Every finding on record at Prairie Lakes Health Campus

Based on interview and record review, the facility failed to report an allegation of resident abuse to the State Agency (Indiana Department of Health) in a timely manner for 1 of 3 residents reviewed for abuse. (Resident B) Findings include:Resident B's clinical record was reviewed on 1/28/26 at 2:47 p.m. Diagnoses included encephalopathy, acute respiratory failure with hypoxia, chronic bronchitis, spondylolisthesis, polyneuropathy, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, and altered mental status. During an interview on 1/28/26 at 3:44 p.m., Resident B indicated, on 1/23/26 after dinner, Laundry Aide/Housekeeper 1 groped her breast and kissed her on the side of her head. The resident indicated she reported the incident to the Dining Assistant. During an interview on 1/29/26 at 2:00 p.m., the Dining Assistant indicated he had been Housekeeper 1's support for several months. Housekeeper 1 required support and direction. On 1/23/26, after lunch, the Dining Assistant and Housekeeper 2 cleaned the dining room. Housekeeper 1 was working behind him and they heard Resident B say 'no'. It was not a scream nor was it loud. The resident didn't sound distressed; it was just a 'no'. Housekeeper 1 asked the resident if she was okay and she said 'yes'. She didn't look upset or anything. The resident left the dining room. Before dinner, the resident came back to the dining room and the Dining Assistant asked the resident if she was okay and she said yes, then she said Housekeeper 1 had hugged her, that's why she said no. That is all the resident said. The Dining Assistant called the Social Service Director to check on the resident.During an interview on 1/28/26 at 2:30 p.m., the DON indicated she was approached by a (then unknown to her) family member who asked for a grievance form. The DON gave the family member a grievance form and asked if there was anything she could help her with. The family member said no. The DON asked if their concern was related to nursing and the family member said no. The DON then asked the family member if they wanted to talk to the Administrator and the family member declined. The facility never did receive a grievance form from the family member. Later, the DON found out the family member was Resident B's family.During an interview on 1/28/26 at 2:30 p.m., the Administrator indicated the facility had not been aware of an abuse allegation until the local police called the facility on 1/27/26 at 3:30 p.m. The facility failed to report the allegation to the State Agency until 8:14 p.m. that day (1/27/26). A current policy, dated 8/29/2019, titled Abuse and Neglect Procedural Guidelines was provided by the Administrator on 1/28/26 at 2:33 p.m. The policy indicated the following: . Reporting/response .ii. Ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and toother officials (including to the State Survey Agency and adult protection services where the state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.This citation relates to Intake 2727978.3.1-28(c)

A. Based on interview and record review the facility failed to allow the residents to manage the process of resident council regarding the meeting time and Resident Council Secretary for for 4 of 4 residents interviewed in a group setting and an interview with the Resident Council President, who was not available during the resident group interview.B. Based on interview and record review, the facility failed to resolve resident council grievances and concerns for 4 of 4 residents interviewed in a group setting and an interview with the Resident Council President, who was not available during the resident group interview. Findings include:A. During a resident group interview on 09/26/2025 11:00 a.m. with residents who attend Resident Council, the following concerns regarding the residents' rights to manage their council were expressed:The facility changed the time of the Resident Council meeting and residents were not allowed to voice their preferences. The residents preferred afternoon Resident Council meetings. They did not get to vote. They were told by the facility that the meeting time was changing.The residents were not in charge of Resident Council anymore. The Activity Director was now the person in charge.The resident who was chosen by the resident group to be Resident Council Secretary, was not allowed to take minutes anymore. The facility had to take notes on a computer. The residents were not allowed to take additional notes on paper. During an interview on 9/26/2025 at 2:39 p.m., the Resident Council President, who had been unable to attend the group interview, indicated the Resident Council meeting time was changed without resident input. Because the facility had to take Council Minutes in the computer, a resident could no longer be the secretary. The residents were not given a choice in this matter.Resident Council minutes for January 2025 through September 2025 were reviewed. The nine months of minutes lacked documentation of the residents voting for or discussing meeting times or a discussion or election regarding the Resident Council Secretary. Activity Calendars for April, May, June, July, and August 2025 indicated the Resident Council meeting was held in the afternoon. The Activity Calendar for September 2025 indicated the Resident Council meeting had been moved to 11:00 a.m.During an interview on 9/26/2025 at 2:18 p.m., the Activity Director indicated the facility had changed the time of the Resident Council meeting to follow the Chef's Circle meeting in hopes of increasing attendance. Additionally, there had been a time conflict because both the Assisted Living Resident Council and Health Care Resident Council wanted to have their meetings at the same time. The time change had not been voted on or discussed with the Resident Council itself. The facility had to record Resident Council minutes on the computer now, therefore she now entered the minutes into the computer. The residents had not been offered an opportunity to discuss this change or voted on the matter. No action had been taken to allow the secretary to retain any of her previous role. B. During a resident group interview on 09/26/2025 11:00 a.m. with residents who attend Resident Council, the following concerns regarding efforts to resolve resident council grievances and concerns were expressed:The facility did not come back with information about how they would resolve Resident Council's grievances and concerns.Examples of concerns which had not been addressed were passing water, changing bed sheets, and long call light waits. These concerns were repeated over and over.Minutes from the last council were not available for review.Minutes from the last meeting were not always read.When minutes were read, they did not always include all that had been discussed.During an interview on 9/26/2025 at 2:39 p.m., the Resident Council President, who had been unable to attend the group interview, indicated the facility had not always provided responses or solutions to Resident Council concerns. An example was passing drinking water.Review of Resident Council Minutes for January 2025 through September 2025 contained the following repeated concerns:9/2/25:Old Business: Staff on cell phones or with ear buds in resident care areas. Concerns regarding long call light waits.New Business: Concerns have escalated regarding staff on cell phones or with ear buds.8/14/25:Old Business: No notes.New Business: Knocking on doors, food temperatures, invitation to activities, access to money on weekends.7/10/25:Old Business: More electronic doors.New Business: Water bottles, bedding not being changed and deep cleaning questions.6/16/25:Old Business: The word Yes.New Business: Call light response times.5/15/25Old Business: Water being passed.New Business: Water being passed in a timely manner, Deep cleaning.4/3/25Old Business: Yes, No information listed.New Business: Water not being passed timely, deep cleaning, Residents feel that old business isn't getting addressed.3/13/25Old Business: Long responses to call lights, staff talking on phones, deep cleaning, ice water not being passed timely.New Business: Ice water not being passed timely, staff on phones, deep cleaning.2/16/25-No meeting1/15/25Old Business: None listedNew Business: Meeting time changed to 1:30 p.m., Ice water machine would be nice.Responses regarding resolutions were not included with Resident Council minutes.During an interview on 9/29/2025 at 9:43 a.m., the Activity Director indicated she reviewed old business each meeting. She did not read the facility's response to each concern. She did not understand what the facility would need to do reviews or audits of such things as if sheets had been changed regularly if the department head stated there was a system for changing them. A current, 6/8/24, facility policy title, Resident Council, which was provided by Administrator in 9/26/25 at 10:00 a.m., indicated: This policy aims to support residents in organizing and participating in groups at Campus for self-determination.Resident Council: A resident-led group organized to promote self-determination and to address resident concerns and suggestions.Responses regarding resolutions will be documented, reviewed by the Executive Director, and kept with Resident Council minutes. 3.1- 3(i)3.1-3(h)

Based on observation, interview, and record review, the facility failed to post accurate staffing information. This deficient practice has the potential to impact 61 of 61 residents. Findings include:Nurse Staffing Posting for 9/23/25, 9/24/25 and 9/25/25 had an incorrect resident census listed as 51. The Facility Census Form provided following the entrance conference on 9/23/25 indicated the facility's health care census was 61. Nurse Staffing Posted for 9/23/25, 9/24/25. 9/25/25, 9/26/25 and 9/29/25 had incorrect staffing information posted as follows:9/23/25: 2:00 p.m. to 10: p.m.- 4 nursing staff were posted for the health care, 3 CNAs and 1 RN,9/24/25: 2:00 p.m. to 10: p.m.- 4 nursing staff were posted for the health care, 3 CNAs and 1 LPN,9/25/25: 2:00 p.m. to 10: p.m.- 4 nursing staff were posted for the health care, 3 CNAs and 1 LPN,9/26/25: 2:00 p.m. to 10: p.m.- 3 nursing staff were posted for the health care, 3 CNAs, 9/29/25: 2:00 p.m. to 10: p.m.- 2 nursing staff were posted for the health care, 1 CNAs and 1 LPN, During an interview on 9/29/2025 at 10:43 a.m., the Scheduler indicated the staffing forms were not reflecting 12 hour shifts or double shifts. A current, 12/17/24, facility policy titled, Guidelines for Staff Posting, which was provided by the DON on 9/30/25 at 9:03 a.m., indicated:At the beginning of the day the number and amount of licensed nurses (RN and LPN) and the number of unlicensed nursing personnel, per shift, who provide direct care to residents will be posted.

