Every finding on record at Heritage Pointe of Huntington

Based on observation, interview, and record review, the facility failed to protect a resident's right to be treated with respect and dignity when being assisted with dining when a CNA aggressively offered food to a resident for 1 of 3 residents reviewed for dignity with dining. (Resident B)Findings include:An anonymous intake report submitted to the Indiana Department of Health indicated CNA 5 was being forceful while feeding Resident B during a lunch meal service on 7/26/26.Resident B's clinical record was reviewed on 8/6/26 at 9:53 a.m. Diagnoses included Alzheimer's disease, dementia, and depression.A 5/1/26, quarterly, Minimum Data Set (MDS) assessment indicated Resident B was moderately cognitively impaired.Resident B's current care plan, revised on 2/5/26, included the following: Resident has the diagnoses of Alzheimer's disease and dementia without behavioral disturbance and currently managed by Aricept (medication used to treat dementia associated with Alzheimer's disease). Interventions include: if resident is restless or agitated, re-approach later. Provide visual cues, verbal prompts and demonstration. Talk with Resident while assisting them with care. Interventions include: encourage fluids. Resident B has shortness of breath due to history of COVID-19. Interventions include: monitor breathing abnormalities, breathing patterns, and pursed lip breathing.On 8/6/26 at 11:24 a.m., Resident B was sitting in the therapeutic dining room, wearing a clothing protector. She was drinking orange juice from a lidded cup with a straw. At 11:44 a.m., Resident B's meal was delivered to her. She retrieved a bowl and began eating her mashed potatoes and gravy before stopping. She tried some cake and stopped eating. Resident B indicated she was done eating. During a review of facility video footage from 7/26/26, observed on 8/6/26 at 10:39 a.m., with the Administrator and DON present, the following was observed:At 11:36 a.m., CNA 5 sat on Resident B's left side and moved Resident B's drinks across the table, out of Resident B's reach. CNA 5 was observed forcefully placing a spoonful of food into Resident B's mouth while Resident B head was tilted backward with her chin pointed upward. Resident B turned her head to the right as CNA 5 placed another spoonful of food into Resident B's mouth. Resident B put up her hand to block CNA 5's hand with a spoonful of food.As of 11:40 a.m., drinks had not been offered to Resident B.During the observation, Resident B repeatedly jerked her head backward and away from CNA 5. CNA 5 continued placing spoonfuls of food into Resident B's mouth as Resident B moved her head from side to side. Resident B again tilted her head backward.At 11:44 a.m., CNA 5 moved drinks back in front of Resident B as Resident B reached for a drink. CNA 5 again moved drinks out of Resident B's reach.At 11:45 a.m., Resident B turned her head away as CNA 5 placed another spoonful of food into Resident B's mouth.At 11:47 a.m., Resident B's head remained tilted backward as CNA 5 provided a drink. Resident B continued moving her head side to side as CNA 5 placed another spoonful of food into Resident B's mouth.During an interview, on 8/6/26 at 11:58 a.m., Nurse Aide in Training (NA) 4 indicated CNA 5 had been mean and aggressive during a previous lunch meal with Resident B. CNA 5 forced spoonfuls of food into Resident B's mouth after Resident B indicated she was done eating.During an interview, on 8/6/26 at 12:34 p.m., the Administrator indicated CNA 5 should have engaged more with Resident B. LPN 6 reported to the DON via text message, on 7/26/26, that CNA 5 was not feeding Resident B appropriately.During an interview, on 8/6/26 at 12:45 p.m., LPN 6 indicated CNA 7 and NA 8 notified her, on 7/26/26, that CNA 5 placed spoonfuls of food into Resident B's mouth while Resident B's head was tilted completely backwards. It had been reported that Resident B had stated, I just want to drink, and CNA 5 responded, No, you don't need to drink, you need to eat. LPN 6 sent a text message to the DON, on 7/26/26 at 1:05 p.m., informing her of the allegation. The DON requested reports of concern be completed by CNA 7 and NA 8 during the exchange of messages. During an interview, on 8/6/26 at 1:16 p.m., CNA 9 indicated CNA 5 had been aggressive while feeding Resident B and continued feeding Resident B even when Resident B turned her head to the side or tilted her head backward.During an interview, on 8/6/26 at 2:16 p.m., CNA 7 indicated CNA 5 did not allow Resident B to have any drinks until she was finished eating. Resident B stuck her tongue out to keep CNA 5 from placing food into her mouth. Resident B had her head tilted back and CNA 5 continued to place food into Resident B's mouth. CNA 5 stated she was sick of this while Resident B was visibly upset.During an interview, on 8/6/26 at 2:37 p.m., CNA 5 indicated she encouraged Resident B to eat food. She placed Resident B's drinks at the top of Resident B's placemat. Resident B was consistent in indicating when she didn't want any more food. Resident B would try to keep her mouth shut. CNA 5 gave Resident B a drink after each spoonful of food. If Resident B told staff more than once or twice that she was done, that was a good indicator Resident B did not want to eat any more food. She did not recall Resident B blocking her hand when trying to give Resident B food.During an interview, on 8/6/26 at 2:46 p.m., NA 8 indicated CNA 5 placed large spoonfuls of food into Resident B's mouth. CNA 5 shoved food into Resident B's mouth when Resident B was showing signs she didn't want to eat. CNA 5 shoved the spoon into Resident B's mouth so hard a clanking sound was heard when the spoon hit Resident B's teeth. At one point during the meal, Resident B tilted her head backward and CNA 5 laughed at Resident B. Resident B mainly wanted to drink water and not eat much food.During an interview, on 8/7/26 at 9:10 a.m., CNA 7 indicated CNA 5 aggressively fed Resident B. CNA 7 placed a report of concern under the DON's door the following morning.During an interview, on 8/7/26 at 9:20 a.m., CNA 10 indicated CNA 5 had forcefully fed Resident B. Resident B indicated she was done eating while CNA 5 continued to force Resident B to eat more food, causing Resident B to get sick.During an interview, on 8/7/26 at 9:33 a.m., the Administrator indicated she was unaware of the reports of concern until 8/6/26 at 11:50 p.m. After reviewing them, she felt the incident felt more abusive than improper feeding. Staff were trained to notify their immediate supervisor, who then notified the DON or ADON, who should then notify the Administrator.During an interview, on 8/7/26 at 11:03 a.m., the DON indicated she forwarded the text message from LPN 6 to the Administrator that same day. The Administrator instructed her to educate CNA 5 regarding resident rights. After reviewing the camera footage, the DON felt CNA 5 had rushed Resident B's feeding and continued feeding when Resident B appeared finished.During an interview, on 8/7/26 at 11:16 a.m., the ADON indicated that after viewing the video footage, CNA 5 appeared to be aggressively feeding Resident B. She believed the footage had been reviewed the week of 7/27/26 but was unsure of the exact date.A current undated facility policy, titled Feeding and Assisting Residents at Meals, provided by the Administrator, on 8/7/26 at 9:15 a.m., indicated the following: .1. All staff members involved in providing feeding assistance to residents promote and maintain resident dignity during mealtimes. 5. Resident requests will be honored during meals to the extent possible. 10. Allow adequate time for residents to complete meal. Do not rush.410 Indiana Administrative Code (IAC) 16.2-3.1-3(t)This citation relates to Intake 3122576.

Based on interview, observation and record review, the facility failed to ensure an allegation of suspected abuse was reported immediately to the Administrator and the Indiana Department of Health (IDOH) for 1 of 3 residents reviewed for abuse (Resident B)Findings include:An anonymous intake report submitted to the Indiana Department of Health indicated CNA 5 had been forceful while feeding Resident B during a lunch meal service on 7/26/26.Resident B's clinical record was reviewed on 8/6/26 at 9:53 a.m. Diagnoses included Alzheimer's disease, dementia, and depression.A 5/1/26, quarterly, Minimum Data Set (MDS) assessment indicated Resident B was moderately cognitively impaired.During a review of facility video footage from 7/26/26, observed on 8/6/26 at 10:39 a.m., with the Administrator and DON present, the following was observed:At 11:36 a.m., CNA 5 sat on Resident B's left side and moved Resident B's drinks across the table, out of Resident B's reach. CNA 5 was observed forcefully placing a spoonful of food into Resident B's mouth while Resident B's head was tilted backward with her chin pointed upward. Resident B turned her head to the right as CNA 5 placed another spoonful of food into Resident B's mouth.During the observation, Resident B repeatedly jerked her head backward and away from CNA 5. CNA 5 continued placing spoonfuls of food into Resident B's mouth as Resident B moved her head from side to side. Resident B again tilted her head backward.During an interview, on 8/6/26 at 11:58 a.m., Nurse Aide in Training (NA) 4 indicated CNA 5 had been mean and aggressive during a previous lunch meal with Resident B. CNA 5 forced spoonfuls of food into Resident B's mouth after Resident B indicated she was done eating.During an interview, on 8/6/26 at 12:45 p.m., LPN 6 indicated CNA 7 and NA 8 notified her, on 7/26/26, that CNA 5 placed spoonfuls of food into Resident B's mouth while Resident B's head was tilted completely backwards. Resident B had stated, I just want to drink, and CNA 5 responded, No, you don't need to drink, you need to eat. LPN 6 sent a text message to the DON, on 7/26/26 at 1:05 p.m., informing her of the situation. The DON requested reports of concern be completed by CNA 7 and NA 8 during the exchange of messages. During an interview, on 8/6/26 at 1:16 p.m., CNA 9 indicated CNA 5 had been aggressive while feeding Resident B and continued feeding Resident B even when Resident B turned her head to the side or tilted her head backward.During an interview, on 8/7/26 at 9:10 a.m., CNA 7 indicated CNA 5 aggressively fed Resident B. CNA 7 placed her report of concern under the DON's door the following morning.During an interview, on 8/7/26 at 9:33 a.m., the Administrator indicated she was unaware of the reports of concern until 8/6/26 at 11:50 p.m. After reviewing them, she felt the incident seemed more abusive than improper feeding. Staff were trained to notify their immediate supervisor, who then notified the DON or ADON, who then notified the Administrator. The DON reviewed the camera footage the Monday following the occurrence. During an interview, on 8/7/26 at 11:03 a.m., the DON indicated she forwarded the text message from LPN 6 to the Administrator that same day, who instructed her to educate CNA 5 regarding resident rights. After reviewing the camera footage, the DON felt CNA 5 had rushed Resident B's feeding and continued feeding when Resident B appeared finished.During an interview, on 8/7/26 at 11:16 a.m., the ADON indicated that after viewing the video footage, CNA 5 appeared to be aggressively feeding Resident B. She believed the footage had been reviewed the week of 7/27/26 but was unsure of the exact date.During an interview, on 8/7/26 at 12:20 p.m., the DON indicated, after rereading the reports of concern, she should have started an abuse investigation and notified the Indiana Department of Health regarding the allegation.A current facility policy, dated 11/25, titled Abuse/Neglect/Exploitation Reporting, provided by the Administrator, on 8/7/26 at 9:15 a.m., indicated the following: . The Administrator or designee will: A. Notify the appropriate agencies immediately, as soon as possible, but no later than 24 hours after discovery of the incident. B. obtain statement from direct care staff. C. Suspend the accused employee pending completion of the investigation. D. Follow up with appropriate agencies, during business hours, to confirm the report was received Cross reference F550.410 Indiana Administrative Code (IAC) 16.2-3.1-28(c)This citation relates to Intake 3122576.

Based on interview and record review, the facility failed to initiate an investigation for an allegation of suspected staff to resident abuse and failed to implement the facility policy to protect residents following an allegation of suspected abuse for 1 of 3 residents reviewed for abuse. (Resident B)Findings include:An anonymous intake report submitted to the Indiana Department of Health indicated CNA 5 had been forceful while feeding Resident B during a lunch meal service on 7/26/26.Resident B's clinical record was reviewed on 8/6/26 at 9:53 a.m. Diagnoses included Alzheimer's disease, dementia, and depression.A 5/1/26, quarterly, Minimum Data Set (MDS) assessment indicated Resident B was moderately cognitively impaired.During a review of facility video footage from 7/26/26, observed on 8/6/26 at 10:39 a.m., with the Administrator and DON present, the following was observed:At 11:36 a.m., CNA 5 sat on Resident B's left side and moved Resident B's drinks across the table, out of Resident B's reach. CNA 5 was observed forcefully placing a spoonful of food into Resident B's mouth while Resident B's head was tilted backward with her chin pointed upward. Resident B turned her head to the right as CNA 5 placed another spoonful of food into Resident B's mouth.During the observation, Resident B repeatedly jerked her head backward and away from CNA 5. CNA 5 continued placing spoonfuls of food into Resident B's mouth as Resident B moved her head from side to side. Resident B again tilted her head backward.During an interview, on 8/6/26 at 11:58 a.m., Nurse Aide in Training (NA) 4 indicated CNA 5 had been mean and aggressive during a previous lunch meal with Resident B. CNA 5 forced spoonfuls of food into Resident B's mouth after Resident B indicated she was done eating.During an interview, on 8/6/26 at 12:45 p.m., LPN 6 indicated CNA 7 and NA 8 notified her, on 7/26/26, that CNA 5 placed spoonfuls of food into Resident B's mouth while Resident B's head was tilted completely backwards. Resident B had stated, I just want to drink, and CNA 5 responded, No, you don't need to drink, you need to eat. LPN 6 sent a text message to the DON, on 7/26/26 at 1:05 p.m., informing her of the situation. The DON requested reports of concern be completed by CNA 7 and NA 8 during the exchange of messages. During an interview, on 8/7/26 at 9:10 a.m., CNA 7 indicated CNA 5 aggressively fed Resident B. CNA 7 placed her report of concern under the DON's door the following morning.During an interview, on 8/7/26 at 9:33 a.m., the Administrator indicated she was unaware of the reports of concern until 8/6/26 at 11:50 p.m. After reviewing them, she felt the incident seemed more abusive than improper feeding. Staff were trained to notify their immediate supervisor, who then notified the DON or ADON, who then notified the Administrator.During an interview, on 8/7/26 at 11:03 a.m., the DON indicated she forwarded the text message from LPN 6 to the Administrator that same day, who instructed her to educate CNA 5 regarding resident rights. After reviewing the camera footage, the DON felt CNA 5 had rushed Resident B's eating and continued feeding her when Resident B appeared finished.During an interview, on 8/7/26 at 12:20 p.m., the DON indicated, after rereading the reports of concern, she should have started an abuse investigation and notified the Indiana Department of Health regarding the allegation.A current facility policy, dated 11/25, titled Abuse/Neglect/Exploitation Reporting, provided by the Administrator, on 8/7/26 at 9:15 a.m., indicated the following: . The Administrator or designee will: . B. obtain statement from direct care staff. C. Suspend the accused employee pending completion of the investigation Cross reference F550.410 Indiana Administrative Code (IAC) 16.2-3.1-28(d)This citation relates to Intake 3122576.

