Every finding on record at Greencroft Healthcare

Based on record review and interview, the facility failed to follow the plan of care for a resident with a history of falls. This deficient practice resulted in a resident falling and sustaining multiple injuries, including bilateral (affecting both sides) small acute subarachnoid hemorrhage along the temporal lobes, a small acute intraventricular hemorrhage in occipital horns, a 0.7 centimeter subdural hematoma and an acute right occipital bone fracture extending into the forearm magnum. (Resident B) Finding includes:Resident B's record review was completed on 12/17/2025 at 11:30 A.M. Diagnoses included, but were not limited to: right side fracture of the base of skull, dementia, traumatic subarachnoid hemorrhage, conversion disorder with seizures or convulsions, senile degeneration of brain, depression, generalized anxiety disorder and obstructive and reflux uropathy. An Annual Minimum Data Set (MDS) assessment, dated 9/11/2025, indicated Resident B had minimal difficulty hearing, had clear speech, had been able to make himself understood and been able to understand others and had adequate vision without glasses. In addition, Resident B had moderate cognitive impairment, had not had any behaviors towards himself, staff or other residents and had not wandered or rejected any care, required moderate assistance of one staff member to move from the seated to standing position, utilized a walker to ambulate and required the assistance of one staff member for supervision or touch assistance while ambulating. A Fall Risk Evaluation, dated 10/3/2025, indicated Resident B required an assistance device while walking (walker) and was a high risk for fall. A current Care Plan, initiated on 8/15/2025, indicated Resident B had a high risk of falls. The interventions included on the plan were staff was to keep walker within reach of resident (initiated on 10/16/2025) and staff were to apply non-skid socks at bedtime (initiated on 10/16/2025).An Incident note, dated 10/10/2025 at 3:55 P.M., indicated Resident B had been found on the bathroom floor in his room. Resident B had not been using his walker at the time of the fall. The care plan for Resident B was not updated after the 10/10/2025 fall with any new preventative interventions until 10/16/2025. An Incident Note, dated 10/16/2025 at 1:48 A.M., indicated Resident B had been found sitting on the floor of his room, near the door. The resident had not been using his walker and had been wearing regular socks and not non skid socks. Resident B's record lacked the documentation he had refused to wear non skid socks. There were no new care plan interventions implemented related to the 10/10 and 10/16/2025 falls.An Incident Note, dated 11/14/2025, indicated Resident B was in the dining room and had gotten up without assistance and without his walker when he fell and hit his head and immediately started to have a seizure. The resident's family declined to have the resident sent to the Emergency Department (ED) to be evaluated. A Nursing Note, dated 11/19/2025 2:42 P.M., indicated staff had called Resident B's POA and requested the resident be sent to the ED for an evaluation from the fall on 11/14/2025 due to increased falls. The note indicated the resident had a witnessed fall on 11/18/2025 and an unwitnessed fall on 11/19/2025, both without injury. Resident B's POA was agreeable to transfer the resident to the ED. A Radiology Report from a local ED, dated 11/19/2025 at 5:52 P.M., indicated Resident B's Computed Tomography (CT) scan had identified a bilateral small acute subarachnoid hemorrhage along the temporal lobes, a small acute intraventricular hemorrhage in occipital horns, a 0.7 centimeter subdural hematoma and an acute right occipital bone fracture extending into the forearm magnum. During an interview on 12/17/2025 at 2:30 P.M., the Assistant Director of Nursing (ADON) indicated she had been the staff member responsible for reviewing falls. The ADON indicated the IDT staff reviewed all falls and after each fall, the Care Plan should have been updated with a new intervention. The ADON indicated Resident B's Care Plan already had an intervention to keep his walker within reach at the time of the fall on 11/14/2025, but staff believed it might have been a tripping hazard for other residents and moved the walker across the room, against the wall, out of Resident B's reach. The ADON indicated she believed the intervention to keep the walker within reach had not applied to the dining room and had only applied to the resident's room. No information had been provided to establish if the intervention should not have been utilized in the dining room or other common areas of the facility before the end of the survey on 12/18/2025 at 4:10 P.M. During an interview on 12/18/2025 at 1:40 P.M., the ADON indicated she had not been aware Resident B's Care Plan regarding fall risk had not been updated with any new intervention or why the IDT had not reviewed the fall from 10/10/2025. The ADON indicated if a resident refused an intervention, the refusal should have been documented in the Electronic Medical Record. During an interview on 12/18/2025 at 1:45 P.M., the Director of Nursing (DON) indicated the facility did not have a policy for following the Care Plan interventions.On 12/18/2025 at 3:00 P.M. the ADON provided a policy, dated 11/15/2025 and titled, Post Fall Assessment Policy and identified it as the policy currently used by the facility. The policy indicated, .9. Update the resident's care plan based on findings from the post-fall assessment and probable root cause of the fall The past noncompliance began on 10/10/2025 when staff failed to implement fall interventions for Resident B. The harm level citation was corrected on 12/4/2025 when the facility implemented a systemic plan that included a review of all residents at risk for falls, review of the care plan interventions for all residents at risk for falls, education of all front line staff regarding fall interventions and care plan implementation and weekly auditing of all falls to ensure the plan had been implemented correctly. This citation relates to Intakes 2643464 and 2677313. 3.1-45 (a)(2)

Based on interview and record review, the facility failed to provide showers timely for a dependent resident for 1 of 4 residents who were reviewed for showers. (Resident D)During an interview on 12/16/2025 at 2:40 P.M., Resident D could not recall the last time he had had a shower. Resident D's record review was completed on 12/18/2025 at 2:45 P.M. Diagnoses included, but were not limited to: displaced fracture of cervical vertebra, Lewy Bodies dementia, Parkinson's disease and right foot drop. An admission Minimum Data Set (MDS) assessment, dated 9/19/2025, indicated Resident D had intact cognition and was dependent on staff for showering. Resident D's record lacked the documentation that he had been given a shower on 11/17, 11/20, 11/27, 12/1 and 12/15/2025 as scheduled. There was no documentation to indicate the resident had been showered on different dates or he had refused a shower on his scheduled dates. A current Care Plan, initiated on 9/16/2025, indicated Resident B had self-care deficit related to bathing. An intervention, initiated 9/16/2025, indicated staff was to help the resident with activities of daily living. During an interview on 12/18/2025 at 3:30 P.M., the Director of Nursing (DON) indicated there was not any more shower sheets or documentation indicating Resident D had received two showers a week. The DON indicated all residents should have been offered two showers or bed baths per week and if the resident refused, the refusal should have been documented in the resident's record. On 12/18/2025 at 3:330 P.M., the DON provided a policy, dated 11/15/2025 and titled, Activities of Daily Living. The DON identified the policy as the one currently used by the facility. The policy indicated, .Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care This citation relates to Intake 2643464.3.1-38(a)(3)

Based on record review and interview, the facility failed to ensure 1 of 3 residents reviewed for medication administration was free from significant medication errors. (Resident B) This deficient practice resulted in the resident experiencing nausea and vomiting and requiring the administration of an additional medication to treat the adverse side effect of the medication errors.Finding Includes:Resident B's clinical record was reviewed on 8/7/25 at 9:11 A.M., diagnoses included but were not limited to a history of stroke with hemiplegia, heart disease, constipation, gastroenteritis, colitis.Resident B was admitted to the facility for respite care from home and under hospice care on 6/3/25. Hospice Physician's orders dated 6/3/25, on admission, included but were not limited to; Morphine concentrate 100 mg/5mL (20 mg/mL), 0.25 mL, orally for shortness of breath or severe pain every 4 hours as needed, Lomotil 2.5 mg- 0.025 mg, 1 tablet orally, every 8 hours as needed for diarrhea, Tums 200 mg chewable tablet, 2 tablets orally, (no time frame given), as needed for gastroenteritis. On 6/4/25 hospice added an order for Zofran 4 mg, 1 tablet every 6 hours as needed for nausea and vomiting.Review of Resident B's Medication Administration Record, dated 6/3/25, indicated the resident was to receive; Morphine concentrate 10 mg/0.5 mL, 0.25 mL, orally for shortness of breath or severe pain every 4 hours at 6:00 P.M., 8:00 P.M., 6:00 A.M., 10:00 A.M., and at 2:00 P.M., Lomotil 2.5 mg- 0.025 mg, 1 tablet orally, every 8 hours for diarrhea, at 2:00 P.M., 10:00 P.M., and at 6:00 A.M., Tums 200 mg chewable tablet, 2 tablets orally every night at bedtime for gastroenteritis. Resident B's Medication Administration Record indicated the resident received the following; Morphine on 6/3/25 at 6:00 P.M. and 10:00 P.M., and on 6/4/25 at 2:00 A.M. and 6:00 A.M., Lomotil on 6/3/25 at 10:00 P.M. and on 6/4/25 at 6:00 A.M., Tums on 6/3/25 at 8:00 P.M., Zofran on 6/4/25 at 2:39 P.M., and on 6/5/25 at 5:29 A.M.The resident's Medication Administration Record on 6/3/25 and 6/4/25 indicated the resident was not experiencing any shortness of breath, pain, or diarrhea. There was no complaint of gastroenteritis documented on 6/3/25.Resident B's Review Assessment/Pain Interview, dated 6/3/25 at 8:56 P.M., indicated the resident was able to express herself to other and able to understand others, in the past 5 days, the resident had not experienced any pain or shortness of breath, and diarrhea was not listed as a current problem or condition.The resident's Interdisciplinary Notes included but were not limited to the following: 6/4/25 at 7:11 A.M., a physician's note indicated the resident took morphine for shortness of breath and pain and was not experiencing any diarrhea. 6/4/25 at 3:54 P.M., .Resident nauseous and vomiting this afternoon. 6/4/25 at 3:30 P.M., Medications clarified with [hospice]. Zofran 4 mg every 6 hours as needed for nausea and vomiting. 6/4/25 at 8:53 P.M., Resident alert, verbal and oriented.Had 2 episodes of vomiting this shift. PRN Zofran given. No complaint of pain. On 8/8/25 at 12:58 P.M. during an interview, the Admissions Coordinator, indicated when Resident B was admitted for respite care, the facility received medication orders from the resident's hospice service and then sent the facility physician who would check and sign the orders and then sent to the unit where the admitting nurse entered the orders in the Electronic Medical system.During an interview on 8/8/25 at 1:05 P.M., the Assistant Director of Nursing indicated Registered Nurse 4 was Resident B's the admitting nurse and entered the resident's orders in the computer incorrectly. She indicated Morphine, Lomotil, and Tums were incorrectly entered into the system as routine medications when they had been ordered as needed.On 8/8/25 at 2:29 A.M., during an interview the hospice nurse indicated, on 6/4/25 at an unknown time, she received a report from the facility that the resident was having nausea and vomiting and that the nurse had withheld her morphine. The hospice nurse indicated she went to the facility at that time and noted Resident B's Morphine, Lomotil, and Tums had been entered in the system to be administered as routine rather than PRN as ordered. The hospice nurse indicated on arrival, the resident was nauseated, so ordered Zofran in response, and then notified the resident's responsible party of the medication error.A policy titled Medication Error Policy, dated 4/19, was provided by the Administrator on 8/11/25 at 8:40 A.M., and deemed as current. The policy indicated, .'Medication error' means the observed or identified.administration of medications.not in accordance with: the prescriber's order.The facility shall ensure medications will be administered as follows: a. According to the physician's orders.This citation relates to Complaint 1699537.3.1-48(c)(2)

Based on record review and interview, the facility failed to provide wound care as directed by the physician for 1 of 3 residents reviewed for wounds.(Resident D).Finding includes:The clinical record for Resident D was reviewed on 8/6/25 at 2:14 P.M. Diagnoses included, but were not limited to, peripheral neuropathy, type 2 diabetes, anxiety, chronic kidney disease, and history of stroke.Resident D's physician's orders included an current order for weekly skin checks. The order was dated 3/4/25 to begin on 3/11/25 and had no stop date. The order indicated the facility was to complete a head to toe assessment of the resident's skin and to re-evaluate and update any existing skin concerns every week on Monday evenings.A Skin Evaluation Record dated 4/9/25 at 2:22 P.M., indicated Resident D had a partial thickness skin tear to the right buttock, described as a scrape measuring 0.2 cm wide x 0.2 cm long x 0.1 cm depth. The wound was treated with zinc oxide.Review on Resident D's Treatment Administration Record indicated Resident D's order for a re-evaluation of the skin concern was signed off, but there were no associated re-evaluations documented on 4/21/25, 4/28/25, 5/5/25, 5/19/25 or 5/26/25.Resident B's Skin Evaluations, from 6/2/25 to 7/7/25, indicated there had been no change in the resident's wound size or condition, with the wound measuring on 7/7/25 at 9:50 P.M.- 0.1 cm wide x 0.1 cm long x 0.1 cm deep. The form indicated the wound continued to be treated with zinc oxide.Review of Resident B's Progress Note dated 7/10/25 at 4:15 P.M., indicated Resident B had requested a skin assessment of his right buttock and the nurse had examined the area per his request. The note indicated the Nurse Practitioner was notified of the wound condition and new orders had been received to begin Nystatin and Triamcinolone (topical creams to treat fungal and yeast infections) topically 2 times daily for 7 days. There was no documentation that a skin assessment had been completed on 7/10/25.A Skin Evaluation Record, dated 7/14/25, indicated a partial thickness skin tear to the right buttock that was described as dark pink and measured - 7.8 cm wide x 5.3 cm long x no depth.A new order had been received on 7/17/25 to extend the treatment of Nystatin and Triamcinolone topically 2 times daily for an additional 7 days.On 8/11/25 at 8:30 A.M., during an interview with the Assistant Director of Nursing, she confirmed there had been a lack of documentation regarding Resident D's Weekly Skin Check re-evaluations related to the wound to the right buttock and that the resident's wounds should have been assessed and documented as ordered.On 8/11/25 at 9:40 A.M., the Administrator provided a copy of the facility policy titled, Skin Assessment, dated 8/19/24, and deemed it to be the current facility policy. The policy indicated, .[A] skin assessment will be conducted by a licensed or registered nurse upon admission and weekly thereafter.Documentation of skin assessment: a. Include date and time of the assessment, your name, and position title. b. Document observations [e.g. skin conditions, how the resident tolerated the procedure, etc.]. c. Document type of wound. d. Describe the wound[measurements, color type of tissue in wound bed, drainage, odor, pain]. e. Document if resident refused assessment and why. f. Document other information as indicated or appropriate.On 8/11/25 at 9:40 A.M., the Administrator provided a copy of the facility policy titled, Wound Documentation, dated 2/26/24, and indicated it was the current policy used by the facility. The policy indicated that wound assessments were to be documented upon weekly and as needed if the resident or wound condition deteriorated.This Citation relates to Complaint 2571559.3.1-37(a)

Based on interview, observation and record review, the facility failed to ensure residents were informed of where the Ombudsman and other state agencies phone numbers were located. This had the potential to affect 145 of 145 residents who resided in the facility. Findings include: During the resident/surveyor meeting, on 5/20/2025 at 10:45 A.M., 11 of 11 residents in attendance indicated they were unaware of where the Ombudsman's contact information or telephone number and where a copy of resident rights was posted. During a random observation, on 5/20/2025 at 11:48 A.M., a poster of the resident rights was hung on a wall in a lounge area past the receptionist desk. A small desk was attached to the wall beneath the Resident Rights poster, making it difficult for a resident using a wheelchair for mobility to be able to visulize the entire poster. In the same lounge area, on a shelf, there was printed paper in a plastic stand with the Ombudsman phone numbers, the State health department and other required agencies and their contact information. During an interview, on 5/20/2025 at 12:10 P.M., the Administrator indicated the Resident Rights and Ombudsman phone numbers were easily accessible to the family. He indicated the residents had been given a handbook with this information on admission. The Administrator indicated the information for the Ombudsman and the Resident Rights should probably be in each hall. On 5/23/2025 at 1:00 P.M., the Administrator provided the policy titled, Facility Required Postings, dated 8/1/2024, and indicated the policy was the one currently used by the facility. The policy indicated .The campus will post required postings in an area that is accessible to all team member(s) and residents 3.1-4(j)(3)