Based on observation, record review, and interview, the facility failed to ensure shift to shift narcotic reconciliation was completed for 3 of 3 carts reviewed for medication storage. (Noble Hall cart, Pioneer front cart, and Pioneer back cart) Findings include: 1. During a medication storage observation of the Pioneer front medication cart, on 12/5/24 at 1:50 p.m., accompanied by RN 6, the Narcotic Count Sheet was reviewed and the following dates lacked shift to shift reconciliation of controlled medications: 11/5/24: 6:00 a.m. - 7:00 a.m. and 10:00 p.m. - 11:00 p.m. 11/6/24: 10:00 p.m. - 11:00 p.m. 11/7/24: 10:00 a.m. - 2:00 p.m. 11/11/24: 10:00 p.m. - 11:00 p.m. 11/12/24: 10:00 p.m. - 11:00 p.m. 11/13/24: 10:00 p.m. - 11:00 p.m. 11/18/24: 10:00 p.m. - 11:00 p.m. 11/19/24: 10:00 p.m. - 11:00 p.m. 11/22/24: 10:00 p.m. - 11:00 p.m. 11/25/24: 10:00 p.m. - 11:00 p.m. 11/27/24: 10:00 p.m. - 11:00 p.m. 11/30/24: 10:00 p.m. - 11:00 p.m. 12/1/24: 2:00 p.m. - 4:00 p.m. During an interview, at the time of the observation, RN 6 indicated the Narcotic Count Sheet was completed with the exchange of the medication cart keys and some employees worked 8 hour shifts while others worked 12 hour shifts. The narcotic cards were counted and then the staff members sign the count sheet together. 2. During a medication storage observation of the Pioneer back medication cart, on 12/5/24 at 1:50 p.m., accompanied by RN 6, the Narcotic Count Sheet was reviewed and the following dates lacked shift to shift reconciliation of controlled medications: 11/6/24: 10:00 p.m. - 11:00 p.m. 11/11/24: 10:00 p.m. - 11:30 p.m. 11/12/24: 10:00 p.m. - 11:00 p.m. 11/13/24: 10:00 p.m. - 11:00 p.m. 11/14/24: 2:00 p.m. - 6:00 p.m. 11/16/24: 6:00 p.m. - 10:00 p.m. 11/17/24: 6:00 p.m. - 10:00 p.m. 11/18/24: 7:00 p.m. - 11:00 p.m. 11/19/24: 10:00 p.m. - 11:30 p.m. 11/20/24: 10:00 p.m. - 11:00 p.m. 11/21/24: 10:00 p.m. - 11:00 p.m. 11/22/24: 10:00 p.m. - 11:30 p.m. 11/25/24: 10:00 p.m. - 11:00 p.m. 11/26/24: 10:00 p.m. - 11:00 p.m. 3. During a medication storage observation of the Noble Hall medication cart, on 12/5/24 at 2:10 p.m., accompanied by LPN 7, the Narcotic Count Sheet was reviewed and the following dates lacked shift to shift reconciliation of controlled medications: 11/5/24: 2:00 p.m. - 6:00 p.m. 11/6/24: 2:00 p.m. - 10:00 p.m. and 10:00 p.m. - 6:00 a.m. 11/12/24: 2:00 p.m. - 6:00 p.m. 11/15/24: 6:00 p.m. - 10:00 p.m. 11/19/24: 2:00 p.m. - 6:00 p.m. 11/20/24: 2:00 p.m. - 6:00 p.m. 11/21/24: 2:00 p.m. - 6:00 p.m. 11/25/24: 2:00 p.m. - 6:00 p.m. 11/27/24: 2:00 p.m. - 6:00 p.m. During an interview, on 12/5/24 at 3:03 p.m., the DON indicated the facility had a night shift nurse who usually worked the Pioneer Hall that needed an adjusted schedule. This nurse arrived an hour later than the scheduled night shift start time. On the nights this nurse worked, the Noble hall night nurse would do the narcotic count with the exiting second shift Pioneer hall nurse and accept the keys for the medication cart. When the late nurse arrived, another count was performed and the Noble hall nurse would turn the medication cart keys over to the incoming Pioneer hall nurse. The DON indicated this was a common practice at the facility, but was not able to locate documentation indicated these counts happened. The expectation for the Narcotic Count Sheets was for a count to happen at every exchange of keys and/or shift change. The documented count and nurse signatures assisted the facility in the prevention of drug diversion. A current facility policy, revised 8/2/16, titled, Guidelines for Narcotic Count, provided by the DON on 12/9/24 at 10:13 a.m., indicated the following: .The narcotic book shall contain a sheet providing space for the off going and oncoming nursing staff to record their signature indicated the narcotics have been reviewed . At the time one nurse or other staff qualified to pass medications relinquishes the keys to the medication cart to another staff member the narcotics shall be reconciled by complaint the medications in the cart to the count sheets . 3.1- 25(b)(3)

Based on observation, interview, and record review, the facility failed to ensure narcotics were reconciled per facility policy for 4 of 4 medication carts reviewed for medication storage. (Noble Lane, [NAME], Pioneer front, and Pioneer back carts) Findings include: 1. During a medication storage observation of the Pioneer back cart, accompanied by RN 6 on 12/15/23 at 10:01 a.m., the Narcotic Count Sheet record was reviewed and the following dates and times/shifts lacked reconciliation of controlled medications: In November 2023- 11/15: 12:00 p.m. - 10:00 p.m. 11/16: 2:00 p.m. - 6:00 p.m. 11/17: 6:00 p.m. - 10:00 p.m. 11/22: 2:00 p.m.- 10:00 p.m. 11/24: 1:00 a.m. - 5:00 a.m. 11/25: 8:00 p.m. - 10:00 p.m. 11/26: 6:00 p.m. - 10:00 p.m. and 10:00 p.m. - 6:00 a.m. 11/29: 6:00 a.m. - 2:00 p.m. and 2:00 p.m. - 10:00 p.m. 11/30: 8:00 p.m. - 10:00 p.m. and 10:00 p.m. - 6:00 a.m. In December 2023- 12/1: 6:00 a.m. - 2:00 p.m. and 8:00 p.m. - 10 p.m. 12/2: 9:00 p.m. - 10:00 p.m. 12/3: 8:00 p.m. -10:00 p.m. and 10:00 p.m. - 6:00 a.m. 12/8: 6:00 a.m. - 2:00 p.m., 2:00 p.m. - 10:00 p.m., and 10:00 p.m. - 6:00 a.m. 12/9: 4:30 p.m. - 10:00 p.m. and 10:00 p.m. - 6:00 a.m. 12/13: 2:00 p.m.- 4:00 p.m. and 2:00 a.m.- 6:00 a.m. 12/14: 2:00 p.m.- 10:00 p.m. 2. During a medication storage observation of the Pioneer front cart, accompanied by RN 6 on 12/15/23 at 10:01 a.m., the Narcotic Count Sheet record was reviewed and the following dates and times/shifts lacked reconciliation of controlled medications: In November 2023- 11/4: 10:00 p.m. - 2:00 a.m. 11/5: 6:00 p.m.- 10:00 p.m. 11/7: 2:00 p.m. - 6:00 p.m. 11/8: 2:30 p.m. - 7:00 p.m. 11/9: 2:30 p.m. - 6:00 p.m. 11/10: 12:00 p.m. - 3:00 p.m. 11/14: 6:00 p.m. - 10:00 p.m. and 10:00 p.m. - 6:00 a.m. 11/27: 10:00 p.m. - 6:00 a.m. 11/29: 7:00 p.m. - 10:00 p.m. In December 2023- 12/1: 6:00 a.m. - 2:00 p.m. and 2:00 p.m. - 10:00 p.m. 12/3: 6:00 p.m. - 10:00 p.m. and 10:00 p.m. - 6:00 a.m. 12/5: 10:00 p.m. - 6:00 a.m. 12/6: 11:00 p.m. - 6:00 a.m. 12/7: 7:00 p.m. - 10:00 p.m. 12/8: 7:00 p.m. - 10:00 p.m. 12/10: 2:00 p.m. - 5:00 p.m. and 10:00 p.m. - 6:00 a.m. 12/12: 2:00 a.m. - 6:00 a.m. 12/13: 6:00 a.m. - 2:00 p.m., 2:00 p.m. - 10:00 p.m., and 2:00 a.m. - 6:00 a.m. 12/14: 2:00 p.m.- 6:00 p.m. and 2:00 a.m. - 6:00 a.m. 3. During a medication storage observation of the Noble hall cart, accompanied by RN 8 on 12/15/23 at 10:15 a.m., the Narcotic Count Sheet record was reviewed and the following dates and times/shifts lacked reconciliation of controlled medications: In November 2023- 11/23: 6:00 a.m. - 8:00 a.m. 11/29: 6:00 p.m. - 10:00 p.m. and 10:00 p.m. - 6:00 a.m. In December 2023- 12/1: 6:00 a.m. - 2:00 p.m. and 2:00 p.m. - 6:00 p.m. 12/14: 6:00 p.m. - 7:00 p.m. 4. During a medication storage observation of the [NAME] cart, accompanied by RN 6 on 12/15/23 at 10:01 a.m., the Narcotic Count Sheet record was reviewed and the following dates and times/shifts lacked reconciliation of controlled medications: In November 2023- 11/7: 4:00 p.m. - 6:00 p.m. 11/9: 10:00 p.m. - 6:00 a.m. 11/12: 6:00 a.m. - 2:00 p.m. 11/14: 9:00 p.m. - 10:00 p.m. and 10:00 p.m. - 6:00 a.m. 11/17: 6:00 p.m. - 10:00 p.m. 11/21: 6:00 p.m. - 8:00 p.m. 11/22: 7:00 p.m. - 8:00 p.m. 11/23: 2:00 p.m. - 10:00 p.m. and 10:00 p.m. - 11:00 p.m. 11/27: 6:00 p.m. - 10:00 p.m. In December 2023- 12/3: 6:00 p.m. - 10:00 p.m. and 10:00 p.m. - 6:00 a.m. 12/4: 8:00 p.m. - 10:00 p.m. 12/5: 8:00 p.m.- 10:00 p.m. 12/6: 6:00 p.m. - 10:00 p.m. 12/7: 6:00 p.m. - 10:00 p.m. 12/8: 6:00 p.m. - 10:00 p.m. and 10:00 p.m. - 6:00 a.m. 12/10: 6:00 p.m. - 10:00 p.m. and 10:00 p.m. - 12:00 a.m. 12/11: 10:00 p.m. - 11:00 p.m. 12/12: 10:00 p.m. - 6:00 a.m. 12/13: 4:00 p.m. - 6:00 p.m. During an interview on 12/15/23 at 3:05 p.m., the Director of Nursing indicated the expectation for staff was the narcotic count book to be signed at the beginning of each shift. Review of a current facility policy, revised 1/17, titled Medication Storage in the Facility, provided by the Administrator on 12/18/23 at 9:59 a.m., indicated the following: .E. At each shift change, or when keys are transferred, a physical inventory of all controlled substances, including refrigerated items is conducted by two staff members as acceptable to location regulations and is documented 3.1-25(b)(3)

Based on interview and record review, the facility failed to follow a physician's order for fluid restriction for 1 of 1 residents reviewed for edema (Resident 5), and failed to follow a physician's order for insulin administration parameters for 1 of 1 residents reviewed for insulin administration. (Resident 36) Findings include: 1. The clinical record for Resident 5 was reviewed on 12/13/23 at 9:56 a.m. Diagnoses included congestive heart failure and chronic obstructive pulmonary disease. Current physician orders included to encourage 1800 ml (milliliters) per day of fluid restriction, dated 9/3/23. A Resident Profile indicated a fluid restriction and to ask the nurse before providing any fluids. Review of the Intake Totals documentation, for November and December of 2023, indicated the resident received greater than 1800 ml of fluids on 11/16/23 (1830 ml, 11/19/23 (2880 ml), 12/1/23 (1920 ml), 12/3/23 (1920 ml), 12/4/23 (1920 ml), 12/8/23 (2240 ml), and 12/14/23 (2880 ml). During an interview on 12/14/23 at 11:19 a.m., CNA 7 indicated she was aware of Resident 5's fluid restriction, but was unsure of the amount. She documented meal fluid intakes and if water was provided to her outside of meals. She had not informed the nurse when providing additional fluids. During an interview on 12/15/23 at 10:26 a.m., the DON indicated Resident 5 had been educated regarding the importance of her fluid restriction. The education had not been documented. The fluid intake documentation under the point of care section in the electronic health record was the total intake for the day. A Self Determination of Care or Informed Refusal and Non-Compliance observation was not completed for the resident. During an interview on 12/15/23 at 10:47 a.m., Resident 5 indicated she was aware of a fluid restriction, but was unsure about the amount. She was unaware of ever going over her allotted intake amount. The staff brought her water if she requested it outside of meal times and when they passed fluids. A current facility policy, revised 12/1/21, titled Guidelines for Fluid Restriction, provided by the Administrator on 12/14/23 at 12:35 p.m., indicated to ensure fluids are provided within the physician order guidelines. Procedures .6. Fluid consumption shall be reviewed by shift to determine adjustments necessary in the fluid intake of the resident on the restriction in order to meet their established fluids needs. 7. The resident and/or responsible party should be educated regarding the reason and importance of fluid restriction. 8. Should the resident and/or responsible party chose not to comply with the recommended fluid restriction a Self Determination of Care or Informed Refusal and Non-Compliance observation should be completed explaining the risk(s) of noncompliance. 2. The clinical record for Resident 36 was reviewed on 12/12/23 at 2:22 p.m. Diagnoses included diabetes mellitus type II and diabetic neuropathy. Physician orders included Humulin (insulin to treat diabetes mellitus) R Kwikpen, 220 units twice a day. Special instructions: hold if blood sugar is less than 200 mg/dL and call if greater than 300 mg/dL. The order was dated 11/17/23 and was discontinued on 11/28/23. A review of the electronic medication administration record (eMAR) for 11/17/23 through 11/28/23, indicated the resident's blood sugar was above 300 mg/dL (milligram per deciliter) on 11/19/23 (426 mg/dl), 11/20/23 (329 mg/dl), 11/22/23 (372 mg/dl), 11/23/23 (441 mg/dl), 11/24/23 (365 mg/dl), 11/25/23 (435 mg/dl), and 11/26/23 (447 mg/dl), when checked for the evening dose. The clinical record lacked documentation of physician notification. A current physician's order, dated 11/28/23, indicated Humulin R Kwikpen, 110 units twice a day. Special instructions: hold if blood sugar is less than 200 mg/dL and call if greater than 300 mg/dL. A review of the eMAR for 11/28/23 through 12/12/23, indicated the resident's blood sugar was above 300 mg/dL on 11/28/23, 11/29/23, 12/1/23 (480 mg/dl), 12/2/23 (415 mg/dl), 12/4/23 (427 mg/dl), 12/7/23 (307 mg/dl), 12/9/23 (406 mg/dl), and 12/11/23 (301 mg/dl) when checked for the evening dose. The clinical record lacked documentation of physician notification. During an interview on 12/13/23 at 11:10 a.m., the DON indicated the physician had wanted to monitor blood sugars over 300 mg/dL and felt he had been notified, but the staff had not documented the notifications. A current facility policy, reviewed 12/31/22, titled, Physician-Provider Notification Guidelines, provided by the DON on 12/14/23 at 1:21 p.m., included: Procedures .11. Attempts to notify the physician/provider and their response should be documented in the resident electronic health record. 3.1-37(a)

