Every finding on record at Freelandville Community Home

Based on observation, interview, and record review, the facility failed to ensure food was served in a sanitary manner for 1 of 3 dining observations. Butter packets were placed on top of food for the residents that were served and an ice scoop was observed in the container with ice used for resident drinks. (Kitchen)Findings include: On 2/19/26 at 11:59 A.M., plating of resident trays was observed. [NAME] 7 grabbed an individual plastic butter container with a gloved hand and placed it directly on top of the food on the plate to be served to the residents. At that time, there was ice in a metal container on a cart with the ice scoop laying in the container on the ice. During an interview on 2/20/26 at 9:47 A.M., the Dietary Manager indicated the ice with the scoop laying in it was used for resident drinks and should not have been laid on the ice. On 2/23/26 at 9:10 A.M., a current Ice machine Policy, dated 12/1/25, was provided by the Business Office Manager (BOM) and indicated, . infection control . is important to decrease the risk of illness to residents, staff, and visitors . 3.1-21(i)(3)

Based on observation, interview, and record review, the facility failed to prevent and appropriately treat a urinary tract infection (UTI) for 1 of 1 resident reviewed for UTI. A resident was observed soiled from previous incontinence care, and an antibiotic was given prior to culture results that was resistant to the bacteria. (Resident 9) Finding includes:On 2/18/26 at 11:12 A.M., Resident 9's clinical record was reviewed. Diagnosis included, but was not limited to, Alzheimer's disease and dementia. The most recent quarterly Minimum Data Set (MDS) assessment, dated 1/20/26, indicated a severe cognitive impairment. Resident 9 was dependent on staff for toileting and always incontinent of bladder and bowel.Cephalexin (an antibiotic) 500mg (milligrams), give 1 tablet by mouth every 12 hours related to urinary tract infection, dated 2/14/26 and discontinued 2/16/26.Cefdinir (an antibiotic) 300mg (Cefdinir), give 1 capsule by mouth two times a day for UTI for 7 days, dated 2/16/26.A current need for assistance with toileting care plan, last revised 1/5/25, indicated but was not limited to and intervention to provide pericare after each incontinence episode, dated 8/14/23.A urinalysis dated 2/14/26 indicated Resident 9 had a UTI. A urine culture was then completed and resulted on 2/16/26 which indicated resistance to Cephalexin.Resident 9's Medication Administration Record (MAR) indicated 4 doses of Cephalexin had been administered prior to the start of Cefdinir.On 2/19/26 at 11:24 A.M., Certified Nurse Aide (CNA) 10 was observed to provide incontinence care for Resident 9. A liquid soaked brief was taken off of the resident, and at that time the resident was not observed to have a bowel movement. While wiping the resident, a brown streak approximately 6 inches long, was observed behind her right thigh. At that time, CNA 10 attempted to wipe it off of her leg and indicated it was stuck to the resident's leg as it had been there a while. CNA 10 indicated Resident 9 had not had a bowel movement that day, so it must have been left from the night shift. On 2/23/26 at 10:48 A.M., the Infection Preventionist (IP) indicated Resident 9's physician had started Cephalexin prior to the urine culture report, as they often do. The bacteria in the culture report was found to be resistant to Cephalexin, and a different antibiotic was then started. On 2/23/26 at 9:18 A.M., the Administrator provided a current Urinary Tract Infection policy, dated 12/1/25, that indicated To prevent UTIs, appropriate perineal hygiene shall be regularly provided to residents who are incontinent of bladder and bowel . Antibiotic therapy shall not be initiated based on symptoms alone; the nurse shall request a physician's orders to obtain a urine specimen, which may include culture, for testing and proper diagnosis and treatment accordingly [sic] to the facilities [sic] defined method for determining infections3.1-41(a)(2)

Based on observation, interview, and record review, the facility failed to ensure ongoing communication between the dialysis center and the facility for 2 of 2 residents reviewed for dialysis. Clinical records lacked complete communication forms and documentation of dialysis access site being assessed after dialysis. (Resident 2, Resident 1)Findings include:1. On 2/18/26 at 12:36 P.M., Resident 1's clinical record was reviewed. Diagnosis included, but was not limited to, end stage renal disease (ESRD). The most recent annual Minimum Data Set (MDS) assessment, dated 2/13/26, indicated no cognitive impairment, and dialysis. Physician orders included, but were not limited to: Dialysis every Monday, Wednesday, and Friday, dated 12/17/25. Dialysis communication forms from January 2026 through February 2026 included, but were not limited to, the following: 1/9/26 no information from the dialysis center 1/14/26 lacked post-dialysis vital signs 2/4/26 no information from the dialysis center 2/6/26 lacked post-dialysis vital signs 2/9/26 form brought back from dialysis center incomplete 2. On 2/19/26 at 10:03 A.M., Resident 2's clinical record was reviewed. Diagnoses included, but were not limited to, dependence on renal dialysis. The most recent quarterly Minimum Data Set (MDS) assessment, dated 11/25/25, indicated Resident 2's cognition was cognitively impaired and on dialysis. Current Physician's Orders included, but were not limited to, the following: Dialysis: Monday, Wednesday, and Friday. Chair time: 11:00 A.M. Dialysis pick up time: 4:00 P.M. at (name and address of dialysis center), ordered 11/26/25 Resident to have right tunneled central venous catheter for dialysis, to be maintained by dialysis center. No directions specified for order, ordered 11/19/25 Observe dialysis access site for signs and symptoms of infection twice daily. If observed, report to Dialysis center and MD, ordered 11/25/25 Complete the Hemodialysis Communication Form (top section) one time a day every Mon, Wed, Fri, ordered 12/8/25 A current Hemodialysis Care Plan, last revised 11/25/25, included, but was not limited to, the following interventions: Check and change dressing per orders at access site. Document.Encourage resident to go for the scheduled dialysis appointments. Resident receives dialysis M-W-F. Monitor/document/report to MD PRN for signs/symptoms of the following: Bleeding, Hemorrhage, Bacteremia, septic shock.Obtain vital signs and weight per protocol. Report significant changes in pulse, respirations and BP immediately. Hemodialysis Communication Forms from 1/1/26-present were reviewed and were missing information for the following dates: 1/7/26-noted pre and post forms were not completed from dialysis 1/30/26-noted no paperwork returned with resident from dialysis 2/2/26-noted Dialysis did not complete pre and post treatment assessment sheet 2/9/26-noted n/a The clinical record lacked any documentation on staff assessing the dialysis access site after dialysis. During an interview on 2/20/26 at 9:52 A.M., Registered Nurse (RN) 22 indicated the nurse should fill out the pre dialysis information on the communication form and send a paper copy with the resident. When the resident returns from dialysis, they should bring the form back and the post dialysis information should be completed by the dialysis center. Sometimes the dialysis center won't fill them out or they come back without a communication form at all. When resident comes back, they usually take him to the bathroom to see how steady and oriented he is and should look at dialysis site for bleeding. That assessment information was not documented but probably should be. The communication form information should be put into the clinical record as assessment and then into medical records to be scanned into the record. During an interview on 2/20/26 at 9:57 A.M., the (Director of Nursing) DON indicated there should be a communication form from returned from dialysis every time the resident went. She would expect documentation on the resident's condition, especially vitals and access site, when they return in the clinical record. If the resident comes back without a form from dialysis, the nurse should call and get it faxed to them completed. On 2/15/26 at 1:58 P.M., a current Dialysis Contract, signed by the facility Administrator and dialysis company on 7/15/24, was provided by the Business Office Manager (BOM) and indicated, . b) . Center shall provide to Facility information on aspects of the management of a Designated Resident's care related to the provision of dialysis services . 5. Medical Records. Center shall maintain reports of all services rendered by Center in accordance with its usual medical records procedures. The ownership and right of control of all such reports, records, and supporting documents prepared in connection with the services shall vest exclusively in Center. Facility shall have the right to photocopy any such reports, records or documents for inclusion in its records . On 9/23/26 at 9:10 A.M., a current Hemodialysis Policy, dated 12/1/25, was provided by the BOM and indicated, . the facility will assure that each resident receives care and services for the provision of hemodialysis consistent with professional standards of practice. This will include: The ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility. Ongoing assessment and oversight of the resident before, during and after dialysis treatments, including monitoring of the resident's condition during treatments, monitoring for complications, implementation of appropriate interventions, and using appropriate infection control practices: Ongoing communication and collaboration with the dialysis facility regarding dialysis care and services . 3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure resident's were treated with dignity and respect for 2 of 2 random observations and 1 of 1 resident reviewed for dignity. A resident totally dependent on staff was observed to wait 44 minutes and 19 minutes to use the bathroom. A resident in a Hoyer lift complained of pain when she was lifted but was not attended to at that time. (Resident 3, Resident 26)Findings include: 1. During the resident council meeting on 2/18/26 at 1:30 P.M., three of 14 residents complained that they had to wait longer than 15 minutes for staff to help them go to the bathroom. 2. On 2/18/26 at 12:26 P.M., Resident 3's clinical record was reviewed. Diagnoses included, but were not limited to, Parkinson's disease and intellectually disabled. The most recent quarterly Minimum Data Set (MDS) assessment, dated 1/30/26, indicated Resident 3's cognition was moderately impaired and was totally dependent on staff for toileting. On 2/19/26 from 10:00 A.M., Resident 3 indicated he needed to go to the bathroom. His call light was observed on and he was sitting in the doorway of his room waiting for staff. On 2/19/26 at 10:23 A.M., Staff 4 asked if he had been to the bathroom yet and resident indicated he had not. Staff 4 asked other staff members where the aide was and walked away. On 2/19/26 at 10:25 A.M., Staff 5 asked other staff members who had Resident 3 on their patient roster that day because he was still waiting to go to the bathroom. Staff members were not sure and walked away. Staff 6 came to the resident and said other staff was going to see if they could find help. On 2/19/26 at 10:27 A.M., Certified Nurse Aide (CNA) 6 was observed to walk down the hallway past Resident 3 with his call light still on. On 2/19/26 at 10:33 A.M., CNA 6 asked CNA 14 if she was busy because she needed help laying Resident 3 down. CNA 14 indicated she was helping another resident at that time. On 2/19/26 at 10:35 A.M.,CNA 6 grabbed the Hoyer lift and told Resident 3 she was going to see if she could find Registered Nurse (RN) 22. On 2/19/26 at 10:37 A.M., Resident 3 indicated he needed to have a bowel movement and was tired of waiting. At that time, he indicated he took a laxative that morning and he usually had to wait on staff to go to the bathroom. On 2/19/26 at 10:38 A.M., CNA 6 brought the resident and Hoyer lift into his room and hooked the resident up to the lift. On 2/19/26 at 10:40 A.M., RN 22 and CNA 14 walked into Resident 3's room to assist with lifting the resident from the wheelchair and laying him into bed. On 2/19/26 at 10:42 A.M., CNA 6 took the Hoyer lift out of the room, washed her hands and put gloves on. CNA 14 left the room. On 2/19/26 at 10:44 A.M., CNA 6 grabbed a bedpan from the closet, pulled Resident 3's pants down, took his incontinence pad off, and RN 22 indicated at that time, she wanted to look at the skin on his buttocks. She proceeded to assess his skin and then CNA 6 placed the bedpan underneath Resident 3. On 2/20/26 at 1:20 P.M., Resident 3 was observed wheeling himself down the hallway. The call light on his room was activated. The Social Services Director (SSD) stopped and asked what he needed. He indicated he needed to go to the bathroom. The SSD went to nurse's station and came back and told resident they will be with him when they get done with another resident. On 2/20/26 at 1:32 P.M., RN 22 asked the resident where he was going and the resident indicated he had to go to the bathroom. She responded Oh, you're waiting for the girls. She proceeded to answer another call light. When she came out of that room, she indicated to the resident, Here (name of resident), you're in the way. Come up here. She pushed the resident up the hallway farther from his room and walked away. On 2/20/26 at 1:35 P.M., housekeeping staff asked the resident where he was going. The resident indicated he had to go to the bathroom. She indicated she couldn't help him with that and pushed him back to his room. She told the resident she would find someone for him. On 2/20/26 at 1:38 P.M., RN 22 returned and indicated Resident 3's call light was on and she would go find the girls. On 2/20/26 at 1:38 P.M., CNA 10 walked down the hall and indicated told the resident she would be back in a minute. On 2/20/26 at 1:39 P.M., CNA 14 and CNA 10 both went into Resident 3's room to assist him. During an interview on 2/20/26 at 10:15 A.M., the Director of Nursing (DON) indicated she expected call lights to be answered and residents taken into the bathroom within 15 min if possible. 44 minutes was much longer than she would expect a resident to wait on staff to go to the bathroom. During an interview on 2/20/26 at 10:17 A.M., RN 22 indicated nurses were able to help take resident's to the bathroom and any CNA or nursing staff could do it even if it was not on their assigned halls. 3. During an interview on 2/17/2026 at 2:01 P.M., Resident 26 indicated about a month ago, after her shower on night shift, she was placed on the Hoyer lift to get her back to bed. At that time, she told the Certified Nurse Aide (CNA) that her skin was being pinched. She indicated that the CNA ignored her and continued to push her toward the bed. She indicated when they got her to bed her right leg was bleeding from a skin tear in a fold of her leg. On 2/18/2026 at 2:08 P.M., Resident 26's medical records were reviewed. Diagnosis included, but were not limited to metabolic encephalopathy, Type II diabetes mellitus, morbid obesity, muscle weakness, and chronic venous hypertension with inflammation of bilateral lower extremities. The most recent Annual Minimum Data Set (MDS), dated [DATE], indicated Resident 26 was cognitively intact, and was dependent on staff for showers, and transfers (Helper does ALL of the effort). Current Physician Orders included, but were not limited to: Resident to use Hoyer lift for all transfers, every day and night shift for safety, dated 12/5/25 Review of Nursing Progress Notes, included but were not limited to the following: On 1/12/26 at 3:27 P.M., Health Status Note: Resident obtained a skin tear/laceration to left inner leg, where she has a skin fold. Injury occurred after transfer from shower chair to the bed. Area cleaned, measured and cream applied. Resident is aware. Risk Management completed. On 1/12/26 at 11:37 A.M., Health Status Note: Reported to MD [Medical Doctor] that res [resident] had rec's [received] a shearing injury to left thigh skin fold during Hoyer transfer after shower. New order rec'd [received], res [resident] aware and agreeable. Clean area to left thigh skin fold with wound cleanser, pat dry with gauze and apply medihoney 2x's [times] daily, re-eval [re-evaluate] tx [treatment] in 2 weeks.Nursing Administration (DON) During an interview on 2/19/2026 at 9:39 A.M., the Director of Nursing (DON) indicated when staff were taking Resident 26 from shower room to her room in the Hoyer lift the pad folded up in a skin fold and caused some shearing of the skin. On 2/23/26 at 11:15 A.M., a Dignity policy, dated 12/1/25, was provided by the Business Office Manager (BOM) which indicated, 5. When interacting with a resident, pay attention to the resident as an individual. 6. Respond to requests for assistance in a timely manner. On 2/23/26 at 9:10 A.M., a Lifting Machine, Using a Mechanical policy, dated 2001, was provided by the Business Office Manager (BOM) which indicated, Steps in the Procedure, 14. Check the resident's comfort level by asking or observing for signs of pinching or pulling of the skin. 3.1-3(a)

