Every finding on record at Forest Park Health Campus

Based on interview and record review, the facility failed to assist a resident timely with incontinence care for 1 of 3 residents reviewed for Activities of Daily Living. (Resident B) Findings include:The clinical record for Resident B was reviewed on 5/14/26 at 12:06 p.m. The diagnoses included, but were not limited to, major depressive disorder, anxiety, and chronic obstructive pulmonary disease (progressive lung disease that blocks air-flow and causes severe breathing difficulty). A Quarterly Minimum Data Set (MDS) assessment, dated 2/5/26, indicated Resident B was cognitively intact, had no behaviors for rejection of care, was dependent with toileting and hygiene (the ability to maintain perineal hygiene, adjust cloths before and after voiding or having a bowel movement), was non-ambulatory, and was always incontinent of bowel and bladder. During an interview with Resident B and her family member on 5/14/26 at 11:35 a.m., indicated Resident B had an incontinent episode of stool while doing activities. Per family member, when they found her, she had stool coming through her brief and pants, and coming out of her front and backside. The family member indicated she had several meetings with staff to tell them Resident B needed to be checked for incontinence between meals because she does not know when she goes and will just sit in it. Resident B indicated it made them feel terrible to have to wait for help and they cry often because they do not know when they need to be changed due to the incontinence and makes them uncomfortable. During an observation and interview with Resident B on 5/15/26 at 11:15 a.m., they were sitting up in their wheelchair. Resident B indicated they had not been toileted since before breakfast time and they did not know if they were soiled or not. A progress note, dated 5/15/26 at 12:39 p.m., indicated Resident B was toileted before breakfast and was offered again at that time (12:39 p.m.). A plan of care, dated 7/12/22, indicated Resident B had potential for decline in Activities of Daily Living (ADLs) due to decreased mobility. The interventions included, but were not limited to, if incontinence occurs, provide incontinent care after each incontinent episode. A plan of care, dated 5/14/26, indicated Resident B had MASD (Moisture Associated Skin Damage) to a gluteal tear skin fold. The interventions included, but were not limited to, keeping resident's skin clean and dry. A Resident Right's policy was provided by the Executive Director (ED) on 5/15/26 at 9:39 a.m. It indicated .Each resident has the right to be treated with dignity and respect. This citation relates to intake 2972144 410 IAC (Indiana Administrative Code) 3.1-38(a)(2)(C)

Based on interview and record review, the facility failed to maintain residents' dignity regarding timely answering call lights for provision of activities of daily living care for 12 of 56 residents in the facility. (Residents 5, 6, 8, 10, 12, 13, 24, 30, 38, 39, 42, and 44) Findings include:1. The clinical record for Resident 6 was reviewed on 2/23/2026 at 2:05 p.m. The resident's diagnoses included, but were not limited to, emphysema (a chronic, progress lung disease) and heart failure (a chronic, serious condition where the heart cannot pump enough blood and oxygen to support the body's needs). A Quarterly Minimum Data Set Assessment, dated 12/11/2025, indicated Resident 6 was cognitively intact, did not exhibit behaviors, occasionally incontinent of bladder, always continent of bowel, needed partial to moderate assistance from staff for transferring and toilet hygiene. An activity of daily living care plan, last revised on 12/26/2025, indicated Resident 6 had fluctuating activities of daily living (ADL) status, but needed supervision with transfers and toileting tasks. An incontinence care plan, last revised on 12/26/2025, indicated staff were to assist Resident 6 with toileting as needed and/or per request. During an interview, on 2/20/2026 at 11:12 a.m., Resident 6 indicated call light wait times were bad. He had nights that he had to wait hours to get assistance. He needed assistance with toileting and was supposed to have someone with him when he transferred, but he could not always wait for someone to help him. There were times he had to wait for someone to help him with toilet hygiene and transferring off of the commode that took every bit of two to three hours and his legs will go to sleep waiting. During an interview, on 2/23/2026 at 11:15 a.m., Resident 6 indicated last night he couldn't get assistance on the call light for over an hour. When he had to wait to get help, it made him feel like a pee-on. 2. The clinical record for Resident 24 was reviewed on 2/25/2026 at 9:59 a.m. The resident's diagnoses included, but were not limited to, heart failure, kidney failure, and muscle wasting. A Quarterly Minimum Data Set Assessment, dated 12/17/2025, indicated Resident 24 was cognitively intact, did not exhibit behaviors of refusal of care, did not have hallucinations or delusions, needed partial to moderate assistance with transferring, and substantial to maximum assistance with toileting hygiene. An activity of daily living care plan, revised 12/31/2025, indicated Resident 24 needed supervision with transferring and partial assistance with toileting. An incontinence care plan, last revised 12/31/2025, indicated staff were to assist Resident 24 with toileting as needed and/or per request. During an interview, on 2/20/2026 at 11:36 a.m., Resident 24 indicated she needs some help, but her spouse (Resident 6) needed a lot more. If it was a good day, they only had to wait 10 to 15 minutes to get their call lights answered. On average it was 30 to 45 minutes and can take up to hours. She did not trust staff to come when the call light was on because she has had to wait so long, so when they really need something like when Resident 6 fell, she will just go out into the hallway and raise a fuss. Resident 24 indicated she didn't want to be that way but it is the only way to get help. When this happened, it was upsetting and frustrating to Resident 24. 3. The clinical record for Resident 42 was reviewed on 2/19/26 at 1:00 p.m. Her diagnoses included, but were not limited to: chronic obstructive pulmonary disease, arthritis, and anxiety. The ADL care plan, revised on 12/9/25, indicated she required staffs' assistance to complete ADL tasks completely and safely. The potential for decline in ADL ability care plan, revised 12/9/25, indicated if incontinence occurred, staff were to provide incontinent care after each incontinence episode. An interview was conducted with Resident 42 on 2/19/26 at 1:10 p.m. She indicated staff did not assist her to use the restroom often enough. They did not routinely assist her to use the restroom between breakfast and lunch, so she would remain in a soiled brief until they assisted her. She preferred to use the bed pan, as opposed to soiling in her brief. 4. The clinical record for Resident 39 was reviewed on 2/20/26 at 12:15 p.m. Her diagnoses included, but were not limited to: dysphagia, chronic kidney disease, chronic obstructive pulmonary disease, and diabetes. The physician's orders indicated she was on a regular diet, pureed consistency, starting 2/11/26. She had episodes of the following swallowing issues: Severe oropharyngeal dysphagia such as coughing or choking during meals or medication pass, loss of liquids/solids from the mouth when eating or drinking, holding food in mouth/cheeks or residual food in mouth after meals, complaints of difficulty swallowing, continuous throat clearing, etc. Continue to monitor for additional or increased frequencies and if noted refer to speech therapy services. Diet as ordered with follow-up to the registered dietician if continued swallowing issues or poor intakes were noted. Monitor for any negative outcomes such as new or worsening swallowing issues and notify the physician, starting 2/11/26. The impaired swallowing care plan, revised on 2/11/26, indicated an intervention was to provide adequate time for Resident 39 to feed herself, and staff were to assist her as needed. An interview was conducted with Family Member 5 on 2/20/26 at 12:24 p.m. She indicated Resident 39 normally ate meals in the assisted dining room. On 2/16/26 for the dinner meal, when Resident 39's backside was hurting and she didn't want to go down and eat in the assisted dining room, the facility refused to allow Resident 39 to stay in her room for dinner, so the staff gave her a nutritional supplement instead and assisted her to bed. An interview was conducted with the Director of Health Services (DHS) on 2/23/26 at 1:01 p.m. She indicated residents were allowed to eat meals in their room if they preferred, even if they required staff assistance to eat. 5. The clinical record for Resident 5 was reviewed on 2/20/26 at 11:05 a.m. Her diagnosis included, but was not limited to, diabetes. An interview was conducted with Resident 5 on 2/20/26 at 11:10 a.m. She indicated it took thirty minutes for staff to answer her call light. She was normally waiting for something to drink. 6. The clinical record for Resident 44 was reviewed on 2/20/26 at 11:14 a.m. Her diagnosis included, but was not limited to, diabetes. An interview was conducted with Resident 44 on 2/20/26 at 11:19 a.m. He indicated it usually took staff over thirty minutes to answer her call light. Normally, she just needed assistance to the dining room for meals. They assisted her, but by the time she got down there, the dining room was full. She would like to get down there earlier. 7. A resident council meeting was held on 2/20/26 at 1:30 p.m. Resident 8, Resident 38, and Resident 44 were in attendance and indicated there were not enough staff to assist them, when they needed it. They discussed it every month during council, and were always told the same thing, that they were working on it. The Resident Council Meeting minutes, dated 1/1/26 and 2/25/26, were provided by the ED (Executive Director) on 2/20/26 at 1:00 p.m. The 2/5/26 minutes indicated call light wait times on the second shift were long. The 1/1/26 minutes indicated there were long call light wait times. Resident 38 indicated her daughter came to help her with showers, because she was scared to shower alone, in case she fell. Having to wait for assistance made her feel like the staff didn't care, like she didn't matter. She worried about it, was humiliated by it, and it made her worry. Resident 8 indicated she had to wait an hour to use the restroom before. It made her feel uncomfortable. She felt bad asking for help, because she knew the facility was short staffed. Resident 13 indicated having to wait too long for assistance made her feel like she was not a person. One aide for three halls, even on third shift, was not reasonable. Resident 8 agreed with Resident 13's comments. An interview was conducted with Certified Resident Care Assistant (CRCA) 6 on 2/24/26 at 2:00 p.m. She indicated she normally worked from 6:00 p.m. to 6:00 a.m., all over the skilled nursing part of the facility. Sometimes they only had one CRCA from 10:00 p.m. to 6:00 a.m. for the entire facility. When she was the only CRCA working, she was not always able to get her work done. She normally assisted residents with using the restroom/incontinence care on her last round, but with her being the only aide, she did not have time to make sure all of the residents' briefs were changed before she left at 6:00 a.m., so they would have to lay there in a soiled brief until the next shift CRCAs assisted them. She started to assist residents at about 2:30 a.m. to get everyone done by 6:00 a.m., but by then, some of the residents she already assisted, soiled themselves again. Resident 30, Resident 10, and Resident 12 were residents who needed changed every two to three hours, that were wet again before she left, but would have to wait until the next shift to be changed, because her shift was over. There was no time to check and change residents every couple of hours, when she was the only CRCA working. It wasn't fair or safe for the residents to only have one aide at night. There were normally one or two nurses also scheduled to work the night shift with her, but not all of them would help with direct care. Resident 30 was scheduled for showers on third shift, but half the time, they skipped it, because there was only one aide working. Resident 30 would have to wait for the next shift to have his shower. When she worked alone on third shift, she would answer a resident's call light, but there would be two or three more on at once by the time she finished assisting the first resident. By the time she got to the final call light, that resident had waited at least thirty minutes for her to answer their call light. This was typically how a night working alone as the only CRCA in the facility went. The nursing schedules, dated 1/30/26 through 2/24/26, were provided by the ED on 2/20/26 at 2:00 p.m. They indicated only one CRCA worked or was scheduled to work from 10:00 p.m. to 6:00 a.m. on the following dates: 1/30/26, 2/3/26, 2/6/26, 2/16/26, 2/20/26, and 2/24/26. An interview was conducted with the DHS on 2/23/26 at 1:00 p.m. She indicated they started tracking call light response times in November of 2025, after it was identified as a concern. The activity director usually responded to resident council about their concerns. The Perineal Care for Incontinence policy was provided by the ED on 2/25/26 at 12:20 p.m. It indicated, OVERVIEW To provide incontinence care that will keep skin from being exposed to prolonged periods of urine and feces. The Guidelines for Answering Call Lights policy was provided by the ED on 2/25/26 at 12:20 p.m. It indicated, The purpose of this policy is to: To respond to the resident's request and needs.Answer the resident's call light as quickly as possible. The Resident Rights Guidelines policy was provided by the ED on 2/23/26 at 1:44 p.m. It indicated, The purpose of this policy is to: To ensure resident rights are respected and protected and provide an environment in which they can be exercised.1. Residents shall not leave their individual personalities or basic human rights behind when they move to a health campus. The following is a list of rights recognized by staff at [name of facility:] 2. Our residents have a right to.a. Be treated with dignity and respect. 410 IAC (Indiana Administrative Code) 3.1-3(t)

