. During a telephone interview with CNA 4 on 1-23-25 at 12:28 p.m., she indicated on the day in question, the facility was short-handed. The resident had asked to be helped to bed and I told her I would be there as soon as possible. In the meantime, [name of Resident B] asked . another resident, who was in a wheelchair, to put her to bed and [name of other resident] helped her. When I came back to her room, a few minutes later, I found out [name of the other resident] had helped her to bed and I became upset and very worried about both [name of Resident B and name of the other resident]'s safety in doing this. I told her she can't just ask other residents to help her lay down. She got really mad at me and called me the N-word and told me I can't tell her what to do. I did cuss at her and I shouldn't have. [Name of RN 5], the nurse on duty, heard us, and he immediately came and talked to me and [name of Resident B] and ended up sending me home. I was suspended for a day or two while they did their investigation and got a written warning and was allowed to come back to work. I did apologize to [name of Resident B] and we are good friends now. She didn't want me to take care of her for a while, but I can now. I did have [receive] a teachable moment about burnout and received some education on that. I will admit it was all me and I shouldn't have acted that way, but I know better now. During an interview with the Executive Director (ED) on 1-23-25 at 9:30 a.m., she indicated, As the new interim ED, I am just now looking into this situation, the same as you. As you know, this occurred with the previous company and previous management. I couldn't really see where the investigation said whether or not they considered this an abuse or not, but it does look like a fairly clear verbal abuse with statements made about the aide being overwhelmed. It looks like they did provide her with information on burnout and stress. I assume this may trigger further investigation from the State in regards to the aide. From what I have heard from staff and residents, there was a time in the Fall where the staffing was kind of rough .I've been told the staffing situation has improved a great deal. We are currently using some agency for staffing with the hopes to decrease the agency staffing as soon as possible. On 1-23-25 at 11:10 a.m., the ED provided a copy of a form entitled Employee Warning, dated 9-27-24. It indicated the document was a 1st Written warning for CNA 4 for violation of Page 63 of Employee Handbook, #13 using profane/abusive language towards or around residents or their family members, on 9-25-24. Indicated, On 9-25-24, Employee [name of CNA 4] was overheard by [name of RN 5] using inappropriate language and speaking to resident with an increased tone stating, you will not call me that, do you f-----g understand? .Employee re-educated on stress/burnout and appropriate resident interactions. The use of profanity is against facility policy and will not be tolerated. Any further writeups may results in further disciplinary action or termination. The document was signed by CNA 4 and the Regional HFA. During an interview with Resident B on 1-22-25 at 3:28 p.m., she denied any concerns with anyone being rough with care or rough/unkind with speech. She indicated she had several falls with head injuries in the past, but she was unable to determine if she had any falls at the facility. She indicated, My memory is pretty bad. The clinical record of Resident B was reviewed on 1-22-25 at 1:10 p.m. Her diagnoses included, but were not limited to, unspecified dementia and benign intracranial hypertension. Her most recent Minimum Data Set assessment, dated 9-6-24, indicated she was moderately cognitively impaired. On 1-22-25 at 3:56 p.m., the ED provided a copy of a policy entitled, Abuse Prohibition, Reporting and Investigation. She indicated this policy was the previous company's policy for Abuse Prohibition which was in effect at the time of the 9-25-24 incident. This policy indicated a revision date of 6/2023. It indicated, This facility shall prohibit and prevent abuse .Verbal Abuse [defined as] oral, written and/or gestured language that willfully includes disparaging and/or derogatory terms to residents or their families, or within hearing distance, regardless of their age, ability to comprehend, or a disability .This facility shall have evidence that all alleged violations are thoroughly investigated and shall prevent further potential abuse .while the investigation is in progress .This facility shall not permit residents to be subjected to abuse by anyone, including employees .Supervisory personnel are responsible to monitor through observation and counseling as needed, staff/resident interactions and the provision of care and services to the resident. Facility personnel exhibiting any trend toward impatience or frustration in routine dealings with residents shall be evaluated for possible temporary assignment or unpaid leave of absence .The facility Administrator is designated as the individual responsible for coordinating all efforts in investigation of abuse allegations and for assuring that all policies and procedures are followed .Residents must be protected from abuse through the provisions of this policy, the procedure for investigation of abuse, orientation training and ongoing inservice education .If Resident Abuse, or Suspicion of Abuse is Reported, the resident(s) involved in the incident shall be removed from the situation at once or facility person shall remain with the resident to ensure safety .Any facility personnel implicated in the alleged abuse shall be immediately removed from resident care and shall remain suspended until an investigation is completed. A thorough investigation shall be initiated .As a result of an investigation, the facility shall take any necessary actions which may include, but not be limited to .Analyzing the occurrence(s) to determine why abuse .occurred, and what changes are needed to prevent further occurrences; Defining how care provision will be changed and/or improved to protect residents receiving services . This citation relates to Complaint IN00444074. 3.1-27(b)

1. Based on observation, interview, and record review, the facility failed to ensure staff effectively implemented fall prevention interventions while using an assistive device in the shower to prevent accidents for 1 of 3 residents reviewed for accidents. This deficient practice resulted in Resident 6 experiencing a fall that required hospitalization for the treatment of a subarachnoid hemorrhage. 2. The facility failed to ensure fall interventions were in place while utilizing an assistive device for 1 of 2 residents reviewed for positioning and mobility. (Resident 23) Findings include: 1. Resident 6's record was reviewed, on 7/11/24 at 10:38 a.m., and diagnoses included, but were not limited to, traumatic subarachnoid hemorrhage, chronic pain syndrome, polyosteoarthritis, morbid (severe) obesity, and muscle weakness. The record indicated Resident 6 was hospitalized , from 4/13/24-4/17/24, after falling off a shower bed. The record indicated Resident 6 sustained a subarachnoid hemorrhage as a result from the fall. A Quarterly Minimum Data Set (MDS) assessment, dated 2/6/24, indicated Resident 6 was dependent- helper does ALL of the effort with shower/bathing, personal hygiene, and bed mobility (rolling left to right). Resident 6 required two staff person assistance with transfers and had impairment on both sides to the upper and lower extremities. The MDS indicated that Resident 6 was cognitively intact for daily decision making and was consistent and reasonable for daily decision making. A written statement from the former maintenance staff, dated 4/13/24 and signed, indicated the following, .Called in Saturday morning around 10:40 a.m. to fix a shower bed that someone had fallen out of. Upon my inspection of the shower bed I found that the pins which hold the siderails up were missing. I went to the hardware store and bought enough bolts of the right size and length to keep the rails in upright position and secure for the shower bed in the 200 hallway. I then went to check the bed in the 100 hallway and secured it as well The hospital discharge summary, dated 4/17/24, indicated the resident