Every finding on record at Hickory Creek at Rochester

Based on observation, record review and interview, the facility failed to store food under sanitary conditions related to foods not sealed tightly and outdated foods and failed to ensure opened foods were labeled with an open date for 1 of 1 kitchen observed. This issue had the potential to affect 26 of 26 residents who received food from this kitchen. Findings include: On 6/8/2025 at 9:24 A.M., a kitchen tour was conducted with [NAME] 3. The following was observed in the fridge: - An opened gallon of milk with no open date. - An opened container of whipped topping with no open date. - An opened bag of sliced tomatoes with no open date. - A bowl of vanilla pudding with no use by date. - A container of pasta with a use by date of 5/11/2025. - An opened bag of sliced cheese with no open date. - An opened bag of mozzarella cheese with no open date. The following was observed in the walk-in freezer: - An opened container of vanilla ice-cream with no open date. The following was observed in the dry storage: - A bottle of Italian dressing with a use by date of 4/23/2025. - An opened box of mashed potatoes not sealed tightly. During an interview, on 6/8/2025 at 9:51 A.M., [NAME] 3 indicated the foods that were opened and not dated should have been dated, expired foods should have been thrown away and the mashed potatoes should have been sealed properly. On 6/11/2025 at 10:43 A.M., the Administrator provided the policy titled, Food Storage, dated 5/2025 and indicated it was the policy currently being used by the facility. The policy indicated, .Policy: Sufficient storage facilities are provided to keep foods safe, wholesome,and appetizing. Food is stored at an appropriate temperature and by methods designed to prevent contamination. 2. Leaking or severely dented cans and spoiled foods should be disposed of promptly or separated from other food to prevent contamination. 7. The food must clearly be labeled with the name of the product, the date it was prepared, and marked to indicate the date by which the food shall be consumed or discarded. 8. Refrigerated, ready-to-eat, potentially hazardous foods purchased from approved vendors shall be clearly marked with the date the original container is opened and the date by which the food shall be consumed or discarded. 11. Refrigeration: g. All foods shall be covered or wrapped tightly, labeled, and dated following the labeling guidelines. 12. Frozen Foods: c. Foods shall be covered or wrapped tightly, labeled and dated with the date the item is being placed in the freezer. 13. Dry Storage: c. All foods shall be covered or wrapped tightly, labeled and dated 3.1-21(i)(3)

Based on observation, record review and interview, the facility failed to provide independent, one on one and group activities for 1 of 2 residents reviewed for activities. (Resident 126) Finding includes: A record review for Resident 126 was completed, on 6/10/2025 at 1:10 P.M. Diagnoses included, but were not limited to: unspecified dementia, delusional disorder and schizophrenia. An admission Minimum Data Set (MDS) assessment, dated 6/4/2025, indicated Resident 126 had severe cognitive impairment and family had provided the following answers for importance of activity preferences: -How important is it to you to have books, newspapers, and magazines to read? Somewhat important -How important is it to you to listen to music you like? Very important -How important is it to you to do things with groups of people? Somewhat important -How important is it to you to do your favorite activities? Very important -How important is it to you to go outside to get fresh air when the weather is good? Very important -How important is it to you to participate in religious services or practices? Very important An assessment, titled, Activity Assessment, dated 6/5/2025 at 11:46 A.M., indicted a resident interview had been conducted. The activity plan of care areas of emphasis included, but were not limited to: coffee and snack, devotions, group activities, trivia, words/brain games, manicures, listening to rock, outdoor visits, bingo [NAME] tennis and going on walks. Independent activities and one on one visits were not indicated. An Activity Care Plan had not been developed as of 6/11/2025 for Resident 126. During an observation, on 6/8/2025 from 9:25 A.M. through 11:07 A.M, Resident 126 was observed in a darken room without television or radio being played in bed sleeping. During an observation, on 2:53 P.M., Resident 126 was observed in bed sleeping. During an observation, on 6/11/2025 from 9:13 A.M. through 10:50 A.M., Resident 126 was observed sleeping in bed. During generalized random observations, from 6/8/2025 through 6/11/2025, Resident 126 was never observed participating in activities or outside her bed sleeping in her dark room without any television or a radio playing. The Activity Calander, dated June 2025, indicated the following activities had occurred: -6/8/2025 at 10:00 A.M., church services -6/9/2025 at 10:30 A.M., coffee and chat -6/9/2025 at 10:30 A.M., daily devotion -6/9/2025 at 11:15 A.M., workout with arm stretches -6/9/2025 at 2:30 P.M., win lose or draw game -6/9/2025 at 2:30 P.M., arts and crafts canvas painting -6/10/2025 at 10:00 A.M., coffee and chat -6/10/2025 at 10:30 A.M., daily devotion -6/10/2025 at 11:15 A.M., leg stretches and sitter Cise -6/11/2025 at 10:00 A.M., coffee and chat -6/11/2025 at 10:30 A.M., morning blessing -6/11/2025 at 10:45 A.M., wonderful workout with aroma sense -6/11/2025 at 2:30 P.M. [NAME] tennis Resident 126 was not observed participating in any of the scheduled activities. A document titled, Monthly Resident Attendance Record, indicated Resident 126 had been active in activities on 6/9/2025, 6/10/2025 and 6/11/2025, but did not indicate the activities Resident 126 had attended. The document also indicated Resident 126 had refused activities on 6/3/2025 and 6/7/2025. The Point of Care documentation from 5/22/2025 through 6/11/2025, indicated Resident 126 had attended a worship service and a one-on-one activity on 6/5/2025 and attended coffee and chat on 6/7/2025. During an interview, on 6/11/2025 at 9:58 A.M., the Activity Director indicated all activity participation was documented electronically in the medical record. During an interview, on 6/11/2025 at 1:20 P.M., the Activity Director indicated that Resident 126 was more bedbound and should have received one on one and small group activities. She indicated she should have had stimulation in her room in the form of a radio or television. A current policy was provided, on 6/11/2025 at 2:20 P.M., by the Regional Director of Clinical Services. The policy titled, Activity Services, indicated, .This facility will provide an ongoing program of activities, based on the comprehensive assessment and care plan and the preferences of each resident, designed to support residents in their choice of activities, both facility-sponsored group and individual activities, and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community 3.1-33(a)

Based on observation, record review and interview, the facility failed to provide proper positioning devices for 1 of 3 residents reviewed for mobility and positioning. (Resident 13) Finding includes: During an observation, on 6/8/2025 at 9:56 A.M., 10:54 A.M. and 11:18 A.M., Resident 13 was observed sleeping in the hallway in her high back wheelchair, leaning to the right without her right shoulder and neck supported and her feet dangling without support. During an observation, on 6/10/2025 at 9:14 A.M., Resident 13 was observed sitting in the hallway in her wheelchair, leaning to the right without her right shoulder and neck supported and her feet dangling without support. During an observation, on 6/10/2025 at 1:08 P.M., Resident 13 was observed in the hallway in her wheelchair with her feet dangling with no support. During an observation, on 6/11/2025 from 9:13 A.M. through 10:50 A.M., Resident 13 was observed sitting in the hallway on her wheelchair with her feet dangling and leaning to the right without support of her right shoulder and neck. A record review for Resident 13 was completed on 6/10/2025 at 9:17 A.M. Diagnoses included, but were not limited to: Alzheimer's disease, muscle weakness and left hip pain. A Quarterly Minimum Data Set (MDS) assessment, dated 5/21/2025, indicated Resident 13 was rarely or never understood, was dependent for transfers and bed mobility, had no range of motion impairment and had not received skilled therapy or restorative therapies. A Physician's Order, dated 1/8/2024, an order for a Pommel cushion (a specialized wheelchair cushion designed to prevent forward sliding and promote proper hip and knee alignment) to the wheelchair for postural control. A Nurse Practitioner Note, with a late entry of 5/12/2025 at 7:16 A.M. for 5/9/2025 at 7:16 A.M., indicated Resident 13 was wheelchair dependent, dependent for all activities of daily living (ADLs), had progressive muscle weakness secondary to Alzheimer's disease and slept 24 hours a day, seven days a week. A Care Plan, initiated on 8/18/2023 and revised on 5/21/2025, indicated Resident 13 was at risk for ineffective issue perfusion related to hypertensive heart disease. Interventions included, but were not limited to: to elevate Resident 13's lower extremities as needed. A Care Plan, initiated on 8/18/2023 and revised on 5/21/2025, indicated Resident 13 was at risk for pain related to arthritis, hypertensive heart disease, restless leg syndrome, pain in the left leg and hip and age-related debility. Internventions included, but were not limited to: to assist with positioning for comfort and to provide non-pharmacologic interventions including repositioning. During an interview, on 6/11/2025 at 11:05 A.M., CNA 2 indicated she had previously asked a nurse for foot pedals for Resident 13's wheelchair, but no foot pedals were available, and the resident never received any foot pedals. CNA 2 indicated that Resident 13 tended to lean to the right all the time, even when lying down in bed. CNA 2 indicated she had concerns about the coloring of Resident 13's feet after she had been in her wheelchair for a period of time. A policy was requested for wheelchair positioning. On 6/11/2025 at 2:20 P.M., the Regional Director of Clinical Services indicated the facility did not have a policy for wheelchair positioning. 3.1-37(a)

