Every finding on record at Homewood Health Campus

Based on observation, interview and record review, the facility failed to ensure fall interventions were in place according to the plan of care for 1 of 2 residents reviewed for accidents. (Resident 28)Findings include:1. During an observation, on 6/9/26 at 10:54 a.m., Resident 28 was sitting up in bed, and the head of the bed was elevated. A mattress was observed propped up between the wall, by the door and a recliner. During an interview, on 6/9/26 at 11:32 a.m., Resident 28 indicated he had fallen out of his bed. During an interview, on 6/9/26 at 11:38 a.m., LPN 1 indicated he was not sure if the fall mat needed to be on the floor when Resident 28 was in bed. The care plan was reviewed, and LPN 1 indicated the fall mat was to be on the floor when the resident was in bed.2. During an observation, on 6/11/26 at 10:04 a.m., Resident 28 was in a high back wheelchair in his room. A call light pad was observed on the sofa directly behind the resident. The resident attempted to reach the call light and indicated he could not find it. During an interview, on 6/11/26 at 10:21 a.m., the Assistant Director of Nursing indicated the call light was out of reach and it should be in the resident's reach.The clinical record for Resident 28 was reviewed on 6/11/26 at 10:33 a.m. The diagnoses included, but were not limited to, hypertension, Guillan-Barre Syndrome (a rare autoimmune disorder where the immune system mistakenly attacks the peripheral nerves), and type 2 diabetes. A fall note, dated 3/27/26, indicated the resident was found on the floor in his room.An interdisciplinary team note, dated 3/30/26, indicated the resident had an unwitnessed fall on 3/27/26 at 11:35 p.m. The resident rolled out of his bed and onto the floor. The intervention placed was for a mattress to be put on the floor when Resident 28 was in bed.A care plan, dated 3/3/26, indicated Resident 28 was at risk for falls. Interventions included but were not limited to, the call light was to be in reach, and a mattress was to be placed on the floor next to the bed when the bed was occupied by the resident. A current facility policy, titled Comprehensive Care Plan Guideline, dated as last reviewed 12/10/25 and received from the Clinical Support Nurse on 6/11/26 at 12:06 p.m., indicated, .To ensure appropriateness of services and communication that will meet the resident's needs, severity/stability of conditions, impairment, disability, or disease in accordance with state and federal guidelines 410 IAC (Indiana Administrative Code) 16.2-3.1-45(a)(2)

Based on observation, interview and record review, the facility failed to ensure Enhanced Barrier Precautions (EBP) were in place and followed for 3 of 5 residents reviewed for pressure ulcers (Residents H, F and G).Findings include:During a facility tour, on 9/9/25, with the Director of Health Services (DHS) and the Assistant Director of Health Services (ADHS), the following residents did not have Enhanced Barrier Precautions (EBP) in place and followed.1. Resident H had a dressing around his right great toe. The ADHS indicated the resident had a pressure ulcer to his right great toe. There were no Enhanced Barrier Precautions in place. When the DHS raised the resident's right foot to make it easier to see the dressing on his toe, she did not put on a gown prior to touching the resident's foot.The clinical record for Resident H was reviewed on 9/10/25 at 3:15 p.m. The diagnoses included, but were not limited to, type II diabetes mellitus, dementia, pulmonary fibrosis, major depressive disorder, and cognitive communitive disorder.A physician's order, dated 9/4/25, indicated Resident H's ulcer wound was to be cleaned with wound cleanser or normal saline, patted dry, then skin prep was to be applied to the peri-wound, and covered with a foam dressing.A physician's order for Enhanced Barrier Precautions was not entered until 9/9/25.There were no signs present in the room or on the door to alert staff Resident H required Enhanced Barrier Precautions.2. The DHS and ADHS stood Resident F up from her wheelchair and pulled her pants down, so her coccyx dressing could be observed. The DHS and ADHS did not put on a gown before having contact with the resident. There were no Enhanced Barrier Precautions in place.The clinical record for Resident F was reviewed on 9/10/25 at 3:30 p.m. The diagnoses included, but were not limited to, type II diabetes mellitus, cognitive communication deficit, pain, and osteoarthritis.A physician's order, dated 8/6/25, indicated Resident F's sacrum wound was to be cleansed with wound cleanser or normal saline, patted dry, skin prep applied to the peri-wound, then covered with a dry protective dressing every three days.A physician's order for Enhanced Barrier Precautions was not entered until 9/9/25.There were no signs present in the room or on the door to alert staff Resident F required Enhanced Barrier Precautions.3. Resident G had a left foot dressing observed to be dry and intact at 2:07 p.m. There were no Enhanced Barrier Precautions in place.The clinical record for Resident G was reviewed on 9/10/25 at 3:45 p.m. The diagnoses included, but were not limited to, type II diabetes mellitus, chronic kidney disease stage 3, cardiac pacemaker, and pressure-induced deep tissue damage of left heel.A physician's order, dated 9/8/25, indicated to cleanse the left heel wound with saline, pat dry, apply Betadine to the skin flap and surrounding tissue, then cover with bordered foam and heel foam and change daily.A physician's order for Enhanced Barrier Precautions was not entered until 9/9/25.There were no signs present in the room or on the door to alert staff Resident G required Enhanced Barrier Precautions.During an interview, on 9/9/25 at 2:07 p.m., the Assistant Director of Health Services indicated there should have been personal protective equipment (PPE) set up in the rooms and they should have had a physician's order for Enhanced Barrier Precautions.During an interview, on 9/9/25 at 3:14 p.m., the Director of Health Services indicated both herself and the Assistant Director of Health Services should have stopped and put on PPE prior to touching residents with wounds.A current facility policy, titled Enhanced Barrier Precautions (EBP) Standard Operating Procedure, dated 4/1/24 and provided by the Executive Director on 9/10/25 at 11:47 a.m., indicated .Guidance for enhanced barrier precautions (EBP) to decrease risk of becoming colonized and developing infections with multidrug-resistant organism (MDRO) status.Enhanced Barrier Precautions (EBP) will be in place during high-contact care activities for residents with the following conditions: a. Residents at an increased risk of MDRO acquisition which include: i. All residents with chronic wounds, including but not limited to, pressure ulcers, diabetic foot ulcers, unhealed surgical ulcers and venous stasis ulcers.Personal Protective Equipment (PPE) should be used even if blood and body fluid exposure is not anticipated. a. At a minimum, staff shall wear gloves and gown during high-contact care activities.This citation was related to Intake 2610362.3.1-18(b)(2)

3. During a resident council meeting, on 5/14/25 at 10:01 a.m., Resident 14 indicated the facility had an issue with the call light response, he indicated it was on and off. Resident 1 indicated she had rung the call light a bunch of times with no answer. The resident council meeting notes were reviewed, on 5/14/25, and indicated: a. The meeting note, dated 7/22/24, indicated concerns about call light response times. There were no further notes about call lights. b. The meeting note, dated 8/19/24, indicated all residents at the meeting were upset about the waiting time for the call lights and indicated some staff would come in, turn off the light, and not return. c. The meeting note, dated 10/22/24, indicated residents were concerned about call lights. There were no further notes about the call lights. d. The meeting note, dated 11/18/24, indicated residents had voiced concerns over the waiting time for call lights, and had indicated at times the wait was over an hour. It was noted all staff had been educated on answering call lights and everyone could answer the call light. e. The meeting note, dated 1/21/25, indicated residents had voiced concerns about call lights. There were no other notes found addressing call lights. f. The meeting note, dated 2/17/25, indicated residents voiced concerns over call light wait times. One resident indicated they had waited 25 minutes in the bathroom. It was noted staff were spoken to regarding waiting times and staff were educated to round and answer call lights in a timely manner. g. The meeting note, dated 3/17/25, indicated residents voiced concerns over call light waiting times. Some residents indicated they had waited over an hour. It was noted staff were educated on call light expectations and answering call lights in a timely manner. h. The meeting note, dated 4/21/25, indicated call light response times were worse between 2:00 p.m. and 6:00 p.m. It was noted staff were educated on the importance of answering call lights in an appropriate time frame. 4. During an observation, on 5/14/25 at 1:37 p.m., Resident 109 activated her call light to get assistance to lay down. The call light was responded to by CNA 9 on 5/14/25 at 1:43 p.m. The CNA was observed to enter the room, address the resident, and turn off the call light. The CNA did not assist the resident and instead, left the room. During an interview, on 5/14/25 at 1:44 p.m., CNA 9 indicated she was not supposed to turn off the light without taking care of the residents' needs. A current facility policy, titled On-Call (Clinical and Caregivers) Policy, last updated in February 2023 and received from Clinical Support 4 on 5/19/25 at 10:40 a.m., indicated .To deliver excellence in customer service, we must provide sufficient staff to meet the needs of our residents. The purpose of this policy is to provide guidance for efficient and orderly administration of the on-call policy .The on-call person will be required to come into the campus if there is a vacancy that has caused the campus to fall below their minimum staffing requirements .The person on-call must be available by phone and must be able to arrive at the campus within two (2) hours of a call .If a significant event or reportable occurs (e.g., abuse, misappropriation, elopement, significant injury, etc.) the ED and DHS/DPAS must be notified regardless of on-call status A facility document, titled Clinical In-Service, dated 4/2/25 and received from the Executive Director on 5/14/25 at 12:08 p.m., indicated .Call lights are to be answered by everyone, not just the aids A current facility policy, titled Guidelines for Answering Call Lights, dated as last reviewed on 12/14/24 and received from Executive Director on 5/14/25 at 12:08 a.m., indicated .Provide the service the resident requested and turn off the call light This citation relates to Complaints IN00454050, IN00455509, IN00458006, IN00458080 and IN00458258. 3.1-17(a) 3.1-17(b)(2) 3.1-17(c)(2) 3.1-17(d) Based on interview and record review, the facility failed to ensure sufficient qualified nursing staff were available to provide nursing and related services to the residents and a licensed staff member was available on-call to cover the staffing needs of the facility. This deficient practice had the potential to affect 92 of 92 residents who resided in the facility. Findings include: 1. A [NAME] Payroll Based Journal (PBJ) for the first quarter of 2025 indicated the facility had a 1-star staffing rating. 2. A nursing progress note, dated 4/19/25 at 2:30 a.m., indicated Licensed Practical Nurse (LPN) 12 heard an alarm sounding. A resident was at the end of the 200-hallway. LPN 12 ran to the end of the hallway. The resident opened the door and stepped outside. While trying to bring the resident back inside, the resident hit LPN 12 in the head with a glass vase full of water and flowers. The resident was brought back inside the facility. The Director of Nursing (DON), Executive Director (ED), Assistant Director of Nursing (ADON) was notified. LPN 12 was given an order from the ED to send the resident to the emergency room to be evaluated and treated. 911 was notified and the police and paramedics arrived to take the resident to the hospital. During an interview, on 5/12/25 at 2:58 p.m., LPN 12 indicated the resident did hit her in the head with a vase and she sustained a concussion. She contacted the DON, and they could not find any staff to cover her. She was the only licensed staff member in the building and no other licensed staff member came in to replace her all night. During an interview, on 5/16/25 at 10:25 a.m., the ED indicated she was aware of the incident, and she had asked the nurse to seek medical treatment immediately. They called to get the nurse a replacement. No other staff member came in to relieve LPN 12. The facility's back up plan was an on-call staff member would come in if something were to happen. The back-up staff were not able to come in. During an interview, on 5/16/25 at 10:56 a.m., the ED indicated the staff member on call the night of the incident was a Qualified Medical Assistant (QMA) and not a licensed staff member. They attempted to call the ADON. The DON lived out of state. The DON tried to make phone calls. They did not have a licensed staff on-call. The facility did not have a licensed nurse available to replace the licensed nurse who was hit on the head with a glass vase and was told to go seek medical attention.

Based on observation, interview and record review, the facility failed to ensure staff wore personal protective equipment (PPE) correctly, performed hand hygiene, and changed gloves for 2 of 2 randomly observed staff members reviewed for infection control. (QMA 10 and RN 7) Findings include: During an observation, on 5/15/25 at 1:17 p.m., RN 7 and QMA 10 tied PPE gowns at the back of their neck, neither staff member tied the gowns closed at their waist and entered Resident C's room. 1. QMA 10 with gloves on, cleaned Resident C's mouth with a toothette (an oral swab) and discard it. QMA 10 then moved the mechanical lift into place. She picked up the resident's catheter drainage system with her left gloved hand and attached the bag to the mechanical lift strap. She ensured the sling was properly connected to the mechanical lift and used the control to lift the resident. The resident was then lowered to the bed. QMA 10 removed the resident's hearing aids and put them onto the charger. She assisted the resident to turn onto her left side. QMA 10 was then observed to handle the resident's oxygen line/nasal cannula and place it on the resident. She was not observed to remove her gloves, perform hand hygiene, or apply new gloves. QMA 10 then assisted in removing the resident's pants. QMA 10 held the catheter bag and tubing to guide it through the resident's pant leg. QMA 10 was observed to handle the cleaning wipe packaging and remove a clean wipe for RN 7. QMA 10 retrieved another clean wipe from the package and handed it to the RN. After handing more wipes to RN 7, QMA 10 was then observed to remove her gloves. She indicated she needed to get washcloths and wash her hands with soap and water. During an interview, on 5/15/25 at 1:28 p.m., QMA 10 indicated she had not changed her gloves between the observed tasks. 2. During an observation, on 5/15/25 at 1:32 p.m., RN 7 used wipes to clean Resident C's bowel movement. She removed and discarded her gloves and put on a pair of clean gloves. She was not observed to have performed hand hygiene after removing her gloves or before applying new gloves. Resident C was then positioned for wound care to the left coccyx area. RN 7 was observed to clean the wound area with normal saline. She then wiped all around the surrounding area and then back to the wound. She repeated the process of cleaning the wound then the surrounding area including the wound area. During an interview, on 5/15/25 at 1:50 p.m., RN 7 indicated she should have cleaned the wound from the inside to the outside, their gowns should have been tied correctly, and gloves should have been changed after handling the catheter bag and in between tasks. During an interview, on 5/16/25 at 8:32 a.m., the Director of Nursing indicated wounds were to be cleaned from the inside to the outside. A current facility document, titled SEQUENCE FOR PUTTING ON PERSONAL PROTECTIVE EQUIPMENT (PPE), undated, and received from the Executive Director on 5/16/24 at 9:17 a.m., indicated .GOWN .fasten in back at neck and waist A current facility policy, titled Guidelines for Handwashing/Hand Hygiene, dated 12/17/24 and received from the Executive Director on 5/16/25 at 9:17 a.m., indicated .Health Care Workers .shall use hand hygiene at times such as .After removing gloves, worn per Standard Precautions for direct contact with excretions or secretions, mucous membranes, specimens, resident equipment, grossly soiled linen, etc This citation relates to Complaint IN00458080. 3.1-18(b)(2) 3.1-18(l)

