Every finding on record at Hamilton Pointe Health and Rehab

Based on observation, interview, and record review, the facility failed to ensure food was served at a palatable temperature for 1 of 1 trays tested for temperature. (600-hall, Resident B, Resident C, and Resident D)Finding includes:1. Interview on 8/12/26 at 10:21 A.M., Resident B indicated that the hot food was not always hot when it was served.Interview on 8/12/26 at 11:21 A.M., Resident C indicated that the hot food was always cold when it was served.Interview on 8/12/26 at 1:08 P.M., Resident D indicated that she ate in the dining room and the hot food was cold when it was served. 2. On 8/12/26 at 12:29 P.M., a test tray was obtained from the 600-hall. Temperatures were:Baked chicken - 107.7 Fahrenheit (F)Buttery noodles - 102.1 FPear cobbler - 96.8 F3. On 8/13/26 at 11:13 A.M., the food temperature log record was reviewed. The lunch meal served on 8/12/26 indicated the following holding temperatures:Entree, general (baked chicken) - 170 Fahrenheit (F)Starch, general (buttery noodles) - 186 FDessert (pear cobbler) - 168 [NAME] 8/13/26 at 11:16 A.M., the Administrator provided a current Food Temperature Monitoring policy, dated 5/16/23, that indicated All hot food items must be cooked to appropriate internal temperatures, then held and served at a temperature of at least 135 degrees F.This citation relates to Intakes 3153440 and 3156673.3.1-21(a)(2)

Based on interview, observation, and record review, the facility failed to ensure professional standards for administering medications ordered by a physician were met for 1 of 3 residents reviewed for medication administration. (Resident B) Resident B was not administered physician ordered medication, the facility documented the medication as administered when it was not, and did not notify the physician the resident had not received the medication for consecutive days. Findings include: On 8/12/26 at 10:21 A.M., Resident B indicated he had not received eye drops in several days. On 8/12/26 at 10:37 A.M., Nurse 6 indicated Resident B had been out of eyedrops for several days, showed that there were none in the medication cart, and provided a reorder for the eyedrops on 8/9/26. On 8/12/26 10:55 A.M., Resident B's clinical record was reviewed. Diagnosis included, but was not limited to, Congestive Heart Failure. The most recent Minimum Data Set (MDS) Assessment, dated 6/5/26, indicated Resident B was cognitively intact and independent for eating and toileting. Physician orders included, but were not limited to: Carboxymethylcellulose Sodium Ophthalmic Solution 0.5% (eyedrops) Instill two drop in both eyes every six hours as needed for lubricating eyes; Start date 12/23/25 Carboxymethylcellulose Sodium Ophthalmic Solution 0.5% (eyedrops) Instill two drop in both eyes one time a day for dry eyes; Start date 2/24/26 The Electronic Medication Administration Record (EMAR) indicated the following Carboxymethylcellulose Sodium Ophthalmic Solution 0.5% administrations:8/9/26 8:00 P.M. - Given by LPN 88/10/26 8:00 P.M. - Medication unavailable 8/11/26 8:00 P.M. - Given by LPN 98/12/26 8:00 P.M. - Given by LPN 10 The clinical record lacked notification to the physician about Resident B's eyedrops not being administered multiple days. On 8/13/26 at 10:57 A.M., The Director of Nursing (DON) indicated she spoke to LPN 8 who stated on 8/9, he checked off eyedrops as given before he administered them, and didn't know how to amend the administration when he realized the eyedrops were not available. The DON indicated the eyedrops were not given on 8/10, and was unsure why staff on 8/11 and 8/12 documented as administered because eye drops were not yet delivered by pharmacy but had requested they be delivered today. On 8/13/26 at 11:15 A.M., the Administrator provided a policy titled Unavailable Medications, dated 11/23, that indicated Staff shall take immediate action when it is known that the medication is unavailable: a. Determine reason for unavailability, length of time medication is unavailable, and what efforts have been attempted by the facility or pharmacy provider to obtain the medication. b. Notify physician of inability to obtain medication upon notification or awareness that medication is not available. Obtain alternative treatment orders and/or specific orders for monitoring resident while medication is on hold. If a resident misses a scheduled dose of the medication, staff shall follow procedures for medication errors, including physician/family notification, completion of a medication error report, and monitoring the resident for adverse reactions to omission of the medication. This citation relates to Intake 3153440. Indiana Administrative Code (IAC) 16.2-3.1-50(a)(2)

Based on observation, interview, and record review, the facility failed to ensure resident's had orders from the attending practitioner for oxygen therapy use and maintenance of equipment for 2 of 3 residents reviewed for oxygen therapy. (Resident B, Resident E)Finding includes: On 1/12/26 at 10:00 a.m., Resident B's clinical record was reviewed. Diagnoses included but were not limited to chronic pulmonary disease, unspecified, pulmonary hypertension, unspecified, acute diastolic (congestive) heart failure, and dependence on supplemental oxygen. An admission Minimum Data Set (MDS) assessment dated [DATE] was coded for oxygen therapy. Resident B was admitted on [DATE] and discharged to the hospital on [DATE]. Care plans were reviewed and included, but were not limited to: I have chronic obstructive pulmonary disease (COPD). Interventions included but were not limited to: I will receive oxygen at 2-3 liters per minute as ordered, date initiated 11/19/25, revision 12/1/25. An admission/readmission evaluation document dated 11/18/25 was reviewed and included, but was not limited to: Most recent O2 sats (oxygen saturation) 96%, Method: Oxygen via nasal at 3L (liter) per minute. Medical devices present: Tubing. Vital signs were reviewed for oxygen saturation and indicated Resident B was receiving O2 per nasal cannula on the following dates in November 2025: 11/18, 11/19, 11/22, 11/24, 11/26, 11/27, 11/28, 11/30. Daily skilled notes were reviewed, and the following dates indicated Resident B was on O2 per nasal cannula : 11/19, 11/22, 11/26, 11/30Progress notes were reviewed and included, but were not limited to:11/18/25 at 4:30 p.m., The resident was admitted for therapy .She has 3 L of oxygen .Nurse practitioner progress notes for November 2025 were reviewed and indicated Resident B was on O2 per nasal cannula on the following dates: 11/19: 4.5 L 11/21: 4.5 L11/24: 4.5 L 11/26: 4.5 L November 2025 physician orders were reviewed and did not contain orders for oxygen therapy. December 2025 physician orders were reviewed and included the following orders: Oxygen at 2 lpm (liter per minute) via nasal cannula continuous. May titrate as needed, every shift for hypoxia, order date 12/1/25.Change oxygen tubing and supplies weekly, every day, shift every Sunday, order date 12/1/25. 2. On 1/13/26 at 9:48 a.m., Resident E was observed in his room sitting on his bed. O2 was observed on the resident per nasal cannula at 2.5 L. Resident E indicated he had recently returned to the facility from a hospital stay and was put on oxygen when he was readmitted to the facility. On 1/13/26 at 9:58 a.m., Resident E's clinical record was reviewed. Diagnoses included but were not limited to: chronic obstructive pulmonary disease, chronic kidney disease. An admission Minimum Data Set (MDS) dated [DATE], indicated Resident E's cognition was intact. Resident 19 was admitted to the facility on [DATE].Progress notes were reviewed and included, but were not limited to the following: 1/10/26 5:28 a.m., Resident POA (Power Of Attorney) had concerns about the resident's low O2 reading, and requested that the resident be put on some oxygen. The resident was placed on 2Liters (sic) of oxygen, and O2 remained at 87% to 92%. The resident was then placed on 3liters (sic) of oxygen and has been ranging from 91% to 95%. The resident has no complaints of pain or discomfort. No s/s of distress noted. All other vitals have been WNL (within normal limits).1/12/26 at 9:35 am., a Nurse Practitioner note included but was not limited to: .Respiratory: Normal respiratory effort, O2 2L . Daily skilled notes were reviewed, and the following dates indicated Resident E was on O2 per nasal cannula: 1/8/261/10/26 1/13/26On 1/14/26 at 10:30 a.m., LPN 2 indicated a resident has to have a physician's order for oxygen therapy. The order is entered into the system, and there is a lady who comes weekly who changes the oxygen tubing. On 1/14/26 at 11:04 a.m., the DON indicated Resident B should have had a physician's order for oxygen therapy; the order typically indicates what the oxygen parameters should be. On 1/13/26 at 1:32 p.m., the Assistant Director Of Nursing provided the current policy on oxygen administration with a implemented date of 1/8/24. The policy included but was notlimited to: .Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences .1. Oxygen is administered under orders of a physician, except in the case of an emergency. In such case, oxygen is administered and orders for oxygen are obtained as soon as practicable when the situation in under control .[NAME], change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated .if applicable, change nebulizer tubing and delivery devices weekly and as needed if they become soiled or contaminated . This citation relates to Intake 2702057.3.1-47(a)(6)

Based on interview and record review, the facility failed to ensure accurate clinical records were in place for 1 of 3 residents reviewed for wounds. A wound to the left extremity was documented as right extremity (Resident C)Finding includes: On 12/12/25 at 9:14 a.m., Resident C's clinical record was reviewed. Diagnoses included but were not limited to, displaced bimalleolar fracture of left lower leg, disruption of external operation (surgical) wound, not elsewhere classified, subsequent encounter, generalized edema, type 2 diabetes without complications, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, lymphedema, not elsewhere classified, morbid(severe) obesity, chronic diastolic (congestive) heart failure. Resident C admitted on [DATE] and discharged to the hospital on [DATE]. Care plans were reviewed and included but were not limited to:I have a left plantar surgical wound with complications as I have diabetes. It is making progress but slowly. Date initiated 6/28/25, revision on 9/4/25. December 2025 physician orders were reviewed and included the following:Paint surgical wound to bottom of left foot with betadine and cover with dry dressing. secure with Kerlix every day shift for wound healing, order date 11/20/25. Skin & Wound evaluation notes were reviewed and the following dates indicated the wound location was to the right plantar foot middle instead of the left: 6/28/256/30/257/7/257/14/257/20/258/4/258/11/258/18/258/25/259/1/259/8/259/22/259/29/2510/8/2510/13/2510/20/2510/27/25Weekly nursing skin observations were reviewed indicated the surgical wound was to the right foot instead of left:7/11/257/18/258/1/258/15/259/12/2510/8/2511/12/2511/26/25The following weekly skin observations were marked no for a surgical wound:8/8/25 9/21/259/29/2511/5/2511/19/25Progress were reviewed and included but were not limited to the following:12/1/25 at 7:37 a.m., Skin Issues : Skin Issue: #001: Skin issue has been evaluated. Location: Right plantar foot. Laterally/Orientation: Middle. Issue type: Surgical wound .Skin issue progress notes on 11/10/25, 11/17/25, 11/24/25, indicated the same location. On 12/12/25 at 2:50 p.m., the facility wound nurse indicated Resident C's surgical wound was to the left foot, on the initial wound note he must have mistakenly charted right foot instead of left, the documentation carried over each time from the initial assessment. He indicated when he is on vacation, weekends, or absent from the facility the nurses do the treatments. On 12/16/25 at 10:30 a.m., the DON indicated the nurse doing the weekly skin observation should be documenting what they see.On 12/16/25 (time not recorded) LPN 2 indicated there is a form that is filled out for weekly skin observations, documentation is for what is seen, Resident C had a wound to the left foot, she will sometimes document to refer to the wound notes. On 12/16/25 at 3:00 p.m., the DON provided the current policy for documentation in medical records with a implemented date ot 1/30/24. The policy included but was not limited to: Each resident's record shall contain an accurate representation of the actual experience of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation . This citation relates to Intake 2690404. 3.1-50(a)(2)

Based on observation, interview, and record review, the facility failed to ensure that medications were kept secure and stored in a locked cart and that residents' privacy rights were protected in 1 of 1 random observations of a medication cart. ( Unit 400, Resident H) Finding includes : On 10/16/25 at 2:40 p.m., a medication cup that contained 6 pills was observed on a medication cart on the 400 unit. The medication cart was observed unlocked. A computer with the screen showing the picture and clinical record information of Resident H was observed on top of the cart. On 10/16/25 at 2:46 p.m., LPN 2 was observed to return to the medication cart carrying a box of medication. LPN 2 indicated she had left the cart because she thought she heard a resident yelling on another unit and was not sure a CNA was available. LPN 2 indicated medications should not be left on top of a cart unattended, the cart should have been locked before she left. On 10/17/25 at 9:04 a.m., the Administrator provided the current medication storage policy with a revision date of 4/6/24. The policy included but was not limited to: It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security .a. All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls .c. During medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart .On 10/17/25 at 9:04 a.m., the Administrator provided the current policy on medication administration with a revision date of 11/11/24. The policy included but was not limited to: Medications are administered by licensed nurses, or staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection .7. provide privacy .This citation relates to Intake 2632925 and 2645674. 3.1-25(m)

Based on observation, interview, and record review, the facility failed to ensure Enhanced Barrier Precautions (EBP) were used for a resident with a wound, orders were in place for care of an ostomy, for 1 of 2 residents observed for incontinence care, and 1 of 1 residents reviewed for ostomy care. (Resident C, Resident D)Findings include:During an observation on 9/4/25 at 11:10 P.M., Qualified Medication Aide (QMA) 1 and QMA 2 provided incontinence care on Resident C. QMA 1 and QMA 2 began care and failed to don EBP supplies. During care, QMA 2 left the room and brought back the Wound Nurse to provide care to Resident C's wound on her buttocks. The Wound Nurse failed to don EBP supplies.On 9/4/25 at 9:25 A.M., Resident C's clinical record was reviewed. Diagnoses included, but were not limited to, unstageable pressure ulcer.The most recent admission Minimum Data Set (MDS) assessment, dated 8/20/25 indicated Resident C had moderate cognitive impairment and was dependent on staff for toileting.Current Physician's Orders included, but were not limited to, Enhanced Barrier Precautions until the wound was healed, revised 8/15/25.Resident C's clinical record lacked a care plan related to EBP.During an interview on 9/4/25 at 11:49 A.M., the Assistant Director of Nursing (ADON) indicated she would expect staff to wear EBP when incontinence care and wound care were provided on Resident C.2. On 9/4/25 at 10:32 am Resident D's clinical record was reviewed. Diagnoses included but were not limited to, gastroesophageal reflux disease without esophagitis, colostomy status. A Minimum Data Set (MDS) assessment dated [DATE], indicated cognition was intact, bowel always incontinent, ostomy (including urostomy, ileostomy, and colostomy ) was marked yes. Care plans were reviewed and included, but were not limited to:I have a colostomy as of 8/19/24 d/t (due to) bowel obstruction, initiated 9/23/25. Interventions included but were not limited to: my colostomy care will be completed as needed, initiated 9/3/25, revision on 8/16/25.September 2025 physician orders were reviewed and no order was in place for the care of the colostomy. The TAR ( Treatment Administration Record) and EMAR (Electronic Medication Administration Record ) for August and September was reviewed and no order was in place for the care of the colostomy.On 9/4/25 at 1:16 p.m., RN 2 indicated normally orders are in place for the care of a colostomy, nursing documents when changing the ostomy bag and providing care. On 9/4/25 at 1:18 P.M., the ADON provided a current Enhanced Barrier Precautions policy, revised 2/5/25 that indicated, .An order for enhanced barrier precautions will be obtained for residents with.chronic wounds such as pressure ulcers.On 9/4/25 at 1:37 p.m., the ADON (Assistant Director Of Nursing ) provided the current policy on pouch changes, colostomy, urostomy, and ileostomy with a revised date of 12/3/24. The policy included but was not limited to: .1. Ostomy care will be provided by the licensed nurses under the orders of the attending physician. The order should include the type of ostomy, frequency of pouch change, and type of equipment .This citation relates to Intake 2597338.3.1-35(g)(1)