Based on record review and interview, the facility failed to provide consented immunizations for 1 of 5 residents reviewed for immunization compliance. (Resident 14) Finding includes: A record review for Resident 14 was completed, on 6/1/2025 at 12:05 P.M. Diagnoses included, but were not limited to: chronic obstructive pulmonary disease (COPD), juvenile osteochondrosis (a condition that disrupts normal bone growth in adolescents), diabetes mellitus type 2 and sleep apnea. An Annual Minimum Data Set (MDS) assessment, dated 4/30/2025, indicated Resident 14 was cognitively intact, had been offered the pneumococcal vaccination and declined and was not up to date for his COVID-19 immunizations. On 4/18/2025, Resident 14 had signed a consent form for immunizations of the COVID-19 and the pneumococcal vaccinations per the Center for Disease Control (CDC) recommendations. There was no documentation the COVID-19 or the pneumoccocal vaccinations had been administered. During an interview, on 6/11/2025 at 12:05 P.M., the Regional Director of Clinical Services (RDCS) indicated the COVID-19 and pneumococcal immunization injections should have been administered after the resident had signed the consents on 4/18/2025. A current policy was provided, on 6/11/2025 at 2:20 P.M., by the RDCS. The policy titled, Resident COVID-19 Vaccination, indicated, .It is the policy of this facility that resident[s] will be offered the COVID-19 vaccine, additional doses, and boosters per CDC recommendations unless it is medically contraindicated A current policy was provided, on 6/11/2025 at 2:20 P.M., by the RDCS. The policy titled, Pneumococcal Vaccination, indicated, .It is the policy of this facility that resident[s] will be offered pneumococcal vaccination [if appropriate] to help prevent the development and transmission of pneumonia 3.1-13(a)

Based on interview and record review the facility failed to ensure safety measures were followed to prevent a resident's fall while riding in the facility bus for 1 of 3 residents reviewed for unusual occurrences. (Resident B). The deficient practice was corrected on 4/18/2025, prior to the start of the survey, and was therefore past noncompliance. Finding includes: During an interview, on 5/7/2025 at 9:58 A.M., Employee 2 indicated a couple weeks ago she had transported Resident B from the facility to (Name of Hospital) to have a suprapubic catheter placed. Employee 2 indicated she had stayed with the resident the entire time during her recovery. The resident was talking and had eaten prior to being transported back to the facility. The resident's wheelchair was secured down on all four areas on the wheelchair to the floor of the bus/van. Employee 2 indicated when she tried to fasten the seat belt on the resident, it was positioned over her abdominal incision site, and the resident said ow, ow. The resident did not want it on because it was hurting her, so Employee 2 indicated she did not fasten the seat belt on the resident. Employee 2 stated, I slowed down and I put the brakes on hard because there was a school bus with the arm out and had stopped. Employee 2 indicated the resident leaned forward and hit her forehead and face on the back of the seat in front of her and then slid all the way out of her wheelchair and landed on her buttocks. Employee 2 indicated she turned into the school parking lot, and I put on the brakes and asked her if she was hurt, she said her head hurt. I asked if she hurt anywhere else and she said, No, I'm ok. Employee 2 indicated she had called the facility and asked what she should do. She indicated the Administrator, the Director of Nursing, the Assistant Director of Nursing and (name of staff) RVPO (Regional [NAME] President of Operations) all came to help with the resident. They lifted the resident up onto the regular bus seat and the Assistant Director of Nursing assessed her. A different seat belt was applied to the resident in the regular bus seat. The belt had to be adjusted because she did not fit in the seat very well. The Assistant Director of Nursing rode back to the facility with the resident. Employee 2 indicated she normally used seat belts on anyone being transported in the bus. The record for Resident B was reviewed on 5/7/2025 at 10:49 A.M. Diagnoses included, but were not limited to diabetes, obesity, hypertension, anxiety and depression. A Quarterly MDS (Minimum Data Set) assessment, dated 3/13/2025, indicated Resident B used a walker for ambulation, required total assist for toileting, partial to moderate assist to move from a seated to a standing position and transfers from a chair to the bed. A Nursing Progress Note, dated 4/16/2025 at 5:24 P.M., indicated the resident had a witnessed fall on the facility bus when she leaned forward and slid out of her wheelchair as it was slowing for a school bus stop. The resident was assessed by the nurses prior to moving her. The resident denied any new pain, moved her extremities with no pain reported and followed commands without difficulty. The resident was assisted off the floor with extensive assist of 4 to a stationary bus seat. The resident was noted to have an abrasion on her right lateral lower back near her waistline, a light pink abrasion to her left knee and a goose egg on her left forehead. A cold pack had been applied to her forehead. Upon return to the facility, neuro-checks and vital signs were initiated. (Name of Physician) was notified of the fall and minor injuries. The physician communicated no new orders but to continue with neuro-checks for changes in LOC (level of conscious). A Nursing Progress Note, dated 4/18/2025 at 1:51 A.M., indicated .Bruising continues to L (left) eye corner, hematoma to forehead, and abrasions to L knee and back During an interview, on 5/7/2025 at 12:20 P.M., the Administrator indicated she had interviewed Employee 2 about why the seat belt had not been used on the resident for the return trip to the facility. Employee 2 stated the resident didn't want it on. The Administrator stated Employee 2 had been disciplined for not using the seat belt on Resident B and had been required to complete more training on the use of seat belts during transporting residents. Employee 2 had been audited by another bus driver on the use of the bus prior to transporting residents again. On 5/7/2025 at 12:45 P.M., the Administrator provided the policy titled, Transportation, last dated 12/2017, and indicated the policy was the one currently used by the facility. The policy indicated .8. Seat belts are required to be worn by driver and passenger(s) This citation relates to Complaint IN00458540. 3.1-45(a)(2)

Based on record review and interview, the facility failed to ensure an allegation of misappropriation of resident property was reported to the appropriate state agency for 1 of 2 residents reviewed for misappropriation of resident property. (Resident E) Finding includes: During an interview, on 4/15/2025 at 2:35 P.M., the Regional Director of Clinical Services (RDCS) indicated she had received a call from a facility nurse, on 3/8/2025, concerning an allegation of another nurse taking antibiotic medications from the medication room. The RDCS indicated there had been an investigation concerning the antibiotic medication, and [NAME] a result of the investigation, it was determined an antibiotic medication had been signed off every day as being administered to Resident F. The RDCS indicated there was no confirmed misappropriation of medication as a result of the investigation. During an interview, on 4/15/2025 at 3:30 P.M., the Administrator indicated she had not reported the allegation of misappropriation to the state because the result of the investigation was antibiotic medication for Resident F had been signed for and the resident had received all ordered doses of the antibiotic. During an interview, on 4/15/2025 at 3:32 P.M., the RDCS indicated no other residents on antibiotics were investigated because the allegation had described description of the container the facility nurse had given her only matched Resident F's medications. On 4/15/2025 at 3:42 P.M., the RDCS provided the policy titled, Long-Term Care Abuse and Reporting Policy , dated 12/8/2023, and indicated the policy was the one currently used by the facility. The policy indicated . 9. Misappropriation of resident property: Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a residents belongings or money without the resident's consent . Abuse and incidents will be reported and submitted to the Indiana Department of Health in compliance with federal regulations and/or state rules and this policy, as applicable . B. Types of Incidents Reportable Under Federal and State Rules . 12. Misappropriation of resident property/exploitation .iii. Missing prescription medications This citation relates to Complaint IN00455366 3.1-38(c)

Based on record review and interview, the facility failed to ensure medication destruction form was completed for a resident that was hospitalized for 1 of 3 residents reviewed for medications. (Resident E) Finding includes: On 4/15/2025 at 11:48 A.M., the Regional Director of Clinical Services (RDCS) provided a Surveillance Log of Resident Infections and Antibiotic Use form, dated February 2025. The form indicated Resident E had a wound infection with an onset date of 2/17/2025. An antibiotic, Augmentin 875/125 mg (milligram) was ordered with a start date of 2/17/2025 and a stop dated of 2/27/2025. The record for Resident E was reviewed on 4/15/2025 at 2:00 P.M. Diagnoses included, but were not limited to paraplegia, psychosis, hypertension and fusion of the spine. A Physician's Order, dated 2/17/2025, indicated Resident E was to receive Amoxicillian-Clauvulante (Augmentin), an antibiotic, 875/125 mg 1 tablet twice a day for 20 doses. The Medication Administration Record (MAR) for February 2025 indicated Resident E had received the first dose of Augmentin on 2/17/2025 at 8:00 P.M. He had received another 13 doses from 2/18/2025 through 2/23/2025, and had refused the morning dose on 2/24/2025. Resident E was admitted to the hospital on 2/24/2025 and did not return until 3/7/2025. The current physician's orders did not include the Augmentin order. There should have been 6 remaining tablets that had not been administered of the antibiotic for Resident E. Resident E's record lacked the documentation to show a Drug Disposition form had been completed for the remaining antibiotic pills. During an interview, on 4/15/2025 at 2:21 P.M., RN 2 indicated if the nurses documented correctly, they should have filled out a drug destruction sheet and placed the form in the pharmacy bag, along with the medication. A copy of the form should have gone to the medical records staff so she could have scanned the form into the electronic chart. RN 2 checked the forms yet to be scanned into the records, but there were no sheets yet to be scanned in for Resident E. In addition, there were no scanned forms in Resident E's electronic chart for the mediction disposition. The medication cart holding Resident E's medications was observed, on 4/15/2025 at 2:00 P.M. and no antibiotic medications were located in the cart for Resident E. During an interview, on 4/15/2025 at 2:28 P.M., the Director of Nursing indicated there were no forms that needed to be scanned into charts at this time. The RDCS indicated she had completed some drug destructions recently but she could not provide a drug destruction sheet for Resident E's remaining Augmentin tablets. On 4/15/2025 at 3:40 P.M., the RDCS provided the policy titled, Drug Disposition Policy, dated 11.2024, and indicated the policy was the one currently used by the facility. The policy indicated .This policy provides procedural guidance on how to properly destroy, return or waste medications and document disposition of those medications . 1. When a non-controlled substance or medication is discontinued by physician's order it will be removed from the medication cart at time of order and placed in the designated location in the locked medication room. 2. The discontinued items need to either be destroyed or sent back to the pharmacy within 7 days via [name of pharmacy] This citation relates to Complaint IN00455366. 3.1-50(a)