Based on interview and record review, the facility failed to ensure physician notification of change for 2 of 2 residents reviewed for dialysis, and 1 of 4 residents reviewed for nutrition. The physician was not notified of a significant weight loss, signs/symptoms of atrial fibrillation (afib), and a resident that wanted to discontinue dialysis. (Resident 1, Resident 28, Resident 2) Findings include:1. On 2/18/26 at 12:36 P.M., Resident 1's clinical record was reviewed. Diagnosis included, but was not limited to, afib (a common heart condition causing a rapid, irregular, and often chaotic heart rhythm). The most recent annual Minimum Data Set (MDS) assessment, dated 2/13/26, indicated no cognitive impairment. A cardiac defibrillator related to atrial fibrillation care plan, last revised 7/14/25, included but was not limited to the following interventions: Monitor vital signs as ordered/per facility protocol and record. Notify MD of significant abnormalities, dated 7/11/25. Monitor, document, and report to MD as needed any signs/symptoms of altered cardiac output, dated 7/11/25. A progress note, dated 1/27/26 at 12:29 P.M., indicated Resident 1's heart rate was 120 an in an irregular rhythm. At that time, the practitioner indicated if the heart rate remained elevated or the resident became symptomatic (of afib) further treatment would be needed. A progress note, dated 1/28/26 at 10:10 A.M., indicated Resident 1 had been using his prn (as needed) Albuterol inhaler routinely every morning and night, and a new order was added for routine use of the inhaler twice a day. Resident 1's vitals from January 2026 through February 2026 included but was not limited to the following heart rates: 1/30/26 112 x2 2/4/26 117 x2 The clinical record lacked notification to the physician of the increased heart rates. Dialysis communication forms from January 2026 through February 2026 included but was not limited to the following: 1/28/26 pre-dialysis heart rate 103, post-dialysis heart rate 96 1/30/26 pre-dialysis heart rate 95, post-dialysis heart rate 92 2/2/26 pre-dialysis heart rate 120, post-dialysis heart rate 120 2/6/26 pre-dialysis heart rate 102 The clinical record lacked notification to the physician of the increased heart rates at dialysis. On 2/19/26 at 9:47 A.M., Registered Nurse (RN) 7 indicated heart rate was monitored via the pulse oximetry machine, and anything over 90 would be considered abnormal. She indicated signs of symptoms of afib would include shortness of breath, increased respirations, and an irregular fast heart rate. She further indicated if a resident was supposed to be monitored for signs and symptoms of afib, the physician should be notified immediately of any one of those symptoms. She indicated when a resident returned from dialysis, the communication form information would be reviewed and added to the resident's clinical record by the nurse on duty. On 2/19/26 at 9:50 A.M., the Director of Nursing (DON) indicated Resident 1's physician should have been notified of any heart rate over 100, or with any symptoms of shortness of breath. 2. On 2/18/26 at 12:34 P.M., Resident 28's clinical record was reviewed. Diagnoses included, but were not limited to, weakness and anemia. The most recent admission Minimal Data Set (MDS) assessment, dated 2/6/26, indicated a severely impaired cognitive status with no behaviors. Resident 28 required setup and cleanup assistance with meals. A current nutritional care plan related to not wanting to eat, last revised on 2/10/26, included but was not limited to and intervention to monitor, record, and report to the physician signs and symptoms of malnutrition, significant weight loss: 3 pounds in 1 week, >5% in one month, >7.5% in three months, or >10% in 6 months, dated 2/3/26. Resident 28's weights from January 2026 through February 2026 included the following: 1/30/26 102.0 pounds 2/2/26 102.0 pounds 2/9/26 98.0 pounds 2/16/26 90.8 pounds (7.34% loss in 1 week, and 10.98% loss in 2 weeks) Resident 28's clinical record lacked notification to the physician of weight loss. On 2/20/26 at 10:00 A.M., Certified Nurse Aide (CNA) 10 was observed to weigh Resident 28. At that time, Resident 28 weighed 88.2 pounds. On 2/23/26 at 10:34 A.M., the Director of Nursing (DON) indicated the nurse should identify weight loss when entering the resident's new weight and comparing it to the old weight. If there was a 3 pound difference in weights, the resident should be re-weighed. At that point, the physician should be notified of any true weight losses. 3. During an interview on 2/17/26 at 11:26 A.M., Resident 2 indicated he had dialysis on Monday, Wednesday, and Fridays. At that time, he indicated he didn't like going because he felt like it made him weak. On 2/19/26 at 10:03 A.M., Resident 2's clinical record was reviewed. Diagnoses included, but were not limited to, dependence on renal dialysis. The most recent quarterly Minimum Data Set (MDS) assessment, dated 11/25/25, indicated Resident 2's cognition was cognitively impaired and on dialysis. Current Physician's Orders included, but were not limited to, the following: Dialysis: Monday, Wednesday, and Friday. Chair time: 11:00 A.M. Dialysis pick up time: 4:00 P.M. at (name and address of dialysis center), ordered 11/26/25 Progress notes from 1/1/26-present were reviewed and included, but were not limited to, the following: On 1/8/26 at 5:50 P.M., Secure Conversation Message: Subject: Dialysis Res [Resident] goes to dialysis 3x's [times] weekly, res often refuses to go and has strong opinions about not liking dialysis. I was looking into his dialysis options and spoke with them yesterday, the dialysis nurse reported to me they only take 200 ml [milliliters] fluid off of [resident name] when he is there each time, is this enough to warrant him going to dialysis 3x's a week, can we check his kidney functions in house, is he ok to only go 2x's weekly if his kidney functions are good, or not at all? Nurse Practitioner (NP) response: We can get a CMP [comprehensive metabolic profile] next lab day- is he still seeing neprhology [sic]/when does he see them next? Nurse note: Will draw lab on the 13th. There is no follow up appointments with Dr. [NAME] except scheduled for venogram access eval on 1/1/2026. Additional notes: resident and daughter aware of lab draw order. On 1/13/26 at 1:50 P.M., a Health Status Note indicated resident had a doppler scheduled for placement of a port for dialysis from the nephrologist. Resident refused to have the procedure done. Explained the reason to resident and resident indicated he was not getting it done and he did not need it. Called Power of Attorney (POA) and left message. The clinical record lacked any further communication and notification to the physician, nephrologist, and resident/resident representative about the resident's request to discontinue dialysis and not have the port replacement appointment. During an interview on 2/20/26 at 9:57 A.M., the (Director of Nursing) DON indicated the resident was currently on dialysis. She would expect notifications and communication with the providers, resident, and family about the requests and refusals from the resident and documentation in the clinical record for all. She was unable to provide the documentation. On 9/23/26 at 9:10 A.M., a current Notifications of Changes Policy, dated 12/1/25, was provided by the Business Office Manager (BOM) and indicated, The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification . Circumstances requiring notification include: 2. Significant change in the resident's physical, mental or psychosocial condition . 3. Circumstances that require a need to alter treatment. This may include: a. new treatment b. discontinuation of current treatment due to: i. adverse consequences ii. acute condition iii. exacerbation of a chronic condition . 3.1-5(a)(2) 3.1-5(a)(3)

Based on observation, interview and record review, the facility failed to ensure the Posted Nurse Staffing form contained the actual hours worked by the registered nurses, licensed practical nurses and certified nurse aides for 4 of 5 days reviewed for the survey. The Posted Nurse Staffing form did not contain the actual hours worked by the staff. (2/17/26, 2/18/26, 2/19/26, 2/20/26).Findings include: On 2/17/26 at 1:10 P.M., the Posted Nurse Staffing form was observed and lacked the actual hours the registered nurses, licensed practical nurses, and certified nurse aides worked.On 2/18/26 at 12:31 P.M., the Posted Nurse Staffing form was observed and lacked the actual hours the registered nurses, licensed practical nurses, and certified nurse aides worked.On 2/19/26 at 9:44 A.M., the Posted Nurse Staffing form was observed and lacked the actual hours the registered nurses, licensed practical nurses, and certified nurse aides worked.On 2/20/26 at 11:18 A.M., the Posted Nurse Staffing form was observed and lacked the actual hours the registered nurses, licensed practical nurses, and certified nurse aides worked.During an interview on 2/20/26 at 2:05 P.M., the Scheduler indicated the night shift nurses filled out the Posted Nurse Staffing form. During an interview on 2/23/26 at 9:44 A.M., the Scheduler indicated she had not read the policy on how to fill out the Posted Nurse Staffing form.On 2/23/26 at 9:10 A.M., a Posted Daily Nurse Staffing Form Information policy, dated 12/1/25, was provided by the Business Office Manager (BOM) which indicated, 1. The facility will provide the required information that needs to be posted daily which includes: . d. Total number of staff and actual hours worked per shift for: Registered NursesLicensed NursesCertified Nurse Aides

