Every finding on record at Miller's Merry Manor

Based on interview and record review the facility failed to protect Resident Funds from misappropriation related to theft of funds by an employee. (Employee 2) This deficiant practice was corrected on 4/30/2026, prior to the start of the survey, and was therefore past noncompliance. Finding includes: During a record review of an incident that had occurred on 4/27/2026, Employee 2 had called to self-report she had borrowed $40.00 from petty cash and $240.00 from the Resident Trust account. Employee 2 was immediately terminated and a police report was filed. The corporate Field Accountant and the Regional [NAME] President were notified as well. In addition, an audit had been completed of financial and resident facility accounts. The Petty Cash Count Form showed a General Ledger total of $200.00 and total cash as $159.65. A withdraw in cash of $40.35 was noted on the form.The Resident Trust Cash Box showed a General Ledger total of $250.00 and total cash as $10.00. A withdraw in cash of $240.00 was noted on the form.A statement from Employee 2 on 4/27/2026 indicated she had admitted to taking $40.00 from petty cash and $240.00 from the Resident Trust cash.On 4/27/2026 an audit by the Corporate Senior Financial Analyst indicated no further missing funds were found. Resident Trust and Petty Cash were replenished without any interruption in services to the residents.During an interview on .5/19/2026 at 10:55 A.M., the ED indicated financial audits were completed at the end of every month. Employee 2 reported her theft before the audit would have been completed since she knew it would have been discovered.The deficient practice was corrected by 4/30/2026 after the facility implemented a plan that included the following actions: continued the practice of educating staff upon hire and annually regarding resident rights and abuse policies and procedures, including misappropriation of resident funds, continued end of month financial audits, improved interview techniques to ensure any potential employee for the position of business office had accounting experience and prior experience with handling cash, and periodic audits, in addition to the monthly audits to ensure there were no further discrepancies with Resident fund accounts. On 5/15/2026 at 2:08 PM a current policy, dated 4/18/2023 and titled, Abuse Prohibition, Reporting, and Investigation was provided by the ED. The policy indicated, .Miller's Health Systems has policies and procedures in place that prohibit mistreatment, neglect, and abuse of residents, and misappropriation of resident property This citation relates to Intake 2996397. 410 Indiana Administrative Code (IAC) 16.2- 3.1-28(a)

Based on record review and interview, the facility failed to develop a comprehensive person-centered care plan for activities for 1 of 15 residents reviewed for care plans (Resident 5) Findings included:1.The clinical record of Resident 5 was reviewed on 12/3/2025 at 2:02 P.M. The resident's diagnoses included, but were not limited to: abdominal aortic aneurysm without rupture, adult failure to thrive, emphysema, difficulty in walking and pressure ulcer of the right hip. A Quarterly Minimum Data Set (MDS) assessment, dated 10/30/2025, indicated the resident was cognitively intact. An admission MDS assessment, completed on 5/15/2025, indicated it was very important for Resident 5 to do her favorite activities but the assessment had not identified her favorite activities.A Physician's Order, dated 5/8/2025, indicated Resident 5 could participate in an individual activity program according to the resident's care plan.Resident 5's clinical record lacked an individualized care plan related to activities.During an interview, on 12/4/2025 at 1:45 P.M., the Activity Director indicated there was no individualized care plan related to activities for Resident 5. The Activity Director indicated Resident 5 had been very resistant to participating in any group or individual activities but she had indicated she enjoyed drinking Coke or Pepsi and had enjoyed eating fresh fruit. The Activity Director indicated she should have included these activities in Resident 5's activity care plan.On 12/5/2025, at 11:35 A.M., the Assistant Director of Nursing provided a policy titled, Care Plan Development & Review, dated 1/24/2020 and indicated the policy was the one currently used by the facility. The policy indicated .The comprehensive care plan is designed to .Build on the resident's strengths .Reflect treatment goals and objectives in measurable outcomes .show evidence of efforts to find alternative means to address problems when resident is refusing treatment .3.1 - 35 (a)

Based on observation, record review and interview, the facility failed to follow the treatment plan for a resident with a pressure injury and failed to notify the provider and responsible party of a worsening pressure injury for 1 of 2 residents who were reviewed for pressure injuries. (Resident 15)Finding includes:Resident 15 was observed in bed and was not wearing a palm guard on her left hand during the following observations: 12/1/2025 at 10:44 A.M., 12/1/2025 at 2:15 P.M. and 12/3/2025 at 9:44 A.M.Resident 15's record review was completed on 12/3/2025 at 10:45 A.M. Diagnoses included, but were not limited to: dementia, major depressive disorder, contracture of the left elbow and left hand. A Quarterly Minimum Data Set assessment, dated 11/12/2025, indicated Resident 15 had severely impaired cognition and had one unhealed stage 2 pressure injury. A current Care Plan initiated on 5/21/2025 indicated Resident 15 was at risk of complications related to her left-hand contracture. Resident 15's Care Plan had a goal, initiated on 5/21/2025, indicating the resident would not have complications related to her left-hand contracture. Interventions to the Care Plan included, but were limited to: wear palm guard in left hand while awake (initiated on 08/05/2025) and splint to left hand during sleeping hours (initiated on 8/5/2025). Resident 15's Wound: Pressure Injury Assessments for her left hand, dated 11/19/2025 and 11/26/2025, indicated a pressure injury had measured 0.4 cm long by 0.7 cm wide by less than 0.1 cm deep. The pressure injury was marked as healing on both the 11/19 and 11/26/2025 assessments. Resident 15's Wound: Pressure Injury Assessment for her left hand, dated 12/2/2025, indicated the pressure injury measured 0.5 cm long by 0.7 cm wide by less than 0.1 cm deep. The pressure injury was marked as not healing on the assessment. Resident 15's record lacked documentation to indicate the treatment for the pressure injury had been updated or a notification of change had been sent to the resident's physician or family member. The record also lacked documentation Resident 15 had refused to wear her palm guard or splint in October 2025, November 2025 or December 2025.During an interview on 12/3/2025 at 10:10 A.M., RN 2 indicated Resident 15 was not wearing a palm guard on her left hand because she was non-compliant. RN 2 was not able to show the refusal of the palm guard in Resident 15's record for 12/3/2025. RN 2 indicated Resident 15's record should had contained a note indicating the physician had been notified that the resident had refused to wear the palm guard.During an interview on 12/3/2025 at 1:50 P.M., the [NAME] President of Operations (VPO) indicated Resident 15's pressure injury had been assessed and found to have worsened, but the physician and family had not been notified of the decline in the wound.During an interview on 12/4/2025 at 10:50 A.M., the Director of Therapy (DOT) indicated Resident 15 had been working with therapy but had been non-compliant with her palm guard during the day and her hand splint during the night. The DOT indicated nurses had reported the resident had been non-compliant with the palm guard and splint and she had witnessed Resident 15 take off the palm guard during therapy. The DOT indicated the treatment plan for Resident 15 was for her to wear a palm guard during the day and a splint at night. The DOT indicated the palm guard had been ordered on 10/28/2025 and was delivered to the facility on [DATE].During an interview on 12/5/2025 at 11:35 A.M., the Assistant Director of Nursing (ADON) indicated if a pressure injury worsened, the provider was to be notified and new orders for different treatment should have been obtained. The ADON indicated the facility did not have for have a policy for following the plan of care or physician orders. She indicated that was considered part of the Standards of Nursing.On 12/5/2025 at 11:35 A.M., the ADON provided an undated policy title, Physician and Family Notification of Condition Changes and indicated it was the policy currently used by the facility. The policy indicated, . II. Notify the physician of any change in condition that may or may not warrant a change in the treatment plan. V. Document the information reported to the physician in the nurses notes including the time and date of notification. VI. Document the response from the physician in the nurses notes. 4. Family notification A. Notify the resident and responsible party of any change in condition that may or may not warrant a change in the treatment plan.3.1-40

Based on observations, interviews, and record reviews, the facility failed to follow care plan interventions related to fall prevention for 1 of 5 residents reviewed for accidents. This resulted in the resident incurring a fall from her wheelchair and sustaining facial bruising and two skin tears (Resident 9) In addition, the facility failed to ensure supervision was provided related to the use of an electrical power strip and coffee maker in 1 of 5 residents reviewed for accidents. (Resident 1) Findings include: 1.The clinical record for Resident B was completed on 12/4/2025 at 10:00 A.M. Diagnosis for Resident B included, but was not limited to, history of falling. A nursing progress note, dated 11/4/2025, indicated Resident B was found lying face down on the floor in front of her wheelchair on 11/4/2025 at 5:45 P.M. by a staff member. Resident B's face was bruised, and she had sustained 2 skin tears. A current Care Plan Problem, related to falls included an intervention initiated 7/2/2024. The intervention indicated Resident B was to be assisted into her recliner or into bed when returned to her room. During an interview on 12/4/2025 at 11:03 A.M., Resident B's daughter indicated that on 11/4/2025 she had been visiting when her mother indicated she wanted to go to bed. The daughter had pushed the call light, an agency Certified Nurse Assistant (CNA) had answered the light and indicated he would be back with linens to put the resident to bed. The daughter then left the facility. She received a phone call on 11/4/2025 at 8:06 P.M. from the facility and was informed her mom had fallen from her wheelchair. The daughter further indicated that she understood that her mom would not be left in her room unless she was in bed or her recliner due to a previous fall. She indicated she had only left her because the CNA indicated he would be right back to put her to bed. During an interview on 12/5/2025 at 12:13 P.M., the DON indicated CNA's had assignment sheets that informed them of the care each resident required. A review of the assignment sheet for Resident B indicated she was not to be left in her room alone in her wheelchair and was to be put in bed if she was being left alone. On 12/5/2025 at 11:35 A.M. the ED provided a current policy dated 1/24/2020, and titled, Care Plan Development and Review. The policy indicated, .5. B. Nurse aides are advised of the residents care plan focuses and interventions that are within their scope of practice via assignment sheets and/or POC (plan of care) located in EMR (electronic medical record) 2. During an observation on 12/1/2025 at 10:57 A.M., Resident 1 had an electrical power- strip plugged in above his sink and resting on the sink counter with an electric coffee pot plugged into it and turned on. During an interview on 12/1/2025 at 10:57 A.M., Resident 1 indicated he had been permitted to have the coffee pot and make coffee whenever he wanted. During an observation on 12/3/2025 at 9:03 A.M., Resident 1 had an electrical power strip plugged in above his sink and sitting on the sink counter with a coffee pot plugged into it and turned on. Resident 1's record review was completed on 12/3/2025 at 9:30 A.M. Diagnoses included, but were not limited to osteomyelitis of the left foot and left ankle, below the knee amputation of right leg, type two diabetes and major depressive disorder. Resident 1's cognition was intact. Resident 1's record did not have a Care Plan indicating he was permitted to have a coffee maker in his room. During an interview on 12/3/2025 at 1:55 P.M., the Assistant Director of Nursing indicated Resident 1 should not have a power strip on the counter next to his sink and should not have had a coffee maker. in his room. During an interview on 12/5/2025 at 1:05 P.M., the Executive Director indicated the facility did not have a policy related to the use of small kitchen appliances in resident rooms or the use of power strip electrical outlets in resident rooms. 3.1-45(a) 3.1-45(a)(2)