Based on interview and record review, the facility failed to protect a resident's right to be free from mental abuse by a staff member when the staff member recorded a cognitively impaired resident with her personal cell phone while the resident was using the restroom and the staff member viewed the recording with others. (Resident B and CNA 3) Using the reasonable person concept, it can be determined Resident B would not expect to be video recorded while using the restroom in his home (the facility) and would experience psychosocial harm, dehumanization, and humiliation as a result of this mental abuse. Findings include:Review of a cell phone video recording, provided by the DON on 3/9/26 at 9:46 a.m., indicated the following:CNA 3 recorded a 14-second-long video. The video showed Resident B's uncovered upper left thigh while he was sitting on a toilet seat riser in the restroom. Resident B's face was not shown in the video. Resident B gripped CNA 3's left wrist with his left hand. CNA 3 proceeded to state Ow, ow, ow, ow. [NAME], let go of me. Stop. CNA 5 proceeded to remove Resident B's hand from CNA 3's wrist. Once CNA 3's wrist was freed, Resident B's left bare calf was shown before the video recording was stopped. CNA 3 and 5's faces were not shown in the video.During the video observation, the DON indicated CNA 4 notified her regarding the video recording. CNA 3 had shown CNA 4 and CNA 6 the video recording.During an interview, on 3/9/26 at 12:23 p.m., CNA 3 indicated she recorded a video of Resident B (in February 2026). Resident B kept trying to hit her. The resident was throwing a soiled brief at her and the resident just kept yelling at her. CNA 3 stated she took the video to have proof of what Resident B was doing to her. CNA 3 showed both CNA 4 and CNA 6 the video recording.During an interview, on 3/9/26 at 2:27 p.m., CNA 4 indicated CNA 3 showed both her and CNA 6 a video she took of Resident B during an incident (last month), while the resident was using the restroom. The video showed Resident B grabbing CNA 3's wrist. She did not know if the video was shown to anyone else.During an interview, on 3/10/26 at 9:50 a.m., Resident B's Representative 7 indicated Resident B would be very upset that someone recorded him in the bathroom.Review of staff statements, provided by the facility on 3/10/26 at 10:00 a.m., indicated the following:A written statement indicated that the DON received a text message at 2:25 p.m. CNA 4 informed her that CNA 3 had shown CNA 4 a video CNA 3 had taken of Resident B. CNA 4 indicated Resident B was called by his first name and CNA 5 was present in the video. The video was sent to the DON to review on 2/20/26 at 3:25 p.m. CNA 3 was interviewed and admitted to recording Resident B during care. Both CNA 3's and CNA 5's employment was terminated after reviewing the video.CNA 3's employee file was reviewed on 3/10/26 at 10:30 a.m. CNA 3 had abuse training on 9/20/25 and resident rights training on 9/22/25. CNA 5's employee file was reviewed on 3/10/26 at 10:45 a.m. CNA 5 had resident rights training on 9/25/25. During an interview, on 3/10/26 at 11:37 a.m., CNA 6 indicated CNA 3 had shown both her and CNA 4 a video recording of Resident B. The video showed Resident B using the restroom with two other CNAs present. CNA 3 showed them the video while at school. There was another girl at their table, but CNA 6 was unsure if she saw the video. CNA 3 was flashing her phone around while showing them the video of Resident B.During an interview, on 3/10/26 at 12:05 p.m., Resident B's Representative 8 indicated Resident B would have been offended and upset about the video recording. Resident B would not have liked the fact that someone recorded him while using the restroom.A facility self-reported incident, submitted to the Indiana Department of Health on 2/20/26 at 4:39 p.m., indicated CNA 3 recorded a resident during care and had shown other employees the video while off facility grounds.Resident B's clinical record was reviewed on 3/9/26 at 10:13 a.m. Diagnosis included dementia with mood disturbance, major depressive disorder, anxiety, restlessness with agitation, muscle weakness and unsteadiness on feet.Current orders included buspirone (antianxiety) 20 milligrams (mg) daily and sertraline (antidepressant) 75 mg daily.A 2/26/26, annual, Minimum Data Set (MDS) assessment indicated Resident B was cognitively impaired. Physical and verbal behavioral symptoms directed toward others occurred 1 to 3 days per week during the assessment period. Resident B required maximal staff assistance with toilet transfers. He was frequently incontinent with bowel and bladder.A current facility policy, undated, titled Employee Handbook policy Summary, provided by the Administrator, on 3/10/26 at 10:58 a.m., indicated the following: .Cell phones, tablets, iPads, smart watches, smart glasses, earbuds, headphones, or any similar personal portable electronic devices (PPEDs) may not be used in resident care areas . Employees are strictly prohibited from taking photographs or video recordings of residents or guests using any PPED or photographic device. This prohibition applies at all times under all circumstances A current facility policy, undated, titled Nursing Policy and Procedure. Dignity- Promoting/ Maintaining Resident Dignity provided by the Administrator, on 3/10/26 at 10:36 a.m., indicated the following: .All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights 410 IAC (Indiana Administrative Code) 16.2-3.1-3(t)This citation relates to Intake 2785417.

Based on observation, record review, and interview, the facility failed to ensure the physician was notified of dietary recommendations for a resident with weight loss for 1 of 6 residents reviewed for nutrition (Resident 41). Finding includes:Resident 41's clinical record was reviewed on 2/9/26 at 10:10 a.m. Diagnoses included protein-calorie malnutrition and dementia. Current orders included regular diet with a half peanut butter and jelly sandwich at lunch and supper, may offer finger foods (1/7/26) and weekly weight - notify physician for five-pound gain or loss (2/2/26). An admission Minimum Data Set (MDS) assessment, dated 1/9/26, indicated the resident was severely cognitively impaired. She required supervision/touching staff assistance with eating. A current care plan indicated the resident was at nutritional risk (revised 1/5/26). Interventions included diet/supplements as ordered (12/22/25). A dietician progress note, dated 2/3/26 at 4:25 p.m., indicated the resident had a weight loss of 4.4 pounds and a recommendation to add a high-calorie supplement shake at breakfast related to the weight losses. Review of Resident 41's recorded weights indicated the resident weighed 138.2 pounds on 12/22/25, 128 pounds on 2/1/26, and 126 pounds on 2/9/26.She had experienced an 8.83 percent weight loss over seven weeks. During an observation, on 2/11/26 at 8:09 a.m., Resident 41 sat in the assisted dining room eating breakfast. Her meal did not include a high-calorie supplement shake. During an interview, on 2/11/26 at the time of the observation, Restorative Aide 6 indicated the resident did not receive a high-calorie supplement shake today. Restorative Aide 5 assisted residents daily in the assist dining room and did not recall the resident receiving a supplement shake with her meals. The nurse passed out the supplement shakes. During an interview, on 2/11/26 at 8:16 a.m., LPN 7 indicated she did not see where Resident 41 was supposed to receive a high-calorie supplement shake. During an interview, on 2/11/26 at 8:18 a.m., the Staff Development Nurse indicated when the dietician made recommendations, they were emailed to the DON, the ADON, and herself. They looked at the dietician's recommendations and sent them to the physician. She was uncertain what had happened with the dietician's recommendation for high-calorie supplement shakes for Resident 41. During an interview, on 2/11/26 at 8:55 a.m., the ADON indicated she received emails from the dietician with her recommendations. She reviewed the recommendations and printed them off for the physician. When she had printed off the recommendations, for some reason, Resident 41's had not printed, so the order had not been given for the supplement shake. She indicated she had recognized that the resident had a 2-pound weight loss in the past week. A current, undated facility policy, provided by the Administrator on 2/11/26 at 4:59 p.m., titled Notification of Physician of Dietitian Recommendations, indicated the following: .It is the policy of this facility to notify the attending physician of all dietitian recommendations that require a change in the resident's diet, nutritional supplements, or plan of care.Nursing staff shall notify the attending physician of the dietitian's recommendations in a timely manner. 3.1-22(b)(1)

Based on interview and record review, a staff member failed to report a resident's allegation of abuse to the administrator for 1 of 1 residents reviewed for abuse (Resident 69) Finding includes:Resident 69's record was reviewed on 2/9/26 at 9:33 a.m. Diagnoses included macular degeneration, hearing loss unspecified ear, and insomnia. A quarterly Minimum Data Set (MDS) assessment, dated 11/13/25, indicated the resident was moderately cognitively impaired. A progress note, dated 1/12/26 at 5:11 a.m., indicated the resident woke up with a headache. She refused pain medication. She rubbed the top of her head and said it hurt when she rubbed her head. No injury was noted. The resident said she did not have any pain when she went to bed. She woke up with the pain. A progress note, dated 1/12/26 at 5:50 a.m., indicated the CNA told the nurse the resident had told her that she remembered what happened. The loud speaking NNN that was just in her room had been swinging something around and hit the resident in the head with it. The nurse went into the room at that time. The resident's eyes were closed and her mouth open. She did not open her eyes when her name was called. The nurse did not have anything in her hand when she spoke to the resident. The CNA told the nurse she was not swinging anything around. The nurse reported the incident to the oncoming nurse. The clinical record lacked additional information on the resident's allegation that someone had hit her with something. During an interview, on 2/10/26 at 3:44 p.m., QMA 9 indicated if a resident told her that someone had hit them or hit them with something she would report it immediately to her supervisor or charge nurse. She would report it even if the resident was confused because the resident's orientation did not matter if they said someone or something hit them. During an interview, on 2/10/26 at 3:46 p.m., CNA 10 indicated she would contact the Administrator right away if any resident said they were hit or hit with something. During an interview, on 2/10/26 at 3:50 p.m., LPN 11 indicated if a CNA told her a resident had said someone had hit them or something had hit them, she would immediately make sure the resident was safe, then follow up with the resident's story. She would notify the DON, the family, and the physician. During an interview, on 2/10/26 at 4:10 p.m., LPN 12 indicated if a resident had said they were hit by someone or by something she would first make sure they were safe and then report to the manager who handles the complaints like the ADON or the DON. During an interview, on 2/11/26 at 11:11 a.m., LPN 16 indicated if a CNA told her a resident said they were hit, she would talk to that resident and try to figure out who was involved in the situation, make sure the resident was safe, see if there were any witnesses, check for injuries, then notify the Administrator or the DON. Sometimes, residents were care planned for making outlandish accusations, but the allegations still needed to be investigated, and the supervisors needed to be notified. She did not remember Resident 69's situation described above being reported to her. During an interview, on 2/11/26 at 11:27 a.m., the Administrator indicated she did not know anything about the resident's allegations that someone had hit the resident or hit the resident with something. She indicated the nurse who documented the situation should have notified her or the DON immediately. They would have done an investigation immediately if they had known about the situation. During an interview, on 2/11/26 at 3:24 p.m., LPN 13, indicated on the above-mentioned situation, the resident had called and said she woke up with a headache. She did not see anything wrong with the resident. Then, the CNA told her the resident said someone came into the resident's room and was swinging something around and hit the resident's head. She did not consider it abuse. She was not sure it was important. She was not sure if the resident said anything more about it. She thought it was more of an accidental thing. Nothing had been reported to her about something happening to the resident on the prior shift. She indicated, to report abuse, she would tell the person coming on to relieve her or leave a note for the DON or ADON. If she thought someone was being abused, she would notify the supervisors right away. She thought the resident was dreaming. She guessed she should have notified the supervisor if the resident said someone was hitting the resident or hitting the resident with something. During an interview, on 2/11/26 at 4:14 p.m., the DON indicated if a resident reported that someone had hit them or hit them with something, she would expect the staff to notify either her or the Administrator immediately. A current policy, dated 11/2025, titled Abuse/Neglect/Exploitation Reporting, provided by the Administrator on 2/11/26 at 2:30 p.m., indicated the following: .It is the policy of this facility to report all allegations of abuse/neglect/exploitation or mistreatment, including injuries of unknown sources and misappropriation of resident property are reported immediately to the Administrator of the facility. 3.1-28(c)

Based on record review and interview, the facility failed to ensure residents and/or resident representatives received a copy of their baseline care plans on admission for 6 of 10 residents reviewed for care plans. (Residents 7, 11, 13, 50, 55, and 76)Findings include:1.Resident 50's clinical record was reviewed on 2/11/26 at 11 a.m. Census information indicated the resident was admitted on [DATE]. The clinical record lacked documentation that the resident or the resident's representative was provided with a copy of the baseline care plan. During an interview, on 2/11/26 at 11:48 a.m., the Administrator indicated a discussion of Resident 50's baseline care plan summary was not conveyed with Resident 50 ,nor to his representative. 2. Resident 55's clinical record was reviewed on 2/11/26 at 11:45 a.m. Census information indicated the resident was admitted on [DATE]. The clinical record lacked documentation that the resident or the resident's representative was provided with a copy of the baseline care plan. During an interview, on 2/11/26 at 11:48 a.m., the Administrator indicated a discussion of Resident 55's baseline care plan summary was not conveyed with Resident 55, nor to his resident representative. 3. Resident 13's clinical record was reviewed on 2/11/26 at 2:18 p.m. A progress note, dated 11/7/25 at 12:30 p.m., indicated Resident 13 was admitted to the facility. The clinical record lacked documentation that the resident or the resident's representative was provided with a copy of the baseline care plan. An email, dated 2/11/26 at 4:00 p.m., sent by the Administrator, indicated a baseline care plan summary was not provided to Resident 13 nor to her resident representative. 4. Resident 76's clinical record was reviewed on 2/11/26 at 3:00 p.m. A progress note, dated 11/10/25 at 4:08 p.m., indicated Resident 76 was admitted to the facility. The clinical record lacked documentation that the resident or the resident's representative was provided with a copy of the baseline care plan. An email, dated 2/11/26 at 4:00 p.m., sent by the Administrator, indicated a baseline care plan summary was not provided to Resident 76, nor to his resident representative. 5. Resident 7's clinical record was reviewed on 2/9/26 at 10:58 a.m. A progress note, dated 2/27/25 at 12:35 p.m., indicated the resident was admitted to the facility. The clinical record lacked documentation that the resident or the resident's representative was provided with a copy of the baseline care plan. During an interview, on 2/10/26 at 4:03 p.m., the MDS (Minimum Data Set) Coordinator indicated she was responsible for the baseline care plans and discussing them with the resident and/or the resident's representative. She had been on leave this past year. When she came back, she realized the person who had filled in for her had not performed the responsibilities the way they should have been done. She was unable to locate in the resident's electronic record where the baseline care plan had been discussed and provided to the family. She had requested medical records to look for the documentation. During an interview, on 2/11/25 at 9:17 a.m., the Administrator indicated she was unable to locate the communication of the resident's baseline care plan with him or his resident representative. 6.Resident 11's clinical record was reviewed on 2/9/26. A progress note, dated 8/25/25 at 5:38 p.m., indicated resident was admitted to the facility. The clinical record lacked documentation that the resident or the resident's representative was provided with a copy of the baseline care plan. During an interview, on 2/11/26 at 11:48 a.m., the Administer indicated the clinical record lacked documentation that the baseline care plan was discussed with Resident 11 and/or their representative. A current policy, undated, titled Baseline Care Plan, provided by the Administrator, on 2/11/26 at 2:30 p.m., indicated the following: .2. The admitting nurse, or supervising nurse on duty, shall gather information from the admission physical assessment, hospital transfer information, physician orders, and discussion with the resident and resident representative, if applicable.

