Every finding on record at New Harmony Health Care Center

Based on observation, interview, and record review, the facility failed to ensure a resident's nutritional status was maintained for 1 of 3 residents reviewed for dietary services. No dietary recommendations were made or additional supplements were added to a resident's plan of care following an unplanned significant weight loss. (Resident B)Finding includes:A record review on 7/15/26 at 1:15 P.M., indicated resident B's diagnoses included but were not limited to, type II diabetes and anemia. The most recent quarterly minimum data set (MDS) assessment dated [DATE] indicated the resident had moderate cognitive impairment and had a weight loss of 5% in one month or 10% in past 6 months while not on a physician prescribed weight-loss regimen. Physician orders included but were not limited to, regular diet, may have finger foods (started 3/10/26) and Vitamin B-12 (started 3/11/26). Resident B's care plan included but was not limited to, resident has the potential for a compromised nutritional status and the potential for significant weight changes related to meal refusals and poor intakes. History of significant weight loss 3/2026 and 6/2026 (revised 6/15/26). Interventions included consult with dietician as needed, dietician to evaluate and make diet change recommendations as needed. Resident B's documented monthly weights included:2/10/26 - 154.0 pounds (lbs)3/1/26 - 143.4 lbs - (6.8% weight loss within 30 days)4/6/26 - 148.2 lbs(Refused weight on 5/30/26)6/9/26 - 121.4 lbs - (18% weight loss within 90 days)A quarterly dietician assessment dated [DATE] indicated the resident's current nutritional prescription included a regular diet with finger foods. Resident B had a significant weight change.Dietary/Nutrition notes included but were not limited to:4/3/26 at 2:22 P.M. - Significant weight loss of 11 lbs in 30 days. Meal intakes of regular diet range between 25 - 50 %. Offer finger foods. Will review weight trend with next monthly weight before recommending supplement. 6/15/26 at 2:09 P.M. - Resident has order for multivitamin, which she refuses at times. Meal intakes of regular diet are poor, no more than 50% at times. Resident is offered finger foods as able. Current weight of 121 Lbs indicates a significant weight loss of 22 lbs within 90 days and 23 lbs within 180 days. An observation and interview on 716/26 at 7:40 A.M., Resident B was lying in bed awake, awaiting breakfast. The resident indicated she eats in her room and often did not care for the facility breakfast. During an interview on 7/16/26 at 8:10 A.M., CNA 4 indicated Resident B often did not eat well and that the resident received a regular meal with nothing added. During an interview on 7/16/26 at 8:25 A.M., the Dietary Manager (DM) indicated the Registered Dietician (RD) visited the facility weekly and made dietary recommendations based on resident monthly weights. The DM indicated Resident B received a regular diet with no additional shakes, magic cups, or supplements. During an interview on 7/16/26 at 9:05 A.M., the assistant director of nursing (ADON) indicated she was unaware of Resident B's significant weight loss. The ADON also indicated no additional dietician assessments had been completed since 4/3/26. A nutritional supplement order was obtained that morning (7/16/26).On 7/16/26 at 10:19 A.M., the Facility Administrator supplied a facility policy titled Dietary Menu Planning and Nourishment, dated 9/23/25. The policy included, XII. Nourishments will be provided to offer therapeutic nutritional support. A physician's order will be required. Residents receiving nourishments may include those who are underweight, who are on therapeutic diets, and those with poor intake, weight loss .This citation relates to intake 3005005. 410 IAC 16.2-3.1-46(a)(1)410 IAC 16.2-3.1-46(a)(2)

Based on interview and record review, the facility failed to ensure the Infection Preventionist (IP) dedicated part time hours to the role of IP for 1 of 1 staff members reviewed for IP. The full time Director of Nursing (DON) also served as the Infection Preventionist. Finding includes:On 12/4/25 at 10:13 A.M., the Director of Nursing (DON) indicated she was also serving as the facility's Infection Preventionist, and indicated she dedicated around two hours each work day to infection control tasks. During an interview on 12/4/25 at 11:50 A.M., the Director of Nursing indicated she had been serving as the Director of Nursing and the Infection Preventionist since September 2025. On 12/4/25 at 1:11 P.M., the Administrator provided an Infection Preventionist job description that indicated The Infection Preventionist is responsible for developing, implementing, and monitoring the facility's Infection Prevention and Control in alignment with federal, state, and local regulations. Position type and hours: full time. On 12/4/25 at 1:11 P.M., the Administrator provided a Director of Nursing job description that indicated The Director of Nursing is responsible for planning, development and overall operation of the Director of Nursing which ensures guests receive quality care 24 hours a day.

Based on interview and record review, the facility failed to ensure the kitchen manager met required qualifications for 1 of 1 dietary manager qualifications reviewed. (Dietary Manager)Finding include:During an interview on 12/1/25 at 9:15 A.M., the Dietary Manager indicated she did not have a Certified Dietary Manager Certification. She indicated that she had the course books for two years but had not had the time to complete the certification. During an interview on 12/3/25 at 8:06 A.M., the Assistant Director of Nursing (ADON) indicated the Dietary Manager was required to take the certification test within six months to a year of being hired. On 12/3/25 at 2:03 P.M., employee files were reviewed. The Dietary Manager was hired on 3/5/24. On 12/4/25 at 1:00 P.M., the Administrator provided a current undated Director of Dietary Services job description. The job description indicated Required Education and Experience.Certified Dietary Manager (CDM) Credential. 3.1-20(e)(2)

Based on observation, record review, and interview, the facility failed to implement infection prevention measures for 2 of 2 residents reviewed for catheters and 1 random dining observation. Catheter bags were observed on the floor and hand hygiene was not offered to residents prior to eating. (Resident 3, Resident 39, and Cardinal Unit)Findings include: 1. On 12/1/25 at 10:20 A.M., Resident 3's catheter bag was observed laying on the floor while the resident was lying in bed. On 12/1/25 at 1:15 P.M., Resident 3's clinical record was reviewed. Diagnoses included, but were not limited to, multiple sclerosis, disorganized schizophrenia, and neuromuscular dysfunction of bladder. The current Quarterly Minimum Data Set (MDS) Assessment, dated 11/6/25, indicated Resident 3 was moderately cognitively impaired. Resident 3 was dependent on staff for transferring, hygiene, and dressing. Resident 3 had a suprapubic catheter. Current physician orders included, but were not limited to:Insert Suprapubic Catheter French (FR) size 20FR, balloon size 3 milliliter (mL). Change Suprapubic catheter and urinary bag monthly and PRN (as needed) for system failure in the morning every 30 days and every 24 hours as needed for PRN and system failure, dated 11/20/25 2. On 12/1/25 at 10:15 A.M., Resident 39 was observed in bed. A catheter bag hanging from the bed was resting on the floor. On 12/2/25 at 11:45 A.M., Resident 39's clinical record was reviewed. Diagnoses included, but were not limited to, neuromuscular dysfunction of bladder and chronic kidney disease. The most current Quarterly Minimum Data Set (MDS) Assessment, dated 10/27/25, indicated that Resident 39 had moderate cognitive impairment, was dependent on staff for toileting, and had an indwelling catheter. Physician orders included, but were not limited to:Insert coude catheter size 16F balloon size 10. Change foley catheter and urinary bag every 14 days for system failure and if urinary bag gets cloudy with sediment, dated 8/22/25 A care plan conference was completed on 10/28/25. The resident declined to attend. Care plans were reviewed. A current risk for infection care plan, initiated 8/20/25, included an intervention to manage indwelling catheters to minimize risk of infection. On 12/2/25 at 2:41 P.M., Resident 39 was observed in bed. A catheter bag hanging from the bed was resting on the floor. On 12/4/25 at 10:13 A.M., the Infection Preventionist indicated that catheter bags should not touch the floor. On 12/4/25 at 11:11 A.M., the Administrator provided a current Catheter Care, Urinary policy, revised March 2020, that indicated Be sure the catheter tubing and drainage bag are below the resident's bladder and kept off the floor. On 12/4/25 at 11:11 A.M., the Administrator provided a current Urinary Drainage Bags policy, reviewed January 2025, that indicated Urinary drainage bags should be maintained below the residents' bladder, off the floor, and in a urinary bag cover. 3. During a random dining observation on the Cardinal Unit, on 12/1/25 at 11:45 A.M., residents were seated in the dining room participating in activities.At 11:59 A.M, the activities staff left the unit.At 12:33 P.M., the dining cart was delivered to unit.At 12:42 P.M., Staff began serving lunch trays to residents. Hand hygiene or clothing protectors were not offered to residents in the dining room. During an interview on 12/4/25 at 10:13 A.M., the Director of Nursing indicated staff serving in the dining room should offer hand hygiene and clothing protectors to residents who may need one. On 12/4/25 at 1:42 P.M., the Administrator provided a policy titled Resident Hand Hygiene Policy and Procedure that indicated ensures that all residents are offered, cued, or assisted with hand hygiene as part of the facility's Infection Prevention & Control Program. Staff will support residents in performing hand hygiene at clinically indicated times to prevent infection and maintain resident dignity . Indicated times when hand hygiene is required to reduce infection risk before: meals, snacks, and drinks. after: group activities. or touching shared surfaces. 3.1-18(b)(1)3.1-18(l)

Based on record review and interview, the facility failed to ensure as needed (PRN) orders for psychotropic drugs, that were ordered beyond 14 days, indicated a specific duration of use for 4 of 5 residents reviewed for hospice services. (Resident 1, Resident 4, Resident 35, and Resident 40) Findings include:1. On 12/2/25 at 1:18 P.M., Resident 35's clinical record was reviewed. Resident 35 was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, Alzheimer's disease. The most recent Significant Change Minimum Data Set (MDS) Assessment, dated 10/17/25, indicated Resident 35's cognition level was unable to be assessed because the resident was rarely understood, was dependent on staff (staff does all the work) for showering, toileting, and transfers, and was taking an antianxiety medication. Physician orders included, but were not limited to: lorazepam intensol oral concentrate (an antianxiety medication) 2 milligrams per milliliter (mg/mL) - Give 0.25 mL by mouth every four hours as needed (PRN) for anxiety, restlessness, shortness of breath, pain; Start date 10/9/25. The order did not contain a stop date. The care plan included, but was not limited to: Resident has a diagnosis of anxiety and takes antianxiety medication Lorazepam; Date Initiated: 8/27/24 2. On 12/1/25 at 10:30 A.M., Resident 4's clinical record was reviewed. Diagnoses included, but were not limited to, dementia with other behavioral disturbance and Chronic Obstructive Pulmonary Disease. The current Quarterly Minimum Data Assessment (MDS) Assessment, dated 10/14/25, indicated Resident 4 was severely cognitively impaired. Resident 4 was dependent on staff for transferring, toileting, and hygiene, and did not receive an antianxiety medication during the 7-day lookback period. Current physician orders included, but were not limited to:lorazepam oral tablet 0.5 milligrams (mg) (an antianxiety medication) - Give 0.5 mg by mouth every 30 minutes as needed for anxiety/restlessness for mild/moderate/severe anxiety, shortness of breath, restlessness. Resident is on hospice services with less than six months life expectancy, start date 10/18/24 with no end date. The care plan included, but was not limited to:Resident takes anti-anxiety medication lorazepam due to end of life care (hospice) Initiated: 10/16/24 3. On 12/1/25 at 11:00 A.M., Resident 1's clinical record was reviewed. Diagnoses included, but were not limited to, chronic respiratory failure and Chronic Obstructive Pulmonary Disease (COPD). The current Quarterly Minimum Data Set (MDS) Assessment, dated 11/25/25, indicated Resident 1 was cognitively intact. Resident 1 required supervision for eating, hygiene, dressing, and transferring, and received an antianxiety medication during the 7-day lookback period. Current physician orders included, but were not limited to:lorazepam oral tablet 0.5 milligrams (mg) - Give 0.5 mg by mouth every two hours as needed for terminal restlessness, moderate to severe restlessness, anxiety, shortness of breath, and pain. Resident is on hospice services with less than six months life expectancy, dated 8/8/25 with no end date. The care plan included, but was not limited to:Resident is taking anti-anxiety Lorazepam. Date Initiated: 10/16/2024 4. On 12/4/25 at 11:07 A.M., Resident 40's clinical record was reviewed. Diagnoses included, but were not limited to, senile degeneration of the brain. Resident 40 was admitted to hospice services on 4/30/25. The most current Quarterly Minimum Data Set (MDS) Assessment, dated 9/15/25, indicated Resident 40 was not assessed for cognitive impairment because she was rarely or never understood. Resident 40 was dependent on staff (staff does all the work) for all Activities of Daily Living (ADLs) and did not receive any antianxiety medications during the 7-day lookback period. Physician orders included, but were not limited to:lorazepam (an antianxiety medication) 0.5 milligrams (mg) - Give one tablet by mouth every two hours as needed (PRN) for anxiety, mild to severe restlessness, shortness of breath, and pain. Resident is on hospice services with less than six months life expectancy, dated 5/6/25 with no stop date The care plan included, but was not limited to:Resident takes lorazepam due to her being on hospice end of life care, initiated 6/18/25 A pharmacy review, dated 9/9/25, indicated Please evaluate the continued need for PRN lorazepam. Please consider: Discontinuing lorazepam PRN. (or) Add stop date to lorazepam PRN for short-term use (max 14 days) and evaluate use. If current order is necessary, then please reevaluate resident and document risk/benefit to continue up to an additional 14 days to assist facility with regulatory compliance. The attending physician or prescribing practitioner must first evaluate the resident to determine if the new order for the PRN anxiolytic is appropriate . Unfortunately, this regulation does not differentiate for hospice patients and does not allow for exceptions to the rule. The physician signed the pharmacy review but did not indicate a response to the request for evaluation. The clinical record lacked documentation to indicate the PRN antianxiety medication had a stop date or that the resident was re-evaluated to determine if the order for the PRN antianxiety medication was appropriate. During an interview on 12/4/25 at 10:05 A.M., the Assistant Director of Nursing (ADON) indicated that PRN antianxiety medications required a stop date of 14 days. Hospice residents had a statement in their order that indicated they had a life expectancy of six months or less; however, if the resident lived longer than six months, the order was left in without a physician re-evaluation, date change, or new order. At that time, the ADON indicated she was unaware that the regulation did not make an exception for residents receiving hospice services. On 12/4/25 at 1:42 P.M., the Administrator provided a current undated PRN Antianxiety Medication Policy and Procedure policy that indicated All PRN antianxiety medication use must follow CMS regulations and facility medication administration standards. On 12/4/25 at 1:58 P.M., the Administrator provided a current Use of Psychotropic Medication(s) policy, dated 10/1/25, that indicated PRN orders for psychotropic medications, excluding antipsychotics, shall be limited to no more than 14 days, unless the attending physician or prescribing practitioner believes it is appropriate to extend the order beyond the 14 days. The medical record should include documentation from the physician or prescriber for the rationale for the extended time period and indicate a specific duration. 3.1-48(a)(2)