Based on record review and interview, the facility failed to ensure employee certifications were active for 2 of 28 employees whose certifications were reviewed. This has the potential to effect 45 of the 45 residents who resided in the facility. (Employee 3 & 4)Findings Include:A review of the employee certifications was completed on [DATE] at 11:00 A.M. Employee 3, a CNA (Certified Nursing Assistant) had a hire date was [DATE]. Employee 3's CNA certification had expired on [DATE].A review of the facility schedule indicated Employee 3 had worked on the following recent dates at the facility as a CNA: 11/6, 11/10, 11/11, 11/13, 11/15-18, 11/20, 11/21, 11/24, 11/25, 11/30, 12/1 and [DATE].During an interview on [DATE] at 11:50 A.M., Employee 3 indicated she had not known her CNA certification had expired on [DATE].2. Employee 4 was hired on [DATE].Employee 4's QMA (Qualified Medication Aide) certification had expired on [DATE] and her CNA certification had expired on [DATE].A review of the facility's recent nursing schedule indicated Employee 4 had worked on the following dates at the facility as a QMA: 11/6, 11/7, 11/8, 11/11, 11/18, 11/20, 11/21, 11/22, 11/25, 11/28, and [DATE] and worked as a CNA: 11/13, 11/23, and [DATE].During an interview with the Director of Nursing (DON), on [DATE] at 1:10 P.M., the DON indicated she had called Employee 4 and Employee 4 indicated she was not aware of her expired certifications.During an interview on [DATE] at 12:40 P.M., the Executive Director indicated the person responsible for employee certifications was the Director of Staff Development and she had left the facility several months ago.On [DATE] at 1:20 P.M., the [NAME] President of Operations supplied a document titled, Director of Staff Development Task List and indicated it was the list currently used by the facility to ensure certifications were active. The task list indicated, .Monthly.Check CNA and QMA certifications are renewed timely.This citation relates to intake 2621113 and 2564067.3.1-14

Based on observation, interview and record review, the facility failed to ensure a resident was free from physical abuse for 2 of 3 residents reviewed. (Resident S and U). This deficient practice resulted in a hand injury and extensive bruising for 1 of 3 residents. (Resident S) Findings include:A report, dated 9/29/25, alleged Resident U had several physical altercations with Resident S due to Resident S wandering into her room. It was alleged there had been no interventions put in place to protect Resident S and staff had been instructed to not document these altercations. It was alleged during one of the altercations, Resident U had caused bruises on Resident S. Resident S had been kicked, punched, and swung at by Resident U, who had allegedly had similar behaviors at another nursing facility prior to being admitted . On 10/6/25, from 11:20 A.M. to 11:40 A.M., residents were observed on the secured memory care unit (MCU). There were 11 female residents on the secured unit. Two residents, Resident S and an unknown resident, were observed walking throughout the hall and dining/activity room and the remaining residents were seated at a large dining table having a snack. Resident S had a steady gait and required no assistance to ambulate. She wore a blank expression on her face, made eye contact but was non-verbal. She was observed leading the unknown resident down the hallway where both residents entered Resident U's room, whose room door was open. There was no signage or stop sign across Resident U's open door to deter entrance into the room. Both residents shortly exited the room and continued walking the hall back towards the dining room. Resident S was observed on 10/7 and 10/8/25 at various times, walking up and down the hallway and dining room area of the MCU. She was non-verbal, expressionless, and walked around with no sense of purpose. She was not observed to be aggressive or intrusive. On 10/6/25 at 12:30 P.M., Resident S's record was reviewed. Diagnoses included early-onset Alzheimer's and severe dementia without behaviors. She was receiving hospice services for her severe dementia.The current care plan for resident S indicated she had severely impaired cognition, was non-verbal, and required assistance with her activities of daily living due to her severe dementia. A care plan, dated 9/26/24, indicated she had behaviors related to her diagnoses and staff were to monitor the resident for anxious behaviors such as pacing to the point of exhaustion if it caused her distress. The care plans did not indicate Resident S wandered frequently into Resident U's room nor were there interventions to prevent the obtrusive wandering. The care plan did not indicate Resident S had been involved in physical altercations with Resident U when she had wandered into her room. A Nursing Progress note, dated 9/9/25 at 4:30 P.M., indicated Resident S had a 1-centimeter (cm) skin tear to her left hand due to Resident U hitting her hand. Resident S's family and staff had witnessed the altercation between Resident S and Resident U. A Social Service note, dated 9/10/25 at 5:36 P.M., indicated the Social Services Designee (SSD) had checked on Resident S, who was observed walking about the MCU as usual. Staff indicated Resident S had had a good day and there had been no concerns voiced related to the resident's mood. On 9/12/25 at 9:40 A.M., a physician's order was obtained to cleanse the skin tear to Resident S's left hand with normal saline and cover with a dry dressing two times per week. There was no further documentation completed regarding the resident-to-resident altercation between Resident S and U, nor had there been any changes made to Resident S or Resident U's care plans to prevent further altercations. Resident S's care plan, dated 9/12/25, indicated she had a skin tear to her left hand and was at risk for complications. Interventions included monitoring the area for complications, completing treatment as ordered and notifying the physician as needed. A New Behavior Initial Assessment form, dated 9/11/25 at 1:59 P.M., indicated Resident U had been observed sitting in her room when a peer came to her doorway. Resident U aggressively made contact with the peers legs and feet. The peer lost her balance and was pushed back. The two residents were separated and Resident U eventually calmed down. Resident U's family was notified, and the family indicated the resident had a history of being physically abusive to her peers. The peer was confirmed to be Resident S. There was no documentation completed in Resident S's record or any assessment completed of her injuries which had resulted from the physical altercation with Resident U. There were no changes made to the care plan to prevent further altercations and injuries from occurring. A Nursing Occurrence Initial Assessment form, dated 9/18/25 at 11:57 A.M., indicated Resident S was observed with scattered bruising to both of her lower legs. Her right lower leg had 5 bruises measuring: #1- 4 cm x 2 cm; #2- 2 cm x 2 cm; #3- 2.5 cm x 2 cm; #4- 3 cm x 2 cm and #5- 5 cm x 4 cm. The left lower leg had 3 bruises measuring: #1- 13 cm x 7 cm; #2- 1 cm x 2 cm and #3- 1 cm x 1.5 cm. There was no description of the color of the bruises or any assessment of pain from the bruises. The physician and family were notified. The form indicated Resident S had wandered and staff were to ensure the resident did not come in contact with anything/anyone harmful.There was no investigation completed for the cause of the extensive bruising to Resident S's legs nor any changes made to the care plan to ensure the resident did not come in contact with anything/anyone harmful. A New Behavior Initial Assessment form, dated 9/19/25 at 11:00 p.m., indicated Resident U had been observed in the hallway in her wheelchair when another resident had walked by her. Resident U began yelling, kicking and hitting the other resident several times until staff intervened. Resident U was taken to her room where she was assisted into bed and stopped yelling. The Administrator was notified of the altercation. The other resident was confirmed to be Resident S. There was no assessment or documentation of any injuries to Resident S completed and no changes were made to either Resident S or Resident U's care plans to prevent further altercations. A Nursing Occurrence Initial Assessment form, dated 9/25/25 at 2:25 p.m., indicated Resident S was observed with a mark on her face below her left eye. The form indicated it was an isolated incident and no further information was documented. Confidential staff interviews, conducted during the survey, indicated staff were aware of the altercations occurring between Resident U and Resident S, had reported the altercations and were concerned for Resident S's safety. Staff indicated the altercations, which had occurred on 9/11 and 9/19/25, were the result of Resident U's behaviors toward Resident S, who frequently wandered into Resident U's room. During interviews, it was alleged but unable to be substantiated, that management was aware of Resident U's behaviors prior to accepting her at the facility and interventions should have been put in place upon admission to prevent the behaviors before they occurred. Staff were concerned there were no interventions put in place to protect Resident S or other ambulatory, wandering residents from injury related to wandering into Resident U's room. Staff indicated Resident U's behaviors were escalating and alleged she had had altercations with other residents who resided on the unit. On 10/7/25 at 12:15 P.M., the Social Services Designee (SSD) was interviewed. When asked, she indicated Resident S had no behaviors and was content to wander throughout the MCU. The SSD indicated she had been made aware of the altercation occurring on 9/9/25, when Resident U hit Resident S on the hand causing a skin tear. She had followed up with Resident S the following day and observed no changes in mood due to the altercation. The SSD indicated she had been unaware of the other altercations and had not known about Resident S's bruises on her legs. During an interview, on 10/8/25 at 1:30 P.M., the Administrator indicated she had not been informed of the extensive bruising observed on Resident S's legs on 9/18/25. In addition, she indicated she had not been notified of the circumstances surrounding the altercations between Resident U and Resident S. She indicated there should have been an investigation into the altercations, interventions put in place to prevent further altercations, and a plan of protection for all residents on the unit who could be affected by Resident U's behaviors. A current policy, titled Abuse Prohibition, Reporting, and Investigation, was provided by the Administrator on 10/6/25 at 12:00 P.M. The policy indicated all residents had the right to be free from abuse including physical abuse which includes hitting, kicking, slapping, biting, and punching. Abuse was defined as being willful with actions done deliberately. If a resident initiated the abuse, he/she would be maintained under direct supervision by staff until the immediate investigation was completed and resident safety maintained. When abuse was observed or alleged, the nurse was responsible to immediately examine and assess the resident to determine if any injuries had occurred and their extent. An investigation was to be completed to ensure other residents had not been affected by the incident or inappropriate behavior. The Interdisciplinary team were to assess a situation of resident-to-resident abuse and make recommendations for interventions to prevent recurrence.This Citation relates to Intake 2629854.3.1-27(a)(b)

