Every finding on record at Hoosier Health & Living Community

Based on observation, interview, and record review, the facility failed to store food safely related to unlabeled and outdated foods, and failed to ensure proper sanitization of dishware related to dishwasher rinse temperatures and monitoring logs for 3 of 3 kitchen observations. This deficient practice had the potential to effect 85 of 85 residents that resided in the facility.Findings include:1. During the initial tour of the kitchen on 08/07/25 at 10:51 A.M., the following items were observed in the refrigerators: - a gallon sized plastic bag contained an open package of unsliced turkey. There was no label to indicate when the turkey was opened,- a small metal pan with several cooked slices of bacon laying on top of a thin layer of solid bacon grease. The pan was covered with plastic wrap and dated 07/27, and - two large, undated metal pans of bread pudding, covered with plastic wrap. During an interview, on 08/07/25 at 10:55 A.M., the Kitchen Manager (KM) indicated they sliced the turkey meat and used it for sandwiches; it should have been labeled when it was opened. The bacon was used for sandwiches and to season green beans when cooking them and was good for 10 days after it was cooked. The bread pudding was prepared the previous evening and should have been labeled. 2. During an interview, on 08/13/25 at 11:10 A.M., the KM indicated there was not a full load of dishes to wash as the staff were caught up on dishes and wouldn't be washing items again until after lunch was served, but she could run the empty rack through a cycle for observational purposes. She placed a rack in the dishwasher and turned it on. The label on the dishwasher indicated the wash cycle temperature needed to reach 150 degrees Fahrenheit (F) and the rinse cycle temperature needed to reach 180 degrees. The KM ran the dishwasher a few times, but the rinse temperature did not get higher than 174 degrees. The KM indicated it sometimes took a few cycles for the dishwasher to get to the appropriate temperature, and it would be better to come back and observe the dishwasher when dishes were washed after lunch. 3. On 08/13/2025 at 1:10 P.M., the dishwasher was observed. A single load of dishes needed to be ran through the dishwasher multiple times before the rinse cycle temperature reached 180 degrees. The dishwasher temperature log for the current month was in a binder near the dishwashing area and was reviewed with the KM at that time. The dishwasher ran three times a day. There were several days, some with multiple times in the same day, that the documented rinse temperature was below 180 degrees. A notice at the bottom of the log sheet indicated staff were to .Notify Dietary Manager Immediately if Temperatures DO NOT Meet Manufacturers Recommended Temperatures.On 08/13/25 at 2:15 P.M., the KM provided the Dish Machine Temperature Log for June and July. Each log was separated into Breakfast, Lunch, and Dinner sections with a Begin Wash, Begin Rinse, End Wash, and End Rinse temperature documented for each section. The June log was complete, but the rinse temperature never reached 180 degrees when the breakfast dishes were washed, only reached 180 degrees one time when the lunch dishes were washed, and only half the time when the dinner dishes were washed. The July log was incomplete, with half of the days of the month blank. Of the days the dishwasher temps were documented, the rinse temperature only reached 180 twice. During an interview, on 08/13/25 at 1:15 P.M., the KM indicated if the dishwasher rinse temperature did not reach 180 degrees, staff were to hand wash the dishes. She did not think the kitchen staff were documenting the temperatures in the logs correctly. During an interview, on 08/13/25 at 3:37 P.M., the Administrator indicated there had been no outbreak of food borne illness in facility.The current INDIANA DEPARTMENT OF HEALTH Retail Food Establishment Sanitation Requirements Title 410 IAC 7-26, effective April 16, 2025, was reviewed on 08/13/25 at 3:00 P.M. The requirements indicated, . refrigerated .food prepared on-premises must be consumed on the premises, sold, or discarded when held at a temperature of not more than forty-one (41) degrees Fahrenheit, five (5) degrees Celsius for a maximum of seven (7) days. The day of preparation is counted as day one (1) . The current facility policy, titled Food and Non-Food Storage, revised in 2012, was provided by the Social Services Director (SSD) on 08/13/25 at 2:15 P.M. The policy indicated, .Foods that have been removed from their original containers are clearly marked with contents, dated and wrapped.The current facility policy, titled Environmental Sanitation/Infection Control, dated 2012, was provided by the SSD on 08/13/25 at 2:15 P.M. The policy indicated, .The dish machine is operated following standards for temperatures.Rinse cycle 180 F.Wash and rinse cycles of the dish machine are recorded after each meal.Unusual temperatures or sanitizer levels are circled for follow up with corrective action and a supervisor is notified.3.1-21(i)(2)3.1-21(i)(3)

Based on observation, record review, and interview, the facility failed to ensure a resident's record accurately reflected current nursing measures or interventions for 1 of 18 residents reviewed. (Resident 68)Findings include:On 08/08/25 at 11:34 A.M., Resident 68 was observed in her room in her bed. The left side of the bed was against the wall. The bed was in a low position with a mat in place on the floor on the right side of the bed.On 08/11/25 at 3:25 P.M., the resident was observed in her room in bed. The bed was in a low position with a floor mat on the right side of the resident's bed. On 08/13/25 at 1:36 P.M., the resident was observed in her room in bed. The bed was in a low position with a floor mat on the right side of the resident's bed. During an interview, on 08/13/25 at 1:38 P.M., Certified Nurse Aide (CNA) 3 indicated she was familiar with the resident. The resident had the floor mat because she had fallen. Once she fell, they put her bed in the lowest position and placed the mat on the floor for safety. The floor mat had been in place since she was most recently readmitted to the facility from a psychiatric hospital.During an interview, on 08/13/25 at 1:42 P.M., RN 4 reviewed the resident's care plan for falls and indicated a floor mat was not listed as an intervention. RN 4 indicated if the resident had a floor mat in place it should be on their care plan. The resident's record was reviewed on 08/13/25 at 1:57 P.M. A Significant Change Minimum Data Set assessment, dated 07/03/25, indicated the resident was readmitted to the facility on [DATE]. The resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, dementia and diabetes. The resident used a wheelchair. The resident required partial to moderate staff assistance with rolling left to right and sitting to laying. The resident required substantial staff assistance with sit to stand transferring and chair to bed transferring. The resident did not attempt to walk during the assessment review period.A Progress Note, dated 05/09/25 at 4:45 P.M., indicated the resident experienced a witnessed fall. The resident injured her lip and had abrasions on her elbows, knees, and the palms of her hands.A Progress Note, dated 05/28/25 at 11:50 A.M., indicated the resident experienced a fall in the hallway. The resident hit her head on the handrail and re-injured the skin on her elbow. The resident was discharged from the facility on 05/28/25 and readmitted on [DATE].A Progress Note, dated 06/28/25 at 8:48 A.M., indicated the resident was found lying on the floor in her room. The resident indicated she slid out of her wheelchair and onto the floor and hit her head in the process.The resident's Electronic Health Record was reviewed and lacked documentation of any kind for the use of a floor mat.During an interview with the Director of Nursing (DON) and the Social Services Director (SSD), on 08/13/25 at 2:18 P.M., the DON indicated the floor mat was not a fall intervention, so it was not required to be in the resident's Fall Care Plan. The floormat was a nursing measure, a comfort measure. The SSD indicated if a resident was fidgety or restless, they could use a floor mat. The facility did not have a policy for updating care plans, they referred to the Resident Assessment Instrument (RAI) manual.The resident's record, including her complete care plan, lacked documentation that indicated the resident was frequently restless or that the resident preferred to spend time laying on the floor.The resident's current physician's orders were provided by Corporate Clinical Support Staff on 08/13/25 at 3:18 P.M. The physician's orders lacked an order for the use of a floor mat.The resident's current care plan for falls was provided by Corporate Clinical Support Staff on 08/13/25 at 3:18 P.M. The care plan interventions included, but were not limited to, a current intervention, with a start date of 04/25/25, to maintain a clear pathway in the room, free of obstacles.3.1-50(a)(2)

Based on record review and interview, the facility failed to obtain a uranalysis and start treatment in a timely manner for 1 of 19 residents reviewed for laboratory services. (Resident 81)Findings include:The clinical record for Resident 81 was reviewed on 08/12/2025 at 10:36 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 05/19/25, indicated the resident was moderately cognitively impaired. The residents' diagnoses included, but were not limited to, hypertension, non-Alzheimer's dementia, anxiety, depression, major depressive disorder, anxiety, and vascular dementia.A Progress Note, dated 06/25/25 at 9:05 P.M., indicated the nurses had received a call from the resident's physician's office. They had received the resident's urine dipstick results. They wanted a sample sent to the laboratory (lab) for a urinalysis (UA) culture and sensitivity (C&S). The nurse completed the paperwork and was waiting for the sample to send it to the lab.A Progress Note, dated 06/26/25 at 8:38 A.M., indicated the resident had hematuria and increased frequency of bladder incontinence with increased urination. The resident also had increased confusion with night sweating.A Progress Note, dated 06/27/25, at 5:10 A.M., indicated the resident's UA results were received and showed 4+ bacteria. The C&S of the urine was pending.A Progress Note, dated 06/28/25 at 12:26 P.M., indicated the nurse had received the C&S results. The results were faxed to the resident's primary care physician.A Progress Note, dated 06/30/25 at 4:04 A.M., indicated the facility was awaiting a reply from the physician about the C&S results.A Progress Note, dated 06/30/25 at 12:55 P.M., indicated the nurse had received a call from the physician's office with a new order for Macrobid 100 milligrams, twice a day, for 7 days for a Urinary Tract Infection (UTI). The family was updated.The June Electronic Medication Administration Record (EMAR) indicated the residents received the first dose of the antibiotic on 06/30/25 from 7:00 P.M. to 11:00 P.M.During an interview, on 08/13/25 at 9:41 A.M., Licensed Practical Nurse (LPN) 8 indicated if a resident had a new order for a UA C&S the lab would come every day of the week to pick it up. Once the results were ready, the lab would fax them to the facility. Once the results were received, the nurse would need to notify the physician. If the resident needed an antibiotic, then she would call the physician to get them started on it immediately. If the resident was seen by an outside physician and it was a weekend, then they always had an on-call provider that could be notified.During an interview, on 08/13/25 at 10:48 A.M., the Director of Nursing (DON) indicated when a UA C&S was obtained and sent to the lab, the lab would send the results back. If the lab showed the residents had a UTI, then the physician would be notified to start them on an antibiotic. If the results came back to the facility on the weekend, then there was an on-call provider that would be notified.During an interview on 08/13/25 at 1:39 P.M., the DON indicated the facility lacked a policy for lab services and they just followed standard nursing practice.3.1-49(a)

Based on record review and interview, the facility failed to provide physician prescribed medications for 1 of 5 residents reviewed for pharmacy services. (Resident 3)Findings include:The clinical record for Resident 3 was reviewed on 08/11/2025 at 2:22 P.M. An Annual Minimum Data Set (MDS) assessment, dated 08/03/25, indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, hypertension, bipolar disorder, depression, stroke, and dementia. The resident's current physician's orders included, but were not limited to, dapagliflozin propanediol (Farxiga) tablet, 10 milligrams by mouth, once daily upon rising, with a start date of 05/20/25. The medication was documented as Not Administered on the following dates: - 05/27/25, Waiting on delivery from pharmacy,- 05/28/25, Waiting on delivery from pharmacy,- 05/30/25, Waiting on delivery from pharmacy,- 05/31/25, Drug/Item Unavailable,- 06/01/25, Drug/Item Unavailable,- 06/02/25, Drug/Item Unavailable,- 06/06/25, Drug/Item Unavailable, and- 06/10/25, Drug/Item Unavailable. During an interview, on 08/13/2025 at 1:56 P.M., RN 4 indicated nurses and QMAs (Qualified Medication Aides) were allowed to order medications for the residents. For a resident who was already receiving a medication, the facility received rolls of packaged medications every Monday, that were for the week. If a resident received a new physician's order, the nursing staff updated the family, called the pharmacy, and faxed the pharmacy the order. The facility would have the medication on the same day they placed the order. If there was a medication the resident needed right away, they could use the Emergency Drug Kit (EDK) located in the building, or they could use a local pharmacy. When documenting on the Electronic Medication Administration Record (EMAR), if a medication was held/not given, there was a button on the EMAR to choose, it would prompt you with a box to put a note in to say why the medication was held. If it was given, it would just have the giver's initials. The current undated PHARMACEUTICAL SERVICES AGREEMENT policy was provided by the Director of Nursing on 08/13/25 at 3:50 P.M. The policy indicated, .Pharmaceutical services are to be available to all residents at this facility for prescription and nonprescription drugs.Provide routine and timely pharmacy service seven days per week and emergency pharmacy service 24 hours per day, seven days per week. 3.1-25(a)