suffered a traumatic brain injury which commonly causes confusion, dizziness, memory loss, nausea, and a headache. A care plan for Potential for Fear and Anxiety was initiated, on 4/19/24, and indicated the following, .the resident has the potential for fear and anxiety due to recent fall out of a shower bed A care plan titled ADL [Activities of Daily Living] Assist Required, initiated on 5/13/22 and revised on 4/29/24, indicated the following, The resident [Resident 6] requires up to x2 [times two] staff. The x2 staff was handwritten on the paper care plan without a date to indicate when Resident 6 was to need staff assistance with two people and for what specific ADL task. An observation was conducted, on 7/11/24 at 11:46 a.m., with the Nurse Consultant. The shower bed was observed to have a pipe rail bed frame with two side rails, which required the insertion of two pins on each side to hold the rail. Each pin was observed to be attached to the side rails with a gray strap. The frame was observed to have four legs with attached, locking wheels. During an interview with Certified Nursing Assistant (CNA) 3, on 7/11/24 at 11:08 a.m., she indicated that she was getting Resident 6 onto the shower bed and had the bed rails in the up position. She indicated she rolled Resident 6 onto her left side to wash her backside and when Resident 6 reached for the siderail, the rail broke off the shower bed, and Resident 6 fell off the bed, and landed on the floor headfirst. CNA 3 indicated the pins were in place before the shower began but came out once Resident 6 put weight on the railing. An interview with CNA 3, on 7/11/24 at 11:48 a.m., indicated she had not locked the shower bed wheels before or after Resident 6 was placed onto the shower bed. CNA 3 indicated she normally did not lock the wheels and she was not familiar with the shower beds. CNA 3 indicated she had only given one shower during clinicals, and, during orientation, shower beds were not covered that much. An interview with Resident 6, on 7/11/24 at 1:55 p.m., indicated the shower bed was not pushed all the way up against the shower wall and there were no siderails up. She indicated she was always told to reach for the handicap rail attached to the wall when turning because the shower bed rails were broken. Resident 6 indicated when CNA 3 instructed her to roll onto her left side, she reached for the handicap rail as she was always instructed to do, but she could not reach it, and the bed rolled, and she fell off the bed onto her head hitting the floor. Resident 6 indicated she knew the wheels were not locked that day. Resident 6 indicated she had a lot of head pain due to the fall and continued to have tingling above her right eyebrow and it still hurt at times. During an observation and interview with Resident 6, on 7/12/24 at 10:58 a.m., she was observed sitting in a mobilized wheelchair and indicated she was dependent on all her daily activities, especially mobility and bathing. An interview with the Executive Director (ED), on 7/11/24 at 12:29 p.m., indicated she was notified of the fall on 4/13/24, and Resident 6 slid off the shower bed. The pins broke and was the root cause of the fall. The ED indicated that the former maintenance staff came into the facility Saturday, believed to be 4/13/24, and stated the pins were gone. So, he (former maintenance staff) got new pins to put onto the shower bed. The ED indicated she was not aware that the brakes were not locked on the shower bed. A policy for Showering a Resident was provided by the Executive Director, on 7/11/24 at 2:18 p.m., and indicated the following, .Assist resident into shower and lock wheels of shower chair . A document titled PVC Healthcare Equipment Owner's Manual was provided by the ED on 7/11/24 at 2:18 p.m. The document indicated the following, .never allow the user to lean outside of the frame of the equipment .always apply the brakes on casters when needed The document did not indicate any weight limit specifications but only referenced always abide by weight limit capacities for each product. 45291 2. The clinical record for Resident 23 was reviewed on 7/12/2024 at 10:45 a.m. The medical diagnosis included Alzheimer's disease. A Quarterly Minimum Data Set Assessment, dated 6/21/2024, indicated Resident 23 was not cognitively intact and dependent on transportation with her manual wheelchair. A fall care plan, reviewed on 4/15/2024, indicated that Resident 23 was at risk for falls related to weakness and dementia. An intervention to ensure that Resident 23 was utilizing her assistive device as indicated, including her Broda chair (a type of manual wheelchair). An in-service for Resident 23, dated 4/7/2024, was provided by the Director of Nursing on 7/10/2024 at 2:30 p.m. The document indicated that Resident 23 is to have her wheelchair dipped when in transit to raise feet form ground. During an observation, on 7/10/2024 at 1:21 p.m., Resident 23 was sitting in her wheelchair in the common area by the nurses' station. CNA 2 pulled Resident 23 backwards in her wheelchair in the common area into the tiled hallway. Resident 23's feet were noted to be contacting the ground during the backwards motion. CNA 2 paused momentum, tilted the wheelchair back some, then began a forward momentum to take Resident 23 to her room. Resident 23's feet were noted to make contact intermittently during the forward momentum. During an interview with CNA 2, on 7/10/2024 at 1:23 p.m., CNA 2 indicated that staff did not use foot pedals with Resident 23. She indicated that Resident 23's feet touch the floor sometimes when she transports Resident 23 in the wheelchair, and that nursing staff are working with PT [Physical Therapy] about a new wheelchair. During an interview with Certified Occupational Therapy Assistant (COTA), on 7/10/2024 at 1:46 p.m., indicated that she was familiar with Resident 23 and her use of a pedal Broda chair. COTA indicated that this chair was selected as the most appropriate option because it would allow Resident 23 to have versatility in her movements and body mechanics. Resident 23 does not utilize foot pedals with it due to her non-functional purposeful movements. Staff are to dip the chair back so that Resident 23's feet have clearance from the floor when assisting her with transportation. A policy entitled, FALL PREVENTIONS PROGRAM, was provided by the Administrator on 7/11/2024 at 2:18 p.m. The policy indicated the purpose of the policy was to identify residents who are at risk for falls and subsequently implement appropriate individualized fall prevention interventions. 3.1-45(a)(1) 3.1-45(a)(2)

Based on observation, interview, and record review the facility failed to provide fresh ice water daily and failed to keep a call light and personal items within reach for 3 of 3 residents reviewed for choices (Resident 20, Resident 17 and Resident 2). Findings include: 1. During an observation and interview with Resident 20, on 7/9/24 at 12:59 p.m., she had a warm pitcher of water on her nightstand. The resident indicated she frequently went without fresh ice water and only received fresh fluids with meals. During an observation, on 7/10/24 at 10:58 a.m., Resident 20 had a water pitcher of water on her nightstand. Review of Resident 20's clinical record, on 7/12/24 at 11:32 a.m., indicated the diagnoses included, but were not limited to, diabetes, hypertension, anxiety, chronic kidney disease, and bladder disorder. The Admission Minimum Data Set (MDS) assessment, dated 6/21/24, indicated Resident 20 was cognitively intact for daily decision making. The resident was consistent and reasonable. The physician order for Resident 20, dated 6/18/24, indicated to offer additional 120 milliliters (ml) every shift. 