Based on interview and record review, the facility failed to ensure adequate assistance was provided during a mechanical lift transfer and ensure staff used the equipment in accordance with facility policy for a resident who required extensive assistance of two staff and mechanical lift for transfers (Resident 137). The facility failed to ensure adequate supervision was provided in the bathroom for a cognitively impaired resident at risk of experiencing falls and failed to ensure a toilet seat was properly attached to the toilet for a resident (Resident 2). The facility failed to ensure new interventions were immediately implemented after a fall for Resident 137 and Resident 2 to prevent further falls for 2 of 3 residents reviewed for falls. This deficient practice resulted in Resident 137 sustaining a right femur fracture and Resident 2 sustaining a right hip fracture that required surgical repair. (Resident 137, Resident 2) Findings include: 1. An Indiana Department of Health (IDOH) incident report, dated 8/29/24, indicated Certified Nurse Aide (CNA) 20 was involved when a resident had fallen during a transfer, was transferred to the hospital, and the hospital nurse reported to the facility Resident 137 had a right femur fracture. On 12/4/24 at 1:28 P.M., Resident 137's clinical record was reviewed. Diagnoses included, but were not limited to, Alzheimer's disease and history of a stroke. The most recent Quarterly Fall Risk Assessment, dated 3/7/24, indicated Resident 137 was a high risk to fall. The clinical record lacked documentation of a Fall Risk Assessment being done between 3/8/24 and 8/29/24. The most recent Significant Change MDS (Minimum Data Set) assessment prior to the fall, dated 8/1/24, indicated Resident 137's cognition was unable to be assessed, had impairment of both lower extremities, used a mechanical lift, and required an extensive assist of two staff for bed mobility and transfers, and was totally dependent on two staff for toileting. A Physician's Order Summary, dated August 2024, did not include information to indicate staff should use a mechanical lift for transfers. A plan of care for falls, revised 8/5/24, included, but was not limited to, interventions to use a mechanical lift for transfers and to perform fall risk assessments quarterly and as needed. The plan did not include documentation to determine the number of staff required for the mechanical lift transfer. A Health Status Note, dated 8/29/24, indicated the resident fell during a transfer, signs of pain were present, and the resident was transferred to the hospital. The note did not include documentation to determine the specific details of the fall, the number of staff present at the time of the fall, and any new interventions to prevent further falls were immediately implemented. The progress notes, fall assessments, and care plans dated 8/29/24 through 9/3/24, did not include documentation of the specific details about the fall or to show immediate interventions were implemented to prevent further falls. On 12/4/24 at 2:08 P.M., the Administrator provided an incident report for the fall on 8/29/24 but indicated it was a facility document only and not part of the clinical record. At that time, she indicated the details about the fall would be documented in progress notes, assessments, and care plans. An internal fall investigation summary tool, dated 8/29/24, provided by the DON indicated the mechanical lift transfer of Resident 137, on 8/29/24, was performed without the extensive assistance of two staff, the mechanical lift was used improperly, and no new interventions were immediately implemented to prevent further falls for Resident 137. During an interview on 12/5/24 at 9:46 A.M., the Director of Nursing (DON) indicated no additional documentation could be provided regarding the resident's fall on 8/29/24. On 12/4/24 at 3:30 P.M., the hospital discharge record, dated 9/3/24, indicated Resident 137 fell from a mechanical lift at the long-term care facility, sustained an acute fracture of mid-femoral diaphysis (a break in the middle of the femur bone) that required surgical repair, and was admitted to the hospital on 8/29/24. The record indicated that the resident was discharged back to the facility on [DATE]. On 12/5/24 at 11:59 A.M., the employee file of CNA 20 indicated mechanical lift skills competency was not completed. The CNA was suspended from duty for performing a mechanical lift transfer without a second staff person present. Education was provided and the CNA was terminated for continued noncompliance of facility policy. During an interview, on 12/5/24 at 11:05 A.M., Licensed Practical Nurse (LPN) 25 indicated she was Resident 137's nurse, on 8/29/24, when the fall occurred. LPN 25 was called to Resident 137's room and upon entering the room, the resident was observed on the floor, a handful of staff were standing in the room, and the mechanical lift was in the room, but she was unsure what position it was in at that time. LPN 25 indicated CNA 20 used the mechanical lift incorrectly and by herself instead of having two staff to do the transfer. LPN 25 indicated she did an assessment of Resident 137, and other than the resident appearing to have pain, there were no outward signs of injury. LPN 25 was not sure if the fall information should have been documented anywhere other than in the progress notes of the clinical record or how often fall risk assessments were completed on residents. LPN 25 indicated her head-to-toe assessment findings should have been documented in an assessment at the time of the fall but was unable to obtain these findings from the clinical record. During an interview, on 12/5/24 at 11:45 A.M., the Administrator indicated CNA 20 transferred Resident 137 alone and did not have the base of the lift all the way out which caused it to tip over and the resident to fall landing on the floor. The Administrator was here at the time of the fall and followed the nurse into Resident 137's room. Upon entry, the Administrator observed the resident laying on the floor in the lift pad and the lift was tipped over. The Administrator indicated CNA 20 was trained in another state where two staff were not required to perform a mechanical lift transfer. At that time, the Administrator indicated CNA 20 should have been trained on the mechanical lift policy and procedures during initial facility orientation but supporting documentation could not be provided to show the training occurred. The Administrator indicated CNA didn't use the lift correctly or ask for help with using the lift for the transfer of Resident 137 when the 8/29/24 fall occurred. 2. On 12/4/24 at 11:32 A.M., Resident 2's clinical record was reviewed. Diagnoses included, but were not limited to, Alzheimer's disease and anxiety. The most recent Annual MDS (Minimum Data Set) assessment, dated 9/13/24, indicated severe cognitive impairment, substantial to maximum assistance required with toileting hygiene and independent with toilet transfers. Resident 2 was at risk for falls, and falls risk assessments were completed on 3/10/23, 3/13/24, and 3/16/24. Current physician orders as of 12/4/24 included, but were not limited to: bed alarm while in bed, dated 5/27/24. No physician orders related to falls interventions were in place prior to 5/27/24. A risk for falls care plan, dated 5/31/23, included the following interventions: if fall occurs, initiate frequent neuro and bleeding evaluations per facility protocol and alert provider, initiate fall risk precautions, properly identify resident to indicate a fall risk to caregivers, review medications for drugs that increase the risk of falls, and utilize devices as appropriate to ensure safety, all dated 5/31/23. A current high risk for falls care plan, dated 4/16/24, indicated, but was not limited to, the following interventions: Anticipate needs, call light within reach and encouragement to use it, appropriate footwear while ambulating or using wheelchair, follow facility fall protocol, and participation in activities that minimize potential for falls, all dated 4/16/24. A current actual fall with the injury care plan, dated 4/16/24, indicated, but was not limited to, the following interventions: check range of motion and increased pain, swelling and bruising every shift until resolved, continue interventions for the at-risk plan, monitor, document and report pain, bruising, change in mental status, confusion, sleepiness, inability to maintain posture, or agitation, all dated 4/16/24. From March 2024 through May 2024, Resident 2 experienced the following falls: Fall 1 An incident note, dated 3/8/24 at 12:40 P.M., indicated Resident 2 had slid off the commode in her room due to a high-rise toilet seat that had been placed on the toilet and was not secured. The resident slid off the toilet with the riser and was found sitting on her bottom on the floor by a Certified Nurse Aide (CNA) who was passing trays. The resident hit the right side of her buttock/hip. The note indicated a full assessment had been completed, although the clinical record lacked the assessment A Health Status Note, dated 3/8/24 at 6:25 P.M., indicated Resident 2 was taken to the emergency room via ambulance. A Health Status Note, dated 3/8/24 at 8:18 P.M., indicated Resident 2 was admitted for a fracture of the right hip. A Health Status Note, dated 3/13/24 at 1:53 P.M., indicated Resident 2 returned to the facility from the hospital, and was transferred to bed with assistance of one staff. A Health Status Note, dated 3/14/24 at 12:32 P.M., indicated Resident 2 had returned to the facility the previous day after an acute hospitalization related to a right hip fracture being surgically repaired. The falls care plan, dated 3/8/24, did not include documentation to indicate interventions were immediately implemented to prevent further falls. During an interview, on 12/6/24 at 11:44 A.M., the Director of Nursing (DON) indicated no documentation could be provided to show interventions to prevent further falls were immediately implemented after Fall 1 and should have been added to the plan of care. The progress notes, assessments, and plans of care, dated from 3/13/24 through 3/16/24 at 9:45 a.m., did not include documentation to indicate new interventions to prevent falls were implemented. Fall 2 A Health Status note, dated 3/16/24, indicated Resident 2 was found in her room on the floor on her back at approximately 10:00 A.M. The note indicated two nurses assessed the resident, although the assessment could not be located in the clinical record. The note indicated the bed would be placed in the lowest position and mats placed on the floor, and resident was to be placed by the nurse's station while awake Fall 3 A Health Status note, dated 5/26/24 at 12:05 A.M., indicated Resident 2 was found sitting on the mat in front of her bed. Neuro checks initiated and vital signs checked. The resident's son requested a bed alarm and was initiated as a new intervention. The progress note indicated that an assessment was completed but was not found in the progress notes or assessments portion of the clinical record. On 12/5/24 at 9:45 A.M., the Director of Nursing indicated all falls information was either in progress notes or assessments. Review of the progress notes and assessments from 5/26/24 through 12/4/24 lacked a falls assessment following the fall on 5/26/24 On 12/4/24 at 2:00 P.M., Licensed Practical Nurse (LPN) 5 indicated she was here at the time of Resident 2's fall on 3/8/24 (Fall 1). She indicated Resident 2 fell off of the toilet due to the seat riser coming loose and sliding off when the resident tried to sit on it. She indicated Resident 2 had a new roommate at that time (no longer in the facility) that was a larger person and possibly shifted the seat riser loose prior to Resident 2 using it. She indicated it was the kind of riser that clicked into place and that the risers were no longer used in the facility for any resident. On 12/5/24 at 1:26 P.M., the Maintenance Supervisor indicated there were two types of toilet seat risers at the facility while in use. They were either screwed on or bolted to the actual toilet bowl. He indicated they were checked periodically, but there were no scheduled checks for them that he was aware of. He indicated all risers had been removed from the residents' bathrooms and were no longer physically in the building. On 12/6/24 at 10:22 A.M., Resident 2 was observed lying in a low bed on a bed alarm. A fall mat was observed on the floor by the bed. On 12/6/24 at 10:31 A.M., LPN 5 indicated she was unaware of any checks that were done for the toilet seat risers when the facility used them. She indicated if the nurses or housekeeping were to notice anything wrong with them, they were supposed to fill out a work order for maintenance. On 12/6/24 at 10:34 A.M., the Director of Nursing (DON) indicated the system that was in place at the time of Resident 2's falls was not conducive to nurse input or documentation. She indicated care plans should have been updated following each fall with a new intervention, but the process to do so had not been in place at the time of the falls. On 12/5/24 at 11:40 A.M., a Mechanical Lift Policy, revised July 2017, was provided by the Administrator and identified as the most current policy. The policy indicated, .At least two [2] nursing assistants are needed to safely move a resident with a mechanical lift . On 12/6/24 at 1:16 P.M., a Falls Policy, dated 9/2012, was provided by the DON and identified as the most current policy. The policy indicated If the individual continues to fall, the staff and physician will re-evaluate the situation and consider other possible reasons for the resident's falling . and will re-evaluate the continued relevance of current interventions . When a resident falls, the following information should be recorded in the resident's medical record . the condition in which the resident was found . assessment data, including vital signs and any obvious injuries . interventions, first aid, or treatment administered . Completion of a falls risk assessment . Appropriate interventions taken to prevent future falls . The staff will seek to identify environmental factors that may contribute to falling . 3.1-45(a)

Based on interview and record review, the facility failed to ensure services of an RN (Registered Nurse) were available at least 8 consecutive hours a day, 7 days a week for 2 of the 7 days reviewed. (November 28, 2024, November 29, 2024) Findings include: On 12/9/24 at 10:35 A.M., staffing was reviewed from 11/23/24 through 11/29/24. The facility lacked an RN in the building for 8 consecutive hours on 11/28/24 and 11/29/24. During an interview on 12/9/24 at 10:52 A.M., the Administrator indicated an RN was not in the building for 8 consecutive hours on 11/28/24 and 11/29/24, and she would expect an RN to be in the building for 8 consecutive hours a day. On 12/9/24 at 11:07 A.M., the Administrator provided a time card for RN 27 that indicated her recorded time at the facility was 3 hours and 47 minutes. On 12/9/24 at 11:07 A.M., a current Staffing, Sufficient and Competent Nursing policy, dated 2001, indicated, .A registered nurse provides services at least eight (8) consecutive hours every 24 hours, seven (7) days a week . 3.1-17(b)(3)

Based on interview and record review, the facility failed to ensure an accurate Minimum Data Set (MDS) Assessment was completed for 2 of 5 residents reviewed for unnecessary medications and 2 of 2 residents listed on the facility matrix as using restraints. The MDS indicated 2 residents used bed rails as restraints when they didn't, one resident received a hypoglycemic and was not coded, and one resident had a diagnosis of dementia that was not listed in the MDS. (Resident 19, Resident 29, Resident 15, Resident 8) Findings include: 1. On 12/5/24 at 10:10 A.M., Resident 19's clinical records were reviewed. Diagnoses included, but were not limited to personal history of traumatic brain injury, functional quadriplegia, and acquired absence of left leg above knee. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 10/8/24, indicated resident was unable to complete the cognitive test, was dependent on staff for bed mobility and transfers, was NPO (nothing by mouth) with a feeding tube, and bed rails were used as a restraint daily. The current physician orders lacked an order and a care plan for a restraint. During an interview on 12/6/24 at 8:11 A.M., LPN (Licensed Practical Nurse) 3 indicated the bed rails were not used for a restraint since Resident 19 was unable to move by himself. 2. On 12/6/24 at 10:59 A.M., Resident 29's clinical records were reviewed. Diagnoses included, but were not limited to cerebral infarction, anxiety disorder, and attention concentration deficit following cerebrovascular disease. The most recent Annual MDS Assessment, dated 9/16/24, indicated Resident 29 had moderate cognitive impairment, needed partial/moderate assistance for bed mobility and transfers, set up or clean up assistance for eating, supervision/touching assistance for toilet use, and bed rails were used as a restraint daily. The clinical record lacked current Physician Orders for a restraint. The clinical record lacked a care plan for restraints. During an interview on 12/6/24 at 8:11 A.M., LPN 3 indicated Resident 29 used bed rails for bed mobility. The bed rails were not a restraint. They didn't have any restraints in the building. During an interview on 12/6/24 at 11:19 A.M., MDS Coordinator indicated she had been taught if the clinical records indicated bed rails were in use, it had to be marked on the MDS as a restraint. She indicated she used the RAI (Resident Assessment Instrument) manual, and if the rails met the criteria of restraint, she marked Restraint on the MDS assessment. The Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, Chapter 3, page P-1 indicated the definition of Physical Restraints was Any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body. Chapter 3, page P-6 indicated Bed rails used with residents who are immobile. If the resident is immobile and cannot voluntarily get out of bed because of a physical limitation or because proper assistive devices were not present, the bed rails do not meet the definition of a physical restraint. 38770 3. On 12/5/24 at 2:03 P.M., Resident 8's clinical record was reviewed. Diagnosis included, but were not limited to, dementia (dated 9/1/23). The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 10/18/24, indicated a severe cognitive impairment, and substantial to maximal assistance with toileting, transferring, bathing, and bed mobility. The MDS indicated Resident 8 did not have dementia. Resident 8 lacked current Physician Orders for any medications related to dementia. A current care plan, dated 11/19/24, indicated a diagnosis of dementia with severely impaired cognition. A current care plan, dated 11/10/23, indicated impaired decision making due to a diagnosis of dementia. On 12/6/24 at 11:26 A.M., the MDS Coordinator indicated in order for a diagnosis to be coded on the MDS Assessment, something had to be done with that diagnosis in the previous 7 day look back period. She indicated she would run the Medication Administration Record (MAR) for information related to medications given and what diagnosis they were given for in order to mark diagnosis on the MDS Assessments. On 12/9/24 at 10:20 A.M., Licensed Practical Nurse (LPN) 3 indicated Resident 8's care for dementia was an every day activity that was not documented, such as encouraging to participate in activities, redirection, giving snacks, toileting, and offering to take naps. On 12/9/24 at 11:25 A.M., the Director of Nursing (DON) indicated Resident 8's daughters did not want the resident taking any medications to manage her dementia, and would rather manage symptoms in non-medicinal ways. 45933 4. On 12/5/24 at 10:34 A.M., Resident 15's clinical record was reviewed. Diagnoses included, but were not limited to, heart failure and diabetes mellitus. The most recent Admission MDS (Minimum Data Set) Assessment, dated 9/4/24 indicated Resident 15 was cognitively intact. The MDS indicated Resident 15 did not receive a hypoglycemic medication. Current Physician Orders included, but were not limited to: Basaglar (hypoglycemic) KwikPen Subcutaneous Solution Pen-injector 100 units per milliliter (Insulin Glargine). Inject 10 unit subcutaneously in the morning for diabetes mellitus, dated 08/30/2024 HumaLOG (hypoglycemic) KwikPen Subcutaneous Solution Pen-injector 100 units per milliliter (Insulin Lispro). Inject 7 units subcutaneously in the evening for diabetes mellitus, dated 8/30/24. Resident 15's MAR (Medication Administration Record) for August and September 2024 indicated Basaglar and Humalog were administered during the assessment period for the 9/4/24 MDS. During an interview on 12/6/24 at 11:29 A.M., the MDS Coordinator indicated she does not code insulin as a hypoglycemic medication. During an interview on 12/6/24 at 11:29 A.M., the MDS Coordinator indicated she used the RAI manual as the policy.