Based on observation, interview, and record review, the facility failed to ensure residents were provided adequate supervision on the dementia unit during 1 of 1 random observations. (Cardinal hall dining room) Finding includes:During a random observation on 12/1/25 at 11:45 A.M. in the Cardinal unit (dementia unit), residents seated in the dining room participated in activities.At 11:59 A.M, the activities staff left the unit.At 12:29 P.M., two residents seated across the table from each other appeared to have a verbal altercation about one resident who knocked on the table. No staff members were observed on the dementia unit or at the nurses' station of the unit.At 12:33 P.M., the dining cart was delivered near the nurses' station by dietary. Licensed Practical Nurse (LPN) 7 was observed exiting a resident's room on the East hall adjacent to the dementia unit. Seven residents were currently residing in Cardinal Hall at the time of meal service. On 12/4/25 at 10:29 A.M., the facility's Alzheimer's/Dementia Special Care Unit form was reviewed. The form indicated the unit should be staffed with one full-time nurse and two full-time certified nurse aides (CNA) during day shift on the unit. On 12/4/25 at 1:11 P.M., the Administrator provided a policy titled Dementia Care Unit Staffing Policy and Procedure that indicated ensures that the dementia care unit is staffed with sufficient, qualified, and dementia trained personnel at all times. Staff must maintain continuous supervision. 3.1-45(a)(2)

Based on interview and record review, the facility failed to ensure complete and accurate documentation was available in resident clinical records for 2 of 4 residents reviewed for falls. (Resident 17 and Resident 35)Findings include:1. On 12/2/25 at 9:14 A.M., Resident 17's clinical record was reviewed. Resident 17 was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, vascular dementia. The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 10/30/25, indicated Resident 17 was severely cognitively impaired, was dependent on staff (staff does all the work) for bathing and was independent for transfers, and had two or more falls since the previous MDS assessment with one fall injury. The current care plan included, but was not limited to: Had an actual fall incident: Fall on 5/7/24, actual fall 9/4/24, actual fall 8/25/25, actual fall 10/16/25, actual fall 10/27/25; Date Initiated: 11/27/2023 A health status progress note, dated 10/28/25 at 8:01 A.M., indicated Resident 17 had swelling present to left knee, Resident complained of moderate pain; Requested x-ray order. A practitioner progress note, dated 10/28/25 at 11:59 P.M., indicated Staff reported resident had a fall yesterday while out of facility at an appointment. The clinical record lacked documentation of the fall that occurred on 10/27/25, or notification to family regarding the fall or x-ray order in clinical progress notes, forms, documents, or assessments. During an interview on 12/3/25 at 9:54 A.M., the Director of Nursing (DON) indicated she would expect staff to document a fall that occurred outside the facility once the resident returned to the facility. 2. On 12/2/25 at 1:18 P.M., Resident 35's clinical record was reviewed. Resident 35 was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, Alzheimer's disease.The most recent Significant Change Minimum Data Set (MDS) Assessment, dated 10/17/25, indicated Resident 35's cognition level was unable to be assessed because the resident was rarely understood, was dependent on staff (staff does all the work) for showering, toileting, and transfers, and had two or more falls without injury since the prior MDS Assessment.The care plan included, but was not limited to: Had an actual fall on: 9/12/2025, 10/11/2025; Date Initiated: 3/19/24Intervention: when up out of bed, place in wheelchair and have in line of sight. Date Initiated: 10/14/25 A nurse's note, dated 10/11/25 at 4:30 P.M., indicated [resident family] and physician aware of fall. The clinical record lacked documentation of the fall that occurred on 10/11/25 in clinical progress notes, forms, documents, or assessments. On 12/4/25 at 1:11 P.M., the Administrator provided a policy titled Falls Clinical Protocol that indicated The staff will evaluate and document falls that occur while the individual is in the facility; for example, when and where they happen, any observations of the events, etc. Falls should be identified as witnessed or unwitnessed events. 3.1-50(a)(1)

Based on interview and record review, the facility failed to ensure Qualified Medication Aides (QMAs) were providing services within their scope of practice for 1 of 5 residents reviewed for medication use. A QMA administered as needed (PRN) medication without prior authorization from a licensed nurse. (Resident 7)Finding includes: On 12/2/25 at 10:28 A.M., Resident 7's clinical record was reviewed. Diagnoses included, but were not limited to, dementia, pain, and migraine headaches.The most current Quarterly Minimum Data Set (MDS) Assessment, dated 10/29/25, indicated Resident 7 was cognitively intact, was independent in all Activities of Daily Living (ADLs), and received an opioid medication during the 7-day lookback period.Physician orders included, but were not limited to:tramadol (an opioid pain medication) 50 milligrams (mg) - Give 50 mg by mouth every eight hours as needed (PRN) for pain, dated 7/2/25sumatriptan succinate (a medication used to treat migraine headaches) 25 mg tablet - Give one tablet by mouth every 24 hours PRN for migraine headaches, dated 11/16/23Resident 7's electronic Medication Administration Record (eMAR) from 10/1/25 to 12/2/25 included, but was not limited to, the following dates that tramadol 50 mg PRN was administered by a Qualified Medication Aide (QMA) without authorization from a licensed nurse:10/5/25 at 8:13 P.M. (given by QMA 12)10/14/25 at 7:22 P.M. (given by QMA 12)10/17/25 at 7:44 P.M. (given by QMA 12)10/18/25 at 7:46 P.M. (given by QMA 12)10/21/25 at 7:14 P.M. (given by QMA 12)10/28/25 at 7:09 P.M. (given by QMA 12)Resident 7's electronic Medication Administration Record (eMAR) from 10/1/25 to 12/2/25 included, but was not limited to, the following dates that sumatriptan 25 mg PRN was administered by a QMA without authorization from a licensed nurse:11/4/25 at 8:04 P.M. (given by QMA 12)During an interview on 12/4/25 at 10:15 A.M., QMA 15 indicated that before a QMA gave a PRN medication, authorization from a nurse was acquired and documented in the medication administration notes.On 12/4/25 at 1:11 P.M., the Administrator provided an undated QMA Scope of Practice that indicated Administer previously ordered pro re nata (PRN) medication only if authorization is obtained from the facility's licensed nurse on duty or on call. If authorization is obtained, the QMA must do the following: . (B) Document in the resident record that the facility's licensed nurse was contacted, symptoms were described, and permission was granted to administer the medication, including the time of contact. 3.1-35(g)(2)

Based on interview and record review, the facility failed to ensure practitioner's diagnostic practices met professional standards of care for 2 of 6 residents reviewed for medication review. Residents had new diagnoses of schizophrenia over [AGE] years of age after admission to the facility. (Resident 4 and Resident 35) Findings include:1. On 12/1/25 at 10:30 A.M., Resident 4's clinical record was reviewed. Diagnoses included, but were not limited to, dementia with behavioral disturbance and schizoaffective disorder. The current Quarterly Minimum Data Assessment (MDS) Assessment, dated 10/14/25, indicated Resident 4 was severely cognitively impaired. Resident 4 was dependent on staff for transferring, toileting, and hygiene, received an antipsychotic medication during the 7-day lookback period, and had a diagnosis of schizophrenia. Current physician orders included, but were not limited to:risperidone (an antipsychotic medication) oral tablet 0.5 milligrams (mg) - Give 0.5 mg by mouth two times a day related to schizoaffective disorder, bipolar, dated 11/18/25. The clinical record lacked documentation to indicate that Resident 4 had a diagnosis of schizoaffective disorder before admission to the facility. The clinical record, including progress notes, documents, and assessments, lacked documentation that indicated when and how the diagnosis was determined. On 12/2/25 at 3:15 P.M., the Assistant Director of Nursing (ADON) was asked to provide documentation to support the mental health diagnosis of schizoaffective disorder, bipolar type, but was unable to provide it. 2. On 12/2/25 at 1:18 P.M., Resident 35's clinical record was reviewed. Resident 35 was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, schizoaffective disorder, bipolar type and Alzheimer's disease. The most recent Significant Change Minimum Data Set (MDS) Assessment, dated 10/17/25, indicated Resident 35's cognition level was unable to be assessed because the resident was rarely understood and was dependent on staff (staff does all the work) for showering, toileting, and transfers. Resident 35 received an antipsychotic during the 7-day lookback period and had a diagnosis of schizophrenia. Physician orders included, but were not limited to:Seroquel Tablet (an antipsychotic medication) 25 milligrams (mg) - Give 12.5 mg by mouth one time a day related to schizoaffective disorder, bipolar type; Start date: 10/18/22, Discontinued: 5/21/25. The clinical record indicated that the schizoaffective disorder, bipolar type diagnosis was not present on admission and was added to the resident's record on 6/29/23. A pharmacy recommendation, signed by the physician on 6/26/23, indicated the physician did not indicate a new diagnosis for schizoaffective disorder, bipolar type. The clinical record, including progress notes, documents, and assessments, lacked documentation that indicated where the diagnoses came from. On 12/3/25, documentation to support the mental health diagnosis of schizoaffective disorder, bipolar type, was requested. On 12/3/25 9:38 A.M., the Assistant Director of Nursing (ADON) indicated she was unsure where the diagnosis came from and was unable to locate a physician assessment or documentation that the physician gave the diagnosis. On 12/4/25 at 1:11 P.M., the Administrator provided a policy titled Nursing Home Documentation Policy that indicated ensure that all documentation in the medical record is accurate, timely, complete, objective, and compliant with federal and state regulations. 3.1-35(g)(1)

Based on interview and record review, the facility failed to revise a resident's care plan with a new intervention following a fall for 2 of 4 residents reviewed for falls. (Resident 23 and Resident 1)Findings include: 1. On 12/3/25 at 9:36 A.M., Resident 23's clinical record was reviewed. Diagnoses included, but were not limited to, alcohol dependence with alcohol-induced persistent dementia. The most current Quarterly Minimum Data Set (MDS) Assessment, dated 10/17/25, indicated Resident 23 had severe cognitive impairment, was dependent on staff for all Activities of Daily Living (ADLs), and had two or more falls with injury and two or more falls without injury since the prior assessment on 7/17/25. A current fall risk assessment, dated 9/11/25, indicated that Resident 23 was at risk for falls. A care plan conference was completed on 10/23/25 with Resident 23's Power of Attorney (POA) in attendance. The care plan was reviewed. A current risk for falls care plan, initiated 7/21/25, included the following interventions:Assist the resident with transfers. Date Initiated: 7/21/25Environment free of clutter. Date Initiated: 7/21/25Resident will be assisted daily with ADL care needs. Date Initiated: 7/21/25Resident will be provided with non skid footwear. Date Initiated: 7/21/25Resident will have therapy as ordered. Date Initiated: 7/21/25 A current actual falls care plan, initiated 7/21/25, indicated Resident 23 had an actual fall on 7/19/25, 9/11/25, 9/17/25, and 11/2/25, and included the following interventions:9/11/2025: Intervention: bed bolsters to aid the resident with bed positioning. Date Initiated: 7/21/259/17/2025 Intervention: When Resident 23 is in a wheelchair, staff to ensure the resident is within the line of vision of staff. Date Initiated: 9/22/25Change of plain mat to the open side of the bed. Date Initiated: 11/13/25 When the resident is experiencing terminal restlessness, the resident is to be in bed with a change of plane to the floor to open the side of the bed. Date Initiated: 11/5/25 Physician orders included the following fall interventions:fall mat to open side of bed, dated 9/16/25Bed in lowest position with bed bolsters to bed, dated 9/16/25Low Air Loss (LAL) mattress with bolster to bed for parameter awareness and prevention of wounds, dated 5/12/25 A Health Status progress note, dated 8/11/25 at 11:00 P.M., indicated that Resident 23 had a witnessed fall while sitting on the side of her bed. The clinical record lacked documentation to indicate that a new intervention was added to the care plan after that fall. During an interview on 12/3/25 at 2:52 P.M., the Assistant Director of Nursing (ADON) indicated that she was unable to find a documented intervention put in place after Resident 23's fall on 8/11/25. 2. On 12/1/25 at 11:00 A.M., Resident 1's clinical record was reviewed. Diagnoses included, but were not limited to, chronic respiratory failure and Chronic Obstructive Pulmonary Disease (COPD). The current Quarterly Minimum Data Set (MDS) Assessment, dated 11/25/25, indicated Resident 1 was cognitively intact. Resident 1 required supervision for eating, hygiene, dressing, and transferring, and had a history of falls. Current Physician orders included, but were not limited to, the following:Nonskid strips in front of the recliner, dated 8/11/25.Commode riser for safety with toileting transfers, dated 2/12/25. A Nurse's Note, dated 11/15 at 1:15 A.M., indicated that Resident 1 had an unwitnessed fall after sliding out of bed. A Post Fall Evaluation Nurse's Note, dated 11/18/25 at 5:36 A.M., indicated that Resident 1 was a High Fall Risk and had an unwitnessed fall at that time. The current Fall Risk Care Plan lacked documentation of new interventions for the unwitnessed falls that occurred on 11/14/25 and 11/17/25. During an interview on 12/2/25 at 3:44 P.M., the Assistant Director or Nursing (ADON) indicated there should be a new intervention after each fall. On 12/4/25 at 2:15 P.M., the Administrator provided a current Comprehensive Care Plan policy dated January 2025. The policy indicated .assessment of residents are ongoing, and care plans are revised as information about the resident and the resident's condition change. 3.1-35(e)

Based on interview and record review, the facility failed to ensure care plan conferences were completed quarterly for 1 of 1 residents reviewed for care plan conferences. (Resident 34)Finding includes: During an interview on 12/1/25 at 12:15 P.M., a family member indicated that she had not had any care plan conferences with the facility since Resident 34 was admitted to the facility. On 12/3/25 at 11:18 A.M., Resident 34's clinical record was reviewed. Diagnoses included, but were not limited to, Alzheimer's Disease. Resident 34 was admitted to the facility on [DATE]. The most current Quarterly Minimum Data Set (MDS) Assessment, dated 9/12/25, indicated Resident 34 had severe cognitive impairment and was dependent on staff for transfers, toileting, and bathing. The most recent care plan conference was completed on 7/9/25 with Resident 34's family member in attendance.The clinical record lacked documentation to indicate that a care plan conference had been completed since 7/9/25.During an interview on 12/3/25 at 2:06 P.M., the Assistant Director of Nursing (ADON) indicated that Resident 34 had not had a care plan conference completed since July. At that time, she indicated care plan conferences were to be completed quarterly.On 12/4/25 at 1:11 P.M., the Administrator provided a current undated Care Conference Policy and Procedures policy that indicated Quarterly Care Conference held every 90 days.3.1-35(d)(2)(B)

