Every finding on record at Heritage Pointe of Warren

Based on observation, interview, and record review, the facility failed to utilize infection prevention and control strategies to prevent contamination of a urinary catheter for 1 of 2 residents reviewed for indwelling catheters. (Resident 70)Findings include:During an observation, on 4/7/26 at 9:53 a.m., Resident 70's indwelling catheter drainage bag hung on the resident's bed frame. The bag touched the floor.On 4/8/26 at 10:58 a.m., Resident 70's indwelling catheter drainage bag hung on the resident's bed frame. The bag touched the floor.On 4/8/26 at 11:18 a.m., Resident 70 was laying on her back in her bed. Her indwelling catheter drainage bag hung on the top of the bed's footboard. The indwelling catheter tubing protruded from under the blanket at the foot of the mattress, ascended upwards, curved over the top of the footboard, and descended to insertion site on drainage bag. The tubing and bag were located above the level of Resident 70's bladder.On 4/8/26 at 2:28 p.m., Resident 70's indwelling catheter drainage bag hung on the resident's bed frame. The bag touched the floor.On 4/9/26 at 10:08 a.m., Resident 70's indwelling catheter drainage bag hung on the resident's bed frame. The bag touched the floor.Resident 70's clinical record was reviewed on 4/9/26 at 10:50 a.m. Diagnoses included chronic kidney disease, urinary retention (inability to fully empty bladder), and obstructive and reflux uropathy (blockage and backward flow of urine).Current physician orders included 18 French 30 milliliter bulb indwelling catheter to be changed every 14 days and as needed (4/1/26), catheter care every shift (9/12/24), urinary drainage bag changed weekly (11/4/25), and position catheter tubing below bladder level (9/12/24).A quarterly Minimum Data Set (MDS) assessment, dated 2/17/26, indicated Resident 70 had severe cognitive impairment. She was dependent on staff assistance for toileting and personal hygiene. She had an indwelling catheter.A current care plan, revised on 10/22/24, indicated Resident 70 had an indwelling catheter due to urinary retention and obstructive uropathy. Interventions included the following: position the catheter bag and tubing below the level of the bladder (3/18/25), catheter care every shift (9/13/24), monitor for signs and symptoms of discomfort and urinary frequency (9/13/24), and monitor, record, and report to medical doctor for signs and symptoms of a urinary tract infection (9/13/24).During an observation, on 4/9/2026 at 11:24 a.m., CNA 8 confirmed Resident 70's indwelling catheter drainage bag hung on the resident's bed frame and the bag touched the floor. The bag was supposed to be hung in a way to ensure it was lower than the resident's bladder because gravity would cause the urine to flow backwards into the bladder if it was not lower than the bladder. The drainage bag was not to touch the floor because of sanitary reasons. A barrier should have been placed between the drainage bag and the floor.During an interview, on 4/9/26 at 11:33 a.m., QMA 9 indicated a urinary drainage bag was to be placed below a resident's waist. A drainage bag was not to touch the floor at any time. It was considered an infection control issue if a drainage bag touched the floor.During an interview, on 4/9/26 at 12:33 p.m., RN 10 indicated a urinary drainage bag was to remain below a resident's bladder. Due to infection control practices, a urinary drainage bag was not to touch the floor and was considered contaminated if it touched the floor. During an interview, on 4/9/26 at 12:39 p.m., the DON indicated proper indwelling catheter bag placement was to be below the level of the resident's bladder and the urinary drainage bag was not to touch the floor. Flooring was not considered clean and if a drainage bag touched the floor, it increased the potential of an infection. Germs were able to enter through the drainage spigot of the bag. Measures were to be taken to ensure urinary drainage bags did not touch the floor.During an interview, on 4/9/26 at 2:48 p.m. the Infection Preventionist indicated urinary drainage bags were not to touch the floor at any time due to the increased risk of bacterial contamination and the urinary drainage bag was able snagged which would cause urine to leak.A current facility policy, dated 8/2025, titled Policy and Procedure: Urinary Catheter Care, provided by the DON on 4/9/26 at 2:15 p.m., included the following: Policy: This facility is committed to ensuring the highest standard of care for residents with urinary catheters. Proper catheter care is essential to prevent infections, promote comfort, and maintain the dignity of residents.Maintaining Unobstructed Urine Flow.3. The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary blader.Infection Control.2.b. Be sure the catheter tubing and drainage bag are kept off of the floor.A current facility policy, dated 8/2025, titled Policy and Procedure: Indwelling Urinary Catheters, provided by the DON on 4/9/26 at 2:15 p.m., included the following: Policy: 9. Ensure the drainage bag is below bladder level and not touching the floor. 410 IAC (Indiana Administrative Code) 16.1-3.1-18(a)(a)

Based on observation, interview, and record review, the facility failed to securely store medications during a random observation of 1 of 6 medication carts (2B New End Medication Cart).Finding includes:During a random observation on the 2B hallway, on 4/9/26 beginning at 8:11 a.m., a medication cup with various pills was observed sitting on top of an unlocked medication cart left unattended in the hallway. No nursing staff members were in visual range of the cart. Activity Assistant 11 walked down the hall and stood by the medication cart, indicating she needed to speak with the nurse. At 8:13 a.m., RN 12 opened a resident's door across the hall and approached the medication cart. During an interview, at the time of the observation, she indicated the medication cart should not have been left unlocked, nor with medications sitting on top. The medications belonged to Resident 92 and were intended for his morning medication pass. RN 12 left the cart unlocked with the medications on top when the resident across the hall began yelling for help and was found to have urinated throughout the room. She closed the door because the resident needed privacy. The medication cart contained the medications for the 11 residents who lived on the 2 B hall. Resident 92's clinical record was reviewed on 4/9/26 at 8:59 a.m. The current orders for the morning medication pass included amlodipine (blood pressure) 5 mg daily, duloxetine (depression) 30 mg daily, ferrous sulfate (iron supplement) 650 mg daily, pantoprazole (gastroesophageal reflux disease) delayed release 40 mg daily, clopidogrel bisulfate (antiplatelet) 75 mg daily, prednisone (anti-inflammatory and immunosuppressant) 10 mg daily, ezetimibe (high cholesterol) 10 mg daily, docusate sodium (stool softener) 10 mg twice a day, furosemide (diuretic) 40 mg twice a day, metformin (diabetes) 1000 mg twice a day, gabapentin (neuropathy) 200 mg three times daily, and potassium citrate extended release 5 milliequivalents (mEq) three times a day.During an interview, on 4/9/26 at 3:49 p.m., RN 6 indicated medications should not be left on top of the medication cart nor should the cart be left unlocked out of the visual range of the nurse. Prior to assisting a resident out of visual range, the medications and the cart should be secured.During an interview, on 4/9/26 at 4:04 p.m., the DON indicated medications should not be left unattended on the medication cart. The medication cart should be locked when out of visual range.A current, undated policy, provided on 4/13/26 at 10:07 a.m. by the Administrator in Training, titled Medication Storage, indicated the following: .All drugs and biologicals will be stored in locked compartments.During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart.410 Indiana Administrative Code 16.2-3.1-25(m)

A. Based on observation, record review, and interview, the facility failed to ensure food was served and handled under safe and sanitary conditions for 2 of 19 residents observed during meal service. (Residents 3 and 57)B. Based on observation and interview, the facility failed to ensure universal precautions and hand hygiene were implemented during the administration of nasal spray for 1 of 4 residents observed during medication administration. (Resident 19) Findings include:A. During a lunch observation, on 4/6/26 at 12:10 p.m., the following was observed: CNA 4 pulled out a piece of bread with her bare hands from the plastic container. The bread was placed on Resident 3's tray. CNA 4 opened another plastic bag containing bread, removed that piece of bread with her bare hands. CNA 4 placed the second piece of bread on top of the first piece on Resident 3's tray. CNA 4 washed her hands with soap and water before walking over to Resident 57. She opened a plastic bag containing a piece of bread. CNA 4 removed the bread with her bare hands and placed it on Resident 57's tray. CNA 4 walked over and sat down next to Resident 3. CNA 4 assisted Resident 3 with eating. CNA 4 grabbed Resident 3's bread with her bare hands and placed it up to Resident 3's mouth. Resident 3 declined taking a bite. CNA 4 touched the bread with both of her hands before placing the bread back down on top of another piece of bread on Resident 3's tray. During an interview, on 4/6/26 at 1:04 p.m., CNA 4 indicated she had touched Resident 3's bread with her bare hands but did not recall touching Resident 57's bread with her bare hands. She should not have touched the bread with her bare hands. During an interview, on 4/9/26 at 12:42 p.m., the DON indicated staff members should not handle food with their bare hands. A current facility policy, dated 4/1/26, titled Dietary Services, provided by the DON, on 4/13/26 at 2:38 p.m., indicated the following: .Food Service: Serve food using clean utensils, and avoid touching food directly with hands B. During a medication administration, on 4/9/26 at 8:20 a.m., LPN 5 prepared medications for Resident 19 at the medication cart. She entered the resident's room and administered the resident's oral medications. She then removed the cap from the fluticasone propionate nasal spray, gently shook the spray, and administered two sprays to each nostril with bare hands. After administration, she replaced the cap on the nasal spray and exited the resident's room without performing hand hygiene. LPN 5 returned the nasal spray back to the medication cart and documented the medications as given without performing hand hygiene. During an interview, on 4/9/26 at 8:35 a.m., LPN 5 indicated she did not wear gloves when giving nasal sprays. She did not touch the resident's nose, so she did not believe gloves were needed. She did not perform hand hygiene when exiting the room as she did hand hygiene when she began getting out the medications for the next resident who required medication. During an interview, on 4/9/26 at 3:50 p.m., RN 6 indicated to administer nasal sprays, first the physician's order was checked, hand hygiene was performed, gloves were applied, the nasal spray was administered, gloves were removed, and hand hygiene was performed. During an interview, on 4/9/26 at 4:04 p.m., the DON indicated gloves should be worn during the administration of a nasal spray. A current policy, dated 8/2025, titled Nasal Spray Storage and Administration, provided by the Administrator in Training on 4/10/26 at 5:08 p.m., indicated the following: .All nasal spray medications shall be stored, handled, and administered in accordance with manufacturer guidelines, physician's orders, and infection control standards.Administration Procedures.2. Perform hand hygiene and wear gloves as appropriate.remove gloves and perform hand hygiene. 410 IAC (Indiana Administrative Code) 16.2-3.1-21(i)(3) 410 IAC (Indiana Administrative Code) 16.2-3.1-18(l)

Based on record review and interview, the facility failed to provide or offer eligible residents and/or the residents' representatives the current pneumococcal immunization according to the Centers for Disease Control and Prevention (CDC) guidelines for 2 of 5 residents reviewed for immunizations. (Resident 57 and Resident 73). Findings include: 1. Resident 73's clinical record was reviewed on 4/8/26 at 3:37 p.m. Diagnoses included type 2 diabetes mellitus, chronic kidney disease, stage 3 a, and heart failure.Resident 73 received the pneumococcal conjugate vaccine (PCV) 13 on 7/14/17 and the pneumococcal polysaccharide vaccine (PPSV) 23 on 11/28/18.An immunization consent, signed on 9/25/25, indicated the resident's representative wanted the resident to receive the most current pneumonia vaccine if eligible and indicated by the physician and have it administered by the facility, specifically the pneumococcal conjugate 20 (PCV 20).The clinical record lacked indication the resident was given the most current pneumonia vaccine, specifically the PCV 20 or the pneumococcal conjugate 21 (PCV 21).During an interview, on 4/10/26 at 10:25 a.m., the Infection Preventionist (IP) indicated she believed the vaccination was complete since the resident had received the PPSV 23 and PCV 13. Resident 73 had not been given the most current pneumococcal vaccination, specifically the PCV 20 or the PCV 21. 2. Resident 57's clinical record was reviewed on 4/9/26 at 10:50 a.m. Diagnoses included chronic obstructive pulmonary disease.Resident 57 received the pneumococcal conjugate 13 (PCV 13) on 10/31/18. The clinical record lacked offering or consent/declination for the PCV 20 or the PCV 21.During an interview on 4/10/26 at 10:34 a.m., the Infection Preventionist (IP) indicated she had not offered any updated pneumococcal vaccines.During an interview on 4/13/26 at 1:04 p.m., the DON indicated the IP was responsible for ensuring the residents receive immunizations according to the CDC (Centers for Disease Control and Prevention) guidelines.According the CDC website, retrieved on 4/13/26 at www.cdc.gov/pneumococcal/vaccines/adults.html#cdc_vaccine_recommendations_section_3-older-adults-who-received-pcv13-and-ppsv23, adults 65 years or older who have received the PCV 13 and PPSV 23 (at or after the age of 65 years) have the option to get the PCV20 or the PCV 21, or to not get additional pneumococcal vaccines based on shared clinical decision making between the adult and the vaccine provider. Adults who received the PCV 13 only should talk with a vaccine provider.A current facility policy, dated 8/2025, provided by the Administrator in Training on 4/10/26 at 5:08 p.m., titled Pneumococcal Vaccine, indicated the following: .Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated.Residents who have previously received a pneumococcal vaccine will have their vaccination status reviewed to determine the need for additional doses.Pneumococcal vaccines will be administered to residents (unless medically contraindicated, already given, or refused) per our facility'/s physician-approved pneumococcal vaccination protocol, according to the CDC's recommended schedule.Administration of the pneumococcal vaccine will be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination.410 Indiana Administrative Code 16.2-3.1-13(a)

Based on record review and interview, the facility failed to administer a COVID-19 vaccination per the Center for Disease and Control (CDC) guidance and per resident request for 1 of 5 residents reviewed for vaccinations. (Resident 70)Finding includes:Resident 70's clinical record was reviewed on 4/9/26 at 10:50 a.m. Diagnoses included pulmonary embolism without acute cor pulmonal (a blood clot in the lung artery that has not caused heart failure or strain), cerebral infarct (stroke), and hypertension (high blood pressure).A quarterly Minimum Data Set (MDS) assessment, dated 2/17/26, indicated her COVID-19 vaccination was not up to date.A review of the resident's vaccination history indicated the following:A vaccination consent form, dated 8/19/24, indicated the resident representative was provided education and consented to the administration of the most current COVID-19 vaccination.The clinical record lacked documentation of the administration of the appropriate COVID-19 vaccination. The clinical record lacked an updated or yearly COVID-19 vaccination consent or declination. During an interview, on 4/10/26 at 11:08 a.m., the Infection Preventionist (IP) indicated Resident 70 did not receive a COVID-19 vaccination after the initial consent was obtained. She was unsure why the COVID-19 vaccination was not administered. The consent had been obtained prior to her becoming the IP. She was unable to locate an updated COVID-19 vaccination consent form.During an interview, on 4/10/26 at 2:32 p.m., the DON indicated she was unsure where Resident 70's updated COVID-19 consent was. It was possible a previous staff member discarded it.The Center for Disease and Control (CDC) website, accessed on 4/10/26 at 9:45 a.m., indicated the following: COVID-19 Vaccination for Long-term Care Residents.Vaccine recommendations: CDC recommends an updated COVID-19 vaccine for most adults ages 18 years and older, including people who live and work in long-term care (LTC) settings, get 1 dose of an updated COVID-19 vaccine. CDC recommends everyone ages 65 and older including people who live and work in LTC settings, get 2 doses of an updated COVID-19 vaccine 6 months apart.Reminder: People who live in LTC settings must give consent or agree to getting a COVID-19 vaccine.A facility policy, dated 8/2025, titled, Policy and Procedure: COVID-19 Vaccination, provided by the Administrator on 4/10/26 at 3:53 p.m., indicated the following: Policy: All residents and employees who have no medical contraindications to the vaccine will be encouraged to receive a COVID-19 vaccine.COVID-19 vaccinations are vital in the effort to keep residents and staff safe during the fight against COVID-19. Immunization is an important part of this facility's ongoing infection control program.10. Administration of the COVID-19 vaccine will be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of vaccination and manufacturer recommendations.410 IAC (Indiana Administrative Code) 16.2-3.1-18(b)(5)

Based on record review and interview, the facility failed to ensure baseline tuberculin skin testing employed the two-step method within the required time frames for 2 of 3 residents reviewed for tuberculin testing. (Resident D and E) Findings include: 1. Resident E's clinical record was reviewed on 6/12/25 at 12:28 p.m. The first-step tuberculin skin test (TST) was given and read at the hospital prior to admission to the facility. The resident record lacked administration and reading of a second-step tuberculin skin test. 2. Resident D's clinical record was reviewed on 6/12/25 at 1:59 p.m. The first step TST was given on 5/26/25 at 8:46 p.m. and read on 5/28/25 at 3:58 p.m. During an interview, on 6/13/25 at 9:04 p.m., LPN 4 indicated residents were given a TST on admission which was read 48 to 72 hours later. A second step TST was given one to three weeks later and also read 48 to 72 hours after given. During an interview, on 6/13/25 at 11:39 a.m., LPN 3 tuberculosis testing was initiated immediately upon admission. The TST was read 48 to 72 hours after given. During an interview, on 6/13/25 at 2:07 p.m., the Infection Preventionist in training indicated the first step TST was given upon admission, and an order to read the first step TST in 48 to 72 hours after given was placed in the resident's electronic medical record. A second step TST was given two weeks after the first step TST was given. During an interview, on 6/13/25 at 3:20 p.m., the DON indicated Resident E had a first step TST prior to admission, but she was unable to locate where the resident had a second step TST that was read. Resident D's second step TST was read four hours too early. Guidance from the Indiana Department of Health Consumer, accessed on 6/13/25 at https://www.in.gov/health/files/IDOH-TB-Assessment-and-Testing-of-New-Residents-8-11-21.pdf, titled Tuberculosis Assessment and Testing of Long-Term Care Residents, updated 8/11/21, indicated the following: .A tuberculin skin test must be completed within three months prior to admission or upon admission unless there is documentation of a previous positive TB test. Testing can be by tuberculin skin test (TST) method or an Interferon Gamma Release Assay (IGRA) blood test . The standard test method for the TST (sometimes called Mantoux test) is intradermal administration of 5 tuberculin units of purified protein derivative (PPD). The TST should be read at 48 to 72 hours. If an initial TST result is negative, a two-step TST procedure is required to boost a potential reaction that has waned over time to establish a reliable baseline. This second test should be performed within one to three weeks after the first test A current, undated facility policy, provided by the DON on 6/13/25 at 4:15 p.m., titled RESIDENT admission: INFECTION CONTROL POLICY, indicated the following: .It is the policy of Heritage Pointe that all residents shall be tested for the presence of tuberculosis at the time of admission, unless a known reactor .Results of a two-step diagnostic intermediate strength PPD [purified protein derivative], if not a reactor, shall have been completed within three months prior to admission, or at the time of admission and read at forty-eight (48) to seventy-two (72) hours. Every resident, if not a reactor, will receive at least one Mantoux [tuberculin skin test] on admission, regardless of preadmission documentation This citation relates to Complaint IN00460844. 3.1-18(e) 3.1-18(f)

Based on interview and record review, the facility failed to complete post-dialysis assessments on 1 of 1 resident reviewed for dialysis. (Resident 48) Findings include: Resident 48's clinical record was reviewed on 2/21/25 at 9:42 a.m. Diagnosis included end stage renal disease, dependence on renal dialysis, type 2 diabetes mellitus, essential hypertension, hypothyroidism, and muscle weakness. Current physician orders included complete dialysis assessment under the assessment tab one time a day every Monday, Wednesday, and Friday. [NAME] dialysis communication binder with current vitals were to accompany resident to every dialysis appointment. Bed bath only due to dialysis port. Review of the clinical record indicated no dialysis assessment was completed on January 8, January 17, February 12, and February 14, 2025. Resident 45's dialysis binder indicated dialysis had been completed on these dates. During an interview, on 2/25/25 at 10:28 a.m., LPN 6 indicated once the resident returns from dialysis, the nurse would complete the post-dialysis assessment. That assessment was located under the assessment tab. During an interview, on 2/25/25 at 10:32 a.m., RN 11 indicated the dialysis assessment was completed each shift. During an interview, on 2/25/25 at 12:23 p.m., the DON indicated when a resident admitted with dialysis needs, staff placed an order to do post-dialysis assessments upon the residents return from dialysis. Resident 45's post dialysis assessments had not been completed. A current facility policy, titled Dialysis Care, provided by the DON on 2/25/25 at 12:23 p.m., indicated the following: .Post- Dialysis assessment will be documented in the resident's EMR. The assessment should include conditions of the site, vital signs, and any abnormal symptoms 3.1-37(a)