Based on observations, record review and interviews, the facility failed to ensure 1 of 3 residents reviewed for resident rights were informed of treatment and medication changes. (Resident 36) Finding includes: A record review For 36 was completed, on 5/21/2025. Diagnoses included, but were not limited to: anxiety disorder and major depressive disorder. A Significant Change Minimum Data Set (MDS) assessment, dated 4/22/2025, indicated Resident 36 had severe cognitive impairment and received anti-anxiety medication. A Physician's Order, dated 5/13/2025, indicated lorazepam 0.5 milligrams every four hours as needed. A Care Plan, dated 10/18/2024, indicated Resident 36 used anti-anxiety medication related to his diagnoses of anxiety. Interventions included, but were not limited to: assessing anxiety level and the need for anti-anxiety medication and administration of anti-anxiety medication per the physician order. During observations on 5/22/2025 at 9:22 A.M., 5/22/2025 at 1:48 P.M. and 5/23/2025 at 8:54 A.M., Resident 36 was observed lying in bed. During an interview, on 5/23/2025 at 9:06 A.M., QMA 2 indicated Resident 36 took lorazepam for restlessness. During an interview, on 5/23/2025 at 1:27 P.M., the Director of Nursing (DON) indicated a notification to Resident 36's representative of the risk of psychotropic medication use could not be found in the medical record. A policy was provided on, 5/23/2025 at 1:00 P.M., by the DON. The policy titled, Psychotropic Medication Policy, indicated, .Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication[s] .5. Residents and/or representatives shall be educated on the risks and benefits of psychotropic drug use, as well as alternative treatments/non-pharmacological interventions 3.1-3(n)(2)

Based on observation, record review and interview, the facility failed to provide a dignity bag to cover a urinary drainage bag for 1 of 2 residents reviewed for urinary catheters. (Resident 36) Finding includes: During an interview, on 5/19/2025 at 1:47 P.M., Resident 36's wife indicated Resident 36 had a suprapubic catheter and had had his urinary catheter for the past two and a half years. A record review for Resident 36 was completed on 5/21/2025. Diagnoses included, but were not limited to: retention of urine and pressure ulcer of sacral region. A Significant Change Minimum Data Set (MDS) assessment, dated 4/22/2025, indicted Resident 36 had severe cognitive impairment, had an indwelling urinary catheter, had an unstageable pressure ulcer and received hospice services. A Physician's Order, dated 5/18/2023, indicated catheter care- use a leg bag when out of bed and replace every shift with urinary drainage bag when in bed. A Care Plan, dated 5/31/2023, indicated Resident 36 had a suprapubic urinary catheter due to a history of urinary retention and a diagnosis of obstructive uropathy. Interventions included, but were not limited to: make sure the urinary catheter bag was emptied at the end of every shift and keep the closed urinary drainage system below the bladder. During an observation, on 5/22/2025 at 9:22 A.M., Resident 36 was observed lying in bed with the urinary drainage bag hooked to the bed frame. Yellow liquid was observed in the urinary drainage bag. A dignity cover was not over the urinary drainage bag and was visible to anyone entering the room. During an observation, on 5/22/2025 at 1:48 P.M., Resident 36 was observed lying in bed with the urinary drainage bag hooked to the bed frame. A dignity cover was not over the urinary drainage bag and was visible to anyone entering the room. During an observation, on 5/23/2025 at 8:54 A.M., Resident 36 was lying in bed, and the urinary drainage bag was seen from the hallway hanging to the bed frame. During an interview, on 5/23/3035 at 8:55 A.M., CNA 6 indicated the urinary drainage bag should have had a dignity cover. A policy was provided on, 5/23/2025 at 1:00 P.M., by the DON. The policy titled, Indwelling Catheter Use and Removal Policy, indicated, .It is the policy of this campus to ensure that indwelling catheters that are inserted or remain in place are justified or removed according to regulations and current standards of practice The policy did not address the use of a dignity bag for resident comfort. 3.1-3(t)

Based on observation, record review and interview, the facility failed to store respiratory equipment in a sanitary manner for 1 of 2 residents reviewed for respiratory care. (Resident 66) Finding includes: During an observation, on 5/19/2025 at 10:45 A.M., Resident 66's nebulizer mask and tubing had not been dated or bagged, and the dirty mask with white colored specs of dried debris was laying on the bed side table. During an observation, on 5/21/2025 at 9:10 A.M., Resident 66's nebulizer mask and tubing had not been dated or bagged, and the dirty mask with white colored specs of dried debris remained on the bedside table. During an observation, on 5/22/2025 at 9:02 A.M., the nebulizer mask and tubing had not been dated or bagged, and the dirty mask with white colored specs of dried debris remained on the bedside table. The record for Resident 66 was reviewed on 5/21/2025 at 11:51 A.M. Diagnoses included, but were not limited to diabetes, depression, dementia, anxiety and chronic obstructive pulmonary disease. Resident 66's current Physician Orders included: Ipratropium-albuterol 0.5 mg (milligram) -3 mg (2.5 mg base)/3 ml Neb Solution 1 ml inhalation every 6 hours as needed for cough and congestion. There were no physician's order specific to changing the nebulizer mark or tubing. During an interview, on 5/22/2025 at 9:17 A.M., RN 19 indicated the nebulizer mask should have been stored in a bag when it was not in use and should have been dated to indicate when the mask and/or tubing had been changed. On 5/23/2025 at 11:29 A.M., the Director of Nursing provided the policy titled, Oxygen Therapy-Nebulizer Treatment, dated 1/2016, and indicated the policy was the one currently used by the facility. The policy indicated .6. After treatment, remove mask, disassemble nebulizer set, rinse and place clean nebulizer set in plastic bag . 9. Tubing, nebulizer set, and plastic bag are changed weekly 3.1-47(a)(6)

Based on record review and interview, the facility failed to ensure required transfer and resident clinical information was completed for 2 of 4 residents reviewed for transfers. (Residents 140 &148) Findings include: 1. The record for Resident 148 was reviewed on 5/22/2025 at 11:51 A.M. Diagnoses included, but were not limited to heart failure, depression, arthritis, pain, diabetes, atrial-fibrillation and septicemia. Resident 148 was admitted on [DATE] and discharged on 5/10/2025. A Nurses Progress Note, dated 5/9/2025 at 2:38 P.M., indicated the resident had complaint of nausea that morning and had been given Zofran, (antiemetic to prevent nausea and vomiting). The resident had continued to refuse medications because they made her sick to her stomach. A Nurses Progress Note, dated 5/10/2025 at 10:54 P.M., indicated Resident 148 had been admitted to the hospital according to the ER nurse. A Nurses Progress Note, dated 5/12/2025, indicated the nurse had received a text from the resident's daughter. The daughter and the resident did not want to hold the resident's bed. They planned to return home with hospice services. A Copy of the Bed Hold form were mailed to Resident. On 5/23/2025 at 12:03 P.M., the Director of Nurses provided a copy of a Notice of Transfer or Discharge form, a progress note dated 5/12/2025 and 11 pages of Resident 148's orders. The record lacked copies of transfer documentation including: the bed hold, the resident's clinical status prior to the transfer, reason for the transfer and most recent diagnostic and lab tests. On 5/23/2025 at 3:10 P.M., the Director of Nursing indicated she could not provide any transfer document or a checklist of what was sent with the resident. She indicated the facility had sent a list of the residents' medications, the POA (power of attorney) information, and had called the hospital to give report. 2. The record for Resident 140 was reviewed on 5/22/2025 at 11:00 A.M. Diagnoses included, but were not limited to malnutrition, atrial valve disorder, cancer and heart failure. Resident 140 was admitted on [DATE] and discharged on 3/31/2025. A Nurses Progress Note, dated 3/31/2025 at 1:34 A.M., indicated the NP (Nurse Practitioner) had been called to notify her of the resident's elevated temperature and low blood pressure. The family had been notified of Resident 140's change of condition and requested the resident be sent out to the ER (emergency room). A Nurses Progress Note, dated 3/31/2025, indicated the EMT (emergency medical technicians) were there to transport the resident to the hospital. A report had been called to the hospital and all the paperwork needed had been provided. The resident's daughter was to meet the resident at the hospital. On 5/23/2025 at 12:04 P.M., the Director of Nurses provided a copy of a Do Not Resuscitate Declaration and Order, copies of medical and financial POA's (Power of Attorney), a progress note, dated 4/1/2025, indicating the facility was unable to reach the family to provide the bed hold informstion prior to the resident's passing/expiring in the hospital, and 11 pages of the Resident 148's orders. The record lacked copies of transfer documentation including: the bed hold form, the resident's clinical status prior to the transfer, the reason for the transfer and the most recent diagnostic and lab tests. On 5/23/2025 at 2:28 P.M., the Director of Nursing indicated she could not provide any sort of transfer document or even a check list for Resident 148. She indicated the facility had sent a list of the residents' medications, the POA (power of attorney) information, and had called the hospital to had give a veral report. On 5/23/2025 the facility policy was requested regarding Discharge/Transfers but one was not provided prior to the survey exit. 3.1-12(a)(6)(A)

Based on record review and interview, the facility failed to develop person centered care plans for a new pressure area and refusal to have facial hair removed for 2 of 31 residents whose care plans were reviewed. (Resident 94 and 33) Findings include: 1. During an interview, on 5/21/2025 at 9:19 A.M., CNA 18 indicated she thought Resident 94 had a very small area on his bottom last week. She indicated it's an independence thing with him. He always wants to stay in his wheelchair because he knows he can go whenever he wants to. She indicated therapy had been working with the resident on self-transfers in and out of bed. During an observation, on 5/21/2025 at 9:26 A.M., Resident 94 was assisted to the bathroom where he was able to stand upright while holding onto the toilet seat riser bars. The aide pulled his pants down and Resident 94 had an open area to the left inner buttock cheek. No dressing was observed covering the area. The record for Resident 94 was completed on 5/21/2025 at 9:37 A.M. Diagnoses included, but were not limited to chronic kidney disease, hemiplegia, insomnia, low back pain, restless leg syndrome and venous insufficiency. A current Care Plan, dated 2/16/2024, indicated the resident had the potential for or actual skin impairment related to venous insufficiency, end stage chronic kidney disease, right hemiplegia and frail skin that tears easily. Interventions included but were not limited to: Observe resident's skin daily with care. Report any changes in skin integrity to nurse. Encourage/assist with frequent position changes if a resident is sitting or lying in the same position for extended periods of time. A current Care Plan, dated 2/16/2024, indicated the resident had impaired physical mobility related to end stage renal failure, bursitis, cellulitis, neck pain, low back pain, right side hemiplegia, venous insufficiency. Interventions included but were not limited to assisting with ADL's (activities of daily living) as directed. He required staff to assist as needed with bed mobility, transfers and toileting and assist/encourage resident to participate with ADL tasks. A current Care Plan, dated 2/16/2024, indicated the resident's skin would remain clean, dry and free of breakdown related to incontinence. Interventions included but were not limited to: Perineal cleansing and apply protective skin barrier after each incontinent episode. Assess and report signs of impaired skin integrity or breakdown. A current Care Plan, dated 5/21/2024, indicated Resident 94 was at risk for further impaired skin integrity related to impaired mobility, moisture, history of pressure ulcers and cellulitis. Interventions included but were not limited to alternating air loss mattress, pressure reducing cushion for wheelchair, treatments as ordered and offer peri care after incontinent episodes and every shift. During an interview, on 5/21/2025 at 10:33 A.M., RN 19 indicated she thought she was notified of the open area on Resident's 94 left buttock cheek. RN 19 was questioned about the procedure when a new skin issue was observed to a resident. RN 19 indicated the area was to be measured, a skin incident was to be completed and entered into the computer, and the physician, family and management were to be notified. RN 19 indicated there was no Skin Incident and no current treatment order for Resident 94's open area. She indicated there should have been a Skin Incident, a treatment order in place and a care plan initiated for the open area. 2. During an observation, on 5/19/2025 at 10:04 A.M., Resident 33 was observed to have a large amount of hair on her chin and upper lip. A record review was completed for Resident 33 on 5/21/2025 at 2:46 P.M. Diagnoses included, but were not limited to: moderate protein calorie malnutrition, anxiety and depression. A Quarterly MDS (Minimum Data Set), dated 5/6/2025 indicated Resident 33's cognition was intact and she required setup and cleanup assistance from staff with personal hygiene. During an interview, on 5/22/2025 at 8:24 A.M., Resident 33 indicated she did not want anyone helping her with her facial hair and she would take care of it when she wanted to. During an interview, on 5/22/2025 at 9:10 A.M., LPN 11 indicated she had asked the resident if she could shave her facial hair in the past and the resident always refused. During an interview, on 5/22/2025 at 10:34 A.M., CNA 15 indicated Resident 33 usually refused to have her facial hair shaved. She indicated that if the resident refused, she documented the refusal in the resident's electronic medical record. A current Care Plan, initiated on 4/13/2020 indicated the resident had the potential for a self care deficit related to requiring staff assistance with ADL's (activities of daily living) and refused showers at times. Interventions included, but were not limited to: assist with ADL's as indicated. The Care Plan lacked documentation that Resident 33 had refused when staff attempted to assist her with the removal of her facial hair. During an interview, on 5/23/2025 at 8:56 A.M., the Househould's Unit Manager indicated that if the resident refused to have staff help her with removing her facial hair then it should have been documented on her care plan. On 5/23/2025 at 9:57 A.M. the Househould's Unit Manager provided the policy titled, Care Plan - Care Plan Reviews, dated 7/2006 and indicated it was the policy currently being used by the facility. The policy indicated, Purpose: To maintain care plans on a current status. 1. The Care Plan team will be responsible for the periodic review and updating of care plans 3.1-35(e)

Based on observation, record review and interview the facility failed to ensure medications were administered based on manufacturers guidelines for 1 of 5 residents reviewed for medication administration (Resident 37). Finding includes: During an observation of medication administration on 5/21/2025 at 11:53 A.M., LPN 9 administered one omeprazole 20 mg (milligrams) delayed release capsule by mouth to Resident 37. During the time of administration, Resident 37 had been sitting in the dining room and had already eaten most of his lunch. A record review was completed for Resident 37 on 5/21/2025 at 2:07 P.M. Diagnoses included, but were not limited to: gastro-esophageal reflux disease. A Physician's Order, initiated on 2/21/2025 indicated the resident was to receive omeprazole 20 mg delayed release tablet every day at noon. During an interview, on 5/22/2025 at 11:19 A.M., the (Pharmacy Name) Pharmacist indicated, ideally the omeprazole 20 mg delayed release capsule should have been given prior to the resident's first meal of the day. On 5/22/2025 at 1:30 P.M. the ADON provided the medication information sheet titled, Omeprazole Delayed-Release Capsules and Tablets, no date. The medication information sheet indicated, Take this drug before meals On 5/23/2025 at 11:08 A.M., the DON provided the policy titled, Medication Administration, dated 12/13/2024 and indicated it was the policy currently being used by the facility. The policy indicated, 17. Administer medication as ordered in accordance with manufacturer specifications. a. Provide appropriate amount of food and fluid 3.1-48(c)(2)