Based on observation, interview, and record review, the facility failed to ensure adequate supervision, monitor behaviors, update the plan of care, and document relevant information to prevent accidents and then following an accident for 2 of 3 residents reviewed for accidents and dementia care. A resident (Resident C) with a history of wandering behaviors was not observed to enter another resident's room (Resident D) which led to a resident-to-resident altercation and a bite wound. (Resident C, Resident D)Findings include:1. During record review on 10/15/25 at 9:30 A.M., Resident C's diagnoses included but were not limited to dementia with behavioral disturbance.Resident C's most recent admission MDS (Minimum Data Set) assessment, dated 10/8/25 indicated the resident had severe cognitive impairment, a behavior of wandered daily during a 7-day review period, and that the wandering did not significantly intrude on the privacy or activities of others.Resident C's physician orders included, but were not limited to, Monitor behavior every shift and document A) No behavior, B) Combative/hitting/kicking, C) Crying/restlessness/agitation, D) Insomnia, E) Hallucinations/Delusions/Psychosis, and/or F) Biting/Spitting - Include 0) No intervention needed, 1) Resident easily redirected, 2) Keep redirecting, 4) Close monitoring, 5) 1-to-1 monitoring (started 9/26/25).Resident C's care plan included but was not limited to; Resident is a wanderer due to disoriented to place, impaired safety awareness, and wanders aimlessly (created and last revised 9/30/25). Resident wanders aimlessly throughout the facility unaware of whereabouts or safety (created and last revised 9/30/25). A goal included, Resident will not injure self or cause injury to othersResident C's progress notes included, but were not limited to:10/6/25 at 12:23 P.M. - Resident brought male resident to nurse and stated that he was going into all the female rooms stealing from them.10/6/25 at 3:33 P.M. - Resident frequently pushing male residents into her room and closing the door. Very difficult to redirect at times.10/7/25 at 1:42 P.M. - Resident was trying to make another resident get out of her bed. Resident became very angry and went into her room and slammed the door.10/13/25 at 2:30 A.M. - Staff intervened in altercation between Resident D and Resident C. Resident C had Resident D by the right arm and was biting her forearm. Residents were separated and Resident D assessed for injury. Resident D had pale blue bruising and some edema to right forearm but no open wound.Resident C's treatment administration record (TAR) for the month of October 2025 included no documented behaviors from 10/1/25 to 10/12/25. No documentation that indicated behavioral monitoring was completed was available on night shift 10/10/25. A response to a behavior on night shift 10/12/25 included 4) close monitoring.Resident C's Psychiatry Progress Note, dated 10/13/25 included, This is a psychiatric follow-up for (Resident C). The primary reason for the encounter is to address an incident involving aggression. Staff. reported that the patient was involved in an altercation with another resident overnight, where she bit the other person and removed a small chunk of flesh. During an interview on 10/15/25 at 1:35 P.M., LPN 4 indicated Resident C often wandered during the day and night shift and was usually easily redirected. During an interview on 10/16/25 at 10:15 A.M., the Social Service Director (SSD) indicated it would have been appropriate to update Resident D' plan of care following an increase in Resident D's behavior of wandering following incidents on 10/6/25 and 10/7/25 that involved other residents and an increase in Resident D's agitation and difficulty with redirection. On 10/16/25 at 10:30 A.M., the Assistant Director of Nursing (ADON) indicated the facility did not have a policy regarding resident behavior and wandering prevention. 2. During record review on 10/15/25 at 9:45 A.M., Resident D's diagnoses included but was not limited to Alzheimer's disease and vascular dementia. Resident D's most recent quarterly MDS assessment dated [DATE] indicated the resident had severe cognitive impairment. Resident D' physician orders included but were not limited to; triple antibiotic external ointment - apply to wound on left forearm topically in the morning for wound care until 10/28/25, cleanse with wound cleanser and cover with dry dressing daily (received 10/13/25 and started 10/14/25 at 9:00 A.M.) Resident D's nurse's progress notes included, but were not limited to:10/13/25 at 2:30 A.M. - Staff intervened in altercation between Resident D and Resident C. Resident C had Resident D by the right arm and was biting her forearm. Residents were separated and Resident D assessed for injury. Resident D had pale blue bruising and some edema to right forearm but no open wound. Resident D complained of pain to wrist and pain on moving her fingers. Physician notified and gave order for Xray of right wrist/forearm.10/13/25 at 10:41 A.M. - Resident complained of pain to left forearm.10/14/25 at 10:50 A.M. - Resident's left arm cleaned. Triple Antibiotic Ointment (TAO) and bandage applied.A Physical Aggression Received report for Resident D, dated 10/13/25 at 12:30 A.M., included an incident description, CNA observed another resident in resident's room, holder her by the right forearm/wrist. CNA observed other resident to bite (Resident D) on the Left forearm/wrist. Injuries observed at the time of the incident included a bruise to the Right forearm and a skin tear to the Left forearm.A Shower Sheet with Resident D's name, dated 10/13/25 indicated the resident had skin tears and an open area. A handwritten note, Bite 1 (inch) in diameter with a line drawn to the outer aspect of the left forearm was noted and signed by the ADON.During an observation on 10/15/25 at 1:10 P.M., Resident D was lying in bed with a dressing over the outer aspect of the left forearm. LPN 4 removed the dressing to reveal what appeared to be a healing skin tear approximately 1 inch long. The skin was closed, dark red in color, and without edema present.During an interview on 10/16/25 at 10:20 A.M., the ADON indicated that when she arrived at the facility the morning of 10/13/25 at the beginning of the day shift, she assessed Resident D and observed a dressing over her left forearm and indicated the area had been bleeding. The ADON then measured the wound to the left forearm and documented on a facility Shower Sheet.On 10/16/25 at 9:40 A.M., the ADON supplied a facility policy titled Assessment of Skin Alteration, dated 11/2017. The policy included, Residents with skin alteration will be assessed and treatment will be provided as ordered by the physician. Procedure: The assessment of any skin alteration should be started immediately upon identification.This citation relates to Intake 2642554. 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure a resident received only the medications ordered by a physician and that medications were properly labeled for 1 of 3 residents reviewed for pharmacy services. A resident was self-administering an antacid medication without the medication being properly labeled or ordered by a physician. (Resident D) Finding includes: During an interview and observation on 3/4/25 at 10:30 A.M., Resident D was sitting in a reclining chair in her room. A clear plastic cup was approximately two-thirds full of multi-colored tablets. The cup contained no labels or information that indicated what the contents of the cup were. Resident D indicated that her stomach had been bothering her and that the Tums (motioned towards the cup of tablets)(calcium carbonate medications) had not helped. Resident D was holding a sheet of paper and indicated that a nurse had just brought her the results of a scan completed the previous day. During record review on 3/4/25 at 2:00 P.M., Resident D's diagnoses included but were not limited to dysphagia, gastro-esophageal reflux disease, congestive heart failure, and type II diabetes. Resident D's most recent quarterly minimum data set (MDS) assessment, dated 2/15/25, indicated the resident had no cognitive impairment. Resident D's physician orders did not contain an order for any calcium carbonate medications. Resident D did have an order to administer insulin per self and keep insulin and accu-check supplies at bedside (ordered 1/16/25). A self administration of medications assessment, dated 1/20/25, indicated Resident D was capable of self-administering medications. Resident D's nurse's progress notes indicated the following: 3/4/25 at 8:00 A.M. - Yesterday's (3/3/25) Doppler results were negative. Resident aware of results. 3/4/25 at 9:00 A.M. - Resident D was in a pleasant mood with no complaints. Resident watching television in recliner. During an interview on 3/4/25 at 2:45 P.M., LPN 6 indicated Resident could keep insulin and accu-check supplies at bedside but did not have an order to self-administer any other medications and that the resident did not have a physician's order for Tums. LPN 6 indicated Resident D's family had likely brought the medication in without informing nursing staff. On 3/4/25 at 3:10 P.M., the Assistant Director of Nursing (ADON) supplied a facility policy titled, Resident Self-Administration of Medication, dated 5/30/23. The policy included, .7. All nurses and aides are required to report to the charge nurse on duty any medication found at the bedside not authorized for bedside storage. Unauthorized medications are given to the charge nurse for return to the family or responsible party . This citation relates to complaint IN00454320. 3.1-25(a) 3.1-25(b)(1) 3.1-25(j)

Based on interview and record review, the facility failed to ensure care plans were revised quarterly in 12 of 13 residents reviewed for care planning and conferences, 1 of 2 residents reviewed for UTI (Urinary Tract Infections) catheters, and 2 of 3 for siderails. (Resident 7, Resident 9, Resident 11, Resident 12, Resident 13, Resident 17, Resident 18, Resident 19, Resident 12, Resident 23, Resident 37, Resident R) Findings include: 1. On 9/12/24 at 10:35 A.M., Resident 7's clinical record was reviewed. Diagnoses included, but were limited to, hypertension and Deep Vein Thrombosis. The current annual MDS (Minimum Data Set) assessment dated [DATE] indicated the resident was cognitively intact. The resident needed supervision with toileting and set up with dressing, eating, and transfer. During the 7 days look back period the resident was on the following types of medications antiplatelets, anticoagulant, antidepressant, diuretic, opioid, and hypoglycemic. Care conferences were offered but declined by the POA (Power of Attorney) on 8/6/24, 6/13/24, and 3/16/24. The clinical record lacked documentation of care plan conferences prior to February 2024. 2. On 9/10/24 at 10:12 A.M., Resident's 11 clinical record was reviewed. Diagnoses included, but not limited to, systemic lupus erythematosus, chronic kidney disease stage 3, and neuromuscular dysfunction of bladder. The Current Quarterly MDS (Minimum Data Set) Assessment date 7/23/24 indicated Resident was cognitively intact and was dependent to transfer and toilet. The assessment indicated that the resident had a restraint of bed rails and used daily. The assessment also identified the resident has an indwelling catheter Current physician orders included, but were not limited to, Bilateral 1/2 siderails every shift related to weakness. For resident to assist with positioning and turning dated 6/12/24. Bed in lowest position and perimeter mattress to bed dated 8/1/23. Catheter care to be done each shift dated 3/12/24 The current falls risk care plan, initiated 8/11/21, indicated Resident 11 had falls and would be free from falls through the review date. Interventions included, but were limited to, bed in lowest position when alone, parameter mattress to bed, and to anticipate and meet the resident's needs. The current restraint care, initiated 6/17/24, indicated Resident 11 uses physical restraints of bilateral; 1/2 rails related to weakness, Goals the resident will be free of complications related to siderail use. Interventions included but were not limited to discuss and record with resident and caregiver, the risks and benefits of siderails dated 6/17/24. The current indwelling catheter care plan indicated Resident 11 uses catheter for obstructive uropathy and would remain free from catheter-related trauma through review date. Interventions included, but were not limited to, monitor and document intake and output and monitor for s/sx of discomfort on urination and frequency. Care plan was not implemented for catheter care on the following dates: July 1, 2, 5, 6, 7, 19, 24, 27, and 28, 2024. August 2, 5, 9,16,19, 20, 21, 22, 25, 26, 27, 30, and 31, 2024 September 1, 5, 6, 7, and 10, 2024 During an interview on 9/13/24 at 3:40 P.M., the DON (Director of Nursing) indicated catheter care should be done every shift output should be documented also. Care conference was conducted on 7/16/24 and was offered on 6/5/24 but was declined by wife. There was no other care conferences conducted before February 2024. 3. On 9/13/24 at 9:37 A.M., Resident 17's clinical record was reviewed. Diagnoses included, but were not limited to, unspecified dementia, unspecified severity, with other behavioral disturbance and psychotic disorder with delusions due to physiological condition. The current 5-day Medicare MDS dated [DATE] indicated Resident 17 was cognitively intact. Resident 17 was independent with eating and transfer but required set up assistance for dressing and hygiene. The 7 days look back for medications indicated the resident was on antipsychotic, antidepressant, antianxiety, antihypnotic, anticoagulant, and antiplatelets. Current physician orders included, but were not limited to: Lexapro Oral Tablet 10 MG (Escitalopram Oxalate) (Antidepressant) Give 10 mg(milligrams) by mouth at bedtime date 8/30/24. Risperidone Oral Tablet 0.25 MG (antipsychotic). Give 0.25 mg by mouth in the morning dated 8/27/24. Apixaban Oral Tablet 5 MG (anticoagulant). Give 5 mg by mouth two times a day dated 9/23/23 Current care plan indicates that Resident 17 is at risk for side effects of due to taking antipsychotic, antidepressants, anticoagulants, antianxiety, and antihypnotics, these interventions included, but are not limited to, monitoring for adverse effects for all these medication and monitoring for behaviors. Care conferences was declined by guardian on 8/14/24 but one was conducted on 5/14/24. There was no other care conferences conducted before February 4. On 9/10/24 at 12:49 P.M., Resident 19's clinical record was reviewed. Diagnoses included, but were not limited to, unilateral primary osteoarthritis of the left knee and Alzheimer Disease. The current 5-day MDS assessment dated [DATE] indicated Resident 9 was mildly cognitively intact, the resident needed assistance to transfer and was dependent for toileting. The 7 days look back indicated the resident was taking anticoagulant, antiplatelels, but not on opioid. Resident does not take an anticoagulant. The MDS also indicated that the resident had a physical restraint of bed rails and was used daily. Current orders included, but not limited to, Bilateral 1/2 siderails on bed for bed mobility every shift dated 7/12/24. The current care plan indicated the Resident 19 uses physical restraints has 1/2 side rails on the bed bilateral r/t (related to) Chronic pain, positioning/bed mobility while in bed, transferring and at their request. During an interview on 9/11/24 at 11:14 A.M., the DON (Director of Nursing) indicated she had coded the MDS wrong. She indicated the restraints care plan template states prepopulates with the interventions for physical restraint and that she would go back and edit the care plans. Care conference was conducted on 5/11/24, and clinical record lacked documentation of a care conferences prior to this date 48057 5. On 9/10/24 at 8:37 A.M., Resident 37's clinical record was reviewed. Resident 37 was admitted on [DATE]. Diagnoses included, but were not limited to, Alzheimer's Disease and abnormalities of gait and mobility. The most recent Significant Change MDS (Minimum Data Set) assessment, dated 8/14/24, indicated Resident 37's cognition was below measurable, was completely dependent on staff for eating, bathing, toileting, and transfers, and was receiving antiphychotic, antianxiety, antidepressant, hypnotic, and opioid medications during the seven day lookback period. Care conferences during the last year were held on 3/7/24 and 8/12/24. 6. On 9/10/24 at 10:28 A.M., Resident 18's clinical record was reviewed. Resident 18 was admitted on [DATE]. Diagnoses included, but were not limited to, hemiplegia and hemiparesis. The most recent Quarterly MDS assessment, dated 8/11/24, indicated Resident 18 was cognitively intact and was dependant on staff for toileting, showers, and transferring. The clinical record lacked documentation of any care conferences held during the past year. 7. On 9/11/24 at 10:21 A.M., Resident 23's clinical record was reviewed. Resident 23 was admitted on [DATE]. Diagnoses included, but were not limited to, multiple sclerosis. The most recent Quarterly MDS assessment, dated 8/20/24, indicated Resident 23 was cognitively intact and was dependent on staff for toileting, showers, and transferring. The clinical record lacked documentation of any care conferences held during the past year. 48147 8. On 9/11/24 at 10:28 A.M., Resident 9's clinical record was reviewed. Diagnoses included, but were not limited to, Alzheimer's disease, anxiety disorder, and schizoaffective disorder. The most current Quarterly Minimum Data Set (MDS) Assessment, dated 9/7/24, indicated Resident 9 was not assessed for cognitive impairment due to being rarely or never understood, and was dependent on staff for toileting and bathing. A care plan conference was documented on 7/16/24. The clinical record lacked documentation of care plan conferences prior to 7/16/24. 9. On 9/22/35 at 11:26 A.M., Resident 12's clinical record was reviewed. Diagnoses included, but were not limited to, dementia and urinary tract infection. The most current Annual Minimum Data Set (MDS) Assessment, dated 6/17/24, indicated Resident 12 had severe cognitive impairment and required substantial to maximal assistance of staff (staff does more than half) for bathing. A care plan conference was documented on 4/17/24. The clinical record lacked documentation of care plan conferences prior to or after 4/17/24. 10. On 9/11/24 at 8:56 A.M., Resident 13's clinical record was reviewed. Diagnoses included, but were not limited to, dementia, atrial fibrillation, and generalized anxiety disorder. The most current Annual Minimum Data Set (MDS) Assessment, dated 7/11/24, indicated Resident 13 had severe cognitive impairment and required substantial to maximal assistance of staff (staff does more than half) for toileting. A care plan conference was documented on 9/27/23 and 4/16/24. The clinical record lacked documentation of care plan conferences between 9/27/23 and 4/16/24 or after 4/16/24. 11. On 9/12/24 at 1:28 P.M., Resident R's clinical record was reviewed. Diagnoses included, but were not limited to, congestive heart failure and diabetes mellitus. The resident was admitted to the facility on [DATE]. The most current Quarterly Minimum Data Set (MDS) Assessment, dated 6/30/24, indicated Resident R had severe cognitive impairment, required supervision of staff for eating, and had verbal behaviors directed towards others daily. The clinical record lacked documented care plan conferences in the past year for Resident R. On 9/12/24 at 2:23 P.M., the Social Services Director indicated there were no care plan conferences for Resident R because she refused them. On 9/13/24 at 10:13 A.M., the Director of Nursing (DON) indicated that MDS meetings were held weekly where residents within their window of MDS comprehensive assessment were discussed. These meetings were not documented. On 9/16/24 at 12:20 P.M., the Regional Consultant provided an undated Care Planning- Interdisciplinary Team policy that indicated A comprehensive care plan for each resident is developed within seven (7) days of completion of the resident assessment (MDS). The care plan is based on the resident's comprehensive assessment and is developed by a Care Planning/Interdisciplinary Team . The resident, the resident's family, and/or the resident's legal representative/guardian or surrogate are encourage to participate in the development of and revision to the resident's care plan. Every effort will be made to schedule care plan meetings at the best time of the day for the resident and family. On 9/16/24 at 12:20 P.M., the Regional Consultant provided a Comprehensive Care Plans policy, dated 9/19/2023, that indicated The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. 3.1-35(a) 3.1-35(d)(2)(B) 3.1-35(e)