Based on observation, record review and interview, the facility failed to ensure a resident received the necessary treatment and services to promote healing and prevent worsening of a pressure ulcer, as well as prevent the development of additional pressure ulcers for 1 of 2 residents reviewed for pressure ulcers. This deficient practice resulted in the worsening of an identified pressure ulcer, from a Stage 2 to a Stage 4 and the development of multiple pressure ulcers which progressed from a DTI (Deep Tissue Injury) to unstageable wounds with slough, the need for treatment from a local wound treatment center and the need for an upcoming surgical colostomy procedure to reduce contamination and damage to the area. (Resident B) The Immediate Jeopardy began on 10/10/24 at 4:28 P.M., when the facility identified a wound to the coccyx upon admission and failed to notify the physician and obtain immediate treatment orders which placed the resident in immediate jeopardy of serious harm. The Administrator, Regional Nursing Consultant and Facility Nursing Consultant were notified of the Immediate Jeopardy on 2/5/25 at 2:50 P.M. The deficient practice was corrected on 11/8/24, prior to the start of the survey, and was therefore past noncompliance. Finding includes: Resident B's clinical record was reviewed on 2/3/25 at 9:21 A.M. Resident B was admitted to the facility on [DATE] from an acute care facility. Diagnosis, included but were not limited to, non-pressure chronic ulcer, paraplegia, muscle wasting, unspecified psychosis, adjustment disorder, chronic total occlusion of artery of extremities, hypertension, fusion of spine, tortuous aortic arch, traumatic compartment syndrome of lower extremity, and an unspecified open wound of the abdominal wall. An Admission Minimum Data Set (MDS) assessment, dated 10/16/24, indicated Resident B had moderate cognitive impairment, no behavioral issues, was always incontinent of bladder, frequently incontinent of bowel, required assistance for bed mobility and was dependent for all transfers and toileting hygiene. The resident required a wheelchair for mobility. The assessment indicated Resident B was at risk for pressure ulcers and had a stage 2 pressure ulcer that was present on admission. The assessment indicated Resident B had pressure reducing devices to his bed and chair. The assessment indicated Resident B was receiving pressure ulcer care including the application of nonsurgical dressings and application of ointments or medications. An Observation Report form, dated 10/10/24 at 3:29 P.M., indicated Resident B was admitted with an ulcer type friction wound to the coccyx measuring 1 cm x 1 cm with no depth. There was no documentation the physician was notified of the pressure ulcer. The Braden Scale for Predicting Pressure Sore Risk assessment, dated 10/10/24 at 4:24 P.M., indicated Resident B was at moderate risk for pressure wound development. The current Care Plans for Resident B related to skin and care needs included the following: Start Date: 10/10/2024 Resident requires assistance with ADLs (activities of daily living) including bed mobility, transfers, eating and toileting related to: recent hospitalization for cellulitis, paraplegia, muscle wasting/atrophy, unspecified psychosis, adjustment disorder with depressed mood, fusion of lumbar spine, and presence of wounds. Start Date: 10/10/2024 Resident requires assistance with ADLs including bed mobility, transfers, eating and toileting related to: recent hospitalization for cellulitis, paraplegia, muscle wasting/atrophy, unspecified psychosis, adjustment disorder with depressed mood, fusion of lumbar spine, and presence of wounds. Start Date: 10/15/2024 Resident was admitted with impaired skin integrity: PRESENT ON ADMISSION pressure to coccyx. Other wounds include sacral wound that merged with coccyx wound, right/left buttocks. Factors contributing to wound development include slightly limited sensory perception, moisture, chair fast, impaired mobility, and friction/shearing, paraplegia, muscle wasting and atrophy, hypoalbuminemia, protein-calorie malnutrition, chronic total occlusion of extremity arteries, HTN, HLD, adjustment disorder with anxiety, and major depressive disorder. Start Date: 10/28/2024, Resident is at risk for skin breakdown or further skin breakdown due to, dx paraplegia and muscle wasting and atrophy, episodes of incontinence, impaired mobility and requiring staff assistance for mobility and transfers. Review of a Wound Management Detail Report for the Coccyx and wound indicated the following wound assessments and progression: 10/10/24 at 4:39 P.M., stage 2 wound 1.5 cm x 1.6 cm x depth of 0.2 cm, 10/18/24 at 1:45 P.M., stage 2 wound 1.5 cm x 1.5 cm x depth of 0.1 cm, 10/25/24 at 9:14 A.M., stage not documented, wound 1.4 cm x 1.5 cm x depth not documented, 10/31/24 at 10:46 A.M. stage not documented, wound 1.8 cm x 1.5 cm x depth of 1.2 cm Resident B's admission orders, dated 10/10/24, included no orders for pressure ulcer treatment. Progress notes between 10/10/24 and 10/31/24 included, but were not limited to the following related to the residents wound on the coccyx and buttock: 10/15/24 at 8:37 A.M., the wound area was to the coccyx and healing. 10/16/24 at 12:49 A.M., the wound area was to the coccyx. 10/17/24 at 3:35 A.M., the wound area was to the coccyx. 10/19/24 at 8:02 A.M., barrier cream was applied to the coccyx and nursing would continue to monitor. 10/20/24 at 10:18 A.M., treatment was applied to buttock per a physician's order. 10/22/24 at 10:20 A.M., there were no signs or symptoms of infection to the buttocks 10/23/24 at 3:58 A.M., the wound area was to the coccyx. 10/23/24 at 9:37 A.M., treatment continued to the buttocks and there was no noted drainage, odor, or signs or symptoms of infection. 10/24/24 at 2:42 A.M., the wound area was to the buttock. 10/24/24 at 10:12 A.M. the area to the buttocks continued with treatments. No noted odor or drainage, no noted worsening. 10/25/24 at 9:52 A.M.,there was no noted drainage or odor to the buttock pressure ulcer. 10/26/24 at 1:22 P.M., there was no noted drainage or odor area to buttock pressure ulcer. 10/27/24 at 8:10 A.M., wound was to the buttock. 10/29/24 at 1:35 A.M., wound was to the coccyx. 10/29/24 at 9:11 A.M., wound on the coccyx was clean dry and intact 10/30/24 at 4:03 A.M., wound area to buttocks and coccyx. 10/31/24 at 2:19 A.M., wounds to coccyx, buttocks. 10/31/24 at 8:57 P.M., resident was in bed and the dressings were clean dry and intact. The progress notes above identified 2 wounds, coccyx and buttock, but did not indicated the physician was notified of the coccyx or buttock wound or any orders were obtained for specific treatment for the areas identified. A Physician's Progress Note, dated 10/21/24, indicated the facility staff had denied any acute issues related to the resident and staff had denied any new wounds for Resident B. An Event Report for a new skin event, dated 10/31/24 at 6:00 A.M., indicated a new deep tissue pressure wound was identified to the left buttock that measured 6.9 cm x 7.2 cm. The report indicated the physician was notified of the new pressure ulcer on 10/31/24 at 6:35 A.M. and a new treatment order was received for collagen (an anti-infective and anti-inflammatory treatment), an air mattress, treatments and labs. Review of a Wound Management Detail Reports for the Sacrum wound indicated the wound was identified on 10/31/24 at 9:17 A.M. and indicated the following wound assessments and progression: 10/31/24 at 9:17 A.M., stage not documented, wound 6.9 cm x 5.8 cm, depth could not be measured. Physician Orders related to skin care and pressure ulcer care included the following: 10/31/24: Cleanse bilateral buttocks, pat dry. Apply remedy repair cream every shift and with peri care. Cleanse coccyx/buttocks with soap and water, pat dry. Moisten collagen and apply to wound bed of DTI (deep tissue injury) and cover with optifoam every day and as needed beginning 10/31/24 to 12/6/24. Positioning/Devices: cushion to wheelchair beginning. Positioning/Devices: Low Air Loss Mattress to bed check functioning every shift beginning. Progress notes between 11/3-11/8/25 indicated DTI to buttocks and both buttocks. The coccyx wound is not mentioned in the notes. 11/03/24 at 8:58 A.M., resident had a deep tissue injury to the buttocks with a treatment ordered. 11/04/24 at 3:48 A.M., resident was checked and changed (for incontinence) every two hours. During every check and change, staff requested the resident to turn side to side to relieve pressure on the buttock wound. The Resident refused every request from staff to turn. Treatment was done to the buttock wounds. 11/05/24 at 3:42 A.M., pressure wound to the buttocks. 11/05/24 10:37 A.M., resident continues to have a deep tissue injury to the buttocks and continues with treatment as ordered. Resident was encouraged to be in bed more often and turn from side to side but was not always compliant with being checked and changed every two hours. The resident remained on a specialty air mattress. Dressings were clean dry and intact. 11/07/24 at 3:30 A.M., open areas to the buttocks with treatment. 11/08/24 at 9:33 A.M., pressure ulcers continued to both buttocks. Treatment was applied as ordered. Physician was there and stated the resident's wounds were definitely starting to heal and educated the resident as well. The resident remained on a low air loss mattress. Physician orders: 12/6/24: Cleanse coccyx/buttocks with soap and water, pat dry. Apply Santly to wound bed of the deep tissue injury and pressure ulcers, then cover them with optifoam every day and as needed 12/7/24-1/15/25: Santyl ointment topical to cleanse coccyx/buttocks with soap and water, pat dry. Apply Santyl to wound bed of DTI and cover with Optifoam daily and as needed. 12/19/24: Left distal gluteus wound: Left distal gluteus wound -cleanse with wound cleanser and apply Santyl Collegenase cut Aquacel ribbon and insert into wound bed as instructed and cover with mepilex border dressing once daily beginning 12/19/24 to 1/15/25. 12/19/24: Right distal gluteus: Right distal gluteus cleanse with wound cleanser apply santyl and cover with mepilex border dressing once daily. 12/19/24: Right superior gluteus: Right superior gluteus cleanse with wound cleanser apply Santyl and cover with mepilex border dressing daily 1/3/25: Appointment with local wound care center. 1/15/25: Wound vac at 125 mm/hg to wounds sacrum/buttocks, will be done at wound care. 2/3/25: Appointment with local wound care center. 2/4/25: Appointment with local hospital anesthia for colostomy consult. During an observation and interview on 2/4/25 at 9:05 A.M., Resident B was observed in his bed on his back with the head of the bed elevated. Resident B indicated when he was admitted to the facility, there had been no treatment for any pressure areas. The resident indicated he has some small pressure areas to his bottom that had gotten much worse after he was admitted to the facility and he had gone 2 to 3 weeks before the facility began any interventions for any pressure areas. Resident B indicated he had been going to a local wound care center for 4 weeks and the pressure ulcers seemed to be improving, but now he had a wound vac and would have to have a colostomy due to the pressure ulcers. During a telephone interview on 2/5/25 at 8:15 A.M., the facility Medical Director indicated he was first made aware of Resident B's pressure ulcers on 11/1/24 when he was at the facility for resident assessments. The Medical Director indicated he gave initial wound care orders on 11/1/24 and had not given any orders for pressure ulcer care before 11/1/24. The Medical Director indicated if the facility staff had notified him about Resident B's pressure ulcers earlier or upon admission, he would have started treatment immediately to possibly avoid the seriousness of the wounds. During an interview on 2/5/25 at 8:54 A.M., the Assistant Director of Nursing indicated she was doing new resident chart audits on 10/18/24 and noted the residents' pressure ulcer that had been identified on 10/10/24. The Assistant Director of Nursing indicated she believed she had notified the physician of Resident B's pressure ulcers on either 10/18/24 or 10/22/24 and received an order to apply Opifoam to the wound. The Assistant Director of Nursing did not document her communication with the physician. During a wound observation on 2/5/25 at 9:15 A.M., Resident B was noted to have four wounds to the sacral and buttock area. A wound was noted to the right of the sacrum that appeared to be approximately 3 cm x 3 cm with 5 cm depth, a wound to the coccyx that tunneled with the sacral wound that appeared to be approximately 5 cm x 5 cm x 5 cm depth, a wound to the right buttock proximal to the anus that appeared to be approximately 3 cm x 3 cm x 5 cm depth, and a wound to the left buttock proximal to the anus that appeared to be approximately 2 cm x 2 cm x 5 cm depth. On 2/4/25 at 4:15 P.M., The Administrator provided a policy titled, Resident Change of Condition, dated 11/04. The policy indicated, .It is the policy of this Community that changes in resident condition will be communicated to the physician and family/responsible party, and that appropriate, timely, and effective intervention occurs .Any sudden or serious change in a resident's condition .will be communicated to the physician with a request for physician visit promptly and/or acute care evaluation. The licensed nurse in charge will notify the physician . On 2/4/25 at 4:30 P.M., the Facility Consultant Nurse provided a policy titled Skin Management Program, most recently updated on 5/22, abd indicated it was the facility's current policy. The policy indicated it was the policy of the facility to ensure a resident with pressure ulcers received necessary treatment and services to promote healing, prevent infection and prevent new ulcers from developing. An avoidable pressure ulcer meant a resident had developed a pressure ulcer and the facility did not define and implement interventions that were consistent with the resident needs. Alterations in skin integrity was to be reported to the physician and treatment orders obtained. The deficient practice was corrected by 11/8/24 after the facility implemented a systemic plan of correction that included the following actions: a facility wide skin sweep to determine any resident with skin alterations/wounds, nursing staff re-education of the facility policies regarding change in condition, notification, assessment, documentation, weekly skin cheeks with notification of change, re-education of nurses and certified nursing assistants on completing shower sheets, notifying the nurse of any change in condition to include skin alterations, changes in condition notification to physician and family and documented in the clinical record, monthly skin sweeps, weekly skin assessments and shower sheet reviews by the interdisciplinary team, current wounds to be assessed for changes with physician notification, Care Plans and all prevention interventions and associated documents related to wound to be initiated or updated, In-service/Education for all licensed nurses regarding wound care, treatment, and physician notification and documentation for any changes in the wound. In addition, room rounds were to be completed daily for 5 weeks to ensure all preventative interventions were in place per the individual plan of care. Compliance for the plan of correction was to be monitored through the Quality Assurance and Performance Improvement Program and an audit tool related to Wound Management was to be completed monthly for 6 months. This Citation relates to complaint IN00452399. 3.1-40(1) 3.1-40(2)