A. Based on observation, interview, and record review, the facility failed to utilize infection prevention and control strategies during wound care for 1 of 1 residents reviewed for pressure ulcers (Resident 76). B. Based on observation, interview, and record review, the facility failed to ensure transmission-based precautions were followed for 2 of 12 residents placed on transmission-based precautions (Resident 44 and Resident 45). Findings include: A. Resident 76's clinical record was reviewed on 2/24/25 at 10:05 a.m. Diagnoses included need for assistance with personal care, gastrostomy status, and encounter for surgical aftercare following surgery on the digestive system. Current physician's orders included the following: apply hydrocolloid (for wound healing) dressing to right and left buttock every day shift every Wednesday for protection related to wound and apply after shower (2/19/2025), Monitor hydrocolloid dressing to bilateral buttocks and replace if dressing is soiled or no longer intact every shift (2/12/25), and enhanced barrier precautions - wear gown/gloves to enter room while performing high contact care activities such as bathing/showering, providing personal hygiene or toileting, transferring residents from one position to another, changing bed linens, performing wound care, caring for indwelling devices. maintain for the duration of stay in the facility every shift for gastrostomy (feeding) tube (1/15/25). A current care plan indicated Resident 76 required enhanced barrier precautions related to her gastrostomy tube. Interventions included the following: Perform hand hygiene upon entering and exiting the resident's room and when donning and doffing personal protective equipment (PPE). During a wound care observation, beginning at 10:11 a.m. on 2/24/25, LPN 6 checked the resident's physician orders, gathered wound care supplies, applied a gown and gloves, and entered the resident's room. She placed the packaged wound dressings directly on the resident's bedside table. She placed a container of normal saline wound cleanser on the packaged dressings. She moved the container of wound cleanser off the wound dressings to set directly on the bedside table. The resident stood up and requested to go to the bathroom. LPN 6 assisted the resident to the bathroom and placed the wound dressing packages and the container of wound cleanser directly on the shelf of the bathroom sink. LPN 6 assisted the resident to pull down her pants and sit down. The resident spilled a cup of ice on the floor. LPN 6 gathered the ice with paper towels, then regular towels and cleaned the ice off the floor. She placed the regular towels in a plastic bag. LPN 6 removed her gloves and washed her hands. The resident requested LPN 6 to perform the wound care while her pants were down in the bathroom. The area was cleansed with the wound cleanser, dried with a gauze dressing pad, then a hydrocolloid dressing was applied. LPN 6 assisted the resident to pull up her pants then she assisted the resident back to her chair. LPN 6 removed her gloves (she did not perform hand hygiene), gathered her supplies and the bagged dirty towels, then began removing her gown. She walked into the hallway and past the next room with her gown halfway on and halfway off. She continued to remove her gown then walked back into the resident's room to throw the gown in the trash. She placed the container of wound cleanser in her pocket. She took keys out of her pocket and went to the medication room. She placed the additional dressings in the resident's section of the wound cart. LPN 6 removed keys from her pocket, walked to and entered the soiled utility, and placed the bagged soiled towels in the laundry barrel. LPN 6 exited the soiled utility and walked to the clean utility. She washed her hands. She turned off the water faucet with a paper towel, passed the contaminated paper towel to her other hand then dried her hands again before she threw away the paper towel. During an interview on 2/24/25 at 10:30 a.m., LPN 6 indicated she should have placed a barrier under her wound supplies in the resident's room. She should have removed her gown in the resident's room before exiting and sanitized her hands immediately after glove removal. She should have thrown the paper towel away after touching the faucet and not used it to dry her hands more. During an interview, on 2/25/25 at 3:56 a.m., the Infection Preventionist (IP) indicated a barrier should be put down to place wound supplies on that may be taken back out of the resident's room. PPE should be removed prior to exiting the room. When handwashing was performed, a clean paper towel should be used to turn off the faucet then thrown away into the trash and not placed into the other hand or used after touching the faucet. A current facility policy, dated 1/1/25, titled Infection Prevention and Control Program, found on the facility conference table on 2/26/25 at 8:30 a.m., indicated the following .All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services A current undated facility policy and procedure, titled HANDWASHING AND SANITIZING, found on the facility conference table on 2/26/25 at 8:30 a.m., indicated the following: .Handwashing/sanitizing will be practiced as follows: . 2. Before and after resident contact .6. Before leaving the resident in an isolation room .Hands must be washed after removing disposable gloves .PROCEDURE .6. Dry hands, and turn off faucets with a clean paper towel. Discard towel B.1. During an observation, on 2/25/25 at 9:58 am, Resident 44 was lying in a recliner, resting with her eyes closed at the nurses' station. During an observation, on 2/25/25 at 10:05 a.m., Resident 44's room had a sign outside the door indicating the resident was under yellow zone transmission-based precautions. Resident 44 was lying in a recliner with her feet elevated and a blanket on her at the nurses' station. She repeatedly stated, I don't feel good. She did not wear a mask or have a mask close to her. The resident's recliner was positioned in a way where a person would have to pass within three feet of her to go between the two halls on the unit unless the person went behind the nurses' station. During an interview, on 2/25/25 at 10:26 a.m., CNA 8 indicated when a resident was on the yellow transmission precautions a surgical mask, gown, and gloves were to be worn to enter the room. If a resident was placed on yellow transmission-based precautions, they should not be out of their room, except for Resident 44 because she wouldn't stay in her bed. She had been out at the nurses station for a while. She was toileted and had just been laid down. She had been up and down all night long. She had been brought out of her room to decrease her risk of falling. During an interview, on 2/25/25 at 10:46 a.m. LPN 6 indicated when a resident was placed on the yellow transmission-based precautions, an N95 mask, a gown, gloves, and a face shield or eye protection was required to enter the room. A resident on yellow transmission-based precautions should not be out of their room. Resident 44 required transmission-based precautions. She kept sitting on her bed and yelling out. The CNAs checked on her and toileted her. The CNAs said she had been up all night. The CNAs brought her out to the nurses' station to reduce her risk of falling. Resident 44's clinical record was reviewed on 2/25/25 at 2:02 p.m. Diagnoses included supraventricular tachycardia (heart condition where the heart beats faster than 100 beats per minute), saddle embolus of pulmonary artery (a large blood clot lodges at the division of the two branches of the main pulmonary artery, potentially blocking blood flow to both lungs) without acute cor pulmonale, hypertension (high blood pressure), and type 2 diabetes mellitus. Current physician's orders included droplet and contact precautions with eye protection - isolation-must wear gown, gloves, mask, eye protection. Awaiting swabs or 24 hours from symptoms every shift for respiratory symptoms (started 2/25/25 at 6:00 a.m.). A Health Status Note, dated 2/25/25 at 2:07 a.m., indicated the resident was awake at the beginning of the shift. When the resident was placed in bed, she began sitting on the side of the bed. She had been repeating I don't feel good. The resident developed a continuous barking cough and slight wheezing upon exhalation. A rapid COVID-19 test was negative. A respiratory panel specimen was collected and was waiting to be sent out. A Behavior Note, dated 2/25/25 at 5:41 a.m., indicated the resident continuously sat on the side of the bed and yelled out for help. The staff were unable to console her, and she did not want to be left alone. The resident was taken to the lounge to sit in a high traffic area for safety. A Nurses Note, dated 2/25/25 at 9:47 a.m., indicated the resident had been reported to be restless throughout the night and requested to rest in the recliner in the lounge. The resident was resting in the recliner in the lounge with her eyes closed. During an interview, on 2/25/25 at 3:56 p.m., the Infection Preventionist (IP) indicated when a resident was placed on yellow transmission-based precautions, they were generally waiting for test results for COVID-19, influenza, and respiratory syncytial virus (RSV). To enter a yellow transmission-based precautions, the staff member should wear a gown, gloves, N95 mask, and a face shield. A resident on yellow transmission-based precautions should stay in their room and not be at the nurses' station. 49411 B.2. During a random observation, on 2/25/25 at 12:15 p.m. CNA 9 entered Resident 45's room wearing gloves, surgical mask, and a gown. CNA 9 was not wearing a face shield or N95 mask. Signage on the door indicated the resident was on yellow transmission- based precaution and required a gown, gloves, N95 mask and face shield/goggles before entering the resident's room. During an interview, on 2/25/25 at 12:20 p.m., CNA 9 indicated she did not don an N95 mask or face shield/goggles before entering the resident's room. During an interview, on 2/25/25 at 12:22 p.m., IP indicated, before entering a resident's room on transmission-based precautions a gown, gloves, N95 mask and face shield/goggles needed to be worn. Resident 45's clinical record was completed on 2/25/25 at 12:30 p.m. Diagnosis included, but were not limited to, acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, essential hypertension, anemia, chronic kidney disease, and hypocalcemia. Current physician's orders included droplet and contact precautions with eye protection-isolation- must wear gown, gloves, mask, and eye protection. Resident resides in room alone, all care and services are being provided in the resident's room, and Tamiflu (anti-viral for influenza) 30 milligrams twice a day for five days. A progress note, dated 2/24/25 at 3:43 p.m., indicated Resident 45 tested positive for Influenza A. A current facility policy, dated 9/2022, titled Transmission-Based (Isolation) Precautions, found on the facility conference table on 2/26/25 at 8:30 a.m., indicated the following: .Facility staff will apply Transmission-Based Precautions, in addition to standard precautions, to residents who are known or suspected to be infected or colonized with certain infectious agents requiring additional controls to prevent transmission .Residents on transmission-based precautions should remain in their rooms except for medically necessary care A facility sign, provided by the IP on 2/25/25 at 4:02 p.m., had a picture of traffic light with the yellow light being shown. The sign indicated YELLOW ZONE and required transmission-based precautions which was contact/droplet. PPE required was N95 mask, face shield or goggles, single gown with each encounter, and gloves. 3.1-18(a) 3.1-18(l)

Based on record review and interview, the facility failed to ensure shift to shift narcotic count and reconciliation was completed for 2 of 3 medication carts reviewed for medication reconciliation. (100 Hall) Findings include: 1. During a medication storage observation of the 100A new medication cart, on 2/21/25 at 10:49 a.m., accompanied by RN 4, the Narcotic Sheet Log/ Tracking Form was reviewed and the following dates lacked shift to shift count and reconciliation signatures of controlled medications: January 2025- lacked a narcotic card, liquid, and/or bottle count: 1/12 on evening shift 1/13 on day shift and evening shift 1/17 on evening shift and night shift 1/18 on night shift 1/19 on day shift 1/20 on day shift, evening shift and night shift 1/21 on day shift and night shift 1/22 on day shift and night shift 1/23 on day shift 1/25 on day shift 1/27 on evening shift 1/31 on evening and night shift February 2025- lacked a narcotic card, liquid, and/or bottle count: 2/1 on day shift and evening shift 2/3 on day shift and night shift 2/5 on night shift 2/6 on day shift, evening shift and night shift 2/8 on night shift 2/9 on day shift 2/10 on day and evening shift 2/13 on night shift 2/14 on day shift 2/15 on night shift 2/16 on day shift and night shift 2/17 on day shift, evening shift and night shift 2/18 on day shift and night shift 2/20 on night shift 2/21 on day shift During an interview, at the time of the observation, RN 4 indicated the narcotic shift count was completed every shift. 2. During a medication storage observation of the 100 A old medication cart, on 2/21/25 at 11:04 a.m., accompanied by LPN 5, the Narcotic Sheet Log/ Tracking Form was reviewed and the following dates lacked shift to shift count and reconciliation signatures of controlled medications: February 2025- lacked a narcotic card, liquid, and/or bottle count: 2/3 on evening shift 2/8 on night shift 2/9 on day shift 2/13 on evening shift 2/14 on day shift 2/15 on night shift 2/16 on day shift 2/17 on evening shift and night shift 2/18 on day shift and night shift 2/19 on day shift and evening shift 2/20 on evening and night shift 2/21 on day shift During an interview, at the time of the observation, LPN 5 indicated the narcotic count was completed by the oncoming nurse and off going nurse during shift change. The narcotic sheet was not completed, and he did not sign the narcotic sheet when he took over the medication cart that morning. During an interview, on 2/21/25 at 11:56 a.m., the DON indicated staff was to complete the narcotic sheet count when the staff member took over control of the medication cart during oncoming and off going shift change. A current facility policy, titled Counting Controlled Substances, provided by the Administrator, on 2/24/25 at 1:50 p.m., indicated the following: . Controlled drugs are counted at shift change or at any time keys to medication cart are given to another licensed nurse or QMA 3.1- 25(b)(3)

Based on observation, interview, and record review, the facility failed to prevent the development of a pressure ulcer for a dependent resident for 1 of 3 residents reviewed for pressure ulcers. (Resident 28) Finding includes: Resident 28's clinical record review was completed on 3/6/24 at 3:03 p.m. Diagnoses included unspecified dementia, intervertebral disc degeneration of the lumbar region, type 2 diabetes mellitus, generalized muscle weakness, unsteadiness on feet, other reduced mobility, and need for assistance with personal care. Current physician orders, dated 1/26/24, included the following: float heels while in bed every night shift for offloading, apply skin preparation (skin protectant) to bilateral heels every shift for protection, and apply pressure relief boot to right foot at all times except during transfers. A current physician order, dated 2/1/24, included a weekly foot inspection on evening shift. A Braden Scale (for predicting pressure sore risk), dated 12/11/23, indicated the following: the ability to respond meaningfully to pressure-related discomfort was slightly limited because the resident could not always communicate discomfort or the need to be turned, skin was exposed to moisture often, and friction and shear was a potential problem due to the resident moved feebly or required minimal assistance. The resident was at risk for pressure ulcers. An annual Minimum Data Set (MDS) assessment, dated 12/11/23, indicated the resident's cognitive status was severely impaired. Rejection of care behaviors were not exhibited. He required substantial/maximal assistance from staff for rolling left and right, lower body dressing, putting on and taking off footwear, and for transfers. He was dependent for toileting. The resident was at risk for pressure ulcers. Skin treatments included, pressure reducing device for bed, pressure reducing device for chair, and application of ointments/medication other than to feet. A significant change MDS assessment, dated 2/20/24, indicated the resident's cognitive status was severely impaired. Rejection of care behaviors were not exhibited. He was dependent for transfers, toileting, lower body dressing, putting on and taking of footwear. The resident required substantial/maximal assistance to roll left and right. He had one unstageable pressure ulcer with coverage of the wound bed by eschar. Skin treatments included a pressure reducing device for chair, bed, nutrition or hydration intervention to manage skin problems, and pressure ulcer care. A current care plan, dated 12/13/18, indicated the resident had an activity of daily living self-care performance deficit related to pain, weakness, and decreased mobility. Interventions included the resident typically required extensive assistance of one staff member for bed mobility (revised 12/13/23) and the resident required a Hoyer (mechanical lift) with two staff members to provide assistance for all transfers (revised 2/2/24). A current care plan, dated 12/13/18, indicated the resident was at risk for pressure ulcers related to pain, weakness, and decreased mobility. The resident had an unstageable pressure ulcer of the right medial heel. Interventions included the following: identify/document potential causative factors and eliminate/resolve where possible (12/13/18), provide a pressure reducing mattress to protect the skin while in bed (12/13/18), float heels in bed as the resident tolerates (1/29/24), and apply a pressure relief boot to right foot at all times except during transfers as resident tolerates (1/27/24). A current care plan, dated 1/26/24, indicated the resident had an unstageable pressure injury (full-thickness wound covered in eschar [darkened dead tissue] or slough [creamy yellow/white dead tissue] with the wound bed unable to be observed) to the right medial heel. Interventions included the following: administer treatments as ordered and monitor for effectiveness (1/26/24), follow facility policies/protocols for the prevention/treatment of skin breakdown (1/26/24), and the resident requires a pressure relief boot to the right foot at all times, except during transfers (1/26/24). A Physician Note, dated 1/16/24 at 9:30 a.m., indicated the resident slept more and had experienced a slight decline since the last visit. Review of the residents Activity of Daily Living Bed Mobility documentation from 1/16/24 to 1/25/24 indicated the resident required extensive assistance to total dependence on staff for bed mobility for 24 out of 30 shifts. The clinical record lacked indication of new interventions for pressure ulcer prevention implemented when the resident experienced the physical decline, prior to the development of the resident's pressure ulcer on 1/26/24. Review of a Nurse's Note, dated 1/26/24 at 6:46 a.m., indicated a blister-like pressure ulcer to the residents right heel was identified. A request for a pressure relief boot order was made in the communication to the physician . A wound note, dated 1/26/24 at 8:21 a.m., indicated the resident's Stage 2 pressure ulcer (partial-thickness wound) to the right medial heel measured 2.7 centimeters (cm) length by 2.7 cm width. New orders were received for skin preparation, pressure relief boot, and floating heels. A wound note, dated 2/1/24 at 7:58 a.m., indicated the resident returned from a short hospital stay. The Stage 2 pressure ulcer remained, blister like, unchanged in size, but now purple in color. A Nurse's Note, dated 2/5/24 at 2:41 a.m. , indicated the resident was sent out for a hospitalization due to left leg swelling and a faint pedal pulse. A Nurse's Note, dated 2/8/24 at 10:56 p.m., indicated the resident returned from a hospitalization and the pressure ulcer to his right heel remained intact and was black. A wound note, dated 2/9/24 at 1:51 a.m., indicated the pressure ulcer to the right heel presented as an unstageable pressure ulcer with black eschar noted to the wound bed. A wound note, dated 2/19/24 at 4:55 p.m., indicated the resident's unstageable pressure ulcer to the right medial heel measured 3 cm length by 2.7 cm width. It remained stable with back eschar. During a wound observation on 3/7/24 at 10:45 a.m., the resident was laying in bed on his right side. A pressure relief boot was on the resident's right foot. His left foot rested against the mattress, did not have a pressure relieving boot in place, and his heels were not floated during the observation. The wound to the right medial heel was intact, circular, black, and approximately the size of a quarter. LPN 7 indicated the resident had one pressure relief boot in place on his right foot and his heels were not floated. The resident had a decline in mobility prior to the development of the pressure ulcer and was spending more time in bed. She thought the pressure ulcer developed because the resident was usually positioned on his left side facing the restroom with his legs bent at the knee. This allowed his right heel to rest against the bed. Staff had encouraged him to lay on his right side since the pressure ulcer developed. Prior to the development of the pressure sore, the pressure ulcer prevention intervention was a standard pressure relief mattress on his bed. After the pressure ulcer developed, they added new interventions for floating bilateral heels and the pressure relief boot. The pressure ulcer developed in the facility. During an interview on 3/8/24 at 9:51 a.m., CNA 9 indicated the resident required extensive assistance of two staff members for repositioning in bed. He was unable to turn on his own and required staff assistance with putting on and taking of any footwear. She indicated the resident should be repositioned every two hours, have his heels floated when he is in bed, and pressure relief boots in place on his feet. The resident was always cooperative with care. Some staff members were not floating the resident's heels or using both pressure relief boots for his care to prevent pressure ulcers. During an interview on 3/8/24 at 10:02 a.m., CNA 8 indicated the resident required staff assistance to turn in bed prior to his pressure ulcer development because he kept his legs bent at the knees. Prior to the development of the pressure ulcer, interventions were in place for pressure ulcers to included a pillow between his legs at the knees and non-skid socks on his feet. Since the pressure ulcer developed, she placed the pressure relief boots on his feet but she was not floating his heels. She indicated the CNA's did not have an area to document when heels were floated. During an interview on 3/8/24 at 3:50 p.m., the DON indicated she could not comment when pressure ulcer prevention measures should have been implemented if a resident had a decline in their mobility. During an interview on 3/11/24 at 3:20 p.m., the Infection Preventionist indicated a resident should be promptly reassessed for pressure ulcer risk when a resident has shown a decline with decreased mobility so pressure relief interventions could be implemented. This typically would trigger when a change of condition form was completed, but she was unable to provide this information for the resident. From 1/16/24 until the resident developed the pressure ulcer on his heel, staff charted the resident required extensive to total dependence for bed mobility. The resident was at risk for pressure ulcers due to weakness prior to the development of the pressure ulcer. His wound was facility acquired. A wound note, dated 3/11/24 at 12:08 p.m., indicated the resident continued with a pressure ulcer to the right medial heel. Eschar was no longer intact. The pressure ulcer was classified as a healing Stage 3 (full-thickness wound with involvement of tissue beneath) pressure injury and measured 2.3 cm length x 2 cm width. A current facility policy, dated 2/1/24, titled Pressure Injury Prevention and Management,provided by the Administrator on 3/8/24 at 12:29 p.m., indicated the following: Policy: This facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries . Policy Explanation and Compliance Guidelines: . 2. The facility shall establish and utilize a systemic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate . 3. Assessment of Pressure Injury Risk . b.Examples of risk factors include, but are not limited to: i. Impaired/decreased mobility and decreased functional ability 3.1-40(a)(1)

Based on observation, interview, and record review, the facility failed to ensure gastrostomy tube placement was confirmed prior to medication administration according to facility policy for 1 of 1 resident reviewed for tube feedings. (Resident 1) Findings include: Resident 1's clinical record was reviewed on 3/6/24 at 10:32 a.m. Diagnoses on the resident's profile included, but were not limited to, post-immunization acute disseminated encephalitis (swelling in the brain and spinal cord that causes damage to the sheath covering the nerve fibers), and dysphagia (difficulty swallowing), A physician's order, dated 5/13/2019, indicated check G-tube placement prior to bolus and medication administration and to maintain NPO (nothing by mouth), no exceptions. A physician's order, dated 7/11/21, indicated administer medications via g-tube, medications may be mixed together and mixed with 30 mL sterile water. Flush with 30 mL before and after medication administration, every shift. An annual MDS assessment, dated 2/7/24, indicated the resident had paraplegia (paralysis affecting the legs), a PEG tube (percutaneous endoscopic gastrostomy or g-tube), anxiety, and a seizure disorder. She was cognitively intact. A current care plan, dated 5/14/19, indicated the resident required tube feedings, (nothing by mouth, no exceptions), related to dysphagia, chewing problems, and swallowing problems. Interventions included check for tube placement and gastric contents/residual volume per facility protocol and record. During a medication administration observation, on 3/7/24 at 11:01 a.m., LPN 19 crushed the resident's medications, placed a bolus syringe in the resident's feeding tube, and flushed with 360 milliliters (mL) sterile water. She added a liquid medication, flushed with more water, added the crushed medications to the syringe, and flushed with more water. During an interview at the time of the observation, she indicated she had failed to check for residual gastric contents to confirm placement. She would have typically checked for residual before administering medications. During an interview with LPN 20, on 3/11/24 at 10:51 a.m., she indicated placement of the feeding tube should be confirmed prior to administering anything through the tube. During an interview with the Director of Nursing, on 3/11/24 at 10:56 a.m., she indicated she would refer to the facility's policy for feeding tube care before she could say what was the process. A current, undated, facility policy titled Tube Feedings, Nasogastric and Gastrostomy, provided by the DON on 3/8/24 at 9:58 a.m., indicated the following: .8) Apply gloves and pull back slightly on the syringe, place the barrel of the syringe into the tube. Listen to the abdomen with the stethoscope while slowly pushing a small amount of air into the abdomen and listening for the air bolus. If air bolus is not heard, pull back on the syringe a little more to see if any residual is noted. If no air bolus or residual assessed, notify physician,. 9) If physician order is to check for placement by checking for residual and the amount of feeding to be given is based on residual, do not check placement with air bolus. Follow order as directed. Under the heading Medication Administration, the second step indicated Check placement of the tube, and flush the tube prior to the medication administration with 30 cc of tap water, or as ordered 3.1-44(a)(2)