Based on interview, observation and record review, the facility failed to ensure a resident who was at risk for pressure ulcers did not develop a stage II pressure ulcer and failed to implement a treatment for 1 of 2 residents reviewed for pressure ulcers. (Resident 94) Finding includes: During an interview, on 5/21/2025 at 9:19 A.M., CNA 18 indicated she thought Residnet 94 had a very small area on his bottom last week. She indicated it's an independence thing with him. He always wants to stay in his wheelchair because he knows he can go whenever he wants to. She indicated therapy had been working with him on self-transfers in and out of bed. During an observation, on 5/21/2025 at 9:26 A.M., Resident 94 was assisted to the bathroom where he was able to stand upright while holding onto the toilet seat riser bars. The aide pulled his pants down and Resident 94 had an opened area to the left inner buttock cheek. The area was approxamately a half inch in diameter with red colored tissue to the center of the wound. No dressing was observed covering the area. The record for Resident 94 was completed on 5/21/2025 at 9:37 A.M. Diagnoses included, but were not limited to chronic kidney disease, hemiplegia, insomnia, low back pain, restless leg syndrome and venous insufficiency. Resident 94's Physician Orders included: Weekly Skin Check. Complete head to toe assessment of skin. Document findings in Skin Condition tab. Re-evaluate and update existing skin concerns. If new conditions are found, initiate the Skin Condition Checklist. A Braden Scale for Predicting Pressure Sore Risk assessment, dated 1/14/2025, indicated Resident 94's score totaled 15, which meant he was at risk for pressure ulcer/injury developement. A Braden Scale for Predicting Pressure Sore Risk assessment, dated 4/8/2025, indicated Resident 94's score totaled 17, which meant he was at risk for pressure ulcer/injury developement. A current Care Plan, initiated on 2/16/2024, indicated the resident had the potential for or actual skin impairment related to venous insufficiency, end stage chronic kidney disease, right hemiplegia and frail skin that tears easily. Interventions included but were not limited to: Observe resident's skin daily with care. Report any changes in skin integrity to nurse. Encourage/assist with frequent position changes if a resident is sitting or lying in the same position for extended periods of time. A current Care Plan, initiated on 2/16/2024, indicated the resident had impaired physical mobility related to end stage renal failure, bursitis, cellulitis, neck pain, low back pain, right side hemiplegia, venous insufficiency. Interventions included but were not limited to assisting with ADL's (activities of daily living) as directed. staff to assist as needed with bed mobility, transfers and toileting and assist/encourage resident to participate with ADL tasks. A current Care Plan, initiated on 2/16/2024, indicated a plan to address the resident's risk for skin impairment. The goal was for the resident's skin to remain clean, dry and free of breakdown related to incontinence. Interventions included but were not limited to: Perineal cleansing and apply protective skin barrier after each incontinent episode. Assess and report signs of impaired skin integrity or breakdown. A current Care Plan, initiated on 5/21/2024, indicated Resident 94 was at risk for further impaired skin integrity related to impaired mobility, moisture, history of pressure ulcers and cellulitis. Interventions included but were not limited to alternating air loss mattress, pressure reducing cushion for his wheelchair, treatments as ordered and offer peri care after incontinent episodes and every shift. During an interview, on 5/21/2025 at 10:33 A.M., RN 19 indicated she thought she had been previously notified of the open area on Resident's 94 left buttock cheek. RN 19 was questioned about the procedure when a new skin issue was observed to a resident. RN 19 indicated the area was to be measured, a skin incident report needed to be completed and entered into the computer, and the physician, family and facility management were to be notified of the open area. RN 19 indicated there was no Skin Incident assessment completeed and no current treatment order for Resident 94's open area. She indicated there should have been a Skin Incident, a treatment order in place and care plan initiated for the new open area. During the interview, on 5/21/2025, RN 19 was questioned regarding the timing of when weekly skin assessments were completed by the nurses. RN 19 indicated the weekly skin assessments were documented on the shower sheets. Resident 94's Shower Sheet/Skin Check sheets for May 2025 had been completed on 5/1 and 5/15/2025 with no open area observed to the left buttocks documented on either form. A Shower Sheet/Skin Check sheet, completed on 5/22/2025, after the observation and interview with RN 19 confirming the open area, indicated the resident's skin was intact, no ulcers/open wounds but yes was checked for reddened area. A Skin Evaluation Form, dated 5/6/2025, indicated General skin check completed-existing wounds noted no changes.The following was marked - Pressure reduction bed: Not applicable. Preventative Protective Skincare: Not applicable. Turning/ Repositioning Program: Not applicable. A Skin Evaluation Form, dated 5/12/2025, indicated General skin check completed indicated the following was marked- No new issues. Pressure reduction bed: Not applicable. Preventative Protective Skincare: Not applicable. Turning /Repositioning Program: Not applicable. A Skin Evaluation Form, dated 5/19/2025, indicated General skin check completed. No new issues. The following was marked - Pressure reduction bed: Inapplicable. Preventative Protective Skincare: In applicable. Turning/Repositioning Program: Inapplicable. A Nurse's Progress Note, dated 5/21/2025 at 1:14 P.M., indicated RN 19 had assessed an open area on Resident 94's left buttock. The area was not on a bony prominence. The area measured 0.5 cm x 1.0 cm. The note indicated the nurse had applied [NAME] oxide and had notified the physician, family and facility management. During an interview, on 5/21/2025 at 2:05 P.M., Resident 94 indicated he was given a shower last Thursday, 5/15/2025, or Friday, 5/16/2025. He indicated hospice had previously been completing his showers, three times a week and since the facility had been giving his showers, he received them two times a week. Resident 94 indicated the facility was having trouble getting them (showers) started again. He indicated that his buttocks hurt. When questioned what type of pain, he indicated it was a continuous severe achy pain.'' In addition, Resident 94 indicated, it hurts unless I get moved. He indicated that I try to shift and get off of it, but I can't get it done. When asked if the aides come in and stand him up or move him in his wheelchair, he stated When I pulled the cord (call light) and ask them to do it, the aides seldom do it. They say 'we have to get a nurse.' They have never changed my position. Resident 94 indicated he had not refused any showers. During an observation, on 5/22/2025 at 3:40 P.M., Resident 94's gel cushion for his wheelchair was almost flat in the middle where his buttocks was positioned. During an interview, on 5/22/2025 at 3:49 P.M., the unit manager indicated the cushion should have been changed. He was unsure if it was a pressure reduction or a pressure relieving device. He indicated the residnet should not have been sitting on the flattened cushion. On 5/23/2025 at 11:29 A.M., the Director of Nursing provided the policy titled, Pressure Injury Prevention and Management, dated 2/26/2024, and indicated the policy was the one currently used by the facility. The policy indicated . Avoidable means that the resident developed a pressure ulcer/injury and that the campus did not do one or more of the following: evaluate the residents clinical condition and risk factors; define and implement interventions that are consistent with resident needs, resident goals, and professional standards it practice; monitor and evaluate the impact of the interventions; or revise the interventions as appropriate . Interventions for Prevention and to Promote Healing. a. After completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions . c. Evidenced-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. Basic or routine care interventions could include, but are not limited to: I. Redistribute pressure (such as repositioning, protecting/or offloading heels, etc.) . c. Provide appropriate, pressure -redistributing, support surfaces . 3.1-40

Based on observation, record review and interview, the facility failed to ensure a safe smoking assessment was completed, smoking materials were locked up and safe disposal of cigarette butts was designated for 1 of 1 resident reviewed for accidents and hazards. (Resident 73) Finding includes: During an observation, on 5/20/2025 at 10:50 A.M., Resident 73 was observed taking himself out of the building to smoke. He was observed on the sidewalk of the facility between South 13th Street and the main entrance. During an observation, on 5/22/2025 at 8:59 A.M.-9:24 A.M., Resident 73 was observed outside smoking. He smoked three cigarettes and was observed putting the cigarette out on his wheelchair by the front wheel and held the smoked cigarette butts in his hand. During an observation, on 5/22/2025 at 2:06 P.M., Resident 73 was in his room. His cigarettes and lighter were lying inside his hat on a table in his room. During an observation, on 5/23/2025 at 9:02 A.M., Resident 73 was observed outside smoking on the facility campus. A record review for Resident 73 was completed, on 5/21/2025 at 9:55 A.M. Diagnoses included, but were not limited to: polyneuropathy, glaucoma, diabetes mellitus type 2 and nicotine dependence. A Quarterly Minimum Data Set (MDS) assessment, dated 3/12/2025, indicated Resident 73 was cognitively intact and used a motorized wheelchair. A Physician's Order, dated 12/18/2024, indicated to educate Resident 73 on the risks of smoking and document in the interdisciplinary notes every shift and smoking paraphernalia was to be placed in a lock box while inside the building. A Care Plan, initated on 1/10/2023 and revised on 1/6/2025, indicated Resident 73 would use nicotine in a safe way and in the designated area. Interventions included, but were not limited to: Resident 73 was aware of the designated area to smoke and to check in with staff before leaving, encouraged to store smoking material in nurses' carts, but declined, a lock box was provided in the room for smoking material and Resident 73 had declined to sign the facility smoking assessment. A Safe Smoking Assessment was not completed and signed by the resident until 5/21/2025. During an interview, on 5/22/2025 at 2:06 P.M., Resident 73 indicated he went outside on his own and always had his cigarettes on him. He indicated he did not throw his cigarette butts on the ground, and sometimes he knocked off the cherry (lighted end of cigarette) and threw the butts in the trash can in his room. During an interview, on 5/23/2025 at 11:47 A.M., QMA 21 indicated Resident 73 was not to smoke on the campus and he was to go across the street to smoke. She indicated Resident 73 did not need supervised and she was unsure where he disposed of his cigarette butts. During an interview, on 5/23/2025 at 1:13 P.M., LPN 3 indicated the facility was a non-smoking campus and Resident 73 chose to cross the road to smoke his cigarettes. She was not sure if Resident 73 placed his cigarette butts in his trash can in his room. During an interview, on 5/23/2025 at 1:16 P.M., the Director of Nursing (DON) indicated the facility was a non-smoking campus. She indicated Resident 73 adamantly refused to sign the safe smoking assessment until he thought the Social Service Director would get in trouble because he had not signed the assessment. The DON indicated the facility staff continually educated Resident 73 for interventions related to his smoking habits. During an interview, on 5/23/2025 at 2:03 P.M., the Social Service Director indicated there were no previously completed safe smoking assessments found in the medical record. A policy was provided, on 5/23/2025 at 1:03 P.M. by the DON. The policy titled, Smoking Policy, indicated, .It is the policy of this facility to provide a safe and healthy environment for residents, visitors, and employees, including safety as related to smoking. Safety protections apply to smoking and non-smoking residents .1. Smoking is prohibited in all areas except the designated smoking area. A 'Designated Smoking Area sign will be prominently posted .2. Safety measures for the designated smoking area will include, but not limited to: a. protection from weather conditions [i.e. covered]. b. Provision of ashtrays made of noncombustible material and safe design .4. All residents and family members will be notified of this policy during the admission process, and as needed. 5. All residents will be asked about tobacco use during the admission process, and during each quarterly or comprehensive MDS assessment process. 6. Residents who smoke will be further assessed using the Resident Safe Smoking Assessment, to determine whether or not supervision is required for smoking, or if resident is safe to smoke at all .12. If a resident or family does not abide by the smoking policy or care plan [e.g. smoking materials are provided directly to the resident, smoking in non-smoking areas, does not wear protective gear], the plan of care may be revised to include additional safety measures 3.1-45(a)(1)

Based on observation, record review and interview, the facility failed to provide identified interventions to promote consumption of meals for 1 of 3 residents reviewed for nutrition. (Resident 31) Finding includes: A record review for Resident 31 was completed on 5/21/2025 at 9:12 A.M. Diagnoses included, but were not limited to: cerebral infarction, dysphagia and hemiplegia of the left side. A Significant Change Minimum Data Set (MDS) assessment, dated 2/22/2025, indicated Resident 31 had severe cognitive impairment, required mechanically altered foods and had impairment to the upper and lower extremity on one side. A review of Resident 31's weights indicated the following: -5/19/2025 1:54 P.M. 108.4 pounds -4/15/2025 9:11 A.M. 116.0 pounds -2/18/2025 9:20 P.M. 125.2 pounds -11/25/2024 3:04 P.M. 131.0 pounds The weights reviewed indicated a 6.55 percent weight loss in one month, a 13.42 percent weight loss in three months and a 15.31 percent weight loss in months. A Nursing Progress Note, on 5/13/2025 at 8:05 A.M., indicated Resident 31 appeared to be overwhelmed by plates of food. The staff had suggested serving one item in a bowl at a time with each bowl introduced as tolerated. The suggestion was reviewed with [NAME] 22 and [NAME] 22 indicated she would share the suggestion with the facility staff. A Care Plan, dated 2/27/2025, indicated Resident 31 was at risk for malnutrition and weight changes related to a recent hospitalization with cerebral infarction with left hemiplegia and her weight had decreased significantly in the past month. Interventions included, but were not limited to: a mechanically soft diet, encouragement to eat at mealtimes, provide assistance as needed to consume meals, serve half servings of one food in a bowl at a time, offer the next bowl and big plates of food were overwhelming. During an observation, on 5/21/2025 at 11:57 A.M., Resident 31 was in the dining room with a plate of noodles and mashed potatoes with gravy in front of her. During an observation, on 5/22/2025 at 12:03 P.M., Resident 31 had eaten in her room with a plate of beets and quiche in front of her. Resident 31 had asked what she should do with the food. During an observation, on 5/23/2025 at 9:09 A.M., Resident 31 had a breakfast tray in front of her with various liquids, a bowl of cornflakes and a cup pf yogurt. She had been sleeping and had not eaten her food. During an interview, on 5/23/2025 at 1:05 P.M., CNA 6 indicated Resident 31's food should be as fun as it could be. During an interview, on 5/23/2025 at 1:07 P.M., QMA 2 indicated Resident 31 should be served small portions in individual bowls. A policy was provided on, 5/23/2025 at 1:00 P.M., by the DON. The policy titled, Weigh Loss/Gain Interventions, indicated, .To identify nutritionally at-risk residents and indicate corresponding interventions to monitor, communicate, and correct weight loss or gain .5. Weight loss or gain interventions shall be addressed on the resident's plan of care 3.1-(a)(1)

Based on record review and interview, the facility failed to follow and administer physician ordered hydration orders for 1 of 1 resident reviewed for tube feeding. (Resident 52) Finding includes: A record review for Resident 52 was completed on 5/21/2025 at 1:04 P.M. Diagnoses included, but were not limited to: functional quadriplegic, adult failure to thrive and protein-calorie malnutrition. A Quarterly Minimum Data Set (MDS) assessment, dated 5/6/2025, indicated Resident 52 had moderate cognitive impairment and received tube feeding with 51 percent of calories from the feedings and 501 cc/day (cubic centimeter per day or equal to one milliliter per day) or more of hydration from the feeding tube. A Physician's Order, dated 3/1/2024, indicated flushing the feeding tube with 120 mL (milliliters) before and after Jevity feedings, totaling a 240 mL flush. A Physician's Order, dated 3/13/2024, indicated Jevity 1.5 tube feeding two cartons (474 mL) daily and Jevity 1.5 tube feeding one carton (237 mL) three times daily. The May 2025 Medication Administration Record (MAR) indicated Resident 52 received the following water flushes below or above the ordered flush orders: -5/1/2025 8:00 A.M. 100 mL -5/1/2025 4:00 P.M. 120 mL -5/1/2025 12:00 P.M. 100 mL -5/1/2025 8:00 P.M. 120 mL -5/2/2025 8:00 A.M. 120 mL -5/3/2025 8:00 A.M. 300 mL -5/4/2025 8:00 A.M. 400 mL -5/5/2025 8:00 P.M. 100 mL -5/6/2025 8:00 A.M. 325 mL -5/8/2025 8:00 A.M. 350 mL -5/9/2025 8:00 A.M. 350 mL -5/10/2025 12:00 P.M. 120 mL -5/12/2025 8:00 P.M. 100 mL -5/13/2025 8:00 A.M. 350 mL -5/13/2025 8:00 P.M. 100 mL -5/14/2025 8:00 P.M. 100 mL -5/15/2025 8:00 P.M. 100 mL -5/17/2025 8:00 A.M. 350 mL -5/18/2025 8:00 A.M. 350 mL -5/20/2025 8:00 A.M. 300 mL -5/22/2035 8:00 A.M. 350 mL -5/22/2025 8:00 P.M. 120 mL -5/23/2025 8:00 A.M. 100 mL -5/23/2025 12:00 P.M. 100 mL A Care Plan, dated 3/5/2023, indicated Resident 52 had a feeding tube necessary for nutritional needs related to swallowing difficulties and a nothing by mouth order. Interventions included, but were not limited to: provide tube feeding and nutritional supplements as ordered, give 120 mL of water before and after each feeding, and monitor for signs of dehydration. During an interview, on 5/23/2025 at 9:18 A.M., LPN 3 indicated Resident 52 should have received 120 mL of water before and after his Jevity tube feedings. She indicated the amount of water provided was documented in the MAR. The MAR lacked documentation of the correct amount of water flushes/hydration being provided before and after feedings and the daily totals were incorrect. A policy was provided on, 5/23/2025 at 1:00 P.M., by the DON. The policy titled, Care and Treatment of Feeding Tubes, indicated, .It is the policy of this campus to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible .4. The campus will utilize a Registered Dietician in estimating and calculating a resident's daily nutritional and hydration needs .7. Direction for team member[s] on how to provide the following care will be provided: .e. Frequency of and volume used for flushing, including flushing medication administration, and what to do when a prescriber's order does not specify 3.1-46(b)