Based on observation, record review, and interview, the facility failed to provide a safe and sanitary environment for residents, staff, and the public for 9 random observations on 6 of 6 days. Urine odors in entrance hallway, conference room and [NAME] unit hallways. (Entrance Hallway, Conference Room, [NAME] Unit Hallways) Findings include: 1. On 9/9/24 at 8:50 A.M., the odor of urine was observed in the entrance hallway and the conference room. On 9/10/24 at 8:55 A.M., the odor of urine was observed in the entrance hallway and conference room. On 9/12/24 at 6:55 A.M., the odor of urine was observed in the conference room. On 9/13/24 at 8:20 A.m., the strong smell of urine was observed in the Entrance Hallway and the Conference Room. 2. On 9/10/24 at 12:48 P.M., the odor of urine was observed by the [NAME] Hall Unit Nurses Station. 3. On 9/11/24 at 8:20 A.M., the odor of urine was observed in hallway outside of the conference room. On 9/11/24 at 11:00 A.M., the strong odor of urine with air freshener was observed in the hallway by the conference room 4. On 9/12/24 at 7:04 A.M., the smell of urine was observed in the [NAME] Unit Hallway. 5. On 9/16/24 at 8:15 A.M. the strong of odor was observed in the conference and the hallway leading to patio. During an interview on 9/16/24 at 9:10 A.M., the Administrator indicated the facility should be free of smells and should be clean. On 9/16/24 at 10:00 A.M., the Regional Clinical Support Nurse provided a current, nondated policy Personal Property-Home Like Environment. The policy indicated .to eliminate odors and prevent pest, resident rooms will be cleaned daily . 3.1-19(f)(5)

Based on observation, record review, and interview, the facility failed to ensure a resident was on EBP (enhanced barrier precautions) for 1 of 2 residents reviewed for catheters, for 3 of 3 random observations reviewed for hand hygiene during incontinence care and medication administration, and for 2 of 2 random observation for cleaning equipment in between residents (Resident 11, Resident 2, Resident 19, Resident 5, Resident 6 Findings include: 1. On 9/9/24 at 9:30 A.M., there was no Enhanced Barrier Precautions (EBP) Sign observed on a Resident 11's door for indwelling catheter. On 9/10/24 at 10:00 A.M., there was no Enhanced Barrier Sign observed on Resident 11's door for and indwelling catheter. On 9/11 at 12:46 P.M., there was no Enhanced Barrier Sign observed on Resident 11's door for and indwelling catheter. On 9/13/24 at 9:07 A.M., there was no Enhanced Barrier sign observed on Resident 11's door for and indwelling catheter. On 9/10/24 at 10:12 A.M., Resident 11's clinical record was reviewed. Diagnoses included, but not limited to chronic kidney disease stage 3, Benign prostatic hyperplasia without lower urinary tract symptoms, neuromuscular dysfunction of bladder. The currently Quarterly MDS (Minimum Data Set) assessment dated [DATE] indicated Resident 11 was cognitively intact. Resident 11 is totally dependent for transferring, toileting, dressing, and has an indwelling catheter. Current physician orders included, but were not limited to: Insert Coudet French size 18, balloon size 10 ml (milliliters). Change Foley (Indwelling Catheter) and urinary bag q (every) 14 days for system failure and if the urinary bag gets cloudy and with sediment, every day shift 14 days for urinary retention (related to) BPH (Benign Prostatic Hyperplasia) change catheter every 14 days dated 8/30/24. Catheter care to be done each shift dated 3/12/2024. The current EBP (Enhanced Barrier Precautions) for indwelling catheter with a goal to be monitored signs and symptoms of infection. Interventions included, but were not limited to: Place the resident on Enhanced Barrier Precautions and educate or encourage the resident on the importance of complying with enhanced barrier precaution measures to prevent the spread of the infection. 2. On 9/24 at 9:19 A.M., RN (Registered Nurse) 11 and CNA (Certified Nurse Aide) 20 were observed performing incontinence care for Resident 2. RN 11 and CNA 20 went into room and did not sanitize. Both placed gloves on with CNA 20 turned resident to left side and cleaned buttocks after bowel movement. Prior to cleaning, CNA 20 removed bed pan and placed in a bag. CNA 20 donned new gloves but did not perform hand hygiene prior to placing gloves. Pulled up clean brief. RN 11 fastened new brief and then began touching items in room with the same gloves on before got to get to the air freshener. Removed gloves and washed hands when completed. 3. On 9/11/24 at 1:20 P.M., RN 7 was observed giving Resident 14 medication and did not sanitize hands after leaving room. 4. On 9/12/24 at 7:11 A.M., RN 18 was observed leaving Resident 19's room after medication pass not sanitizing hands. RN 18 proceeded into Resident 5's room to move them up in bed. RN donned gloves but did not perform hand hygiene prior to entering and after leaving Resident 25's Room. 5. On 9/12/24 at 7:40 A.M., RN 18 was observed going into Resident 2's and did not perform hand hygiene prior to entering Resident 2's room. While in Resident 2's, RN 18 performed a blood pressure on BP was 151/85. RN exited Resident 2's room without performing hand hygiene or cleaning the BP (Blood Pressure) cuff. 6. On 9/12/24 at 11:35 A.M., RN 18 was observed performing an Accu-Chek on Resident 11. The test was performed, and the nurse left the room but did not clean machine after using it During an interview on 9/12/24 at 11:40 A.M., RN 17 indicated that each resident has their own machine and should be cleaned after each use. During an interview on 09/16/24 at 8:57 A.M., the ADON (Assistant Director of Nursing) indicated hands needed to be washed before, after, and during if there were glove changes. Equipment should be cleaned before and after the procedure complete such as a blood pressure cuff and glucometers. 48057 7. During a wound treatment observation on 9/12/24 at 2:59 P.M. RN 3 was observed putting on PPE (personal protective equipment) in the hall. RN 3 began by putting on gloves, mask, then gown. RN 3 entered Resident 23's room, removed a dressing from Resident 23's lower right buttock and sacrum, and began cleansing the wounds with wound cleanser and gauze. RN 3 removed gloves and put new gloves on, dried both wounds with gauze. RN 3 applied Leptospermum honey to the wound beds with her gloved finger, applied calcium alginate and dry dressings over sacral wound. RN 3 applied skin prep around the lower wound dressing, performed a glove change, applied the lower dressing, applied Desitin around both dressings, and performed a glove change. RN 3 rolled Resident 23 back over, retrieved linens out of the closet, put new linen on Resident 23's bed, put the soiled linen in a trash bag, assisted Resident with getting dressed. RN 3 removed her gown and gloves in the room, turned down the air conditioner temperature by the window, and adjusted the bed position with the bed remote. RN 3 exited the room, retrieved hand sanitization foam and rubbed hands together for 4 seconds, then walked back to the nurses station. During an interview on 9/16/24 at 9:08 A.M., the ADON indicated if a nurse is applying medication directly to a wound bed, they should be using sterile cotton applicators, and that hand hygiene should be performed before wound care, during wound care if there are glove changes, and after wound care. On 9/16/24 at 12:30 P.M., the Regional Clinical Support Nurse provided a current policy Policy/Guidelines on Enhanced Barrier Precautions dated 9/23/22. The policy indicated .indications for EBP included but not limited to .indwelling medical devices . which includes .urinary catheters. During this same time, the Regional Clinical Support Nurse provided a current policy Hand-Hygiene dated 5/29/24. The policy indicated .indicated all staff will perform proper hand hygiene procedures to prevent the spread of infections to other personnel, residents, and visitors .if task requires gloves, perform hand hygiene prior to donning, and immediately after removing gloves. An additional current policy Cleaning and Disinfection of Resident-Care Equipment dated 5/29/24. The policy indicated .resident-care equipment can be a source of indirect transmissions of pathogens . each staff is responsible for routine cleaning and disinfection of multi-resident items after each use, particularly before use for another resident . 3.1-18(b) 3.1-18(l)