Based on observation, interview, and record review, the facility failed to provide adequate supervision for a cognitively impaired resident to prevent repeated falls for 1 of 3 residents reviewed for accidents (Resident 41). Finding includes: During an observation, on 2/6/26 at 9:58 a.m., Resident 41 sat in her recliner with her feet elevated. Nonskid strips were in front of recliner. She wore nonskid slippers and her eyes tracked the television program. Resident 41's record was reviewed on 2/9/26 at 10:10 a.m. Diagnoses included dementia, severe, major depressive disorder, anxiety disorder, fracture of unspecified part of neck of the left femur, and chronic pain syndrome. Current physician orders included the following: sertraline (antidepressant) 50 mg twice a day (2/2/26), tramadol/acetaminophen (pain reliever) 37.5-325 mg twice a day (12/22/25), gabapentin (anticonvulsant) 300 mg twice a day (12/22/25), and non-skid strips in front of recliner, keep walker within reach (1/27/26). An admission Minimum Data Set (MDS) assessment, dated 1/9/26, indicated the resident was severely cognitively impaired. She required substantial/maximal staff assistance with toileting hygiene, showering hygiene, upper body dressing, moving from sitting to lying, lying to sitting, sitting to standing, chair to bed/chair transfers, toilet transfers, and walking 10 feet. She was dependent on staff assistance for lower body dressing, putting on/taking off footwear, and wheelchair mobility for 50 and 150 feet. She was frequently incontinent of bowel and bladder. She received routine and as-needed pain medications and non-medication interventions for pain. She complained of almost constant pain with an intensity of 10/10. The pain frequently affected day-to-day activities and therapy, and occasionally affected sleep. She received physical and occupational therapy. A current care plan, revised on 1/5/26, indicated the resident was at risk for falls due to a recent fall with hip fracture and impaired safety awareness related to diagnosis of severe dementia. Interventions included the following: Call light and personal items within reach (12/22/25), Keep walker within reach (1/27/26), Non-skid strips in front of recliner (12/26/25), PT/OT (physical therapy/occupational therapy) evaluate and treat (1/13/25), Instruct on appropriate safety measures (12/22/25), Maintain safe environment (12/22/25), and Ambulation devices as needed (12/22/25). A progress note, dated 12/22/25 at 11:47 a.m., indicated the resident was alert and oriented to person and family. She required supervision and cueing for all activities of daily living (ADLs). A progress note, dated 12/22/25 at 2:02 p.m., indicated an evaluation was done. The resident required partial/moderate staff assistance with toileting hygiene, showering/bathing, upper body dressing, lower body dressing, putting on/taking of footwear, and personal hygiene. She required supervision/ touching staff assistance with walking 10, 50, and 150 feet. A progress note, dated 12/24/25 at 1:56 p.m., indicated the resident fell at 9:30 a.m. The fall was witnessed. The resident ambulated unassisted. She wore regular socks. She slid onto the floor directly in front of her recliner. She did not utilize her walker. No injuries were noted. A progress note, dated 12/24/25 at 4:00 p.m., indicated the staff noticed the resident standing in front of her recliner with no walker. The staff educated the resident on call light use and to wait for staff assistance. The staff assisted the resident to sit down in her recliner. The staff left the room and turned around. The resident was standing in front of her recliner again. The staff assisted her to her chair. The resident denied any needs. The staff left the room, turned around, and saw the resident standing in front of her recliner holding her call light. The staff assisted the resident back to her chair and educated the resident on using her call light. A progress note, dated 12/24/25 at 10:26 p.m., indicated the resident was found lying on the floor in her room at 8:12 p.m. The resident was lying on her left side in front of her recliner with her feet facing the bed. She wore one shoe. The call light cord was wrapped around the resident's right foot. The resident was oriented to self and did not know how she fell. The resident denied pain but cried out when the left leg/hip was palpated. The resident was sent to the hospital for a possible fracture. A progress note, dated 12/24/25 at 11:30 p.m., indicated the resident returned from the hospital. The hospital diagnosed a bladder infection and frequent falls. Imaging was performed at the hospital for the pelvis, cervical spine, chest, and hips. The imaging was negative for acute findings. A progress note, dated 12/25/25 at 7:51 a.m., indicated the resident walked out into the hall. The nurse assisted the resident back to her room. The resident was assisted with bedtime care and changed into pajamas. She was assisted into her recliner, and a movie was tuned on the television. The resident was given something comforting to hold. A progress note, dated 12/25/25 at 9:48 p.m., indicated the resident was found lying on her left side in front of her recliner with her head leaning on the dresser feet facing the bed. The recliner was tipped down with the foot portion elevated. The resident tried to self-transfer without assistance from her recliner with the foot portion elevated and rolled onto the floor into her dresser. She was unable to state what she was trying to do. The resident was assisted to her feet and taken to the bathroom. She was assisted to her recliner and given something comforting to hold. No injuries were noted. A progress note, dated 12/27/25 at 2:11 a.m., indicated the staff heard a noise coming from the resident's room. The staff found the resident lying on the bathroom floor in front of the sink. The resident said she was trying to use the bathroom. The resident was incontinent of stool at the time of her fall. The resident was toileted. Her bed was lowered to the lowest level. Nonskid footwear was applied to her feet, and she was educated on call light use. A progress note, dated 12/27/25 at 10:50 a.m., indicated the resident was pleasantly confused. She was observed several times walking unassisted in her room without her walker. The resident was toileted, then assisted to her recliner with her call light, water, TV remote within reach. Shortly after the resident was assisted to her recliner, she was observed walking in the hallway without her walker, saying she couldn't find her walker. The walker was found sitting next to the resident's recliner. A progress note, dated 12/27/25 at 2:12 p.m., indicated the resident was found up walking in her room. She was toileted by staff. A progress note, dated 12/27/25 at 3:40 p.m., indicated the resident requested a peanut butter and jelly sandwich. The staff returned with the sandwich five minutes later to find the resident walking in her room. The resident was looking for her jacket. The resident was given a sweater, reminded to call for assistance, and given something comforting to hold. A progress note, dated 12/27/25 at 3:47 p.m., indicated the resident walked to the doorway of her room with the TV remote in her hand and asked for help with the television. The resident was assisted back to her recliner and shown how to turn off the television. She was covered with a blanket, shown her call light button, and reminded to use her call light button. A progress note, dated 12/27/25 at 4:04 p.m., indicated the resident fell at 4:01 p.m. The fall was not witnessed. The resident continued to get up without assistance. The resident was using incontinence supplies at the time of the fall. A progress note, dated 12/27/25 at 7:04 p.m., indicated the resident continued to transfer self. The staff had walked by the resident's room a few minutes earlier, and the resident was in her recliner. The staff heard a loud boom and the resident yelling. The resident said she was trying to get the blanket from the end of her bed. The resident was helped to her feet and assisted to the lounge area to sit with a CNA. No injuries were noted. A progress note, dated 12/28/25 at 10:15 a.m., indicated the resident's roommate's visitor pulled the code blue cord because the resident was getting up unassisted. The staff assisted with the resident's needs. The resident denied pain or a need to use the bathroom. A progress note, dated 12/28/25 at 11:00 a.m., the resident's roommate's visitor alerted staff to come to the room because the resident was up unassisted without her walker in the bathroom. The resident was assisted to the recliner by the staff. The resident denied needing to use the bathroom and said she wanted to take a nap. A progress note, dated 12/28/25 at 1:43 p.m., indicated the resident was observed walking in her room without her walker unassisted. The resident was rummaging through things behind her recliner and bending over, reaching for things. The resident was unable to say what she was doing. The resident was assisted to her recliner. She denied pain and the need to go to the bathroom. A progress note, dated 12/28/25 at 3:53 p.m., indicated the staff left the resident's room to get the resident's medication and returned to find the resident standing up with the television remote. The resident indicated she was trying to turn the television off. The staff explained to the resident she could turn the television off and on by pointing it at the television while sitting in her recliner. A progress note, dated 12/28/25 at 7:30 p.m., indicated the resident was up in her room messing with her bed. The staff assisted the resident to sit down and told her they could pull back her bed linens. The staff assisted the resident with bedtime care. A progress note, dated 12/28/25 at 8:45 p.m., indicated the resident stood naked in her room. The staff assisted her with dressing and laying down in bed. As the staff was leaving the room, the resident tried to get up. The staff asked what the resident needed, and she said she needed to get an item. Staff obtained it for her. A progress note, dated 12/29/25 at 2:39 p.m., indicated the resident was seen by the nurse practitioner (NP). A new order was received to refer the resident to the psychiatric provider and to discontinue an antibiotic as the urine culture was negative. A progress note, dated 12/29/25 at 6:06 p.m., indicated the resident was found lying on her back on the floor in her room. The resident was confused and screamed out when her head and left hip were touched. The resident was sent to the hospital for evaluation per the NP's order. A CT (Computed Tomography) report indicated a CT of the lower left extremity without contrast was performed on 12/29/25 at 7:56 p.m. Radiographs performed on 12/29/25 showed irregularity in femoral neck. The finding was an acute subcapital left femoral neck fracture (a break in the upper thighbone, occurring just below the head of the left hip joint). A progress note, dated 1/2/26 at 6:00 p.m., indicated the resident returned to the facility at 5:30 p.m., from the hospital with a diagnosis of left hip fracture. The resident was able to bear weight as tolerated to her left lower extremity. A progress note, dated 1/10/26 at 10:32 a.m., indicated the resident was observed walking unassisted without her walker from the dining room to her room. A progress note, dated 1/26/26 at 1:36 p.m., indicated the resident was heard screaming. The resident was found lying on the floor in her bathroom, lying on her left side. The resident had gotten up from her recliner and walked unassisted, without her walker and without her shoes, to the bathroom. An immediate intervention was frequent checks on the resident and ensuring she wore proper footwear. A progress note, dated 2/2/26 at 12:57 p.m., indicated the resident was observed up walking unassisted without pants on in her room two times during the shift. A progress note, dated 2/3/26 at 1:06 p.m., indicated the resident was walking unassisted in her room without her shoes and her walker. The resident was assisted by staff to her recliner. The resident wanted to talk with her daughter. The daughter came to the resident's room and later told the nurse she thought the mail on the resident's table was making the resident nervous, so she took the mail with her. During an observation, on 2/9/26 at 4:10 p.m., the resident's call light was on. She was sitting up in her recliner with her feet on the floor and was looking around the room. During an observation, on 2/9/26 at 4:15 p.m., the resident was walking unassisted in her room using her walker. The call light remained on. During an observation, on 2/9/26 at 4:18 p.m., the resident's roommate's visitor entered the room and encouraged the resident to sit down in her recliner as she continued to walk about her room. The call light remained on. During an observation, on 2/9/26 at 4:21 p.m., the staff entered the room and answered the call light. During an interview, on 2/10/26 at 11:18 a.m., LPN 7 indicated she checked on the resident every chance she got to prevent her from falling. She often would get the resident comfortable in her recliner and applied a topical analgesic to her legs, then five minutes later the resident got up on her own again. The staff checked on the resident as much as they could. During an interview, on 2/10/26 at 3:26 p.m., CNA 8 indicated, to prevent falls for the resident, she gave her comforting items she had in her room. The staff tried to talk to the resident when she got antsy. They tried to check on her often. During an interview, on 2/10/26 at 3:42 p.m., QMA 9 indicated she tried to watch for the resident to prevent falls. If the resident was up, she would give the resident something comforting to hold and put cowboy programs on the television. She also offered to call the resident's daughter at times. During an interview, on 2/10/26 at 3:43 p.m., CNA 10 indicated some fall interventions for the resident were to offer her something to eat. The resident loved both chocolate and bubble gum. She also distracted the resident from getting up by putting Westerns on the television. During an interview, on 2/11/25 at 9:58 a.m., the ADON indicated the interventions for the falls were as follows: for the 12/24/25 9:30 a.m. fall - skid strips were placed in front of the recliner, for the 12/24/25 8:12 p.m., fall - a urinalysis was done indicating a urinary tract infection and an antibiotic was started, for the 12/25/25 9:48 p.m. fall - an evaluation for physical, occupational, and speech therapy was ordered, for the 12/27/25 2:11 a.m., fall - an rug was removed from the resident's bathroom, for the 12/27/25 4:01 p.m. fall - a pharmacy medication review was done, and for the 12/29/25 5:30 p.m. fall - the resident was sent to the hospital and returned to have physical, speech, and occupational therapy. She indicated there was not a fall on 12/27/25 at 7:04 p.m. The nurse had written a post fall evaluation earlier in the day at 4:11 p.m. when it happened then added more details later at 7:04 p.m. She had not included the removal of rug on the care plan as she indicated she did not know how she would do that. The rug removal was listed on the daily huddle sheets - which she provided. She indicated each resident's fall interventions were listed on the inside of their closet doors. These interventions came from the care plan.During an interview, on 2/11/26 at 4:08 p.m., the DON indicated the resident had fallen several times. She was uncertain what had caused the resident to fall multiple times. However, A move from the assisted living to the skilled nursing portion of the building was a huge change. She indicated she had told her staff to peek in the resident's room frequently to make sure if she was up or down and to make sure the resident's needs were met. A current, undated policy, titled Fall Risk Assessment & Prevention Program, provided by the Administrator on 2/11/26 at 2:30 p.m., indicated the following: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure physician prescribed diets were followed and resident food preferences were honored for 1 of 3 residents reviewed for nutrition (Resident 9). Finding includes: During an interview, on 2/5/26 at 3:33 p.m., Resident 9 indicated she did not have natural teeth and did not wear dentures. She occasionally received chopped up meat with her meals. She was unsure why sometimes the meat was chopped and other times it was not. She preferred to have her meat chopped at every meal because having no teeth made it difficult to chew. Resident 9's clinical record was reviewed on 2/9/26 at 1:20 p.m. Current physician orders included a regular diet with regular texture, regular consistency, ground meat and no added salt (1/21/26). A current care plan, revised on 8/28/24, indicated Resident 9 was at nutritional risk related to diagnosis of diabetes, hyperlipidemia, anemia, depression, and significant weight gain. She received a therapeutic diet related to her diagnosis of diabetes. Interventions included the following: diet and supplements as ordered (6/26/23), educate resident on healthy intake, lifestyle, and portion sizes (2/29/24), resident typically required independence to supervision with set up assist with eating (6/26/23), and report choking, swallowing, and chewing problems, (6/26/23). A dental note, dated 12/4/25, indicated Resident 9 had no teeth. The resident had a flat lower ridge and minimal bone on the upper arch. She was not a denture candidate. During an observation, on 2/10/26 at 11:43 a.m., Resident 9's tray contained country fried steak. A staff member cut the country fried steak into strips. The staff member then cut a few of the strips into bite size pieces, leaving the remaining cut strips on the plate. Resident 9 finished cutting the remaining country fried steak as she ate. During an interview, on 2/10/26 at 12:03 p.m., the Dietary Manager indicated country fried steak was not considered ground meat. It needed to be run through a food processor if the order was for ground meat. Ground meat terminology was interchangeable with mechanical soft. Resident 9 was not automatically given ground meat unless she asked for it. During an interview, on 2/10/26 at 12:20 p.m., Resident 9 indicated it was difficult to eat the meat served at lunch and wanted any type of meat served with her meals to be ground up. She did not want to ask for ground meat each time, especially after being served regular meat at a meal. She was unsure why sometimes it came out of the kitchen already ground up and other times it was not. The resident reiterated she had no teeth and eating meat was hard to do. During an interview, on 2/10/26 at 12:24 p.m., CNA 14 indicated she usually cut up Resident 9's meat into bite size pieces, but not all the time. Resident 9 only wanted her meat ground up because someone who sat at her table a while back had ground meat and she only requested it because they had it. During an interview, on 2/10/26 at 12:29 p.m., CNA 9 indicated she usually cut up Resident 9's meat for her but sometimes it came from the kitchen already cut up into bite size pieces. Resident 9 occasionally received ground meat, not on regular basis, maybe once a day. During an interview, on 2/11/26 at 9:55 a.m., the ADON indicated Resident 9's diet was changed on 12/24/25 per Resident 9's request to have ground meat. Due to the physician order stating regular, ground meat, that meant ground meat would only be given upon Resident 9's request for ground meat. The order did not indicate ground meat was to automatically be given. A current facility policy, undated, titled Diet Change Orders, provided by the Administrator, on 2/11/26 at 2:30 p.m., indicated the following: Policy: All residents will be provided with the appropriate diet prescribed to meet their nutritional needs. Procedure: 5. Make the necessary revision to the diet order in the resident's electronic medical record under orders as well as in the resident's plan of care to reflect the changed diet order. 6. Assess the resident's meal tray upon delivery to ensure the change in diet was communicated effectively and that proper diet is served to the resident.

Based on interview and record review, the facility failed to ensure the Infection Preventionist (IP) role was filled by a staff member with the appropriate schedule to support the ability to perform IP responsibilities by having the full-time DON assume IP responsibilities.Findings include:During the entrance conference, on 2/5/26 at 9:20 a.m., the Administrator indicated the DON was the Infection Preventionist for the facility.The facility census, provided on 2/5/26 at 10:31 a.m. by the Administrator, indicated the facility census was 75.During an interview, on 2/9/26 at 1:35 p.m., the DON indicated she oversaw the infection prevention and control program with the staff development nurse. The DON was scheduled for 40 hours a week and spent about 10 hours a week performing Infection Prevention duties.During an interview, on 2/10/26 at 3:45 p.m., the Administrator indicated the DON was unable to provide a time sheet to show hours she worked as the DON compared to when she worked as the Infection Preventionist. Depending on what was going on within the facility, the DON could be performing IP duties several times throughout the day.A current facility job description for Infection Preventionist, provided by the Administrator on 2/10/26 at 1:38 p.m., and signed by the DON on 9/28/25, indicated the following: .the Infection Preventionist develops and implements an ongoing infection prevention and control program to prevent, recognize, and control the onset and spread of infections in order to provide a safe, sanitary, and comfortable environment. Maintain established facility- wide systems for prevention, identification, reporting, investigation and control of infections and communicable diseases of residents, staff, and visitors. Develops and implements written policies and procedures in accordance with current standards or practice and recognized guidelines for infection prevention and control. Oversees resident care activities that increase risk of infection (i.e., use and care of urinary catheters, wound care, incontinence care, skin care, point-of-care blood testing, and medication injections. Oversees the facility's antibiotic stewardship program. Able to occasionally work overtime based on facility or resident's needs.A current facility job description for the Director of Nursing, provided by the Administrator on 2/10/26 at 1:38 p.m., and signed by the DON on 7/21/23, indicated the following: .the DON plans, organizes, develops, and directs the overall operations of the Nursing Service Department in accordance with local, state and federal standards and regulations.The DON works beyond normal working hours and on weekends, holidays when necessary. On call 24 hours per day, 7 days per week.An undated current facility policy, titled Infection Control Policy and Procedure, provided by the Administrator, on 2/11/26 at 2:30 p.m., indicated the following: . The facility will designate a qualified individual as Infection Preventionist (IP) whose primary role is to coordinate and be actively accountable for the facility's infection prevention and control program to include the antibiotic stewardship program.