Based on observation, interview, and record review, the facility failed to timely address a resident's family grievance, regarding missing pajamas, for 1 of 1 resident reviewed for personal property. (Resident 39) Findings include:The clinical record for Resident 39 was reviewed on 2/20/26 at 12:15 p.m. Her diagnoses included, but were not limited to: dysphagia, chronic kidney disease, chronic obstructive pulmonary disease (a progressive, treatable, but generally irreversible lung disease characterized by long-term inflammation and restricted airflow,) and diabetes. She received hospice services at the facility. An interview was conducted with Family Member 5 on 2/20/26 at 12:18 p.m. She indicated Resident 39 was currently missing a set of red plaid pajamas and a set of green plaid pajamas. The pajamas had been missing since Christmas of 2025. She'd asked staff about it several times since then, including several Certified Resident Care Assistants (CRCAs) and a nurse, described as Licensed Practical Nurse (LPN) 7. The Executive Director (ED) provided the grievance log from 9/1/25 to present on 2/23/26 at 12:38 p.m. It did not include any missing pajamas for Resident 39. An interview was conducted with the ED and Social Services Director (SSD) on 2/24/26 at 2:50 p.m. The ED indicated she had not heard anything about missing pajamas for Resident 39. Typically, staff should fill out a grievance form for missing items. The SSD indicated she hadn't heard anything about missing pajamas for Resident 39 either. Resident 39's family member did not mention the missing pajamas at her care plan meeting a few days ago, but they did not ask specifically about missing items, just about any general concerns. An interview and observation were conducted with the Director of Environmental Services (DES) on 2/24/26 at 3:07 p.m. The DES was coming out of Resident 39's room, holding several pajama pieces in her hand. She indicated no one mentioned anything to her about the missing pajamas until today. They kept notes posted in the laundry room of missing items, but none of them were for Resident 39. She found the articles she was currently holding in the laundry room and had just checked to see if they were the ones missing, but they weren't. The Resident Concern Process policy was provided by the ED on 2/23/26 at 12:38 p.m. It indicated, Purpose To provide a process for handling, tracking and resolving customer concerns to provide excellence in customer service. Procedures: 1. The facility will provide an open and customer friendly atmosphere for residents and their families and representatives to voice concerns and problems with the assurance that their concerns will be heard and acted upon. 2. The facility will be committed to the on-going education of their employees on immediately responding to and resolving customer concerns. 3. The facility staff will follow the Resident Concern Process flow chart when any concern or complaint is voiced.5. Enter the concern using the desktop icon labeled 'Resident Concern Form'. All concerns should be entered electronically, however Environmental and Dining departments may use a paper Resident Concern Form, submitting to their supervisor who will enter. We never ask a family member to complete the form. 6. Concerns are reviewed in morning meeting, noting new entries and assigning them for follow up and resolution. 7. Follow up from the department leader will occur within 24-48 [sic] with resolution entered in [name of database.] 8. The Executive Director will review and manage the follow up of the concerns. 410 IAC (Indiana Administrative Code) 3.1-7(b)

Based on interview, observation, and record review, the facility failed to provide nail care to an dependent resident for 1 of 4 residents reviewed for activities of daily living. (Resident 10) The clinical record for Resident 10 was reviewed on 2/24/2026 at 11:07 a.m. The medical diagnoses included, but were not limited to, acute respiratory failure and metabolic encephalopathy. An annual MDS assessment, dated 1/8/2026, indicated Resident 10 had mild cognitive impairment, did not exhibit behaviors of rejection of care, had impairments of one upper extremity and both lower extremities, substantial to maximal assistance with personal hygiene needs. An ADL care plan, revised 1/19/2026, indicated Resident 10 required staff assistance for self care and mobility. The interventions included, but were not limited to, staff were to provide nail care on shower days and as needed. During an observation and interview, on 2/19/2026 at 1:06 p.m., Resident 10 was observed in bed. Resident 10's fingernails were long and had yellow substance under them. Resident 10 indicated he would like his fingernails trimmed.During an observation and interview, on 2/20/2026 at 11:30 a.m., Resident 10 was observed in bed. Resident 10's fingernails were long and he indicated he would like his fingernails trimmed.During an observation and interview, on 2/23/2026 at 11:46 a.m., Resident 10 was observed in bed. Resident 10's were long. LPN 4 indicated Resident 10's fingernails nailed needed to be trimmed and Resident 10 was not a diabetic so it should be completed with Resident 10's bathing. During an interview, on 2/23/2026 at 2:14 p.m., Director of Health Services indicated nail care should be provided to residents weekly during bathing and as needed. The direct care nurses and aides were responsible for providing nail care. 410 IAC (Indiana Administrative Code) 3.1-38(a)(3)(E)

Based on interview, observation, and record review, the facility failed to ensure the placement of a palmgrip as ordered for 1 of 1 residents reviewed for range of motion. (Resident 10)The clinical record for Resident 10 was reviewed on 2/24/2026 at 11:07 a.m. The diagnoses included, but were not limited to, acute respiratory failure and metabolic encephalopathy. An annual MDS assessment, dated 1/8/2026, indicated Resident 10 had mild cognitive impairment, did not exhibit behaviors of rejection of care, had impairments of one upper extremity and both lower extremities, substantial to maximal assistance with personal hygiene needs. A pain care plan, revised 1/19/2026, indicated Resident 10 was at risk for skin breakdown and pain related to left hand join contracture. The interventions included, but were not limited to, to ensure there was protective padding to prevent skin on skin contact and palmgrip per MD orders. Resident 10's palmgrip was a soft cushion device intended to be placed in the palm of the left hand. A physician's order, dated 1/05/2026, indicated for Resident 10 to wear a left palm protector daily to decrease risk of further loss of range of motion and to maintain skin integrity. The resident's palm protector was to be removed daily for activities of daily living and to be laundered as needed.During an observation and interview, on 2/19/2026 at 1:06 p.m., Resident 10 was observed in bed. Resident 10's left hand was observed to be contracted without any padding or brace in place.During an observation and interview, on 2/20/2026 at 11:30 a.m., Resident 10 was observed in bed. Resident 10's left hand was observed to be contracted without any padding or brace in place.During an observation and interview, on 2/23/2026 at 11:46 a.m., Resident 10 was observed in bed. Resident 10's left hand was noted to be contracted without any padding or brace in place. LPN 4 indicated Resident 10 should have a palmgrip in place. The palmgrip was located in the top drawer of the bedside table but was soiled. LPN 4 took it to be laundered at that time. During an interview, on 2/23/2026 at 2:14 p.m., Director of Health Services indicated direct care nurses and aides were responsible for ensuring the palmgrip or other padding was in place for Resident 10's left hand contracture.410 IAC (Indiana Administrative Code) 3.1-42 (a)(2)