Based on observation, interview, and record review, the facility failed to ensure residents with diagnoses of dementia, received locomotion and seating assistance, pre-meal stimulation, toileting assistance, and mask wearing assistance, in a manner to promote dignity for 6 of 6 residents reviewed for assistance to promote dignity. (Residents 4, 34, 37, 47, 57 and 77) Findings include: 1. During a pre-meal and meal observation on 2/24/23 on the 1B Memory Care unit, the following was observed: At 11:01 a.m., an unknown staff member wheeled Resident 47 down the hallway to the dining area. The unknown staff member told the resident she would be eating soon. The resident was placed, in her wheelchair, facing the table as if ready to dine. At the time the resident was placed at the table, there was a trivia/conversational activity occurring in the adjoining common area/TV lounge. The resident was not asked if she would like to join the activity. With the exception of passing water, the resident was not offered any form of sensory stimulation, nor was she conversed with, until her meal was served. She sat at the table and spoke random words. Occasionally, she sat with her eyes closed and her chin resting almost on her chest. She sat alone at the table for a period of approximately 45 minutes, when the activity ended and other residents entered the dining area. The resident did not interact with any table mates. She spoke to staff when offered a drink. No stimulation was introduced into the environment when the other residents arrived in the dining area. The resident sat facing the table, without stimulation, until 12:02 p.m. (one hour and 1 minute from when she was placed at the table) when her meal was served. During a pre-meal and meal observation on 2/27/23 on the 1B Memory Care unit, the following was observed: At 11:44 a.m., an unknown staff member wheeled Resident 47 from the table where she had been involved in an activity, and placed her wheelchair facing the table, as if ready to dine. With the exception of passing water, the resident was not offered any form of sensory stimulation, nor was she conversed with, until her meal was served. While the resident sat awaiting her meal, she spoke random words or set with her eyes closed and her chin to her chest. There was no auditory stimulation such as music, nor diversionary materials offered, as she waited. Her meal was served at 12:34 p.m. (a period of 50 minutes since she was placed at the table). Resident 47's clinical record was reviewed on 2/23/23 at 1:43 p.m. Current diagnoses included dementia, cognitive communication deficit, anxiety, depression, and hallucinations. A 2/25/23, annual, Minimum Data Set (MDS) assessment indicated the resident had severe cognitive impairment, used a wheelchair, and required extensive assistance from the staff for purposefully movement. A current care plan problem/need, last reviewed on 2/25/23, indicated the resident had a risk for psychosocial well-being issues. An approach to this need was to encourage the resident to participate in activities to encourage socialization. A current care plan problem/need, last reviewed on 2/25/23, indicated the risk for an altered mood and tearfulness. An approach to this need was to provide and encourage in meaningful activities. A current care plan problem/need, last reviewed on 2/25/23, indicated a potential for increased restlessness especially when anxious. An approach to this need was to provide meaningful activities. 2. During a pre-meal and meal observation on 2/24/23 on the 1B Memory Care unit, the following was observed: At 11:09 a.m., an unknown staff member escorted Resident 34 down the hallway to the dining area. The resident walked with a rolling walker. The unknown staff member told the resident she would be eating soon. The resident was assisted to sit in a chair, and face the table, as if ready to dine. At the time the resident was placed at the table, there was a trivia/conversational activity occurring in the adjoining common area/TV lounge. The resident was not asked if she would like to join the activity. She sat at the table, drank water, and looked around. She sat alone at the table for a period of approximately 40 minutes, when the activity ended and other residents entered the dining area. The resident spilled her water at 11:43 a.m. Staff spoke to her as they cleaned up the water and then left. No stimulation was introduced to the environment when the other residents arrived in the dining area. The resident sat facing the table, without stimulation, until 12:18 p.m. (one hour and 9 minute from when she was placed at the table), when her meal was served. Resident 34's clinical record was reviewed on 2/28/23 at 11:35 a.m. Current diagnoses included, dementia with behavioral disturbances, anxiety, and cognitive communication deficit. A 1/4/23, quarterly, MDS assessment indicated the resident required extensive assistance from the staff for purposeful movement on the unit. A current care plan problem/need, reviewed on 1/4/23, indicated a risk for impaired cognitive function and impaired thought processes which could fluctuate related to dementia. A care plan problem/need, last reviewed on 1/4/23, indicated the resident was at risk for altered moods due to anxiety, worry, and fretfulness. 3. During a pre-meal and meal observation on 2/27/23 on the 1B Memory Care unit, the following was observed: At 11:42 a.m., an unknown staff member hand held walked Resident 77 from the hallway and sat her facing the table as if ready to dine. With the exception of passing water, the resident was not offered any form of sensory stimulation, nor was she conversed with, until her meal was served. While the resident sat awaiting her meal, she drank water or looked around. There was no auditory stimulation such as music, nor diversionary materials, offered as she waited. Her meal was served at 12:10 p.m. (a period of 28 minutes since she was placed at the table). Resident 77's clinical record was reviewed on 2/23/23 at 1:46 p.m. Current diagnoses included, dementia, anxiety, and Alzheimer's disease. A 2/9/23, quarterly, MDS assessment indicated the resident had severe cognitive impairment and required extensive assistance from the staff to purposefully move about the unit. A current care plan problem/need, last reviewed on 2/9/23, indicated impaired cognitive functioning. Approaches to this problem were to encourage activities and provide a home like environment. 4. During a pre-meal and meal observation on 2/27/23 on the 1B Memory Care unit the following was observed: At 11:39 a.m., an unknown staff member wheeled Resident 57 from the hallway and placed her wheelchair facing the table, as if ready to dine. With the exception of passing water, the resident was not offered any form of sensory stimulation, nor was she conversed with, until her meal was served. While the resident sat awaiting her meal, she spoke random words or sat with her eyes closed and her chin to her chest. There was no auditory stimulation such as music, nor diversionary materials, offered as she waited. Her meal was served at 12:18 p.m. (a period of 49 minutes since she was placed at the table). Resident 57's clinical record was reviewed on 2/23/23 at 1:53 p.m. Current diagnoses included, dementia, depression, and Parkinson's disease. A 12/7/22, significant change, MDS assessment indicated the resident had severe cognitive impairment, used a wheelchair, and required extensive assistance from the staff for purposeful movement. A current care plan problem/need, reviewed on 12/7/22, indicated a risk in communication problems related to dementia and Parkinson's disease. 5. During a pre-meal and meal observation on 2/27/23, on the 1B Memory care unit, the following was observed: At 12:00 p.m., an unknown staff member wheeled Resident 37 from the hallway and placed her geri chair facing the table, as if ready to dine. At 12:05 p.m., Resident 37 was observed to have rubbed her mask over her eyes. The dependent resident sat, without assistance to remove the mask from her eyes, until 12:35 p.m. (a period of 30 minutes). As the resident sat with the mask over her eyes, staff members provided services at her table, or walked within inches of her table, at the following times: 12:17 p.m., 12:20 p.m., 12:24 p.m., 12:28 p.m., and 12:30 p.m. As well as having the mask over her eyes, the resident was not offered any form of sensory stimulation, nor was she conversed with, until her meal was served. There was no auditory stimulation such as music, nor diversionary materials, offered as she waited. Her meal was served at 12:35 p.m. (a period of 35 minutes since she was placed at the table). Resident 37's clinical record was reviewed on 2/28/23 at 11:30 a.m. Current diagnoses included, dementia, Alzheimer's disease and expressive language disorder. A 12/14/22, quarterly, MDS assessment indicated the resident rarely or never understood others and was totally dependent on staff for all mobility in a wheelchair and required total assistance with activities of daily living. A current care plan problems/need, last reviewed on 12/14/22, indicated a risk for a communication deficit, the need for total assistance with all activities of daily living, and a risk for additional cognitive decline. During an interview, on 2/27/23 at 12:36 p.m., CNA 4 indicated Resident 37 was unable to remove the mask from over her eyes, and would require staff assistance to do so. 6. During an activity observation on 2/27/23, on the 1B Memory Care unit, the following was observed: At 10:08 a.m., Resident 4 was asked if he would like to participate in a cash drawer activity. At 10:20 a.m., the resident indicated he needed to use the restroom, before wheeling away from the table. Activity Assistant 1 was in the immediate area when the resident made the request. Activity Assistant 1 was not observed requesting any assistance from direct care staff at this time. At 10:26 a.m., the resident was wheeling about and heading towards the currently vacant part of the unit. At 10:35 a.m., the resident was once again in the activity, and had not been toileted. At 10:51 a.m., the resident asked about the bathroom again and rolled away from table. Activity Assistant 1 was in the immediate area when the resident made the request. Activity Assistant 1 told the resident the staff would be with him soon. At 10:56 a.m., the resident continued to ask about the restroom. Activity Assistant 1 again told the resident someone would help him soon. At 10:59 a.m., an unknown nursing department employee walked through the area, and was not asked by the activity assistant to tend to the resident's request. At 11:01 a.m., an unknown staff member assisted the resident to move to a different table than where he was earlier, to sort money again. The resident had not been to the bathroom. At 11:06 a.m., the resident was rolling away from the activity area again. At 11:07 a.m., Activities Assistant 1 was with the resident, outside the bathroom door. She informed him he could not go alone and help would come. She repeatedly said just a minute. At 11:08 a.m., the resident was again asked about the cash drawer activity, this time by a therapy staff member. At 11:09 a.m., the resident was escorted to the restroom by CNA 9 (a period of 49 minutes since his first request to go to the bathroom). Resident 4's clinical record was reviewed on 2/28/23 at 11:23 a.m. Current diagnoses included, dementia, anxiety, constipation, chronic kidney disease, and delusional disorder. A 1/3/23, quarterly, MDS assessment indicated the resident had severe cognitive impairment, required extensive assistance from staff for purposeful movement and toileting, had an indwelling catheter, was occasionally incontinent of urine and frequently incontinent of bowel. A current care plan problems/needs, last reviewed on 1/3/23, indicated a diagnosis of constipation. The goal for this need was to have a normal bowel movement at least every day. An approach to this need was to encourage resident to sit on toilet to evacuate bowels if possible. A current care plan problems/needs, last reviewed on 1/3/23, indicated the resident had impaired cognitive function or impaired thought processes related to dementia, delusional disorder. A goal for this need was the resident will be able to communicate basic needs on a daily basis through the review date. A current care plan problems/needs, last reviewed on 1/3/23, indicated the resident had an ADL (activities of daily living) self-care performance deficit. A goal for this need was the resident will maintain current level of function in ADL's through the review date. During an interview, on 2/27/23 at 11:22 a.m., CNA 9 indicated Resident 4 had not been wet when she just checked him. He had a catheter, but needed to be reminded that he had one. This helped him if he was worried. Also, he thought he needed to have a bowel movement, and sometimes just passed significant gas. He did ask to go to the bathroom for bowel movements, and could remain continent of bowel during the daytime if he was taken to sit on the commode. During an interview on 2/28/23 at 9:56 a.m. with RN 2, who was the charge nurse on 1B Memory Care unit, indicated the residents should not be taken to the dining room any sooner than 30 minutes before a meal. Some form of stimulation should be offered before meals. They had a CD player to play music prior to meals, but it had been misplaced since the remodel. Resident 4 should have been taken to the bathroom when he asked in order to assist with bowel continence. During an interview, on 2/28/23 at 10:04 a.m., CNA 3 indicated residents should not be taken to the dining room any earlier than 30 minutes before a meal. The staff should provide stimulation when the residents wait for meals, such as putting music on the CD player. If Resident 4 asked to go to the restroom, he should be reminded he had a catheter for urine and take him if he says he needed to have a bowel movement. During an interview on 2/28/23 at 10:10 a.m. with the Administrator, who was also the Memory Care director, she indicated the following residents should be escorted to meals approximately 30 minutes or less before meals. The environment should offer sensory stimulation, like music or trivia as they await meals. She had not been told the staff could not find the CD player following the remodel. There were other CD players in the facility that could be used. Resident 4 should be taken to the restroom if he requested, or reminded he had a catheter to reduce his concern. A mask should be promptly removed from a resident's eyes if they rub their face and move it over their eyes. A current facility document, titled Healthcare Meal times and locations of dining rooms, left on the conference table on 2/22/23 as part of a survey readiness binder, indicated the following: . Lunch-12:00 p.m.Dining rooms are located on each unit .1B A current, 9/2022, facility policy, titled, Resident Rights, provided by the Administrator on 2/28/23 at 11:27 a.m., indicated the following: .Respect and dignity. The resident has a right to be treated with respect and dignity 3.1-3(a)

Based on observation, record review, and interview, the facility failed to ensure qualified staff provided a resident transfer for 1 of 1 residents observed. (Resident 29) Findings include: During an random observation on 2/27/23 at 3:36 p.m., in the resident lounge on the 2 B Memory Care unit, Hostess 6 was observed assisting a Certified Nursing Assistant (CNA) to transfer Resident 29 from a recliner to a wheelchair. The two staff members held the resident under the axillary (armpit) area and lifted her to a standing position. The resident appeared unsteady and her knees buckled, but was able to maintain a standing position with assistance of staff. The resident was then pivoted to a wheelchair. Staff had not used a gait belt. Resident 29's clinical record was reviewed on 2/23/23 at 11:54 a.m. Diagnoses included, but were not limited to, Alzheimer's disease, heart failure, pain in bilateral knees, muscle weakness, and need for assistance with personal care. A quarterly Minimum Data Set (MDS) assessment, dated 2/17/23, indicated the resident had severe cognitive impairment, required extensive assistance of two staff for transfers, and was only able to stabilize when standing with staff assistance. A Morse Fall Scale assessment, dated 2/18/23, indicated the resident was a high fall risk. The assessment included the resident had difficulty rising from a chair, had an impaired gait, and had a history of previous falls. During an interview, on 2/27/23 at 3:39 p.m., Hostess 6 indicated she was not a CNA, but had assisted with transfers to help staff. She would not transfer a resident on her own. During an interview, on 2/28/23 at 11:30 a.m., the Director of Nursing (DON) indicated Hostess 6 was not trained to assist with transferring a resident and should not have assisted. Staff should use a gait belt for all resident transfers. A current, undated, facility policy titled Job Description for Nursing Hostess, provided by the Administrator on 2/28/23 at 12:40 p.m., indicated the following: .Responsibilities: .Nursing hostess may not provide/perform/assist with the following direct resident care: assisting with ambulation, feeding of a resident, ADL's [Activities of Daily Living], or toileting assistance A current, undated, facility policy titled, Positioning/Transfer, Assisting Resident To/From Wheelchair or Chair to Bed, provided by the Administrator on 2/28/23 at 12:40 p.m., indicated the following: Procedure: .1 Use gait belt 6. Grasp gait belt on each side of resident's waist, and ask resident to stand on the count of three. 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure a physician order and baseline care plan was in place for oxygen use for 1 of 1 residents reviewed for respiratory care. (Resident 232) Findings include: During an interview, on 2/22/23 at 9:30 a.m., Resident 232 indicated she had recently admitted to the facility from the hospital. She planned to ask staff for lip balm because her mouth and lips felt dry. During the interview, her lips had visible dryness and cracking. She had oxygen on at two liters per minute, by nasal cannula. A humidification bottle (used to humidify oxygen) was sitting on a counter in her room, and there was no humidification bottle connected with her oxygen tubing. During an observation on 2/23/23 at 1:57 p.m., she was sitting in a recliner in her room, with oxygen on per nasal cannula. A humidification bottle was on the counter, and not connected through the oxygen tubing. Resident 232's clinical record was reviewed on 2/24/23 at 9:52 a.m. Diagnoses included, but were not limited to, pulmonary hypertension. Current physician orders did not include an order for oxygen. Her baseline care plan did not include use of oxygen. An Admit/Readmit Screener, dated 2/18/23 at 10:21 p.m., indicated she had admitted to the facility from the hospital. She had shortness of breath with exertion, and had oxygen at 2 liters per minute per nasal cannula. During a medication administration observation, on 2/27/23 at 10:42 a.m., Resident 232 was sitting in a recliner, with oxygen on per nasal cannula at two liters per minute. A humidification bottle was on the counter in her room, and no humidification was connected with oxygen tubing. During an interview, on 2/27/23 at 10:49 a.m., LPN 7 was unable to locate an order for oxygen. She indicated if a resident received oxygen, she would have expected to find an order. Review of a current, undated, facility policy, titled Oxygen, Administration Of, provided by the Administrator on 2/27/23 at 12:03 p.m., indicated the following: .Purpose: To facilitate normal breathing, as ordered by a physician .Procedure: 1. Check doctor's orders .5. The flow of oxygen is started and regulated, per order, and according to facility policy Review of a current facility policy titled, Resident Care Plan, with a revised date of 10/2016 and provided by the Administrator on 2/28/23 at 12:37 p.m., indicated the following: .A baseline care plan for each resident will be developed, within 48 hours of admission, which includes the instructions needed to provide effective and person-centered care that meets professional standards of care. * Includes initial goals, physician orders 3.1-47(a)(6)