Based on record review and interview, the facility failed to ensure the documentation was completed and accurate for 5 of 6 residents reviewed for accuaracy of falls documentation. (Resident 9, Resident 12, Resident 19, Resident 7, Resident 11) Findings include: 1.On 9/11/24 at 10:28 A.M., Resident 9's clinical record was reviewed. Diagnoses included, but were not limited to, Alzheimer's disease. The most current Quarterly Minimum Data Set (MDS) Assessment, dated 9/7/24, indicated Resident 9 was not assessed for cognitive impairment because the resident was rarely or never understood, required partial to moderate assistance of staff (staff does less than half) for transfers, and had no falls since the prior assessment. A falls risk assessment, dated 9/13/23, indicated the resident was at high risk for falls. A potential for falls and injuries care plan, dated 6/23/21, included the intervention ensure well lit/clutter free area. Fall 1: On 10/7/23 at 6:15 P.M., Resident 9 had a witnessed fall. The resident was standing in the hallway by the nurses station and another resident ran into her with their walker. The resident sustained an abrasion to her back. The clinical record lacked documentation to indicate the fall was discussed by the Interdisciplinary Team (IDT). The care plan was not updated with a new intervention. A falls risk assessment, dated 10/17/23, indicated the resident was at high risk for falls. Fall 2: On 3/18/24 at 5:25 A.M., Resident 9 had an unwitnessed fall while attempting to self-toilet. The clinical record lacked documented neuro checks. The clinical record lacked documentation to indicate the fall was discussed by the IDT. A current Actual Falls care plan, initiated 3/18/24 and revised 8/16/24, indicated the resident had actual falls on 3/18/24, 5/14/24, and 8/16/24. The intervention [Resident 9] is to have a nightlight in her room was added to the care plan on 3/19/24. A falls risk assessment, dated 3/18/24, indicated the resident was at high risk for falls. Fall 3: On 5/14/24 at 2:32 A.M., Resident 9 had an unwitnessed fall while wandering around the hallway in her socks. The clinical record lacked documented neuro checks. The clinical record lacked documentation to indicate the fall was discussed by the IDT. The intervention Staff are to ensure that resident has non-skid socks when not wearing shoes was added to the care plan on 5/15/24. A falls risk assessment, dated 5/14/24, indicated the resident was at high risk for falls. Fall 4: A Nursing progress note, dated 8/9/24 at 6:00 A.M., indicated Resident 9 had a small tear on a finger on her right hand due to a fall that occurred on 8/8/24. The clinical record lacked facility documentation of the fall on 8/8/24. The clinical record lacked a Post Fall Evaluation for the fall that occurred on 8/8/24. The clinical record lacked documented neuro checks. The clinical record lacked documentation to indicate the fall was discussed by the IDT. The intervention Resident is not to be left unattended by staff when toileting was added to the care plan on 8/8/24. On 9/12/24 at 11:33 A.M., the Assistant Director of Nursing (ADON) indicated there was no fall evaluation for the fall that occurred on 8/8/24, and no documented neuro checks for the falls that occurred on 3/18/24, 5/14/24, and 8/8/24. 2. On 9/10/24 at 10:42 A.M., Resident 12 was observed in the activities room on the locked unit sitting in her wheelchair with a purple bruise on the right side of her face covering her temple, eye, and cheekbone. On 9/11/24 at 11:26 A.M., Resident 12's clinical record was reviewed. Diagnoses included, but were not limited to, dementia. The most current Annual Minimum Data Set (MDS) Assessment, dated 6/17/24, indicated Resident 12 had severe cognitive impairment, required supervision of staff for transfers, was independent in walking, did not use mobility devices, and had no falls since the prior assessment. A fall risk assessment, dated 9/29/23, indicated the resident was at low risk for falls. A risk for falls, dated 8/3/23, included the interventions anticipate needs, call light in reach, and footwear. A potential for a fall incident care plan, dated 10/17/23, that included the interventions assist with transfers, free of clutter, assist with adl (activities of daily living) care, and nonskid footwear. Fall 1: On 2/5/24 at 8:40 P.M., Resident 12 had an unwitnessed fall while attempting to self-toilet. The resident sustained a right eyelid laceration and a right facial bruise. An Interdisciplinary Team (IDT) note, dated 2/6/24 at 2:51 P.M., indicated the fall was discussed on 2/6/24 and the care plan had been updated. The intervention Motion sensored [sic] night light placed in resident room was added to the care plan on 2/20/24, two weeks after the IDT met. Fall 2: On 3/16/24 at 7:25 P.M., Resident 12 had an unwitnessed fall while adjusting the window blinds in the dining room. The clinical record lacked documented neuro checks. The clinical record lacked documentation to indicate the fall was discussed by the IDT. The intervention Visual reminder to walker was added to an actual fall incident 3/16/24 care plan on 3/18/24. Fall 3: A Trauma History and Physical from the hospital, dated 8/31/24, indicated [Resident 12] presented to the hospital from nursing facility after an unwitnessed fall . On evaluation, she is extremely lethargic and is minimally responsive. She does respond to pain . Scattered bruising noted throughout forearms and elbows. Hematoma noted to right forehead. Unable to obtain any history . A computed tomography (CT) scan of the head revealed no acute injuries. A urinalysis indicated the resident had a UTI (urinary tract infection). The resident was admitted to the hospital for monitoring. She was discharged back to the facility on [DATE] with an order for oral antibiotics. The clinical record lacked facility documentation of the fall on 8/31/24. The clinical record lacked a Post Fall Evaluation for the fall that occurred on 8/31/24. The clinical record lacked documentation that staff notified the physician of the fall and orders were received to send the resident to the hospital. The clinical record lacked documentation that staff notified the resident's representative of the fall. The clinical record lacked documentation to indicate the fall was discussed by the IDT. The intervention Bathroom light is to be left on in room at night was added to an actual fall incident 8/31/24 care plan on 8/31/24. On 9/12/24 at 11:33 A.M., the Director of Nursing (DON) indicated there was no fall evaluation for the fall that occurred on 8/31/24. On 9/12/24 at 9:50 A.M., the DON indicated that the facility had a fall prevention protocol. After a resident fell , the nurse did an assessment of the resident. If the fall was unwitnessed, neuro checks were initiated. The nurse completed a Post Fall Evaluation form. The physician, resident representative, and DON were notified of the fall. IDT met daily and talked about each new fall to determine the root cause of the fall and appropriate interventions to prevent future falls. A new and relevant intervention was added to the care plan immediately. IDT meetings were documented on an internal form and were not a part of the clinical record. All information in the IDT meetings would be documented as a progress note. 3. On 9/10/24 at 12:49 P.M., Resident 19's clinical record review was reviewed. Diagnoses included, but were not limited to, unilateral primary osteoarthritis of left knee, and pain in left knee. The current Five- Day MDS assessment dated [DATE] indicated Resident 9 was mildly cognitively impaired. The resident needed partial assistance to transfer and dressing and was dependent for toileting. Current physician's orders 7/12/2024 included, but were not limited to, resident is one assist with transfers to BS (Bedside) commode. Not to be left unattended while using BS commode dated 7/20/24. The current falls care plan dated 7/12/24 indicated Resident 19 was a fall risk and will resume usual activities without further incident by the next review. Interventions included, but were not limited to, call light in reach, encourage nonskid footwear, and ensure the room is well lit and clutter free. On 7/12/2024 at 5:30 A.M., an Alert Note indicated Resident 19 was assisted to the restroom by staff but decided to walk to the bed by their self without using the bathroom call bell. The resident became dizzy, lost their balance by the bed hitting their head and elbow. The nurse did an assessment but failed to complete a post fall evaluation and neuro check and did not use the call bell and decided to walk back to the bed by themself. The resident became dizzy and lost their footing by the bed, hit their head and elbow. The nurse did an assessment, but the incident lacked post fall evaluation and neurochecks. During an interview on 9/11/24 at 11:22 A.M., the ADON indicated there was no paperwork for the post fall evaluation or the neurochecks for the fall from 7/12/24. 4. On 9/12/24 at 10:16 A.M., Resident 7's clinical record was reviewed. Diagnoses included, but were not limited to, unilateral primary osteoarthritis, right hip and unspecified thoracic, thoracolumbar, and lumbosacral intervertebral disc disorder. The current annual MDS (Minimum Data Set) assessment dated [DATE] indicated the resident was cognitively intact. The resident needed supervision with toileting and set up with dressing, eating, and transfer. The resident used a walker and a wheelchair with ambulation. There were no falls indicated at this assessment. The most recent order recapitulation included, but were not limited to, Anticipate the resident's needs dated 4/1/2024. Encourage resident to properly use the assistive devise when ambulating with walker dated 4/1/2024 Non-skid stripes in front of bed dated 1/3/2024 revised on 4/3/24 Staff are to ensure that bed/chair alarms are functioning properly and in place dated 4/26/2024. Staff to ensure that alarming pad to chair is functioning properly (Resident is deaf alarm is alert the staff dated 4/25/2024 and revised on 5/14/2024. Staff are to toilet resident after each meal dated 5/22/2024. Staff are not to leave resident unattended while using the restroom dated 8/1/2024 and revised 8/26/2024. Fall#1 A Fall Risk Evaluation dated 12/31/23 at 3:05 A.M., indicated Resident 7 had an unwitnessed fall of sliding out recliner on slick floor falling on their bottom. Head to Toe assessment, vital signs, and neuro checks were initiated at 3:15 A.M. no injuries, deformities, or pain was noted. Fall Risk Score: 11.0 On 1/3/2024 7:11 A.M, The IDT (Interdisciplinary Team) Alert Note indicated that the root cause of the fall was due to the slick floor because the resident had slick house shoes on, and the intervention add was placing nonskid stripes in front of the recliner. On 9/16/24 at 11:30 A.M., the ADON provided a document The Neuro Assessment that was initiated on 12/31/23 at 3:15 A.M., the assessments were completed as per the required times but lacked an assessment of verbal responses for the first 15 minutes of the assessment. Fall #2 A Nurses Notes dated 3/30/2024 at 2:41 P.M., indicated that Resident 7 was found by a QMA (Qualified Medicine Aid) sitting on floor in front of bed. Resident indicated they was going from recliner to bed and floor was slick and slid on their bottom. Resident had a head-to-toe assessment with no injuries observed vital signs and neuro checks were initiated. On 9/12/24 at 10:30 A.M., the ADON provided a document Neuro Assessment that was initiated on 3/22/24 at 11:45 P.M., the assessments were completed at the required times but lacked every 4 hours times 3 on 3/23/24 at 11:30 P.M. On 9/16/24 at 11:30 A.M., the ADON provided a document The Neuro Assessment that was initiated on 3/30/24 at 3:00P.M., the assessments were completed as per the required times but lacked an assessment for the last 2 hours times 4 neuro checks at 2:45 A.M. Fall #3 A Nurse's Notes dated 3/30/2024 at 2:41 P.M., indicated that Resident 7 was found by a QMA (Qualified Medicine Aid) sitting on floor in front of bed. Resident indicated they was going from recliner to bed and floor was slick and slid on their bottom. Resident had a head-to-toe assessment with no injuries observed vital signs and neuro checks were initiated. A Post Fall Evaluation dated 3/30/2024 at 2:53 P.M., indicated the fall was unwitnessed and the resident was trying to transfer from chair to bed. Resident was wearing nonskid socks, but the personal alarm was ringing when Resident was found. Fall Risk Score: 13.0 Fall #4 A Nursing Health Status note dated 8/1/2024 at 6:50 A.M., indicated Resident 7 had an unwitnessed fall in bathroom while trying to self-toilet. Assessment, vital signs and neuro checks were initiated, but no documentation of the neuro checks was provided. A post-fall evaluation note done on 8/1/24 at 6:50 A.M., indicated the resident was attempting to self-toilet and the reason for the fall was not evident. The resident had on nonskid socks but did not use the call bell. New interventions were to not leave the resident unattended in the restroom. Fall risk score was. Fall Risk Score: 23.0 On 9/16/24 at 11:30 A.M., the ADON provided a document The Neuro Assessment that was initiated on 12/31/23 at 3:15 A.M., the assessments were completed as per the required times but lacked an assessment of verbal responses for the first 15 minutes assessment. The ADON (Assistant Director of Nursing) indicated they should have been done and documented completely. 5. On 9/10/24 at 10:12 A.M., Resident 11's clinical record was reviewed. Diagnoses included, but were not limited to, systemic lupus erythematosus unspecified, chronic kidney disease stage 3 unspecified, neuromuscular dysfunction of bladder. The current Quarterly MDS assessment dated [DATE] indicated Resident 11 was cognitively intact. The resident was totally dependent for transferring, toileting, dressing, and mobility. No falls this assessment. Current physician orders included, but were not limited to, Bed in lowest position and perimeter mattress to bed dated 8/1/23. Revised on 3/27/2024. On 8/1/2024 at 10:52 A.M., from a Fall Risk Evaluation indicated that the fall risk score is 13. The falls risk care plan, initiated 8/11/21, indicated Resident 11 had falls and would be free from falls through the review date. The care plan was revised on 8/16/2024. Interventions included, but were limited to, anticipate and meet resident need, have call bell within reach and encourage the resident to use, bed in lowest position initiated 8/11/202. Parameter mattress to bed initiated 7/14/2023 and revised 1/26/2024. Increased supervision until UTI (Urinary Tract Infection) initiated 3/27/22. PT evaluate and treat as ordered initiated 12/13/2022. Therapy to evaluate and treat as indicated initiated on 5/24/2023. These were all in place prior to fall the newest intervention started staff are to place over bed table on the opposite side of the where the change of plane mattress is not present. A Health Status Note dated 8/1/24 at 9:45 A.M., indicated a CNA (Certified Nurse Aide) heard resident crying out, and found resident laying the left side between bed and mat. Resident had repositioned self after when falling from bed. Had complaint of head pain. Nurse started head to toe assessment was completed but lacked neuro check initiation for 8/1/24. On 9/12/24 at 10:30 A.M., the ADON provided a document Neuro Assessment that was initiated on 3/22/24 at 11:45 P.M., the assessments were completed at the required times but lacked every 4 hours times 3 on 3/23/24 at 11:30 P.M. On 9/16/24 at 12:20 P.M., the Regional Consultant provided a current undated Assessing Falls and Their Causes policy that indicated After a Fall: If a resident has just fallen or is found on the floor without a witness to the event, the nursing staff will record vital signs and evaluate for possible injuries to the head, neck, spine, and extremities . Once an assessment rules out significant injuries, the nursing staff will .document relevant details . Nursing staff will observe for delayed complications of a fall for approximately forty-eight (48) to seventy-two (72) hours after an observed or suspected fall and will document findings in the medical record . An incident report must be completed for resident falls. The incident report form should be completed by the nurse on duty at the time . When a resident falls, the following information should be recorded in the resident's medical record: The condition in which the resident was found . Assessment data, including vital signs and any obvious injuries. Interventions, first aid, or treatment administered. Notification of the physician and family . Completion of a fall risk assessment. Appropriate interventions taken to prevent future falls . On 9/16/24 at 1:00 P.M., the Regional Consultant indicated the facility did not have a policy for Documentation Requirements. It was the facility's policy that staff follow standard nursing practice and document accurately and completely. 3.1-50(a)(1) 3.1-50(a)(2)

Based on observation, interview, and record review, the facility failed to ensure food was stored, labeled, and dated properly in accordance with professional standards for food service and ensure chemical sanitization was monitored for 2 of 2 kitchen observations. Findings include: On 9/9/24 at 8:57 A.M., an initial tour of the kitchen was conducted. The following items were observed: In the dry storage area,1 bottle apple cider vinegar labeled open 1/24/24 use by 4/24/24 In the walk in freezer: 1 bag of spanish rice labeled 5/14/24 use by 6/14/24 2 bags of coffee cake; 1 labeled 7/24/24 use by 8/24/24 and 1 with no dates/label 4 plastic containers labeled jalapeno's 8/16 use by 8/20 1 plastic container with foil covering top labeled tomatoes 8/13 to 8/18 1 unlabeled/undated package of raw meat 1 bag labeled pizza sauce 6/29 use 7/29 1 bag labeled biscuits 7/23/24 use 8/23/24 In the walk in fridge: 2 unlabeled/undated pitcher of brown liquid 2 unlabeled/undated pitchers of orange liquid 2 unlabeled/undated pitchers orange juice 1 box of black bananas with no dates 1 unlabeled/undated ketchup bottle 1 unlabeled/undated mustard bottle 1 bottle labeled ketchup 8/23 use by 8/26 1 bottle ketchup labeled 8/23 During an observation on 9/11/24 at 9:50 A.M., the following was observed: In the walk in freezer: 1 bag of spanish rice labeled 5/14/24 use by 6/14/24 2 bags of coffee cake; 1 labeled 7/24/24 use by 8/24/24 and 1 with no dates/label 4 plastic containers labeled jalapeno's 8/16 use by 8/20 1 plastic container with foil covering top labeled tomatoes 8/13 to 8/18 1 unlabeled/undated package of raw meat 1 bag labeled pizza sauce dated 12/21 1 bag labeled biscuits 7/23/24 use 8/23/24 In the walk in fridge: 1 box of black bananas with no dates 1 unlabeled/undated pitcher of orange juice 2 unlabeled/undated pitchers of red liquid During an interview on 9/9/24 9:35 A.M., the kitchen manager indicated the high temperature dishwasher was used for washing most items, but handwashed items were washed in the three compartment sink. The kitchen manager used a chemical test strip to test the sanitization level and indicated the kitchen staff did not keep a log of test results. On 9/16/24 at 12:45 P.M., the regional consultant provided a document titled Date Marking for Food Safety, dated 4/16/24, that indicated Refrigerated, ready to eat, time/temperature control for safety food shall be held at a temperature of 41 degrees Fahrenheit or less for a maximum of 7 days. The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. On 9/16/24 at 12:45 P.M., the regional consultant provided a document titled Manual Warewashing 3 Compartment Sink, dated 4/9/24, that indicated Sanitization solution shall be tested by a test kit or other device that accurately measures the concentration in MG/L. Testing will occur periodically but not limited to: When the sink is initially filled, at least once per shift, with extended use, and as needed. 3.1-21(i)(2) 3.1-21(i)(3)