Based on observation, interview and record review, the facility failed to ensure medications were labeled with pharmacy labels and the date the medications were opened in 2 of 2 medication carts reviewed for medication storage. (100 hall and 200 hall) Findings include: 1. The medication cart, on the 100-hall, was reviewed on 5/15/25 at 10:11 a.m. The following was observed: a. The first drawer contained an open bottle of Carbamide Peroxide 6.5% (ear drops). The medication was not labeled with the date it had been opened. b. The second drawer contained an open bottle of liquid Haloperidol (an antipsychotic medication). The bottle was half empty and was not labeled with the date the medication had been opened. During an interview, on 5/15/25 at 10:20 a.m., LPN 2 indicated the medications should have been labeled with the date they were opened. 2. The medication cart, on the 200-hall, was reviewed on 5/15/25 at 10:55 a.m. The following was observed in the top drawer: a. Spiriva (an inhalation spray), with a sticker, indicating the medication should be discarded 90 days after being opened. The medication was not labeled with the date it had been opened. b. Lispro (an insulin injection pen) without a pharmacy label. c. Lantus (an insulin injection pen) without a pharmacy label. During an interview, on 5/15/25 at 10:55 a.m., QMA 3 indicated the pharmacy labels must have fallen off the insulin injection pens, and all medications should be dated when they are opened. A current facility policy, titled Medication Storage in the Facility, dated 11/18 and received from the Executive Director on 5/16/25 at 9:57 a.m., indicated .Medications and biologicals are stored safely, securely, and properly, following manufacture's recommendations or those of the supplier .All medications dispensed by the pharmacy are stored in the container with the pharmacy label .When the original seal of a manufacturer's container or vial is initially broke, the container or vial will be dated .A [date opened] sticker shall be placed on the medication .The expiration date of the vial or container will be [(30)] days unless the manufacturer recommends another date or regulations/guidelines require different dating 3.1-25(j) 3.1-25(k)(1) 3.1-25(k)(2) 3.1-25(k)(3) 3.1-25(k)(4) 3.1-25(k)(5) 3.1-25(k)(6) 3.1-25(k)(7)

Based on interview and record review, the facility failed to ensure Abnormal Involuntary Movement Scale (AIMS) assessments were completed for evaluation of adverse reactions related to antipsychotic medications for 1 of 5 residents reviewed for unnecessary medications. (Resident 19) Findings include: The clinical record for Resident 19 was reviewed on 5/14/25 at 11:10 a.m. The diagnoses included, but were not limited to, psychosis not due to a substance or known physiological condition, dementia with psychotic disturbance, psychotic disorder with hallucinations due to a known physiological condition, delirium due to known physiological condition, major depressive disorder, anxiety disorder, auditory hallucinations, and visual hallucinations. A physician's order, dated 8/12/24, indicated to give olanzapine (an antipsychotic medication) 5 milligrams at bedtime. A psychiatry progress note, dated 9/23/24, indicated the resident was taking olanzapine and the last AIMS assessment was completed on 6/21/23. A care plan, dated 11/1/24, indicated Resident 19 was at risk for adverse consequences related to antipsychotic medications and to conduct an AIMS test per guidelines. During an interview, on 5/16/25 at 11:09 a.m., Clinical Support Nurse 4 indicated the facility could not find a documented AIMS assessment and one should have been conducted. A current facility policy, titled Guidelines for: Abnormal Involuntary Movement Scale, dated 12/17/24 and received from the Executive Director on 5/16/25 at 1:25 p.m., indicated .To assess residents that have prescribed antipsychotic medications to identify symptoms that may indicate the presence of Tardive Dyskinesia; a neurologic disorder characterized by abnormal involuntary movements which may occur .The AIMS assessment will be completed .at the earliest possible time; either after admission; after medications .are prescribed; and with dosage changes. 3. The AIMS assessment will be repeated .every six months 3.1-48(a)(3)

Based on observation, interview and record review, the facility failed to ensure physician's orders were obtained and followed for 2 of 2 residents reviewed for oxygen administration. (Resident C and 109) Findings include: 1. During an observation, on 5/12/25 at 12:16 p.m., Resident C was observed in the dining room with a portable oxygen tank set to administer two (2) liters per minute of oxygen via nasal cannula. During an observation, on 5/13/25 at 9:43 a.m., Resident C was in an activity with a portable oxygen tank set to administer two (2) liters per minute of oxygen via nasal cannula. During an interview, on 5/13/25 at 9:53 a.m., the Director of Nursing (DON) reviewed Resident C's physician's orders. She indicated Resident C was to receive four (4) liters per minute of oxygen and Resident C's tank was set at two (2) liters. During an observation, on 5/13/24 at 1:54 p.m., Resident C's oxygen was set at four (4) liters per nasal cannula. The clinical record for Resident C was reviewed on 5/14/25 at 10:45 a.m. The diagnoses included, but were not limited to, saddle embolus of the pulmonary artery with cor pulmonale (a clot at the bifurcation of the pulmonary artery which obstructed blood flow), pulmonary fibrosis, and atelectasis (part or full collapse of the lung). A care plan, dated 11/5/24, indicated the resident had the potential for cardiovascular distress and to administer oxygen per the order. A care plan, dated 11/5/24, indicated the resident had the potential for complications due to pulmonary fibrosis and to administer oxygen per the orders. A physician's order, dated 11/19/24, indicated to administer oxygen at four (4) liters per nasal cannula as needed to maintain saturation of 92 percent or greater. The order was noted to be discontinued and a new order for oxygen at two (2) liters was initiated on 5/13/25 at 12:17 p.m. 2. During an observation, on 5/12/25 at 2:12 p.m., Resident 109 was observed to receive supplemental oxygen set between 2.5 and 3 liters per minute via nasal cannula. During an observation, on 5/14/25 at 1:36 p.m., Resident 109 was observed with supplemental oxygen at three (3) liters per minute via nasal cannula. The clinical record for Resident 109 was reviewed on 5/14/25 at 9:47 a.m. The diagnoses included, but were not limited to, chronic respiratory failure, chronic lung disease, and emphysema. A care plan, dated 4/17/25, indicated the resident had a potential for functional and cognitive decline related to pulmonary fibrosis. An intervention indicated to administer oxygen per the physician's orders. A care plan, dated 4/17/25, indicated Resident 109 had the potential for shortness of breath while lying flat. An intervention indicated to administer oxygen per the physician's order and as needed. A physician's order, dated 4/17/25, indicated the resident had chronic lung disease to manage oxygen administration in coordination with the physician to prevent respiratory acidosis. Resident 109 did not have a physician's order which addressed how much oxygen the resident was to receive. A current facility policy, titled Administration of Oxygen, dated 12/13/24 and received from the Corporate Minimum Data Set (MDS) nurse, indicated .Verify physician's order This citation relates to Complaint IN00458258. 3.1-47(a)(6)

Based on interview and record review, the facility failed to ensure catheter urine output was accurately recorded as ordered for 1 of 1 resident reviewed for urinary catheters. (Resident 26) Findings include: The clinical record for Resident 26 was reviewed on 5/14/25 at 1:49 p.m. The diagnoses included, but were not limited to, sepsis, infection and inflammatory reaction due to indwelling urethral catheter, bacteremia, hematuria, obstructive and reflux uropathy, and retention of urine. A physician's order, dated 11/11/24, indicated to place an indwelling urinary catheter for obstructive and reflux uropathy. A physician's order, dated 1/26/24, indicated to monitor the catheter output three times a day. A physician's order, dated 7/31/24, indicated give 20 milligrams of Lasix (a diuretic medication) twice a day for edema (swelling). A facility document, dated 5/1/25 through 5/15/25, indicated the following: On 5/2/25 at 3:19 a.m., large was recorded. On 5/2/25 at 9:13 a.m., large was recorded. On 5/3/25 12:28 p.m., medium was recorded. On 5/3/25 10:22 p.m., large was recorded. On 5/4/25 12:04 p.m., medium was recorded. On 5/4/25 9:06 p.m., medium was recorded. On 5/5/25 12:57 p.m., large was recorded. On 5/5/25 8:00 p.m., large was recorded. On 5/5/25 9:57 p.m., large was recorded. On 5/6/25 at 1:08 a.m., large was recorded. On 5/6/25 at 12:56 p.m., medium was recorded. On 5/6/25 at 8:15 p.m., large was recorded. On 5/6/25 at 11:30 p.m., large was recorded. On 5/7/25 at 10:59 a.m., medium was recorded. On 5/7/25 at 2:22 p.m., medium was recorded. On 5/7/25 at 8:18 p.m., large was recorded. On 5/7/25 at 9:30 p.m., large was recorded. On 5/8/25 at 12:58 a.m., large was recorded. On 5/8/25 at 9:21 p.m., large was recorded. On 5/9/25 at 3:12 p.m., medium was recorded. On 5/9/25 at 9:31 p.m., large was recorded. On 5/10/25 at 3:17 p.m., large was recorded. On 5/10/25 at 11:36 p.m., large was recorded. On 5/11/25 at 1:35 p.m., medium was recorded. On 5/12/25 at 11:56 a.m., medium was recorded. On 5/13/25 at 10:39 a.m., medium was recorded. On 5/13/25 at 2:03 p.m., medium was recorded. On 5/13/25 at 10:06 p.m., medium was recorded. On 5/14/25 at 1:35 a.m., large was recorded. On 5/14/25 at 12:27 p.m., large was recorded. On 5/14/25 at 11:55 p.m., large was recorded. On 5/15/25 at 1:09 p.m., large was recorded. During an interview, on 5/15/25 at 10:39 a.m., Certified Nursing Assistant (CNA) 9 indicated the staff should use a urinal to measure the urine when emptying residents' catheters and then record the exact milliliter (ml) each shift in the medical record. During an interview, on 5/16/25 at 2:57 p.m., Clinical Support Nurse 4 indicated it was not acceptable to use the terms small, medium, or large for catheter output in the medical record. A current facility policy, titled Emptying Urinary Bag, dated 12/16/24 and received from Clinical Support Nurse 4 on 5/16/25 at 2:55 p.m., indicated .Assemble the equipment and supplies .Measuring container (calibrated) . Position the measuring container under the drainage bag .Measure and record the urinary output .The following information as applicable may be recorded in the resident's medical record .The amount of urine emptied from the drainage bag A current facility policy, titled Urinary Catheter Care, dated 12/16/24 and received from the Executive Director on 5/15/25 at 1:15 p.m., indicated .Observe the resident's urine level for noticeable increases or decreases .Maintain an accurate record of the resident's daily output 3.1-41(a)(2)

2. The clinical record for Resident 6 was reviewed on 5/15/25 at 12:56 p.m. The diagnoses included, but were not limited to, falls, chronic pain, and low back pain. An interdisciplinary team (IDT) note, dated 5/5/25 at 11:00 a.m., indicated Resident 6 was found lying on the floor in her room. She was more than two (2) feet from her bed. The bed was documented to be in a semi-low position. The resident had indicated to the staff she had rolled out of the bed. She was barefoot and laying on her right side. The root cause of the fall was related to the resident rolling from her bed. The intervention was to provide a perimeter mattress. A care plan, dated 9/13/24, indicated the resident was at risk for falling related to weakness. An intervention, initiated on 5/5/25, indicated .Perimeter mattress During an observation and interview, on 5/16/25 at 1:51 p.m., the Director of Nursing indicated the mattress on the bed of Resident 6 was not a perimeter mattress. The resident should have had a perimeter mattress as it was part of her fall precautions. During an interview, on 5/16/25 at 2:08 p.m., the Director of Nursing indicated the mattress had been moved to a different room during the remodeling of the resident's room. The mattress was not moved back to the resident's room after the remodel. It should have been moved back to her room with her. A current facility policy, titled Fall Management Program Guidelines, dated 12/17/24 and received from Clinical Support Nurse 4 on 5/19/25 at 10:40 a.m., indicated .The purpose of this policy is to .mitigate fall risk factors and implement preventative measures .Care plan interventions should be implemented .Any orders received from the physician should be noted and carried out This citation relates to Complaints IN00458006 and IN00458258. 3.1-45(a)(1) 3.1-45(a)(2) Based on observation, interview and record review, the facility failed to ensure a resident was transferred according to the plan of care to prevent a fall and a post fall parameter mattress intervention was in place for 2 of 8 residents reviewed for accidents. (Resident 2 and 6) Findings include: 1. The clinical record for Resident 2 was reviewed on 5/14/25 at 1:53 p.m. The diagnoses included, but were not limited to, age related osteoporosis, history of falling, and unspecified glaucoma. A physician's order, dated 6/4/24, indicated to use the sit-to-stand lift to transfer Resident 2 in and out of bed only per Resident 2's request and therapy approval. A current care plan, dated 10/10/24, indicated staff should use the sit-to-stand lift to transfer Resident 2 in and out of bed. A nursing progress note, dated 4/28/25 at 6:24 p.m., indicated an aide was assisting the resident into bed when the resident started to lose strength and balance. The resident was then assisted to the floor without further incident. No injury was noted. Additional staff were able to assist Resident 2 off the floor and into bed. An interdisciplinary team (IDT) note, dated 4/30/25 at 10:01 a.m., indicated the IDT team reviewed the incident, and it was found the staff did not use the sit-to-stand lift to transfer the resident to the bed. The root cause was the staff did not use the proper lift, and Resident 2 had an increased weakness. During an interview, on 5/15/25 at 10:34 a.m., the Director of Nursing (DON) indicated the staff should have used the sit-to-stand lift to transfer the resident in and out of bed. During an interview, on 5/15/25 at 10:42 a.m., the DON indicated the aide used the wrong transfer method. She was supposed to use the sit-to-stand lift. During an interview, on 5/16/25 at 11:45 a.m., the DON indicated they did not complete audits on the other residents to ensure they were receiving proper transfers.