Based on observation, interview, and record review, the facility failed to ensure dishwasher temperatures were within range and food was prepared under sanitary conditions for 2 of 2 kitchen observations. The temperature on the final rinse of the dishwasher did not reach required levels, floors were sticky, and bulk food was outdated. (Kitchen)Findings include:1. On 7/29/25 at 9:17 A.M., an initial tour of the kitchen was completed with the Kitchen Manager. During the initial tour, the following was observed:A dishwasher cycle was observed. The final rinse temperature was 175 degrees Fahrenheit (F). At that time, the Kitchen Manager indicated the dishwasher was a high temperature dishwasher and she expected the temperature of the wash cycle to reach 160 degrees F and the final rinse cycle to reach at least 180 degrees F. Staff checked the temperatures three times a day. At that time, the Dishwasher Chart for July 2025 was reviewed. The chart indicated the dishwasher was a low temperature dishwasher. The log indicated that staff were to check the temperature of the wash and the rinse cycle three times a day (morning, noon, and evening). The following days were below the expected wash and rinse cycle temperatures or did not have a temperature listed:7/1/25 morning - final rinse 165 F7/1/25 evening - no temperatures listed7/2/25 morning, noon, and evening - no temperatures listed7/3/24 morning, noon, and evening - no temperatures listed7/4/25 morning, noon, and evening - no temperatures listed7/5/25 morning, noon, and evening - no temperatures listed7/6/25 morning, noon, and evening - no temperatures listed7/7/25 morning - final rinse 170 F7/7/25 evening - no temperatures listed7/8/25 morning - final rinse 171 F7/8/25 evening - no temperatures listed7/9/25 noon and evening - no temperatures listed7/10/25 morning, noon, and evening - no temperatures listed7/11/25 morning - final rinse 170 F7/11/25 evening - no temperatures listed7/12/25 morning - final rinse 169 F7/12/25 noon - final rinse 179 F7/12/25 evening - no temperatures listed7/13/25 morning and noon - no temperatures listed7/13/25 evening - final rinse 130 F7/14/25 morning - wash 140 F, final rinse 165 F7/14/25 noon - final rinse 179 F7/14/25 evening - final rinse 178 F7/15/25 evening - final rinse 170 F7/16/25 morning, noon, and evening - no temperatures listed7/17/25 morning, noon, and evening - no temperatures listed7/18/25 morning - final rinse 165 F7/18/25 noon and evening - no temperatures listed7/19/25 morning - final rinse 163 F7/19/25 noon and evening - no temperatures listed7/20/25 morning - wash 158 F, 166 F7/20/25 noon and evening - no temperatures listed7/21/25 morning, noon, and evening - no temperatures listed7/22/25 morning - final rinse 170 F7/22/25 evening - no temperatures listed7/23/25 morning, noon, and evening - no temperatures listed7/24/25 morning, noon, and evening - no temperatures listed7/25/25 morning, noon, and evening - no temperatures listed7/26/25 morning - final rinse 170 F7/26/25 evening - no temperatures listed7/27/25 morning, noon, and evening - no temperatures listed7/28/25 morning, noon, and evening - no temperatures listed The floor was sticky in the dry storage area.Cheerios in a bulk container had a label that indicated must use by 7/24/25.2. On 8/1/25 at 10:23 A.M., a follow-up visit to the kitchen was completed with the Kitchen Manager.A dishwasher cycle was observed. The final rinse temperature was 175 degrees Fahrenheit (F). At that time, the Kitchen Manager indicated the dishwash was a high temperature dishwasher and they did not test it with sanitization strips.The floor was sticky in the dry storage area.Cheerios in a bulk container had a label that indicated must use by 7/24/25.On 8/5/25 at 12:48 P.M., the Administrator provided a current Food Safety Requirements policy, dated 4/9/24, that indicated Food will .be stored, prepared, distributed and served in accordance with professional standards for food service safety . Storage of food in a manner that helps prevent deterioration or contamination of the food, including from growth of microorganisms.On 8/5/25 at 12:48 P.M., the Administrator provided a current Dishwasher Temperature policy, dated 11/1/23, that indicated All items cleaned in the dishwasher will be washed in water that is sufficient to sanitize any and all items . For high temperature dishwashers (heat sanitization): The wash temperature shall be . For a single tank, conveyor, dual temperature machine: 160 F . The final rinse temperature shall be 180 F or above but not to exceed 194 F . Corrective actions shall be taken for final temperatures below the required final rinse temperatures . Water temperatures shall be measured and recorded prior to each meal and/or after the dishwasher has been emptied or re-filled for cleaning purposes.On 8/6/25 at 9:46 A.M., the Administrator provided a current Cleaning Schedules policy, revised 6/2020, that indicated The Dining and Nutrition Services staff will maintain the cleanliness and sanitation of the dining and food service areas.3.1-21(i)(2)3.1-21(i)(3)

Based on interview and record review, the facility failed to ensure designation of a certified Infection Preventionist (IP). The full time director of nursing was unable to provide documentation of infection prevention certification, and did not currently dedicate at least part time to the role of IP for 1 of 1 staff members reviewed for IP. Finding includes:During an interview on 8/5/25 at 10:07 A.M., the full-time Director of Nursing (DON) indicated she was managing the Infection Preventionist (IP) role, and dedicated about two hours each working day to the infection prevention program tasks. On 7/29/25 at 9:11 A.M., the Administrator indicated the facility had a full time DON.On 8/5/25 at 2:36 P.M., a copy of the Infection Prevention certification was requested; the DON indicated she was unable to provide a infection prevention certification. On 8/5/25 at 12:48 P.M., the Administrator provided a job description titled Infection Preventionist that indicated Minimum qualifications: have completed specialized training in infection prevention and control and must work at least part time

Based on observation, interview, and record review, the facility failed to ensure the kitchen was free of pests during 2 of 2 kitchen observations. Gnats were observed in the dry storage room and flies were observed in the food holding area. (Kitchen)Findings include:On 7/29/25 at 9:17 A.M., an initial tour of the kitchen was completed with the Kitchen Manager. Gnats were observed in the dry storage room. On 8/1/25 at 10:51 A.M., a follow-up visit of the kitchen was completed with the Kitchen Manager. Mexican corn and Spanish rice were observed on the steam table and were not covered. A fly was observed flying around the uncovered food. On 8/5/25 at 9:04 A.M., the Kitchen Manager indicated there was an open drain in the dry storage room which was where the pests were coming from. On 8/5/25 at 2:54 P.M., the Administrator provided a current Maintenance Policy, revised 7/2024, that indicated The Director of Plant Operations will monitor the contract services for pest control on a regular and as-needed basis and assure the building is kept free of any possible infestations of rodents or insects. This shall be accomplished by maintaining window screens in good repair and eliminating sites of breeding and entry. 3.1-19(f)(4)

Based on observation, interview, and record review, the facility failed to ensure the development and implementation of care plans for 1 of 3 residents reviewed for notification of change, 1 of 2 residents reviewed for urinary tract infections (UTI) or catheter, and 1 of 3 residents reviewed for falls. A resident on comfort measures did not have a care plan related to palliative care, monitoring was not completed following a seizure, and a fall intervention was not in place. (Resident S, Resident M, Resident L)Findings include:1. On 7/30/25 at 1:29 P.M., Resident L's clinical record was reviewed. Diagnoses included, but were not limited to, displaced intertrochanteric fracture of the right femur, history of falling, and dementia. The most current Annual Minimum Data Set (MDS) Assessment, dated 4/7/25, indicated Resident L had severe cognitive impairment, was independent in rolling left to right and for sit to stand transfers, required supervision of staff for toilet transfers, toileting, and bathing, used a walker, and had two or more falls without injury and one fall with injury since the prior assessment. A Quarterly Fall Risk Assessment, dated 4/27/25, indicated Resident L was at high risk for falls. A current risk for falls care plan, revised 7/28/25, included, but were not limited to, the following interventions:Bedside table with locked wheels, dated 7/2/25 A nursing falls progress note, dated 6/21/25 at 4:10 P.M., indicated Resident L had an unwitnessed fall. The resident was observed on the floor next to his roommate's bed. The bedside table was sideways on the floor, and the dishes were on the floor. The resident complained of severe pain in the right hip. There was external rotation of the right foot noted, and the right leg appeared shortened. The resident was transported to the hospital by ambulance. Hospital discharge paper, dated 6/25/25, indicated Resident L was admitted to the hospital on [DATE] with a right intertrochanteric femur fracture. On 6/22/25, the resident underwent a cephalomedullary fixation (a surgical procedure used to stabilize and fix fractures of the proximal femur, specifically involving the femoral neck and intertrochanteric region) for the right intertrochanteric femur fracture. The resident was discharged back to the facility on 6/25/25. A Quarterly Fall Risk Assessment, dated 6/26/25, indicated Resident L was at moderate risk for falls. A Significant Change MDS Assessment was completed on 7/2/25. Resident L had severe cognitive impairment, was dependent on staff (staff does all of the work) for eating, toileting, and to roll left to right, required substantial to maximal assistance of staff (staff does more than half of the work) for bathing, and sit-to-stand and toilet transfers were not attempted. The resident used a wheelchair and had a fall with a fracture in the last month. On 7/31/25 at 2:34 P.M., Resident L was observed in bed in his room. He indicated that staff had just helped him back to bed after he attended an activity. A large bedside table with wheels was observed next to his bed. The bedside table's wheels were not locked. There was a smaller stationary table without wheels next to his recliner. The smaller stationary table was not in reach of the resident's bed. On 8/1/25 at 9:11 A.M., Resident L was observed sitting in his wheelchair next to his bed. A large bedside table with wheels was observed at the foot of his bed. The large bedside table had breakfast dishes on it. The bedside table's wheels were not locked. There was a smaller stationary table without wheels next to his recliner. The smaller stationary table was not in reach of the resident. On 8/1/25 at 2:22 P.M., Resident L was observed in bed working with Speech-Language Pathologist (SLP) 5. A large bedside table with wheels was observed next to the resident's bed. A smaller stationary table without wheels was next to his recliner and not in reach of Resident L. At that time, SLP 5 indicated that the large bedside table was not locked. On 8/6/25 at 9:45 A.M., the Director of Nursing (DON) indicated that Resident L fell on 6/21/25 while using his roommate's bedside table to balance himself while attempting to sit on his roommate's bed. The facility attempted to replace the large bedside table with wheels with the smaller stationary table, but neither the resident nor the resident's family member liked it, so the larger bedside table with wheels was left in the room. 2. On 7/31/25 at 10:53 A.M., Resident S's clinical record was reviewed. Diagnoses included, but were not limited to, Chronic Obstructive Pulmonary Disease (COPD). The resident was admitted to the facility on [DATE]. The current Quarterly Minimum Data Set (MDS) Assessment, dated 6/17/25, indicated Resident S was cognitively intact and required partial to moderate assistance of staff (staff does less than half of the work) for Activities of Daily Living (ADLs). Nursing orders included, but were not limited to:Resident under the care of (name of Palliative Care) admitted with terminal diagnoses, COPD (with oxygen dependency. The condition/chronic disease may result in a life expectancy of less than six months. Please contact the Palliative service with all changes in conditions, to receive orders, dated 7/24/2025 A Care Plan Conference was completed on 7/24/25 with the resident and the resident's family members in attendance. Advanced Care Planning and current Advance Directives were reviewed. The clinical record lacked a care plan related to palliative care services. On 8/1/25 at 10:17 A.M., MDS Coordinator 11 indicated Resident S did not have a care plan for palliative care.3. On 8/01/25 at 1:40 P.M., Resident M's clinical record was reviewed. Resident M was admitted on [DATE]. Diagnosis included, but was not limited to, epilepsy. The most recent Quarterly Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident M was moderately cognitively impaired and was dependent on staff (staff do all of the work) for toileting and transfers. Physician orders included, but were not limited to: Onfi oral tablet 20 MG (milligrams), give 20 mg by mouth at bedtime for seizures; Start date 4/1/25Levetiracetam Oral Tablet 750 MG, give 750 mg by mouth two times a day for seizures; Start date 4/1/25Lamictal Tablet 200 MG, give one tablet by mouth two times a day for seizures; Start date 4/1/25 Current care plan included, but was not limited to: I am currently prescribed an anticonvulsant for seizure disorder; Date Initiated: 11/26/24 I have a seizure disorder and convulsions; Date Initiated: 8/10/20 During a witnessed seizure, you will observe for type of activity (jerks, convulsive movements, tremors), duration of seizure, level of consciousness during and after seizure, and incontinence. Date Initiated: 7/6/23 Report and observe for speech changes, headache, change in mental status or level of consciousness, weakness, changes in the pupil; Date Initiated: 8/10/20 A nursing progress note dated 7/3/2025 7:08 P.M., indicated Resident began having seizure activity in the hallway. Tremors of all extremities, particularly arms. Hands grasping and eyes blinking. Lasted no more than 3 minutes. She was then taken to her room. She had seizure activity twice more. Complain of headache. The clinical record, including progress notes, assessments, and documentation, lacked observation of changes for Resident M post-seizure activity. During an interview on 8/5/25 at 10:20 A.M., the Director of Nursing indicated that after a resident experienced a seizure, staff should monitor the resident and notify the family and physician. On 8/5/25 at 12:36 P.M., the Administrator provided a current Comprehensive Care Plans policy, revised 2/5/25, that indicated It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality . The comprehensive care plan will describe, at a minimum, the following: . The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. On 8/5/25 at 12:48 P.M., the Administrator provided a current Fall Investigation and Risk Evaluation policy, revised 8/2024, that indicated It is the policy of this facility to provide an environment that is free from accident hazards over which the facility has control and provides supervision and assisted devices to prevent avoidable accidents. This tag relates to complaint 2567193. 3.1-35(a)3.1-35(b)(1)3.1-35(g)(1)

Based on observation, record review, and interview, the facility failed to ensure proper infection control protocols) for 1 of 2 residents for catheter and 3 random observations of cleaning equipment and using Personal Protective Equipment (PPE). ( Licensed Practical Nurse (LPN) 2 Registered Nurse (RN) 3, Certified Nursing Assistant (CNA) 6, CNA 10, Resident S, Resident 10)Findings include: 1. On 7/29/25 at 9:10 A.M., a wrist blood pressure cuff/monitor was observed sitting on top of the 500 Hall medication cart with several layers of tape attached to the top of it. On 8/5/25 at 9:27 A.M., the 800 Hall vitals machine was observed. The oxygen saturation tubing was observed with tape wrapped around the area where the two sections of tubing were connected. The ends of the tape were discolored. On 8/5/25 at 11:07 A.M., the Director of Nursing (DON) indicated she was unaware of any tape on the blood pressure cuff or oxygen saturation machines, but would look into them. On 8/6/25 at 8:31 A.M., the DON indicated a piece had broken off the blood pressure cuff/monitor, and the tape had been placed to keep the batteries in, and the oxygen saturation monitor had two cords with a latch between them that had broken, and someone had put tape around the connection to keep it together. She indicated that staff education was needed. 2. On 7/29/25 at 10:07 A.M., Resident S was observed lying in bed. His catheter bag was uncovered and lying on the floor beside his bed. On 7/31/25 at 10:53 A.M., Resident S's clinical record was reviewed. Diagnoses included, but were not limited to, neurogenic bladder and obstructive uropathy. The current Quarterly Minimum Data Set (MDS) Assessment, dated 6/17/25, indicated Resident S was cognitively intact, required partial to moderate assistance of staff (staff does less than half of the work) for toileting, and had an indwelling catheter. A care plan conference was completed on 7/24/25 with the resident and the resident's family members in attendance. Care plans were reviewed. Current care plans included, but were not limited to:I require enhanced barrier precautions related to a medical device (supra pubic catheter), dated 7/22/24 I have a suprapubic catheter related to Benign Prostatic Hypertrophy, Neurogenic bladder, dated 7/15/24 Physician orders included, but were not limited to:Suprapubic Catheter: 16 French 10 milliliter balloon for neuromuscular dysfunction of bladder, dated 7/24/25 Enhanced Barrier Precautions (EBP) implemented due to an Indwelling Medical Device (Foley Catheter) will require EBP until the device is removed - Gown and Gloves required for Direct Care, dated 7/24/25 On 7/31/25 at 2:36 P.M., Resident S was observed sitting in his motorized wheelchair. His catheter bag was hanging on the arm of the wheelchair above the level of his bladder. On 8/1/25 at 9:11 A.M., Certified Nurse Aide (CNA) 6 and CNA 10 were observed performing perineal care and a bed bath for Resident S. CNA 6 and CNA 10 were not wearing a gown. On 8/1/25 at 9:25 A.M., Resident S was observed sitting in his motorized wheelchair. His catheter bag was hanging on the arm of the wheelchair above the level of his bladder. On 8/5/25 at 10:07 A.M., the Director of Nursing (DON) indicated she also served as the Infection Preventionist (IP). She indicated that catheter bags should not touch the floor and should be placed below the waistline. Staff should wear a gown and gloves while providing care to any resident with an indwelling line, such as a catheter. 3. On 8/4/25 at 1:30 P.M., Licensed Practical Nurse (LPN) 2 was observed performing catheter care on Resident 10 without putting on Personal Protective Equipment (PPE) when the resident is on Enhanced Barrier Precautions. 4. On 8/4/25 at 12:15 P.M., during a random observation, Registered Nurse (RN) 3 was observed going into room [ROOM NUMBER] and performed an Accu-Chek and did not clean the glucometer. Took blood sugar in room [ROOM NUMBER]. Put the glucometer back in the med cart without cleaning it. Locked the cart and walked away. During an interview on 8/4/25 at 1:45 P.M., LPN 2 indicated she forgot to put on the required PPE before entering the room. During an interview on 8/5/25 at 2:34 P.M., the Director of Nursing (DON) indicated the staff should clean the glucometer between each resident. On 8/5/25 at 12:36 P.M., the Administrator provided a current Catheter Care policy, revised 6/7/24, that indicated Ensure drainage bag is located below the level of the bladder to discourage backflow of urine. Ensure tubing and catheter bag does not touch the floor. On 8/5/25 at 12:36 P.M., the Administrator provided a current Enhanced Barrier Precautions policy, revised 2/5/25, that indicated An order for enhanced barrier precautions will be obtained for residents with any of the following: . indwelling medical devices (e.g., .urinary catheters .) even if the resident is not known to be infected or colonized with a MDRO . PPE (personal protective equipment) for enhanced barrier precautions is only necessary when performing high-contact care activities . High-contact resident care activities include: Dressing, Bathing, Transferring, Providing hygiene .Changing briefs or assisting with toileting . On 8/6/25 at 11:21 A.M., the Administrator provided a current policy, Glucometer Disinfection dated 2/12/24. The policy indicated . glucometers will be cleaned and disinfected after each use and according to the manufacturer's instructionsregardless of whether they are intended for single resident or multiple resident use .'' 3.1-18(b)(1)3.1-18(b)(2)