Based on observation, interview, and record review, the facility failed to ensure proper storage of medications for 3 of 3 medication carts, 1 of 1 treatment cart, and 1 of 1 medication storage room observed. Loose pills were observed in the medication cart drawers, medication was not labeled, and medication room refrigerator temperature logs were not completed. (200-M Hall, 400 Hall, 300 Hall, [NAME] Medication Storage Room) Findings include: 1. On 9/9/24 at 9:18 A.M., the 200-M Hall medication cart was reviewed. The following loose pills were observed in the bottom of the drawers: 1 white circle pill with marking TCL 340 1 white circle pill with marking 44 157 2. On 9/9/24 at 9:23 A.M., the 200-M Hall treatment cart was reviewed. The following items were observed opened, without labels, and not in a resident bag: Triple Antibiotic Ointment Ready Prep Therahoney Gel At that time, Licensed Practical Nurse (LPN) 10 indicated that once house stock items were opened, they were stored in individual resident bags. 3. On 9/9/24 at 9:58 A.M., the 400 Hall medication cart was reviewed. The following items were observed without a label: clinical treatment antifungal powder 4. On 9/9/24 at 10:00 A.M., the 300 Hall medication cart was reviewed. The following loose pills were observed in the bottom of the drawers: 1 white oval pill with marking m10 1 white circle pill with marking 300 .5 red oval pill with marking 252 A bottle of Tylenol was observed in the cart with no resident name or label. At that time, LPN 15 indicated that the bottle of Tylenol needed a label, and she would get one printed off for it. 5. On 9/10/24 at 9:13 A.M., the [NAME] medication storage room was reviewed. The September 2024 refrigerator temperature log was observed on the locked refrigerator. Temperatures were not recorded on 9/2, 9/4, 9/5, 9/7, 9/8, and 9/9. At that time LPN 10 indicated the log got filled out by a nurse or whoever remembered to fill it out. On 9/12/24 at 1:35 P.M., the Assistant Director of Nursing (ADON) indicated either the nurses or the Qualified Medication Aides (QMA) would clean out the medication carts. On 9/16/24 at 12:20 P.M., the Regional Consultant provided a current Medication Storage policy, dated 5/30/2023, that indicated It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations . Refrigerated Products: Temperatures are maintained within 36-46 degrees F (Fahrenheit). Charts are kept on each refrigerator and temperature levels are recorded daily by the charge nurse or other designee . The pharmacy and all medication rooms are routinely inspected by the consultant pharmacy for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. These medications are destroyed . On 9/16/24 at 12:20 P.M., the Regional Consultant provided a current Labeling of Medications and Biologicals policy, dated 4/16/2024, that indicated All medications and biologicals used in the facility will be labeled in accordance with applicable federal and state requirements and current accepted pharmaceutical principles and practices . Labels for individual drug containers must include: the resident's name; the prescribing physician's name; the medication name (generic and/or brand name); the prescribed dose, strength, and quantity of the medication; the prescription number (if applicable); the date the drug was dispensed; appropriate instructions and precautions .; the expiration date when applicable; the route of administration . Labels for medications designed for multiple administrations .the label will identify the specific resident for whom it was prescribed. 3.1-25(j) 3.1-25(l) 3.1-25(m)

Based on observation and interview, the facility failed to ensure the safety of resident's by not utilizing an emergency call system for 6 of 6 days during survey. (Public Restroom) Finding includes: During random observations throughout the week of survey from dates September 9 to September 16, 2024. The visitor restroom located in the main hallway across from the beauty shop lacked an emergency call system. During an interview on 9/16/24 at 9:55 A.M., the DON (Director of Nursing) indicated that residents from the beauty shop used that restroom and there was no emergency call light system in the visitor restroom. A current nondated policy was provided by the Regional Clinical Support Nurse at 10:00 A.M. The policy Personal Property-Home Like Environment lacked information concerning call lights. 3.1-19(b)

Based on observation, interview, and record review, the facility failed to ensure that appropriate treatment and services were provided to prevent urinary tract infections (UTI) that resulted in hospitalization s for 1 of 2 residents reviewed for Urinary Catheter and UTI. This failure resulted in 11 UTIs which resulted in 5 hospital admissions and treatment with 12 antibiotics over the past year. (Resident 21) Finding includes: On 6/7/23 at 10:13 A.M., CNA 14 and CNA 19 were observed to provide catheter care for Resident 21. Both staff entered the room and put on gloves. Two basins of water and folded washcloths were observed prepared on a bedside table. CNA 19 moved the bed to the side by grasping the footboard. CNA 19 shut the door. CNA 19 obtained a trash bag from supplies on bed side table. CNA 19 raised the bed using the handheld bed remote and then moved the call light off of the bed. CNA 19 and CNA 14 pulled Resident 21's blanket down to his ankles. At that time Resident 21 only had on a brief. The catheter bag was observed lying at the foot of the bed with a dark yellow liquid inside it. CNA 19 and CNA 14 then removed Resident 21's brief. Without changing gloves, CNA 19 placed a washcloth in the basin on right side, grasped Resident 21's penis in her left hand and cleaned the meatus with the washcloth in her right hand. Using the same washcloth, CNA 19 cleaned down the shaft of the penis. Using the same washcloth, CNA 19 moved the catheter tubing and penis aside and cleaned Resident 21's testicles. CNA 19 disposed of the washcloth in the open trash bag. CNA 19 obtained a new washcloth, put it in the water basin, and, holding the top of Resident 21's penis and grasping the catheter tubing between her left thumb and pointer finger, cleaned down the tube. CNA 19 disposed of the washcloth in the open trash bag and obtained a new washcloth. CNA 19 cleaned around the meatus and around the testicles, then disposed of the washcloth in the open trash bag. CNA 19 obtained another washcloth, put it in the water basin, and cleaned around the meatus, around the testicles and thighs, and then grasped the tip of the penis and catheter tubing in her left hand and cleaned down the tubing. CNA 19 obtained a dry washcloth and patted Resident 21's genital area dry. CNA 19 removed the catheter bag from the bed and clipped it to the bars on the lower right side of the bed. CNA 19 obtained a tube from a basin of supplies. She indicated it was an antifungal cream. CNA 19 applied the cream to her left pointer finger and smeared it all over Resident 21's testicles. CNA 19 indicated to CNA 14 that they would leave Resident 21 without a brief on to air out. CNA 14 pulled the blanket over Resident 21. CNA 19 and CNA 14 pulled Resident 21 up in bed. CNA 14 used the handheld bed remote to lift Resident 21's feet and head up and lower the bed. CNA 19 emptied the two water basins. At that time CNA 19 and CNA 14 removed their gloves and performed hand hygiene using soap and water. CNA 19 put on new gloves and emptied the catheter bag of a dark yellow liquid. CNA 19 indicated she emptied 900 mL (milliliters) of fluid into the toilet. CNA 19 then emptied more dark yellow liquid from the catheter bag and indicated she emptied another 200 mL from the catheter bag. CNA 19 removed her gloves and performed hand hygiene. On 6/7/23 at 8:40 A.M., Resident 21's clinical record was reviewed. Resident 21 was admitted on [DATE]. Resident 21's diagnoses included, but were not limited to, chronic obstructive pulmonary disease, diabetes mellitus, chronic kidney disease, systemic lupus erythematosus, retention of urine, and major depressive disorder. The most recent annual MDS (Minimum Data Set) Assessment, dated 3/2/23, indicated the resident was cognitively intact, had an indwelling catheter, was always incontinent of bowel, required extensive assistance of two plus staff for toileting and bed mobility, and required total assistance of two plus staff for bathing. A Catheter Assessment, dated 2/28/23, indicated permanent placement due to urinary retention. Current orders included, but were not limited to: Catheter care to be done each shift two times a day, initiated 5/4/23. Flush F/C (foley catheter) with 60 mL (milliliters) of NS (normal saline) Q (every) day at bedtime, initiated 7/6/22. Foley Catheter output every shift two times a day, initiated 6/16/22. Change Foley catheter every 14 days at bedtime, initiated 5/24/23. Previous orders included, but were not limited to: Nurse to chart the use of cipro (ciprofloxacin, an antibiotic medication) for UTI. Chart urine characteristics, pain, burning at foley site, fever, lethargy every shift from 7/21/22 to 7/31/22. Ceftriaxone Sodium Solution Reconstituted 1 GM (gram) IM (intramuscularly) at bedtime for UTI from 9/2/22 to 9/8/22. Amoxicillin-Pot Clavulanate Tablet 500-125 MG (milligrams) by mouth three times a day for bacterial infection from 11/19/22 to 11/28/22. Nurse to chart the use of amoxicillin (an antibiotic medication) for uti. Chart output, color of urine, sediment, fluid intake, catheter care, pain, burning at catheter site, pain in abdomen every shift from 11/20/22 to 11/28/22. Cipro tablet 250 MG by mouth two times a day for UTI from 12/15/22 to 12/22/22. Bactrim DS Oral Tablet 800-160 MG by mouth two times a day for UTI from 2/2/23 to 2/9/23. Fosfomycin Tromethamine Oral Packet 3 GM by mouth in the morning every 3 days for UTI from 2/8/23 to 2/14/23. Augmentin Oral Tablet 500-125 MG by mouth three times a day for UTI-Klebsiella from 2/23/23 to 3/5/23. Ertapenem Sodium Injection Solution Reconstituted 1 GM intravenously one time a day for UTI from 3/6/23 to 3/9/23. Levaquin Oral Tablet 750 MG by mouth at bedtime for UTI from 5/5/23 to 5/12/23. Macrobid Oral Capsule 100 MG by mouth two times a day for UTI from 5/23/23 to 5/30/23. Ertapenem Sodium Injection Solution Reconstituted 1 GM intravenously one time a day for UTI from 5/25/23 to 6/4/23. Resident 21 had the following UTIs: Occurrence 1. On 7/17/22 a progress note indicated Resident was not feeling well and urine was dark yellow with sediment and foul order. On 7/18/22 a UA (urinalysis) and C&S (culture and sensitivity) was obtained. A lab report, dated 7/20/22, indicated Escherichia Coli was detected. A progress note, dated 7/21/22, indicated the resident was started on ciprofloxacin (an antibiotic medication) for UTI. A lab report, dated 7/20/22, indicated ciprofloxacin was resistant (ineffective) to Escherichia Coli. The MAR (medication administration record) from 7/2022 and 8/2022 indicated the resident received ciprofloxacin from 7/20/22 to 8/3/22. Occurrence 2. On 8/25/22 a progress note indicated Resident was having pelvic pain and urine was dark yellow with foul order. The note also indicated that a UA was sent. On 8/26/22 a progress note indicated Resident complaining of urinary leakage around tip of penis, noted approx. 100ml cloudy yellow urine in bedside drainage bag. Noted a moderate amount of urine in brief. Resident reports tenderness to left lower quadrant (Abdomen), tender with palpation, slight distension noted. Removed coude catheter, tip intact, and successfully reinserted an 18fr 30ml coude foley catheter, with immediate urine return, cloudy yellow, 100ml, to drainage bag. By end of procedure, another 300ml collected to drainage bag. Resident reported relief from catheter change, and bladder distension resolved. Will continue to monitor. A review of the census indicated that Resident 21 was admitted to the hospital from 8/26/23 to 9/2/23. A progress note on 9/2/22 indicated that the resident returned from the hospital where he was treated for a UTI with an order for ceftriaxone sodium (an antibiotic medication). The MAR from 9/2022 indicated the resident received ceftraixone sodium from 9/2/22 to 9/8/22. Occurrence 3. On 10/15/22, a progress note indicated F/C (foley catheter) leaking at this time. Resident total bed change. Removed Coduet [sic] French size 18F/10 ml at this time. Resident tolerated well. Inserted Coduet [sic] French size 18F/10 ml with no return of urine and large amount thick blood surrounding external cath. Insertion of Coduet [sic] attempted by second nurse at this time with success and returned of this mucus and medium blood clot noted. Urine clear amber in color. A progress note, dated 10/17/22, indicated the resident was admitted to the hospital for a UTI. A progress note, dated 10/20/22, indicated the resident returned to the facility. Occurrence 4. On 11/15/22, a progress note indicated Resident complained of bladder pain and burning. MD was notified and order given to send the Resident to the ER (emergency room ) for evaluation and treatment. On 11/18/22, a progress note indicated Resident returned to the facility. A progress note, dated 11/19/22, indicated the resident was receiving antibiotics for a UTI. The MAR from 11/2022 indicated the resident received Amoxicillin-Pot Clavulanate (an antibiotic medication) from 11/19/22 to 11/28/22. Occurrence 5. On 12/13/22, a progress note indicated Resident's urine was yellow and cloudy with a strong foul odor. On 12/14/22, a UA and C&S was obtained. A lab report, dated 12/15/22, indicated multiple potential uropathogens present in the specimen indicating probable contamination and a recollection was recommended. The clinical record lacked documentation of recollection or follow up lab reports. A progress note, dated 12/15/22, indicated the MD (medical doctor) ordered ciprofloxacin (an antibiotic medication) for UTI. The MAR from 12/2022 indicated the resident received ciprofloxacin from 12/15/22 to 12/22/22. A progress note, dated 12/27/22, indicated a new order for Macrobid 50 MG once daily prophylactically for recurrent UTI. The MAR for 12/2022, 1/2022, 2/2022, and 3/2022 indicated the resident received Macrobid (an antibiotic medication) from 12/27/22 to 3/2/23. Occurrence 6. On 1/8/23, a progress note indicated that Resident had cloudy yellow urine with strong foul odor and the resident was receiving prophylactic antibiotics for chronic UTI. On 1/10/23, a progress note indicated that Resident had yellow urine with foul odor and sediment, and the resident was receiving Macrobid prophylactically for chronic UTI. The clinical record lacked documentation of MD notification. Occurrence 7. On 2/1/23, a progress note indicated the Resident was transferred to the hospital. On 2/2/23, a progress note indicated the Resident was transferred back to the facility with an order for Bactrim to treat UTI. The MAR from 2/2022 indicated the resident received Bactrim (an antibiotic medication) from 2/2/22 to 2/9/22, Occurrence 8. On 2/14/23, a progress note indicated Resident had amber urine with foul odor. On 2/16/23, a progress note indicated the IP (Infection Preventionist) nurse reviewed UA results with WBC (white blood cells) and bacteria noted. Culture in progress with resident on prophylactic Macrobid daily. A lab report, dated 2/18/23, indicated Klebsiella Pneumoniae was detected. On 2/20/23, a progress note indicated an order was received for IV Pipeacill/Tazob (an antibiotic medication). On 2/22/23, a progress note indicated the Resident refused IV placement because he was tired of getting stuck. On 2/23/23, a progress note indicated a new order for oral augmentin (an antibiotic medication) was received. A lab report, dated 2/18/23, indicated Klebsiella Pneumoniae carried an intermediate classification (response rates may be lower). On 2/24/23, a progress note indicated Resident, resident's wife, and IP nurse met for a care conference to discuss treatment. Wife and Resident agreed to continue with oral antibiotics and hold off on IV antibiotics at that time. On 2/25/23, a progress note indicated Resident was observed with temperature of 102.0 degrees Fahrenheit. An order was received to transfer the resident to the hospital for evaluation. On 3/2/23, a progress note indicated the Resident returned to the facility from the hospital where he was treated for acute pyelonephritis (kidney infection) with orders for IV antibiotics. The MAR for 3/2023 indicated the resident received Ertapenem Sodium (an antibiotic medication) from 3/3/23 to 3/9/23. Occurrence 9. On 4/6/23, a progress note indicated the Resident complained of pain in the bladder, was confused, and urine was amber in color with sediment present. MD notified and order given for UA and C&S if indicated. A lab report, dated 4/8/23, indicated Klebsiella Pneumoniae and Providencia Stuartii detected. On 4/8/23, order received for IV Amikacin. The MAR for 4/2023 indicated the resident received Amikacin Sulfate (an antibiotic medication) from 4/9/23 to 4/15/23. Occurrence 10. On 5/2/23, a progress note indicated Resident was confused and complained of burning. NP (nurse practitioner) notified and orders received for UA and C&S. A lab report, dated 5/6/23, indicated Klebsiella Pneumoniae was detected. Levofloxacin (an antibiotic medication) was ordered for UTI on 5/5/23. A lab report, dated 5/6/23, indicated Klebsiella Pneumoniae was resistant (ineffective) to levofloxacin. The MAR for 5/2023 indicated the resident received levofloxacin from 5/5/23 to 5/11/23. Occurrence 11. On 5/17/23, a progress note indicated Resident was confused and verbally expressed pain. NP notified and orders given for UA and C&S. A lab report, dated 5/19/23, indicated Enterococcus Faecalis and Klebsiella Pneumoniae were detected. On 5/19/23, a progress note indicated the NP was notified of UA and C&S results. A progress note, dated 5/21/23, indicated a PICC (peripherally inserted central catheter) was placed. On 5/22/23, a progress note indicated Resident continued to have confusion and NP contacted for orders. On 5/23/23, a progress note indicated orders were received for Macrobid (an antibiotic medication) for UTI. It also indicated resident complained of bladder pain. A lab report, dated 5/19/23, indicated Klebsiella Pneumoniae was resistant (ineffective) to Macrobid. A progress note, dated, 5/24/23, indicated that Resident attended an appointment with a urologist and a new order for IV antibiotics was received. The MAR for 5/2023 and 6/2023 indicated the resident received Ertapenem Sodium (an antibiotic medication) from 5/26/23 to 6/2/23 and Macrobid from 5/23/23 to 5/30/23. The TAR (treatment administration record) for July 2022 indicated the following: Foley catheter output every shift two times a day was not completed on 7/5, 7/10, 7/11, 7/16, 7/21, 7/23, 7/24, and 7/25. Nurse to chart cipro use for uti was not completed on 7/24 day shift. Flush foley catheter 60 mL NS (normal saline) daily at bedtime was not completed on 7/10, 7/18, and 7/24. The TAR for August 2022 indicated the following: Foley catheter output every shift two times a day was not completed on 8/1, 8/2, 8/3, 8/15, and 8/16. Flush foley catheter 60 mL NS daily at bedtime was not completed on 8/15. The TAR for September 2022 indicated the following: Foley catheter output every shift two times a day was not completed on 9/2, 9/8, 9/14, 9/24, and 9/25. Flush foley catheter 60 mL NS daily at bedtime was not completed on 9/22. The TAR for October 2022 indicated the following: Foley catheter output every shift two times a day was not completed on 10/11 and 10/23. The TAR for November 2022 indicated the following: Foley catheter output every shift two times a day was not completed on 11/13, 11/14, and 11/26. Nurse to chart every shift the use of amoxicillin for uti was not completed on 11/25 night shift. Flush foley catheter 60 mL NS daily at bedtime was not completed on 11/3, 11/7, and 11/20. Change Foley catheter and urinary bag at bedtime every 30 days for urinary retention was not completed on 11/7. The TAR for December 2022 indicated the following: Foley catheter output every shift two times a day was not completed on 12/3, 12/4, 12/12, 12/14, 12/17, 12/22, and 12/25. Flush foley catheter 60 mL NS daily at bedtime was not completed on 12/13, 12/18, and 12/22. The TAR for January 2023 indicated the following: Foley catheter output every shift two times a day was not completed on 1/4, 1/9, and 1/30. Flush foley catheter 60 mL NS daily at bedtime was not completed on 1/14. The TAR for March 2023 indicated the following: Foley catheter output every shift two times a day was not completed on 3/2, 3/7, and 3/22. Flush foley catheter 60 mL NS daily bedtime was not completed on 3/14. The TAR for April 2023 indicated the following: Foley catheter output every shift two times a day was not completed on 4/3, 4/16, 4/17, 4/23, 4/25, and 4/29. The TAR for May 2023 indicated the following: Foley catheter output every shift two times a day was not completed on 5/15. During an interview on 6/8/23 at 10:21 A.M., the DON (Director of Nursing) indicated that blank spaces in the MAR and TAR meant the treatment and/or medication was not provided. She further indicated that she expected all orders to be followed. During an interview on 6/7/23 at 2:24 P.M., CNA (Certified Nursing Aide) 4 indicated that when providing catheter care, gloves should be changed and hand hygiene performed after touching dirty items such as a remote, blanket, or table and before touching the resident or catheter tubing. During an interview on 6/9/23 at 10:05 A.M., the IP (Infection Preventionist) Nurse indicated new gloves should be put on before starting catheter care. She indicated that CNA's are not evaluated for catheter care competency. During an interview on 6/8/23 at 1:54 P.M., the IP Nurse indicated that she looks at antibiotic use daily for indications of use, susceptibility, side effects, and end dates. She indicated that she reviews all antibiotics whether they are prescribed in or out of facility. She indicated the antibiotics prescribed to Resident 21 on 7/20/22 and 5/5/23 were not appropriate for organism detected. At that time, the IP Nurse provided the facility tracker and Resident 21 was identified on September 2022 to May 2023 forms. On 6/9/23 at 9:59 A.M., a current Catheter Care policy, dated 11/28/22, was provided by the Administrator, and indicated steps to catheter care included, but were not limited to, Perform hand hygiene. Don gloves . Gently grasp penis. Using circular motion, cleanse the meatus with a clean cloth moistened with water and perineal cleaner (soap). With a new moistened cloth, starting at the urinary meatus moving down, cleanse the shaft of the penis. With a new moistened cloth, starting at the urinary meatus moving outward, wipe the catheter making sure to hold the catheter in place so as to not pull on the catheter. Pat area with towel. On 6/7/23 at 12:44 P.M., a current Administration of Medications policy, dated 10/15, was provided by the Administrator, and indicated each dose administered shall be properly recorded on the resident's Mediation administration record or in the treatment administration record immediately following the administration by initial the box indicated for the medication given. On 6/5/23 at 11:30 A.M., a current Antibiotic Stewardship Program policy, dated 11/2017, was provided by the Administrator, and indicated the facility will review the use of antibiotic 2-3 days after antibiotics are initiated to answer . is the resident on the most appropriate antibiotic(s), dose, and route of admission. 3.1-41(a)(2)

