Every finding on record at Northview Health and Living

Based on interview and record review, the facility failed to ensure residents received care in a respectful and dignified manner for 1 of 4 residents reviewed for resident rights. (Residents B and D) Findings include:1. Resident B's clinical record was reviewed on 6/22/26 at 12:00 p.m. Diagnoses included left hip osteoarthritis and cerebral infarction without residual effects.A quarterly Minimal Data Set (MDS) assessment, dated 6/16/26, indicated the resident was impaired in both lower extremities; required substantial to maximum assistance for toilet hygiene, toilet transfers, dressing upper and lower body. The resident was moderately cognitively impaired.During an interview on 6/22/26 at 12:37 p.m., Resident B indicated, on the evening of 6/19/26, CNA 1 was assisting her off the toilet. The resident indicated she had a system for transferring from the toilet to her wheelchair. The resident requested to have the wheelchair positioned in a specific position. CNA 1 did not position the wheelchair as requested and repeatedly asked the resident if she needed her assistance. The resident indicated she was beginning to experience pain from sitting on the toilet, became upset and turned the call light on to request someone else to come to assist her. CNA 1 then turned the call light off and took the call light away from the resident. The resident indicated she felt like the CNA was attempting to make her beg for assistance. The resident became frustrated and attempted to get into the wheelchair and fell into the wheelchair. CNA 1 took the resident back to her bed and wanted to pick the resident up and put her into the bed. The resident told her no. The resident threw herself back into bed. The resident told CNA 1 she was going to report her for the way she had treated her and did not want the CNA to provide her care any longer. Resident B indicated she was afraid of CNA 1 and did not want her to return to her room. The resident indicated she reported the incident to an unidentified staff member when her evening meal tray was brought to her. During the interview, the resident became tearful.During an interview, on 6/22/26 at 12:55 p.m., CNA 2 indicated, on the morning of 6/20/26, Resident B was crying and complained about how CNA 1 had treated her the previous evening. The resident asked CNA 2 to call the resident's family member.During an interview, on 6/22/26 at 1:15 p.m., Resident B's family member indicated, on the morning of 6/20/26, the resident called her and indicated she was very upset related to an incident that had happened the night before. Resident B told her CNA 1 tried to make her beg to get off the toilet.2. Resident D's clinical record was reviewed on 6/23/26 at 11:38 a.m. Diagnoses included cerebral infarction and legal blindness.A significant change MDS assessment, dated 4/7/26, indicated the resident required supervision/touch assistance for eating and dependent for all other activities of daily living. The resident was cognitively intact.During an interview, on 6/22/26 at 12:54 p.m., Resident D indicated, on 6/19/25 during the evening meal, CNA 1 came into their room to assist her with the meal. The resident indicated she was blind, but she liked to feed herself when she could. The resident always requested a towel to cover her chest so she would not get messy while eating. CNA 1 told the resident she would clean her up if she got messy and did not honor her request for the towel. The resident also indicated she and her roommate liked to keep the privacy curtain open unless they were receiving personal care, such as changing clothing. CNA 1 repeatedly closed the curtain even after they requested it to remain open. The resident indicated she did not want to receive care from CNA 1 in the future.During an interview on 6/22/26 at 12:55 p.m., CNA 2 indicated Resident D required assistance with meals and always requested a towel to cover her chest during meals. CNA 2 indicated that both Resident D and her roommate had complained to her about how they were treated by CNA 1.During an interview, on 6/23/26 at 9:06 a.m., LPN 7 indicated, on 6/19/26 at approximately 5:00 p.m., she entered Resident B's room. The resident was tearful and appeared to be upset. The resident indicated CNA 1 had mistreated her. LPN 7 called the Administrator. The Administrator returned to the facility and spoke with the resident. LPN 7 heard yelling coming from another resident room and investigated. Resident D and her roommate were upset about how Resident D was treated by CNA 1. Resident D had requested a towel to cover her chest while she was eating, and CNA 1 did not provide the towel.CNA 1 was unavailable for interview during the survey.A current facility policy, dated 5/9/23 and last revised 10/24, titled Abuse, Neglect and Exploitation was provided by the DON on 6/22/26 at 12:41 p.m. The policy indicated the following: .Policy: It is the policy of this facility to provide protection s for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.This citation relates to Intake 3050008.410 Indiana Administrative Code 3.1-27(a)(3)

Based on observation, interview, and record review, the facility failed to protect a resident's right to be free from verbal abuse from staff for 1 of 3 residents reviewed for abuse, as evidenced by CNA 3 placing soap and/or hot sauce in the resident's mouth and expressing threats of washing the resident's mouth out with soap. (Resident B) Using the reasonable person concept, it can be determined that Resident B experienced psychosocial harm from these abusive actions and threats of corporal punishment taking place in her home (the nursing facility). Findings include: During a confidential interview, one of Resident B's representatives indicated they had been contacted by the facility regarding an allegation of Resident B being abused by an employee. They were informed a staff member put either soap, hot sauce, or both on their loved one's mouth (Resident B). Their loved one was cognitively impaired. Resident B did not remember the event. Prior to her cognitive impairment, she would have considered soap or hot sauce in the mouth to be abusive. She might have believed she had done something wrong and was being punished. In her day, she may have thought some people put soap in a child's mouth for lying or cursing. Resident B probably believed she was being punished. During an interview on 3/2/26 at 2:28 p.m., LPN 4 indicated she did not remember the time, but the event occurred after supper (around 6:40 p.m.) on 1/26/26. She heard Resident B ask for water and she was given water. At this time, she first heard rumors or gossip about CNA 3 giving, or threatening to give, Resident B hot sauce and /or soap. She asked the nursing staff to figure out what was going on and she went on break. She did not remove CNA 3 from providing patient care. The gossip or rumors felt odd, and she thought the Administrator should be aware. She notified her at about 9:40 p.m. She should have notified the Administrator immediately when she heard gossip of or a rumor of abuse.During an interview on 3/2/26 at 2:22 p.m. CNA 7 indicated she did not see anything on the night of 1/26/26. She did hear CNA 3 say the words wash your mouth out with soap or something like that. She saw CNA 3 with soap, water, and a toothbrush. CNA 5 told her that CNA 3 had been talking about putting hot sauce in Resident B's mouth. She believed LPN 4 and LPN 6 were aware of all that was happening and were taking care of it. She should have reported to the Administrator as soon as she heard of an allegation of abuse.During an interview on 3/2/26 at 1:53 p.m., the Administrator indicated she was notified on 1/26/26 at approximately 10:00 p.m. that CNA 3 may have put hot sauce and/or soap in Resident B's mouth and may have threatened to wash her mouth out with soap. When she was called, she had been asleep. She woke up when they called her and was somewhat confused, therefore she didn't report the allegation to the IDOH until 1/27/26. She should have reported the allegation to IDOH sooner. She did not realize she needed to give a detailed report of the allegation when reporting to the state. She had called the non-emergency police to report the allegation, but they hadn't called her back. She instructed LPN 4 when she called to remove CNA 3 from the floor and send her home pending investigation. The time lapse from the event until staff notified her resulted in CNA 3 working on the floor with resident contact for approximately three hours after staff first became aware of an allegation of abuse. Review of a facility security video with the Administrator present, on 3/2/26 at 3:15 p.m., indicated the following: The time stamp at the top of the video indicated 1/26/26 at 6:31 p.m. Resident B was seated in a wheelchair in the lounge facing the hallway and the nurse's station. CNA 3 walked by the resident several times and spoke to her on multiple occasions. The resident spit on the floor at least two times. (The video had no sound, and the conversation could not be heard.) At 6:58 p.m., CNA 3 entered the frame standing at a cart across from where the resident was seated. The CNA was carrying a cup, a toothbrush, and a white squeeze bottle container. The CNA wet the brush and distributed some liquid from the white squeeze bottle on the toothbrush. She then approached the resident carrying all three items. She held the toothbrush towards the resident. Her stance then blocked the view of the camera. She could be seen moving her arm back and forth. She then turned and walked back toward the cart or counter. She sat all items on the counter. She picked up the squeeze bottle and walked back to the resident. Once again, she stood in a manner that all activity was not visible. She turned the bottle upside down and appeared to squeeze out liquid on the resident's hand or finger. She then turned and walked back to the counter and collected all items and walked away. The resident spit toward the floor after this encounter.During an observation on 3/3/26 at 10:28 a.m., accompanied by the Administrator, the supply cabinet was observed. The cabinet contained a small white squirt bottle of soap, consistent with the bottle seen on the video. A Facility Self-Reported Incident, submitted to the Indiana Department of Health (IDOH) on 1/27/26, indicated the following: The staff overheard CNA 3 make inappropriate comments to Resident B and intervened and directed the CNA to cease interaction with resident. The employee was removed from schedule pending investigation. The nurse practitioner (NP), Director of Nursing (DON), Administrator, and family were notified. The witnessing staff was identified as LPN 4.Review of the facility investigation, provided by the Administrator on 3/2/26 at 4:08 p.m., indicated the following:A (misdated), 1/25/26, written statement (event occurred 1/26/26), indicated LPN 4 overheard rumors of concern on 1/26/26 after the evening meal. She told staff to figure out what was going on. CNA 3 remained on the floor, interacting with residents. LPN 4 went on break. She came back from break and asked some questions and investigated the rumors and reported the allegation to the Administrator at 9:40 p.m. At this time, she reported (9:40 p.m.) LPN 4 was informed to send CNA 3 home pending investigation. CNA 3 had remained on the floor approximately three hours after the time this nurse became aware of the allegations. CNA 5's, 1/26/26, written statement indicated she witnessed CNA 3 take a red packet from a cart or drawer and put it in Resident B's mouth. CNA 3 told her she had put hot sauce in the resident's mouth for spitting. She heard CNA 3 threatened to wash the resident's mouth out with soap for spitting. She later saw the CNA with soap. She did not report her concerns to anyone. A 1/27/26, written statement from LPN 6 indicated she heard CNA 3 threaten to wash Resident B's mouth out with soap. She told the CNA to stop saying that. She did not intervene, report the threat to the Administrator, or remove CNA 3 from the floor. CNA 3 continued working on the floor until approximately 9:40 p.m., when LPN 4 called the Administrator. CNA 5 was unavailable for interview during the survey dates.CNA 3 was unavailable for interview during the survey dates.LPN 6 was unavailable for interview during the survey dates.Resident B's clinical record was reviewed on 2/26/26 at 3:30 p.m. Current diagnoses included gastroesophageal reflux disease, depression, anxiety, and vascular dementia. A current, 1/11/21, care plan problem/need indicated the resident had depression.A current, 6/9/22, care plan problem/need indicated the resident gastrointestinal upset due to gastroesophageal reflux disease and a history of nausea and vomiting. An approach to this problem was to remind me to avoid foods or beverages that tend to irritate esophageal lining such as alcohol, caffeine, chocolate, acidic or spicy foods.A 2/18/26 Psychiatric Progress Note indicated Resident B required behavioral follow-up for behavioral symptoms associated with dementia. She experienced periods of altered lucidity. She also had a history of delusions. A 1/21/26 Psychiatric Progress Note indicated the resident was seen due to depression and vascular dementia. She was a poor historian due to cognitive/psychiatric impairment. A current, 10/22, facility policy, titled Reporting od Reasonable Suspicion of a Crime: Reporting, Investigating/Preventing/ Correcting Any Alleged Violation , which was provided by the Administrator via email on 3/2/26 at 5:15 p.m. indicated: To also ensure all alleged violations involving abuse, neglect. Exploitation, or mistreatment .are reported immediately.Administrator or designee will notify the appropriate agencies immediately.all employees.obligation to report any suspicion of a crime. A current, 10/22, facility policy, titled Abuse Neglect and Exploitation , which was provided by the Administrator via email on 3/2/26 at 5:15 p.m. indicated: .The resident has the right to be free from mistreatment, neglect.Resident must not be subject to abuse by anyone. Report allegations of suspected abuse, neglect, or exploitation immediately to the Administrator. Other officials in accordance with state law.Physical abuse includes but not limited to.controlling behaviors through corporal punishment. This tag relates to Intake 2727362. 410 IAC (Indiana Administrative Code) 16.2-3.1 - 27(a)

Based on observation, interview and record review, the facility failed to ensure menus were prepared in advance, signed and approved by a Registered Dietitian, had portion size guidance, and ensured nutritional adequacy. This deficient practice had the potential to impact 72 of 72 residents who ate meals prepared in the facility kitchen.Findings include:During an interview on 3/4/26 at 11:09 a.m., the DON indicated when the survey began the facility had a census of 74. Of the 74 residents, 72 consumed food by mouth and ate meals prepared in the facility kitchen.During an observation of the puree process, on 3/2/26 at 10:33 a.m., [NAME] 11 began to puree the entree of baked potato bar or topped baked potatoes. He had a steam table pan with peeled baked potatoes. The potatoes had flecks of orange and brown on them. During an interview, at the time of the observation, [NAME] 11 indicated the orange flecks were cheese and the brown flecks were bacon. He indicated he did not measure the cheese or bacon to ensure each resident received an adequate amount of protein. He indicated he sprinkled some cheese and bacon on top of the pan with 10 potatoes. He then demonstrated an amount of less than 1/2 cup cheese and 1/4 cup bacon for the entire pan of potatoes. He indicated he did not have a recipe, menu, or portion size guidance for the baked potato entree. While he pureed the food, he added tap water from the sink as a thinning liquid. He did not add a liquid which contained nutritive value. He indicated he would serve the same portion size of potatoes as were served when baked potatoes were a side dish.During an interview, on 3/2/26 at 10:40 a.m., the Dietary Manager indicated the facility did not have a menu, a recipe, or portion sized guidance for the potato bar meal. She additionally indicated the RD (Registered Dietitian) had not approved the menu being served. The menu had changed to offer more variety, and the residents liked the potatoes. She did not know how much cheese, bacon, sour cream, and butter pats should be served to equal the protein needed for the meal. There was no other source of protein served to balance the resident's needs. Even though the RD had not reviewed and approved the menu, she was preparing to serve the item as listed on the Menu document. She indicated the cook should have used liquid canned cheese sauce instead of shredded cheese. Unless a resident chose an alternate food item, every diet type was to receive a topped baked potato. During an observation at this time, the canned queso cheese she had planned to use to top the potatoes was noted to have a label which indicated there was zero protein per serving. During an interview on 3/3/26 at 1:25 p.m., the RD indicated she had not developed the menu for the potato bar/topped potato entree, nor approved the menu for the meal before food preparation was begun on 3/2/26. An untitled, undated, facility document was provided via email by the Administrator on 3/2/26 at 11:40 a.m., following the observation and interview regarding protein, indicating the facility had then requested a review of the topped baked potato meal to be served on 3/2/26. The RD added two ounces of ham as protein to ensure nutritional adequacy.An untitled and undated facility document was provided via email by the Administrator on 2/25/26 at 9:07 a.m., and indicated lunch on Monday, 3/2/26, was menued to be baked potato bar, broccoli, cheese sauce, sour cream, bacon bits, Mandarin oranges, chives, and margarine. No additional protein was listed. The menu was not signed as approved by the RD.A current, 5/5/25, facility policy titled Menus and Adequate Nutrition, was provided by the Administrator via email on 3/3/26 at 3:06 p.m., and indicated the following: .The facility will ensure that menus meet the nutritional needs of the resident in accordance with established national guidelines. 8. The facility's dietitian or other clinically qualified nutrition professional will review all menus for nutritional adequacy and approve the menus. 410 IAC (Indiana Administrative Code) 16.2-3.1 - (20)(i)(1)410 IAC 16.2-3.1 - (20)(i)(3)410 IAC 16.2-3.1 - (20)(i)(4)