Based on interview and record review, the facility failed ensure a resident's responsible party was notified in a timely manner of condition and roommate changes for 1 of 3 residents reviewed for notification, (Resident B). Finding includes, During an interview on 2/4/25 at 9:37 A.M., Resident B's family member indicated that the residents' POA (Power of Attorney) and emergency contact was never notified that Resident B had been assessed to have a pressure area when he was admitted to the facility, that the pressure ulcer had worsened or that an additional pressure ulcer had developed. In addition, Resident B had multiple roommate changes and there was no notification of those changes. During an interview, on 2/4/25 at 2:12 P.M., the Administrator indicated Resident B had had room and roommate changes and the residents' POA and/or family member was not notified of the changes. The Administrator indicated the facility's Social Service Director, at the time of the moves, should have notified the resident's POA and/or family member. The Administrator indicated roommate changes had occurred on 10/19/24, 10/25/24, 11/17/24, 12/22/24, and 12/29/24 and the resident's POA and/or family member should have been notified. Resident B's clinical record was reviewed on 2/3/25 at 9:21 A.M. Resident B was admitted to the facility on [DATE] from an acute care facility. Diagnosis included, but were not limited to, non-pressure chronic ulcer, paraplegia, muscle wasting, unspecified psychosis, adjustment disorder, chronic total occlusion of artery of extremities, hypertension, fusion of spine, tortuous aortic arch, traumatic compartment syndrome of lower extremity, and an unspecified open wound of the abdominal wall. An Admission Minimum Data Set (MDS) assessment, dated 10/16/24, indicated Resident B had moderate cognitive impairment, was always incontinent of bladder, was frequently incontinent of bowel, and had a stage 2 pressure ulcer that was present on admission. An Observation Report form, dated 10/10/24 at 3:29 P.M., indicated Resident B was admitted with an ulcer type friction wound to the coccyx measuring 1 cm x 1 cm with no depth. There was no documentation the POA and/or family member was notified of the pressure ulcer. A Nursing Progress Note, dated 10/16/24 at 12:49 A.M., indicate the resident had a wound to the coccyx area. There was no documentation that indicated POA and/or family notification. A Nursing Progress Note, dated 10/24/24 at 2:42 A.M., indicated the resident had a wound to the buttock. There was no documentation that indicated Resident B's POA and/or family had been notified of the new wound. A Nursing Progress Note, dated 10/30/24 at 4:03 A.M., indicated Resident B had wound areas to the buttocks and coccyx. There was no documentation that indicated POA and/or family notification. A Nursing Progress Note, dated 10/31/24 at 10:33 P.M., indicated Resident B's family member was informed of Resident B's new skin area to the buttocks. A Care Plan dated 10/15/24 indicated Resident B was admitted to the facility with impaired skin integrity that was present on admission regarding a pressure ulcer to the coccyx. The care plan also referred to other wounds, including a sacral wound that merged with a coccyx wound, and right/left buttocks wounds. On 2/4/25 at 4:15 P.M., the Administrator provided a policy titled, Resident Change of Condition, dated 11/04. The policy indicated, .It is the policy of this Community that changes in resident condition will be communicated to the physician and family/responsible party, and that appropriate, timely, and effective intervention occurs. This citation relates to complaint IN00452399. 3.1-5(a)(2) 3.1-5(b)(1)

Based on observation, interview and record review, the facility failed to ensure kitchen equipment were in good working condition in 1 of 1 kitchen reviewed. Finding includes: During a kitchen tour with the Dietary Manager on 6/4/2024 at 9:26 A.M., the following was observed: -broken seals to both doors of the freezer. -broken seals to both doors on 2 refrigerators. During an interview on 6/4/2024 at 9:45 A.M., the Dietary Manager indicated the seals needed to be fixed. On 6/10/2024 at 1:36 P.M., the Regional Nurse Consultant provided the policy titled,Kitchen Safety Guidelines, dated 4/2024, and indicated the policy was the one currently used by the facility. The policy indicated .2. All employees will report defective equipment, unsafe condition,acts, or safety hazards to the supervisor and/or the maintenance department . 13. The maintenance department is responsible for routine inspections and repair of fans, vents and equipment 3.1-21(i)(3)

Based on interview and record review the facility failed to ensure performance evaluations were completed annually for 4 of 4 employee files reviewed. (CNA 3, CNA 4, CNA 7 & CNA 8) Findings include: 1. During an interview on 6/10/2024 at 10:05 A.M., CNA 3 indicated they (the facility) do not do competencies every year or evaluations. 2. During an interview on 6/10/2024 at 11:01 A.M., CNA 4 indicated she had not received a performance evaluation since she started working here (at the facility). 3. During an interview on 6/10/2024 at 1:23 P.M.,the Business Office manager indicated they (the facility) used to do them (competency evaluations) but when the new company took over they gave out the raises in January and they just didn't get done, but we are starting it back again. 4. During an interview on 6/10/2024 at 1:29 P.M., the Administrator indicated she and the Director of Nursing complete them and they should be done every year. There were some that were done, but there was a lot of turn over and she did not think they were all done. The employee file for CNA 3 was reviewed on 6/10/2024 at 1:36 P.M. CNA 3 was hired on 2/8/2023. No annual performance evaluation was located in the file. The employee file for CNA 4 was reviewed on 6/10/2024 at 1:38 P.M. CNA 4 was hired on 4/17/2023. No annual performance evaluation was located in the file. The employee file for CNA 7 was reviewed on 6/10/2024 at 1:40 P.M. CNA 7 was hired on 8/11/2017. No annual performance evaluation was located in the file. The employee file for CNA 8 was reviewed on 6/10/2024 at 1:43 P.M. CNA 8 was hired on 9/22/2019. No annual performance evaluation was located in the file. During an interview on 6/20/2024 at 1:45 P.M., the Business Office Manger indicated the performance evaluations should be done every year. During an interview on 6/10/2024 at 1:46 P.M., the Administrator indicated she did not have a policy regarding the performance evaluations. 3.1-14(h)