Based on interview and record review, the facility failed to ensure staff obtained and documented a resident's vital signs prior to administering a medication with physician's ordered hold parameters for 1 of 1 resident reviewed for quality of care. (Resident 22) Findings include: The clinical record for Resident 22 was reviewed on 5/15/25 at 11:07 a.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease, type 2 diabetes mellitus with diabetic polyneuropathy and hypoglycemia, hypertension, cognitive communication deficit, edema, and bradycardia. A physician's order, dated 4/18/25, indicated to give metoprolol succinate (a medication which lowers blood pressure and heart rate) 25 milligrams once a day with special instructions to hold the medication for a heart rate of less than 55 or a systolic blood pressure less than 110. A physician's order, dated 4/18/25, indicated to obtain a blood pressure and heart rate reading twice a day for 7 days. A Medication Administration Record (MAR), dated April 2025, indicated Resident 22's vital signs were obtained as ordered 4/18/25 through 4/26/25. Metoprolol was given with a documented heart rate of less than 55 on the following dates: On 4/19/25, with a heart rate of 51. On 4/20/25, with a heart rate of 48. On 4/22/25, with a heart rate of 51. After 4/26/25, the MAR did not include a documented heart rate or blood pressure to verify the safety of giving the metoprolol. A MAR, dated 5/1/25 through 5/15/25, indicated the only vital signs recorded for Resident 22 was on 5/3/25. The heart rate recorded was 53. Metoprolol was administered. The MAR did not include any other documented heart rate or blood pressures to verify the safe administration of metoprolol according to the hold parameters for the remaining administrations. During an interview, on 5/15/25 at 10:43 a.m., LPN 2 indicated vital signs should have been obtained and recorded on the MAR before administering a medication with physician ordered hold parameters. During an interview, on 5/16/25 at 11:09 a.m., the Clinical Support Nurse 4 indicated she could not find any verification of vital signs being obtained prior to the medication administration. A current facility policy, titled MEDICATION ADMINISTRATION-GENERAL GUIDELINES, dated 11/18 and received from Clinical Support Nurse 4 on 5/19/25 at 3:58 p.m., indicated .Medications are administered in accordance with written orders of the prescriber 3.1-37(a)

Based on interview and record review, the facility failed to ensure documentation showed as needed (PRN) medications were administered under the direction of a licensed nurse for 1 of 1 resident reviewed for pain. (Resident 26) Findings include: The clinical record for Resident 26 was reviewed on 5/14/25 at 1:49 p.m. The diagnoses included, but were not limited to, type 2 diabetes mellitus with diabetic neuropathy, spondylosis of the lumbar region, and pain. A current care plan, dated 10/19/23, indicated Resident 26 was at risk for pain and to administer medications as ordered. 1. A physician's order, dated 7/20/24, indicated to give acetaminophen 650 milligrams (mg) for mild to moderate pain every 6 hours as needed. The Medication Administration Record (MAR) dated 5/1/25-5/16/25, indicated acetaminophen was given as needed for pain by a QMA without record of an assessment or permission from a licensed nurse on 5/2/25 and 5/8/25. 2. A physician's order, dated 7/11/24, indicated to give Norco (a narcotic pain medication) 7.5 mg- 325 mg for moderate to severe pain every 6 hours as needed. The MAR, dated April 2025, indicated Norco was given as needed for pain by a QMA without a record of an assessment or permission from a licensed nurse on 4/4/25, 4/24/25, and 4/30/25. The MAR dated 5/1/25-5/16/25, indicated Norco was given as needed for pain by a QMA without record of an assessment or permission from a licensed nurse on 5/10/25 and 5/16/25. During an interview, on 5/15/25 at 10:43 a.m., LPN 2 indicated the QMA should let her know if a resident needed a PRN medication and she would assess the resident, verify the appropriateness of giving the medication, and then authorize the administration based on the physician's order. The process would all be charted in the medical record on the MAR. During an interview, on 5/15/25 at 10:50 a.m., QMA 10 indicated if a resident needed a PRN medication, a licensed nurse on duty would be asked to assess the resident and give permission to administer the medication. It would then be charted the medication was given under the direction of the nurse on the MAR. During an interview, on 5/16/25 at 2:55 p.m., Clinical Support Nurse 4 indicated a QMA was required to have a nurse assess the resident and give permission for the PRN administration. A current facility policy, titled ADMINISTRATION OF PRN MEDICATIONS, dated 12/13/24 and received from the Executive Director (ED) on 5/16/25 at 1:25 p.m., indicated .If PRN medication is to be administered by a QMA, the Standards of Practice for PRN medication administration by a Qualified Medication Assistant shall be observed under the direction of licensed nurse A current facility policy, titled MEDICATION ADMINISTRATION- GENERAL GUIDELINES, dated 11/18 and received from Clinical Support Nurse 4 on 5/19/25 at 3:58 p.m., indicated .Medications are administered only by .personnel authorized by state laws and regulations to administer medications A current job description, titled Certified Resident Medication Associate, (QMA) received from the Clinical Support Nurse 4 on 5/16/25 at 2:55 p.m., indicated .Follow the policies and procedures of the facility governing the administering of medications to residents This citation relates to Complaints IN00454050 and IN00458258. 3.1-35(g)(1) 3.1-35(g)(2)

Based on observation, interview and record review, the facility failed to ensure a Minimum Data Set (MDS) assessment was coded correctly for 1 of 1 resident reviewed for MDS assessments. (Resident C) Findings include: During an observation, on 5/12/25 at 12:16 p.m., Resident C was receiving oxygen from a portable oxygen tank. During an observation, on 5/13/25 at 9:43 a.m., Resident C was receiving oxygen from a portable oxygen tank. During an observation, on 5/13/24 at 1:54 p.m., Resident C was receiving oxygen. During an observation, on 5/14/25 at 9:19 a.m., Resident C was receiving oxygen from a portable oxygen tank. The clinical record for Resident C was reviewed on 5/14/25 at 10:45 a.m. The diagnoses included, but were not limited to, saddle embolus of the pulmonary artery with cor pulmonale (a clot at the bifurcation of the pulmonary artery which obstructed blood flow), pulmonary fibrosis, and atelectasis (part or full collapse of the lung). Resident C's care plan, dated 11/5/24, indicated to administer oxygen per the physician's order. A physician's order, dated 11/19/24, indicated to administer oxygen at four (4) liters per minute as needed to maintain saturation of 92 percent or greater. A quarterly Minimum Data Set (MDS) assessment, dated 2/20/25, indicated the resident was not receiving oxygen administration. During an interview, on 5/13/25 at 9:53 a.m., the Director of Nursing indicated Resident C received four (4) liters of oxygen. During an interview, on 5/14/25 at 3:29 p.m., MDS Coordinator 11 indicated the resident was on supplemental oxygen and it was not correct on the MDS assessment. A current facility document, titled CMS's RAI Version 3.0, dated 10/2023 and received from the Executive Director on 5/16/25 at 9:33 a.m., indicated .Code continuous or intermittent oxygen administered via mask, cannula, etc 3.1-31(c)(6)

Based on interview and record review, the facility failed to ensure there was documentation the bed hold policy was provided to a resident for 1 of 1 resident reviewed for bed hold policy. (Resident 6) Findings include: The clinical record for Resident 6 was reviewed on 5/12/25 at 10:52 a.m. The diagnoses included, but were not limited to, falls, chronic pain, and low back pain. A nursing progress note, dated 12/3/24, indicated the resident had sustained a fracture to the tail bone and was transported to the hospital. A copy of the bed hold policy was not located in the resident's clinical record. During an interview, on 5/19/25 at 1:45 p.m., the Corporate Minimum Data Set (MDS) nurse indicated a bed hold policy was not provided. A current facility policy, titled Bed Hold Notification, dated as last reviewed 1/8/25 and received from the Corporate MDS nurse on 5/19/25 at 1:59 p.m., indicated .Residents and Responsible Parties have a right to be notified verbally and in writing on reserve bed payment policy per the state plan when someone goes out to the hospital .Before a nursing facility transfers a resident to a hospital .the nursing facility must provide written information to the resident and resident representative that specifies the duration of the state bed hold policy 3.1-12(a)(25)(A) 3.1-12(a)(25)(B)

Based on interview and record review, the facility failed to ensure a resident's preference of having female caregivers was documented and followed for 1 of 1 resident reviewed for accommodation of needs. (Resident 25) Findings include: During an interview, on 5/12/25 at 1:55 p.m., Resident 25 indicated she preferred females to complete catheter care on her and there were males who would complete her catheter care. During an interview, on 5/13/25 at 1:50 p.m., Certified Nursing Assistant (CNA) 8 indicated the staff knew Resident 25 did not like male staff members to complete peri-care or catheter care for her. It was known, females should be completing the catheter and peri-care for Resident 25 and not male staff members. The clinical record for Resident 25 was reviewed on 5/13/25 at 1:44 p.m. The diagnoses included, but were not limited to, Parkinson's disease and heart failure. A physician's order, dated 12/21/21, indicated to complete catheter care every shift, three (3) times per day. A quarterly Minimum Data Set (MDS) assessment, dated 3/12/25, indicated Resident 25 was cognitively intact and had indwelling catheter. There was no documentation in the clinical record to indicate Resident 25 preferred female caregivers and there was no care plan related to Resident 25's preference for female caregivers prior to 5/13/25. A Medication Administration Record (MAR), dated May of 2025, indicated the following: a. catheter care was completed by Registered Nurse (RN) 15 (a male nurse) on the 3rd shift on 5/1/25, 5/14/25, and 5/18/25. b. catheter care was completed by Licensed Practical Nurse (LPN) 14 (a male nurse) on the 3rd shift on 5/3/25, 5/9/25, and 5/12/25. c. catheter care was completed by CNA 13 (a male CNA) on the 3rd shift on 5/5/25, 5/6/25, 5/7/25, 5/8/25, and 5/11/25. During an interview, on 5/16/25 at 3:07 p.m., the Director of Nursing (DON) indicated it was known the resident did not want male staff members caring for her. This was an off and on thing for Resident 25. A current facility policy, titled Resident Rights Guidelines, dated 12/17/24 and received from Clinical Support Nurse 4 on 5/19/25 at 10:40 a.m., indicated .Residents shall not leave their individual personalities or basic human rights behind when they move to a health campus. The following is a list of rights recognized by staff .Our residents have a right to .Be treated with dignity and respect. b. Be given the information necessary to participate in decisions which affect them both individually and cooperatively .Be consulted and encouraged to have input into their care plan which guides the services delivered to the residents 3.1-3(n)(3) 3.1-3(t) 3.1-3(u)(1) 3.1-3(u)(3) 3.1-3(v)(1)

Based on interview and record review, the facility failed to ensure an informed consent for antipsychotic medication use was obtained for 1 of 5 residents reviewed for unnecessary medication. (Resident 34) Findings include: The clinical record for Resident 34 was reviewed on 5/14/25 at 8:48 a.m. The diagnoses included, but were not limited to, dementia with psychotic disturbance, anxiety, and depression. A physician's order, with a start date of 4/15/25, indicated Resident 34 was to take risperidone (an antipsychotic medication) 0.5 milligrams twice a day. A care plan, dated 4/16/25, indicated Resident 34 was at risk for adverse consequences related to receiving an antipsychotic medication. There was no documentation found in Resident 34's electronic health record to indicate the resident or the resident's representative was informed of the risks and benefits of the antipsychotic medication, treatment alternatives, and the option to choose the preferred treatment. During an interview, on 5/15/25 at 5:20 p.m., Resident 34's daughter indicated Resident 34 was admitted to an area hospital for evaluation in April 2025. Resident 34 had been discharged from the hospital and had returned to the facility. The facility did not inform the family of the changes to Resident 34's medication regimen. During an interview, on 5/16/25 at 8:33 a.m., the Interim Director of Nursing indicated Resident 34's medications were reviewed with Resident 34's Power of Attorney (POA) during a care planning meeting but informed consent was not completed at the time the meeting took place. During an interview, on 5/16/25 at 2:54 p.m., Resident 34's POA indicated she was not aware of any medication changes made during the hospital stay. The facility had not informed her of black box warnings or the risks and benefits for any medications since Resident 34 had returned to the facility. A current facility policy, titled Psychotropic medication use and gradual dose reduction guidelines, dated 3/2025 and received from Clinical Support Nurse 4 on 5/16/25 at 1:43 p.m., indicated .To ensure every effort is made for residents receiving psychoactive medications to obtain the maximum benefits with minimal unwanted side effects through appropriate use, evaluation and monitoring by the interdisciplinary team .A consent shall be obtained upon admission for ordered psychotropic medications to ensure appropriate indications for use and that the Resident/Responsible party is educated on the risks, benefits, alternative treatment options and applicable black box warnings 3.1-3(n)(2)