Based on observation, interview, and record review, the facility failed to ensure a resident's wound was identified prior to the resident developing an unstageable pressure ulcer for 1 of 3 residents reviewed for pressure ulcers. (Resident 4) Findings include:The Clinical record for Resident 4 was reviewed on 08/11/25 at 11:19 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 05/28/25, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, coronary artery disease, diabetes, hypertension, and stage 3 chronic kidney disease. The resident required staff assistance for all Activities of Daily Living (ADLs) except for eating. A mechanical lift was used for transfers. The resident had a specialty mattress for his bed and cushion for his chair. A Wound Management note, dated 07/29/25 at 10:42 A.M., indicated the resident had an Unstageable (a type of wound where the depth of tissue damage cannot be determined due to the presence of slough [dead tissue] or echar [a black layer of dead tissue]) - Deep Tissue Injury (DTI) (a type of pressure injury that develops under intact skin appearing as purple or maroon discoloration) pressure ulcer measuring 1.7 centimeters (cm) by 0.7 cm by 0.1 cm deep on his sacrum. The wound was covered with 100% slough (a moist non-viable tissue). A wound physician's note, dated 07/29/25, indicated the resident had an Unstageable - DTI measuring 1.7 cm by 0.7 cm by 0.1 cm. on his sacrum estimated time to heal 2 to 4 months. treatment plan was to apply calcium alginate and cover with a foam border dressing daily and as needed for 30 days. A Wound Management note, dated 08/05/25 at 7:21 A.M., indicated the resident had an Unstageable - DTI pressure ulcer measuring 1.5 cm by 0.7 cm by 0.1cm on his sacrum. The wound was covered with 100% slough. A wound physician's note, dated 08/05/25, indicated the resident had an Unstageable - DTI measuring 1.7 cm by 0.7 cm by 0.1 cm. on his sacrum. The wound underwent a treatment with non-contact, non-thermal, low frequency ultrasound instead of sharp debridement. A wound physician's note, dated 08/12/25, indicated the resident had an Unstageable - DTI pressure wound was healed. The clinical record lacked documentation the resident had been absent from the facility for any services for an extended period of time during the month of July.During an interview, on 08/12/2025 at 3:07 P.M., Certified Nurse Aide (CNA) 5 indicated Resident 4 required assistance with everything except eating. A mechanical lift was used to transfer him. He was incontinent of both bowel and bladder. When he was changed or given a shower, the resident's skin was observed. If a new skin issue was discovered, the nurse would be notified. The resident was turned and repositioned every two hours when in bed or sitting in his chair. The resident was compliant with care. They did not have paper shower sheets for documentation. During an observation and interview, on 08/13/2025 at 10:29 A.M., Resident 4 was in bed laying on his back. CNA 7 and CNA 9 rolled the resident on to his right side. The resident had no wound on his sacrum. The Director of Nursing (DON) indicated the wound doctor had been in the facility yesterday and had said the wound was healed. During an interview, on 08/13/2025 at 1:13 P.M., the facility wound nurse indicated the floor nurses saw residents' wounds at least twice a day when treatments were done. She would see the wounds weekly and more often if a skin issue was brought to her attention. On 07/29/25, she visualized and documented the wound on Resident 4's sacrum. When the resident's wound was first identified it was an Unstageable wound. She indicated an Unstageable pressure ulcer was a wound where the depth couldn't be measured because it would be covered with slough or eschar (a black layer of dead tissue). The current facility policy, titled WOUND MANAGEMENT POLICY, dated February 1, 2019, was provided by the DON on 08/13/25 at 2:00 P.M. The policy indicated, .[NAME] and Associates, Inc. is committed to providing quality care to our residents by implementing clinical guidance and best practices for the management of wounds and other skin conditions throughout a residents' stay in our [NAME] communities . 3.1-49(a)(2)

Based on record review, interview, and observation, the facility failed to administer As Needed (PRN) medications related to blood pressure values; and identify and address a resident's skin impairment for 2 of 19 residents reviewed for Quality of Care. (Residents 3 and 7)Findings include:1.The clinical record for Resident 3 was reviewed on 08/11/2025 at 2:22 P.M. An Annual Minimum Data Set (MDS) assessment, dated 08/03/25, indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, hypertension, diabetes, bipolar disorder, depression, stroke, and dementia. The physician's orders included, but were not limited to, the following: - - With a start date of 04/26/25 and a discontinued date of 07/31/25, the resident's blood pressure was to be assessed, twice a day. Staff were to assessed the resident's blood pressure upon rising, 6:00 A.M. to 10:00 A.M., and Before Bedtime, 7:00 P.M. to 11:00 P.M. If the resident's Systolic Blood Pressure (SBP), the top number, was equal to or greater than 160, staff were to administer a PRN clonidine. - - With a start date of 06/01/25 and a discontinued date of 07/31/25, the resident was to receive Clonidine, 0.1 milligrams, every 12 hours as needed for SBP greater than 160. The Electronic Medication Administration Record (EMAR) for July 2025 was provided by the Director of Nursing (DON), on 08/13/25 at 3:50 P.M. The record indicated the resident did not receive the prescribed Clonidine medication for high blood pressure values on the following dates and times: On 07/03/25, upon rising, when the resident's blood pressure was 166/76. On 07/03/25, before bedtime, when the resident's blood pressure was 167/67. On 07/07/25, upon rising, when the resident's blood pressure was 185/78. On 07/09/25, before bedtime, when the resident's blood pressure was 170/68. On 07/10/25, upon rising, when the resident's blood pressure was 190/81. On 07/14/25, upon rising, when the resident's blood pressure was 176/71. On 07/20/25, at bedtime, when the resident's blood pressure was 174/88. On 07/21/25, at bedtime, when the resident's blood pressure was 167/68. During an interview, on 08/13/2025 at 1:56 P.M., RN 4 indicated when documenting on the EMAR, if a medication was held/not given, there was a button on the EMAR to choose, it would prompt you with a box to put a note in to say why the medication was held. If it was given, it would have the initials of the staff member who administered the medication. During an interview on 08/13/25 at 1:39 P.M., the DON indicated the facility lacked a policy for following physician's orders, they just followed standard nursing practices. 2. During an interview and observation, on 08/08/2025 at 10:49 A.M., Resident 7 indicated she had bumped her arm on the mechanical lift that day when staff had gotten her up. There was a silver dollar sized bruise with a dry L-shaped scab in the middle of the bruise on her lower left arm. During an observation, on 08/12/25 at 9:42 A.M., Certified Nurse Aide (CNA) 6 and 7 assisted the resident out of bed and into her chair using the mechanical lift. The resident was wearing a short-sleeved T-shirt. The resident had a silver dollar sized bruise with a dry L-shaped scab in the middle of the bruise on her lower left arm. During an observation, on 08/13/25 at 9:35 A.M., the resident was sitting in her room in her wheelchair. She had a short-sleeved T-shirt on and had a silver dollar sized bruise with a dry L-shaped scab in the middle of the bruise on her lower left arm. The clinical record for Resident 7 was reviewed on 08/12/2025 at 10:00 A.M. An Annual MDS assessment, dated 06/05/25, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, diabetes, anemia, hypertension, and depression. The resident was dependent on staff for all transfers. The clinical record lacked documentation that the resident had a skin impairment to the left lower arm. During an interview, on 08/13/25 at 9:41 A.M., LPN 8 indicated if a resident had a new skin tear or bruise the staff should alert the nurse. The area would be assessed, and the physician would be notified. A treatment would be initiated, if need be, and the nurse would open an event in the resident's clinical record. Within the event a progress note would be made about the skin impairment. During an interview, on 8/13/2025 at 10:51 A.M., the DON indicated if a resident had a new skin tear or bruise then there would be monitoring in the EMAR. The nurse would open an event, notify the physician, and get treatment orders. During an interview, on 08/13/25 at 10:53 A.M., the Facility Wound Nurse indicated she was unaware of Resident 7 having skin impairments. During an interview, on 08/13/25 at 10:55 A.M., the DON indicated the staff should have started an event and let someone know that the resident had an area to the left arm. The current facility policy titled, Skin Assessment, dated February 1, 2019, was provided by the DON on 08/13/25 at 1:39 P.M. The policy indicated, .ensuring the completion of thorough skin assessments on admission and throughout the residents' stay.If a new skin condition is identified.the nurse will open the appropriate Skin Integrity Event.Notify the MD, obtain and enter a treatment order.apply the initial treatment.Notify family.Document. 3.1-37(a)

Based on observation, interview, and record review, the facility failed to complete Minimum Data Set (MDS) assessments accurately related to falls for 2 of 19 resident records reviewed. (Residents 8 and 83) Findings included:Based on observation, interview, and record review, the facility failed to complete Minimum Data Set (MDS) assessments accurately related to falls for 2 of 19 resident records reviewed. (Residents 8 and 83) During an observation and interview, on 08/11/2025 at 9:42 A.M., Resident 8 was sitting in a chair in her room. The resident's walker was sitting nearby. She was alert and oriented and indicated she had recently fallen near the outside entrance to the facility while getting into a family member's vehicle to go to a doctor's appointment. She twisted her ankle when she fell. During an interview, on 08/11/2025 at 1:58 P.M., the Social Services Director (SSD) indicated the resident had fallen while getting into a family members vehicle who was taking the resident to an appointment. The family was educated to have staff assist the resident into and out of the vehicle from now on. During an interview, on 08/13/2025 at 10:47 A.M., the Assistant Director of Nursing (ADON) indicated the resident had a fall while getting into a vehicle with a family member to go to an appointment. The fall was witnessed by the family member. The family normally took the resident to take her appointments. The nurse assessed the resident following the fall, talked with the family member, and educated the family on having a staff member assist the resident when getting into the vehicle. The resident had some bruising and swelling to an ankle. They x-rayed the ankle, and it was negative for a fracture. During an interview, on 08/13/2025 at 2:13 P.M., the ADON indicated Resident 8 had only one fall since she had been recently admitted to the facility. The clinical record was reviewed on 08/11/2025 at 10:34 A.M. An Annual MDS assessment, dated 01/17/25, indicated the resident was cognitively intact, was independent with sit to stand, transfers from bed to chair, and to toilet, and walking 150 feet. A Discharge MDS assessment indicated the resident discharged to the hospital on [DATE], and returning to the facility was anticipated. An Entry tracking MDS assessment, dated 07/21/25, indicated the resident returned to the facility on [DATE]. Section J, of a Quarterly MDS assessment, dated 08/12/25, was provided by the ADON on 08/13/25 at 2:00 P.M. The record indicated the section was completed on 08/01/25, and the resident had one fall with no injury since the last assessment. A Post Fall Assessment Event Report, dated 07/29/25 at 8:44 A.M., indicated the resident had a fall outside of the building on the facility grounds. A Progress Note on the report indicated the resident's right ankle was swollen with bruising. 2. During an interview, on 08/13/2025 at 10:59 A.M., the ADON indicated Resident 83 came to the facility after she was unable to take care of herself. Her dementia had progressed. On admission, the resident was up and walking freely about the unit. She had poor safety awareness. The resident was admitted on [DATE] and had several falls since admission. The clinical record for Resident 83 was reviewed on 08/12/2025 at 11:04 A.M. A Quarterly MDS assessment, dated 05/16/25, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, dementia, hypertension, anxiety, and depression. The resident required Supervision or touching assistance with going from sitting to standing and with chair to bed transfers. The resident had one fall with no injury since the prior assessment, an admission assessment, dated 03/15/25. The admission MDS assessment, dated 03/15/25, indicated the resident was severely cognitively impaired. Post Fall Assessment Event Reports, dated between 03/15/25 and 05/16/25, were provided by the ADON on 08/13/25 at 1:40 P.M., and included the following: 04/26/25 at 10:33 A.M., unwitnessed, the resident acquired a skin tear to her right elbow. 04/27/25 at 8:30 P.M., unwitnessed, the resident had no injury, 05/02/25 at 11:50 A.M., unwitnessed, the resident hit her head and had swelling and a hematoma to the back of her head, 05/02/25 at 12:45 P.M., witnessed, the resident hit the back of her head again, and her right pupil was sluggish, 05/04/25 at 6:10 P.M., unwitnessed, in the dining room, the resident had broken teeth and received four sutures to her chin, and 05/13/25 at 2:45 P.M., witnessed, the resident had no injury. The facility failed to document the correct number of falls in the resident's MDS assessment, dated 05/16/25. During an interview, on 08/13/2025 at 11:50 A.M., MDS Coordinator 2 indicated the falls were documented on Section J of the MDS assessments. On the 05/16/25 assessment, the documentation indicated the resident had one fall. She obtained her information about falls from the Matrix (software type) Electronic Health Record for each resident. On the Matrix they look for the falls since the last assessment. There should have been more falls documented on the 05/16/25 Quarterly MDS assessment. They did not have a policy on completing the MDS assessments, they followed the RAI (Resident Assessment Instrument) manual. 3.1-(d)(3)