Based on observation, record review and interview, the facility failed to ensure proper infection control practices were implemented related to Enhanced Barrier Precautions (EBP) for 1 of 4 residents reviewed for EBP; failed to follow infection control practices when completing a blood sugar check for 1 of 1 resident reviewed for blood sugar assessments and failed to complete changing gloves and hand washing during catheter care for 1 of 1 resident observed for urinary catheter care. (Resident 28, QMA 2, CNA 5, Resident 23) Findings include: 1. During an interview on 6/5/2024 at 8:27 A.M., Resident 28 indicated he went to dialysis 3 times a week. There was no signage and or indication the resident was to be in EBP isolation. The record for Resident 28 was reviewed on 6/6/2024 at 9:58 A.M. Diagnoses included, but were not limited to: cellulitis to the right leg, diabetes type 2, and end stage renal disease. A current Care plan, dated 5/7/2024 at 3:46 P.M., indicated the resident was receiving hemodialysis and was at risk for complications such as fluid imbalance, bleeding or infection due to a right jugular perma catheter. During an interview on 6/10/2024 at 10:05 A.M., CNA 3 indicated they had 3 residents on EBP. Resident 28 was not named. During an interview on 6/10/2024 at 10:27 A.M., the Director of Nursing indicted the resident had a porta cath (implanted port). The Regional Nurse Consultant indicated yes that is an indwelling catheter. 2. During an observation of a blood sugar check, on 6/6/2024 at 12:11 P.M.,with QMA 2, the following was observed: QMA 2 placed the glucometer (a device for obtaining a blood sugar level) on the bedside table without placing a barrier first. She then donned gloves. QMA 2 wiped the residents' finger with an alcohol pad, then with an opened hand fanned the area that had just been cleansed. She then obtained a blood sample. QMA 2 exited the resident's room with her gloves on, and went to the medication cart. She removed the gloves and threw away her trash. During an interview on 6/6/2024 at 11:56 A.M., QMA 2 indicated she should have used a barrier, not fanned the area, and removed her gloves prior to coming out of the room. 3. During an interview on 6/4/2024 at 9:46 A.M., Resident 6 indicated she had 2 catheters. The record for Resident 6 was reviewed on 6/5/2024 at 10:43 A.M. Resident 6's diagnoses included, but were not limited to Multiple Sclerosis, pressure ulcers stage 4 sacral region, left buttocks, right buttocks, and neuromuscular dysfunction of bladder. A Quarterly MDS (Minimum Data Set) Assessment, dated 3/28/2024, indicated the resident required total assist of 2 staff for bed mobility, transfers, and toilet use. A Care Plan, dated 5/6/2024, indicated the resident required a suprapubic (SP) urinary catheter and also had a Foley indwelling catheter due to: diagnosis of neuromuscular dysfunction of bladder. The resident had an indwelling Foley catheter placed upon return to the facility due to leakage of the SP catheter to keep urine off of her wounds to her bottom. On 6/7/2024 at 1:40 P.M., CNA 5 was observed to provide catheter care to Resident 6. The aide put her supplies on the over-the-bed table. She then washed her hands, applied a gown and gloves and filled the water basins with water. She then completed the washing, rinsing and drying of the catheter tube and the peri area. With the same gloves on, CNA 5 then rearranged the residents legs, moved a pillow, used the bed controls and then rearranged the sheet over the resident. During an interview, on 6/7/2024 at 2:02 P.M., CNA 5 indicated she knew she should have washed her hands and changed her gloves after completing peri and catheter care. 4. During an observation on 6/4/2024 at 11:11 A.M., Resident 13 was observed to have an urinary catheter drainage tube with a large amount of sediment in the tubing. The record for Resident 13 was reviewed on 6/5/2024 at 2:36 P.M. Resident 13's diagnoses included, but were not limited to: diabetes, neuromuscular dysfunction of bladder, and intellectual disabilities. A Quarterly MDS (Minimum Data Set) Assessment, dated 3/22/2024, indicated the resident required extensive assist of 1 staff for bed mobility, transfers, and extensive assist for 2 staff for toilet use, and had an indwelling urinary catheter. A current Care Plan, dated 5/4/2023, indicated the resident required an indwelling urinary catheter due to neuromuscular dysfunction of the bladder. Interventions included,, but were not limited to: Do not allow the tubing or any part of the drainage system to touch the floor. Store the collection bag inside a protective dignity pouch. During an observation, on 6/6/2024 at 10:29 A.M., Resident 13's catheter drainage bag was uncovered with the catheter tubing on the floor. During an observation, on 6/6/2024 at 12: 15 P.M., Resident 13's catheter tubing was on the floor. During an observation, on 06/6/2024 at 1:14 P.M., Resident 13's catheter tubing was on the floor. During an observation, on 6/6/2024 at 3:16 P.M., Resident 13's catheter tubing was on the floor. During an observation, on 6/7/2024 at 2:06 P.M., Resident 13's catheter tubing was on the floor. During an interview, on 6/7/2024 at 3:25 P.M., the Director of Nursing indicated the catheter tubing should have been off the floor. During an observation, on 6/10/2024 at 10:16 A.M., Resident 13's catheter tubing was on the floor. On 6/10/2024 at 1:36 P.M., the Regional Nurse Consultant provided the policy tithed,Shared Glucometer Cleaning and Disinfecting, dated 1/2024, and indicated the policy was the one currently used by the facility. The policy indicated . 2. Throughout thee procedure, perform appropriate hand hygiene. c. Perform hand hygiene immediately after removal of gloves and before touching other medical supplies intended for use on other residents On 6/10/024 at 1:36 P.M., the Regional Nurse Consultant provided a Skills Competency- Title:Catheter Care (Urinary), dated 5/2023, and indicated the policy was the one currently used by the facility. The policy indicated .17. Remove gloves. 18. Perform hand hygiene. 19. Dispose of soiled linen properly. 20. Perform hand hygiene On 6/10/2024 at 1:30 P.M. the Regional Nurse Consultant provided the policy titled,Bowel and Bladder Program, dated 5/2019. The policy did not address the catheter tubing and or drainage bag placement.

Based on record review and interview, the facility failed to provide a transfer/discharge form for 2 of 2 residents reviewed for hospitalization s. (Residents 11 & 1) Findings include: 1. A record review for Resident 11 was completed on 6/6/2024 at 9:49 A.M. Diagnoses included, but were not limited to, sepsis, Alzheimer's disease, and cerebral infarction (stroke). A Nurse's Note, dated 5/28/2024 at 5:59 P.M., indicated Resident 11 refused to eat or drink. She had eaten one bite of pureed food, and refused to swallow which allowed food to run out of her mouth. Vital signs included: blood pressure 100/48 mmHg (millimeters of mercury), pulse 102 beats per minute, respirations 20 per minute, and temperature 98.9 Fahrenheit. The physician was notified, and he indicated the resident's Power of Attorney (POA) wanted Resident 11 sent to the hospital. During an interview, on 6/10/2024 at 10:18 A.M., the Director of Nursing (DON) indicated the transfer/discharge form was part of the Hospital-ER Transfer Form under the Observation tab of the electronic health record. She indicated the form should have been completed when a resident was transferred from the facility. The form, Hospital-ER Transfer Form could not be found in the electronic medical record for Resident 11. 2. A record review for Resident 1 was completed on 6/5/2024 at 10:37 A.M. Diagnoses included, but were not limited to, nondisplaced intertrochanteric fracture of right femur, hemiplegia and hemiparesis following CVA (stroke), and osteoporosis. A Nurse's Note, dated 4/13/2024 at 11:00 P.M., indicated Resident 1 was helped with a transfer when she stumbled and spun around, falling on her buttocks. Resident 1 complained of right hip and back pain. The physician was notified, and an order was obtained to send Resident 1 to the emergency department. A Nurse's Note, dated 4/14/2024 at 2:00 A.M., indicated Resident 1 was admitted to the hospital. During an interview, on 6/10/2024 at 10:18 A.M., the Director of Nursing (DON) indicated that the transfer/discharge form was part of the Hospital-ER Transfer Form under the Observation tab of the electronic health record. She indicated the form should be completed when a resident is transferred from the facility. The form, Hospital-ER Transfer Form, dated 4/13/2024 at 11:00 P.M., indicated the resident or resident representative was not provided the transfer/discharge form. A form titled, Notice of Transfer or Discharge was provided by the Regional Nurse Consultant on 6/10/2024 at 12:49 P.M. A policy was not attached to the form. 3.1-12(a)(6)(A)

Based on record review and interview, the facility failed to provide the bed hold policy for 2 of 2 residents reviewed for hospitalization s. (Residents 11 & 1) Findings include: 1. A record review for Resident 11 was completed on 6/6/2024 at 9:49 A.M. Diagnoses included, but were not limited to, sepsis, Alzheimer's disease, and cerebral infarction. A Nurse's Note, dated 5/28/2024 at 5:59 P.M., indicated Resident 11 refused to eat or drink. She had eaten one bite of pureed food and refused to swallow, which allowed food to run out of the her mouth. Vital signs included: blood pressure 100/48 mmHg (millimeters of mercury), pulse 102 beats per minute, respirations 20 per minute, and temperature 98.9 Fahrenheit. The physician was notified, and he indicated the Resident's Power of Attorney (POA) wanted Resident 11 sent to the hospital. During an interview, on 6/10/2024 at 10:18 A.M., the Director of Nursing (DON) indicated that the bed hold policy was part of the Hospital-ER Transfer Form under the Observation tab of the electronic health record. She indicated the policy should be completed when a resident is transferred or discharged from the facility. The form, Hospital-ER Transfer Form could not be found in the electronic medical record for Resident 11. 2. A record review for Resident 1 was completed on 6/5/2024 at 10:37 A.M. Diagnoses included, but were not limited to, nondisplaced intertrochanteric fracture of right femur, hemiplegia and hemiparesis following CVA (stroke), and osteoporosis. A Nurse's Note, dated 4/13/2024 at 11:00 P.M., indicated Resident 1 was helped with a transfer when she stumbled and spun around, falling on her buttocks. Resident 1 complained of right hip and back pain. The physician was notified, and an order was obtained to send Resident 1 to the emergency department. A Nurse's Note, dated 4/14/2024 at 2:00 A.M., indicated Resident 1 was admitted to the hospital. During an interview, on 6/10/2024 at 10:18 A.M., the Director of Nursing (DON) indicated the bed hold policy was part of the Hospital-ER Transfer Form under the Observation tab of the electronic health record. She indicated the policy should be completed when a resident was transferred or discharged from the facility. The form, Hospital-ER Transfer Form, dated 4/13/2024 at 11:00 P.M., indicated neither the resident nor the resident's representative was provided with a copy of the bed hold policy. A policy was provided on, 6/10/2024 at 12:49 P.M. by the Regional Nurse Consultant. The policy titled, Bed Hold, indicated, .If a private pay resident leaves the facility for a temporary stay in an acute hospital or elsewhere for a medical therapeutic leave, the resident or resident's responsible party may request the facility to hold open the resident's bed during the absence by paying the full daily rate. If a Medicare/Medicaid resident leaves the facility for a temporary stay in an acute hospital or elsewhere for a medical therapeutic leave, the bed will be held .2. The residents will be provided the bed hold policy at the time of the hospital transfer or therapeutic leave. 3. The Resident's Representative will be informed of the bed hold policy at the time of notification of the transfer. The Resident's Representative will be provided a copy of the bed hold policy. 4. The staff will document the notification to thee resident and resident representative of the bed hold policy on the Emergency Resident Transfer Form 3.1-12(a)(25)(A)