Based on record review and interview, the facility failed to limit an as needed psychotropic medication to a 14-day duration without required documentation for continued use of the psychotropic med for 1 of 5 residents reviewed for unnecessary medications. (Resident 36) Finding includes: A record review For 36 was completed, on 5/21/2025. Diagnoses included, but were not limited to: anxiety disorder and major depressive disorder. A Significant Change Minimum Data Set (MDS) assessment, dated 4/22/2025, indicated Resident 36 had severe cognitive impairment and received antianxiety medication. A Physician's Order, initiated on 11/14/2024 and discontinued on 1/6/2025, indicated lorazepam 0.5 milligrams (an antianxiety medication) every four hours as needed. A Physician's initiated on 1/6/2025 and discontinued on 3/14/2025, indicated lorazepam 0.5 milligrams every four hours as needed. A Psychiatric Progress Note, dated 12/2/2024, had no documentation of the lorazepam use. A Psychiatric Progress Note, dated 12/30/2024 and 1/27/2025, indicated Resident 36 was co-managed with hospice services and his symptoms were currently managed with citalopram 30 milligrams. The note had no mention of the lorazepam use. Resident 36 received lorazepam, on 12/3/2024, 12/10/2024, 12/12/2024, 12/22/2024, 12/28/2024, 12/29/2024,1/22/2025, 1/28/2025, 1/29/2025, 1/30/2025, 2/4/2025 and 2/20/2025, beyond the 14-day as needed limit without documentation for continued use of the medication. A Care Plan, dated 10/18/2024, indicated Resident 36 used anti-anxiety medication related to his diagnoses of anxiety. Interventions included, but were not limited to: assessing anxiety level and the need for anti-anxiety medication and administration of anti-anxiety medication per the physician order. During an interview, on 5/23/2025 at 9:06 A.M., QMA 2 indicated Resident 36 took lorazepam for restlessness. During an interview, on 5/23/2025 at 9:17 A.M., LPN 3 indicated as needed psychotropic medications had a limit of 14 days for use. A policy was provided on, 5/23/2025 at 1:00 P.M., by the DON. The policy titled, Psychotropic Medication Policy, indicated, .Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication[s] .10. PRN [as needed] orders for all psychotropic drugs shall be used only when the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record, and for a limited duration [i.e. 14 days] .a. If the attending physician or prescribing practitioner believes this it is appropriate for the PRN order to be extended beyond 14 days, he or she shall document that rationale in the resident's medical record and indicate the duration for the PRN order 3.1-48(a)(2)

Based on record review and interview, the facility failed to provide daily fistula checks for 1 of 1 resident reviewed for dialysis. (Resident 75) Finding includes: During an interview, on 5/20/2025 at 9:28 A.M., Resident 75 indicated she received dialysis on Mondays, Wednesdays and Fridays. Resident 75's fistula access site was observed in her left bicep. A record review for Resident 75 was completed on 5/21/2025 at 2:22 P.M. Diagnoses included, but were not limited to: end stage renal disease, diabetes mellitus type 2 and anemia. An Annual Minimum Data Set (MDS) assessment, dated 4/4/2025, indicated Resident 75 was cognitively intact and received dialysis treatments. A Physician's Order, dated 7/11/2024, indicated the dialysis access site was in the left bicep. A Care Plan, dated 5/3/2024, indicated Resident 75 has end stage renal disease and required hemodialysis three times per week. Interventions included, but were not limited to: assess, observe and document care of the access site and to document in the interdisciplinary notes monitoring for complications. A review of the interdisciplinary notes and the treatment/medication administration records had no documentation of the fistula site having been accessed on a daily or shift basis. During an interview, on 5/22/2025 at 2:11 P.M., RN 7 indicated the fistula access site was only monitored on Resident 75's dialysis days and assessments were not completed on the non-dialysis days. A policy was provided on, 5/23/2025 at 1:00 P.M., by the DON. The policy titled, Hemodialysis, indicated, .This facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences, to meet the special medical, nursing, mental, and psychosocial needs of residents receiving hemodialysis .14. The nurse will ensure that the dialysis access site is checked before and after dialysis treatments and every shift for patency by auscultation for a bruit and palpating a thrill 3.1-47

8. During an observation in Resident 94's bathroom, on 5/21/2025 at 2:50 P.M., there was a small bottle sitting on the sink counter. The container had a label indicating it was nystatin powder for the residents' abdominal folds. The record for Resident 94 was completed on 5/21/2025 at 3:16 P.M. Diagnoses included but were not limited to hypertension, hemiplegia, anxiety, depression, and renal insufficiency. Current Physician Orders included 100,000 unit/gram topical powder-apply topical twice a day (BID) as needed for rash and redness in abdominal folds. During an observation of Resident 94's bathroom, on 5/22/2525 at 3:33 P.M., the Nystatin bottle remained on the counter in the bathroom. During an interview, on 5/22/2025 at 3:35 P.M., the Households Unit manager indicated the nystatin should not have been in the residents' room. On 5/23/2025 at 11:08 A.M., the DON provided the policy titled, Labeling of Medications and Biological's, dated 4/13/2024 and indicated it was the policy currently being used by the facility. The policy indicated, Policy: All medications and biological's used in the campus will be labeled in accordance with current state and federal regulations to facilitate consideration of precautions and safe administration of medications. 1. All medications and biological's will be labeled in accordance with applicable federal and state requirements and current accepted pharmaceutical principles 3.1-25(m) Based on observation, interview and record review the facility failed to ensure medications were not left unattended in resident rooms (Resident 94), failed to ensure medications were labeled and dated when opened and failed to ensure expired medications were properly disposed of in 5 of 6 medication carts reviewed and 2 of 3 medication rooms reviewed. ([NAME], Oasis, [NAME], [NAME] and Vista medication carts and [NAME] and Vista medication rooms). Findings include: 1. During a medication storage observation, on 5/21/2025 at 9:13 A.M., on the Oasis medication cart with QMA 10, the following was observed: - six opened bottles of polyethylene glycol with no open date. During an interview, on 05/21/2025 at 9:18 A.M., QMA 10 indicated the opened bottles of polyethylene glycol should have been dated when opened. 2. During a medication storage observation, on 5/5/2025 at 11:02 A.M., on the [NAME] medication cart with LPN 11, the following was observed: - An opened bottle of meclizine 25 mg chewable tablets with no open date. - An opened bottle of risiquad 2 30 mg capsules with no open date. - An opened bottle of Centrum Silver tablets with no open date. - An opened bottle of polyethylene glycol with no open date. During an interview, on 5/21/2025 at 9:26 A.M., LPN 11 indicated the opened bottles of medications should have had open dates. 3. During a medication storage observation, on 5/22/2025 at 9:25 A.M., on the [NAME] medication cart with LPN 12, the following was observed: - An opened bottle of gas relief chews 25 mg with no open date. - An opened bottle of omega 3 1000 mg capsules with no open date. During an interview, on 5/22/2025 at 9:35 A.M., LPN 12 indicated the opened medications should have been dated when opened. 4. During a medication storage observation, on 5/23/2025 at 9:06 A.M., on the Vista medication cart with LPN 12, the following was observed: - An opened Breo Ellipta inhaler with no open date. During an interview, on 5/23/2025 at 9:09 A.M., LPN 12 indicated the Breo Ellipta inhaler should have been dated when opened. 5. During a medication storage observation of the Vista medication room, on 5/23/2025 at 9:10 A.M. with LPN 12, the following was observed: - 19 packages of povidone iodine swabs with an expiration date of 4/2025. During an interview, on 5/23/2025 at 9:16 A.M., LPN 12 indicated the expired povidone iodine swabs should have been thrown away. 6. During a medication storage observation of the [NAME] medication room, on 5/23/2025 at 9:22 A.M. with QMA 13, the following was observed: - four boxes of probe covers with an expiration date of 3/31/2025. During an interview, on 5/23/2025 at 9:29 A.M. QMA 13 indicated the probe covers should have been thrown away. 7. During a medication storage observation, on 5/23/2025 at 11:33 A.M., of the [NAME] medication cart with LPN 14, the following was observed: - An opened bottle of flaxseed oil 1000 mg with no open date. During an interview, on 5/23/2025 at 11:37 A.M., LPN 14 indicated the opened flaxseed oil should have been dated when opened.

Based on observation, record review and interview, the facility failed to provide enhanced barrier precautions for 1 of 2 residents reviewed for urinary catheters. (Resident 36) Finding includes: During an interview, on 5/19/2025 at 1:47 P.M., Resident 36's wife indicated Resident 36 had a suprapubic catheter and had had the urinary catheter for the past two and a half years. A record review for Resident 36 was completed on 5/21/2025. Diagnoses included, but were not limited to: retention of urine and pressure ulcer of sacral region. A Significant Change Minimum Data Set (MDS) assessment, dated 4/22/2025, indicted Resident 36 had severe cognitive impairment, had an indwelling urinary catheter, had an unstageable pressure ulcer and received hospice services. A Physician's Order, dated 5/23/2024, indicated enhanced barrier precautions (EBP) every shift for a suprapubic catheter. A Care Plan, dated 5/24/2024, indicated Resident 36 required enhanced barrier precautions for an indwelling medical device and a pressure ulcer to the sacral region. Interventions included, but were not limited to: implement and follow EBP during high-contact resident care activities as ordered (gown and glove use) and educate family/representative as needed. During an observation, on 5/22/2025 at 1:48 P.M., CNA 4 and CNA 5 were observed providing incontinent care in Resident 36's room without wearing gowns. During an interview, on 5/22/2025 at 1:48 P.M., CNA 5 indicated Resident 36 was on EBP and they should have been wearing personal protective equipment (PPE) for Resident 36's care. A policy was provided on, 5/23/2025 at 1:00 P.M., by the DON. The policy titled, Enhanced Barrier Precautions, indicated, .It is the policy of this community to implement enhanced barrier precautions for the prevention of transmission of multi-drug resistant organisms .2. Initiation of Enhanced Barrier Precautions .b. An order for enhanced barrier precautions will be obtained for residents with the following: wounds .indwelling medical devices .even if the resident is not known to be infected or colonized with a MDRO [multi-drug resistant organism] .3. Implementation of Enhanced Barrier Precautions: a. Make gowns and gloves available immediately near or outside of the resident's room .b. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities .4. High-contact resident care activities include: e. changing linens, f. Changing briefs or assisting with toileting 3.1-18(b)

Based on interviews and record review, the facility failed to ensure hot food temperatures were assessed and logged consistently in the main kitchen to ensure food was served at palatable temperatures. This deficient practice had the potential to affect 155 of 155 residents in nursing care who were served from the main kitchen. Finding includes: During an interview, on 9/16/24 at 12:28 P.M., the Dietary Team Lead staff member indicated food was prepared in the main kitchen and then delivered to the unit servery kitchens, where it was held in steam tables. She indicated she had heard some concerns the food was not always as warm as it should be when served. She indicated hot foods should be held and served at at least 140 degrees Fahrenheit. During an interview, on 9/17/24 at 10:20 A.M., Resident B indicated he/she had been served cold food many times. Resident B indicated when food that was supposed to be served hot was served cold, he/she lost their appetite. Residen Bt indicated he/she had refused to eat cold food and planned to throw their tray across the dining room if food was ever served cold to them again. During a Resident Council meeting, conducted on 9/17/24 at 10:45 A.M., 3 of 12 alert and oriented residents indicated the hot food on the Knolls and Vista units was sometimes served cold. During an interview on 9/20/24 at 10:37 A.M., the Interim Dietary Manager indicated all hot and cold foods should be checked for adequate temperatures as indicated in the facility policy. The Interim Dietary Manager indicated the kitchen had not been consistently documenting food temperatures in the kitchen before serving food to the nursing units. The Kitchen Food Temp Log sheets were reviewed for 8/11/24 to 9/15/25 and indicated no recorded food temperatures were logged for the following days: 8/11,12,13,14, 16, 17, 18, 21, 22, 23, 25, 26, 27, 28, 29, 2024 and 9/1, 2, 4, 5, 6, 11, 2024. On 9/19/24 at 1:03 P.M., the Executive Director provided a policy titled, Record of Food Temp Policy, dated 3/1/22 indicating it was the current facility policy. The policy indicated, .It is the policy of this facility to record food temperatures daily to ensure food is at the proper serving temperature(s) before trays are assembled .Hot foods will be held at 135 degrees Fahrenheit or greater .cold food temperatures will be kept at or below 41 degrees Fahrenheit .Measure and record the temperatures for each food product and milk at all meals. Record temperature on temperature log . This citation relates to Complaint IN00442353. 3.1-21(a)(2)