Based on observation, interview, and record review, the facility failed to prevent the development and worsening of pressure injuries for dependent residents for 3 of 7 residents reviewed for pressure injuries. This deficient practice resulted in 3 residents' pressure injuries progressing to and/or being discovered at Stage 3 (full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present) pressure injuries (Residents 138, 15, and 49). Findings include: 1. On 4/20/22 at 1:28 p.m., Resident 138 was in bed, with CNA 50 assisting her with positioning. On 4/21/22 at 8:46 a.m., she was seated in her wheelchair in the dining room for breakfast. She kept her eyes closed while being assisted to eat her meal. On 4/21/22 at 11:19 a.m., she was seated in her wheelchair near the nurses' station. On 4/22/22 at 12:51 p.m., she was seated in her wheelchair in the dining room for lunch. On 4/25/22 at 8:44 a.m., she was up in her wheelchair for breakfast. Resident 138's clinical record was reviewed on 4/21/22 at 2:30 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A 4/8/22, admission, Minimal Data Set (MDS) assessment indicated she was severely cognitively impaired, required extensive assistance for bed mobility, and was dependent for transfers and locomotion. Her skin was intact. She had a current, 4/14/22, care plan problem of ADL self-care deficit related to right sided weakness and expressive [CONDITION(S)]. She required extensive to total assistance with ADLs and a mechanical lift for transfers. She had a current, 4/14/22, care plan problem of potential for impairment to skin integrity. She had a current, 4/18/22, care plan problem of a deep tissue injury (DTI) (Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION(S)] separation revealing a dark wound bed or blood filled blister resulting from intense and/or prolonged pressure and shear forces) to her right outer ankle. Interventions included treatment per order, monitor nutritional status, and weekly documentation. The care plan did not include the use of pressure relief boots. She had a current, 4/18/22, care plan problem of potential for skin impairment and the need for pressure relieving/reducing mattress to protect her skin while in bed. Review of a 4/1/22 hospital history and physical document indicated she had right-sided weakness and slurred speech due to a stroke. Review of a 4/7/22 Braden assessment (risk for skin breakdown) indicated a score of 12, which was high-risk for skin breakdown (10-12 high risk). A 4/11/22 progress note indicated her physical therapy had been discontinued. A 4/14/22 physician note indicated she was not progressing as much as hoped and was experiencing gastrointestinal upset. A 4/14/22 progress note indicated she had non-blanchable redness to her right outer ankle. Orders were received to apply skin protectant and keep her feet afloat while in bed. Review of a 4/15/22 Wound Nurse initial assessment indicated she had a pressure injury to her right outer ankle. It presented as a DTI, and measured 1.2 centimeters (cm) long (L) x 1.4 cm width (W) and was deep purple in color. Review of a 4/19/22 weekly wound assessment indicated her right outer ankle DTI remained, with improvement noted as evidenced by decrease in size of 1 cm L x 0.8 cm W. It was deep red, slight purple in color, and remained intact, with no open areas noted. Review of 4/19/22 progress notes indicated she required hypodermoclysis hydration of 250 milliliters (mL) of 0.9% normal saline and catheterization due to retention of urine. During an attempted wound observation, on 4/22/22 at 2:55 p.m., the resident was asleep in bed. LPN 51 attempted to rouse her, but she would not awaken. Review of a 4/24/22 assessment note indicated she continued with the pressure injury to her right outer ankle. The area was improving as evidenced by a smaller size. During a wound observation, on 4/25/22 at 9:27 a.m., accompanied by LPN 53, the resident's right ankle wound was open and approximately the size of a lady bug. LPN 53 indicated she had just finished the application of the skin protectant. She confirmed the wound was open, but the skin protectant would sometimes make wounds look like that. She replaced the resident's pressure relief boots and left the room. During a wound observation, on 4/25/22 at 10:01 a.m., the facility Wound Nurse indicated the resident's wound had probably developed from her laying in bed and not doing a lot. The wound measured 0.9 cm L x 0.6 cm W, and the overlaying skin had came off, so it was a stage 3 pressure injury. She indicated the other nurses would be expected to notify the physician to change treatment orders if a change was observed in a wound. Review of the resident's April 2022 treatment record indicated LPN 53 had performed the resident's treatment twice daily for the two days prior to the wound observation on 4/25/22. 2. During an observation on 4/20/22 at 1:40 p.m., Resident 15 was sitting in a tilt in space positioning chair in the common area near the nurses' station. During an observation on 4/20/22 at 1:43 p.m., CNA 7 assisted him to his room where PCA 2 was in his room with a mechanical lift. They transferred him from the chair to the bed with the mechanical lift. He was rolled onto his right side while the lift sling was being rolled against his side, his incontinent brief was checked for soilage, a wound dressing was visible over his coccyx, he was rolled onto his left side, the lift pad was removed from underneath him and his pants were pulled back up. Pillows and a wedge cushion were used to prop him on his left side. On 4/21/22 at 9:11 a.m., he was in his room sitting in the tilt in space positioning chair, the mechanical lift sling was underneath him, there was a pressure reducing cushion on the chair under the lift sling. On 4/21/22 at 1:12 p.m., he was sitting in tilt in space positioning chair in the common area near the nurses' station. During a wound care observation, on 4/22/22 at 10:09 a.m., the resident was positioned on his right side, a wound dressing over his coccyx was removed, the wound was cleansed and dried, it was the size of a quarter, 90% of the wound bed was covered with slough (non-viable tissue), the remaining 10% was red tissue. Maceration (occurs when skin is in contact with moisture for too long) was visible to the tissue surrounding the wound. Calcium alginate with silver was placed over the wound bed, the wound was then covered by a bordered foam dressing. His clinical record was reviewed on 4/20/22 at 11:22 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] a. Z-guard (protectant skin barrier) to bilateral buttocks and scrotum every shift for blanchable redness, the order date was 8/21/21. b. Z-guard to bilateral buttocks and scrotum as needed for soilage, the order date was 8/21/21. c. Active Critical Care (liquid protein supplement) 30 ml (milliliter) three times a day for promotion of wound healing, the order date was 1/28/22. d. Turn and reposition every two hours to remain off of coccyx, every shift for skin/wound pressure area, the order date was 2/7/22. e. Cleanse coccyx with soap and water, pat dry, then apply silver alginate to wound base and cover with super absorbent dressing, every day shift for skin/wound pressure area, the order date was 2/18/22. f. To be laid down after meals for wound healing, reposition every two hours for wound healing, the order date was 3/22/22. A 2/4/22 quarterly MDS (Minimum Data Set) assessment indicated she had severe cognitive impairment. He required extensive assistance with bed mobility, dressing, eating and personal hygiene, total dependence for transfers, toilet use and locomotion on and off the unit. He was at risk for the development of pressure ulcers, had a Stage 3 pressure ulcer (the NPIAP [National Pressure Injury Advisory Panel] defined a Stage 3 as full-thickness loss of skin, adipose (fat) is visible in the ulcer. If slough or eschar [dry, non-viable tissue] obscures the extent of tissue loss this is an Unstageable Pressure Injury). A current care plan, initiated on 5/4/16 and revised on 4/15/22, indicated he was at risk for pressure ulcers related to decreased mobility, incontinence, [CONDITION(S)], history of [CONDITION(S)] [CONDITION(S)] to right cheek/forehead. The interventions included, but were not limited to, Active Critical Care liquid three times a day, dated 12/18/20 and monitor/document location, size and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . A current care plan, initiated on 1/31/22 and revised on 2/2/22, indicated the resident had a Stage 3 pressure ulcer to his coccyx. The goal was for the area to show signs of healing and remain free from infection by/through review date, the target date was 5/5/22. The interventions included, but were not limited to, administer treatments as ordered and monitor for effectiveness, revised date was 2/2/22 and to be laid down after meals for wound healing, dated 3/23/22. A Braden scale assessment, dated 11/4/21, indicated he was at high risk for skin breakdown. A progress note, dated 1/26/22 at 9:36 p.m., indicated an area of concern to the resident's coccyx had been noted, Z-guard applied and staff instructed to reposition off his coccyx at least hourly. Wound nurse was notified and would assess Friday when she returned. A progress note, dated 1/27/22 at 12:53 p.m., indicated a new area had been found to his sacrum and barrier cream had been applied. A progress note, dated 1/27/22 at 9:02 p.m., indicated a new area had been noted to his sacrum, barrier cream had been applied and a message had been sent to the wound nurse evaluate. An initial wound nurse assessment, dated 1/28/22 at 9:25 a.m., indicated a new area to coccyx/sacrum. Area presented as a Stage 3 pressure injury with full thickness loss. The area measured 1.8 cm (centimeter) in length and 1.2 cm in width with depth less than 0.2 cm, 100% granulation tissue to wound base. He voiced pain with cleansing area. Current preventative measures included a low-air loss mattress, Active Critical Care, repositioning every two hours, gel cushion to chair and Z-guard to buttocks. New order to cleanse with soap and water, pat dry, apply bordered hydrogel dressing. A weekly wound nurse assessment, dated 1/31/22 at 12:28 p.m., indicated the Stage 3 wound to his coccyx measured 1.5 cm in length and 0.6 cm in width with depth at less than 0.2 cm. Moderate amount of serous (clear) drainage noted. Current preventative measures included a low-air loss mattress, Active Critical Care, repositioning every two hours, gel cushion to chair and Z-guard to buttocks. Continue with current treatment. A weekly wound nurse assessment, dated 2/7/22 at 8:01 a.m., indicated Stage 3 wound noted with significant decline as evidenced by an increase in size and now presented as a DTI (Deep Tissue Injury) (The NPIAP defined a DTI as persistent non-blanchable deep red, maroon or purple discoloration with intact or non-intact skin). The area measured 3.0 cm in length and 2.0 cm in width. 50% granulation tissue to outer edges of wound base and 50% deep purple tissue to center of the wound. Moderate amount of serous drainage noted. New order to discontinue the bordered hydrogel dressing and begin hydrogel and cover with super absorbent dressing. Current preventative measures included a low-air loss mattress, Active Critical Care, repositioning every two hours, gel cushion to chair and Z-guard to buttocks. A progress note, dated 2/8/22 at 9:47 a.m., indicated a new order to discontinue current treatment to coccyx and begin treatment to cleanse wound with soap and water, pat dry, apply silver collagen to wound base and cover with super absorbent dressing daily. A weekly wound nurse assessment, dated 2/15/22 at 9:27 a.m., indicated Stage 3 wound to coccyx improved as evidenced by a decrease in size. Wound now presented as Unstageable, (The NPIAP defined an Unstageable Pressure Injury as full-thickness skin and tissue loss in which the extent of tissue within the ulcer cannot be confirmed because it is obscured by slough or eschar). The area measured 2.0 cm in length and 1.2 cm in width, pink granulation tissue to 50% of wound and other 50% with pale, yellow slough and moderate amount of serous drainage. Current preventative measures included a low-air loss mattress, Active Critical Care, repositioning every two hours, gel cushion to chair and Z-guard to buttocks. A weekly wound nurse assessment, dated 2/21/22 at 8:03 a.m., indicated Stage 3 wound presented as Unstageable, measured 0.5 cm in length and 1.1 cm in width. The wound had 50% pink tissue and 50% pale, yellow slough and a moderate amount of serous drainage. Current preventative measures included a low-air loss mattress, Active Critical Care, repositioning every two hours, gel cushion to chair and Z-guard to buttocks. No change in treatment order. A weekly wound nurse assessment, dated 2/28/22 at 11:01 a.m., indicated Stage 3 wound presented as Unstageable. Measured 0.8 cm in length and .08 cm in width. The wound bed had 50% pink tissue and 50% pale, yellow slough and a moderate amount of serous drainage. Continued with same treatment. Current preventative measures included a low-air loss mattress, Active Critical Care, repositioning every two hours, gel cushion to chair and Z-guard to buttocks. A weekly wound nurse assessment, dated 3/7/22 at 9:33 a.m., indicated Stage 3 wound had a decrease of slough with 100% red, viable tissue to wound base, measured 0.8 cm in length and 0.8 cm in width with a depth of less than 0.2 cm and a moderate amount of serous drainage. No change in treatment order. Current preventative measures included a low-air loss mattress, Active Critical Care, repositioning every two hours, gel cushion to chair and Z-guard to buttocks. A weekly wound nurse assessment, dated 3/14/22 at 10:06 a.m., indicated Stage 3 wound measured 0.8 cm in length and 0.6 cm in width with a depth of less than 0.2 cm, 100% red tissue to wound base and moderate amount of serous drainage. Continue with the same treatment. Current preventative measures included a low-air loss mattress, Active Critical Care, repositioning every two hours and gel cushion to chair. A weekly wound nurse assessment, dated 3/21/22 at 8:13 a.m., indicated Stage 3 wound now presented as Unstageable, measured 1.5 cm in length and .06 cm in width, wound base covered with 100% slough and moderate amount serous drainage. Continue with current treatment. Current preventative measures included a low-air loss mattress, Active Critical Care, repositioning every two hours and gel cushion to chair. A weekly wound nurse assessment, dated 3/28/22 at 8:16 a.m., indicated Stage 3 wound continue to present as Unstageable Pressure Injury, measured 1.5 cm in length and 0.6 cm in width, wound bed with 90% slough and 10% red tissue and moderate amount of serous drainage. Continue with current treatment. Current preventative measures included a low-air loss mattress, Active Critical Care, repositioning every two hours and gel cushion to chair. A weekly wound nurse assessment, dated 4/4/22 at 11:09 a.m., indicated Stage 3 wound continued to present as Unstageable Pressure Injury, measured 1.5 cm in length and 0.5 cm in width, wound bed with 50% slough and 50% red tissue and moderate amount of serous drainage. Continue with current treatment. Current preventative measures included a repositioning wedge, low-air loss mattress, Active Critical Care, repositioning every two hours and gel cushion to chair. A weekly wound nurse assessment, dated 4/12/22 at 8:48 a.m., indicated Stage 3 wound continued to present as Unstageable, measured 1.5 cm in length and 0.5 cm in width, wound bed with 50% slough and 50% red tissue and moderate amount of serous drainage. Tissue surrounding the wound with hypopigmentation (patches of skin lighter than your overall skin tone). Continue with current treatment. Current preventative measures included a repositioning wedge, low-air loss mattress, Active Critical Care, repositioning every two hours and gel cushion to chair. A weekly wound nurse assessment, dated 4/19/22 at 7:58 a.m., indicated Stage 3 wound continued to present as an Unstageable Pressure Injury, measured 1.5 cm in length and 0.5 cm in width. Wound bed with 50% slough and 50% red tissue and moderate amount of serous drainage. Continue with current treatment. Current preventative measures included a repositioning wedge, low-air loss mattress, Active Critical Care, repositioning every two hours and gel cushion to chair. During an interview, on 4/21/22 at 1:47 p.m., LPN 5 indicated the resident was usually up only for meals, pillows and a wedge cushion were used to prop his off his coccyx. During an interview, on 4/25/22 at 9:26 a.m., the Wound Nurse indicated the resident had an open wound and she followed the wound weekly. During a follow-up interview, on 4/27/22 at 12:52 p.m., LPN 5 indicated she had written the note on 1/26/22 about the area of concern to his coccyx, she had sent a notification to the Wound Nurse, didn't think the wound looked that deep and had applied Z-guard to the area. She didn't measure or stage wounds, the Wound Nurse did that, but she should have described it more in her progress note. 3. During an observation, on 4/20/22 at 1:32 p.m., Resident 49 was sitting in a recliner in her room looking at a newspaper. During an interview, on 4/20/22 at 3:10 p.m., the resident indicated she had a sores on her bottom for about a year that they were doctoring and thought they were getting better. During a wound care observation, on 4/25/22 at 9:15 a.m., the Wound Nurse indicated the Stage 3 wounds were resolved, the skin still had areas from shearing and friction but the pressure injuries were resolved. The resident was lying on top of the covers, the Wound Nurse assisted her with rolling over onto her side, the resident indicated her bottom was sore. Unblanchable redness, the size of a saucer, was spread over both buttocks and the coccyx area, an open area, the size of a dime, visible to her right buttock, wound bed was red. The Wound Nurse indicated the treatment had been changed to a protectant skin barrier since the area was no longer related to pressure. (The NPIAP defined a pressure injury as an injury that occurs as a result of intense and/or prolonged pressure or pressure in combination with shear). Her clinical record was reviewed on 4/20/22 at 2:18 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] a. Cleanse bilateral buttocks and apply skin prep every day and evening shift, the order date was 4/4/22. b. [MEDICATION(S)]/A&D mixture (protectant skin barrier), to coccyx and bilateral buttocks every day and evening shift for blanchable redness and incontinence, the order date was 4/4/22. c. Cleanse right buttock Stage 3 pressure injury with soap and water, pat dry, apply hydrogel to wound base and cover with bordered absorbent dressing every day shift on Monday, Wednesday and Friday, the order date was 4/13/22. d. Cleanse left upper buttock Stage 3 pressure injury with soap and water, pat dry, apply hydrogel to wound base and cover with bordered absorbent dressing every day shift on Monday, Wednesday and Friday, the order date was 4/13/22. e. Cleanse left lower buttock Stage 3 pressure injury with soap and water, pat dry, apply hydrogel to wound base and cover with bordered absorbent dressing every day shift (may use same dressing to cover both areas), the order date was 4/13/22. A 3/9/22 quarterly MDS assessment indicated she was cognitively intact. She required extensive assistance with bed mobility, locomotion on the unit, toilet use, personal hygiene and total dependence for transfers. She was at risk for the development of a pressure ulcer. A current care plan, initiated on 2/19/15 and revised on 4/6/22, indicated she was at risk for pressure ulcers related to dementia, weakness and a history of pressure ulcers. Actual impairment: history of pressure ulcers to buttocks. The goal was for her to maintain or develop clean and intact skin by the review date, the target date was 6/9/22. Interventions included, but were not limited to, monitor/document location, size and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . A current care plan, initiated 4/13/22, indicated she had the following pressure ulcers: Stage 3 left lower buttock and right buttock. The goal indicated the pressure ulcers would show signs of healing and remain free from infection by/through review date, target date was 6/9/22. Interventions included, but were not limited to, monitor/document/report as needed any changes in skin status: appearance, color, wound healing, signs or symptoms of infection, wound size and stage, dated 4/14/22. A Braden scale assessment, dated 3/9/22, indicated she was at risk for the development of pressure injuries. A progress note, dated 3/31/22 at 9:45 p.m., indicated the CNA had reported the [MEDICATION(S)] dressings had come off due to loose stools. Area was cleansed and [MEDICATION(S)] dressings to applied to bilateral buttocks, wounds looked better and the open areas with granulation were smaller. An initial wound nurse assessment, dated 4/13/22 at 8:57 p.m., indicated left upper buttock presented as a Stage 3 Pressure Injury, same site as a previous Stage 3 injury, measured 0.4 cm in length and 0.3 cm in width with a depth at less than 0.2 cm, 100% granulation tissue to wound bed, minimal amount of serous drainage. New order to cleanse with soap and water, pat dry, apply hydrogel to wound bed and cover with border dressing. Left lower buttock presented as a Stage 3 Pressure Injury, same site as a previous Stage 3 injury, measured 0.4 cm in length and 0.2 cm in width with a depth of less than 0.2 cm, 100% granulation tissue to wound bed, minimal amount of serous drainage. New order to cleanse with soap and water, pat dry, apply hydrogel to wound bed and cover with border dressing. Right buttock presented as a Stage 3 Pressure Injury, same site as a previous Stage 3, measured 0.2 cm in length and 0.4 cm in width with a depth of less than 0.2 cm, 100% granulation tissue to wound bed, minimal amount of serous drainage. New order to cleanse with soap and water, pat dry, apply hydrogel to wound bed and cover with border dressing. A weekly wound nurse assessment, dated 4/19/22 at 8:35 a.m., indicated left upper buttock Stage 3 was resolved. Left lower buttock presented as Stage 3, measured 0.3 cm in length and 0.2 cm in width with a depth of less than 0.2 cm. Continue with current treatment. Right buttock presented as Stage 3, measured 0.2 cm in length and 0.2 cm in width with a depth of less than 0.2 cm. Continue with current treatment. A weekly wound nurse assessment, dated 4/25/22 at 12:49 p.m., indicated left lower buttock pressure injury was resolved and right buttock pressure injury was resolved. New skin issue included partial thickness loss from friction and shearing to bilateral buttocks with minimal amount serous drainage. New order to discontinue hydrogel an bordered dressings and begin [MEDICATION(S)]/A&D mixture twice a day and as needed for soilage, due to friction and shearing. During an interview, on 4/25/22 at 9:24 a.m., the Wound Nurse indicated it did not have all the redness to bilateral buttocks, nurses do a weekly skin inspection of all residents, CNA's inspect resident skin with morning and bedtime care, during showers, with toileting, bed checks and other encounters, they are to report any changes to the nurse, the nurse would notify her. Review of a current facility policy titled Pressure Ulcer/Skin Condition Assessment Policy, updated March 2015 and provided by the Administrator on 4/25/22 at 2:53 p.m., indicated the following: .To establish guidelines for assessing, monitoring, and documenting the presence of skin breakdown and assuring intervention is implemented, and to provide a system to evaluate the response to medical, nursing, and dietary treatment, and intervention of all pressure areas .Skin observations are made daily during bathing and dressing residents and administering treatment procedures .Changes shall be promptly reported to the licensed nurse for a complete assessment .The licensed nurse or Wound Nurse is responsible for notifying Attending Physician, Director of Nursing, and Infection Control Nurse of any changes .The resident's care plan will be revised to include the skin problem and approaches and goals for care. The resident's care plan will be promptly revised to reflect any alteration of the skin integrity and/or revisions to approaches being used 3.1-40(a)(1) 3.1-40(a)(2)

Based on observation, interview and record review, the facility failed to ensure adequate supervision to prevent falls with major injury for 2 of 4 residents reviewed for falls (Resident 23 and Resident 82). Findings include: 1. On 4/20/22 at 1:40 p.m., Resident 23 was in her Broda chair (high back chair with wheels), she was pushed up to her desk and a meal tray was in front of her, the back of the chair was towards the entrance to her room. Broda chair brakes were locked. On 4/20/22 at 2:15 p.m. the ADON indicated to staff they needed to lie her down do to her being busy. On 4/20/22 at 2:36 p.m. she was observed in bed with fall mat and motion sensor in place. On 4/21/22 at 9:03 a.m., the door to her room was slightly open, she was in her Broda chair, the brakes were locked, motion sensor lying on the floor behind Broda chair, the back of her chair was towards the entrance to room. On 4/21/22 at 11:16 a.m., she was in her Broda chair facing towards the entrance to her room, her call light was in reach and the motion sensor was to her right on the floor. On 4/22/22 at 12:56 p.m., Hostess 79 sat outside of the residents room, she indicated she sat there to watch her eat. The resident was in her Broda chair, her eyes were closed, the overbed table was in front of her. On 4/25/22 at 9:45 a.m she was in her room, in her Broda chair and the back of the chair faced the entrance to her room. The brakes were locked on the Broda chair. Resident 23's clinical record was reviewed on 4/20/22 at 11:25 a.m. Diagnoses included, but was not limited to, nondisplaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing, fracture of orbital floor, left side, subsequent encounter for fracture with routine healing, unspecified fracture of shaft of humerus, left arm subsequent encounter for fracture with routine healing, displaced fracture of greater tuberosity of right humerus, subsequent encounter for fracture with routine healing, effusion, unspecified shoulder, cognitive communication deficit, unspecified dementia with behavioral disturbance, anxiety disorder, delusional disorders, Alzheimer's disease, muscle weakness (generalized), and other abnormalities of gait and mobility. Her orders for July 2021 included, but were not limited to, [MEDICATION(S)] 10 mg daily, [MEDICATION(S)] 25 mg daily, [MEDICATION(S)] 200 mg daily, [MEDICATION(S)]-acetaminophen 10-650 mg three times daily, [MEDICATION(S)] 0.5 mg one time only on 7/16/21, sling to left arm, check CSM (circulation, sensation and motion) each shift, no motion to left shoulder, may come out of sling to work on wrist and elbow motion, low bed every shift (7/19/21), motion sensor alarm while in room (7/19/21), rolling recliner chair for comfort (7/19/21) An admission MDS (Minimum Data Set), dated 7/19/21, indicated she was moderately cognitively impaired. She required extensive assistance of two staff members for bed mobility, transfers, locomotion on/off unit, dressing, toilet use and personal hygiene. She required limited assistance of one staff member for walking in room/corridor. She had an impairment to one side of her upper extremity. She used a wheelchair. She was frequently incontinent of bladder and always continent of bowel. A motion sensor alarm was used daily. She had one fall with major injury. A fall risk assessment dated [DATE] indicated she was at a high risk for falls. She had a care plan that indicated she was at risk for falls related to Alzheimer's dementia, history of falls with fracture, hypertension and anxiety initiated on 7/12/21. Her goal was she would have a reduction in falls and serious injury or hospitalization related to injury as needed through next review date initiated on 10/1/20. Her interventions included, but were not limited to, gripper socks at bedtime revised on 7/13/21, anticipate and meet her needs revised on 7/13/21, be sure her call light was within reach in her room and encourage her to use it for assistance as needed. She needed prompt response to all requests for assistance revised on 7/13/21, she needed a safe environment with: even floors free from spills and/or clutter; adequate, glare-free light, a working and reachable call light, side rails as ordered, handrails on walls, personal items within reach revised on 7/13/21, encourage her to participate in activities that promote exercise, physical activity for strengthening and improved mobility initiated on 7/13/21. Her incident notes and care plans indicated, but was not limited to, the following: On 7/17/21 at 8:53 p.m., she was ambulating on her own and fell in front of the wheelchair restroom. She was laid in the recliner and complained of right shoulder pain, mobile x-ray was called. An xray report for her right humerus, dated 7/18/22, indicated a fracture of the proximal humerus with mild impaction and angulation. On 7/19/21 at 8:47 a.m., her care plan was reviewed and room was inspected due to a fall on 7/17/21 at 8:25 p.m. She was on the floor by to community bathroom on the unit. She reported pain to right shoulder. Staff assisted up and placed in a recliner in the lounge for comfort. She continued to have pain to shoulder and was sent to the ER. Resident returned with a diagnosis of fracture to right humerus. Hourly rounding was started upon return from the hospital. Also added low bed and motion alarm in her room. She had a new order for a Hoyer (mechanical lift) for transfers. Transfer to recliner was discontinued and now to rolling recliner for comfort. On 7/19/21 at 9:30 a.m., her fall and new interventions were reviewed and discussed with IDT (Interdisplinary Team) this am and was agreeable to current interventions. A star was also added to her door due a fall just prior to admission. On 7/19/21 a care plan intervention was initiated for a low bed and motion alarm when in her room. On 8/24/21 a care plan intervention was initiated to assist her to call her daughter when restless and other interventions had not been effective. On 7/28/21 at 7:20 a.m., she continued to be have increased restlessness and combativeness with staff, hourly visual checks would continue at this time. On 7/30/21 at 9:29 p.m., she was found laying on floor in her room. She indicated she was trying to walk. She was brought to the lounge and put into recliner for one on one. On 7/30/21 at 9:33 p.m., the writer provided one on one with resident from time of fall to 10:00 p.m. She had been sleeping in recliner in lounge during this time. A new order was received for scoop mattress for fall prevention. On 8/2/21 at 9:40 a.m., her care plan was reviewed and her room was inspected and fall reviewed with IDT due to a fall on 7/30/21. She was on the floor beside her bed. Her motion alarm was sounding. She reported she tried to get up to walk. Staff assisted her up and brought her out to the lounge for one on one until 10:00 p.m. A scoop mattress was added to her bed for bed parameter. On 8/2/21 a care plan intervention was initiated for a scoop mattress on her bed and skid strips to her bed, chair and toilet. On 8/3/21 at 10:41 a.m., she had a motion alarm when in her room. She continued to be at risk for falls. She continued to attempt to get up unassisted and would often become resistive to staff assist. Motion alarm remained appropriate at this time. On 8/16/21 at 11:42 a.m. she had not had any falls since 7/30/21. Interventions included, but not limited to, scoop mattress and hourly visual checks had been effective. On 8/18/21 at 10:02 a.m., she was found on floor on her knees next to her bed. She was able to maneuver her legs back into bed without assistance. No injuries were noted. On 8/18/21 at 2:31 p.m., she was found on the floor in her room next to her bed. Resident noted with a small skin tear and a raised area above her right eye. Floor mat at bedside. On 8/19/21 at 12:22 p.m., she was found sitting on the floor in front of her wheelchair in the lounge. Approximately 30 minutes prior to fall, writer had noticed she was beginning to slouch down and offered to help her sit up better so she didn't slide out of wheel chair, but she indicated she was fine and comfortable right where she was. She had crossed her legs and laid her head back on the wheelchair. On 8/20/21 at 6:33 a.m. her care plan was reviewed and her room was inspected on 8/18/21 due to a fall 8/18/21 at 6:30 a.m. She was on her knees next to the bed and reported she tried to go to the bathroom. Staff toileted and resident wanted to continue to rest in bed. Care plan updated to include to place her on the bed pan around 6:00 a.m. On 8/20/21 at 6:47 a.m., her care plan was reviewed and her room was inspected on 8/19/21 due to a fall on 8/18/21. She was on her knees beside her bed. Staff immediately placed a mat on the floor beside her bed. The intervention was not written on the careplan but was in place. Staff educated on the importance of updating the care plan immediately. Spoke with unit charge nurse and reported that She liked to lay down and that she is exhausted after lunch, but would not stay down long. Would try laying resident down immediately following lunch and get back up in her chair before 2:00 p.m. On 8/20/21 at 6:58, her care plan was reviewed and her room was inspected on 8/19/21 due to a fall on 8/19/21 at 11:15 a.m. She was sitting in the lounge area in her wheelchair and slid her bottom out of the chair and to the floor. Discussed using a gerichair for residents comfort. Nurse reported therapy was working with resident and did not want her to use the gerichair due to maintaining upper body strength. Dycem was placed in the seat of her chair at this time. On 8/20/21 a care plan intervention was revised to have a mat on her floor beside her bed. On 8/22/21 at 1:56 a.m., a CNA was in with another resident and heard her alarm going off by the time she got to her room she was on the floor mat next to the bed. She was assisted into the bed and indicated she didn't know how to get help, call light was next to her on the floor mat. The call light was changed out to a touchpad, writer educated and encouraged her to use call light for assistance. On 8/23/21 at 10:43 a.m., her care plan was reviewed and room was inspected due to a fall 8/21/21 at 11:50 p.m. She was on the floor mat next to her bed. She reported to staff that she did not know how to call for help. Call light was replaced with a soft touch call light. Visual checks would be increased to every 1/2 hour due to recent increase in falls. On 8/23/21 at 6:00 p.m., her motion alarm was sounding, immediately went to room and found her on the floor beside her bed. No injuries were noted. On 8/23/21 at 6:45 p.m., CNA responded to call light and alarm sounding and found she had slid out of bed onto the floor at 6:23 p.m. and was trying to crawl across the floor and indicated she needed to go to Bluffton. No injuries were noted. On 8/23/21 a care plan intervention was initiated for a soft touch call light. On 8/24/21 a care plan intervention was initiated to assist her to call her daughter when restless and other interventions had not been effective. On 8/25/21 at 6:30 a.m., her care plan was reviewed and her room was inspected 8/24/21 due to a fall 8/23/21 at 6:00 p.m. She was on the floor beside her bed. Staff immediately assisted her up and a hostess sat with her and assisted with activities in her room. She was currently on isolation due to possible exposure to covid. Visual checks were increased from every 1/2 hour to every 15 minutes and would reevaluate when resident was off of isolation. On 8/29/21 at 12:34 p.m., she was in her room due to being on isolation, her motion alarm was sounding and she was found lying on the floor under her bedside table. she indicated she was trying to her her colored pencils and fell forward out of her chair. On 8/30/21 at 10:46 a.m., her care plan was reviewed with unit staff and room inspected due to a fall 8/29/21 at 12:26 p.m. She leaned forward to attempt to get her colored pencils and fell out of her wheelchair. Staff added interventions of offering to lay resident down in bed or transfer to recliner after meals. Discussed with unit staff not placing resident in her wheelchair while still on isolation in her room. Staff reported that resident would not be able to reach her tray at meal time due to limitations to both shoulders. Staff also reported that resident often drops colored pencils onto the floor. She now had a tray table with an edge to help her keep things in place. Her care plan was also updated to keep personal items in place. On 8/30/21 a care plan intervention was initiated to keep personal items in reach (water and coloring items) and offer to transfer her to bed/recliner after meals. On 9/8/21 at 6:16 a.m., she had not had a fall since 8/29/21. Current interventions had been effective and would discontinue 1/2 hour visual checks and start hourly rounding. On 9/12/21 at 3:20 p.m., she sat in the lounge in front of the TV in her wheelchair, last attended to less than 10 minutes prior to fall. She leaned forward and slid from her wheelchair to the floor and onto her knees, witnessed fall. No injuries were noted. no injury,did not hit head. Intervention was to have dycem on top of the Hoyer pad and underneath. She was already on hourly visual checks. On 9/13/21 at 12:14 p.m., her care plan was reviewed and her room was inspected due to a fall 9/12/21 at 3:09 p.m. She slid out of her wheelchair in the lounge area. Staff assisted her up and placed dycem between her and the Hoyer lift net, she already had dycem in the seat of her chair. The star would remain on the residents door for 30 more days. On 9/21/21 at 7:38 a.m., her care plan was reviewed and her room was inspected due to a fall 9/20/21 at 4:00 p.m., she was on the floor in front of her recliner. Staff assisted her up and laid her down in bed. Her care plan was updated to use motion alarm at all times and would continue motion alarm in room and motion alarm when in recliner in the lounge. A star on her door would continue for 30 more days. On 9/23/21 at 11:01 a.m., her care plan was reviewed and her room was inspected due to a fall 9/22/21 at 8:49 p.m., her alarm was sounding and she was sitting on the floor beside her bed. Staff assisted up and increased visual checks from hourly to every 1/2 hour and motion alarm would be continued. A star would remain on her door for an additional 30 days. Spoke with her daughter regarding ideas to help decrease falls and she felt that increasing activities would be most useful, due to the resident liked to stay busy with her hands. Suggestions included fidgets, writing letters to family and assist her to send them, a baby to hold and ceramics. On 10/14/21 a care plan intervention was initiated to add dycem to her wheelchair. On 10/19/21 at 7:59 a.m., she had not had a fall since 9/22/21. Her current interventions had been effective and the hourly visual checks would be discontinued. On 10/26/21 at 7:08 a.m., she continued to do well with current fall interventions. She has not had a fall since 9/22/21. The star would be remove from her door. On 12/27/21 at 12:45 a.m. while doing bed check, CNA found that resident had fallen in the TV lounge, second shift had got resident up and was sitting in lounge due to not being sleepy. Third shift CNA was doing bed check but checked on resident frequently after leaving each residents rooms. CNA saw that resident was not seated in chair anymore and found resident lying directly in front of nurses station. Resident appeared to have gotten up and hit head on nurses station. Skin tear to right eyebrow. Cleansed and 3 steri strips applied. Assist up per two person and sat with writer behind nurses station after fall for close observation. On 12/27/21 at 9:37 a.m. her care plan was reviewed and room inspected due to a fall on 12/27/21 . She was in the lounge and attempted to get up per self. Care plan was updated to include place motion alarm on her in the lounge if she was up on third shift. On 12/27/21 a care plan intervention was initiated for her motion alarm to be used in the lounge if she was up on third shift. On 4/24/22 at 8:41 p.m., she was found laying on floor in her room and looked like she had attempted to get out of her Broda chair unassisted as the chair was laying on its side. She was very distressed. When asked if she was in pain she indicated she was. She could not give a specific area that was in pain. No injuries other than a skin scrape on her back. No bleeding. Resident was put into bed and calmed down. 4/25/22 at 10:44 a.m., her care plan was reviewed and her room was inspected due to a fall on 4/24/22. She was restless and tipped her Broda chair. Staff assisted resident to bed and she rested comfortably. Care plan was updated to assist to bed if restless. On 4/25/22 a care plan intervention was initiated to assist her to bed when she was restless. During an interview with LPN 77, on 4/22/22 at 10:18 a.m., she indicated she had came to the unit very angry when she moved from assisted living, she had behavioral issues and her dementia was progressing. She fell in assisted living and had fractures. She fell on second shift and broke her other humerus bone, it healed up awesome. Her interventions were a motion sensor alarm in room, orange juice, she used to love to color, but the movement in shoulders was not as good, she liked to paint, fold clothes and her stuffed cat and dog. She would push herself back and they lock her brakes because she would try to stand, she was only in her room due to being in isolation because she was covid positive. She liked animals and looked at cards with faces, word search book, and she had a picture book of her and her husband. 2. On 4/20/22 at 1:37 p.m. Resident 82 was in bed, non skid strips on floor next to bed, her walker was next to her bed and quarter side rails were up. On 4/21/22 at 9:06 a.m., she was lying in bed, her shoes were on and her walker was beside her bed. On 4/22/22 at 3:28 p.m., she was lying in bed, her shoes were on and her walker was beside her bed. On 4/25/22 at 8:53 a.m., she sat in a facility chair in front of the TV in the common area, a gait belt was around her waist and her walker was in front of her. Resident 82's clinical record was reviewed on 4/21/22 at 12:56 p.m. Diagnoses included, but was not limited to, fracture of unspecified part of neck of left femur, subsequent encounter for closed fracture with routine healing, nondisplaced fracture of coronoid process of right ulna, subsequent encounter for closed fracture with routine healing, unspecified fracture of upper end of right ulna, subsequent encounter for closed fracture with routine healing, other lack of coordination, Alzheimer's disease, mild cognitive impairment, unspecified dementia with behavioral disturbance, delusional disorders, anxiety disorder, muscle weakness, other abnormalities of gait and mobility and [CONDITION(S)] right eye category 3. Her December 2021 orders included, but were not limited to, [MEDICATION(S)] 75 mg daily, trazadone 100 mg daily, [MEDICATION(S)] 1 mg daily hourly visual check (document on paper at the nurses station and motion alarm for fall prevention for two weeks. A quarterly MDS, dated [DATE], indicated she was moderately cognitively impaired. She required extensive assistance of one staff member for bed mobility, transfers, walk in room/corridor, locomotion on/off unit, dressing, toilet use and personal hygiene. She used a wheelchair. She was occasionally incontinent of bladder and bowel. She had one fall with no injury. A fall risk assessment dated [DATE] indicated she was at a high risk for falls. On 11/21/21 at 9:56 a.m., she fell while getting a sweater from her closet. She had a small shear to her right low extremity and elbow. On 11/22/21 at 7:46 a.m., her care plan was reviewed and her room was inspected due to a fall on 11/21/21 at 9:52 a.m. She attempted to get a sweater out of her closet and lost her balance. Her care plan was updated to include offer a sweater or keep sweater in reach. On 12/1/21 at 7:55 p.m., she had unwitnessed fall and was lying on her left side in the restroom. Clothes and shoes were on. She was assess for injuries with no deficits noted. CNA and Nurse assisted resident to standing and supervised her walking to her chair. On 12/2/21 at 9:52 a.m., her care plan was reviewed due to a fall 12/1/21 5:50 p.m. She attempted to go to the bathroom when she lost her balance. Her care plan was updated to toilet her after every meal. She currently had a star on her door. On 12/4/21 at 9:19 p.m., she was found on the floor in her room and lying on her right side. She stated she was trying to help her family bring a fridge into her room. Staff put her to bed and encouraged call light use. On 12/6/21 at 10:02 a.m., her care plan was reviewed on 12/6/21 due to a fall on 12/4/21 at 9:09 p.m., she was found on floor in room with walker tipped over, stating she was trying to move the fridge into her room. IDT met on 12/6/21 and agreeable to trial of motion alarm while in room at all times due to increased falls. She recently failed GDR (Gradual Dose Reduction) attempt of [MEDICATION(S)] and med recently increased. An alarm was to be trialed for two weeks then re-evaluated by IDT. On 12/17/21 at 1:32 p.m., at 1140 a.m., she was found on the floor in her room, laying on her left side. When asked what she was doing she stated she was taking a nap. Assisted to feet per two staff assist and brought out to lounge. Reported that she did fall and hit her head. She had a hematoma to her left temple, slightly larger then a golf ball. She remained adamant that she can do what she wanted, when she wanted, that her family are all around her to keep an eye on her. She had a pair of pants she had removed from the closet on the floor beside her and she did not have shoes on. Reported that her socks were slippery. She did have shoes on previously, so had removed them herself. On 12/20/21 at 9:52 a.m., her care plan was reviewed and her room was inspected due to a fall 12/17/21 at 11:44 a.m., she was on the floor in her room. She had removed her gripper socks and she had removed a pair of pants from her closet. Skid strips added to toilet, chair and closet. She was later sent to ER due to hip pain and was admitted for a left hip fracture. Discussed in IDT would continue to use motion alarm. Would move resident up the hallway to a room closer to the nurses station for her safety. During an interview with LPN 77, on 4/22/22 at 10:13 a.m. she indicated she had was not having behaviors and was doing amazing, she had a long history of mental health issues with delusions and hallucinations, she talked to people that were not there and would not take her medication. She had a tough period when she came in November. She fell and broke hip in December. She stopped eating and wouldn't not take medication. They had to crush her medication and dissolve her medication in chocolate boost. She snow balled due to a GDR of her medications. An undated policy titled, Fall Intervention Policy and Procedure, lying on table in the conference room, on 4/26/22 at 1:15 p.m., indicated the following: Purpose: To assess residents at risk for falls and to implement fall/injury prevention plan of care. Due to age, physical, and cognitive status, and possible environmental factors, long-term care residents are likely candidates for falls and not all falls will be prevented. Utilizing a multidisplinary team evaluation of resident falls will enhance the prevention and/or reduction of continuing resident falls and/or injury prevention . 3.1-45(a)