Based on interview and record review, the facility failed to ensure a resident's right to be informed and involved in care planning was upheld for 1 of 3 residents reviewed (Resident O).Findings include:A report, dated 9/11/25, indicated Resident O had been prescribed opioid pain medication to be given routinely every 4 hours. The resident had taken the opioid as prescribed and alleged they had experienced withdrawal symptoms when they requested the medication be decreased in dose and frequency.During an interview, on 10/8/25 at 12:36 P.M., with Resident O she indicated she had had a short-term stay at the facility in August 2025 for rehabilitation following a right knee replacement and had since been discharged home. She indicated, during her stay, she was prescribed pain medication which was to be taken every 4 hours. Resident O indicated she was told by a nurse, she should take the medication as prescribed to keep ahead of the pain. She indicated she had missed a dose of pain medication, one day during her stay, and started to feel sick. She was given the pain medication 2 hours after the missed dose and she felt better immediately. She realized she was addicted to the pain medication and told staff she was concerned. A nurse notified the physician and he reduced the frequency of the opioid medication to every 12 hours. She indicated after the frequency of the medication was reduced, she began to have worsening symptoms of withdrawal. She indicated she had experienced chills, hot flashes, runny nose, pain, anxiety, nausea, vomiting, tremors, watery eyes, decreased appetite and difficulty sleeping. Another nurse had explained to her that she should have been tapered off the pain medication more slowly to avoid the withdrawal symptoms. When asked, she indicated she had not known why she was to take the pain medication every 4 hours around the clock and had not been told about the potential side effects and withdrawal symptoms she could experience when the pain medication was decreased. She indicated the doctor, Nurse Practitioner (NP), nor the nursing staff had involved her in the decision to use opioids routinely to treat her right knee pain nor was she offered a non-medication treatment to deal with the pain. On 10/8/25 at 12:55 P.M., Resident O's record was reviewed. Diagnoses included right artificial knee joint replacement. A hospital record, dated 8/6/25, indicated the resident was admitted to the hospital on recommendation of the orthopedic surgeon following right knee replacement with severe post-operative pain. She was discharged to the facility on 8/9/25 after her pain had improved and she was no longer requiring intravenous morphine for her pain. She had been prescribed and received a prescription for Percocet (opioid) 10-325 mg tablets-1 tablet every 6 hours as needed for moderate to severe pain for 12 doses. She had been given a dose of the Percocet prior to leaving the hospital. The care plans for Resident O indicated she was had been admitted to the facility for rehabilitation and would be discharged back home after completion of her therapy. Her plans indicated she was to receive occupational therapy for assistance with transfers and self-care, required supervision with activities of daily living, had no cognitive impairments and had the potential for pain due to her recent right knee replacement.A Skilled Nurse Assessment, dated 8/10/25 at 12:40 A.M., indicated the resident's pain level on 8/9/25 at 11:03 P.M. was rated at a 9 out of 10 with 10 being the worst pain felt. She was given Percocet 10-325 mg tablet-1 tablet by mouth for the right knee pain. The resident indicated her pain was constant but had not affected her sleep or ability to do day to day activities. Following the administration of the Percocet, Resident O indicated effectiveness with her pain level as it had decreased to a 2 out of 10.A Skilled Nurse Assessment, dated 8/10/25 at 10:07 a.m., indicated Resident O rated her pain at a 5 out of 10. The assessment indicated the interventions for pain control included the use of Percocet (Opioid), ice machine, and repositioning. A physician's order, dated 8/10/25, was to give Percocet 10-325 mg tablets-1 tablet every 4 hours routinely for pain.There was no documentation completed indicating the reason for changing the order for the Percocet from every six hours as needed to every 4 hours routinely. There was no documentation indicating Resident O had been notified of the reason for change in her opioid medication nor the risks vs benefits of taking opioid medication routinely, including the risk for tolerance and addiction.During an interview, on 10/8/25 at 2:00 P.M., Registered Nurse (RN) 2 indicated on 8/10/25, she had assessed Resident O and observed her in severe distress from her right knee pain. She had contacted the NP and obtained the order changing the Percocet 10-325 mg tablets to be given every 4 hours in an attempt to help relieve the resident's pain. When asked, she indicated she had not spoken with the resident about the plan to give her opioid/pain medication every 4 hours nor had she explained the risks vs benefits of taking routine opioid medication. She indicated she had not documented notification to the NP or the change in orders in the clinical record.On 10/8/25 at 2:15 P.M., the Director of Nursing (DON) and Assistant Director of Nursing (ADON) were interviewed. Both indicated Resident O had complained of withdrawal symptoms when attempting to wean her off the opioid medication. The physician and NP had been notified and orders had been received for medications to treat the withdrawal symptoms. The DON indicated staff should have consulted with and involved the resident in decisions about her pain management plan. Resident O should have been educated on the risks vs benefits of using routine opioids for pain control and possible withdrawal symptoms which could occur when decreasing dosages and frequency of opioids.During an interview, on 10/8/25 at 4:05 P.M., the Regional Nurse Consultant indicated the facility had no specific policy for resident rights but followed Federal guidelines which indicated residents have the right to be involved in their care. She indicated Resident O should have been notified in advance of changes to her opioid medication orders, the risk and benefits of the change, the potential for withdrawal symptoms, and alternative, non-pharmacological interventions should have been offered.This Citation relates to Intake 2616114.3.1-3(n)(2)

Based on interview and record review, the facility failed to ensure allegations of physical abuse were reported for 2 of 2 cognitively impaired residents reviewed for abuse (Resident S and Resident U).Findings include:A report, dated 9/29/25, alleged Resident U had several physical altercations with Resident S due to Resident S wandering into her room. It was alleged there had been no interventions put in place to protect Resident S and staff had been instructed to not document these altercations. It was alleged during one of the altercations, Resident U had caused bruises on Resident S from kicking, punching, and swinging at her. On 10/6/25 at 12:30 P.M., Resident S's record was reviewed. Diagnoses included early-onset Alzheimer's and severe dementia without behaviors. A Nurses Progress note, dated 9/9/25 at 4:30 P.M., indicated Resident S had a 1-centimeter (cm) skin tear to her left hand due to Resident U hitting her hand. Resident S's family and staff had witnessed the altercation between Resident S and Resident U. There was no follow up documentation, investigation completed or reporting of the altercation as required. A Nursing Occurrence Initial Assessment form, dated 9/18/25 at 11:57 a.m., indicated Resident S was observed with scattered bruising to both lower legs. Her right lower leg had 5 bruises measuring: #1- 4 cm x 2 cm; #2- 2 cm x 2 cm; #3- 2.5 cm x 2 cm; #4- 3 cm x 2 cm and #5- 5 cm x 4 cm. The left lower leg had 3 bruises measuring: #1- 13 cm x 7 cm; #2- 1 cm x 2 cm and #3- 1 cm x 1.5 cm. There was no description of the color of the bruises or assessment of pain from the bruises. There was no investigation, incident reporting or follow up documentation completed for the cause of extensive bruising to Resident S's legs. A New Behavior Initial Assessment form, dated 9/19/25 at 11:00 p.m., indicated Resident U had been observed in the hallway in her wheelchair when Resident S walked by her. Resident U began yelling, kicking and hitting the other resident several times until staff intervened. The Administrator was notified of the altercation, but there was no documentation of an investigation into the altercation nor was the incident reported as required by State and Federal regulations. A Nursing-Occurrence Initial Assessment form, dated 9/25/25 at 2:25 p.m., indicated Resident S was observed with a mark on her face below her left eye. The form indicated it was an isolated incident and no further information was documented. There was no documentation completed indicating the injury of unknown origin had been investigated, the cause determined, and reporting completed as required.During an interview, on 10/8/25 at 1:30 P.M., the Administrator indicated she had not been informed of the extensive bruising observed on Resident S's legs on 9/18/25. She had not been notified of the circumstances surrounding the 4 alleged altercations between Resident U and Resident S. She indicated there should have been an investigation into the altercations and results of investigation reported to State and Federal agencies as required. A current policy, titled Abuse Prohibition, Reporting, and Investigation, was provided by the Administrator on 10/6/25 at 12:00 P.M. The policy indicated all residents had the right to be free from abuse including physical abuse which includes hitting, kicking, slapping, biting, and punching. Abuse was defined as being willful with actions done deliberately. The policy indicated alleged abuse and unusual occurrences must be reported to the Administrator immediately. The facility was to report allegations of abuse/unusual occurrences with 2 hours of discovery if the resident had visible injuries or 24 hours when no injuries were visible. An investigation was to occur immediately and results of the investigation reported to the Indiana Department of Health within 5 days of the initial report.This Citation relates to Intake 2629854.3.1-28(c)