Based on observation, interview, and record review, the facility failed to ensure an assessment was completed for a resident who self administered medications for 1 of 1 random observation. A bottle of eye drops was observed in a resident's room. (Resident 13)Finding includes: On 8/1/25 at 6:55 A.M., Resident 13 was observed lying in his bed with a bedside table next to him during a medication pass with Licensed Practical Nurse (LPN) 9. A bottle of eye drops with no label was observed on the bedside table. After the resident's medications were administered, LPN 9 did not address or obtain the bottle of eye drops. After being asked about the bottle, LPN 9 obtained the eye drop bottle and carried it to the medication cart in the hall. At that time, LPN 9 indicated Resident 9 did have an order for eye drops, but did not have an order to self administer them, and did not have a self administration assessment for the eye drops on file. A separate bottle of eye drops with a label that indicated they were for Resident 13 was then observed in the medication cart. LPN 9 indicated the resident's family would sometimes bring in items such as the eye drops, and that the bottle would be returned to them. On 8/1/25 at 10:44 A.M., Resident 13's clinical record was reviewed. Diagnoses included, but was not limited to, dry eyes. The most recent quarterly Minimum Data Set (MDS) assessment, dated 5/31/25, indicated no cognitive impairment and no behaviors. Resident 13 required supervision or touching assistance for bed mobility and transfers. Current physician orders included, but were not limited to:Refresh tears 0.5% solution, 1 drop in each eye every hour as needed for dry eyes, dated 5/13/25. Resident 13's clinical record lacked a care plan related to self administration of eye drops. Resident 13's clinical record lacked a self administration assessment for eye drops. On 8/5/25 at 2:00 P.M., the Administer provided a current Self Administration of Medications policy, dated 6/26/24, that indicated A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely. 3.1-11(a)

Based on observation, interview, and record review, the facility failed to ensure a resident with an indwelling urinary catheter received appropriate services and treatment related to catheter placement for 1 of 3 residents reviewed for catheter use. A resident with an indwelling urinary catheter received the wrong size catheter. (Resident B)Finding includes:On 7/31/25 at 8:50 A.M., Resident B's clinical record was reviewed. Diagnoses included, but were not limited to, ulcerative colitis, anxiety, and depression. The most recent quarterly Minimum Data Set (MDS) assessment, dated 7/17/25, indicated no cognitive impairment, and use of an indwelling urinary catheter. Resident 10 was dependent on staff for bed mobility and toileting.Current physician orders included, but were not limited to:Foley catheter: 16 French (size of catheter)/30cc (milliliter) balloon, dated 3/14/25.Foley catheter: change catheter as needed 16 French/30cc balloon every 8 hours as needed for maintaining catheter, dated 3/14/25.An indwelling catheter care plan, created 3/17/25, indicated, but was not limited to, an intervention to change catheter system when clinically indicated or ordered, dated 3/17/25.A progress note on 4/22/25 at 6:40 A.M. indicated Resident B's indwelling catheter was changed using an 18 French catheter anchored with 20cc normal saline.A progress note on 7/13/25 at 12:07 P.M. indicated resident's catheter had been unable to flush, and was replaced with a 20 French catheter. On 8/4/25 at 11:02 A.M., Licensed Practical Nurse (LPN) 21 was observed to change Resident B's wound dressing on the buttocks. At that time, Resident B's urine was observed to be bloody with bleeding from the vaginal area. On 8/5/25 at 9:27 A.M., Registered Nurse (RN) 3 indicated the size of an indwelling catheter would be on the physician's order and staff should not deviate from the size ordered. On 8/5/25 at 2:00 P.M., the Administrator provided a current Appropriate Use of Indwelling Catheters policy, dated 11/27/23, that indicated The use of an indwelling urinary catheter will be in accordance with physician orders, which will include the diagnosis or clinical condition making the use of the catheter necessary, size of the catheter, and frequency of change (if applicable).3.1-41(a)

Based on interview and record review, the facility failed to ensure accurate documentation for 1 of 2 residents reviewed for change of condition, and 1 of 2 residents reviewed for urinary tract infections (UTI) or catheter. (Resident B, Resident 21)Findings include:1. On 7/31/25 at 8:50 A.M., Resident B's clinical record was reviewed. Diagnoses included, but were not limited to, ulcerative colitis, anxiety, and depression. The most recent quarterly Minimum Data Set (MDS) assessment, dated 7/17/25, indicated no cognitive impairment and use of an indwelling urinary catheter. Resident B was dependent on staff for bed mobility and toileting.Current physician orders included, but were not limited to:Foley catheter: 16 French (size of catheter)/30cc (milliliter) balloon, dated 3/14/25.An indwelling catheter care plan, created 3/17/25, indicated, but was not limited to, an intervention to change the catheter system when clinically indicated or ordered, dated 3/17/25.A progress note on 7/3/25 at 5:15 P.M. indicated . Catheter was changed with a 15g/30cc . On 8/5/25 at 9:27 A.M., Registered Nurse (RN) 3 indicated urinary catheters came in sizes 14, 16, 18, or 20. She indicated that to her knowledge, there was no size 15g urinary catheter. RN 3 observed the note on 7/2/25 and indicated it could have been a slip of the fingers when entering it into Resident B's medical record. 2. On 7/31/25 at 8:43 A.M., Resident 21's clinical record was reviewed. Diagnoses included, but were not limited to, renal failure, dementia, anxiety, depression, and psychotic disorder. The most recent quarterly Minimum Data Set (MDS) assessment, dated 7/11/25, indicated a mild cognitive impairment, and was not on hospice. Current physician orders included, but were not limited to:Comfort measures: No further hospitalizations or diagnostics. Call (name) for comfort orders when needed, dated 6/1/25. Resident 21 lacked an order for hospice services. A current care plan, dated 6/2/25, indicated comfort measures were elected, and to notify the hospice provider if medications were ineffective, dated 7/26/25. Progress notes included, but were not limited to, the following:5/29/25 at 9:06 A.M. Nurse Practitioner was notified related to daughter's expression for palliative/hospice option for care. 6/2/25 at 11:32 A.M. Daughter stated family wished to proceed with hospice/palliative care. Psychiatry Progress/Encounter notes included, but were not limited to, the following:6/11/25 at 12:00 A.M. She was recently placed on hospice . Hospice discontinued her olanzapine . Namenda 10 mg [milligrams] twice a day - discontinued by hospice . 6/25/25 at 12:00 A.M. She remains on hospice . Hospice discontinued her olanzapine . Namenda - discontinued by hospice . 7/30/25 at 12:00 A.M. Hospice discontinued her olanzapine . Namenda - discontinued by hospice . On 8/5/25 at 9:43 A.M., the Director of Nursing (DON) indicated Resident 21 was in the hospital from [DATE] through 5/11/25 and during that time had a feeding tube placed that she came back to the facility with. The resident did not like it, and the daughter and Nurse Practitioner were called about it. During those discussions, it was decided that the resident would be on comfort care through the facility Nurse Practitioner, as the resident would not have liked hospice staff taking care of her. She indicated the psychiatric provider assumed Resident 21 was on hospice because of the order for comfort care and included hospice in their notes. She also indicated there was no specific care plan for comfort care, so it was possible that the verbiage just had not been changed to exclude hospice from the care plan intervention. On 8/5/25 at 2:00 P.M., the Administrator provided a current Documentation in Medical Record policy, dated 1/30/24, that indicated Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation . Principles of documentation include, but are not limited to . Documentation shall be factual, objective, and resident centered . False information shall not be documented . Documentation shall be accurate, relevant, and complete, containing sufficient details about the resident's care and/or responses to care. 3.1-50(a)(2)

Based on record review and interview, the facility failed to notify the residents' families for 2 of 3 residents reviewed for notification of changes. A resident's family was not notified of a change in the resident's physical condition and a resident's fall. (Resident F, Resident M)Findings include: 1. On 7/30/25 at 2:37 P.M., Resident F's clinical record was reviewed. Diagnoses included but were not limited to hypertension and acute respiratory failure. The Current admission Minimum Data Set (MDS) assessment dated [DATE] indicated the resident was cognitively intact. Resident F needs supervision for transferring, setting up for eating, partial assistance with hygiene, and substantial/maximum assistance of 2 for toileting and dressing. Current physician orders included, but were not limited to, Tylenol Extra Strength Oral Tablet (pain relief) 500 Milligrams (MG). Give 1 tablet by mouth three times a day for Shoulder pain dated 7/24/25. The Current Fall Risk Care Plan dated 7/1/25 indicated the resident was at risk for falls due to a history of falls and impaired balance. Current interventions included but were not limited to, call bell within reach, call don't fall sign to bathroom door, and wear proper footwear or non-slip footwear when up. A nursing progress dated 7/20/25 at 10:00 A.M., composed by RN 7, indicated the daughter came to visit and was informed at that time that the resident had a fall. The daughter noticed that the resident had a mental status change and wanted the resident sent to the hospital. During a phone interview on 7/30/25 at 8:38 A.M., the Power of Attorney indicated she was not notified about the fall until the family came to visit and found Resident F confused. She also indicated that the nurse who was assigned to the resident did not start the paperwork until after the family was made aware. During an interview on 7/31/25 at 10:15 A.M., RN 7 indicated she probably should have called the family at the time the resident had fallen instead of doing her medications and several other things at this time. 2. On 8/01/25 at 1:40 P.M., Resident M's clinical record was reviewed. Resident M was admitted on [DATE]. Diagnosis included, but was not limited to, epilepsy. The most recent Quarterly Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident M was moderately cognitively impaired and was dependent on staff (staff do all the work) for toileting and transfers. Physician orders included, but were not limited to: Onfi oral tablet 20 MG (milligrams), give 20 mg by mouth at bedtime for seizures; Start date 4/1/25Levetiracetam Oral Tablet 750 MG, give 750 mg by mouth two times a day for seizures; Start date 4/1/25Lamictal Tablet 200 MG, give one tablet by mouth two times a day for seizures; Start date 4/1/25 Resident M's special instructions for plan of care indicated: Please contact Palliative service with all changes in conditions, to receive orders. Current care plan included, but was not limited to: I am currently prescribed an anticonvulsant for seizure disorder; Date Initiated: 11/26/24 I have a seizure disorder and convulsions; Date Initiated: 8/10/20 A nursing progress note dated 7/3/2025 7:08 P.M., indicated Resident began having seizure activity in the hallway. Tremors of all extremities, particularly arms. Hands grasping and eyes blinking. Lasted no more than 3 minutes. She was then taken to her room. She had seizure activity twice more. Complain of headache. The clinical record, including progress notes, assessments, and documentation, lacked notification to family, physician, or palliative care post-seizure activity. During an interview on 8/5/25 at 10:20 A.M., the Director of Nursing indicated that after a resident experienced a seizure, staff should monitor the resident and notify the family and physician. On 7/31/25 at 10:31 A.M., the Administrator provided a current policy Notification of Change dated August 2024. The policy indicated .The facility must inform the resident, consult with the resident’s physician and /or notify the resident’s family member or legal representative when there is a change requiring such notification . This citation relates to complaint 2567193 3.1-59(a)(1)3.1-5(a)(2)

Based on observation, interview, and record review, the facility failed to revise a resident's plan of care to reflect current interventions for 1 of 3 residents reviewed for accidents. A resident's falls care plan was not updated to reflect implementation of a call don't fall sign. (Resident 2)Finding includes:On 7/31/25 at 9:15 A.M., Resident 2's clinical record was reviewed. Diagnosis included, but was not limited to, fracture to right humerus. The most recent quarterly Minimum Data Set (MDS) assessment, dated 7/7/25, indicated mild cognitive impairment, and no falls since the prior assessment. A current risk for falls care plan, last revised on 7/30/25, lacked an intervention for a call don't fall sign in the resident's room. A progress note on 6/13/25 at 10:02 A.M. indicated Resident 2 fell, but did not remember how it happened. An immediate intervention was a call don't fall sign in place. An IDT note on 6/16/25 at 8:49 A.M. indicated the resident had fallen on 6/13/25, and would evaluate upon return from hospital for any new interventions. On 7/31/25 at 2:00 P.M., Resident 2's room was observed with a call don't fall sign on the bathroom door. On 8/1/25 at 10:06 A.M., the MDS Coordinator indicated all falls were discussed the following day at a morning clinical meeting. Any new interventions would be added immediately to the resident's care plan following the meeting by either the MDS Coordinator, the Director of Nursing (DON), or the nurses on the floor. She indicated since Resident 2 had went to the hospital after the fall on 6/13/25, the plan was to re-evaluate when he got back for a new intervention and that was not done. The immediate intervention was to put up the sign, but it was not updated to the resident's care plan. On 8/5/25 at 2:00 P.M., the Administrator provided a current Comprehensive Care Plans policy, last revised 2/5/25, that indicated The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed. 3.1-35(c)3.1-35(d)