Based on interview, and record review, the facility failed to ensure staff reported allegations of abuse immediately to the Administrator or designee and failed to ensure self-reported incidents were communicated to the Indiana Department of Health in a manner that was accurate, detailed, complete, and thorough to allow the department to evaluate the need to advocate for the health and safety of the facility residents for 1 of 3 self- reported incidents reviewed. (Resident B) Findings include:Findings include: A Facility Self-Reported Incident, submitted to the Indiana Department of Health (IDOH) on 1/27/26, indicated the following: The staff overheard CNA 3 make inappropriate comments to Resident B and intervened and directed the CNA to cease interaction with resident. The employee was removed from schedule pending investigation. The nurse practitioner (NP), Director of Nursing (DON), Administrator, and family were notified. The witnessing staff was identified as LPN 4.During a confidential interview, one of Resident B's representatives indicated they had been contacted by the facility regarding an allegation of Resident B being abused by an employee. They were informed a staff member put either soap, hot sauce, or both on their loved one's mouth (Resident B). Their loved one was cognitively impaired. Resident B did not remember the event. Prior to her cognitive impairment, she would have considered soap or hot sauce in the mouth to be abusive. She might have believed she had done something wrong and was being punished. In her day, she may have thought some people put soap in a child's mouth for lying or cursing. Resident B probably believed she was being punished. Neither the original incident report, nor the five day follow up, indicated the resident had been threatened by the staff member or that there was an allegation of placing soap and/or hot sauce in the resident's mouth.During an interview on 3/2/26 at 2:28 p.m., LPN 4 indicated she did not remember the time, but the event occurred after supper (around 6:40 p.m.) on 1/26/26. She heard Resident B ask for water and she was given water. At this time, she first heard rumors or gossip about CNA 3 giving, or threatening to give, Resident B hot sauce and /or soap. The gossip or rumors felt odd, and she thought the Administrator should be aware. She notified her at about 9:40 p.m. She should have notified the Administrator immediately when she heard gossip of or a rumor of abuse.During an interview on 3/2/26 at 2:22 p.m. CNA 7 indicated she did not see anything on the night of 1/26/26. She did hear CNA 3 say the words wash your mouth out with soap or something like that. She saw CNA 3 with soap, water, and a toothbrush. CNA 5 told her that CNA 3 had been talking about putting hot sauce in Resident B's mouth. She believed LPN 4 and LPN 6 were aware of all that was happening and were taking care of it. She should have reported to the Administrator as soon as she heard of an allegation of abuse.During an interview on 3/2/26 at 1:53 p.m., the Administrator indicated she was notified on 1/26/26 at approximately 10:00 p.m. that CNA 3 may have put hot sauce and/or soap in Resident B's mouth and may have threatened to wash her mouth out with soap. When she was called, she had been asleep. She woke up when they called her and was somewhat confused, therefore she didn't report the allegation to the IDOH until 1/27/26. She should have reported the allegation to IDOH sooner. She did not realize she needed to give a detailed report of the allegation when reporting to the state. CNA 5 was unavailable for interview during the survey dates.CNA 3 was unavailable for interview during the survey dates.LPN 6 was unavailable for interview during the survey dates.Resident B's clinical record was reviewed on 2/26/26 at 3:30 p.m. Current diagnoses included gastroesophageal reflux disease, depression, anxiety, and vascular dementia. A current, 10/22, facility policy, titled Reporting of Reasonable Suspicion of a Crime: Reporting, Investigating/Preventing/ Correcting Any Alleged Violation , provided by the Administrator via email on 3/2/26 at 5:15 p.m., indicated: To also ensure all alleged violations involving abuse, neglect. Exploitation, or mistreatment .are reported immediately.Administrator or designee will notify the appropriate agencies immediately.all employees.obligation to report any suspicion of a crime. A current, 10/22, facility policy, titled Abuse Neglect and Exploitation , provided by the Administrator via email on 3/2/26 at 5:15 p.m. indicated: .The resident has the right to be free from mistreatment, neglect.Resident must not be subject to abuse by anyone. Report allegations of suspected abuse, neglect, or exploitation immediately to the Administrator. Other officials in accordance with state law.Physical abuse includes but not limited to.controlling behaviors through corporal punishment. Cross reference F600. This tag relates to Intake 2727362. 410 IAC (Indiana Administrative Code) 16.2-3.1-28(c)

Based on interview and record review, the facility failed to protect residents from the potential for further abuse when an alleged perpetrator (CNA 3) was permitted to continue providing care to residents for approximately three hours following an allegation of abuse. (Resident B)Findings include: Findings include: During a confidential interview, one of Resident B's representatives indicated they had been contacted by the facility regarding an allegation of Resident B being abused by an employee. They were informed a staff member put either soap, hot sauce, or both on their loved one's mouth (Resident B). Their loved one was cognitively impaired. Resident B did not remember the event. Prior to her cognitive impairment, she would have considered soap or hot sauce in the mouth to be abusive. She might have believed she had done something wrong and was being punished. In her day, she may have thought some people put soap in a child's mouth for lying or cursing. Resident B probably believed she was being punished. During an interview on 3/2/26 at 2:28 p.m., LPN 4 indicated she did not remember the time, but the event occurred after supper (around 6:40 p.m.) on 1/26/26. She heard Resident B ask for water and she was given water. At this time, she first heard rumors or gossip about CNA 3 giving, or threatening to give, Resident B hot sauce and /or soap. She asked the nursing staff to figure out what was going on and she went on break. She did not remove CNA 3 from providing patient care. The gossip or rumors felt odd, and she thought the Administrator should be aware. She notified her at about 9:40 p.m. She should have notified the Administrator immediately when she heard gossip of or a rumor of abuse.During an interview on 3/2/26 at 2:22 p.m. CNA 7 indicated she did not see anything on the night of 1/26/26. She did hear CNA 3 say the words wash your mouth out with soap or something like that. She saw CNA 3 with soap, water, and a toothbrush. CNA 5 told her that CNA 3 had been talking about putting hot sauce in Resident B's mouth. She believed LPN 4 and LPN 6 were aware of all that was happening and were taking care of it. She should have reported to the Administrator as soon as she heard of an allegation of abuse.During an interview on 3/2/26 at 1:53 p.m., the Administrator indicated she was notified on 1/26/26 at approximately 10:00 p.m. that CNA 3 may have put hot sauce and/or soap in Resident B's mouth and may have threatened to wash her mouth out with soap. She instructed LPN 4 when she called to remove CNA 3 from the floor and send her home pending investigation. The time lapse from the event until staff notified her resulted in CNA 3 working on the floor with resident contact for approximately three hours after staff first became aware of an allegation of abuse. Review of the facility investigation, provided by the Administrator on 3/2/26 at 4:08 p.m., indicated the following:A (misdated), 1/25/26, written statement (event occurred 1/26/26), indicated LPN 4 overheard rumors of concern on 1/26/26 after the evening meal. She told staff to figure out what was going on. CNA 3 remained on the floor, interacting with residents. LPN 4 went on break. She came back from break and asked some questions and investigated the rumors and reported the allegation to the Administrator at 9:40 p.m. At this time, she reported (9:40 p.m.) LPN 4 was informed to send CNA 3 home pending investigation. CNA 3 had remained on the floor approximately three hours after the time this nurse became aware of the allegations. CNA 5's, 1/26/26, written statement indicated she witnessed CNA 3 take a red packet from a cart or drawer and put it in Resident B's mouth. CNA 3 told her she had put hot sauce in the resident's mouth for spitting. She heard CNA 3 threatened to wash the resident's mouth out with soap for spitting. She later saw the CNA with soap. She did not report her concerns to anyone. A 1/27/26, written statement from LPN 6 indicated she heard CNA 3 threaten to wash Resident B's mouth out with soap. She told the CNA to stop saying that. She did not intervene, report the threat to the Administrator, or remove CNA 3 from the floor. CNA 3 continued working on the floor until approximately 9:40 p.m., when LPN 4 called the Administrator. CNA 5 was unavailable for interview during the survey dates.CNA 3 was unavailable for interview during the survey dates.LPN 6 was unavailable for interview during the survey dates.Resident B's clinical record was reviewed on 2/26/26 at 3:30 p.m. Current diagnoses included gastroesophageal reflux disease, depression, anxiety, and vascular dementia. A current, 1/11/21, care plan problem/need indicated the resident had depression.A current, 10/22, facility policy, titled Reporting of Reasonable Suspicion of a Crime: Reporting, Investigating/Preventing/ Correcting Any Alleged Violation, provided by the Administrator via email on 3/2/26 at 5:15 p.m. indicated: To also ensure all alleged violations involving abuse, neglect. Exploitation, or mistreatment .are reported immediately.Administrator or designee will notify the appropriate agencies immediately.all employees.obligation to report any suspicion of a crime. A current, 10/22, facility policy, titled Abuse Neglect and Exploitation, provided by the Administrator via email on 3/2/26 at 5:15 p.m. indicated: .The resident has the right to be free from mistreatment, neglect.Resident must not be subject to abuse by anyone. Report allegations of suspected abuse, neglect, or exploitation immediately to the Administrator. Other officials in accordance with state law.Physical abuse includes but not limited to.controlling behaviors through corporal punishment. Cross reference F600.Cross reference F609.This tag relates to Intake 2727362.410 IAC (Indiana Administrative Code) 16.2-3.1-28(d)

Based on interview and record review, the facility failed to provide residents and/or their representatives with written notice of transfer/discharge and bed hold policy for 3 of 4 residents reviewed for hospitalizations. (Residents 77, 69, and 7)Finding includes: 1.Resident 7's clinical record was reviewed on 3/2/26 at 10:18 a.m. Diagnoses included chronic obstructive pulmonary disease (COPD), Parkinson's disease, and hypertension. A 1/23/26, discharge MDS assessment indicated the resident discharged with a return anticipated. A 1/23/26, progress note indicated Resident 7 complained of pain in the left knee and hip related to a previous fall. A new order to send the resident to the emergency room was obtained. The clinical record lacked indication the resident and/or representative was provided with a copy of the transfer/discharge form and bed hold policy. Review of notice of transfer/discharge forms and bed hold policy, dated 1/23/26, provided by the RN Clinical Support on 3/3/26 at 3:49 p.m., indicated the resident was discharged to the hospital. The documents did not indicate the resident or resident's representative were provided with the notices. The forms lacked documentation regarding who received the paperwork. 2.Resident 69's clinical record was reviewed on 3/2/26 at 1:20 p.m. Diagnoses included right sided hemiplegia (paralysis) and hemiparesis (weakness). A 9/23/25, progress note indicated Resident 69 was unable to follow commands, unable to speak, or track with his eyes. A new order to send the resident to the emergency room was obtained. A 10/2/25, progress note indicated Resident 69 was unable to answer questions correctly. A new order to send the resident to the emergency room was obtained. A 12/25/25, progress note indicated Resident 69 had altered mental status and the resident's wife requested the emergency room transfer. The clinical record lacked indication the resident and/or representative was provided with a copy of the transfer/discharge form and bed hold policy for any of the transfers. Review of notice of transfer/discharge forms and bed hold policy, dated 12/25/25, 10/2/25, and 9/23/25, provided by the RN Corporate Consultant on 3/3/26 at 3:49 p.m., indicated the resident was discharged to the hospital. The documents did not indicate the resident or resident's representative were provided with the notices. The forms lacked documentation regarding who received the paperwork. 3.Resident 77's record was reviewed on 3/4/26 at 9:56 a.m. Diagnoses included dementia and hypertension. A 12/21/25, progress note indicated the resident was in respiratory distress and was transported to a local hospital by emergency services. The family and administrator were notified. A 12/21/25 online e-Interact transfer form lacked notice of discharge or bed hold policy. The clinical record lacked indication the resident and/or representative was provided with a copy of the transfer/discharge form and bed hold policy. During an interview, on 3/3/26 at 3:19 p.m., RN 9 indicated, when sending a resident to the emergency room, she would print out resident specific documents such as the face sheet, orders, and code status. She would ensure the resident specific documents and report were provided to the Emergency Medical Technicians (EMTs). During an interview, on 3/3/26 at 3:23 p.m., LPN 10 indicated when sending a resident to the emergency room she would print out resident specific documents such as the face sheet, orders, progress notes, and code status. She would also provide a copy of the facility bed hold policy. She would ensure the resident specific documents and report were provided to EMTs. During an interview, on 3/3/26 at 3:26 p.m., the DON indicated when a resident was sent to the emergency room, the nurse would complete the online e-Interact form and print out resident specific documents such as the face sheet, medication lists, and provide a copy of the facility bed hold policy. The staff provided these documents to the EMTs to take to the hospital. During an interview, on 3/4/26 at 10:10 a.m., the DON indicated the resident information packet, transfer/discharge form, and bed hold policy should be provided to the resident if they were alert and oriented. If the resident was not alert and oriented, then the facility should contact the resident's representative and give them the transfer/discharge forms and bed hold policy. The staff should document in the clinical record who received these documents. During an interview on 3/4/26 at 11:56 a.m., the DON indicated she was unable to locate Resident 77's transfer/discharge forms and bed hold policy. A current facility policy, titled, Transfer and Discharge (Including AMA), implemented 5/15/25, and provided by the Administrator on 3/4/26 at 11:42 a.m., indicated the following: .3. The facility's transfer/discharge notice will be provided to the resident and resident's representative in a language and manner in which they understand.4. Generally, the notice must be provided at least 30 days prior to a transfer or discharge of the resident.10 Emergency Transfers to Acute Care.d. The original copies of the transfer form and Advance Directive will accompany the resident. Copies will be retained in the medical record.g. Provide a notice of transfer and the facility's bed hold notice policy to the resident and representative as indicated. 410 IAC (Indiana Administrative Code) 16.2-3.1-12(a)(6)(A)(i)