Based on observation, record review, and interview, the facility failed to properly store a Bi-Pap (bi-level positive airway pressure) mask for 1 of 1 resident reviewed for oxygen/respiratory equipment. (Resident 131) Finding includes: A record review for Resident 131 was completed, on 6/5/2024 at 1:08 P.M. Diagnoses included, but were not limited to, pulmonary hypertension, chronic obstructive pulmonary disease (COPD), and obstructive sleep apnea. During an observation, on 6/4/2024 at 9:35 A.M., Resident 131's Bi-Pap mask was observed on the floor under the bed. A Physician's Order, dated 5/31/2024, indicated Bi-Pap on at bedtime and off upon waking. A Care Plan, dated 6/3/2024, indicated Resident 131 had the potential for impaired gas exchange related to pulmonary hypertension and COPD. The goal indicated Resident 131 would have adequate respiratory functions as evidenced by decreased or absence of dyspnea, improved breath sounds, decreased or absence of shortness of breath, and improved oxygen saturation results. The care plan did not address the use of the Bi-Pap. During an interview, on 6/10/2024 at 10:17 A.M., the Director of Nursing (DON) indicated the Bi-Pap mask should be stored in a respiratory bag when not in use. A policy was provided on, 6/102024 at 12:49 P.M. by the Regional Nurse Consultant. The policy titled, Bi-Level Therapy. The policy did not address the storage of the mask when not in use. 3.1-47(a)(6)

Based on record review and interview, the facility failed to effectively treat a resident's pain for 14 days and failed to notify the physician of the residents' continued complaint of pain and after receiving results of an x-ray that revealed the resident had a spiral fracture of the left leg for 1 of 3 residents reviewed for notification. (Resident B) Finding includes: A record review was completed, on 5/4/2023 at 9:44 A.M. Resident B's diagnoses included, but were not limited to hypertension, hemiplegia, cerebral vascular accident, dementia, and a spiral fracture of the left leg. An Annual MDS (Minimum Data Set) Assessment, dated 3/20/2023, indicated the resident required extensive assist of 2 staff for bed mobility, total assist of 2 staff for dressing, toilet use and transferred via Hoyer lift and had limitation in range of motion to both upper and lower extremities to the left side. A care plan, revised on 5/1/2023, indicated the resident was at risk to experience pain related to diagnoses of heart failure, hypertension, diaphragmatic hernia, and fractured left femur. Interventions included, but were not limited to pain assessments done quarterly, annually and with any significant change, and as needed. Staff to report to MD if new pain or worsening pain, and staff to monitor for signs and symptoms of nonverbal pain. Resident B's current Physician Orders, dated 2/23/2023, included Acetaminophen (analgesic) 325 mg (milligrams) 2 tablets every 6 hours as needed for unspecified abnormalities of gait and mobility. A MAR (Medication Administration Record), dated April 2023, indicated Resident B had received Acetaminophen 4/13/2023 for pain which was effective and on 4/18/2023 with somewhat effective. A Physician's Progress Note, dated 4/13/2023, indicated the resident had been seen for possible pain in the leg. The skin looked good and there was no erythema (redness) or tenderness. Leg edema is better with no infection noted. A Nurse's Note, dated 4/14/2023 at 4:48 P.M., indicated a new order per (name of doctor) received for Colchicine(anti- inflammatory) 0.6 mg (milligrams) twice daily for 14 days related to signs and symptoms of gout in the left leg. Resident B continued to complain of increased pain in left leg. Routine Tylenol continues and appears to help a bit. A Nurse's Note, dated 4/15/2023 at 11:59 A.M., indicated the resident continued to complain of pain to the left leg. A Nurse's Note, dated 4/16/2023 at 11:15 A.M., indicated the resident continued to complain of pain with movement. PROM (Passive Range of Motion) performed without difficulty. A Nurse's Note, dated 4/16/2023 at 3:29 P.M., indicated the Colchicine continued per order. Resident B continued to complain of left leg pain, mostly with movement. The resident has wanted to stay in bed the past few days related to complaints of pain. The resident was positioned every 2 hours and as needed. Nursing continuing to monitor effectiveness of new medication. A Nurse's Note, dated 4/17/2023 at 5:31 P.M., indicated the resident continued to complain of pain with movement. A Nurse's Note, dated 4/18/2023 at 1:02 P.M., indicated the resident continued to complain of pain with movement. PROM performed without difficulty. A Nurse's Note, dated 4/19/2023 at 12:45 P.M., indicated Resident B complained of knee pain when moved. A Nurse's Note, dated 4/19/2023 at 9:32 P.M., indicated the resident continued to complain of pain and discomfort with movement. Bilateral ankles continue to be swollen. Bilateral lower extremities elevated while in bed with pillows. A Nurse's Note, dated 4/20/2023 at 10:01 A.M., indicated the resident continued to complain of pain and discomfort with movement. Bilateral ankles continue to be swollen. Bilateral lower extremities elevated while in bed with pillows. A Physician Progress Note, dated 4/20/2023 at 5:51 P.M., and recorded as a late entry on 4/27/2023 at 5:53 P.M., indicated the physician saw the resident and she had no signs of pain on moving the legs, but thin legs likely from osteoporosis. Not in distress. Resident likely has osteoporosis. A Nurse's Note, dated 4/20/2023 at 8:24 P.M., indicated Resident B continues to complain of pain and discomfort during transferring. Bilateral ankles continue to be swollen with +1 pitting edema. The resident requested to stay in bed because of pain. The resident was encouraged to get out of bed. A Nurse's Note, dated 4/21/2023 at 12:17 A.M., indicated the resident had complained of pain when she had knee movement. A Nurse's Note, dated 4/22/2023 at 3:06 A.M., indicated the resident continued to complain of left leg pain with movement. Resident B was positioned every 2 hours and PRN (as needed). Nursing continuing to monitor effectiveness of this medication and pain level. A Nurse's Note, dated 4/22/2023 at 11:49 P.M., indicated the resident yells out when moved. A Nurse's Note, dated 4/23/2023 at 1:55 P.M., indicated the resident's left knee and leg were swollen, very painful with ROM (range of motion), outer extension/rotation noted at knee bend. The resident was crying out when moved. The Physician was notified and order for a STAT (Immediately) x ray. A Nurse's Note, dated 4/2320/23 at 8:08 P.M., indicated waiting on the mobile x-ray company to come do the x-ray of the left knee. The resident continued to cry out in pain with even the slightest movement of the left leg. A Nurse's Note, dated 4/23/2023 at 9:43 P.M., indicated the x-ray company called and informed the facility that they would not be here until 4/24/2023 to do the knee x-ray. A Nurses Note, dated 4/24/2023 at 9:11 A.M., indicated the x-ray was obtained and showed a left femur fracture. The physician was notified, and order received to send to the ER for evaluation and treatment. During an interview, on 5/4/2023 at 3:04 P.M., CNA 6 indicated the week before she was sent to the hospital, she had complained of her left leg hurting. The pain occurred mainly when she was rolled over in bed and or when using the Hoyer lift. During an interview, on 5/4/2023 at 3:12 P.M., LPN 4 indicated they had been treating the resident for gout. She indicated that the resident had complained of pain, one of the nurses had talked to him about the pain and the doctor stated that gout was painful and has flare ups, it comes and goes and he would see the resident again in a few days. LPN 4 indicated a nurse had called her, on 4/23/2023, and expressed concern about the pain, so she instructed the nurse to reach out to the MD one more time. LPN 4 indicated it was her understanding that the physician was notified from the time they had treated the resident for gout to when they had the x-ray done, but it was not documented. During an interview, on 5/5/2023 at 3:13 P.M., CNA 5 indicated Resident B had been complaining of pain when she was moved and had informed the nurse when the resident had complained of pain. On 5/5/2023 at 10:00 A.M., the Corporate Nurse provided the policy titled,Resident Change in Condition Policy, dated 11/2018, and indicated the policy was the one currently used by the facility. The policy indicated .It is the policy of this facility that all changes in resident condition will be communicated to the physician and family/responsible party, and that appropriate, timely, and effective interventions takes place. 3.a. All symptoms and unusual signs will be documented in the medical record and communicated to the attending physician promptly . b. The nurse in charge is responsible for notification of physician and family/responsible party prior to end of assigned shift when a significant change in the residents condition is noted. c. If unable to reach the physician or family/responsible party, all calls to physician or exchanges and family/responsible party requesting callbacks will be documented in th medical record . f. Document resident change of condition and response in the medical record. Documentation will include time and family/physician response On 5/5/2023 at 10:00 A.M., the Corporate Nurse provided the policy titled,Pain Management Policy, dated 4/2023, and indicated the policy was the one currently used by the facility. The policy indicated .It is the policy of [name of company] to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing, including pain management . 4. Non- Interviewable Resident- Pain medications will be prescribed and given based upon nursing assessment of the following. NON VERBAL SOUNDS (crying, whining, gasping, moaning, or groaning) VOCAL COMPLAINTS OF PAIN (that hurts, ouch, stop) . 5. The physician will be notified of unrelieved or worsening pain The past non-compliance began on 4/14/2023. The tag was removed and the deficient practice corrected on 4/28/2023 after the facility implemented a systemic plan that included the following actions: in-serving education to Licensed nurses related to physician notification for unresolved pain/worsening pain, giving as needed pain medication when showing signs of pain and requesting new pain medications, notification to the physician for any delay in obtaining an x-ray, education on thorough assessments with changes in condition, education on Pain Management Policy, Change of Condition Policy, and SBAR with any change of condition guidelines, CNA's skills validation check off in using a Hoyer lift with the observations of staff participating in transfers and ongoing monitoring. This Federal tag relates to complaint IN00407220. 3.1-5(a)(2)