Based on observation, interview, and record review, the facility failed to ensure adequate safety measures were in place to prevent accidents for 2 of 3 residents reviewed. This deficient practice resulted in Resident C requiring hospitalization , sutures, and a subarachnoid hemorrhage. (Resident B, Resident C) Findings include: 1. On 4/8/25 at 1:28 p.m., Resident C's clinical record was reviewed. Resident C was admitted on [DATE] and discharged to the hospital on 2/26/25. The diagnoses included, but were not limited to, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, visuospatial deficit and spatial neglect following cerebral infarction, cerebral infarction due to thrombosis of right middle cerebral artery, muscle weakness (generalized), unsteadiness on feet, other abnormalities of gait and mobility, need for assistance with personal care. An admission Minimum Data Set (MDS) assessment, dated 1/27/25, indicated Resident C's cognition was intact, range of motion impairment upper and lower one side, toileting dependent substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort), toilet transfer substantial/maximal assistance, lying to sitting on side of bed (the ability to safely move from lying on the back to sitting on the side of the bed with feet flat on the floor, and with no back support) substantial/maximal, no falls 2-6 months prior to admission. The Care Plans included but were not limited to: Resided needed assistance with activities of daily living (ADL's) related to cerebrovascular accident (CVA) with left hemiplegia. The interventions included but were not limited to: - Resident required assist of two when toileting with transfers, on/off the commode, do not leave unattended on commode, initiated 1/24/25. - Resident required assist of two with transfers to the right side. Use bilateral platform walker and gait belt pivot transfer only. Resident to only ambulate with therapy at this time, initiated 1/24/25 and revised 2/25/25. - Resident required assist of one with transfers to the right side. Use bilateral platform walker and gait belt, initiated 1/24/25 and revised 1/27/25. Resident was at risk for falls related to decreased mobility, new CVA with flaccid left sided hemiplegia, unsteady gait, initiated 1/24/25. The interventions included, but were not limited to: - Do not leave unattended when sitting on the commode, initiated 2/27/25. - Increased assistance with transfers to two person assist including transfers on/off commode, initiated 2/27/25. A Physical Therapy communication to nursing note with a therapist signature, dated 1/24/25, and nurses signature, dated 1/27/25, indicated the resident was a one assist with transfers, set up, to right side, use bilateral platform rolling walker and gait belt. Progress notes were reviewed and included but were not limited to: On 2/24/25 at 11:51 a.m., a physician progress note indicated the patient's plan of progress was discussed with nursing staff and therapy. Patient was seen up in her recliner. She was alert and oriented. She reported she did not feel well today. She reported she had been having dry heaving due to phlegm and was coughing frequently. She also reports increased congestion. No complaints of chest pain, shortness of breath, nausea, vomiting, fever or chills. Patient's pain is controlled. On 2/24/25 at 9:43 p.m., indicated . 1700, [5:00 p.m.] residents room. BP [blood pressure] 111/78 P [pulse] 93 R [respirations] 16 T [temperature] 100.6, oxygen 93% on RA [room air] Description of fall: CNA notified this nurse that resident was lowered to the floor. CNA was assisting resident with ambulating from recliner to bed, gait belt in place. As resident was turning around to sit on edge her bed her legs gave out and CNA assisted resident to the floor on her side. When this nurse entered resident's room, resident was noted lying face down on floor. Resident began to dry heave and had small amount of emesis on floor. Resident was assisted onto her back, assisted to seated position. No complaintsof [sic] pain. ROM WNL [range of motion within normal limits] to bilateral extremities. Resident assist to standing position with 2 staff assist Range of motion; mental status, neurochecks if unwitnessed or hit head; ROM WNL, witnessed fall as CNA assisted resident to the floor Immediate intervention: Resident's transfer status changed to assist x [of] 2 due to increased weakness from not feeling well. Physician notification; family (responsible party notification: MD [medical doctor] and Spouse made aware of fall. On 2/25/25 at 9:49 a.m., Fall IDT (Interdisciplinary Team) Note, Late Entry: Attendees present: MDS, CM (case manager), Therapy. On 2/24/25 at 7:00 p.m., CNA was assisting resident with ambulating from recliner to bed and just as resident was turning around to sit on edge her bed her legs gave out and CNA assisted resident to the floor on her side. When this nurse entered resident's room, resident was noted lying face down on floor. Resident began to dry heave and had small amount of emesis on floor. Resident was assisted onto her back, assisted to seated position. No complaints of pain. ROM WNL to bilateral extremities. Resident assisted to standing position with two staff assist. Root cause of fall: Resident not feeling well and legs became weak. Intervention and care plan updated. Updated transfers status for two staff due to increased weakness. On 2/25/25 at 12:23 p.m., Followed up with NP (Nurse Practitioner) regarding resident's increased weakness, temperature noted on 2/25/25 and vomiting. New order received for Tamiflu prophylactic due to suspected Influenza A. Family aware. On 2/28/25 at 9:46 a.m., Notice of Transfer & Discharge and (name of facility) Bed Hold Authorization mailed via United States Postal Service Certified Mail to resident address for transfer on 2/26/25. On 2/28/25 at 9:52 a.m., Fall IDT Note, Attendees present: HFA (Health Facility Administrator), DON (Director Of Nursing), Therapy, CM, MDS. On 2/26/25 at 10:00 a.m., resident was being assisted by staff to toilet. Staff briefly exited room to get linens to assist resident with bathing needs and returned to find resident on floor in front of commode. Root cause of fall: impaired sitting balance. Intervention and care plan updated: will re-evaluate upon hospital return. An NP progress note, dated 2/26/25 indicated after initial visit and prior to leaving facility patient experienced a fall in the bathroom of SNF (skilled nursing facility). She apparently struck her head, causing a laceration to outer left eyebrow that appears to need sutures. Patient recently had CVA and was on ASA (aspirin) and plavix (blood thinner), putting her at risk for bleed. Neurological deficits noted to baseline and appeared relatively unchanged with limited exam. Staff also stated that she did have a LOC (loss of consciousness) with the fall. Advised nursing to send urgently to ER (emergency room ) for evaluation and treat. A hospital document, dated 2/26/25 at 11:45 a.m., included but was not limited to: Alert and non-toxic, lying flat with cervical collar in place speaking in full sentences, obvious laceration to the left temporal. Radiology/procedures: Computed Tomography (CT) Head WO (without) contrast comparison CT head 12/30/24. Scattered areas of subarachnoid hemorrhage. On 4/10/25 at 10:00 a.m., Therapy 1 indicated the therapy notes from 2/24/25 indicated Resident B was feeling ill and was a minimum assist of one on the commode during the therapy session. At 12:08 p.m., Therapy 1 indicated from a therapy note, dated 2/20/25, Resident C was able to sit without assist before she became ill. Her assist was changed to two assist because she had become ill and was requiring assist to sit upright during the therapy session on 2/24/25, therapy normally put a communication note in the Kardex and MDS updated the care plan. At 12:24 p.m., Therapy 1 indicated Resident C's care plan indicated she was a two assist when toileting and was not supposed to be left on the commode alone. Therapy 1 indicated Resident C had been changed to assist of one prior to the falls for transfers, set up to right side, but therapy had not changed her assist of two and to not be left alone on the commode. An interview on 4/10/25 at 11:00 a.m., with Assistant Director Of Nursing (ADON) indicated CNA 2 put Resident C on the commode by herself, CNA 2 had told her she was unaware the resident had been made a two assist again. Normally if a resident fell , in the morning meeting IDT reviewed interventions, the care plan was updated, the Kardex was updated, it was on the computer and the CNA's had access to review it. An interview on 4/10/25 at 11:03 a.m., with the Case Manager indicated when Resident C had the fall on 2/24/25 she was changed back to a two assist while under an acute episode. An interview on 4/10/25 at 12:18 p.m., with Therapy 2 indicated therapy notes on 2/20/25 indicated Resident C was able to sit unsupported without assist, notes on 2/24/25 indicated she was a minimum assist of one during the therapy session and needed help to sit upright due to leaning to the side and feeling ill. Therapist 2 indicated Resident C's care plan, dated 1/24/25 for two assist to toilet and to not leave alone on the commode had not been changed by therapy. Resident C had always been a 2 assist to toilet and not be left alone on commode. 2. On 4/8/25 at 1:00 p.m., a State reportable incident for Resident B was reviewed. The incident indicated on 3/30/25 at 1:30 p.m. staff were transferring resident in a mechanical lift and the resident experienced a fall. Trauma work up was negative. A written statement, dated 3/30/25, by CNA 3 indicated, after lunch at approximately 1:10 p.m., CNA 3 was laying Resident B in her bed with the mechanical lift. When they were almost to her bed, the left foot of the mechanical lift hit the bottom wheel of bed. At that time, resident fell out side of mechanical lift sling, to floor. All straps were secured in place before the transfer. A written statement, dated 3/30/25, by LPN 2 indicated LPN 2 called to resident number. CNA stated Resident B had just fell out of the mechanical lift. LPN 2 entered resident room and noted mechanical lift between the beds in in the room, legs together. Resident was lying on her back, her head was at the opening of the mechanical lift and her feet were on top of the mechanical lift legs. CNA stated when she placed the mechanical lift close to the bed, she hit the wheel of the bed frame, resident began rocking and then fell out of the lift. On 4/8/25 at 11:20 a.m., Resident B's clinical record was reviewed. The diagnoses included, but were not limited to, mild cognitive impairment, history of falling, other reduced mobility, need for personal assistance, and vascular dementia. A quarterly MDS assessment, dated 3/5/25, indicated Resident B's cognition was moderately impaired, chair to bed transfer dependent (helper does all of effort resident does none of the effort to complete activity). Care plans included but were not limited to: Resident needed assistance with ADL's revised 6/13/23. Interventions included, but were not limited to, resident required a mechanical lift and two person assist for all transfers, revised 4/1/25. A progress note, dated 3/30/25 at 1:40 p.m., indicated at 1:10 p.m., CNA called nurse to resident room stating resident was on the floor. Upon entering resident room, noted resident lying on floor on her back. Mechanical lift in room. On 4/8/25 at 1:09 p.m., the DON indicated one staff member was transferring Resident B when she fell out of the mechanical lift. On 4/8/25 at 1:13 p.m., Resident B indicated she thought she fell at her brother's house and not at the facility. Resident B was observed to be confused. On 4/9/25 at 8:39 a.m., CNA 4 and CNA 5 indicated when using a mechanical lift two staff were required. On 4/8/25 at 2:04 p.m., the ADON provided the current policy on safe handling/transfers with a implemented date of 2/28/24. The policy included, but was not limited to, it was the policy of the facility to ensure that residents were handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines. The resident's mobility needs would be addressed on admission and reviewed quarterly, after a significant change in condition, or based on direct care staff observations or recommendations. Two staff members must be utilized when transferring residents with a full body mechanical lift. On 4/8/25 at 2:04 p.m., the ADON provided the current manual for the mechanical lift used for the transfer of Resident B. The manual included, but was not limited to: .Warning : [name of mechanical lift manufacturer] strongly recommends that two caregivers take part in the lifting process . On 4/10/25 at 12:57 p.m., the ADON provided the current policy on fall investigation and risk evaluation, revised date of 8/2024. The policy indicated it was the policy of the facility to provide an environment that was free from accident hazards over which the facility has control and provides supervision and assisted devices to prevent avoidable accidents. Implement interventions, including adequate supervision and assistive devices, consistent with a resident's needs, goal, care plan and current professional standards of practice in order to eliminate the risk, if possible, and, if not, reduce the risks of an accident. This citation relates to Complaints IN00456718 and IN00456869. 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure infection control practices were maintained and Personal Protective Equipment (PPE) was worn entering isolation rooms for 3 of 7 halls observed. (300 Hall, 500 Hall, 900 Hall ). Findings include: 1. On 2/27/25 at 8:20 a.m., Activity Staff 2 was observed to enter room [ROOM NUMBER] to pass out activity calendars, standing and speaking with the residents before leaving the room. room [ROOM NUMBER] had a sign posted on the door that indicated droplet precautions, wear gloves and gown upon entering room, wear a surgical mask (N-95 mask if available) upon entering the room, goggle or face shield to be worn if performing aerosol respiratory treatments, hand hygiene before and after patient or environment contact, with soap and water or alcohol-based hand sanitizer. PPE was available at the entrance. Activity Staff 2 did not don PPE upon entering the room. Activity Staff 2 was observed to enter non isolation rooms [ROOM NUMBERS] to pass calendars after leaving room [ROOM NUMBER]. 2. On 2/27/25 at 8:23 a.m., CNA 6 was observed to deliver a breakfast tray to room [ROOM NUMBER]. CNA 6 did not don PPE before entering the room. A droplet precaution sign was hanging on the door. 3. On 2/27/25 at 8:52 a.m., CNA 2 was observed to DON gloves, N95 mask and gown before entering room [ROOM NUMBER]. CNA 2 did not tie the gown at the neck. A droplet precaution sign was hanging on the door. On 2/27/25 at 8:52 a.m., CNA 2 indicated before entering a droplet precaution room a gown, mask and gloves should be donned, the gown should be tied at the waist and neck. 4. On 2/27/25 at 10:28 a.m., CNA 3 and RN 2 were observed to enter room [ROOM NUMBER], no PPE was donned before entering the room. room [ROOM NUMBER] had PPE hanging on the outside of the door and a droplet precaution sign hanging on the PPE box. 5. On 2/27/25 at 10:40 a.m., CNA 3 and RN 2 indicated they did not DON PPE before entering room [ROOM NUMBER]. CNA 3 indicated she was walking down the hallway and noticed a resident in room [ROOM NUMBER] sitting on the side of the bed and went to get RN 2 to assist her so the Resident didn't fall. On 2/27/25 at 11:19 a.m., the Director of Nursing (DON) indicated the facility staff were following the droplet precaution signs posted on the Influenza A isolation rooms for PPE required to enter the rooms. During the survey the facility had rooms on isolation for Influenza A and Respiratory Syncytical Virus (RSV). Norovirus had recently affected some residents and staff in the facility. On 2/27/25 at 11:13 a.m., the DON provided the current Infection Prevention and Control Program policy with a implemented date of 2/16/24. The policy included, but was not limited to: This facility has established and maintains an infection control prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines .All staff shall use personal protective equipment (PPE) according to established facility policy governing the use of PPE . On 2/27/27 at 11:13 a.m., the DON provided the current transmission based (Isolation) Precautions policy with a revised date of 6/4/24. The policy included but was not limited to: .droplet precautions refer to actions designed to reduce/prevent the transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions .Droplet precautions .Healthcare personnel will wear a facemask for close contact with an infectious resident. Based upon the pathogen or clinical syndrome, if there is risk of exposure of mucous membranes or substantial spraying of respiratory secretions is anticipated, gloves and gown as well as goggles (or face shield) should be worn . On 2/27/25 at 11:13 a.m., the DON provided the current policy on Personal protective Equipment with a review date of 6/4/24. The policy included but was not limited to: .All staff who have contact with residents and/or their environment must wear personal protective equipment as appropriate during resident care activities and at other times in which exposure to blood, body fluids, or potentially infectious materials is likely . This citation relates to Complaint IN00453974 and IN00453228. 3.1-18(b) 3.1-18(j)

Based on observation, interview, and record review, the facility failed to ensure food was served in a sanitary manner in accordance with professional standards for food service safety for 2 of 2 observations of the kitchen, 1 of 1 observations of meal service. Gloves were not changed, bare hands touched plates, fingers were licked, floors soiled. (Kitchen) Findings include: 1. On 2/25/25 at 9:30 a.m., the kitchen floor was observed to have debris along the walls, behind and under tables, equipment, racks, and in the dry panty. The same was observed on 2/27/25 at 10:10 a.m. 2. On 2/25/25 at 9:25 a.m., Dietary Aide 2 was observed with gloved hands to be standing at a table preparing 6 plates of salad. Dietary Aide 2 left the food prep table, walked to the walk in refrigerator carrying a food container, went in and back out, obtained a cutting board and walked to the food prep table and laid it down. Dietary Aide 2 picked up a food container containing tomatoes, covered it with plastic wrap, walked to the food scale, weighed the tomatoes, touching the screen of the scale with gloved hands. He then walked to the refrigerator with the tomatoes, went in and back out. Dietary Aide 2 was observed to walk back to the food prep table, grab a bag of lettuce, fold the top of the bag over and lay it on the table, grab pieces of cut up ham and put them on top of the lettuce and tomatoes on 6 plates. Dietary Aide 2 took the container of ham to the food scale, weighed it, picked it up, walked in the refrigerator and back out, walked back to the food prep table. Dietary Aide 2 used a knife to cut open a bag of shredded cheese, reached into the bag with a gloved hand, obtained cheese to put on 6 plates of salad. Dietary Aide 2 wrapped the bag of cheese in plastic wrap, took it to the food scale to weigh, touching the screen with gloved hands. Dietary Aide 2 laid the bag of cheese on the table, took off his gloves and washed his hands. 3. On 2/25/25 at 10:49 a.m., Dietary Aide 3 was observed carrying a stack of plates to a food prep table touching the middle of the top plate with bare fingers. Dietary Aide 3 was observed to put a cinnamon roll onto the top plate, wrap it in plastic wrap, put on a tray on a food rack that was later used for meal service. 4. On 2/25/25 at 11:03 a.m., Dietary Aide 5 was observed to be organizing the meal tickets, periodically licking his fingers to separate the tickets. The meal tickets were laid on a a shelf on top of the steam table, later were sent with the plates of food given to residents. 5. On 2/25/25 at 11:17 a.m., Dietary Aide 4 was observed plating lunch, touching some of the plates with his bare fingers where the food was placed. 6. On 2/27/25 at 10:13 a.m., Dietary Aide 6 indicated that when doing food prep, gloves should be worn if touching food, any time you walk away and touch other items, gloves should be taken off, hands washed, new gloves put on. On 2/27/25 at 10:16 a.m., the Dietary Manager indicated floors are cleaned twice a day, the staff follow a cleaning schedule for under racks, behind equipment. On 2/27/25 at 11:33 a.m., the Director of Nursing (DON), provided the current policy on food handling with a revised date of 2/20. The policy included but was not limited to: .All employees of the dining and nutrition services department will wash hands and change gloves (if worn), following any contact with non-sterile surfaces or items. Examples of non-sterile surfaces might include as hair, skin, uniform or hot pad, trash can, door knob, steam table knobs, cooler handles and raw meat .When performing a food preparation function that cannot be done without hand contact, gloves may be worn. Employees will wash hands and put on food-safe gloves prior to direct contact with food, following the Glove Usage policy. Gloves hands are considered a food contact surface that can get contaminated or soiled. If used, single use gloves shall be used for only one task, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation . On 2/27/25 at 11:33 a.m., the DON provided the current cleaning policy on kitchen cleaning with a revision date of 6/2020. The policy included, but was not limited to: .Cleaning tasks shall be designated to be the responsibility of specific positions in the department, i.e.; AM cook, AM Dining Aide, PM Cook, PM Dishwasher, etc, as opposed to being assigned in individual employee names .The Director of Dining and Nutrition Services will routinely check that cleaning is being done to meet the regulation standards. The Registered Dietitian completes quarterly sanitation inspection . This citation relates to Complaint IN00453228 and IN00453974. 3.1-21(i)(3) 3.1-21(i)(2)

Based on interview and record review, the facility failed to ensure a newly admitted resident had immediate orders for pressure wounds for 1 of 3 residents reviewed for pressure wounds. (Resident B) Finding included: On 12/9/24 at 9:44 a.m., Resident B indicated he was admitted to the facility in June of 2024, and had pressure wounds on admission to his buttock. On 12/9/24 at 10:10 a.m., Resident B's clinical record was reviewed. Diagnoses included, but were not limited to, anemia, unspecified, unspecified protein-calorie malnutrition, paraplegia, complete, pressure ulcer of right buttock stage IV (4), type 2 diabetes mellitus with unspecified complications, colostomy status, other acute osteomyelitis, right femur, other acute osteomyelitis right ankle and foot, peripheral vascular disease, pressure ulcer left hip, unstageable, pressure ulcer of right buttock, unstageable. Resident B was admitted to the facility on [DATE]. An admission MDS (Minimum Data Set) assessment dated [DATE], indicated Resident B's cognition was intact, admitted with one stage VI pressure ulcer, one unstageable pressure ulcer, two unstageable- deep tissue suspected. Care plans were reviewed and included, but were not limited to: I require enhanced barrier precautions related to osteomyelitis, pressure wound, IV (intravenous) antibiotics, date initiated 6/27/24. Interventions included but were not limited to: You will provide my treatments as ordered; date initiated 6/27/24. I need assistance with my ADL's (Activities of Daily Living) related to paraplegia with wounds, date initiated 6/26/24. I have deep tissue injury on my right buttock related to extended pressure secondary to altered mobility, date initiated 7/1/24. Interventions included but were not limited to: I will receive treatment as ordered, date initiated 7/1/24. I have a stage IV pressure ulcer related to immobility d/t paraplegia; date initiated 6/28/24. Interventions included but were not limited to, I will receive my treatment as ordered, date initiated 6/28/24. I have an unstageable pressure injury to my left 1st toe related to necrotic tissue covering the wound bed, skin failure, date initiated 7/1/24. Interventions included but were not limited to, I will receive my treatment as ordered, date initiated 7/1/24. I have a deep tissue injury to my right 5th toe related to extended pressure secondary to altered mobility, date initiated 7/1/24. Interventions included but were not limited to: I will receive my treatment as ordered, date initiated 7/1/24. June 2024 physician orders with an active date of 6/25/24, were reviewed and included but were not limited to: Daptomycin intravenous solution reconstituted use 400 milligrams intravenously one time a day for infection/wound for 36 administrations, order date 6/25/24. No orders were recorded in the record for wound treatments on admission on 6/25, until 6/28/24. June 2024 physician orders with an active date of 6/30/24, were reviewed and included but were not limited to: wound vac to stage IV sacral wound, maintain vac and change dressing as ordered every 24 hours as needed for change as needed, order date 6/28/24. wound vac to stage IV sacral wound, maintain vac and change dressing as ordered every day shift every 3 day(s), order date 6/28/24. An initial pressure ulcer report with an effective date of 6/25/24, was reviewed and included, but was not limited to: Site- right buttock Type- pressure Stage IV Site - right toe Type - pressure Stage- suspected deep tissue injury Site- left toe Type- pressure Stage- unstageable Comments .res has wound vac, Foley catheter and ostomy for bowels pressure reducing mattress in place 1/4 SR x 2 for T&R/mobility aide. No measurements were recorded on the report dated 6/25/24. On 12/10/24 at 9:26 a.m., RN 2 indicated Resident B came to the facility with pressure wounds, wound treatments should have been placed on admit, even if temporary until the facility wound nurse could do assessment, treatments were clarified and initiated on 7/1/24 for all wounds. On 12/10/24 at 1:55 p.m., RN 3 indicated if pressure wounds are found on the initial admit skin assessment and no orders were sent, triage should be faxed or called for orders. On 12/10/24 at 12:25 p.m., the DON provided the current admission orders policy with a implemented date of 11/28/23. The policy included but was not limited to: A physician must personally approve, in writing, a recommendation that an individual be admitted to a facility. A physician, physician assistant, nurse practitioner or clinical nurse specialist must provide written and/or verbal orders for the residents immediate care and needs .The orders should allow facility staff to provide essential care to the resident consistent with the resident's mental and physical status on admission . This citation relates to Complaint IN00448583. 3.1-30(a)