Based on observation, interview and record review, the facility failed to ensure an effective behavior care plan, behavior monitoring and documentation was completed related to dementia for 1 of 3 residents reviewed for dementia needs. (Resident U). Findings include:A report, dated 9/29/25, alleged Resident U had several physical altercations with another resident who would wander into her room. It was alleged there had been no interventions put in place to protect the other resident and staff had been instructed to not document these altercations. It was alleged during one of the altercations, Resident U caused bruises on the other resident from being kicked, punched, and swung at. Resident U allegedly had similar behaviors at another nursing facility prior to being admitted . On 10/6/25 at 12:12 P.M., Resident U's record was reviewed. Diagnoses included dementia, psychotic disorder with delusions, depression, and sleep disorder. A quarterly Minimum Data Set (MDS) assessment, dated 8/19/25, indicated Resident U had moderately impaired cognition, had no mood indicators but had had physical behaviors towards others 1-3 days during the assessment, required supervision to partial assistance with her activities of daily living and used a wheelchair for mobility which she propelled herself. The current care plans for Resident U included the following: -Resident U displayed mood issues of excessive nervousness and worrying. She had behaviors of becoming territorial of her space and hitting/kicking staff when they attempted to enter her room or provide care. Interventions included monitoring her behaviors of hitting/kicking staff and excessive nervousness/worry; when behaviors occurred, staff were to reapproach her at later time; offer snack/drink; offer diversional activity like watching TV; offer to help resident call her daughters; talk with her about past interests; and offer 1:1 conversation/assurance. - The resident had confused thoughts and at times, delusions which were not distressing to her and didn't interfere with her care. Interventions included: staff were not to argue with or correct the resident when she had confused thoughts; if upset or distressed, check for unmet needs; reintroduce self with each interaction with resident; and break activities into manageable subtasks and explain procedures prior to providing care. - Resident U resided on the Memory Care Unit due to her dementia and the need for dementia programming. Interventions included: provide specialized programming.The clinical record indicated Resident U had been admitted to the facility from a sister facility, owned by the same corporation. Records from the sister facility indicated the resident had a diagnosis of dementia with other behavioral disturbances. There were no other records available, indicating what the behavioral disturbances the resident had displayed at her previous facility had been.On 10/6/25, from 11:20 A.M. to 11:40 A.M., residents were observed on the secured memory care unit (MCU). There were 11 female residents. Resident U was observed seated at the dining room table participating in an activity and snack. Two ambulatory residents were observed walking throughout the hall and dining/activity room. The two ambulatory residents wandered down the hall and walked into Resident U's room. The room door for Resident U's room was open. There was no signage or stop sign across the open door to deter entrance into the room observed. Both residents shortly exited the room and continued walking the hall back towards the dining room.On 10/8/25 at 11:18 A.M., Resident U was observed outside the doorway of her room, seated in her wheelchair. An unknown resident walked towards the doorway of Resident U's room and walked in. She picked up a hat from a chair and brought it to Resident U. Resident U indicated other residents always came into her room and picked things up because her room was so nice. When asked if it bothered her when other residents came into her room uninvited, she indicated it did not. A nurse progress note, dated 9/9/25 at 6:32 p.m., indicated Resident U's daughter had been notified of the resident hitting another resident's hand causing a skin tear. The Administrator and Director of Nursing (DON) had also been notified of the event.Refer to F600.There was no further documentation completed for the altercation occurring between Resident U and a peer. There were no changes made to the care plan and no interventions put in place to prevent further altercations from occurring. A New Behavior Initial Assessment form, dated 9/11/25 at 1:59 p.m., indicated Resident U had been observed sitting in her room when a peer came to her doorway. Resident U aggressively made contact with the peers legs and feet. The peer lost her balance and was pushed back (by Resident U). The two residents were separated and Resident U eventually calmed down. Resident U's family was notified, and the family indicated the resident had a history of being physically abusive to her peers.A New Behavior follow-up Assessment form, to be completed every shift for 72 hours after the identification of new behavior, dated 9/11/25 at 9:24 p.m.; 9/12/25 at 6:14 a.m., 3:17 p.m., and 8:57 p.m.; 9/13/25 at 6:07 a.m., 1:43 p.m., and 8:43 p.m.; 9/24/25 at 2:36 p.m. and 7:57 p.m. all indicated Resident U had had no behaviors observed.There were no changes made to the care plan to prevent further altercations and injuries between Resident U and other peers from occurring after the resident, again, struck out at her peer. A New Behavior Initial Assessment form, dated 9/19/25 at 11:00 p.m., indicated Resident U had been observed in the hallway in her wheelchair when another resident walked by her. Resident U began yelling, kicking and hitting the other resident several times until staff intervened. Resident U was taken to her room where she was assisted into bed and stopped yelling. The Administrator had been notified of the altercation.A New Behavior follow-up Assessment forms, dated 9/20/25 at 3:00 a.m., indicated Resident U had been up in her wheelchair going in and out of her room. She was told it was nighttime and had been assisted back to her room.-At 3:30 a.m., Resident U was observed screaming/yelling/cursing/hitting/kicking/pinching and throwing objects. A staff member was helping her back to her room when the resident began having behaviors toward the staff member. She pinned the staff member in a corner of the room and was swinging a stuffed animal at the staff member, trying to hit them. She eventually allowed staff to assist her into bed where she appeared calm.-Resident U had no further behaviors observed on 9/20, 9/21 or 9/22/25.There were no changes made to the care plan to prevent further altercations and injuries between Resident U, other peers, and staff from occurring after a 3rd altercation had occurred. There was no documentation completed to indicate the Interdisciplinary Team had investigated and tried to determine the cause of Resident U's behaviors and effective interventions put into place.An undated Certified Nurse Aide (CNA) care sheet, provided by the DON on 10/8/25 at 11:31 A.M., indicated Resident U was combative and was at high risk for falls. The CNA care sheet did not indicate who combative behaviors were directed toward (staff or other residents) nor were there any specific interventions or safety precautions to be taken for preventing resident to resident altercations between Resident U and her peers.Behavior tracking forms, dated 9/1 through 9/30/25, indicated Resident U's behaviors of physical aggression (hitting/kicking) towards staff while being provided care or redirection interventions were monitored every shift. Physically aggressive behaviors towards staff was documented to have occurred during the day shift on 9/11 and 9/16/25. Behaviors had occurred during the evening shift on 9/9, 9/11, 9/13, 9/15, 9/25, and 9/27/25. On the night shift, behaviors were documented as having occurred on 9/19/25. The behavior tracking form had not identified Resident U as having aggressive behaviors towards other residents and those behaviors were not being monitored.Confidential staff interviews, conducted during the survey, indicated staff were aware of altercations occurring between Resident U and another resident on the MCU, had reported the altercations, and were concerned for resident safety. Staff indicated altercations, which had occurred on 9/11 and 9/19/25, were the result of Resident U's behaviors toward another resident who frequently wandered into Resident U's room. During interviews, it was alleged but unable to be substantiated, management was aware of Resident U's behaviors prior to accepting her at the facility, because she had come from a sister facility. Staff indicated interventions should have been put in place upon admission to prevent the behaviors before they occurred. Staff indicated concern with there being no current interventions in place to protect ambulatory, wandering residents from injury related to wandering into Resident U's room. Staff indicated that Resident U's behaviors were escalating and staff alleged she had had altercations with multiple residents who resided on the unit.On 10/7/25 at 12:15 P.M., the Social Services Designee (SSD) was interviewed. The SSD indicated she had been made aware of an altercation occurring on 9/9/25, when Resident U hit another resident on the hand causing a skin tear. She indicated she had followed up with Resident U and the other resident involved in the altercation and neither resident indicated changes in mood or behaviors. When asked, the SSD indicated when a new behavior was identified, nurses were to complete a New Behavior Initial Assessment form, notify her, the Administrator and DON, and complete a 72 hour follow up assessment. She indicated after the 72 hour follow up assessments were completed, the Interdisciplinary Team (IDT) would meet and discuss any needed changes to the care plan. When asked if these meetings were documented in the resident's records, she indicated they had not been. She indicated she had been unaware of the other altercations and had not known about injuries to another resident, caused by Resident U. When asked, the SSD indicated Resident U was not being monitored on the behavior tracking forms for aggressive behaviors towards other residents, only towards staff.On 10/7/25 at 10:47 A.M., the DON provided a current copy of the facility policy titled, Behavior Assessment and Management which indicated the purpose of the policy was to have a systematic method for identifying specific behaviors which could impact a resident's quality of life or cause concern for other residents. Dangerous behaviors were to be observed for, documented in the clinical record, and attempts made to determine the cause and prevention of such behaviors. When new behaviors occurred, which could present a danger to the resident or others, interfere with activities of daily living, and/or cause the resident distress, nurses were to document the episode on the New Behavior Initial Assessment form, communicate the new behavior to all disciplines, and complete 3 days of behavior follow up assessments. After the 3 day assessments were completed, the IDT would review and document their evaluation and plan for the resident in the medical record. The IDT were responsible for determining whether the behavior or distress was preventable or required further assessment and would initiate a behavior management care plan, if needed, with interventions to assist in reducing or eliminating problem behaviors.This Citation relates to Intake 2629854.3.1-37

Based on record review and interview, the facility failed to develop a comprehensive care plan for a resident with depression for 1 of 19 residents reviewed for comprehensive care plan development. (Resident 34) Finding includes: A record review for Resident 34 was completed on 1/9/2024 at 2:21 P.M. Resident 34's diagnoses included, but were not limited to: depression and cerebral infarction. Resident 34's record lacked the documentation to show she had a care plan for depression. An interview with the Social Services Director (SSD) was completed on 1/11/2024 at 10:10 A.M. The SSD indicated that Resident 34 didn't have a care plan for depression, but should have had a care plan for depression. On 1/11/2024 at 3:00 P.M., the Director of Nursing (DON) provided a policy, dated 1/24/2020 and titled, Care Plan Development and Review. The DON indicated that the policy was the one currently used by the facility. The policy indicated, .2. Care Plan Development: A. An interdisciplinary team, in conjunction with the resident, physician and representative will develop a comprehensive care plan for each resident 3.1-35(a)