Based on record review and interview, the facility failed to ensure a resident was permitted to exercise their right to determine their own treatment by denying transfer to an emergency room for reported pain. (Resident 69)Findings include:Resident 69's clinical record was reviewed on 3/2/26 at 1:20 p.m. Diagnoses included right sided hemiplegia (paralysis) and hemiparesis (weakness), calculus of kidney (kidney stones), urine retention, and presence of ureteral stents.Current physician orders include oxycodone (a narcotic medication) 5 milligrams (mg) by mouth every 4 hours as needed (PRN) for mild to moderate pain and acetaminophen (an analgesic pain reliever) 500 mg by mouth every 8 hours PRN for pain.A 9/4/25, admission, Minimum Data Set (MDS) assessment indicated the resident was cognitively intact.A 10/2/25 at 3:31 a.m., progress note indicated Resident 69 reported back pain and requested his pain medication. The resident's narcotic pain medication had been provided at 12:36 a.m., and another dose was not available yet. The resident's analgesic pain reliever was offered instead. Resident 69 indicated he wanted to go to the hospital for his back pain. The nurse contacted the on-call provider and explained the situation. The resident was unable to provide additional details about the back pain. The on-call provider and nurse reviewed Resident 69's diagnosis to try and determine the cause of the back pain and why he would want to be sent to the emergency room. They could not find any diagnosis that would suggest going to the hospital was appropriate. The on-call provider advised the nurse that they did not send residents to the hospital for just back pain alone. The nurse should monitor him for relief from the acetaminophen and provide his PRN narcotic as soon as available.A 10/2/25 at 4:37 p.m., progress note indicated the resident's lab results returned with elevated white blood cells. Upon entering the resident's room, he could not answer questions correctly. His blood pressure was 165/93 millimeters of mercury (mmHg), and his pulse was 135 beats per minute (bpm). The nurse practitioner (NP) was contacted and an order to send the resident to the emergency room was obtained.A 10/2/25, hospital lab report, provided by the DON on 3/3/26 at 3:49 p.m., indicated the residents' white blood cell count was elevated. The diagnosis attached to the lab report indicated the resident had sepsis (a life-threatening, emergency response to infection) without acute organ dysfunction, due to an unknown organism.A 10/7/25, hospital discharge summary indicated the resident was admitted with acute encephalopathy (broad term for any disease or dysfunction altering brain function) and had pseudomonas aeruginosa (a bacteria) in his urine.During an interview, on 3/3/26 at 3:19 p.m., RN 9 indicated if a resident requested to be sent out to the emergency room for pain, she would contact the physician to obtain an order. If a physician refused to provide an order to send the resident to the emergency room, she would speak with the resident again and see if they still wanted to be sent out. If the resident still wanted to be sent out to the hospital, she should follow the facility procedure to send the resident out as requested. All residents have the right to be sent to the emergency room/ hospital as they requested.During an interview, on 3/3/26 at 3:23 p.m., LPN 10 indicated if a resident requested to be sent out to the hospital or emergency room for pain, she would contact the physician to obtain an order. If the physician refused to send the resident out to the hospital, she would speak with the resident again and suggest alternative interventions and/or medications. If the resident still requested to be sent to the emergency room, she would follow the facility procedure to send the resident out. The residents have the right to request they be sent to the emergency room for evaluation and treatment.During an interview, on 3/3/26 at 3:26 p.m., the DON indicated if a resident requested to be sent to the hospital for pain, the staff would contact the physician and obtain an order to send the resident out. If the physician refused to provide an order to send the resident out, they would re-address the situation with the resident. If the resident still wished to be sent out for evaluation and/or treatment, then the staff would follow the facility procedure to send a resident to the emergency room/hospital. The residents have the right to be sent out to the hospital. The DON indicated she had never had a physician refuse to send a resident to the emergency room. Resident 69 should have been sent out to the hospital when he requested this on the morning of 10/2/25.A current undated facility policy, titled, Know Your Rights under Federal Nursing Home Regulations, provided by the RN Corporate Consultant on 3/3/26 at 3:44 p.m., indicated the following: You have the right to a dignified existence, self-determination, and communication with and access to the persons and services inside and outside the facility. You have the right to be informed, and participate in, your treatment. This includes the right to: . Participate in the development and implementation of your person-centered plan of care.Be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option you prefer. Request, refuse, and/or discontinue treatment. You have the right to and the facility must promote and facilitate self-determination through support of resident choice, including: The right to choose activities, schedules.healthcare, and providers of health care services consistent with your interest, assessments, plan of care and other applicable provisions of this part.410 IAC (Indiana Administrative Code) 16.2-3.1-3(a)410 IAC (Indiana Administrative Code) 16.2-3.1-3(n)(3)

Based on interview and record review, the facility failed to ensure nursing staff competently administered medication when admission orders were not clarified for 1 of 4 at risk residents with the potential of causing adverse effects. (RN 1 and Resident E)Findings include:Resident E's clinical record was reviewed on 12/30/25 at 2:27 p.m. Diagnoses included displaced fracture of base of neck of right femur, Parkinson's Disease, anxiety disorder, restless leg syndrome, conversion disorder with seizures or convulsions, and COVID-19. The most current admission MDS (Minimal Data Set) assessment, dated 12/15/25, indicated the resident was dependent for toilet hygiene; required maximum assistance for personal hygiene and dependent to maximum assistance for repositioning and bed mobility. A current care plan, dated 12/26/25, indicated the resident had Parkinson's Disease. Interventions included, give medications as ordered by the physician. Monitor/document side effects and effectiveness. A current activity of daily living care plan, dated 12/26/25, indicated the resident required substantial/maximum assistance for toileting, bed mobility, and transfers. Interventions included 1-2 staff participation to reposition and turn in bed, 1 staff participation with personal hygiene and oral care, 1 staff participation to use toilet, and 2 staff participation with transfers. Hospital discharge orders, dated 12/4/25, indicated the following orders: 1. carbidopa-levodopa (anti-Parkinson's agent) immediate release) 25-100 mg, 1.5 tablets by mouth, give 1.5 tablets in the morning, around noon, in the evening, and at bedtime 2. carbidopa-levodopa ER (anti-Parkinson's agent extended release) 50-200 mg, give 1 tablet in the morning, around noon, in the evening and at bedtime. Hospital discharge orders, dated 12/26/25, indicated the following orders: 1. carbidopa-levodopa 25-100 mg, 1.5 tablets give 1.5 tablets in the morning, around noon, in the evening, and at bedtime 2. carbidopa-levodopa ER 50-200 mg. give 1 tablet in the morning, around noon, and 2 tablets at bedtime as needed. A Nurse Practitioner (NP) progress note, dated 12/28/25 at 2:03 p.m., indicated the resident had no changes in chronic Parkinson's symptoms and remained on a high dose of carbidopa-levodopa per neurologist to be followed with neurologist direction. The note also listed carbidopa-levodopa 25-100 mg, 1.5 tablets to be given 4 times a day and carbidopa-levodopa ER tablet Extended Release 50-200 mg to be given every 6 hours as needed.Review of the December 2025 Medication Administration Record indicated Resident E had not received any carbidopa-levodopa ER since facility re-admission on [DATE]. During an interview on 12/30/25 at 10:16 a.m., Pharmacist 2 indicated it was highly unusual for carbidopa-levodopa ER to have been ordered to be taken as needed. Extended-release medications were usually given as routine for long term effect. Regular dose medications would have been given as needed for immediate effect. The order should have been questioned and clarified. During an interview on 12/20/25 at 10:45 a.m., the NP indicated they had been unaware the carbidopa-levodopa ER had been ordered for as needed use. It was believed the orders may have been transcribed incorrectly. However, after clarifying the hospital discharge order, it was determined the order should have been clarified.During an interview on 12/30/35 at 3:29 p.m., Resident E's neurologist office's nurse indicated the last communication the office had with the facility was on 12/10/25 with RN 1. During that communication, on 12/10/25, the facility was advised to continue giving Resident E both carbidopa-levodopa and extended-release carbidopa-levodopa. The order was clarified as carbidopa-levodopa ER 50-200 mg 4 times daily- upon waking, late morning, late afternoon and in the evening and carbidopa-levodopa 25-100 mg 4 times daily - upon waking, late morning, late afternoon and in the evening. Both carbidopa-levodopa ER 25-100 and carbidopa-levodopa 1.5 tablets were to be given together. There had been no communication between neurology office and the facility since 12/10/25. During an interview on 12/30/25 at 3:45 p.m., RN 1 indicated she audited orders from the hospital websites. RN 1 intended to clarify the carbidopa-levodopa orders with the Nurse Practitioner (NP) due to the amount confusion with the carbidopa-levodopa orders during the last admission. RN 1 indicated the orders should have been clarified. During an interview on 12/31/25 at 9:15 a.m., LPN 4 indicated any unclear or questionable order should have been clarified with the NP. The NP would usually order to hold the medication until they could review the order. The NP was in the facility at least three times a week. During an interview on 12/31/25 at 11:27 a.m., both the DON and ADON indicated Resident E's admission orders on 12/26/25 should have been clarified. During an interview on 12/31/25 at 12:51 p.m., Resident E's neurologist indicated the neurologist office had not had any communication with the facility since 12/10/25. The neurologist indicated Resident E had been taking carbidopa-levodopa in both regular and extended release form at the same time routinely for the past 1-2 years. Due to issues with the electronic record between the hospitals and the neurologist office, the neurologist had not been aware the resident was re-admitted to the facility and was unaware the medication order had been changed. The neurologist indicated the resident had experienced a recent decrease in mobility and the medication was under revision due to resent significant weigh loss. The neurologist indicated the situation was not ideal and the facility should have reached out for clarification of the order. The original order should be resumed, and the facility should communicate with the neurology office. A review of the job description titled Charge Nurse was provided by the DON on 12/31/25 at 9:48 a.m. and signed by RN 1 on 5/10/25. The job description indicated the following: . SPECIAL SKILLS AND ABILITIES REQUIRED: .4. Communicate effectively with physicians and pharmacies regarding resident needs and necessary orders.5. Knowledgeable of facility policies in order to assure compliance.A Nurse Orientation Checklist was provided by the DON on 12/31/ at 9:48 a.m. The checklist was signed by RN 1 on 5/14/25. The checklist indicated RN 1 was checked off on admission/discharge procedures, resident clinical record/electron heath records, medication and treatment charting, transcription of orders and admission procedures.A current undated policy, titled Medication Reconciliation was provided by the DON on 12/31/25 at 6:48 a.m. The policy indicated the following: . Definitions: Medication reconciliation refers to the process of verifying that the resident's current medication list matches the physician's order for the purpose of providing the correct medications to the resident at all points throughout his or her stay.Policy Explanation and Compliance Guidelines:1. Medication reconciliation involves collaboration with the resident/representative and multiple disciplines, including admission liaisons, licensed nurses, physicians, and pharmacy staff.4. admission Processes:a. Verify resident identifiers on the information received.b. Compare orders to hospital records, etc. Obtain clarification orders as needed. This citation is related to Intake 2681141. 3.1-14(i)

Based on observation, interview, and record review, the facility failed to ensure a resident's dignity was maintained during dining by providing assistance with their meal. (Resident 49) Findings include: During a dining observation on 2/21/25 at 12:32 p.m., Resident 49 struggled to get food on her fork. She held the fork upside down and tried to get a bite of a cookie. She attempted to take a bite, and tried again as there was no food on the fork. At 12:46 p.m., CNA 9 asked the resident if she was okay. The resident nodded yes, and continued to unsuccessfully try to get food on her fork. The rest of her food was uneaten and out of her reach. At 12:49 p.m., CNA 9 helped her turn the utensil around and the resident was able to get a few bites of beans into her mouth. The plate with collard greens, fried potatoes, and cornbread remained out of Resident 49's reach. The resident coughed following a bite of beans and CNA 9 told her to take a drink. The drink was not within reach. The resident tried to reach the chocolate pudding, but it was out of reach. At 1:03 p.m., CNA 9 moved the pudding closer to the resident. The lunch plate remained out of the resident's reach. During an interview with CNA 9, on 2/21/25 at 1:11 p.m., she indicated she moved food closer to Resident 49 when it was necessary. She thought a divided plate might have been helpful because the resident had a tendency to eat one thing at a time. During an observation on 2/24/25 at 12:40 p.m., Resident 49 had her fork in the correct position and her lunch plate was within reach. Her drinks were out of reach. She held the fork just beneath her chin, not taking a bite. At 12:44 p.m., an unidentified staff member sat down and assisted her with her lunch. During an observation on 2/25/25 at 12:06 p.m., Resident 49 was sitting in a wheelchair alone at a dining table. At 12:39, her meal was delivered and a staff member cut up a baked sweet potato. Her drinks were not within reach. She repeatedly reached towards her plate, with no silverware in hand. She touched the food with her fingers, then withdraw her hand. At 12:43, she peeled off a piece of sweet potato skin, then tried to flick it off her finger. She tried to eat some of the potato with her finger, without success. She pointed at the sweet potato. At 12:45 p.m., she reached for her pudding, touched the bowl, then lowered her hand. At 12:46, LPN 7 offered a fork to the resident and helped her get a bite of the sweet potato. LPN 7 stood next to the resident, offered her a drink, and continued to assist her for approximately five minutes. LPN 7 remained standing throughout. At 12:51 p.m., LPN 7 ceased assisting her with her meal. Resident 49 made attempts to get food on her fork, dropped the fork, and was given a clean fork by LPN 7. The resident's attempts to get a bite of food were unsuccessful. At 12:54 p.m., CNA 9 gave the resident a drink and offered her a bite of food. At 12:56 p.m., CNA 9 returned to another resident to assisted with their lunch. Resident 49 continued to attempt to use the fork to eat her meal without success. During an interview with LPN 7, on 2/25/25 at 2:30 p.m., she indicated she wondered if Resident 49 was having trouble seeing. Usually, the resident fed herself, but was not doing well at lunch and seemed to be distracted. During an interview with the Assistant Director of Nursing (ADON), on 2/25/25 at 2:38 p.m., she indicated Resident 49 might have been experiencing a problem with depth perception. She was going to notify staff. During an interview with CNA 8, on 2/25/25 at 2:39 p.m., she indicated Resident 49's need for assistance had increased. The resident sometimes got her utensils confused and was a very slow eater. Sometimes, the staff took the resident's plate to her unit and she finished eating there. Resident 49's clinical record was reviewed on 2/24/25 at 2:45 p.m. Diagnoses included type 2 diabetes mellitus, hypertension, major depressive disorder, and unspecified dementia, unspecified severity, with anxiety. Current physician orders included health shake once daily at lunch for weight loss, fortified food program with meals, regular diet, regular texture, regular/thin consistency, as tolerated; caregivers may cut meats bite-sized (7/12/23). A 10/2/24, quarterly, Minimum Data Set (MDS) assessment indicated Resident 49 required partial to moderate assist for eating, including the ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal was placed before the resident. A 12/30/24 quarterly MDS assessment indicated the resident required substantial/maximal assist for eating - including the ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident. A current care plan for activities of daily living (ADL) self care performance deficit, initiated on 7/28/22, indicated the resident needed substantial to dependent assist for toileting, bed mobility, transfers, and set-up for eating and drinking, all related to weakness or debility. One goal of the ADL focus was the resident would feed herself at each meal through the next review date. Eating interventions included the resident will be able to hold cup, feed self, eat finger foods independently, and encourage the resident to participate to the fullest extent possible with each interaction. The care plan did not include revisions indicated by the 12/30/24 quarterly MDS assessment which identified the resident's need for substantial/maximal assist for eating. A current care plan, initiated 8/3/22, indicated the resident had a nutritional problem or potential for nutritional problems related to type 2 diabetes mellitus, dementia, hypertension, hypercholesterolemia, hypothyrodism, and a vitamin D deficiency. The resident required total assistance, and refused to eat. Meal intakes were inadequate to her nutritional needs and required supplementation. Interventions included maintenance of weight without significant changes through next review, monitor nutritionally related labs as needed/referred, obtain and evaluate weights as ordered/per policy and/or at minimum, monthly. Notify the physician, dietitian and family of any significant changes. Provide medications and adaptive equipment as ordered. A fortified food program was initiated on 6/17/24, as well as a daily health shake supplement. Monitor and record intake, and offer meal substitutions as needed. The care plan did not include revisions indicated by the 12/30/24 quarterly MDS assessment which identified the resident's need for substantial/maximal assist for eating. A current care plan for a restorative program, initiated on 10/17/22, for active range of motion to all extremities related to a risk for decline in strength and range of motion, post therapy, and dementia. Interventions included encouraging the resident to participate in exercise group and praise her efforts. Give directions slowly and repeat to ensure the resident understands. A restorative nursing program assessment, dated 2/19/25 at 4:21 p.m., indicated the resident was receiving active range of motion (ROM) therapy for bilateral upper extremities (BUD). The plan of care did not include receiving therapy for eating/dining. A 9/2024 facility policy, titled Care Plan Revisions Upon Status Change, provided by the ADON on 2/25/25 at 4:01 p.m., indicated the following: Policy Explanation and Compliance Guidelines: .2) Procedure for reviewing and revising the care plan when a resident experiences a status change: a) Upon identification of a change in status, the nurse will notify the MDS Coordinator, the physician, and the resident representative, if applicable. b) The MDS Coordinator and the Interdisciplinary Team will discuss the resident condition and collaborate on intervention options .d) The care plan will be updated with the new or modified interventions 3.1-35(d)(2)(B)