Based on observation, interview and record review, the facility failed to develop a care plan for 2 of 5 residents reviewed for Unnecessary Medications. Residents were administered a diuretic, insulin, anticoagulant, opioid, and antiplatelet medication and did not have a care plan related to the medication. (Resident 14, Resident 15) Findings include: 1. On 12/5/24 at 10:34 A.M., Resident 15's clinical record was reviewed. Diagnoses included, but were not limited to, heart failure, atrial fibrillation, end stage renal disease, and diabetes mellitus. The most recent Admission MDS (Minimum Data Set) Assessment, dated 9/4/24 indicated Resident 15 was cognitively intact. The MDS indicated Resident 15 received an anticoagulant, insulin, diuretic, opioid, and antiplatelet medication. Resident 15's current Physician's Orders included, but was not limited to: Apixaban oral tablet 2.5 mg (milligrams) (anticoagulant), give 1 tablet by mouth two times a day related to atrial fibrillation, dated 9/11/24 Aspirin 81 mg (antiplatelet) by mouth at bedtime, dated 10/2/24. Basaglar KwikPen Subcutaneous Solution Pen-injector 100 units per milliliter (Insulin Glargine). Inject 10 units subcutaneously one time a day for diabetes mellitus, dated 11/10/24. Furosemide 40 mg (diuretic) one time a day every Tuesday, Thursday, Saturday, and Sunday for heart failure, dated 9/12/24. Oxycodone HCL (hydrochloride) 5 mg (opioid) 1 tablet every 4 hours as needed for pain, dated 8/29/24. Tramadol HCL 50 mg (opioid) 1 tablet by mouth two times a day for left knee pain, dated 9/11/24. Resident 15's clinical record lacked a care plan for antiplatelets, insulin, and opioids. 46416 2. On 12/4/24 at 1:16 P.M., Resident 14's clinical record was reviewed. Diagnoses included, but were not limited to, Parkinson's disease and heart failure. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 10/15/24, indicated Resident 14's cognition was moderately impaired and a substantial/maximum assist for toileting, bathing, transfers, and receiving a diuretic medication. Current Physician's Orders included, but were not limited to, the following: furosemide (Lasix) oral tablet (diuretic), Give 20 mg by mouth one time a day related to heart failure, dated 9/11/24 The clinical record lacked a care plan for the use of a diuretic. During an interview on 12/6/24 at 10:44 A.M., the Director of Nursing (DON) indicated the MDS Coordinator was responsible for putting care plans into the clinical record, but the DON does it as well. She indicated if the resident was being treated with a medication, a diuretic, insulin, anticoagulant, opioid, and antiplatelet, it should be in the resident's care plans. On 12/6/24 at 1:15 P.M., a current Comprehensive Care Plans Policy, dated March 2022, was provided by the DON, and indicated . A comprehensive, person-centered care plan includes services need to meet the resident's physical, psychosocial, and functional needs is developed . The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. The comprehensive, person-centered care plan is developed within seven [7] days of the completion of the required MDS [Minimum Data Set] Assessment . Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change . 3.1-35(a)

Based on interview and record review, the facility failed to ensure detailed reporting of incidents for 2 of 3 facility incident reports reviewed. (Resident 2, Resident 137) Finding includes: 1. On 12/4/24 at 11:20 A.M., facility incident reports were reviewed. An incident that involved Resident 2, dated 3/8/24, indicated the resident was using the bathroom in her room and slid off of the toilet. The resident was assessed, sent to the emergency room , and admitted with a right femoral fracture. A follow-up added 3/14/24 indicated Resident 2 had been confused the morning of the fall, and was found on the floor along with a toilet seat riser. The reason for the riser sliding off was undetermined. The report indicated Resident 2 had a history of fidgeting with things, and was anxious due to getting a new roommate. On 12/4/24 at 11:32 A.M., Resident 2's clinical record was reviewed. Diagnoses included, but were not limited to, Alzheimer's disease and anxiety. The most recent Annual MDS (Minimum Data Set) Assessment, dated 9/13/24, indicated a severe cognitive impairment and substantial to maximum assistance required with toileting. An incident note, dated 3/8/24, indicated Resident 2 had fallen off of the toilet due to an unsecured high-rise toilet seat. On 12/4/24 at 2:00 P.M., Licensed Practical Nurse (LPN) 5 indicated she was at the facility on 3/8/24 when Resident 2 had fallen in the bathroom, and the fall occurred due to the toilet seat riser sliding off of the toilet. She indicated the roommate (who was no longer at the facility) was a larger person, and could have possibly shifted it loose prior to Resident 2 using it, causing it to slide off. 46416 2. An Indiana Department of Health (IDOH) incident report, dated 8/29/24, indicated Certified Nurse Aide (CNA) 20 was involved when a resident had fallen during a transfer, was transferred to the hospital, and the hospital nurse reported to the facility Resident 137 had a right femur fracture. Follow up was added on 9/5/24 indicating Investigation complete. Care plans reviewed and updated. Resident is a Hospice patient and will not be evaluated by therapies. The facility has educated all CNAs on the importance of reviewing the Kardex in the EHR [electronic health record] and to review the plan of care. All residents with similar needs were reviewed and care plans and Kardex were updated as applicable. All staff re-educated for skills competencies in transfers and participated in return demonstration. Resident has returned from the hospital and continues with Hospice services with no change from prior level of functioning. On 12/4/24 at 1:28 P.M., Resident 137's clinical record was reviewed. Diagnoses included, but were not limited to, Alzheimer's disease and history of a stroke. The most recent Significant Change MDS (Minimum Data Set) Assessment prior to the fall, dated 8/1/24, indicated Resident 137's cognition was unable to be assessed, had impairment of both lower extremities, used a mechanical lift, and required the extensive assist of 2 staff for bed mobility and transfers, and was totally dependent on 2 staff for toileting. A Health Status Note, dated 8/29/24, indicated res [resident] fall [sic] during transfer. Signs of pain present. Notified MD [Medical Doctor], son, hospice, and DON [Director of Nursing] aware [sic]. Bed hold police [sic] sent, report called to [Name of Hospital]. Res sent via ambulance. On 12/4/24 at 3:30 P.M., hospital records from the hospitalization that occurred from 8/29/24 to 9/3/24 were reviewed. A Discharge Summary, dated 9/3/24, indicated Resident 137 presented to the emergency department via EMS (Emergency Medical Services) on 8/29/24 after a fall from a mechanical lift at the long term care facility where she resided. Upon exam, the resident's right leg was shortened with external rotation. An x-ray of the right femur demonstrated an acute fracture of the mid femoral diaphysis (a break in the middle of the femur bone). An orthopedic surgeon was contacted and the resident was admitted . On 8/30/24, the resident underwent a right femur retrograde intramedullary nail fixation (surgically inserting a metal rod (nail) into the hollow center of the femur bone where it is then secured with screws to stabilize the fractured bone and promote healing). The resident was discharged back to the facility on [DATE]. On 12/5/24 at 11:59 A.M., CNA 20's employee file was reviewed and indicated CNA 20 was hired on 7/15/24 as a CNA. At that time, she was currently certified through the Tennessee Nursing Board, issued 4/16/24, and working on getting her certification in Indiana within the 120 day window allowed. On 7/15/24, CNA 20 signed a document that indicated she had read the job description of a CNA, understood the qualifications, duties, and performance requirements. A facility Nurse's Aide Checklist for Orientation form, dated 7/15/24, lacked a skills competency for using mechanical lifts. An Employee Warning Notice and Disciplinary Action Report, dated 8/29/24 and 9/30/24, and signed by the Administrator and the employee indicated CNA 20 was suspended pending investigation from an incident on 8/29/24 where she operated a mechanical lift without a second person, resulting in a resident's fall during transfer. After CNA 20 was educated on the use of a mechanical lift, she proceeded to transfer another resident with the lift pad placed improperly underneath them. Due to the policy violation and failure to follow instructions, she was placed on leave of absence until she obtained her certification through Indiana. During an interview on 12/5/24 at 11:45 A.M., the Administrator indicated CNA 20 transferred Resident 137 alone and did not have the base of the lift all the way out which caused it to tip over and the resident to fall landing on the floor. The Administrator was here at the time of the fall and followed the nurse into Resident 137's room. Upon entry, the Administrator observed the resident laying on the floor in the lift pad and the lift was tipped over. During an investigation, CNA 20 indicated she was trained on using mechanical lifts in Tennessee but wasn't told to have 2 people to assist in transfer when using them. CNA 20 was trained initially at the facility during orientation to have 2 people when a mechanical lift was used, but she didn't ask for help with the transfer of Resident 137. The lift was not used after the incident so maintenance could determine it was not faulty equipment. It was found to be in good working condition but was ultimately replaced with a new one that had more safety features. The Administrator indicated when she sent the reportable to IDOH, she reported fall during a transfer because that was what happened. On 12/6/24 at 1:33 P.M., a current non dated Unusual Occurrence Reporting Policy, was provided by the Administrator and indicated . A written report detailing the incident and actions taken by the facility after the event shall be sent or delivered to the state agency . 3.1-28(c)

Based on interview and record review, the facility failed to ensure services of an RN (Registered Nurse) were available at least 8 consecutive hours a day, 7 days a week for 4 of the days reviewed from the PBJ (Payroll Based Journal) Staffing Data Report during Quarter 3 of 2023 (April 1, 2023 through June 30, 2023). Findings include: On 11/12/23 at 5:30 P.M., the [NAME] report was reviewed and indicated there was not an RN for 8 consecutive hours on the following dates: 5/29/23 6/3/23 6/4/23 6/30/23 On 11/14/23 at 11:30 A.M., the as worked nursing schedules for Monday, 5/29/23, Saturday 6/3/23, Sunday 6/4/23, and Friday 6/30/23 were provided by the DON (Director of Nursing) and indicated there was no RN coverage. During an interview on 11/15/23 at 3:55 P.M., the DON indicated the BOM (Business Office Manager) submitted the staffing data to PBJ. During an interview on 11/15/23 at 4:00 P.M., the BOM indicated she did submit the facility staffing data for Quarter 3 of 2023 to PBJ. She indicated 5/29/23, 6/3/23, 6/4/23, and 6/30/23 did not have RN coverage because they did not have the staff to do it at that time. On 11/16/23 at 11:45 A.M., a current Nursing Services and Sufficient Staff policy, dated August 2023 was provided by the DON and indicated . A registered nurse shall be scheduled 8 consecutive hours seven days a week in accordance with the regulations . 3.1-17(b)(3)

Based on observation, interview, and record review, the facility failed to ensure infection control practices were followed for 1 of 2 residents observed for urinary catheter care. The facility lacked preventative measures to keep legionella from forming in the water system for 3 of 3 halls. Gloves were not changed between dirty and clean tasks during catheter care. (Resident 16, Resident Halls[Wings] A, B, C) 1. During an observation on 11/16/23 at 10:42 A.M., urinary catheter care was performed by Certified Nurse Aide (CNA) 6 and CNA 8. CNA 6 failed to change gloves and sanitize or wash hands after catheter care was performed and Resident 16 was rolled to his side and CNA 6 used 2 washrags to wipe stool off of Resident 16. CNA 6 ran out of washrags and the Administrator brought in more washrags. At that time, CNA 6 washed hands and changed gloves. CNA 6 used the washrags and continued to wipe stool, then used another washrag to rinse his bottom, and then patted his bottom dry with another washrag. CNA 6 proceeded to place a clean brief under Resident 16 with the same soiled gloves. During an interview on 11/16/23 at 11:47 A.M., Licensed Practical Nurse (LPN) 3 indicated that during any kind of care, gloves should be changed and hands should be washed between dirty and clean tasks. On 11/16/23 at 1:25 P.M., a current catheter care and glove use policy was requested, but not received. 38770 2. On 11/13/23 at 1:00 p.m. the alphabetical listing of all residents was received from the Administrator, three resident units were identified Wing A, Wing B, and Wing C. On 11/16/23 at 11:00 A.M., the Maintenance Director indicated the maintenance department did not test for Legionella or other opportunistic waterborne pathogens. He indicated he thought dietary did the testing. He also indicated he did not have a description of the building water systems using text and flow diagrams where Legionella and other opportunistic waterborne pathogens could grow and spread. On 11/16/23 at 11:33 A.M., the Kitchen Manager indicated she did not and had never tested the water for Legionella. On 11/16/23 at 12:15 P.M., the Director of Nursing (DON) indicated there was not a current system in place to test the water for Legionella. She indicated a policy had been written, but the team had not put it in place yet. On 11/16/23 at 12:04 P.M., the DON provided a current Legionella Water Management Program policy, revised 9/2022, that indicated The purposes of the water management program are to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk for Legionnaire's disease . The water management program includes the following elements: . A detailed description and diagram of the water system in the facility . The identification of areas in the water system that could encourage the growth and spread of Legionella or other waterborne bacteria . Specific measures used to control the introduction and/or spread of Legionella 3.1-18(b) 3.1-18(l)