Based on interview and record review, the facility failed to update a fall care plan with a new interventions after a fall for 1 of 2 resident reviewed for falls. (Resident 27) Finding includes: During an interview on 1/8/2024 at 2:00 P.M., Resident 27 indicated he had a fall but was unsure of the date. A record review was completed on 1/11/2024 at 9:00 A.M. Diagnoses included, but were not limited to: heart failure, presence of left artificial hip, and difficulty walking. An MDS (Minimum Data Set) assessment, dated 12/22/2023, indicated Resident 27 had intact cognition, transferred with supervision of one staff assist, toileting with supervision of one staff assist, independent with walking and walker. A Care Plan, dated 1/19/2022, indicated Resident 27 was at risk for falls related to condition and risk factors and required the use of assistive devices. Interventions included but were not limited to: encourage to use call light and wait for staff to assist as needed, although likes to toilet self, encourage resident to use handrails or assistive devices properly, encourage and assist with wearing non-skid footwear. Interdisciplinary Notes, dated 12/3/2023, indicated Resident 27 was in the bathroom and his knee buckled, Resident 27 guided himself to the floor by grabbing hold of the towel bar, Nursing assessment was completed with no injury. A Nurse Practitioner's Progress Note, dated 12/5/2023, indicated Resident 27 had been evaluated by the Nurse Practitioner and indicated Resident 27 had a ground level fall without injury on 12/3/2023. Physical therapy was ordered, and a flat mat at bedside and toilet for foot stability should have been considered. During an interview on 1/12/2024 at 9:23 A.M., the MDS Coordinator indicated she was unaware of the Nurse Practitioner Progress note, dated 12/5/2023, indicating the consideration of using mats for foot stability for Resident 27. She indicated the fall care plan should have been updated then. On 1/11/2024 at 3:00 P.M., the Director of Nursing provided a policy titled, Care Plan Development and Review, dated 1/24/2020, and indicated the policy as the one currently used by the facility. The policy indicated .3. Care plans with be revised daily and as needed as changes in the resident's condition dictate. Changes include but are not limited to changes in Physician Orders, diet changes, therapy changes, behavior changes, ADL [Activities of Daily Living] changes, skin changes, etc. 3.1-35(c)(1)

Based on observations, record reviews, and interviews, the facility failed to notify the physician of blood sugars out of the ordered range for 1 of 5 residents reviewed for unnecessary medications and failed to follow physician orders for a resident at risk for skin breakdown for 1 of 1 resident reviewed for edema. (Residents 28 & 10) Findings include: 1. A record review for Resident 28 was completed on 1/9/2024 at 2:09 P.M. Diagnoses included, but were not limited to: diabetes mellitus type 2 and unspecified dementia. Physician's Orders included the following: - 9/24/2023, check blood sugar three times a day, and notify the physician of a blood sugar less than 60 or greater than 400. - 9/30/2023, give Novolog Injection Solution, inject 5 units subcutaneously three times a day for a blood sugar greater than 150. - 11/23/2023-12/27/2023, give Lantus 100 units per milliliter, inject 10 units subcutaneously daily A blood sugar review indicated the following: - 12/2/2023 11:09 A.M. 435 - 12/4/2023 4:10 P.M. 401 - 12/6/2023 11:45 A.M. 467 - 12/13/2023 12:15 P.M. 503 - 12/15/2023 11:15 A.M. 445 - 12/16/23 11:13 A.M. 431 - 12/20/2023 11:32 A.M. 433 - 12/20/23 4:01 P.M. 432 - 12/23/2023 10:40 A.M. 423 - 12/25/2023 11:27 A.M. 431 - 12/28/2023 4:22 P.M. 455 During an interview on 1/11/2024 at 11:30 A.M., QMA 2 indicated a blood sugar over 400, unless otherwise stated in the chart would be reported the physician. In her capacity, she would report the blood sugar to the nurse so the physician could be notified for an extra one-time dose of insulin. On 1/11/2024 at 1:17 P.M., the Director of Nursing (DON) indicated the Physician's Order would indicate when the physician would want to be notified for blood sugar readings. The DON reviewed Resident 28's orders, and indicated that a blood sugar reading over 400 should be reported to the physician. The DON reviewed the medical record, and could not find documentation of the physician being notified of the blood sugars over 400 listed above. She indicated the physician should have been notified of the blood sugars greater than 400. A policy was provided by the Director of Nursing on 1/12/2024 at 8:45 A.M. The policy titled, Diabetic Care Guidelines, indicated, .Physician notification for all blood sugars < [less than] 50 and > [greater than] 400, unless other physician call parameters are in place 48145 2. During an observation on 1/8/2024 at 1:45 P.M., Resident 10 was in bed and was not wearing heel protector boots on either foot. Resident 10's record review was completed on 1/9/2024 at 10:24 A.M. Diagnoses included, but were not limited to: seizures, dementia, depression, chronic kidney disease, and spondylosis of cervical region. An Annual Minimum Data Set (MDS) assessment, dated 10/26/2023, indicated Resident 10 had intact cognition and was dependent on staff for putting on and removing footwear. A Physician's Order, dated 11/1/2023, indicated to wear heel protector boots while in bed. During an observation on 1/9/2024 at 1:24 P.M., Resident 10 was in bed and was not wearing heel protector boots. During an observation on 1/10/2024 at 1:40 P.M., Resident 10 was in bed and was not wearing heel protector boots. During an interview on 1/10/2024 at 2:23 P.M., The ADON indicated Resident 10 was not wearing heel protector boots while in bed, but should be wearing heel protector boots as ordered. A policy for following Physician's Orders was requested, but the ADON indicated the facility did not have a policy for following Physician's Orders. 3.1-37(a)

Based on observation, record review, and interview, the facility failed to implement measures to prevent pressure areas for 1 of 1 residents reviewed for pressure ulcers. (Resident 36) Finding includes: During an interview on 1/8/2024 at 10:31 A.M., Resident 36 indicated he had an open area to his bottom. A record review was completed on 1/8/2024 at 10:45 A.M. Resident 36's diagnoses included, but were not limited to depression, hyperglycemia, hypertension, and benign prostatic hyperplasia. A Patient Transfer Nurse Assessment- Extended Care from [name of hospital], dated 12/12/2023, indicated Resident 36 was alert and oriented, was ambulatory with 1 assist, was incontinent of urine and had erythema (superficial reddening) of the skin on his coccyx area. An Admission MDS (Minimum Data Set) assessment, dated 12/19/2023, indicated the resident was able to make his own decisions, required maximum assist to roll side to side, total dependence for transfers, was always incontinent and had no pressure ulcers on admission. A Nursing Admission Assessment, dated 12/12/2023, indicated Resident 36 was alert and oriented, had no edema to the lower extremities, left hemiplegia with maximum to total assist with bed mobility. Lower extremities have the following pressure prevention in place: Pressure relieving boots. Sit to lying: substantial/maximal assist. Pedal pulses present right and left feet. A Nursing Braden Scale (Assessment for Pressure Risk), dated 12/12/2023, indicated Resident 36's sensory perception was slightly limited; the resident was occasionally moist; chairfast with ability to walk severely limited or non-existent; mobility was slightly limited; nutrition was probably inadequate; and there could be potential problem with friction and shear. A Nursing Assessment- Skilled Form, dated 12/22/2023 at 2:16 A.M., indicated the resident had no hemiplegia, the lower extremities did not have pressure relieving boots, and the resident did not decline lower extremity pressure injury preventative care. Currently has wound/incision receiving treatment but not infected: 1. Pressure related, Non pressure related, incision and none of the above. None of the above was checked. A Nursing New Skin Alteration Assessment (non occurrence), dated 12/22/2023 at 1:50 P.M., indicated a new wound, skin alteration - left buttocks near coccyx. 4.5 x 3.0 cm (centimeter) bruise that is sheared in the middle, skin unrolls back over area, DTI (deep tissue injury) to right the heel. A Nursing Assessment - Skilled form, dated 12/24/2023 9:42 P.M., indicated Resident 36 had a wound -pressure related. DTI to sacrum. Resident is turned/repositioned per plan of care. A Nursing Assessment- Skilled form, dated 12/25/2023 at 8:57 P.M., indicated Resident 36 had no wound- pressure area, non pressure area or incision. A Wound Pressure Injury Assessment, dated 12/26/2023 at 1:36 P.M., indicated Resident 36 had a deep tissue pressure injury to the sacrum, originally noted on 12/22/2023, measuring 6 cm x 4 cm <.1 cm (centimeters). Deep purple, moist and open. Sanguineous (bloody) drainage. MD notified. Current treatment was to cleanse with normal saline and apply hydrocolloid (Non adherent) dressing, and change weekly and as needed. A Nursing Braden Scale (Assessment for Pressure Risk), dated 12/26/2023 at 1:36 P.M., indicated Resident 36's sensory perception was slightly limited; very moist; chairfast ability to walk severely limited or non existent; mobility was very limited; nutrition was probably inadequate; and potential problem with friction and shear. A Wound Pressure Injury Assessment, dated 1/2/2024 at 2:26 P.M., indicated the in house developed pressure wound to sacrum, measured 7.5 cm x 7.0 cm. The wound bed was red, moist with scattered yellow and black moist eschar (dead tissue) covering 75% of the wound bed. Moderated Sanguineous drainage. MD notified. Treatment was cleanse area with normal saline and apply bordered foam dressing. Change every 3 days and as needed A Wound Pressure Injury Assessment, dated 1/10/2024 at 6:44 A.M., indicated Resident 36 had an in house developed pressure injury to the sacrum (DTI - deep tissue injury) now open into unstageable wound. Measured 8 cm x 7 cm x 0. Wound bed was red, moist with yellow/tan slough firmly adhered to the wound bed. Had moderate serosanguinous drainage. Necrosis (dead tissue). MD notified. Current treatment of cleanse with normal saline, apply calcium alginate with silver and cover with bordered dressing, change every 3 days and as needed. Wound Pressure Assessments for the right heel indicated the following: 12/27---in house DTI RIGHT HEEL -2 cm X 3.5 cm 1/2--- Right heel in house DTI 8 cm x 5 cm 1/3--- MD notification 1/10---Right heel-in house DTI- 8 cm x 6 cm 1/10-MD notification The shower documentation for Resident 36 indicated from admission 12/12/2023 to current 1/11/2024-- the resident had a shower on 12/28/2023, 1/7/2024 and on 1/10/2024 with no mention and or documentation of pressure areas. A current Care Plan, dated 12/26/2023, indicated the resident had developed an pressure injury. Location: sacrum and right heel related to exposure of skin to urinary and fecal incontinence, impaired/decrease mobility and decrease functional ability, refusal of some aspects of care and treatment, under nutrition, malnutrition and hydration deficits. Interventions included, but were not limited to: Assist to turn and reposition approximately every 2 hours while in bed, float heels off bed, lay down between meals to offload sacrum, low air loss mattress settings based on weight. During an observation on 1/11/24 at 10:20 A.M., RN 16 indicated the area to his sacrum was currently unstageable. The resident was lying on an air mattress with a bottom sheet and 2 bed pads. On 1/12/24 at 9:01 A.M., during an interview with Resident 36, he indicated during the hours of 10-6 A.M., the staff usually would turn and reposition him every 3 hours. From 6 A.M. to 2 P.M., they usually didn't turn him and from 2 P.M., to 10 P.M., it was usually one time. During an interview on 1/12/2024 at 10:30 A.M., QMA 2 indicated they try to encourage the resident to get up, he would get up for therapy. He was supposed to be checked & changed every 2 hours, he was continuously wet. He wets a little at a time with smears of stool when doing checks. They (management) are now looking into getting him side rails to assist turning. On 1/12/2024 at 10:30 A.M., the Assistant Director of Nursing provided the Operational Manual for the air mattress Protect Aire 3000/3500/3600. Installation Instructions . You may place a thin cotton sheet over the quilted mattress top cover .Patients can directly lie on the mattress or cover with a sheet and tuck loosely to increase the comfort of the patient. On 1/12/2024 at 10:34 A.M., the Assistant Director of Nursing provided the policy titled, Skin Management Plan, dated 8/14/2014, and indicated the policy was the one currently used by the facility. The policy indicated .F. Support Surfaces/Pressure reducing or relieving: . II. Ensure the surface is being used according to manufacture's instructions On 1/12/2024 at 10:35 A.M., the ADON provided the policy titled, Specialty Mattress Use, dated 4/2/2013, and indicated the policy was the one currently used by the facility. The policy indicated .VII. Use of a flat sheet to prevent hammocking of mattress, and minimal use of linen layers should be used to ensure therapeutic effectiveness of mattress. Refer to manufacture's guidelines for specific indications regarding linen and incontinence pad use During an interview, on 1/12/2024 at 10:55 A.M., the Assistant Director of Nursing indicated the resident should have been on 1 sheet per the manufacturer's guidelines. 3.1-40