Based on record review and interview, the facility failed to provide notifications of discharges to the Long-Term Care Ombudsman for 2 of 4 residents reviewed for hospitalizations. (Resident 53 and 30) Findings include: 1. Resident 53's clinical record was reviewed on 2/21/25 at 11:48 a.m. Diagnoses included heart failure, change of fatty liver, generalized muscle weakness, unsteadiness on feet, and need for assistance with personal care. A discharge Minimum Data Set (MDS) assessment, dated 12/18/24, indicated the resident discharged with a return anticipated. A Nurse's note, dated 12/18/24 at 6:46 p.m., indicated the resident was transported to the hospital for evaluation due to lethargy. A Nurse's note, dated 12/28/24 at 3:52 p.m., indicated the resident returned from the hospital and was readmitted to the facility. 2. Resident 30's clinical record was reviewed on 2/24/25 at 2:58 p.m. Diagnoses included dementia, generalized muscle weakness, unsteadiness on feet, and need for assistance with personal care. A discharge MDS assessment, dated 1/12/25, indicated the resident discharged with a return anticipated. Review of a discharge transfer form, dated 1/12/24, indicated the resident was discharged to the hospital due to an elevated pulse, high fever, and lethargy. A Nurse's note, dated 1/12/25 at 12:32 p.m., indicated the resident was admitted to the hospital. An entry MDS assessment, dated 1/14/25, indicated the resident returned to the facility. During an interview on 2/25/25 at 10:15 a.m., the Social Services Director (SSD) indicated on the first Monday of each month she ran the Admission/Discharge report, saved it to the desktop, and utilized the Ombudsman link to submit the Ombudsman notifications for resident transfers and discharges. Once completed, she printed off confirmation and kept it in a binder. She ran the Discharge report again and indicated Resident 53 and Resident 30 were not on the discharge report utilized for the Ombudsman notifications. She was unaware of any other report she could have utilized. She believed the way Resident 53 and Resident 30 were placed in census prevented them from showing on the discharge report. The census was done by the admission Coordinator. During an interview on 2/25/25 at 10:27 a.m., the admission Coordinator indicated the Hospital Tracking Report should have been referenced to ensure other payer sources were accounted for in the discharge process. On 2/29/25 at 9:20 a.m., the ADON indicated a provided facility discharge report, dated from 12/1/24 to 12/31/24, was utilized by the facility for Ombudsman notification. The report lacked Residents 53 and 30's name and discharge information. A current facility document, undated, titled Notice of Discharge to Ombudsman, provided by the Administrator on 2/25/25 at 12:10 p.m., indicated the following: . Emergency Transfer . When a resident is temporarily transferred on an emergency basis to an acute care facility, a notice of transfer must be provided to the resident and resident representative as soon as practicable before the transfer. Copies of notices for emergency transfers must also still be sent to the ombudsman, but they may be sent when practicable, such as in a list of residents on a monthly basis 3.1-12(a)(6)(A)(iv)

Based on observation, interview, and record review, the facility failed to provide assistance and cuing with dining to maximize residents' current abilities for 2 of 2 residents reviewed for activities of daily living (ADLs). (Residents 49 and 223) Findings include: During a dining observation on 2/21/25 at 12:32 p.m., Resident 49 struggled to get food on her fork. She held the fork upside down and tried to get a bite of a cookie. She attempted to take a bite, and tried again as there was no food on the fork. At 12:46 p.m., CNA 9 asked the resident if she was okay. The resident nodded yes, and continued to unsuccessfully try to get food on her fork. The rest of her food was uneaten and out of her reach. At 12:49 p.m., CNA 9 helped her turn the utensil around and the resident was able to get a few bites of beans into her mouth. The plate with collard greens, fried potatoes, and cornbread remained out of Resident 49's reach. The resident coughed following a bite of beans and CNA 9 told her to take a drink. The drink was not within reach. The resident tried to reach the chocolate pudding, but it was out of reach. At 1:03 p.m., CNA 9 moved the pudding closer to the resident. The lunch plate remained out of the resident's reach. During an interview with CNA 9, on 2/21/25 at 1:11 p.m., she indicated she moved food closer to Resident 49 when it was necessary. She thought a divided plate might have been helpful because the resident had a tendency to eat one thing at a time. During an observation on 2/24/25 at 12:40 p.m., Resident 49 had her fork in the correct position and her lunch plate was within reach. Her drinks were out of reach. She held the fork just beneath her chin, not taking a bite. At 12:44 p.m., an unidentified staff member sat down and assisted her with her lunch. During an observation on 2/25/25 at 12:06 p.m., Resident 49 was sitting in a wheelchair alone at a dining table. At 12:39, her meal was delivered and a staff member cut up a baked sweet potato. Her drinks were not within reach. She repeatedly reached towards her plate, with no silverware in hand. She touched the food with her fingers, then withdraw her hand. At 12:43, she peeled off a piece of sweet potato skin, then tried to flick it off her finger. She tried to eat some of the potato with her finger, without success. She pointed at the sweet potato. At 12:45 p.m., she reached for her pudding, touched the bowl, then lowered her hand. At 12:46, LPN 7 offered a fork to the resident and helped her get a bite of the sweet potato. LPN 7 stood next to the resident, offered her a drink, and continued to assist her for approximately five minutes. LPN 7 remained standing throughout. At 12:51 p.m., LPN 7 ceased assisting her with her meal. Resident 49 made attempts to get food on her fork, dropped the fork, and was given a clean fork by LPN 7. The resident's attempts to get a bite of food were unsuccessful. At 12:54 p.m., CNA 9 gave the resident a drink and offered her a bite of food. At 12:56 p.m., CNA 9 returned to another resident to assisted with their lunch. Resident 49 continued to attempt to use the fork to eat her meal without success. During an interview with LPN 7, on 2/25/25 at 2:30 p.m., she indicated she wondered if Resident 49 was having trouble seeing. Usually, the resident fed herself, but was not doing well at lunch and seemed to be distracted. During an interview with the Assistant Director of Nursing (ADON), on 2/25/25 at 2:38 p.m., she indicated Resident 49 might have been experiencing a problem with depth perception. She was going to notify staff. During an interview with CNA 8, on 2/25/25 at 2:39 p.m., she indicated Resident 49's need for assistance had increased. The resident sometimes got her utensils confused and was a very slow eater. Sometimes, the staff took the resident's plate to her unit and she finished eating there. Resident 49's clinical record was reviewed on 2/24/25 at 2:45 p.m. Diagnoses included type 2 diabetes mellitus, hypertension, major depressive disorder, and unspecified dementia, unspecified severity, with anxiety. Current physician orders included health shake once daily at lunch for weight loss, fortified food program with meals, regular diet, regular texture, regular/thin consistency, as tolerated; caregivers may cut meats bite-sized (7/12/23). A 10/2/24, quarterly, Minimum Data Set (MDS) assessment indicated Resident 49 required partial to moderate assist for eating, including the ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal was placed before the resident. A 12/30/24 quarterly MDS assessment indicated the resident required substantial/maximal assist for eating - including the ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident. A current care plan for activities of daily living (ADL) self care performance deficit, initiated on 7/28/22, indicated the resident needed substantial to dependent assist for toileting, bed mobility, transfers, and set-up for eating and drinking, all related to weakness or debility. One goal of the ADL focus was the resident would feed herself at each meal through the next review date. Eating interventions included the resident will be able to hold cup, feed self, eat finger foods independently, and encourage the resident to participate to the fullest extent possible with each interaction. The care plan did not include revisions indicated by the 12/30/24 quarterly MDS assessment which identified the resident's need for substantial/maximal assist for eating. A current care plan, initiated 8/3/22, indicated the resident had a nutritional problem or potential for nutritional problems related to type 2 diabetes mellitus, dementia, hypertension, hypercholesterolemia, hypothyrodism, and a vitamin D deficiency. The resident required total assistance, and refused to eat. Meal intakes were inadequate to her nutritional needs and required supplementation. Interventions included maintenance of weight without significant changes through next review, monitor nutritionally related labs as needed/referred, obtain and evaluate weights as ordered/per policy and/or at minimum, monthly. Notify the physician, dietitian and family of any significant changes. Provide medications and adaptive equipment as ordered. A fortified food program was initiated on 6/17/24, as well as a daily health shake supplement. Monitor and record intake, and offer meal substitutions as needed. The care plan did not include revisions indicated by the 12/30/24 quarterly MDS assessment which identified the resident's need for substantial/maximal assist for eating. A current care plan for a restorative program, initiated on 10/17/22, for active range of motion to all extremities related to a risk for decline in strength and range of motion, post therapy, and dementia. Interventions included encouraging the resident to participate in exercise group and praise her efforts. Give directions slowly and repeat to ensure the resident understands. A restorative nursing program assessment, dated 2/19/25 at 4:21 p.m., indicated the resident was receiving active range of motion (ROM) therapy for bilateral upper extremities (BUD). The plan of care did not include receiving therapy for eating/dining. 2. Resident 223's clinical record was reviewed on 2/21/25 at 9:38 a.m. Diagnoses included benign prostatic hyperplasia without lower urinary tract symptoms, chronic kidney disease, anxiety disorder, dementia in other diseases classified elsewhere, unspecified severity, with mood disturbance, and type 2 diabetes mellitus. A 2/12/25 admission MDS assessment indicated the resident required extensive assistance with transfers, toileting, and eating/drinking. A current care plan for activity of daily living self-care performance deficit indicated he needed substantial/maximal assistance for toileting, bed mobility, transfers, and set-up/partial assistance for eating and drinking. The resident would feed himself 50% of each meal and staff would assist him when he could not feed himself. A progress note, dated 2/7/25 at 8:17 a.m., indicated the resident required maximum to dependent assistance with bed mobility, eating, toileting, and transfers. A progress note, dated 2/13/25 at 2:45 p.m., indicated the resident required minimum to moderate assistance on most tasks. During an observation on 2/21/25 at 10:41 a.m., Resident 223 lay flat in his bed. His breakfast tray sat on the bedside table with over half of the food remaining. During a dining observation on 2/24/25 at 12:44 p.m., Resident 223 drank some water from his lunch tray, but did not eat the food. He intermittently slept. No staff approached the resident to cue him or assist him with lunch. At 12:55 p.m., CNA 10 approached the resident and asked if he was ready to go. Seventy-five percent of the meal remained on the plate. The CNA did not ask him if he would like something else to eat before assisting him to the activities room. During an observation on 2/25/25 at 12:09 p.m., Resident 223 was assisted into the dining room by staff and provided a clothing protector. At 12:18 p.m., drinks were offered. At 12:29 p.m., the resident took a drink of milk and played with the napkin. At 12:34 p.m., his lunch plate was delivered and set-up. He took a bite of the sweet potato at 12:37 p.m. He struggled to get food on his fork. He looked around the room and leaned far over his plate to get a bite. At 12:49 p.m., his cauliflower was half-eaten, and two thirds of his sweet potato remained. There was no staff interaction with Resident 223 after his plate was delivered. During an interview with CNA 10 on 2/25/25 at 10:53 a.m., she indicated Resident 223 was often confused. A current facility policy, titled Activities of Daily Living, and provided by the ADON on 2/25/25 at 4:00 p.m., indicated the following: .Policy: Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility must provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrates that such diminution was unavoidable. The facility must provide care and services in accordance with regulations for the following activities of daily living .Dining - eating, including meals and snacks .A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition 3.1-38(a)(2)(D)