Based on observation, interview, and record review the facility failed to transfer a resident in a manner that was safe and comfortable and failed to follow the resident's care profile for a mechanical lift for 1 of 2 residents reviewed for accidents (Resident 43). Finding include:During an interview with Resident 43's family member on 2/19/2026 at 1:39 p.m., the family member indicated the resident was unable to bare weight during transfers on either leg. The facility staff transferred the resident by lifting her underneath her arms with two people and no gait belt. The family member was concerned this was painful to the resident because the resident would moan during transfers. During an observation on 2/23/2026 at 10:45 a.m., the Assistant Director of Health Services (ADHS) and Certified Resident Care Assistant (CRCA) 5 placed a gait belt around Resident 43's waist, the staffs' hands were underneath the resident's arms and transferred the resident from the geriatric chair to the bed. The resident was unable to bare weight on either of her legs and moaned during the transfer. The ADHS and CRCA 5 had to lift the resident underneath her arms to get her to the bed, the resident was totally dependent on the staff during the transfer. CRCA 5 indicated the resident needed to be transferred a 100% (percent) by a mechanical lift, it was not fair to the resident because staff had to tug on her. The ADHS and CRCA transferred the resident with a gait belt and their hands underneath the resident's arms from the bed back to the geriatric chair and the resident did not bare weight and moaned during the transfer. The ADNS indicated he would report the resident was not baring weight during transfers and have therapy assess the resident. Review of the clinical record for Resident 43 on 2/23/26 at 1:00 p.m., indicated the resident's diagnoses included, but were not limited to, chronic kidney disease, depression, hemiplegia and hemiparesis (paralysis) left non dominant side and cerebral infarction (stroke caused by blockage). The admission Minimum Data Set (MDS) assessment for Resident 43, dated 1/29/26, indicated the resident severely impaired for daily decision making. The resident was totally dependent on staff for transfers. The care profile for Resident 43, dated 1/26/26, indicated the resident was to be transferred using a mechanical lift. During an interview with the Director of Health Services (DHS) on 2/23/2026 at 12:50 p.m., the DHS indicated a lift assessment should have been completed for Resident 43 if the resident was unable to bare weight during a transfer. During an interview with the ADHS on 2/23/2026 at 1:19 p.m., the ADHS indicated it was communicated to staff how to transfer residents by the care profile in the electronic health record. During an interview with CRCA 5 on 2/23/2026 at 1:25 p.m., the CRCA indicated she reported that Resident 43 was unable to bare weight during transfer to nursing, but was unable to remember which nurse she had reported it to. 410 IAC (Indiana Administrative Code) 3.1-45(a)(2)

Based on interview and record review the facility failed to ensure a resident's code status post form and physician order matched the resident's wishes for end of life care for 1 of 1 resident reviewed for accurate documentation (Resident 67). Finding include :During an interview with the Director Of Health Services (DHS) on 2/23/26 at 12:50 p.m., the DHS indicated the admitted nurse and the clinical review team were responsible to ensure Resident 67's post form for code status and her doctors orders matched each other. The facility did talk with Resident 67 and she decided at this time she would like to be a full code. Review of the clinical record of Resident 67 on 2/23/2026 at 1:45 p.m., indicated the resident's diagnoses included, but were not limited to, chronic obstructive pulmonary disease with (acute) exacerbation, acute on chronic diastolic (congestive) heart failure, acute respiratory failure with hypercapnia and acute and chronic respiratory failure with hypoxia, acute. The post form for Resident 67, dated 10/30/25, indicated the resident wished to be a Do Not Resuscitate (DNR). The post form was signed by Resident 67 and the physician. The physician's order for Resident 67, dated February 2026 indicated the resident was ordered to be a full code. The advanced directives policy provided by the Executive Director (E.D.) on 2/23/26 at 1:44 p.m., indicated the facility would ensure to obtain and follow the resident's advanced directives regarding end of life care. The resident would be advised on admission and quarterly regarding their wishes for end of life directives and code status. The nursing staff would confirm the code status and obtain a physician order. The DNR form would be completed documenting these desires and scanned in the medical record. 410 IAC (Indiana Administrative Code) 3.1-50(a)(2)

Based on observation, interview, and record review, the facility failed to have the interdisciplinary team (IDT) determine and document that self-administration of medications was clinically appropriate for 1 of 1 resident randomly observed with medications at the bedside. (Resident 39) Findings include: The clinical record for Resident 39 was reviewed 1/31/25 at 9:46 a.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease, hypertensive heart disease with heart failure, and obesity. During an observation and interview with Resident 39 on 1/30/25 at 10:28 a.m., a full cup of open pills and a clear vial of fluid used for breathing treatments was located beside Resident 39. He indicated the cup of pills were all his morning medications and the vial was his medicine for his breathing treatments that he administered himself. An Annual Minimum Data Set assessment, completed 12/12/24, indicated he was cognitively intact for daily decision making. Resident 39's clinical record, reviewed on 1/31/25 at 11:00 a.m., did not have a physician's order for self-administration of medication and/or self-administration of medication assessment completed. The medication administration record (MAR) was provided by Clinical Support 3 on 2/3/25 at 12:52 p.m. It indicated Resident 39 had orders for the following oral medications to be administered between the hours of 6:00 a.m. to 10:00 a.m.: aspirin, bisoprolol fumarate, cetirizine, citalopram, furosemide, gabapentin, guaifenesin, isosorbide mononitrate, mirtazapine, pantoprazole, potassium chloride, ranolazine, spironolactone, tamsulosin, and ropinirole. An ipratropium-albuterol solution for nebulization was to be given every four hours and the MAR indicated it was given at 8:00 a.m., on 1/30/25. During an interview with the Director of Nursing (DON) on 2/3/25 at 12:09 p.m., indicated Resident 39 should not have medications left at the bedside. The DON indicated it was the IDT's responsibility to ensure a self-medication administration assessment was completed on any resident who self-administers medications. The DON also indicated it was nursing's responsibility to ensure there was a physician's order for anyone who self-administers medications. A Guidelines for Self-Administration of Medications Policy was provided by Clinical Support 2 on 1/31/25 at 1:30 p.m. The policy indicated the following, . 1. Residents requesting to self-medicate or has self-medication as a part of their plan of care shall be assessed using the observation [name of corporation] Self Administration of Medication within the electronic health record. Results of the assessment will be presented to the physician for evaluation and an order for self-medication . 3.1-11(a)

Based on observation, interview, and record review, the facility failed to ensure residents received assistance with bathing as preferred for 3 of 3 residents reviewed for activities of daily living. (Resident 7, Resident 41, and Resident 31) Findings include: 1. The clinical record for Resident 7 was reviewed on 1/30/2025 at 1:10 p.m. The medical diagnoses included pulmonary disease and osteoarthritis. A Quarterly Minimum Data Set assessment, dated 11/15/2024, indicated Resident 7 was cognitively intact and needed substantial/maximal assistance with bathing. An activities of daily living care plan, revised 11/25/2024, indicated Resident 7's preference for showers were on Mondays, Wednesdays, and Saturdays. During an observation and interview on 1/29/2025 at 1:31 p.m., Resident 7 indicated she was lucky to get one [shower] a month. Resident 7's hair was noted to be greasy at that time. Resident 7 indicated she did not feel clean and she had not had a shower in about a week. Review of the shower documentation indicated Resident 7 only received two showers for the month of January 2025 and two other baths. During an interview on 1/31/2025 at 1:05 p.m., Resident 7 indicated she did not receive her last scheduled shower because the Certified Nurse Aide (CNA) told her they did not have enough help. Per Resident 7, her hair remained greasy at that time. 2. The clinical record for Resident 41 was reviewed on 1/31/2025 at 11:30 a.m. The medical diagnoses included respiratory failure and anxiety. A Quarterly Minimum Data Set assessment, dated 1/8/2025, indicated Resident 41 was cognitively intact and needed substantial/maximal assistance with bathing. An activities of daily living care plan, dated 1/30/2025, indicated Resident 41 was scheduled for showers on Tuesdays and Fridays. During an observation and interview on 1/29/2025 at 12:55 p.m., Resident 41 indicated she did not get showers as often as she would like them. She indicated in the last month, she had less than four showers in total and would like them at least a couple times a week. When asked to clarify, she said two to three times a week would be her preference. Review of shower documentation, for January of 2025, indicated Resident 41 received four showers and one other bath for the whole month. 25054 3. During an observation and interview with Resident 31 on 1/30/25 at 11:16 a.m., he indicated he was supposed to have showers on Monday and Thursday, and he did not receive his showers for weeks at a time. Resident 31 indicated his preference was to have three showers a week, but he could not get two showers a week, so there was no way he would get three. The staff were wetting him down a little in bed and he does not feel clean without a shower. The resident indicated when they do provide a bed bath, they do not always wash his hair. Observation of the resident's hair was greasy and uncombed. During an observation on 1/31/25 at 1:40 p.m., Resident 31's hair was greasy and uncombed. During an interview with the Director of Nursing (DON) on 2/3/25 at 12:32 p.m., she indicated it was all of nursing staff's responsibility to ensure resident's receive showers twice a week. Review of the record of Resident 31 on 2/3/25 at 12:24 p.m., indicated the diagnoses included, but were not limited to, hemiplegia/hemiparesis, atherosclerotic heart disease, atrial fibrillation, contracture of the left hand, head injury, cerebral vascular accident (stroke), abnormal gait, peripheral vascular disease, major depression, anxiety, muscle weakness and osteoarthritis. The Quarterly Minimum Data Set assessment for Resident 31, dated 11/6/24, indicated the resident was cognitively intact for daily decision making. The resident had no behaviors of rejecting care. The resident was dependent on staff for showers and required substantial/maximal assistance for personal hygiene (including combing his hair). The care plan profile for Resident 31, dated 3/16/23, indicated the resident was to have two showers a week on Monday and Thursday. The shower documentation for Resident 31, dated from 11/1/24 to 1/30/25, indicated the resident had two showers and nine complete bed baths. The bathing preference policy provided by the DON, on 2/3/25 at 1:40 p.m., indicated the resident shall determine their preference for bathing, the day of the week, time of day, and type of bathing (tub bath, bed bath or shower). 3.1-38(a)(3)(A) 3.1-38(a)(3)(B)