Based on observation and interview, the facility failed to post nurse staffing daily for 2 of 2 observations. Findings include: During an observation, on 04/24/25 at 11:12 A.M., a bulletin board by the Unit Manager's office on the 300 Hall had a daily nurse staff posting dated for 10/31/24. The bulletin board also held an Activity calendar for April. During an observation, on 04/24/25 at 1:12 P.M., a bulletin board by the Unit Manager's office on the 300 Hall had a daily nurse staff posting dated for 10/31/24. The bulletin board also held an Activity calendar for April. During an observation and interview, on 04/24/25 at 1:17 P.M., the Director of Nursing (DON) went to the bulletin board on the 300 Hall and indicated the nurse staff posting was posted there and should be changed daily by herself, the Assistant Director of Nursing, or the scheduler. During an interview, on 04/24/25 at 1:58 P.M., the DON indicated there was not a facility policy on nurse staff posting, they would just follow the regulation.

Based on interview, observation, and record review, the facility failed to provide safe water temperatures for 10 of 18 resident rooms observed. (Rooms 114, 141, 142, 143, 310, 324, 325, 329, 330, and 343) Findings include: 1. During an interview and observation in Resident room [ROOM NUMBER] on 10/24/24 at 12:20 P.M., The resident indicated the water in his bathroom got hot. You couldn't keep your hand under it for very long. The water in the resident's bathroom sink was felt and found to be hot. The water stream was too hot to keep a hand under the water flow without discomfort. The water temperature was tested with a probe thermometer and was found to be 126.5 degrees Fahrenheit. The resident indicated he had not been burned by the water. On 10/24/24 at 12:49 P.M., the water in the Resident Room next door to room [ROOM NUMBER] (room [ROOM NUMBER]) was checked with a probe thermometer and the water temperature was found to be 126.9 degrees Fahrenheit. The following water temperatures were observed on 10/24/24, with the Maintenance Director using the facility's probe thermometer: - At 1:04 P.M., Resident room [ROOM NUMBER] the water temperature was 126.5 degrees Fahrenheit, - At 1:06 P.M., Resident room [ROOM NUMBER] the water temperature was 125.3 degrees Fahrenheit, - At 1:07 P.M., Resident room [ROOM NUMBER] the water temperature was 124.5 degrees Fahrenheit, and - At 1:10 P.M., Resident room [ROOM NUMBER] the water temperature was 122.7 degrees Fahrenheit. During an interview on 10/24/24 at 1:33 P.M., the Maintenance Director indicated he did random checks of the water temperatures in the resident rooms, but he did not document the actual temperatures of the water from the individual sinks. He documented the temperature reading he obtained from the water heater gauge in his office. The water heater temperature reading was 120 degrees Fahrenheit. 34232 2. On 10/24/24, the following water temperatures were checked using a probe thermometer: - At 12:52 P.M., Resident room [ROOM NUMBER] the water temperature was 125.2 degrees Fahrenheit, and - At 12:54 P.M., Resident room [ROOM NUMBER] the water temperature was 124 degrees Fahrenheit. Resident 69, who resided in the room, was able to get up and use the bathroom on their own. They indicated they had not been burned by the water. During an interview on 10/24/24 at 1:35 P.M., the Administrator indicated if they had a policy related to water temperatures in resident rooms, it probably stated the state regulation of between 100 degrees and 120 degrees Fahrenheit. During an interview on 10/24/24 at 2:17 P.M., the Administrator indicated the staff had rounded with the residents and no residents had any concerns related to the hot water. The Maintenance Director indicated he had turned down the water temperature and was running water at the farthest ends of the building to flush out the lines. 38769 3. During an observation on 10/24/24 the following water temperatures were observed using a probe thermometer: - At 12:29 P.M., Resident room [ROOM NUMBER], the water temperature was 122.9 degrees Fahrenheit, - At 12:30 P.M., Resident room [ROOM NUMBER], the water temperature was 122.0 degrees Fahrenheit, - At 12:32 P.M., Resident room [ROOM NUMBER], the water temperature was 121.0 degrees Fahrenheit, the resident indicated the water would get pretty warm, - At 12:37 P.M., Resident room [ROOM NUMBER], the water temperature was 122.7 degrees Fahrenheit, - At 12:39 P.M., Resident room [ROOM NUMBER], the water temperature was 122.9, degrees Fahrenheit, and - At 12:41 P.M., Resident room [ROOM NUMBER], the water temperature was 122.7 degrees Fahrenheit. During an observation on 10/24/24 the following water temperatures were observed with the Maintenance Director: - At 1:14 P.M., Resident room [ROOM NUMBER], the water temperature was 122.5 degrees Fahrenheit, - At 1:16 P.M., Resident room [ROOM NUMBER], the water temperature was 119.5 degrees Fahrenheit, - At 1:23 P.M., Resident room [ROOM NUMBER], the water temperature was 122.5 degrees Fahrenheit, - At 1:23 P.M., Resident room [ROOM NUMBER], the water temperature was 120.5 degrees Fahrenheit, and - At 1:24 P.M., Resident room [ROOM NUMBER], the water temperature was 121.0 degrees Fahrenheit. During an interview on 10/24/24 at 1:09 P.M., the Maintenance Director indicated he would try to keep the hot water temperatures between 120 to 125 degrees Fahrenheit. During an interview on 10/24/24 at 2:18 P.M., the Maintenance Director indicated he had turned the water heater down and was flushing the tanks at that time. The current facility policy titled, Water Temperature Inspection with a review date of 03/02/22, was provided by the Administrator on 10/24/24 at 2:18 P.M. The policy indicated, .Hot water in resident area will range from 100-120 degrees Fahrenheit . 3.1-19(r)(1) 3.1-19(r)(2)

Based on observation, interview, and record review, the facility failed to maintain oxygen therapy equipment in a clean and safe manner and assess a resident during breathing treatments for 1 of 2 residents reviewed for oxygen therapy. (Resident 69) Findings include: During an observation and interview on 10/24/24 at 1:07 P.M., Resident 69 had a breathing treatment nebulizer machine sitting on her nightstand. The face mask was attached to the side of the machine and open to air. The face mask and the attached tubing were not dated as to when the equipment was put into use. No plastic bag or other breathing treatment equipment was visible in the general vicinity. The resident indicated they received breathing treatments for Chronic Obstructive Pulmonary Disease (COPD). During an observation on 10/28/24 at 10:17 A.M., the breathing treatment nebulizer machine was sitting on the resident's nightstand. The face mask was attached to the side of the machine and open to air. The face mask and the attached tubing were not dated as to when the equipment was put into use. No plastic bag or other breathing treatment equipment was visible in the general vicinity. A small amount of fluid was visible in the reservoir of the breathing treatment apparatus. During an observation and interview on 10/28/24 at 3:17 P.M., the breathing treatment nebulizer machine was sitting on the resident's nightstand. The face mask was attached to the side of the machine and open to air. The face mask and the attached tubing were not dated as to when the equipment was put into use. No plastic bag or other breathing treatment equipment was visible in the general vicinity. A small amount of fluid was visible in the reservoir of the breathing treatment apparatus. The resident indicated there was no plastic bag and the staff did not use a bag for her equipment. She had not been on an antibiotic recently, but she did have COPD. During an observation and interview on 10/28/24 at 3:19 P.M., the Assistant Director of Nursing (ADON), while looking at the resident's uncovered breathing treatment nebulizer machine with undated tubing and mask, indicated oxygen tubing was changed every Sunday night. There was usually a plastic bag on top of the mask. The residents had a physician's order to have the mask and tubing changed on the Electronic Medication Administration Record/Electronic Treatment Administration Record (EMAR/ETAR). The staff dated the equipment with a marker when it was put into use, including the tubing, the mask, and the plastic bag. During an interview on 10/28/24 at 3:33 P.M., Qualified Medication Aide (QMA) 9 indicated oxygen tubing was changed weekly. The clinical record was reviewed on 10/25/24 at 1:50 P.M. A Quarterly Minimum Data Set (MDS) assessment, dated 09/11/24, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, anxiety and COPD. The EMAR/ETAR for September and October 2024, were provided by the Director of Nursing (DON) on 10/29/24 at 10:59 A.M. The records lacked a physician's order to change the resident's breathing treatment equipment. The records included, but were not limited to, the following current physician's order: - Albuterol Sulfate Nebulization Solution, 3 milliliters, inhale orally via nebulizer two times a day related to COPD, with a start date of 06/27/24. The duration of the treatment in minutes, the resident's pulse, number of respirations, and oxygen saturation values were to be documented with each treatment. The records lacked documentation of the values on the following dates: - September 1, through September 30, 2024 (no values were documented for the entire month of September), and - October 1, through October 27, 2024. The Progress Notes for September and October 2024, were provided by the DON on 10/29/24 at 10:59 A.M. The records lacked any indication the resident's breathing treatment equipment had been change or that the resident had been monitored during their breathing treatments. During an interview on 10/29/24 at 2:13 P.M., QMA 6 indicated the vital signs should be taken at the time of the medication administration. The current Oxygen Administration policy, with a reviewed date of 12/21/11, was provided by the Administrator on 10/29/24 at 3:39 P.M. The policy indicated, .Tubing must be changed weekly and must be labeled with date and initials of the individual who changed the tubing . The current Nebulizer policy, with a revised date of 12/21/11, was provided by the DON on 10/29/24 at 10:59 A.M. The policy indicated, .nursing staff will administer and monitor the effectiveness of nebulizer treatments as ordered by the resident's physician .Auscultate lung sounds and assess respiratory rate .assess heart rate . 3.1-47(a)(6)