Based on observation, interview, and record review, the facility failed to identify and implement individualized, non-pharmacological interventions for residents with expressions of behavior for 2 of 6 residents reviewed for dementia care (Residents 29 and 59). Findings include: 1. On 4/19/22 at 9:40 a.m., Resident 29 was in his room, using an electric razor. On 4/20/22 at 8:29 a.m., he was asleep in his recliner. On 4/20/22 at 1:37 p.m., he was asleep in his recliner. On 4/21/22 at 8:52 a.m., he was asleep in his recliner. On 4/22/22 at 8:22 a.m., he was eating breakfast in the dining room. On 4/22/22 at 2:32 p.m., he was in his room, watching TV On 4/25/22 at 10:26 a.m., he was walking in the hallway with a fitness staff member. Resident 29's clinical record was reviewed on 4/20/22 at 9:26 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . He was admitted to hospice services in May 2021. A 2/14/22, quarterly, Minimum Data Set (MDS) assessment indicated he was moderately cognitively impaired, had no [CONDITION(S)] or behaviors, and required extensive assistance for ADLs. He had a current, 12/1/21, care plan problem of altered sleep pattern related to [CONDITION(S)]. Interventions included, but were not limited to, medications, monitoring, assessment, and observation. He had a current, 6/2/21, care plan problem of impaired cognitive function and impaired thought processes related to dementia with behaviors, fluctuating periods of confusion and potential for hallucinations. Interventions included, but were not limited to, medications, yes/no questions, cuing, identify yourself, and reduce distractions. He had a current, 6/22/21, care plan problem of depression, dementia and adjustment disorder, anxiety, hallucinations, nightmares, and [CONDITION(S)]. His mood may be effected by admission, changes in health and separation from spouse who lives elsewhere. He is at risk for altered moods, anger, frustration, and sadness. Interventions included, but were not limited to, music (artist specified) and offer to go for a walk in the hall. He had a current, 6/9/21, care plan problem of [CONDITION(S)] medication use related to hallucinations and [CONDITION(S)]. The care plan did not identify his hallucinations or define his [CONDITION(S)] expressions. Review of progress notes and assessments indicated the following: On 5/26/21 at 10:05 a.m., indicated the resident had come out of his room, heading to the nursing station at approximately 5:45 a.m., appearing angry and frustrated. He yelled at staff that he was barricaded in his room, his furniture was placed to prevent him from escaping, and his door was locked. He had hallucinations of a care accident and was not able to be consoled. He began tumbling backward so a CNA went to help catch him from falling and the resident rose his hand in the air to her in a threatening manner. It was noted his room was clean and well-organized with a clear pathway to the door. He began yelling to call his family and was informed it was 6:00 a.m.; he began cursing. A family member came to sit with him, and the behavior lasted about 30 minutes. On 5/27/21, he had been noted to have bad day the day prior, starting very early in the morning, with increased confusion and delusional thinking. Later in the day, he was noted to be sitting on his roommate's bed and refused to move, stating he was getting out of here. He had new orders to check his urine for infection and for [MEDICATION(S)] (anti-anxiety) as needed, which was given in the afternoon, along with a family member coming in to sit with him. During their visit, the resident was noted to state he wasn't right in the head and crying at times. It was also noted he was hallucinating, petting a cat on his lap, a boy comes to his room at night, he saw a mouse run across the floor, and he had 'bolts' that weren't there. His urine dip was negative. A 5/31/21 Nurse Practitioner note indicated to try and remove the [MEDICATION(S)] (opiate pain medication) patch he used to see if it cleared up his hallucinations and delusions. The resident complained of diarrhea since and not sleeping well. He was also to be moved to a different room. On 5/31/21, his roommate had been readmitted and Resident 29 didn't want to go back to his side of the room. He became very agitated and was going to be transferred to another room temporarily. On 6/1/21 at 8:36 p.m., he had slept most of the shift in his recliner; he had been up to the bathroom twice due to loose stools. On 6/1/21, his family reported he had seen a cat in their apartment and was having periods of mild agitation with his spouse and he had experienced a COVID-19 infection, which made these symptoms worse and it took him a while to recover. He had not been the same or back at his baseline since then. He had become selfish, frustrated that staff were giving his roommate more attention than him. The facility would begin behavior monitoring related to increased agitation episodes in past week. A 6/2/21 progress note indicated [MEDICATION(S)] 0.5 mg at bedtime was ordered, as the resident did describe trouble sleeping the previous night. A 6/2/21 progress note indicated the resident had slept in his recliner chair until 7:30 a.m. On 6/2/21 at 2:45 p.m., he fell between his bed and recliner. He became agitated when being assessed and assisted to stand with a gait belt. He calmed down when the gait belt was removed. On 6/3/21, he had not slept well and was sitting on the side of the bed all night, or had been easily awakened. On 6/3/21 at 10:58 a.m., he was noted to be agitated this hour, attempting to get up and down. He was given a dose of [MEDICATION(S)] for anxiousness. On 6/3/21 at 9:59 p.m., he was sleepy at the beginning of the shift. He had been up to the bathroom around 4:00 p.m., and was very awake trying to get out of chair - had dumped water on the floor and was bending over to get his oxygen tubing. He would try to get up without help or would sit on the side of the bed. He hadn't slept any of the shift and was agitated after dinner. He wanted to [NAME] the facility because he wasn't supposed to be there. He was given the ordered [MEDICATION(S)] and was trying to sleep on the other end of bed. On 6/4/21 at 9:12 a.m., he was up for breakfast, and noted to attempt to get up by himself several times. On 6/4/21, it seemed he was adjusting to the single room placement. He was noted at times to be restless and unsafe related to falls. He was seen by the Nurse Practitioner and would be starting new medications due to his expressing some [CONDITION(S)]-type nightmares and he was irritable and not sleeping well at night. A 6/4/21 behavior note indicated he complained about his eyes, stating that he was seeing things move around even while laying with eyes closed. He stated items in his room move on own and his family also reported to facility staff he stated he wouldn't sleep in bed because things move all over the room and made him sick. A compress was applied to his eyes. On 6/4/21, multiple attempts were made to assist the resident with peri-care or to get ready for bed. He would start to get a little testy with staff and make inappropriate comments. Confusion and possible hallucinations could be contributing. A 6/4/21 Nurse Practitioner note indicated he had healing rib fractures and rapidly progressing dementia. His pain patch had been put on hold. On 6/6/21, he resident reported he didn't like anyone looking at him while he was trying to sleep. He continued to have loose stools indicative of dumping syndrome after eating. On 6/9/21 at 6:15 p.m., he was found on the floor in his room and stated he had sat down, before he was going to fall. A 6/9/21 pharmacist note indicated [MEDICATION(S)] may cause involuntary movements including tardive dyskenesia. A 6/11/21 pharmacist note indicated the use of [MEDICATION(S)], [MEDICATION(S)] (opiate pain medication), [MEDICATION(S)], [MEDICATION(S)] (blood pressure), [MEDICATION(S)], [MEDICATION(S)] (water pill), [MEDICATION(S)] (diabetes medication), and [MEDICATION(S)] (blood pressure) and the resident had been experiencing new onset or worsening of falls, dizziness, or impaired coordination. On 6/12/21, the [MEDICATION(S)] was not helpful for sleep, and [MEDICATION(S)] 5 mg was started. On 6/13/21, he had been having diarrhea since four days prior. He was starting to get agitated because he couldn't get to the bathroom fast enough. He was given an as needed dose of [MEDICATION(S)] at 7:07 p.m. As of around 8:00 p.m., he appeared calm and un-agitated. A 6/14/21 Social Services note indicated a review of the resident's behaviors, which were noted as some restlessness, getting up on his own without assistance, frustration with staff (stating he didn't need babysat), and using derogatory terms with staff. He had gone into another resident's room on 6/12/21 late on 2nd shift; the other resident was sleeping at the time and was not disturbed. The Nurse Practitioner made a recommendation for an increase of his [MEDICATION(S)] to three times daily and to add [MEDICATION(S)] 50 mg at bedtime for sleep. On 6/14/21 at 8:15 p.m., he was found in his room between the recliner and bathroom door. He had the call light on, but had proceeded to transfer himself before the CNA arrived. A 6/15/21 behavior summary note indicated he had 10 behavior notes in the previous two weeks, with six of them on 6/12/21, of frequently getting up on his own, and being restless. Staff had observed him coming out of another resident's room in the late evening while the other resident was sleeping. He had been noted in the past two weeks to be irritable with staff and making some inappropriate comments. On 6/15/21, his family brought in a CD player with his favorite artist's music, hoping it would help ease him at night. On 6/22/21, he reported seeing a large bug in his room, but no bug was seen by the nurse. A 6/29/21 behavior summary note indicated a hallucination on 6/22/21 and irritability on a few days, especially on 6/17/21. He was frustrated with staff checking on him frequently - spying on him - because of a fall. He was noted to be moving around his room without assistance and even coming out into the hall without assistance. He believed someone had stolen his cookies and was given some cookies from facility. He was also noted to swat at an aide when they were trying to assist him. His medication changes seemed to be beneficial related to improved mood overall and decreased behaviors. Staff was also working out for a family member to have the noon meal with the resident a few days a week. A 7/5/21 progress note indicated his family expressed concern he did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/5/21, the [MEDICATION(S)] was re-ordered on an as-needed basis for anxiety, as he was difficult to re-direct when restless and agitated. On 7/7/21 at 2:23 a.m., he was found on the floor in his room and stated he must have fallen out of the recliner. He had an abrasion to his right eyebrow. A 7/12/21 Behavior Management meeting note indicated the Nurse Practitioner reported the resident was very anxious related to being short of breath and [CONDITION(S)] and weight gain were noted. She stated he told her that he was still dreaming a lot and seeing things, but not as frequently A 7/13/21 behavior summary note indicated he was noted on three occasions to be getting up in his room unassisted, usually to use the bathroom. He was not fully aware of safety at times, getting tangled in oxygen tubing, trying to walk out into the hall once without switching to his portable tank, and stretching the tubing. He would get frustrated with staff when they came to help him, or would state he thought staff were just keeping him in healthcare to get more money from him. He received [MEDICATION(S)] on 7/6, 7/9, and 7/10. A 7/20/21 medication review note indicated he had been on [MEDICATION(S)] for [CONDITION(S)] since June 2021 and had since improved drastically with his fears, paranoia, and accusations that he was having with irrational thought processes. There was no recommendation for reduction due to still being in an adjustment period. A 7/27/21 behavior summary note indicated he had not received any [MEDICATION(S)] since 7/10/21. However, on 7/27/21, when the resident's family member was leaving his room (having 2 noon meals together weekly), he was standing up unassisted and the nurse went to stand close to intervene for safety related to past falls. The resident became frustrated by his family member telling him to sit down and then staff standing by for safety. He was becoming agitated and stated he hadn't fallen in 3 months which was inaccurate. The nurse administered a dose of as-needed [MEDICATION(S)]. An 8/10/21 behavior summary note indicated he had become irritable with his family members and staff on 8/1/21 as staff was assisting him to transfer to a wheel chair so he could go outside, and needed guiding to not sit on the arm of the chair. He became upset and accused staff of trying to make him fall. He had recently required an increase in his diuretic. An 8/23/21 note indicated he had anxiety, agitation, and irritability at times. [MEDICATION(S)] had been administered twice in 30 days and an attempt would be made to reduce the [MEDICATION(S)] to twice daily as needed. An 8/24/21 behavior summary note indicated he had been noted in the pool on 8/20/21 to be going from deep water to shallow without help and scraped his toe. Then, in the evening of 8/21/21, he had been irritable with staff after his meal, not wanting to wait for staff to walk with him, ambulating without assistance, and taking off his oxygen. Staff had provided reminders and reassurance, but it was not effective. On 9/1/21, he was found on the floor in his room; he stated he tripped over his portable oxygen tank. On 9/3/21, he was diagnosed with an upper respiratory infection. A 9/7/21 behavior summary note indicated on 8/24/21, the resident was wanting to be independent in his room so he could go back to live with his wife. He was frustrated with staff for wanting him to call for assistance and didn't think he needed it - he believed staff were just trying to keep him separated from his spouse for no reason. A 9/11/21 behavior note indicated the resident had self-transferred onto the toilet and turned on the bathroom call light. He was having increased confusion and having moderate amount of anxiety evidenced by moving from recliner, to bed, to restroom, back to recliner, to restroom. He had a worried and almost pained expression on his face and was clenching his fists. He didn't know why he had to be guarded all of the time and didn't believe the nurse was his nurse. He was swearing at staff and calling them idiots and stating he should be going home. He did not recall his family visiting earlier in the day. A dose of [MEDICATION(S)] was administered. A 9/21/21 behavior summary note indicated he would become upset when trying to do things on his own which are not safe. Staff intervention to help would cause him to become more agitated. He had tried to walk out of his room with his oxygen still attached and resisted assistance when staff tried to walk with him. He felt he was a prisoner of the facility. He received a dose of [MEDICATION(S)] for both episodes noted. A 10/12/21 medication reduction note indicated no changes were recommended due to recent stabilization. A 10/19/21 behavior summary note indicated he was found twice to be agitated with staff when he was wanting to go for a walk and didn't want staff to assist/stand by for safety. He also believed the facility was keeping him there and he didn't belong there. A dose of [MEDICATION(S)] was given that morning. An 11/2/21 behavior summary note indicated he kept taking off his oxygen and walking in his room unassisted. He also had an episode of irritability after his family member left from a visit. He was administered [MEDICATION(S)], which was noted to be effective as he decided then to go to bed. On 11/6/21, he was found on the floor against his recliner. On 11/7/21, he was noted to be punching the air in his sleep. A 12/13/21 Social Services note indicated he was confused at times, usually in the evening. He would get up unassisted in his room, and would tell people different stories - this was related to dementia and confusion and poor decision making and was not considered behavioral, per the behavior team. His mood had been stable and pleasant, with no anger or distress, therefore the team recommended removing him from routine behavior management. On 12/20/21, he told the nurse he had seen a big dog fight outside of the window. He said he had seen a [NAME] and a mixed breed dog going at it. He then stated it was snowing. The resident was looking out the window, but neither event had taken place. A 12/21/21 Nurse Practitioner dose reduction note indicated he had been having excessive falls related to hallucinations and was distressed during each episode. He was very difficult to re-orient and return to reality and the episodes would often last for hours. Since he was now at the best he had been for quite some time, it was felt he was clinically at the lowest effective dose and risk for injury would occur with reduction. On 4/19/22, a gradual dose reduction of eliminating two doses of [MEDICATION(S)] a week was initiated. During an interview, on 4/25/22 at 10:21 a.m., Nurse Aide 54 indicated the resident had seen kids in his room in the past, but it didn't upset him. He would accept care without problem. During an interview, on 4/25/22 at 10:23 a.m., CNA 55 indicated the resident did not have any behaviors. She had been told he had some in the past, but she hadn't cared for him back then. He would yell out sometimes at night, but she didn't know what for- she just looked in to make sure he as okay. During an interview, on 4/25/22 at 1:53 p.m., LPN 59 indicated the resident was monitored for restlessness and hallucinations. Interventions would be found in the care plan or in his physician orders. During an interview, on 4/25/22 at 2:26 p.m., the Social Service Director indicated she would have to look into why he was on the [CONDITION(S)] medications. During an interview, on 4/25/22 at 2:53 p.m., the ADON indicated the resident's behaviors were random; he would get out of control with pacing, he wouldn't sit down. They had to get his family member out of bed to settle him down. The Social Service Director indicated in May of 2021, he had seen a car outside, thought the room was barricaded, had seen a boy in his room, a cat that wasn't there, and nuts and bolts that weren't there. It was very distressing to him and he would break into a sweat, raise his voice, and get aggressive. Per the Nurse Practitioner note, he had been having issues prior to admission to the healthcare facility, but they weren't reported to the facility. During an interview, on 4/26/22 at 8:18 a.m., the DON, ADON, and Administrator indicated the resident had been very difficult to handle. Interventions had included calling his family to sit with him, family having lunch with him, 1:1 with staff, trial of movie night with family, fitness staff walking with him, using the pool, CD player, TV, and walking away and reapproaching him. If the medications had not been started, he would have required inpatient treatment at another facility. 2. On 4/20/22 at 1:36 p.m., Resident 59 sat in a gerichair with her legs elevated in the nurses station with a staff member. On 4/21/22 at 9:31 a.m., she sat in the gerichair with her feet elevated half way. The nurse asked a staff member to watch her in the common area while they laid down the hoyer residents down and not to turn her back on the resident. On 4/21/22 at 1:23 p.m., she sat in a facility chair in front of television, gerichair was sitting behind her, her head was tilted forward. On 4/21/22 at 2:17 p.m., she walked from the restroom and back to the gerichair. The staff member sat next to the resident and rubbed her back. She tried to stand up and the staff member indicated she needed to stay seated. On 4/21/22 at 2:24 p.m., she stood up from her chair and indicated she wanted to go to church, staff member indicated there was not church but could put hymns on for her. On 4/22/22 at 9:05 a.m., she sat in the gerichair pushed up to the table in the dining room, then staff assisted her hand in hand to the wheelchair bathroom, another staff member pushed the gerichair behind her. On 4/22/22 at 1:01 p.m., she was toileted and assisted into the gerichair in front of the television. She pulled on the arms of chair to pull herself up and laid her right foot off to the side of her chair. The nurse approached her and asked if she wanted to go for a walk, nurse walked her down the hall. On 4/22/22 at 3:53 p.m., she sat in the reclined gerichair during an activity, a staff member sat beside her. She was trying to get out of the gerichair and put her feet off to the left side of the gerichair. The staff member that sat next to her asked the Activity Assistant for assistance with her. The Activity Assistant approached the resident and indicated to her to lay back. They pulled her up in her chair and he indicated to the staff member to hold her hand, that helped calm her. On 4/25/22 at 9:31 a.m. staff took her for walk outside in her wheelchair. On 4/25/22 at 1:42 p.m., she was sitting in facility chair with her head down. On 4/25/22 at 2:41 p.m., she was awake, sitting in a facility chair, the nurse assisted her with eating sherbet. On 4/25/22 at 2:47 p.m she stood up from facility chair, gait belt around waist, nurse was washing her hands in the sink in the DR while res in front of TV, activity assistant had his back to her, the nurse was alerted that she stood up and activity assistant assisted her with sitting back down in chair. Then the nurse assisted her to the bathroom. On 4/26/22 at 9:39 a.m. she sat in the facility chair in front of the TV in the common area, an overbed table was in front of her, her head was titled down and her eyes are closed. Resident 59's clinical record was reviewed on 4/20/22 at 1:47 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Her current medications included, but were not limited to, the following: a. [MEDICATION(S)] (antidepressant) 7.5 mg daily for other recurrent depressive disorders, order date was 12/6/21. b. [MEDICATION(S)] (antipsychotic) 5 mg daily for delusional disorders, order date was 12/6/21. c. [MEDICATION(S)] (treat obsessive compulsive disorder) 100 mg daily for anxiety disorder, order dated was 12/6/21. d. [MEDICATION(S)] (treat obsessive compulsive disorder) 50 mg daily for restlessness/anxiety, order dated was 3/30/22. e. [MEDICATION(S)] (antianxiety) 0.5 mg twice daily for anxiety disorder, ordered date was 4/13/22, Behaviors - monitor for the following: tearful, anxiety, delusions, hallucinations, groggy, difficulty arousing, sleep disturbances, if present complete a behavior assessment. A quarterly MDS dated [DATE], indicated she was severely cognitively impaired. No behaviors were exhibited. She had a care plan that she had a potential for increased restlessness with repeatedly trying to get up/ambulate per self; history of wandering around the unit with potential to go into others' rooms related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Her goal was her safety would be maintained through the review date. Her interventions included, but was not limited to, identify pattern of wandering purposeful, aimless, or escapist? Is she looking for something, checking on her patients or doing her rounds? (resident worked as a nurse). Does it indicated the need for more exercise? Intervene as appropriate, revised on 1/24/22. Her triggers for increased restlessness with trying to get up per self wandering are wanting to walk, wanting to go home, wanting to check out things (she may be checking on her patients or doing her rounds as she used to work as a nurse). Her behaviors were de-escalated by conversation, folding wash cloths may like holding mechanical dog, may enjoy coloring with markers, may try taking her for a walk or walking with her, may try singing with her (she likes hymns), may try painting her nails initiated on 12/7/21. She was at risk for altered moods related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Her goal was that she would have stable moods with no signs or symptoms of depression, anxiety or sad mood by/through review date. Interventions included, but were not limited to, provide her with a program of activities that was meaningful and of interest: enjoys walking, folding washcloths, conversation (may try asking her about her experiences working as a nurse), coloring with markers, may enjoy holding a mechanical dog, she enjoys going for walks, likes listening to hymns. Encourage and provide opportunities for exercise, physical activity. initiated on 12/6/21 and she needed adequate rest periods. She prefers to rest when she verbalized she was tired initiated on 12/6/21. She had a 1/6/22 resolved care plan that she was a new admission and would need time to adjust. She was unfamiliar with staff faces/names, facility routine, etc. initiated on 12/6/21. A 12/6/ 0:54 Social Service Note, dated 12/6/21 at 10:54 a.m. indicated she moved from AAL (Alzheimer's Assisted Living) to Unit 2B. She had been noted with needing more assistance with all ADLS (Activities of Daily Living) and was no longer meeting criteria for continued stay on AAL. A behavior assessment, dated 12/21/21 at 1:26 p.m., indicated she paced the hallway and indicated she needed to go down there to keep an eye on him. Sometimes he is nice and friendly and sometimes he is not. Staff asked resident who she was referring to. She indicated a younger gentleman, he slept at night but was busy during the day, She needed to go check on him and keep an eye on him. She continually paced and when stopping to ask resident how she was, she continued to speak about this man and how she needed to take care of him. Offered lunch, she sat at table and then proceeded to get up from table in regards to checking on this man. Able to re-direct and sat near staff to talk with. Helpful for a little while, but unable to re-direct. Partially effective interventions were one on one talking, lunch offered and sat near staff to speak. A behavior assessment, dated 12/21/21 at 8:10 p.m., indicated she was distressed this shift. Wandered in and out of others rooms. Instead of her usual slow gait, she is walking very fast up and down hallways. Ineffective interventions were took to the bathroom, offered a snack and a warm blanket. A social service note, dated 12/22/21 at 6:47 a.m., indicated two behaviors in past 24 hours, day shift yesterday, paced halls talked about a man she needed to check on and keep an eye on. Noted with continued to pace, when she would stop staff would ask how she was, resident would continue to speak of a man she needed to take care of. Given lunch, she only sat briefly then up again to check on this man (not a real person). Staff encouraged her to sit near them which helped for a short time. Her busyness continued into evenings, noted to wander in/out of others rooms. Staff tried to redirect with toileting, offered snacks and warm blanket - none noted to be effective. A behavior assessment, dated 12/22/21 at 2:26 p.m. indicated she wandered into room [ROOM NUMBER] and proceeded to try and urinate in the trash can, missed and hit the floor. Effective interventions were took her to her own bathroom and one on ones, an activity was offered and partially effective. A social service note, dated 12/23/21 at 7:51 a.m. indicated she was noted with behavior yesterday afternoon, going into other's room and attempted to urinate in trash can, but missed and urinated on floor. Staff took resident to her own room and offered activity for distraction along with one on one all noted to be effective. A behavior assessment, dated 1/20/22 at 8:22 p.m., indicated she paced up and down the hallway at a faster pace than normal and stooped over. More distressed than usual. She wandered in and out of other residents rooms. Resistant to being redirected. Ineffective interventions were redirection, snack offered and taken to the bathroom. A social service note, dated 1/21/22 at 10:34 a.m., she was noted on 1/20 on second shift with wandering into others' rooms and was resistive to redirection. She was described as being more distressed than usual with pacing,waking faster than usual, and with being stooped over. She would continue to be closely observed. IDT (Interdisplinary Team) aware of wandering and it was noted that were no reports of other residents being distressed by this resident's wandering. A behavior assessment, dated 1/23/22 at 7:23 p.m., indicated she had been very anxious this shift. She opened other residents' doors and walked into their bathrooms when care was being completed. Writer asked her to please exit the room and explained that was not her room, she insisted it was her room. She was put into bed with night gown on, 30 minutes later she got out of bed and walked down the hall without any clothes on. Ineffective interventions were redirection, showed her where her room was and explained the situation to her. A social service note, dated 1/24/22 at 10:35 a.m., indicated she was noted on 1/23 on second shift with increased anxiety with walking into others' rooms and bathrooms and then insisted it was her room when staff would ask her to leave. When she was assisted to bed for the night, she got up after approximately 30 minutes and took off her night clothes and walked down the hall. IDTaware of behaviors and there were no reports of other residents being distress by her behaviors. A behavior assessment, dated 1/25/22 at 8:29 p.m., indicated she paced up and down hallway. Wandered into other residents rooms, sometimes removing clean linens from bathroom. She was found trying to get into bed with another female resident. Ineffective interventions were snack, taken to the bathroom and shower her to her room. A social service note, dated 1/26/22 at 9:57 a.m., she was noted on 1/25 on second shift with pacing, wandering into others' rooms -sometimes removing clean linens from the bathrooms, and attempted to get into bed with another female resident (staff intervened and no reports of other resident being upset by this). Interventions of snacks, toileting, and showing her her own room were not effective. Resident has had an increase in restlessness recently and will continue to be closely observed. IDT aware of behaviors. Care plans reviewed and remain appropriate at this time. A behavior assessment, dated 3/22/22 at 4:47 a.m., indicated she had been up walking the halls and trying to go into resident's rooms. She had been toileted, helped to bed, sat in the TV lounge with warm blanket and resident will not sit down for more than a minute. Ineffective interventions were taken to bed, toileted and given a warm blanket. A soc [TRUNCATED]