Based on record review and interview, the facility failed to ensure pharmacy recommendations were reviewed by the physician and collaboratively acted upon for 2 of 5 residents reviewed for unnecessary medications. (Resident 15 and Resident 2) Finding includes: 1. Resident 15's clinical record was review on 12/14/23 at 3:03 p.m. Current diagnoses include, vascular dementia, bipolar disorder, and personality disorder. The residents current physician's orders included the following psychotropic medications: Depakote 250 mg (an antiseizure medication used as a mood stabilizer)- one tablet two times daily, ordered on 7/17/22. Latuda 40 mg ( an antipsychotic medication)- one tablet one time daily, ordered on 7/3/22. Sertraline 25 mg ( an antidepressant medication)- one tablet one time daily, ordered 1/28/23. A July 31, 2023 pharmacy recommendation indicated the resident was receiving sertraline, Latuda, and depakote, which were due for gradual dosage reduction (GDR) evaluation. If GDR was clinically contraindicated, documention that risk vs. benefits had been considered was to be completed. A September 6, 2023 pharmacy recommendation indicated the resident was receiving sertraline, Latuda, and depakote, which were due for gradual dosage reduction (GDR) evaluation. If GDR was clinically contraindicated, documention that risk vs. benefits had been considered was to be completed. An October 1, 2023 pharmacy recommendation indicated the resident was receiving sertraline, Latuda, and depakote, which were due for gradual dosage reduction (GDR) evaluation. If GDR was clinically contraindicated, documention that risk vs. benefits had been considered was to be completed. A November 1, 2023 pharmacy recommendation indicated the resident was receiving sertraline, Latuda, and depakote, which were due for gradual dosage reduction (GDR) evaluation. If GDR was clinically contraindicated, documention that risk vs. benefits had been considered was to be completed. The recommendation had been declined without rationale per progress note discussed in a GDR meeting. The clinical record lacked responses to any of the above pharmacy recommendations. During an interview on 12/15/23 at 10:59 a.m., the DON indicated the facility had talked about GDRs in the behavior and psychoactive medication meetings. She was not aware how the pharmacy recommendations were communicated with the Psychiatric Nurse Practitioner (NP) and she did not know if the NP made written statements of contraindications. During an interview on 12/18/23 at 10:00 a.m., the DON indicated she did not have any written responses to the pharmacy recommendations for Resident 15. 40339 2. Resident 2's clinical record was reviewed on 12/12/23 at 3:26 p.m. Diagnoses included dementia and anxiety disorder. A pharmacy recommendation, dated 5/4/23, indicated quetiapine (an antipsychotic medication) 25 mg (milligram), two times daily, lacked an allowable diagnosis to support its use. The recommendation was to add an appropriate diagnosis, or consider a reduction to being tapering off the medication. The electronic health record (EHR) lacked indication of physician review. A follow-up recommendation, dated 6/1/23, indicated the outcome as pending, with no indication of physician review in the EHR. A pharmacy recommendation, dated 9/11/23, indicated the resident had an order for bupropion immediate release (to treat anxiety) 150 mg daily. The immediate release formulation was recommended to be administered two to three times daily, whereas the XL (extended release) was a once daily dosing. The recommendation was to change the order to the XL 150 mg daily. A follow-up recommendation, dated 10/10/23, indicated the outcome as declined without rationale, with no documentation of a physician review in the EHR. During an interview on 12/18/23 at 2:20 p.m., the DON indicated she was unaware of any documentation regarding specific contraindication statements or physician signed recommendation forms. The interdisciplinary team (IDT) reviewed the recommendations in monthly meetings, but she was unaware of any documentation regarding the recommendations. During a telephone interview on 12/18/23 at 2:43 p.m., the IDT Social Services Director indicated she was unaware of any specific documentation regarding contraindication statements or specific documented reason for declining recommendations. There was no physician or nurse practitioner signed pharmacy recommendations. During an interview on 12/18/23 at 3:13 p.m., the Corporate Nurse Consultant indicated the facility had no specific policy regarding pharmacy recommendations and followed the CMS (Centers for Medicare and Medicaid) regulatory guidelines. 3.1-25(i)

Based on record review and interview, the facility failed to ensure staff provided safe transfer of a physically impaired resident. (CNA 1 and Resident B) Findings include: The clinical record for Resident B was reviewed on 11/21/2022 at 10:33 a.m. Diagnoses included, but were not limited to, cerebral infarction, [CONDITION(S)], [CONDITION(S)] and heart failure. A 10/6/22, quarterly, Minimum Data Set (MDS) assessment indicated the resident required extensive assistance of 2 persons for transfers and was cognitively impaired. Review of a nursing progress noted, dated 11/12/202 at 9:49 a.m., indicated during a transfer from the bed to a wheelchair, the resident encountered a loss of coordination and slid to the floor. The resident hit her head on the side rail and was unable to provide details of the incident due to a diagnoses of [CONDITION(S)] and post cerebral infarct. They had a 1.0 centimeter laceration of the scalp to the posterior of the head. The resident was sent to the emergency room for revaluation and treatment and returned to the facility with three staples to the laceration. Review of the resident's Care Plan History indicated an intervention for two person assistance for transfers began on 3/11/2022 and ended on 11/21/2022. This document as provided by the DON and reviewed on 11/21/2022 at 1:37 p.m. Review of Resident B's current care plan for falls indicated an intervention for use of a mechanical lift was initiated on 11/14/2022. This document was provided by the DON and reviewed on 11/21/2022 at 1:37 p.m. During an interview, on 11/21/2022 at 12:00 p.m., the Director of Nursing (DON) indicated the resident was totally dependent for care. During the transfer, the resident had leaned back, slid down, and hit her head. The facility included an intervention to use a mechanical lift for transfers afterwards. During an interview, on 11/21/2022 at 12:20 p.m., CNA (Certified Nursing Aide) 1 indicated on 11/12/2022, she had transferred the resident without assistance. During the transfer, the resident started shaking. The CNA indicated she did not know the resident required 2 persons for transfer until afterwards. The resident had slid off the bed and hit her head on the bed frame. The last time she had gotten her up before this, her daughter had helped. During an interview, on 11/21/2022 at 1:29 p.m., RN 2 indicated CNA 1 had not followed proper protocol while attempting to transfer the resident without assistance. The resident's profile indicated she required two persons for transfers and CNA 1 should have known. During an interview, on 11/21/2022 at 1:42 p.m., RN 3 indicated Resident B had a history of becoming fearful before procedures, even if you explained them to her before doing anything. CNA 1 should not have attempted the transfer without assistance. Review of a current policy, dated 3/17/2022 and provided by the DON on 11/20/2022 at 1:37 p.m., titled Resident Transfers indicated the following: .Overview . To ensure the safety of residents and staff when performing mobility/transfer tasks . 3. Campuses determine the amount of assistance required for transfers and record this on the Nursing Admission Observation, the CareAssist profile, and the Resident Care Plan to provide communication to all staff regarding safe transfers This Federal tag relates to Complaint IN 537. 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to provide sufficient staff to ensure individual resident needs were met regarding prompt call light responses, stimulation for cognitively impaired residents, supervision and assistance when dinning, Activities of Daily Living (ADLs) services for hygiene and elimination, and timely medication administration. This had the potential for affect 57 or 57 residents residing on the skilled care units of the facility. Findings include: 1. A confidential interview was conducted during the course of the survey. The confidential interviewee indicated several times the staffing consists of three staff for the three halls on the skilled care units. They indicated the staffing does affect resident care due to long call light waits and the inability to check and change incontinent residents in a timely manner. The facility Resident Census and Conditions of Residents form, submitted following entrance conference, indicated the total current residents residing on the skilled care units was 57. The form indicated the following: a. Residents who were occasionally or frequently incontinent of bladder was 45, or 79% of the resident census. b. Residents who were occasionally or frequently incontinent of bowel was 48, or 84 % of the resident census. c. Residents who required assistance of one or two staff for bathing, dressing, and transferring was 55, or 96.5% of the resident census. d. Residents who had a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . e. Residents who required staff assistance of one to two staff for eating was 10, or 17.5% of the resident census. A review of the facility schedule and time Staffing Report for the week of 10/16/22 to 10/22/22, indicated the following staffing for the night shift for the 57 residents residing on all three halls on the skilled units: a. On 10/16/22, one registered nurse (RN) and two certified nursing assistants (CNA), or 3 staff members. b. On 10/17/22, two licensed practical nurses (LPN), one CNA, and one qualified medication aide (QMA), or 4 staff members. c. On 10/18/22, one LPN, one QMA, and one CNA, or 3 staff members. d. On 10/19/22, on LPN and two QMA's, or 3 staff members. e. On 10/20/22, three LPNs and one CNA, or 4 staff members. f. On 10/21/22, one RN and one CNA, or 2 staff members. g. On 10/22/22, one RN, two QMA's and one CNA, or 4 staff members. During an interview on 10/25/22 at 4:21 p.m., the Administrator indicated there was no formula used to determine staffing. The facility assessment/status/condition/acuity are used to fill needs. Sometimes the facility was low on scheduled staff and administration would help when present. The facility had no policy regarding staffing. 2. During an observation on 10/21/22 from 9:40 a.m. to 11:22 a.m., (1 hour 43 minutes), Resident D, who was dependent on staff assistance for mobility, was unable to self initiate activities and was unable to ask for assistance, was in her specialized wheelchair in the 200 hall lounge. During this time no staff member spoke to her, offered her food, or offered her an activity. During an observation on 10/21/22 at 11:22 a.m., Resident D was in her custom wheelchair in the lounge interacting with the activity assistant for five minutes. Resident D's clinical record was reviewed on 10/21/22 at 10:17 a.m. Current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly Minimum Data Set (MDS) assessment, dated 7/30/22, indicated the resident was severely cognitively impaired, had no speech-absence of the spoken word, had severely impaired vision, used a wheelchair for mobility, and required staff assistance for mobility. 