Based on observation, interview, and record review, the facility failed to ensure a safe, functional, sanitary, and comfortable environment for residents. The water temperature was above 120 degrees Fahrenheit in 1 of 3 halls. Items were sitting on bathroom floors uncovered, a call light cord was resting on a resident's bathroom floor, a privacy curtain was hanging off of the track, and a resident's wall was scuffed with paint chipping in 2 of 3 halls observed. (A Hall, C Hall) Findings include: 1. On 11/14/23 from 10:06 A.M. through 10:18 A.M., the following resident bathroom temperatures were observed in A Hall: Bathroom between rooms [ROOM NUMBERS]: 124.1 degrees Fahrenheit. The resident in room [ROOM NUMBER] indicated she used the bathroom sink and it was sometimes hot. Bathroom between room [ROOM NUMBER] and the therapy room: 123.1 degrees Fahrenheit. Bathroom between rooms [ROOM NUMBERS]: 125.6 degrees Fahrenheit. Bathroom between rooms [ROOM NUMBERS]: 120.1 degrees Fahrenheit. On 11/14/23 from 11:08 A.M. through 11:10 A.M., the Maintenance Director was observed to obtain the following temperatures from resident bathrooms in A Hall: Bathroom between rooms [ROOM NUMBERS]: 123 degrees Fahrenheit. Bathroom between room [ROOM NUMBER] and the therapy room: 122 degrees Fahrenheit. Bathroom between rooms [ROOM NUMBERS]: 121 degrees Fahrenheit. Bathroom between rooms [ROOM NUMBERS]: 123.2 degrees Fahrenheit. On 11/14/23 at 11:31 A.M., the weekly water temps log, dated from 8/20/23 through 11/23/23, indicated temperatures were checked in the visitor restroom, laundry room, and each hall's sink and shower. When asked, the Maintenance Director could not verbalize where exactly the temperatures were taken. 2. On 11/13/23 at 10:48 A.M., the bathroom between rooms 4 and the therapy room was observed with two buckets, 1 bedpan, and 3 washbasins on the floor under the sink uncovered. The call light cord was observed coiled up and resting on the floor between the wall and the toilet. The same was observed on 11/16/23 at 12:29 P.M. with the exception of the bedpan. 3. On 11/14/23 at 10:06 A.M., the bathroom between rooms [ROOM NUMBERS] was observed with a bedpan on the floor behind the toilet uncovered. 4. On 11/14/23 at 10:04 A.M., the shower room sink on A Hall was observed 3/4 full of water. At that time, the Housekeeper 5 indicated it was clogged, and had done that before. 45933 5. During an observation on Hall C on 11/15/23 at 7:35 A.M., the privacy curtain between Resident 33 and Resident 22's had 4 hooks that were not connected and the curtain hung down. At that time, the wall on the right of Resident 33's bed had 2 large oval areas of paint that peeled off and was hanging down. During an observation on 11/16/23 at 11:06 A.M., the privacy curtain between Resident 33 and Resident 22's had 4 hooks that were not connected and the curtain hung down. At that time, the wall on the right of Resident 33's bed had 2 large oval areas of paint that peeled off and was hanging down. During an interview on 11/16/23 at 11:06 A.M., the Maintenance Director indicated the wheels must have been pulled out from the curtain and he was unaware of the paint that was peeled off of the wall. Staff would tell him if they notice a problem or they would submit a work order and he had not received one. On 11/14/23 at 11:15 A.M., the Maintenance Director indicated he was unsure of the appropriate water temperatures in resident bathrooms, and thought they could be as high as 124 degrees Fahrenheit. He indicated he had been told to check the water temperatures monthly, but he tried to check them weekly. He further indicated he did not check the water in resident bathrooms, but did from other areas of the building such as the hall bathroom and shower room. He indicated he was unable to adjust the water temperature on his own, and needed to call an outside company to come in and adjust the temperature. He indicated he was aware of the clogged sink in the A Hall shower room, and had to have a plumber out several times in the past for that sink. On 11/16/23 at 12:30 P.M., Licensed Practical Nurse (LPN) 3 indicated anything on a resident's bathroom floor should have been covered such as washbasins and bedpans. On 11/15/23 at 7:55 A.M., the Administrator provided a current Water Temperature Policy/Procedure, last reviewed 4/2023, that indicated The hot temperature for all bathing and hand washing facilities shall be controlled by automatic control valves. The water temperature at the point of use must be maintained between: (1) one hundred (100) degrees Fahrenheit; and (2) one hundred twenty (120) degrees Fahrenheit On 11/15/23 at 11:56 A.M., the Administrator provided a current Maintenance/Housekeeping Policy, dated 6/2023, that indicated It is the policy of facility to assure that the building is comfortable and clean in accordance with the regulation 3.1-19(f) 3.1-19(r)

Based on observation, interview, and record review, the facility failed to ensure residents with limited mobility received appropriate services to maintain or improve mobility for 3 of 6 residents reviewed for restorative therapy. Residents did not receive intervention of restorative nursing services as indicated . (Resident 10, Resident 12, Resident 23) Findings include: 1. On 11/13/23 at 11:55 A.M., Resident 10 was observed seated in the main dining room. On 11/14/23 at 1:36 P.M., Resident 10's clinical record was reviewed. Diagnoses included, but were not limited to, Alzheimer's, cerebral infarction, and diabetes mellitus type II. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 7/23/23, indicated Resident 10's cognition status was unable to be assessed, he had not received any restorative therapy, and he was an extensive assist of 1 staff for transfers and toileting. Current Physician's Orders were reviewed and lacked an order for restorative therapy. Current interventions/tasks for Resident 10 included, but were not limited to, the following intervention: Active ROM (Range of Motion) Resident 10 will complete 10 reps (repetitions) to upper bilateral extremities and lower bilateral extremities (arm rolls/leg lifts/knee bends/arm circles)safety maintained in group setting 5 out of 6 days a week Sunday-Friday A current Self Care Deficit Care Plan, dated 4/8/22 included, but was not limited to, the following intervention: Evaluate resident's ability to perform ADLs (Activities of Daily Living), initiated 4/8/22 On 11/15/23 at 3:52 P.M., a current list of resident's who were supposed to be receiving restorative therapy was provided by CNA (Certified Nurse Aide) 8 and included Resident 10. On 11/15/23 at 7:15 A.M., current CNA Assignments were provided by the DON (Director of Nursing) and Resident 10's care did not include restorative therapy. The last physical therapy evaluation of Resident 10 was requested but not provided during the survey period. A CNA tasks document that included the intervention of active range of Motion from October 1-31, 2023 was provided on 11/16/23 at 12:30 P.M., by the MDS Coordinator and indicated the intervention for Resident 10 was not applicable on the following days: Sunday, 10/1/23 Monday, 10/2/23 Tuesday, 10/3/23 Friday, 10/6/23 Wednesday, 10/11/23 Thursday, 10/12/23 Monday, 10/15/23 Sunday, 10/22/23 Tuesday, 10/24/23 Wednesday, 10/25/23 Thursday, 10/26/23 Monday, 10/30/23 During an interview on 11/15/23 at 3:43 P.M., CNA 8 indicated she noticed Resident 10 seemed weaker and had a harder time transferring. 2. On 11/13/23 at 12:07 P.M., Resident 12 was sitting in the front room eating with staff present. On 11/14/23 at 1:00 P.M., Resident 12's clinical record was reviewed. Diagnoses included, but were not limited to, dementia and muscle weakness. The most current MDS Assessment, dated 9/29/23, indicated Resident 12 had severe cognitive impairment, no restorative therapy, and an extensive assist of two staff for bed mobility and transfers. Current Physician's Orders were reviewed and lacked an order for restorative therapy. Current interventions/tasks for Resident 12 included, but were not limited to, the following interventions: Active ROM: Resident 12 will complete 10 reps (repetitions) to upper bilateral extremities and lower bilateral extremities (arm rolls/leg lifts/knee bends/arm circles)safety maintained in group setting 5 out of 6 days a week Sunday-Friday, dated 11/15/22 Walking: Resident 12 will meet and or exceed walking goal of approximately 50 feet with RW (rollating walker) 5 out of 6 days a week, dated 11/9/22 A current LTC (Long Term Care) Care Plan, dated 4/10/23, included, but was not limited to, the following intervention: Staff will assist with ADL care PRN (as needed), initiated 4/10/23 On 11/15/23 at 3:52 P.M., a current list of resident's who were supposed to be receiving restorative therapy was provided by CNA 8 and included Resident 12. The last physical therapy evaluation of Resident 12 was requested but not provided during the survey period. A CNA tasks document that included the intervention of active range of Motion from October 1-31, 2023 was provided on 11/16/23 at 12:30 P.M., by the MDS (Minimum Data Set) Coordinator and indicated the intervention for Resident 12 was not applicable on the following days: Sunday, 10/1/23 Monday, 10/2/23 Tuesday, 10/3/23 Friday, 10/6/23 Wednesday, 10/11/23 Thursday, 10/12/23 Monday, 10/15/23 Sunday, 10/22/23 Tuesday, 10/24/23 Wednesday, 10/25/23 Thursday, 10/26/23 Monday, 10/30/23 A CNA tasks document that included the intervention of walking from October 1-31, 2023 was provided on 11/16/23 at 12:30 P.M., by the MDS (Minimum Data Set) Coordinator and indicated the intervention for Resident 12 was not applicable on the following days: Sunday, 10/1/23 Monday, 10/2/23 Tuesday, 10/3/23 Friday, 10/6/23 Sunday, 10/8/23 Monday, 10/9/23 Wednesday, 10/11/23 Thursday, 10/12/23 Monday, 10/15/23 Thursday, 10/19/23 Sunday, 10/22/23 Tuesday, 10/24/23 Wednesday, 10/25/23 Thursday, 10/26/23 Monday, 10/30/23 During an interview on 11/14/23 at 9:56 A.M., Resident 10's family member indicated she thought he was slowing down a bit when asked about ADLs declining. 45933 3. During an observation on 11/13/23 at 12:00 P.M., Resident 23 was observed sitting in the dining room. On 11/16/23 at 10:07 A.M., Resident 23's clinical record was reviewed. Current diagnoses included, but were not limited to, dementia, anxiety, and depression. The most recent quarterly Minimum Data Set (MDS) Assessment, dated 10/5/23, indicated the restorative nursing program was not completed for active range of motion, passive range of motion, or splint and brace assistance. Resident 23 lacked a current order for range of motion. Resident 23 lacked a care plan related to range of motion. On 11/15/23 at 3:52 P.M., a current list of resident's who were supposed to be receiving restorative therapy was provided by CNA 8 and included Resident 23. The last physical therapy evaluation of Resident 23 was requested but not provided during the survey period. Current tasks included, but were not limited to, NURSING REHAB: Walking [name of Resident] will meet and or exceed walking goal of approx [approximately]. 25 ft [feet] to/from meals with stand by assist of 1 for cueing/supervision to help maintain safety. Staff to cue resident to pick feet up when walking as he tends to have a shuffle gait at time .Sunday thru [sic] Friday. The facility failed to complete the task on the following days for the month of October 2023: 10/1/23 10/2/23 10/3/23 10/7/23 10/8/23 10/11/23 10/12/23 10/14/23 10/15/23 10/21/23 10/22/23 10/24/23 10/25/23 10/26/23 10/28/23 10/30/23 During an interview on 11/15/23 at 3:33 P.M., the DON indicated there used to be a full time restorative aide but they needed her on the floor. She was not exactly sure when that transpired, but since the DON started the end of July 2023, there has not been a restorative aide. The CNAs are responsible for doing that since then and they would document it under their tasks in (name of computer program). She indicated that the tasks were considered orders and she expected those interventions to be completed as ordered. At that time, she indicated that the MDS Coordinator was supposed to monitor those residents to make sure restorative therapy was completed with the resident. During an interview on 11/16/23 at 11:45 A.M., CNA 6 indicated she does not perform the restorative care because it was not her responsibility. During an interview on 11/16/23 at 11:50 A.M., CNA 10 indicated she does not do the restorative care because therapy does it. During an interview on 11/16/23 at 12:00 P.M., the MDS Coordinator indicated when residents were admitted the nurses would put in interventions for them and the facility technically did not have anyone working as a restorative aide at that time. She further indicated CNAs should do the active range of motion with morning and night care. She indicated staff talked about their charting a lot and not applicable is probably a button that is set up in there and needs to be fixed. At that time, she indicated CNAs know they are responsible for that task and they should mark it complete when it is done and residents are evaluated by therapy when Quarterly MDS Assessments were due to look for declines in the resident's mobility. On 11/16/23 at 1:25 P.M., a current Restorative Nursing Program Policy, dated 10/23/22, was provided by the DON and indicated . It is the policy of the facility to assist each resident to attain and or maintain their individual highest most practicable functional level of independence and well-being, in accordance to State and Federal Regulations . Residents will be screened and evaluated by therapy services and or nurse designated to oversee the restorative nursing process for inclusion into the appropriate facility restorative nursing programs when it has been identified by the interdisciplinary team that the resident is in need or may benefit from such program(s) . The above programs will be documented on the facility designated restorative care forms/tools in the resident's electronic medical record . the designated nurse will be responsible for the following: a. Documentation on a monthly basis (at a minimum), and b. Initiation (sic) and updating restorative care plans . Once in an appropriate restorative nursing program, the designated nurse will continue to monitor the resident's progress . 3.1-42(a)(2)