Based on observation, record review and interview, the facility failed to ensure that an oxygen humidification bottles were changed weekly for 1 of 2 residents reviewed for oxygen use. (Resident 2) Finding includes: During an observation, on 1/9/2024 at 1:59 P.M., Resident 2's humidification bottle was dated 12/25/2023 and 12/31/2023. A record review was completed on 1/9/2024 at 2:12 P.M. Resident 2's diagnoses included, but were not limited to: Morbid obesity, nocturnal hypoxia, cerebrovascular disease and unspecified intracranial injury. A Physician's Order, dated 7/21/2021, indicated to change the oxygen tubing, humidifier, and clean concentrator filter weekly every night shift on Sundays. A Physician's Order, dated 7/11/2021, indicated Resident 2 was to wear oxygen at 2 liters per nasal cannula on at night. During an observation on 1/10/2024 at 7:28 A.M., Resident 2's humidification bottle was dated 12/25/2023 and 12/31/2023. During an observation on 1/11/2024 at 9:58 A.M., Resident 2's humidification bottle was dated 12/25/2023 and 12/31/2023 with no oxygen tubing storage bag present. During an interview on 1/11/2024 at 10:03 A.M., RN 3 indicated that there were two dates written on the humidification bottle, 12/25/2023 and 12/31/2023, and there should be an oxygen tubing storage bag present. RN 3 indicated all oxygen tubing, humidification bottles and oxygen storage bags are to be changed by the night nurse on Sunday nights. A policy was requested on 1/12/2024 at 10:14 A.M. The MDS (Minimum Data Set Coordinator indicated the facility does not have a specific policy stating when the humidification bottle should be changed, only when the oxygen tubing should be changed, and the bottle was usually changed with the tubing weekly. 3.1-47(a)(6)

Based on record review and interview, the facility failed to limit use of an as needed anti-anxiety medication for 1 of 5 residents reviewed for unnecessary medications. (Residents 3) Finding includes: During an interview with Resident 3's representative, she indicated Resident 3 had been on hospice for approximately a month's time. A record review was completed on 1/10/2023 at 11:42 A.M. Diagnoses included, but were not limited to: unspecified dementia, psychotic disorder with delusions, anxiety disorder, and depressive disorder. A Physician's Order, dated 10/28/2023, indicated Resident 3 was to receive lorazepam oral concentrate 2 milligrams per milliliter (mg/ml), 0.25 ml every two hours as needed for anxiety and restlessness. The lorazepam order was discontinued on 11/27/2023. Resident 3 received the as needed lorazepam per the Medication Administration Record on 11/16/2023 at 11:18 A.M., 11/17/2023 at 12:24 P.M., 11/20/2023 at 8:11 A.M., 12:52 P.M., and 3:30 P.M., 11/21/2023 at 6:15 P.M., 11/22/2023 at 10:39 A.M., 11/23/2023 at 9:04 A.M., and 11/25/2023 at 5:41 P.M. A Physician's Progress Note, dated 11/10/2023, indicated Resident 3 was seen and examined. The note indicated to continue with the current medications, but did not address the continued use of lorazepam. A Nurse's Note dated, 11/16/2023 at 11:18 A.M., indicated Resident 3 received the as needed lorazepam for appearing anxious and repeatedly asking people to take her to places while down in the dining room. On 11/20/2023 at 12:52 P.M., a Nurse's Note indicated Resident 3 received as needed lorazepam for repeated phrases of, Do you need me?, Are you Ready?, Where are we going?, and Is that for me? while reaching out her hands to staff. On 11/20/2023 at 3:30 P.M., a Nurse's Note indicated Resident 3 continued to be restless, and making statements of wanting to throw herself away. On 11/21/2023 at 12:31 P.M., a Nurse's Note indicated Resident 3 had anxiety. On 11/23/2023 at 9:04 P.M., a Nurse's Note indicated Resident 3 continued to grab at staff and repeated herself. She continued to repeat, Just take me., while reaching out to staff. During an interview on 1/11/2024 at 1:33 P.M., the Social Service Director (SSD) indicated that as needed psychotropic medications should only be ordered for 14 days, and the initial order should have a stop date for use. If the as needed psychotropic medication needed to be continued, a doctor's note was needed. She indicated the hospice company ordered the medication incorrectly without a stop date. A policy was provided by the Director of Nursing (DON) on 1/12/2024 at 8:45 A.M. The policy titled, Psychotropic Medication Use, indicated, .PRN [as needed] Psychotropic medications: PRN orders will be limited to 14 days, unless the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond the 14 days. He/she should document their rationale in the resident's medical record and indicate the duration of the PRN order 3.1-48(a)(2)

Based on observation, interview, and record review, the facility failed to follow general Infection Control Practices during incontinence care and a pressure ulcer treatment for 1 of 1 residents reviewed for pressure ulcers. (Resident 36) Findings include: 1. On 1/11/2024 at 10:10 A.M., CNA 4 was observed providing incontinence care to Resident 36. CNA 4 applied gloves, a gown and entered the resident's room. She used the bed controls and raised the bed. CNA 4 removed Residents' soaked brief and placed it in a trash can by the bed. She then removed the top bed pad and put it on the floor, next to the trash can. The aide completed the peri care. After completing the peri care, and without changing her dirty gloves, she applied a new brief to the resident and a new bed pad to the bed. With her gloved hands, CNA 4 rearranged the bed linens, then removed her dirty gloves and picked up a breakfast tray from the over the bed table and exited the room. During an interview, on 1/11/2024 at 10:20 A.M., CNA 4 indicated she should have removed her gloves, washed her hands and applied new gloves. 2. On 1/11/2024 at 10:20 A.M., RN 3, was observed to completed the treatment to Resident 36's pressure ulcer to his sacrum. RN 3 applied her gloves and gown and assisted the resident to turn to the left side. RN 3 applied wiped the residents peri rectal area due to loose stool. She removed the urine/feces soaked dressing to the coccyx. The area was black with irregular edges and approximately a 1'' ring of redness around the entire wound. RN 3 pulled the residents brief towards her to remove it. She removed her gloves and used hand gel on her hands. RN 3 applied gloves, sprayed the area with normal saline, and wiped the area with a gauze pad With the same gloved hands, she removed a piece of Calcium Alginate and placed it on the mepilex dressing, then placed the dressing on the wound. With the same gloved hands she tried to remove the top bed pad. RN 3 removed her gloves, assisted the resident in bed and rearranged the bed linens. During an interview, on 1/11/2024 at 10:30 A.M., RN 3 indicated she should have removed her gloves and washed her hands after cleaning the wound. On 1/12/2024 at 10:35 A.M., the Assistant Director of Nursing provided the policy titled,Use of Medical Gloves (application and removal), dated 6/9/2010, and indicated the policy was the one currently used by the facility. The policy indicate . 3. Guidelines: A. Hands should be washed initially prior to putting on the gloves . D. Gloves should be removed and hands washed with soap and water immediately after glove removal. E. Gloves should be removed and hands washed between care activities with patients On 1/12/2024 at 10:36 A.M., the Assistant Director of Nursing provided the policy titled,Hand Washing and Hand Asepsis, dated 10/27/2016, and indicated the policy was the one currently used by the facility. The policy indicated, .3. Key procedural points: A. Specific Times Hands Must Be Washed: . III. Before and after direct resident care . 3.1-18(b)

Based on interview and record review, the facility failed to ensure Quality Assurance and Performance Improvement Plan (QAPI) was carried out per their policy. Finding includes: On 11/21/2022 at 10:30 A.M., during the review of the QAPI facility task the Administrator indicated she had not done QAPI since the pandemic, she thought it was on hold. She recently started it back up on 10/25/2022. She should have been conducting QAIP meeting; their policy is monthly. The Infection Preventionist did the nursing part, but they did not meet as a group. During an interview, on 11/21/2022 at 10:50 A.M., the Infection Preventionist indicated she went over the monthly infection control with the Director of Nursing and provided a report to the medical director and the nurse practitioner but did not meet in a group setting such as QAPI. No past noncompliance provided. On 11/21/2022 at 10:40 A.M., the Administrator provided a policy titled, Quality Assurance and Performance Improvement Plan and Program, dated 11/8/2022, and indicated the policy was the one currently used by the facility. The policy indicated . Element 2: Governance and Leadership 1. The Administrator will be the owner of the QAPI process oversight. 2. The steering committee of the QAPI program will be the members of the exiting QAA committee including the Medical Director, Administrator, Director of Nurses, Infection Prevention Nurse and will include a member of the Miller's Health System Executive Committee when available. 3. The QAPI Steering committee will meet no less than monthly. More meetings may be conducted as needed