3. During an observation on 10/21/22 at 9:45 a.m., Resident F was assisted by an activity staff member to the table in the 200 hall lounge. Her wheelchair was placed at the table so the back wheel of the wheelchair were a few inches from the decorative cabinet. A breakfast meal tray was placed in front of her. The resident began to eat. The resident ate without a staff member present from 9:45 a.m. until 10:41 a.m., (56 minutes). On 10/21/22 at 10:41 a.m., the meal tray was moved from in front of the resident. At 10:48 a.m., the resident attempted to move her wheelchair away from the table but could not move it because it was placed too close to the cabinet. No staff were present to assist her. The resident moved her wheelchair back against the cabinet multiple times from 10:48 a.m. to 11:24 a.m., (24 minutes) with no staff in the area. At 11:24 a.m., an activity assistant offered the resident an activity and moved her wheel chair. Resident F's clinical record was reviewed on 10/19/22 at 3:09 p.m. Current diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly MDS assessment, dated 7/19/22, indicated the resident was severely cognitively impaired, had unclear speech, holds food in her mouth, and needs limited assistance to eat. 4. During an observation on 10/21/22 from 9:25 a.m. to 10:39 a.m., (one hour and 15 minutes), Resident E was seated in his wheelchair at a table in the 200 hall lounge. There was a breakfast tray containing biscuits and gravy in front of the resident. The meal appeared uneaten. The resident was asleep with his chin on his chest, softly snoring. During the one hour and 15 minutes, the staff had not spoken to Resident E or encouraged him to eat. At 10:39 a.m., a staff member asked the resident if he was finished and took the uneaten breakfast tray away. The resident's coffee was freshened up and left in front of him. The resident took a few sips of coffee and feel asleep with his hand touching his coffee cup on the table. The resident slept at the table holding his coffee cup from 10:46 a.m. to 11:20 a.m., (34 minutes), with no staff speaking to the resident nor interacting with the resident. Resident E's clinical record was reviewed on 10/21/22 at 2:43 p.m. Current diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission MDS assessment, dated 8/4/22, indicated the resident understood others, was understood by others, required supervision for eating, used a wheelchair for mobility, and often required staff assistance with mobility. 5. During an observation on 10/21/22 at 11:20 a.m., Resident G had taken the coffee cup from Resident E's hand. Resident G then propelled her wheel chair repeatedly into the wheels on Resident E's wheelchair. After successfully passing Resident E's wheelchair, Resident G began to drink from Resident E's used coffee cup. No staff were in the area to observe the resident drinking from the used coffee cup. Resident G's clinical record was reviewed on 10/20/22 at 9:42 a.m. Current diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An significant change MDS assessment, dated 8/20/22, indicated the resident was severely cognitively impaired. 6. During a continuous observation on 10/17/22 at 12:42 p.m., Resident C's call light was lit up above his door. Licensed Practical Nurse (LPN) 7 was seated at the computer in the 300 hall Nurse's Station. No other staff members were observed on the unit at this time. Resident C's light remained activated, with the door closed and a Red Zone Isolation Sign on the door. At 12:47 p.m., Resident C was heard excessively coughing while in the 300 hall. At 12:56 p.m., a soft tone was heard approximately every seven seconds near the computer at the 300 hall Nurse's Station. Resident C's call light remained activated. No staff members were located at the Nurse's Station. At 1:00 p.m. (18 minutes since the original observation), LPN 7 walked by Resident C's room with the call light still activated. At 1:06 p.m., an unidentified staff member came down the hallway and began to pass lunch trays. Resident C's call light remained unrecognized and the call light tone still sounded as the staff member passed lunch trays. At 1:16 p.m., (34 minutes after the observation began), LPN 7 knocked on Resident C's door and entered the room to deliver the resident's meal tray. The call light was answered and deactivated. Review of the Respiratory Surveillance Line Listing on 10/19/22 at 3:53 p.m., indicated 23 residents in healthcare were COVID-19 positive from 10/13/22 to 10/19/22. These resident were dispersed throughout all units. During an interview on 10/21/22 at 03:22 p.m., Certified Nurse's Aide (CNA) 6 indicated they usually were scheduled with one Nurse and one CNA for the 300 hall Unit. The facility never have enough staff to get all of the showers completed timely and provide timely resident care. The facility had a Shower Aide scheduled in the past, but this position was not scheduled anymore. There had been other times, especially when someone called in, that some units had no CNA scheduled. Many times the nursing staff was left on hall by themselves to pass medications and complete resident care. Several residents had told her they had not been showered according to their preference every week. The lack of showers had been reported to the Director of Nursing, Assistant Director of Nursing, and the Scheduler. It had been reported to management that the staff were exasperated from working without sufficient staff. Resident C's clinical record review was completed on 10/25/22 at 10:50 a.m. The resident admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission MDS assessment indicated the resident was cognitively intact. He required extensive assistance from one staff member for dressing, toileting, and personal hygiene and extensive assistance from two staff for bed mobility and transfers. The resident was always incontinent of urine and frequently incontinent of bowel. During an interview at the time of observation on 10/25/22 at 11:36 a.m., CNA 6 indicated they had not had anyone scheduled to work at the Nurse's Station during the shift to alert the staff of activated call lights. The soft tone that sounded every seven seconds at the time of interview at the Nurse's Station was the normal tone of the call light notification. This tone was unable to be heard when a staff member was in a resident's room especially the rooms that were not near the Nurse's Station. Staff did not have a way to know if a call light had been activated when they were in a resident's room because they had not had a device that alerted them if they could not see the lights. During an interview on 10/25/22 at 3:38 p.m., the Corporate Nurse Consultant indicated they would typically monitor call lights by performing audits. A request was made for the audits at this time. Further documentation of call light monitoring was not provided. During an interview on 10/25/22 at 4:39 p.m., the DON indicated she was aware of a lack of timely showers for residents. She was uncertain of the timeframe when this occurred. Regarding staffing for the 300 hall unit, the facility continued to staff at baseline with one Nurse and one CNA for the 300 Unit. She indicated the baseline staffing for the 300 Unit had unchanged when the 300 unit had increased acuity related to 10 out 16 COVID-19 positive residents in isolation during the survey observations. 7. During an interview on 10/18/22 at 10:26 a.m., Resident H indicated she required assistance with her showers but due to a shortage of help she had only received her showers once each week rather than her agreed upon plan of showers twice weekly. Resident H's clinical record was reviewed on 10/20/22 at 4:26 p.m. She admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission MDS assessment, dated 9/15/22, indicated the resident was cognitively intact, required limited assistance from staff for transfers and total dependence on staff for bathing. The resident lacked any rejection of care behaviors. A care plan for Activities of Daily Living (ADL), dated 9/27/22, indicated the resident required staff assistance to complete ADL tasks completely and safely. A care plan for Profile Care Guide, dated 9/27/22, indicated the resident preferred showers on Wednesdays and Saturdays on the evening shift. During an interview on 10/21/22 at 03:22 p.m., CNA 6 indicated they usually were scheduled with one Nurse and one CNA for the 300 Unit and they never have enough staff to get all of the showers completed timely and provide timely resident care. They used to have a Shower Aide but this position was not scheduled anymore. There have been other times, especially when someone called in, that some halls did not have an Aide. These times left the nurse on the whole unit by herself for medication pass and resident care. Random residents told her they have not been showered according to their preference every week and it has been reported to the Director of Nursing, Assistant Director of Nursing, and the Scheduler. Often, it was also expressed to management how staff were exasperated from working without sufficient staff. Upon management notification of a lack of timely shower care, CNA 6 was encouraged to try to get the showers worked in during the shift but they were not always done by the end of the shift. The residents should have had 2 showers every week. If they missed a regular shower, it was required to have been made up on Sunday. She indicated any shower refusals were documented in the electronic medical record in the same location they document the showers provided. She indicated this information was required to be documented when the shower was provided or refused. During an interview on 10/25/22 at 10:35 a.m., the Corporate Nurse Consultant was requested to provide all documentation of bathing for the resident. Review of the ADL Report from 9/10/22 to 10/25/22, indicated the resident only received showers on the following dates: 9/17/22, 9/28/22, 10/5/22, 10/19/22, and 10/24/22. Further shower documentation was not provided prior to survey exit on 10/25/21 at 5:45 p.m. During an interview on 10/25/22 at 4:39 p.m., the DON indicated she was aware of a lack of timely showers for residents. She was uncertain of the timeframe when this occurred. Regarding staffing for the 300 Unit, the facility continued to staff at baseline with 1 Nurse and 1 Aide for the 300 Unit. She indicated the baseline staffing for the 300 Unit was unchanged when the 300 unit had increased acuity related to 10 out 16 COVID positive residents in isolation during the survey observations. A document, revised 12/15/21, titled, Facility Assessment Tool, provided by the Administrator following entrance conference, included, but was not limited to, the following: Part 3: Facility Resources Needed to Provide Competent Support and Care for our Resident Population Every Day and During Emergencies .3.3 Individual staff assignment .Campus considers census, resident acuity, resident preferences, and staff competencies to determine the number and competency requirements of staff in order to meet each resident's needs Review of some areas included but are not exclusive list: .2. The number of residents assigned to each staff member. 3. Acuity of the resident on assignment 5. Patterns of resident care needs being met: Bathing, toileting needs, call lights response time, resident assisted timely, etc. This Federal Citation is related to Complaint IN 656. 3.1-17(a)