Based on observation, interview, and record review, the facility failed to timely investigate an elopement when the incident occurred for 1 of 1 resident, reviewed for eloping from the facility (Resident B). Finding includes: During an interview on 08/21/24 at 10:29 a.m., the Corporate Support Nurse indicated on 07/18/24, Resident B exited the campus out the 300 hall door. The alarm did sound and a family member observed the resident exit and reported it to staff immediately. The staff responded. The resident used the side walk to the Health Care Center parking lot and crossed the street. She was observed by the home owner, across the street, who was out in the yard. Responding staff did get to the resident. It took about three (3) minutes. The resident had been last observed by a nurse at 8:22 p.m. The nurse then had to go print reports, due to the internet outage. The responding staff returned Resident B to the facility at 8:33 p.m. Staff did all the right things (followed the elopement policy) and it was documented on paper (due to the system being down). It was not reported to the state because the Corporate Support Nurse had not been made aware of the incident. The Director of Nursing, at the time) told the CNAs to falsify documentation. The Executive Director told the CNAs to report the facts. It was reported to the Executive Director. Attempts to contact the Director of Nursing were made, but she would not respond and she did not return to the facility. The incident was treated like it happened yesterday (08/20/24) and the report to the state was currently in process. During an observation on 8/21/22 at 10:33 a.m., the road was noted to allow two way traffic and had a speed limit of 30 miles per hour. The road runs east to west. The house was noted to be directly across the street from the Health Care parking lot and entrance. There was little traffic at that time of the day. There was no answer at the house. A second attempt to speak with the occupant of the house was made at 12:45 p.m. There was no answer. A facility document titled, Trilogy Health Services, LLC Statement of Witness Form, dated 08/20/24. and received from the Corporate Support Nurse on 08/21/24 at 2:43 p.m., indicated, on 07/18/24 the charting system went down and staff were unable to access the electronic medical record system. The writer went to the Assisted Living and attempted to get the offline Medication and Treatment Records for the residents. She returned to the hall at 8:33 p.m. At that time the CNAs were bringing Resident B down the hallway. The CNAs stated the resident had exited the facility from the 300 Unit door and had been found outside. The writer took the resident to her room and assessed her. No injuries were noted and the resident's wander guard was in place. The resident was then placed on monitoring. The Executive Director(ED), Director of Nursing (DHS), and Nurse Practitioner (NP) were notified. The last time the resident was observed by the writer was shortly prior to her going to the Assisted Living side of the facility at 8:20 p.m. The resident was up and in her wheel chair at the time. The document was dated 08/20/24 and signed by RN 3. A facility document titled, Trilogy Health Services, LLC Statement of Witness Form, dated 08/20/24 and received from the Corporate Support Nurse on 08/21/24 at 2:43 p.m., indicated, on 07/18/24 the writer was assisting CNA 1 with a resident. She went to get resident care items and was informed by a family member an alarm was sounding on the 300 Hall. The writer asked the family member if a resident had exited the door and returned. The family member informed her a resident went out but she did not see the resident return. CNA 1 was informed of the incident and both staff members checked the residents. They found that Resident B was not in the campus. She then went outside and upon exiting the Health Center door she observed Resident B across the street with the neighbor. The resident was returned to the facility and RN 3 assessed her. The ED and DHS were made aware. The document was dated 08/20/24 and signed by CNA 2. A facility document titled, Trilogy Health Services, LLC Statement of Witness Form, dated 08/20/24, and received from the Corporate Support Nurse on 08/21/24 at 2:43 p.m., indicated, on 07/18/24, the writer was working on his hall, putting residents to bed. CNA 2 was assisting. CNA 2 went to get supplies that were needed and when she returned she informed him an alarm was sounding and they needed to do a head check (check all residents). They realized Resident B was not in the campus and CNA 2 went outside and found the resident across the street at the neighbors house. They returned the resident back to the facility and RN 3 was notified. The ED and DHS were also notified. The document was dated 08/20/24 and signed by CNA 1. A facility document titled, Trilogy Health Services, LLC Statement of Witness Form, dated 08/20/24, and received from the Corporate Support Nurse on 08/21/24 at 2:43 p.m., indicated the writer was not made aware Resident B had exited the campus and was .without remaining in the line of sight . A staff member did .reach out to her but no details were provided with the exception that the incident had been reported to the DHS. She requested the staff members write out a statement and submit it to the DHS, but they refused to write the witness statements at that time. The document referenced the incident date as 07/18/24, was dated 08/20/24 and signed by the ED. A facility document titled, Trilogy Health Services, LLC Statement of Witness Form, dated 08/20/24, and received from the Corporate Support Nurse on 08/21/24 at 2:43 p.m., indicated the DHS notified the writer a resident had exited the facility but was .within sight . She reviewed the Interdisciplinary Team note the next day and .no concerns were noted . The document referenced the incident date as 07/18/24, was dated 08/20/24 and signed by the ED. A facility document titled, Trilogy Health Services, LLC Statement of Witness Form, dated 08/20/24, and received from the Corporate Support Nurse on 08/21/24 at 2:43 p.m., indicated the neighbor, living directly across from the Health Care entrance (located on [NAME] 250 N.) stated at approximately 8:25 p.m. (07/18/24) he noted the resident .tooling around on sidewalk of [NAME] building and in parking lot The resident crossed the street and was friendly and began a conversation with him. Someone from the facility then came approximately two (2) minutes later and took the resident back to the facility. The document had no signature of the neighbor and was dated 08/20/24. A facility docent titled, CHECKLIST FOR POST ELOPEMENT, dated 08/20/24, and received from the CSN on 08/21/24 at 2:43 p.m., indicated .ED/DHS .assist with investigation/audits .ED/DHS or designee to start investigation: get statements from employees nursing and non-nursing .Have DVP and Clinical Support review and approve reportable paperwork before sending to agencies (State Department of Health, Ombudsman, Adult Protective Services, and or local law enforcement as indicated .Complete five day final and have DVP and Clinical Support review and approve prior to sending to agencies This citation relates to Complaints IN00439455 and IN00439970. 3.1-28(e)

Based on observation, interview, and record review, the facility failed to ensure an elopement of a resident was reported to the Indiana Department of Health for 1 of 2 residents reviewed for elopement (Resident B). Finding includes: During an observation on 08/20/24 at 8:58 a.m., Resident B was in her room dressed, clean and dry and wearing a wander guard bracelet on her wrist. She was alert, able to sit up on the side of the bed without assistance and very friendly. She currently resided in the Legacy Memory Care Unit of the Assisted Living Facility. Her wheel chair was noted to be parked in close proximity to her bed and within reach. During an interview on 08/21/24 at 10:29 a.m., the Corporate Support Nurse indicated on 07/18/24, Resident B exited the campus out the 300 hall door. The alarm did sound and a family member observed the resident exit and reported it to staff immediately. The staff responded. The resident used the side walk to the Health Care Center parking lot and crossed the street. She was observed by the home owner, across the street, who was out in the yard. Responding staff did get to the resident. It took about three (3) minutes. The resident had been last observed by a nurse at 8:22 p.m. The nurse then had to go print reports, due to the internet outage. The responding staff returned Resident B to the facility at 8:33 p.m. Staff did all the right things (followed the elopement policy) and it was documented on paper (due to the system being down). It was not reported to the state because the Corporate Support Nurse had not been made aware of the incident. The Director of Nursing, at the time told the CNAs to falsify documentation. The Executive Director told the CNAs to report the facts. It was reported to the Executive Director. Attempts to contact the Director of Nursing were made, but she would not respond and she did not return to the facility. The incident was treated like it happened 08/20/24 and the report to the state was currently in process. During an observation on 8/21/22 at 10:33 a.m., the road next to the facility was noted to allow two way traffic and had a speed limit of 30 miles per hour. The road ran east to west. The house was noted to be directly across the street from the Health Care parking lot and entrance. There was little traffic at that time of the day. There was no answer at the house. A second attempt to speak with the occupant of the house was made at 12:45 p.m. There was no answer. During an interview on 8/21/24 at 12:47 p.m., CNA 1 indicated last month (July 2024) the computer system was out. Staff was getting residents ready for bed. He was in the 100 hall and the CNA 2 went to get supplies. A family member stopped CNA 2 to inform her an alarm was sounding in the 300 Hall and a resident left and had not come back. CNA 1 and CNA 2 did a head count and searched the rooms in the 300 Hall. CNA 1 was unable to identify how long it took to check the rooms and do the head count. Both CNAs then went outside via the emergency door of the 300 unit, where the alarm was sounding. The went to the parking lot in the back of the facility and observed the resident across the street. The neighbor, across the street, was under his car. The CNAs returned the resident, the resident seemed o.k. They entered the facility using the main door to the Assisted Living and took the resident to the nurse. CNA 2 did place calls to the Executive Director, while they were with the resident, across the street. She tried to contact all of management. The Executive Director did finally answer. The Executive Director was made aware of the incident while they were across the street with the resident. The Director of Nursing, at that time, was in the Assisted Living facility. They took the resident to the nurse and went back to patient care. While they were assisting residents the former Director of Nursing came to the room they were working in and told both CNAs they needed to write a statement. While they were still providing care, in the room, he indicated the former Director of Nursing told them to write a statement to indicate the resident did not make it across the street and she was in full sight the whole time. He refused to write a statement and indicated it was not true and the Director of Nursing was informed that would be falsification. The former Director of Nursing left. She returned about five (5) minutes later and informed CNA 1 she had spoke with the Executive Director and the Executive Director said to write the statement, give the facts, so the incident could be reported. He did not write the statement. The next day the Executive Director asked him to write the statement. She pulled him into an empty room on the 300 unit and asked him what was wrong. He was frustrated and felt both the Executive Director and former Director of Nursing wanted him to falsify a statement. The Executive Director indicated the Director of Nursing was leaving anyway; he still refused to write a statement. During an interview on 8/21/24 at 2:15 p.m., CNA 2 indicated CNA 1 and her were working on the floor, she had finished her work on her hall and CNA 1 asked her to get supplies. On her way back, a family member stopped her and said an alarm was going off. She asked if the family member had seen a lady in a wheelchair and the family member responded yes. She went to CNA 2 and informed him. Both CNAs went to the 300 Hall and searched the rooms, Resident B was not found. They both walked out of the building and observed Resident B across the street. The neighbor was under his car working. CNA 2 indicated she apologized, and the neighbor responded it was o.k. She then made calls to the Director of Nursing, Executive Director, and the MDS Coordinator. None of them answered. She kept calling the Executive Director and she finally answered. CNA 2 indicated the Executive Director was informed of the incident while both CNAs were in the neighbor's driveway. CNA 2 indicated the Executive Director kept saying, so she [Resident B] was inside the whole time. CNA 2 indicated she responded, no that is not what happened. The Director of Nursing was in the facility on the Assisted Living side. The Executive Director informed CNA 2 that she would call the Director of Nursing and inform her. A little later the Director of Nursing came and told both CNA 1 and CNA 2 not to include, in their statements, that the resident was across the street. CNA 2 asked the Director of Nursing if she wanted them to lie and per the CNA, the Director of Nursing responded it was not lying it was emphasizing. CNA 2 did not write any statements. During the interview CNA 2 shared her phone record. It was noted calls were placed on 07/18/24 to the Executive Director twice with a history of 2 seconds as well as the other management staff, also 2 seconds. On July 18, 2024 at 8:32 p.m., the third call to the Executive Director had a duration of one (1) minute. During an interview on 08/21/24 at 3:49 p.m. the Executive Director indicated she was notified that Resident B had eloped off campus, the same day it happened. She was told the resident was within the line of sight. She realizes now it should have been reported and it will not happen again. At the time the facility records system was off-line due to outages that affected the country. There was a lot happening. She did get the call and it was quick. She did not get a lot of details. After the incident occurred, she did ask for witness statements and was told they (the CNAs) would type them up. They did not type up statements. She indicated she did try to contact the Director of Nursing and was not able to contact her. She never questioned if the incident needed to be reported to the state agency. During a telephone interview on 08/21/24 at 4:00 p.m., the former Director of Nursing indicated on that evening (July 18, 2024) she was on her way to the facility to print paperwork due to the system was down. She did not have password access to the area of the system, but she was going to try to print the information. While on her way to the facility she received a call from the Executive Director and was informed of the incident and told to assess Resident B. The record for Resident B was reviewed on 08/21/24 at 9:54 a.m. Diagnoses included, but were not limited to unspecified dementia, unspecified fracture of the lower end of the right femur (upper leg) and chronic diastolic heart failure. The resident admitted to the Health Care Center on 06/01/24 and was transferred to the locked memory care unit on the assisted living on 07/23/24. The resident had a Brief Interview for Mental Status (BIMS) assessment score of 5 indicating the resident had severe cognitive impairment dated 06/27/24. The progress notes indicated Resident B had exited the building using an emergency exit on 07/07/24 but she had not got off of the facility property. Staff responded promptly and returned the resident to the facility. The resident was placed in the memory care activity program and engaged in activity. She was noted, on 07/09/24, to self propel herself in her wheel chair and wander into other residents' rooms. On 07/15/24 Resident B was self propelling her wheel chair and asking which exit would get her to the .front of the nursing building On 07/16/24 a note indicated Resident B had attempted to exit the doors at the end of the hall twice. The alarms sounded and staff returned the resident to the common area. She was then taken to the Legacy Memory Care Unit, a locked unit, for the remainder of the day. A nursing note, dated 07/18/24 at 11:45 p.m. indicated the resident was in bed, she had no exit seeking behavior on the shift. The resident was on safety checks. She had no complaints of pain and staff would continue to monitor. The signature of the writer was not legible. An Interdisciplinary Team note, dated 07/19/24 at 9:30 a.m., indicated the resident had exited the campus on 07/18/24 by way of the 300 Hall emergency exit and was brought back inside by staff at 8:33 p.m. The resident was assessed and denied any pain, She was put on 1 on 1 observation until she was calm. It was noted the wander guard was in place. The resident indicated she was checking the cats. She was found to be dressed appropriately in jeans, sweater, socks and shoes. She was not found to have any psychosocial distress. She was unable to recall the events. A document titled INDIANA STATE DEPARTMENT OF HEALTH SURVEY REPORT SYSTEM was received from the Corporate Support Nurse on 08/21/24 at 2:43 p.m. The report was filed to the Indiana State Department of Health on 08/21/24 (33 days after the incident). The incident was dated 07/18/24 and the description indicated, .8/21/24 Resident exited the campus and went across the street safely to visit with neighbor A facility policy related to reporting incidents to the Indiana Department of Health was requested of the Corporate Support Nurse. A policy titled, External Reporting, last reviewed on 12/31/23 and received from the Corporate Support Nurse on 08/21/24 at 2:43 p.m., did not cover reporting incidents to Indiana Department of Health. At the time the policy was provided the Corporate Support Nurse indicated the facility followed the state regulations and the incident should have been reported to the state. A facility docuemt titled, CHECKLIST FOR POST ELOPEMENT, dated 08/20/24, and received from the CSN on 08/21/24 at 2:43 p.m., indicated .ED/DHS .assist with investigation/audits .ED/DHS or designee to start investigation: get statements from employees nursing and non-nursing .Have DVP and Clincial Support review and approve reportable paperwork before sending to agencies (State Department of Health, Ombudsman, Adult Protective Services, and or local law enforcement as indicated .Complete five day final and have DVP and Clinical Support review and approve prior to sending to agencies This citation relates to Complaints IN00439455 and IN00439970. 3.1-28(c)

Based on record review and interview, the facility failed to personalize resident care plans for advanced directives for 5 of 5 residents reviewed for advance directive care plans (Resident 11, 19, 32, 35, and 40). Findings include: 1. On [DATE] at 12:52 p.m., a record review was completed for Resident 11. She had the following diagnoses which included, but not limited to urinary tract infection, chest pain, chronic obstructive pulmonary disease (COPD), atrial fibrillation (A-Fib), hyperlipidemia, and dementia. Resident 11 had a care plan indicating she had chosen to have the following advanced directive, but failed to indicate whether she was to have CPR (cardiopulmonary resuscitation) or DNR (do not resuscitate). She had an order, dated [DATE], for a DNR. 2. On [DATE] at 2:46 p.m., a record review was completed for Resident 19. He had the following diagnoses which included but were not limited to COPD, type II diabetes mellitus, morbid obesity, chest pain, heart failure, and major depression with psychotic symptoms. Resident 19 had an order for him to have CPR (Full Code). He lacked a care plan addressing his desire to have CPR. 3. On [DATE] at 2:12 p.m., a record review was completed for Resident 32. He had the following diagnoses which included but were not limited to urinary tract infection, swelling of left lower leg, bradycardia (a slow heartbeat), type 2 diabetes mellitus, and major depressive disorder. Resident 32 had an order for DNR dated [DATE]., He lacked a care plan addressing his desire to be a DNR. 4. On [DATE] at 11:43 a.m., a record review was completed for Resident 35. She had the following diagnoses which included but were not limited to COPD, heart failure, type 2 diabetes, chronic kidney disease, depression, and chest pain. She had an order for full code dated [DATE]. Her care plan, dated [DATE], lacked addressing her desire to be a full code. 5. On [DATE] at 2:34 p.m., a chart review was completed for Resident 40. He had the following diagnoses which included but were not limited to juvenile myoclonic epilepsy (an epilepsy syndrome characterized by myoclonic jerks (quick jerks of the arms or legs), generalized tonic-clonic seizures), dysphagia (difficulty swallowing), pain, major depressive disorder, and general anxiety disorder. He had an order, dated [DATE], for him to be a DNR. He lacked a care plan addressing his desire to be a DNR. A policy titled, Comprehensive Care Plan Guideline was provided by the Regional Nurse Support on [DATE] at 2:32 p.m. It indicated, .Comprehensive care plans need to remain accurate and current . 3XXX,d+[DATE](c)(1)