Based on record review and interview, the facility failed to implement a fall intervention to prevent further falls for 1 of 3 residents reviewed for falls. (Resident 53) Finding includes: Resident 53's clinical record was reviewed on 2/21/25 at 11:48 a.m. Diagnoses included heart failure, change of fatty liver, generalized muscle weakness, unsteadiness on feet, need for assistance with personal care, depression and anxiety. Current orders included clopidogrel bisulfate (anti-platelet) 75 milligrams (mg) 75 mg by mouth once daily, trazodone hydrochloride (insomnia) 50 mg administer 25 mg by mouth at bedtime, tramadol (opioid pain reliever) 50 mg by mouth every six hours as needed and metoprolol succinate (blood pressure and heart rate) extended release 50 mg by mouth twice a day, staff may use the mechanical lift for transfers with the assistance of two staff members (11/25/24), apply a pull tab alarm to the chair every shift (2/3/25), apply the off-loading boot to the resident's right heel every shift when he is in the wheelchair (2/20/25). An annual Minimum Data Set (MDS) assessment, dated 11/28/24, indicated the resident was cognitively intact. He had a functional limitation in range of motion in both lower extremities. The resident was dependent on staff assistance for toileting, bathing, transfers, dressing lower extremities, donning and doffing of footwear, and sit to stand mobility. He had two or more falls with no injury since his last assessment. A significant change MDS assessment, dated 1/13/25, indicated the resident had an altered level of consciousness that fluctuated. He used the wheelchair for mobility. The resident was dependent on staff assistance for eating, toileting, bathing, dressing, personal hygiene, transfers, repositioning, and donning and doffing of footwear. He did not have any falls since admission or his prior assessment. A current care plan for activities of daily living self-care performance deficit, dated 6/19/23, indicated the resident was dependent on staff assistance for toileting, bed mobility, and transfers. Interventions included the following: the resident required two staff participation with transfers and a mechanical lift (6/19/23), the resident required one to two staff participation with transfers (9/25/23), the resident required one to two staff participation with transfers, may use the mechanical lift (7/3/24), the resident required two staff participation with transfers and the mechanical lift (11/26/24). A current fall care plan, dated 8/14/23, indicated the resident had falls on 6/7/24, 10/2/24, 10/7/24, and 2/2/25. Interventions included the following: non-skid socks in place (10/28/23), chair alarm to wheelchair (initiated on 1/29/24 and removed on 11/20/24), two person assistance from staff for transfers (10/2/24), staff educated on the need to follow the care guides (10/8/24), and placed alarm in chair (2/3/25). An Interdisciplinary Team (IDT) note, dated 6/7/24 at 7:45 a.m., indicated the resident had a witnessed fall when a CNA attempted to transfer the resident from the bed to the wheelchair without the use of a gait belt. Socks and shoes were on the resident's feet at the time of the fall. The resident lost his balance, fell forward onto the floor, and hit his head on the floor, which resulted in a reddened area. The resident had participated in therapy due to weakness and decline in activities of daily living. The immediate intervention was staff education regarding gait belt assistance with all assisted transfers. A fall risk assessment, dated 6/7/24, indicated the resident was at high risk for falls. A nurse's note, dated 10/2/24 at 5:15 p.m., indicated the resident had a witnessed fall when he was assisted by a CNA to transfer from the bed to the wheelchair. The resident's knees buckled due to weakness and he was lowered to the floor. A gait belt was in use. The resident had his shoe on his left foot and the boot ordered to his other foot. No injuries were found during the assessment. A new order was received for the resident to have two staff member assistance. The resident representative, provider, and management were notified. An IDT note, dated 10/2/24 at 5:15 p.m., indicated the resident was on therapy case load for a decline in activities of daily living when the resident was lowered to the floor on 10/2/24 at 5:15 p.m. The IDT team agreed the resident required two staff member assistance. A fall risk assessment, dated 10/2/24, indicated the resident was at high risk for falls. A Nurse's note, dated 10/7/24 at 1:53 p.m., indicated the resident had a witnessed fall when he was assisted by a CNA to transfer from the wheelchair to the bed with a gait belt in use. The resident had a non-skid sock on his left foot and the right foot was bare. The resident became weak and was lowered to the floor during the transfer. No injuries were identified during the assessment. The immediate interventions included the CNA was re-educated to follow the CNA Care Guide. The resident representative and provider were notified. An IDT note, dated 10/7/24 at 1:30 p.m. indicated the resident was lowered to the floor on 10/7/24 by a CNA who attempt to transfer the resident from the wheelchair to the bed. The resident began to lean back while standing and the CNA eased the resident to the floor. When the nurse entered the room, the resident was upright on the floor parallel with the bed. His right foot was bare because the CNA removed the off-loading boot prior to the transfer. The CNA stood next to the resident with the gait belt grasped. The wheelchair was behind the resident with the brakes locked. The CNA was given re-education for failure to follow the CNA Care Guide that listed the resident as a two staff member transfer. The IDT agreed with the plan of care. A fall risk assessment, dated 10/7/24, indicated the resident was at high risk for falls. During an interview on 2/25/25 at 2:27 p.m., CNA 6 indicated Resident 53 required assistance from two staff members for transfers. The resident had fallen earlier this month on her shift. The resident was in his wheelchair when she went to lunch. Just as she returned from lunch, she found him on the floor when she went to answer a call light. He was on the floor in his room on his stomach and his wheelchair was beside him. No alarms were sounding when she found him on the floor. His non-skid socks were on his feet. She could not recall any other fall interventions in place when she found him on the floor. CNAs were required to use the CNA Care Guides and followed them for reference every shift. She had a CNA Care Guide in her pocket and provided a copy of the current CNA Care Guide from the Nurses station. Review of the CNA Care Guide on 2/25/25 at 2:29 p.m., indicated Resident 53 was a fall risk. In the Equipment Assist column, it indicated the resident used a wheelchair and mechanical lift. The form lacked how many staff were required to provide assistance for the resident's transfers. Four other residents were listed on the form with a mechanical lift and indicated two staff members were required to provide assistance for these residents. During an interview on 2/25/25, at 2:47 p.m., LPN 5 indicated Resident 53 had been a high fall risk for quite some time. She believed she was on duty when an aide lowered him to the floor back in October. She did not recall all of the details, but only one aide was present for the transfer during the fall. Education was provided to the aide who lowered the resident to the floor. She was unable to recall what fall interventions were in place when the resident was lowered to the floor on her shift in October. Around July/August of 2024, the resident required one to two person staff assistance. The resident had declined since then and required a mechanical lift and two person staff assistance now. When a resident had a fall, nursing was required to find the root cause of the fall and implement a fall intervention immediately, to prevent further falls. Once a fall intervention was implemented, it remained in place and should have been followed. The care plan interventions did not carry forward on the CNA Care Guides. Instead, management manually updated the CNA Care Guides. They tried to update them the date the intervention change occurred. During an interview on 2/25/25 at 3:02 p.m., the ADON indicated she was unable to provide copies of the CNA Care Guides for 10/2/24, 10/7/24, and 2/2/25, as the updates were saved in place of the previous dates. Once care plan interventions were developed, they should have been followed until they were discontinued. When the resident was lowered to the floor by one staff member on 10/2/24, the immediate fall intervention included two person assistance. On 10/7/24 the resident was lowered to the floor again by one staff member. The staff member was educated due to a failure to implement the fall intervention developed on 10/2/24 to prevent further falls. A current facility policy, dated 10/2017, titled Comprehensive Care Plans, provided by Unit Manager 11 on 2/25/25 at 4:15 p.m., indicated the following: Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality A current facility policy, dated 10/2017, titled Fall Prevention Program, provided by the ADON on 2/25/25 at 4:20 p.m., indicated the following: Policy: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Definitions: A fall is an event in which an individual unintentionally comes to rest on the ground, floor, or other level, but not as a result of an overwhelming external force . The event may be witnessed, reported, or presumed when a resident is found on the floor or ground, and can occur anywhere . Policy Explanation and Compliance Guidelines: . 3. The nurse will indicate . the resident's fall risk and initiate interventions 3.1-35(g)(1) 3.1-45(a)

Based on observation and interview, the facility failed to appropriately label and date medications for 3 of 5 carts reviewed for medication storage. (100 hall medication cart #1, 100 hall medication cart #2, and 100 hall respiratory cart) Findings include: During a medication storage observation on [DATE] at 10:13 a.m., accompanied by LPN 15, the 100 hall medication cart #1 had an opened and undated vial of insulin lispro. The vial was ,d+[DATE] full. LPN 15 indicated insulin should be labeled with an opened date. On [DATE] at 10:23 a.m., accompanied by QMA 13, the 100 hall medication cart #2 had an opened and undated insulin glargine (Quikpen) with 4 units remaining. QMA 13 indicated the insulin was supposed to be dated when opened. On [DATE] at 12:11 p.m., accompanied by QMA 13, the 100 hall respiratory cart was observed with the following: albuterol sulfate (bronchodilator) HFA inhaler with an expiration date of [DATE] lacked an open date; albuterol sulfate HFA inhaler with an expiration date of [DATE] lacked an open date; fluticasone/umeclidinium/vilanterol powder (inhaled medication) breath activated, 100 mcg/6.2 mcg/25 mcg, with an expiration date of ,d+[DATE] lacked an open date; albuterol sulfate HFA with an expiration date of [DATE] lacked an open date and was expired; ipratropium-albuterol (bronchodilator) solution 0XXX,d+[DATE].5 mg/3 mL, with an expiration date of [DATE] lacked an open date; albuterol 108 mcg/act HFA inhaler with an expiration date of [DATE] lacked an open date. QMA 13 indicated she dated inhalers when opened. She was not allowed to provide nebulizer treatments. During an interview with the Respiratory Therapist on [DATE], at 9:21 a.m., she indicated both inhalers and nebulizer ampules should have been dated when opened. Manufacturer expiration dates were on the packages. During an interview with Unit Manager 11, on [DATE] at 12:37 p.m., she indicated insulin, eye drops, and inhalers should be dated when opened. If staff found undated medications, they could ask other staff when the medication was opened. If unsuccessful, those medications should not have been used and staff should have disposed of them properly. If a medication was expired, it should have been appropriately disposed. Staff should have notified the pharmacy to update them on the status of any expired or undated, open medications. A current facility policy, titled Medication Administration - Labeling of Medication, was provided by the ADON on [DATE] at 10:30 a.m., and indicated the following: Policy - To ensure that the facility, in coordination with the licensed pharmacist, provide for accurate labeling to facilitate safe administration of medications and consideration of precautions in accordance with the currently accepted professional principles .3) Multi-dose medication vials/devices should be labeled with the date opened/accessed 3XXX,d+[DATE](o)

Based on observation, interview, and record review, the facility failed to post complete nurse staffing information daily for residents and visitors. This had the potential to affect 70 of 70 residents in the facility. Finding includes: During an observation on 2/19/25 at 4:00 p.m., the facility nurse staffing, dated 2/19/25, was posted on a bulletin board in the main hallway across from the dining room. The posting lacked the facility census for the day. During an observation on 2/20/25 at 2:55 p.m., the facility nurse staffing, dated 2/20/25, was posted on the bulletin board in the main hallway across from the dining room. The posting lacked the facility census for the day. Staffing, dated 2/20/25, was posted as follows for the individual shifts: First Shift: Registered Nurse - one at 8 hours Licensed Practical Nurse - three at 8 hours Qualified Medication Aide - two at 8 hours Certified Nurse Aide - nine at 7.5 hours Total Hours: 113.5 (inaccurate- totals 115.5) Second Shift: Registered Nurse - one at 4 hours Licensed Practical Nurse - three at 8 hours Qualified Medication Aide - two at 4 hours Certified Nurse Aide - eight at 7.5 hours Total Hours: 100 (inaccurate- totals 96) Third Shift: Registered Nurse - blank Licensed Practical Nurse - two at 8 hours, one at 4 hours Qualified Medication Aide - one at 8 hours Certified Nurse Aide- four at 7.5 hours Total Hours: 58 During an observation on 2/21/25 at 4:18 p.m., the facility nurse staffing, dated 2/20/25, remained posted on the bulletin board in the main hallway across from the dining room. The posting lacked the facility census. The nurse staffing hours worked and totals for the licensed nurses and certified aides were not updated for the current date and remained as listed above. During an interview on 2/21/25 at 4:31 p.m., the Business Office Manager indicated the staffing posting was still from 2/20/25. The Scheduler typically did the daily nurse staffing posting. It had not been updated for the current date because she was not working. She was unaware who was assigned to post the staffing in her absence. The daily nurse staffing was always posted in the same location each day, on the bulletin board across from the dining room, by her office. During an interview on 2/21/25 at 4:34 p.m., the Administrator indicated the nurse staffing should have been posted in the morning for the current day. The posting remained unchanged from the staffing posted on 2/20/25. The Scheduler was off work and the duties had not been reassigned to someone else. She indicated the staffing posted each day lacked the facility census on the form. A current facility policy, dated 10/2017, titled Nurse Staffing Posting Information, provided by the Administrator on 2/24/25 at 10:15 a.m., indicated the following: Policy: It is the policy of this facility to make nurse staffing information readily available in a readable format to residents, staff, and visitors at any given time. Policy Explanation and Compliance Guidelines: 1. The Nurse Staffing Sheet will be posted on a daily basis and will contain the following information: a. Facility name b. The current date c. Facility's current resident census d. The total number and actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: i. Registered Nurses ii. Licensed Practical Nurses/Licensed Vocational Nurses iii. Certified Nurse Aides 2. The facility will post the Nurse Staffing Sheet at the beginning of each shift. 3. The information posted will be: a. Presented in a clear and readable format. b. In a prominent place readily accessible to residents, staff, and visitors

Based on observation, interview, and record review, the facility failed to implement infection prevention strategies related to enhanced barrier precautions and medication administration for 2 of 4 residents reviewed for transmission-based precautions (Resident 23 and 56) and 1 of 4 residents observed for medication administration (Resident 23). Findings include: 1. During an interview, on 3/19/24 at 11:57 a.m., RN 11 indicated a resident in the building was in contact isolation for an acute case of Candida auris (a fungal infection that may cause severe illness and develop resistance to treatment). During an interview, on 3/20/24 at 10:04 a.m., Resident 56 indicated the staff sometimes did not put on gowns when assisting him with dressing and washing. During an observation, on 3/21/24 at 9:38 a.m., CNA 16 put on gloves, entered Resident 56's room, and answered the call light. She spoke with the resident's roommate then to the resident. She closed the door. She did not apply a gown. An orange sign with stop signs on the door titled Enhanced Barrier Precautions, indicated EVERYONE MUST: Clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Wear gloves and a gown for the following High- Contact Resident Care Activities. Dressing, Bathing/Showering, Transferring, Changing Linens, Providing Hygiene, Changing briefs or assisting with toileting, Device care or use: central line, urinary catheter, feeding tube, tracheostomy; Wound Care: any skin opening requiring a dressing. A yellow container, hung on the wall beside the resident's door, contained personal protective equipment (PPE). During an interview, on 3/21/24 at 9:45 a.m., CNA 16 indicated she assisted Resident 56 from his wheelchair to the bathroom and utilized a gait belt during the transfer. For enhanced barrier precautions (EBP), she would have put a gown on for his roommate because he had a wound she thought. She did not have to wear a gown for Resident 56. Because some of the residents were different, she asked what the residents needed when she received report. The resident's clinical record was reviewed on 3/22/24 at 9:45 a.m. Diagnoses included pressure-induced deep tissue damage of the right heel. Current physician orders included enhanced barrier precautions due to a wound (6/20/23). 2. During an observation, on 3/19/24 at 4:19 p.m., Resident 23 sat in her wheelchair in her room watching television. No signage was posted on her door. During an observation, on 3/20/24 at 11:22 a.m., the resident sat in her wheelchair. She had a bandage on her right lower leg. During an interview, at the same time, the resident indicated she had received seven stitches in her leg, and the nurses thought it was infected now. No signage was posted on her door. During an observation, on 3/21/24 at 10:39 a.m., the resident sat in her wheelchair in her room watching television. No signage was posted on her door. During an observation, on 3/21/24 at 3:02 p.m., the resident sat in her wheelchair in her room and looked at papers on her bedside table. An enhanced barrier precautions sign was posted on her door. A three-drawer chest was placed beside her door containing personal protective equipment. The resident's clinical record was reviewed on 3/22/24 at 11:49 a.m. Current physician orders included enhanced barrier precautions for wound (3/21/24). A progress note, dated 3/7/24 at 11:36 a.m., indicated the resident had surgical incision to lower extremities. Dressings were changed to the areas and a scant amount of serosanguineous (thin, pink, and watery fluid containing red blood cells) drainage was noted from both shins. A progress note, dated 3/13/24 at 9:47 a.m., indicated the treatment was performed on the resident's right lower leg. The old dressing contained sanguineous (bloody) drainage. A progress note, dated 3/15/24 at 9:43 a.m., indicated the right lower leg wound had a moderate amount of serosanguineous drainage. A progress note, dated 3/20/24 at 4:17 p.m., indicated a moderate amount of yellow/green drainage was noted from the right lower leg wound. The surgeon was notified, and the treatment was changed. During a wound observation, on 3/22/24 at 3:19 p.m., LPN 9 removed a dressing from resident's right lower leg. The wound center was brown. The edges of the wound had scant amount of active bleeding when the wet to dry dressing was removed. The wound was the size of a half dollar. During an interview, on 3/22/24 at 4:10 p.m., LPN 9 indicated the wound had gotten worse, prompting the surgeon to change the order on 3/20/24. During an interview, on 3/22/24 at 4:10 p.m., the ADON, who also served as the Infection Preventionist (IP), indicated the wound originally was red like a burn and was not open. When the wound began to worsen, a new treatment was received and that was when enhanced barrier precautions were initiated. She was unaware the resident had been having drainage from the wound days before the treatment was changed and the resident was put on EBP. A wound with drainage was open. People with wounds, g-tubes, catheters, colostomies, IVs, and urinary catheters should be in enhanced barrier precautions to protect the resident in which they provide direct care from getting any type of infection. PPE should be worn in EBP rooms when direct care was being provided for the site or reason the resident required EBP. The facility had been doing EBP a long time prior to having Candida auris in the building. EPB signage was placed on the doors of residents who required EPB and indicated the PPE that should be worn. During an interview, on 03/22/24 at 4:38 p.m., the ADON indicated the facility did not have a specific policy regarding enhanced barrier precautions. The facility followed the CDC guidelines regarding enhanced barrier precautions. A copy of the signage placed on the EBP rooms was provided on 3/22/24 at 4:41 p.m. by the ADON. 42685 3. Resident 23's clinical record was reviewed on 3/22/24 at 10:51 a.m. A physician order, dated 3/20/24, included Tobramycin (antibiotic eye drops) solution 0.3% - instill two drops in the left eye four times a day for infection. During a random medication administration observation on 3/22/24 at 9:07 p.m., LPN 17 opened the top drawer of the medication cart and took Resident 23's Tobramycin eye drop canister out of the drawer. It was stored in the top drawer of the Dogwood 1 Unit medication cart, in a compartment along with six other residents' eye drops. The canister was placed on the medication cart without a barrier. The eye drop bottle was not removed from the canister prior to entering the resident's room. After preparation of the all the resident's medications, LPN 17 performed alcohol based hand rub and donned a gown, gloves, and a mask. She picked up the eye drop canister with her gloved hands. During an interview on 3/22/24 at 9:25 a.m., LPN 17 indicated the resident was in enhanced barrier precautions due to wounds. The resident also had an infection in her left eye. During an observation on 3/22/24 from 9:31 a.m. to 9:35 a.m., LPN 17 entered the resident room with a cup of pills in the left hand and the closed canister in the right hand. She set the cup of pills onto the resident's meal tray, which was sitting on the edge of the overbed table. The overbed table was not cleaned upon entry to the room. The canister of eye drops was placed directly against the overbed table surface, in front of the resident, and without the use of a barrier. She removed the canister lid with her left hand and placed it upside down on the overbed table. After the resident took her pills, LPN 17 took the bottle of eye drops out of the canister with her right hand and removed the lid to the eye drop bottle with her left hand. She placed the lid right-side-up directly against the overbed table. Hand washing was not performed prior to administering the resident's eye drops and clean gloves were not donned. She used her left gloved hand to pull down the residents left bottom eye lid and used the right hand to instill the 2 drops. With her left hand she placed the cap back on the eye drop bottle without cleaning the lid. The bottle was placed back into the canister, gloves doffed, lid placed back on the canister, and the canister moved to the television stand without a barrier in the resident's room. LPN 17 washed her hands with soap and water, doffed her gown and mask, picked up the eye drop canister off of the resident's television stand, and exited the resident's room. Without cleaning the eye drop canister or performing hand hygiene, she unlocked the medication cart and placed the eye drop canister back into the top drawer compartment along with six other resident's eye drops. LPN 17 then locked the medication cart and walked towards the nurses' station. During an interview on 3/22/24 at 9:51 a.m., LPN 17 indicated she did not remove the eye drop bottle from the canister prior to entering the resident room. A barrier was not used in the resident's room on the overbed table prior to setting the canister and the lid directly against the contaminated surface. The canister for the eye drops nor the lid to the eye drop bottle was cleaned prior to placing it back on the eye drop bottle and into the medication cart where it shared a compartment in the top drawer along with six other resident's eye drops. This was an infection prevention and control concern due to possible contamination. During an interview on 3/22/24 at 4:11 p.m., the Infection Preventionist indicated during medication administration, a barrier should have been used on the resident's overbed table prior to setting a medication canister on the overbed table. The medication lid should have been cleaned prior to placing the lid back on the medication bottle and the canister should have been cleaned prior to placing it back into the medication cart with other resident's eye drops. During an interview on 3/25/24 at 6:20 p.m., the Corporate Nurse Consultant indicated 14 residents had medications stored in the Dogwood 1 Unit medication cart. The CDC website for implementation of PPE, last updated 7/12/22, accessed on 3/26/24 at 3:04 p.m. at https://www.cdc.gov/hai/pdfs/containment/PPE-Nursing-Homes-H.pdf., indicated .Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs . The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization . Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: Dressing, Bathing/showering, Transferring, Providing hygiene Changing linens, Changing briefs or assisting with toileting, Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator, Wound care: any skin opening requiring a dressing A current facility policy, dated 5/20/22, titled Ophthalmic Drop Administration, provided by the Infection Preventionist on 3/22/24 at 4:41 p.m., indicated the following: Policy: To establish guidelines for correctly administering ophthalmic drop medication(s) according to State and Federal regulations, manufacturer's guidelines and physician/prescriber order(s) . Procedure: . 2) Perform hand hygiene per facility policy . 5) Apply clean gloves . 9) Remove cap taking care to avoid touching dropper tip, place cap upright on barrier or clean, dry surface .20) Re-cap bottle after administration and discard barrier A current facility policy, dated 10/2017, titled Infection Control Program, provided by the DON on 3/19/24 at 12:30 p.m., indicated the following: Policy: The Infection Prevention and Control Program is based on the Individual Facility Assessment and follows the accepted National Standards. All staff engaged in direct patient care shall be instructed in correct techniques and be familiar with our facilities established infection control policies and procedures. The primary purpose of this policy is to prevent the spread of infections through identification of infectious agents requiring isolation. Policy Explanation and Compliance Guidelines: 1. Our Infection Preventionist serves as a consultant to our staff on infectious diseases, patient room placement, implementing of isolation precautions, staff and patient exposures, and epidemiological investigations of exposures of infectious diseases to patients, staff and outbreak investigations and education. 2. Our RNs and LPNs supervise our direct care staff in daily activities to: assure appropriate precautions/techniques are observed, assess the patient's isolation needs, initiate appropriate precautions in accordance with our established policies and current CDC infection Control Isolation Guidelines 3.1-18(b)(2) 3.1-18(l)