Based on observation, interview and record review, the facility failed to ensure proper infection prevention and control strategies to mitigate the spread of COVID-19 during a facility COVID-19 outbreak and high community transmission for 5 of 10 residents reviewed for infection control. (Resident 10, Resident 30, Resident 33, Resident 41 and Resident 43) Findings include: 1. During an observation on 10/17/22 at 11:34 a.m., Resident 30's room contained a Red Zone contact/droplet isolation sign on the door closed. Required personal protective equipment (PPE) was listed as, an N95 (respirator) facemask, eye protection, gown, gloves and frequent hand hygiene. During an observation on 10/17/22 at 12:10 p.m., Licensed Practical Nurse (LPN) 7 entered the resident's Red Zone isolation room with a surgical mask worn underneath an N95 facemask. Red Zone isolation signs remained on the door during the observation. During an observation on 10/17/22 at 12:21 p.m., LPN 7 exited the resident's room after he doffed (removed) his PPE, pulled the door closed, then opened the PPE container to the left of the door and obtained a new N95 facemask and face shield. Hand hygiene was not observed before he touched the PPE container outside the room or before he donned (applied) the new facemask and eye protection. Review of the Respiratory Surveillance Line Listing on 10/19/22 at 3:53 p.m., indicated Resident 30 had tested positive for COVID-19 on 10/16/22 with a symptom onset date of 10/16/22. The resident resided on the 300 unit. 2. During a random observation on 10/17/22 at 11:36 a.m., Housekeeper 8 was observed in Resident 43's Red Zone isolation room. She had on a surgical mask with an N95 facemask worn over the top of the surgical mask while she cleaned the resident's room with the resident in the room. A Red Zone sign indicated the room was a contact/droplet isolation. Required personal protective equipment included an N95 facemask, eye protection for all health care providers regardless of vaccination status, gown, gloves, and frequent hand hygiene. During an interview on 10/17/22 at 11:59 a.m., LPN 7 indicated the facility had not designated dedicated staff member to enter the Red Zone Isolation rooms, but all staff were required to wear appropriate PPE for contact/droplet isolation before they entered. Review of the Respiratory Surveillance Line Listing on 10/19/22 at 3:53 p.m., indicated Resident 43 had tested positive for COVID-19 on 10/16/22 with symptom onset date of 10/16/22. This resident resided on the 300 unit. During an interview on 10/21/22 at 11:03 a.m., Housekeeper 8 indicated an N95 facemask over a surgical mask was not appropriate in a Red Zone isolation room. 3. During an observation on 10/17/22 at 12:00 p.m., Resident 41's door was closed with a Red Zone sign that indicated contact/droplet isolation. During an interview with the Director of Nursing (DON) on 10/18/22 at 9:47 a.m., she indicated six more residents had tested positive for COVID-19 on the health care units and two more staff members had tested positive for COVID-19. During an observation on 10/19/22 at 2:53 p.m., the Social Service Director (SSD) had on a surgical mask and approached Resident 41's Red Zone isolation room. A Red Zone contact/droplet isolation sign remained on the door with a list of the required PPE. PPE required for the resident's room included an N95 facemask, eye protection, gown, gloves and frequent hand hygiene. She donned an N95 mask over the top of her surgical mask, a face shield, gown and gloves then entered the resident's room and assisted the resident. During an interview at the time of observation on 10/19/22 at 3:01 p.m., the SSD exited the resident's room. She indicated she should not have placed the N95 facemask over the top of the surgical mask before she entered the resident's Red Zone isolation room because the N95 facemask would not fit properly against the face with the surgical mask worn under it. She had prior training on proper masking but she had been in a hurry to get in the room. While she was in the resident's room she held the resident's hand to calm her down. She indicated an improperly donned N95 facemask in an isolation room increased risk for potential spread of COVID-19. During an interview on 10/19/22 at 3:39 p.m., the DON indicated Resident 41 had tested positive for COVID-19. Review of the Respiratory Surveillance Line Listing on 10/19/22 at 3:53 p.m., indicated Resident 41 had tested positive for COVID-19 on 10/16/22 with symptom onset date of 10/16/22. This resident resided on the 300 unit. During an interview on 10/19/22 at 3:57 p.m., the DON indicated staff who entered a Red Zone isolation room were required to have worn an N95 facemask, goggles or face shield, gloves and a gown. An N95 facemask should not be donned over a surgical mask to enter a Red Zone isolation room due to lack of appropriate seal against the face. 4. During a random observation on 10/17/22 at 12:34 p.m., an unidentified Certified Nurse's Aide (CNA) walked down the 100 Unit hallway with a surgical mask secured to her ears but worn below her nose with her entire nose visible. She approached Resident 10's Red Zone isolation room to answer an activated call light, donned a gown and gloves without sanitizing hands, and entered the resident's room with her surgical mask below her nose. She had not donned an N95 facemask or eye protection before she entered. The door contained a Red Zone sign that listed required PPE as an N95 facemask, eye protection, gown, gloves and frequent hand hygiene. Review of the Respiratory Surveillance Line Listing on 10/19/22 at 3:53 p.m., indicated Resident 10 had tested positive for COVID-19 on 10/16/22 with symptom onset date of 10/16/22. This resident resided on the 100 Unit. 5. During an observation of medication administration on 10/21/22 at 10:14 a.m., Qualified Medication Aide (QMA) 9 indicated Resident 33 was in Red Zone contact/droplet isolation. The resident's room door contained a Red Zone isolation sign and indicated required PPE. QMA 9 retrieved the resident's [MEDICATION(S)] 0.5% solution (antibiotic eye drops) from the center compartment of the top drawer in the 200 hall medication cart with other resident's eye drop containers. The eye drop bottle was in a prescription bottle container and placed on top of the medication cart during preparation. The eye dropper was not removed from the prescription bottle. QMA 9 donned PPE and the prescription bottle for the eye drops was picked up and taken into the resident's room. The prescription bottle was place on the overbed table with out a barrier, within one foot of the resident. QMA 9 removed the dropper for administration with her gloved hands, pulled down the resident's lower right eye lid, instilled the drop, placed the container back into the prescription bottle, and put the prescription bottle in to her pocket without cleaning the bottle. She doffed her attire in the room and performed hand hygiene upon exit. She removed the prescription bottle from her pocket with bare hands and placed it on top of the medication cart without a barrier. Without performing hand hygiene, QMA 9 unlocked the medication cart with her keys, opened the top center drawer of the medication cart and placed the eye drop prescription bottle back into the compartment against the other residents' containers stored in the same compartment. The prescription bottle was not disinfected at any time during the observation. During an interview on 10/21/22 at 10:48 a.m., QMA 9 indicated she should not have taken the bottle into the room and set it on the resident's table without cleaning it. She would typically have taken the drops out of the prescription bottle before she entered the resident's room and cleaned it before she placed it back into the medication cart. The lack of proper infection prevention and control practices caused a risk for the spread of infection. Review of the Respiratory Surveillance Line Listing on 10/19/22 at 3:53 p.m., indicated Resident 33 had tested positive for COVID-19 on 10/17/22 with symptom onset date of 10/17/22. This resident resided on the 200 unit. During an interview on 10/21/22 at 10:55 a.m., the Corporate Nurse Consultant indicated the medication container should not have been set on the residents over bed table in a Red Zone isolation room and placed back into the medication cart without a cleaning process. During an interview on 10/25/22 at 5:05 p.m., the Administrator indicated the facility followed the Center for Disease Control (CDC) and Indiana Department of Health guidelines and regulations regarding infection prevention and control during a COVID-19 facility outbreak and high community transmission. During an interview on 10/25/22 at 5:09 p.m., the Administrator indicated the community COVID-19 transmission rate had been high from 10/7/22 through 10/25/22, except for 10/24/22 when the community transmission was indicated as substantial. A current policy, titled, Infection Prevention and Control Program, provided by the Administrator on 10/17/22 following the entrance conference, included, but was not limited to, the following: PURPOSE .To establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections PROCEDURES 1. The campus has a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases that: a. Covers all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement b. Is based on the individual facility assessment c. Follows accepted national standards . 3.1-18(b)(1) 3.1-18(l)

Based on observation, interview and record review, the facility failed to ensure a resident with developmental disabilities received individualized services to maintain or improve quality of life for 1 of 1 resident reviewed. (Resident D) Findings include: Resident D's clinical record was reviewed on 10/21/22 at 10:17 a.m. Current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had a current physicians order for General Diet: Soft foods, thin liquid, supplements via PEG tube. Special Instructions: prefers: pancakes, scrambled eggs with cottage cheese, mashed potatoes with gravy, oatmeal This order originated 01/19/2022. A 6/15/22, Notice of PASRR [Pre-Admission Screening and Resident Review] Level II Outcome indicated the following: You have had limitations since birth, mobility, self care, self direction, learning, understanding and living independently. You are non-verbal, will smile and laugh. You are diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .You do not have mental health diagnosis. You are non verbal, blind and need total care for all of you (sic) needs You are severely impaired, profound intellectual disability. You find comfort in holding stuffed animals and soft blankets.You do not have a history of psychiatric hospitalization or outpatient mental health treatment. You enjoy listening to music and television.You are able to eat soft mushy foods by mouth but need help to eat . You use a wheelchair to get around, wheeled by others .You would benefit from socialization with staff, residents, and others to help with symptoms of mental health and boredom.Self Direction/Planning is affected due to the condition. A 3/3/22, Notice of PASRR Level II Outcome indicated the following: Medication review: Your previous records, current L1[level 1] PASRR, and the assessor reported that you are taking [MEDICATION(S)], but this medication was not listed in your current medical record. You would benefit from review of your medications to ensure that they are appropriate and necessary for your needs. Obtain archives psychiatric records to clarify history: Your previous PASRR included limited information about a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff should obtain records to clarify whether you have this diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .Socialization/leisure/recreation activities: Staff should help you participate in activities you enjoy and help you spend time with others in the nursing home safely .You enjoy listening to cartoons on TV.You enjoy being around staff at the nursing home. A current care plan problem/need, originated 7/29/21, indicated the resident was at risk for side effects due to anitpsychotic medication use. Approaches to this problem included, but were not limited to, GDR [gradual dose reduction] at least twice a year unless contraindicated, Encourage resident to participate in intellectually appropriate leisure and structured activity (sic). A current care plan problem/need, originated 8/1/22, indicated the resident had limited mobility related to [CONDITION(S)]. A current care plan problem/need, originated 8/11/21, indicated the resident had a HAB (habilitation) plan with the objective for the resident to continue to make verbalizations to indicate needs and wants. A current care plan problem/need, originated 7/29/21, indicated the resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Approaches to this problem included, but were not limited to, encourage the resident to participate in intellectually appropriate leisure and structured activity (sic). A current care plan problem/need, originated 7/29/21, indicated the resident had limited verbal communication due to aphagia. The goal to this problem was, Resident's impaired ability to communicate due to: mental [CONDITION(S)] will not result in unmet psychosocial needs. A current care plan problem/need, originated 7/27/21, indicated the resident had the potential of limited activity participation due to her diagnosis. A goal to this problem was, My goal is to engage in activities of interest, such as listening to music, spending time outside, mindful moments, and hand massages. A second goal for this problem was, My goal is to participate in a 15 min (minute) 1:1 (one to one activity), one time per week. A 1:1 Needs Assessment, dated 7/4/22, indicated the non-verbal resident, who could not self initiate activities, had experienced the following during the assessment period: Resident receives visits from family, significant others or pastor several times a week; Resident watches TV and/or listens to audio books or radio of choice and makes preferences known; Resident listens to music of choice and makes preferences known; Resident attends activity programs. These responses resulted in a score of 12, indicating the resident should be provided at least one 1:1 activity, [MEDICATION(S)] 15 minutes, weekly. A quarterly Minimum Data Set (MDS) assessment, dated 7/30/22, indicated the resident was severely cognitively impaired, had no speech-absences of the spoken word, had severely impaired vision, had no hallucinations or delusions, displayed no maladaptive behaviors, used a wheelchair for mobility, required staff assistance for mobility, used an anitpsychotic medication seven of seven days during assessment, and the anitpsychotic medication had not had a GDR attempt or documented statement of contraindication. Review of the resident's activity attendance record for 9/24/22 to 10/24/22, which was provided by the Activity Director on 10/25/22 at 11:19 a.m., indicated the resident had attended only nine activities in the 30 day period as follows: 10/24/22 at 4:22 p.m.