A. Based on observations, interviews and record reviews, the facility failed to properly prevent and/or contain COVID-19 by failing to ensure 100% of the 49 staff were vaccinated and had 11 residents who were COVID-19 positive in the past 4 week, one of which expired at the hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . (Residents M, N, P, R, S, T, V, W, X, Y, BB) B. Based on interview and record review, the facility failed to follow CDC/CMS guidelines for medical exemptions for 3 of 3 staff, and failed to track Covid -19 vaccination status for staff which included booster vaccinations. (Staff 1, Staff 2, Staff 3) The immediate jeopardy began on [DATE] when the facility failed to ensure that 100% of the staff were vaccinated. The Assistant Director of Nursing [ADON] and RN 1 were notified of the immediate jeopardy at 2:10 P.M. on [DATE]. The immediate jeopardy was removed on [DATE] but the noncompliance remained at the lower scope and severity level of pattern of no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: A1. On [DATE] at 1:15 P.M., the Administrator provided a spreadsheet of current employees. The spreadsheet indicated the following: 49 staff members. 7 were partially vaccinated. 24 were completely vaccinated, and 8 had exemptions. 3 of those were medical exemptions (Staff 1, Staff 2, and Staff 3). 3 employees were not vaccinated, and had no exemptions (Staff 4, Staff 5, and Staff 6). 73.4% staff were vaccinated, partially vaccinated and had approved exemptions. On [DATE] at 1:45 P.M., Staff 4 was interviewed. Staff 4 indicated she was unvaccinated, and did not have an exemption. On [DATE] at 2:00 P.M., Staff 5 was interviewed. Staff 5 indicated she was unvaccinated, and didn't plan on getting vaccinated, and did not have an exemption. On [DATE] at 9:50 A.M., the Administrator provided the timesheets for Staff 4, Staff 6 and Staff 5. Staff 4 worked 7 days from [DATE]-[DATE]. The Administrator indicated Staff 4 normally worked 5 days a week. Staff 6 worked 1 day between [DATE]-[DATE] and Staff 5 worked 6 days between [DATE]-[DATE]. On [DATE] at 11:20 A.M., during an interview with the HR [Human Resources] director, she indicated she looked at the employee files, and verified that Staff 4, Staff 5 and Staff 6 were unvaccinated and without exemptions. A2. On [DATE] at 9:15 A.M., the ADON provided a list of residents who had been diagnosed with COVID-19 in the facility in the previous 4 weeks. The list included Residents M, N, P, R, S, T, V, W, X, Y, and BB. The dates of diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . One resident, Resident P, had passed away in the hospital from COVID. The ADON indicated there were 7 residents currently ([DATE]) in the facility Red Zone, who were COVID positive. Three of those residents had been admitted from the hospital with COVID. The clinical record of Resident P was reviewed on [DATE] at 9:35 A.M. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurses notes did not indicate when the resident was diagnosed with COVID+. The first documentation in the clinical record that mentioned Resident P and COVID, dated [DATE] at 10:00 P.M., included, Resident is alert with intermittent confusion. [Vital signs within normal limits]. Denies c/o [complaints of] body aches .Takes fluids well. Pleasant mood with staff. Remains on Covid precautions. Nurses notes included the additional notations: [DATE] at 10:01 A.M.: Res [resident] remains on Covid precautions. Pleasant mood this am. Res continues to improve . VS [vital signs] remain stable . Poor appetite this am . Will continue to monitor. [DATE] at 7:07 A.M.: Res continues with good oral acceptance .remains on precautions due to previous positive results with Covid. [DATE] at 10:40 A.M.: Resident coughing up brown fluid from lungs . labored breathing. Resident also has small amount of blood coming from [NAME] [sic] at this time. This nurse asked resident if was feeling ok. Resident stated that he did not feel well and hurt all over. Notified MD at this time. received order to send resident to [name of hospital] for evaluation. The resident was transferred to the hospital on [DATE] at 11:21 A.M. A hospital emergency room record, dated [DATE], included: Chief Complaint: Patient presents with COVID +, Hemoptysis [coughing up blood] .Patient presents via [ambulance service] from nursing home for evaluation of weakness and cough and not eating or drinking well. Patient tested positive for COVID-19 one week ago. Timing of onset was gradual. Severity is rated as severe. Quality is described as weakness and cough. Symptoms have been worsening .Assessment: 1. Acute [CONDITION(S)] 2. Pneumonia due to COVID-19 virus A hospital discharge summary, dated [DATE], indicated the resident had expired on [DATE]. The summary included: Discharge Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] .COVID-19 pneumonia. On [DATE] at 11:30 A.M., the Assistant Director of Nursing provided [CONDITION(S)] COVID-19 Testing Documentation for Resident P. The documentation indicated Resident P had a routine COVID test on [DATE] at 1:00 P.M., which was positive. B1. On [DATE] at 10:25 A.M., the ADON provided the Medical Exemption form for Staff 3. The form, dated [DATE], indicated, Requested accommodation: COVID 19 vaccine exemption .I have already been exposed to COVID 19 and never tested positive. The form did not specify the type of vaccine or a valid clinical reason for the exemption. On [DATE] at 9:50 A.M., the Administrator provided the working schedule for Staff 3. Staff 3 worked 7 days from [DATE]-[DATE]. The schedule indicated Staff 3 normally worked 5 days a week. On [DATE] at 10:25 A.M., the ADON provided the Medical Exemption form for the Staff 1. The form, dated [DATE], indicated, Requested accommodation: COVID 19 vaccine exemption .tested on [DATE] for COVID 19 Antibodies positive. Already had COVID ,d+[DATE]. The form did not specify the type of vaccine or a valid clinical reason for the exemption. On [DATE] at 9:50 A.M., the Administrator provided the timesheet for Staff 1. Staff 1 worked 6 days in nursing from [DATE]-[DATE]. The Administrator indicated Staff 1 normally worked 5 days a week. On [DATE] at 9:30 A.M., the Human Resources (HR) Director provided the Medical Exemption form for Staff 2, dated [DATE]. The form indicated, Patient has medical reasons not to obtain the COVID vaccine .Risk of miscarriage. The form did not specify which COVID vaccine the staff member could not take. On [DATE] at 9:50 A.M., the Administrator provided the working schedule for Staff 2. Staff 2 worked 2 days from [DATE]-[DATE]. The schedule indicated Staff 2 normally worked ,d+[DATE] days a week. On [DATE] at 10:20 A.M., during an interview with the HR director, she indicated that the spreadsheet does not include booster vaccination information. Staff are supposed to inform her when they get a booster, and then a copy is made of their card and put in their employee files. That would be the only way the facility would know of booster information. On [DATE] at 2:20 P.M., the HR director provided the current facility policy, Vaccination of Facility Staff, dated [DATE]. The policy included: All staff shall be fully vaccinated for COVID-19 except where exemption or temporary exemption from this requirement has been approved .Employees without approved exemptions shall provide they have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series .prior to providing any care, treatment, or other services for the facility and/or its residents .Requests for medical exemption are to be submitted to the Administrator and/or Human Resource department and shall be approved for recognized clinical contraindications to COVID-19 vaccines if supporting documentation .contains information specifying which of the authorized COVID-19 vaccines are clinically contraindicated .based on the recognized clinical contraindications The immediate jeopardy that began on [DATE] was removed on [DATE] when the facility started an audit of the vaccination status of all employees; placed staff on leave who were not in compliance with CMS/CDC guidelines; revised the facility's medical exemption form; and began a new system to track staff vaccinations, including boosters, but the noncompliance remained at the lower scope and severity level of pattern of no actual harm with potential for more than minimal harm that is not immediate jeopardy because the facility was continuing their monitoring, tracking, and implementation for new employees. 3.,d+[DATE](a)