Based on observation, interview, and record review, the facility failed implement interventions to prevent the development of a pressure injury during a change in condition (Resident 56) and failed to assess and develop interventions to promote healing of pressure injuries (Resident 37) for 2 of 5 residents reviewed for pressure injuries. Findings include: 1. During an observation, on 3/20/24 at 9:49 a.m., Resident 56 was resting in his bed, with the head of the bed elevated. During an observation, on 3/20/24 at 10:04 a.m., the resident was lying in bed with heel protector boots on. The resident pointed to his right foot and indicated he had a bad area that turned into a hole. The resident's clinical record was reviewed on 3/22/24 at 9:45 a.m. Diagnoses included arteriosclerotic heart disease of the native coronary artery with unstable angina pectoris (thickening or hardening of the arteries where the heart does not get enough blood flow and oxygen), hypertensive heart disease with heart failure (heart disease developed over years of high blood pressure), type 2 diabetes mellitus, need for assistance with personal care, foot drop of right foot (difficulty lifting the front part of foot), and pressure-induced deep tissue damage of the right heel. Current physician orders included apply skin protectant wipes to both heels every shift (6/19/23), cleanse right heel with normal saline, pat dry. Apply house skin cream to right foot and heel. Apply skin protectant wipes to wound bed every shift and as needed for soilage or displacement (3/13/24), Pressure reducing/relieving, redistributing cushion to chair every shift (6/19/23), and pressure reducing/relieving, redistributing mattress to bed every shift (6/19/23), and heel protector boots (soft boots with a cushioned bottom that float heels off the surface of the mattress) to be worn at all times when resident is resting in bed every shift (11/20/23). A quarterly Minimum Data Set (MDS) assessment, completed on 11/16/23, indicated the resident was cognitively intact. He required substantial to maximal assistance with lower body dressing, putting on and taking off footwear, rolling left and right, moving from sitting to lying position, and moving from lying to sitting position. He was at risk for developing pressure injuries. A care plan for potential for skin impairment was initiated on 6/19/23. The interventions included pressure relieving/reducing mattress to protect the skin while in bed (6/19/23), encourage good hydration and nutrition (6/19/23), and treatments as ordered (6/19/23). A progress note, dated 11/17/23 at 5:18 p.m., indicated the resident was seen for an acute visit of Coronavirus infection (COVID-19), presence of heart failure, chronic kidney disease, diabetes mellitus, and hypertension. The resident's symptoms were beginning to minimize. He continued to receive oxygen support. A progress note, dated 11/20/23 at 2:26 p.m., indicated an area was found to the right heel. The area measured 4.4 centimeters (cm) length (L) by 5.8 cm width (W). The area was an intact fluid filled blister with a deep purple color. A care plan for skin impairment, initiated on 6/19/23, indicated the resident had a deep tissue injury to the right heel on 11/20/23. The interventions included heel protector boots as ordered (12/20/23). A consultant wound assessment performed on 12/6/23 indicated the area was a pressure injury, was unstageable, and measured 4.0 cm L by 6.0 cm W. The wound bed tissue composition was 100% eschar (dead tissue). A consultant wound assessment performed on 1/31/24 indicated the pressure injury was a stage 3 (a full skin thickness loss with depth to the subcutaneous tissue) and measured 3.0 cm L by 3.0 cm W. The wound bed tissue composition was 100 % epithelial (thin layer of tissue that covers structures in the body). A consultant wound assessment performed on 3/20/24 indicated the pressure injury was a stage 3 and measured 1.5 cm L by 1.4 cm W by less than 0.1 cm depth. The wound bed tissue composition was 100 % epithelial. During an observation, on 3/21/24 at 3:20 p.m., LPN 9 removed the resident's heel protector boots and dressing to the resident's right heel. The pressure injury was the size of the diameter of an AA battery. The wound bed was beefy red. During an interview, on 3/25/24 at 3:44 p.m., CNA 15 indicated when the resident had COVID-19 he continued to get up in his wheelchair. She did not remember him requiring more assistance at that time. During an interview, on 3/25/24 at 4:47 p.m., LPN 9 indicated the resident's pressure injury developed just prior to going to the hospital. He had COVID-19 at that time and was a little weaker. 2. During an observation and interview on 3/19/24 at 11:20 a.m., Resident 37 was asleep in bed, on a low air loss mattress, laying on his back. He indicated he had wounds on his buttocks that were painful. He had them for quite awhile, although he was uncertain of the length of time. He required staff's assistance for mobility in bed, transfers, and for toileting. Resident 37's clinical record was reviewed on 3/21/24 at 4:37 p.m. Diagnoses included, personal history of transient ischemic attack, stage 2 pressure ulcer of the right buttocks, stage two pressure ulcer of the left buttocks, iron deficiency anemia, and need for assistance with personal care. A current physician order, dated 1/5/24, indicated to apply barrier cream to both gluteal/buttocks, perineal area, coccyx/sacrum every shift for prevention and protection. A current physician order, dated 1/8/24, included a low air loss mattress for wounds. A physician order, dated 1/10/24, included Pro Stat (supplement for wound healing) 30 milliliters by mouth twice daily. A physician order, dated 1/10/24, indicated the following: cleanse the left and right buttock with normal saline, pat dry, apply Anasept gel (wound treatment), cover with a superabsorbent polymer (SAP) dressing, and change daily and as needed. This order was discontinued on 1/17/24. A physician order, dated 1/17/24, indicated the following: cleanse the left and right buttock with normal saline, pat dry, apply Anasept gel to the open wound bed, apply skin barrier cream to the remainder area, cover with a SAP dressing, and change daily and as needed. This order was discontinued on 1/24/24. A physician order, dated 1/24/24, indicated the following: cleanse the right buttock with normal saline, pat dry, apply Calcium Alginate (wound treatment used for partial and full thickness draining wounds) to open wound beds, cover with SAP dressing, and change daily and as needed. This order was discontinued on 2/7/24. A physician order, dated 2/7/24, indicated the follow: cleanse the right buttocks with normal saline, pat dry, apply Silvasorb (wound treatment) gel to open wound beds, cover with SAP dressing, and change daily and as needed. This order was discontinued on 2/14/24 A physician order, dated 2/14/24, indicated the following: cleanse the bilateral buttocks with normal saline, pat dry, apply Silvasorb gel to open wound beds, apply Xeroform (wound treatment) to bleeding areas, cover with an SAP dressing, and change daily and as needed. This order was discontinued on 2/28/24. A physician order, dated 2/28/24, indicated the following: cleanse the bilateral buttocks with normal saline, pat dry, apply Calcium Alginate AG, cover with an SAP dressing, and change daily and as needed. This order was discontinued on 3/13/24. A physician order, dated 3/13/24, indicated the following: cleanse the bilateral buttocks with normal saline, pat dry, apply calcium alginate, cover with an SAP dressing, and change daily and as needed. This order was discontinued on 3/20/24. A current physician order, dated 3/20/24, indicated the following: cleanse the bilateral buttocks with normal saline, pat dry, apply Silvasorb to the wounds, and cover with a foam dressing daily and as needed. A quarterly Minimum Data Set, dated dated [DATE], indicated the resident was cognitively intact. He required substantial/maximal assistance with toileting, bathing, and lower body dressing. He required moderate assistance for transfers and rolling left and right in bed. The resident had an indwelling catheter and frequent bowel incontinence. He was at risk for pressure ulcers and had two unhealed stage 2 pressure ulcers (partial thickness loss presenting as a shallow crater/wound). A current care plan for self care performance deficit, dated 1/5/24, indicated the resident required assistance with activities of daily living. Interventions included the following: the resident required assistance of one to two staff members to reposition and turn in bed(1/5/24), the resident required skin inspections daily for any redness, open areas, scratches, cuts, bruises (1/5/24), any skin changes were required to be reported to the Nurse (1/5/24), and the resident required assistance of one staff member for toileting (1/5/24). A current care plan for skin impairment, dated 1/5/24, indicated the resident had a left and right buttock pressure injury upon admission. Interventions included the following: the resident required a low air loss mattress as ordered (1/8/24), treatment as ordered (1/8/24), notification to the provider if the wound was not healing or had signs of infection (1/8/24). A progress note, dated 1/6/24, indicated the provider's skin assessment identified an area to the coccyx and top of the head. The record lacked measurement of these areas. The note lacked indication of wounds to the left and right buttocks. A Nurse's Note, dated 1/11/24 at 9:53 p.m. indicated the resident continued with open areas to bilateral buttocks with deep purple discoloration. The areas were tender with increased facial grimacing and moaning with bed mobility and incontinence care. The resident reported relief when he was placed on his side for bedtime care. The clinical record lacked wound assessments of the left and right buttocks indicating a description and measurements of wounds prior to the initial assessment on 1/10/24. A review of weekly skin assessments indicated the following: On 1/10/24, an initial wound assessment of the right buttock indicated the resident had a stage 2 pressure injury measuring 2.5 centimeters (cm) length, 2.0 cm width, and less than 0.1 cm depth. It had minimal exudate. The wound onset date was 1/5/24. On 1/10/24, an initial wound assessment of the left buttock indicated the resident had a stage 2 pressure injury measuring 3.5 cm length, 3.0 cm width, and less than 0.1 cm depth. It had minimal drainage. The wound onset date was 1/5/24. On 1/17/24, a weekly wound assessment of the right buttock indicated the resident had a healing stage 2 pressure injury measuring 1.5 cm length, 1.0 cm width, and less than 0.1 cm depth. It had minimal drainage. On 1/17/24, a weekly wound assessment of the left buttock indicated the resident had a healing stage 2 pressure injury measuring 0.5 cm length, 0.5 cm width, and less than 0.1 cm depth. On 1/24/24, a weekly wound assessment of the right buttock indicated the resident's stage 2 pressure injury was healed. An initial assessment of the right buttock, dated 1/24/24, indicated the resident had moisture associated skin damage with moderate drainage. The assessment lacked a wound measurement. On 1/24/24, a weekly wound assessment of the left buttock indicated the resident's stage 2 pressure ulcer to the left buttock was healed. On 1/31/24, a weekly wound assessment indicated the resident was not seen during wound rounds due to a procedure. A skin assessment was not completed. On 2/7/24, an initial wound assessment of the bilateral buttocks indicated the resident had moisture associated skin damage with moderate drainage and redness. The assessment lacked a wound measurement. The weekly wound assessments of the resident's bilateral buttocks from 2/14/24 to 3/20/24 lacked wound measurements. The wound was documented as healing moisture associated skin damage with varying amounts of drainage. During an interview on 3/21/24 at 5:00 p.m., the resident was sitting up in his wheelchair in his room and indicated his buttocks were very sore when sitting up in his wheelchair, due to the wounds he had on his buttocks. During an interview on 3/22/24 at 4:53 p.m., the resident indicated he was uncertain what caused the wounds on his buttocks. During an interview on 3/22/24 at 5:00 p.m., CNA 5 indicated she had provided the resident's care approximately a month ago. The resident had a urinary catheter and wounds on his buttocks at that time. Pressure relief interventions during that time included a low air loss mattress. During an interview on 3/25/24 at 12:30 p.m., LPN 13 indicated the resident was very cooperative and compliant with his care. During a wound observation on 3/25/24 from 3:11 p.m. to 3:35 p.m., the resident was laying on his back in bed upon entry to the resident's room. LPN 10 provided moderate assistance to turn the resident onto his left side. A SAP dressing, dated 3/24/24, was removed from the bilateral buttocks pressure injuries by LPN 3. It contained scant serosanguineous drainage. Both LPN 3 and LPN 10 told the resident his wounds looked much better. The resident had an open, circular wound, approximately the size of a nickel coin, on his left buttock. The right buttock also had an open, circular wound, approximately the size of a nickel coin. Both of the wounds presented with a beefy red wound base and both had discernable depths, but were not measured during the observation. The surrounding skin on each buttock was pale and fragile. The wounds were cleaned and Silvasorb was applied to the open wound bases. A clean SAP heart shaped dressing was applied to cover both wounds. LPN 10 turned the resident onto to his back. When LPN 3 and LPN 10 moved him up in bed and put pillows under his head, the resident grimaced and indicated his buttocks were painful. LPN 3 offered the resident pain medication. The resident was not offered repositioning with pillows in a manner to relieve the pressure to his buttock area. Both LPN 3 and LPN 10 left the room with the resident in supine position. During an interview at the time of observation, LPN 10 indicated the wounds were previously categorized as moisture associated skin damage covering the resident's entire bilateral buttocks. This had decreased in size, but the stage of the wounds had worsened. During an interview on 3/25/24 at 3:40 p.m., LPN 3 indicated the resident's bilateral buttocks wounds had improved over time, but the nickel-sized open pressure areas to the left and right buttocks were not moisture associated skin damage. Instead, they were, at minimum, stage 2 pressure injuries. During an interview on 3/25/24 at 3:50 p.m., LPN 3 indicated the resident's wounds to his buttocks were present on admission 1/5/24, healed out on 1/24/24, and then reopened on 2/7/24. During an interview on 3/25/24 at 4:54 p.m., LPN 9 indicated she accompanied the Wound Nurse Practitioner during wound rounds on a regular basis. The resident's bilateral buttocks wounds had never completely healed. Instead, the documentation was changed to moisture associated skin damage, which is why the documentation indicated the wounds were healed. Wound categorization should not be downgraded. The facility had not identified a change to the resident's bilateral buttock wounds category prior to the wound observation during survey. During an interview on 3/25/24 at 4:55 p.m., the Corporate Nurse Consultant indicated wounds should not be down graded from the initial assessment as they heal. All wounds were required to have measurements during the assessments to identify any change in the wound. Notifications should have been made immediately when a change in the wound was identified. Review of an undated, NPIAP Pressure Injury Stages, document was retrieved on 3/26/24 from the National Pressure Injury Advisory Panel website at https://npiap.com/page/PressureInjuryStages. The guidance included the following: .The updated staging system staging system includes the following definitions: Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear . Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis . Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) A current facility policy, dated 7/26/21, provided by the Administrator on 3/25/24 at 5:25 p.m., titled Wound Program Policy and Procedures, indicated .Nursing staff will employ preventative measures to successfully manage skin integrity of those residents who are identified to be at risk .When a wound/rash is found, if identified by non-licensed personnel, the resident's nurse will be notified immediately. This nurse is responsible to do a wound/skin interruption assessment on the affected area, chart this, notify the MD/NP, get treatment orders, and notify the family. Additionally, as part of that review, the facility wound nurse (designee in their absence), should also assess wound, and ensure the care plan is congruent with the plan of care to be established .Charting Parameters for any wound will include: . 2. Wound dimensions: Length x Width x Depth .10. If the wound is a pressure injury, or has a pressure injury component, it must be staged according to the current National Pressure Ulcer Advisory Panel (NPUAP) guidelines 11. Reverse staging of pressure injuries is not permitted for clinical charting 3.1-40(a)(1) 3.1-40(a)(2)