Based on observation, record review and interviews, the facility failed to ensure 1 of 3 residents reviewed for accidents was provided safe transfer assistance utilizing a mechanical stand lift This deficient practice resulted in a significant injury which required a transfer to an acute care center for treatment, hospice admission and death, (Resident B). Finding includes: A record review for Resident B was completed on [DATE] at 11:00 A.M. Resident B's diagnoses included dementia, deep venous thrombosis, rheumatoid arthritis, anxiety, and history of hip fracture. The resident was admitted to the facility on [DATE], was hospitalized for a fall on [DATE], was readmitted to the facility under hospice care on [DATE], and expired on [DATE]. A Quarterly Minimum Data Set (MDS) assessment, dated [DATE], indicated the resident had severe cognitive impairment, was dependent on others for transfer assistance from a chair to the bed and to stand from a seated position. The resident required substantial assistance to move from sitting on the side of the bed to laying flat on the bed, and required a wheelchair for mobility. A Physical Therapy Evaluation and Plan of Treatment, dated [DATE], indicated the resident was dependent for all transfers, had impaired strength to both the right and left lower extremities and was able to sit unsupported for 30 seconds when her feet were flat on the floor without back support, though she was unable to stand without without support for 10 seconds. The current Care Plans for Resident B included: Assistance for activities of daily living related to impaired function of late loss of activities of daily living due to dementia, dated [DATE]. One approach, dated [DATE], indicated 2 staff were to assist the resident with transfers when using the [NAME] Lift (a lift-to-stand mechanical device). Resident B had poor safety awareness due to dementia, dated [DATE], and included an approach indicating staff were encouraged to call for assist with transfers and toileting. Resident B had a diagnosis of depression and anxiety and was fearful of falling, and included an approach to see the care plan for assistance for daily living, including assistance needed, dated [DATE] Resident was at risk for complications from blood thinning medications with an intervention that indicated to prevent fall which could potentially cause high risk of bleeding due to anticoagulant use, dated [DATE] Resident had a potential for falls related to impaired cognition, new living environment and impaired mobility, and included an approach to see the care plan for assistance for daily living, including assistance needed, dated [DATE]. A fall risk assessment completed on [DATE], indicated Resident B had a fall risk of 20 which indicated a high risk for falls. A physician's order dated [DATE], indicated the resident required a mechanical stand lift. Review of an incident reported to Indiana State Department of Health, submitted by the Administrator, indicated on [DATE] at 9:21 A.M., Resident B was sitting on the bed after she was transferred and reached to grab the mechanical lift when Certified Nurses Aide (CNA) 2 was moving it away and the resident fell to the floor. The resident sustained lacerations around the left eye and right scalp, and sustained a right subdural hematoma (a condition where blood collects between the skull and the surface of the brain). The resident was sent to a local hospital for evaluation and treatment. An incident follow up dated [DATE], indicated and investigation into the fall was completed, and indicated the resident had fallen from the bed and was observed on the floor between the bed and the nightstand. The resident required sutures and staples for the lacerations, and treatment for the hematoma. The resident returned to the facility from the hospital Review of Resident B's Incident Report, dated [DATE] at 7:00 P.M., indicated CNA 2 approached Licensed Practical Nurse (LPN) 6, and stated he had a resident fall. LPN 6 entered the room to find Resident B laying on her left side between the bed and the nightstand. The resident was noted to have blood on her face. LPN 6 assisted the resident to a partial sitting position. A large open laceration was noted above the resident's left eyebrow, a laceration to her scalp, and a skin tear on her left shoulder extending from her shoulder to her left elbow. LPN immediately applied pressure to the lacerations and instructed another staff member to call 911. The resident remained alert and oriented and was able to engage in conversation with LPN 6 in an effort to keep her awake. The resident was unable to explain how she fell . A review of an investigation/follow-up documented by LPN 6, dated [DATE] at 1:16 A.M., indicated, CNA [CNA 2] reports that he had transferred resident to her bed via mechanical lift, once resident was sitting on bed he attempted to remove lift and resident reached out causing her to fall. [CNA 2] approached writer and stated he had a resident fall. Writer entered room to find resident laying on her left side between the bed and the nightstand. Resident noted to have blood on her face. Writer assisted resident to partial sitting position. Large open laceration above left eyebrow, laceration to scalp, skin tear on left shoulder extending to left elbow Writer immediately applied pressure to lacerations and instructed another staff member to call 911. Resident remained alert and oriented was able to engage in conversation. Vitals obtained by paramedics in rout to hospital . A review of an interview statement by the Administrator from CNA 2, dated [DATE] (no time documented) indicated the following: Resident B was in her recliner with her feet up and the CNA was getting her ready for bed. CNA removed the resident's shirt and placed a gown on her. He indicated he used the stand lift, attached the sling and stood the resident up. He cleaned her bottom area and changed her brief. CNA then wheeled her over to the bed in the stand lift, sitting her on the bed at an angled position with her bottom on the bed and body leaning back after he removed the sling. CNA 2 quickly glanced behind him to move the lift back and that is when Resident B fell off the bed. He was confused and did not know if the resident grabbed the lift. CNA 2 indicated he did not have assistance with the lift and no other staff were in the room at the time of the fall. He indicated the resident's feet were still on the platform of the lift and she tubi grips on her feet. CNA indicated he assumed the resident grabbed the stand lift, but did not feel her grab it. CNA 2 indicated he knew the transfer status of the resident was on the care sheets and through CNA report. Review of Resident B's emergency room (ER) note dated [DATE] at 8:31 P.M., the ER physicians indicated Resident B presented the ER with complaints of a ground level fall. He indicated the resident sustained a large left supraorbital laceration of about 4 cm that was gaping and into the muscle layer which required 9 sutures to repair, a right frontotemporal hematoma, a right scalp laceration of about 9 cm which was repaired with unspecified number of staples, and a significant skin tear covering most of the deltoid region at the left shoulder. Review of Resident B's emergency room (ER) note, dated [DATE] at 8:31 P.M., indicated the ER physicians documented Resident B presented to the ER with complaints of a ground level fall. He indicated the resident sustained a large left supraorbital laceration of about 4 cm that was gaping and into the muscle layer which required 9 sutures to repair, a right frontotemporal hematoma, a right scalp laceration of about 9 cm which was repaired with unspecified number of staples, and a significant skin tear covering most of the deltoid region at the left shoulder. A radiology report for Resident B, dated [DATE] at 8:27 P.M., indicated a subdural hematoma with a thickness of 2 to 3 mm. An ER note dated [DATE] at 4:00 A.M., indicated, Critical Care Attestation: Upon my evaluation, this patient had a high probability of imminent or life-threatening deterioration . A Hospital Discharge Summary, dated [DATE] at 11:00 A.M., indicated the following: hemoglobin was noted to be low likely related to acute subdural hematoma. Patient was evaluated by hospice, plan was for the patient to be discharged back to the facility where the hospice team will evaluate her and admit her over there A physician's order dated [DATE], indicated to admit to local hospice for hospice diagnosis. A review of hospice Certification of Terminal Illness Statement, dated [DATE], indicated Resident B's Terminal Diagnosis was, Traumatic subdural hemorrhage . On [DATE] at 12:10 P.M., the Director of Nursing provided Resident B's Indiana State Department of Health Certificate of Death, dated [DATE]. The certificate indicated the, Immediate cause (Final Disease Or Condition Resulting in Death) A. Complications From a Fall Striking Her Head . A review of the Validation Checklist with sit to stand to wheelchair using a stand up mechanical lift, was provided on [DATE] by the Director of Nursing indicating this was the current validation education tool for mechanical lifts. The checklist indicated, .Second assist flush to resident while instructing the resident to pull with their arms and straighten their legs if able .Operator to lift resident by pressing 'up' on controller. Unlock the wheels of the stand lift. Second assist to remain beside resident during standing . During an interview, on [DATE] at 11:05 A.M., the Administrator indicated CNA 2 transferred Resident B from her recliner to the bed using the stand up mechanical lift. The Administrator indicated the facility staff know they are to use 2 staff for all mechanical lift transfers. During an interview on [DATE] at 11:45 A.M., CNA 2 indicated he transferred Resident B from her recliner to the bed using the mechanical stand lift. He indicated he did not ask for assistance and he transferred the resident alone. CNA 2 indicated the bed had to be raised a few inches to fit the legs of the stand lift under the bed and placed it at a slight angle. CNA 2 indicated he transferred the resident to the bed and had her sitting at an angle because it was easier to swing the resident's legs in the bed when higher up in the bed and at an angle. CNA 2 indicated he removed the sling, placed it over the lift and went to pull the lift back. CNA 2 indicated he glanced behind him to ensure the area was clear and pulled the stand up lift back away from the bed. He indicated the resident's feet were on the foot rest after she was placed in the bed and when he went to move the stand lift back, he indicated the resident must have grabbed the handle of the lift causing her to fall. He said he did not feel resistance as if she was holding on because the stand lift was heavy and required effort to move it. On [DATE] at 9:30 A.M., the Director of Nursing provided a policy titled, Mechanical Lift Use Policy, dated [DATE], and indicated it was the current mechanical lift policy. The policy indicated, .Mechanical lift transfers will be conducted by 2 team members at all times . This citation relates to Complaints IN00436194 and IN00435888.

Based on observation, interview and record review, the facility failed to prevent a pressure ulcer from developing on the heel and buttock, for 1 of 3 residents reviewed for pressure ulcers. (Resident F) Finding includes: On 9/19/23 at 1:35 P.M., a review of the clinical record for Resident F was conducted. The resident's diagnoses included, but were not limited to: diabetes, anemia, arthritis, unsteadiness on feet, and a prosthetic heart valve. A Quarterly Braden Scale for Predicting Pressure Score Risk form, dated 6/16/23, indicated the resident scored a 14. The form indicated .If the residents total is 18 or less, consider him/her at risk for pressure ulcer/injury development A Minimum Data Set (MDS) Significant Change assessment, dated 8/7/23, indicated the resident's cognitive status was moderately impaired, required extensive assist of 2 persons with bed mobility and toileting. In addition, was totally dependent of 2 persons with transfers. The Assessment indicated the resident weighed 127 pounds, was always incontinent of her bladder function and had acquired an unstageable pressure ulcer/deep tissue injury. A Care Plan, dated 12/17/19, indicated the resident was at risk for skin breakdown due to incontinence and needed help with bed mobility. On 7/3/23, Moisture-Associated Skin Damage (MASD) to the sacral area was added and on 7/26/23 Deep Tissue Injury (DTI) to heel was added to the care plan. The interventions included, but were not limited to: reposition with routine rounds, as needed, during the day when in bed or in chair, monitor skin during bathing, assess skin weekly, float heels when non-blanchable redness or softness was noted, treatments per physician orders, measure wound weekly and administer nutritional supplement, as ordered. A Progress Note, dated 7/26/23, indicated .Resident noted to have 1.8 x 2.0 cm [centimeter] DTI to left heel The nurse practitioner and family were notified of the observed area. An Interdisciplinary Team (IDT) Note, dated 8/1/23, indicated resident had an area on her heel and appeared to be possible trauma from her scooter. Area was dry, callused with intact skin. The order received was to apply skin prep and facility initiated a Prevalon boot (floats the heel) for protection. A Progress Note, dated 8/3/23, indicated Active (a liquid protein supplement) was ordered for twice a day and facility provided an air alternating mattress. An IDT Note, dated 8/7/23, indicated the DTI on the left heel had the first layer of skin coming off. The wound measured 3.4 x 2.7 cm and treatment was Allyven (a layered foam dressing) was to be changed every 3 days. The Note indicated resident had been compliant with the heel protector boot. An IDT Note, dated 8/9/23, indicated the heel wound was now a Stage II pressure ulcer, which measured 0.8 x 2.0 x 0.4 cm. with good granulation, color-yellow. The treatment was to apply Allyven every 3 days. A Progress Note, dated 8/15/23, indicated a Nurse Aide had notified the Nurse regarding a rash, (raised clusters of pustules) between the residents breasts, along her left side and back. The Physician was notified and the resident was diagnosed with Shingles. An IDT Note, dated 8/16/23, indicated .entered room to assess previous open area to the left heel and noted her in the recliner with out heels floated. immediately did this and assessed the wound noted previous was resolved, however this area is dark purple in color continue to monitor and continue same dressing. family and md [medical doctor] notified A Progress Note, dated 8/16/23, indicated a dark purple discoloration to the back of the heel further from the previous wound site, and it measured 1.0 x 1.0 cm. A Progress Note, dated 8/23/23, indicated the purple area was now pink granulation, a Stage II pressure ulcer which measured 4.0 x 2.5 x 0.3 cm. Continued with heel protector boots, air mattress and Allyven dressing every 3 days. A Progress Note, dated 8/31/23, indicated .top layer of skin gone and yellow slough noted in center of left heel The Stage II pressure ulcer measured 3.0 x 2.0 x 0.1 cm. A new order was received for medihoney with boarder gauze, change every day. A Progress Note, dated 9/6/23, indicated .top layer of skin gone and granulation with 15% yellow slough noted in center of left heel The Stage II pressure ulcer measured 3.0 x 2.0 x 0.1 cm. No change in the treatment. On the same day, it was documented the resident had MASD to the right upper buttock area which measured 0.1 x 0.2 cm. An IDT Note, dated 9/7/23, indicated resident had a pressure injury to her left heel with a yellow center, which measured 3.0 x 2.0 x 0.1 cm. Supplements were Active Protein twice a day and added health shakes daily. New Stage II ulcer on her left buttock which measured 2.8 x 1.7 x 0.4 cm. Treatment for the buttock wound was Allyven dressing every 3 days. The Physician had been notified and lab work was ordered. Progress Note, dated 9/14/23, indicated left heel, Stage II pressure ulcer measured 3.0 x 2.0 x 0.1 cm with pink granulation and the Stage II pressure ulcer on the coccyx measure 2.8 x 1.7 x 0.4 cm. and was slight pink with 5% slough noted in the area. No change in treatments for either wound. On 9/19/23 at 2:42 P.M., Resident F was observed in a recliner with footrest up. The resident had no pressure reducing device on her left foot. Her meal tray was in front of her. There was no cushion/pressure relieving device underneath her buttocks. The resident's bed was observed to be an air alternating bed. A Prevalon Boot was located at head of the bed. During an interview, on 9/19/23 at 3:01 P.M., CNA 2 indicated the resident had been sitting, in the recliner, since before lunch and indicated lunch was served around 11:30 A.M. On 9/19/23 at 3:07 P.M., an observation of the wounds was conducted with LPN 2-Team Lead. There were no dressings covering the wounds. The left heel area had firm dark brown eschar (dead tissue within a wound) which measured 1.3 x 1.8 x 0.3 cm. The resident pulled away and said Ouch during the observation and reapplying of the dressing. The right side of the buttock area had a small area of MASD and the left side of the buttock there was observed an unstageable pressure ulcer which measured 1.1 x 0.7 cm. This wound had no drainage, no odor but entire area was covered with yellow slough, with no areas of granulation. On 9/19/23 at 3:40 P.M., the Assist Director of Nursing (ADON) provided a policy titled, Pressure Injury Prevention and Management, dated 12/2019 and revised on 8/8/23, and indicated the policy was the one currently used by the facility. The policy indicated .This facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries . This Federal tag relates to complaint IN00417490. 3.10-40(2)