Based on observation, interview, and record review, the facility failed to assess a resident for bedrails for 1 of 1 resident reviewed for bedrails. (Resident 78) Findings include: During an observation on 10/24/24 at 12:54 P.M., Resident 78 had a half bedrail up on the side of her bed. During an observation on 10/28/24 at 10:15 A.M., Resident 78 was sitting in a chair in her room. There were half bedrails in place on both sides of the resident's bed. During an observation on 10/28/24 at 1:16 P.M., Resident 78 was sitting in a chair in her room. There were half bedrails in place on both sides of the resident's bed. During an observation on 10/29/24 at 9:40 A.M., Resident 78 was sitting in a chair in her room. There were half bedrails in place on both sides of the resident's bed. During an observation and interview on 10/29/24 at 2:13 P.M., Certified Nurse Aide (CNA) 8 indicated the resident had half bed rails on both sides of her bed. During an interview on 10/29/24 at 2:16 P.M., the Assistant Director of Nursing (ADON) indicated if a resident had an enabler bar on their bed, then they should have a physician's order for the bar. The clinical record for the resident was reviewed on 10/28/24 at 2:32 P.M. A Quarterly Minimum Data Set (MDS) assessment, dated 09/19/24, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, unspecified dementia, hypertension, anxiety. The resident had used a bedrail less than daily. The clinical record lacked a physician's order for bedrails or an assessment for bedrails prior to 10/29/24. During an interview on 10/29/24 at 3:40 P.M., the ADON indicated the resident should have had an order and an assessment prior to the bedrails being placed on her bed. During an interview on 10/29/24 at 3:57 P.M., the Maintenance Director indicated the nurses would let him know when a resident had an order for bedrails to be on their bed and then he would put them on. He was unsure when Resident 78's bedrails were placed on her bed. They were not placed that day. He would inspect resident bedrails once a month. The current facility policy titled, Use of Rails (Side Rails, Bed Rails, Grab Bars, Assist Bars) with a revision date of 12/12/17, was provided by the Director of Nursing (DON) on 10/30/24 at 9:41 A.M. The policy indicated, .After proper assessment, side rails/bed rails/grab bars/assist bars may be used .If alternatives were considered but deemed inappropriate to attempt for a resident, the resident will be assessed for rail use .A physician order will be obtained for the type of rail(s) to be utilized and when the rail is to be utilized (i.e. when in bed) . 3.1-45(2)

Based on record review and interview, the facility failed to follow physician's orders related to hold parameters and gave medications without adequate need for use for 2 of 5 residents reviewed for unnecessary medications. (Residents 18 and 5) Findings include: 1. The clinical record for Resident 18 was reviewed on 10/28/24 at 10:33 A.M. An Admission Minimum Data Set (MDS) assessment, dated 08/09/24, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, fractures, anemia, hypertension, atrial fibrillation, anxiety, and depression. A current physician's order, dated 09/07/24, indicated the resident was to be administered Digoxin 125 (micrograms) MCG, once a day for atrial fibrillation. The staff were to hold the medication if the resident's heart rate was less than 60. The September and October 2024, Electronic Medication Administration Record/Electronic Treatment Administration Record (EMAR/ETAR) indicated the resident had received the medication on the following dates when the heart rate was less than 60: - 09/08/24, when the heart rate was 49, - 09/17/24, when the heart rate was 58, - 09/25/24, when the heart rate was 51, - 10/08/24, when the heart rate was 56, - 10/15/24, when the heart rate was 56, and - 10/18/24, when the heart rate was 51. 33613 2. The clinical record for Resident 5 was reviewed on 10/25/24 at 12:56 P.M. A Quarterly MDS assessment, dated 07/23/24, indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, diabetes, end stage renal disease, and hypertension. An open-ended physician's order, with a start date of 08/22/24, indicated the resident was to take Midodrine (a blood pressure medication) 5 milligrams three times a day. The staff were to hold the medication if the resident's systolic blood pressure (top number) was greater than 105. The August and September 2024 EMAR indicated the resident received the medication on the following dates and times when the systolic blood pressure was greater than 105: - 08/23/24 at 8:00 A.M., when the blood pressure was 114/56, - 08/24/24 at 4:00 P.M. when the blood pressure was 109/60, - 08/25/24 at 8:00 A.M. when the blood pressure was 138/64, - 08/25/24 at 12:00 P.M. when the blood pressure was 107/58, - 08/26/24 at 8:00 A.M. when the blood pressure was 119/55, - 08/27/24 at 8:00 A.M. when the blood pressure was 112/58, - 08/27/24 at 12:00 P.M. when the blood pressure was 138/64, - 08/27/24 at 4:00 P.M. when the blood pressure was 138/64, - 08/29/24 at 8:00 A.M. when the blood pressure was 120/51 - 08/30/24 at 12:00 P.M. when the blood pressure was 112/74, - 09/06/24 at 4:00 P.M. when the blood pressure was 110/65. - 09/07/24 at 4:00 P.M. when the blood pressure was 128/62, - 09/13 24 at 4:00 P.M. when the blood pressure was 117/51, - 09/16/24 at 8:00 A.M. when the blood pressure was 147/68, - 09/16/24 at 12:00 P.M. when the blood pressure was 135/65, - 09/16/24 at 4:00 P.M. when the blood pressure was 110/65, - 09/19/24 at 8:00 A.M. when the blood pressure was 116/63, - 09/20/24 at 4:00 P.M. when the blood pressure was 118/60, - 09/21/24 at 4:00 P.M. when the blood pressure was 116/56, - 09/24/24 at 8:00 A.M. when the blood pressure was 121/57, - 09/24/24 at 12:00 P.M. when the blood pressure was 115/56, and - 09/28/24 at 12:00 P.M. when the blood pressure was 116/53. During an interview on 10/29/24 at 2:13 P.M., Qualified Medication Aide (QMA) 6 indicated she would obtain residents vital signs at the time she was going to administer the medications. If the vital sign was outside of the parameter per the physician order, then she wouldn't administer the medication. If there was a check on the EMAR/ETAR then that meant the resident was given the medication. The current facility policy titled, MEDICATION ADMINISTRATION-GENERAL GUIDELINES with an effective date of September 01, 2023, was provided by the Director of Nursing (DON) on 10/29/24 at 4:01 P.M. The policy indicated .Medications are administered in accordance with written orders of the prescriber . 3.1-48(a)(3)

Based on observation, interview, and record review, the facility failed to ensure resident skin assessments accurately reflected the condition of a resident's skin/nails for 1 of 2 residents reviewed for skin conditions. (Resident 80). Findings include: On 10/29/24 at 10:46 A.M., Resident 80's bare feet were observed. The resident's toenails were long. The toenails on the resident's big toes were thick, yellow, and curved in on the sides. The skin under the third toe on the resident's right foot was black in color under the toenail. The toenail appeared raised from the nail bed but was attached to the skin. The resident's toes were observed with the Director of Nursing (DON) on 10/29/24 at 3:19 P.M. The DON indicated the resident's toe was black and it looked like the nail was coming off. The nails were pretty thick. Nursing staff would normally document a skin condition in the resident's record. The weekly skin assessments included a place to document on the resident's toes and toenails. During an interview on 10/29/24 at 3:44 P.M., Certified Nurse Aide (CNA) 2 indicated the resident had been treated for a wound on her bottom but it had healed. She gave the resident a bed bath yesterday and didn't see any skin impairments. She did have an area on one of her toes that looked like the toe had been caught on something. The toe was discolored. The resident moved to this unit of the facility at the beginning of this month and the toe looked like that when the resident came to the unit. If she identified a skin impairment, she would go straight to the charge nurse and tell them. She thought the nurses knew about the resident's toe. During an interview on 10/30/24 at 11:38 A.M., Licensed Practical Nurse (LPN) 3 indicated she was familiar with the resident and cared for her routinely until she moved to another unit in the beginning of October. There were no wounds on the resident's feet that she could recall, and no injuries to the resident's toes. She was not sure how the resident would have injured her toe. She was dependent for all care and the staff used a mechanical lift to transfer her. During an interview on 10/30/24 at 1:36 P.M., CNA 4 indicated she routinely cared for the resident until she moved to another unit at the beginning of October. She had trimmed and filed the resident's nails before. She would notify the nurse if there was a skin issue. The resident's toe was discolored. She had not seen an open area, but she would consider the condition of the toe to be a skin impairment. They were supposed to document skin impairments in the resident's record. She had told a few nurses about the toenail. She was not sure when she first saw the skin impairment, who she told, or when she told them. She was not sure if there was any documentation about the toenail. The resident's clinical record was reviewed on 10/29/24 at 2:41 P.M. An Admission Minimum Data Set (MDS) assessment, dated 07/29/24, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, stroke, hemiplegia, hypertension, and aphasia. The resident was impaired on one side of their upper and lower extremities and used a wheelchair. The resident required substantial to maximal staff assistance with eating and was dependent on staff for all other Activities of Daily Living (ADLs). A Progress Note, dated 10/29/2024 at 6:04 P.M., indicated the nurse was notified about a discoloration to the third toe on the right foot. The area under the third toenail was black in color but did not appear to be causing any pain or discomfort. The toenails were very thick and long. The nurse completed the assessment and updated the physician and the family of the new area. They updated the Social Services Director on the need for a podiatry visit if consent was in place. The resident's clinical record lacked documentation of an identified skin impairment prior to the progress note dated 10/29/24. During an interview on 10/29/24 at 3:27 P.M., the Administrator indicated residents were offered ancillary services, including podiatry services, on admission. Additionally, ancillary services were discussed during quarterly Care Plan meetings and on an as needed basis. The podiatrist was in the building at least monthly and would come sooner if there was an urgent need. The resident's family declined podiatry services when the resident was admitted to the facility in July of 2024. She spoke to the family, and they now wanted podiatry services. The current facility policy, titled Skin Check Policy, effective 02/23/21, was provided by the DON on 10/30/24 at 2:42 P.M. The policy indicated, .Complete the head to toe assessment weekly as scheduled or when deemed necessary .Examine status of toenails and fingernails .Document the findings . 3.1-50(a)(2)

Based on observation, interview, and record review, the facility failed to ensure a resident that self-administered medications was appropriately assessed for self-administration for 1 of 17 residents reviewed for self administration of medications. (Resident 18) Findings include: During and observation on 10/28/24 at 10:23 A.M., Resident 18 was sitting in his recliner in his room. His over the bed table was in front of him and he was finishing his breakfast. On the left side of the table sat a bottle of severe cold and cough syrup. During an observation on 10/28/24 at 1:06 P.M., Resident 18 was sitting in his recliner in his room. His over the bed table was in front of him. On the left side of table was a bottle of severe cold and cough syrup. During an observation and interview on 10/29/24 at 9:35 A.M., Resident 18 was sitting in his recliner in his room. His over the bed table was in front of him. There was a bottle of severe cold and cough syrup sitting on the table. The resident indicated he only took the medication when he had something caught in his throat. During an interview on 10/29/24 at 11:44 A.M., RN 7 indicated if a resident self-administered medications a fax would be sent to the resident's physician to get an order to have the medication at the bedside and the resident had to be mentally competent to have them at the bedside. Resident 18 did not self-administer any medications. She was unaware the resident had any cough syrup at his bedside. She went into the resident's room and removed the cough syrup. The clinical record for the resident was reviewed on 10/28/24 at 10:33 A.M. An Admission Minimum Data Set (MDS) assessment, dated 08/09/24, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, fractures, anemia, hypertension, atrial fibrillation, anxiety, and depression. The clinical record lacked an assessment or a physician's order for the resident to self-administer medications. The resident lacked a physician's order for cough syrup. The current facility policy titled, Self-Administration of Medications with a review date of 02/07/11, was provided by the Director of Nursing (DON) on 10/29/24 at 1:52 P.M. The policy indicated, .The interdisciplinary team is responsible for ensuring the resident is capable and all required documentation is completed .If the resident chooses to self-administer drugs, the interdisciplinary team must assess the resident's cognitive, physical, and visual abilities to carry out this responsibility .A physician's order will be obtained and recorded in the chart. The order will also include if specific medications may be stored at the resident's bedside . The current facility policy titled, Bedside Medication Storage, with an effective date of 09/01/23, was provided by the DON on 10/29/24 at 1:52 P.M. The policy indicated, .Bedside medications storage is permitted for residents who wish to self-administer medications, upon the written order of the prescriber and once self-administration skills have been assessed and deemed appropriate in the judgement of the facility's interdisciplinary resident assessment team . 3.1-11(a)