Based on observation, interview, and record review, the facility failed to provide adequate supervision and assistance to prevent a fall during a mechanical lift transfer and ensure 2 staff members transferred a resident with a mechanical lift; and failed to properly secure the straps of the lift sling, resulting in a fall from the mechanical lift. This resulted in multiple facial fractures, a neck fracture, and resulting [CONDITION(S)]. This affected 1 of 3 residents reviewed for falls. (Resident B) The immediate jeopardy began on 11/9/21 when 1 staff member transferred a resident using a mechanical lift, without securing the straps of the sling, resulting in a fall from the lift. The Administrator and Assistant Director of Nursing were notified of the immediate jeopardy at 4:00 P.M. on 11/29/21. The immediate jeopardy was: removed on 12/1/21, but noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Findings include: The clinical record of Resident B was reviewed on 11/29/21 at 10:05 A.M Diagnoses included, but were not limited to, nondisplaced fracture of first cervical vertebra (neck area), [CONDITION(S)] (paralysis of arms and legs), and fracture of facial bones. A care plan, initially dated 5/20/21 and updated 11/16/21, indicated, I need assistance with my ADLs [activities of daily living] . The Interventions included, 5/11/21: I need a total mechanical lift and staff assistance for transfers. A new intervention, dated 11/17/21, indicated, Mechanical lift for transfers with Therapy Staff only at this time. A care plan, initially dated 5/20/21 and updated 11/12/21, indicated, I am at risk for falls related to falls . Anxiety, [CONDITION(S)], Spinal Stenosis . The Interventions included, 11/12/21: I will be transferred with the mechanical lift and two staff in attendance. A quarterly Minimum Data Set (MDS) assessment, dated 8/23/21, indicated Resident B had a slight memory problem, did not ambulate, and required extensive assistance of two or more staff for transfer. The resident required supervision and set-up help only for locomotion on the unit, the limited assistance of 1 person for eating, and had no impairment in range of motion of the upper extremities. A Physician's order, dated 8/24/21, indicated, Hoyer (mechanical) lift for transfers r/t [related to] physical limitations The following Nurses Note was marked out with the notation Error. 11/9/21 at 9:43 P.M.: Error - Time of fall; location of fall; vital signs: 18:45 [6:45 P.M.], residents [sic]room . Description of fall: Transferring for [sic] wheel chair to bed per hoyer lift, CNA stated traps [straps] were secure, upon this nurse assessment left strap was not secure, nurse assessment resident lying face down with head over leg of hoyer and bilateral legs out behind her, resident states no discomfort, fall was witnessed, Range of motion; mental status, neurochecks if unwitnessed or hit head; injuries: assessed head to toe, ROM [range of motion] good for this resident, resident disoriented to place, Immediate intervention: Called 911, sent to [hospital] An ambulance report, dated 11/9/21 at 7:10 P.M., indicated, Arrived at pt [patient] side, found her laying prone on tile floor of her bedroom .staff at the pt's side. Staff state that pt was in Hoyer Lift being transferred and fell out, landing on her left side on the tile floor. Staff does admit that pt. was not secured in the lift properly, which led to her falling out. Pt is alert and oriented x 4 at the time of our arrival, but staff does state that pt lost consciousness 'for a little bit.' Pt's main complaint is left scapula [shoulder] and clavicle [collarbone] pain .left clavicle is bruised .noted to have a small amount of blood in the nares [nose]. Pt has hematoma [raised bruise] and abrasion to left temporal area [behind the ears] A hospital emergency room nurses note, dated 11/9/21 at 8:01 P.M., indicated, Pt reports to ED [emergency department] by [ambulance service] from [name of nursing home] after falling out of her hoyer lift from around 3-5 feet. Reported pt hit her left shoulder and left side of her head with positive loss of consciousness. Pt denies any numbness or tingling. An ER Physician's note, dated 11/9/21 at 9:57 P.M., indicated, Chief Complaint .Per report, patient accidentally fell from a hoyer lift from a height of approximately 5 ft. Patient reported landed on her left shoulder and head. Since the accident the patient indicates she has pain in her left shoulder. She has an obvious left frontal skull deformity with overlying abrasion .Impression: 1. Closed nondisplaced fracture of first cervical vertebra .2. Closed fracture of frontal bone. A hospital history and physical, dated 11/9/21 at 10:17 P.M., included: .She complains of headache and left shoulder/back pain. She has associated BUE [bilateral upper extremity] weakness and tingling. Pt and husband report she usually has normal grip strength and is able to lift her arms . large left scalp hematoma . Left periorbital [around the eye] ecchymosis [bruising] and swelling. Neurologic: BUE weakness, unable to grip and lift arms A hospital discharge note, dated 11/12/21, indicated: Hospital Course: Patient was admitted to Trauma Services after she was found to have the below listed injuries following a fall from a Hoyer lift at her skilled nursing facility. She was seen by Neurosurgery for an acute C1 fracture resulting in central cord syndrome. Patient ultimately decided she did not want any type of surgical intervention. Recommended continuing with a Miami J collar [neck collar]. She was seen . for multiple facial fractures, recommended non operative management. Palliative care was consulted for goals of care, patient was made DNR/DNI [do not resuscitate/do not intubate]. She was evaluated by speech therapy who recommended a dysphagia [for difficulty swallowing] level to diet. A nursing readmission assessment, dated 11/12/21 at 9:38 P.M., indicated Resident B was alert and oriented to person, place, and time; had bruising on the left side of her chin and left eye; and was dependent on staff for ADLs. The resident's mobility was documented as bedrest. A Nurse Practitioner note, dated 11/15/21, indicated, .presents with physical debility following a stay at [hospital] from 11/9-11/12/21 d/t [due to] following a fall from a hoyer lift at SNF [nursing home] with complaints of headache and left shoulder/back pain and BUE weakness and tingling. Pt found to have an acute C1 fracture. Was seen by neurosurgeon with pt choosing to not have any surgical intervention. Pt will continue to wear Miami J collar. Pt also noted to have multiple facial fractures and was seen by ENT [ear, nose, throat] who recommended non operative management. Pt also seen by palliative care and code status changed to DNR .Patient resting in bed at time of visit. Complains of muscle spasm in right arm and left leg at times .Pt is struggling with the inability of being able to feed self and play games on her tablet .Assessment/Plan: 1. Physical debility, 2. Closed nondisplaced fracture of first cervical vertebra .3. Closed fracture of face bones .4. [CONDITION(S)] A MDS note, dated 11/23/21 at 12:49 P.M., indicated: Resident needs total care this day to be fed meals x 1 staff, needs total assistance with toileting and bed mobility. Resident needs total assistance x 2 staff and mechanical lift for transfers and is only able to transfer with therapy staff at this time. Resident has c-collar to be worn at all times. Dx: C1 fracture and has dx: [CONDITION(S)]. On 11/29/21 at 10:45 A.M., Resident B was observed lying in bed with a neck collar on. Resident B indicated, I broke my neck. Resident B indicated she fell from a Hoyer lift approximately 3 weeks previously. One staff member was attempting to transfer her from the wheelchair to the bed. Resident B indicated, I'm not going to lie. But I forgive him. Resident B indicated 1 staff member usually transferred her with the mechanical lift. On 11/29/21 at 11:30 A.M., the Administrator provided a written statement from CNA 1, dated 11/11/21. The statement indicated, On 11/19/21 [sic] @ about 6:45 I took a Hoyer Lift to [Resident B's] room to help her to bed. I hooked the sling straps to the Hoyer Lift. I then lifted her out of her chair, pulled the hoyer back, shut the legs. I turned her body and started to push the Hoyer Lift. The strap came undone and she fell out of sling. [LPN 1] was outside this room. When she came in she told me to go get [another staff member]. At that time, the Administrator also provided an incident report, dated 11/9/21 at 6:45 P.M. The report included: Transferring from wheel chair to bed per mechanical lift. CNA stated straps were secure. Nurse assessment revealed left strap was not connected to lift when responding to fall. Resident was lying face down over leg of hoyer and bilateral legs out behind her .Resident disoriented to place .No injuries observed at time of incident. No injuries observed Post Incident At that time, the Administrator indicated that he inspected the sling that was used on Resident B after the incident, and did not find any tears in the sling. He had CNA 1 do a return demonstration on how he hooked Resident B up, and CNA 1 thought he did everything right. It was the facility policy to always use 2 staff members when using a mechanical lift. The CNA did not indicate why he did not get another staff member to assist him. The CNA could not definitely state if all of the sling hooks were securely placed on the lift. The Administrator did an audit, and found that 11 residents required a Hoyer lift. On 11/29/21 at 2:35 P.M., LPN 1 was interviewed. LPN 1 indicated she was standing in the hallway at her medication cart on 11/9/21. She heard CNA 1 state, Oh my gosh, she fell . She went into Resident B's room, and found her lying on the floor, with her head lying over the leg of the Hoyer lift. She did notice that the left front strap of the sling was undone. The sling did not appear to be ripped or torn. CNA 1 was transferring the resident from the wheelchair to the bed by himself. He did not ask LPN 1 for assistance. Prior to this incident, Resident B was able to move her arms. She was able to operate her electric wheelchair. LPN 1 indicated the documentation in the Nurses Notes regarding the fall was accurate, but because she labeled the fall mistakenly as an elopement in a different part of the electronic record, and deleted that documentation, the Nurses Note was also struck out. On 11/30/21 at 1:53 P.M., CNA 1 was interviewed. He indicated he had transferred Resident B independently previous to 11/9/21 without incident. On 11/9/21, he retrieved the Hoyer lift and proceeded to transfer the resident from the electric scooter to the bed. The nurse was in the hall. He lifted the resident, standing at the back of the Hoyer, moved around to position the resident, and then moved back to the controls. That is when the strap fell and out she went. LPN 1 came in right away. Prior to the fall she did feed herself, and would tell staff when she needed the bedpan or go back to bed. Now she is total care, has to be fed by staff, and knows the sensation of toilet needs. But now she sometimes just tells them when she's wet or needs changing. Now we use three to transfer so one person can hold her head and neck. He indicated he moved her alone because she was small in stature and he thought he could. He understands now the manufacturer's instructions on the importance of two people for transfer. On 11/29/21 at 2:20 P.M., the Administrator provided the user manual for the Hoyer lift used on Resident B. The manual included: Warning: [Name of company] recommends that two attendants be used when transferring a patient to and from a wheelchair. At that time, the Administrator provided the current facility policy, Total Mechanical Lift, dated 12/20. The policy included: Always follow the manufacturer's instructions for the specific lift that you are using .The lift will be completed with two staff On 11/29/21 at 3:15 P.M., the Administrator provided the current facility policy, Fall Investigation and Risk Evaluation, dated 6/21. The policy included: It is the policy of this facility to provide an environment that is free from accident hazards over which the facility has control and provides supervision and assisted devices to prevent avoidable accidents The immediate jeopardy that began on 11/9/21 was removed on 12/1/21 when the facility educated staff regarding mechanical lift transfers, but the noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy, because not all staff had been re-educated about Hoyer lift transfers, and the removal plan had been updated regarding the staff and resident monitoring to include complete random mechanical lift observations of two staff members during the resident transfers, observations to be conducted by a third person. This Federal tag relates to Complaint IN 201. 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to provide supervision and assistance to prevent accidents for 1 of 2 residents reviewed for falls. Supervision and effective fall interventions were not in place for a resident, which resulted in a resident receiving a femur fracture and surgical intervention. (Resident A) Findings include: The clinical record for Resident A was reviewed on 6/18/19 at 8:26 a.m. [DIAGNOSES REDACTED]. The admission assessment, dated 2/9/19 at 2:59 p.m., indicated the resident required the assistance of 1 (one) person for ambulation and transfers. The assessment indicated the resident had a history of [REDACTED]. The admission care plan indicated the resident was at risk for falls. The admission care plan lacked documentation of any goals or interventions. physician's orders [REDACTED]. The facility lacked a physician's orders [REDACTED]. The MAR (Medication Administration Record), dated 2/1/19-2/28/19, indicated the resident had received [MEDICATION NAME] 325 mg (milligrams) 2 (two) tablets by mouth every 4 hours as needed for pain, start date 2/9/19. The MAR indicated [REDACTED]. A progress note, dated 2/9/19 (Saturday) at 2:59 p.m., indicated the admission assessment had been completed and the resident was a high fall risk. A progress note, dated 2/9/19 (Saturday) at 5:20 p.m., indicated Resident A had a change of plane. Resident A was noted to be on their back with their leg in front of them. The note indicated the resident had non-skid socks on their feet and their head was facing the window. The note indicated when the resident was questioned what had happened, the resident replied, they were attempting to go to the restroom, use the phone, and change the television channel. The note indicated the resident had just been admitted , oriented to the room and amenities of the room including call light which was clipped to the resident's clothing. The note indicated the resident complained of severe left hip pain. Immediate intervention included the resident was assessed for injuries, was reoriented to call light and features. The note indicated nursing home triage was notified, new orders received and noted. The note further indicated the portable X-ray service had been notified and the facility was awaiting their arrival. A progress note, dated 2/10/19 (Sunday) at 2:13 a.m., indicated the facility had faxed the X-ray results to the resident's physician' triage group. The note indicated the results demonstrated an acute intertrochanteric left femoral fracture as noted vs (versus) summation artifact and recommended repeat CT (computed tomography) scan. A fall IDT (intradepartmental team) note, dated 2/11/19 (Monday) at 9:07 a.m., indicated on 2/9/19 at 5:40 p.m., the resident had attempted to ambulate unassisted. The note indicated the resident was noted to be laying on their back, wearing non-skid socks. The note indicated the resident had attempted to use the bathroom, get the phone and change the television channel. No new injuries at this time. The note indicated the resident was complaining of left hip pain. The root cause of the fall was the resident was transferring unassisted. Intervention and care plan update included to educate the resident to use call light prior to transfers and educated the staff to clip the call light to the bed and not to clothing. A progress note, dated 2/11/19 (Monday) at 9:58 a.m., indicated the facility received orders to send the resident to the emergency room and the resident left the facility via ambulance at 10:25 a.m. A progress note, dated 2/11/19 at 4:12 p.m., indicated the facility had spoke to the emergency room and confirmed the resident had a left femur fracture with no confirmed surgery at that time. On 6/18/19 at 2:33 p.m., LPN 3 indicated if a resident was admitted on off hours, the admitting nurse should fill out the care plan for the resident with the initial assessment and include goals and interventions for the 48 (forty-eight) hour care plan and then the facility would begin a more in-depth care plan on the next business day with more details. The current facility policy, revised 2/2019, obtained from the DON (Director of Nursing) on 6/24/19 at `12:01 p.m., indicated it was the policy of the facility to provide supervision and assisted devices to prevent avoidable accidents. This Federal tag relates to Complaint IN 489 and Complaint IN 823. 3.1-45(a)