-Music, [NAME] with (name) 10/24/22 at 8:51 a.m.-One On One, Mindful Moments 10//21/22 at 2:09 p.m.-One On One, Mindful Moments 10/21/22 at 8:53 a.m.-One On One, Mindful Moments 10/18/22 at 10:21 a.m.-One On One-Mindful Moments 10/12/22 at 9:01 a.m., One On One-Mindful Moments 10/6/22 at 8:40 a.m., One On One 9/27/22 at 4:38 p.m.-One On One-Talked to her 9/26/22 at 5:30 p.m.-Music, [NAME] During an interview on 10/25/22 at 11:19 a.m., the Activity Director indicated the information provided was the only record of activity attendance during the past month. A physician's progress note completed prior to the resident's admission to the long term care facility, dated 7/2/21, included, but was not limited to, the following: Current Medication(s): .[MEDICATION(S)] 1 mg (milligram) tablet, take 1/2 (g] tablet in am [morning] and 1 tablet HS [at bedtime].started on May 14, 2021 .maintenance drug risperdone 0.5mg tablet, 01 Tablet(s) GTube three times a day .start on May 11, 2021 .maintenance drug.Psychiatric: The patient denied anxiety, .obtained from [family member] due to mental capacity of patient. Non-verbal, She can smile and laugh, but cannot speak . During an interview on 10/25/22 at 3:49 p.m., the MDS Coordinator indicated Resident D had not exhibited any maladaptive behaviors, including delusions. The resident had a current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order originated on 3/28/22. A diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The clinical record lacked a medical evaluation, examination, or assessment related to this diagnoses. The clinical record lacked any documentation of physician's services related to a psychotic disorder or delusions prior to admission. The clinical record lacked any documentation of an evaluation or assessment for symptoms or conditions associated with a psychotic disorder or delusions following admission. The clinical record lacked any documentation regarding any symptoms of delusions. The clinical record for 8/1/22 to 10/20/22, had no documented episodes of delusions or any other maladaptive or psychotic behaviors. A 10/01/2022, Nurse Practitioners progress note indicated the following: psychiatric: Unable to respond due to diagnosis . The medication [MEDICATION(S)] and a psychotic disorder with delusions were not mentioned in this note. The note lacked any documentation regarding emotional distress or behavioral concerns. The note focused on pain management as it related to the resident's pain. A 10/2/22, [CONDITION(S)] & Sedative/Hypnotic Utilization By Resident, pharmacy report indicated the following: Antipsychotic-[MEDICATION(S)] 0.5 mg -Last GDR Date: Comments: 10/21 psych reduced to 0.5 mg bid [two times daily] (will try to taper and DC [discontinue]) .3/22 reduced to 0.25 mg bid, 6/22 psych pn [typo NP-nurse practitioner]-tolerating reduction in March without exacerbation; currently stable; no further adjustments at this time. The clinical record lacked any documented delusions or psychotic behaviors from March 2022 to October 25, 2022. During an interview on 10/25/22 at 1:31 p.m., the Administrator, Director of Nursing (DON), Activity Director and Social Services Director (SSD) were interviewed regarding the facilities method to assess/evaluate Resident D, and how she was provided on-going mental stimulation, socialization, and activity needs. How she was assessed for targeted behaviors for psychiatric medications use, and how the psychiatric diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/25/22 at 3:55 p.m., the Administrator provided an untitled document which she indicated was in response to the questions asked on 10/25/22 at 1:31 p.m. The document indicated the following: What we (are) doing to ensure that [Resident D's name] has socialization and stimulation for her developmental needs: Despite her Level II stating she has no specialized services or needs, we ensure that she has socialization and stimulation by interacting with her on a daily during ADL [activities of daily living] tasks (this includes AM/PM care, incontinence care, medication administration, pleasure/comfort feeding), bringing her to the common living room even if she can't participate in the group activity she is present for sounds and stimulation, she is taken to the dining room for restorative pleasure feeding, when she is in her room we turn on the radio. [Name] responses to stimulation are inconsistent for us to know if she is communicating or not .Life enrichment has revised her 1:1 care plan to increase to daily visits instead of one time per week, also noted to increase her attendance at music events .The life enrichment tool used to assess her activity ability is being revised . Review of consumption records for 9/21/22 to 10/20/22, identified concerns for 16 of 30 days as follows: a. 10/17/22, no documentation of a meal being offered or meal consumption for breakfast, lunch or dinner. b. 10/16/22, no documentation of a meal being offered or meal consumption for breakfast, lunch or dinner. c. 10/15/22, no documentation of a meal being offered or meal consumption for lunch. d. 10/14/22, no documentation of a meal being offered or meal consumption for breakfast, lunch or dinner. e. 10/13/22, no documentation of a meal being offered or meal consumption for dinner. f. 10/12/22, the documentation indicated the resident had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . g. 10/11/22, no documentation of a meal being offered or meal consumption for dinner. h. 10/10/22, no documentation of a meal being offered or meal consumption for breakfast or lunch. i. 10/5/22, no documentation of a meal being offered or meal consumption for lunch or dinner. j. 10/04/22, no documentation of a meal being offered or meal consumption for dinner. k. 10/3/22, no documentation of a meal being offered or meal consumption for dinner. l. 10/2/22, no documentation of a meal being offered or meal consumption for breakfast, lunch or dinner. j. 10/1/22, no documentation of a meal being offered or meal consumption for dinner. k. 9/29/22, no documentation of a meal being offered or meal consumption for dinner. l. 9/28/22, no documentation of a meal being offered or meal consumption for breakfast, lunch or dinner. m. 9/26/22, no documentation of a meal being offered or meal consumption for dinner. n. 9/24/22, no documentation of a meal being offered or meal consumption for breakfast, lunch or dinner. o. 9/22/22, no documentation of a meal being offered or meal consumption for breakfast, lunch or dinner. p. 9/21/22, no documentation of a meal being offered or meal consumption for breakfast, lunch or dinner. During the survey, the following was observed: a. On 10/17/22 at 11:55 a.m., the resident was seated in the 200 hall lounge. There was no activity or event. No other resident or staff were interacting with Resident D. b. On 10/18/22 at 11:08 a.m., the resident was seated in her wheel chair in the 200 hall lounge. She was curled up with her legs drawn up toward her chest. The staff offered her a blanket. c. On 10/18/22 at 1:48 p.m., the resident was seated in her wheel chair in the 200 hall lounge. She was curled up in her wheelchair. Her chin was resting on her chest. d. On 10/19/22 at 10:27 a.m., the resident was seated in her wheel chair in the 200 hall lounge. Her chin was resting on her chest. e. On 10/19/22 at 2:34 p.m., the resident was seated in her wheel chair in the 200 hall lounge. Her head was titled back and her chin was toward the ceiling. She was seated away from the other residents in the lounge. She lacked a soft toy or blanket or any manipulative device. f. On 10/20/22 at 9:25 a.m., the resident was in bed in her room. g. On 10/20/22 at 11:59 a.m., the resident remained in bed in her room. h. On 10/21/22 from 9:40 a.m. to 11:22 a.m., (1 hour 43 minutes), Resident D was seated in her wheel chair in the 200 hall lounge. During this time, no staff member spoke to her, offered her food, offered her an activity. i. On 10/21/22 at 11:22 a.m., Resident D was seated in her wheel chair in the lounge interacting with the activity assistant for 5 minutes. 3.1-37(a)

Based on observation, interview and record review, the facility failed to provide individualized activities to meet resident needs for 1 of 1 resident reviewed (Resident D) Findings include: During an observation on 10/17/22 at 11:55 a.m., Resident D was seated in the 200 hall lounge with no activity or event taking place. No other residents or staff were interacting with the resident. During an observation on 10/18/22 at 11:08 a.m., the resident was seated in her wheel chair in the 200 hall lounge. She was curled up with her legs drawn up toward her chest. The staff offered her a blanket. During an observation on 10/18/22 at 1:48 p.m., the resident was in her wheel chair in the 200 lounge. She was curled up in her wheelchair. Her chin was resting on her chest. During an observation on 10/19/22 at 10:27 a.m., the resident was seated in her specialized wheelchair in the 200 lounge. Her chin was resting on her chest. During an observation on 10/19/22 at 2;34 p.m., the resident was seated in her wheel chair in the 200 lounge her head was titled back and her chin was toward the ceiling. She was seated away from the other residents in the lounge. She did not have a soft toy or blanket or any manipulative device. During an observation on 10/20/22 at 9:25 a.m., the resident were in bed in her room. During an observation on 10/20/22 at 11: 59 a.m., the resident remained in bed in her room. During an observation on 10/21/22 from 9:40 a.m. to 11:22 a.m., (1 hour 43 minutes) Resident D was in her specialized wheelchair in the 200 lounge. During this time no staff member spoke to her, offered her food, offered her an activity. During an observation on 10/21/22 at 11:22 a.m., Resident D was in her custom wheelchair in the lounge interacting with the activity assistant for 5 minutes. Resident D's clinical record was reviewed on 10/21/22 at 10:17 a.m. Current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was admitted to the facility on [DATE]. A 7/30/22, Quarterly, MDS (Minimum Data Set) Assessment indicated the resident was severely cognitively impaired, had no speech-absence of the spoken word, had severely impaired vision, used a wheelchair for mobility, and required staff assistance for mobility. A current care plan problem/need, which originated 7/27/21, indicated the resident had the potential of limited activity participation due to her diagnosis. A goal to this problem was, My goal is to engage in activities of interest, such as listening to music, spending time outside, mindful moments, and hand massages. A second goal for this problem was, My goal is to participate in a 15 min (minute) 1:1 (one to one activity), one time per week. A current care plan problem/need, which originated 8/1/22, indicated the resident had limited mobility related to [CONDITION(S)]. A current care plan problem/need, which originated 7/29/21, indicated the resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Approaches to this problem included, but were not limited to, encourage the resident to participate in intellectually appropriate leisure and structured activity (sic). A 1:1 Needs Assessment, dated 7/4/22, indicated the non-verbal resident , who could not self initiate activities, had experienced the following during the assessment period Resident receives visits from family, significant others or pastor several times a week, Resident watches TV and/or listens to audio books or radio of choice and makes preferences known, Resident listens to music of choice and makes preferences known, Resident attends activity programs. These responses resulted in a score of 12 indicating the resident should be provided, at least 1 1:1 15 min. (minutes) weekly. A 6/15/22, Notice of PASRR Level II Outcome indicated the following: You have had limitations since birth, mobility, self care, self direction, learning, understanding and living independently. You are non-verbal, will smile and laugh. You are diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . You are non verbal, blind and need total care for all of you (sic) needs You are severely impaired, profound intellectual disability. You find comfort in holding stuffed animals and soft blankets. You enjoy listening to music and television. You use a wheelchair to get around, wheeled by others .You would benefit from socialization with staff, residents, and others to help with symptoms of mental health and boredom.Self Direction/Planning is affected due to the condition. A 3/3/22, Notice of PASRR Level II Outcome indicated the following: .Socialization/leisure/recreation activities: Staff should help you participate in activities you enjoy and help you spend time with others in the nursing home safety .You enjoy listening to cartoons on TV.You enjoy being around staff at the nursing home. Review of the resident's activity attendance record for 9/24/22 to 10/24/22, which was provided by the Activity Director on 10/25/22 at 11:19 a.m., indicated the resident had attended only 9 activities in the 30 day period as follows: 10/24/22 at 4:22 p.m.