Based on observation, interview, and record review, the facility failed to provide adequate supervision for a cognitively impaired resident to prevent repeated falls for 1 of 3 residents reviewed for accidents. (Resident B) Finding includes:During an observation, on 10/20/25 at 11:49 a.m., Resident B was sitting in a wheelchair at a dining room table, eating. The front of the wheelchair was slightly elevated, allowing the resident to be tilted back. Anti-tippers were secured to the wheelchair. An elevated slanted wheelchair cushion was in place. The resident was able to rest his toes on the floor as he ate. During an observation, on 10/20/25 at 3:21 p.m., Resident B sat in a recliner, with his feet elevated, in a common area in front of the nurse's station. No staff were present. The resident wore nonskid footwear. He occasionally made a grunting noise. He kicked off his left shoe and slid down in the recliner. After a couple of minutes, a staff member approached the resident and redirected the resident to wait until a 2nd staff member could assist to take him to the bathroom. Resident B's clinical record was reviewed on 10/20/25 at 12:10 p.m. Diagnoses included dementia, restlessness and agitation, anxiety, insomnia, and personal history of healed traumatic fracture. Current fall intervention orders included may use side rails (4/26/25), nonskid pad to w/c, skid strips in front of recliner, bed in lowest position with floor mat, offer favorite TV channel 48 weather, nonskid pad to pod 3 recliner, offer and encourage daily activities, apply lavender calming lotion at HS, gripper socks to bed at night, bariatric bed, offer Bible at POD, dump w/c seat, flat call light, sound machine, night light, keep bedside table within reach when in bed, weighted blanket, offer men's busy board or activity pillow (7/18/25), may apply analgesic gel prn, engage in conversation about the air force, take for a walk outside, offer soda/pop, ask about model boat in room, nonskid on top of cushion, offer hot chocolate, offer memory lane activities, offer newspaper, offer to call family, offer to lower room temp to 71, passive essential oil diffuser, limit caffeine after lunch, DVD movie about air force/military, offer urinal, offer bedtime snack, offer to ride exercise bike in therapy gym, offer fluid (7/28/25), offer pop it fidget, utilize body pillow, may self-propel wheelchair with supervision, glow in the dark tape to call light, take for walk when restless, may fill med cups with hand lotion, preferred bedtime 9pm (9/17/25). A quarterly Minimum Data Set (MDS) assessment, dated 8/3/25, indicated the resident was severely cognitively impaired and had disorganized thinking. He required a walker for mobility and substantial/maximal staff assistance for toileting assistance, shower/bathing, upper and lower body dressing, footwear, rolling left and right, sit to stand, chair/bed to chair transfers, toilet transfers, and shower transfers. The resident was dependent for wheelchair mobility and wheeling 50 feet with two turns. The resident was frequently incontinent of bowel and bladder. The resident received routine and as needed pain medication for pain that occasionally affected his sleep and day to day activities. Since the prior MDS assessment, the resident had sustained 2 or more falls without injury, 2 or more falls with injury, and no falls with a major injury. A progress note, dated 8/1/25 at 8:17 p.m., indicated that Resident B was found sitting on the floor beside his bed. The resident indicated he slid to the floor when he tried to get out of the bed to use the bathroom. The resident was assessed for injuries and then assisted off the floor and taken to the bathroom. The care plan lacked an updated intervention for the 8/1/25 fall. A progress note, dated 8/4/25 at 10:15 p.m., indicated Resident B scooted himself out of his wheelchair and onto the floor. The resident was taken to the memory care unit for monitoring and was given Tylenol for discomfort. A fall scene investigation, dated 8/4/25 at 10:28 p.m., indicated the fall was unwitnessed and occurred in the hallway. The care plan lacked an updated intervention for the 8/4/25 fall. A progress note, dated 8/10/25 at 7:17 p.m., indicated Resident B had ignored staff's repeated instructions to sit back in his wheelchair. Staff left the resident and upon their return, found the resident on his knees in front of his wheelchair. The resident scooted himself out of his wheelchair. The resident was assessed for injuries and routine pain medication was administered. A fall scene investigation, dated 8/10/25 at 7:19 p.m., indicated the resident was found on the floor, in the hallway, and had scooted himself out of his wheelchair. The resident was alone at the time of the incident. The clinical record lacked an immediate intervention, and the care plan lacked an updated intervention for the 8/10/25 fall. A progress note, dated 8/15/25 at 10:25 p.m., indicated Resident B had been yelling and staff found him sitting on the floor mat beside his bed. The resident indicated he rolled out of his bed and he had to go to the bathroom. The resident was found to be incontinent of his bowels and bladder. The resident was assessed and assisted back into his bed. Staff performed incontinent care. Analgesic gel was applied to the resident's bilateral lower extremities, neck, and shoulders. The care plan lacked an updated intervention for the 8/15/25 fall. A progress note, dated 8/21/25 at 9:30 p.m., indicated Resident B had an unwitnessed fall in the entry way of his room. The resident appeared to have crawled out of bed and crawled to the entry way. The resident was assessed and assisted from the floor and back into his bed. A post fall evaluation progress note, dated 8/21/25 at 9:32 p.m., indicated Resident B had attempted to self-toilet at the time of the fall and the reason for the fall was not evident. The clinical record lacked an immediate intervention, and the care plan lacked an updated intervention for the 8/21/25 fall. A progress note, dated 8/30/25 at 5:15 a.m., indicated Resident B was found sitting on the floor mat beside his bed. The resident was incontinent of his bowels and bladder. The resident was assessed and assisted back into his bed. Incontinent care was given. The resident's call light and personal items were within reach. The clinical record lacked an immediate intervention. A care plan intervention was initiated on 9/2/25 to add glow in the dark tape to the resident's call light for the resident's 8/30/25 fall. A progress note, dated 8/30/25 at 11:37 a.m., indicated Resident B fell out of his wheelchair at the end of the hallway. The resident was confused and aggravated prior to the incident. Staff redirection was unsuccessful, and staff allowed the resident to self-propel his wheelchair in the hall unattended. The resident attempted to put the code in to open the door at the time of the fall. The resident was assessed, educated on the importance of waiting for help to get out of his wheelchair, and taken to lunch. A fall scene investigation, dated 8/30/25 at 12:53 p.m., indicated Resident B had indicated he had tried to leave to go to church. A care plan intervention was initiated on 9/2/25 which indicated Resident B may self-propel his wheelchair with supervision. A progress note, dated 9/6/25 at 9:08 p.m., indicated Resident B was restless and scooted to the edge of his wheelchair. Staff witnessed this behavior, and the resident ignored the nursing staff's safety requests. The resident indicated he wanted to get up and he liked the attention. The resident was assessed for injuries. A progress note, dated 9/6/25 at 10:41 p.m., indicated Resident B was found lying on his back in the commons area with his feet tangled in the pedals of his wheelchair. The resident was noted to have a bruise and skin tear to his right wrist. A fall scene investigation, dated 9/6/25 at 11:24 p.m., indicated the resident was found on the hallway floor (unwitnessed) and fell to the floor (witnessed). The resident was attempting to self-transfer and slid out from wheelchair. The resident was alone and/or unattended and assisted with more help than the care plan described. A staff member was not present at the time of the fall. The clinical record lacked an immediate intervention for both falls that occurred on 9/6/25. A care plan intervention was initiated on 9/9/25 which indicated staff were to take Resident B for a walk when he was restless. A progress note, dated 9/9/25 at 10:35 p.m., indicated Resident B was found on the floor beside his bed. The resident indicated that he had to use the toilet. The clinical record lacked an immediate intervention, and the care plan lacked an updated intervention related to the 9/9/25 fall. A progress note, dated 9/10/25 at 7:47 p.m., indicated Resident B was found sitting on the floor, in front of his wheelchair, in the lounge. The resident indicated he was trying to find a paper airplane. He sustained a small skin tear to his left elbow. The clinical record lacked an immediate intervention, and the care plan lacked an updated intervention related to the 9/10/25 fall. A progress note, dated 9/11/25 at 9:30 p.m., indicated staff found Resident B lying on his floor mat beside his bed at 8:10 p.m. His back rested against the bed. The resident slid out of his bed onto his bottom. The resident stated he was not tired and did not want to go to bed yet. The resident was assessed and assisted into his wheelchair. The care plan lacked an updated intervention related to the 9/11/25 fall. A progress note, dated 9/13/25 at 7:30 p.m., indicated Resident B attempted to self-transfer from a reclined lift chair. The resident scooted himself to the elevated footrest and slid to the floor. The resident was assessed and assisted into a wheelchair. A care plan intervention was initiated on 9/15/25 which indicated staff may fill medication cups with hand lotion. A progress note, dated 9/16.25 at 7:15 p.m., indicated Resident B was found on the floor in front of a recliner. The resident indicated he wanted to get into his wheelchair and get into bed. A care plan intervention was initiated on 9/17/25 which indicated Resident B's preferred bedtime was 9 p.m. A progress note, dated 9/18/25 at 6:13 p.m., indicated Resident B was found at 4:40 p.m. sitting on the floor with his back still in the recliner in the lounge area. The resident had scooted himself forward in the recliner and it tipped forward. The resident indicated he tried to get up to get in his wheelchair. The resident was assessed for injuries. The clinical record lacked an immediate intervention, and the care plan lacked an updated intervention for the 9/18/25 fall. A progress note, dated 9/28/25 at 4:20 a.m., indicated Resident B was found on his knees on the floor mat beside his bed. The resident indicated he rolled out of bed and was going to the bathroom. The resident was assisted from the floor and assisted back to bed. Analgesic gel was applied to the resident's knees due to the resident complained of his knees being sore. A care plan intervention was added on 9/29/25 which indicated to offer Resident B a bedtime snack. A progress note, dated 9/30/25 at 9:38 p.m., indicated Resident B was found on his bedside mat on his knees. The resident indicated he purposely climbed out of bed and was unsure why he tried to get up. The care plan lacked an updated intervention for the 9/30/25 fall. A progress note, dated 10/7/25 at 7:57 p.m., indicated Resident B had an unwitnessed fall. The resident was found sitting on the floor in front of a recliner that was tipped forward with the elevated footrest resting on the floor. The care plan lacked an updated intervention for the 10/7/25 fall. A progress note, dated 10/19/25 at 11:40 p.m., indicated Resident B was found sitting upright on the floor beside his bed. The resident indicated he slid out of bed when he attempted to get out of bed. Staff offered the resident the bathroom and the resident indicated he had just gone. Staff assisted the resident from the floor and back into bed. The care plan lacked an updated intervention related to the 10/19/25 fall. Resident B's clinical record indicated that he sustained 53 falls between 4/26/25 and 10/19/25. During an interview, on 10/20/25 at 4:01 p.m., CNA 2 indicated Resident B was totally dependent on staff, other than he was able to feed himself. The resident was not consistently able to voice his needs, such as going to the bathroom. Staff were aware of watching the resident for nonverbal cues. Resident B was often antsy and had a lot of falls. Multiple interventions were in place. Confirmed no concave mattress was not in place and the resident used a body pillow. She confirmed no glow in the dark tape was on the call light. During an interview on 10/20/25 at 4:46 p.m., the DON indicated Resident B had sustained a lot of falls when he attempted to get up from his wheelchair or recliner. He was known to slide out of his bed onto his buttocks. Multiple interventions were put into place to aide with fall reduction. Physician orders were to be followed, and care plans were to match physician orders. The order for a concave mattress should have been discontinued due to the intervention had changed to a body pillow. She was unsure if specialty tape, such as glow in the dark tape, was used but indicated Resident B's call light had been switched from a push button to a touch pad. Resident B needed more one on one to assist in preventing the resident from falling. MDS nurse was on medical leave and staff had been trying their best to implement interventions and update the clinical record. A current facility policy, provided by the Administrator on 10/20/25 at 4:55 p.m., titled Fall Prevention Program, indicated the following: Policy: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls.9. When any resident experiences a fall, the facility will: f. Review the resident's care plan and update as indicated. g. Document all assessments and actions. This citation relates to Complaint 2645919. 3.1-45(a)(1)3.1-45(a)(2)