Based on interview and record review, the facility failed to ensure a resident with a leaking suprapubic catheter did not develop a wound, for 1 of 3 residents reviewed with skin impairments, in a sample of 10. Resident A Findings include: The closed clinical record of Resident A was reviewed on 1/9/17 at 10:00 A.M. [DIAGNOSES REDACTED]. An admission Minimum Data Set (MDS) assessment, dated 11/8/16, indicated Resident A scored a 15 out of 15 for cognition, indicating no memory impairment. The resident required limited assistance of two+ staff for bed mobility, and extensive assist of two+ staff for hygiene and bathing. The resident was frequently incontinent of bowel. He had 2 pressure areas, which were unstageable. A Care Plan, dated 11/2/16, indicated, I have C6 spinal cord injury with limited use of my lower extremities. The Interventions included: Assist and encourage me to reposition frequently. Implement Skin prevention as indicated. 12/20/16 at 6:56 A.M.: Dressing over suprapubic catheter wet. Area cleansed and new dressing applied. Has red area left side of groin. Multipodus boots applied to both feet. Dressing to wound vac dry and intact. Documentation that the physician was notified of the red area on the left groin was not found in the clinical record. A Urology note, dated 12/21/16, indicated, Chief Complaint: leaking at insertion site .Comes in today mainly to discuss our treatment plan .Skin: General Appearance of extremities: no [MEDICAL CONDITION] (swelling). Inspection and palpation: no rash or [MEDICAL CONDITION] and normal temperature . The note did not mention assessing a skin impairment to the groin. Wound assessments, dated 12/23/16, indicated the following: Type: Moisture Associated Skin Damage (MASD), Location: Groin, Acquired: In-House, Wound Age: Exact Date 12/23/16, Wound Measurements: Length: 3/12 cm, Width: 5.0 cm .Surrounding Tissue: Macerated: Wet, white waterlogged tissue .Resident has paralysis which prevents resident sensation to lower body .Additional Care: .Repositioning device(s), Incontenience (sic) management .Area noted to left groin. Resident has a supra pubic catheter and area has been leaking moderate urine Skin noted to be macerated and sloughed off. Resident has apt (sic) with urologist regarding catheter. MD notified of skin condition and orders received. A physician's orders [REDACTED]. Apply skin prep to surrounding area and vitamin A&D ointment to area of skin damage. Cover with dry gauze or abdominal pad and secure with tape every shift for wound healing. Nurses Notes continued: Late Entry: 12/23/16 at 13:44 (1:44 P.M.) Returned from (name of urologist) appt. Suprapubic catheter was not changed and orders for left groin tx (treatment) are unchanged. 12/26/16 at 1:48 P.M.: This nurse notified by wound nurse that nephrostomy tube to right back was displaced and appears to be intact .md on-call notified. Rec'd order for pt (patient) to be sent to ER to have nephrostomy tube replaced .pt alert and oriented to self time place and situation at time of transfer Hospital flow sheets indicated the following: Wound 12/26/16 Pressure Ulcer Left Groin, Date First Assessed: 12/26/16, Time First Assessed: 2218 (10:18 P.M.), Present on Admission? Yes .Assessment: Brown; Yellow; Black; Red, 95% necrotic, 5% red/pink, Wound Length: 8 cm, Wound Width: 7 cm, Depth: 01 cm A hospital Social Services Note, dated 12/27/16 at 5:05 P.M., indicated, .Patient was discharged from (name of hospital) on 12/9/16 to (name of facility), was readmitted on [DATE] with new decubitus ulcers on his buttocks, groin, and heel area. Patient advises he was only turned every four hours at the SNF (skilled nursing facility) and only from back to right side. Patient states the groin wound is from his catheter leaking at the facility and not being moved. Pictures of the wounds were taken by Physical Therapy On 1/11/17 at 10:30 A.M., during an interview with RN # 2, he indicated he was the wound care nurse who cared for Resident A. He indicated Resident A's suprapubic catheter was draining a lot. He indicated the resident went to the urologist, but the urologist did not change the catheter. He indicated the urine leaking onto the resident's skin caused the top layer to come off. On 1/11/17 at 11:40 A.M., during an interview with the Director of Nursing, she indicated she was actually not in the facility from 12/16/16 until 12/27/16, due to illness. She indicated she did communicate with the Wound Nurse, and was unaware of any pressure ulcer on the resident's heel or back. On 1/12/17 at 9:45 A.M., the DON provided the current facility policy on Wound Prevention Protocol, revised 5/2016. The policy included: .Skin inspection also should be done as a component of routine care (for example, at bath time, prior to transfer from the facility, upon discharge and upon readmission to the facility). Resident specific interventions will be care planned .Inspect the entire body for any areas with redness or open areas This Federal tag relates to Complaint IN 300. 3.1-37(a)

Based on observation, interview, and record review, the facility failed to provide timely incontinent care to a resident with a pressure ulcer, and failed to implement interventions to prevent the deterioration of pressure wounds and the development of new wounds, resulting in a deep tissue injury on a heel, for 2 of 3 residents reviewed with pressure ulcers, in a sample of 10. Resident B, Resident A Findings include: 1. On 1/8/17 at 4:15 P.M., RN # 1 indicated Resident B had pressure areas, and had fallen recently. On 1/9/17 at 8:40 A.M., Resident B was observed getting a bath by a hospice aide. On 1/9/17 at 11:00 A.M., Resident B was observed lying in bed. On 1/9/17 at 1:45 P.M., Resident B was observed lying with 1 leg on the bed and 1 leg off of the bed. His covers were saturated and lying on the floor. His bed pad was saturated with a dark brown stain. His brief was observed to be saturated, and leaking out. Staff was alerted at that time. On 1/10/17 at 9:10 A.M., Resident B was observed trying to get out of bed by himself. Staff was alerted. The resident was observed to have a saturated brief on, and his bed pad was soiled with a brown ring. BM was observed going up and under a loose dressing on his buttocks. CNA # 2 indicated she had been at the facility since 6:00 A.M., but hadn't had a chance to check him. On 1/10/17 at 9:20 A.M., a wound assessment was requested. LPN # 1 indicated, The Wound Care Nurse usually does his dressings. She removed the soiled dressing over the resident's coccyx/buttocks area. A pressure ulcer, approximately the size of a small dinner plate, was observed. The area was completely necrotic (black), with a foul odor. The resident also had a dressing on his left leg. His toes were unwrapped, and observed to be necrotic. The clinical record of Resident B was reviewed on 1/10/17 at 11:35 A.M. [DIAGNOSES REDACTED]. The resident was receiving hospice services. An admission Minimum Data Set (MDS) assessment, dated 12/5/16, indicated the resident scored a 10 out of 15 for cognition, with 15 indicating no memory impairment. The resident required extensive assistance of two+ staff for bed mobility and dressing, and did not ambulate. The resident was frequently incontinent of bowel and bladder, and had 2 pressure areas. A Care Plan, dated 11/29/16, indicated, I am at risk for developing pressure ulcers related to immobility. The Interventions included: I will turn and reposition frequently and ask for assistance as needed. The most recent Wound Assessment, dated 1/9/17, indicated, Type: Pressure, Stage: Unstageable: Obscured full-thickness skin and tissue loss, Due to: Slough/Eschar (black tissue), Location: Coccyx .Wound Measurements . Length 11.96 cm, Width 8.0 cm .% Eschar 100% of wound filled .Exudate (drainage): Moderate .Wound Pain, Cognitively Impaired .Additional Care: .Repositioning device(s), Incontinence (sic) management .Progress: Deteriorating .Resident continues to decline 2. The closed clinical record of Resident A was reviewed on 1/9/17 at 10:00 A.M. [DIAGNOSES REDACTED]. An admission Minimum Data Set (MDS) assessment, dated 11/8/16, indicated Resident A scored a 15 out of 15 for cognition, indicating no memory impairment. The resident required limited assistance of two+ staff for bed mobility, and extensive assist of two+ staff for hygiene and bathing. The resident was frequently incontinent of bowel. He had 2 pressure areas, which were unstageable. A Care Plan, dated 11/2/16, indicated, I am at risk for developing pressure ulcers related to impaired physical mobility. I have a history of ulcerations. The Interventions included: I will turn and reposition frequently and ask for assistance as needed. You will float my heels off the mattress when I am in bed. The resident was admitted to the hospital, and discharged on [DATE]. Wound assessment sheets, dated 12/16/16, indicated the following: Sacrum, Unstageable:Obscured full-thickness skin and tissue loss, Due to: Slough/Eschar, Measurements: Length: 1.25 cm, Width: 0.6 cm .Exudate (drainage) Light .Resident has paralysis that prevents feeling to lower body Sacrum, Unstageable .Length: 1.66 cm, Width: 1.7 cm .Exudate: Light .Surrounding Tissue: Macerated: Wet, white, waterlogged tissue, Discoloration - black/blue Sacrum, Unstageable .Length: 0.9 cm, Width: 0.7 cm .Exudate: Light Left buttock, Unstageable .Length: 1.34 cm, Width 0.9 cm .Exudate: Light Coccyx, Unstageable .Length: 2.42 cm, Width: 2.3 cm, Depth: 2.0, Undermining: 1.0 cm, Tunneling: 3.0 cm .Exudate: Moderate .Surrounding Tissue: Macerated .Discoloration .Fragile .Progress: Stable Left Ischial Tuberosity, Unstageable .Length: 6.33 cm, Width: 4.3 cm, Depth: 3.0 cm .Exudate: Moderate .Stable Nurses Notes included the following notations: 12/20/16 at 6:56 A.M.: Dressing over suprapubic catheter wet. Area cleansed and new dressing applied. Has red area left side of groin. Multipodus boots applied to both feet. Dressing to wound vac dry and intact. Wound assessments, dated 12/23/16, indicated the following: Sacrum, Unstageable .Area 19.2 cm, Length: 5.96 cm, Width: 4.9 cm .Wound was previously one of three unstageable wounds .On this date, the three wounds have merged into one wound The pressure ulcer(s) had increased in size from the previous week. Left Buttock, Unstageable . Length: 2.34 cm, Width: 1.0 cm .Progress: Improving . The wound had increased in size from the previous week. Coccyx, Unstageable .Length: 3.57 cm, Width: 3.3 cm, Depth: 3.0 cm, Undermining: 3.0 cm, Tunneling: 3.0 cm The pressure ulcer had increased in size from the previous week. Left Ischial Tuberosity, Unstageable .Length: 6.65 cm, Width: 6.5 cm, Depth: 4.0 cm .Stable The pressure ulcer had increased in size from the previous week. Documentation of any pressure areas on the heels was not found in the clinical record. Nurses Notes continued: 12/25/16 at 11:47 P.M.: Triaged (sic) faxed regarding foul smelling wound drainage, asking for cultures and labs, awaiting call back. 12/26/16 at 1:48 P.M.: This nurse notified by wound nurse that nephrostomy tube to right back was displaced and appears to be intact .md on-call notified. Rec'd order for pt (patient) to be sent to ER to have nephrostomy tube replaced .pt alert and oriented to self time place and situation at time of transfer A hospital emergency room note, dated 12/26/16 at 1:56 P.M., included: Chief Complaint: Tube/Catheter problems .Physical Exam: Skin .Decubitus Ulcers .Neurologic: Alert and appropriate Speech is clear Hospital flow sheets indicated the following: Wound 12/26/16 Pressure Ulcer Heel Left, Date First Assessed: 12/26/16, Time First Assessed: 2219 (10:19 P.M.), Present on Admission? Yes .Assessment Fragile; Brown; Light purple blister, deep tissue injury, Wound Length: 5 cm, Wound Width: 8 cm Wound 12/26/16 Pressure Ulcer Back Mid;Medial, Dated First Assessed: 12/26/16 Time First Assessed: 2100 (9:00 P.M.), Present On Admission? Yes, Wound Type: Pressure Ulcer, Assessment: Yellow; Black: Brown 100% necrotic, Wound Length: 7.5 cm, Wound Width: 8.5 cm A hospital Social Services Note, dated 12/27/16 at 5:05 P.M., indicated, .Patient was discharged from (name of hospital) on 12/9/16 to (name of facility), was readmitted on [DATE] with new decubitus ulcers on his buttocks, groin, and heel area. Patient advises he was only turned every four hours at the SNF (skilled nursing facility) and only from back to right side On 1/11/17 at 10:30 A.M., during an interview with RN # 2, he indicated he was the wound care nurse who cared for Resident A. He indicated he did not notice a deterioration in the wounds, or an increase in size, on 12/26/16. He indicated the facility had been using a new wound measurement tool, which had lots of glitches. He indicated he did not observe a pressure wound on Resident A's heel or back. On 1/11/17 at 11:40 A.M., during an interview with the Director of Nursing (DON), she indicated she was actually not in the facility from 12/16/16 until 12/27/16, due to illness. She indicated she did communicate with the Wound Nurse, and was unaware of any pressure ulcer on the resident's heel or back. On 1/12/17 at 9:45 A.M., the DON provided the current facility policy on Wound Prevention Protocol, revised 5/2016. The policy included: .Skin inspection also should be done as a component of routine care (for example, at bath time, prior to transfer from the facility, upon discharge and upon readmission to the facility). Resident specific interventions will be care planned .Inspect the entire body for any areas with redness or open areas This Federal tag relates to Complaint IN 300. 3.1-40(a)1 3.1-40(a)2

Based on observation, interview, and record review, the facility failed to provide supervision for a resident at risk for falls, and utilized alarms in place of supervision, resulting in a fall with a fractured elbow, for 1 of 3 residents reviewed for falls, in a sample of 4. Resident B Findings include: The clinical record of Resident B was reviewed on 1/27/16 at 1:30 P.M. [DIAGNOSES REDACTED]. A Fall Risk Assessment, dated 10/16/15, indicated the resident had intermittent confusion, had a history of [REDACTED]. The Assessment indicated the resident was a high fall risk. Nursing Progress Notes, dated 10/29/15 at 6:02 P.M., indicated, Called to room by CNA. Found resident sitting up on buttocks, on the floor, next to her bed .Floor alarm is sounding .no changes noted in cognition .Round, swollen, pink area noted on forehead above left eye .Resident assisted to standing position by 2 employees .Immediate intervention: Trash can moved within resident's reach. Floor alarm on A quarterly Minimum Data Set (MDS) assessment, dated 10/30/15, indicated the resident scored a 5 out of 15 for cognition, with 15 indicating no memory impairment. The resident required extensive assistance of two + staff for transfer, and limited assistance of one staff for ambulation in her room. The resident required extensive assistance of one staff for toileting. The MDS assessment indicated Resident C had fallen previously; 1 fall with no injury, and 1 fall with injury (except major). Nursing Progress Notes included the following notations: 12/4/15 at 7:54 A.M.: .Called to residents (sic) room after staff found her in the floor beside her bed. Resident was on her buttock leaning to the Left side/hip .Unwitnessed and no injuries. Immediate intervention: Resident was removed from the floor and placed on the side of the bed 12/4/15 at 9:04 A.M.: Fall IDT (interdisciplinary team) Note .Root cause of fall: Resident transferring self to the bathroom. Intervention and care plan updated: .Staff to offer toileting approximately every two hours while awake. 12/6/15 at 4:51 A.M.: .Resident observed sitting on floor beside her bed, on alarm mat Sensor alarm was under resident's pillow, and not sounding because of low battery .Resident confused, which is normal for resident .Alarm battery replaced. New order for U/A/ C&S (urinalysis, culture and sensitivity) 12/7/15 at 6:35 P.M.: Housekeeper came to nurse's station reporting resident on floor. When this nurse entered room resident was sitting on butt right outside the bathroom. Resident had taken her alarm apart. Resident was wearing slippers. Resident states she was going to the bathroom and lost balance causing her to fall .Will continue to monitor. 12/8/15 at 8:50 A.M.: Fall IDT Note .Root cause of fall: Resident states she lost her balance and fell .Care plan reviewed .Staff to increase toilet offering until UTI (urinary tract infection) is resolved. 12/20/15 at 4:37 A.M.: .Alarm sounding, resident observed sitting on floor, on her backside/buttocks, beside her bed. Resident noted to have bruising & swelling to (L) elbow .Resident confused, normal for resident .Immediate intervention: Alarms checked, and resident reminded to use call light when needing assistance with transfers 12/21/15 at 7:50 A.M.: Fall IDT Note .Root cause of fall: Resident transferring self from bed to bathroom .Care plan reviewed and updated. Offer/encourage assistance with toileting every two hours while abed. 12/22/15 at 4:51 P.M.: Bruised area to left elbow and wrist larger than yesterday .Order received to obtain xray of area 12/23/15 at 5:48 A.M.: Faxed X-ray of elbow and wrist to (name of physician). Facture (sic) proximal radius (elbow). An annual MDS assessment, dated 12/22/15, indicated the resident scored a 4 out of 15 for cognition. The resident required extensive assistance of two + staff for transfer, and limited assistance of one staff for ambulation in her room and corridor. The resident required extensive assistance of one staff for toileting. The MDS assessment indicated Resident C had fallen previously; 2 falls with no injury and 1 fall with a major injury. Progress Notes, dated 1/16/16 at 1:59 A.M., indicated, Resident was found sitting in the floor of her room by the bed .Resident had unplugged her bed alarm and it was not sounding Progress Notes, dated 1/21/16 at 2:06 A.M., indicated, .standing in bathroom, turned and fell .resident was unattended. Immediate intervention: do not leave unattended while in bathroom A care plan, dated 3/11/14 and updated 12/21/15, indicated, Focus: I am at risk for falls r/t (related to) intermittant (sic) confusion, weakness with balance issues, ambulatory and incontinence at times, low bims (brief interview for mental status) score .Has history of refusing therapy for strengthening, refusals/agitation with use of hip protectors and inappropriate use of assistive devices/footwear not consistently used. Interventions: Assistance to be provided with her ADLs (activities of daily living) and as needed .Encourage walker use, with assistance, and have within reach at all times. Ensure that I am wearing appropriate footwear when ambulating or mobilizing in w/c (wheelchair) .Offer/encourage assistance with toileting every 2 hrs while in bed (12/21/2015). Resident requires supervision during toileting. (1/21/2016). Toilet resident at approximately 3A (12/04/2015) .Trial alternate distance alarm (01/18/2016). On 1/27/16 at 2:20 P.M., Resident B was observed in the bathroom with CNA # 1 assisting her. Resident B's room was towards the end of the hallway. CNA # 1 indicated, I heard her alarm sounding, and she was already in here by herself. The resident's left elbow was assessed, and was found to have slight bruising and swelling. Resident B indicated, It hurts when I touch it. Resident B indicated the left elbow was black and blue clear from my wrist to my elbow. On 1/28/16 at 9:35 A.M., during an interview with the Director of Nursing (DON) and RN # 1, the DON indicated she would like to eliminate the use of alarms. RN # 1 indicated she did not know why the staff person left Resident B in the bathroom by herself; she indicated she thought the staff person was a PRN (as needed) nurse. RN # 1 indicated they had tried many different interventions for Resident B in an attempt to reduce her falls. RN # 1 indicated the resident's family had refused to move the resident closer to the nursing station. On 1/28/16 at 1:50 P.M., the Administrator provided the current facility policy Fall Evaluation and Investigation, revised 8/2013. The policy included: Purpose .To identify high-risk residents and implement interventions to reduce falls and the consequences of falls .All residents will have a care plan developed by the interdisciplinary team On 1/28/16 at 2:15 P.M., during an interview with the Corporate Consultant, she indicated the facility did not have a specific fall prevention policy. This Federal tag relates to Complaint IN 725. 3.1-45(a)(2)