Based on interview and record review, the facility failed to ensure Quarterly MDS (Minimum Data Set) Assessments were completed timely for 3 of 23 residents reviewed. (Resident 10, Resident 33, Resident 19) Findings include: 1. On 11/14/23 at 1:36 P.M., Resident 10's clinical record was reviewed. The most recent Quarterly MDS (Minimum Data Set) Assessment was dated 7/23/23. The record indicated the MDS Assessment due on 10/23/23, with a completion date of 11/6/23, was in progress. 45933 2. On 11/14/23 at 12:28 P.M., Resident 33's clinical record was reviewed. Resident 33's most recent admission Minimum Data Set (MDS) Assessment was dated 7/28/23. The facility failed to complete the quarterly MDS that should have been completed on 10/27/23. 3. On 11/16/23 at 10:29 A.M., Resident 19's clinical record was reviewed. Resident 19's most recent quarterly MDS was dated 7/23/23. The facility failed to complete the annual MDS that should have been completed on 10/23/23. During an interview on 11/16/23 at 12:00 P.M., the MDS Coordinator indicated that she was an LPN (Licensed Practical Nurse) and there was an RN consultant that signs off on the facilities MDS Assessments when they were completed. She indicated the consultant worked remotely and had the capability to sign off on the MDS assessments within 7 days after completion. During an interview on 11/16/23 at 12:28 P.M., the MDS Coordinator indicated they did not have a policy, but follow the Resident Assessment Instrument (RAI) manual for the MDS process. 3.1-31(d)(3)

Based on interview and record review, the facility failed to implement a care plan for 1 of 1 residents reviewed for urinary catheters and 1 of 5 residents reviewed for unnecessary medications. A resident with a urinary catheter lacked a care plan related to the catheter, and a resident on an antidepressant lacked a care plan related to the antidepressant. (Resident 17, Resident 6) 1. On 11/14/23 at 1:04 P.M., Resident 17's clinical record was reviewed. Diagnoses included, but were not limited to, heart failure and anemia. The most recent quarterly Minimum Data Set (MDS) Assessment, dated 11/14/23, indicated Resident 17 had an indwelling catheter. Current Physician Orders included, but were not limited to, change indwelling catheter every 28 days, dated 10/23/23. Resident 17's clinical record lacked a care plan related to the urinary catheter. During an interview on 11/15/23 at 1:30 P.M., the Director of Nursing (DON) indicated there should have been a care plan related to the urinary catheter. 38770 2. On 11/14/23 at 2:05 P.M., Resident 6's clinical record was reviewed. Diagnoses included, but were not limited to, insomnia. The most recent Quarterly MDS Assessment, dated 8/18/23, indicated no cognitive impairment, and use of antidepressants. Current physician's orders included, but were not limited to: Trazodone HCl (an antidepressant) 25mg (milligrams) by mouth at bedtime related to insomnia, dated 5/30/23. Resident 6's clinical record lacked a care plan related to use of antidepressants. On 11/16/23 at 10:54 A.M., the Director of Nursing (DON) indicated Resident 6 should have had a care plan in place for antidepressant use implemented by Social Services. On 11/16/23 at 1:25 P.M., the DON provided a current Comprehensive Care Plans policy, revised 8/2023 that indicated An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident 3.1-35(a)

Based on interview and record review, the facility failed to ensure residents using psychotropic medications received gradual dose reductions (GDR) for continued use of the medications for 2 of 5 residents reviewed for unnecessary medications. Antidepressants and antianxiety medications were not reduced and a clinical contraindication for the reduction was not documented. (Resident 6, Resident 9) Findings include: 1. On 11/14/23 at 2:05 P.M., Resident 6's clinical record was reviewed. Diagnosis included, but was not limited to, insomnia. The most recent Quarterly MDS (minimum data set) Assessment, dated 8/18/23, indicated no cognitive impairment, and use of antidepressants. The MDS indicated no GDR had been attempted, and a clinical contraindication to the GDR had not been documented. Current physician orders included, but were not limited to: Trazadone HCl (an antidepressant) 25mg (milligrams) by mouth at bedtime related to insomnia, dated 5/30/23. The original date on the order was 6/24/22, with no change made when the new order was put in on 5/30/23. Resident 6's clinical record lacked information related to a GDR for Trazodone for the last 12 months, and lacked a clinical contraindication to the GDR. On 11/15/23 at 9:00 A.M., a Complete Psychotropic Listing form was provided that indicated discontinuing Trazodone was refused by family on 6/21/23, family provided history of REM sleep behavior disorder symptoms when Trazodone was discontinued in the past on 7/19/23. At that time, the DON indicated the form was not part off the resident's clinical record, and no one was able to locate that information in Resident 6's clinical record. 2. On 11/15/23 at 8:51 A.M., Resident 9's clinical record was reviewed. Diagnosis included, but were not limited to, depression and anxiety. The most recent annual MDS Assessment, dated 9/19/23, indicated no cognitive impairment, and use of antidepressant and antianxiety medications. The MDS indicated no GDR had been attempted, and a clinical contraindication to the GDR had not been documented. Current physician orders included, but were not limited to: Wellbutrin XL (an antidepressant) 300mg, give 1 tablet by mouth daily for depression, dated 11/9/23, originally ordered on 5/2/14. Wellbutrin XL 150mg, give 1 tablet by mouth daily in addition to the 300mg tablet for a total of 450mg daily for depression, dated 11/9/23, originally ordered on 5/2/14. Buspirone HCl (an antianxiety) 15mg, give 1 tablet by mouth twice a day related to depressive episodes, dated 5/26/23, originally ordered on 9/29/22. A current psychotropic/psychoactive medication care plan, dated 1/24/14, included, but was not limited to, and intervention to follow GDR schedule. Resident 9's clinical record lacked information related to a GDR for Wellbutrin XL or Buspirone for the last 12 months, and lacked a clinical contraindication to the GDR. A Consultant Pharmacist Communication to Physician form, dated 3/15/23, indicated a GDR request from the pharmacist for Wellbutrin XL with no physician response checked. A Consultant Pharmacist Communication to Physician form, dated 3/15/23, indicated a GDR request from the pharmacist for Buspirone with no physician response checked. A handwritten note on the form indicated the order was changed on 5/26. The clinical record lacked a dosage change at that time. On 11/15/23 at 12:00 P.M., the DON indicated prior to her arrival, several pharmacy recommendation forms had not been scanned, and staff may have been shredding them. She indicated she was aware that GDRs needed to be done for psychotropic medications, and was currently working on a system for those to be completed on time. On 11/16/23 at 11:47 A.M., the DON provided a current non-dated Medication Monitoring and Management policy that indicated Other Psychopharmacological Medications . After the first year, a tapering should be attempted annually, unless contraindicated 3.1-48(b)(2)

Based on interview and record review, the facility failed to ensure a notice of transfer or discharge was given to residents or resident representatives for 2 of 3 residents reviewed for hospitalization s. There was no documentation of a resident or representative receiving a notice of transfer or discharge at the time of hospitalization . (Resident 22, Resident 73) Findings include: 1. On 4/20/22 at 9:33 A.M., Resident 22's clinical record was reviewed and indicated they were admitted from the facility to the hospital on 3/18/22 and returned back to the facility from the hospital on 3/21/22. Resident 22's records lacked a notice of transfer/discharge given to the resident or a representative at the time of the transfer. During an interview on 4/20/22 at 2:38 P.M., the Administrator indicated the facility did not have a record of Resident 22 or Resident 22's representative receiving a notice of transfer or discharge on 3/18/22. 2. During an interview on 4/19/22 at 10:10 A.M., Resident 73 indicated they had just come back from the hospital, and was unsure if any notices were provided to themselves or their family at the time of discharge. On 4/20/22 at 3:40 P.M., Resident 73's clinical record was reviewed and indicated they were admitted from the facility to the hospital on 3/27/22 and returned back to the facility from the hospital on 4/6/22. Resident 73's record included page 1 of 2 from a notice of transfer or discharge form, dated 3/27/22. The record lacked the second page of the form. At that time, the Administrator indicated the second page could not be located, and were unsure if it was provided to the resident or representative at the time of discharge. During an interview on 4/20/22 at 2:38 P.M., the Administrator indicated when a notice of transfer or discharge form is completed, it should be provided to the resident or resident's representative, and scanned into the clinical record immediately. On 4/21/22 at 9:45 A.M., the Administrator indicated while the facility did not currently have a notice of transfer/discharge policy, one had just been created, and was provided at that time. The policy, dated 4/21/22, indicated when a resident is discharged to a hospital, the facility should Complete the State required Notice of Transfer/Discharge form . Make a copy for the clinical record and give the original to the resident. The nurse will be responsible for providing the resident a written copy of the Notice of Transfer/Discharge Notice . 3.1-12(a)(6)(A)(i) 3.1-12(a)(6)(A)(ii)

Based on interview and record review, the facility failed to provide necessary documentation to ensure a resident or responsible party was issued a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) before the proposed end of services for 2 of 3 beneficiary notices reviewed. (Resident 22, Resident 9) Findings include: 1. On 4/21/22 at 10:45 A.M., during review of three randomly chosen resident Medicare Part A discharge notices, Resident 22 and Resident 9's notices stated, The facility/provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted, and a SNF ABN notification form was not provided. At that time, the Business Office Manager (BOM) indicated a SNF ABN should have been completed and provided for Resident 22 and Resident 9 and was not. On 4/21/22 at 3:22 P.M., the Administrator indicated while the facility did not currently have a SNF ABN notification policy, one had just been created, and was provided at that time. The policy, dated 4/21/22, indicated The ABN is a notice given to beneficiaries in Original Medicare to convey that Medicare is not likely to provide coverage in a specific case . The ABN must be reviewed with the beneficiary or his/her representative and any questions raised during that review must be answered before it is signed 3.1-4(i)