Based on observation, record review, and interview, the facility failed to ensure transmission-based precautions were implemented to prevent the spread of infectious gastroenteritis for 1 of 9 residents with gastroenteritis (Resident 15). This deficient practice resulted in the development of gastroenteritis for 8 of the remaining 16 residents who resided on the secured unit (Resident 20, 41, 61, 25, 50, 32, 52, and 38). Findings include: During an interview, on 12/27/24 at 9:02 a.m., the Administrator indicated the secured unit had experienced an outbreak. Five residents began experiencing nausea, vomiting, and diarrhea through the night. The residents had been tested for COVID-19, respiratory syncytial virus (RSV), and influenza. The facility was awaiting the results to determine what type of infection the residents had contracted. 1. During an observation, on 12/26/24 at 12:11 p.m., Resident 15 sat in the dining room, eating lunch. Resident 15's clinical record was reviewed on 12/30/24 at 4:09 p.m. Diagnoses included Alzheimer's disease with late onset. Physicians' orders included loperamide (antidiarrheal) 4 milligrams (mg) one time for loose stools (12/25/24), loperamide 2 mg as needed every 24 hours for loose stools for 10 days (12/25/24), ondansetron (for nausea and vomiting) 4 mg every 6 hours as needed for nausea and vomiting for 10 days. A Nurses' Note, dated 12/25/24 at 1:15 p.m., indicated the resident had vomited five to six times and had diarrhea during the shift. A Nurses' Note, dated 12/25/24 at 1:32 p.m., indicated the Nurse Practitioner (NP) was notified. New orders were received for loperamide and ondansetron. A Nurses' Note dated 12/25/24 at 2:49 p.m., indicated the resident's representative was notified of the resident's new orders related to the intestinal flu. The resident's clinical record lacked testing and indication the resident was placed in transmission-based precautions for her symptoms of vomiting and diarrhea. During an interview, on 12/30/24 at 10:02 a.m., the Infection Preventionist (IP) indicated the residents who experienced nausea, vomiting, and/or diarrhea on 12/27/24 had tested negative for COVID-19. The droplet/contact precautions were changed to contact isolation to continue until 48 hours after the resolution of symptoms. She was uncertain who had the first case of gastroenteritis with this outbreak. She had indicated review of the dietary staffing and other staffing had shown no staff had been ill with similar symptoms. She had not worked the week prior to 12/26/24. The DON monitored the infections when she (the IP) had time off. During an interview, on 12/31/24 at 9:08 a.m., RN 5 indicated when a resident experienced vomiting or diarrhea, she would check to see if the symptoms were normal for the resident, then call the physician, check for COVID-19, and put the resident in transmission-based precautions for COVID-19. If the results were negative for COVID-19, then the isolation would be changed from the isolation for COVID-19 to contact isolation for the nausea, vomiting, and diarrhea. During an interview, on 12/31/24 at 11:33 a.m., RN 6 indicated if a resident experienced nausea, vomiting, and/or diarrhea, a rapid COVID-19 test would be performed. If the test was negative, then another COVID-19 test would be taken and sent to the hospital. The resident would be placed in transmission-based precautions for COVID-19. If the COVID-19 test sent to the hospital was negative, the precautions would be changed to contact isolation until 48 hours after the resolution of the symptoms. During an interview, on 12/31/24 at 1:33 p.m., the DON indicated when a resident experienced nausea, vomiting, and/or diarrhea, a COVID test was performed and sent to the hospital if the rapid COVID-19 test was negative. The resident was placed in precautions for COVID-19. If the COVID-19 test sent to the hospital was negative, then the resident's precautions were changed to contact isolation for gastroenteritis. An infection screener was to be filled out whenever an infection was suspected. She was unaware Resident 15 had experienced multiple episodes of vomiting prior to the outbreak of eight other residents with gastroenteritis. She was uncertain if Resident 15 had been tested for COVID-19 or had been put in transmission-based precautions. During an interview, on 1/3/25 at 3:45 p.m., the DON indicated Resident 15 had not been tested for COVID-19 or been put on transmission-based precautions as she would have expected to be done. 2. During an observation, on 12/26/24 at 12:10 p.m., Resident 41 sat in a chair in the dining room, eating lunch. Resident 41's record was reviewed on 12/31/24 at 10:01 a.m. She shared a room with Resident 15. Diagnoses included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. A Nurses' Note, dated 12/27/24 at 10:49 a.m., indicated the resident had vomiting and diarrhea. An Infection Report, dated 12/27/24 at 11:28 a.m., indicated McGeer's criteria (used to define infections for long-term care) was met for gastroenteritis (inflammation of the stomach and intestines). 3. During an observation, on 12/26/24 at 12:18 p.m., Resident 20 sat in her wheelchair in the dining room. During an observation, on 12/27/24 at 9:07 a.m., Resident 20's door had an isolation sign on it and was closed. Resident 20's clinical record was reviewed on 12/30/24 at 11:11 a.m. Diagnoses included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. A Nurses' Note, dated 12/27/24 at 5:41 a.m., indicated the resident vomited. The rapid COVID-19 test was negative. An Infection Report, dated 12/27/24 at 11:31 a.m., indicated McGeer's criteria was met for gastroenteritis. 4. During an observation on 12/26/24 at 12:09 p.m., Resident 61 sat in a chair in the dining room eating her lunch with the assistance of her resident representative. During an observation on 12/27/24 at 9:07 a.m., Resident 61's door was closed with an isolation sign on it. Resident 61's clinical record was reviewed on 12/30/24 at 3:03 p.m. Diagnoses included Alzheimer's disease with early onset. A Nurses' Note, dated 12/27/24 at 3:00 a.m., indicated the resident wandered into the hallway holding feces in her hand. She was assisted back into her room and began vomiting into her bathroom sink. She continued to vomit. An Infection Report, dated 12/27/24 at 11:21 a.m., indicated McGeer's criteria was met for gastroenteritis. 5. During an observation, on 12/26/24 at 12:12 p.m., Resident 25 sat at a table in the dining area, eating lunch. Resident 25's clinical record was reviewed on 12/31/24 at 10:04 a.m. Diagnoses included unspecified dementia, unspecified severity, with anxiety. A Nurses' Note, dated 12/27/24 at 11:08 a.m., indicated the resident vomited and had diarrhea. An Infection Report, dated 12/27/24 at 11:27 a.m., indicated McGeer's criteria was met for gastroenteritis. 6. During an observation, on 12/26/24 at 12:19 p.m., Resident 50 sat at a table in the dining room and fed herself lunch. During an observation, dated 12/27/24 at 9:07 a.m., Resident 50's door was closed with an isolation sign on it. Resident 50's clinical record was reviewed on 12/31/24 at 10:05 a.m. Diagnoses included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. A Nurses' Note dated, 12/27/24 at 11:21 a.m., indicated the resident experienced nausea, vomiting, and diarrhea. An Infection Report, dated 12/27/24 at 11:30 a.m., indicated McGeer's criteria was met for gastroenteritis. 7. During an observation, on 12/26/24 at 12:18 p.m., Resident 32 sat in the dining room, eating lunch. During an observation, on 12/27/24 at 9:09 a.m., Resident 32's door was closed with an isolation sign on it. Resident 32's clinical record was reviewed on 12/31/24 at 12:25 p.m. Diagnoses included unspecified dementia, severe, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. A Nurses' Note, dated 12/27/24 at 2:27 a.m., indicated the resident had vomited all over himself, his bed, and his floor. He was also covered in feces. A Nurses' Note, dated 12/27/24 at 2:59 a.m., indicated the resident vomited again and had more diarrhea. An Infection Report, dated 12/27/24 at 11:32 a.m., indicated McGeer's criteria was met for gastroenteritis. 8. During an observation, on 12/26/24 at 12:18 p.m., Resident 52 sat in a wheelchair at a table in the dining room. Resident 52's clinical record was reviewed on 12/31/24 at 10:06 a.m. Diagnoses included Alzheimer's disease, unspecified. A Nurses' Note, dated 12/28/24 at 8:05 a.m., indicated Resident 52 was covered in emesis and diarrhea. She was placed in COVID-19 transmission-based precautions. A Nurses' Note, dated 12/29/24 at 6:46 a.m., indicated the resident's COVID-19 results were negative, and the resident was put on contact isolation. 9. Resident 38's clinical record was reviewed on 12/30/24 at 4:07 p.m. Diagnoses included Alzheimer's disease with late onset. A Nurses' Note, dated 12/27/24 at 11:24 p.m., indicated the resident experienced nausea, vomiting, and diarrhea. A Nurses' Note, dated 12/27/24 at 3:52 p.m., indicated the resident was given an ondansetron pill for nausea and vomiting. An Infection Report, dated 12/27/24 at 11:29 p.m., indicated McGeer's criteria was met for gastroenteritis. Norovirus Facts and Stats, (May 2024) was retrieved on 1/3/25 from the Centers for Disease Control and Prevention (CDC) website. The guidance included the following: .Norovirus is the leading cause of vomiting and diarrhea from acute gastroenteritis among all people of all ages in the United States Norovirus infection, (March 2022) was retrieved on 1/3/25 from the Mayo Clinic website. The guidance included the following: .Norovirus infection can cause severe vomiting and diarrhea that starts suddenly. Noroviruses are highly contagious .Diarrhea, stomach pain, and vomiting typically begin 12 to 48 hours after exposure. Norovirus infection symptoms usually last 1 to 3 days .Norovirus infection occurs most frequently in closed and crowded environments. Examples include hospitals, nursing homes A current, undated facility policy, titled Contact Precautions/Nausea & Vomiting, provided by the Administrator on 1/2/25 at 9:05 a.m., indicated the following: .Contact precautions are used for patients who are known or suspected to be infected with microorganisms that can be transmitted by [1] Direct contact with the patient [2] Indirect contact with environmental surfaces or patient care items [3] Secretions or drainage that cannot be contained .Contact precautions for residents can be removed when resident has been free from nausea & vomiting and are showing no other signs of infection for 48 hours 3.1-18(b)(2)

Based on observation, interview, and record review, the facility failed to provide daily grooming assistance for 1 of 3 residents reviewed for Activities of Daily Living (ADLs). (Resident 3) Findings include: During a random observation, on 12/26/24 at 12:40 p.m., Resident 3 was sitting in a wheelchair in front of her television. Her fingernails were long and had a brown substance under the tips. Resident 3 indicated staff normally kept up on her nails, but they had been busy lately. During an interview, on 12/27/24 at 9:50 a.m., Resident 3 indicated she had received a shower yesterday. Resident 3's fingernails were observed to be long and had a brown substance under the tips. During an interview, on 12/30/24 at 9:51 a.m., Resident 3 indicated she would get a shower that night and she wanted her nails cut. Her nails remained long and had a brown substance underneath the tips. Resident 3's clinical record was reviewed on 12/30/24 at 10:01 a.m. Diagnoses included major depressive disorder, bipolar disorder, chronic kidney disease stage 3, emphysema, dyspnea, and borderline intellectual functioning. An annual Minimum Data Set (MDS) assessment, dated 9/29/24, indicated Resident 3 was cognitively intact. No behaviors were identified during the assessment period. She required partial/ moderate assistance of staff for showering/bathing self, upper and lower body dressing and personal hygiene. Rejection of care was not present during the assessment period. The Point of Care notes for nail care indicated Resident 3 had accepted complete nail care (clean, cut, and file) on 12/2/24, 12/9/24, 12/16/24, 12/23/24, and 12/30/24. During an interview, on 12/31/24 at 8:39 a.m., Resident 3 indicated she had asked staff to cut her nails the night before. Her nails remained long and had a brown substance underneath the tips. During an interview, on 12/31/24 at 8:47 a.m., CNA 10 indicated activities staff trimmed residents' nails once a week. During an interview, on 12/31/24 at 8:48 a.m., Activities Staff 45 indicated the nurse, or the CNAs trimmed the residents' nails. During an interview, on 12/31/24 at 9:00 a.m., CNA 12 indicated the nurse trimmed Resident 3's nails on shower days. During an interview, on 12/31/24 at 9:04 a.m., the ADON indicated the facility did monthly nail checks on all the residents. If a resident refused nail care, it would be documented in the progress notes. Nail care meant the nails would be cleaned, but not necessarily cut. She indicated she would speak with Resident 3 about receiving nail care. During an interview, on 12/31/24 at 1:40 p.m., the DON indicated CNAs trimmed non-diabetic residents' nails on their shower days. It would be documented under their point of care charting tab. During a random observation, on 1/2/25 at 2:26 p.m., Resident 3's nails were short and had a brown substance underneath the tips. During an interview, on 1/2/25 at 1:59 p.m., CNA 14 indicated Resident 3's nails were not that long and didn't feel they were too dirty. She did not try to cut the residents' nails as the resident liked them mid-length but did clean them. Nails should be trimmed on the first shower day of the week. During an interview, on 1/2/25 at 2:05 p.m., CNA 15 indicated she cleaned Resident 3's nails during her shower. The resident's nails were mid-length, but not that dirty. It was normal for Resident 3 to have her nails clean and by the next morning have debris under her nails. Resident 3 didn't normally ask for her nails to be trimmed. A current facility policy, provided by the Administrator on 1/2/25 at 2:10 p.m. and titled Activities of Daily Living, indicated . A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene 3.1-38(3)(E)

Based on interview and record review, the facility failed to provide supervision to prevent repeated falls for 1 of 3 residents reviewed for falls. (Resident 30) Findings include: Resident 30's clinical record was reviewed on 12/30/24 at 9:11 a.m. Diagnoses included Alzheimer's disease with late onset, dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, essential hypertension, and anxiety disorder. Current physician orders, on 12/30/24, included amlodipine besylate (anti-hypertensive) 2.5 milligram (mg), Celexa (antidepressant) 10 mg, buspirone (antianxiety) 10 mg, and Rozerem (sedative) 8 mg. Ordered fall interventions included the following: non-skid strips next to bed, chair and toilet, red non-slip placemat to bedside table, touch pad call light, leave bathroom light on at night, Dycem (anti-slip mat) to recliner, bed height marked at 24 inches top of mattress per therapy, keep walker within reach at all times, Every one hour safety checks, stop sign to bathroom door (keep door shut with sign up, do not leave on toilet unsupervised, keep call light on left side when in bed, door chime to bathroom door, concave mattress, offer bedtime snack, call light wrapped in glow in the dark tape, floor mat at bathroom side of bed, weighted blanket while in bed, encourage to sit in lounge during the day, bed against well, and frequent verbal cues to utilize call light. A quarterly Minimum Data Set (MDS) indicated Resident 30 was moderately cognitively impaired. She had no impairment on her upper and lower extremities. She needed moderate assistance from staff for upper and lower body dressing, and toileting. She required substantial/ maximal assistance from staff for personal hygiene. She required supervision or touching assistance from staff for sit-to-stand transfers, toilet transfers and shower transfers. Resident 30 experienced two or more falls since the prior assessment. A care plan, initiated on 11/11/21 and revised on 10/28/24 , indicated Resident 30 would be free from falls with significant injury thru the next review. Interventions included: assess fall risk potential at admit, quarterly and with significant changes, assist with transfers, toileting, and ambulation as needed, bed against the wall, bed height marked at 24 inches top of mattress per therapy, call light cord wrapped in glow in the dark tape, concave mattress to bed, do not leave the resident on the toilet unsupervised, door chime to bathroom door, Dycem to recliner, encourage resident to sit in the lounge during the day, floor mat on bathroom side of bed, frequent verbal cues to utilize call light, keep call light and personal belongings within reach, keep call light on left side of bed when in bed, keep walker within reach at all times, leave bathroom light on at night, monitor blood pressure per order, monitor for medication side effects, monitor in fall risk meeting for four weeks after admit or fall, motion alarm sensor to the bathroom door, non-skid strips next to bed and chair and in front of the toilet, offer a bedtime snack, orient to room, bathroom and call light, Every one hour safety checks 3P's, red non-slip placemat on bedside table, restorative nursing program six times per week, stop sign to bathroom door, touch pad call light, vitamin D per orders and weighted blanket while in bed. A nursing progress note, dated 10/12/24 at 5:32 p.m., indicated Resident 30 was sitting on the floor directly in front of her recliner. She was sitting up on her buttocks with her legs bent up in front of her. The resident indicated she was going to the bathroom and lost her balance causing her to fall. Resident 30's walker was within reach; she was wearing socks and shoes. A head-to-toe assessment was completed. No injuries, redness, or bruising was noted due to the fall. The resident was assisted off the floor and into a standing position by two staff members. The resident denied any pain or discomfort and she was ambulating per her usual. A nursing progress note, dated 10/13/24 at 2:15 p.m., indicated Resident 30 had complaints of left wrist pain and was requesting Tylenol. Resident 30's left wrist was slightly discolored and appeared to be turning into a bruise, although the discoloration wasn't quite purple in color. Her left wrist was slightly swollen. A suspected cause was from the resident being found on the floor around midnight last night. A new order was received for a left wrist x-ray. A nursing progress note, dated 10/14/24 at 3:21 a.m., indicated Resident 30 had a left distal radial fracture (a break in the radius bone near the wrist). A progress note, dated 10/14/24 at 9:51 a.m., indicated the nurse practitioner ordered that the resident be seen in the orthopedics' walk in clinic that day. A nursing progress note, dated 10/14/24 at 11:00 a.m., indicated Resident 30 returned for the orthopedic walk- in clinic with a cast placed on her left wrist. The resident was able to move all her fingers and thumb. She was to follow up with the orthopedics walk-in clinic in three weeks for x-rays and to ensure proper healing. A nursing progress note, dated 10/14/24 at 3:12 p.m., indicated Resident 30's code blue alarm was sounding. Resident 30 was sitting on her buttocks on the bathroom floor directly in front of the toilet. Staff were with the resident at the time of the fall and stated the resident left go of the railing and started to fall backwards. The staff member were able to lower the resident down to the floor. The resident did not hit her head. A head to toe assessment did not indicate injuries. A Morse Fall Scale report, dated 10/21/24, indicated Resident 30 was at a high risk of falling. A nursing progress note, dated 11/7/24 at 1:28 p.m., indicated Resident 30 was found sitting on the floor on the far side of the bed. The resident stated she slid/ lowered herself to the floor. She was assessed for injuries and denied hitting her head. The resident was assisted off the floor by staff members and her bed was moved against the wall. A nursing progress note, dated 11/17/24 at 11:26 p.m., indicated Resident 30 was found sitting beside her bed on the protective floor mat. A walker was beside the resident. Resident 30 indicated she was not trying to go to the bathroom. The resident denied bumping her head or having any pain/ discomfort. The resident was assisted back to bed by staff members. No apparent physical injuries were noted after the resident was assessed for injuries. A Fall Risk Evaluation, dated 11/17/24, indicated Resident 30 had three or more falls in the past three months, intermittent confusion, she was ambulatory, had poor vision, balance problems with walking, and decreased muscular coordination. A nursing progress note, dated 11/30/24 at 7: 45 p.m., indicated Resident 30 was found on the floor in her bathroom. The resident's walker was in the bathroom with the resident. The resident was wearing her tennis shoes. She indicated she was trying to go to the bathroom and missed the toilet. No injuries were noted after assessing the resident. A nursing progress note, dated 12/5/24 at 10:29 p.m., indicated staff heard a crash and found Resident 30 sitting on the floor mat by her bed. The nurse assessed the resident for injuries. The resident denied hitting her head and denied any pain. The resident's left elbow was pink and had a superficial scratch without any drainage. The resident was assisted to her feet by staff members and ambulated to the restroom. A progress note, dated 12/9/24 at 11:37 a.m., indicated a Fall Risk sign was placed in the resident's room. Point of Care documentation for every hour safety checks for the month of December 2024 were not completed as ordered. During an interview, on 1/2/25 at 9:42 a.m., CNA 17 indicated Resident 30 was on fall interventions including multiple motion censors and every hour safety checks which included checking for pain, potty, and position. Documentation was under the task tab in the computer. During an interview, on 1/2/25 at 9:43 a.m., the ADON indicated Resident 30 had numerous fall interventions in place, including hourly safety checks. Those safety checks included making sure the resident's needs were met. Documentation was listed under the task tab on the computer. Staff members checked it off once they have completed the checks. It should be checked off every hour. During an interview, on 1/2/25 at 10:31 a.m., CNA 18 indicated Resident 30 was on hourly rounding. Hourly rounding documentation was listed under the task tab. During an interview, on 1/2/25 at 1:53 p.m., the Administrator indicated the CNAs generally charted at the end of their shift and it would take time to back time all of their rounding's throughout their shift. A current policy, titled Fall Program, provided by the Administrator, on 1/2/25 at 2:10 p.m., indicated the following: .Interventions will be put in place based upon the assessment and as prevention for all new residents along with care plan review 3.1-45(a)(2)