Based on interview and record review, the facility failed to properly provide care in that staff ran over a resident's foot with a bedside table, causing a fracture of her left toe, and failed to provide appropriate supervision to prevent falls, for 1 of 3 residents reviewed for accidents, in a sample of 4. Resident D Findings include: 1. The closed clinical record of Resident D was reviewed on 11/17/14 at 2:15 P.M. The resident was admitted to the facility with [DIAGNOSES REDACTED]. A Progress Note, dated 9/20/14 at 11:48 A.M., indicated, "Needs extensive assist of one staff for transfers. Needs extensive (sic) assist of one for ambulation. Needs extensive assist of one for bed mobility...Resident complains of weakness...." A "Fall IDT (interdisciplinary team) Note," dated 9/24/14 at 11:39 A.M., indicated, "Summary of the fall: Staff responded to call light, upon entering room, nurse found resideny (sic) sitting on the floor on buttocks in front of statinonary (sic) chair in room...Resident stated that she attempted to transfer self from chair. Intervention and care plan updated: Resident encouraged to call for assistance with transfers, pressure alarm placed and (sic) bed and chair." Documentation which indicated on what date or time that the resident actually fell was not found in the clinical record. An admission Minimum Data Set (MDS) assessment, dated 9/26/14, indicated the resident scored an 11 out of 15 for cognition, with 15 indicating no memory impairment. The MDS assessment indicated the resident required limited assistance of one staff for transfer and ambulation. A test of "Balance During Transitions and Walking" indicated "Not steady, only able to stabilize with staff assistance." The resident had fallen one time since admission. Progress Notes included the following notations: 9/27/14 at 2:00 P.M.: "This nurse answered call light and found resident sitting on the floor. Daughter stated, 'I was assisting mother to the bathroom and had to assist her to the floor on her bottom due to weakness...." 9/28/14 at 10:00 A.M.: "Needs extensive assist of one staff for transfers. Needs extensive assist of one for bed mobility...Resident is alert. Oriented to person. Oriented to place. Oriented to time. Speech is clear...." 9/28/14 at 12:37 P.M.: "Resident has bruise to right (sic) foot. Resident able to move foot and toes. No swelling. Resident reports staff ran over foot with bedside table when given food." A Skin Report, dated 9/28/14, indicated, "Date First Observed, 09/28/2014...Bruise...Description (left blank), Treatment/Recommended Changes, bruise to left foot...Date MD notified 09/28/2014. Date family notified 09/28/2014." Progress notes continued: 9/29/14 at 1:35 P.M.: "(Name of physician) and family notified awaiting orders. DON (Director of Nursing) notified." 9/30/14 at 6:56 A.M.: "Called Triage to ask if they ever received a (sic) authorization for an order to x-ray her left foot due to a bruise. (Son) called office to request for a xray...." 9/30/14 at 10:00 A.M.: "Needs extensive assist of one staff for transfers...Complains of pain in foot." 9/30/14 at 4:35 P.M.: "Received x-ray report...left foot shows fracture to left 5th metatarsal. Notifed (name of physician) and received orders to see orthopedic and Tramadol 50 mg every 6 hours as needed for pain. Call placed to (Orthopedic name) and they recommended to send resident to Urgent Care for faster service as there (sic) foot MD is going on vacation. Call placed to son (name) to notify of x-ray results and orders for ortho visit and pain medication. To speak to sister...." A Physical Therapy note, dated 10/1/14 at 2:51 P.M., indicated, "Precautions: Fall risk...Pain-General...Patient verbalized pain level; Does pain limit patient's functional activities? = Yes; Pain limits the following functional activites: Walking and standing with RW (rolling walker), What relieves pain? Sitting down; What exacerbates pain? = Standing...Frequency= Constant; Location: left foot; Pain Description/Type: left foot sharp pain with weight bearing...Patient very fearful of hurting left foot with movement...." Progress notes continued: 10/1/14 at 6:21 P.M.: "When assisting resident to bathroom this evening resident had tremors noted to all extremities. Resdient (sic) also very weak and taking extensive assist of 2 to transfer. Spoke with daughter about resident decline over last few days of increased weakness and tremors...." 10/1/14 at 6:52 P.M.: "Received call from daughter (name) and she stated that her and her brother agree that she should be sent to ER although they does (sic) not want her to go until the morning...Call placed to (name of physician) at that time and he agreed to send resident for evaluation in the morning." The resident was transferred to theER on [DATE] at 9:48 A.M. A hospital ER note, dated 10/2/14 at 9:51 A.M., indicated, "Chief Complaint:...she is recently (sic) sustained a crush injury to her left foot sustaining a toe fracture at (name of facility)...Final Impression:...3. Recent fracture left foot, sustained at (name of facility)...." An ER note, dated 10/2/14 at 2:46 P.M., indicated, "Walker boot placed on left foot - pt (patient) tolerated...Pt is alert and oriented...." The resident returned to the facility on [DATE] at 3:53 P.M. Progress notes continued: 10/2/14 at 9:04 P.M.: "Needs extensive assist of two staff for transfers. Resident did not ambulate today. Needs extensive assist for two staff for bed mobility...Needs extensive assist of two staff for dressing and grooming...." 10/4/14 at 10:00 A.M.: "Needs extensive assist of two staff for transfers. Resident did not ambulate today...Needs extensive assist with dressing and grooming...." 10/6/14 at 10:20 A.M.: "Fall IDT Note...Summary of the fall: Resident attempting to toilet self fell . Root cause of fall: Poor safety awareness resident attempting to toilet self. Intervention and care plan updated: Assess for toileting program." Documentation which indicated on what date and time that the resident actually fell was not found in the clinical record. Documentation which indicated if the resident's alarm was sounding was not found in the clinical record. Progress notes continued: 10/9/14 at 8:42 P.M.: "Needs extensive assist of two staff for transfers. Resident did not ambulate today...Resident is alert. Oriented to person...Gait is unsteady. Has impaired balance while standing...." 10/14/14 at 3:51 P.M.: "Fall IDT Note. Summary of the fall: IDT reviewed fall documentation. No injury or pain noted. Resident feel (sic) out of wheelchair...Resident was in wheelchair trying to reach papers on table and fell . Intervention and care plan updated: Resident not to be left in room in wheelchair unattended." Documentation of what date and time the resident actually fell was not found in the clinical record. Documentation regarding if the alarm was sounding or not was not found in the clinical record. At 11/18/14 at 11:15 A.M., the Administrator was requested to provide further information regarding the resident's bruise and fracture of her left foot, and of her falls. At 11/18/14 at 1:30 P.M., the Administrator and Director of Nursing (DON) provided "Fall Investigation Worksheets" for falls on 9/22/14, 9/27/14, 10/4/14, and 10/11/14. The Administrator also provided electronic fall worksheets regarding the falls. She indicated these documents were not a part of the clinical record. She indicated the staff were supposed to transfer the information to the progress notes. The DON indicated an IDT note was usually documented 1-2 days after a fall, in addition to the progress note. A Falls Investigation Worksheet, dated 9/22/14, included: "Number of falls in the last 30 days? (Left blank), Locations of this fall: Resident Room, Time of this fall: (Left blank)...what was resident trying to do? Transfer on own...Unwitnessed fall...What recommendations/interventions were put in place at time of fall? Pressure alarm to bed and chair...." A Falls Investigation Worksheet, dated 10/4/14, included: "...Behavior at the time of this fall: Restless...(increased) confusion R/T (related to) UTI (urinary tract infection), Number of Falls in the past 31-180 days: ?, Location of this fall? Resident Room, Time of this fall: 2030 (8:30 P.M.)...What were the recommendations/interventions in place at the time of the fall? Walker, pressure alarm to bed and wheelchair. What recommendations/interventions were put in place at time of fall? Toileting schedule. Conclusion...Resident attempting to transfer self to toilet." A Falls Investigation Worksheet, dated 10/11/14, included: "...Number of Falls in the past 31-180 days (a check mark was documented), Location of this fall: Resident Room, Time of this fall: 1637 (4:37 P.M.)...what was resident attempting to do? pick up papers...require supervision? Yes; Resident at nurses station; not to be left in room while up in w/c (wheelchair)...Was the resident injured? No...What were the recommendations/interventions in place at the time of the fall? Pressure alarm to bed and chair...Encourage resident to use call light when assistance is needed. What recommendations/interventions were put in place at time of fall? Resident taken to nurses station. Resident is not to be left in room when up in wheelchair. Conclusion...Resident found on floor on left side in front of wheelchair. Resident stated that she was 'trying to get papers on table.'" On 11/18/14 at 2:30 P.M., the Administrator provided an "Investigation of Skin Tear, Bruises, and Abrasions," undated and signed by the current Director of Nursing. The Administrator indicated the current DON was not the DON during this incident. The document was unsigned by the Administrator. The Investigation indicated, "Exact location of area: Rt (right) (sic) foot cross top of foot...bruise Rt foot...Resident reports when staff brought lunch they rolled her bedside table over her foot. Most likely cause: bruise. Staff Interviews conducted? No. New Intervention implemented, encourage resident to eat at table in room. Reported to Department of Health? No...." On 11/18/14 at 2:40 P.M., during an interview with the Skilled Unit Manager, she indicated she was "working the floor" on 9/28/14. She indicated she had to "rack my brain" to remember what happened to Resident D's foot. She indicated "from what she could remember," the resident complained to her that they ran over her foot with a cart or bedside table or something." She indicated she took off the resident's sock, and noticed bruising over the top of her toes. She indicated she did not know who the staff might have been who caused the bruising. At that time, the Rehab Unit Manager indicated Resident D "would try to get up by herself, so we moved her closer to the nurses station." On 11/18/14 at 3:00 P.M., the Administrator indicated staff had spoken to the nurses who filled out the incident sheets regarding the falls on 10/4/14 and 10/11/14. She indicated LPN # 1, who was working on 10/4/14, thought she remembered the resident's alarm sounding. She indicated RN # 2, who was working on 10/11/14, could not remember if an alarm was sounding or not. 2. On 11/19/14 at 1:30 P.M., the Administrator provided the current facility policy on "Fall Evaluation and Investigation," revised 8/2013. The policy included: "Purpose: 1. To detect root cause of falls to extent possible and to identify supportive aides to prevent falls. 2. To identify high-risk residents and implement interventions to reduce falls and the consequences of falls..." This Federal tag relates to Complaint IN 903. 3.1-45(a)(1) 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure a cognitively impaired resident was supervised while outdoors unattended, resulting in a fall with multiple skin tears, laceration, and a pelvic fracture, for 1 of 3 residents reviewed for falls, in a sample of 3. Resident A Findings include: 1. On 8/7/14 at 9:25 A.M., during the initial tour, RN # 1 indicated Resident A had fallen recently in the courtyard. RN # 1 indicated no staff was with the resident when she fell . The clinical record of Resident A was reviewed on 8/7/14 at 10:40 A.M. [DIAGNOSES REDACTED]. A resident care plan, dated 2/17/14, indicated: "The resident is at risk for falls r/t (related to) Vision/hearing problems, Gait/balance problems...Interventions: The resident needs a safe environment...Follow facility fall protocol...Ensure appropriate footwear." An additional resident care plan, dated 2/17/14, indicated: "The resident has impaired cognitive function or impaired thought processes r/t short term memory loss, Dementia...Interventions: Communicate with family regarding residents (sic) capabilities and needs...Keep routine consistent...." A Fall Risk Evaluation, dated 5/17/14, included: "Intermittent confusion, 1-2 falls in past 3 months, Vision Status Adequate...." The resident's score rate was documented as "13.0," and Category of fall risk was "High." A Minimum Data Set (MDS) assessment, dated 5/21/14, indicated the resident had a cognitive score of 6, with 15 indicating no memory impairment. The MDS assessment indicated the resident required extensive assistance of one staff for transfer and ambulation. A test for "Balance During Transitions and Walking" indicated, "Not steady, only able to stabilize with staff assistance." The assessment indicated the resident had fallen one time since the previous assessment. Nursing Progress Notes included the following notations: 6/30/14 at 4:43 P.M.: "Resident found outside, face down on concrete, unattended. Resident had a new skin tear to her left forearm and her forehead. Resident sent to (name of hospital) via ambulalance...." An emergency room history and physical, dated 6/30/14 at 6:00 P.M., indicated: "[AGE] year old female presents to the Emergency Department (ED) from (name of facility) post fall. Patients (sic) daughter states that patient fell out of wheelchair on concrete on the patio at nursing home 1.5 hours prior to arrival...Patient complains of pain to her head, and has a hematoma and laceration to right eye. Patient presents to ED with skin tears to her right knee, left forearm, and right eye. Patient has (prior medical history) of dementia...Physical Exam...2 cm (centimeter) skin tear on right patella (knee); 11 cm skin tear over the ...forearm; 2.9 cm laceration skin tear above right eye; black eye and abrasion to right orbital...Pertinent Results, X-Ray Pelvis...Possible fracture right superior pubic ramus...Procedures...Location above right orbital, Length (cm) 2.9...wound closed with wound adhesive...." The hospital Patient Discharge Disposition document indicated: "Diagnosis, Contusion of head, Fall on same level from slipping...Gait disturbance, Multiple skin tears, Laceration of face, Abnormal x-ray of pelvis." Nursing Progress Notes continued: 6/30/14 at 9:00 P.M.: "Resident returned to facility per car, family with her...skin tear to right eye brow - 3.0 x 0.1, skin tear right knee 2.3 x 0.1 with abrasion, skin tear left forearm 8.1 x 0.1...will monitor." 7/1/14 at 2:44 P.M.: Received call from triage that pelvic xray shows possible fracture. Triage in (sic) scheduling CT scan...." A CT pelvis report, dated 7/2/14, indicated, "Nondisplaced fracture right paramidline pubic ramus." On 8/7/14 at 1:20 P.M., during an interview with the Director of Nursing (DON), she indicated her investigation into the incident with Resident A on 6/30/14 revealed CNA # 1, who was on light duty, took the resident outside and left her unattended at approximately 1:40 P.M. CNA # 1 visually checked on the resident at 1:50 P.M., and then went off-duty at 2:00 P.M. CNA # 1 informed the DON that she was given permission by LPN # 1 to take the resident outside. At approximately 2:45 P.M., a housekeeper observed the resident outside lying on the ground, and notified the nurse. The DON indicated she terminated both CNA # 1 and LPN # 1. The DON indicated there was a policy in place regarding leaving residents outside unattended, but that the resident would not have been eligible anyway due to her impaired cognition, unsteady gait, and blindness. The DON indicated that CNA # 1 should have stayed with the resident. On 8/7/14 at 2:00 P.M., the DON provided statements from staff regarding Resident A. A statement written by CNA # 1 indicated, "On June 30th 2014 around 1:15 I was aproched (sic) by (name) asking me to sit with the residents that were in the dining room finishing up. While sitting there I noticed that (Resident A) was walking and looked as if she was gonna fall. I got her wheelchair and she sat down in it. She stated that she wanted to go outside. I had never took care of (Resident A) and was not sure if she could sit out there by herself. I then pushed her to the nurses station. I asked (LPN # 1) if she was her nurse. (LPN # 1) stated yes and it was okay for her to sit outside it was around 1:25 pm that I took her outside. Around 1:50 I checked on her and she was fine...." An additional statement, written by the DON, indicated: "On the evening of June 30th, I ask (sic) (LPN # 1) who had taken (Resident A) out in the courtyard. (LPN # 1) stated that she did not know (Resident A) was in the courtyard until (housekeeper # 1) had reported it to her. (LPN # 1) left duty without completing an incident report or completing a statement of incident...On the morning of July 1, 2014, I requested a statement of the incident from (LPN # 1). She at that time informed me that she was not sure but thought that she may have mistakenly thought that (CNA # 1) was referring to another resident...No written statement provided. (LPN # 1 was terminated July 1, 2014." On 8/7/14 at 2:50 P.M., housekeeper # 1 was interviewed. She indicated she was taking her break on 6/30/14 from 2:30 P.M. until 3:00 P.M. She indicated she was unsure what time she looked outside, but "it was probably closer to 3." She indicated she saw Resident A lying face down on the concrete, with her wheelchair behind her. She indicated she immediately ran outside, and the resident was yelling, "Help, help." She indicated, "It was hot out that day." She indicated she then notified a nurse. According to the National Weather Service, on 6/30/14 at 1:54 P.M., it was 90 degrees; at 2:54 P.M., it was 91 degrees. 2. On 8/8/14 at 9:45 A.M., the Director of Nursing provided documentation of inservices that she gave to the nursing staff on 6/30/14 and 7/1/14. An In-Service Training Record indicated, "Subject/Topic: Residents are not to be left unattended in the courtyard." An additional In-Service Training Record indicated, "Protocol for Residents Going Outside." The protocol for "Residents Going Outdoors at the Facility Unattended," dated 6/29/09, included: "Residents requesting to go outdoors unattended must have the following criteria completed: 1. Cognitive status should be assessed. MDS section...Short Term Memory and ...Daily Decision Making Skills should not be impaired nor should the resident have a [DIAGNOSES REDACTED]. 2. Resident and responsible party should be informed of potential negative outcomes of being outdoors unsupervised including falls, injury, lack of immediate medical attention should it be needed etc. (This should be documented in the resident's clinical record). 3. A physician's orders [REDACTED]. protocol was a "Consent/Waiver To Go Outdoors Unsupervised" which included: "I have been informed of the potential negative outcomes of being outdoors unsupervised such as, but not limited to: Heat and Cold Exposure, Sunburn, Risk of Falling, Injury, Lack of Immediate Medical Attention Should it be Needed...." This Federal tag relates to Complaint IN 039. 3.1-45(a)(2)