Based on observation, interview, and record review, the facility failed to follow appropriate infection control guidelines related to indwelling urinary catheter care and to administer antibiotics in a timely manner for 2 of 4 residents reviewed for Urinary Catheters and Urinary Tract Infections. (Residents 32 and 88) Findings include: 1. Resident 32 was observed on 08/25/23 at 10:49 A.M. He was in his room sitting in a recliner with his feet propped up. He indicated he was getting an antibiotic for a UTI (urinary tract infection) thru his PICC (Peripherally Inserted Central Catheter) line. He had just gotten the PICC line the day before. A plastic ball was attached to his PICC line, and he indicated it contained his antibiotic. His indwelling urinary catheter bag was hanging from the metal that suspended his footrest on his recliner. Over an inch of the bag was laying flat against the floor. During an interview on 08/29/23 at 2:35 P.M., RN 5 indicated the resident was unable to move himself except from the neck up. He required total assistance from staff members with everything including transfers, eating, and toileting. During an interview on 08/30/23 at 2:42 P.M., CNA (Certified Nurse Aide) 4 indicated the urinary catheter drainage bag should not be touching the floor, if it was, they were to make sure there was a bath basin underneath the catheter bag. A Quarterly MDS (Minimum Data Set) assessment, dated 07/07/23, indicated the resident was cognitively intact. The diagnoses included, but were not limited to Multiple Sclerosis, neurogenic bladder, and depression. The Progress Note, dated 08/22/23 at 8:55 A.M., indicated the resident's POA (Power of Attorney) informed the nurse the resident was not acting right, was slightly lethargic, slow to answer questions, and more sleepy than usual. The resident's vital signs were assessed. The resident's temperature was 97.3 degrees, the pulse 103 beats per minute, and the blood pressure was 141/101. The POA requested the resident be sent to the ER (emergency room ). The Physician's order, dated 02/28/23, indicated the resident was prescribed Cefuroxime Axetil, 500 mg (milligrams) by mouth, two times a day. (antibiotic for a UTI) The Physician's order, dated 03/22/23, indicated the resident was prescribed Levofloxacin, 250 mg by mouth, one time a day for 10 days. (antibiotic for a UTI) The Physician's order, dated 08/22/23, Zosyn, 3.375 grams intravenously, four times a day for 10 days. (antibiotic for a UTI) The current Incontinence and Catheter Management policy, with a revised date of 09/27/21, was provided by the Administrator on 08/30/23 at 3:33 P.M. The policy indicated, .ensure/provide .catheter care .to prevent urinary tract infections . 38239 2. Resident 88's clinical record was reviewed on 08/28/23 at 11:45 A.M. A Quarterly MDS assessment, dated 07/11/23, indicated the resident was severely cognitively impaired. The diagnoses included, but were not limited to, stroke, hemiplegia following stroke, hypertension, obstructive uropathy, and non-Alzheimer's dementia. The resident had an indwelling urinary catheter. A progress note, dated 07/17/23 at 5:56 A.M., indicated the resident had a change in condition. The resident had experienced increased restlessness and yelling out. The resident's urine had a foul odor and was amber in color. A progress note, dated 07/17/23 at 2:28 P.M., indicated the resident's urine had been obtained and the sample was available for the courier to pick up. A progress note, dated 07/19/23 at 4:46 A.M., indicated the initial urinalysis results were received. The C&S (Culture and Sensitivity results that determine the appropriate antibiotic to use for the infection) were not available yet. A progress note, dated 07/24/23 at 9:35 A.M., indicated the MD responded to the final C&S results with an order for Ciprofloxacin (an antibiotic) 250 mg by mouth twice a day for five days and an order for a probiotic by mouth three times a day for 10 days. The resident's July EMAR (Electronic Medication Administration Record) indicated the resident received the first dose of the antibiotic on 07/24/23 at 8:00 P.M. The ADON (Assistant Director of Nursing) provided the laboratory report for the resident's urinalysis and C&S on 08/30/23 at 10:56 A.M. The report indicated the urine sample was received by the lab on Monday, July 17, at 6:45 P.M. The final urine culture and sensitivity was verified on Thursday, July 20, at 11:32 A.M. During an interview on 08/28/23 at 3:01 P.M., LPN (Licensed Practical Nurse) 2 indicated nursing staff would obtain a urine sample and a courier would pick it up and take it to the lab. If a C&S of the sample was indicated, the lab would fax the results to the facility on ce it was completed. A C&S usually took three days. The nurses could contact the lab if they were waiting on the results. Once the nurse received the results, they would notify the MD. The MD would order an antibiotic if one was indicated. Nursing staff would usually receive a reply from the MD the same day, especially if they notified the MD of the results during normal business hours. If they received an order to start an antibiotic during the day, the resident could usually begin the antibiotic that same evening, if that was what the MD wanted. If it was a common antibiotic, they could pull it from the EDK (Emergency Drug Kit). If it wasn't available in the facility, the pharmacy could send it with that evening's pharmacy delivery. During an interview on 08/30/23 at 10:12 A.M., the local hospital lab technician indicated they received the resident's urine sample on 07/17/23. The sample met criteria for a C&S. The C&S results were complete on 07/20/23 and faxed to two different numbers at the facility on 07/20/23 at 12:02 P.M. The results were faxed again on 07/23/23, likely at the facility's request. During an interview on 08/30/23 at 11:08 A.M., The DON indicated they did not have a facility policy related to urinalysis and C&S timeframes. The current facility policy, titled Laboratory Services and Reporting Policy, with a revision date of 12/12/17, was provided by the ADON on 08/30/23 at 10:56 A.M. The policy indicated, .The facility is responsible for the timeliness of services .promptly notify .of laboratory results that fall outside the clinical reference range . 3.1-41(a)(2)

Based on observation, record review, and interview, the facility failed to follow a physician's order related to blood pressure medication parameters for 1 of 6 residents reviewed for unnecessary medications. (Resident 37) Findings include: During and observation and interview on 08/28/23 at 9:17 A.M., Resident 37 was sitting in a wheelchair outside of his room. The resident was awake. The clinical record for the resident was reviewed on 08/29/23 at 2:38 P.M. A Quarterly MDS (Minimum Data Set) assessment, dated 08/03/23, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, unspecified convulsions, hypertension, and depression. A current physician order, with a start date of 06/01/21, indicated the resident was to receive Clonidine 0.3 mg (milligrams), twice a day. The medication was to be held if the systolic (top number) blood pressure was less than 120. The January through August 2023 EMAR (Electronic Medication Administration Record) indicated the resident had received the medication on the following dates and times when the systolic blood pressure was less than 120: - 01/01/23 at 4:00 P.M., the blood pressure was 116/53, - 01/03/23 at 4:00 P.M., the blood pressure was 107/70, - 01/06/23 at 8:00 A.M., the blood pressure was 100/64, - 01/09/23 at 4:00 P.M., the blood pressure was 118/64, - 01/13/23 at 4:00 P.M., the blood pressure was 118/74, - 01/14/23 at 4:00 P.M., the blood pressure was 108/58, - 01/24/23 at 4:00 P.M., the blood pressure was 104/64, - 01/26/23 at 8:00 A.M., the blood pressure was 93/61, - 01/27/23 at 8:00 A.M., the blood pressure was 114/62, - 01/30/23 at 8:00 A.M., the blood pressure was 115/68, - 01/31/23 at 8:00 A.M., the blood pressure was 114/78, - 02/01/23 at 8:00 A.M., the blood pressure was 104/58, - 02/02/23 at 4:00 P.M., the blood pressure was 118/58, - 02/05/23 at 8:00 A.M., the blood pressure was 109/64, - 02/09/23 at 8:00 A.M., the blood pressure was 111/70, - 02/14/23 at 8:00 A.M., the blood pressure was 100/64, - 02/20/23 at 8:00 A.M., the blood pressure was 104/67, - 02/24/23 at 8:00 A.M., the blood pressure was 110/73, - 02/24/23 at 4:00 P.M., the blood pressure was 118/64, - 03/01/23 at 4:00 P.M., the blood pressure was 79/49, - 03/25/23 at 4:00 P.M., the blood pressure was 118/60, - 03/26/23 at 4:00 P.M., the blood pressure was 118/63, - 04/04/23 at 4:00 P.M., the blood pressure was 118/60, - 04/08/23 at 4:00 P.M., the blood pressure was 118/60, - 04/15/23 at 8:00 A.M., the blood pressure was 108/60, - 04/17/23 at 4:00 P.M., the blood pressure was 93/63, - 05/10/23 at 4:00 P.M., the blood pressure was 116/76, - 05/22/23 at 8:00 A.M., the blood pressure was 98/56, - 06/02/23 at 4:00 P.M., the blood pressure was 118/64, - 06/08/23 at 4:00 P.M., the blood pressure was 108/74, - 07/26/23 at 4:00 P.M., the blood pressure was 106/66, - 07/29/23 at 4:00 P.M., the blood pressure was 118/64, - 08/10/23 at 4:00 P.M., the blood pressure was 105/58, - 08/25/23 at 8:00 A.M., the blood pressure was 114/70, and - 08/29/23 at 4:00 P.M., the blood pressure was 113/61. During an interview on 08/30/23 at 10:36 A.M., RN 3 indicated the resident had hold parameters for his clonidine medication. She would obtain the blood pressure before administering the medication. If the blood pressure was out of the parameter she would not give the medication and document in the EMAR that the medication was held. The EMAR would give them a number to input if the medication was to be held. If the medication was given it would have a check on the EMAR. The current facility policy titled, Medication Administration-General Guidelines, dated 12/01/14, was provided by the DON (Director of Nursing) on 08/30/23 at 2:14 P.M. The policy indicated, .Medications are administered in accordance with written orders of the prescriber . 3.1-48(a)(3)

Based on interview and record review, the facility failed to follow the physician's orders to obtain blood tests for 1 of 11 residents reviewed for laboratory services. (Resident 83) Findings include: Resident 83's clinical record was reviewed on 08/28/23 at 1:30 P.M. A Quarterly MDS (Minimum Data Set) assessment, dated 06/01/23, indicated the resident was severely cognitively impaired. The diagnoses included, but were not limited to, CAD (coronary artery disease), hypertension, non-Alzheimer's dementia, and diabetes. A General Communication Form, dated 03/21/23, indicated the resident had experienced an 11 pound weight gain in one week. The resident's lungs sounded clear, but their bilateral lower extremities were moderately swollen. A provider response, dated 03/22/23, indicated nursing staff were to obtain a chest x-ray, increase the resident's Lasix (a diuretic medication), and obtain the following blood tests on the next lab day: - A CBC (Complete Blood Count), - A BMP (Basic Metabolic Panel), - An A1C (Glycated Hemoglobin Test), - A Vitamin D level, and - A BNP (B-Type Natriuretic Peptide level). Another BMP was to be drawn in one week. A progress note, dated 3/22/2023 at 2:17 P.M., indicated the NP (Nurse Practitioner) was in the facility and added new orders. The resident's family was updated, and the lab requisition was faxed. The resident's clinical record lacked documentation of blood tests obtained until 9 days later on 03/31/23. During an interview on 08/28/23 at 3:01 P.M., LPN (Licensed Practical Nurse) 2 indicated nursing staff would send a fax to the local hospital when there was an MD order to obtain labs. The hospital would send lab technicians to draw labs on Mondays, Wednesdays, and Fridays. If a lab needed to be obtained on a day when the lab techs weren't coming, the nurses in the facility would obtain the labs themselves. The hospital also had couriers that came in the facility every day to pick up any samples that needed to go to the lab. During an interview on 08/28/23 at 2:36 P.M., the ADON (Assistant Director of Nursing) indicated the labs were drawn on 03/31/23. They should have been drawn the next lab day after they were ordered on 03/22/23 and they were not. The current facility policy, titled Laboratory Services and Reporting Policy, with a revision date of 12/12/17, was provided by the ADON on 08/30/23 at 10:56 A.M. The policy indicated, .The facility is responsible for the timeliness of services . 3.1-49(a)