Based on observation, record review, and interview, the facility failed to ensure appropriate clinical indications for the use of an antipsychotic medication for 1 of 5 residents reviewed for unnecessary medications. (Resident 2) Findings include: During an observation, on 12/26/24 at 12:42 p.m., Resident 2 sat in a recliner with her feet elevated. The television was on. During an observation, on 12/30/24 at 9:44 a.m., the resident sat in a recliner with her feet elevated. The television was on. During an observation, on 1/3/25 at 2:35 p.m., the resident sat in a recliner and looked at a book. Resident 2's record was reviewed on 12/30/24 at 10:24 a.m. Diagnoses included other recurrent depressive disorders, anxiety disorder, unspecified dementia, moderate with mood disturbance, unspecified dementia, moderate, with anxiety, and major depressive disorder, single episode, severe with psychotic features. Physician's orders included donepezil (for Alzheimer's) 10 milligrams (mg) - daily at bedtime (12/16/24), citalopram (antidepressant) 20 mg daily (5/2/24), risperidone (antipsychotic) 0.25 mg daily at bedtime (11/6/24), and tramadol (for pain) 50 mg two times a day (11/19/24). A 12/20/24 Minimum Data Set (MDS) assessment indicated the resident was cognitively intact. The resident felt down, depressed, or hopeless two to six days of the assessment period. She sometimes felt lonely or isolated from those around her. The resident exhibited verbal behavioral symptoms directed toward others one to three days of the assessment period. The resident wandered one to three days of the assessment period. The wandering did not put the resident at significant risk at getting into a potentially dangerous place. The resident's current behavior status, care rejection, and wandering had worsened since the prior assessment completed on 11/6/24. The resident required partial/moderate assistance with eating, oral hygiene, toileting, showering /bathing self, upper and lower body dressing, putting on /taking off footwear, and personal hygiene. Resident 2's current care plan for anxiety indicated episodes of anxiety and was to be observed for repetitive questions or statements, irritability, shortness of breath, and difficulty finding words she desired to use in conversation (initiated 11/24/23 and revised 12/28/24). The interventions included allow the resident time to answer questions and to express her feelings and/or fears, play calming music or a television program of interest, and redirect to meaningful activities of potential interest or activities of preference (all initiated 11/24/23). A current care plan for depression indicated she had stated she was experiencing episodes of depression and was to be observed for a decrease in socialization, a decrease in participation in activities of interest, irritability, and episodes of tearfulness. She had diagnoses of other recurrent depressive disorder and depressive disorder with psychotic features and took risperidone (initiated 11/24/23 and revised on 12/28/24). The interventions included allow the resident time to vent feelings and validate, encourage the resident to reminisce/share life stories, observe and report moods and behaviors, offer activities of preference or past enjoyment, and offer emotional support and reassurance (all initiated 11/24/23). A current care plan for resistance to care related to dementia indicated the resident could become verbally and physically combative with staff during care (initiated 12/26/24 and revised 12/28/24). Interventions included allow the resident to make choices, allow the resident to talk about feelings, assume a non-threatening posture: smile and talk with the resident in a pleasant, cheerful tone of voice, encourage as much participation/interaction by the resident as possible during care activities, establish a routine that is comfortable for the resident, maintain routine/minimize changes, give clear explanation of all care activities prior to and as they occur during each contact, give positive feedback, and if irritated, reapproach (all initiated 12/26/24). A current care plan for behaviors of getting up without assistance, not wanting/refusing assistance to use the bathroom, or using the walker indicated the resident could become irritated when staff attempted to assist the resident (initiated and revised 12/26/24). Interventions included anticipate and meet the resident's needs, assist the resident to a quiet area, reduce noise and stimulation around her, consider psych evaluation if appropriate, encourage participation in activities of enjoyment or previous interest, evaluate antecedents, such as noise levels, time of day, being tired, etcetera, evaluate the resident for items such as a recent medication change, an infection, etcetera, explain all procedures to the resident before starting and allow the resident time to adjust to changes, if the resident continues to be agitated but safe, leave the area and reapproach later, offer opportunities for physical exercise, snacks/nutrition and fresh air, provide opportunity for positive interactions, attention, for example, stop and talk with the resident as passing by, provide positive feedback to the resident, and talk with the resident in a calm voice (all initiated 12/26/24). A current care plan for the potential to be physically aggressive indicated the resident had a history of being physically aggressive with staff (initiated and revised on 12/26/24). Interventions included one on one with the Social Services Director (SSD), administer medications as ordered and monitor/document for side effects and effectiveness, allow the resident time to express herself and her feelings about the situation, anticipate and meet the resident's needs, consider counseling if appropriate, encourage as much participation/interaction by the resident as possible during care activities, give the resident as many choices as possible about care and activities, identify potential antecedents to physical aggression, if the resident continues to be agitated but safe, leave the area and reapproach later, and when resident becomes agitated, intervene before agitation escalates: guide away from source of distress; engage calmly in conversation (all initiated 12/26/24). A current care plan for being verbally aggressive indicated the resident had a history of yelling and cursing at staff (initiated and revised on 12/26/24). Interventions included one on one with the SSD, observe and document behavior, including attempted interventions, provide positive feedback to the resident, and redirect/distract with activities of interest (all initiated 12/26/24). A 9/6/24 at 10:01 a.m. progress note by the psychological services Nurse Practitioner (NP), indicated the resident was seen to follow up on a request by the pharmacy to attempt a gradual dose reduction of her psychotropic (drugs that affect a person's mental state) medications. The risperidone was discontinued. A gradual dose reduction attempt for the citalopram, lorazepam (antianxiety), and trazodone (antidepressant) was clinically contraindicated due to the discontinuation trial of the risperidone. A Nurses' Note, dated 9/18/24 at 1:40 p.m., indicated the resident told the CNA she was cold. When the CNA explained, they were going to go to the bathroom and get some clothes on, the resident called her a bitch. The room temperature was 73 degrees according to the room thermometer. A Nurses' Note, dated 9/21/24 at 11:08 a.m., indicated the resident had a knot and bruise on the right side of her upper forehead. The resident indicated she had hit her head on her bedside table when she fell asleep in her chair and denied pain or discomfort. Neurological checks were initiated. The medical provider was notified. A Nurses' Note, dated 9/25/24 at 11:30 p.m., indicated the resident kept getting out of bed by herself, would not leave her gown on, or leave or bed pad on her bed. She continued to transfer herself without her walker or wheelchair and did not use her call light. She urinated on the floor. A Nurses' Note, dated 9/25/24 at 11:41 p.m., indicated the resident was lying naked in her bed. Her hospital gown and bed pad were on the floor in her bathroom. She did not have a brief on. She indicated to the nurse she did not wear gowns at night, and she got them in the morning. The resident refused to put a gown on and got agitated. A Nurses' Note, dated 9/26/24 at 7:59 p.m., indicated the resident was in the hallway without clothes on. The resident was assisted to the bathroom, and morning care was given. The resident ambulated to the dining room with a scowl on her face. The resident yelled she wanted cold tea when asked if she would like hot tea. Iced tea was prepared. The resident yelled she wanted it in a mug. The resident refused to speak anymore. She fed herself in the dining room. A Progress Note, dated 9/26/24 at 11:40 a.m. by the psychological services NP, indicated the resident was seen to follow up on the recent discontinuation of the risperidone. The resident was visited in her room with no distress noted. Medications and behaviors were reviewed. The current psychiatric plan of care was continued. A Nurses' Note, dated 9/26/24 at 1:05 p.m., indicated the resident had removed all her clothing and refused to get dressed. She eventually agreed to get dressed. A Nurses' Note, dated 9/27/24 at 12:28 p.m., indicated the resident had a behavior and did not listen to suggestions to go to the recliner and rest. The resident did not want to take her UTI stat medication. She was encouraged to transfer and move but was not amenable. She seemed to understand, but did not seem to want to follow instructions. An assessment for stroke was performed, and no signs or symptoms of stroke were observed. The resident moved her tongue out of mouth involuntarily multiple times. A Nurses' Note, dated 9/27/24 at 5:55 p.m., indicated the resident did not act appropriately. She was found walking in the room with no clothes or shoes on. The resident was assisted with dressing and assisted to chair. She was found again with no shirt or shoes on. The resident indicated she did not want to be dressed because her back hurt. The resident declined to put hard sole shoes on but did accept slippers. A Nurses' Note, dated 9/28/24 at 1:07 a.m., indicated the resident got up from bed twice through the shift and walked beside her bed using the wheelchair as a walker. She told the staff she went to the bathroom, but no output was seen in the toilet bowl. A Nurses' Note, dated 9/28/24 at 7:22 a.m., indicated the resident was resting in bed and declined to get dressed and come down to breakfast. She complained of back pain. Acetaminophen (oral pain med) and trolamine salicylate (topical cream for pain) were administered. A Nurses' Note, dated 9/28/24 at 9:24 a.m., indicated the resident was up ambulating in her room completely dressed with her walker. She denied pain or urgency with urination. Her urine was clear amber color with no foul odor. A Nurses' Note, dated 9/28/24 at 11:26 a.m., indicated the resident had removed her clothing and sat in her chair. She refused to eat lunch in the dining room. A Nurses' Note, dated 9/28/24 at 1:12 p.m., indicated the resident wore a gown and sat in her recliner. She had a large bowel movement in her chair. A Nurses' Note, dated 9/28/24 at 1:41 p.m., indicated the primary care NP was notified. New orders were received for a stat urinalysis with a culture and sensitivity, vital signs every shift for 48 hours, initiate hypodermoclysis (administration of fluids into the subcutaneous tissue to provide hydration) to the abdomen of normal saline 1000 milliliters (ml) at 50 ml/hour and ceftriaxone (antibiotic) 1 gram intramuscularly on 9/28/24 and 9/29/24. A Nurses' Note, dated 9/29/24 at 5:04 a.m., indicated a urine specimen was collected and sent to the lab. A Nurses' Note, dated 9/29/24 at 9:42 a.m., indicated the urinalysis results indicated a culture was not indicated. The resident's morning care was completed without difficulty and she fed herself breakfast in her room. A Nurses' Note, dated 9/29/24 at 1:02 p.m., indicated the resident had no abnormal behaviors that shift. A Nurses' Note, dated 9/29/24 at 9:03 p.m., indicated the resident was found standing up using her walker without assistance twice. She was found once after taking herself to the toilet. A Nurses' Note, dated 9/30/24 at 9:49 a.m., indicated the psychological services NP was notified of the increase in behaviors. The NP indicated she would like the resident to be monitored for sleep patterns to ensure the resident was getting adequate sleep. A Nurses' Note, dated 9/29/24 at 10:23 p.m., indicated the resident was found on the floor in her room lying on her left side. Her gown was wet. A Nurses' Note, dated 9/30/24 at 12:11 p.m., indicated the resident refused to get up in the morning. She lay in bed until 11:00 a.m. She was incontinent of bowel and bladder and used the call light multiple times saying she did not get her medications. A Nurses' Note, dated 9/30/24 at 1:05 p.m., indicated the resident was thrusting her tongue out of her mouth constantly. A Nurses' Note, dated 9/30/24 at 7:06 p.m., indicated the resident was found lying in front of the window. The resident indicated she was trying to close the blinds for the evening and tripped on her call light cord. She hit her elbow on the air conditioning unit. A Nurses' Note, dated 9/30/24 at 10:13 p.m., indicated the resident was reminded to call for help. She was brought out to the lounge area to sit after supper. She was assisted to the bathroom and brought back out to the lounge. She asked to get ready for bed at 8:45 p.m. She was assisted with bedtime care, assisted to her recliner, and reminded to call when she was ready to go to bed. She was checked on at 9:30 p.m. She had transferred herself to her bed. A Nurses' Note, dated 10/1/24 at 5:03 p.m., indicated the resident was checked on throughout the night. The resident was awake each time. The resident indicated she had not slept at all. A Nurses' Note, dated 10/1/24 at 12:13 p.m., indicated the resident stated she was up all night. She had not been seen napping throughout the shift, which was a change, as the resident normally napped some throughout the day. A Nurses' Note, dated 10/1/24 at 11:30 p.m., indicated the resident was upset and wanted a bed pad on her bed, but wanted a white one not a blue one. She scooted to the bottom of the bed and curled up in a ball. She repeatedly said she needed a white bed pad on her pad. Staff attempted various things to help her, and resident refused. A Nurses' Note, dated 10/2/24 at 3:00 a.m., indicated the resident was found on the floor sitting by her room chair with her walker overturned. The resident had a bruise on her left foot. The resident indicated she was going to the bathroom when she fell . A Nurses' Note, dated 10/2/24 at 9:12 a.m., indicated the resident was in the hallway repeatedly stating she was ready for dinner and ready to go up. The resident became agitated with the foot pedals on her wheelchair, When the foot pedals were removed to get the wheelchair closer to the table the resident insisted on having foot pedals on and under her feet. The foot pedals were moved back. The resident continued to request the foot pedals be moved back and forth. She leaned forward as far as she could nearly falling several times. She repeatedly put her finger in her hot water in her tea cup and stated it was cold. The resident's brow was furrowed with facial grimacing. The hot water had steam. A Nurses' Note, dated 10/2/24 at 10:45 a.m., indicated the resident's neck and back were massaged with a topical menthol analgesic. The resident smacked her lips and fixated on a bracelet. A Nurses' Note, dated 10/2/24 at 11:34 a.m., indicated the psychological services NP was notified of the staff's report of the resident being restless and agitated. The resident sat at the table for lunch. The resident was smiling and talkative. She indicated she had fallen last night and was looking for her blanket. The resident had some difficulty finding her words and smacked her lips repeatedly throughout the conversation. A Nurses' Note, dated 10/2/24 at 12:33 p.m., indicated the psychological services NP gave a new order for risperidone 0.25 mg every bedtime for dementia with behavioral disturbance. A Nurses' Note, dated 10/3/24 at 9:55 p.m., indicated the resident refused morning care. She indicated it was only 5:15 a.m., and she would get up at 9:00 a.m. The resident was told it was 10:00 a.m. She yelled it was not. The resident had not been sleeping all morning. She had been awake and refused to get out of bed with all staff attempts. A Nurses' Note, dated 10/3/24 at 1:11 p.m., indicated the resident continued to lie in bed and refused morning care. She refused to go to the bathroom for toileting. She allowed the CNA to reposition her in bed twice during the shift. A Progress Note, by the psychological services NP, dated 10/4/24 at 11:06 a.m., indicated the resident was seen to follow up on a failed attempt to discontinue risperidone. The notable events were agitation and uncontrolled tongue thrusts. The staff reported that the resident experienced irritable moods and a worsening of symptoms of insomnia. The staff reported the resident had been hyper fixated on multiple issues. The resident was visited in the dining room with no distress noted. A Nurses' Note, dated 10/7/24 at 12:20 a.m., indicated the resident was restless and complained the room was too hot. She was offered a fan, and she said it would get too cold. She was assisted to the bathroom and a sheet was obtained for her to use instead of a blanket. A Nurses' Note, dated 10/7/24 at 6:21 a.m., indicated the resident was restless throughout the night and had the call light gripped in both hands. She turned on the call light frequently to let staff know she was awake, she was in bed, or she wished the staff would leave her alone so that she could get some sleep. A Nurses' Note, dated 11/1/24 at 4:32 p.m., indicated the resident tried to walk with a wheelchair. The CNA encouraged the resident to use her walker. A Nurses' Note, dated 12/4/24 at 4:05 p.m., indicated the resident continued to attempt to use a wheelchair as a walker. During an interview on 1/3/25 at 12:41 p.m., the SSD indicated the resident had been on the risperidone for a long time. She had a gradual dose reduction and experienced all kinds of behaviors. She provided pink behavior sheets filled out by the CNAs for the behaviors during the gradual dose reduction trial. A behavior sheet, dated 9/21, provided by the SSD on 1/3/25 at 12:41 p.m., indicated the resident had been denying the time, when she was told breakfast was over soon. She said she was not ready to get up. When the CNA left, the resident got herself dressed and started walking down to breakfast. The resident said the staff did not get her up or it was too late. She complained of not sleeping. A behavior sheet, dated 9/28/24 at 1:53 p.m., provided by the SSD on 1/3/25 at 12:41 p.m., indicated the resident refused to keep her clothes on and removed them three times. She removed her brief and had a trail of feces from her chair to the toilet. A behavior sheet, dated 9/29/24 at 8:00 p.m., provided by the SSD on 1/3/25 at 12:41 p.m., indicated the resident pushed her call button repeatedly. She was mean and aggressive. A behavior sheet, dated 9/30/24 at 9:00 p.m., provided by the SSD on 1/3/25 at 12:41 p.m., indicated the resident yelled at the CNA because the resident's wheelchair was not in the right place. When the CNA fixed the wheelchair location, the resident screamed at the CNA to get out. A behavior sheet, dated 9/30/24 at 4:00 p.m., provided by the SSD on 1/3/25 at 12:41 p.m., indicated the resident kept getting up on her own. She then fell . She wanted to get up on her own all the time. During an interview, on 1/3/25 at 2:20 p.m., the SSD indicated the resident had previously gone to a mental health center and had been diagnosed with other specified disruptive, impulse control, and conduct disorder. During an interview, on 1/3/24 at 2:35 p.m., CNA 7 indicated if any residents have any behaviors a pink behavior slip is filled out. She had not provided care often for the resident, but had not had any problems with her when she did provide care. She was uncertain where to look for the interventions to provide for a resident's care such as behaviors and falls but would speak to her supervisor to ensure she had the right answer. During an interview, on 1/3/25 at 2:38 p.m., RN 8 indicated the last time the resident's medication was changed, she had an increase in confusion. The resident had a lot of tongue movements too. RN 8 had performed multiple assessments on the resident checking for stroke and other possible causes for her change in behavior. The NP had been notified at that time. The resident was sometimes alert and oriented to person, place, and time. The resident was offered snacks and activities to help her mood. She had always been compliant taking her medications for RN 8. During an interview, on 1/3/25 at 2:45 p.m., CNA 7 indicated when they charted, they could see some of the interventions, but not all of them. She would check with the nurse to find out what the interventions were for the residents to make sure she was using all of them. During an interview, on 1/3/25 at 2:48 p.m., LPN 9 indicated she had been providing care for the resident for about a month. She had been trying to use her wheelchair instead of her walker for ambulation. She went to therapy, and they worked with her and got her a different walker. She did not use her wheelchair anymore. The psychological services NP had recently discontinued the resident's antianxiety medication and increased her pain medication. LPN 9 believed the resident was having more pain than anxiety. The change had helped her. The resident had no other behaviors of which she was aware. During an interview, on 1/3/25 at 3:13 p.m., CNA 7 indicated she was not sure what the resident's behaviors were other than trying to walk with her wheelchair instead of her walker. Her mood changes could also go into psychosis, she thought as the resident thought she was more capable than she really was. During an interview, on 1/3/25 at 3:16 p.m. LPN 9 indicated she believed the resident's psychosis was exhibited by her not being able to be redirected, and it was difficult to explain. For example, the resident insisted on using a wheelchair for walking instead of the walker because she believed therapy had told her to use the wheelchair for a walker. The resident did not hit or yell, she just argued. She had difficulty understanding concepts when she was experiencing her psychosis. During an interview, on 1/3/25 at 3:20 p.m., RN 8 indicated when she took care of the resident during her episodes of tongue movements and her ability to understand and comprehend was impaired that was when the resident was exhibiting her symptoms of psychosis. She believed the psychosis mimicked a stroke. During an interview, on 1/3/25 at 3:24 p.m., the SSD indicated for the resident's psychosis the staff told her the resident can be very delusional. The staff told her a couple of months ago the resident was not making sense. She thought the resident's psychosis presented as the resident told the staff one day her resident representative took her remote control. The SSD found the remote and did not put a progress note in. The resident representative had taken the remote to the staff and asked them to turn on happy shows and not sad as he believed sad shows worked her up. Another example was when the resident sat on her walker and wheeled herself backwards. The SSD tried to talk to the resident. The resident told the SSD she was done. Then, she ignored the SSD. The resident was just different. The SSD indicated she did not really know how to explain what the resident's psychosis symptoms looked like. During an interview, on 1/3/25 at 3:46 p.m., the DON indicated the resident's psychosis was the behaviors she had. When she was experiencing psychosis, they had her at the nurses' station to keep her occupied. She did not respond to redirection at all. The resident was not herself. She did not believe the resident was self-aware of any of the behaviors she demonstrated. The Risperdal (risperidone) manufacturer's label, accessed 1/3/25 at 2:25 p.m. at the accessdata.fda,gov website, had a black box warning which indicated WARNING: INCREASED MORTALITY IN ELDERLY PATIENTS WITH DEMENTIA-RELATED PSYCHOSIS .Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Risperdal is not approved for use in patients with dementia-related psychosis. Risperdal's indications for use included only the treatment of schizophrenia, for short-term treatment of acute manic or mixed episodes associated with Bipolar I disorder, and the treatment of irritability associated with autistic disorders. A current facility policy, revised 11/2016, titled PSYCHOTROPIC MEDICATIONS, provided by the DON on 1/3/25 at 4:32 p.m., indicated .Psychotropic medications shall only be used when there is adequate indication for their use. The facility will not allow psychotropic medications of any type for the purpose of resident discipline of staff convenience 3.1-48(a)(4)