Based on interview and record review, the facility failed to prevent staff to resident verbal abuse for 1 of 3 residents reviewed for abuse ( Resident B). Findings include: During an interview on 1/13/22 at 11:45 a.m., Resident B indicated she had received care from LPN 1 in the past and had no issue. She indicated LPN 1 had received some upsetting news and she felt that was what caused her to act the way she did. She indicated she felt safe at the facility and loved all the staff. On 1/13/22 at 9:30 a.m., the Administrator provided an Indiana Department of Health (IDOH) incident report, investigation and statements obtained related to the allegation. The incident investigation indicated the following: a. On January 3, 2022 at 8:01 p.m., an incident of a staff person yelling at a resident was heard. The Administrator was notified and the employee was immediately suspended pending an investigation. b. An initial statement by CNA 2 on 1/3/22, indicated she was outside of Resident B's room when she heard the verbal confrontation between Resident B and LPN 1. Resident B stated she waited over an hour for her patch and the nurse yelled back that it had not been more than 1 hour. CNA 2 asked LPN 1 to calm down. CNA 3 was coming down the hall with another resident and also heard the argument. CNA 2 reported the incident to the charge nurse. c. During a telephone clarification interview, CNA 2 indicated LPN 1 was not provoking Resident B, but more arguing with her and not talking to her in her normal voice. She indicated the resident was already aggravated prior to the incident due to pain. She felt LPN 1 was unprofessional verses abusive. d. An initial statement provided by CNA 3 on 1/3/22, indicated she was walking down the hall after giving another resident a shower when she heard LPN 1 say what, are you going to yell some more? LPN 1 continued to provoke Resident B to the point where Resident B cried. e. During a telephone clarification interview, CNA 3 indicated LPN 1 asked Resident B more than once what are you going to yell some more but she only caught the end of the exchange. She felt LPN 1 was very unprofessional. f. A statement by RN 4, dated 1/3/22, indicated she was passing medications and CNA 2 approached her and reported LPN 1 was yelling at Resident B. She also reported CNA 3 witnessed the confrontation. She notified the house supervisor and went to the resident's room to reassure her and to see if she needed anything. g. A statement provided by CNA 8 on 1/3/22, indicated Resident B had her call light on around 6:00 p.m. The resident stated her patch had fallen off. She did not see the nurse in the hall, so left the patch on the chair by her arm and finished getting her ready for bed. She left and found LPN 1 and informed her the patch had fallen off and then went on break. She did not hear the confrontation between Resident B and LPN 1. h. A statement provided by Resident B, dated 1/3/22, indicated she was interviewed by House Supervisor 5 at 8:30 p.m. Resident B indicated the [MEDICATION(S)] (opioid) patch fallen off in the restroom around 6:00 p.m. and the CNA could not locate the nurse. At 6:55 p.m., LPN 1 came in and she asked what took her so long. LPN 1 responded by yelling she was busy and they both began shouting and eventually the topic changed to LPN 1's former husband and some debt he had and owing back taxes. LPN 1 was talking about this while applying a topical cream to her knees. A progress note, dated 1/4/22 at 9:20 a.m., indicated the Social Service Director (SSD) followed-up with Resident B. Resident B reported as the day went on, she did not feel well and her left arm was sore and she began to feel sore all over. She was getting ready for bed and took off her shirt and something fell off. She asked the aide to get the nurse so a new [MEDICATION(S)] patch could be put on. The aide left around 6:00 p.m. to look for the nurse and returned saying she was unable to find the nurse. Around 7:00 p.m., LPN 1 was at her door yelling that she had been with another resident and could not come until right then. Resident B said the aide had been up and down the halls looking for her and the nurse continued to yell that she was busy. LPN 1 left and returned calmer. She brought in some muscle cream and a new patch. LPN 1 then started to talk about her personal problems related to her ex-husband. A progress note, dated 1/6/22 at 10:10 a.m., SSD followed up with Resident B after being made aware the resident had been tearful. Resident B indicated she was brought to tears due to the words exchanged with LPN 1. Resident B indicated she was made to feel that her problem was not important to the nurse as she just kept telling her she was busy with someone else. The clinical record for Resident B was reviewed on 1/13/22 at 9:17 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent quarterly Minimum Data Set (MDS) assessment, dated 12/8/21, indicated the resident was cognitively intact. She required extensive assistance with one-person physical assist with Activities of Daily Living (ADL). The resident received a scheduled pain medication regimen and when needed pain medication. The MDS assessment indicated she experienced frequent pain in the past 5-days. A health care plan, dated 7/24/17, indicated the resident was on a narcotic pain medication therapy that included [MEDICATION(S)] and [MEDICATION(S)] (to relieve severe pain). Interventions included, but were not limited to, administer pain medication as ordered and document effectiveness every shift. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A progress note, dated 1/1/22 at 7:53 p.m., indicated the resident was noted to have left-hand [CONDITION(S)] and pain was noted to the left elbow and the physician was notified. A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was currently under pain management care and received [MEDICATION(S)] and [MEDICATION(S)]. On 1/3/22 at 8:30 p.m., a progress note indicated the resident had complained of pain to her left side and current medications were typically effective. Review of the January Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The patch was for unspecified pain in the knee and right should pain. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On January 3, LPN 1 indicated the placement of the patch was right upper quadrant. A health status note by House Supervisor, dated 1/3/22 at 9:39 p.m., indicated the resident was a little tearful earlier around 7:30 p.m. During an interview on 1/13/22 at 11:35 a.m., the Director of Nursing (DON) indicated LPN 1 provided a text statement related to the incident, but she no longer had a copy of it. LPN 1 denied any wrongdoing on the message. LPN 1 did not provide a written statement. During an interview on 1/13/22 at 1:25 p.m., SSD indicated she followed up with Resident B today. Resident B had indicated she felt safe here and had no concerns with her care. She indicated the resident was tearful, but did not seem to have any [MEDICATION(S)] problems related to the incident. During an interview on 1/13/22 at 1:55 p.m., CNA 2 indicated Resident B's pain patch fell off, but she was not in the room. About 6:30 p.m., she was clearing out the dining room and heard Resident B asked where the nurse was and seemed upset and said she was waiting for the nurse and her medication. She then told LPN 1 and she said after she finished with the resident she was helping, she would head down there. Around 6:50 p.m., LPN 1 went into Resident B's room so she stood by the nurses' station because she knew the resident was upset. She was standing about 2 rooms away and could hear them yelling at each other. Resident B said it had been an hour and LPN 1 said it was not an hour. CNA 3 had a resident on a shower chair in the hall and had asked for help to transfer the resident. She indicated CNA 3 no longer worked at the facility. CNA 2 indicated she asked CNA 3 to go and let the charge nurse know what was going on and when she got done with her resident, she also told the charge nurse what she heard. The charge nurse then called the house supervisor who was already in the facility. The charge nurse then went to the resident's room to check on her and LPN 1 was asked to leave the facility During a telephone interview on 1/13/22 at 12:45 p.m., LPN 1 indicated she had two other residents who were having behaviors. After dinner, she was told the [MEDICATION(S)] patch had come off, but she was helping another resident. After that, she took her cart down to Resident B's room and the resident was yelling and screaming at her and said she had been in pain all day. She told Resident B she came as quickly as she could, got the patch and put it on her. She may have raised her voice to be heard over the yelling and may have been a little short with Resident B since she was yelling at her, but did not feel as if she did anything wrong. During an interview on 1/13/22 at 2:38 p.m., the DON indicated the house supervisor was working at that time he received the call. The house supervisor then took over the medication cart and the charge nurse stayed with Resident B. LPN 1 was immediately sent home and the Administrator received a text at 9:09 p.m. letting her know of the allegation. Review of a current facility policy, dated 2010 and revised 9/17, titled ABUSE DEFINITIONS/IDENTIFICATION, which was provided by the Administrator on 1/13/22 at 9:30 a.m., indicated the following: Abuse is defined at the willful infliction of injury, unreasonable Also, verbal abuse .Verbal Abuse is the oral, written and/or gestured language that includes disparaging and/or derogatory terms to residents or their families, either directly or within their hearing This Federal tag relates to Complaint IN 311. 3.1-27(b)