Based on observation, record review and interview, the facility failed to ensure bowel incontinence was thoroughly assessed for 1 of 3 residents reviewed for incontinence. (Resident 24) Finding includes: Resident 24 was admitted to the facility with diagnoses including, but not limited to: Alzheimer's disease, aneurysm of the renal artery, ataxia, hypertension, psychosis, major depressive disorder, single episode, history of COVID -10, psychotic disorder with hallucinations, atrophy, dysphasia, unsteadiness on feet weakness, anxiety disorder, history of falling, anemia, hypercholesterolemia and GERD. The most recent Minimum Data Set (MDS) assessment, completed on 11/4/2022 indicated the resident was moderately cognitively impaired, required supervision and set up help for transfers and toileting needs, required limited staff assistance of one for hygiene needs and was frequently incontinent of her bowels and bladder The most recent bowel incontinence assessment, completed on 6/30/2022 indicated the resident was frequently incontinent of her bowels, was mentally and physically aware of the need to have a bowel movement, had constipation issues but had did not have any toileting plan. The assessment indicated the resident transferred herself on and off the toilet, adjusted her clothing per self and needed staff assistance as needed for peri care and to ensure proper hygiene. The 6/29/2022 assessment did not indicate if any bowel patterning had been completed. The previously completed Quarterly MDS review, completed on 4/7/2022, indicated the resident was occasionally incontinent of her bowels. Resident 24 was observed, during the survey from 11/14/2022 through 11/18/2022 during the day, to spend large amounts of time, seated in her room in her wheelchair. She was not observed to be prompted or assisted by staff to utilize the toilet. She was observed, on 11/17/2022 at 11:24 A.M., propelling herself out of the restroom in her room. The licensed nurse passing medications in the hallway outside her room was unaware of where the resident was and did not realize she was in the bathroom, toileting herself. During an interview with CNA 7 , conducted on 11/18/2022 at 2:03 P.M., the resident was identified as usually continent of her bowel, capable of toileting herself and will notify staff if she has an accident. The CNA indicated she did not usually prompt or routinely toilet Resident 24. During an interview with the Minimum Data Set (MDS) nurse, conducted on 11/21/22 at 10:35 A.M. she indicated she did not complete a bowel patterning for Resident 24 with her annual assessment. The MDS nurse confirmed she could not locate and herself had not completed any voiding patterning for bowel incontinence for Resident 24 in the past 12 months. Review of the current Bladder and Bowel Rehabilitation Program policy, provided by the Assistant Director of Nursing on 11/18/2022 at 8:50 A.M. included the following procedures: .Bowel Rehab Procedure: 1. Complete the bowel assessment form at admission, annually, and with significant changes .2. The 3-day bowel pattern is to be completed on all incontinent residents, upon admission and with significant changes to continent status to determine if any natural patterns can be determines 3.1-31(c)(4)

Based on observations, record review and interviews, the facility failed to ensure care plans were complete for 2 residents in a sample of 12. (Resident 15 and 6) Findings include: 1. The clinical record for Resident 15 was reviewed on 11/16/22 at 11:06 A.M. Resident 15 was readmitted to the facility with diagnoses including, but not limited to: status post amputation right above the knee, type 2 diabetes mellitus, cardiac pacemaker, peripheral vascular disease, diastolic congestive heart failure, hypertension, chronic kidney stage 3, hypokalemia, aorocoronary bypass [NAME], urine retention, weakness, hx acute kidney failure, anxiety disorder, anemia and vitamin D deficiency. The current medication regimen included Ferrous Sulfate Tablet 325 (65 Fe) MG Give 1 tablet by mouth one time a day for iron supplement and Ergocalciferol Capsule 1.25 MG (50000 UT)- Vitamin D, 1 capsule by mouth one time a day every 7 day(s) for supplement. The current care plans for Resident 15 did not include any plan to address the Ferrous Sulfate use or the Ergocalciferol (Vitamin D) use. During an interview with the MDS nurse on 11/21/2022 at 10:35 A.M. she indicated she did not necessarily care plan every supplement and confirmed a care plan had not been initiated for Ferrous Sulfate and/or Vitamin D use. 44111 2. A clinical review was completed on 11/16/2022 at 11:00 A.M., for resident 6, diagnoses included, but not limited to: chronic obstructive pulmonary disease, hemiplegia and hemiparesis cerebral infarction affecting the left non-dominant side, end stage renal disease, and anxiety disorder. During an observation on 11/14/2022 at 3:12 P.M., resident was wearing a left wrist support on. A Physician Order, dated 7/5/2022 indicated nursing to donn/doff left wrist support. Resident to wear during daytime/waking hours, off for hygiene or at residents request. Skin checks daily when donning/doffing at bedtime for wrist support. A Physician Order, dated 7/7/2022 indicated nursing to donn/doff left wrist support. Resident to wear during daytime/waking hours. Off for hygiene or at residents request. Skin checks with donning/doffing every day shift for wrist support apply upon waking. During an interview on 11/18/2022 at 8:38 A.M., MDS Nurse indicated she could not find a care plan for the wrist support and she should have had one. On 11/17/2022 at 9:30 A.M., the Assistant Director of Nursing provided a policy titled, Care Plan Development and Review, dated 1/24/2020, and indicated the policy was the one currently used by the faciliity. The policy indicated . To assure that a comprehensive care plan for each resident includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment process 3.1-35(a)

Based on observation, interview and record review, the facility failed to ensure a care plan was revised for 1 out of 13 residents reviewed for care plan revision. (Resident 6) Finding includes: A clinical record review was completed on 11/16/2022 at 11:00 A.M., for resident 6. Diagnoses included, but not limited to: chronic obstructive pulmonary disease, hemiplegia and hemiparesis cerebral infarction affecting the left non-dominant side, end stage renal disease, and anxiety disorder. A Physician Order, dated 12/6/2021, indicated heel protectant boots while in bed. During an interview on 11/16/2022 at 11:33 A.M., MDS Nurse indicated that she does not see the heel protectant boots on the care plan and they should have been care planned. On 11/21/2022 at 12:03 P.M., the ADON provided the policy titled, Millers Health System, Inc. Policy Care Plan Development and Review, dated 11/21/2022 and indicated the policy was the one currently used by the facility. The policy indicated . It is the policy of Millers Merry Manor Overall review of the care plan is completed in conjunction with the MDS quarterly, annual and significant change assessments. and Care plans will be revised daily and PRN as changes in the resident conditions dictate. Changes include but are not limited to changes in Physician orders, diet changes, therapy changes, ADL changes, skin changes ect 3.1-31(e)