Based on observation and interview, the facility failed to dispose of unlabeled and unused medications for 2 of 3 medication carts reviewed for medication storage and labeling. (Medication Cart B and Medication Cart C) Findings include: During a medication storage observation of Medication Cart B, accompanied by RN 8 on [DATE] at 9:45 a.m., a pill in an unlabeled medication cup was in the second drawer, towards the back of the cart. RN 8 indicated the medication had been pulled from the drawer prior to checking a resident's blood pressure. Since the blood pressure was not within range, the medication was not administered. Two additional pills were found loose on the bottom of the drawer. RN 8 indicated the pills should be disposed of. During an interview with the ADON, on [DATE] at 9:48 a.m., she indicated the loose medications should be disposed of immediately. During a medication storage observation of Medication Cart C, accompanied by QMA 16 and the ADON on [DATE] at 10:03 a.m., a pill in an unlabeled medication cup was in the top drawer. QMA 16 indicated the medication had been there for a long time. An additional pill was loose at the bottom of the drawer. The ADON indicated the pills should be disposed of. During an interview with the Administrator, on [DATE] at 11:22 a.m., she indicated the medication carts had just been gone through a week prior. During an interview with RN 8 on [DATE] at 9:51 a.m., she indicated loose pills should be placed in the drug buster solution for disposal. A current, undated facility policy, titled Destruction of Medications, provided by the Administrator on [DATE] at 3:52 p.m., indicated the following: .All unused, contaminated, or expired prescription drugs shall be disposed of in accordance with state laws and regulations .1) Drugs will be destroyed in a manner that renders the drugs unfit for human consumption and disposed of in compliance with all current and applicable state and federal requirements. 2) Unused, unwanted and non-returnable medications should be removed from their storage area and secured until destroyed 3XXX,d+[DATE](j)

Based on interview and record review, the facility failed to ensure staff reported a resident's change in condition to the nurse before proceeding with care and failed to complete a physical assessment after an unwitnessed fall with head injury for a cognitively impaired and dependent resident for 1 of 3 residents reviewed for accidents (Resident B). Findings include: The clinical record for Resident B was reviewed on [DATE] at 10:45 a.m. Diagnoses included dementia, spastic hemiplegia to non-dominant left side, hypertension, stage 3 chronic kidney disease, anxiety disorder, and osteoarthritis. The most current, quarterly, MDS (Minimum Data Set) assessment, dated [DATE], indicated Resident B was severely cognitively impaired and rarely or never understood. The resident lived on the secured unit and required extensive assistance of 2 persons for transfers and toileting. A progress note, dated [DATE] at 6:20 a.m., indicated Resident B was found lying on her left side next to the toilet, with a pool of blood running next to her head. She was unresponsive. Per the CNA, the resident was sitting on the toilet and fell off. RN 2 and two CNAs assisted Resident B off the floor and into a wheelchair. The resident was very heavy during the transfer. During the transfer into the wheelchair, the resident turned blue in color and was not responding. CPR was not initiated as she had elected a DNR (Do Not Resuscitate) order. RN 2 and three CNAs assisted the resident from her wheelchair and onto the bed. RN 2 and LPN 1 determined Resident B was deceased . A progress note, dated [DATE] at 6:20 a.m., indicated LPN 1 responded to a code blue light for Resident B. Resident B was noted to by laying on the floor with her bilateral feet near the toilet and her head pointed toward the bathroom door, with blood pooling under the left side of her head with her eyes open. The CNA indicated the resident fell off of the toilet. RN 2 stayed with the resident and 2 CNAs while LPN 1 left to call 911. Staff notified LPN 1 that the residents' respirations had ceased and she was without a pulse, and was blue in color. Her DNR status was confirmed. The clinical record lacked assessment of Resident B after the unwitnessed fall. The most current vital signs were documented on [DATE]. The Post Fall Investigation, dated [DATE] at 6:30 a.m., indicated vital signs were not within normal range, but did not indicate measurements of vital signs. In a written statement from the facility investigation, on [DATE], CNA Student 3 indicated that CNA 4 and herself assisted Resident B out of bed and placed her on the toilet. Resident B looked stable and the CNA stated they normally left the resident unattended while on the toilet. The CNAs left the restroom and started providing care to Resident B's roommate. They heard a bang and went into the restroom and found Resident B on the floor and bleeding from her head. CNA Student 3 pulled the code blue light to alert staff that assistance was needed. In a written statement from the facility investigation, on [DATE], CNA 4 indicated prior to transferring Resident B to the toilet, the resident didn't have her normal color and was almost pale, with a gray undertone. Both herself and Student CNA 3 placed a gait belt around Resident B, causing the resident to start tensing up. This caused the CNAs to have trouble getting their arms around the resident to get her up. They placed the resident on the toilet and adjusted her ,d+[DATE] times to make sure she was far enough back. After adjusting her, they both left to strip her bed. CNA 4 walked into the bathroom and saw the resident a couple inches off the ground. After CNA Student 3 pulled the code blue cord, CNA 4 left to go find help. RN 2 arrived and told them they needed to get Resident B up off the floor. They struggled to get the resident off the floor and into her wheelchair while holding a towel on her head. CNA 4 noticed the resident looked gray. They transferred the resident from her wheelchair into bed. Resident B did not make any sounds while she was falling or laying on the ground. During an interview on [DATE] at 1:03 p.m., LPN 1 indicated on [DATE], at approximately 6:20 a.m., the code blue light went off. LPN 1 and RN 2 ran to the resident's room. The resident was on the floor with their feet towards the toilet, and the left side of their forehead on the floor, with blood pooling beneath their head. The resident's eyes were open, but the resident was unresponsive. LPN 1 did not hear the resident make any noise. LPN 1 indicated the resident's color was good. LPN 1 left the room and called 911 and the physician. After making the calls, LPN 1 started to return to the room. On the way to the resident's room, LPN 1 was informed by staff the resident had died . When LPN 1 arrived at the resident's room, the resident's color was off. LPN 1 and RN 2 monitored the resident for breath sounds and heart beat, but Resident B did not have either present. During an interview on [DATE] at 1:27 p.m., Student CNA 3 indicated, on [DATE] during the morning care, she and CNA 4 were getting Resident B up for the day. The CNAs transferred the resident to the wheelchair and then to the toilet. They had to adjust the resident on the toilet ,d+[DATE] of times before leaving the resident alone in the bathroom. CNA Student 3 indicated the resident had requested privacy. CNA Student 3 had never provided care to Resident B before, and was not familiar with the resident. While providing care to the resident's roommate, they heard a big bang and went to the bathroom to investigate. Resident B was observed on the floor and her head was bleeding. The resident did not say anything. CNA Student 3, CNA 4, and RN 2 picked the resident up and placed her in a wheelchair, then transferred the resident from the wheelchair to the bed. The resident did not make a sound during any of the transfers. Once the resident was in bed, RN 2 checked for respirations and found none. During an interview on [DATE] at 2:03 p.m., RN 2 indicated, on [DATE], she had just gotten to work and received report when the code blue alarm sounded. RN 2 and LPN 1 ran to the resident's room. The resident was on the bathroom floor, with her head bleeding. RN 2 indicated their first reaction was to get the resident to safety and get help. The resident was verbally unresponsive, had a gray pallor, and the resident's eyes were open and not moving. She was not making any sounds. RN 2 told LPN 1 to call 911 and the physician. RN 2, CNA Student 3, and CNA 4 transferred the resident to the wheelchair and then from the wheelchair to the bed. Once the resident was in bed, she turned blue. The resident was found to have no pulse or heartbeat. She did not remember if the resident had any independent movement during the transfers. RN 2 did not assess the resident. During an interview, on [DATE] at 3:12 p.m., LPN 11 indicated Resident B was verbal at times, but normally would just yell. Resident B required two-person assistance with transfers and activities of daily living. During an interview, on [DATE] at 3:27 p.m., CNA 8 indicated Resident B needed complete support with her activities of daily living including transferring on and off the toilet. She did not leave the resident unattended in the bathroom, due to resident leaning toward her left side while sitting on the toilet. During an interview, on [DATE] at 4:06 p.m., ADON indicated, during an unwitnessed fall with injury for a cognitively impaired resident, she would start doing assessments and not move the resident to prevent further harm if they were unconscious. During an interview, on [DATE] at 9:46 a.m., the ADON indicated it was not appropriate to move/transfer a resident who was found unresponsive after an unwitnessed fall. The nurse should assess the resident. During an interview, on [DATE] at 12:59 p.m., the DON and ADON indicated when a resident fell , an assessment should always be completed. An assessment should contain vital signs and a head to toes assessment. After reviewing the clinical record, neither the DON nor the ADON could find an assessment of Resident B after the fall on [DATE]. The DON and ADON both indicated there should have been an assessment completed and staff should not have moved the resident from the floor. During an interview, on [DATE] at 1:34 p.m., both the DON and ADON indicated if a resident presented with a change in condition, this information should be discussed with the nurse. Review of a current policy, darted [DATE], titled Head Injury was provided by the Administrator on [DATE] at 9:15 a.m. The policy indicated the following: Procedure: 1. Assess resident following a known, suspected, or verbalized head injury. The assessment shall include, at a minimum: a. Vital Signs. b. General condition and appearance. c. Neurological evaluation for changes in: i. Physical functioning 11. Behavior iii. Cognition iv. Level of consciousness v. Dizziness vi. Nausea vii. Irritability viii. Slurred speech or slow to answer questions. d. Evaluation of the head, eyes, ears, and nose for significant changes in vision, hearing, smell, or bleeding Review of a current policy, dated ,d+[DATE], titled Fall Assessment Policy was provided by the Administrator on [DATE] at 4:20 p.m. The policy indicated the following: Procedure: 1. Call for nurse and stay with the resident 2. Check to see if resident is breathing 3. Do not move resident 4. Reassure resident by talking to him/her in a calm and supportive manner 5. Apply direct pressure to any bleeding area 6. Check resident's pulse, respiratory rate and blood pressure; If resident is a DIABETIC-MAY check the residents blood glucose level. This citation relates to Complaint IN00432892. 3XXX,d+[DATE](a)