Based on observation and interview, the facility failed to date and/or label insulin pens, eye drops, and inhalers when opened, and remove expired insulin pens and lorazepam from the cart when expired for 2 of 3 medication carts and 1 of 1 medication storage room reviewed for medication storage. Findings include: 1. The following medications were in the 100-hall medication cart: a. Resident 14 had a bottle of lorazepam 2mg/ml in the refrigerator. It expired on [DATE]. b. Resident 29 had basaglar insulin dated [DATE]. It was expired. c. Resident 33 had basaglar insulin with no date to indicate when it was opened. She also had lantus insulin with a date opened of [DATE]. It was expired. She had a bottle of refresh eye drops in the cart. The drops lacked a label. d. Resident 5 had an albuterol inhaler HFA 90mcg per actuation. It lacked a date to indicate when it was opened. She had an inhaler trelegy ellipta 100mcg/62.5mcg/25mcg in the cart. It lacked a date to indicate when it was opened. e. Resident 42 had an albuterol inhaler HFA 90mcg per actuation. It lacked a date to indicate when it was opened. He had a bottle of genteal tear solution sent from the pharmacy on [DATE]. It lacked a date to indicate when it was opened. f. Resident 4 had a bottle of latanoprost and genteal tears solution. Both lacked dates to indicate when they were opened. g. Resident 26 had a bottle of latanoprost sol 0.005% solution in the medication cart. It lacked a date to indicate when it was opened. h. Resident 21 had a bottle of carboxymethyl solution 0.5% in the medication cart that lacked a date to indicate when it was opened. 2.)The following was observed on the 300 hall medication cart: a. Resident 6 had novolog insulin indicating it was opened on [DATE]. On [DATE] at 12:20 p.m., RN 6 was present during the observation and confirmed findings. A current policy, titled, Medication Storage in the Facility, dated ,d+[DATE], was provided by the Regional Clinical Support (RCS), on [DATE] at 9:55 a.m. A review of the policy indicated, .Medications and biologicals are stored safely .Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications .are permitted to access medications .Certain medications .such as .multiple dose injectable vials, ophthalmics .once opened, require an expiration date shorter than the manufacturer's expiration date to insure medication purity and potency 3XXX,d+[DATE](j) 3XXX,d+[DATE](m) 3XXX,d+[DATE](n)

Based on record review and interview, the facility failed to properly dispose of medications belonging to residents for 1 of 6 resident reviewed for medication disposition (Resident 204, 205 and 50). Findings include: 1. On [DATE] at 11:36 a.m., a record review was completed for Resident 204. He has the following diagnoses which included but were not limited to hypertension, hyperlipidemia, hypothyroidism, insomnia, and pain. He was discharged from the facility on [DATE]. He had the following medications unaccounted for after being discharged from the facility. a.) Amlodipine 5 milligrams (mg) b.) Aspirin 81 mg c.) Atorvastatin 80 mg d.) Cholecalciferol 1,250 micrograms (mcg) (50,000 unit) e.) Ipratropium-albuterol 0.5 mg - 3 mg (2.5mg/3ml) f.) Levothyroxine 112 mcg g.) Melatonin 5 mg h.) Ondansetron 4 mg i.) Tylenol 325 mg 2. On [DATE] at 11:47 a.m., a record review was completed for Resident 205. She had the following diagnoses which included but were not limited to hypertension, heart failure, diabetes mellitus type 2, and depression. She was discharged from the facility on [DATE]. She had the following medication unaccounted for after being discharged from the facility. a.) Furosemide 20 mg b.) Humalog U-100 insulin pen c.) Coreg 12.5 mg d.) Lantus U-100 insulin pen e.) Sertraline 50 mg daily f.) Tylenol 500 mg g.) Glucagon emergency kit 1mg 3. On [DATE] at 2:32 p.m., a comprehensive record review was completed for Resident 50. She had the following diagnoses which included but were not limited to hypertension, hyperlipidemia, and constipation. She discharged from the facility on [DATE]. She had the following medications unaccounted for after being discharged from the facility. a.) Miralax 3350 17 gram (gm) powder b.) Oxycodone 5 mg c.) Potassium chloride 20 milliequivalents (meq) d.) Protonix 40 mg e.) Aspirin 81 mg f.) Atorvastatin 80 mg g.) Plavix 75 mg h.) Furosemide 40 mg i.) Lorazepam 0.5 mg j.) Magnesium oxide 400 mg k.) Metoprolol 25 mg On [DATE] at 10:46 a.m., the Regional Support Nurse indicated it was difficult to account for medications disposed of because they got individual pill packs for a week at a time for residents. She indicated they put controlled substances into a secured box for pharmacy to pick up and destroy. On [DATE] at 11:30 a.m., Pharmacy indicated they were unable to find medication disposition logs on for the residents listed above. They indicated controlled substances should be destroyed at the facility level. If the facility put controlled substances in the secured box, the medications went to a DEA facility for proper destruction. A policy titled, PackEdge SOP for Medication Changes, Discontinued Medications, and Medication Destruction, was provided by the Director of Nursing Services (DNS) on [DATE] at 10:46 a.m. It indicated, .The facility should destroy any controlled narcotic medications from the multi-dose packaging system for any unneeded, discontinued medications within the medication destruction disposal solution. The facility shall return to the pharmacy any non-controlled medications for resident's medications that are discontinued, expired and/or discharged 3XXX,d+[DATE](a) 3XXX,d+[DATE](b)(1) 3XXX,d+[DATE](c)

Based on observation, interview and record review, the facility failed to ensure preventative interventions (foot pedals) were in place to prevent a fall for 1 of 5 residents reviewed for accidents (Resident #28). This deficient practice resulted in Resident #28 being thrown forward from her moving wheelchair resulting in facial and head injuries requiring hospitalization . Finding includes: On 1/23/17 at 1:30 p.m., a large egg size knot protruding from Resident #28's forehead was observed between her eyebrows and it was farther toward and above the right eyebrow. A large purple/bluish colored bruise under the resident's left eye covering her entire left cheek was observed. She had a large green/yellowish colored bruise under her right eye covering her entire right cheek. She had a scab under her right eye on the cheekbone and a scab on the knot next to the right eyebrow. She had edema to her face. She indicated she was on an outing to go to eat with the facility when she fell out of her wheelchair (w/c) about two weeks ago. She indicated the bus from the facility took her and other residents to (Name of the city) on an outing to a restaurant, which did not accept wheelchairs, but there was a restaurant up the street approximately one and a half blocks up the road, so someone from the facility was pushing her in her w/c and she fell out of it. She indicated the sidewalk was uneven and some of it was high and some of it was low and the person ran into a piece of sidewalk,which was significantly higher and she fell out of the w/c onto the sidewalk face first. She indicated her right eye was swollen for two days and she could not open it and she spent four days in the hospital. She was the only resident on the outing in a w/c and the rest of the residents were ambulating to the restaurant behind her. She indicated she did not have foot pedals on her w/c at the time of the fall. During an interview on 1/23/16 at 3:07 p.m., RN #12 indicated the resident had bruising to her face with a hematoma beside and above her right eyebrow. She indicated she had a small laceration, which had been steri stripped above her right eye from a fall from her w/c onto a concrete sidewalk, while out on a facility outing. She indicated a staff member was pushing Resident #28 in her w/c and she dropped her feet and fell forward onto the concrete sidewalk. She indicated the resident did not have foot pedals on her wheelchair and her glasses were destroyed. She was hospitalized for [REDACTED]. Resident #28's record was reviewed on 1/25/17 at 8:25 a.m. [DIAGNOSES REDACTED]. The resident had a Care Plan dated 9/13/16, which addressed the problem she was at risk for falls related to weakness. Interventions included, but were not limited to 1/11/17--Please ensure that I have pedals on my wheel chair when going on outing as to prevent falls and/or fall related injury An annual MDS (Minimum Data Set) assessment, dated 12/28/16, indicated the resident had a BIMS (Brief Interview Mental Score) score of 14. Her functional status indicated the residents transfer score was 3/2 (Extensive assist/one person physical assist), Locomotion on the unit score was 3/2, and locomotion off unit score was 3/2. An ER (emergency room ) Physician Exam V8, dated 1/9/17, indicated .Physical Examination .Eyes: R (Right) eye area is so swollen raccoon eye that the pt (patient) nor myself can open it. Nose has dried blood inside .Skin: Very large R periorbital hematoma. Raccoon eye. R eye swollen shut. Radiology Interpretation: Opacification (not able to be seen through or not transparent) of the R frontal and ethmoid Sinuses suggesting sinus drainage pathway obstruction. Large R frontal and periorbital soft tissue hematoma .ER Diagnosis: [REDACTED]. History and Physical from (Name of Hospital), dated 1/10/17, indicated .Date of Service 1/10/17 .Chief Complaint: Sent from outside hospital Emergency Department with facial hematoma after fall .HPI (History Physical Information): .out on a pass for dinner this evening. She was taken to an outside hospital Emergency Department after falling from her wheelchair. The patient says she was being pushed in the wheelchair when they hit a concrete curb and she fell out face first onto the cement. The patient sustained right periorbital hematoma with her eye swollen shut. She also has swelling and bruising to her nose and left eye. She was transferred to (Name of Hospital) for ENT (Ear, Nose and Throat) Services .The patient also was having bilateral shoulder pain as well as right finger pain . Review of Systems: .Skin: Multiple areas of bruising after falling tonight . HEENT (Head, Eyes, Ears, Nose Throat): Left eye swollen shut as per HPI. Facial swelling as HPI .Musculoskeletal: Having pain to right hip area, finger and shoulders post fall .The patient had multiple imaging studies including .CT (Computed Tomography) maxillofacial: Impression: Large right frontal and periorbital soft tissue hematoma. No acute maxillofacial fracture. Opacification (not able to see through or not transparent) of the right frontal and anterior ethmoid sinuses suggesting sinus drainage pathway obstruction . Physical examination: HEENT: Right periorbital hematoma. The patient's eye is swollen shut. Left eye also has bruising, has raccoon eyes. Left is opening. The patient also has swelling and bruising to her nose . Impression and Plan: 1. Facial hematoma, bruising and swelling Hospital Provider Daily Note dated 1/10/17, indicated .Physical Exam: .Head: Other (large area of bruising over the entire upper face, worse on the right eye) ENT: Other (Upper lip swollen) . Assessment/Plan: 1. Fall from wheelchair with facial contusion and bleeding .CT report from (Name of Hospital) suggests bleeding into the sinuses An untitled document, dated 1/11/17, indicated Date of Incident 1/9/17. Event--Resident was being propelled toward a restaurant when her feet fell to the ground and her shoe fell off and the wheelchair came to a stop which propelled the resident out of the chair onto the ground. The resident hit her eye on the sidewalk and cut open her head Root Cause of Analysis--The accident occurred because the resident dropped her feet to the ground while the wheelchair was in motion Skin Integrity Event, dated 1/12/17 at 10:15 a.m., indicated the resident returned from the hospital stay after a fall. Bruising was noted on her face including both her eyes. The right eye was noted to be a little more edematous and discolored. This skin integrity event was a bruise event, which was present on readmission to the facility. The location of and size of Bruise #1 was face (both eyes) Right eye. Bruise Color #1 was Black-Blue; the character of the bruise: Swelling. The location and size of Bruise #2 was the left eye. Bruise Color #2 was Black-Blue and yellowish-green. The character of the bruise was swelling. The activity during the bruise occurrence was locomotion-walking/wheeling in her wheelchair. On an outing with the activity department and her feet slipped off her w/c and got caught on the sidewalk, thus projecting her forward to the ground. The temporary Care Plan Update indicated to make sure the equipment is in good repair and check placement of her feet while in the wheelchair. The short description: Resident returned from hospital stay after fall. Bruising noted on face including both eyes. The right eye is noted to be a little more edema and discoloration. Facility Physician Visit Note, dated 1/16/17, indicated Chief Complaint: Fall F/u (Followup) HPI: Pt seen today s/p (status [REDACTED]. Sustained a fall 1/9/17 continued with ecchymosis (bruising) to bilat (bilateral) forehead right with lg (large) amt (amount) edema and discoloration .Occasional headache . CT scanned showed opacification of right frontal and anterior ethmoid sinuses .Eyes: small bilat (bilateral) conjunctival (lines in inside of the eyelids and covers the sclera) hemorrhages ((an escape of blood from a ruptured blood vessel) Right forehead lg hematoma, tender .Assessment: 1. Bilat frontal hematomas 2. Conjuctival hemorrhages 3. Sinus disease Progress note, dated on 1/25/17 at 5:47 p.m., indicated Resident has hematoma present above right eye from previous fall. Resident was seen by (Name of Physician) and received new orders. Measurements obtained per physician request. Area measures 7cm (centimeters) x5cm and is elevated 1.5cm in height During an interview on 1/25/17 at 4:03 p.m., the Executive Director indicated the LEA's were not Certified Resident Care Assistants (CRCA's). A handwritten statement written by LEA (Life Enrichment Aid) #3 dated 1/9/17, indicated Arrival at (Name of the Restaurant) in (Name of City) at 11:00 am. (Name of Resident) was the last resident to exit the bus. She went down the lift and we were on our way to (Name of Restaurant), which was a way down the sidewalk. I heard a scraping noise and asked if she could pick her feet up. She did, but a few seconds later I heard the noise again and then all of a sudden the wheelchair came to a halt and the resident was propelled face forward onto the sidewalk. The Residents shoe had come either partially or completely off and had gotten stuck underneath the wheels of the wheelchair, causing the chair to stop and the resident to fall forward During an interview on 1/25/17 at 4:49 p.m., the Life Enrichment Director (LED) and LEA #3 was in attendance. LEA #3 indicated she was the staff member pushing Resident #28 in the wheelchair when she fell out of it. LEA #5 parked down the street from the restaurant, which was two buildings (the library then the community center) down. She indicated the sidewalk was flat from the area the resident was removed from the bus to the restaurant. She was pushing the resident in the w/c without foot pedals as she had always done when she went out on the outings. LEA #3 indicated Resident #28 usually used her feet to walk with the w/c as she pushed her in it, but lately she had been holding up her feet as she was being pushed. She indicated the resident had been planting her feet down in front of the w/c, while staff was pushing her without giving staff advance warning she was going to do this. She indicated the resident would plant her feet in her w/c at the facility, on the carpet and she would stop the wheelchair quickly, usually as she got close to her room, but she had been doing it more frequently lately. LEA #3 indicated Resident #28 was holding her feet up while she was pushing her wheelchair the day of the outing towards the restaurant and she heard a scraping noise and asked the resident to pick up her feet and she did. A few seconds later she heard the same scraping noise again, then all of a sudden the w/c stopped and the resident went forward out of her w/c and was laying face forward on the sidewalk. She indicated she checked on the resident and ran to the bus to tell LEA #5 the resident fell and she needed help. LEA #3 indicated when she and the Administrator in Training (AIT) was putting the resident's belongings away when LEA #3 got back to the facility she noticed one of her shoes had scuff marks on it and they thought her shoe probably got caught in the wheel of the w/c, which was the reason she fell out of the w/c. The LED indicated the activity staff had concerns earlier that week regarding the resident having trouble keeping her feet lifted when they pushed her in her w/c on outings and in the facility because she planted her feet and made the w/c stop suddenly. She indicated LEA #4 talked to PT (Physical Therapist) #9 prior to the restaurant outing regarding the concern of the resident not holding her legs up while being transported and what could be done, but the LED did not know what PT #9 had decided because the resident went on the outing and fell out of her w/c and now she was on the PT caseload. On 1/25/17 at 5:28 p.m., the area in (Name of the City) where Resident #28 fell was observed and there was no handicap ramp observed in front or near (Name of the Restaurant) in (Name of City). There was a handicap ramp on the corner to the left of the restaurant two buildings down, which was next to the community center and the library. There was a slight elevation in the sidewalk as the ramp came up from the street onto the connecting sidewalk leading towards the restaurant. The sidewalk leading towards the restaurant was flat without any high or low areas in the sidewalk. There were large blocks of cement with cracks in between each block, which there were no elevation of the sidewalk between each block. The three blocks of sidewalk leading right up to the sidewalk in front of the restaurant was not smooth. It was rough and there were pieces of the sidewalk that had been chipped away, but they were not large pieces. There was a slight downward slant as the sidewalk went toward the restaurant. During an interview on 1/26/17 at 8:39 a.m., LEA #3, LEA #4 and LED was in attendance. LEA #4 indicated she was walking down the hallway one day and she walked past PT #9 and in passing mentioned if she knew why Resident #28 dropped her feet and PT #9 indicated she did not know because she was not her resident, but she would check into it. LEA #4 indicated the resident would do real good for awhile holding her feet up, while being pushed in her wheel chair, then she dropped her feet and the wheelchair stopped suddenly and she leaned forward, so everyone just knew when you were pushing her to go slow with her in case she dropped her feet. She didn't know why the resident dropped her feet. During an interview on 1/26/17 at 9:45 a.m., CRCA (Certified Resident Care Assistant) #6 and CRCA #7 were in attendance. CRCA #7 indicated the resident moved her feet slowly on the floor at times while being transported in the w/c. The CRCA's transported her where ever she needed to go. CRCA #6 indicated Resident #28 held her legs up in a criss-cross manner and when she planted her feet on the floor all of a sudden without warning the w/c stopped, so suddenly with such force, the person transporting her was propelled into the back of the w/c forcefully and the resident tipped forward in the wheelchair. CRCA #6 indicated she was afraid she would fall out of the wheelchair at some point. She indicated the last time she reported the resident dropping her feet during transport was a few months ago and she had reported her doing this a few times, but she did not know how many times and she would not want to guess. She indicated she reported it to her nurse. CRCA #6 indicated Resident #28 did not get her foot pedals until she fell out of her wheelchair onto the sidewalk. She indicated she did not have foot pedals available prior to the fall because no one could find the foot pedals, which went with her wheelchair and the foot pedals to the wheelchairs were hard to find. CRCA #7 indicated PT #9 was looking for the resident some foot pedals two to three months ago, but she never got them until she fell . She indicated therapy had worked with the resident before. During an interview on 1/26/17 at 10:08 a.m., RN #8 indicated the resident did not have foot pedals until she fell out of her w/c on the activity outing. She indicated when she was transporting her or when she seen other staff members transporting her she would see the resident plant her feet on the floor and she would tip forward in the w/c at times. She indicated she did not notify anyone because she understood the resident did not want the foot pedals, but that request was not written anywhere. During an interview on 1/26/17 at 10:12 a.m., PT #9 indicated Resident #28 would pitch forward in her w/c when her feet dropped without her foot pedals. She indicated she did not document anything about the concern from LEA #4 regarding the residents feet dropping or the foot pedals being applied to the wheelchair after the concern was brought to her attention. 3.1-45(a)(2)