2. During an observation and interview with Resident 17, on 7/9/24 at 1:27 p.m., her cell phone, water, magazines, TV remote, and call light was across the room and out of reach for the resident. The resident indicated the staff frequently forget to place her personal items and call light within her reach and she had to yell for help. The resident's call light was activated and Certified Nursing Assistant (CNA) 1 came into the room and indicated whoever assisted the resident to bed was responsible to ensure her call light and personal items were within her reach. CNA 1 placed all items in reach the resident. During an observation and interview with Resident 17, on 7/10/24 at 1:30 p.m., her personal items and water was across the room and out of reach. The resident indicated she had to push her call light frequently to alert staff her personal items were out of reach. The resident indicated she was unable to walk. Review of Resident 17's clinical record, on 7/10/24 at 12:52 p.m., indicated the diagnoses included, but were not limited to, peripheral vascular disease, congestive heart failure, anxiety, major depressive disorder, pain, diarrhea, insomnia, and difficulty walking. The Admission MDS assessment, dated 6/15/24, indicated Resident 17 was cognitively intact for daily decision making. The resident was consistent and reasonable. The State Optional MDS for Resident 17, dated 6/15/24, indicated she was dependent on two people for transfers. During an interview with the Director of Nursing (DON), on 7/11/24 at 12:40 p.m., they indicated nursing staff were responsible for ensuring water, call lights, and personal items were within reach of the residents. 45291 3. The clinical record for Resident 2 was reviewed on 7/11/2024 at 11:15 a.m. The medical diagnosis included edema. A Quarterly MDS Assessment, dated 6/13/2024, indicated Resident 2 was set up assistance for eating and drinking. A physician order, dated 12/16/2022, indicated Resident 2 drank thin liquids. During an interview and observation with Resident 2, on 7/9/2024 at 12:57 p.m., indicated that he had warm water in a pitcher at the beside with no ice present. Resident 2 stated, This is the same water from yesterday and it is warm. Resident 2 indicated the staff rarely pass fresh ice water. During an interview and observation with Resident 2, on 7/11/2024 at 11:46 a.m., indicated that he had warm water in a pitcher at the beside with no ice present. Resident 2 indicated the staff did not pass ice water to him at all within the last day and the water in his pitcher was stale and warm. During an interview with the DON, on 7/11/24 at 12:40 p.m., she indicated nursing staff are responsible for ensuring water, call lights, and personal items are within reach. A policy, entitled Water, Fresh Ice, was provided by the Executive Director on 7/12/2024 at 10:15 a.m. The policy indicated, . Fresh drinking water shall be provided to each resident and be available to each resident at all times . 3.1-3(v)(1)

Based on observation, interview, and record review, the facility failed to provide and administer a resident's medication, as ordered, for 1 of 1 resident reviewed for antibiotic use. (Resident 18) Findings include: The clinical record for Resident 18 was reviewed on 7/10/24 at 11:17 a.m. The diagnosis included, but were not limited to, urinary tract infection. The chronic urinary tract infection care plan, last revised 7/1/24, indicated the goal was for Resident 18 to be free from signs and symptoms of urinary tract infection. Two of the interventions were to administer medications as ordered and Macrobid 100 milligrams (mg) on Monday, Wednesday, and Friday for 36 doses. The 6/20/24, Urology Visit Summary indicated, Chief Complaint as stated by patient: f/u [follow up] UTI [urinary tract infection.] How long have you been experiencing this issue?: weeks What improves/worsens this issue?: Requesting ongoing low dose abx [antibiotic ] PLAN .pt [patient] here for more UTI .Will get str [straight] cath [catheter] cx [culture] sent out and start on low dose preventative antibx [antibiotic] based on it for 3 months. The 7/1/24, 11:00 a.m. nurse's note indicated Resident 18's urologist's office called and gave a new order for Macrobid 100 mg by mouth every Monday, Wednesday, and Friday for 36 does related to UTI. The physician's orders indicated Macrobid capsule of 100 mg, once a day, every other day, and only given on Monday, Wednesday, and Friday, starting 7/3/24. The July 2024 MAR (medication administration record) indicated the Macrobid was scheduled to be given every other day, instead of scheduled to be given on Monday, Wednesday, and Friday only. It indicated Resident 18 received the Macrobid on the following dates: Wednesday 7/3/24, Friday 7/5/24, and Sunday 7/7/24. It indicated the medication was not administered on 7/9/24, because it was supposed to be given on Monday, Wednesday, and Friday and was given yesterday (7/8/24.) It indicated it was not given on 7/11/24 because it was to be given on Monday, Wednesday, and Friday. An interview was conducted with the DON (Director of Nursing) on 7/12/24 at 12:17 p.m. She reviewed the July 2024 MAR and indicated the Macrobid was set up to be administered incorrectly as every other day and should have been set up to be administered on Monday, Wednesday, and Friday only. An observation of Resident 18's Macrobid inside the medication cart was made with the DON on 7/12/24 at 12:23 p.m. There were 36 capsules sent from the pharmacy and four were missing. The Medication Administration policy was provided by the DON on 7/15/24 at 1:35 p.m. It indicated, Guidelines For Medication Administration: 1. Medications are administered to residents only as prescribed and only be person licensed or qualified to do so 4. Read orders carefully to be sure that they are understood. Clarify any questions with the charge nurse or the physician. Carefully repeat and clarify verbal orders, if received 10. Always observe the six rights of giving each medication. Right Resident, Right Medicine, Right Time, Right Dose, Right Route, Right Documentation. 3.1-25(a) 3.1-25(b)(1)

Based on observation, interview, and record review the facility failed to store a Bi Pap facial mask and nebulizer mouthpiece in a bag to maintain good infection control practices for 1 of 4 residents reviewed for respiratory therapy (Resident 17). Findings include: During an observation, on 7/09/24 at 1:31 p.m., Resident 17's Bi Pap (airway support administered through a mask) facial mask was lying on the nightstand and not in a bag. The facial mask had brown substance around the facial mask. During an observation, on 7/10/24 at 10:57 a.m., Resident 17 was sitting in her geriatric chair and her nebulizer machine mouthpiece was lying on the bedside table with no bag. During an observation and interview, on 7/10/24 at 1:30 p.m., Resident 17's nebulizer machine mouthpiece was lying on the bedside table with no bag. The resident indicated some nurses put the nebulizer mouthpiece in a bag and some do not. Review of the record for Resident 17, on 7/10/24 at 12:52 p.m., indicated the resident's diagnoses included, but were not limited to, peripheral vascular disease, congestive heart failure, anxiety, major depressive disorder, pain, diarrhea, insomnia, and difficulty walking. The Admission Minimum Data Set (MDS) assessment for Resident 17, dated 6/15/24, indicated the resident was cognitively intact for daily decision making. The resident was consistent and reasonable. The physician recapitulation orders for Resident 17, dated July 2024, indicated resident received a nebulizer treatment three times and a day and every four hours, as needed, for shortness of breath and congestion related to congestive heart failure. The resident had ordered BI-PAP mask at bedtime with 2 liters per minute setting. The resident was ordered oxygen 2 liters continuous/intermittent every shift. During an interview with the Director of Nursing (DON), on 7/11/24 at 12:40 p.m., they indicated nursing staff and respiratory staff were responsible to ensure the residents respiratory equipment was stored in a bag for infection control measures. The nebulizer handheld policy provided by the DON, on 7/12/24 at 10:25 a.m., and indicated upon completion of the treatment the delivery device would be placed in a bag labeled with the resident's name and date to be maintained at the bedside. An interview conducted with the DON, on 7/12/24 at 11:30 a.m., indicated Bi pap mask were to be stored in a bag for infection control purposes. 3.1-47(a)(6)