Based on observation, interview, and record review, the facility failed to ensure a cognitively impaired resident, who had exhibited exit seeking behavior, did not elope from the facility, placing the resident at risk for severe adverse outcome, for 1 of 3 residents reviewed for elopement risk. (Resident B) The immediate jeopardy began on 1/31/22 when Resident B eloped from the facility by climbing out of a window, and drove a car unaccompanied into a nearby town. The Administrator was notified of the immediate jeopardy at 12:15 P.M. on 2/23/22. The immediate jeopardy was removed on 2/24/22, but noncompliance remained at the lower scope and severity level of isolated of no actual harm with potential for more than minimal harm that is not immediate jeopardy. · Findings include: On 2/16/22 at 11:20 A.M., the clinical record of Resident B was reviewed. Diagnoses included, but were not limited to, dementia with behavioral disturbance. The resident was admitted to the facility on [DATE]. Nurses notes included the following notations: 11/11/21 at 9:57 P.M.: admitted to facility today, to dementia secured unit .Alert to self, unaware of surroundings .Ambulates without difficulties .continues to pace hallway of secured unit, to continue to monitor. 11/15/21 at 11:31 P.M.: Res [resident] continues to wander throughout the secured unit with confusion .Res approaches nrsg [nursing] with repetitive verbalizations with exit seeking behaviors as evidenced by attempting to exit and follow staff out of doors 11/18/21 at 12:56 A.M.: Res continues to approach staff frequently when awake with exit seeking verbalizations and behaviors as witnessed by staff observing res requesting staff and others to phone his family to pick him up . Res will approach exit doors and attempt to push locked secured doors. Res is gently guided with 1:1 and re-assurance offering res activities-food-fluids. Res is receptive to meds-snacks and fluids at this time. Res continues with repetitive actions throughout the evening, res resting at this time. An admission Minimum Data Set (MDS) assessment, dated 11/18/21, indicated Resident B had a severely impaired cognition, had behaviors of rejecting care and wandering 1-3 days, and required supervision of set up help to walk in room and hall. Nurses notes continued: 11/19/2021 at 9:08 P.M.: Res requires repeated re-approaches to successfully manage res to accept meds to control current health needs. Res is witnessed frequently with hurried gait wandering without purpose with at times verbalizing exit seeking behaviors with attempts to follow others out and approaching staff to let him leave Now. Res is easily distracted with poor retention . 11/29/21 at 11:39 A.M.: Resident has increased agitation today. Resident moving objects that do not belong to him into his room. When explaining to resident that these are his items and he can not move them due to it being unsafe, resident becomes very agitated and aggressive with staff and other residents. Resident also refusing shower and getting aggressive with staff when trying to attempt, re approaching is unsuccessful. 12/2/21 at 2:21 A.M.: Res up fully dressed will not allow staff to assist with changing clothing, res observed pacing back and forth unaware of his surroundings as he wanders without purpose, mood is rude towards staff with attempts to provide reminders and assist with care-res frequently rejects food when up wandering throughout the night res is offered alternate activities and exhibits poor retention and exits away. Res denies pain yells at staff when attempting assessments. 12/11/21 at 10:57 P.M.: Res wandering throughout the unit without purpose rejecting food and fluids. Res is alert to self and unaware of his surroundings, res frequently exits away from staff with staff attempting to assist. Res becomes easily annoyed and verbally agitated with staff with attempts to assist. 12/21/21 at 11:39 A.M.: .Up ad lib pacing the hallways w/o [without[ purpose 1/12/22 at 3:38 P.M.: Social Services .IDT [interdisciplinary team] behavior review. [Resident B] has been noted to have several behaviors. Accusing of others, threatening others, rummaging, exit seeking, hoarding, refusing care. Redirection and 1:1 did not change behavior .Meds are to be reviewed. Sees [psychology service] for psych services. Will continue to monitor. A Psychology note, dated 1/13/22, indicated, Staff report resident has behaviors of aggression, cursing and threatening others .Resident is positive for dementia related behaviors such as confusion, wandering A care plan regarding wandering behaviors or exit seeking was not observed in the clinical record. An elopement assessment, dated 1/31/22, indicated the resident had a history of or an attempted elopement while at home, had a history of or attempted leaving the facility without informing staff, verbally expressed the desire to go home, wandered aimlessly, and was at risk for elopement. Clinical Suggestions included: Monitor location frequently. Utilize exit alarm(s). Encourage participation in recreational activities, and Notify staff of wandering risk. An elopement assessment prior to 1/31/22 was not observed in the clinical record. An Indiana State Department of Health incident indicated, Incident Date: 01/31/2022. Incident Time: 11:30 AM .[Resident B] was noted to be missing during regular rounding by staff. An immediate search of the facility and grounds did not locate him .Resident was subsequently located at a private home and returned to the facility .Investigation: .Police findings confirmed that this resident was located at at community private home and he had driven a car to this home by himself .Resident continued to exit-seek after he returned to the facility. He kept attempting to climb out facility windows .In addition, during an inspection of the facility grounds, a window screen was noted to be removed from the window and lying on the ground outside. Due to these observations, the facility believes it is likely that the resident climbed that [sic] window On 2/16/22 at 12:15 P.M., Resident B was observed in his room on the Memory Care unit, pacing. He stated, Are you going to get me out of here now? Resident B had an irritated look on his face. CNA 1 indicated at that time that she was not working when Resident B climbed out of the window. She indicated she heard he pushed out the screen of a fell ow Resident's room window, climbed out, and then took a car. CNA 1 indicated Resident B was pretty sharp. CNA 2 indicated at that time that she was not working when Resident B climbed out of the window. She indicated that she heard the incident occurred when staff were busy setting up the COVID unit. Since that incident, a screw had been placed in all of the windows, so that windows could only be opened approximately 6 inches. On 2/16/22 at 2:40 P.M., the Administrator was interviewed. She indicated a staff member informed her they couldn't find Resident B. Staff searched for the resident on and off the grounds. The police were called. The resident had popped out a window screen, and climbed out of the window. He found a staff member's car which still had the keys in the ignition, and took the car to a nearby residence. The police found the resident, and returned him to the facility. The resident was out of the facility for approximately 1 1/2 hours. During their investigation, it was discovered that the Maintenance Supervisor had removed screws in the windows, which would have prevented the windows from opening fully. The Maintenance Supervisor thought the screws were a fire safely hazard. At that time, the Administrator indicated there had not been a care plan regarding the resident's behaviors until the first day of the survey, 2/16/22. The corporate nurse had created a care plan regarding the resident's behaviors on 2/16/22. On 2/23/22 at 11:30 A.M., the Administrator indicated she was unsure when the screws had been removed, but it would have been sometime prior to November 2021. On 2/21/22 at 1:45 P.M., the Social Services Director (SSD) was interviewed. She indicated she created the behavior plans on the memory care unit. The facility started having monthly behavior meetings in January. CNAs can fill out a behavior sheet, and nurses can document a behavior note. She will run a report at the end of the month. If there are behaviors, the staff can discuss interventions and the physician can make medication recommendations. On 2/24/22 at 9:10 A.M., the Administrator provided the current Guide to Elopement Risk Assessment, dated 2/23/22. The policy included: 1. Upon admission, a resident's potential for elopement will be determined by risk factors which may include, but not limited to: History of wandering/elopement, New Admission with adjustment difficulties or desire to return home, Dementia .Restlessness, irritability, Acute or chronic confusion/disorientation, Anxiety. 2. Risk factors will be identified and documented in the appropriate assessments. 3. Interventions will be developed and entered on the interim plan of care for all residents identified as being an elopement risk. 4. Communication of residents' risk and interventions will be completed daily Inservice education and elopement drills will be conducted quarterly on different shifts to strive to assure that all staff is aware of what steps to take to prevent or interrupt elopement attempts. The Administrator indicated at that time that there had not been an elopement risk policy prior to that date. The immediate jeopardy that began on 1/31/22 was removed on 2/24/22 when the facility ensured that the screws were in place in all of the windows, elopement assessments were completed and care plans initiated, staff were inserviced on elopement drills, but the noncompliance remained at the lower scope and severity level of isolated of no actual harm with potential for more than minimal harm that is not immediate jeopardy because the facility will continue to monitor residents for any change in emotional, mental, or behavioral conditions and environmental safety risks. Elopement drills continue on all shifts. This Federal tag relates to Complaints IN 378 and IN 320. 3.1-45(a)(2)

Based on interview, observation, and record review, the facility failed to ensure residents who were admitted with no pressure ulcers, did not develop pressure ulcers for 1 of 2 residents reviewed for pressure ulcers. This deficient practice resulted in a resident developing an unstageable pressure injury to the right heel. (Resident G) Findings include: On 11/1/17 at 2:22 p.m., RN 1 indicated Resident G had a Stage I to the heel. On 11/2/17 at 2:25 p.m., Resident G was observed in bed with heels elevated. She indicated she had to come back to bed because her butt and her hip were giving her fits and she was going to rest now. On 11/6/17 at 9:26 a.m., the record for Resident G was reviewed. [DIAGNOSES REDACTED]. BIMS (Brief interview for mental status) score of 15 per the Quarterly MDS (Minimum data set) dated 10/12/17, which indicated no cognitive impairment. The MDS further indicated Resident G had a Stage I (intact skin with non blanchable redness) pressure ulcer. Telephone Order dated 10/25/17 indicated: clean R (right) heel open area with [MEDICATION NAME], cover with dry dressing, apply heel protector boot R (right foot). Telephone Order dated 11/2/17 indicated: D/C heel protector boot to R (right) foot. On 11/6/17 at 9:26 a.m., during care observed for Resident G, a dressing dated 11/6/17 was observed on Resident G's right heel. A red to maroon colored, linear area extending from webbing of great toe and second toe to below the pad of the great toe approximately the width of a pencil. CNA 4 indicated this was new and the nurse needed to see it. LPN 5 entered the room and indicated the area appeared to be a bruise, possibly from hitting her wheelchair. LPN 5 then obtained measurements and indicated she would notify the doctor. She further indicated Resident G could get out of bed. The heels up device was observed to have dried red to white substance under the right heel area. The resident indicated she had been in bed all weekend due to her heel. On 11/6/17 at 10:01 a.m., wound tracking records for Resident G which indicated a Stage I to right heel, dated 8/20/17, measurements were length 3.1 cm by width 2.0 cm by depth 0. The weekly measurements continued till 10/11/17. The record lacked documentation for the week of 10/18/17. The next measurement dated 10/22/17 measuring length 1.0 cm by width 1.0 cm by depth 0 with wound bed red, drainage small amount, serous, no odor, color pink/red. Documentation in the progress notes dated 10/22/17 at 10:15 a.m., indicated the reddened area was 5 cm x 2 cm with a small open area measuring 1 cm x 1 cm and the doctor was notified. On 11/7/17 at 8:56 a.m., LPN 1 was observed to remove the dressing to Resident G's right heel. The wound was irregular in shape with color varying from white to dark brown in areas, with the appearance of a ruptured blister over the right heel with open area red, approximately dime size. LPN 1 indicated she would guess the stage to be a 2 or a 3, and further indicated the wound was larger than when she measured it last Wednesday. The MDS Coordinator entered the room to obtain measurements and indicated the wound was length 5.2 cm by width 5.4 cm and did not indicate depth. She further indicated the wound was unstageable (Known but not stageable due to coverage of wound bed by slough and/or eschar). Resident G questioned the nurse as to what caused the wound. LPN 1 indicated she thought it was because her heel was resting on the mattress. Resident G denied pain to the right heel. On 11/7/17 at 10:02 a.m., Resident G was observed sitting in her wheelchair with her heels resting on foot pedals, wearing white socks. On 11/7/17 at 2:50 p.m., Resident G was observed to be sitting in her wheelchair with heels resting on the foot pedals of the wheelchair, wearing white socks. On 11/8/17 at 11:07 a.m., the DON indicated they utilized a heels up device while in bed. The MDS Coordinator indicated they had discontinued the pressure relieving boot because it was vinyl lined and was macerating the wound. No other interventions were implemented to protect or promote healing to the right heel while up in the wheelchair. On 11/8/17 at 1:12 p.m., the MDS Coordinator provided the current facility policy Pressure Ulcer - Clinical Protocol, undated. The Policy indicated, but was not limited to: The interdisciplinary team will review and modify the care plan as appropriate when wounds are not healing as anticipated or new wounds develop despite existing interventions. The Federal tag relates to Complaint IN 973. 3.1-40(a)(1) 3.1-40(a)(2)