Based on observation, record review and interview, the facility failed to maintain a safe environment for a resident with known safety awareness deficiency resulting in a open tibia fracture that required hospitalization and surgical intervention (Resident 126) and update plan of care with fall interventions to decrease the likelihood of falls (Resident 12) for 2 of 4 residents reviewed for accidents. Findings include: 1. During an observation, on 2/14/19 at 1:23 P.M., Resident 126 was noted to have a green/purple bruise noted to her left cheek by her eye and an ace noted to her left lower extremity. Resident 126 indicated her cheek was bruised and her leg was broken from a recent fall. The clinical record for Resident 126 was reviewed on 2/15/19 ay 12:15 P.M. The [DIAGNOSES REDACTED]. A significant change MDS (Minimum Data Set) assessment, 2/2/19, indicated Resident 126 had a BIMS (Brief Interview of Mental Status) score of 10, mild cognitive impairment, required extensive assist with ADLs (activities of daily living) and had a fall with major injury. A care plan for dementia, dated 10/10/18, indicated Resident 126 was forgetful and confused about her surroundings. A care plan for falls, dated 10/10/18, indicated Resident 126 was at risk for falls due to recent fall resulting in [MEDICAL CONDITION] at home, a history of knees buckling, decreased weakness and mobility. The interventions included, but were not limited to, requires extensive assist from staff with bed mobility, transfers and toileting, provide verbal cues for safety during daily activities and repeat as needed, and keep call light in reach and remind resident to call for help when needs to get up. A Progress Note, dated 10/30/18, indicated Resident 126 had an unwitnessed fall. There were no updates noted to the plan of care for falls. A Progress Note, dated 11/14/18, indicated Resident 126 had a fall unwitnessed fall. There were no updates noted to the plan of care. A Progress Note, dated 1/15/19, indicated Resident 126 was found lying on floor in room on her left side at 3:33 A.M. There was blood pooling on the carpet from the left side of her head. Her left eye was swollen, black and purple. Her left lower extremity had a large open area with bone exposed, actively bleeding onto her carpet. Her left knee was swollen and discolored. The bed was noted to be in highest position and resident was known to raise bed up to adjust the blinds per the CNAs (Certified Nursing Aide). Resident 126 was transferred to the local emergency room at 4:30 A.M. The physician progress notes [REDACTED]. The resident underwent [REDACTED]. She required 2 units of blood transfusion postoperatively with a hemoglobin of 7.3 gm/dl (gram/deciliter) - normal is 12.0-15.5 gm/dl. During an interview, on 2/15/19 at 1:37 P.M., the MDS coordinator indicated no updates were made to the fall care plan after her previous falls. During an interview, on 2/18/19 at 10:25 A.M., the DON (Director of Nursing) indicated the fall care plans should have been updated after each fall and that he was aware that resident moved the bed up and down. He indicated that should have been care planned. DON indicated that if facility was aware that residents move their beds up and down the maintenance director could have put the beds on out mode to prevent the bed from moving up and down. On 2/19/19 at 4:08 P.M., the DON provided the Fall Committee policy, dated 6/2013, and indicated this was the policy currently being used by the facility. The policy indicated of the facility to identify any resident who was at risk for fall and review falls that have occurred and work with staff to develop interventions that would minimize the resident's risk of falling and sustaining injury. 2. A clinical record review was completed on 2/18/19 at 9:26 A.M., indicating Resident 12's current [DIAGNOSES REDACTED]. A MDS (Minimum Data Set) assessment, dated 10/15/18, indicated Resident 12 was unable to complete the mental interview for cognitive status, was rarely understood, had memory problems and rarely made decisions. She required extensive assist of 1 staff for bed mobility, transfers, dressing, toilet use and was supervision and set up with eating. Was frequently incontinent of bladder and bowels and had 2 or more falls coded on the MDS assessment. A Fall risk assessment, dated 1/18/19, indicated Resident 12 was at high risk for falls and had 6 falls since last assessment. A nurses' note, dated 12/28/18 at 10:20 P.M., indicated the resident was found on the floor, uninjured, assisted back to bed, repositioned and medications given. A Post fall investigation form, dated 12/28/18 at 10:19 P.M., indicated Resident 12 was checked 15 minutes prior to fall, was getting out of bed, last time resident was toileted was documented as 8, factors contributing to fall were documented as resident refused bed time medications, action plan was documented attempt to give medications earlier. A nurses' note, dated 1/18/19, indicated at 11:30 P.M., the Resident 12 was found lying on the floor on the left side between bed and recliner. No injuries noted. Range of motion was within normal limits and neuro checks started. A Post fall investigation form, dated 1/18/19 at 2:09 A.M., indicated: Resident 12's brief was wet, last toileted 120 minutes ago, factors contributing to the fall documented as resident was incontinent of urine. The action plan section was blank. A nurses' note, dated 1/19/19, indicated at 12:30 A.M., certified nursing assistant notified the nurse the resident was on the floor beside her bed. No injury noted, range of motion to all extremities within normal limits. A Post fall investigation form, dated 1/19/19 at 8:42 A.M., indicated Resident 12 slid out of bed, unaware of safety and the action plan was keep bed in lowest position. A current, 10/3/16, care plan problem indicated Resident 12 had the potential for falls related to history of falling, weakness, increased forgetfulness, [MEDICAL CONDITION] right [MEDICAL CONDITION]. Interventions included, but were not limited to: instruct in safe transfer techniques -lock wheelchair, lift footpedals, use walker for support, provide stand by assist to limited assist of 1, check more frequently especially through night, remind/encourage to use call light, resident is very impatient and sometimes does not use the call light, re-encouragement and redirection, repetitive reminder to wait for assistance and be patient, night shift to check on frequently during the night to ensure she does not have her bed in the highest position and reposition in bed or place in recliner or bring out to be with staff when restless. During an interview, on 2/19/19 at 7:49 A.M., Qualified Medication Aide 8 indicated she thought the resident was on the Go Green Program, but was not for sure, because there was no green tag on her door plate or on her wheel chair. During an interview, on 2/19/19 at 3:40 P.M., nurse team leader 5 indicated Resident 12 was on the Go Green program, but did not have the green items on the wheel chair or door signifying she was on the program. The certified nursing care sheet for Resident 12 lacked the documentation indicating the resident was on the Go Green fall prevention program or was at High Risk for Falls. On 2/18/19 at 2:45 P.M., the Director of Nursing provided the policy titled, Go Green Program (Fall Prevention), dated 6/2013, and indicated the policy was the one currently used buy the facility. The policy indicated .A resident with (2) or more falls in a 30 -day period or resident reviewed by the Fall Committee will be placed on the GO GREEN program. a. Put a green ribbon on the resident's wheelchair or walker. Place a green dot by their name on the outside of their door. b. Note High Risk for Falls on the Certified Nursing Assistant assignment sheet. On 2/18/19 at 2:45 P.M., the Director of Nursing provided the policy titled, Fall Prevention Plan, dated 6/2016, and indicated the policy was the one currently used by the facility. The policy indicated .1. Safety precutions will be implemented for all residents in accordance with the Fall Prevention Protocols in an attempt to maintain an environment free of accident hazards as to prevent falls to the degree possible. 2. Licensed and certified staff on duty when a resident is identified to be at risk of falls will be responsible for initiation of the planned fall prevention interventions. Licensed charge nurses on each shift will be responsible for ensuring on-going interventions are maintained at all times. 3.1-45(a)(1)(2)

Based on observation, interview and record review, the facility failed to prevent the development of unstageable and/or Stage 3 (III) ulcers in 3 of 4 residents reviewed for pressure ulcers. (Resident E, Resident G and Resident J) Findings include: 1. On 9/27/18 at 11:37 A.M., Resident E's coccyx wound was observed with RN 2. The buttock had a wound dresssing and wound vac (a negitive pressure wound therapy-using a vacuum dressing to promote healing and draws moisture from the wound) over the sacrum and coccyx area. RN 2 removed the dresssing and there was no redness noted on the resident's buttocks. The wound vac was in position and was draining a brown blood tinged liquid into vacuum reservoir. After the dresssings were removed, a Stage III pressure wound was observed. The edges of the wound and wound bed had a small amount of serous drainage. The pressure wound measured 5.7 x 3.3 x 2.5 cm (centimeters) with 12:00 o'clock tunneling measuring 0.8 cm, 1:30 o'clock tunneling measuring 2.5 cm and 3:00 tunneling measuring 2.5 cm. The tunneled areas were packed with Puracol Plus AG (silver), a skin prep was applied to the outlying skin after the cleansing of the wound. A Duoderm dressing was applied over the wound area, with a cut out in the center the size of the wound. Then foam was inserted into the wound area, with a piece of tracking foam. A clear adhesive was placed over the wound foam, Duoderm and tracking foam and then attched to the wound vac. The wound vac was set a 125 mmHg (millimeters of mercury). During an interview, on 9/28/18 at 2:00 P.M., Resident E responded appropriately to cognition screening questions. She indicated she did not recall if she refused to be turned and/or repositioned. She does remember being in a lot of pain and was taking pain medications. She indicated she had pain issues, prior to her admission, due to her arthritis. She said when she was admitted to the facility she also had pain due to a [MEDICAL CONDITION] and clavicle, sustained from a fall at home. She indicated she spends 2 hours in a wheelchair at therapy and then staff bring her back to her room and lie her down. She's in that position until lunch time, then she sits at the edge of bed to eat. Then she was repositioned back to bed, switching sides. She feels staff are turning or repositioning more often than they first did after her admission. On 9/27/18 at 1:32 P.M., a review of the clinical record for Resident E was conducted. The record indicated the resident was admitted on [DATE], sent to the hospital and readmitted on [DATE]. The resident's [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) Assessment, dated 7/12/18, indicated the resident was an extensive assist, requiring 2 persons for bed mobility. A Braden scale (a scale for predicting pressure sore risk), dated 3/12/18, was 16 which indicated the resident was at a high risk for developing a pressure ulcer. A Care Plan, dated 3/15/18, indicated the resident was at risk for skin breakdown related to impaired mobility from current fracures and advanced [MEDICAL CONDITION] arthritis, frequent bowel movements, and recent weight loss. The interventions included, but were not limited to: assist with peri care, encourage adequate nutrition, call light within reach, observe for new breakdown, air alternating flow mattress (added on 4/2/18), pressure relieving cushion on wheelchair, and alternate resting side of Foley tubing each shift. Another care plan for unstageable pressure injury to coccyx, dated 3/15/18, due to slough and evolved to Stage III pressure ulcer. The interventions included but were not limited to: assess wound weekly, reposition every 2 hours, air flow mattress, treatments at wound clinic, encourage intake of healthshakes and treatments as ordered. A Progress Note, dated 3/9/18, indicated there were no pressure areas noted, during her admission assessment, to the facility. A Progress Note, dated 3/10/18, indicated the resident was restless, crying out, wanted out of bed due to being uncomfortable. She indicated her left lower extremity was hurting. CNA's (Certified Nurses Aides) tried to transfer resident to her wheelchair with a total assist, but were unable due to resident not putting any weight on her extremities. The note indicated the transfer was tried twice without success. The resident was placed back into bed. The resident was unable to be transferred by a Hoyer lift due to the clavicle and [MEDICAL CONDITION]. The note indicated the resident was on the call light every 15-30 minutes wanting repositioned. A [MEDICATION NAME] (muscle relaxer medication) was administered. The Progress Note explained a Physical Therapist was called to the unit, and assisted with the transfer. The resident was transferred by the therapist to a wheelchair and she sat there for several hours, until the therapist transferred the resident back to bed. A Progress Note, dated 3/15/18 at 1:33 P.M, indicated there was an area discovered on the resident's coccyx, which measured 2. 0 x 1.5 centimeters (cm). The area was reddened, non-blanchable and appeared to be fluid filled. A [MEDICATION NAME] dressing was applied. A Pyscho-Social Assessment, dated 3/15/18, indicated .Nursing Note on 3/10 resident is restless and crying out r/t (related to) pain, discomfort, and inability to find a position that is soothing to her, 3/11 groaning & moaning, when asked what is hurting, resident does not respond, 3/14 tearful, uncomfortable, sobbing, staff attempt numerous times to reposition her for her comfort it appears that little relief is accomplished with the varitety of interventions offered .Nursing is working on effective pain management and options for repositioning resident into a more comfortable laying or sitting position Progress Note, dated 3/16/18, indicated the resident was incontinent and dressing to coccyx wound was changed to be more waterproof. The dressing consisted of [MEDICATION NAME] covered with a [MEDICATION NAME], to be changed every 3 days. A Skin Evaluation Form, dated 3/21/18, indicated the resident had a new wound which appeared to be a yellow scab, to her right ankle The would measured 0.7 x 0.3 cm. The treatment consisted of Calvilon wipe to area every shift and resident to wear a moon boot when in bed. This wound resolved on 4/26/18. A Progress Note, dated 3/22/18, indicated the resident had a Stage II pressure ulcer to her coccyx, which measured 1.2 x 1.0 x < (less than) 0.2 cm. The wound bed was pink with moderate amount of serosanguinous drainage. The treatment for [REDACTED]. A Skin Evaluation Form, dated 3/29/18, indicated the wound on the coccyx was unstageable and measured 1.8 x 2.4 x 0.1. The wound description: .wound bed with slough covering the center of wound bed, small serosanguinous drainage margins intact and well defined No change to treatment to the wound, remained silver alginate and cover with [MEDICATION NAME]. A Progress Note, dated 3/29/18, indicated resident did not like laying on her side because it hurt her hips. A Treatment Record (TAR) for (MONTH) of (YEAR), indicated the following: .Reposition resident q (every) 2 hours to keep pressure of coccyx . This treatment had a start day of 3/29/18 A Progress Note, dated 4/3/18, indicated .Res (Resident) noted to have an air flow mattress in place and stated I love it, and reported that it is helping relieve the pain from her pressure injuries. Res (Resident) had a cushion in place on her WC (wheelchair) A Transfer form, dated 4/6/18, indicated the resident was sent to the emergency room for suspicion of a [MEDICAL CONDITION] Embolism. The form indicated the resident had a Stage II pressure ulcer on her coccyx. A Hospital Discharge Summary, dated 4/10/18, had no indication the resident had a pressure ulcer while at the hospital, however there was a discharge order for a Santyl ointment to be applied daily to coccyx area. A Nursing Admission Assessment, dated 4/11/18, indicated the resident had a Stage III ulcer on her coccyx and a scab on her right ankle. The coccyx ulcer measured 4 x 3 cm and the scab measured 1 x 1 cm. The treatment ordered for the ulcer was Santyl and meplex dressing. A Skin Evaluation Form, dated 4/12/18, indicated .wound bed with slough covering center of wound bed, moderate serosanguinous drainage margins intact and well defined. Periwound pink and blanchable The wound measured 2.0 x 2.0 x 0.1 cm and was staged as an unstageable wound. The treatment was Santyl with [MEDICATION NAME] border dressing. A Skin Evaluation form, dated 5/8/18 indicated the resident had an unstageable pressure ulcer to her coccyx. The wound bed was covered with 100% firmely adherent slough. The form indicated the resident had been compliant with lying on her sides and off her bottom. The form indicated the wound was improving and measured 2.0 x 2.0 x 0.2 cm. The treatment remained the same: Santyl with [MEDICATION NAME] border dressing. The wound continue to be evaluated weekly and treatment remained the same until the resident was seen at a wound clinic. The last measurement of the coccyx, prior to the wound clinic assessment, was on 6/14/18. The wound measured 2.0 x 2.0 x 0.4 cm and was covered with slough. A Progress Note, dated 6/8/18, indicated there was a Stage I pressure area to the resident's right ankle. The ankle area was dark in appearance and was non-blanchable. A new order was received to use a [MEDICATION NAME] wipe twice a day until healed. There were no other Progress notes or Skin Evaluation forms indicating further assessment of this wound until observed by the Wound clinic. A Wound Clinic Report, dated 6/18/18, indicated the resident presented to the wound clinic with a pressure ulcer to her coccyx and right ankle. The right ankle wound was a Stage III ulcer, which measured 1.3 x 1.5 x 0.1 cm. The coccyx wound was a Stage III ulcer, which measured 2.3 x 1.5 x 1.1 cm, with 5.2 cm at 10 to 1 oclock with little slough present and no exposed bone. Treatment ordered to coccyx was Silver Alginate (packed), ABD (abdominal dressing) and [MEDICATION NAME] tape, daily. The treatment for [REDACTED]. The facility was to obtain a Prevalon boot to avoid pressure to right ankle and resident was to be up only for therapy and meals-20 minutes max. She was to have a multivitamin and have her dietary protein increased. A Skin Evaluation Form, dated 6/22/18, indicated a pressure wound had developed on the resident's right outer ankle. The Stage III wound measured 2.0 x 2.0 x <0.2 cm. A plan of care for the Stage III pressure injury to the right ankle, dated 6/22/18, did not indicate Prevalon boot usage as an intervention. The resident continued to be seen by the wound clinic physician for both wounds. The right ankle wound continued to improve and was closed on 9/12/18. A Nursing Assessment completed , on 7/2/18, by the wound clinic nurse indicated the Stage III coccyx wound measured 2.0 x 2.0 x 1.1 cm and had a foul odor when dressing was removed. A new order was ordered: [MEDICATION NAME] (antibiotic) 250 mg tablet, crushed, and placed in wound with the Purachol Plus and wound vac negative pressure at 100 mmHg. A Skin Evaluation Form, dated 7/27/18, indicated the coccyx/sacral wound measured 1.7 x 1.4 x 1.4 cm with undermining, 2.6 cm at 12 o'clock with a continued treatment of [REDACTED]. This treatment continued until 8/29/18. A Wound Clinic Progress Note, dated 8/29/18, indicated the coccyx/sacral wound was scheduled for a debridement next week due to not getting good wound healing. After the debridement the Wound Clinic Progress Note, dated 9/12/18, indicated the wound measured 6.0 x 3.5 x 2.0 cm with undermining up to 3.3 cm. The plan implemented was to hold the wound vac for 1 week, apply Santyl, a damp to dry gauze, then an ABD dressing to cover wound. A Wound Clinic Progress Note, dated 9/24/18, indicated coccyx/sacral wound measured 5.0 x 4.0 x 1.1 cm. The treatment was a wound vac with an increase of negative pressure to 125 mmHg, collagen with silver, skin prep and duoderm around the wound. During an interview, on 10/1/18 at 11:11 A.M., LPN 3-Unit Manager indicated there was no documentation indicating the Prevolon boot ordered by the wound care physician, in June, was placed on the resident left foot. And the boots use was not added to the care plan. There documentation indicating the resident had received a multivitamin. She indicated the wound nurse was no longer employed by the facility, since June. 2. On 9/27/18 at 10:43 A,M., Resident G was observed in an activity, sitting in a padded wheelchair. The acitivity had started at approximately 10:00 A.M. At 11:04 A.M., the resident was observed, sitting in her wheelchair, in a common area, talking with a volunteer. At 11:16 A.M., the resident was taken to her room by Health Care Assistant 6. The resident requested a jacket/sweater, which was provided. The resident was then propelled to the dining area for lunch. On 9/27/18 at 3:12 P.M., Resident G was observed sitting in recliner, in a common area, drinking a healthshake. She indicated she was getting her nails done. There was no visible waffle cushion placed underneath her as she was sitting in the recliner. The resident answered cognition screening questions without difficulty and indicated the staff was treating her for a wound on her bottom. She indicated there was no special cushion underneath her. During an interview, on 9/27/18 at 3:15 P.M., CNA 4 indicated Resident G was to have her pull up checked and changed every 2 hours. CNA indicated they assisted the resident into the recliner, to get her off her sore, and when in bed at night, the resident was to be turned every 2 hours. On 9/28/18 at 10:15 A.M., a review of the clinical record for Resident G was conducted. The record indicated the resident was admitted on [DATE]. The resident's [DIAGNOSES REDACTED]. An Admission MDS Assessment, dated 7/25/18, indicated resident was at risk for pressure ulcers. A Significant Change Assessment, dated 8/19/18, indicated the resident was an extensive transfer and toileted with a 2 person assist. She had an unstagable wound measuring 1.0 x 2.0 cm. with slough present. A Braden score assessment, dated 7/18/18 was 15, high risk for development of pressure ulcers. A Care plan dated, 8/3/18, indicated the resident had the potential for skin breakdown related to impaired mobility and frequent bowel/bladder incontinence. The interventions included but were not limited to: [MEDICATION NAME] (a barrier cream) to peri area and coccyx every shift, braden assessment, monitor skin during bathing and weekly, reposition every 1-2 hours during the day, encourage food intakes and repostion every 2-3 hours at night. A care plan, dated 8/10/18, for unstageable pressure injury to coccyx, covered with eschar. The interventions were: measure weekly, update skin sheet, [MEDICATION NAME] dressing to coccyx, change every 3 days, turn/reposition every 2 hours approximately, med pass 60 ml (mililiters) 3 times a day, pressure reducing mattress, pressure reducing cushion on wheelchair and recliner, and encourage mobility. A Progress Note, dated 7/21/18 indicated resident had a red, blanchable coccyx, [MEDICATION NAME] cream applied and resident was positioned on her left side . A waffle cushion added to her wheelchair. A Progress Note, dated 8/1/18, indicated the resident had a 6 cm reddened area on her coccyx, which was blanchable. The area was covered with a [MEDICATION NAME] sacrum dressing. A Skin Evaluation form, dated 8/10/18, indicated the resident had an unstageable pressure ulcer on her coccyx. The wound measured 1.5 x 1.0 with a black area. The interventions were as follows: protein supplement, turning/repositioning program and pressure reducing chair. The treatment was [MEDICATION NAME] sacrum dressing, change every 3 days, added a waffle cushion, while in the recliner and turn every 2 hours. A Skin Evaluation form, dated 8/16/18, indicataed the coccyx wound measured 1.0 x 2.0 cm with top half of wound covered with eschar and bottom half of wound was a Stage II. Surrounding area pink and blanchable. No change in treatment of [REDACTED]. A Skin Evaluaation form, dated 8/23/18, indicated wound measured 1.3 x 1.7 cm. with no eschar, but where eschar was now white. Dressing changes were: Opifoam sacrum dressing, change every Thursday and as needed. The most recent Skin Evaluation form, dated 9/27/18, indicated wound measured 0.2 x 0.3 cm with small amount of clear drainage. The pressure area was pink in center with granulation tissue. On 9/28/18 at 10:25 A.M. Resident G was taken to her room for an observation of her wound with RN 5. Th resident was assisted to a standing position. Her brief was dry. The old dressing, dated 9/27/18 was removed, by RN 5. The wound was observed to be pink with grandulaltion tissue and measured 0.2 x 0.3 x <0.1 cm. The wound appeared to be close to being resolved. The inflatable waffle cushion was noted to be partially deflated and unable to provide pressure relief on the buttock/coccyx area. The padded cushion underneath the waffle was observed to be flat and hard, therefore not providing pressure relief for the resident. RN 5 agreed and contacted the therapy department to provide the resident with a new pressure relieving device for her wheelchair. 3. On 9/27/18 at 10:43 A,M., Resident J was observed in an activity, sitting in a chair, with her walker in front of her. At 11:06 A.M., she was observed in a common area, on the unit, sitting in padded chair, with walker in front of her. On 9/27/18 at 11:19 A.M., CNA 7 approached the resident and asked if she was ready to go into the dining room. Resident J was assisted with standing and then she proceeded to dining area without assistance.The resident had no shoe on her left foot, only a non skid sock Observation 9/27/18 at 3:08 P.M., Resident J observed coming out of her room with her walker. Then back to room and sat in her chair. The resident was confused and unable to appropriately respond to cognition screening questions. During an interview, on 9/27/18 at 3:15 P.M., CNA 4 indicated Resident J was to wear a gripper sock on her left foot with no shoe and at night staff were to float her heels when she's in her bed or recliner. On 9/28/18 at 9:46 A.M., a review of the clinical record for Resident J was conducted. The resident's [DIAGNOSES REDACTED]. A Quarterly MDS Assessment ,dated 8/17/18, indicated the resident was an extensive assist of 1 person with transfers and has an unstageable pressure wound measuring 1.2 x 2.0 x 0.1 cm, covered with eschar. A Braden score, dated 1/12/18, was 12 which indicated the resident was at risk for pressure ulcer development. A care plan indicated the resident was at risk for skin breakdown/pressure ulcers due to decreased mobility and frequent urinary and occasional bowel incontinence. The interventions included, but were not limited to: assist resident with perineal care, change pull up when incontinent, pressure reducing mattress and encourage intake of foods and fluid daily. A care plan for the unstageable pressure area to left heel had the following interventions: float heels when in bed, evaluate heel daily and [MEDICATION NAME] wipe BID (twice a day) to left heel until healed. A Skin Sheet, dated 1/25/18, indicated suspected deep tissue injury to left heel, and measured 5.0 x 7.0 cm. Deep purple localized area of skin. Feels boggy and mushy. No warmth noted and resident denied pain to area. Treatment included Calilon (no sting wound barrier) film BID and float heels and waffle boat. A Skin Sheet, dated 3/15/18, indicated heel wound measured 2.2 x 3.0 cm with eschar covering 100% of wound bed. Treatments same as 1/25/18 skin sheet documentation. A Skin Sheet, dated 5/17/18, indicated wound measured 1.1 x 2.0 cm with eschar covering 100% of wound bed. Treatment same as 1/25/18 assessment of wound. A Skin Sheet, dated 7/12/18, indicated wound measured 1.1 x 2.0 cm with eschar covering 100% of wound bed. Treatment was iodine wipe BID, float heels, wear sock without shoe. A Skin Sheet, date 9/27/18, indicated heel wound measured 1.7 x 1.9 x 0.2 cm with scabbed area, small white center measured 0.1 x 0.1 cm. Calvalon wipe BID continued. On 9/28/18 at 1:40 P.M., an observation was made of the resident's left heel with RN 5. The gripper sock was removed and exposed a 1.6 x 2.0 x 0.2 unstageable pressure wound. The wound bed was covered with a hard yellow substance, edges were also yellow and hardened. The resident did not complain of pain while RN was dressing the wound with [MEDICATION NAME]. The resident indicated the staff make sure when she is sitting in the recliner her feet aren't touching the foot rest. On 9/28/18 at 10:11 A.M., the Assistant Director of Nursing (ADON) provided a policy titled, Pressure Ulcer Monitoring, dated 8/1998 with revision on 5/2015 and indicated the policy was the one currently used by the facility. The policy indicated .Procedure 3. Appropriate nursing interventions shall be implemented immediately and documented in the Care Plan. Suggested interventions included but are not limited to, notification of Physician Therapy for pressure ulcer screen and Occupational Therapy for wheelchair position if applicable, turning and repositioning schedules, protective mattresses and other devices, incontinence care as indicated by the resident's spicific condition, and referral to wound consultant .7. The presence of the wound will be added to the resident's care plan, with appropriate goals and approaches indicated. 9. It will be the responsibilty of the skin nurse or Nurse Team Leader to monitor progress of wounds. Lack of progress in the healing of a wound over 2-4 week period will be reported to the physician to reevaluate treatment regimen This Federal tag relates to complaint IN 289. 3.1-40(a)(1)