Based on record review and interview, the facility failed to have 8 consecutive hours of RN coverage in the facility. This deficient practice affected 31 of 31 Residents who resided in the facility. Finding includes: During an interview, on 4/20/2023 at 2:47 P.M., the Director of Nursing indicated they staff the day and evening shifts with one nurse, one QMA and 3 aides and on the night shift 1 nurse and 2 aides. The DON indicated if the facility were without RN coverage, she would be the one to come in and cover the shift. The PBJ staffing data report dated January, February and March 2023 indicated the facility did not have 8 hours of RN coverage on the following dates: 1/21, 1/22, and 1/27/2023; 2/4 only 1.03 hours covered, 2/5 only 1.4 hours covered, 2/18, and 2/19, 3/4, 3/5, 3/18, 3/19 and 2 hours covered on 3/26/2023. During an interview, on 4/21/2023 at 11:29 A.M., the Administrator indicated the Director of Nursing had not worked the above dates for R.N coverage. During an interview, on 4/21/2023 at 11:30 A.M., the Administrator and Business office manager indicated there should have been 8 hours of RN coverage on the above documented dates. On 4/21/2023 at 4:18 P.M. the Administrator indicated she had no policy on RN coverage. 3.1-17(b)(3)

Based on observation, interview and record review, the facility failed to ensure medications were labeled, dated when opened, and failed to provide a clean medication cart for 1 of 1 medication carts observed. (Front Hall Medication Cart) Finding includes: During a medication storage observation with LPN 3, on 4/21/2023 at 11:02 A.M., the following was observed: An opened and undated bottle of Milk of Magnesia for Resident 1. An opened and undated bottle of liquid Docusate Sodium for Resident 11. An opened and undated bottle of Mucinex D for Resident 5. An an opened bottle of fiber well gummies and an opened bottle of Centrum Silver vitamins with no resident labels. Three of the four drawers had a white powdery and gritty substance along the back edges of the drawers. During an interview, on 4/21/2023 at 11:14 A.M., LPN 3 indicated the medications's should have been labeled and dated when opened, and the medication cart needed to be cleaned. On 4/21/2023 at 12:03 P.M., the Administrator provided the policy titled,Storage and Expiration Dating of Medications, Biological's, with a revision date of 7/21/2022, and indicated the policy was the one currently used by the facility. The policy indicated . 5.1 Facility staff may record the calculated expiration date based on date opened on the medication container A policy was requested for labeling medications and medication cart cleaning, on 4/21/2023, but none were provided. 3.1-25(j)

Based on record review and interview, the facility failed to notify the local Ombudsman of a discharged resident for 1 of 2 residents reviewed for discharge. (Resident 29) A record review for Resident 29 was completed on 11/17/21 at 9:17 A.M. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An Admission MDS (Minimum Data Set) assessment, dated 6/28/21, indicated Resident 29 was expected to stay in this facility and did not want to speak with anyone about returning to the community. A Nurses' Note, dated 06/21/2021 at 1:18 P.M., indicated Resident 29 admitted to the facility as a long-term admission. A Care Plan on 6/28/21 indicated, My family and I wish for me to remain in the facility and age in place for as long as my needs can be met here. A Nurses' Note, dated 9/21/2021 at 3:58 P.M., indicated the Social Service Director, spoke with resident about discharging and resident explained that she was sad because she likes it here and enjoys all of the staff, but that her daughter works at the [receiving facility]. A Nurses' Note, dated 09/23/2021 at 8:31 A.M., indicated Resident 29 discharged to another long-term care facility via car accompanied by Daughter On 11/17/21 at 2:21 P.M., the Administrator provided the discharge summary, and information given to the receiving facility. The administrator also provided the discharge/admission summary report. There was no confirmation attached that the Ombudsman had been notified. During an interview on 11/17/21 at 3:36 P.M., the Administrator indicated in October, the September discharge list was faxed to the ombudsman but could not provide a conformation of the fax being sent. The Administrator then indicated in November, the discharge list for September and October were emailed. The Administrator could not provide confirmation of the email sent to the Ombudsman. On 11/17/21 at 4:05 P.M., a policy entitled, Interfacility Transfers/Discharges, was provided by the Dietary Manager. The policy indicated, .7. The Notice of Transfer/Discharge will be disturbed to: .The local long-term care ombudsman program 3.1-12(a)(6)(A)

Based on record review, observation and interview, the facility failed to submit a Level II PASARR evaluation as indicated for 1 of 1 residents reviewed for PASARR. (Resident 18) Finding includes: Resident 18 received a Level I PASARR Assessment on 10/9/2017 indicating there was no serious mental illness. The clinical record indicated a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A Care Plan, dated 10/8/2018, indicated dementia and altered mental status with bouts of confusion related to these Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Intervention, dated 11/09/2020, indicated to provide reassurance and support if the resident spoke of hallucinations or delusional thoughts and offer a change of environment such as assisting the resident out of her room to the dining room. A Care Plan, dated 12/22/20, indicated the resident was on caseload with (Provider name). Consult with psych as needed and include psych in the behavior/psych med reviews. Progress Notes, dated 6/5/21, indicated Resident 18 had occasional hallucinations and yelling. Progress Notes, dated 6/7/21, indicated psych nurse present. No new recommendations given at this time. Continues with medication at current doses. No new behaviors or adverse effects noted. Will continue to monitor. Progress Notes, dated 6/12/21, indicated Resident 18 was having some delusions or hallucinations. Progress Notes, dated 6/15/21, indicated Resident 18 was having some delusions or hallucinations. Progress Notes, dated 6/17/21 at 7:23 p.m., indicate Resident 18 refused to talk today but urine is very concentrated consistent with dehydration. Progress Notes, dated 7/1/21 at 10:58 p.m. (Recorded as Late Entry on 7/14/21 at 4:01 p.m.), indicated Resident 18 continued with confusion and with some delusions. The resident was able to answer questions appropriately when asked. Progress Notes, dated 8/23/21, indicated FOLLOW-UP dementia, hallucinations, depression Staff report moods are at baseline; no new behaviors. Progress Notes, dated 10/15/21, indicated the reason for visit: FOLLOW-UP dementia, hallucinations, depression . HPI: Resident to be seen for psychiatric assessment of dementia, During an interview with the Social Service Director (SSD) on 11/18/21 at 3:58 p.m., regarding if there was a submission for Level II PASARR evaluation 12/29/2020 and 6/2/2021 for [CONDITION(S)] diagnoses, she indicated she had to look into when the submission happened. Follow up interview with the SSD on 11/19/21 at 9:19 a.m. indicated the PASARR was completed, being reviewed on the online (Program name), and it was not submitted until 11/18/21. Interview with the Nurse consultant on 11/19/21 at 12:50 PM, indicated there was not a policy for PASARR.

Based on interview and record review, the facility failed to follow physician orders [REDACTED]. (Resident #32) Finding includes: A clinical record review was conducted on 6/15/2017 at 10:30 A.M., and indicated his [DIAGNOSES REDACTED]. A MDS (minimum data set) assessment, dated 3/16/2017, indicated Resident #32's BIMS (brief interview of mental status) score was 13, which indicated he was cognitively intact. An admission orders [REDACTED]. A form titled POWER CATHETER, indicated Resident #32 was ordered to have a [MEDICATION NAME] lock 2.5 ml (milliliters) to follow a NS (normal saline) flush and to [MEDICATION NAME] (inject [MEDICATION NAME] into the PICC line after use) all locked lumens (actual PICC line) at least every 12 hours. A medication list from the discharging hospital resident had been transferred from, indicated Resident #32 was ordered to have a [MEDICATION NAME] lock flush 25 units as needed and a [MEDICATION NAME] lock flush every 12 hours. A review of Resident #32's MAR (medication administration record), indicated a physician order, .[MEDICATION NAME] Lock Flush Solution Use 2.5 ml intravenously (into the PICC line) every 12 hours as needed for 10U/ml (units/milliliter) flush if no continuous fluids infusing. [MEDICATION NAME] all locked lumans at least every 12 hours -Start Date- 02/18/2017 0645 -D/C Date- 03/09/2017 1343 The MAR indicated [REDACTED]. A physician order, dated 2/21/2017, indicated the discontinuation of the [MEDICATION NAME] flush orders. A PICC care plan for Resident #32, dated 2/20/2017, indicated staff was to: .Administer my medications as ordered by my doctor, Flushes as ordered by MD, Monitor for abnormalities/complications (infection, dislodgement, difficulty flushing). Notify MD if noted A review of progress notes indicated on 2/18/2017, the residents PICC line had no warmth, redness, or [MEDICAL CONDITION]. On 2/20/2017 the PICC line was patent. On 2/21/2017, the PICC line was without signs or symptoms of infection, on 2/23/2017 the PICC was patent with no signs or symptoms of infection or infiltration. A health status note, dated 2/22/2017, indicated Resident #32 had a trace amount of [MEDICAL CONDITION] noted to hands. A health status note, dated 2/24/2017, indicated Resident #32 had a clogged PICC line. A health status note, dated 2/24/2017, indicated Resident #32 had slight [MEDICAL CONDITION] noted to his right arm. A health status note, dated 2/24/2017, indicated an order was given for Cathflo (a medication used to unclog PICC lines), given to Resident, and his PICC was unclogged. A health status note, dated 2/25/2017, indicated Resident #32's upper right arm was slightly [MEDICAL CONDITION] and indicated the resident voicing complaints of tenderness to the area and was medicated for pain. No documentation noted to indicate physician notification of the significant change. A health status note, dated 2/26/2017, indicated Resident #32 had some [MEDICAL CONDITION] noted to his bilateral hands, a trace amount of [MEDICAL CONDITION] to his right arm in elbow area, and tissue surrounding PICC is pink and slightly warm to touch. No documentation noted to indicate physician notification of the significant change. A health status note, dated 2/27/2017, indicated Resident #32 had some warmth and [MEDICAL CONDITION] noted to the PICC area. A health status note, dated 2/27/2017, indicated a family member called the facility and indicated Resident #32 was at an emergency room with a blood clot in his upper right arm. A Complex Progress Note: dated 2/27/2017, indicated Resident #32 was seen at a local hospital. The note indicated .PICC line in the right upper extremity for long-term IV antibiotics, was seen at Infectious Disease office today and had complaints of right upper extremity pain, swelling, and redness and was sent for an ultrasound, which showed a right upper extremity [MEDICAL CONDITION] ([MEDICAL CONDITION] During an interview, on 6/15/2017 at 1:36 P.M., MDS nurse indicated staff had sent Resident #32 to a scheduled physician appointment and from there he went to the hospital due to a blood clot in his right arm, from his PICC line. During an interview, on 6/16/2017 at 2:30 P.M., Corporate nurse indicated Resident #32 was ordered to have a [MEDICATION NAME] flush every 12 hours and as needed and it was not administered and indicated the physician should be contacted when there is a significant change. A policy was provided by administration, on 6/14/2017 at 12:34 P.M., titled CENTRAL VENOUS CATHETER PROCEDURES, undated, and indicated this was the policy currently used by the facility. The policy indicated .If there is an order for [REDACTED]. 3.1-47(a)(2)