Based on record review, observation, and interview, the facility failed to provide dementia services for 1 of 2 residents reviewed for dementia care. (Resident C) Findings include: The clinical record for Resident C was reviewed on 03/13/23 at 11:14 A.M. A Quarterly MDS (Minimum Data Set) assessment, dated 02/15/23, indicated the resident was severely cognitively impaired. The diagnoses included, but were not limited to, anemia, hypertension, renal insufficiency, and non-Alzheimer's dementia. The Complete Care Plan was provided by the Administrator on 03/13/23 at 3:24 P.M. The Care Plan included the following: - The resident had impaired cognitive function/dementia related to dementia. An intervention included, but was not limited to, requires approaches that maximize involvement in daily decision making and activity limit choices, use cuing, task segmentation, written list and instructions. - The resident was to carry out activities individually with the help of staff or on own. The interventions included, but were not limited to, ask resident how they are doing? If the resident was upset, listen, and reassure them, and report to the Social Services after the visit. Greet the resident and introduce self. A facility reported incident, dated 02/16/23, indicated that staff members had reported to the charge nurse that Activity Aide 2 was overheard being argumentative with Resident C. During an observation on 03/13/23 at 11:31 A.M., CNA (Certified Nurse Aide)/Activity Aide 2 was sitting in the Main Dining Room with other staff assisting a resident with their meal. She was conversing pleasantly with the resident. During an interview on 03/13/23 at 2:13 P.M., CNA (Certified Nurse Aide) 3 indicated on 02/16/23, she was in a resident room when she heard Resident C and CNA/Activity Aide 2 in the day room. She had gone out and caught the end of the situation and believed Resident C had a maraca that she sat down on the table and was picking it back up when CNA/Activity Aide 2 tried to take it out of her hands. Resident C indicated get off me you B****, I am going to hit you if you don't get off me. The CNA/Activity Aide 2 indicated If you do, I am going to knock you on your butt. She reported it to the charge nurse. During an interview on 03/13/23 at 2:15 P.M., the Social Service Director indicated after the incident on 02/16/23, the staff had gone to the charge nurse, and they alerted her. She had told CNA/Activity Aide 2 she had to go home related to an incident and that the Administrator would be in contact with her. CNA 3 was in a resident's room and only heard the last of the incident. She went and interviewed all the staff working on the unit and other residents that lived on that unit, as that was CNA/Activity Aide 2's primary work area. During an interview on 03/13/23 at 2:22 P.M., CNA 5 indicated on 02/16/23, Resident C was in the day room at the activity counter when CNA/Activity Aide 2 got upset and told her to leave. Resident C didn't like the tone of CNA/Activity Aide 2 and told her she was going to knock her out to which CNA/Activity Aide 2 responded back No you won't I will throw you to the ground. The resident didn't know what she was saying half of the time. The CNA/Activity Aide 2 was angry, but she didn't believe she would harm the resident and thinks everyone has bad days. She reported the incident to the charge nurse. During an interview on 03/13/23 at 2:26 P.M., CNA/Activity Aide 2 indicated on 02/16/23 the resident was at the activity counter. She liked to hoard things. She had gone up behind the resident and asked her if she needed something. The resident had coloring supplies in her hands and asked her to leave them there. The resident told her no they are mine and had said something about backing up. She had told the resident if she backed up, they would both end up on the floor on their butts. She wasn't mad at the resident. When the Social Service Director came and talked to her, she was confused. Her schedule was reassigned to where she doesn't work on the dementia unit, and she had to complete education related to communication with dementia, resident rights, and abuse. She had completed all the training the was required after the incident. During an interview on 03/13/23 at 2:35 P.M., the Administrator indicated after the incident was reported and completed staff and resident interviews. She told CNA/Activity Aide 2 tones can be interrupted different by other bystanders. She was remorseful and the staff didn't feel that she would have acted upon anything. CNA/Activity Aide 2 was reassigned to a different area in the building and had to complete additional training. She was also educated on joking with residents and what is not appropriate. The current facility policy titled, Skilled Memory Care Neighborhood with an effective date of February 11, 2021, and provided by the Administrator on 03/13/23 at 3:46 P.M. The policy indicated, .our goal is to fight stigma and support quality of life for person's living with dementia . The current facility policy titled, Resident Rights with an effective date of December 17, 2020, and provided by the Administrator on 03/13/23 at 3:24 P.M. The policy indicated, .Respect and dignity. The resident has a right to be treated with respect and dignity .Safe environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely . The deficient practice was corrected prior to the start of the survey, therefore was considered past noncompliance. The facility had completed staff education, in-servicing, and monitoring. This Federal tag relates to Complaint IN00401954. 3.1-37(a)

Based on observation, record review, and interview, the facility failed to provide adequate assistance for bed mobility and personal hygiene that resulted in a fall with a fracture (Resident 70) and to follow a resident's care plan intervention for a resident who was at risk for falls (Resident 73) for 2 of 5 residents reviewed for accident hazards. Findings include: 1. During an interview and observation on 08/25/22 at 12:19 P.M., Resident 70 was sitting in her bed that had one side flush against the wall. She indicated she had fallen out of bed and broken her hip about three weeks ago when she was given a bed bath. The clinical record for Resident 70 was reviewed on 08/26/22 at 10:06 A.M. An Admission MDS (Minimum Data Set) assessment, dated 07/30/22, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, heart failure, hypertension, anxiety, respiratory failure, and [CONDITION(S)]. She required extensssive assistance of two staff members for bed mobility and personal hygiene. A Progress Note, dated 8/9/2022 at 6:45 P.M., indicated NA (Nurse Aide) 5 was assisting Resident 70 with a bed bath, as NA 5 rolled the resident toward her, the resident rolled out of bed and onto the floor. The resident was assessed for injuries, and placed back in the bed with a manual lift. A Progress Note, dated 8/9/2022 at 8:14 P.M., indicated the resident was having pain in her left leg when she was moved. The resident was transported to the local emergency room for an evaluation. A Progress Note, dated 8/10/2022 at 1:35 A.M., indicated the resident was being admitted to the local hospital with a fractured left hip. A Skilled Progress Note, dated 8/8/2022 at 7:00 P.M., indicated the resident required the use of a manual lift with the assistance of two staff members and required extensive assistance of two staff members for bed mobility. During an interview on 08/26/22 at 1:11 P.M., CNA (Certified Nurse Aide) 3 indicated prior to receiving her broken hip Resident 70 required the assistance of two staff members for all ADLs. During an interview on 08/30/22 at 2:19 P.M., LPN (Licensed Practical Nurse) 22 indicated NA 5 had been giving Resident 70 a bed bath when the resident's foot and leg slid off the bed. The weight of the leg pulled the rest of the resident off the bed and onto the floor. The resident denied any pain at the time of the fall. The resident later complained of left leg pain and was sent to the emergency room . The current facility policy titled Fall Prevention - Steady Steps Policy, with a revision date of February 17, 2020, was provided by the ADON (Assistant Director of Nursing) on 08/30/22 at 2:51 P.M. The policy indicated .It is the policy of Christian Horizons to provide each resident with an appropriate assessment and interventions to prevent falls . 2. On 08/26/22 at 1:25 P.M., Resident 73 was observed lying in her bed. The bed was in a low position and had a scoop mattress. The resident's call light was within reach and a thick pad was on the floor next to the resident's bed. The clinical record was reviewed on 08/29/22 at 2:28 P.M. A Quarterly MDS assessment, dated 08/03/22, indicated the resident was rarely/never understood. The diagnoses included, but were not limited to, Alzheimer's disease, dementia, anxiety, depression, [CONDITION(S)], and repeated falls. The resident had two or more falls since the previous assessment. The progress notes were provided by the ADON on 08/30/22 at 11:23 A.M., and included, but were not limited to, the following: - a note, dated 07/11/22 at 3:30 P.M., indicated staff were called to the resident's room. Through a crack in the door, the resident could be seen lying on her back on the floor in her room cross ways in front of the door. The staff had to enter the resident's room through an adjoining room. The resident was alert but not able to answer questions due to advanced dementia. No apparent injuries were noted. The resident had been incontinent of bowel and had two blankets tangled around her ankles. The staff were educated on getting the resident up between 2:30 P.M. and 3:00 P.M., per the resident's care plan. During an interview on 08/26/22 at 1:27 P.M., CNA 6 indicated the resident usually laid down after meals. The staff got her up by 3:00 P.M., because she was a fall risk. The resident attempted to get out of bed by herself and was unable to stand or walk unassisted anymore. During an interview on 08/30/22 at 9:58 A.M., CNA 9 and CNA 10 indicated they knew what was on a resident's care plan by logging into the Kardex on their tablets. They completed their charting on the tablets. It was a routine that the resident was to be up by 3:00 P.M., daily. The resident's care plan should have her fall preventions listed. They laid the resident down after lunch and she usually took a nap. They often got her up before their shift ended at 2:00 P.M. If she was sleeping really well, they would let the oncoming shift know during the walk through report session to have her up by 2:30 P.M. They laid eyes on each resident during the walk through report. If the resident was awake at that time, they would help the second shift staff transfer her and bring her out to the common room. They tried to keep all fall risk residents in a common community area where a staff member could see them. During an interview on 08/30/22 at 2:13 P.M., CNA 11 indicated she had worked at the facility for over five years. She had been in the building when the resident had fallen at times but could not remember the details of the fall on 07/11/22. The resident currently required extensive assistance of two staff members for mobility and had special instructions to have her up before 3:30 P.M. Today, the staff were to have her up by 2:30 P.M. During an interview on 08/30/22 at 2:20 P.M., CNA 12 and CNA 13 indicated the resident used to get out of bed on her own and had fallen a few times. The intervention to get the resident up by 3:00 P.M., was just put in place in the last couple of months. They had both been working in the facility for about two years. They could not remember the resident's fall on 07/11/22. The Neurological Assessment Flow Sheet for the resident's fall on 07/11/22, was provided by the ADON on 08/30/22 at 11:23 A.M. The assessments began at 3:30 P.M., at the time of the fall. The care plan, provided by the ADON on 8/30/33 at 11:23 A.M., indicated the resident was at risk for falls related to dementia. An intervention, with a start date of 02/17/22, indicated the staff were to assist the resident, following her afternoon nap after lunch, in getting her up between 2:30 P.M., and 3:00 P.M. An intervention, with a start date of 06/17/22, indicated the staff were provided education on assisting the resident in getting up, daily, between 2:30 P.M., and 3:00 P.M. An intervention, with a start date of 07/11/22, indicated the staff were re-educated pertaining to the resident's plan of care. The current Comprehensive Care Plans policy, with a reviewed date of 05/18/17, was provided by the ADON on 08/30/22 at 2:24 P.M. The policy indicated, . It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident .to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment .care plan will describe .The services that are to be furnished to attain or maintain the resident's highest practical physical, mental, and psychosocial well-being .Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions . 3.1-45(a)(1) 3.1-45(a)(2)