Based on observation, interview, and record review the facility failed to ensure adequate supervision was provided to prevent falls for 2 of 3 resident reviewed for falls who had a high risk for falls. This resulted in Resident #16 experiencing a left hip fracture. (Resident #16, Resident #23) Findings include: 1. On 2/8/16 at 11:20 A.M., Resident #16 was observed lying in a low bed with no distress noted. One side of Resident #16's bed was against the wall and the other side had a mat on the floor. On 2/11/16 at 12:25 P.M., Resident #16 was observed sitting in a Broda chair in the main dining room. On 2/8/16 at 12:13 P.M., Resident #16's clinical record was reviewed. Resident #16 had been admitted to facility on 5/19/14. Admission [DIAGNOSES REDACTED]. A 9/28/15 Significant Change Minimum Data Set assessment (MDS) indicated extensive assistance of 2 or more staff needed for bed mobility and walking in corridor with a total dependence of 2 or more staff needed for transfers. The MDS lacked a resident interview regarding mental status. A short and long term memory problem was noted with severe impaired cognition for decision making . A Quarterly MDS dated [DATE], indicated extensive assistance of 2 or more staff for bed mobility, transfers and walking in the corridor. The 12/16/15 Quarterly MDS indicated Resident #16 had a severely impaired cognition score of 3. His current care plan with latest revision on 2/2/16 indicated, Resident #16 was at a high risk for falls: . triggers high risk for falls r/t (related to) hx (history of) multiple falls at home and fall with compression fx (fracture) to back, fx to pelvis while at home, weakness, decreased mobility, unsteady gait, poor safety awareness and confusion r/t poor cognition r/t Alzheimer's, Orthostatic Hypotension hx and hx spontaneous syncope and collapse at home, Seizure disorder. Hx of falls. Attempts to get up without assist at times . Goal was no further injury and to accept assist with transfers. Interventions included but was not limited to, 15 minute checks initiated 9/14/15 and resolved on 11/12/15, body pillow each side of bed initiated on 9/14/15, broda chair when up initiated on 9/28/15 and revision on 2/2/16, call light in reach initiated on 5/20/14 and revision on 10/14/14, check and change every hour during night hours- initiated on 9/14/15 and revision on 2/2/16, dysom to wheelchair initiated 5/26/15 and resolved on 11/3/15, lay down after all meals initiated on 1/22/16, low bed with padded mat beside bed initiated on 5/19/14, mattress with bolsters to bed every shift initiated on 10/6/15, sensor alarm to bed and chair initiated on 5/20/14 and canceled on 3/27/15, snap alarm seat belt while in wheelchair initiated on 3/9/15 and canceled on 9/3/15. Review of the clinical record on 2/11/16 at 9:11 A.M., indicated the following falls had occurred: 1st fall-A progress note dated 3/8/15 at 9:30 P.M., indicated, This nurse found resident sitting on floor in C-Hall hallway. It appears resident has fallen but resident denies remembering how got on the floor. Resident is A (Alert) & O (Oriented) x 1 with confusion and forgetfulness which is normal for resident d/t (due to) impaired cognition. Upon assessment, neuro checks WNL (with-in normal limits). Speech clear. Hand grasps strong and equal bilaterally. Pupil size 2 mm (millimeters) bilateral with brisk reaction. VS (vital signs):B/p: 137/78, P (pulse) 88, R (respirations): 20, T (temperature) 98.0, O 2 (oxygen) Sat (saturation): 95 % RA (room air). MAE (Moving All Extremities). No bruising or swelling noted. No external rotation noted. Denies pain or discomfort. Resident stated, 'I am just fine.' Full ROM (range of motion) and was able to be assisted up and to bathroom by staff x 2. Family notified. Neurochecks and vital sign checks will continue. 2nd fall- A progress note dated 5/20/15 at 7:15 P.M., indicated, Resident slipped out of wheelchair onto floor while in the lobby watching television. No injuries noted. V/S (vital signs) 97.7-80-20-150/78. Interventions: 1) dysom mat to wheelchair at all times; buckle type seat belt to wheelchair at all times. Family, Dr. (physician's name), Administrator, and DON (Director of Nursing) notified. A progress note dated 5/21/15 at 5:30 A.M., indicated, Nurse and CNA went to Resident's room to get Resident up for the day. Bruising noted to Resident's right eye. Bruising reported to family, Dr. (physician's name), Administrator, and DON (Director of Nursing). Resident apparently bruised eye when he slipped out of wheelchair on 5/20/15 . 3rd fall- A progress note dated 9/14/15 at 6:18 A.M., indicated, CNA (CNA's name) alerted this nurse to residents room. Upon entering room, this nurse observed res. (resident) sitting on floor on mat next to room mates (sic) foot of bed. Res is conscious, disoriented x 4, his normal before said incident. No bruises, bumps, swelling, or open areas observed. MAE (Moves All Extremities), no c/o (complaints) pain. Res (Resident) is incont (incontinent) of B/B (bowel and bladder), kept CD (clean and dry) per staff. Res had been checked 30 min (minutes) prior to incident. Assisted res to his feet, able to stand with assistance x 2, and transferred to W/C (wheelchair). VS (Vital Signs) 128/72-88-20-97.7 O 2 (oxygen) sat (saturation) 95% on RA (Room Air). Res was toileted, bathed, dressed, and brought to lobby by nurses station. 15 min (minute) checks started. MD (physician) and family notified of incident. Documentation was lacking resident was provided with supervision at time of fall. A progress note dated 9/14/15 at 9:00 A.M., indicated,Reported to Dr. (physician's name) resident c/o (complaint) left leg pain, not bearing weight. New order received for x-ray left leg. Family notified. A progress note dated 9/15/15 at 10:35 A.M., indicated, .Recent radiology report shows fracture to L (left ) femur . 4th fall- A progress note dated 9/28/15 at 11:30 A.M., indicated, This person was coming down hall and her (sic) a noise and found resident out of wheelchair on right side with feet against pedals. V/S (Vital Signs) 136/70, 70, 18, 97.2 oxygen 96%. Noticed abrasion on right side of forehead, alert and oriented times one . Documentation was lacking resident had been provided with supervision at time of fall. A progress note dated 9/28/15 at 2:25 P.M., indicated, Follow up to resident occurrence. Upon investigation and interview with staff, resident was placed at nurses station in wheelchair to awaiting lunch. Resident fell out of w/c (wheelchair) onto floor causing abrasion to right forearm and slight redness to forehead . 5th fall- A progress note dated 1/22/16 at 9:05 A.M., indicated, Heard noise in lobby from nurses station. Resident observed lying on L (left ) side on floor. Fall not witnessed by staff. (Resident name) alert and disoriented x 3 WNL (Within Normal Limits) for resident. Resident was reclined in broda chair, but appeared to have leaned forward and lost center of gravity and fell out of broda chair. Pink area to forehead with no bleeding observed . Resident #16's clinical record in regard to falls was reviewed with the Director of Nursing (DON) on 2/11/16 at 1:35 P.M. The DON indicated since admission to the facility Resident #16 had needed assistance to ambulate. The DON indicated at the time of the first fall (3/8/15) Resident #16 utilized a sensor alarm to his wheelchair and bed. The DON indicated Resident #16 had been found sitting on the floor in C hall. The DON indicated he had fallen from his wheelchair and the immediate intervention had been to notify his physician who had ordered a Velcro alarm seat belt which the resident could not consistently remove. The DON indicated Resident #16 had slipped out of his wheelchair in the lobby while watching TV on 5/20/15 at 7:15 P.M. The DON indicated the intervention initiated had been to add a dycom mat to his wheelchair and an alarmed Velcro snap seatbelt which the resident could not consistently remove. The DON indicated the 3rd fall had occurred on 9/14/15 at 6:18 P.M., when the resident was found sitting on the floor next to his roommates's bed. She indicated Resident #16 stood post fall without pain but pain developed after breakfast and x-ray revealed a left hip fracture. Interventions implemented were 15 minute checks, body pillows, and check and change every hour during night (due to urinary incontinence noted). The DON indicated Resident #16 was already using a low bed with a mat. The DON also indicated Resident #16 returned to the facility on [DATE], after a partial hip replacement. The DON indicated on return the resident was on weight bearing as tolerated with walker, body pillows, and 15 minute checks had been resumed, low bed (no alarms), use of a wheelchair and was receiving therapy. The DON indicated the 4th fall had occurred on 9/28/15 at 11:30 A.M., when the resident had fallen out of his wheelchair and was found on his right side in the lobby. The DON indicated staff had just assisted Resident #16 up for lunch. The intervention implemented after the fall was to utilize a Broda chair. The DON indicated the next fall had occurred on 1/22/16 at 9:05 A.M., after breakfast, when Resident #16 was sitting slightly reclined in his Broda chair watching television in the lobby. Resident #16 had been found on the floor by staff. The intervention implemented had been to lay Resident #16 down after meals. On 2/12/16 at 10:36 A.M., during interview with the DON, she indicated Fall Risk Assessments were completed after a fall had occurred. The DON provided an admission Fall Risk Assessment (5/19/14 score of 20-High Risk )and a Fall Risk assessment dated (2/14/15 score of 13- High Risk ) before the 3/8/15 fall. The DON also indicated at that time that a Post Fall Assessment was completed by nurses after residents had fallen. The Post Fall Assessment was completed each shift for 3 days following each fall. The DON was made aware the 3 Post Fall Assessments for the 9/14/15 fall indicated the fall had occurred on 9/14/15 (fracture date) at 4:50 A.M., not 6:18 A.M., as was documented in the progress notes. The Neurological Flow sheet initiated 9/14/15 (fracture date) first time was illegible and the next times documented were 5:15 A.M.,, 5:30 A.M., 5:45 A.M., 6:00 A.M., before the fall was documented as occurring on 6:18 A.M. on the 9/14/15 progress note. The Fall Risk Assessment completed after the 9/14/15 fall was dated 9/14/15 and time completed was documented at 5:29 A.M. The DON indicated at that time she was unaware of a second fall occurring on 9/14/15 and could not explain the discrepancies in the documentation of the time of the fall at 4:50 A.M., and 6:18 A.M., on the 9/14/15 fall. On 2/12/16 at 11:21 A.M., the DON was made aware documentation was lacking of evidence that Resident #16 had received adequate supervision to prevent falls. The DON indicated at that time she understood the concern and would provide the facility fall policy. 2. Resident #26 was observed in his/her room on 2/8/16 at 1:38 P.M. exiting the bathroom, walking across the room towards a personal chair. Resident #26 was observed, at that time, to have an unsteady gait and to not be using an assistive device. The clinical record of Resident #26 was reviewed on 2/12/16 at 2:00 P.M. The record indicated the [DIAGNOSES REDACTED]. The Annual MDS (Minimum Data Set) assessment dated [DATE] indicated Resident #26 experienced severe cognitive impairment, had no history of falls, required the limited assist of two staff and a walker for transfers, toileting, and walking in the room. The assessment further indicated Resident #26 experienced unsteady balance during transitions and walking. The Quarterly MDS dated [DATE] indicated Resident #26 experienced severe cognitive impairment, had not experienced a fall since the previous assessment, required the limited assist of two staff and a walker for transfers, toileting, and walking in the room. The assessment further indicated Resident #26 experienced unsteady balance during transitions and walking. The February 2016 physician's orders [REDACTED]. An IDT (Interdisciplinary Team) note dated 10/13/15 indicated Resident #26 experienced a fall and further indicated, root cause analysis .fell in rm (room) .up with assist of 1, got dizzy and lost balance . A Care Plan for ADL's (Activities of Daily Living) dated 10/14/15 indicated, needs assist with ADL's r/t (related to) weakness, Dementia with confusion at x's (times) .1 assist with transfers . A PT (Physical Therapy) Evaluation & Plan of Treatment dated 10/26/15 indicated .Posture=kyphotic (excessive curvature of the upper spine) .Safety Awareness=impaired .frequently forgets to use assistive device for ambulation in room .the patient is at risk for falls . A Care Plan for, .high risk for falls . dated 11/18/15 included interventions of, call light in reach, instruct to utilize staff assistance when searching for things in room, keep path free of clutter, maintain bed in lowest postion (sic), non skid foot wear to be worn, notify md (sic) (medical doctor) prn (as needed), provide adequate lighting A Restorative Nursing Progress Note dated 12/21/15 indicated, .while walking with restorative staff, VC's (verbal cues) provided to educate on safety awareness, proper RW (rolling walker) . An IDT note dated 2/2/16 indicated, Falls: .root cause analysis .socks-slipped-PT (Physical Therapy) will screen. A Rehab screen dated 2/2/16 indicated, .All transfers .mod (moderate) assist .gait .device-rolling walker .assist-mod independent .balance-good with rolling walker .safety- fair .will continue to be up ad lib at this time in the facility with her Rolling (sic) walker. A Fall Risk assessment dated [DATE] at 12:45 P.M. indicated Resident #26 experienced a fall in the previous 3 months, had a balance problem while walking, and required the use of an assistive device. A Post-Fall Root Cause Analysis report dated 2/2/16 indicated Resident #26 experienced a fall with injury in the resident's room at 6:30 A.M. The report further indicated all care plan interventions were not followed .Resident was wearing .house slippers (slick soled) .require assistance with toileting-No .last time .toileted-6:15 A (A.M.) .Conclusion: Resident was not wearing proper shoes .not using Rolling walker .New intervention .upon arising, resident is to wear proper shoes @ (at) all times . The report contained a hand-drawn diagram of the scene at the time of incident discovery. The diagram lacked any indication a walker was contained in the scene. A Nursing note dated 2/2/16 at 6:30 A.M. indicated, .resident up in room in house slippers and not using walker messing with some stuff on top of bedside dresser when resident stated she lost her balance .noticed a knot on top of head, and red area on top of back . The note lacked any documentation to indicate a new intervention to prevent falls was implemented. A Nursing note dated 2/2/16 at 1:53 P.M. indicated, .found on floor by housekeeping sitting between closet and side table .resident was up ad lib in room going through .belongings when resident stated, 'I lost my balance'. Was noted resident was not using walker during ambulation. Resident then fell to floor and was found in a sitting position .noted 'bump' to top of right side of head. Small redness noted to upper back .resident wearing house slipper with slick soles. Removed slippers immediately wand (sic) was replaced with non-skid footwear .has history of not alerting staff for assist and not using walker. Staff alerts resident with constant reminders to use walker . A Care Plan for Falls dated 2/2/16 indicated new interventions of, Replace non skid footwear .up adlib (sic) with walker were implemented. A Restorative Nursing note dated 2/3/16 at 3:27 P.M. indicated, Resident is maintaining previous mobility level , walking over 600 feet daily with steady gait RW ad lib .no decline in functional/ADL limitations .hx (history of) preferring to walk on own without any assistive device. Responds well to verbal reminders to utilize RW and is compliant, but always insists that she is fine without it .continues to need reminders to utilize call light for staff assistance . During an interview with on 2/12/16 at 11:15 A.M. the ADON (Assistant Director of Nursing) indicated no documentation could be provided to indicate a new effective intervention or supervision to prevent further falls was implemented. During an interview on 2/12/16 at 11:30 A.M., the DON (Director of Nursing) indicated the new, effective interventions should be implemented when a resident experiences a fall. The Policy and Procedure for Falls provided by the DON on 2/12/16 at 11:51 A.M. indicated, .provide appropriate strategies and interventions directed to resident, environmental factors .implement fall prevention interventions and modify plan of care as necessary . 