Based on observation, record review, and interview, the facility failed to monitor weights and implement additional interventions to prevent further loss for a resident's weight loss for 1 of 2 residents reviewed for nutrition (Resident 22). Finding includes: During an observation, on 3/21/24 at 12:08 p.m., the resident was sitting up in bed. A meal tray was delivered to the resident. The chicken included in the meal was not cut up by the staff. During an observation, on 3/21/24 at 12:12 p.m., a staff member checked on the resident and assisted her with cutting up her chicken. During an observation, on 3/21/24 at 12:16 p.m., the resident ate her meal without difficulty. She indicated the meal was good. The resident's clinical record was reviewed on 3/21/24 at 9:04 a.m. Diagnoses included dementia, Alzheimer's disease, hypothyroidism, gastro-esophageal reflux disease, hypothyroidism, and depressive disorder. Current physician orders included regular diet with regular texture and health shakes with lunch and dinner (5/30/19), health shakes twice a day to maintain weight with lunch and dinner (8/2/23), weekly weight for four weeks for weight loss (3/3/24), levothyroxine sodium (thyroid medication) 75 mcg (micrograms) daily (1/30/24), and venlafaxine extended release (anti-depressant) 37.5 mg every other day (4/22/22). The 2/9/24 quarterly Minimum Data Set (MDS) assessment indicated the resident was moderately cognitively impaired. She required set up or clean up assistance with eating. She had a weight gain of 5% or more in a month or gain of 10% or more in 6 months and was on a physician prescribed weight gain regimen. A current care plan, initiated on 6/4/19, included the following interventions: monitor/record/report to physician as needed signs and symptoms of malnutrition emaciation (abnormally thin), muscle wasting, significant with loss: 3 pounds in one week, greater than 5 percent in one month, greater than 7.5 percent in 3 months and greater than 10 percent in 6 months (8/17/21) and registered dietician to evaluate and make diet change recommendations as needed (6/17/19). The resident's weight record was reviewed. The resident's weight, in pounds, was as follows: 142.6 on 9/1/23, 143.6 on 10/1/23, no weight obtained in 11/2023, 138.2 on 12/5/23, 124.4 on 1/17/24, 130.6 on 1/18/24, 136.6 on 2/1/24, 130.0 on 3/1/24, 130.6 on 3/8/24, and 128.8 on 3/15/24. From 12/5/23 to 1/18/24 the resident lost 5.5 percent of her weight. From 10/1/23 to 3/15/23 the resident lost over 10 percent of her weight. A nutritional risk assessment was completed on 1/2/24. The dietician utilized the 12/5/23 weight of 138.2 as reference and indicated the resident's oral intakes were likely adequate to meet needs. No significant weight change for 180 days. A nutritional risk assessment was completed on 2/8/24. The dietician utilized the 1/17/24 weight of 124.4 and the 2/1/24 weight of 136.6 as reference and indicated the resident had a significant weight gain. A progress note by the Nurse Practitioner (NP), dated 1/24/24 at 6:19 p.m., indicated the resident was seen for weight loss in the presence of hypothyroidism, gastroesophageal reflux disease, and medication change. The resident's weight decreased after a recent acute illness of influenza at the end of the year with symptoms now resolved. As of 1/18/24 the resident had a significant weight loss over the last 6 weeks, weight down 7.6 pounds, and more significantly over the last 90 days, weight down 13 pounds. Her weight historically hovered around 140 pounds for most of 2023. The assessment/plan requested nursing to increase weight monitoring to weekly, repeat laboratories on Monday, and use supplementation and dietitian's direction. A progress note by the NP, dated 1/30/24 at 8:51 a.m., indicated the resident was seen for weight loss. Labs were reviewed. The assessment/plan for abnormal weight loss indicated the weight was trending down in the presence of recent acute illness and iatrogenic (dosage of thyroid medicine is too high) hyperthyroidism. Levothyroxine (for thyroid) was decreased, adequate and consistent intakes were to be encouraged, and dietician to follow with supplementation. A progress note, dated 3/3/24 at 1:49 p.m., indicated the NP ordered weekly weights related to weight loss. The clinical record did not reflect an active order for weekly weights had been implemented following the 3/3/24 exam. During an interview, on 3/25/24 at 10:26 a.m., LPN 18 indicated the NPs typically wrote their own orders after a resident visit. During an interview, on 3/25/24 at 10:33 a.m., LPN 13 indicated the NP came to the facility three times a week. He went over his orders verbally with the nurse on duty for the specific resident he saw. During an interview, on 3/25/24 at 4:05 p.m., the ADON checked the paper chart for a telephone order for the weekly weights requested on 1/24/24 by the NP. She indicated an order had not been written for weekly weights. She indicated the progress notes are often put in after the NP leaves and not reviewed for orders since he writes them himself and goes over them with the nurse. Weekly weights were initiated 3/3/24. During an interview, on 3/25/24 at 4:07 p.m., the Nurse Consultant indicated the dietician's most recent assessments were on 1/2/24 and 2/9/24. The resident had an unplanned weight loss in the past 180 days. During an interview, on 3/25/24 at 4:18 p.m., the ADON indicated she did not remember the resident coming up for the nutritional risk program. She was unable to find a weight for November and was uncertain why it had not been completed. During an interview, on 3/25/24 at 4:26 p.m., LPN 10, who kept the list for the nutritional at risk program, indicated the resident had not been on her list for weight gain or weight loss in January of 2024. A current facility policy, dated 7/26/21 and provided by the Administrator on 3/25/24 at 5:25 p.m., titled Weight Monitoring Policy and Procedure, indicated .Significant unintended changes in weight (loss or gain) or insidious weight loss (gradual unintended loss over a period of time [)], may indicate a nutritional problem .Suggested Weight Schedule .Residents with weight loss - weekly .all others monthly .Weights shall be reviewed weekly by an interdisciplinary team that should include at least dietary and nursing . The Registered Dietician or Dietary Manager should be consulted to assist with interventions; actions are recorded in the nutrition progress notes .Observations pertinent to the resident's weight status should be recorded in the medical record as appropriate 3.1-46(a)(2)

Based on observation and interview, the facility failed to ensure medication/treatment carts were free of loose medication in 2 of 4 medication carts observed for medication storage. (Rosewood 1 medication cart and Rosewood 2 medication cart) Findings include: During a medication storage observation, accompanied by LPN 12, on 3/25/24 at 3:39 p.m., the Rosewood 1 medication cart was observed to have 1.5 small, round, white pills loose in the bottom of the 3rd drawer. During the same observation, the Rosewood 2 cart had 3 loose pills in the bottom of the 2nd drawer, including 1 large, oblong, yellow pill, 1 small, round, white tablet, and 1 small, round, orange tablet. The 3rd drawer had 7 loose medications in the bottom, including 3 brown and tan capsules, 2 medium, round, white tablets, 1 small, round, white tablet, and 1 small, round, tan tablet. The 4th drawer had 4 loose pills in the bottom, including 1 large, oblong, brown pill, 1 medium, round, white pill, 1 very small, round, white pill, and 1 small, round, white pill. During an interview with LPN 12, at the same time as the observation, he indicated he would discard any loose pills, if found, according to facility policy. During an interview with LPN 14, on 3/24/24 at 6:27 p.m., she indicated the Rosewood 1 medication cart contained medications for 15 residents. The Rosewood 2 medication cart contained medications for 15 residents. A current facility policy titled Facility Drug Product Storage Requirements, revised on 2/22/22, and provided by the Corporate Nurse Consultant on 3/25/24 at 5:39 p.m., indicated the following: .Policy: To ensure proper and efficient conditions of storage for all drugs and drug products, providing safe and compliant drug distribution to facility residents. Procedure: All drug products, regardless of storage device used, will be stored under the proper conditions defined by Federal and State regulations to provide at a minimum .4) Be maintained in a clean and orderly condition 3.1-25(j)

Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from physical abuse by staff. (Resident D and CNA 12) Findings include: Review of Resident D's clinical record was completed on 12/20/23 at 10:42 a.m. Diagnoses included Type 2 diabetes mellitus, essential hypertension, anxiety disorder, and blindness. An Indiana Report Form, dated 10/27/23 at 11:26 a.m., indicated a nurse heard Resident D crying. The resident was distraught. When asked why she was upset, the resident was quoted to say That girl, she grabbed me and hurt me! The nurse assessed the resident and was able to help her calm down. The report indicated CNA 12 was identified, clocked out, and sent home pending an investigation. A progress note, dated 10/23/23 at 5:27 a.m., indicated the resident was visibly upset and crying out. The resident complained of bilateral wrist pain and bilateral leg pain. Her vital signs were stable. A skin assessment was performed by the nurse on duty (LPN 16). The nurse notified the Nurse Practitioner. During an interview, on 12/20/23 at 10:21, the resident was in her bed listening to Christmas music. The resident indicated staff did not treat her kindly. She had been struck by a staff member, but the staff member had been terminated. A signed written statement by CNA 12, dated 10/26/23, indicated she went to Resident D's room to change her. The resident refused and insisted CNA 12 get out of her room. The resident did not want to be changed. The CNA continued the process of getting the resident changed. She told the resident she had to change her because she did not want on-coming staff to find Resident D wet. CNA 12 indicated the resident complied at that time. A signed written statement by LPN 16, dated 10/26/23 at 5:23 a.m., indicated she found Resident D crying during the morning medication pass. When asked what was wrong, the resident indicated that girl, she grabbed me and hurt my wrists, my legs are all banged up. They just hurt me. Why do you let people treat me like that? I didn't want her in here anymore! The LPN indicated the resident was bawling and in a panicked state. The LPN indicated CNA 12 had told the resident they would go out to breakfast together if she would agree to let the CNA change her. A signed written statement by LPN 10, dated 10/29/23, indicated the resident reported to her that she had to fight someone who was trying to give her a bed bath. Even after telling the CNA no, the CNA continued to change her. The resident indicated she was forced to be changed. The resident also indicated she was hit and scratched several times. LPN 10 indicated the resident had several scratches on her right knee and rear right thigh. An undated investigation note, indicated CNA 12 verified she had gone ahead and cleaned the resident, even though the resident asked her not to. A care plan, dated 10/4/23, indicated Resident D, at times, refused medications, treatments, appointments, and care. Interventions included going back later to try again. Another intervention was to provide a different staff member. It was advised to use two staff members when providing care for Resident D. During an interview with the Administrator, on 12/21/23 at 12:06 p.m., she indicated CNA 12 was concerned the next shift staff would be unhappy with her if she did not change Resident D. Care was supposed to be in pairs. CNA 12 had gone in alone to provide care for Resident D. The CNA went in without another staff member and provided care. CNA 12 was not available for interview and could not be reached by phone. A current facility policy, dated 4/2017, titled Abuse, Neglect and Exploitation, provided by the Administrator on 12/21/23 at 12:00 p.m., indicated the following: .It is the policy of the Essential Senior Health and Living that each resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, exploitation, and involuntary seclusion. The resident has the right to be free from mistreatment, neglect and misappropriation of property. Residents must not be subject to abuse by anyone, including, but not limited to; facility staff, other residents, consultants, or volunteers, staff of other agencies serving the resident, family members, legal guardians, friends, or other individuals This citation relates to Complaint IN00420648. 3.1-27(a)(b)