Based on record review and interview, the facility failed to ensure adequate supervision and interventions to prevent multiple falls for 2 of 3 residents reviewed for falls (Resident B and Resident C). This deficient practice resulted in Resident B sustaining two hip fractures, a large acute right cerebral convexity subdural hematoma, a large acute right hemispheric subdural hematoma with right to left shift of midline structures and a subarachnoid hemorrhage in the right temporoparietal region and Resident C sustaining a fracture to her right hip. The immediate jeopardy began on 1/09/21, when Resident B fell and fractured her hip. She had experienced multiple falls previously and continued to fall with significant injuries including another hip fracture, head injuries and death, four days after her last fall, on 3/22/21. The Administrator was notified of the immediate jeopardy on 4/01/21 at 9:15 a.m. The immediate jeopardy was removed on 4/1/21 at 4:17 p.m., but noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: 1. Resident B's clinical record was reviewed on 3/25/21 at 11:15 a.m. Diagnoses included, but were not limited to, muscle weakness (generalized), other abnormalities of gait and mobility, need for assistance with personal care, cognitive communication deficit, essential (primary) hypertension, other specified depressive episodes, unspecified [CONDITION(S)], anxiety disorder, unspecified dementia without behavioral disturbance, unspecified mood (affective) disorder, delusional disorders, type II diabetes mellitus without complications, and age-related [CONDITION(S)] without current pathological fracture. A quarterly (Minimum Data Set) MDS assessment, dated 10/23/20, indicated the resident was severely cognitively impaired. She required supervision with bed mobility, transfers, walking in room and corridor, dressing, eating and personal hygiene. She required limited assistance with toilet use. She was occasionally incontinent of bladder and bowel. The resident's physician orders, from the March 2021 order recapitulation, included, but were not limited to, monitor for the following: anxiety, delusions, sleep disturbances and document interventions, may be up with assistance and assistive device if applicable, motion alarm at all times every shift for safety, acetaminophen (pain reliever) 650 mg twice daily, [MEDICATION(S)] (antidepressant) 100 milligram (mg) daily, [MEDICATION(S)] (promotes sleep) 10 mg daily, [MEDICATION(S)] (antihypertensive) 25 mg twice daily, [MEDICATION(S)] (antipsychotic) 2.5 mg daily, [MEDICATION(S)] (treats [CONDITION(S)]) inject one syringe subcutaneously every six months and [MEDICATION(S)] (antianxiety) 0.25 mg twice daily. A health care plan, initiated on 2/20/20, indicated the resident was a fall risk due to a history of falls with fracture, confusion, and anxiety. An intervention, dated 12/1/20, indicated the resident was a fall risk and increase supervision related to not feeling well and on isolation precautions. A progress note, dated 12/5/20 at 7:17 a.m., indicated the resident was found on the floor leaning against her bed with no brief, socks or shoes on. The resident was assisted to the bathroom by staff and morning care was completed. Review of a post fall assessment, dated 12/5/20, indicated Resident B fell at 7:05 a.m. She was found on the floor in her room. The resident attempted to self-transfer and no staff member was present during the fall. The resident was last toileted at 4:00 a.m. The resident was alert, but lethargic. Immediate interventions to prevent any further falls included increased supervision and toileted immediately. A progress note for a second fall, dated 12/6/20 at 8:35 a.m., indicated the resident was found on the floor in her room with her head under her bed and her feet pointing out. The resident had removed her brief and was assisted off the floor by staff and taken to the bathroom. A post fall assessment, dated 12/6/20, indicated the resident lost her balance and was found on the floor in her room. The assessment indicated the resident attempted to self-transfer and no staff member was present during the fall. Immediate interventions to prevent any further falls included increased supervision, toileted immediately and increased fluids. On 12/6/20 at 11:40 p.m., a health status note indicated the resident had unwitnessed falls. No injuries were noted, and the resident appeared to have increased tremors and weakness. The resident was not able to hold a cup or to sit up in bed without assistance. A family member was notified and would check in the following day. A post fall assessment, dated 12/20/20 at 10:00 a.m., indicated the resident had lost her balance and her fall was intercepted, and she was lowered to the ground. The assessment indicated a staff person was present during the fall. Immediate intervention to prevent any further falls included to toilet immediately. A post fall Morse Fall Scale (determined the resident's risk for falls), dated 12/20/20, indicated the resident was at a high risk for falling. The resident's care plan for falls was updated on 12/22/20 and indicated to increase supervision related to not feeling well. An incident note, dated 1/9/21 at 6:05 a.m., indicated staff entered the resident's room after she was heard calling out for help. The resident was on the floor behind her room door leaning against the closet doors with her underwear around her ankles, and her pants were sitting on the chair directly in front of her. The resident was unable to describe what she was doing. Range of motion was normal, except her left hip and leg. No rotation was noted. The resident reported pain in her left hip and guarded her left hip, and indicated she has to fix her leg, it hurt. The resident was carried by staff from the door to her bed. Neurological checks were completed. The nurse practitioner (NP) was notified, and the family was to be notified later due to the time difference. A fall scene investigation for the fall, dated 1/09/21 at 6:05 a.m., indicated the resident lost her balance and was found on the floor (unwitnessed) in the resident's room, 10 feet from the transfer surface. She was ambulating prior to the fall, she was alone and unattended, and staff was not present at the time of the fall. The resident was confused, she had dementia, and this was normal for the resident prior to the fall. She was barefooted. An alarm was not being used at the time of the fall. The last time she was toileted was 1/09/21 at 5:30 a.m. A neurological assessment was completed, she had pain, six out of a ten on the pain scale, and movement and sensation were not intact in her left leg. The immediate interventions provided after the fall to prevent further falls was increased supervision. A post fall huddle, dated 1/09/21 at 6:05 a.m., indicated the assessment was completed, and it was unknown if she hit her head as the fall was not witnessed. The follow up plan was staff to check and assist resident first thing in the morning. The resident was sent to the hospital on 1/09/21 at 1:40 p.m. Results of an x-ray of the resident's left anteroposterior (AP) and lateral hip, dated 1/09/21 at 2:38 p.m., indicated probable intertrochanteric fracture of the left hip. A Computed Tomography (CT) could be performed for evaluation of bony detail. A health status note, dated 1/09/21 at 8:42 p.m. indicated staff had followed up with the hospital regarding the resident, and the hospital nurse stated the resident had been admitted and the orthopedic surgeon would schedule surgery to pin the resident's left hip. The resident returned to the facility on [DATE] around 12:45 p.m. A skin/wound care note, dated 1/13/21 at 1:39 p.m., indicated a dry dressing was in place to the resident's left hip surgical incision and bruising was noted around the wound tissue. An admission Morse Fall Scale, dated 1/13/21, indicated the resident was at a high risk for falling. An incident note, dated 1/14/21, indicated the care plan was reviewed due to the fall on 1/09/21 with hip fracture. The resident attempted to dress herself when she lost her balance. Staff immediately assisted resident to her bed and increased supervision. Resident was then sent to the emergency room (ER) due to hip fracture. The care plan was updated on 1/14/21 to include frequent visual checks, gripper socks at bedtime and get resident up first thing in the a.m. A fall scene investigation for a fall, dated 1/25/21 at 4:00 p.m., indicated the resident was found on the floor in the lounge, next to transfer surface, and she was ambulating just prior to fall. She was alone and unattended. The resident indicated she was trying to walk just before the fall. The resident was confused, she had dementia, and this was normal for the resident prior to the fall. She had shoes on. An alarm was not being used at the time of the fall. She was last toileted on 1/25/21 at 12:00 a.m. The resident had anti-anxiety, anticoagulants, diuretic and [MEDICATION(S)] was given within eight hours prior to fall. A neurological assessment was completed. The immediate interventions provided after the fall to prevent further falls was increased supervision. A post fall huddle, for the 1/25/21 fall, indicated the resident was trying to get ready prior to the fall, it was unknown if she hit her head, and the fall was not witnessed. She was taking [MEDICATION(S)] (blood thinner) and aspirin (nonsteroidal anti-inflammatory). Follow up plan was do not leave the resident in wheelchair unattended and one on one supervision when the resident was anxious. An incident note for this fall on 1/25/21, was dated 1/25/21 at 8:40 p.m. and indicated staff was called to the lounge area because the resident was on the floor, lying on her side. She had no apparent injury, and staff assisted the resident back up into wheelchair. It was explained to the resident that she had a hip fracture and she needed to stay in the wheelchair. The resident responded that she had no idea about the hip fracture and would stay seated. Staff had reminded the resident several times that afternoon not to walk around due to hip fracture and had done so minutes prior to the fall. A few minutes after the fall, staff approached the writer with the resident, and she had a very small abrasion on her right knee which had a scant amount of blood draining from it. The area was cleansed, and a band aid was placed. The resident said she tried to walk but fell to the floor. A GDR (gradual dose reduction)/psych medication review note, dated 1/25/21 at 2:16 p.m., indicated the resident had used PRN (as needed) [MEDICATION(S)] (antianxiety medication) 11 times in the last 14 days. Her [MEDICATION(S)] (anti-depressant) order had fallen off her orders after hospitalization and she was no longer on [MEDICATION(S)] (another anti-depressant), so [MEDICATION(S)] 50 mg daily for her anxiety would be restarted. [MEDICATION(S)] would be continued PRN, and if she continued to have issues, [MEDICATION(S)] would be increased at that time and re-evaluate again in 14 days. A review of the Medication Administration Record (MAR) for behavior monitoring indicated to monitor for anxiety, delusions, and sleep disturbances. The MAR indicated the resident had no behaviors and no interventions were documented for 1/24/21 or 1/25/21 prior to the fall. An incident note, dated 1/26/21 at 7:04 a.m., indicated the care plan was reviewed with unit staff and the Interdisciplinary Team (IDT) due to the fall on 1/25/21 at 4:00 p.m. when the resident was on the floor in the lounge area. Staff immediately increased supervision. The resident was noted to have increased anxiety and up and down often at times. Medications had been adjusted. The care plan was updated to include do not leave in wheelchair unattended and provide 1:1 supervision during periods of increased restlessness. A physician progress note, dated 1/26/21 at 10:04 a.m., indicated the resident was vaguely aware she had fallen the day before (un-witnessed in the lounge area). She complained of right thigh pain and not wanting to ambulate or bear weight. Staff reported some increased behaviors and moods. [MEDICATION(S)] was initiated. The plan was to obtain an x-ray of the right femur. A health status note, dated 1/26/21 at 2:15 p.m., indicated the resident's x-ray results were faxed around 12:05 p.m., and the doctor was notified. The resident was noted to have a right femoral neck fracture. The resident's family member was notified and stated he would like the resident to be sent back to the local hospital and he would contact the orthopedic surgeon. The resident was on her way to the hospital at that time with facility transport. The results of the resident's x-ray to her right hip and pelvis, dated 1/26/21 at 3:12 p.m., indicated an acute subcapital right femoral neck fracture. Her care plan interventions, initiated on 1/26/21, included one on one supervision as needed during periods of increased restlessness and do not leave in wheelchair unattended. The clinical record lacked indication the facility had increased supervision prior to or after this fall. A readmission Morse Fall Scale, dated 1/30/21, indicated the resident was at a high risk for falling. A communication with the physician/nurse practitioner note, dated 2/01/21 at 4:54 p.m., indicated the NP was on the unit and gave an order to restart the resident's previous [MEDICATION(S)] PRN order due to resident's anxiousness and would re-evaluate in two weeks. An incident note, dated 2/02/21, indicated the resident was found lying on the floor in the center of her room on her left side. A pool of blood was noted coming from the back left side of her head, and pressure was applied immediately. Range of motion was checked and the resident was assisted to her feet with two staff assist. Pupils were equal and reactive. She was alert and talkative. The resident was unable to describe what happened. Vital signs were taken. The head wound continued to bleed even with pressure. The NP was updated and gave an order to send the resident to the ER for evaluation and treatment. A family member was updated and wished for her to go to local hospital. The resident was on blood thinners and post bilateral hip fractures with repair in past two to three weeks. A fall scene investigation, dated 2/02/21, indicated the resident lost her balance and was found on the floor (unwitnessed) in the resident's room. She was attempting to self-transfer prior to the fall. She was alone and unattended, and a staff member was not present at the time of fall. She was alert, confused as per usual. She had gripper socks on. She was last toileted on 2/02/21 at 6:30 a.m. She had received anticoagulants, [MEDICATION(S)] and narcotic within eight hours prior to fall. A neurological assessment was completed, and she was not able to follow finger with her eyes. The immediate interventions provided after the fall to prevent further falls was increased supervision. The result of a CT of the head without contrast, dated 2/02/21 at 10:50 a.m., indicated an acute right cerebral convexity subdural hematoma (type of bleeding inside your head) primarily overlaid the right temporal and frontal lobes and focally measured up to 14 millimeters (mm) in thickness. There were additional acute subdural blood products along the right falx and tentorium. A post fall huddle, dated 2/02/21 at 8:45 a.m., indicated the resident was taking aspirin, [MEDICATION(S)] and [MEDICATION(S)], and she was sent to the ER due to head injury and anticoagulant medication. The follow up plan indicated the nurse was to place an alarm box on the medication cart while doing medication pass, the resident was sent to ER, and they would discontinue motion alarm and start pressure alarm. A review of the MAR for behavior monitoring for anxiety, delusions and sleep disturbances indicated the resident had no behaviors, and no interventions were documented on 2/01/21 or 2/02/21 prior to the fall. An incident note, dated 2/03/21 at 6:52 a.m., indicated the care plan was reviewed with unit staff and IDT due to a fall 2/02/21 at 8:45 a.m. The resident was on the floor in the middle of her room on her left side. The resident's breakfast tray was on her tray table in front of her recliner. Resident likely had stood from her recliner and lost her balance immediately. Resident noted to be bleeding from the back of her head. A pressure dressing was applied. Staff stayed with resident until she was transferred to the ER due to head injury, and the resident was on anticoagulant medications. The resident remained at the hospital. A pressure alarm would be added to the resident's plan of care and non-skid strips added to the floor in front of recliner, beside bed and toilet. A health status note, dated 2/03/21 at 1:26 p.m., indicated the resident arrived back to facility around 1:00 p.m. via cot. The DON and the writer were in with the resident at that time. The resident had a laceration on the left posterior head with four staples. Serosanguineous drainage was noted at that time. Bruising continued on the right hip and had spread under her right upper thigh where minimal swelling was noted. Bruising also continued on her left hip, right shoulder, right knee, and back of her right hand from previous falls and surgeries. New orders were received to start [MEDICATION(S)] (anti-seizure) 100 mg tab twice daily for six days, and [MEDICATION(S)], [MEDICATION(S)] ([MEDICATION(S)]) and aspirin were discontinued. The resident's care plan lacked added interventions after the fall on 2/02/21. A significant change Minimum Data Set (MDS) assessment, dated 2/06/21, indicated the resident was severely cognitively impaired. This assessment indicated the resident's activities of daily living (ADL) status had declined compared to the 10/23/20 MDS assessment. She now required assistance of two staff members for bed mobility, transfers, dressing and toilet use. She was totally dependent on staff for locomotion on the unit. She required extensive assistance of one staff member for eating and personal hygiene. She had an impairment to both of her lower extremities. She used a wheelchair. She was always incontinent of bladder and bowel. She had one fall with major injury since admission or prior assessment. She had surgery, to repair a fracture of the pelvis, hip, leg, knee or ankle (not foot). She used an alarm (a physical or electronic device that monitors the resident's movements and alerts staff when movement is detected) daily. A post fall Morse Fall Scale, dated 3/10/21, indicated the resident was at a high risk for falling. An incident note, dated 3/18/21 at 2:02 p.m., indicated the writer saw the resident start to stand up from the wheelchair from the other side of the nurse's station. As the writer ran towards the resident, she fell on her right side, and she hit her head against the floor. The resident was immediately assessed for injuries. Respirations were labored and sounded wet, as if she was going to vomit. The writer raised the resident up from the floor, and 911 was called immediately. More staff was around the resident to help support her, and first aid was applied to hematoma until the Emergency Management Services (EMS) arrived. A fall scene investigation, dated 3/18/21 at 2:02 p.m., indicated the resident lost her balance. She had a witnessed fall to the floor in the lounge. She was ambulating and attempted to self-transfer. She received assistance per care plan at the time of the fall. A staff member was present at the time of the fall. The resident was pleasantly confused and was normal for the resident prior to the fall. She had on shoes. She was last toileted on 3/18/21 at 12:40 p.m. She received anti-anxiety, antidepressant, cardiovascular, [MEDICATION(S)] and narcotic within eight hours prior to fall, and she had received a new medication/changed dose within the last 30 days prior to fall. A neurological assessment was completed, and vital signs were not within normal limits for the resident, her left and right pupils were not reactive to light and she could not follow finger with her eyes. Initially she was unresponsive and pupil unreactive. The immediate interventions provided after fall to prevent further falls was increased supervision. A post fall huddle, for the fall on 3/18/21, indicated the resident had a hematoma to the right side of her head. Her pupils were initially unreactive, and she had changes in her mental status and nausea. She hit her head and her fall was witnessed. She was transferred to ER and the plan would be reviewed upon her return to the facility. The results of a CT of the head without contrast, dated 3/18/21 at 3:40 p.m., indicated a large acute right hemispheric subdural hematoma measuring approximately 18 mm in thickness and demonstrating right to left shift of midline structures measuring approximately 12 mm. In addition, there was a slight subarachnoid hemorrhage in the right temporoparietal region. A communication with family/Power of Attorney (POA)/resident note, dated 3/18/21 at 7:12 p.m., indicated the resident's family member was called to inform him the resident had returned to the facility and updated him on her vitals and talked about a hospice referral. He agreed for hospice to evaluate her. A review of the MAR for behavior monitoring for anxiety, delusions, and sleep disturbances indicated the resident had no behaviors and no interventions were documented on 3/18/21 prior to the fall. An incident note, dated 3/19/21 at 9:31 a.m., indicated the care plan was reviewed with unit staff and IDT due to a fall on 3/18/21 at 2:02 p.m. Staff witnessed the resident stand up from her wheelchair and fall to her right side hitting her head on the floor. The resident was noted to have a hematoma to her head. Staff immediately provided care for the hematoma. Staff noted that resident had been at the medication cart for 1:1 supervision due to increased anxiety after lunch. The nurse walked away from resident, but staff was able to visualize her. Staff saw the resident stand, but could not get to her in time. The resident's family member did not want the resident to be admitted to the hospital, and she returned to the facility. The resident was referred to hospice per family request. Medications were discontinued and new orders received for [MEDICATION(S)] (pain reliever) and [MEDICATION(S)] (antiemetic). The resident had been receiving Physical Therapy (PT) services, which family opted to discontinue. The unit nurse would request a Broda chair (high back reclining chair with wheels) from hospice once the resident was enrolled and would also get a recliner placed in the resident's room, as resident currently had a straight back chair that does not recline. Staff would continue to check the resident frequently and provide 1:1 as needed and continue the motion alarm in room. The resident continued to have a star on her door to alert staff of increased risk of falls. A terminal note, dated 3/22/21 at 3:00 p.m., indicated the writer assessed the resident before breakfast, and the resident appeared gray, eyes fixed and unresponsive, and breath sounds shallow. The resident's respirations had ceased (RHC) around 1:20 p.m. and was verified by LPN and NP. NP gave the order to release body to funeral home. A 3/23/21 revised care plan, indicated the resident was at risk for falls related to confusion, anxiety, history of falls with fracture and history of subdural hematoma. Her goal was she would have a reduction in falls and serious injury, or hospitalization related to injury as needed through the review date. Her interventions included the following: Fall risk initiated on 12/1/20. A star added to resident's door due to two falls in 30 days initiated 12/7/20. Anticipate and meet the resident's needs initiated on 2/20/20. Be sure the resident's call light was within reach in resident's room and encourage the resident to use it for assistance as needed. The resident's needs prompt response to all requests for assistance initiated on 2/20/20. Ensure that the resident was wearing appropriate footwear when ambulating or mobilizing in wheelchair initiated on 2/20/20. Motion alarm at all times in room (keep alarm box on med cart or in staff pocket on the unit) initiated 2/15/21. Notify the nurse if resident is restless, nurse evaluate for pain and anxiety, administer as needed medication as appropriate initiated on 2/24/21. The DON indicated on 3/26/21 at 8:55 a.m., they did not have documentation for the one on one supervision, but they would be stated in the progress notes. On 3/26/21 at 9:47 a.m., LPN 33 indicated the one on ones were on the care plan and the task list, they had fall alarms and motion sensor alarms, and they monitor everyone closely. No one is on one on ones all that time on the unit, and when a resident was on one on one's, they sit closer to the staff and have them do activities. There are stars on doors that indicated to staff the residents were a fall risk and to watch them closely as needed. There was no documentation for one on ones, and they only have documentation for the 15 minute checks. She would document the one on one's in the nurses notes or in a behavior note. On 3/26/21 at 9:55 a.m., LPN 36 indicated for the one on one's, a staff member would do activities with the resident and she would document in behaviors or progress notes. Some of the staff already knew how the residents were and stayed close to them. For one on ones, they would walk, listen to music, color pages, watch their favorite show and stay with them until the anxiety stops, and if she would have to leave, she would make sure they had another staff member with them. 2. Resident C's clinical record was reviewed on 3/25/21 at 11:13 a.m. Diagnoses included, but were not limited to, Alzheimer's disease with early onset and unsteadiness on feet. A care plan, initiated on 8/26/19, indicated the resident was at risk for falls related to confusion and unaware of safety needs. The goal indicated she would have a reduction in falls and serious injury, or hospitalization related to injury through the review date of 3/31/21. Interventions included, but were not limited to, when restless, wandering, attempt to meet needs (toilet, offer snack, drink, have nurse assess for pain), added 12/8/20, star added to resident's door due to increased falls and bring to lounge when awake, both added on 1/22/21, if resident was restless, toilet her and then offer a warm blanket and skid strips in front of recliner, both added 2/1/21, offer to lay down or attempt to provide simple activities in the afternoon, added 2/11/21, and two person assist for ambulation, pull wheel-chair behind for safety, added 2/22/21. A care plan, dated as revised 2/04/21, indicated the resident had potential for increased restlessness with repeatedly getting up/down and ambulating per self, wandering and may go into others' rooms related to diagnoses of dementia, anxiety, and disorientation to place. The goal indicated the resident's safety would be maintained through the review date of 3/31/21. Interventions included, but were not limited to, the resident resided on secure unit for specialized environment and safety, added 12/8/20, and provide structured activities: toileting, walking inside and outside, reorientation strategies including signs and pictures, with a revised date of 2/1/21. Progress notes and assessments included, but were not limited to, the following: a. A fall scene investigation, dated 1/20/21 at 9:00 p.m., indicated the resident had an unwitnessed fall in her room, and the immediate interventions were to toilet immediately and increased supervision. An incident progress note, dated 1/20/21 at 9:30 p.m., indicated the resident was found sitting on the floor in her room by her recliner, fall was not witnessed, and the resident was unable to give details. A Morse Fall Scale assessment, dated 1/20/21, indicated a high risk for falls. A fall scene investigation, dated 1/21/21 at 4:15 p.m., indicated the resident had an unwitnessed fall in her room, and immediate intervention was increased supervision. A fall scene investigation, dated 1/21/21 at 6:34 p.m., indicated she had an unwitnessed fall in her room, and immediate intervention was increased supervision. A health status progress note, dated 1/21/21 at 5:58 p.m., indicated the resident had fallen twice in a period of 20 minutes, both unwitnessed, and had fallen yesterday, no bruising noted. A Morse Fall Scale assessment, dated 1/21/21, indicated a high risk for falls. The clinical record lacked indication the facility had increased supervision prior to or after the falls. b. A fall scene investigation, dated 1/31/21 at 3:35 p.m., indicated the resident had an unwitnessed fall in her room, and immediate intervention was increased supervision and a warm blanket. A health status progress note, dated 1/31/21 at 3:48 p.m., indicated she had been found in her room on the floor, with no injury or complaints of pain. A Morse Fall Scale assessment, dated 1/31/21, indicated a high risk for falls. c. A fall scene investigation, dated 2/03/21 at 6:50 a.m., indicated the resident had been lowered to the floor, and immediate intervention was increased supervision. An incident note, dated 2/03/21 at 6:51 a.m., indicated the resident had attempted to ambulate by herself in the lounge, and was carrying a blanket that had tangled around her feet. Staff assisted to get blanket untangled, the resident started to sit down without a chair around her, and the staff member lowered the resident to the ground. The resident did not have any injury. A Morse Fall Scale assessment, dated 2/3/21, indicated a high risk for falls. d. A 3/19/21 annual MDS (Minimum Data Set) assessment indicated the resident was rarely/never understood and had short term and long term memory problems. She required extensive assistance of two persons with transfers, to walk in room, to walk in corridor, and with locomotion on the unit. She had two or more falls without injury since her prior MDS assessment. A fall scene investigation, dated 3/20/21 at 4:20 p.m., indicated the resident had a witnessed fall in the lounge, she had last been assisted with toileting on 3/20/21 at 2:00 p.m., and immediate interventions were to toilet immediately and increased supervision. A health status note, dated 3/20/21 at 4:54 p.m., indicated the resident had been wandering throughout the day, had fallen to the floor while attempting to sit in a chair, and denied pain or discomfort. A Morse Fall Scale assessment, dated 3/20/21, indicated a high risk for falls. An incident note, dated 3/23/21 at 12:29 p.m., indicated the care plan had been reviewed with unit staff due to a fall on 3/20/21 at 4:20 p.m. The resident had been busy up and down often, and staff immediately toileted and increased supervision. Staff were reminded to check frequently and toilet per schedule. She was inconsistent with ambulation and was in therapy due to increased falls. e. A fall scene investigation, dated 3/23/21 at 3:55 p.m., indicated the resident had been found on the floor in her room, she had last been assisted with toileting on 3/23/21 at 1:00 p.m. She had verbal and non-verbal expressions of pain. The immediate intervention was increased supervision. A Morse Fall Scale assessment, dated 3/23/21, indicated a high risk for falls. A communication progress note, dated 3/23/21 at 4:00 p.m., indicated the resident's daughter had been informed of the resident's fall and was being transferred to a local hospital. A health status note, dated 3/23/21 at 4:11 p.m., indicated the resident had an unwitnessed fall in her room and was complaining of right hip pain. An order to obtain an X-ray was received. A health status note, dated 3/23/21 at 7:35 p.m., indicated the resident was experiencing severe right hip pain, and one leg was shorter than the other. Order was received to send to the emergency ro [TRUNCATED]