Based on observation, interview and record review, the facility failed to ensure pressure ulcers were assessed appropriately for 5 of 5 residents (Residents F, G, H, J and K) and the facility failed to implement pressure ulcer prevention interventions and ensure treatments were ordered in a timely manner for 3 of 3 residents being reviewed for pressure ulcers. (Residents F, H and J) This deficient practice resulted in Resident H developing an Unstageable pressure ulcer (Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray green or brown) and/or eschar (tan, brown or black) in the ulcer bed. Until enough slough or eschar is removed to expose the base of the ulcer, the true depth and therefore stage cannot be determined.) to her sacral area. Findings include: 1. Resident H's record was reviewed on 11/18/15 at 2:27 p.m. [DIAGNOSES REDACTED]. Nursing Admission Assessment & Data Collection dated 7/11/15, under the Skin Plan of Care indicated the body diagram had an X marked on the sacral area with no explanation as to why the X was documented on the diagram. A Skin Impairment Circumstance Assessment and Intervention sheet dated 8/9/15, indicated the resident had a Stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink ulcer bed without slough. May also present as an intact or open/ruptured serum filled blister) pressure ulcer to her sacrum area. No measurements were documented. A Pressure/Stasis/Arterial/Diabetic Ulcer Assessment dated 8/26/15, indicated the resident had a Unstageable pressure ulcer to her sacrum. The wound measured 3.0 x 2.5 cm (centimeters). The color of the wound was red outer edges with yellow slough wound bed. The initial identification of the wound was dated 8/26/15. There were signs and symptoms of infections and the resident indicated she was having pain at the site. The wound was a facility acquired wound. The Physician orders [REDACTED]. Roho mattress to bed-check inflation every shift by pressing down with palm of hand. Roho cushion to wheelchair-check inflation every shift, re-inflate if needed. Typed interview statement by the Medical Records staff member dated 9/11/15, indicated, During CCM (Clinical Care Meeting) 8/10, the team reviewed a skin impairment circ (circumstance) form for resident (name of this resident) dated 8/9-pressure area to sacrum at a stage 2. There was no treatment order listed for this resident. (Name of nurse) wrote on his pad of paper / 'to do' list to follow up. (Name of nurse) not at work on 8/26. He asked (Name of Medical Record staff member) and (Name of Staffing Coordinator) to complete wound rounds. During CCM, they reviewed a skin circ form for resident (name of this resident) for pressure area to sacrum described as Unstageable. This triggered them to review her during wound rounds. During observation of resident on 8/26, a dressing ([MEDICATION NAME]) was noted to the sacrum area-no order in place, not on MAR (Medication Administration Record) to be signed off. The dressing 'appeared' to have been on there awhile-edges rolled up. Wound observation to sacrum-angry around the edges, yellow slough covering wound bed. Wound bed 'soggy' with clear drainage Typed interview statement by the Staffing Coordinator dated 9/11/15, indicated, During 8/9 CCM she (Staffing Coordinator) was in CCM and reviewed 100/200 hall. (Name of nurse) reviewed his hallway of responsibility 300 hall, where resident (name of this resident) resides. Reviewed 8/9 circ form for this resident was in place for a stage 2 to the coccyx. No treatment was listed. (Name of nurse) stated 'I will follow up on that.' He wrote on his note pad to follow up, as he normally does. 8/26, (Name of nurse) was out this day and asked (Name of Staffing Coordinator) and (Medical Records staff member) to do wound rounds. During CCM, they noted on the 24 hour report for resident (Name of this resident)-'please look at coccyx-it looks bad.' This triggered them to include her into the wound rounds. Wound observation- .Noted [MEDICATION NAME] in place to sacrum and dressing 'appeared' to have been on there for a 'long time.' Resident complained of pain to the area when they removed it. Outer area was red/angry, inner area was covered with slough. Could not measure depth . Looked through res (resident's) chart. Noted admit assessment on 7/11 had a X marked on the sacral area, but no description. Nurse was interviewed and she told (Name of Staffing Coordinator) the area was not open, only red. Found 8/9 skin circ documenting a stage 2 to the sacrum and that nothing had been done with it at that time (no treatment implemented) On 11/19/15 at 11:36 a.m., the Executive Director, Director of Health Services (DHS) and the Assistant Director of Health Services (ADHS) were all in attendance. At that time the DHS indicated the management team reviewed all the wounds in the building. She indicated the process to identify wounds started with the CNA's when they gave the residents their showers they would notify the charge nurse if they found any new areas. She indicated after the nurses were notified they would document the new areas either on a pink or green sheet, then they would follow up with the physician for orders. The ADHS indicated the issue with Resident H's pressure ulcer was no one noticed it when it was a Stage II, so there was no treatment or interventions implemented, then it progressed to an Unstageable wound. The ADHS indicated the reason the nurses did not notice the Stage II pressure ulcer on Resident H's sacrum, which progressed to an Unstageable wound was because skin checks were not completed every Wednesday as ordered. On 11/19/15 at 11:48 a.m., with the ED, DHS, ADHS, Medical Records staff member and Staffing Coordinator were all in attendance. At that time the Staffing Coordinator indicated Resident H's pressure ulcer developed into an Unstageable wound between 8/9/15 and 8/25/15. She indicated RN #6 wrote notes on his pad of paper during the morning clinical meeting the day the Stage II pressure ulcer was brought to their attention. She indicated RN #6 always wrote notes indicating he would follow-up on things, so she thought he was following up on the Stage II pressure ulcer from 8/9/15, so she did not have any idea the resident's wound was not being treated until the next time it was brought to their attention on 8/26/15 during the clinical care meeting. She indicated they had pulled all the CNA shower sheets up to that date and they all indicated the shower sheets were signed off by the CNA's and nurses and the skin was Okay. She indicated she and the Staffing Coordinator did wound rounds on 8/26/15, for RN #6 and that was when they discovered the Unstageable wound to Resident H's sacrum with no treatment or interventions implemented. 2. Resident K's record was reviewed on 11/23/15 at 11:11 a.m. [DIAGNOSES REDACTED]. A Nursing Admission Assessment & Data Collection note dated 11/13/15, indicated the Skin Plan of Care had an X marked on the body diagram on the left side of the middle of the back. abrasion was documented above the X with a line drawn toward the X mark on the diagram. A Pressure/Stasis/Arterial/Diabetic Ulcer Assessment sheet dated 11/19/15, indicated the initial identification of the pressure ulcer was 11/19/15. The wound was facility acquired. The location of the wound was to the right second toe. No stage was documented on the form. The wound measured 0.7 x 0.5 cm. The color was black. The Physician order [REDACTED]. The Physician order [REDACTED]. During an interview on 11/19/15 at 11:15 a.m., the DHS indicated the Nursing Admission Assessment did not indicate Resident K had an Unstageable pressure ulcer to her right 2nd toe area. She indicated the pressure area was found when management did a skin sweep on 11/19/15. The DHS indicated she identified this pressure ulcer as a facility acquired wound since the nursing staff did not identify it upon the resident's admission to the facility. She indicated the wound was an Unstageable pressure ulcer and was inside the resident's hammer toe. On 11/23/15 at 2:01 p.m., the Assistant Director of Health Services removed the piece of gauze between the right great and 2nd hammertoe. On the inner right 2nd toe area a black circle area the size of a pencil point tip was observed with redness surrounding the black area. The gauze was replaced between the two toes. 3. The clinical record of Resident #F was reviewed on 11/19/2015 at 10:45 a.m. [DIAGNOSES REDACTED]. Resident #F was admitted to the facility on Monday 11/9/2015 and was assessed for pressure ulcers. Resident #F had an Unstageable ulcer on her right foot/ heel and a pressure ulcer on her left inner ankle area which was red. No measurements were taken by admitting staff. A Physician order, dated 11/11/2015, indicated Skin Prep to inner right heel every shift until heeled. A Physician order, dated 11/12/2015, indicated Skin Prep every shift to left inner heel/ankle. On 11/19 /2015 at 2:02 p.m., the Director of Health Services(DHS) was observed assessing Resident #F for pressure ulcers. Resident #F did have a stage 1 pressure ulcer to her left ankle with a 2 cm x 2 cm measurement . Resident #F had an Unstageable right ankle pressure ulcer measurement of 1.7 cm x 0.5 cm. During an interview on 11/19/2015 at 11:30 a.m., the Director of Health Services(DHS) indicated Resident #F was admitted to the facility on [DATE] and treatment for [REDACTED]. The Director of Health Services indicated Resident #F should have been treated for [REDACTED]. 4. The clinical record of Resident #J was reviewed on 11/23/2015 at 1:55 p.m. [DIAGNOSES REDACTED]. Resident #J was admitted to the facility on Wednesday 8/26/2015 and was assessed for pressure ulcers. Resident #J had an Unstageable ulcer on her right heel, which measured 2.5 cm x 2.5 cm and the color was black. A Physician order [REDACTED]. A Physician order [REDACTED]. A record review of the Medication Administration Record [REDACTED]. No other weekly assessments were completed for the resident. During an interview on 11/19/2015 at 11:30 a.m., the Director of Health Services indicated Resident #J was admitted to the facility on [DATE], and treatment for [REDACTED]. Medication record sheet indicated weekly skin assessments were completed x 1 on 9/4/2015, and no other assessments were completed. The Director of Health Services indicated Resident #J should have been treated for [REDACTED]. 5. On 11/18/15 at 1:59 p.m., the record review for Resident G was completed. [DIAGNOSES REDACTED]. The AMDA (The Society for Post Acute and Long Term Care Medicine) 2008 Stages of Pressure Ulcers indicated: Stage II- Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink ulcer bed without slough. May also present as an intact or open/ruptured serum filled blister. Stage III- Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. A document titled 'Wound Tracking', dated 10/14/15,. indicated the resident had a Stage III Wound on the right hip. On 11/19/15 at 11:30 a.m., the wound sheets were provided by the Director of Health Services for Resident G's current wounds. The wound sheets indicated: 9/30/15 -Week #1-Right hip area #2 was a Stage 2 and measured 5.2 centimeters (cm) x 3.0 cm x 0.1 cm. The exudate (drainage of fluid from a wound) was pink. The wound bed Color/tissue type/percent/location- pink tissue. The Periwound was documented as pink. The comments section indicated the treatment was [MEDICATION NAME] and to continue current treatment and indicated 'healing'. 10/7/15- Week #2 -Right hip area #2, there was no stage documented. The wound was 2.0 cm x 3.0 cm x <0.1 cm and exudate was pink. The wound bed Color/tissue type/percent/location- pink tissue. The Periwound was documented as pink. The comments section indicated the treatment was [MEDICATION NAME] and to continue current treatment and indicated healing. 10/14/15- Week #3-Right hip area #2, indicated was now a Stage III. The wound measured 2.5 cm x 3.0 cm. The exudate indicated slough, no odor and scant amount of drainage. There was pain and the treatment was changed to Collagen. Current preventative interventions portion of documentation indicated, .wound worse MD/resident notified 10/21/15- Week #4- Right hip area #2 indicated pressure Stage II. The area measured 1.6 cm x 1.6 cm x 0.1 cm . The exudate was red. There was no odor Amount : 0 Consistency : 0 . Wound bed Pain: 0 Color/tissue type / percent/ location: granulation tissue. The wound margins were intact. The surrounding tissue was pink. The current treatment was Collagen. Current preventative interventions: Significant improvements. The medical interventions section was left blank. 10/27/15- Week #5- Right hip area #2- Stage II. The area measured 0.6 cm x 1.0 cm x <0.1 cm. The exudate was documented as Color: red Center Odor: 0 Amount : 0 Consistency :0 Wound bed : Pain : no. Color/tissue type / recent/ location : Pink. Current treatment : Collagen & dressing Current preventative interventions: wound is healing. 11/3/15: Week #6- Right hip area #2 -Stage II The area measured 0.5 cm x 1.0 cm x <.1 cm. The exudate: red center. Pain: A little Color/tissue type / recent/ location : pink. Wound Margins: Intact. Surrounding tissue: pink and the current treatment was Collagen and [MEDICATION NAME] . 11/11/15: Week #7- Right hip area #2. Stage II. The area measured 2.2 cm x 2 cm x <0.1 cm. The exudate was documented as beige consistency, some slough. Color/tissue type / percent/ location : pink. Wound Margins: Intact. Surrounding tissue: pink and the treatment was changed to dressing. The current preventative interventions was check fitting on wheelchair , Thera honey and [MEDICATION NAME] change daily and monitor. A request was made from the DHS on 11/19/15 at 11:09 a.m. for the pressure prevention information or any policies. In an interview on 11/19/15 at 12:02 p.m., the DHS indicated they were not sure why the wound for Resident G was assessed at Stage 2 on 10/7/15, then on 10/14/15, as a Stage III with slough, then Stage II again on 10/21/15. The DHS indicated she understood concern with difference in assessment of wound as well as the documentation for assessment was not complete in regards to exudate, wound bed, and interventions and treatment. A current policy titled Basic Wound Interventions undated, provided by the DHS on 11/19/15 at 11:00 a.m., indicated .8. Evaluate wound daily . 9. Assess and document progress toward healing at least every 7 days or with significant change in appearance of wound. Documentation includes, but is not limited to size, color, drainage and odor A current policy titled Pressure Prevention Guidelines undated, provided by the DHS on 11/19/15 at 11:35 a.m., indicated Purpose: To maintain good skin integrity and avoid development of pressure ulcers . Hygiene: Inspect the skin daily during care for signs of breakdown or changes to the skin. Activity/Mobility: Place on pressure reduction support surface (bed-chair), Place on pressure relief mattress, Obtain an advanced pressure reduction cushion for wheelchair A current policy titled General Wound and Skin Care Guidelines undated, provided by the DHS on 11/19/15 at 11:35 a.m., indicated . Procedure: The following general wound and skin care guidelines should be followed for all residents with potential and/or actual impairment in skin integrity .15. Reevaluate dressing and skin integrity every shift. 16. Reevaluate the wound's response to the prescribed treatment. Make recommendations for changes PRN (as needed). Inform MD (doctor) of changes in wound status . 20. Document type of wound, location, stage (if applicable), length, width, depth (in cms (centimeters)), base drainage, periwound tissue, and treatment of [REDACTED]. This Federal tag relates to Complaint IN 782. 3.1-40(a)(1) 3.1-40(a)(2)