-Music, [NAME] with (name) 10/24/22 at 8:51 a.m.-One On One, Mindful Moments 10//21/22 at 2:09 p.m.-One On One, Mindful Moments 10/21/22 at 8:53 a.m.-One On One, Mindful Moments 10/18/22 at 10:21 a.m.-One On One-Mindful Moments 10/12/22 at 9:01 a.m., One On One-Mindful Moments 10/6/22 at 8:40 a.m., One On One 9/27/22 at 4:38 p.m.-One On One-Talked to her 9/26/22 at 5:30 p.m.-Music, [NAME] During an interview on 10/25/22 at 11:19 a.m., the Activity Director indicated the information provided was the only record of activity attendance during the past month. She additionally indicated the activity goal of one 1:1 activity one time per week did not consider the residents inability to self-initiate activities. During an interview on 10/25/22 at 1:31 p.m., the Administrator, DON, Activity Director and Social Services Director were interviewed regarding the facilities method to assess/evaluate Resident D and provide on-going mental stimulation, socialization, activity needs and the related assessments. On 10/25/22 at 3:55 p.m., the Administrator provided an untitled document which she indicated was in respond to the questions asked on 10/25/22 at 1:31 p.m. The document indicated the following: What we (are) doing to ensure that [Resident D's name] has socialization and stimulation for her developmental needs: Despite her Level II stating she has no specialized services or needs, we ensure that she has socialization and stimulation by interacting with her on a daily during ADL tasks (this includes AM/PM care, incontinence care, medication administration, pleasure/comfort feeding), bringing her to the common living room even if she can't participate in the group activity she is present for sounds and stimulation, she is taken to the dining room for restorative pleasure feeding, when she is in her room we turn on the radio. [Name] responses to stimulation are inconsistent for us to know if she is communicating or not . Life enrichment has revised her 1:1 care plan to increase to daily visits instead of one time per week, also noted to increase her attendance at music events . The life enrichment tool used to assess her activity ability is being revised . 3.1-33(a)

Based on observation, interview and record review, the facility failed to ensure residents who received antipsychotic medications had documented medical indications for use, had appropriate diagnoses for use, had gradual dose reductions and/or contraindication for reductions for 1 of 3 residents reviewed for psychoactive medication use. (Residents D) Findings include: Resident D's clinical record was reviewed on 10/21/22 at 10:17 a.m. Current diagnoses included, but were not limited to, congenital malformation of the corpus callussom (the bundle of nerve fibers which connect the two brain hemispheres), immobility syndrome, [CONDITION(S)], and intellectual disability/intellectual developmental disorder severe. The resident was admitted to the facility on [DATE]. A physician's progress note, completed prior to the residents admission to the long term care facility, dated 7/2/21, indicated the following: Current Medication(s): .[MEDICATION(S)] [an antipsychotic medication] 1 mg [milligram] tablet, Take 1/2 [0.50 mg] tablet in am [morning] and 1 tablet HS [at bedtime].started on May 14, 2021 .maintenance drug risperdone 0.5 mg tablet, 01 Tablet(s) GTube three times a day .start on May 11, 2021 .maintenance drug. Psychiatric: The patient denied anxiety, .obtained from [family member] due to mental capacity of patient. Non-verbal, She can smile and laugh, but cannot speak . The resident had a current physician's order for [MEDICATION(S)]/risperal (an anitpsychotic medication) tablet, 0.25 mg, one twice a day. The order originated 3/28/22. A diagnoses of psychotic disorder due to another medical condition, with delusions was added to the resident's medical record on 10/4/2021. The clinical record lacked a medical evaluation, examination, or assessment related to this diagnoses. The clinical record lacked any documentation of physician's services related to a psychotic disorder or delusions prior to admission. The clinical record lacked any documentation of an evaluation or assessment for symptoms or conditions associated with a psychotic disorder or delusions following admission. The clinical record lacked any documentation regarding how this none verbal resident displayed symptoms of delusions. The clinical record for 8/1/22 to 10/20/22, lacked documentation of episodes of delusions, any other maladaptive, or psychotic behaviors. A 10/2/22, [CONDITION(S)] &Sedative/Hypnotic Utilization By Resident pharmacy report, indicated the following: Anitpsychotic-Resperidone 0.5 mg -Last GDR Date: Comments: 10/21 psych reduced to 0.5 mg bid { two times daily] (will try to taper and DC [discontinue]) .3/22 reduced to 0.25 mg bid, 6/22 psych pn [typo NP-nurse practioner]-tolerating reduction in March without exacerbation; currently stable; no further adjustments at this time. The clinical record lacked any documented delusions or psychotic behaviors from March 2022 to October 25, 2022. A quarterly Minimum Data Set (MDS) assessment, dated 7/30/22, indicated the resident had severe cognitive impairment, had no speech-absence of the spoken word, had severely impaired vision, had no hallucination or delusions, displayed no maladaptive behaviors, used an antipsychotic medication seven of seven days during assessment, and the antipsychotic medication lacked a gradual dose reduction (GDR) attempt or statement of contraindication. A current care plan problem/need, which originated 7/29/21, indicated the resident was at risk for side effects due to antipsychotic use. Approaches to this problem included, but were not limited to, GDR at least twice a year unless contraindicated, Encourage resident to participate in intellectually appropriate leisure and structured activity (sic). A 6/15/22, Notice of PASRR [Pre-Admission Screening and Resident Review] Level II Outcome indicated the following: You have had limitations since birth, mobility, self care, self direction, learning, understanding and living independently. You are non-verbal, will smile and laugh You do not have mental health diagnosis .You are severely impaired, profound intellectual disability . You do not have a history of psychiatric hospitalization or outpatient mental health treatment. A 3/3/22, Notice of PASRR Level II Outcome indicated the following: Medication review: Your previous records, current L1[level 1] PASRR, and the assessor reported that you are taking [MEDICATION(S)], but this medication was not listed in your current medical record. You would benefit from review of your medications to ensure that they are appropriate and necessary for your needs. Obtain archives psychiatric records to clarify history: Your previous PASRR included limited information about a new diagnosis of Psychotic Disorder with no information about mood symptoms or behaviors to explain this diagnosis. Staff should obtain records to clarify whether you have this diagnosis and if you need treatment. A 10/01/2022, Nurse Practitioners note indicated the following: psychiatric: Unable to respond due to diagnosis . The medication [MEDICATION(S)] and a psychotic disorder with delusions were not mentioned in this note. The note lacked any documentation regarding emotional distress or behavioral concerns. The note focused on pain management. During an observation on 10/17/22 at 11:55 a.m., the resident was seated in the 200 lounge no activity or event was taking place. No other resident or staff were interacting with Resident D. During an observation on 10/18/22 at 11:08 a.m., the resident was seated in her wheel chair in the 200 lounge. She was curled up with her legs drawn up toward her chest. The staff offered her a blanket. During an observation on 10/18/22 at 1:48 p.m., the resident was in her wheel chair in the 200 lounge. She was curled up in her wheelchair. Her chin was resting on her chest. During an observation on 10/19/22 at 10:27 a.m., the resident was seated in her specialized wheelchair in the 200 lounge. Her chin was resting on her chest. During an observation on 10/19/22 at 2;34 p.m., the resident was seated in her wheel chair in the 200 lounge her head was titled back and her chin was toward the ceiling. She was seated away from the other residents in the lounge. She did not have a soft toy or blanket or any manipulative device. During an observation on 10/20/22 at 9:25 a.m., the resident were in bed in her room. During an observation on 10/20/22 at 11: 59 a.m., the resident remained in bed in her room. During an observation on 10/21/22 from 9:40 a.m. to 11:22 a.m., (1 hour 43 minutes) Resident D was in her specialized wheelchair in the 200 lounge. During this time no staff member spoke to her, offered her food, offered her an activity. During an observation on 10/21/22 at 11:22 a.m., Resident D was in her custom wheelchair in the lounge interacting with the activity assistant for 5 minutes. During an interview on 10/25/22 at 1:31 p.m., the Administrator, DON, Activity Director and Social Services Director were interviewed regarding the facilities method to assess/evaluate Resident D's targeted behavior for psychiatric medications, how the psychiatric diagnoses was obtained. As of the exit on 10/25/22 the facility had not provided information regarding the resident obtaining a psychiatric diagnosis or how the resident displayed delusions. During an interview on 10/25/22 at 3:49 p.m., the DMS Coordinator indicated Resident D did not exhibit any maladaptive behaviors including delusions. A current, 9/17/12, facility policy, titled Psychoactive Drug Monitoring, which was provided by the Social Services Director in 10/25/22 at 3:28 p.m., indicated the following: Residents receive a psychoactive medications only if designated medically necessary by the prescriber. Residents receive anti-psychotic medication only for behaviors that are quanitively and objectively documented . Residents receive anti-psychoactive medications only for behaviors that are persistent, that are not caused by a preventable reasons, and are causing the resident to: Present a danger it self or others, Continuously scream, yell, or pace, Experience psychotic symptoms . 3.1-48(b)