A. Based on observation, record review and interviews, the facility failed to ensure an assistive device was safe and adequate supervision was provided to prevent accidents with injury for 1 of 1 residents in an ambulator (Merry Walker, walker/chair combination). This deficient practice resulted in Resident #168 sustaining multiple skin tears from accidents and falls while in an ambulator. (Resident #168) B. Based on observation, record review, and interview, the facility failed to provide a safe environment for residents, related to power strips that were not properly attached to the wall and had medical devices plugged into them, for 7 of 40 resident rooms observed for power strips in their room. (Room 134, 142, 143, 206, 221, 223 and 243) Findings include: A.1. Resident #168 was observed on 01/05/16 at 2:37 P.M. ambulating on the nursing unit in a merry walker restraint. Resident #168 was heard asking for a key and then was noted to push the Merry Walker beside a recliner and climb partially out of the Merry Walker. He was seated on the arm rest of the merry walker with his feet on the seat of the merry walker before staff intervened and assisted him out of the Merry Walker and into a recliner. However, in less than 10 minutes he was assisted back into the Merry Walker by nursing staff. The clinical record for Resident #168 was reviewed on 01/08/2016 10:37 A.M. Resident #168 was admitted to the facility on [DATE], with diagnoses, including but not limited to: [DIAGNOSES REDACTED], hypertension, malaise and fatigue post traumatic seizures, difficulty walking, debility, history of falls and anxiety state. The quarterly MDS (Minimum Data Set) assessment, completed on 12/17/15, indicated the resident scored a 4 on a BIMS (Brief Interview for Mental Status) which indicated he was severely cognitively impaired. Resident #168 demonstrated physical and verbally aggressive behaviors, required limited staff assistance for bed mobility, required supervision and set up for ambulation in room, and locomotion on unit. He required extensive staff assistance for transfers, dressing, eating, toilet use, personal hygiene and bathing needs. The resident was also documented as having 1 fall without injury and two falls with injuries since his admission. The resident's weight had also decreased from 116 on admission to 99 pounds. The assessment did not indicate any restraint use. A potential for falls care plan, initiated on 06/19/15 and current through 03/24/16, indicated the resident was at risk for falls and injury. The interventions were as follows: staff to anticipate and meet all needs every shift, staff to assist to rest in recliner in lounge or bed between meals and activities, staff extensive 1-2 manual assist with transfers, staff to watch for decline in ADL's (Activities of Daily Living) r/t (related to) daily use of Zyprexa (antipsychotic) , Lexapro (antidepressant), Ativan (antianxiety) and Remeron (antidepressant) and report complications to physician. Resident is increasingly confused and non-compliant, makes unexpected, sudden moves. Staff to be as watchful as possible at all times, when staff know that resident is awake, bring out of room if resident will allow or start 15 minute checks if resident doesn't want to leave room, allow resident to move around in Merry Walker when he becomes restless, watch resident when he puts his feet on the bars of the ambulator, and try to prevent him from doing so as this makes him slide off the seat, toilet resident as soon as note odor or as soon as resident becomes restless and indicated that he need to use the rest room, lock wheelchair at bedside when resident in bed to help resident have another location to sit if he should get out of bed alone, resident will be asked periodically if he has any needs, when resident is awake and restless or agitated, have him where he can be easily observed and watched. Toilet frequently. Allow resident to rest on his mattress on the floor in the lounge to better observe him and prevent falls, per family (resident's name) can be in lounge as needed for safety, resident needs to be in sight of staff if possible while awake. Continues to climb out of bed without help, resident may be up in ambulator when restless so that he may be able to ambulate safely, toilet prior to recliner or bed, resident at times likes to place self on floor when tired, care plan reviewed after 11/30/fall- no new interventions at this time, trial periods under close supervision out of ambulator (Merry Walker), Hospice will initiate therapy screen, go green program, may sleep on floor on mattress if resident is restless. A nursing note, dated 09/06/15, indicated the resident was using an ambulator (Merry Walker). A nursing note, dated 09/15/15, indicated the resident was complaining about the Merry walker and called it a cage but had experienced less falls since being placed in the ambulator. A fall note, dated 10/12/15 at 11:00 A.M., indicated staff heard a thud and found resident on the floor in the hallway with the ambulator tipped over. The resident was noted to have two abrasions to the back of his head. The note indicated the resident had been very active in the ambulator most of the day, walking and sitting with his legs up on the sides. There was no follow up action documented on the fall investigation forms. A fall note, dated 10/20/15 at 10:30 P.M., indicated the resident had up his feet up on the ambulator and slid out of the seat part of the ambulator and fell to the ground. The resident was not assessed to have received any injuries and there was no follow up action documented. A fall note, dated 11/30/15 at 12:30 P.M.,indicated the resident had been in his ambulator and was later found walking in the hallway without the ambulator with blood on his hands and head. The resident received three flap type skin tears. One on the top of the head measuring 3 cm (centimeters) x (by) 2 cm. One skin tear to the left lower extremity measuring 0.8 x 1 cm. One skin tear to the left back flank area measuring 0.6 cm x 0.3 cm. There was no follow up action documented. A nursing note, dated 12/04/15 and 12/13/15, indicated the resident was climbing out of the ambulator and diving onto other furniture. On 12/13/15 he received two skin tears due to this action. A fall note, dated 12/10/15, at 10:00 A.M., indicated the resident tipped his ambulator over and fell . He sustained a V shaped skin tear to his left elbow measuring 2 cm. There was no follow up action documented. A fall note, dated 12/17/15, indicated the resident attempted to dive out of his ambulator and landed with his leg caught in the strap of the ambulator and the ambulator was turned upside down. The resident did not receive any injuries. There was no follow up action documented. On 12/24/15, as a result of the resident's multiple falls, including the falls from the ambulator, a screen from occupational therapy was ordered. During an interview,on 01/11/2016 at 10:12 A.M., LPN (Licensed Practical Nurse) #33 indicated because Resident #168 was receiving Hospice services, the Occupational Therapy screen had to be approved by the Hospice company, then contracted and completed by an Occupational Therapist of their choice. She indicated the holidays might have also delayed the intervention. The Occupational Therapy evaluation, completed on 01/08/16, indicated the resident was in the ambulator for part of the assessment and attempted to climb out of the ambulator. The therapist recommendations were the following: Patient has very poor immediate memory recall and did not follow commands with therapist. He has days when he is apparently stronger than other days, on his weaker days he attempts to climb over the sides of furniture and he falls. There is no equipment that will provide patient with a safe environment without close staff interventions. Patient requires 24 hour close staff supervision. During an interview, on 12/12/16 at 10:30 A M., LPN #33 indicated Resident #168 continued to try to climb out of his ambulator at times and the facility had discontinued the ambulator but then reinitiated the ambulator. It was unclear when this occurred and why the unsafe restraint was reinitiated. The facility assessments for the Merry Walker, completed in September, October and November 2015, did not indicate any safety issues with the device. LPN #33 indicated there was no part of any assessment utilized to determine if the restraint was a safe intervention for the resident. On 1/12/16 at 1:12 P.M., the Administrator provided a current policy titled, Restraints - physical restraints, revised on 07/06, included the following: .Policy: Restraints will only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully B.1. On 1/11/16 from 9:15 A.M.-10:00 A.M., an environmental tour was conducted of the facility with the Maintenance Director and a Maintenance employee, during which the following was observed: At 9:25 A.M., Resident room 206 bed W was observed with a power strip not securely attached to the wall, the plug in part of the strip was on the floor beside the residents chair. The power strip had a nebulizer machine (delivers inhalation medication) plugged into it. An interview with the Maintenance Director at this time indicated power strips were okay to use but they should not have medical equipment plugged into it. At 9:30 A.M., Resident room 223 bed D was observed with a power strip not securely attached to the wall, the plug in part of the strip was on the floor. The power strip had a lift chair plugged into it. An interview with the Maintenance Director at this time indicated the lift chair was plugged into the power strip because the lift chair cord would not reach the plug in on the wall. At 9:35 A.M., Resident room 243 bed D was observed with a power strip on the floor not attached to the wall, the power strip had a lift chair plugged into it. At 9:40 A.M., Resident room 221 bed D was observed with a power strip draped across a bedside stand with a television and a power wheelchair charger plugged into it. An interview with the Maintenance Director at this time indicated the resident plugs his power wheelchair into the power strip daily to charge the battery for his wheelchair. At 9:50 A.M., Resident room 142 bed D was observed with a power strip on the floor beside the residents recliner, a metal assistive device used to pick objects up from the floor was observed tangled in the power strip cord. At 9:55 A.M., Resident room 143 bed W was observed with a power strip hanging from the wall plug in, the power strip was not attached to the wall and was stretched across the end of the bed. The power strip had a television and a clock plugged into it. Bed D was observed with a power strip on the floor beside the residents chair, a television was plugged into the power strip and multiple plug in cords were observed tangled around the power strip. At 10:00 A.M., Resident room 134 bed W was observed with a power strip on the floor not attached to the wall, multiple cords were observed tangled around the power strip. During an interview on 1/11/16 at 10:05 A.M., the Maintenance Director indicated the facility follows the life safety regulations regarding the use of power strips, he further indicated when he monitors resident rooms he finds medical equipment plugged into power strips. On 1/11/16 at 11:00 A.M., a review of the current policy titled Fire Safety, undated, received from the Administrator indicated .Environmental services staff will be monitoring all healthcare areas for proper use of electrical connections .Environmental staff will notify the nursing staff on their unit if medical equipment being used is not plugged into wall outlets 3.1-45(a)(2) 3.1-19(c)