Based on observation, interview, and record review, the facility failed to identify a skin alternation for 1 of 2 residents reviewed for general skin impairments. (Resident 45) Findings include: The clinical record for Resident 45 was reviewed on 2/3/2025 at 2:03 p.m. The medical diagnoses included edema and dysphagia. An admission assessment, dated 12/12/2024, indicated Resident 45 did not have any skin impairments. A physician order, dated 12/12/2024, indicated Weekly skin assessment completed. New treatments and notifications completed for any new areas noted. Review of the Medication Administration Record for Resident 45's weekly skin assessments were completed each week. The MAR reflected only then the initials of the staff completing the assessment, but no other results were recorded. During an observation and interview on 1/29/2025 at 1:21 p.m., Resident 45 indicated he had an abrasion on his right ankle. Resident 45 stated this area had been present for over a year and he was treating it with over-the-counter cortisone spray he bought from a local store then covered the area with a paper towel from the bathroom. During an observation and interview on 1/31/2025 at 2:44 p.m., Registered Nurse (RN) 1 indicated Resident 45 had abrasions on his right ankle. RN 1 indicated they had never seen Resident 45's ankle before. RN 1 was not aware of Resident 45 being able to self-administer cortisone spray on the bedside table. A policy, entitled Guidelines for Weekly Skin Observations, was provided by Clinical Support 3 on 2/3/2025 at 1:00 p.m. The policy indicated, Upon admission the admitting nurse shall include as part of the admission orders a weekly skin observation. The order shall read: Weekly skin observation on (day of the week). 0= no areas on skin impairment .1= new area of skin impairments (see wound event) .2= existing area of impairment (see wound management tool and/or event). 3.1-37(a)

Based on interview and record review, the facility failed to ensure the documentation of meal intakes were recorded by facility staff for 3 of 3 residents reviewed for pressure ulcers and nutrition. (Residents B, C and D) Findings include: 1. The clinical record of Resident B was reviewed on 3-21-24 at 11:45 a.m. Her diagnoses included, but were not limited to, Lewy body dementia with parkinsonism features, dysphagia (difficulty with swallowing), recurrent coccyx ulcer and osteomyelitis (bone infection). This resident was identified by the facility as having at least one pressure ulcer, weight loss and required assistance with meals for intake. A review of Resident B's recent weights indicated she has had significant weight loss since her admission to the facility. Her admission weight on 11-22-23, was 122.8 pounds (#). Her weight on 2-21-24, was 107.2# and the most recent weight on 3-20-24, was 101.8#. Resident B's clinical record indicated she was monitored by the facility's interdisciplinary team for concerns related to weight, nutrition and pressure ulcers. A review of Resident B's care plans indicated multiple care plans under the general categories of Nutrition and ADL [activities of daily living] with interventions that included, but are not limited to, not rushing the resident with tasks, observing the resident for any decline in functional abilities and reporting any decline and provision of eating assistance and/or supervision with meals. A review of Resident B's meal intakes from 2-1-24 to 3-20-24 indicated of 146 potential meals, consisting of breakfast, lunch and dinner, she had 11 meals, or 7.5 percent without documentation of the meal intakes, as follows: -2-18-24, no documentation of breakfast or lunch consumption. -2-20-24, no documentation of breakfast or lunch consumption. -3-3-24, no documentation of breakfast or lunch consumption. -3-4-24, no documentation of dinner consumption. -3-14-24, no documentation of breakfast or lunch consumption. -3-19-24, no documentation of breakfast or lunch consumption. In an interview on 3-22-24 at 2:05 p.m., with the Administrator, she indicated all resident meal intakes are to be documented and placed in the resident's electronic clinical record. She indicated the facility staff are trained on this. In a second interview on 3-22-24 at 2:30 p.m., the Administrator indicated she could not locate a specific policy, related to nutrition, that addresses that dietary intakes are to be documented for each resident at each meal, but we are to make sure that happens. 2. The clinical record of Resident C was reviewed on 3-21-24 at 3:05 p.m. His diagnoses included, but were not limited to, pressure wound to the left buttocks, gallstones with sludge of gallbladder, cognitive developmental delay and a speech impediment. This resident was identified by the facility as having at least one pressure ulcer, has had weight loss and requires meal assistance. A review of Resident C's recent weights indicated he has had weight loss in the recent past. Resident C's clinical record indicated he was monitored by the facility's interdisciplinary team for concerns related to weight, nutrition and pressure ulcers. A review of Resident C's meal intakes from 2-1-24 to 3-20-24 indicated of 119 potential meals, consisting of breakfast, lunch and dinner, he had 9 meals, or 7.6 percent without documentation of the meal intakes, as follows: -2-25-24, no documentation of breakfast or lunch consumption. -2-25-24, no documentation of lunch consumption. -3-1-24, no documentation of breakfast or lunch consumption. -3-4-24, no documentation of breakfast or lunch consumption. -3-7-24, no documentation of dinner consumption. In an interview on 3-22-24 at 2:05 p.m., with the Administrator, she indicated all resident meal intakes are to be documented and placed in the resident's electronic clinical record. She indicated the facility staff are trained on this. In a second interview on 3-22-24 at 2:30 p.m., the Administrator indicated she could not locate a specific policy, related to nutrition, that addresses that dietary intakes are to be documented for each resident at each meal, but we are to make sure that happens. 3. The clinical record of Resident D was reviewed on 3-22-24 at 10:30 a.m. His diagnoses included, but were not limited to, dementia, severe protein-calorie malnutrition and sacral area pressure ulcer. This resident was identified by the facility as having at least one pressure ulcer and has had recent weight fluctuations. A review of Resident D's recent weights indicated he has had recent weight fluctuations. Resident D's clinical record indicated he was monitored by the facility's interdisciplinary team for concerns related to weight, nutrition and pressure ulcers. A review of Resident D's meal intakes from 2-1-24 to 3-20-24 indicated of 138 potential meals, consisting of breakfast, lunch and dinner, he had 19 meals, or 13.7 percent without documentation of the meal intakes, as follows: -2-11-24, no documentation of breakfast or lunch consumption. -2-24-24, no documentation of breakfast or lunch consumption. -2-25-24, no documentation of lunch or dinner consumption. -2-28-24, no documentation of breakfast or lunch consumption. -3-1-24, no documentation of breakfast or lunch consumption. -3-3-24, no documentation of dinner consumption. -3-4-24, no documentation of breakfast or lunch consumption. -3-7-24, no documentation of dinner consumption. -3-15-24, no documentation of dinner consumption. -3-18-24, no documentation of breakfast or lunch consumption. -3-19-24, no documentation of lunch consumption. -3-20-24, no documentation of lunch consumption. In an interview on 3-22-24 at 2:05 p.m., with the Administrator, she indicated all resident meal intakes are to be documented and placed in the resident's electronic clinical record. She indicated the facility staff are trained on this. In a second interview on 3-22-24 at 2:30 p.m., the Administrator indicated she could not locate a specific policy, related to nutrition, that addresses that dietary intakes are to be documented for each resident at each meal, but we are to make sure that happens. This Federal tag relates to Complaint IN00430792. 3.1-46(a)(1) 3.1-46(a)(2)

Based on observation, interview, and record review, the facility failed to promote dignity a resident by not ensuring a urinary drainage bag was not covered. This affected 1 of 2 residents reviewed for dignity. (Resident 18) Findings include: An observation, on 10/31/23 at 10:35 a.m., indicated Resident 18 was lying in bed and had an uncovered urinary drainage bag that hung on the bed frame on the window side of his bed. On 11/02/23 at 11:02 a.m., Resident 18 was observed in bed and his catheter bag sat on floor with no cover on the catheter bag. On 11/02/23 at 11:04 a.m., Certified Resident Care Assistant 5 indicated it should have a dignity cover and not be on the floor and she checks it twice a day or more. She said she would get another bag that had an attached cover on it. Resident 18's record was reviewed on 11/02/23 at 1:28 p.m. The record indicated Resident 18 had diagnoses that included, but were not limited to, urinary tract infection, hypertensive heart disease with heart failure, congestive heart failure, type 2 diabetes mellitus, urinary frequency and kidney stones. Physician's orders for foley catheter included, but were not limited to: - Indwelling Urinary Catheter size 16 French with a 10 cubic centimeter balloon for benign prostatic hypertrophy with obstruction. A Significant Change Minimum Data Set assessment, dated 9/25/23, indicated Resident 18 had modified independence in cognitive status for daily decision making, and had an indwelling urinary catheter. A care plan for the catheter indicated a start date of 5/14/2021 with the problem of: Resident uses a Foley catheter for dx (diagnosis) of: obstructive uropathy. Interventions included but were not limited to: Resident will be free from adverse effects from catheter use. Maintain a closed system with urinary bag below the residents bladder and cover A Policy for Preserving Dignity With Indwelling Catheter was provided on 11/6/23 at 11:53 a.m. by Clinical Nurse Support. The policy included, but was not limited to: Overview: To preserve resident dignity by concealing urinary drainage bags .a) Keep drainage bag covered with an appropriate device 3.1-3(t)