Based on interview and record review the facility failed to transfer a resident in a safe manner for 1 of 4 residents reviewed for accidents (Resident B). Finding include: During an interview with Resident B's family member on 6/1/23 at 10:19 a.m., indicated on 4/18/23 Resident B was in the bathroom and pushed her call light for help getting up. CNA 1 came into the bathroom and was pulling on the resident's arm and pants to get her off the toilet. The CNA did not use a gait belt and ripped the resident's pants during the transfer. During an interview with CNA 1 on 6/2/23 at 2:20 p.m., indicated on 4/18/23 she transferred Resident B from the toilet by holding the resident under her arm and by her pants. CNA 1 indicated she did not use a gait belt during the transfer. The CNA indicated she felt rushed that day. Review of the record of Resident B on 6/5/23 at 12:45 p.m., indicated the resident's diagnoses included, but were not limited to, muscle weakness, unsteadiness on feet, anxiety, difficulty walking, major depression disorder, acute kidney disorder, low back pain, syncope, and anemia. The fall risk assessment for Resident B, dated 3/1/23, indicated the resident was at high risk of falling. The Annual Minimum Data Set (MDS) assessment for Resident B, dated 3/2/23, indicated the resident cognitively intact for daily decision making. Decisions were consistent and reasonable. The resident required extensive assistance of one person for transfers and toileting needs. The resident utilized a wheelchair and a walker. The plan of care for Resident B, dated 3/10/23, the resident required staff assistance to transfer from one surface to another. The potential for falls and significant injury lacking staff assistance. The interventions included, but were not limited to, staff would utilize a gait belt. The fall prevention program provided by the Administrator on 6/6/23 at 1:00 p.m., indicated the purpose was to identify residents who were at risk for falls and subsequently implement appropriate individualized fall prevention interventions. It was the policy of the facility to identify any resident who was at increased risk for falls. Identified residents shall be monitored by the Interdisciplinary Team (IDT) to implement fall prevention interventions that minimize occurrence of falls thereby minimizing the risk for injury. This Federal tag relates to Complaint IN00409078. 3.1-45(a)(2)

Based on observation, interview, and record review the facility failed to provide a resident with oral care for 1 of 2 residents reviewed for Activities of Daily Living (ADLs). (Resident 18) Finding include: During an observation on 5/31/23 at 1:40 p.m., Resident 18 had a thick film with white substance on his teeth and gum line. During an observation on 6/1/23 at 2:08 p.m., Resident 18 had a thick film with white substance on his teeth and gum line. During an observation on 6/2/23 at 3:01 p.m., Resident 18 had a thick film with white substance on his teeth and gum line. During an observation and interview with Resident 18 on 6/5/23 at 1:55 p.m., the resident had a thick film with white substance on his teeth and gum line. Resident 18 indicated the facility staff did not assist him with brushing his teeth or flossing. The resident indicated he was right-handed, and it was difficult to brush his own teeth because he was missing four fingers on his right hand. Resident 18 indicated he would appreciate it if staff would help him with oral care. Review of the record of Resident 18 on 6/5/23 at 2:00 p.m., indicated the resident's diagnoses included, but were not limited to, diabetes, muscle weakness, anxiety disorder, colon cancer, end stage renal failure, dependence on renal dialysis and history of cellulitis of finger, and gangrene of finger to right hand. The dental exam for Resident 18, dated 4/20/23, indicated the resident had poor oral hygiene. The dentist recommended for the resident's teeth to be brushed twice a day and flossed 1 time a day with mouth rinse. The Quarterly Minimum Data Set (MDS) assessment for Resident 18, dated 5/8/23, indicated the resident was cognitively intact for daily decision making. The resident was consistent and reasonable. The resident required extensive assistance of one person for teeth brushing. The plan of care for Resident 18, dated 5/12/23, indicated the resident required special attention to oral care. Obvious or likely broken or cavity of natural teeth. The interventions included, but were not limited to, provide assist with oral care daily and as needed. During an interview with the Director of Nursing (DON) on 6/5/23 at 2:20 p.m., indicated CNAs (Certified Nursing Assistants) were responsible to ensure Resident 18 received the oral care he needs. During an observation and interview on 6/5/23 at 2:25 p.m., the DON verified Resident 18 had a thick film with white substance on his lower teeth. The oral care policy provided by the Nurse Consultant on 6/5/23 at 3:10 p.m., indicated the purpose was to maintain oral mucosa (mouth, teeth, gums and tongue) in optimum condition in an effort to improve residents' sense of well-being and appearance, and improve sense of taste, enhancing appetite. Nursing personnel was responsible to ensure oral care was completed at least daily and as indicated for those residents unable to provide their own mouth care. 3.1-38(a)(3)(C)

Based on observation, interview, and record review the facility failed to keep bedroom wall in good repair, maintain and odor free environment and keep bedroom window clean and good repair for 3 of 3 residents reviewed for environment (Resident E, Resident F and Resident B). Findings include: 1. During an observation on 5/31/23 at 11:18 a.m., Resident E had peeling paint and scratches on the bedroom wall. During an interview with Resident E's family member on 5/31/23 at 2:25 p.m., indicated the resident had always been particular and clean. The resident's bedroom wall was in disrepair with peeling paint. 2. During an interview and observation on 5/31/23 at 11:41 a.m., Resident F's bedroom had a strong odor of urine. Resident F indicated he could smell the urine in his room. The resident indicated the facility did not clean his mattress regularly and would change his sheets without washing the bed. During an observation on 6/1/23 at 2:12 p.m., Resident F's bedroom had a strong smell of urine. During an observation on 6/2/23 at 2:20 p.m., Resident F's bedroom had a strong smell of urine. 3. During an interview with Resident B's family member on 6/1/23 at 10:19 a.m., indicated Resident B had resided in room ***. The resident thought it was raining all the time because her window were so dirty, and she could not see out of it. The family member had expressed his concerns about the dirty window in a care plan meeting, but no one ever cleaned the window. Review of the care plan meeting for Resident B, dated 3/20/23, indicated the resident's windows were dingy. During an observation on 6/2/23 at 2:58 p.m., Room *** window had a thick film on it and dirty. During an environmental tour with the Administrator on 6/5/23 at 3:07 p.m., the Administrator verified Resident E had scratches and peeling paint on the wall. The Administrator indicated it was Maintenance responsibility to maintain resident bedroom walls in good repair. The facility was in transition and had a part time help with Maintenance. The Administrator verified Bedroom *** window had a film on it and dirty. The Administrator indicated housekeeping was responsible to keep the windows clean and the window in room *** needed to be replaced. The Administrator indicated Resident F's sheets were changed on shower days and if the mattress needed cleaned the CNAs should clean them at that time. The Administrator indicated housekeeping deep cleaned the resident's mattress one or two times a month. This Federal tag relates to Complaint IN00409078. 3.1-19(f)