Based on observation, interview and record review, the facility failed to ensure interventions related to alarms, footwear, and toileting were in place to prevent residents from falling resulting in a resident (#36) sustaining a fractured neck. This practice affected 5 of 7 residents with falls in a sample of 14. (Residents #17, #36, #44, #45, #50). Findings include: 1. Resident #36's record was reviewed on 08/16/2011 at 1:35 P.M. [DIAGNOSES REDACTED]. A MDS (Minimum Data Set) assessment, dated 02/20/2011, indicated the resident required supervision and a one person physical assist for transfers and for toilet use. The MDS indicated Resident #36 required the use of a walker for mobility. The resident was admitted to the hospital for congestive heart failure and returned to the facility on [DATE]. A nursing admission assessment and data collection form, dated 03/11/2011, indicated Resident #36 was independent with use of a wheelchair. The form indicated resident "has disease or condition that predisposes to falls...Y (yes) circled... Takes meds that may affect balance, cognition or gait....Y circled..." The safety plan of care section of the form indicated no interventions were checked. The nursing assessment indicated resident experienced urge incontinence and "...can't get to bathroom in time..." The form indicated resident was alert and oriented. A care plan, dated 04/13/2011, indicated resident fell [DATE]. Interventions marked indicated "...invite, encourage, remind, escort to activity programs consistent with resident interests to enhance physical strengthening needs...." An accident/incident report, dated 03/29/2011 at 12:15 A.M., indicated..."res (resident) found on floor at foot of lazy boy chair, lying on left side, states did not know how she got from chair to floor AOx3 (alert and oriented times three). No visible injuries noted. Physician statement/orders: observe... Additional information: found out that (res) took sleep aide (sic) as prescribed prn (as needed) reminded (res) to lie down in bed. (Res) requesting to sit up in chair." An interview with the DON on 08/16/2011 at 2:20 P.M., indicated Resident #36 had taken Ambien (sleeping pill) prior to the fall. The DON indicated resident refused to go to bed and wanted to sit in her recliner. A Fall Circumstance, Assessment, and Intervention form provided by the DON on 08/16/2011 at 2:20 P.M., indicated resident fell on [DATE] at 12:15 A.M. The form indicated Resident #36 was "... transferring herself...safety equipment in place and functioning at time of incident...N (no) circled." The fall risk reassessment completed on the form indicated "...Resident requires assistance to transfer.. N circled.... Resident requires assistance to ambulate safely with or without assistive devices...N circled...Resident refuses to comply with safety measures such as call light use, alarms, appliances, etc...N circled." The prevention update completed on the form indicated, "...instructed to always use call light and encouraged to go to bed p (after) becoming sleepy...neurochecks initiated...." An accident/incident report, dated 03/29/2011 at 4:40 A.M., indicated..."res sitting in chair asleep at 4:20 A.M., roommate call out (sic) at 4:40 A.M., when res fell getting up call lite (sic) on armrest." The report indicated "....observed on floor...no apparent injury.... neck pain...." A nurses note, dated 03/29/2011 8:20 A.M., indicated "Late entry...d/c (discontinue) Ambien 10mg (milligrams) PO (by mouth) QHS (every night at bedtime), x-ray of L (left) side neck spine et (and) clavicle area, r/t (related to) pain c (with) recent falls...." A nurses note, dated 03/29/2011 at 1:30 P.M., indicated "...received x-ray result via fax of residents L side neck/spine et clavicle area, discussed results with (nurse practitioner). Writer et NP (nurse practitioner) assessed resident, she was c/o (complaining of) headache et neck pain. NP wrote new orders to send to ER (emergency room ) c cervical collar et hold coumadin (blood thinner) ... EMS called...." A Fall Circumstance, Assessment, and Intervention form provided by the DON on 08/16/2011 at 2:20 P.M., indicated resident fell on [DATE] at 4:40 A.M. The form indicated Resident #36 "...found on the floor...sitting in chair fell asleep fell out." The form indicated "...sleeping pill given..." The fall risk re-assessment completed on the form indicated..."Resident requires assistance to transfer...Y circled...Resident requires assistance to ambulate safely with or without assistive devices...Y circled....Resident requires use of an assistive device and/or often forgets to use device...Y circled..." The prevention update completed on the form indicated, "....neurochecks, bed and or chair alarm, bed in low position...." A history and physical from the hospital, dated 03/29/2011, indicated, "...resident who sustained 2 falls...she states she hit the right side of her head...the family believes she was given a sleeping pill before she went to sleep and got up on her own....radiology studies...CT (cat scan) of her neck shows C2 (cervical spine #2) vertebral body fracture and C5 fracture...." A nursing admission, assessment and data collection form, dated 03/31/2011, indicated Resident #36 was admitted from the hospital with C2 and C5 fractures with a cervical collar on. The form indicated resident was dependent on staff with an assist of one for grooming, transfers, bathing, dressing and toileting. The form indicated resident was experiencing moderate amount of pain frequently in her neck. An interview with the DON on 08/16/2011 at 4:30 P.M., indicated after the first fall, the nurse had encouraged Resident #36 to go to bed but she was placed back in the recliner. The nurse had made sure her call light was in reach. DON indicated no other interventions were initiated and indicated resident's mental status was likely affected by the use of the sleeping pill. An interview with the MDS Coordinator during initial tour on 08/15/2011 at 9:35 A.M., indicated Resident #36 had fallen in the facility and had received the cervical fractures. The MDS Coordinator indicated the resident had a setback from the fractures, resulting in decreased mobility. Resident had recently had the cervical collar removed and had been undergoing therapy. Interview on 8/19/11 at 10:50 A.M., with the Executive Director indicated there was no neurological assessment on the investigation form after the first fall. She stated "if the nurse thought there was a problem with her orientation, she wouldn't have put her back in the recliner." 2. The record for Resident #45 was reviewed on 08/18/11 at 8:45 a.m. [DIAGNOSES REDACTED]. The most recent quarterly Minimum Data Set (MDS) Assessment, dated 06/22/11, indicated Resident #45 had impaired cognition. Resident #45 missed reporting the correct year by 2-5 years, recalled 2 of 3 words after first attempt, but recalled 0 of these 3 words later in the assessment. Resident #45 was assessed to need extensive assistance with one person physical assist for transfers and toilet use. The MDS indicated the resident used a wheelchair. When moving from seated to standing position or moving on and off the toilet, Resident #45 was not steady and could not stabilize without human assistance. The MDS indicated Resident #45 had two or more falls without injury since admission. A recapitulation dated for 08/01/11 through 08/31/11 indicated, "...Apply Velcro self-releasing belt to w/c for resident safety. Check every shift...." A care plan, dated 07/12/2011, titled, "Restraint/Enabler," indicated, Resident #45 had poor safety awareness and had a history of [REDACTED]." A care plan, dated 07/12/2011, titled, "Falls," indicated, "At risk for fall/injury AEB (as evidence by) History of Falls...R/T (related to) Disease process/condition (list): Dementia...." Interventions included, but were not limited to, "...Call light within reach...Provide/monitor use of adaptive devices...Wheelchair...Lock breaks (sic) on bed, chair, etc before transferring...Appropriate footwear...Additional approaches: Sensor alarm to bed...Velcro self-release seat belt to w/c (wheel chair)...Offer to toilet frequently while awake...." A Fall Circumstance, Assessment and Intervention form, dated 05/08/11, indicated a certified nursing assistant heard the resident fall at 7:30 a.m., in the resident's bathroom. The form indicated Resident #45 was transferring self. Coccyx was listed as injury location. The form indicated, "...Equipment inspection: Safety equipment in place and functioning at time of incident?...." A capital "N" was circled next to that line. The form indicated, "...wheelchair brakes locked?...." A capital "N" was circled next to that line. The "Fall" care plan had an entry dated 05/08/11 that indicated, "...maintain current fall precautions keeping resident safe...." A Fall Circumstance, Assessment and Intervention form, dated 06/09/11, indicated Resident #45 was found on the floor of the bathroom.. The boxes for transferring self and toileting were checked related to the activity at time of fall. The form indicated, "...Wheelchair brakes locked?...." A capital "N" was circled next to this line. The "Fall" care plan had an entry dated 06/09/11 that indicated, "...continue all safety measures to keep safe when...falls...." A Fall Circumstance, Assessment and Intervention form, dated 06/14/11, indicated Resident #45 was found on the floor of the room at 10:00 a.m. The form indicated the activity at the time of the fall was transferring self. The "Fall" care plan had an entry, dated 06/14/11, that indicated, "...continue all safety measures...." A Fall Circumstance, Assessment and Intervention form, dated 07/22/11, indicated Resident #45 was found on the floor at bedside. The form indicated the activity at the time of the fall was transferring self. The form indicated, "...Equipment inspection:...Wheelchair brakes locked?...." A capital "N" was circled next to that line. The "Fall" care plan had an entry dated 07/22 (no year) that indicated, "...continue...safety measures...." During an interview on 08/18/11 at 1:10 p.m., when asked about new interventions after each fall, the Director of Nursing (DoN) indicated, "We didn't know what else to do." The DoN indicated Resident #45 recently started day programming on the dementia unit. 3. On 8/15/11 at 11:15 A.M., Resident #50 was observed in his room. There was a sensor alarm and scoop mattress in place on the bed. There was a floor mat next to the bed. On 8/17/11 at 10:45 A.M., Resident #50 was observed sitting in his wheelchair in the hallway. There was an alarming seat belt in place. The record for Resident #50 was reviewed on 08/16/11 at 10:30 a.m. [DIAGNOSES REDACTED]. The most recent quarterly Minimum Data Set (MDS) Assessment, dated 06/08/11, indicated Resident #50 was cognitively impaired. The mental status questions were answered by staff. The MDS indicated Resident #50 had a short and long-term memory problem. The MDS indicated Resident #50 was severely cognitively impaired. The MDS indicated Resident #50 required extensive assistance with two or more person assist for transfers and toilet use. The MDS indicated the resident used a wheelchair and was only able to stabilize with human assistance. The MDS indicated Resident #50 had two or more falls without injury since admission. A recapitulation, dated for 08/01/11 through 08/31/11, indicated, "...self-releasing seat belt to w/c (wheelchair) for safety & check function/placement every shift...." A physical therapy discharge summary, dated 06/22/11, indicated, "...has had a decline in his functional mobility since falling out of his W/C on 05/13/11...resident with hx (history) falls and current use of self-releasing seat belt...able to ambulate only with assist...D/C (discharge) due to reaching max potential at this time...remains at risk for falls due to poor safety awareness/cognitive impairments. Continued use of self-releasing belt in w/c indicated...." A care plan titled, "Falls" dated 03/01/2011 indicated, "Falls At risk for fall/injury AEB (as evidence by) History of Falls...poor safety awareness...." Interventions included, but were not limited to, "...Call light within reach...Wheelchair...Lock breaks (sic) on bed, chair etc before transferring...self releasing seat belt...." Restraint/Enabler Circumstance, Assessment and Intervention form, dated 02/03/11, indicated a self-releasing seat belt alarm was considered. "Fall" was circled as the reason for request. A Fall Circumstance, Assessment and Intervention form, dated 02/17/11 at 4:30 p.m., indicated Resident #50 was found on the floor of the bathroom. The form indicated, "...Placed in B.R. (bathroom). The form lacked documentation of the specific circumstances of the incident. The form indicated the activity at the time of the fall was transferring self and toileting. An entry on the "Fall" care plan, dated 02/17/11, indicated to evaluate the function of the seatbelt. A Fall Circumstance, Assessment and Intervention form, dated 02/27/11 at 7:45 a.m., indicated the resident fell in the bedroom without injury. "...Bedside mat..." was added to "Fall" care plan. A Fall Circumstance, Assessment and Intervention form, dated 03/18/11 at 10:15 a.m., indicated Resident #50 was found on the floor and was transferring self. "Resident to remain in common areas..." was added to "Fall" care plan. A Fall Circumstance, Assessment and Intervention form, dated 04/18/11 at 1:00 p.m., indicated Resident #50 was found on the floor of the resident's room. The activity at the time of the fall indicated Resident #50 was transferring self. , "...Remind staff to re-connect seat belt {the sign for after} meals...." was