Based on interview and record review, the facility failed to use a gait belt during the transfer of a resident, or the assistance of two staff as care planned, resulting in a skin tear which developed into a skin laceration requiring sutures, for 1 of 3 residents reviewed who required assistance with transfers, in a sample of 7. (Resident D) Findings include: 1. On 3/13/14 at 10:00 A.M., the Administrator provided an Indiana State Department of Health (ISDH) Incident Report Form. The form included: "...Resident hit right arm on wheelchair and opened area measuring 17 cm x 3 cm x 3 cm...Follow up added 2/27/14 Investigation reveals that resident obtained laceration to right arm during transfer. Resident stated she bumped her arm on her wheelchair...." The Administrator indicated at that time that she reported the incident to the ISDH due to the size of the laceration. The closed clinical record of Resident D was reviewed on 3/13/14 at 10:15 A.M. The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment, dated 1/28/14, indicated the resident required extensive assistance of two+ staff for transfer ("how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position"). A care plan, dated 2/3/14, indicated: "Focus: (Resident D) has an ADL (activities of daily living) Self Care Performance Deficit r/t (related to) weakness, incontinence at times, requires assistance with her ADL's." The Interventions included: "Transfer: (Resident D) required 2 staff participation." A computerized listing of "Activities of Daily Living" transfers indicated the resident required extensive assist of two staff from 1/28/14 until 2/18/14. Progress Notes included the following notations: 2/18/14 at 8:30 P.M.: "...Needs extensive assistance of two staff for transfers. Needs extensive assist of two for ambulation. Needs extensive assistance of two staff for bed mobility...Has edema lower extremity...Resident complains of weakness...." A Physical Therapy Recertification & Updated Plan of Treatment, dated 2/18/14, indicated: "...LTG (long term goal), Patient will transfer sit<>stand and stand pivot with min A (minimal assistance) with AD and cues for safe technique in order to facilitate increased independence with ADLs and prepare for gait Baseline (2/18/2014) mod A x 2 with 100% v/c's (verbal cues)." Progress Notes continued: 2/19/14 at 8:30 P.M.: "...Needs extensive assistance of one staff for transfers...." An Occupational Therapy Treatment Encounter note, dated 2/20/14, included: "Mod A transfers to and from toilet with use of grab bars...." Progress Notes continued: 2/22/14 at 8:08 A.M.: "Called to resident's room by CNA stating resident had bumped arm on wheelchair and obtained a skin tear. Upon exam found a laceration measuring 17 cm x 3 cm x 3 cm. Wrapped arm in towel and called physician (name). Orders received to send to emergency room for evaluation. Family and on call nurse notified." A hospital emergency room note, dated 2/22/14 at 8:33 A.M., indicated: "...presents to the Emergency Department by EMS (emergency medical services) from a nursing home with complains (sic) of skin tear to right arm...the nursing home reported to EMS that patient hit her arm on the wheel of a wheelchair and cut it open. Patient states that she fell but is unable to tell us information about the fall...Patient has dressings on bilateral legs for old ulcers. Patient had edema in bilateral legs...Physical Exam: Laceration to right forearm that extends 18 cm...Procedures: Repair nylon, Skin # (Nylon) 15...actively bleeding...." A hospital history and physical, dated 2/22/14, indicated: "The patient sustained a right forearm laceration in a nursing home...apparently sustained a large right arm laceration as it got caught in a wheelchair and was brought into the ER. Her laceration was sutured up...." On 3/13/14 at 11:00 A.M., during interview with CNA # 1, she indicated she had transferred Resident D from the bed to the wheelchair. She indicated the resident was a "1 person assist." CNA # 1 indicated she did not use a gait belt during the transfer, and demonstrated how she wrapped her arms around the resident's waist. CNA # 1 indicated she noted a small skin tear on the resident's arm, and went and told the nurse. CNA # 1 indicated when she returned with the nurse, the skin tear was "all the way up her arm." On 3/14/14 at 9:25 A.M., during interview with LPN # 1, she indicated CNA # 1 came and got her and told her Resident D had a skin tear. LPN # 1 indicated when she saw the resident, "it looked like her arm had just split open." LPN # 1 indicated the resident's skin was "real fragile." LPN # 1 indicated the resident was confused at times, but was usually alert. LPN # 1 indicated the resident was able to stand and pivot with one assist sometimes. On 3/14/14 at 1:40 P.M., during interview with PTA # 1, she indicated the staff was "always supposed to use a gait belt during transfers." 2. On 3/14/14 at 2:10 P.M., the Director of Nursing provided the current facility policy on "Resident Handling Policy," undated. The policy included: "Gait belt usage is mandatory for all resident handling with the exception of bed mobility & medical contraindications. The gait belt will be readily available for use...." This Federal tag relates to Complaint IN 071. 3.1-45(a)(2)

Based on observation, interview and record review, the facility failed to provide necessary care and services following a fall with a head injury, in that the assessment was incomplete, resulting in hospitalization for [MEDICAL CONDITION], for 1 of 5 residents sampled for post-fall assessments, in a sample of 14. Resident A Findings include: 1. The clinical record of Resident A was reviewed on 8/8/13 at 11:50 A.M. The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment, dated 6/7/13, indicated Resident A had no memory impairment. Progress Notes, dated 6/13/13 at 11:32 P.M., indicated, "...Resident is alert. Oriented to person. Oriented to place...Speech is clear. Gait is steady...." An Occupational Therapy note, dated 6/14/13, indicated, "Rehab Potential:...Patient demonstrates excellent rehab potential as evidenced by high PLOF (previous level of function), recent onset, low number of comorbidities, good cognition...." A Speech Therapy note, dated 6/14/13, indicated, "...Patient continues with dysphagia (difficulty swallowing) and cognitive-linguistic deficits...Patient demonstrates excellent rehab potential as evidenced by high PLOF, attentive to tasks, and positive results from previous therapy...." Progress Notes, dated 6/14/13 at 7:30 P.M.: "Late Entry...Time of fall; location of fall; vital signs: 1930 (7:30 P.M.) room...Description of fall: on floor sitting verbalized walking across floor to doorway. Range of motion; mental status neurochecks if unwitnessed or hit head...alert and oriented neuro checks within normal limits for this resident small raised area on back of head...Immediate interventions: checked for injuries small raised area to back of head neuro checks done and ok assisted with 2 staff back to chair...." A "Neurochecks" document, dated 6/14/13 at 7:30 P.M., included: "...Most Recent Temperature 6/14/13, 13:35 (1:35 P.M.) Most Recent Pulse 6/14/13, 13:36 (1:36 P.M.) Most Recent Respiration 6/14/13, 13:36...Pupils round, Yes both pupils...Grip equal bilaterally? Yes...1 hour... Most Recent Blood Pressure 118/60, Date: 6/14/13, 13:38 (1:38 P.M.)...." The last assessment signed, dated 6/14/13 at 11:30 P.M. indicated: "Most Recent Blood Pressure 120/60, 6/14/13 , 13:47 (1:47 P.M.) Most Recent Pulse, Date 6/14/13, 13:48 (1:48 P.M.)...." The Comments sections were left blank on all of the assessments. The electronic record indicated the neuro checks were signed as completed for the initial assessment and following 4 hours, but the documentation indicated the vital signs were not reassessed. The electronic documentation regarding hand grips and pupils was the same as in the initial neuro check assessment. Progress Notes continued: 6/16/13 at 6:32 P.M.: "...Resident is alert...Speech is unclear. Has impaired balance while standing...." 6/17/13 at 11:26 A.M.: "Resident having noted periods of slurred speech and stuttering at times this morning. Also noted to have some jerking movements with right upper extremity at times. Resident states that she had fell and hit her head and noticed yesterday her speech being slurred...Call placed to triage and notified of new symptoms...." The resident was transferred to the hospital on [DATE] at 12:20 P.M. A hospital history and physical, dated 6/19/13, included: "...came to the emergency room with a short episode, probably just a few seconds of slurred speech and right arm tremor...She then reported on Friday, four days ago, taking a fall at the nursing home hitting the back of her head against the ground. Since then she has had episodes where her speech is slurred and involved the motions of her right arm and she will grab her right arm with her left to try and control the movement...The patient is now admitted to the hospital for neurologic evaluation...." On 8/8/13 at 12:45 P.M., during interview with Resident A, she indicated, "I was here for therapy, and was just about ready to go home. I had my walker and tripped in the doorway and hit my head on this hard floor. I've been having [MEDICAL CONDITION] ever since." During the interview, Resident A was observed to start to have disjointed slurred speech every few minutes, would take a couple of deep breaths, and then have normal speech. Resident A indicated, "It's so frustrating. Therapy told me when my speech becomes slurred to just take a couple of breaths." On 8/9/13 at 8:15 A.M., during interview with the Administrator, Director of Nursing (DON), and nurse consultant, the nurse consultant indicated the neuro checks "should have been done." 2. On 8/9/13 at 9:40 A.M., the Administrator provided the current facility policy on "Fall Evaluation Policy," revised 1/2012. The policy included: "...When you find a resident that has fallen...Conduct physical and mental evaluation...Note level of consciousness and perform neuro checks if head injury suspected or fall is unwitnessed...." On 8/9/13 at 2:15 P.M., the Director of Nursing provided a "Neuro Check Completion Checklist," undated. The checklist included: "...Neurochecks will include at a minimum: vital signs, change in LOC (level of consciousness), Mental Status change, PERLA (pupils equal reactive to light assessment), and hand grip strength." The Director of Nursing then conferred with her consultant, who then indicated neuro checks are to completed every hour x 4, then every 2 hours x 4, then every 4 hours x 5, and then every 8 hours x 5. This Federal tag relates to Complaint IN 703. 3.1-37(a)

Based on interview and record review, the facility failed to ensure a resident with a multiple fall history had supervision to prevent falls, in that alarms were used in place of supervision, resulting in a fall in which the resident obtained T1 and T4 thoracic fractures, for 1 of 5 residents sampled with falls, in a sample of 14. Resident B Findings include: 1. The closed clinical record of Resident B was reviewed on 8/8/13 at 3:30 P.M. The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Fall Risk Evaluation, dated 4/11/13, indicated the resident had intermittent confusion, had a history of [REDACTED]. Progress Notes included the following notations: 4/11/13 at 10:42 P.M.: "...Alert but confused. Lying across bed a lot. Alarms in place bed/chair/floor...Fracture to right hip...." 4/13/13 at 12:10 A.M.: "Patient sitting on floor on buttocks. No injuries noted. See report." Fall # 1. Documentation of further information regarding the fall, including if an alarm was present and/or sounding, was not found in the clinical record. A Care Plan, dated 4/15/13, indicated: "Potential for falls related to: History of falls, confusion." The Interventions included: "Bed pad alarm, Chair pad alarm, 5/15/13 Dysom in wheelchair seat...5/9/13 Low bed with mat(s) on floor...5/11/13 Offer to assist resident to bed after dinner." A Minimum Data Set (MDS) assessment, dated 4/18/13, indicated the resident scored a 6 out of 15 for cognition, with 15 indicating no memory impairment. The MDS assessment indicated Resident A required extensive assistance of two + staff for bed mobility, transfer, and walking in the room and corridor. A test for balance indicated "Not steady, only able to stabilize with staff assistance." The MDS assessment indicated the resident had fallen in the 1 month prior to admission, and had sustained a fracture from a fall in the 6 months prior to admission. A Physical Therapy Progress Note, dated 5/1/13, indicated, "...Pt (patient) with significantly increased confusion and increased difficulty following directions over the past week with noted increase in agitation...Pt with decline in functional status...Precautions: R (right) hip precautions; fall risk...." Progress Notes continued: 5/8/13 at 8:00 P.M.: "(Ambulance) transferred patient to (hospital) at this time. 5/8/13 at 10:00 P.M.: "Attempted to call (physician) three times regarding patients (sic) fall...." 5/9/13 at 1:21 A.M.: "Resident returned from (hospital)...stated that resident had Xray of right hip and hip is still in place. No new orders at this time...Fall mat and alarms in place and functioning. Neuro checks and fall follow up resumed at this time...." 5/9/13 at 4:29 P.M.: "Post fall note, Vital Signs...Any blood noted/location: none noted...Resident can perform active range of motion with upper extremities and left lower extremities with no complaints of pain. Complaints of pain?: right hip, aching 4/10...." Fall # 2. Documentaion of a fall on 5/8 or 5/9 was not found in the clinical record. Progress Notes continued: 5/11/13 at 7:04 P.M.: "Time of fall; location of fall; vital signs: Resident room @ 1855 (6:55 P.M.)...Description of fall: (left blank)...Pain to right hip/leg...Xray of right hip/pelvis ordered. Moved to bed. To be assisted to bed after dinner...." Fall # 3. Further documentation regarding the fall, including if alarms were on and/or sounding, was not found in the clinical record. 5/13/13 at 2:44 P.M.: "IDT (interdisciplinary team) Note...Resident not to be left unattended when up in wheelchair in room. Resident to have rest periods during the day to prevent being so tired and to allow additional comfort for leg...." 5/18/13 at 6:00 P.M.: "...Description of fall: Called to room by CNA who was alerted to residents (sic) room by alarm going off. Resident noted sitting upright on floor in front of wheelchair inside entrance of room. Resident states 'she was turning her wheelchair around and slid out of wheelchair.'...Resident assessed...no apparent injury noted...Resident assisted back into wheelchair per staff x 3 using gait belt and then to bed. Alarm reapplied and is functioning. Dysom applied to resident's wheelchair seat...." Fall # 4. 5/20/13 at 1:27 P.M.: "Educated staff that resident is to be in view at all times while up in wheelchair. Note posted in room and placed on CNA flow sheet." 6/15/13 at 12:49 A.M.: "On floor sitting had turned alarm off and said she was going to the bathroom did not use call bell no injuries." Fall # 5. 6/24/13 at 7:00 P.M.: "...Resident lying on floor...Staff heard alarm sounding and noted resident lying on floor. Resident complain of (sic) chest pain...Informed resident to use call light when in need of assistance." Fall # 6. The resident was transferred to the hospital on [DATE] due to further complaints of chest pain. A hospital discharge summary, dated 6/28/13, included: "Final Diagnoses: [REDACTED]." On 8/9/13 at 8:15 A.M., during interview with the Director of Nursing (DON), she indicated she was not employed at the facility at the time of this resident's falls. She indicated she was unable to find additional documentaion regarding the falls. On 8/13/13 at 3:30 P.M., the corporate nurse provided incident reports related to the falls. She indicated the incident reports were not a part of the clinical record. The incident reports included the following information: "4/13/13 at 17:30 (5:30 P.M.), Revision Date: 4/29/13 at 15:44 (3:44 P.M.)...Patient was trying to transfer self..." The report did not indicate where the resident was located or if an alarm was on and/or sounding. "5/8/13 at 22:37 (10:37 P.M.), Revision Date: 5/13/13...Alarm going off. Found patient on floor on back. Had been trying to transfer self...Checked patient. Called (ambulance) and kept patient on floor due to recent hip relocation on 5/7/13...Complaining of back and right hip pain...." "6/15/13 at 00:40 (12:40 A.M.), Revision Date: 7/30/13...Sitting on floor no injuries resident had turned off her alarm, verbalized she was going to the bathroom...Confused at times...." Additional information regarding the fall on 6/24/13 was not provided by survey exit on 8/13/13 at 3:40 P.M. 2. On 8/9/13 at 9:40 A.M., the Administrator provided the current facility policy on "Fall Evaluation Policy," revised 1/2012. The policy included: "Purpose: 1. To detect root cause of falls to extent possible and to identify supposrtive aides to prevent falls. 2. To identify high-risk residents and institute interventions to reduce falls and the consequences of falls. Policy: 1. A Fall Risk Evaluation will be completed on each resident: a. On Admission b. Quarterly c. When a Significant Change Occurs...2. Any resident scoring a '10' or above on the Fall Risk Evaluation will have a fall care plan developed by the Interdisciplinary Team...." On 8/13/13 at 11:40 A.M., the Director of Nursing indicated the facility did not have a further policy regarding fall prevention. This Federal tag relates to Complaint IN 642 and Complaint IN 703. 3.1-45(a)(1)