Based on interview and record review the facility failed to provide a respectful and dignified environment during care for 1 of 2 residents reviewed for dignity (Resident B). Finding include: During an interview with Resident B's family member on 6/1/23 at 10:19 a.m., indicated they were visiting their family member on 4/18/23. The resident was in the bathroom and pushed the call light for assistance. CNA (Certified Nursing Assistant) 1 came into the resident's room and said what do you want I have better things to do. Resident B indicated to the family member that girl was mean to me. The family member filed a grievance and within in an hour was contacted by the Administrator. The Administrator indicated CNA 1 was having a bad day and the facility would retrain her. The family member did not feel the grievance was resolved and CNA 1 was rude and disrespectful to Resident B. During an interview with CNA 1 on 6/2/23 at 2:20 p.m., indicated on 4/18/23 Resident B was in the bathroom and had pushed the call light. CNA 1 went into the bathroom and the resident told her she had bugs crawling on her, CNA 1 told her no she did not have bugs on her and said, are you ready I have other people to help. The CNA indicated she needed to get Resident B off the toilet because she had other people to take care of. CNA 1 indicated she felt rushed that day. CNA 1 indicated the Administrator talked to her about the situation with Resident B, about what not to say and not to say certain things to residents and told her about how to talk to residents. During an interview with the Administrator on 6/5/23 at 3:12 p.m., indicated she did not get a statement from CNA 1 related to the incident on 4/18/23 with Resident B. The Administrator did a teachable movement with CNA 1 about attitude and approach with residents. Review of the record of Resident B on 6/5/23 at 12:45 p.m., indicated the resident's diagnoses included, but were not limited to, muscle weakness, unsteadiness on feet, anxiety, difficulty walking, major depression disorder, acute kidney disorder, low back pain, syncope and anemia. The Annual Minimum Data Set (MDS) assessment for Resident B, dated 3/2/23, indicated the resident cognitively intact for daily decision making. Decisions were consistent and reasonable. The report of concern for Resident B, dated 4/18/23, indicated the resident's family overheard a CNA in the bathroom with the resident. The CNA had a bad attitude with the resident. The CNA said to the resident what do you need, I have better things to do. I don't have time. The facility met with Resident B for an interview. No mental anguish noted. The resident stated she felt the CNA had a bad day at home and brought it to work with her. The resident stated that CNA 1 had bad attitude. The resident felt that CNA 1 did not intend to harm her, just had a bad day and needed to slow down and be kind. Staff re-education on staff burnout. The resident rights policy provided by the Nurse Consultant on 6/5/23 at 3:10 p.m., indicated the facility shall treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. This Federal tag relates to Complaint IN00409078. 3.1-3(t)

Based on interview, observation, and record review, the facility failed to implement nonpharmacological pain control, failed to administer as needed pain medication for verbal reports of pain, and failed to notify the physician of breakthrough pain for 1 of 2 residents reviewed for pain management. (Resident 11) Findings include: The clinical record for Resident 11 was reviewed on 6/2/2023 at 1:05 p.m. The medical diagnosis included chronic pain. A Quarterly Minimum Data Set Assessment, dated 2/22/2023, indicated that Resident 11 was cognitively intact and experiences constant pain. An interview with Resident 11 on 5/31/2023 at 1:41 p.m. indicated he had a history of chronic pain related to breaking his tailbone in the past. He indicated that his pain was currently a 4/10 and he had already told the nurse working, but she did not do anything to help him. He stated he received his routine Tylenol around lunch. In the past when he reported his pain to the staff, they do not give him anything like medication or offer heat/ice, massage, or any other intervention. He reported only takes routine Tylenol for pain, which is somewhat helpful, but does not fully relieve his daily pain. Resident 11 stated he does not have anything else in between at this time. In the past, he had tried tramadol but that was ineffective for him. Resident 11 stated he experienced pain at least daily, but some days are worse than others. Today the pain is keeping him from sitting up on the side of the bed and watching television. An interview with Resident 11 on 6/2/2023 at 1:30 p.m. indicated his pain was a 5/10 today. He reported his acceptable pain level was two or less, but no higher than a three. He indicated today, and the last four days prior, his pain was keeping him from getting up and moving around his room. He was also not able to sit up on the side of his bed long, was not able to watch television, and cannot generally get around like normal. He reported he told the nurse that morning he was hurting but did not give a number. He reported he did take his routine Tylenol this morning, but he did not experience relief. A physician order for Resident 11, dated for 1/24/2023, indicated assess for pain, if present, refer to PRN [as needed] medications. A physician order for Resident 11, dated for 1/27/2023, indicated gabapentin 300 milligrams (mg) four times a day for chronic pain. A physician order for Resident 11, dated 4/21/2023, indicated Tylenol extra strength 650 mg three times a day for pain. A physician order for Resident 11, dated 5/18/2023, indicated Norco 5/325 mg twice as day as needed for pain. The medication administration record for Resident 11, indicated that in May of 2023 he reported the following pain levels over 3/10: 5/1/2023 Day - 4/10 5/2/2023 Day - 4/10 5/4/2023 Day - 8/10 5/6/2023 Day - 6/10 5/8/2023 Day - 4/10 5/12/2023 Day - 8/10 5/12/2023 Evening - 5/10 5/18/2023 Day - 6/10 5/20/2023 Day - 4/10 5/22/2023 Day - 7/10 The aforementioned assessment did not include location, description, or frequency of the reported pain. An interview with the Director of Nursing on 6/2/2023 at 3:05 p.m. indicated that Resident 11 had not received any as needed pain medication in May of 2023. An interview with Nurse Consultant on 6/6/2023 at 11:00 a.m. indicated that the nurse is responsible for ensuring pain relief interventions are taken and that the physician is notified of breakthrough pain. The nurses did not complete a pain assessment for location, frequency, what makes it better, what makes it worse nor was the physician notified of breakthrough pain in May of 2023. The pain assessment policy provided by the DON on 6/5/23 at 1:30 p.m., indicated the purpose was to identify those residents who utilize routine medications for pain or who utilize frequent use of as needed pain medications in effort to ensure adequate pain control is achieved. If ineffective relief is noted, a pain assessment shall be completed to assess location, frequency, etc. and notify the physician accordingly to ensure currently ordered pain medication is evaluated and revised, as necessary. If a resident verbalizes pain, unaffected by the currently ordered pain medication or exhibits non-verbal communication that pain is present, resident shall be identified through completion of regularly scheduled MDS to ensure pain symptoms are evaluated and communicated to the physician. 3.1-37(a)

Based on observation, interview and record review the facility failed to provide a dependent resident with Range Of Motion (ROM) exercise for 1 of 2 residents reviewed for ROM (Resident 3). Findings include: During an interview and observation with Resident 3 on 3/29/22 at 11:47 a.m., indicated she would like to be in a restorative program for ROM. The resident indicated the staff did not do any type of ROM with her. The resident was unable to do exercises on her own. The resident was laying in bed and was able to lift her legs slightly up in the bed. Review of the record of Resident 3 on 3/30/22 at 2:38 p.m., indicated [CONDITION(S)], uterine cancer, [CONDITION(S)], scoliosis, [CONDITION(S)], [CONDITION(S)], unsteady gait, leg weakness, peripheral vascular disease, leg [CONDITION(S)], gout, anxiety and weakness. The Quarterly Minimum Data Set (MDS) assessment for Resident 3, dated 1/28/22, indicated the resident was cognitively intake for daily decision making, decisions consistent and reasonable. The resident had no rejection of care. The resident had limitation in her range of motion on one side of the lower and upper extremities. The plan of care, dated 2/2/22, indicated resident had the potential for pain due to functional limitation ROM of the left upper and left lower extremities. The plan of care, dated 2/2/22, indicated resident was at risk to develop pressure ulcers related to functional limitation ROM of the left upper and left lower extremities. The plan of care, dated 