Based on record observations, reviews and interviews, the facility failed to ensure adequate supervision of Resident "C," who was known to have nocturnal (nighttime) wandering. This resulted with Resident "C" entering the room of Resident "D," and moving Resident "D" from the bed, which resulted in Resident "D" sustaining a fall and fracture of the (L) (Left) tibia and fibula. This deficiency affected 1 of 5 residents reviewed for supervision and accidents in a sample of 5. Finding includes: During the Initial Tour, on 04/07/15, between 8:40 a.m. and 9:15 a.m., accompanied by LPN #8, Resident "C" was identified as a "wanderer," who wandered in the facility, primarily during the night. LPN #8 indicated Resident "C" walked independently at a brisk, almost running pace, and required frequent monitoring. The record of Resident "C" was reviewed on 04/07/15 at 10:20 a.m. Resident "C" was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The most recent Annual MDS (Minimum Data Set) assessment, dated 02/19/15, indicated Resident "C" was severely cognitively impaired, exhibited behaviors of resisting care/assistance, wandering, and required supervision when walking. The record indicated: "03/22/15 2:28 a.m. At 12:30 a.m. this resident was found in resident (Resident "D")room. Resident (Resident "D") was laying on the floor and this resident was grabbing her (Resident "D") hands saying, "let me help you up." Staff quickly intervened and assisted resident (Resident "C") out of room without difficulty. Within a few minutes resident (Resident "C") does not remember incident and is in a pleasant mood. Currently put on 1-1 (monitoring)...." Resident "C" was observed throughout the survey, either sleeping in bed or sleeping while seated in chairs in common areas and dozing while seated in the facility's beauty shop. The closed record of Resident "D" was reviewed on 04/07/15 at 11:20 a.m. Resident "D" was admitted to the facility for short term rehabilitation and therapies on 03/15/15, with [DIAGNOSES REDACTED]. The resident had a vertebroplasty (surgery to stabilize spinal fractures) on 03/10/15. The 5 Day- MDS, dated [DATE] and following the fall, indicated Resident "D" was cognitively intact and required extensive assistance of 2 or more for transfers and ambulation. The record indicated the following: "03/21/15 10:33 p.m. Resident resting in recliner at bedside chatting with visitor when checked earlier in evening. Alert and interactive. Able to make needs known....Attends therapy as scheduled with goal of return to home. Transfers 1 extensive assist. Ambulates 1 limited assist using walker...." "03/22/15 2:07 a.m....12:30 a.m. Writer heard yelling and found resident laying on (L) side with feet extended outward at side of bed. Call light on. Resident (Resident "C") standing at foot of bed with arm extended outward saying "let me help you". Resident (Resident "C") escorted out of room without difficulty. Resident (Resident "D") had complaints of pain in (L) lower leg. Purple bruising noted on medial (middle) area above (L) ankle. Foot rotated outward. Slight swelling noted. Denied hitting head..." The on call physician and the resident's family were notified and the resident was transferred by EMS (Emergency Medical Service) to the ACF (Acute Care Facility: Hospital) ER (emergency room ). "03/22/15 3:50 a.m. Son, (name), called from ER. Resident has FX (fracture) in 2 spots in (L) leg. Leg has been splinted and hosp (hospital) sending back NWB (Non-Weight Bearing) and to follow up with (orthopedic group name) on Monday for possible surgical repair consult." "03/22/15 4:05 a.m. Recvd (received) call from (nurse's name) @ (at) (ACF name) ER. Resident has fractured (L) Tib/Fib (Tibula/Fibula)...." "03/22/15 4:25 a.m. Resident returned from (hospital name) via (by way of) (EMS name). Air splint on...." "03/24/15 11:19 a.m. Resident LOA (Leave Of Absence) this AM at 0815 (8:15 A.M.) for appointment...Received call from nurse at (Orthopedic group name) that resident was to be direct admitted to (ACF name)..." The ACF "EMERGENCY DEPARTMENT REPORT," dated 03/22/15, indicated: "...EXTREMITIES: The patient has a deformity, Ecchymosis (discoloration: bruising) tenderness left distal calf. Left foot is rotated externally approximately 30 degrees...." "DIAGNOSTIC TESTING: Left ankle X-ray with oblique distal tibia fracture and transverse distal fibula fracture with approximately 20-30 degrees posterior angulation...Post reduction X-ray shows better alignment through now slightly anterior angulated...." "Diagnosis: [REDACTED]. Distal left fibula fracture." Confidential interviews were conducted during the survey, between 04/07/15 and 04/08/15, with nursing staff, family members, and residents. During the interviews, 2 of 3 nursing staff indicated Resident "C" was on hourly monitoring prior to the incident and 3 of 3 nursing staff indicated Resident "C" remained on 15 minute checks since 03/22/15, following the 1:1 monitoring. Interviews indicated Resident "C" had not had physical contact with residents prior to the 03/22/15 incident and no further physical contact with other residents since. Interviews indicated Resident "C" continues to wander, primarily at night, and is redirected and/or followed to prevent wandering into other residents rooms. The resident continues, at times, to ambulate to the Gables Unit, which is connected to the North Unit and South Unit by a long hallway, approximately 100 steps, which turns and is not visible from the North Unit and South Unit. During an interview on 04/08/15 at 11:42 a.m., LPN #5 indicated Resident "C" was observed asleep while sitting in the hallway near the South Unit nurses station on 03/22/15, during the night shift. LPN #5 continued with assigned duties and then observed Resident "C" seated on the love seat near the North Unit nurses station and appeared to be dozing. The units are located next to each other along a continuous hallway. LPN #5 indicated she left the area to check on another resident and when she returned to the nurses station, Resident "C" was gone, and at the same time, she received a phone call from a Gables Unit staff member that Resident "C" had wandered to the Gables Unit. LPN #5 indicated Resident "C" was seated next to a staff member at the Gables Unit nurses station and indicated the entire episode, from last observation until seeing the resident on the Gables Unit was less than 15 minutes. LPN #5 indicated Resident "C" is quick and moves at a brisk pace. LPN #5 indicated Resident "C" continues to wander and is followed per staff and redirected as needed. Resident "D" was interviewed and the record was reviewed, in her current ECF (Extended Care Facility: nursing home), on 04/08/15 at 8:55 a.m. Resident "D" was transferred to the current ECF, on 03/30/15, following surgery on her left ankle. Resident "D" was seated in a wheelchair with both legs elevated and had an occlusive (unable to see through) wrap on her left lower leg. Resident "D" remained alert and oriented as corroborated by her most recent 5 day MDS, dated [DATE]. The MDS further indicated Resident "D" required extensive assistance of 2 or more for mobility, transfers, hygiene, and toileting. The resident was non-ambulatory. A review of current Physician order [REDACTED]. The records indicated Resident "D" had surgical procedures: "03/24/15 External fixation of left distal tibia and fibula shaft fracture." "04/01/15 ORIF (Open Reduction Internal Fixation) (L) tibia and fibula fracture." During the interview, Resident "D" related the sequence of events in regards related to her fall. Resident "D" indicated she was sound asleep when she was awakened by someone pulling on her. Resident "D" indicated she initially thought it was a CNA and told the person she did not need to get up to the bathroom, and clearly stated to the person, "I didn't ring my buzzer." Resident "D" indicated the person was, "pulling on me, yanking on me, ...I don't have to get up." Resident "D" indicated the person (Resident "C") told her she needed to get up, at which time Resident "D" began screaming, "let me alone," and the "next thing I knew, I was on the floor." Resident "D" indicated she continued to scream to the person "you broke my leg" at which time nursing staff entered the room. Resident "D" indicated prior to the incident she was ambulating with minimal assistance and was anticipating a discharge home with family within the following week. Resident "D" indicated she has had 2 surgeries as a result of the incident and is fearful she will no longer be able to walk. Resident "F," room mate of Resident "D" at the time of the incident, was interviewed on 04/08/15 at 2:05 p.m. Resident "F" indicated she clearly recalled the incident and correctly noted the day it occurred. Resident "F" indicated she was lying in her bed, awake, on 03/22/15, with the privacy curtain drawn between her & the room mate. Resident "F" heard a commotion at approximately 12:00 a.m. The resident indicated it sounded as if someone was rummaging around and as she thought it was a CNA, and did not turn on her call light. Resident "F" indicated she heard a conversation indicating her room mate (Resident "D") did not want to go to the bathroom and indicated the person (Resident "C") had awoken Resident "D," which was followed by screaming and yelling by her room mate, Resident "D," and she had been dropped on the floor, yelling, "You broke my leg," at which time Resident "F" activated her call light and staff arrived almost simultaneously. Resident "F" indicated Resident "C" had not wandered into her room since. This Federal tag relates to Complaint IN 526. 3.1-45(a)(2)

Based on interview and record review, the facility failed to ensure fall interventions were initiated to prevent falls for 3 of 8 residents reviewed for falls in a sample of 30, resulting in a fall with fracture for Resident #197 (Resident #197, Resident #73, Resident #145). Findings include: 1. Resident #197's record was reviewed 10-19-2011 at 1:00 p.m. Resident #197's [DIAGNOSES REDACTED]. Review of the most recent MDS (Minimum Data Set: a tool to assist in providing resident care), dated 09/17/11, indicated Resident #197 had short and long term memory loss, and had decision making impairment, resulting in Resident #197 requiring 1 person assist for dressing, hygiene, and bathing. Resident #197 was assessed as being at risk for falls. according to her care plan dated 6-23-2011 due to her history of falls and fast gait. Care plan interventions included nonskid footwear, call light in reach, eyeglasses on, top siderails at night, and reviewing lab results as available. The care plan had been updated 9-7-2011 and 9-21-2011 with additional fall interventions. Nurse's notes dated 5-19-2011 indicated at 1:00 p.m. Resident #197 sustained a fall. The post fall investigation did not indicate any new interventions to prevent falls. Nurse's notes dated 9-1-2011 at 3:55 a.m., indicated Resident #197 had fallen and was complaining of pain in her left leg. Resident #197 had been found on the floor, lying on her right side, in the hallway next to the doorway of the resident's room. The nurse indicated Resident #197 yelled out in pain during range of motion on her left leg, but did not yell out when range of motion was performed on her other extremities. The note further indicated the physician was notified by fax. A nurse's note dated 9-1-2011 at 4:22 a.m. indicated Resident #197 refused Tylenol for the pain. At 5:50 a.m., the nurse's notes record Resident #197 finally accepted Tylenol for left leg pain. The on-call physician was paged at 7:15 a.m. Resident #197 was sent to the hospital at 8:20 a.m. and was admitted with a left hip fracture. In an interview, on 10-20-2011 at 9:50 a.m., Unit Manager #4 indicated she had been the nurse working the night of Resident #197's fall. She indicated Resident #197 yells out a lot when repositioned and always has done so. Unit Manager #4 indicated she had been unable to tell if Resident #197 was calling out truly in pain or if she was really hurt. In an interview on 10-20-2011 at 9:53 a.m. LPN #5 indicated an intervention was to be put into place each time there was a fall. She additionally indicated if the resident cries out with pain after a fall, the resident should have been sent to ER right away and the physician called. 2. Resident #145's record was reviewed on 10-18-2011 at 10:35 a.m. Resident #145's [DIAGNOSES REDACTED]. Resident #145's care plan indicated he was at risk of falls due to confusion and unsteady gait. The care plan also indicated resident #145 was at risk for elopement. Interventions had been added to the care plan on 9-12 indicated to initiate the go green program, 9-26 indicated therapy treatment, 9-30 to take Resident #145 outside when he wanted to go, and 10-10-2011 to leave the courtyard gate open. A review of Resident #145's nurse's notes indicated Resident #145 fell on ,[DATE], 8-17, 9-9, 9-11, 9-25, 9-27, twice on 9-30, 10-3 and 10-10. A review of Resident #145's Post fall investigations indicated the following: the post fall investigation dated 8-15 indicated there were no fall prevention action put into place; the post fall investigation dated 8-17 indicated Resident #145 was receiving therapy, but no further actions were put into place; the post fall investigation dated 9-9 indicated no actions were put into place to prevent further falls; the post fall investigation dated 9-25-2011 indicated to monitor resident closely when he got up to walk and a referral had been made to therapy; the post fall investigation dated 9-27 indicated no new actions were taken to prevent falls; the post fall investigation dated 9-30-2011 at 4:30 p.m. indicated to remind Resident #145 to ask for help when needed. The Minimum (MDS) data set [DATE] indicated Resident #145 had significant memory loss. The post fall investigation dated 9-30-2011 at 6:40 p.m. indicated to remind Resident #145 to ask for help. No other new interventions had been taken to prevent falls. The post fall investigation dated 10-3-2011 indicated to monitor for fatigue and restless behavior and assist Resident #145 if needed. The post fall interventions dated 10-10-2011 indicated to remind visitors to check with staff before helping residents that are not family members. Unit Manager #4 was interviewed on 10-19-2011 at 9:45 a.m. and indicated no new interventions were put into place for Resident #145. 3. Resident #73's record was reviewed 10-19-2011 at 10:10 a.m. Resident #73's [DIAGNOSES REDACTED]. Resident #73's Minimum (MDS) data set [DATE], indicated Resident #73 was alert and oriented and able to make good decisions. Resident #73's nurse's notes indicated he fell [DATE] trying to adjust his recliner. The immediate prevention measures were to be aware of surroundings. The post fall investigation indicated under action plan there were no new plans to prevent falls at that time. Resident #73's care plan indicated Resident #73 was at risk for falls due to weakness, pain medication use and poor balance. The interventions written 7-22-2011 were to encourage Resident #73 to wear nonskid footwear, instruct in transfer techniques, provide rolling walker, keep call light and personal items in reach, monitor vital signs, blood sugars and effects of medications, and to continue therapy per orders. There were no indications any new interventions were put into place to prevent falls after the fall of 9-17-2011. Unit Manager #4 was interviewed on 10-19-2011 at 9:45 a.m. and indicated no new interventions were put into place for Resident #73. A current policy dated 8/06 and revised 11/09 titled Incident Report indicated documentation would include preventative measures. 3.1-45(a)(2)