Based on observation and interview, the facility failed to store food in a sanitary manner for 2 of 3 observations in the kitchen and snack refrigerator related to expired dates, food storage, hand hygiene and mask usage. Findings include: 1. During an initial tour of the kitchen on [DATE] at 10:05 A.M., the following was observed: - a reach-in refrigerator near the steam table had 19 pint-sized cartons of nutritional drinks with a use by date of [DATE]. The Dietary Manager removed the drinks and threw them away. She indicated they should have already been taken out. - in the walk-in refrigerator on the bottom wired shelf was a 5-pound package of sealed turkey deli meat. A box of ground beef was sitting on top of the deli meat thawing. The ground beef box had no leaks, and the turkey was sealed. The meats were not sitting on trays. The Dietary Manager removed the ground beef from atop the deli meat. - in the walk-in freezer there were two boxes sitting on the floor. A box of frozen chicken was removed from the floor and placed in the refrigerator to thaw. A box of bratwurst were removed from the floor. The bratwurst had a delivery date of [DATE]. The Dietary Manager removed the bratwurst and threw them away, she indicated the boxes should not have been sitting on the floor. - by the dishwasher area was a wired rack with dry dishes. There was a tray that contained a stack of clean red bowls and various other clean dishes. Beside the red bowls was a set of keys on a lanyard and a plastic fast food restaurant cup without a lid that was half full of a liquid. The Dietary Manager indicated those items were not to be sitting there and instructed a staff member to remove them from the shelf. - the dry storage room contained a sugar and flour bin that was half full. each bin had a scoop inside. The Dietary Manager indicated the scoops should be stored outside of the containers and her staff knew better. During an observation on [DATE] at 10:43 A.M., Dietary Aide 14 was standing by the steam table when she touched her face mask with her gloved right hand. She then retrieved a tray of drinks from the reach in refrigerator. She sat the tray down on a cart and removed each glass from the tray with her right hand and sat them in a tub. During an observation on [DATE] at 1:41 P.M., Dietary Aide 15 and Dietary Aide 16 were standing at a prep table with their mask under their chin and nose. They were moving a dessert from a pan to cups. Dietary Aide 17 was standing on the opposite side of the prep table with her mask under her chin. During a follow up visit to the kitchen on [DATE] at 10:00 A.M., the following was observed: - a reach in refrigerator by the steam table contained 32 power puddings with a date of [DATE]. The Dietary Manager indicated there were made on [DATE] and would need to be used ,d+[DATE] days after making them. She removed them and threw them away. - a reach-in refrigerator, located next to the walk-in refrigerator, contained a 5-pound carton of liquid whole eggs that was 1/4 full and had an open date of [DATE]. The label on the side indicated the eggs should be used within 3 days of opening. 2. During an observation and interview on [DATE] at 9:52 A.M., a snack refrigerator on the 300 Hall contained the following: - two energy drinks LPN (Licensed Practical Nurse) 2 indicated the drinks belonged to staff and shouldn't have been in there, - a one quart milk jug that was ,d+[DATE] full of a red substance. It was unlabeled and undated. LPN 2 indicated she believed it was tomato juice for a resident, but she was unsure how long it had been in there, - a 1.5-liter container of unopened chocolate milk that had no name. The milk had a use by date of [DATE]. LPN 2 indicated the resident's snack refrigerators were to be cleaned out by the 3rd shift nursing staff. During an interview on [DATE] at 10:40 A.M., the Administrator indicated there had not been any food borne illnesses in the building. During an interview on [DATE] at 2:24 P.M., Nurse Aide 18 indicated masks should be covering the nose and mouth. The current facility policy titled, Infection Prevention and Control Manual Dietary, dated 2017, was provided by the Administrator on [DATE] at 11:13 A.M. The policy indicated, .Labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by date, or frozen (where applicable) or discard .Store raw meat (e.g., beef, pork, lamb, poultry, and seafood) separately and in drip-proof containers and in a manner that prevents cross-contamination of other food in the refrigerator . The current facility policy titled, Food from Family, Visitors, Community dated 2016, was provided by the Dietary Manager on [DATE] at 12:00 P.M. The policy indicated, .Food stored for residents should be labeled and dated appropriately, and discarded per safe food storage guidelines. A facility may choose to utilize a specific refrigerator or area of cooler for resident food . The current facility policy titled, Masking Technique dated 2020, was provided by the Administrator on [DATE] at 11:13 A.M. The policy indicated, .Staff, visitors, and family will wear a mask .Place mask over nose and mouth .The mask is intended to fully cover the nose and mouth . 3.,d+[DATE](i)(3)

Based on observation, interview and record review, the facility failed to ensure residents at risk for falls and elopement were supervised to prevent elopement and interventions were implemented to prevent repeated falls for 2 of 18 residents reviewed for supervision and fall prevention strategies in the sample of 18. (Resident #60 and #84) This failure resulted in Resident #60 eloping from the facility and falling causing facial lacerations requiring four stitches to upper left eye. Findings include: 1. The clinical record for Resident # 60 was reviewed on 8/9/11 at 11:00 A.M. The record indicated Resident # 60 had [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) assessment, dated 6/16/11, indicated Resident # 60 had severely impaired cognition. Resident # 60 required limited assistance of one with bed mobility, extensive assistance of two with transfers, ambulation and toilet use. Resident # 60 had fallen three times since the previous assessment; two falls with no injuries and one fall with injuries. A Neuropsychology Testing Report, dated 3/10/11, indicated "...Her cognitive status significantly worsened with her apparent head injury from a fall this January...." A Resident Fall Risk Assessment, dated 4/12/11, indicated a score of 28. The form indicated "over 13 points = At risk." The admission orders ...Wanderguard at all times..." An Elopement Risk Assessment, dated 4/12/11, indicated one of the ten questions was answered yes, with the other nine questions answered no. The form indicated "Resident with more than 5 'YES' answers or any 'YES' response to a * (asterisks) statement are at high risk for elopement. Proceed with elopement interventions." The one question answered 'YES' did not have an *. A Care plan, dated 4/12/11, indicated a problem of "Potential for fall R/T (related to) Hx (history) of falls, dx (diagnosis) of Alzheimer's and psychotropic drug use." The interventions were "Fall protocol. Get rd (resident) up at 0630 (6:30 A.M.). Complete Fall Risk Assessment. Provide assistive devices as needed walker. PT (physical therapy)/OT (occupational therapy) to screen/evaluate/treat per P.O. (physician order)." The Nursing Notes, dated 4/14/11 at 0715 (7:15 A.M.), indicated "Light was on. Went into room to see what she wanted. Had removed personal alarm and was lying on floor on abdomen...0.5 cm ST (skin tear) noted R (right) wrist. No further injuries noted...Did not hit head. Denied having to go to bathroom. Was not incontinent of bowels or bladder." The fall care plan, dated 4/12/11, was updated on 4/14/11 to include the interventions of "concave mattress and non-skid strips on floor." A Care plan, dated 4/19/11, indicated a problem of "Impaired safety with risk for falls and elopement r/t (related to): [DIAGNOSES REDACTED]." The approaches included but were not limited to: "Complete elopement risk assessment quarterly. Wanderguard alarm to RLE (right lower extremity). Monitor location of resident frequently and observe for any safety concerns. Provide 1:1 (one to one) interaction as needed. Encourage resident to engage in activities. Check door alarms promptly. PT (physical therapy) and OT (occupational therapy) services as ordered. Complete fall risk assessment quarterly. Call light within reach. Half rails up at HOB (head of bed) to serve as an enabler. Concave mattress on bed. Non-skid strips on floor beside bed. Resident is a early riser assist out of bed at 0630 (6:30 A.M.) if resident desires. Monitor for unsafe actions and intervene as needed." The care plan was updated on 4-25-11, with interventions of "Bed alarm on bed. Toilet rd after AM meal et(and) lay down if she desires. Monitor freq (frequently) while in bed et assist back up et out to common area upon awakening." The Nursing Notes, dated 5/2/11 at 1300 (1:00 P.M.), indicated "Rd (resident) went out door 6- very resistive to return inside. TLC (tender loving care) given. Staff sitting with Rd offered B.R. (bathroom), fluids and food. Rd crying wants to go home." The Nursing Notes, dated 5/6/11 at 0045 (12:45 A.M.), indicated "Resident roommate called CNA to room to say resident had gotten up unassisted. Resident noted to have gone out side door. Staff went to find her. Resident found across street from parking area. Resident noted to have fallen and had abrasions and laceration to L (left) side of face. Resident brought back to facility. MD notified and order rec'd (received) to transport to ER (emergency room ) for eval (evaluation). Areas to L face cleansed and ice applied. Res refused to allow staff to further assess for injuries...Areas to L face abrasion on jaw approx (approximately) 3 cm x (by) 1 cm, 2 smaller areas noted higher on cheek. Laceration upper L eye approx 2.5 cm long well approximated." The Nursing Notes, dated 5/6/11 at 0445 (4:45 A.M.), indicated "Res (resident) returned from (name) ER...Res states her L knee is sore and areas to L face sore...Bed alarm on and functioning...Res has 4 stitches noted upper left eye...Stitches to be removed in 5 days. Will cont (continue) to monitor." The safety care plan, dated 4/19/11, was updated on 5/6/11 to include the approach of "Staff will do 15 min (minute) checks, offer foods, flds (fluids), toileting, and assess for pain." The Nursing Notes, dated 5/10/11 at 1300 (1:00 P.M.), indicated "Abrasions on L side of face and above L eye healing without s/s (signs or symptoms) infection. Areas are dark purple and yellow. 4 sutures above upper L brow intact and 2 areas L cheeck (sic) with ii (two) sutures in each area intact..." The safety care plan, dated 4/19/11, was updated on 5/22/11 to include the approaches of "Ambulate with i (one) assist keep hands on gait belt at all times and Resident rec's (receives) 1:1 (one to one) supervision during waking hours et checked on frequently while asleep." The Nursing Notes, dated 5/24/11 at 0715 (7:15 A.M.), indicated "Got up out of bed and found in doorway between room et foyer. Had blood in hair. Noted 1" (inch) long laceration on L (left) scalp near crown. Alert et (and) talking Didn't fall...." The Nursing Notes, dated 5/24/11 at 0815 (8:15 A.M.), indicated "Dr (name) informed of hitting head on corner of doorway and receiving laceration on L scalp, approx (approximately) 1" long, near crown of head. Order to send to ER (emergency room ) for eval (evaluation) rec (received) and noted..." The Nursing Notes, dated 5/24/11 at 1130 (11:30 A.M.), indicated "Returned to room via (name) ambulance with ii (two) attendants. Has 5 sutures in laceration on scalp." In an interview with the Director of Nursing, on 8/9/11 at 2:30 P.M., she indicated the resident had a Wanderguard on and the door alarm did sound. In an interview with the Director of Nursing, on 8/10/11 at 10:45 A.M., she indicated the bed alarm was sounding at the time of the incident on 5/24/11. The Nursing Notes, dated 7/15/11 at 0410 (4:10 A.M.), indicated "At 0350 (3:50 A.M.) Rd PA (personal alarm) sounded. CNA on hall went to room and resident was not there. Rd found immediately in neighbors across the hall, room sitting on floor. Rd stated she sat down to go to bathroom. No injuries..." The Nursing Notes, dated 7/15/11 at 0413 (4:13 A.M.), indicated "CNA stated resident not on floor on basket peeing. CNA then stated when done resident got off basket and on floor." (sic) The Nursing Notes, dated 7/15/11 at 0500 (5:00 A.M.), indicated "Dr (name) informed of going into another room et urinating in a wicker basket. Staff came and lowered her to the floor." The Nursing Notes, dated 7/15/11 at 2125 (9:25 P.M.), indicated "Aide was in room with res and res kept sliding her butt down in her recliner and had her butt between the foot rest and cushion of recliner all of a sudden recliner tipped causing res to slide down foot rest hitting her buttocks on floor. Res received i (one) bruise to coccyx and i bruise to L (left) buttock both purplish in color...Intervention is to ask housekeeping if we can get res a new recliner...." The safety care plan, dated 4/19/11, was updated on 7/15/11 to include the approach of "Replace recliner in rm (room). Toilet rd if restless offer foods and fluids. Ambulate Rd if she desires." A Care plan, dated 7/15/11, indicated "Resident at risk for falls." The interventions were "1.) Keep room, pathways uncluttered. 2.) Encourage to use assistive devices as needed. 3.) Check on resident frequently. 4.) Keep call light within reach. 5.) Assure resident wears proper footwear for transfers. 6.) Assist with toileting as needed. 7.) Keep personal and frequently used items within resident's reach. 8.) Provide adequate lighting. 10.) (sic) Replace res (resident) recliner with a different one that does not jerk was replaced with an electric chair." In an interview with Nurse Supervisor # 1, on 8/10/11 at 10:50 A.M., she indicated the care plan, dated 7/15/11, with interventions 1 through 8 is what the facility uses as the "Fall Protocol." On 8/10/11 at 9:40 A.M., the Director of Nursing indicated the Wanderguard system has two doors which lock when a bracelet is near, but all the doors sound an alarm. She indicated Resident # 60 went out the same door on 5/2 and 5/6/11, which was a door that alarms only. She indicated the resident's room had been two doors away from the exit door at the time of the incidents on 5/2 and 5/6/11. On 8/10/11 at 11:30 A.M., the Director of Nursing provided the Code Alert Systems policy and procedure dated 9/10/08. She indicated the Code Alert System was the Wanderguard system. The policy indicated "...When the door alarm is activated available staff will go to exit door..." 2. Resident #82 was identified by the DON (Director of Nursing) on 8/8/11 at 9:30 A.M. during the initial tour of the facility, as cognitively impaired and not interviewable. Resident #82 was observed on 8/10/11 at 9:15 A.M., sitting in her room in her wheelchair, sleeping. The wheelchair had anti-roll back devices in place. Resident #82 was observed to have on non skid socks. Resident #82's clinical record was reviewed on 8/10/11 at 9:15 A.M. [DIAGNOSES REDACTED]." The most recent MDS (Minimum Data Set), a change of condition assessment, dated 7/7/11, indicated the resident had disorganized thinking which fluctuated-came and went or changed in severity. The resident had behaviors of physical and verbal behaviors directed towards others. Resident #82 required extensive assistance of two staff with bed mobility, transfers, ambulation, and toiling. The resident was occasionally incontinent of bladder and bowels and did not have a toileting program in place. The resident had two or more falls since the last assessment. The CAA (Care area assessment) review, dated 7/7/11, "falls" included: "...has had deterioration in adls (activities of daily living)...has been occasionally incontinent of urine...increased mental confusion noted...Resident was not steady, only stabilized with human assistance, when moving on and off toilet, when turning around and facing the opposite direction and when moving from seated to standing...Resident is non-compliant with asking for assistance...staff will give frequent reminders to use call light to request assist and will check on resident frequently..." The resident fall risk assessment, dated 7/7/11, indicated a score of 28, with over 13 points as high risk. The Resident Care Plan, included a problem, dated 4/15/11, for "impaired safety with risk for falls due to diagnosis (sic) of schizophrenia, bipolar, anxiety and other mood disorders with psychotropic drug usage" "5/24/11 res non compliant with asking for help using call light to get assist for transfers." Interventions included: "Staff to check on resident frequently and assist resident as needed. 5/15/11, non skid socks. 5/23, encourage resident to back up to mattress/bed until back of knees touch bed then to sit down, upper side rails up to help with positioning and mobility. 5/24/11, encourage to use call light when needing up with transfers, check on frequently, encourage res to attend activities lounge area. 5/26/11, 2 assist with transfers, praise for using call light. 6/11/11, give frequent reminders to lock wheelchair, antiroll back device. 6/28/11, toilet after meals ask res if she wants to be assisted to bed or come to lounge after meals. 6/30/11, toilet res at the beginning of every round 930, 130, 0300, 0500 during the night. 7/2/11, ensure resident receives hour of sleep snack or juice prior to going to bed. 8/1/11, supply with a reacher, monitor for loose stool. 8/2/11, when resident goes to activities assist back to unit as soon as activity over." Another problem for falls, dated 8/2/11, indicated interventions of "keep room pathway uncluttered, encourage to use assistive devices, check on frequently, keep call light in reach, assure proper foot wear, assist with toileting as needed, keep personal items in reach, provide adequate lighting." CNA #5, provided the CNA assignment sheet for Resident #84 on 8/10/11 at 11:00 A.M. The assignment sheet indicated the resident required two assist for transfers, remind to lock wheelchair, offer snack at night, check resident first during night rounds to see if toilet needed, toilet before and after meals, non skid socks, remind to use call light, keep light in reach, check on every 30 minutes, after meals see if wants to go to bed or come to lounge area, monitor room to make sure roommate is not blocking entry to room, toilet residents 9:30 p.m., 11:30 p.m., 3:00 A.M. and 0600 (6:00 a.m.), praise for using call light." A physician progress notes [REDACTED]." Nurses notes indicated: 5/14/11 1045 A, " resident found on floor in restroom incontinent of urine...Alert and oriented times 3...non skid socks applied..." 6/3/11 1530 (330 P.M.), "res was found on floor sitting in upright position by bathroom in room, Res was not using walker, wearing on skid socks stated lowered self to floor." 6/3/11 1700 (5 p.m.), "res found on floor in upright positioning by bed...was trying to go to bathroom..." 6/4/11 1725 (525 P.M.), "CNA had placed res on toilet in her bathroom and told her to pull call light when done. Found res sitting on buttocks in doorway of bathroom...stated was going back to her chair..." 6/4/11 1745 (545 P.M.), "this nurse was walking past res room, res sitting on buttocks on floor beside bed..res reminded she needs to use call light then wait for assistance prior to getting up-voices understanding and able to easily locate light and able to use it appropriately..." 6/7/11 135 a.m., " CNA walking past res room. Res sitting on buttocks on floor beside bed...Res stated 'I slid out of bed trying to get a drink of water.' res call light in reach but res did not use it..reminded to use call light and wait for assist..." 6/11/11 1250 p.m., "found res on floor in her room in front of her bed, w/c on other side of room brakes were not locked, res stated she was putting herself to bed and the w/c slipped out from under her..." 6/12/11 1500 (3 p.m.), "res was found on floor outside room laying on left side..." 6/14/11 1845 (645 P.M.), "found res sitting on knees on floor in room Res stated 'I was moving from chair to wheelchair." "I used my call light' call light was not on..." 6/28/11 1820, "res was found sitting on floor on buttocks in room (not hers but room that connects to her through the bathroom) resident wheelchair in her room...stated she was getting out of bed..." 6/30/11 5:15 a.m. "res found on floor in bathroom resident stated 'trying to go to bathroom' ...interventions non skid socks." 8/1/11 1045 a.m., "resident was noted at this time sitting on floor with leg out in front of her...stated she was going to the bathroom..." 8/1/11 2400 (midnight), "aide heard noise and entered room and found resident laying on floor in front of sink in her room. Resident was last seen at 2345 (11:45 p.m.) when aides repositioned her in chair and she refused to go to bed." 8/2/11 1455 ( 255 p.m.), "staff was called to dining room res had gotten up and walked and res fell backwards and hit her head on her wheelchair...received a cut to back of head...stated she fell cause she was going to get her children..." During interview with Nurse Supervisor #1 on 8/10/11 at 11:00 A.M., she indicated the facility had considered a personal alarm on 6/7/11, but felt it would agitate her more, as the resident had made comments about other residents having the alarms. 3.1-45 (a)(1) 3.1-45(a)(2)