Based on observation, interview, and record review, the facility failed to ensure a current copy of the resident's advance directive was in their clinical record for 1 of 1 residents reviewed for advance directives. (Resident 54) Review of Resident 54's clinical record was completed on [DATE] at 3:08 p.m. Diagnoses included unspecified dementia, episodic paroxysmal anxiety, depressive disorder with severe psychotic symptoms, and body dysmorphic disorder. A current, [DATE], physician order indicated the following: Description - DNR Advance Directive Status: Verified With Family Only. During a review of a [DATE] care plan, on [DATE] at 3:30 p.m., it indicated the resident desired to be a DNR (do not resuscitate) and her wishes would be honored. Instructions were to get a signed DNR with a physician's signature. Code status was to be reviewed as needed. There was no advance directive document in the resident's electronic health record. During an interview on [DATE] at 9:06 a.m., the DON provided a document titled Treatment Option Declaration - Patient with Capacity, signed by Resident 54. The document indicated the resident chose supportive care with no CPR (cardiopulmonary resuscitation), had designated a health care representative, and signed and dated the document on [DATE]. The DON indicated she was unable to find the original document and had provided a new one to the resident. There was no physician's signature. A current facility policy/procedure, dated ,d+[DATE], provided by the Administrator on [DATE] at 5:00 p.m., indicated the following: .Advance Directives & Residents' Rights - It is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an advance directive. Definitions: 'Advance Directive' is a written instruction, such as a living will or durable power of attorney for health care, recognized under state law (whether statutory or as recognized by the courts of the state), relating to the provision of health care when the individual is incapacitated. Policy Explanation and Compliance Guidelines: .1) On admission, the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident would like to formulate an advance directive .3) Upon admission, should the resident have an advance directive, copies will be made and placed on the chart as well as communicated to the staff .9) Any decision making regarding the resident's choices will be documented in the resident's medical record and communicated to the interdisciplinary team and staff responsible for the resident's care 3XXX,d+[DATE](ii)(5)

Based on observation, interview, and record review, the facility failed to apply a dynamic elbow brace per physician's order for 1 of 1 resident reviewed for range of motion. (Resident 50). Findings include: Resident 50 clinical record was reviewed on 2/24/24 at 9:08 a.m. Diagnoses included dementia and spastic hemiplegia affecting left nondominant side (muscle tightness and involuntary contractions in extremities on left side of body). Current orders included the resident to wear dynamic elbow splint to left upper extremity; put on at 8 a.m. and remove at 12 noon. During an observation, on 2/22/24 at 8:45 a.m., she was lying in bed and was not wearing her dynamic elbow brace. The brace was laying on the recliner. During an observation, on 2/22/24 at 10:10 a.m., she was lying in bed and was not wearing her dynamic elbow brace. The brace was laying on the recliner. During an observation, on 2/22/24 at 11:24 a.m., she was lying in bed without wearing her dynamic elbow brace. The brace was laying on the recliner. During an interview, on 2/22/24 at 11:26 a.m., the Resident representative indicated when he arrived, the resident was lying in bed and was not wearing her dynamic elbow brace. During an observation, on 2/22/24 at 11:52 a.m., she was eating lunch without wearing her dynamic elbow brace. During an interview, on 2/23/24 at 10:07 a.m., CNA 12 indicated the resident did not wear her brace while lying in bed. Her dynamic elbow brace was applied once she got into her chair. During an observation, on 2/23/24 at 1:30 p.m., she was sitting in her wheelchair wearing her dynamic elbow brace to her left arm. During an interview, on 2/23/24 at 1:31 p.m., QMA 13 indicated the resident wore her dynamic elbow splint once she was out of bed. During an interview, on 2/26/24 at 4:12 p.m., RN 14 indicated she constantly wore her dynamic elbow brace, even when she was lying in bed. During an interview, on 2/26/24 at 4:17 p.m., the DON indicated she expected the resident to be wearing her dynamic elbow brace between 8 a.m. and noon per physician order. During an interview, on 2/26/24 at 4:40 p.m., the DON indicated the resident usually refused to wear her dynamic elbow brace. During her record review, on 2/26/24 at 4:45 p.m., clinical record lacked indication of the residents refusal to wear the dynamic elbow brace. Review of the current policy, revised 1/23, titled Splinting Interventions, provided by the Administrator on 2/26/24 at 2:40 p.m., indicated the following: .1. Verify physician's order for splint; which extremity, and frequency of splinting 3.1-37(a)

Based on observation, interview and record review, the facility failed to ensure the abuse of a resident did not occur in regards to a personal photograph and/or video having been taken and shown to other people without proper consent and failed to ensure verbal coercion did not occur in regards to a staff member requesting a resident say something inappropriate prior to receiving assistance for care for 1 of 3 residents reviewed for abuse (Residents B, CNA 1). Finding include: An Indiana Department of Health (IDOH) reportable was provided by the Administrator on 4/21/22 at 8:45 a.m. The reportable indicated a member of the community reported to the facility a video of a resident was on the phone of a CNA who had worked at the facility. The community member knew the CNA had worked at the facility back in September 2021. The video was of a female resident with her pants down around her ankles. The person on the video was heard saying I'll let you get up if you say it, kill, kill, kill. The resident attempted to stand and the person stated sit down say it and I will help you get up. The community member was not made aware the person in the video was a resident at the facility. The community member indicated CNA 1 also told her and others that when she has cared for men she would flip their testicles while she was wiping them. The police and spouse were notified of the incident. The clinical record for Resident B was reviewed on 4/21/22 at 8:12 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident B admitted to the facility on [DATE] from another facility. The most recent 5-day Minimum Data Set (MDS) assessment, dated 4/6/22, indicated the had moderate cognitive impairment. She required extensive 2-person assistance with toileting, dressing and transfers. Resident B resided on the Memory Care Unit. A health care plan, dated 7/30/21, indicated the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included, but were not limited to, speak in a calm manner and make sure the resident feels respected and supported. Another health care plan, dated 10/21/21, indicated the resident had behaviors during staff care that included yelling inappropriate words. Interventions included, but were not limited to, provide opportunity for a positive interaction. Resident B received the following medications: [MEDICAL RECORD OR PHYSICIAN ORDER] a. [MEDICATION(S)] (medication for [CONDITION(S)] and acute [CONDITION(S)] [CONDITION(S)]) 500 mg twice daily for [CONDITION(S)] disorder. b. [MEDICATION(S)] (to treat dementia in people with [CONDITION(S)] disease) patch 9.5 mg/24 hours for Alzheimer's disease. c. [MEDICATION(S)] (antipsychotic medication) 3 mg twice daily for [CONDITION(S)] disorder. A psychiatric visit progress note, date 8/12/21 at 9:31 a.m., indicated the resident recently had an increase in [MEDICATION(S)] which was reported as helpful. A behavioral report, dated 8/21/21 at 9:33 a.m, indicated during morning care, the resident was making comments that included kill you!, kill you!, kill you! and i s--- my pants. The resident was impatient at breakfast and yelling out demands. A behavior report, dated 8/22/21 at 12:50 p.m., indicated the resident was yelling out during care stating i'm [sic] going to kill you. A behavior report, dated 9/5/21 at 12:31 p.m., indicated the resident yelled I'M GONNA KILL YOU! KILL KILL KILL! Staff left and re-approached later with a different staff person. Review of the staff schedule, CNA 1 worked on Memory Lane on 8/21/21 from 5:49 a.m.- 2:03 p.m., 9/5/21 from 5:50 a.m.- 2:05 p.m., and 9/13/21 from 1:53 p.m.- 10:01 p.m. Review of task documentation, CNA 1 indicated she provided activities of daily living-bathing for Resident B on 9/13/21 at 8:19 p.m. Review of CNA 1's new-hire education courses, she completed the following: a. Dementia training 1/14/21. b. Reporting a reasonable suspicion of a crime - Elder Justice Act 1/14/21. c. Social media policy and cell phone use 1/14/21. d. Our specialized population 1/14/21. During an interview on 4/21/22 at 9:49 a.m., the Administrator indicated she interviewed the 2nd shift supervisor and the Memory Lane Director. Neither employee voiced any concerns or knowledge any other staff person were aware of the photograph and/or video images of Resident B being taken. On 8/21/22 at 11:56 a.m., the Administrator indicated the video was time-stamped at 8:00 p.m. on 9/13/22. The video showed the resident in the common bathroom on Memory Lane. On 4/21/22 at 12:22 p.m., the cell phone video was viewed with the Administrator and was consistent with the IDOH reportable. Review of a current facility policy, dated 2010 and revised 9/17, titled Abuse, Neglect and Exploitation, which was provided by the Administrator on 4/21/22 at 8:12 a.m., indicated the following: Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of property. Definitions: .Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment It includes verbal .facilitated or enabled through the use of technology. .IV. Identification of Abuse, Neglect and Exploitation .B. Possible indicators of abuse include, but are not limited to: .7. Psychological abuse of a resident observed 8. Failure to provide care 9. Evidence of photographs or videos of a resident that are demeaning or humiliating in nature, regardless of whether the resident provided consent This Federal tag relates to Complaint IN 803. 3.1-27(a)(1)

Based on interview and record review, the facility failed to ensure the necessary number of people to assist in transfer to prevent a fall for 1 of 3 residents reviewed for accidents. This failure resulted in surgical repair of a hip fracture and a subdural hematoma (a collection of blood between layers of the tissue that surround the brain). (Resident B, CNA 1) Findings include: The clinical record for Resident B was reviewed on 9/25/17 at 9:07 a.m. [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS), dated [DATE], indicated Resident B was cognitively intact. Resident B required total dependence with two person assistance with transfers. A physician's orders [REDACTED]. On 8/11/17, a Morse Fall Scale (a rapid and simple method of assessing a patient's likelihood of falling), indicated Resident B was at a high risk for falls. A progress note, dated 9/17/17 at 9:59 a.m., indicated CNA 1 notified the nurse that Resident B was on the floor. Upon entering the room, the nurse indicated Resident B was laying on her right side with a pillow under the right side of her head. The mechanical lift was over the resident with the loops unattached to the lift. The nurse indicated Resident B had blood on the pillow from the right side of her head. The nurse indicated Resident B's left hip was shorter than the right hip. Resident B complained It hurts. A fall scene investigation, dated 9/17/17, indicated equipment malfunction. The report indicated Resident B was being transferred by staff at the time of the fall. Only one staff person was listed as having been present during the fall. Resident B was sent to the local hospital on [DATE], then transferred to a larger hospital on [DATE] with a [DIAGNOSES REDACTED]. Resident B had surgical repair of her left hip fracture on 9/18/17. A progress note, dated 9/23/17, indicated Resident B had a Percutaneous Endoscopic Gastrostomy (PEG) tube placed 8/22/17. She was noted to have an overall decline. Resident B returned to the facility on [DATE]. She was readmitted with 13 staples to three incisions on her left hip. Resident B returned to the facility under hospice care with a [DIAGNOSES REDACTED]. During an interview on 9/25/17 at 12:15 p.m., the Director of Nursing (DON), indicated CNA 1 had been terminated for not following facility policy for a two person transfer with a mechanical lift. Review of a current health care plan, dated 7/13/17 and revised 9/25/17, indicated Resident B required assistance with Activities of Daily Living (ADL) related to [DIAGNOSES REDACTED] and a history of a cerebrovascular accident. Interventions included, but were not limited to, Hoyer lift x 2 for transfers. Review of an in-service for proper use of the mechanical lift, dated 8/23/17, CNA 1 demonstrated correct use of the lift. A current health care policy, dated 10/2012, titled HOYER LIFT provided by the DON on 9/25/17 at 3:12 p.m., indicated the following: PURPOSE: A Hoyer Lift enables nursing personnel to lift and transfer a Resident to and from bed as safely and as easily as possible. POLICY: A Hoyer Lift .never to be used without two (2) staff members present. This Federal tag relates to Complaint IN 887. 3.1-45(a)(2)

Based on interview and record review, the facility failed to ensure residents who were transferred using a mechanical lift were transferred with sufficient staff assistance to prevent accident and injury for 1 of 3 residents reviewed for accidents. This failure resulted in a tibia and fibula fracture of the left leg of the resident (Resident D). Findings include: The clinical record for Resident (D) was reviewed on 3/24/14 at 10:00 a.m. [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) assessment, dated 3/18/14, indicated Resident (D) was cognitively intact. Resident (D) received the following Activities of Daily Living (ADL) assistance; transfer-total assist with two person assist, dressing, bathing and hygiene-extensive assistance with two person assist and eating-limited assistance with one person assist. Resident (D) was frequently incontinent of bowel and bladder. During review of the clinical record, a progress note, dated 3/11/14 at 7:54 p.m., indicated CNA #5 was transferring Resident (D) to the bathroom via Sara lift. Resident (D)'s foot was not completely on the platform and she began to fall. The CNA pulled the cord for assistance and staff responded. Resident (D) was moved from the bathroom to the bed. She had an observed skin tear to her left upper arm measuring 4.0 cm x 3.0 cm. The physician and Power of Attorney (POA) for Resident (D) were notified. A progress note, dated 3/12/14 at 3:44 a.m., indicated Resident (D) complained of knee pain. She again complained of pain at 8:32 a.m. The physician was notified and an order for [REDACTED]. The x-ray was obtained on 3/12/14 at 10:45 a.m. The x-ray noted a fracture of the left fibula. Resident (D) was seen by an orthopedic physician and returned to the facility on [DATE] at 2:45 p.m. Resident (D)'s left leg was immobilized related to a tibia and fibula fracture. Resident (D) was to remain non-weight bearing, no bending of left knee and bed rest at all times except for meal time. A health care plan problem, dated 2/14/11, indicated Resident (D) was a fall risk related to a history of falls and weakness. One of the approaches for the problem indicated "stand lift for transfer with 2 staff assist". During an interview on 3/26/14 at 10:45 a.m., the Director of Nursing (DoN) indicated Resident (D) was a 2 person assist. She indicated the CNA failed to follow the care plan as written, resulting in a fall and fracture. Review of the PRN (as necessary) medication report from 3/11/14 to 3/27/14, Resident (D) received the following medications for pain relief; hydrocodone-acetaminophen 5-325 mg 0.5 tablet- 3/11/14 at 8:36 p.m., 3/13/14 at 4:40 a.m., 3/14/14 at 8:25 a.m., 3/14/14 at 10:02 a.m., 3/15/14 at 2:52 p.m., 3/16/14 at 7:59 p.m., 3/17/14 at 2:49 p.m., 3/18/14 at 1:25 a.m., 3/21/14 at 1:23 a.m. and 3/22/14 at 1:47 a.m. hydrocodone-acetaminophen 5-325 mg 1 tablet- 3/12/14 at 3:44 a.m., 3/12/14 at 8:32 a.m., 3/12/14 at 4:45 p.m., 3/13/14 at 10:57 a.m., 3/13/14 at 5:06 p.m., 3/14/14 at 2:00 p.m., 3/14/14 at 9:26 p.m., 3/15/14 at 10:09 a.m., 3/15/14 at 9:34 p.m., 3/16/14 at 3:44 p.m., 3/17/14 at 12:33 a.m., 3/17/14 at 11:26 a.m., 3/17/14 at 9:12 p.m., 3/19/14 at 12:41 a.m., 3/21/14 at 12:21 p.m., 3/22/14 at 5:29 p.m., 3/25/14 at 6:20 p.m. and 3/26/14 at 11:27 a.m. Resident (D) was also receiving Methadone (synthetic opioid) 5 mg, 1/2 tablet every 12 hours for back pain with a start date of 3/20/14. During an interview on 3/26/14 at 2:00 p.m., 5 family members of Resident (D) gathered in the facility to discuss concerns related to the recent fall. One family member indicated the resident had significant pain and discomfort since the fall. The family member also indicated the resident had been less oriented and alert. In addition, the family member indicated the resident was sleepier and more confused since the fall. Resident (D) was observed on 3/24/14 at 7:50 a.m., asleep in bed. She was again observed on 3/25/14 at 7:45 a.m., dressed and seated in her wheelchair with eyes closed. She was observed at 7:50 a.m., seated at the assist table for breakfast with her eyes closed. On 3/27/14 at 11:10 a.m., Resident (D) was asleep in bed. Review of a current facility policy, dated 5/11, titled "Sara Lift", which was provided by the DoN on 3/26/14 at 1:30 p.m., indicated the following: "PURPOSE: Mechanical lifts are used to lift residents... PROCEDURE: STEP ACTION 1. Explain the procedure... 8. Ensure the resident's feet are supported evenly and flat on the foot rest plate." This Federal tag relates to Complaint IN 007 and IN 410. 3.1-45(a)(2)