2/2/22, indicated resident required assistance of two staff for Activities Of Daily Living (AD) assistance due to functional limitation ROM of the left upper and left lower extremities. The plan of care, dated 2/2/22, indicated resident had risk factors for falls including functional limitation ROM of the left upper and left lower extremities. The plan of care, dated 2/8/22, indicated resident had recovered from COVID 19 and was at risk for post COVID challenges such as weakness and fatigue. The interventions included, but were not limited to, restorative services to regain strength. The plan of care, dated 3/30/22, indicated the resident had multiple health conditions which included, but were not limited to, pain and stiffness in joints. During an interview with the Nurse Consultant on 4/1/22 at 12:15 p.m., indicated the facility did not have a restorative program and there was no documentation that Resident 3 received ROM services. The ROM policy provided by the Director Of Nursing on 4/1/22 at 12:25 p.m., indicated ROM exercises were indicated for residents with temporary or permanent loss of mobility. Restorative measures would prevent loss of function, muscle contracture and/or deformity. ROM exercises were provided to assist residents to reach and maintain highest level of ROM possible and to prevent avoidable decline. 3.1-42(a)(2)

Based on observation, interview and record review the facility failed to assist a dependent resident to transfer out of the bed and failed to monitor and evaluate a resident's response to therapy recommendations of sitting on the side of the bed daily for 2 of 2 residents reviewed for Activities of Daily Living (ADL) assistance (Resident 3 and Resident 12). Findings include: 1.) During an interview and observation with Resident 3 on 3/29/22 at 11:47 a.m., indicated she wanted to get out of bed every day around 11:00 a.m., the staff had to use a mechanical lift to get her out of bed and she was not assisted out of bed very often. The resident indicated the staff had not given her a reason why they were not assisting her out of bed, but she thought it was because it takes a long time to transfer her. The resident indicated she got bored laying in bed all the time and yesterday she slept all day because she bored. The resident was observed laying in bed. During an observation on 3/30/22 at 10:25 a.m., Resident 3 was laying in bed awake. During an observation on 3/30/22 at 2:16 p.m , Resident 3 was laying in bed awake. During an interview with Resident 3 on 3/31/22 at 11:00 a.m., indicated she wanted to be up every day by 11:00 a.m., even if they sit her by the bird cage she felt bored staying in the bed all the time. The resident indicated she did not refuse to get up unless she was not feeling well that day, her desire was to get up every day. The staff did not explain to her why they do not get her up she thinks it is because she uses a mechanical lift and it takes too long. During an observation on 4/1/22 at 10:15 a.m., Resident 3 was sitting in bed awake. During an observation on 4/1/22 at 11:10 a.m., Resident 3 was sitting in bed awake. Review of the record of Resident 3 on 3/30/22 at 2:38 p.m., indicated [CONDITION(S)], uterine cancer, [CONDITION(S)], scoliosis, [CONDITION(S)], [CONDITION(S)], unsteady gait, leg weakness, peripheral vascular disease, leg [CONDITION(S)], gout, anxiety and weakness. The Quarterly Minimum Data Set (MDS) assessment for Resident 3, dated 1/28/22, indicated the resident was cognitively intake for daily decision making, decisions consistent and reasonable. The resident had no rejection of care. The resident was not transferred. The plan of care for Resident 3, dated 8/11/21, indicated the resident was at risk for falls and required the assistance of two people to transfer with a mechanical lift. The therapy in service for Resident 3, dated 10/12/21, indicated the resident was to use a mechanical lift for all transfers and to encourage the resident to get up daily. Document if the resident refused to get up. The therapy discharge recommendations for Resident 3, dated 2/18/22, indicated the facility would continue to encourage the resident to sit up in the wheelchair daily to reduce risk of complications from immobility. The ADL documentation for Resident 3, dated March 2022, indicated the resident was assisted with a transfer out of bed 4 times in 31 days. There was no documentation of refusal to get out of bed. During an interview with the Nurse Consultant and DON on 4/1/22 at 12:15 p.m., when a resident completes therapy they do an in service on what therapy recommends for each resident. 2. During an interview, on 3/29/22 at 1:51 p.m., Resident 12 indicated she was supposed to be getting range of motion after her rehab was over, but she isn't. She is supposed to sit on the edge of her bed every day but the CNA's tell her they don't have time. Resident 12's record was reviewed on 3/30/22 at 2:15 p.m. The record indicated Resident 12 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly Minimum Data Set (MDS) assessment, dated 2/3/22, indicated Resident 12 was cognitively intact, was totally dependent on 2 staff for bed mobility, did not transfer or walk, required extensive assistance for activities of daily living (ADLs), had functional limitation in range of motion on one side of upper extremities, and in both sides of lower extremities, did not use any mobility devices, and had one hour of occupational therapy during the MDS assessment period. A joint mobility screen, dated 11/9/21, indicated, for the upper body, resident is able to look from side to side, touch the opposite shoulder with hand, start with arm at side and raise lower arm (bending at elbow), and make a fist and fully open. She could not touch the back of her neck with both hands. For her lower body, she could not bring her knee to the chest or left each left off of bed. She could separate legs and point toes toward and away from body. Resident 12 had care plans that addressed she needed ADL care, that she rejected care sometimes, including ADL care, and she did not have a care plan that addressed sitting on the edge of her bed. A Physical Therapy Progress & Discharge Summary, dated 2/22/22, indicated: Patient discharged to same SNF (skilled nursing facility) with recommendations including for nursing to continue assist patient to sit up in WC (wheel chair) or EOB (edge of bed)bed daily to reduce risk of complications from immobility. During an interview, on 3/31/22 at 11:40 a.m., Resident 12 indicated she is not being set on the edge of the bed like she is supposed to be, and she wants to get her range of motion and sit up but they say they don't have time. On 4/1/22 at 12:40 p.m., the Administrator indicated it should be on the CNA assignment sheets that she is sitting on the edge of her bed daily. She provided the assignment sheets, which indicated encourage to sit on side of bed daily. On 4/1/22 at 12:52 p.m. the Director of Nurses said makes rounds every day, and staff does offer to assist her to sit on the edge of the bed, and she will refuse 99.9% of the time. Once in a while you will offer and she will sit on the side of the bed, but they don't document it anywhere. 3.1-38(a)(2)(A) 3.1-38(f)