Based on record review and interview, the facility failed to supervise a resident to prevent falls resulting in skin tears and hematomas for 1 of 5 residents with falls in a sample of 7. (Resident B). At the time of one fall, Resident B's chair alarm was not in place, and she was unsupervised. Injury from the fall required transfer to the emergency room for management of a subdermal scalp hematoma and shoulder contusion with pain. Finding include: Resident B's closed clinical record was reviewed on 5/25/11 at 11:30 A.M. Resident B's [DIAGNOSES REDACTED]. Resident B's quarterly MDS (Minimum Data Set) assessment, dated 3/17/11, indicated Resident B was severely impaired cognitively. The assessment indicated Resident B needed extensive assistance of two to transfer to and from her bed, chair, wheelchair, toilet, and to stand. The assessment indicated she needed extensive assistance of one person to walk. She was assessed as not steady, only able to stabilize with human assistance for balance when standing, walking, turning around and transferring from one surface to another surface, including toileting. She used a wheelchair or a walker while moving through the facility. The MDS indicated she had falls after she had been admitted to the facility, but she had no injuries. Resident B's April 2011 and May 2011 monthly rewritten orders indicated orders first written on 1/24/2011 for "Sensor pad while in bed. Check function every shift. Sensor pad while up in chair. Check function every shift." The "Fall Risk Assessment" completed on 3/26/11, 4/10/11, 5/12/11, and 5/16/11, indicated a total score of 23 on 3/26/11 and 22 on the last 3 dates. The key indicated "If the total score is '10' or greater, the resident is considered at HIGH RISK for potential falls. Interventions should be initiated immediately & the care plan updated." There was a care plan for the problem of "I am at increased risk for falls. I require a pressure alarm on my chair and on my bed" dated 11/10/2010 with additional hand written dates of 1/10/11 and 3/23/11. The interventions included, but were not limited to, "2. My room will be kept free from clutter. 3. My call light will be within reach. 4. My rollater walker will be kept in my reach. 5. I will call for assistance if needed. 8. My alarms will be checked each shift." On 3/7/11 additional interventions were added of "11. Fall Risk Assessment. 13. Lowered bed. 14. Non skid materials in chair. 19. 2 staff to assist to toilet. 20. Medicine changed." The nurses' notes indicated on 4/10/11 at 11:00 A.M. "Called to room as resident got up to get walker to go to bathroom. When reaching for walker, resident tripped on floor mat, falling into walker. Received 6 X 5 cm. (centimeter) Lt (light) purple raised area to (L) (left) forehead and 1.7 X 0.7 cm. skin tear to (L) forearm.... c/o slight headache. Neuro checks initiated... Sensor pad was on and alarming at the time. Then ambulated with assist to bathroom...." The incident/accident report dated 4/10/11 indicated "alarm sounding - resident walking to walker & tripped on floor mat causing her to fall into walker bumping head on walker receiving 6 X 5 cm. raised area to (L) forehead and 1.7 X 0.7 cm skin tear to (L) forearm. No other injuries noted at this time able to move extremities per usual...." The section for "Additional comments and/steps to prevent re-occurrence:" was blank. The fall investigation report dated 4/10/11 indicated the sensor pad alarm was in use and it sounded. The resident account of the incident was "getting walker to go to bathroom." The conclusion was the fall was caused by the resident "got up unassisted." The prevention was "pick up floor mat p (after) resident gets OObed (out of bed). During an interview with the LPN #1, on 5/25/11 at 3:00 P.M., who wrote the notes and did the initial assessment, she indicated Resident B had been sitting in her recliner at the foot of her bed, she got up and walked to the head of her roommate's bed where her walker was sitting. On her way she tripped on her roommate's mat on the floor. She indicated the roommate was in bed at the time. Resident B did not have a mat on the floor. She further indicated the floor mat had been taped to the floor. She did not know why Resident B's walker was on her roommate's side of the bed. She indicated Resident B was not always steady on her feet, even with the walker, and needed one person to walk with her. There were no new interventions added to the care plan after this fall. The nurses' notes indicated on 5/12/11 at 9:00 P.M., "Resident got self up to walk to room without informing staff. Resident fell backwards - hitting head - goose egg noted to back of head, Ice applied. Neuro checks initiated - within parameters for resident. Assisted up to feet - ambulated rest of way to bed.... send resident to (name) ER for evaluation & treat...." The ER history and physical for 5/12/11 indicated "Fall (without loss of consciousness) with resultant 3 cm left occipital parietal subdermal scalp hematoma and left shoulder contusion with mild pain.... Patient already is on a Duragesic patch for pain...." The incident/accident investigation indicated, "The alarm was not in use," and "forgot to put in chair." "Resident in front of the nurses' station eating snack. Got up and started walking to room. fell over backwards hitting head - goose egg - hematoma to back of head...." The "Additional comments and/or steps taken to prevent re-occurrence" section of the report indicated, "Make sure alarm on & functioning." The conclusion was "res was agitated & got up on own & fell ." The prevention was "Remind staff to use alarm even when transferred (Transfer alarm also)." During an interview with LPN #1, on 5/25/11 at 3:05 P.M., she indicated she had placed Resident B in her chair in front of the nurses' station and gave her a snack. LPN #1 was sitting at the desk charting, but when she looked up the resident was gone. She walked out of the nurses' station through the hall and around the corner, but when she got around the corner, Resident B was falling onto the floor. She said there was no alarm on the resident. The Administrator, who was listening to the interview, indicated this was "human error." The screen completed on 5/13/11 for physical therapy indicated, "Pt. didn't have chair alarm in place. Pt. not therapy appropriate." There were no new interventions added to the care plan after this fall. The nurses' notes indicated on 5/16/11 at 7:45 A.M., "Chair alarm sounding. When writer responded to alarm - found resident lying on floor in room (number) with head up against night stand. Voicing c/o headache. Noted to have 1.5 cm diameter raised area to back of head. Attempted to apply ice but resident refused." The incident/accident report dated 5/16/11 indicated "Alarm sounding - resident got up and ambulated to room (number) (the room next to hers). Found lying on back with head against night stand. 1.5 cm diameter raised area noted to back of head...." The section for "Additional comments and/or steps taken to prevent re-occurrence" was blank. The fall investigation report dated 5/16/11 indicated the resident's alarm was on and sounding. The conclusion of what caused the fall was "Res. continues to get up on own before staff can reach her." The section for "How will this incident be prevented from occurring again? had an intervention of "attempt to involve in more activities." During an interview with LPN #1 on 5/25/11 at 3:07 P.M., she indicated the resident had been sitting in her wheelchair in front of her room waiting to be taken to the Dining Room for breakfast. She said she was passing trays and the CNA's were in the back of the building on the other side when she heard Resident B's chair alarm, but by the time she was able to get to her, Resident B had walked from in front of her door into the next resident's room and had fallen. She indicated she did not know why the CNAs who had placed her in her wheelchair had not moved her to the dining room. There was a care plan for the problem of "I am at increased risk for falls. I require a pressure alarm on my chair and on my bed" had an a new intervention added on 5/16/11 of "Encourage & provide activities, magazines, pictures, snacks, drinks, etc." During interivew on 5/25/11 at 3:40 p.m., the DON indicated she thought the resident just needed to be busy to help prevent the falls. Review of the policy for "Fall Prevention Program" dated 11/02 with the latest revision date of 7/09 indicated "It is the policy of this facility to identify residents at risk for falls and to implement a fall prevention program to reduce the risk of falls and possible injury." The procedure included, but was not limited to, "...The Interdisciplinary Team (IDT) will review the resident's fall risk prevention plan no less often than quarterly, as part (sic) the care conference.... the plan will be reviewed and modified as needed, after each fall to make sure that the interventions are as current as possible....The DON will conduct the investigation and complete the back side of the Fall Investigation Report form....The DON will review the Fall Investigation Report with the Interdisciplinary Team at the next scheduled morning management meeting to develop a fall prevention plan, including the development of new interventions or revision of existing ones. If staff training is identified as a need, the training session(s) will be scheduled at that time...." This federal tag relates to Complaint IN 339. 3.1-45(a)(2)