Based on observation, interview and record review, the facility failed to ensure a CNA (Certified Nursing Assistant) did not apply personal creams or ointments to a residents perineal area and notified the nurse when there was a change in the resident's condition for 1 of 3 residents reviewed for treatments (Resident C). Findings include: During an observation of CNA 17 providing care to Resident C, on 3/15/21 at 10:10 a.m., the residents coccyx was red, she had a reddened raised area on her left upper coccyx area, the size of a dime and on the back of her thigh near her buttocks was several darker round reddened areas, approximately the diameter of a pea. There were no open areas observed. CNA 17 indicated the resident's bottom was healing, her treatment had been switched and her bottom was super bad but was now clearing up. The resident's bottom was bright red and raised, she had some diarrhea when she first came to the facility. During the observation, Resident C indicated her bottom hurt, due to the areas on her bottom and not having much padding, she walked from the the bathroom to her recliner and wore a pull up brief with no pants. During an interview at the time of the observation, CNA 17 indicated there were conflicting stories that CNA 6 applied a mixture to Resident C's bottom, because CNA 6 denied that she had applied a cream/ointment that she got from her car. On 3/7/21, CNA 17 had walked into Resident C's room and CNA 6 was caring for her, CNA 6 pulled two items out of her pocket and indicated she mixed the two creams together and applied it to the resident's bottom, one was petroleum jelly and the other was a white and pink bottle. She did not know of any other residents she may have used the mixture on and she reported CNA 6 to LPN (Licensed Practical Nurse) 21. Resident C's clinical record was reviewed on 3/15/21 at 10:41 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Allergies included, but were not limited to, [MEDICATION(S)], [MEDICATION(S)] diagnostic agents, adhesive tape, latex, triiodobenzoic acids and petroleum jelly was added to the allergy list on 3/12/21. Her orders on 3/7/21 included, but were not limited to, [MEDICATION(S)] (anti-fungal) ointment 100,000 unit/gram (gm) apply to coccyx and vaginal area topically every shift for [MEDICATION(S)] infection for 10 days, started on 3/6/21 and discontinued on 3/8/21, [MEDICATION(S)] powder (anti-diarrheal) 4 gm/dose, one dose every 24 hours as needed for diarrhea, she received one dose on 3/6/21 and 3/10/21, [MEDICATION(S)] (HCL) (anti-diarrheal) 2 milligram (mg) every 24 hours as needed for diarrhea, she received 2 mg on 3/6/21, 3/11/21 and 3/14/21. A one time only dose of 2 mg on 3/7/21. Her current orders included, but were not limited to, [MEDICATION(S)] cream 100,000 unit/gm, apply to vaginal area topically every shift for excoriation to vaginal area, [MEDICATION(S)] powder 4 gm/dose one dose by mouth every 24 hours as needed for diarrhea, [MEDICATION(S)] HCL 2 mg every 24 hours as needed for diarrhea, pressure reduction mattress, equagel cushion to chair (as resident tolerates) every day and evening shift for moderate risk, reposition per facility policy every day and evening shift for moderate risk for Braden assessment (tool used to predict pressure ulcer risk). An Admission Minimum Data Set (MDS), dated [DATE], indicated the resident was cognitively intact. She required extensive assistance for bed mobility, toilet use and personal hygiene. She was frequently incontinent of bladder and bowel. She had a pressure reducing device for her chair and bed. She had ointments/medication applied other than to her feet. An Admit/Readmit Screener assessment, dated 3/1/21 at 2:45 p.m., indicated the resident's skin color and turgor was normal and her skin was warm. She had bruising to her bilateral upper extremities, she had excoriation on her abdomen and her coccyx was red. A focused care plan for potential/altered skin integrity was initiated, her goal was to prevent/heal pressure ulcers/other breech in skin integrity. Her interventions were assist with repositioning bed and wheelchair/ as needed, provide incontinent care as needed, treatments as ordered, immediately report any skin redness or skin breakdown to charge nurse. A comment box indicated antifungal powder applied to abdominal area where resident crease was from leaning over, Z-guard (skin protectant) applied to coccyx. A Health Status note, dated 3/1/21 at 7:32 p.m., indicated the resident arrived to the facility by her family and was brought to the unit via wheelchair and one assist. Upon a skin inspection, it was noted that the resident had a moderate amount of vaginal discharge and the area was cleansed. Bruising was noted on bilateral upper extremities in different stages, excoriation in abdominal area where abdomen creases from the resident hunched over (antifungal powder applied), coccyx was red (Z-guard applied). The resident was assisted into her bed via one assist via pivot transfer. The resident stated that she was exhausted and wanted to take a nap. A Health Status note, dated 3/6/21 at 10:23 a.m., indicated a conversation between LPN 21 and the nurse practitioner, LPN 21 indicated the resident's coccyx and vaginal area was very sore from diarrhea and looked like a [MEDICATION(S)] infection, she requested a different treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident just cried out in pain when staff tried to clean her from being so sore. The resident received her as needed (PRN) [MEDICATION(S)] powder. The nurse practitioner indicated it was ok to give the resident immodium 2 mg daily PRN and to change to [MEDICATION(S)] ointment to the area three times daily for 10 days. A Health Status note, dated 3/8/21 at 2:48 p.m., indicated a conversation between LPN 21 and the nurse practitioner, LPN 21 indicated the third shift nurse reported to her that she had put on the residents [MEDICATION(S)] last night when it arrived. When looking at the area closer this a.m., it was noted the resident had multiple blisters to her vaginal/coccyx area. When talking about this area, a CNA notified writer that it was told to her that the CNA on previous shift had put something on this area that she had gotten from her car. CNA stated that one of the bottles was petroleum jelly and the other was a white and pink tube but not sure what it was called. Writer then alerted house nurse of this issue and she notified administration. The resident was taken to the shower to wash whatever was applied to her off. Most of the blisters popped but she still has three unpopped blisters with blister clusters. The area was noted to be 15 centimeters (cm) wide on the right and 8 cm on the left with the length being 26 cm. The area was more angry looking than the night prior. Staff left the residents brief off of her for the area to get air. No creams had been applied since the shower. The nurse practitioner indicated so are we thinking this is skin reaction to what was applied or possibly shingles like? LPN 21 indicated possibly a reaction to what was applied. A late entry, dated 3/10/21 at 1:21 p.m., indicated the nurse practitioner was updated on the residents perineal area. Area continued with redness and irritation. The nurse practitioner questioned if the resident was having a reaction to the petroleum in the A and D ointment (skin protectant) or even small amount of petroleum in [MEDICATION(S)] cream (skin protectant). An order was received to discontinue A and D ointment, [MEDICATION(S)] and the Z-guard. The nurse practitioner only wanted [MEDICATION(S)] utilized at that time. The investigation was provided by the Administrator, on 3/15/21 at 12:00 p.m., she indicated an investigation was completed the CNA 6 had been let go for not following facility policy. The investigation included, but was not limited to the following: Staff reported concern on 3/7/21 that a CNA 6 applied personal ointment on a resident. It was reported by CNA 17 on 3/7/21 at 9:00 a.m. Administrator was notified on 3/7/21 at 10:30 am. Assistant Administrator phoned CNA 6 and questioned her related to event. She denied bringing personal stock of cream to facility or applying any cream already provided for resident. She stated she has been a CNA for [AGE] years and knew better. A handwritten statement by CNA 17, dated 3/7/21, indicated she went to answer Resident C's call light around 6:00 a.m., upon entering found CNA 6 was already in the room cleaning the resident up. CNA 6 explained that resident had been up majority of the night due to diarrhea. She went on to explain they had received residents new cream for bottom and that nurse had applied it. CNA 17 asked how she tolerated it CNA 6 stated not good at all and that resident had been crying a lot throughout the night due to the pain. Then CNA 6 pulled out two bottles she had in her pockets and stated she had mixed the two together and applied them to the resident's bottom. One bottle was white and pink and one was white with blue print and read petroleum jelly. CNA 17 went in after breakfast to check on the resident as to her knowledge, the resident hadn't called for a while. When she looked it seemed like she had what looked to be blisters but couldn't tell for sure due to the lighting. She explained to resident she was going to grab her phone so that she could see better by using her flashlight. When she returned she seen that indeed they were blisters and immediately got LPN 21. LPN 21 then got another nurse for an opinion. LPN 21 asked her if the new cream was all that had been put on it. CNA 17 told her about the conversation with CNA 6 earlier. LPN 21 contacted the house supervisor. The resident was showered in an attempt to wash all the cream off without causing further irritation to area. A handwritten statement by LPN 21, dated 3/8/21, indicated CNA 17 got her and told her that Resident C had blisters all over her vaginal area. LPN 21 called another nurse as both of them had looked at resident the day prior. Upon inspecting the resident's vaginal area, multiple blisters and bright redness were noted and worse than it was the day before. It also had something on it that made the area look shiny. LPN 21 asked CNA 17 what had been put on it and if anything else been on it besides the [MEDICATION(S)] ointment. CNA 17 told her that CNA 6 had told her that she had put creams on her that she had gotten from her car. LPN 21 immediately called for the house supervisor and gave CNA 17 permission to give Resident C a shower to wash off whatever was/or had been applied to her vaginal area. After the shower most of the blisters had popped. A handwritten statement by CNA 25, on 3/8/21, indicated when she came in for her shift, CNA 6 gave her report in the hall and when she came to Resident C, CNA 6 indicated the nurse didn't bring her cream so she said I used my cream on her and it was helping throughout the night. CNA 25 didn't think of anything at the time until CNA 17 went to do care and freaked out. CNA 17 pulled CNA 25 to look and between the residents legs was very red (redder than normal) and had many blisters. There was no color to the cream, but it was shinny. A handwritten statement by CNA 29, on 3/8/21, indicated on 3/7/21, she worked with CNA 6. CNA 6 went out to her car and got three tubes of cream. She said that she was going to try to put it on Resident C's bottom. CNA 29 told CNA 6 that they didn't use them at the facility. The one cream CNA 29 had seen, but had never seen the other two creams before. CNA 29 had never went into Resident C's room with her, she didn't know if CNA 6 really put the cream on the resident or not. A nurse practitioner note, with the encounter date of 3/8/21 at 2:00 p.m., indicated it was an acute visit for rash and irritation to the perineal area. Over the weekend the patient developed a rash to her buttocks and perineal area that appeared like fungal so [MEDICATION(S)] was ordered. Then yesterday the patient began having blistering and worsened [CONDITION(S)] to entire perineal area after having petroleum jelly and another cream applied. This was immediately washed off and Nurse stated the area was less irritated today. The patient had diarrhea also that contributed to her irritation to her bottom. She denied being incontinent of this. The area was approximately 21 cm x 21 cm, areas were to groin folds, labia and buttock /rectum region. No blistering noted today. On 3/9/21, the Administrator and DON requested CNA 6 to come to facility and meet to discuss events. She was questioned about events on 3/7. She reported the resident had been experiencing loose stool all night of watery bright green stool multiple times continuously all night and the resident had a blistered area before speaking to other CNA 29 and asked her to come look at it. CNA 6 stated she did not notify nurse of her concerns. CNA 6 stated she only applied cream the nurse had given her that was in a small medicine cup which came from a small white tube. She described the cream as clear Vaseline/yellowish tint in color. CNA 6 indicated there was a cream on a paper towel beside bathroom sink that was pink in color with powder and sometime during the night this had been moved to residents bedside table. CNA 6 was pressed multiple times about why other staff would report she showed them cream and stated she utilized it. CNA 6 was unable to explain other than stated she did not do any of the alleged events and only applied what was given to her by nurse or was in residents bathroom indicated for resident. A statement signed by the Assistant Administrator, on 3/11/21, indicated CNA 6 had stated to him that resident had small blisters forming prior to speaking with CNA 29. CNA 6 stated she did not notify a nurse of residents condition. On 3/15/21 at 2:03 p.m. LPN 21 indicated the area had looked yeasty the day before. Then on 3/7/21, she looked at it again because CNA 17 had reported it to her, the cream/ointment that was on the resident was shiny and it was not like the creams that they had at the facility. She contacted the house supervisor and they contacted administration and then notified the nurse practitioner. If you touched her bottom the resident would scream out in pain, so they gave her a shower, they used baby shampoo to wash her with, her bottom was so sore and it looked like the skin had just peeled off and looked raw. They did not put a brief or anything on her the rest of that day to let her air out. The [MEDICATION(S)] ointment treatment was changed to [MEDICATION(S)] mix and kept getting worse, which had petroleum jelly in it. The CNAs normally don't put creams/ointments on unless its [MEDICATION(S)] or something like that. The Administrator indicated on 3/15/21 at 1:33 p.m., she had a job description for CNA's and another policy but did not have a policy related to skin. This Federal tag relates to Complaint IN 446. 3.1-37(a)

Based on observation, interview, and record review, the facility failed to provide supervision to prevent recurrence of falls, and failed to develop and implement interventions to prevent falls, for 1 of 6 residents reviewed for falls (Resident 55). This deficient practice resulted in a resident having two falls in one day, and sustaining a non-survivable head injury. Findings include: On [DATE] at 8:59 a.m., Resident 55 was in his room, sitting in his recliner chair, with his feet elevated. He had a gauze bandage on the right side of his forehead, with reddish-brown drainage visible on the bandage. On [DATE] at 8:05 a.m., the resident was in bed with his eyes closed. He had a large adhesive bandage on his right forehead, a darkened area to his right forearm, and wound closures to an area near the base of his right thumb. A baseball-sized raised area, with dark red and brown drainage, was present to the back of his head. RN 13 performed oral care and obtained vital signs; he was not responsive to either action. Resident 55's clinical record was reviewed on [DATE] at 9:01 a.m. [DIAGNOSES REDACTED]. Current orders included, but were not limited to, Eliquis (blood thinner) 5 mg (milligram) twice daily, [MEDICATION NAME] (antibiotic) 2 grams intravenously (IV) every 8 hours until [DATE] [MEDICAL CONDITION], monitor hematomas to right ear, border dressing to right shoulder every 3 days, border dressing to right forearm every 3 days, and border dressing to right forehead every 3 days. A [DATE], admission, Minimum Data Set (MDS) assessment indicated he was cognitively intact, required limited assistance with transfers and ambulation, and extensive assistance with toileting. He was frequently incontinent of bladder, and was continent of bowel. An [DATE], significant change, MDS assessment indicated he was moderately cognitively impaired, required extensive assistance with bed mobility, transfers, toileting, and hygiene. He ambulated in his room once or twice and did not ambulate in the corridor. He was frequently incontinent of both bowel and bladder. He had almost constant pain, which interfered with his sleep and limited his day-to day activities. He had a current, [DATE], care plan problem of risk for falls. Interventions included, but were not limited to, evaluate for unsteady gait, instruct on appropriate safety measures, proper footwear, ambulation devices as needed, and maintain a safe environment. He had a current, [DATE], care plan problem of risk for falls due to deconditioning, gait/balance problems, and history of falls with fracture. Interventions included, but were not limited to, gripper socks, encourage call light and answer it promptly, proper footwear, maintain a safe environment, and provide adaptive equipment as indicated. The care plan was updated on [DATE] to include 1:1 supervision during periods of increased restlessness and frequent visual checks. He had a current, [DATE], care plan problem of impaired cognitive function/dementia or impaired thought processes related to a cognitive assessment result of moderate impairment, possibly due to a [MEDICAL CONDITION] infection. He had a current, [DATE], care plan problem of anticoagulant therapy. Interventions included, but were not limited to, medications, monitor for adverse reaction, daily skin inspection, and labs per order. Review of a [DATE] fall risk assessment indicated he was at high risk for falls due to a history of falls, no use of ambulatory aides, and impaired gait. Review of an [DATE], fall risk assessment indicated he remained at high risk for falls, with an increased score, due to IV therapy. Review of an [DATE], fall risk assessment indicated he was at very high risk of falls, related to he now overestimated or forgot his own limits. An [DATE] physician's note indicated he had experienced a functional decline due to having [MEDICAL CONDITION]. Review of a [DATE], fall risk assessment indicated he remained at very high risk for falls. Review of a Fall Scene Investigation note, dated [DATE] at 7:15 a.m., indicated he had attempted to self-transfer without staff and without a device. Immediate interventions of supervision, toileting, and 1:1 supervision were provided. Review of a progress note, dated [DATE] at 7:15 a.m., indicated staff found the resident lying on the floor on his right side, at the foot of his bed in his room. Blood and hematomas were noted to the right side of his face and his hand, and blood was on his shirt and on the floor. He was able to talk, but was unaware of what he was doing, was unaware of what he hit his head on. He had confusion, complaints of pain to his left upper extremity, and a history of chronic pain. He denied pain to the right side of his body. He was assisted with incontinence care, and needed verbal cueing to complete tasks. There were skin tears to his right forehead, right forearm, and right shoulder. He had hematomas to his right ear and right cheek, which were dark purple in color. There was a moderate amount of bleeding to all areas, except his right ear and right cheek. The resident's family member had arrived while he was still on the floor, and indicated the resident had called their cell phone twice that morning, but did not speak and had ended the call. Vital signs and a skin assessment were completed. A [DATE] progress note indicated the physician was notified at 10:14 a.m. of the fall. There was no mention of the resident being on a blood thinner. A [DATE] progress note indicated at 1:18 p.m., he was alert and oriented to person, place, time, with confusion noted throughout shift, and a blank stare when speaking with him. He required verbal cueing to complete tasks, with extensive to total assistance needed. His gait had been unsteady throughout the shift, and received pain medication for pain to his left upper extremity/shoulder, and was elevating his arm on a pillow. He had [MEDICAL CONDITION] throughout his body, more on his left side than his right. Review of a Fall Scene Investigation note, dated [DATE] at 7:58 p.m., indicated he had lost his balance and was found on the floor, after attempting to self-transfer. He had last toileted at 4:30 p.m. Immediate interventions of increased supervision, 1:1 supervision, and a snack were provided. A [DATE] progress note indicated at 8:12 p.m., the nurse and CNA were walking in the corridor and heard someone yelling for help. The resident was lying on his back on the floor in front of his recliner. The recliner was still in a reclined position. He had a hematoma with an abrasion (the site was not specified in the note). He was assisted by staff into his wheelchair and brought to the nurses station. A [DATE] progress note indicated the physician was notified of the fall at 7:56 p.m. There was no mention of the resident being on a blood thinner. A [DATE] late entry for 6:46 a.m., created at 9:48 a.m., indicated there had been frequent visual checks made of the resident by nursing staff. The resident had been resting quietly in bed that morning, with bed low and call light within reach. A [DATE] progress note indicated at 7:35 a.m., therapy staff had entered the resident's room, and couldn't arouse the resident. Nursing staff assessed him, and found him to be non-responsive. Active bleeding was noted from the back of his head. He was transferred from the facility to the hospital via emergency medical services. A [DATE] physician notification indicated at 7:50 a.m., the resident had been non-responsive, with snoring respirations, and unequal pupils. Review of neurological assessments indicated they had been completed on [DATE] at 10:44 a.m., [DATE] at 7:08 p.m., [DATE] at 4:28 a.m., and [DATE] at 7:35 a.m., when he was found to be unresponsive with his left eye non-reactive and dilated, and his right eye non-reactive. A [DATE] progress note indicated at 2:17 p.m., the resident's care plan had been reviewed due to two falls. Following the first fall, he had been immediately toileted, and provided with 1:1 and then increased supervision. Following the second fall, he had been confused and unable to tell staff what had happened. Staff had immediately brought him up to the nurses station, provided 1:1 and then increased supervision. His care plan was updated to include risk for falls. No further interventions were added at the time, due to his being sent to the hospital due to a change in condition in the night. Review of a [DATE] computed tomography (CT) scan of the resident's head indicated he had a large complex density subdural hematoma (occurs when a blood vessel near the surface of the brain bursts, usually caused by a head injury), which likely represented an acute on chronic hemorrhage, less likely representing acute hemorrhage alone. Review of [DATE] emergency room report, indicated he had a non-survivable subdural hematoma with intraventricular extension. He was to be discharged to hospice care. His [DIAGNOSES REDACTED]. A progress note, dated [DATE] at 7:39 p.m., included, but was not limited to, the following skin issues upon return from the hospital: 1. A hematoma/abrasion to the left back side of his head. 2. An abrasion to the right side of his forehead. 3. Bruising to his right cheekbone area. 4. Bruising to his right ear. 5. A bruise to the left side of his chin. 6. Adhesive skin closures to an abrasion to the base of his right thumb. 7. Bruising to his right upper extremity. 8. Bruising to his left upper extremity. 9. Non-[MEDICAL CONDITION] to his left upper extremity. 10. Adhesive skin closures to his left lower arm. A [DATE] progress note indicated he had remained unresponsive, and was admitted to hospice services. Resident 55 died at the facility on [DATE] at 7:06 p.m. During an interview, on [DATE] at 1:59 p.m., RN 13 indicated her shift had started at 6:00 a.m. on [DATE], and the resident had been asleep. He would usually awaken for the day between 6:30 and 7:00 a.m., for breakfast. A therapy staff member had gone into his room, and RN 13 had gone in as well, with the wound nurse, to look at his head wound. The therapist could not get him to awaken, so they began assessing him. During an interview, on [DATE] at 2:04 p.m., CNA 15 indicated the resident had been sleeping nice and quiet, so she had wanted to wait to assist him until closer to breakfast. She had been told in report, he had fallen twice the previous day, and she wanted to let him rest. Third shift had reported he had been awake through the night and didn't get much sleep. He had appeared to be sleeping like normal, and she hadn't noticed any change in his breathing until she was called in the room to assist, after he had been found to be unresponsive. During an interview, on [DATE] at 2:07 p.m., the DON indicated the third shift nurse had told her she had observed the resident around 3:00- 4:00 a.m., when his IV medication had been administered, and she hadn't noticed anything wrong. Neurological assessments were to be completed once a shift, unless the doctor ordered something different, so the third shift nurse had last completed the assessment at 3:00 or 4:00 a.m. During an interview, on [DATE] at 2:11 p.m., RN 17 indicated she was on duty when Resident 55 had fallen in the evening of [DATE]. He fell around 7 p.m., and had sustained a goose-egg on the back of his head, with an abrasion over it. His range of motion and vital signs were good, so staff had assisted him to his wheelchair. They started 1:1 supervision, and took him into the dining room, a family member came to visit with him for about an hour, then he was assisted to bed. RN 17 had checked on him in his bed around 10:10 p.m., and he was awake and talking to her. She had not documented a neurological assessment for him until the day following the fall, as she was not aware of where to document in the clinical record. Review of an undated, current facility policy, titled HEAD INJURY INCIDENT REPORT/NEUROLOGIC CHECK FLOWSHEET, provided by the DON on [DATE] at 2:24 p.m., indicated the following: .a neurological assessment will be done in all cases of head injury to the resident .The neurological assessment should be completed at the time of injury. A full set of vital signs and a neurologic check must be completed every shift for 72 hours .This information must be documented (in the) EMR (electronic medical record) Review of a current facility policy, titled ACCIDENT/INCIDENT POLICY, dated ,[DATE] and provided by the DON on [DATE] at 2:24 p.m., indicated the following: .1. Resident : Provide emergency care if necessary. Immediately notify physician .if evidence of fracture, life threatening situation, and/or head injury that requires physician's intervention .PR[NAME]EDURE: .8. Residents who have been involved in an accident/incident shall have timely and appropriate assessments performed and monitored in accordance with assessed needs 3XXX,[DATE](a)(2)