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure a resident identified as a high risk to fall received adequate supervision and/or failed to ensure interventions were initiated after falls to prevent further falls for 1 of 2 residents reviewed for falls in the sample of 2 residents who met the criteria for review of falls. This practice resulted in Resident #2 experiencing 17 falls and receiving lacerations, skin tears, and a hematoma. Resident #2 Findings include: On 11/20/13 at 11:55 A.M., Resident #2 was observed sitting in the main dining room in his wheelchair. The wheelchair had in place an anti-roll back system. The resident also had a alarmed velcro seat belt intact. Resident #2's clinical record was reviewed on 11/18/13 at 2:00 P.M. He was admitted to the facility on [DATE]. His current [DIAGNOSES REDACTED]. The Minimum Data Set Assessment ((MDS) dated [DATE], indicated a severe cognitive impairment with a score of 5. The assessment indicated supervision and set up help only (1,1) for transfers and to walk in room or corridor. A MDS assessment dated [DATE], indicated independence and no set up or physical help from staff (0,0) for bed mobility, and walk in room and corridor. The assessment also indicated a cognition score of 2 (severe cognitive impairment). Resident #2 had a care plan initiated on 06/07/13 that addressed the resident being a high risk for falls. Goals included to remain as independent as possible and to maintain safety with falls with no injuries or fractures. Interventions included, but were not limited to, "... allow to do for self as able...and call light in reach." On 11/19/13 at 2:40 P.M., the DON (Director of Nursing) was interviewed regarding Resident #2's falls in regard to reviewing Resident #2's fall progress notes. A progress note dated 06/07/13 at 12:10 P.M., indicated, "...Resident attempted to get up on own, and fell hitting his head and landing on right shoulder and side..." A progress note dated 06/07/13 at 1:37 P.M., indicated, "Assessed resident's room no environmental hazards in room. Was in regular bed with call light in reach attached to side rail. Resident had been resting all morning unable to arouse gently. Then he got up with sheets wrapped feet and fell in room. Charge nurse (nurse's name) started neuro (neurological) checks and resident denied any pain but very confused. Has altered mental status with dementia. Resident was very high risk for falls but refuses hipsters, helmet, non-skid socks and refuses to ask for assist or use call light. Wife aware of fall risk. Stated, 'he fell ,[DATE] times a week at home and also would fall upon standing and catch himself on things.' Noted on admission laceration above left eye with sutures and bruising scattered all over body but mostly to head and arms. admitted yesterday evening with orders for PT to eval (evaluate) and treat as indicated. Received new order for from Dr. (Dr.'s name) for non-skid mat by bed. Placed non-skid mat by bed at this time. Is on scheduled toileting plan and checked every 2 hours and prn (when needed) for incontinence... Resident is in room close to the nurses station for frequent monitoring." A second fall documented in progress note dated 06/22/13 at 7:30 P.M., indicated, "Late entry: CNA reported to this nurse that resident was found on floor by his bed...Res (resident) continues on 15 min (minute) checks and has wanderguard intact." On 11/19/13 at 2:40 P.M., the Director of Nursing indicated the resident had been put on 15 minute checks and a wanderguard had been placed on 06/21/13, after the resident had exited the facility and was found on the facility grounds on 06/21/13 at 3:00 A.M. by staff. Fifteen minute checks remained in place until resident was hospitalized from [DATE] to 07/17/13 on a psychiatric unit. A follow up progress note to the 06/22/13 fall dated 06/24/13 at 1:20 P.M., indicated, "... Resident high risk and anticipate falls due to frequent falls, history of multiple falls at home, weakness, non-compliance with safety, weakness, and episodes of dizziness. Antivert (anti-dizziness medication) 12.5 mg (milligram) changed from prn to routinely TID (3 times a day) x 5 days due to c/o (complaint of) episodic dizziness. Sitting and standing BP (blood pressure) to be recorded twice daily x (times) 5 days to evaluate for orthostatic hypotension. Resident requires assistance for transfers and ambulation however resident non-complaint with assistance and gets up without assist. Safety devices to prevent injury declined per family/POA (Power of Attorney) such as hipsters and helmet. Resident demonstrates impaired balance and gait. Receiving PT 5x wkly (weekly) for therapeutic exercises, gait training, and balance. Resident placed on a low bed with mat at bedside. Resident demonstrates ability to get up from low bed therefore, not considered a restraint. Grab poles in room maintained. Resident on 15 min rounding..." On 11/19/13 at 2:40 P.M., during interview with the DON she indicated Resident #2 had been hospitalized at a psychiatric hospital from 07/08/13 to 07/17/13 and then returned to the facility. The DON indicated after hospitalization the Psychiatrist had recommended to staff that Resident #2 needed to keep his normal routine. The Psychiatrist indicated that staff intervention may increase his behaviors. A progress note dated 07/22/13, late entry for 5:15 A.M., indicated, "Found res on floor next to his bed on right side..." A progress note dated 07/23/13 at 10:27 A.M., indicated, "Follow up to resident found lying on floor next to bed... Resident is up ad lib in room/facility. Toilets self as is changed per nursing staff PRN due to occassional incontinence. Resident has grab poles (initiated 06/11/13) in room to aid in transfers/ambulation. Non-skid mat at bedside. Resident has 1/2 side rails on bed for enablers and demonstrates safe use. Resident is on 30 minute checks. POA/Family has declined use of low bed, helmet, or hipsters... Resident non-complaint with use of call light for assist. Continues to receive physical therapy 5 x weekly..." "...15 min checks re-implemented..." A progress note dated 07/25/13 at 10:00 P.M., indicated, "Resident found on floor beside bed by nurse..." A progress note dated 07/27/13 at 2:19 P.M., indicated, "Motion sensor alarm to bed-on when in bed. Resident refuses to have sensor alarm. Resident threw alarm." A progress note dated 07/28/13 at 11:45 P.M., indicated, "... CNA reported to this nurse that res was on the floor..." A progress noted dated 07/29/13 at 3:42 P.M., "... Resident severely cognitively impaired. Up ad lib in facility/room with walker. Resident high risk for falls and falls are anticipated related to history of falls and non-compliance with safety measures. Resident declines use of call light for assist. 1/2 SR (side rail) to bed for enablers. Grab poles in room. Non-skid mat to bedside. Family/POA declines hipsters, helmet, and low bed. Motion sensor alarm to bed attempted as resident took alarm off bed and threw it in hallway. Resident on 15 min checks. Toilet self and change prn per nursing staff for occasional incontinence... Documentation was lacking of a new intervention initiated after the 07/28/13 fall. During interview with the DON on 11/19/13 at 2:40 P.M., she indicated the motion sensor alarm initiated after the 07/25/13 fall had been discontinued on 07/30/13. The DON indicated at that time no new intervention had been initiated after the 07/28/13 fall. A progress note dated 08/11/13 at 3:30 A.M., indicated, "CNA, (CNA's name) heard noise in resident's room. (CNA's name) found resident on the floor next to chair, and bedside commode was flipped over...Resident was bleeding from right anterior forehead and right two knuckles on right hand...Resident has approximate 5 inch hematoma with a one inch laceration on the anterior right side of forehead...Resident also received an abrasion to right knee with no bleeding noted..." A progress note dated 08/12/2013 at 3:12 P.M., addressed the 08/11/13 fall. The documentation indicated the resident was up ad lib in facility with his walker. He was receiving physical therapy and 15 minute checks continued. Interventions that remained were: grab poles x 2, non-skid mat beside bed, 1/2 side rails as enablers. A low bed had been attempted with family refusal. Resident had removed alarms and had thrown alarm. Documentation was lacking of a new intervention initiated to prevent falls after the 08/11/13 fall. On 11/19/13 at 2:40 P.M., during interview the DON indicated no new intervention had been initiated after the 8/11/13 fall. A progress note dated 08/15/13 at 4:15 A.M., indicated, "resident walked into the living room using walker and had bleeding from the back of head. Resident has approximate one inch laceration to the back of head. Resident stated he had fallen in his room..." A progress note dated 08/15/13 at 1:03 P.M., indicated Resident #2 had been sent to a hospital emergency room and had returned to the facility with 4 staples to laceration of his head. An environmental check of his room was done without concerns noted. Current interventions continued with 15 minute checks, non-skid mat, grab poles and 1/2 side rails. Documentation was lacking of a new intervention initiated. A progress note dated 09/04/13 at 6:42 A.M., indicated, "Found resident on floor with dining table on top of resident. Assisted resident up and to toilet. Resident c/o (complained) left shoulder pain with tenderness with extension of elbow. Call placed to Dr. (physician's name) with order to send to (hospital name) ER for eval and tx (treatment)." A progress note dated 09/04/13 at 12:59 A.M., indicated, the resident was found on floor under table in his room. He had been sent to hospital emergency room and returned to facility without fracture. The resident had sustained bilateral skin tears from the fall. Interventions continued with grab poles, side rails, and 15 minute checks. Documentation indicated the resident remained up ad lib with walker at the facility. Documentation was lacking of a new intervention initiated after the 09/04/13 fall to prevent further falls. On 11/19/13 at 2:40 P.M., the DON indicated the facility had tried a sleeve device to prevent skin tears. A progress noted dated 09/25/13 at 8:45 A.M., indicated, "Resident in the dining room for breakfast, resident stood up from table, attempted to turn around, lost balance and fell , hitting back of head on floor...." A physician's orders [REDACTED]. A progress noted dated 09/28/13 at 3:15 A.M., indicated, "A loud noise came from resident's room and resident was found on floor next to recliner. Resident was lying on ground on left shoulder and left hip..." A progress note dated 09/30/13 at 6:38 A.M., indicated, "Late entry for 09/29/13 2210 (10:10 P.M.)... CNA came to this nurse, reported that res (resident) was sitting on floor in own room. Went to assess res, found res sitting on floor next to recliner..." A progress note dated 9/30/13 at 3:17 P.M., indicated, "Occurrence follow up from falls 09/28/13 and 09/29/13. Resident alert with severely impaired cognition. Resident has history of several falls. Resident up ad lib with walker. Frequent reminders for resident to use walker are given per staff. Re-educated resident and family regarding risks and consequences with falls. Resident and family continue to decline safety devices such as low bed, alarms in room, helmet, or hipsters. Resident non-complaint with safety measures. Resident continues on 15 min checks and neuro (neurological) checks post fall. Resident is not consistent with alerting staff for assist. Resident toilets self with staff assist at times for occasional incontinence..." "... Will continue 15 -min checks and continue to re-educate resident and family regarding falls as necessary. Continue current plan on care." Documentation was lacking of new interventions initiated after falls of 09/28/13 and 09/29/13. A progress note dated 10/3/13 at 11:56 P.M., indicated , "... CNA came to this nurse and reported that res was on the floor next to bed. Went to assess res, CNA #2 is with res sitting on floor next to bed. CNA #2 states res was faced down on floor. Res is alert, asking to get up. MAE (Moves all extremities) w/o (without) difficulty. Skin above left eyebrow and right eye pink slightly swollen...15 min checks cont.(continue)." A progress note dated 10/04/13 at 3:51 P.M., indicated, "Follow up from resident fall. Upon investigation, resident attempted to get up from bed and fell ...Resident continues on 15 min checks. Re-educated resident and family regarding risks and consequences regarding falls. Continue to decline low bed, alarms in room, hipsters, or helmet. Grab poles remain in room. 1/2 SR (side rails) used as enablers. Will continue to re-educate resident and family regarding falls as necessary. Continue current plan of care." Documentation was lacking of a new intervention initiated to prevent falls. A progress note dated 10/08/13 at 12:07 A.M., indicated, " Resident's sensor alarm sounded. CNA (CNA's name) and I both arrived to resident's room and upon entering room, resident fell on to the floor. Resident was attempting to turn off his sensor alarm (alarm mat) at bedside table and lost balance and fell to ground...Resident has an approximate 1 inch gash on right side of head..." A progress note dated 10/08/13 at 9:11 A.M., indicated, "Follow up to resident fall..."Returned from (hospital name)-ER with 2 staples in place...Alarm mat bed side bed continues. Resident remains on 15 min checks. Grab poles remain in room. Resident uses 1/2 SR for enablers. Re-educated resident and family regarding risks and consequences with falls and decline low bed, hipsters, and helmet. Resident up per self with walker. Toilets self with assist at times and as resident will allow staff to assist. Resident is high risk for falls and falls are anticipated due to history of several falls at home, non-compliance with safety measures, getting up without assist/walker. Will continue to re-educate resident and family regarding as deemed necessary. Will continue current plan of care." Documentation was lacking of an intervention initiated after the 10/08/13 fall to prevent further falls. A progress note dated 10/20/13 at 6:08 A.M., indicated, "Resident was found on floor at the foot of bed on left side, bedside commode tip over in front of bed. Resident yelling get me up !!!..." A progress note dated 10/21/13 at 9:48 A.M., indicated, "...Grab poles to room, 1/2 SR utilized for enablers. POA/family aware of risks associated with frequent falls such as tissue injury, fractures, and death. POA/family and resident decline hipsters, helmet, and low bed. Continues on 15 min checks...Sensor alarm mat beside bed when in bed and in front of recliner when in recliner continues and functional. Will continue current plan of care and re-educate POA/family and resident with risks associated with falls." Documentation was lacking of an intervention initiated after the 10/20/13 fall to prevent further falls. A progress note dated 10/23/13 at 1:55 P.M., indicated, "Resident fell hitting head was not using walker, alarm on and functioning but not sounding. Walked around device. Neuro (neurological) check started. Dr. (Dr.'s name) aware. Resident refused all interventions, hipster, helmet, etc. POA (Power of Attorney) notified of fall. Resident at risk for further falls due to poor safety awareness." A progress note dated 10/24/13 at 1:06 P.M., indicated, "Follow up to fall 10/23. Upon investigation, resident up from bed per self without walker. Was ambulating out of room and fell hitting head on wall. Was noted alarm mat not sounding but was turned on. Investigated alarm functional status and was noted to be functional as staff stepped on mat to alarm. It appears resident stepped around mat or towards the end of mat as not to step on mat to alarm...15 -min checks continue...Resident non-compliant with safety measures. Motion sensor alarm attempted with resident refusal as evidenced by resident throwing alarm. Low bed previously attempted with POA/family refusal. Family/POA and resident decline hipsters, helmet. POA/family aware of risks of falls such as tissue injury, fractures and death. Resident unsteady with weakness. Staff assists with ambulation as resident allows. Will continue current plan of care and continue to re-educate POA/family and resident on risks associated with falls." A progress note dated 10/24/13 at 7:30 A.M., indicated, "Alarm mat sounding, CNA, (CNA's name) found lying on floor, with head against bathroom door frame. No new injuries noted..." A progress note dated 10/24/13 at 4:15 P.M., indicated, "Follow up to resident's fall this day. Staff responded to resident's sounding alarm and found resident lying on back with head against bathroom door frame. MAEs. No red, open, or edematous areas noted..." "... Meeting with interdisciplinary care team and wife, daughter, and Ombudsman to discuss falls, risk and consequences of falls, and safety interventions. Wife and daughter at this time is agreeable to attempt low bed. Also agreeable to wheelchair with velcro seat belt as resident has displayed unsteadiness and weakness. Discussed resident will not be left unattended in wheelchair with wife and daughter's verbalization of understanding. Rear anti-tipsters and rollbacks to wheelchair. At this time, wheelchair with velcro seat belt alarm in place without resident agitation. Resident made comment regarding his wheelchair with velcro belt as 'cadillac.' Continue 15-min checks...Resident's toileting plan discussed with interdisciplinary care team and family/wife and was changed to toileting plan before meals, after meals, and bedtime, and as needed. Alarm mat at bedside maintained and functional. Will continue current plan of care." On 11/21/13 at 9:23 A.M., the Director of Nursing was interviewed regarding Resident #2's falls. The DON was made aware of the problem of lack of adequate supervision being provided to prevent falls. She indicated at that time she agreed there was a problem with adequate supervision. On 11/21/13 at 10:06 A.M., the DON was made aware of the problem of a lack of interventions being initiated after the 7/28/13, 8/11/13, 8/15/13, 9/4/13, 9/28/13, 9/29/13, and 10/20/13 falls. No further information was provided by the DON. On 11/20/13 at 4:00 P.M., the facility's fall policy was received and reviewed. The policy included but was not limited to: "... POLICY: Each resident must be assessed on admission, quarterly, any changes in condition, and recent fall for potential risk for falls to ensure preventative measure are approached..." "...PURPOSE: 2. Initiate preventative approaches..." 3.1-45(a)(2)