Based on record review and interviews, the facility failed to initiate Cardio-pulmonary Resuscitation (CPR) on a resident with a full code status, who showed signs of Cardiac and Respiratory arrest which resulted in the death of 1 of 3 residents reviewed death. (Resident F) The Immediate Jeopardy began on [DATE], when the facility failed to initiate CPR when Resident F's vital signs had ceased and the resident had physician authorized directive to initiate CPR in the event the resident was found to be without vital signs. The Administrator and the Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) at on [DATE] at 2:00 P.M The Immediate Jeopardy was removed on [DATE], but noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that was not Immediate Jeopardy. Finding includes: On [DATE] at 1:26 P.M., a review of the clinical record for Resident F was conducted. The record indicated the resident was admitted on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident's code status, dated [DATE], was to initiate CPR and authorized by a physician's signature on [DATE]. A care plan, dated [DATE], indicated the resident's code status was to initiate CPR. The interventions included, but were not limited to: blue code bracelet on at all times, ensure code status form sent to hospital/physician appointments, ensure code status form is signed and on the chart. A Progress Note, dated [DATE] at 5:49 A.M., indicated a phone call was made to nurse practitioner due to Resident F having respiratory distress. The resident's oxygen saturation level was at 80% and the resident was started on oxygen at 3 liters per a nasal cannula. The note indicated the resident was unable to respond and a new order was received to send the resident to a local hospital emergency room . A Progress Note, dated [DATE] at 6:30 A.M., indicated .(local town) emts here. vs (vital signs) ceased The next note, dated [DATE] at 11:10 A.M., indicated the body was released to a funeral home. A form titled Nursing Home to Hospital Transfer Form, dated [DATE] at 5:52 A.M., and completed by the DON and reported via telephone by LPN #2 indicated the reason for the transfer was respiratory arrest and a full code status. The form indicated the resident's vital signs were as follows: blood pressure: ,[DATE], heart rate 74, respirations 20, oxygen saturation: 92% and weight 204.2. The form indicated the resident was receiving oxygen per a nasal cannula/mask at 3 liters/minute. The vital signs results from the tranfer form were documented on the weights and vitals summary with the following dates and times they were taken- [DATE] : weight was 204.2 [DATE] 3:28 P.M.: blood pressure was ,[DATE] [DATE] 4:11 P.M.: respirations were 20 and blood sugar was 127 [DATE] 3:40 A.M.: temperature was 100.2 [DATE] 3:48 A.M.: pulse was 74 and oxygen saturation was 92% on room air. During an interview, on [DATE] at 11:50 A.M., the DON indicated she was not in the building during the incident but had been told the resident expired while in the process of transfer, but was still in the building. She indicated the ambulance personnel did not start CPR. During a telephone interview, on [DATE] at 1:26 P.M., LPN (Licensed Practical Nurse) 2 indicated she was Resident F's nurse on [DATE]. She reported the resident's condition was changing rapidly and had been directed by the nurse practioner to send the resident to the local emergency room . She had the CPR back board in the room and was ready to start CPR if needed. She indicated she was not in the room with the resident as she was busy making calls to physician, the ambulance company and to the family. She indicated she had informed the ambulance company the resident had a full code status During a telephone interview, on [DATE] at 2:16 P.M., EMT 3 indicated he was one of the EMT's who came to the facility, on [DATE], to transport Resident F to the hospital emergency room . The dispatch had told him the resident was in respiratory distress. When he arrived at the resident's room, a nurse was in the room. The resident had cyanotic (bluish discoloration of skin) lips and had started to have mottled skin (sign of impending death-circulation changes). He indicated the room was warm but the resident's skin was cool to touch, the resident had no vital signs and was not breathing. He did not observe the staff at the facility performing CPR at this time, and CPR was not started by the EMT's. The EMT indicated he observed a back board in the room but it was not underneath the resident. He observed a vital sign machine in the room but not hooked up to the resident but was positioned on the other side of the room. During a telephone interview, on [DATE] at 3:10 P.M., LPN 4 indicated she had worked the morning of [DATE] on another unit but was in the resident's room approximately 5 to 7 minutes prior to the arrival of the ambulance. The LPN indicated the resident was hooked up to a vital sign machine which was constantly recording the residents oxygen saturation level (02 sats) and pulse. She indicated she had not recorded the machines 02 sats or pulse results. She indicated the resident was still breathing when the EMT's arrived but could tell the resident was going. She had not observed the resident to have blue lips. She reported she was aware of the resident's full code status but indicated she did not initiate CPR when the resident's vital signs ceased. During an interview, on [DATE] at 12:43 P.M., CNA 5 indicated she had worked the morning of [DATE]. CNA 5 indicated she entered the room to clean the resident, as the resident was being sent to a local hospital. She indicated the resident had some foam in her mouth and she tried to clean it out. She indicated the resident moaned a little and was becoming less and less responsive. She indicated LPN 2 and LPN 4 were in the room when the ambulance arrived and they had her run to meet the EMT's to hurry them along. When she arrived back in the room LPN 4 stepped out of the room and LPN 2 remained in the room. She heard LPN 2 and EMT discussing the resident's code status, but indicated CPR was not initiated. A form from the local town EMS, dated [DATE], indicated .Called to the above (MMM-Walkerton) to evaluate 70 y/o (year old) for possible fluid in the lungs. Upon arrival, ECF (Extended Care Facility) RN (registered nurse) made comment on way by nursing station, I think we lost her. Upon arrival in room, found the above pt (patient) lying supine in bed apneic and pulseless with no CPR in progress. ECF Staff related pt. possibly had some fluid in her lungs ,[DATE] minutes prior to calling 911. Pt was conscious and talking to them. When asked when the last time the pt. was seen conscious they related it was ,[DATE] minutes prior. Pt. was ashen with cyanosis about the face and lips. Pt slightly cool to the touch for the temperature in the room. Pt. rolled and noted mottling beginning on her posterior side. AED (Automated External Defibrillator) attached which advised no shockable rhythm. Due to pt. apparent down time, no CPR prior to arrival and presenting signs and symptoms, pt was pronounced @ 6:15 The destination details indicated 911 call received at 6:03 A.M., dispatched at 6:04 A.M., on scene at 6:09 A.M. and at patient at 6:09 A.M. The initial assessment indicated resident F was unresponsive, had no pulse, no respirations, her skin was cyanotic, mottled and pale. The eyes were dilated and non-reactive and the carotid and radial pulse was absent. An AED was applied but resident was not defibrillated due to non-shockable rhythm. Resuscitation was no attempt considered futile. On [DATE] at 1:15 P.M., the DON provided current CPR Certifications for LPN 2 and LPN 4. On [DATE] at 10:30 AM., the DON provided an Medication Administration Record [REDACTED]. The record indicated the Full Code blue wristband was documented as being on Resident F. On [DATE] at 2:58 P.M., the DON provided a policy titled Cardiopulmonary Resuscitation Policy, dated [DATE], and indicated the policy was the one currently used by the facility. The policy indicated .A. It is the policy of Miller's Health Systems, Inc doing business as Miller's Merry Manor to initiate cardio-pulmonary resuscitation to residents who have requested the procedure at the time of admission or have made the request at any time during their stay The Immediate Jeopardy began on [DATE] was removed on [DATE] when the facility implemented systematic changes, such as: in-servicing all licensed nurses on the facility's policy regarding CPR, charting procedures and ensuring each full code resident was identified with a blue bracelet on their wrist, but noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that was not Immediate Jeopardy because of the facility's need to continue in-services. This Federal tag related to complaint IN 441.

A. Based on interview and record review, the facility failed to provide adequate supervision and assistance to prevent an accident that resulted in a femur fracture during a fall for 1 of 6 residents reviewed for accidents. (Resident #5) B. Based on observation, interview and record review, that facility failed to label 2 bottles of cleaner in 2 of 2 shower rooms. (Unit I and Unit II) Finding includes: A.1. On 6-25-15 at 1:40 P.M., an interview was conducted with the Unit Manager (RN - Registered Nurse #3). RN #3 indicated Resident #5 had a fall in May that resulted in a hip fracture. On 6-29-15 at 2:15 P.M., the clinical record for Resident #5 was reviewed. Resident #5 was admitted on [DATE], and [DIAGNOSES REDACTED]. A Nursing - Occurrence Initial Assessment, dated 5-7-15, indicated .date and time of occurrence: 5-7-15 17:40.location of occurrence: (Resident #5's room number) bathroom.Describe details of occurrence as observed: resident was attempting to transfer from w/c (wheelchair) to toilet w/ (with) 1 assist when rt (right) foot slipped causing him to sit down on the toilet extra hard; assessment revealed no red areas, no abnormalities to hip/leg, no swelling. did complain of pain to rt hip/upper leg; resident assisted to easy chair after being washed up for bed.Head to toe assessment completed: Yes.Resident was sent to ER (emergency room ): No. A Facility - Post Occurrence IDT (Interdisciplinary team) & fall risk assessment', dated 5-7-15, indicated .summary of occurrence: was being assisted by a nurse to get onto the toilet-his right foot slipped while he was standing up from the w/c to get onto the toilet and he sat down hard on the toilet-he had an initial c/o (complaint of) pain to hip-he said 'I slipped, my hip hurts'.Root cause: slippers on-needs shoes or a second person.IDT recommendations: make sure he has shoes on or use two persons. A Nurse's note, dated 5-8-15 at 1:45 P.M., indicated Emailed (Doctor's Name) ipad: Patient is on incident due to falling hard on to the toilet seat last evening. This morning when his assessment was done he stated he was in no pain. This afternoon he is now complaining of pain to his right hip. Can we have an order to x-ray the hip please? Please advise. A Nurse's note, dated 5-8-15 at 9:12 P.M., indicated .emailed (Doctor's Name) at approx (approximately) 2112 to remind him of previous shift's request of x-ray to Rt hip/upper leg d/t (due to) continuing c/o pain; no abnormalities to areas; c/o pain only. A Nurse's note, dated 5-10-15 at 12:13 A.M., indicated (Doctor's Name) responded back from recent email Yes to request of x-ray to R (right) hip/upper thigh d/t c/o pain and recent fall. A Physician order, dated 5-10-15, indicated .X-ray of R hip and R femur full view r/t complaint of pain and recent fall. A Radiology report, dated 5-10-15, indicated Conclusion: Acute right proximal femur fracture. A MDS (Minimum Data Set) assessment, completed on 3-23-15, indicated in the areas of transferring and toilet use, Resident #5 needed extensive assist of 2 persons physical assist. A Fall Risk care plan, initiated on 7-2-14, indicated .Fall Risk characterized by risk factors: history of falls, unsteady gait, poor trunk control, weakness.Interventions: Assist with transfers using 2 staff assist. An Activities of Daily Living care plan, initiated on 7-13-14, indicated .Needs total assist with dressing and personal hygiene, extensive assist with bed mobility, transfers, toileting and eating due to: dementia, memory deficit, weakness.Interventions: Assist with all transfers using 2 staff assist. On 6-30-15 at 2:30 P.M., an interview was conducted with LPN (Licensed Practical Nurse) #6. LPN #6 indicated she was the one who was with Resident #5 when he fell on [DATE], .It was after supper that he came rolling past the nurses station and he told me he needed to use the restroom. I told him I would meet him in his room. I followed him in there and he started to get up by himself. I told him to wait and he was already getting up. I tried to put my arm under his to stabilize him but his knees gave out and he sat down hard on the toilet.I was the only one in there with him.No, I don't ever have a second person in there with me. On 6-30-15 at 2:45 P.M., review of the current Fall Management Procedure, dated 8-28-14, received from the DON (Director of Nursing) at 2:05 P.M., indicated .A. To assess all residents for risk factors that may contribute to falling and to provide planned interventions identified by the team as appropriate for resident use in maintaining or returning to the highest level of physical, social, and psychosocial functioning as possible. On 6-30-15 at 3:00 P.M., review of the completed inservice list for LPN #6 indicated she had been inserviced on Resident Lifting and Transfers on 4-5-15, and inserviced on Understanding Falls on 5-2-15. B.1. On 6-25-2015 at 10:45 A.M., a bottle of light blue liquid in a spray bottle marked Unit II shower room, Please leave in Unit II shower room was observed in an unlocked cabinet in the unlocked shower room on Unit II. On 6-25-2015 at 11:12 A.M., a bottle of clear liquid in a unmarked spray bottle was observed in an unlocked cabinet in the unlocked shower room on Unit I. On 6-30-2015 at 1:21 P.M., during an interview, the DON (Director of Nursing) indicated, .this bottle contains Quat (an all purpose cleaner), it should be locked up in a cabinet when not in use and it should be labeled. On 6-30-2015 at 2:10 P.M., a record review of the current policy titled, Hazard Communication Program, with a policy start date of 9-19-2008, received from the DON at this time, indicated, .6. CONTAINER LABELS AND OTHER FORMS OF WARNING.The departmental supervisor will be responsible for monitoring all containers of hazardous chemicals entering their work area or department. He or she will ensure that the chemical containers are properly labeled with: A. Chemical identity; B. Hazard warning; and C. Name and address of manufacturer, importer, or responsible party.All secondary containers can be an extra copy of the manufacturer's label or a generic label. All secondary labels must list chemical identity, hazard warning and manufacturer's or importer's name and address. 3.1-45(a)(1) 3.1-45(a)(2)