Based on interview and record review, the facility failed to protect a resident's right to be free from physical abuse by another resident, resulting in facial bruising and bleeding for 1 of 3 residents reviewed for abuse. (Resident 1) Findings include: On 10/31/23 at 11:00 a.m., Resident 1 was observed to have a bruise under his right eye. Resident 1 indicated his roommate (Resident 36) hit him and they moved him to another room. Resident 1's record was reviewed on 11/01/23 at 10:24 a.m. and indicated diagnoses that included, but were not limited to, lung disease, stroke with weakness, chronic atrial fibrillation, seizure disorder, depression, insomnia, generalized weakness, and cognitive communication deficit. An Annual Minimum Data Set assessment, dated 9/7/23, indicated Resident 1 was cognitively intact, had no behaviors or moods, and did not walk. During an interview, on 11/01/23 at 10:53 a.m., Resident 1 indicated he had turned his television off about 1:30 in the morning and his roommate got mad. His roommate had his own television. When [Resident 36] hit him, it was the first time it happened, it hadn't happened before or after but he had been afraid it would happen again. Resident 36 hit him 8 to 10 times all over his face. They took Resident 36 out of his room and he didn't come back in for the rest of the night. He said his roommate had not gotten agitated before this happened but the least little thing could set him off. They had been roommates for 2 or 3 months. He had not heard of this happening to another resident. The night nurse was close by and heard the noise and came in and stopped it. He said he didn't have much pain afterwards and he had a little bleeding from the right side of his face. Progress notes, for Resident 1, included, but were not limited to: Recorded as a late entry on 10/15/23 at 2:05 a.m. for the event occurring on 10/15/23 at 1:00 a.m., indicated: Resident roommate came out of room on walker and approached this nurse at approximately 0100 and stated I want out of my room immediately. This nurse asked resident roommate why he wanted out of his room and resident stated That guy was running his mouth so I knocked him (referring to this resident). This nurse went to assess this and noticed resident bleeding out of right temple. This nurse applied bandage to this resident. Resident stated He turned my TV off and I told him to turn it back on and he hit me lots of times all over. Upon assessment of resident, no bruising was noted in any other area besides right temple on this resident. Resident pupils were PERRLA (pupils are equal, round and reactive to light and accommodation) and neuro checks were WDL (Within Defined Limits). Resident roommate at this time asked Can I go back in my room and get my stuff. This nurse told resident no immediately and to go sit in waiting room at this time. ED [Executive Director] and DON [Director of Nursing] aware at this time. 10/15/2023 at 1:10 a.m. slight bruise under right eye with slight swelling, redness to right side of face, and scab area to right temple with small amount bleeding, dressing applied. head to toe assessment completed with no other issues noted, residents immediately separated from each other 10/15/2023 at 7:14 a.m.: [Resident 1's family member] notified if (sic) incident last night, aware of bruise under right eye and redness to right side of face and scab bleeding to right temple with dressing in place, aware that roommate was removed from room 10/16/2023 at 12:09 p.m. IDT (Interdisciplinary Team) Review: Resident has bruising and scab to right eye from encounter with room mate. No swelling noted by nursing staff. Will continue to monitor. Neuro checks initiated. MD and family aware. Social Services followed up with a psychosocial evaluation for Resident 1, on 10/16/23 at 1:53 p.m., 10/17/23 at 1:58 p.m., 10/19/23 at 1:38 p.m., and 10/24/2023 at 1:17 p.m., with no concerns or mood changes. The Executive Director provided a reportable incident, dated 10/15/23 at 1:01 a.m. that indicated Resident 36 Entered the hall and told nurse he wanted his roommate to live in another room. When entering room the roommate stated he had been struck by his roommate. Type of Injury - Small bruise to the right eye. Immediate Action Taken - Residents immediately separated. Both residents assessed for injury. Physician, families, ED and DHS were notified. No new orders at this time. Preventative Measures Taken - Residents will be kept separated. Carepans (sic) will be assessed and updated. The agressor (sic) will be kept on 15 minute checks. Follow up added - Residents monitored for psychosocial effects with no adverse effect noted. 15 minute checks remained in pllace (sic) until [Resident 36] was discharged . No further resident to resident contact made. On 11/6/23 at 3:16 p.m., the Executive Director indicated this incident was reported to her immediately by a phone call when it happened. She had been on vacation and her back up handled it right then, and reported it to IDOH. Review of the record of Resident 36, on 11/3/23 at 1:45 p.m., indicated the resident's diagnoses included, but were not limited to, Alzheimer's disease, dementia, psychosis, age related debility, cerebrovascular disease, dementia and major depression. The Quarterly Minimum Data Set (MDS) assessment for Resident 36, dated 9/13/23, indicated the resident was severely cognitively impaired for daily decision making. The resident did not require a mobility device for ambulation. The resident required supervision only for ambulation. The progress note for Resident 36, dated 10/10/23 at 9:35 a.m., indicated the resident was upset that his roommate asked for the door to be closed. The resident begun raising his voice to room mate and stated I know you want the door the door shut ! So here! (Door slamming) Spouse made aware and Nurse Practitioner (NP) made aware due to this was not in residents character. The progress note for Resident 36, dated 10/15/23 at 1:00 a.m., indicated resident came out of room on walker and approached this nurse at approximately and stated I want out of my room immediately. This nurse asked resident why he wanted out of his room and the resident stated That guy was running his mouth so I knocked him (referring to his roommate). Resident roommate stated He turned my TV off and I told him to turn it back on and he hit me lots of time all over. Upon assessment of residents roommate pupils were PERRLA (pupils equal reactive to light). Upon assessment of residents roommate, no bruising was noted in any other area besides right on resident roommate. Resident roommate pupils were PERRLA and neurological checks were within defined limits. This resident at this time asked Can I go back in my room and get my stuff. This nurse told the resident no immediately and to go sit in waiting room at this time. Executive Director and Director Of Nursing (DON) aware at this time. The progress note for Resident 36 dated, 10/15/23 at 1:06 p.m., indicated the resident immediately taken to the lounge area and separated from roommate, head to toe skin assessment done, no new skin issues notes. The progress note for Resident 36, dated 10/15/23 at 10:17 a.m., the resident attempted to walk towards old room and reminded him that he cannot go down there. When he asked why I told him because he hit his roommate and he stated Well he deserved it! and asked What the hell does that have to do with going to the dining room? Redirected resident to the dining room. The progress note for Resident 36, dated 10/16/23 at 12:16 p.m., the resident having increased behaviors and hit another resident. Resident removed from room and put into a temporary room to keep separated from roommate. Resident on 15 minute checks until plan is established for resident increased behaviors. A Policy for Abuse and Neglect Procedural Guidelines was provided by the Executive Director, on 11/3/23 at 1:55 p.m. The policy included, but was not limited to: .Purpose: Trilogy Health Services LLC (THS) has developed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident abuse and neglect .3. Definitions: ABUSE is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish .b. PHYSICAL ABUSE - includes hitting, slapping, pinching, spitting, holding or handling roughly, etc .i. Resident to resident abuse with or without cause 3.1-27(a)(1)

Based on observation, interview and record review the facility failed to ensure a resident's catheter bags or tubing were not touching the floor to prevent infection for 1 of 3 residents reviewed for catheter use. (Resident 18) Findings include: On 11/02/23 at 11:02 a.m., Resident 18 was observed in bed and his catheter bag sat on floor with no cover on the catheter bag. On 11/02/23 at 11:04 a.m., Certified Resident Care Assistant 5 indicated it should have a dignity cover and not be on the floor and she checks it twice a day or more. She said she would get another bag that had an attached cover on it. Resident 18's record was reviewed on 11/02/23 at 1:28 p.m. The record indicated Resident 18 had diagnoses that included, but were not limited to, urinary tract infection, type 2 diabetes mellitus, urinary frequency and kidney stones. Physician's orders for foley catheter included: - Indwelling Urinary Catheter size 16 French with a 10 cubic centimeter balloon for benign prostatic hypertrophy with obstruction. A Significant Change Minimum Data Set assessment, dated 9/25/23, indicated Resident 18 was moderately cognitively impaired and had an indwelling urinary catheter. A care plan for the catheter indicated a start date of 5/14/2021 with the problem of: Resident uses a Foley catheter for dx (diagnosis) of: obstructive uropathy. Interventions included but were not limited to: Resident will be free from adverse effects from catheter use. Maintain a closed system with urinary bag below the residents bladder and cover A Policy for Preserving Dignity With Indwelling Catheter was provided on 11/6/23 at 11:53 a.m. by the Clinical Support Nurse. The policy included, but was not limited to: Overview: To preserve resident dignity by concealing urinary drainage bags .c) Urinary drainage bags and catheter tubing should be kept from touching the floor surface. 3.1-41(a)(2)