Based on interview and record review, the facility failed to ensure a staff member followed the facility's recommendations for safe transfer of 1 of 3 residents reviewed for falls. (Resident D) Findings include: The clinical record of Resident D was reviewed on 9-20-21 at 3:04 p.m. Her diagnoses included, but were not limited to, [CONDITION(S)] and [CONDITION(S)] (paralysis of one side of the body) following an unspecified [CONDITION(S)] disease affecting the right dominant side, unsteadiness on her feet, an above the knee amputation, general muscle weakness, unspecified heart failure, difficulty in walking and a history of transient ischemic attacks (TIA's or mini-strokes). Her most recent Minimum Data Set (MDS) assessment, dated 7-14-21, indicated she was moderately cognitively impaired, required extensive assistance of 2 or more persons with bed mobility and transfers, was dependent of 2 or more persons for toileting, was unable to walk and utilized a wheelchair for mobility. In review of a facility post-fall investigation, dated 5-19-21, it indicated Resident D had a fall at 1:35 p.m., in her room. CNA [3] was transferring pt [patient] from WC [wheelchair] to bed; pt lost balance; CNA [3] set her on floor. Resident D had no apparent injuries. After the resident was assessed by the licensed nurse, she was assisted into bed with 2 staff persons. Resident D's cognitive status was 12, indicating a moderate cognitive impairment. The resident indicated she had lost her balance during the transfer. The investigation did not specify if a gait belt was used by CNA 3. The post fall investigation indicated immediate intervention (actions) included, but were not limited to, CNA education provision with the topic of education not indicated. The investigation indicated contributing factors to the fall included, but were not limited to, incontinence, amputation(s), [CONDITION(S)] (stroke) and use of a narcotic [MEDICATION(S)]. It indicated no chronic or acute conditions or unsteadiness contributed to the fall, nor did confusion, wandering or cognitive decline. The post-fall investigation indicated, Immediate Intervention(s) Implemented: Have CNA's x2 for transfers. On 9-20-21 at 3:40 p.m., the Administrator provided a copy of a training, dated 5-19-21, which indicated, Under NO circumstances are we to ever transfer someone other than the way therapy recommends. If you see improvement or decline, please speak to therapy before changing the way they are transferred. They will need to be screened/eval to make sure it is the safest way for them You are to follow the CNA assignment sheets. Not following the assignment sheets can cause someone to get hurt. It was signed by the Administrator and initialed by nine staff members. In an interview with the Administrator on 9-20-21 at 3:40 p.m., she was not 100 percent sure the above referenced training was directly related to the fall with Resident D, but thought it was. She could not recall if it was related to not using a gait belt or not enough persons to assist with the transfer. She indicated she has no idea if the aide assignment sheets for that date would still be available to specify the transfer needs for this resident as the aide assignment sheets are constantly updated. She added, from looking at the care plans for the fall risk and ADL needs, she was not sure if the resident required 1 or 2 people to help with transfers. But it kind of looks like there was a problem, doesn't it? She indicated the staff member involved with the fall left employment several months after the incident. She could not recall if the staff member involved with the fall was personally educated regarding the fall, or only received the previously referenced staff training. In an interview on 9-20-21 at 4:34 p.m., with COTA 4, she indicated Resident D had been on and off therapy caseload throughout her stay at the facility, due to her health problems, including her right above the knee amputation. I don't recall her ever being any less than a 2-person assist because of her above the knee amputation and possible balance issues. She provided a copy of a therapy evaluation, dated 4-22-21, approximately one month prior to the 5-19-21, fall. It indicated Resident D's transfer from sitting to standing position was unchanged from prior functional abilities to the present and anticipated functional status of requiring moderate assistance of 2 persons. Review of Resident D's care plans for ADL (activities of daily living) assistance, updated on 1-28-21, 2-8-21, 2-17-21, 5-17-21 and 7-21-21, The resident requires up to x2 assist in performing ADL's .provide assist with ADL's as resident requires .Monitor for changes in ADL participation and notify nurse of any changes for further evaluation .Refer to therapy as indicated. Review of Resident D's care plans for falls, updated on 1-28-21, 2-17-21, 5-17-21 and 7-21-21, indicated, The resident has multiple risk factors for falls .Therapy to evaluate as indicated, Staff re-educated on fall [and sign for number] of staff, dated on 5-19-21. On 9-17-21 at 11:25 a.m., a Corporate Support Staff, provided a copy of the Fall Prevention Program, with a revision date of 10-2014. This policy indicated, Purpose: To identify residents who are at risk for falls and subsequently implement appropriate, individualized fall prevention interventions. Policy: It is the policy of this facility to identify any resident who is at increased risk for falls. Identified residents shall be monitored by the Interdisciplinary Team (IDT) in an effort to implement fall prevention interventions that minimize occurrence of falls thereby minimizing risk of injury. The IDT shall review those residents identified as being at risk for falls or those residents who have sustained falls and are at risk for recurrent falls .Tools needed to conduct each IDT review .Care plan and assignment sheet (or applicable communication device in use) of each resident to be reviewed .During meetings, IDT members will review and discuss applicable residents addressing any falls which have occurred since the last meeting .address current intervention(s) for each resident being reviewed for efficacy thereof; and determine if other/additional interventions are warranted at the time of the review .The resident's plan of care should be updated/revised to reflect fall prevention review, interventions implemented, or to denote if current interventions remain appropriate after each fall .Unit Managers/Charge Nurses are responsible to ensure interventions are implemented as discussed. This deficiency relates to Complaint IN 784. 3.1-45(a)(2)

Based on interview and record review, the facility failed to ensure twice weekly Covid-19 testing was routinely conducted of all employees. This deficient practice has the potential to adversely affect all residents of the facility and potentially expose the residents to staff with unidentified Covid-19. (Staff 2, 3, 4) Findings include: The employee record of Staff #3 was reviewed on 12-30-20 at 1:25 p.m. It indicated she had Covid [MEDICATION NAME] testing conducted on 11-12-20, 11-17-20, 11-19-20, related to routine testing based upon the facility's county positivity rate of greater than 10 percent and on 12-2-20, related to a facility outbreak and on 12-9-20, related to the staff member being symptomatic. The testing results of the above dates prior to 12-9-20, had been negative with the 12-9-20, test yielding a positive result. In review of the testing, this employee was to have been tested twice weekly. On the dates, 11-19-20 to 12-2-20, there were 14 days in which Covid-19 testing did not occur. On the dates, 12-2-20 to 12-9-20, there were 7 days in which Covid-19 testing did not occur. Review of Staff #3's time card indicated she was working in the facility on the following dates: 11-12-20, 11-17-20, 11-18-20, 11-19-20, 11-21-20, 11-22-20, 11-24-20, 11-27-20, 11-30-20, 12-1-20, 12-2-20, 12-5-20, 12-6-20, 12-9-20. Her time card indicated she worked on a per diem or as needed basis. In an interview with the Director of Nursing (DON) on 12-30-20 at 1:25 p.m., she indicated the Executive Director (ED) normally is the person who tracks the Covid testing and was unsure how the process of tracking occurred or if a policy for that existed. She clarified Staff #3 worked on a PRN (as needed basis), but speculated she typically worked two to three days weekly. In an interview with the ED on 12-30-20 at 2:10 p.m., she indicated, The nurses are the ones who do the actual covid testing and just give me the information to put on the employee covid testing log. If it looks like it's been a while, then I will get with the employee to see what the problem is. I don't really use an employee roster to track the employees. Maybe I should do that to make sure everyone is getting tested like they should. I really hadn't thought much about putting anything down as to why they might not be tested ; maybe I should. In an interview with the Corporate Regional Director on 12-30-20 at 2:10 p.m., she indicated she had checked with the facility's corporate offices to see if they had a policy on testing the PRN staff. She indicated the corporate office staff had checked with the IDOH's Director of the Long Term Care regarding the use of PRN staff. She continued, if they work on an irregular basis, then they should be tested when they come into work.