added to "Fall' care plan. A Fall Circumstance, Assessment and Intervention form, dated 04/27/11 at 4:30 p.m., indicated resident fell and to continue with all safety measures. The form indicated the resident was trying to stand. A Fall Circumstance, Assessment and Intervention form dated 05/28/11 at 1:50 p.m., indicated the resident took apart alarm and tried to ambulate and fell in the television lounge. A "Fall" care plan entry, dated 05/28/11, indicated, "...MD notified of (sign for increase) anxiety. A Fall Circumstance, Assessment and Intervention form, dated 05/11/11 at 11:00 a.m., indicated resident lifted the lift chair independently and attempted to transfer self. Other comments indicated to contact the family to provide a different chair. A Fall Circumstance, Assessment and Intervention form, dated 07/05/11 at 11:00 a.m., indicated Resident #50 fell in resident's room. The form indicated, "...Resident's chair alarms working , but @ x (time) of fall it was off...." Other comments indicated, "...Staff education to turn SB (seat belt) back on (sign for after) meals....' A Fall Circumstance, Assessment and Intervention form, dated 07/29/11 at 9:00 a.m., indicated, Resident #50 fell in resident's room and complained of right hip pain. The activity at the time of fall was transferring self. The form indicated, "Equipment inspection: Safety equipment in place and functioning at time of incident?...." A capital "N" was circled at the end of that line. "....Wheelchair brakes locked?...." A capital "N" was circled at the end of that line. The other comments indicated, "...staff educ (educated) Therapy screen...." A Rehabilitation Screen for Resident #50, dated 08/01/11, indicated, "...Report of fall in room...possibly attempting to transfer self...remains fall risk...poor safety awareness. Continues (sign for with) self-releasing (alarm) seat belt...No skilled intervention this date...." A Rehabilitation Screen for Resident #50, dated 08/10/11, indicated, " ...continues to require alarming seat belt...No skilled intervention this date...." During an interview on 08/18/11 at 1:10 p.m., the Director of Nursing (DoN) indicated staff was re-educated to fasten seat belt after meals. the DoN indicated staff had been re-educated multiple times. The DoN indicated Resident #50 should not have had access to remote on lift chair and fall reports should be more detailed. 4. On 8/15/11 at 9:45 A.M., during an initial tour with LPN #1, Resident #17 was identified as being in a wheelchair, incontinent, having a bed and chair alarms, and having had a fall the previous weekend with no injuries. On 8/15/11 at 11:50 A.M., Resident #17 was observed sitting in a wheelchair in the dining room. There was a chair alarm in place. On 8/16/11 at 3:05 P.M., Resident #17 was observed sitting in a wheelchair next to his bed in his room. There was a chair alarm in place. There was no motion sensor in the room. Resident #17's clinical record was reviewed on 8/16/11 at 1:35 P.M. The record indicated the resident was admitted with [DIAGNOSES REDACTED]. A hospital charting report, dated 7/19/11, indicated "...He is demonstrating significant memory difficulties that are consistent with his report and would certainly not be inconsistent with a generalized pathology such as normal pressure [DIAGNOSES REDACTED]...the patient clearly requires 24 hour supervision, and does not appear cognitively able to independently manage his own affairs at the present time...balance: fair to sit, poor to stand...up with assist; high fall risk (balance, cognition)..." A physician's admission orders ...Safety Devices: bed alarm...Mobility: Up with assist only until cleared by PT (physical therapy)..." A physical therapy note, dated 8/8/11, indicated "...Decline in functional mobility with several recent falls backwards and difficulty walking...Balance...Static Standing...Fair...Dynamic Standing...Fair-/Fair...Fall Risk...Max (maximum)...Safety Awareness...Fair-...He presents with weakness, slow gait with decreased heel strike and difficulties with tranfers (sic). He requires assist for gait and all mobility at this time..." A "Nursing Admission Assessment & Data Collection" form, dated 8/6/11, indicated "...Transfer with assist of one...Assistive device:...Walker/W/C (wheelchair)...Safety...Alarm type: bed...High fall risk, recent falls...Safety Plan of Care...Toilet resident per toileting schedule...Implement restraint to assist with fall prevention: Type: bed alarm..." An "Occupational Therapy Initial Plan of Care," dated 8/8/11, indicated "...Toilet hygiene...Mod (moderate)...Static Standing...Fair-...Dynamic Standing...Poor+...Fall Risk...High...Safety Awareness...Imp (impaired)..." A fax to the physician, dated 8/8/11, indicated "Res (resident) found sitting on floor in BR (bathroom). ROM (range of motion) WNL (within normal limits). Denies pain or discomfort." A "Fall Circumstance Assessment and Intervention" form, dated 8/8/11 indicated "...Time of fall 1600 (4:00 PM)...Location of fall: Bathroom...Witnessed: N (no) (circled)...Found on floor: (indicated by checkmark)...Activity at time of fall: Transferring self (indicated by checkmark)...Toileting (indicated by checkmark)...Personal inspection:...Toileting needs (indicated by checkmark)...Safety equipment in place and functioning at time of incident? Y (yes) (circled)...Prevention Update...Bed alarm ...Being seen in therapy for multiple falls. Adding chair alarm..." Documentation was lacking related to whether the resident was sitting in a wheelchair or in bed at the time of the fall. A "Safety Plan of Care," dated 8/6/11 and updated 8/9/11, indicated "...chair alarm..." A fax to the physician, dated 8/9/11, indicated "...fell in bathroom - small abrasion to coccyx (L) (left) upper back & (L) leg. Denies pain, able to move all extremities..." A "Fall Circumstance Assessment and Intervention" form, dated 8/9/11, indicated "...Time of fall 2P...Location of fall: restroom...Witnessed: N (no) (circled)...Found on floor: (indicated by checkmark)...Activity at time of fall: Transferring self (indicated by checkmark)...Personal inspection:...Toileting needs (indicated by checkmark)...Safety equipment in place and functioning at time of incident? Y (yes) (circled) alarm sounded...brought self to bathroom - wearing socks, slid...Prevention Update...Therapy evaluation...Frequently used items within reach...Nonskid footwear..Teach w/c safety...chair alarm (has)...Add non-skid footwear..." Documentation was lacking related to whether the resident was sitting in a wheelchair or in bed at the time of the fall. A "Safety Plan of Care," dated 8/6/11 and updated 8/10/11, indicated "...non-skid footwear..." A fax to the physician, dated 8/14/11, indicated "...Slid off side of bed trying to stand to use urinal. No injury noted..." A "Fall Circumstance Assessment and Intervention" form, dated 8/14/11, indicated "...Time of fall 2315 (11:15 P.M.)...Location of fall: (room number)...Witnessed: N (no) (circled)...Found on floor: (indicated by checkmark) next to bed...Activity at time of fall: Turning in bed (indicated by checkmark)...Turning in bed to use urinal slipped off side of bed...Resident had bed higher than usual with foot of bed elevated also...Safety equipment in place and functioning at time of incident? Y (yes) (circled)...Resident had moved bed higher off ground. Was attempting to stand next to bed to use urinal and was unable to touch the floor due to bed higher...Prevention Update...Call bell...Low bed...Bed in low position...Motion detector...Add scoop mattress..." A "Safety Plan of Care," dated 8/6/11, indicated documentation was lacking to address keeping the bed in low position and the use of a scoop mattress. Interview on 8/17/11 at 8:25 A.M., with OT (occupational therapist) #3 indicated Resident #17 was a high fall risk and his standing balance was "fair." He required assistance for toileting and ambulation. Interview on 8/17/11 at 8:28 A.M., with PT (Physical Therapist) #4 indicated Resident #17 "needs cueing" and was a high fall risk. She indicated there were "safety concerns." She stated "he has short-term memory problems." Interview on 8/16/11 at 3:06 P.M., with the Director of Nursing indicated the bed alarm "apparently was not sounding" for the 8/8/11 fall. She indicated the resident did not have a motion detector at the bedside. She indicated there was no documentation of a toileting program for the resident. 5. On 8/15/11 at 9:45 A.M., during an initial tour with LPN #1, Resident #44 was identified as being ambulatory with a walker, having no alarms, being incontinent, and having had no falls. On 8/16/11 at 2:35 P.M., with LPN #2, Resident #44 was observed ambulating with a walker to and from the bathroom. After leaving the bathroom, the resident went back to her bed. She left the walker at the bedside and started to walk to the door to the room. LPN #2 reminded the resident to get her walker. The resident got her walker and left the room with no staff in attendance and ambulated to the nurses' station. Resident #44's clinical record was reviewed on 8/17/11 at 12:40 P.M. The record indicated the resident was admitted with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) 30-Day Assessment, dated 7/26/11, indicated the resident was cognitively intact, required limited one-person physical assistance for transfer, ambulation, and toilet use, was not steady but able to stabilize without human assistance, and had had one fall without injury. An "Occupational Therapy Initial Plan of Care," dated 6/1/11, indicated "...Static Standing...fair+...Dynamic Standing...fair...Fall Risk...mod (moderate)...." A "Physical Therapy Initial Plan of Care," dated 6/1/11, indicated "...Static Standing...fair-...Dynamic Standing...poor+...Fall Risk...Elevated..." A resident care plan, dated 6/20/11, indicated "...Falls...remind resident and reinforce safety awareness...appropriate footwear..." A fax to the physician, dated 7/9/11, indicated "...Resident found on floor near bathroom door. Res didn't call for assistance nor did she use her walker. No noticeable injuries but resident stated she hit her head & c/o (complains of) lower back pain..." A "Fall Circumstance Assessment and Intervention" form, dated 7/9/11, indicated "...Time of fall 0330 (3:30 A.M.)...Location of fall: residents room...Witnessed: N (no) (circled)...Found on floor: (indicated by checkmark)...Walking to bathroom unassisted without walker (non-compliant c (with) walker use)...Activity at time of fall: Transferring self (indicated by checkmark)...Toileting (indicated by checkmark)...Ambulating (indicated by checkmark)...Resident had no shoes or grippy socks...Safety equipment in place and functioning at time of incident? Present/Available...Resident chose to take self to bathroom without use of walker or staff assistance...Prevention Update...Toilet q20 (every two hours) as desired c (with) assistance...nonskid footwear...Remind resident to use walker & non-skid socks..." A resident care plan, dated 6/20/11 and updated 7/11/1,1 indicated "...non-slip socks..." Documentation was lacking to address toileting the resident every two hours. A nurses' note, dated 7/20/11 at 9:30 A.M., indicated "Residents (sic) seems to be confused @ times...Today resident is transferring self c (with) out safety devices. Writer reminding resident to use walker. Resident also as (sic) an unsteady gait et (and) c/o not feeling well..." A fax to the physician, dated 7/23/11, indicated "...Res (resident) became dizzy this AM when getting out of bed. Knees became weak et fell to knees the to (L) elbow et shoulder. 0 (no) injuries noted at this time..." A "Fall Circumstance Assessment and Intervention" form, dated 7/23/11, indicated "...Time of fall 0650 (6:50 A.M.)...Location of fall: Res room...Witnessed: N (no) (circled)...Found on floor: (indicated by X)...Activity at time of fall: Transferring self (indicated by X)...Toileting (indicated by X)...Ambulating (indicated by X)...Improper fitting footwear (indicated by X)...Safety equipment in place and functioning at time of incident? Y (yes)...Prevention Update...nonskid footwear...Call bell...Therapy to eval (evaluate)..." A resident care plan, dated 6/20/11 and updated 723/11, indicated "...Therapy to screen..." Documentation was lacking related to any other additional interventions implemented to prevent falls. An "Occupational Therapy Progress Note," dated 7/31/11, indicated "...Noted confusion this week, requiring redirection with tasks...Safety cues for use of walker...Standing balance...Fair - dynamic balance/impulsive with forgetting to use walker..." Interview on 8/17/11 at 1:05 P.M., with CNA #5 indicated the resident had cognitive deficits and she required cueing to remember to use her walker. She indicated "because of her cognitive deficits she would be a fall risk." Interview on 8/17/11 at 1:25 P.M. with OT #6 indicated the resident was a "safety risk because of her confusion." She indicated the resident "has trouble sequencing" when performing tasks. She stated "I think she's a risk (falls)." Interview on 8/17/11 at 1:26 P.M., with PT #7 indicated Resident #44 required staff with her to provide verbal cues when ambulating. Interview on 8/17/11 at 1:27 P.M., with the Director of Nursing indicated the facility did not have any policies related to fall prevention. She indicated falls were "followed in CAR (clinically at risk) committee." She indicated the residents were "probably not on a toileting schedules." She indicated the facility did not have a toileting program because "we're waiting for a restorative aide to start in September." She stated "I understand your concerns." 3.1-45(a)(2)