Based on interview, observations, and record review, the facility failed to promote a safe environment by safeguarding perineal cleaner for a resident with a history of placing non-edible items in her mouth and potentially ingesting jewelry cleaner for 1 of 4 residents reviewed for accidents. (Resident 29) Findings include: The clinical record for Resident 29 was reviewed on 11/1/2023 at 1:40 p.m. The medical diagnoses included dementia and stroke. A Quarterly Minimum Data Set Assessment, dated 10/2/2023, indicated that Resident 29 was cognitively impaired and was a supervision assistance for walking with a walker. A care plan, dated for 9/27/2022, indicated that Resident 29 would place non-edible food items in her mouth. The Profile Care Guide, dated for 3/23/2022, indicated that Resident 29 would .ingest non edible food items . A nursing progress note, dated 7/26/2023, indicated .This writer entered room, staff reported that resident had Jewelry cleaner in had and had something in her mouth. When this writer entered bathroom res[ident] was found to be swishing mouth out and proceeded to spit into the toilet. Staff informed writer that she did swallow some of this. This writer call Poison control [sic] . A nursing progress note, dated 7/31/2023, indicated Resident confused of what a trash can is used for. Resident removed trash from trash can and placed on bedside table. Resident was then noted trying to eat things from said trash . A nursing progress note, dated 10/29/2023, indicated Resident 29 was having paranoia with staff, was unable to be redirected, and was yelling. An observation on 11/1/2023 at 1:28 p.m. indicated that Resident was sitting in her room on her bed with a bottle of light green liquid labeled as perineal cleaner to her right on the bedside table. Resident was very hard of hearing and confused. She indicated she did not know what that was, she then got up with her walker and began to walk around her room. An interview with LPN 3 on 11/1/2023 at 2:05 p.m. indicated that Resident 29 does have behaviors. She has good and bad days but had recently been yelling and wandering. The resident has a history of eating things she is not supposed to. An interview with the Clinical Support Nurse on 11/1/2023 at 2:35 p.m. indicated that she was not sure if the resident was a risk for accidental ingestion, but she would not keep the perineal cleaner on the bedside table. A nurse practitioner note, dated for 11/1/2023, indicated that Resident 29 was seen for .evaluations of risk for possibly ingesting non-food substances . and that she .does have significant dementia therefore risk of this will always be present as with any dementia patient . A material safety data sheet was provided by the facility for the perineal cleaner on 11/2/2023 at 2:00 p.m. First-aid measures indicated if the substance was ingested, .Dilute by giving a large amount of water. Allow vomiting to occur, then get medical attention . An interview on 11/6/2023 at 2:00 p.m. with Clinical Support Nurse indicated that they do not have a policy for perineal cleaner left at bedside. 3.1-45(a)(1)

Based on interview, observations, and record review, the facility failed to promote a resident's positioning by utilizing foot pedals for a resident unable to self propel for 1 of 1 reviewed for positioning. (Resident 41) Findings include: The clinical record for Resident 41 was reviewed on 11/3/2023 at 11:45 a.m. The medical diagnoses included degenerative changes of the nervous systems and stroke. A Quarterly Minimum Data Set Assessment, dated for 8/9/2023, indicated that Resident 41 was cognitively impaired and needed substantial assistance for propel his wheelchair. An observation on 10/31/2023 at 10:53 a.m. indicated that Resident 41 was sitting in his wheelchair with it tilted back, his feet were dangling off of the ground with no foot pedals in place. An observation on 11/1/2023 at 2:35 p.m. indicated that Resident 41 was sitting in his wheelchair with it tilted back, his feet were dangling off of the ground with no foot pedals in place. An interview with the Director of Health Services on 11/2/2023 at 1:09 p.m. indicated that the chair was not made for foot pedals. An interview with the Clinical Support Nurse on 11/2/2023 at 1:15 p.m. indicated that the facility did not have a policy regarding foot pedals. She indicated that they are waiting for the manufacture guidelines, the resident does not self-propel, and are they would be ordering foot pedals for the chair if they were made. The manufacture guidelines provided by the Clinical Support Nurse on 11/2/2023 at 2:35 p.m. included a picture of the wheelchair with foot pedals as well as safe usage guidance for use to the wheelchair with foot pedals. She indicated they would be ordering some foot pedals for the wheelchair and the resident would have a hospice evaluation next week. 3.1-42(a)(2)

Based on observation, interview and record review the facility failed to implement pressure relieving boots and failed to float a resident's heels for a resident who had an unstageable pressure ulcer for 1 of 4 residents reviewed for pressure ulcers (Resident 154). Finding include: During an observation on 9/07/22 at 11:40 a.m., Resident 154 was laying in bed, no heel protectors in place, heels laying flat on the resident's bed. During an observation on 9/8/22 at 11:15 a.m., Resident 154 was laying in bed with eyes closed. The resident did not have heel protectors in place, heels laying flat on the resident's bed. The resident's heel protectors observed to be up on top of her closet. During an observation on 9/9/22 at 3:00 p.m., the Wound Nurse and LPN 7 provided the wound care treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The right heel had a black open area with callous skin around with some black drainage on the old dressing. The resident wound nurse measured the wound .5 centimeters cm by .6 cm. The resident was sitting in her recliner with her heels flat on the recliner foot rest. LPN 7 placed a pillow under heels to float them. The resident's heel protectors were observed on top of her closet. The resident indicated staff had only placed the heel protectors boots on her one time when she was in bed since she had been at the facility. The resident indicated it did not bother her to wear the heel protector boots and she had never refused to wear them, staff just did not put them on her. During an observation on 9/12/22 at 10:05 a.m., Resident 154 was sitting in her recliner, heels were not floated and were were laying flat on the recliner foot rest. The resident indicated she did have a pillow to float her heels while in the recliner, but she was unsure what happened to it. During an interview with the Director Of Health Services (DHS) on 9/12/22 at 12:47 p.m., indicated the nurse was responsible to ensure Resident 154 had heel protector boots on while in bed and ensure her heel were floated while in the recliner. Review of the record of Resident 154 on 9/12/22 at 12:56 p.m., indicated the resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician recapitulation for Resident 154, dated September 2022, indicated the resident was ordered heel protectors or antipressure boots while in bed as resident will allow. The plan of care for Resident 154, dated 6/9/22, indicated the resident had a pressure ulcer on the right heel. The Admission Minimum Data Set (MDS) assessment for Resident 154, dated 6/10/22, indicated the resident was cognitively intact for daily decision making. The resident was consistent and reasonable. The resident had no behaviors of rejection of care. The resident required extensive assistance of two staff for bed mobility and transfers. The resident was at risk of developing a pressure ulcer. The resident had one unstageable-deep tissue injury. The resident had pressure reducing device for the bed and chair. The pressure ulcer assessment for Resident 154, dated 9/9/22, indicated the resident had an unstageable pressure ulcer with slough and eschar on the right heel. The pressure ulcer measured 0.6 cm by 0.5 cm. The resident had serpurulent (yellow or tan, cloudy and thick drainage). 3.1-40

Based on interview, observation, and record review, the facility failed to assist Resident 37 with optometry services for 1 of 1 residents reviewed for visual impairments. Findings include: The clinical record for Resident 37 was reviewed on 9/6/2022 at 2:19 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly Minimum Data Set Assessment, dated 8/8/2022, indicated that Resident 37 was cognitively intact, does not wear glasses and had adequate vision. An observation with Resident 37 on 9/66/2022 at 2:19 p.m. indicated she wears glasses. An interview with Resident 37 on 9/6/2022 at 2:19 p.m. indicated that she cannot remember the last time she saw the eye doctor, and she reported her vision gets blurry. The last optometry visit for Resident 37 was on 9/4/2019 and recommended new glasses. An eye care consent for Resident 37 was completed on 6/8/2021 for in house ancillary services. An interview with Clinical Support on 9/12/2022 at 3:16 p.m. indicated that there was not a specific appointment for scheduling ancillary services, but clinical staff would assist with scheduling and obtaining ancillary services, such as dental or vision services. 3.1-39(a)(1)

Based on interview, observation, and record review the facility failed to complete preventative dressing changes to heels and the right fourth finger for Resident 37 for 1 of 6 reviewed for non-pressure skin impairments. Findings include: The clinical record for Resident 37 was reviewed on 9/6/2022 at 2:19 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly Minimum Data Set Assessment, dated 8/8/2022, indicated that Resident 37 was cognitively intact. A physician order, dated 3/18/2021, indicated for Resident 37 to have heel protectors on while in bed as resident will allow. A physician order, dated 6/10/2021, indicated for Resident 37 to have a preventative foam dressing to the right fourth finger changed every week and as needed. An interview with Resident 37 on 9/6/2022 at 2:19 p.m. indicated that she did not ever wear heel protectors or the dressing to her right hand because they were uncomfortable. An observation on 9/6/2022 at 2:19 p.m. indicated that Resident 37 was laying in bed with her legs on towels due to seeping areas. She did not have heel protectors on or a foam dressing to the right fourth finger. An observation on 9/8/2022 at 2:51 p.m. indicated Resident 37 was laying in bed with her legs on towels due to seeping areas. She did not have heel protector on or a foam dressing to the right fourth finger. She stated she did not want any dressings at this time. An observation on 9/9/2022 at 1:31 p.m. indicated Resident 37 was laying in bed with her legs on towels due to seeping areas. She did not have heel protector on or a foam dressing to the right fourth finger. She stated she did not want any dressings at this time. The Administration Record indicated the Resident 37 had heel protectors in place on 9/6/2022, 9/8/2022, and 9/9/2022. The Administration Record indicated that Resident 37 had a foam dressing changed to the right fourth finger changed on 9/8/2022 and was in place on 9/6/2022, 9/8/2022, and 9/9/2022. An interview with LPN 1 on 9/9/2022 at 2:32 p.m. indicated that treatment orders should be completed per physician order. 3.1-37(1)