Based on record review and interview, the facility failed to ensure staff reported an injury of unknown origin to the Administrator immediately, which delayed the submission of the incident within the required timeframe to the State Agency for 1 of 3 facility reported incidents reviewed. (Resident E) Findings include: The clinical record for Resident E was reviewed on 12/19/23 at 12:51 p.m. Diagnoses included chronic obstructive pulmonary disease, long term use of antithrombotics/antiplatelets, and stage 4 pressure ulcer of the sacral region. Review of the facility self reportable, dated 11/27/23, indicated on 11/25/23 staff noted a bruise (injury of unknown origin) on the neck of the resident. On 11/26/23 the bruise was reported as large and reported to the Administrator. The Administrator submitted the reportable to the State Agency on 11/27/23 at 11:45 a.m. During an interview on 12/19/23 at 12:47 p.m., Resident E indicated she had a bruise on her neck, but did not know how she got it. During an interview on 12/19/23 at 1:00 p.m., the Transporter indicated on 11/24/23 the resident was transported via the facility van to an offsite appointment. The Transporter indicated the resident did not complain of any pain or discomfort outside of the usual. No bruising was noted. The resident transported via wheelchair and the seat belts for wheelchair seat belts secured the resident around the waist and not across the body. During an interview on 12/19/23 at 1:13 p.m., CNA 3 indicated assisting with transporting the resident via the facility van to an offsite appointment. They did not see any bruising at the time of transport. The resident transported via wheelchair and the wheelchair seat belts go around the waist and not across the body. During an interview on 12/20/23 at 11:24 a.m., the Administrator indicated the bruising should have been reported to her immediately, on 11/24/23, when it was first noted. The Administrator was not notified of the injury of unknown origin until the evening of 11/26/23, a Sunday, and it was not reported until 11/27/23, Monday morning. During an interview on 12/20/23 at 2:22 p.m., LPN 5 indicated CNA 6 informed her of the bruising on Saturday 11/25/23. The resident was assessed. LPN 5 finished the medication administration pass and then forgot about the bruising. The next day, Sunday 11/25/23, she remembered the bruising and reported it. LPN 5 indicated she should have been reported the incident immediately. During an interview on 12/20/23 at 3:09 p.m., CNA 6 indicated she found bruising on the left side of resident's neck on 11/25/23 during morning care. The resident did not know how the bruising occurred. CNA 6 indicated she immediately reported the bruising to LPN 5. A current facility policy, dated 5/20/2016 and provided by the Administrator on 12/18/23 at 3:00 p.m., titled Abuse, Neglect And Exploitation indicated the following: Compliance Guidelines: 1. The Abuse Coordinator in the facility is the Director of Nursing, Administrator, or facility appointed designee. Report allegations or suspected abuse, neglect of exploitation immediately to Administrator Other Officials in accordance with State Law State Survey and Certification agency though established procedures IV. Identification of Abuse, Neglect, And Exploitation The facility will consider factors indicating possible abuse, neglect, and/or exploitation of residents, including, but not limited to, the following possible indicators: Physical marks such as bruises or patterned appearances such as a handprint, belt or ring mark on a resident's body Physical injury of a resident, of unknown origin This citation relates to Complaint IN00422735. 3.1-28(c)

Based on record review and interview the facility failed to ensure staff members implemented transfer and ambulation interventions to prevent falls in 2 of 3 residents reviewed for falls (Resident B and Resident D). This deficient practice resulted in a fractured femur for Resident B. Findings include: 1. The clinical record for Resident B was reviewed on 7/20/2021 at 9:31 a.m. Diagnoses included, but were not limited to, [CONDITION(S)], malignant neoplasm of bladder, [CONDITION(S)], hypertension, muscle weakness, unsteadiness on feet and lack of coordination. The most recent significant change Minimum Data Set (MDS) assessment, dated 6/9/2021, indicated Resident B was cognitively intact. Resident B received the following Activities of Daily Living (ADL) assistance; extensive assistance of two persons for transfers and toilet use, extensive assistance of one person for bed mobility, dressing and personal hygiene. Moving on/off toilet: not steady, only able to stabilize with staff assistance. Review of a discharge MDS, dated [DATE], indicated Resident B received the following ADL assistance; extensive assistance- resident was involved in activity while staff provided weight-bearing support for bed mobility, transfers, walking in room, locomotion on and off the unit, dressing, toilet use and personal hygiene. A care plan, dated 5/18/2021 and last revised on 6/11/2021, indicated the resident was at risk for falls r/t weakness and pain following recent surgery, UTI (urinary tract infection) and pneumonia. Interventions included, but were not limited to, Nurse spoke to CNA [Certified Nursing Aide] that resident is not to be free standing with ambulation. Resident likes to take off and not wait for staff to be beside him during assistance. 06/17/21. A care plan, dated 6/17/2021, indicated the resident had sustained a fall on 6/17/2021. The resident did not sustain an injury. The only intervention was CNA not to let resident free stand when assisting with ambulation tp [sic] prevent reccurrence [sic] (6/17/2021). Review of the Admission Fall Risk Assessment, dated 6/17/2021, indicated the resident was a high risk for falls. Review of a Fall Risk assessment, dated 7/11/2021, indicated the resident was a high risk for falls. Review of the state reportable, dated 7/11/2021, indicated CNA 1 was assisting the resident during a transfer from the toilet. The resident lost his balance and fell to the floor. Review of the hospital physician noted, dated 7/18/2021, indicated the resident was admitted from the emergency room with a diagnoses of left femur fracture and [CONDITION(S)]. The resident was taken to surgery on 7/12/2021 for a surgical intervention for the fractured femur. During an interview on 7/20/2021 at 11:55 a.m., the Director of Nursing (DON) indicated whenever staff assist any residents who was not independent with transfers and ambulation, a gait belt should be used. The DON indicated the CNA1 did not use a gait belt while assisting Resident B with his transfer from the toilet. She indicated CNA 1 was from an agency and the facility had re-educated her and she had not worked in the facility since the incident. She indicated this was not a new policy and it had always been the facility's expectation that staff use gait belts. During an interview on 7/20/2021 at 4:06 p.m., RN2 indicated she had been involved with the care of Resident B on the night of the incident. She indicated she was bringing the resident his medication during a medication pass. She stated the resident was in the bathroom on the toilet and she performed a skin assessment. She indicated she and CNA 1 assisted the resident to a standing position with difficulty so she could perform his skin assessment. He is weak in his right arm. She indicated they had not used a gait belt. She left the room and had been in the hallway when she heard a loud noise and the CNA 1 yelling Ow. Ow. She indicated when she entered the bathroom, the resident was on the floor and there was no gait belt in use. During an interview on 7/21/2021 at 10:13 a.m., Resident B indicated he had been walking with his walker from the toilet to the shower when he lost his balance and fell . He did not remember if the CNA had her hands on him or not at the time. He indicated there was no gait belt used. He stated he was in a great deal of pain as a result of the fall and fracture of his leg. 2. The clinical record for Resident D was reviewed on 7/20/2021 at 1:14 p.m. Diagnoses included, but were not limited to, cerebral infarction, chronic obstructive pulmonary disease, [CONDITION(S)] and [CONDITION(S)], type 2 diabetes and dementia. The most recent quarterly Minimum Data Set (MDS) assessment, dated 5/17/2021, was reviewed on 7/20/2021 at 1:14 p.m. The MDS indicated Resident D was cognitively impaired. Resident D received the following ADL assistance: extensive assistance of 1 person for bed mobility, transfers, dressing and toilet use, limited assistance of one person for walking, locomotion and personal hygiene. The resident had impaired upper and lower extremities on one side. Review of a Fall Risk Assessment, dated 5/17/2021, indicated the resident was a high risk for falls. Review of a progress noted, dated 7/15/2021 at 10:20 a.m., indicated Resident D tripped over her walker while reaching for a banana. The resident sustained no injury. Review of a progress noted, dated 7/15/2021 at 10:30 a.m., indicated the Activity Assistant followed resident back to her room. Resident was using walker and went back to her room and put her walker by the bed and began to walk around to her bed. Reminded by activity assistant that she needed to use her walker and when resident went to grab her walker her leg got tangled in the walker and she began to lose her balance. Activity assistant placed her arms around the resident and under her arms to prevent the fall and then lowered her to the ground. Resident had no injury at this time. Resident was not using walker properly. Staff educated on gait belt use. Review of the CNA Assignment sheet indicated Resident D was an assist of 1 with gait belt. During an interview on 7/20/2021 at 2:34 p.m., Activity Assistant 3 indicated she had been assisting the resident to an activity when the resident decided she needed to return to her room to get a banana. The Activity Assistant indicated she assisted the resident back to her room and the resident tripped over her walker when she reached for a banana. The Activity Assistant indicated she had not been using a gait belt. She indicated staff should use a gait belt for residents who require assistance with ambulation. Review of a current undated policy, revised 7/14/2021, titled Policy/Procedure-Gait Belts, indicated the following: POLICY/PROCEDURE The use off a gait belt promotes safety, facilitates movement control, prevents caregiver injury by reinforcing proper body mechanics, promotes fall prevention by allowing the safe correction of loss of balance and improves confidence by providing a sense of security. 1) A gait belt is to ALWAYS be utilized when mobilizing a resident. (i.e., transfers of al toes including toileting, changing surfaces, bed to w/c [wheelchair] to bed, ambulation. This Federal tag relates to Complaint IN 928. 3.1-45(a)(2)

Based on interview and record review, the facility failed to ensure a resident was free from falls during his stay at the facility for one of three residents reviewed for accidents. This deficit practice resulted in the ORIF (open reduction and internal fixation) that requiring a repeat surgery due to a fall at the facility. (Resident #118) Findings include: A review of the medical record for Resident #118 began on 02/18/2016 at 2:46 p.m., indicated the [DIAGNOSES REDACTED]. The most recent MDS (Minimum Data Set) assessment indicated Resident #118 was severely cognitively impaired. During an interview with a family member of Resident #118 on 02/18/2016 at 1:07 p.m., she indicated that Resident #118 was at the facility for rehabilitation and recovery after a fall at his home. She indicated that, two days prior to this interview, Resident #118 fell while trying to get out of his bed and as a result of that fall needed to have another surgery on 2/19/2016. She indicated that Resident #118 was supposed to have had an alarm on to alert staff if he was trying to get out of bed on his own. She then indicated Resident #118 did not have an alarm on at the time of the fall. During an interview with Unit Manager #1 on 02/23/2016 at 11:04 a.m., she indicated that Resident #118 lived at this facility then discharged to home where he fell and broke his hip. She indicated Resident #118 then returned to this facility for rehabilitation after hip surgery. She indicated Resident #118 then fell again on 2/16/2016 and was sent out to the emergency room for a cat scan (CT) and X-rays. Unit Manager #1 then indicated that the hospital called and indicated the results of both tests were negative. The resident returned to the facility however went to the regularly scheduled orthopedic appointment he was scheduled for where they found the failed repair. Unit Manager #1 indicated the alarms that were supposed to be in place were not and that Resident #118 was wearing regular socks not gripper socks. Unit Manager #118 indicated Resident #118 had increased confusion during the time prior to the fall and did not offer any other indications as to why Resident #118 fell . During an interview with PTA (Physical Therapy Assistant) #2 on 2/24/2016 at 10:25 a.m., she indicated that Resident #118 was definitely a fall risk prior to his fall on 2/16/2016. She indicated that Resident was also very out of it and lethargic in the days prior to the fall. During an interview with COTA #1 (Certified Occupational Therapy Assistant) on 2/24/2016 at 10:32 a.m., he indicated that he had worked with Resident #118 prior to the fall on 2/16/2016. He indicated that although Resident #118 was doing better with Occupational Therapy at the time of the fall, he was still a fall risk. COTA #1 indicated Resident #118 was out of it due to the anesthesia from previous surgery and daily medication the resident was taking. During an interview with LPN #10 on 2/24/2016 at 12:54 p.m., she indicated that Resident #118 was a fall risk and his risk factors prior to the fall on 2/16/2016 included confusion, previous hip repair and the resident not being full weight bearing. LPN #10 indicated the interventions added after the fall were alarms and 15 minute checks. LPN #10 indicated that Resident #118 had a problem with anesthesia indicated by lethargy and being out of it. The physician orders, signed on 2/8/2016, were provided by Unit Manager #1 on 2/23/2016 at 11:36 a.m., indicated PBA (personal body alarm) on at all times to alert staff of unassisted transfers. Confirm placement and function q (every) shift. Bed alarm on when in bed to alert staff of unassisted transfer, confirm placement and function q shift. F/U (follow up) (Physician Name) 2/17/2016 at 10:00 a.m. A document titled FALL FOLLOW UP was provided by Unit Manager #1 on 2/23/2016 at 11:36 a.m., and indicated Resident #118 had a fall on 2/16/2016 at 6:45 p.m. The incident description indicated LPN #11 found Resident #118 next to his bed laying on his back parallel to the bed. Resident #118 was noted to be unable to move his left lower extremity and sent to the emergency room as precaution. Predisposing Physiological factors were listed as confused, gait imbalance, recent change in cognition, recent illness, weakness/fainted, impaired memory. Predisposing Situational Factors were listed as improper footwear, recent room change and side rails up. A document titled FSI- FALL SCENE INVESTIGATION REPORT provided by Unit Manager #1 on 2/23/2016 at 11:36 a.m., indicated Resident #118 had an unobserved fall on 2/26/2016 at 6:45 p.m. in room 310. The investigation indicated Resident #118 was resting alone in bed just prior to the fall. The investigation then indicated Resident #118 was unable to verbalize actions at this time as to what he was doing just prior to the fall. The investigation indicated the resident was wearing socks, had no assistive devices and there was no alarm being used at the time of the fall. Root causes of the fall was listed as alarm, footwear, medical status/physical condition/[DIAGNOSES REDACTED]. The fall team meeting notes indicated the alarms did not come with Resident #118 when he transferred from Rose Wood Hall and had no order for them in the electronic medical record . The order for the alarm was on the paper physician orders [REDACTED]. A copy of the physician progress notes [REDACTED].#1 2/23/2016 at 11:36 a.m., indicated Failed ORIF (open reduction internal fixation) left hip from surgery by (Doctor Name) due to fall. A note signed by the ADON, dated 2/17/2016, was provided by Unit Manager #1 on 2/23/2016 at 11:36 a.m., indicated the following Resident returned from (Name of Orthopedic Physician's Office) with surgery schedule to change hardware to Lt (left) hip r/t (related to) failed ORIF. Daughter reported to nurse that resident's hip was 'broken' and this writer called for clarification. Spoke with PA/NP (Physician Assistant/Nurse Practioner) (PA/NP Name) who assessed resident at appointment. (PA/NP Name) stated that resident's hardware to hip was displaced and no longer in alignment and hardware would have to be replaced. When this writer inquired as to XRAY report from hospital stating 'fractures' (PA/NP Name) stated that fractures that were seen on X-rays were the fractures that occurred with fall which required surgery in the first place. Fractures would not be healed as yet The Morris Fall Risk Assessment document for Resident #118 was dated 2/8/2016 and was provided by Unit Manager #1 on 2/23/2016 at 2:57 p.m., indicated he was at high risk for falling and to implement high risk fall prevention interventions. The care plan for Resident #118 was provided by Unit Manager #1 on 2/23/2016 at 11:36 a.m. It indicated the care plan was initiated on 2/11/2016 and that Resident #118 was high risk for falls related to being unaware of safety needs, confusion, deconditioning and gait/ balance problems. The goal was that Resident #118 would be free of falls with injury through the review date. Interventions included but were not limited to The resident uses: PBA (Personal Body Alarm)/ bed electronic alarm. Ensure the device is in place as needed. No further information was provided at time of exit on 2/24/16. 3.1-45(a)(2)