Based on observation, interview and record review, the facility failed to ensure the carpeting in public areas and resident rooms, and resident bathrooms with tiling were clean, sanitary and safe. (Residents C, D, E, Administrator, Housekeeping Supervisor and Housekeeper 3) Findings include: During the initial entrance into facility on 6-20-19 at 8:54 a.m., and during traveling through the facility with the Office Secretary to room [ROOM NUMBER], the area the facility offered as a work area for the duration of the survey, observations of the facility's flooring were conducted. The area of the entrance and the main hallway were observed to be clean tiles. The area near the nurse's station and down the two resident hallways were observed to have multiple areas of light gray, brown and dark brown/black stains present of multiple shapes and sizes. Upon entrance to room [ROOM NUMBER], the carpeting had significant staining of light gray, brown and dark brown/black stains present of multiple shapes and sizes. An area of approximately 12 inches by 12 inches of thickened dark black staining was located between the two empty resident beds in the room, to the left of the foot of the bed for the window bed. Housekeeping staff was observed using the carpet cleaner on hallways on 6-20-19 at 11:00 a.m. Stains persisted. In an interview with Housekeeper 3 on 6-20-19 at 11:06 a.m., she indicated she was uncertain as the frequency carpets were cleaned in the facility. I have noticed the carpeting in the building is very stained. In an interview with the Housekeeping Supervisor on 6-20-19 at 1:34 p.m., she indicated, Carpet cleaning in halls are done weekly. Room carpets are deep cleaned when the room is emptied or as needed (and) spot cleaned as needed. Hall carpets were cleaned by (the) machine this morning. When the Housekeeping Supervisor was queried as to when resident rooms are routinely cleaned, she reiterated, room carpets are deep cleaned when the room is empty or as needed. She provided an example of when the room is empty, like when someone discharges or passes away. She did not indicate resident room carpets are cleaned on a routine basis. On 6-20-19 at 10:25 a.m., the Administrator provided a copy of the facility's most recent discharges for the last three months. The two most recent deaths listed on this document were dated to have occurred on 6-13-19 and 6-16-19. Random room and hallway observations were conducted on 6-20-19 at 1:50 p.m., with the Housekeeping Supervisor with the following observations: -room [ROOM NUMBER]: Carpeting in the resident room has multiple light to dark brown circular and irregular stains to bedroom carpet. Bathroom, shared with room [ROOM NUMBER], has stickiness noted to the tiling when walked on. -room [ROOM NUMBER]: Carpeting in the resident room minor staining present. Bathroom, shared with room [ROOM NUMBER], has stickiness noted to the tiling when walked on. -room [ROOM NUMBER]: Carpeting in the resident room has brown circular and irregular stains to bedroom carpet. -room [ROOM NUMBER]: Carpeting in the resident room has significant staining of light gray, brown and dark brown/black stains present of multiple shapes and sizes. An area of approximately 12 inches by 12 inches of thickened dark black staining was located between the two empty resident beds in the room, to the left of the foot of the bed for the window bed. -room [ROOM NUMBER]: Carpeting in the resident room has minor staining present. Bathroom, shared with room [ROOM NUMBER], has stickiness noted to the tiling when walked on. -room [ROOM NUMBER]: Carpeting in the resident room has multiple light to dark brown circular and irregular stains to bedroom carpet. Bathroom, shared with room [ROOM NUMBER], has stickiness noted to the tiling when walked on. -room [ROOM NUMBER]: Carpeting in the resident room has minor staining present. Bathroom, shared with room [ROOM NUMBER], has stickiness noted to the tiling when walked on. -100 and 200 hallways for resident rooms have carpeting in both hallways have multiple stains present, ranging from very light gray to dark brown/black. These stains are present from nursing station area to the end of each hall. On 6-20-19 at 2:02 p.m., an interview was conducted with the Administrator. She indicated, We are aware of the carpets needing to be replaced. They were put down about four years ago. We recently received approval from Corporate to replace the hallway carpeting in the resident care areas with tiling, like is in the front hall. I would also like to take the tiles into the resident rooms, too, but I don't have approval from Corporate yet for that. The stains in room [ROOM NUMBER] must have happened recently. The person that was in there just passed away and the room had not been deep cleaned yet. The Administrator was unable to provide a time table for replacement of the hall carpeting. In an interview with Resident C on 6-20-19 at 11:45 a.m., he indicated he had noticed the carpeting in his room is stained. In an interview with Resident [NAME] on 6-20-19 at 11:30 a.m., she indicated when I go into the bathroom, the floor feels really sticky to me when I walk on it. It's not dirty, but it is sticky and I worry that I might fall because of it. In an interview with Resident D on 6-20-19 11:20 a.m. she indicated the carpeting in her room has very minor stains present. On 6-21-19 at 11:23 a.m., the Administrator provided an undated copy of a procedure entitled, Shampoo and Extract. This procedure explained how to use the facility's carpet shampooing machine. This policy did not indicate the frequency in which the carpet shampoo machine would be utilized for hallways or resident rooms. In an interview with the Administrator at this time, she indicated, Our policy doesn't address the frequency of the carpet cleaning, but we clean the halls and resident rooms weekly and spot clean as needed. This Federal tag relates to Complaint IN 092. 3.1-19(f)