Based on observation, interview, and record review, the facility failed to assist a resident with a meal per their care plan (Resident 51) and failed to assist a dependent resident with showering activities (Resident 204) for 2 of 3 residents reviewed for activities of daily living. Findings include: 1. The clinical record for Resident 51 was reviewed on 9/8/2022 at 2:35 p.m. The medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly Minimum Data Set assessment dated [DATE], indicated that Resident 51 was mildly cognitively impaired and needed extensive assistance of one staff member for eating. An observation of Resident 51 on 9/6/2022 at 12:43 indicated she was alone and laying in bed, leaning to the left with her lunch tray in front of her on the over bed table. She was attempting to eat meat and vegetables. An observation of Resident 51 on 9/6/2022 at 1:02 p.m. indicated she was alone and laying in bed, leaning to the left with less than half of her meal consumed. A care plan, dated 3/22/2022, indicated that Resident 51 was to .Go to DR. [Dining Room] If in bed need to assist with meals . An interview with Clinical Resident Care Associate 2 on 9/8/2022 at 2:50 p.m. indicated that Resident 51 is supposed to go to the dining room for meals, but if she stays in bed then they are to help her with her meals. 2. The clinical record for Resident 204 was reviewed on 9/6/2022 at 3:17 p.m. The medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An Admission Minimum Data Set assessment dated [DATE], indicated that Resident 204 admitted on [DATE], was cognitively impaired, and needed assistance of one staff for bathing services. A care plant dated 9/6/2022, indicated the Resident 204 was to receive showers on Mondays and Wednesdays. An interview and observation of Resident 204 on 9/6/2022 at 3:14 p.m. indicated she reported not having a shower since she admitted to the facility. Her skin appeared dry, and her hair appeared unkempt and greasy. Shower documentation indicated that Resident 204 had not received a shower from 9/1/2022 until 9/7/2022. A policy entitled, Guidelines for Bathing Preference, was provided by the Executive Director on 9/12/2022 at 10:30 a.m. The policy indicated, .Bathing shall occur at least twice a week unless resident preference stated otherwise. 3.1-38(a)(2)(B) 3.1-38(a)(2)(D)

Based on observation, interview and record review the facility failed to provide supervision and assistance for a resident during toileting resulting in the resident falling off the toilet and acquiring an acute subdural hemorrhage (brain bleed) for 1 of 3 residents reviewed for accidents (Resident B). Finding include: Review of the record of Resident B on 10/25/21 at 1:00 p.m., indicated the resident's diagnoses included, but were not limited to, [CONDITION(S)], Alzheimer's disease, dementia, dysphagia, major depressive disorder, anxiety, hypertension, muscle weakness, difficulty walking, unsteadiness on feet, history of falling, Parkinson disease and traumatic brain injury. The fall care plan, dated 5/19/21, indicated the resident was at risk for falling related to Alzheimer's disease, traumatic brain injury, muscle weakness, cerebral disease, chronic pulmonary disease, hypertension, anxiety, [CONDITION(S)], convulsions, tremors and [CONDITION(S)]. The interventions included, but were not limited to, do not leave the resident alone on the toilet (7/24/21). The fall risk re-assessment, dated 6/27/21, indicated the resident's risk factors for falls were as follows- the resident had cognitive or memory impairment that effects safety and judgement, had difficulty understanding and following directions, required assistance with transfers, refused to comply with safety measures such as call light use and had a neurological disorder. The Quarterly Minimum Data Set (MDS) assessment for Resident B, dated 7/16/21, indicated the resident severely cognitively impaired for daily decision making. The resident required extensive assistance of two people to transfer and did not ambulate. The resident utilized a wheelchair for mobility. The fall event report dated 7/23/21 at 1:43 p.m., indicated the resident had a fall in her bathroom that was unwitnessed. The resident complained of pain in her buttocks. The resident had no injury. The immediate intervention implemented was do not leave resident alone on the toilet. The nurse was called to the resident's room due to the resident was found on the floor beside her toilet. The resident had tried to get herself off the toilet. The fall event report dated 7/25/21 at 7:16 p.m., indicated the resident had an unwitnessed fall in her bathroom, the resident was attempting to get herself off the toilet. The resident complained her head was hurting. The physician was notified and an order was received to send the resident to the emergency room . The local hospital emergency room report, dated 7/25/21 at 9:49 p.m., indicated the resident Computed Tomography (CT) scan of the head due to a fall with resulting in head trauma and pain. The resident had an acute subdural hemorrhage in the left parietal region measuring 3 millimeters in thickness. The finding was discussed with the Major Medical hospital neurosurgeon and it was decided to transfer the resident to the Major Medical Hospital. The Careflight note, dated 7/26/21 at 1:40 a.m., indicated the resident had been at an extended care facility, slid off the toilet striking her head. The resident was loaded into the aircraft and took to the Major Medical Hospital in serious condition. The Major Medical Hospital note, dated 7/26/21, indicated the resident presented with a head injury, the resident was found to have a subdural hemorrhage from falling from the toilet and striking her head. The resident had a nonfocal neurological exam. The resident was alert and conversive. The trauma team was contacted and the resident would be hospitalized for further work-up and management. The recommendations for Resident B included, but were not limited to do not leave unattended while toileting. The resident was discharged back to the facility on [DATE]. During an observation and interview on 10/26/21 at 1:09 p.m., QMA 1 and CNA 2 transferred Resident B from the wheelchair to the toilet using a sit to stand mechanical lift. QMA 1 and CNA 2 indicated they never left Resident B unattended on the toilet, because other staff had before and the resident fell off the toilet. During an interview with RN 3 on 10/27/21 at 12:49 p.m., indicated Resident B fell off the toilet on 7/23/21. The resident had been left unattended by staff. RN 3 was unsure who the CNA was that left the resident unattended on 7/23/21. RN 3 indicated on 7/25/21 Resident B was left unattended on the toilet by CNA 4 who no longer works at the facility and fell requiring hospitalization . CNA 4 should not left a cognitively impaired resident unattended on the toilet. During an interview with the Assistant Director of Health Services on 10/27/21 at 2:00 p.m., indicated when Resident B fell on [DATE] she should have been transferred by two CNA's and a gait belt and when she fell on [DATE] the resident should have been transferred with a sit to stand mechanical lift and one staff. The fall management program provided by Clinical Support on 10/26/21 at 11:55 a.m., indicated the facility strives to maintain a hazard free environment, mitigate fall risk factors and implement preventative measures. This Federal tag relates to Complaint IN 382. 3.1-45(a)