Based on observation, interview and record review, the facility failed to ensure 1 of 3 residents reviewed for falls in a sample of 3 was provided proper safety interventions to prevent a dependent resident from falling face forward onto the ground from a lift, resulting in the resident sustaining laceration which required sutures and a fractured nose. (Resident #A) Findings Include: On 02/04/11 at 10:25 a.m. Resident #A was observed to be transferred via an EZ Lift from her Broda chair to the resident's bed. The resident was observed to have a healed scar above her left eye. Interview of CNA #1 on 02/04/11 at 10:30 a.m. indicated the scar above Resident #A's left eye was due to falling from the bus platform. Interview of the DON (Director of Nursing) on 02/04/11 at 10:40 a.m. indicated on 01/14/11 Resident #A was returning to the facility via the facility van from a doctor's appointment. The DON indicated the "Transfer Aide" pushed Resident #A in the resident's Broda chair onto the van platform and was ready to lower the resident down. The DON indicated the Transfer Aide locked the back brakes, but could not reach the front brakes due to there wasn't room for the Aide and the resident both on the platform. The DON indicated it was impossible to lock the front brakes on the platform due to the surface not being flat on the platform The DON indicated the brakes were lever type brakes that have to be pushed down to lock and it was impossible to reach around with your foot and lock the front brakes. The DON indicated the Broda Chair (in which resident #A was seated) scooted forward a slight amount and the resident who "did not have good upper body strength" fell forward onto the ground "approximately 1 foot." The DON indicated this was the first time a resident who used a Broda Chair had been transferred on the facility van. The DON indicated a policy was immediately implemented for residents in Broda chairs to be transferred out for appointments by ambulance only. Interview of the Administrator on 02/04/11 at 2:30 p.m. indicated it was impossible for the Transfer Aide to lock the front brakes on the Broda chair due to "you have to use your foot to push the levers down to lock and it was not possible for the Transfer Aide to reach her foot around in front of the Broda Chair while standing behind it to lock the brakes." Review of Resident #A's clinical record on 02/04/11 at 12:00 p.m. indicated the following: Resident #A had [DIAGNOSES REDACTED]. An Emergency Department triage report, dated 09/25/10, indicated Resident #A was seen in the emergency room due to falling forward out of a wheelchair striking her face The report indicated the resident sustained [REDACTED]. A quarterly MDS (minimum data set) assessment, dated 12/30/10, indicated Resident #A had altered level of consciousness and psychomotor retardation. The assessment indicated the resident required extensive assistance of staff for transfers. A care plan initiated 07/12/10 with a most recent goal date of 01/14/11 indicated, "...Impaired safety with risk for falls (related to) (decreased) muscle strength, dementia, and history of falls...Transfers with EZ-lift and 2 assist...Up in Broda Chair as tolerated...(Occupational Therapy) for chair positioning...01/14/11 Transport only via ambulance due to Broda Chair positioning." A nurse's note, dated 01/14/11 at 11:05 a.m. indicated, "(Resident #A) left facility for MD (Medical Doctor) (appointment). Upon arrival back to facility while bus driver was (lowering) res (Resident #A) in (Broda Chair) on the lift on the bus res (Broda Chair) and res pitched forward face forward onto the sidewalk. Res had a laceration to above her (left) eye and nose. Res had not lost consciousness while receiving first aide from staff. (Staff member's name) at res head holding pressure on res to help stop bleeding. Res (blood pressure) 218/105...(heart rate) 120...MD called for (order) to send to ER (emergency room ) (for) eval & tx (evaluation and treatment)...." A nurse's note, dated 01/14/11 at 3:45 p.m., indicated, "(Local Hospital) (emergency room staff) called to give report: (Resident #A) has (fractured) nose, laceration repair to area over (left) eye. Bacitracin (antibiotic ointment) to open area on nose, head injury instructions being sent. Stitches will need to be removed in 5 days...." A copy of an investigative report was provided by the DON on 02/04/11 at 11:00 a.m. The report indicated, "Investigation completed; findings as follows: Broda chair back locks were locked, the front locks on the Broda chair were not locked due to inability to lock the front brakes when the chair is on the lift. The chair rolled forward on the lift as it was coming down and the momentum of the resident's weight pushed the front wheels of the chair over the safety bar on the lift, allowing the resident's weight to shift forward out of the chair onto the ground. Risks Identified: Using the Broda chair with just the back brakes being locked...the weight of the resident...Conclusions: The lift on the bus is not safe for the broda chair...." Review of a "Fax/Incident Report" form provided by the DON on 02/04/11 at 11:00 a.m. indicated Resident #A was seated in her Broda Chair on a lift on the facility bus. The report indicated, "...While lift declining resident (#A) tipped forward out of chair falling to ground." The report indicated Resident #A sustained a laceration above her (left) eye. A manufacturer's instruction booklet (for a Broda chair) was provided by the DON on 02/04/11 at 1:55 p.m. The booklet indicated, "...Broda Chair hazards...Immediately after a resident is transferred into a chair, we recommend that the chair's seat be tilted sufficiently to prevent the resident from sliding or falling forward off the chair. The amount of seat tilt should be determined by the resident's caregiver who is responsible for seating...Danger of tipping. We recommend that the chair's seat be tilted sufficiently to prevent...resident from tipping...We recommend that a chair only be located on a level surface to minimize the risk of tipping over...Total Lock Brakes - "Danger of falling." The special casters found on the Broda chair have total lock brakes which prevent the wheels from turning and swiveling. The brakes must be applied when:...2. A resident is being transferred (moved) into or out of the chair; and, 3. the chair is not being moved by a caregiver...We recommend Broda chairs for indoor use within a long-term care institution and where there is not enough slope to cause the chairs to move unaided. Chairs used where the surface is uneven or sloped are at risk of unintended movement and could become a serious danger to the resident...Outdoor use is appropriate only under the strict supervision and full attention of a caregiver who is physically capable of preventing any unintended movement over any services that are to be traveled on. We recommend that a second caregiver assist when the chair is moved over surfaces that could cause significant unintended movement..." This federal tag relates to complaint IN 395. 3.1-45(a)(2)