Based on observation, interview and record review the facility failed to identify the root cause of falls in order to develop individualized careplan and interventions for 2 of 4 residents who met the criteria for accidents, this resulted in a fracture T2 & T5 for Resident #157 (Resident #157 and Resident #50). Findings include: 1.) Review of the record of Resident #157 on [DATE] at 1:17 p.m., indicated the resident's [DIAGNOSES REDACTED]. The local hospital history and physical for Resident #157 dated [DATE], indicated the resident lived alone and was found by a family member laying on the floor face down. The resident was very confused and was not able to give any additional information. Cat Scan (CT) of her head did not show any acute abnormality. The hip X-rays showed no fracture bilaterally. Resident #157 was admitted to the facility on [DATE] from the local hospital. The Nursing admission assessment for Resident #157 dated [DATE], indicated the resident was one assist for transfers and ambulation and used a walker and wheelchair. The fall risk assessment for Resident #157 dated [DATE], indicated the resident had a mobility impairment, past history of falls and medical condition/[DIAGNOSES REDACTED]. The safety careplan for Resident #157 dated [DATE], indicated the interventions were; provide assistance for transfers and ambulation, ensure glasses clean and in place, observe for side effects of medications, toilet the resident per toileting schedule and ensure the call light was in reach. The careplan for Resident #157 indicated she was at risk for falls. The interventions included but were not limited to, ([DATE]) please ensure I have nonskid footwear in place for transfers and ambulation, ([DATE]) I have a floor sensor pad on my floor, ([DATE]) Please ensure my bed is in the lowest position, ([DATE]) please ensure cushion pad is placed beside my bed, the sensor can be removed, ([DATE]) 30 minute visuals for 72 hours, ([DATE]) 30 minute visuals to continue through [DATE] and while up in wheelchair place in the TV room by nurse station. The Medication Record Administration (MAR) dated [DATE], indicated the resident had a bed and chair alarm due to decrease safety awareness. The Fall circumstance, assessment and intervention record for Resident #157 dated [DATE] at 10:00 p.m., indicated the resident had an witnessed fall in her room with no injury. The root cause was the resident was up with staff "footing slipped" and was lowered to the ground. The prevention update was nonskid footwear. The nursing note for Resident #157 dated [DATE] at 10:30 p.m., indicated the resident had to be lowered to the floor by staff. The resident lost "footing" with staff. Interview with the Campus Clinical Support Nurse on [DATE] at 10:45 a.m., indicated the nurse who was assisting Resident #157 on [DATE] when she was lowered to the ground should have ensured the resident had on appropriate footwear. The Fall circumstance, assessment and intervention record for Resident #157 dated [DATE] at 6:35 p.m., indicated the resident had an unwitnessed fall in her room. The root cause of the fall was the resident was non compliant with calling for assistance and had been unplugging alarms. The documentation indicated there was no injury, no pain and no treatment required. The local emergency room orders and report for Resident #157 dated [DATE], indicated the resident fell at the facility hit her head and complained of pain in her tailbone and headache. The resident had a CT scan of her spine and there were no fractures. The Fall circumstance, assessment and intervention record for Resident #157 dated [DATE] at 5:00 p.m., indicated the resident had an unwitnessed fall in her room. There were no injuries. The root cause of the fall was the resident was up without assistance related to dementia. The prevention update was bed in low position and monitor for triggers for rising. Interview with the Campus Clinical Support Nurse on [DATE] at 1:30 p.m., indicated the bed in the low position was not an appropriate intervention after the fall on [DATE] because the bed should have already been in the lowest position. The Campus Clinical Support Nurse indicated she was unsure why this intervention would have been put in place. The Fall circumstance, assessment and intervention record for Resident #157 dated [DATE] at 8:00 p.m., indicated the resident had an unwitnessed fall in her room. There was no injuries. The root cause of the fall was the resident was up without assistance related to dementia. The prevention update was to remove the floor sensor and place a floor mat by the bed. The Fall circumstance, assessment and intervention record for Resident #157 dated [DATE] at 9:30 a.m., indicated the resident had an unwitnessed fall in her room. The resident was sent to the emergency room due to increased drowsiness and complaints of pain of her head of pain rated an 8 on the ,[DATE] pain scale. The root cause of the fall was the resident was up without assistance due to noncompliance and dementia. The prevention update was to send the resident to the emergency room for treatment and 30 minute visuals for 72 hours. The local hospital note for Resident #157 dated [DATE], indicated the resident fell at the Extended Care Facility (ECF). The resident was very noncompliant per ECF staff. The resident was found on the floor complaining of neck and back pain. The CT scan of the residents spine showed a new T2 and T5 compression fracture. The Fall circumstance, assessment and intervention record for Resident #157 dated [DATE] at 8:10 p.m., indicated the resident had an unwitnessed fall in her room. The resident hit her head and was complaining of pain rated as 9 on the ,[DATE] pain scale. The root cause of the fall was resident continues to be up without assistance related to non compliant and dementia. The resident was sent to the emergency room . The prevention update was keep in the TV room by the nursing station. The local emergency room department discharge orders for Resident #157 dated [DATE], indicated "up with help only". The nursing note for Resident #157 dated [DATE] at 11:00 a.m., indicated the fire department transported the resident to the local hospital emergency room for mental status change. The local hospital note for Resident #157 dated [DATE], indicated the resident expired shortly after being admitted . Interview with the Campus Clinical Support Nurse on [DATE] at 1:30 p.m., indicated there was no documented assessment for Resident #157 on [DATE]. The Campus Clinical Support Nurse indicated she was unable to find a thorough investigation into the root cause of this fall. The Campus Clinical Support Nurse indicated the facility did not have a careplan meeting with Resident #157's family to discuss possible solutions to prevent the resident's falls. 2. On [DATE] at 10:44 a.m., Resident #50 was observed seated in his recliner in his bedroom with his feet elevated. He stated "I'm not even supposed to walk to the bathroom with nobody with me." Resident #50's record was reviewed on [DATE] at 8:45 a.m. His [DIAGNOSES REDACTED]. Resident #50's Admission Minimum Data Set (MDS) assessment dated [DATE], indicated he was moderately impaired in his cognitive daily decision making skills. He required extensive assistance of 2 plus persons for bed mobility. He required extensive assistance of 1 person for transfers, walking in his room, and toileting. His mobility devices included a walker and wheelchair. He had not experienced any falls within 6 month prior to his admission to the facility and had not fallen at the facility since his admission. He was occasionally incontinent. A Care Plan for Resident #50 indicated the following: "I am at risk for falls r/t (related to) dementia, HOH (hard of hearing), anemia, urinary frequency. Place my bed at an appropriate level for my body height to facilitate safe transfers. Lock the brakes. Keep my call light and frequently used items with easy reach to prevent me from overstretching. Ensure my environment is appropriately lit for the time of day and my pathways are free of clutter. [DATE]: Place a PSA (Personal Safety Alarm) on my bed/chair. [DATE]: Please encourage and remind me to use my call light to call for assistance when I need to get up or transfer. [DATE]: Please have therapy to screen me for any needs. My goal is to have no falls or at least no injuries from falls. Please review my interventions by [DATE] to determine if any changes are needed." A Nurse's Note for Resident #50 dated [DATE] at 5:00 p.m., indicated the following: "Res (Resident) was found on floor of his bedroom at 1625 (4:25 p.m.) between his bed et recliner. Res stated that he stood up et fell backwards et hit his head pretty hard. Res also c/o (complained of) mid back pain. Res was left on the floor until 911 personnel arrived. This res also c/o pain to the EMT's." His neurological assessment was within normal limits. His vital signs were obtained. He was transported to a local hospital at 4:35 p.m. A Fall Circumstance, Assessment and Intervention form for Resident #50 indicated the following: Resident #50 had an unwitnessed fall in his room on [DATE] at 4:25 p.m. He had hit his head and was sent to the local emergency room for evaluation. He had no complaint of pain. His activity at the time of the fall was transferring himself. A personal inspection indicated he had toileting needs. A prevention update indicated a bed and chair alarm and he was sent to the local emergency room . The IDT (Interdisciplinary Team) Review identified the root cause of the fall to be a bed alarm. An appropriate root cause was not identified for Resident #50's fall on [DATE]. A physician's orders [REDACTED]." A Nurse's Note for Resident #50 dated [DATE] at 3:25 p.m., indicated "Resident was found on floor in bathroom of room." His vital signs were obtained and he would continue to be observed. A Fall Circumstance, Assessment and Intervention form for Resident #50 indicated the following: Resident #50 was found on the floor in his bathroom on [DATE] at 3:25 p.m. He had no injuries. He had no complaint of pain or non-verbal signs of pain. His activity at the time of the fall was ambulating. An environmental inspection indicated he had become dizzy and lost his balance attempting to toilet himself and did not call for assistance or use his walker. A prevention update indicated a walker, call bell, and bed and/or chair alarm. The IDT Review identified the root cause of the fall as he was found sitting on the floor in his bathroom and stated he became dizzy and lost his balance. Other IDT Review comments indicated he would be encouraged and reminded to use his call light for assistance and to use his walker with assistance from staff. The Fall Circumstance, Assessment and Intervention form or the Nurse's Note for Resident #50 dated [DATE], did not indicate his PSA was alarming when he was found on the floor of his bathroom. The prevention update on the Fall Circumstance, Assessment and Intervention listed interventions that were documented previously as already being in place. An appropriate root cause was not identified for Resident #50's fall on [DATE]. A Nurse's Note for Resident #50 dated [DATE] at 9:50 a.m., indicated a CNA was walking by Resident #50's room and observed him attempting to transfer from his wheelchair. The CNA assisted him to the floor as he lost his balance. He had no injuries noted and denied any pain. His vital signs were obtained. He was assisted back to his wheelchair and and his alarm was in place. His call light was within reach. A Fall Circumstance, Assessment and Intervention form for Resident #50 indicated the following: Resident #50 was assisted to the floor in his room on [DATE] at 9:50 a.m. He had no injuries. He had no complaint of pain. His activity at the time of fall was transferring himself. The Care Plan section indicated toilet every 2 hours, call bell, and bed and chair alarm. The IDT Review identified the root cause of the fall as Resident #50 was attempting to transfer from his wheelchair to his chair. He was observed by a CNA and was assisted to the floor and his alarm was sounding. He would be screened and picked up for therapy. The Fall Circumstance, Assessment and Intervention form for Resident #50 being lowered to the floor on [DATE], while attempting to transfer from his wheelchair to his chair did not provide any new immediate appropriate interventions to prevent falls. On [DATE] at 9:57 a.m., Resident #50 was observed ambulating in the therapy room with the use of a rollator (walker with wheels) and therapy staff holding on to a gait belt fastened around the residents waist. Resident #50 ambulated with a slow gait and he was slightly bent over at his trunk. On [DATE] at 10:24 a.m., Resident #50 was observed seated in his recliner in his bedroom with his feet elevated. His bedside table was placed in between his recliner and bed and his call light was tied around his bed rail out of reach. After being informed, LPN #11 provided Resident #50 with his call light. On [DATE] at 2:03 p.m., the Campus Clinical Support Nurse indicated the bed alarm documented as the root cause on the IDT Review section of the Fall Circumstance, Assessment and Intervention form for Resident #50's fall on [DATE], was an intervention not the root cause. The Nurse's Note for Resident #50 dated [DATE], "said he stood up and fell backwards. I would say that is the root cause. He was responding to his toileting needs." The documentation didn't say where he was getting up from, it just said he was transferring himself. The Prevention Update section on the Fall Circumstance, Assessment and Intervention forms was where new interventions were supposed to be documented.. At that time, after reviewing the Fall Circumstance, Assessment and Intervention form for Resident #50's fall on [DATE], it looked to her the IDT decided to have therapy screen him and not do the toileting every 2 hours. The call bell and bed and chair alarm were already in place. On [DATE] at 3:46 p.m., the Campus Clinical Support Nurse indicated she could not provide any documentation Resident #50's PSA was sounding when he was found on the floor of his bathroom on [DATE]. The Falls Management Program Guidelines provided by the Campus Clinical Support Nurse on [DATE] at 10:45 a.m., indicated the facility strives to maintain a hazard free environment, mitigate fall risk factors and implement preventative measures. The care plan interventions should be implemented that address the resident's risk factors. Should the resident experience a fall the attending nurse shall complete the "Fall Circumstance and Reassessment Form". The form includes an investigation of the circumstances surrounding the fall to determine the cause of the episode, a reassessment to identify possible contributing factors, interventions to reduce the risk of a repeated episode, and review by the Interdisciplinary Team (IDT) to evaluate thoroughness of the investigation and appropriateness of the interventions. The nursing staff will monitor and document continued resident response and effectiveness of interventions for 72 hours. 3XXX,[DATE](a)(2)