Based on record review and interview the facility failed to prevent the abuse of a totally dependent resident for 1 of 3 residents reviewed for abuse by a staff member. (Resident B and CNA1 [Certified Nursing Aide]). This deficient practice resulted in the resident being bathed and left unclothed and without a call light for several hours. Findings include: The clinical record for resident B was reviewed on 2/16/2022 at 10:00 a.m diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent Quarterly Minimum Data Set (MDS) assessment, dated 12/2/2021, was reviewed on 2/16/2022 at 10:00 a.m. The MDS indicated the resident was a totally dependent and required the assistance of 2 persons for bed mobility, transfers, walking, dressing, toilet use. The resident required extensive assistance of one person for eating and personal hygiene with impairment to both upper and lower extremities on both sides. Review of a facility interview with Resident B indicated the resident stated CNA1 entered her room during the night shift of 1/25/2022 to give her a bed bath and she declined and stated she was going to get bathed by hospice on 1/26/2022. CNA1 bathed the resident anyway. After the bed bath she asked CNA1 to put a gown on her and the call light and bed control within reach. CNA 1 left the room and closed the door without putting a gown on her or placing the call light, over the bed table with her remote and telephone within reach. The resident indicated she was cold and had to use her teeth and hands to pull the sheet over her. The resident also stated she asked CNA1 to leave the door open so she could say nurse please help me, but she closed the door when she left the room. The resident indicated she told CNA2 what happened and reported it to the psych councilor. Review of a written statement of CNA2, dated 1/26/2022, indicated when she entered the room the call light was in the left corner of the bed, the call light and her remote were on the left side and her door had been closed. CNA2 indicated the resident was upset about getting a bed bath at 1:00 a.m. Review of a written statement by CNA1, dated 1/26/2022, indicated she entered the resident's room and found her incontinent, so I washed her up. CNA1 indicated the resident asked why she got a bed bath at 1:00 a.m. and she explained to her that she as soaked and needed to be washed up. CNA1 indicated she left the over bed table, and call light within the resident's reach. CNA1 indicated the resident never voiced any concerns about the door being closed or discomfort. During an interview on 2/16/2022 at 12:06 p.m., the Director of Nursing (DON) indicated the current MDS had assessed the resident as totally dependent with the assistance of 2 for bed mobility. She provided the following timeline for a facility abuse allegation investigation: a. 1/26/2022 at 11:58 a.m. the Social Service Director was notified of an allegation of abuse. b.1/26/2022 at 12:56 p.m. the DON was made aware of the abuse allegation. c. 1/26/2022 at 1:40 p.m. the DON and Assistant Director of Nursing (ADON) started the facility investigation. 1/26/2022 at 1:56 p.m. the investigation was completed and determined the allegation was unsubstantiated. d.1/26/2022 at 2:00 p.m. the DON obtained a statement form the CNA1. e. 1/26/2022 at 2:15 p.m. a skin assessment was performed on Resident B and other residents on the 200 hall. During an interview on 2/16/2022 at 1:33 p.m., the MDS Coordinator indicated on 1/26/2022 the SSD arrived in her office to prepare for upcoming care conferences around noon. The SSD indicated she had received an allegation of abuse from a psych councilor. The MDS Coordinator asked her if she had reported this to the DON because the Administrator was out of the facility on medical leave and the DON was in charge. The SSD indicated she had not reported the allegation to the DON. The MDS Coordinator indicated she then used her personal phone to call the DON and handed her phone to the SSD. After the SSD spoke to the DON she left the office to meet with the DON. When the SSD returned they moved forward with the care conferences. After they were completed, the SSD told her she saw CNA1 on the unit and went to the DON to ask that CNA1 be suspended until the end of the investigation. The SSD told the MDS Coordinator the DON became upset and did not suspend CNA1 and indicated she had completed the investigation. The MDS Coordinator stated that about 3:30 p.m., the SSD returned to her office and was visibly upset about her conversation with the DON. The MDS Coordinator indicated she suggested she call the Administrator with her concerns. When the SSD returned to her office after speaking with the Administrator, she was again upset and crying stating the Administrator said the DON had already done the investigation. During an interview on 2/16/2022 at 3:49 p.m., Resident B indicated on 1/25/2022 on the night shift at approximately 1:00 a.m. (1/26/2022), CNA 1 entered her room and began giving her a bed bath. The resident indicated she told CNA1 she did not want a bed bath, the CNA indicated she had to be cleaned up. The resident indicated during the bed bath, CNA1 turned and repositioned her in a rough manner and she told the CNA repeatedly that she was hurting her. She indicated the CNA was unresponsive and did not change her behavior. The resident indicated after the bed bath, CNA1 left her undressed under a sheet and moved her over the bed table to the end of the bed where she could not reach it. CNA1 also placed the resident's call light out of reach and closed the door to her room when she left. CNA 1 closed the door to the resident's room when she left. The resident indicated she was upset that she was unable to call for help and left undressed, cold with only a sheet to cover her. The resident indicated she remained undressed and unable to call for help until a day shift CNA (CNA 2) entered her room at 9:00 a.m. She indicated she had told the facility she did not want CNA1 to care for her in the future. During an interview on 2/17/2022 at 8:54 a.m., CNA 2 indicated on the morning of 1/26/2022, she was approached by a male, she believed to be a from hospice, stating Resident B needed to see her. CNA 2 indicated when she entered the room she found the resident was naked under a sheet and her over the bed table at the end of her bed out of reach. She indicated the call light was located in the upper left hand corner of the bed also out of reach of the resident. The resident told her she had been given a bed bath at 1:00 a.m. She indicated the resident was upset the night shift CNA had not returned to dress her and put her over the bed table and call light within her reach. She indicated the resident stated she no longer wanted CNA1 to provide her care. CNA 2 indicated the day shift nurse was made aware. CNA2 indicated it was known that the resident prefered her door left open and staff were only to provide care when the resident puts on the call light. CNA2 indicated she had planned to talk to CNA1 about the condition the resident was found in herself when she reported for her shift that evening but did not report this to the Administrator. During an interview on 2/17/2022 at 11:00 a.m., the hospice Administrator indicated a hospice aide had provided care for the resident but had arrived at the facility after 3:00 p.m. on 1/26/2022. During an interview on 2/17/2022 at 11:48 a.m., CNA1 indicated she had provided the resident with a bed bath during the night shift on 1/25/2022 into 1/26/2022. She indicated the resident had not complained of pain or discomfort during the bed bath and when she exited the room the resident had her call light and over the bed table within reach. She indicated she put the call light in the resident's left hand. She indicated the resident was a total care and was unable to reposition or dress/undress herself. During an interview on 2/17/2022 at 1:55 p.m., the Psych Councilor indicated on 1/26/2022 Resident B told her CNA1 had left her undressed under a sheet, placed her call light and over the bed table out of her reach and closed the door to her room. She indicated the resident was upset over the incident. The Councilor contacted the facility SSD, her usual point of contact, and reported the incident. Review of a current policy, dated 8/29/2019, titled Abuse and Neglect Procedural Guidelines indicated the following: . c. Deprivation of Goods and Services by Staff: staff has the knowledge and ability to provide care and services, but choose not to do it, or acknowledge the request for assistance form a resident(s), which result in care deficits to a resident(s) . e. Mental/Emotional Abuse- Mental abuse is the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. This policy was provided by the Administrator on 2/16/2022 at 10:42 A.M. This Federal tag relates to Complaint IN 887. 3.1-27(a)(1)

Based on interview and record review, the facility failed to report to the Administrator or State agency allegations of abuse of a totally dependent resident by a staff member for 1 of 3 residents reviewed for abuse. (Resident B and CNA 1 [Certified Nursing Aide]). Findings include: The clinical record for resident B was reviewed on 2/16/2022 at 10:00 a.m diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent Quarterly Minimum Data Set (MDS) assessment, dated 12/2/2021, was reviewed on 2/16/2022 at 10:00 a.m. The MDS indicated the resident was a totally dependent and required the assistance of 2 persons for bed mobility, transfers, walking, dressing, toilet use. The resident required extensive assistance of one person for eating and personal hygiene with impairment to both upper and lower extremities on both sides. During an interview on 2/16/2022 at 12:06 p.m., the Director of Nursing (DON) provided the following timeline for a facility abuse allegation investigation: a. 1/26/2022 at 11:58 a.m. the Social Service Director was notified of an allegation of abuse. b. 1/26/2022 at 12:56 p.m. the DON was made aware of the abuse allegation. c. 1/26/2022 at 1:40 p.m. the DON and Assistant Director of Nursing (ADON) started the facility investigation. d. 1/26/2022 at 1:56 p.m. the investigation was completed and determined the allegation was unsubstantiated. e. 1/26/2022 at 2:00 p.m. the DON obtained a statement form the CNA1. f. 1/26/2022 at 2:15 p.m. a skin assessment was performed on Resident B and other residents on the 200 hall. The facility reportable was made on 1/27/2022 at 5:32 p.m. 29.5 hours after the facility was made aware of the allegation. During an interview on 2/16/2022 at 1:33 p.m., the MDS Coordinator indicated on 1/26/2022 the SSD arrived in her office to prepare for upcoming care conferences. The SSD indicated she had received an allegation of abuse from a psych councilor. The MDS Coordinator asked her if she had reported this to the DON because the Administrator was out of the facility on medical leave and the DON was in charge. The SSD indicted she had not reported the allegation to the DON. The MDS Coordinator indicated she then used her personal phone to call the DON and handed her phone to the SSD. After the SSD spoke to the DON she left the office to meet with the DON. When the SSD returned they preceded with the care conferences. After they were completed, the SSD told her she saw CNA1 on the unit and went to the DON to ask that CNA1 be suspended until the end of the investigation. The SSD told the MDS Coordinator the DON became upset and did not suspend CNA1 and indicated the investigation had been completed. The MDS Coordinator stated that about 3:30 p.m., the SSD returned to her office and was visibly upset about her conversation with the DON. The MDS Coordinator indicated she suggested she call the Administrator with her concerns. When the SSD returned to her office after speaking withe the Administrator she was again upset and crying stating the Administrator said the DON had already done the investigation. During an interview on 2/17/2022 at 8:54 a.m., CNA2 indicated on the morning of 1/26/2022, she was approached by a male, she believed to be a companion from hospice, stating Resident B needed to see her. CNA2 indicated when she entered the room she found the resident was naked under a sheet and her over the bed table at the end of her bed out of reach . She indicated the call light was located in the upper left hand corner of the bed also out of reach of the resident. The resident told her she had been given a bed bath at 1:00 a.m. She indicated the resident was upset the night shift CNA had not returned to dress her and put her over the bed table and call light within her reach. She indicated the resident stated she no longer wanted CNA1 to provide her care. CNA 2 indicated the day shift nurse was made aware CNA2 indicated it was known that the resident prefers her door left open and staff are only to provide care when the resident puts on the call light. CNA2 indicated she planned to talk to CNA1 about the incident when she reported for her shift but did not report this to the Administrator. Review of a current policy, dated 8/29/2019, titled Abuse and Neglect Procedural Guidelines provided by Administrator on 2/16/2022 at 10:42 a.m., indicated the following: . g. Reporting/response 1. Any staff member, resident, visitor or resident representative may report known or suspected abuse, exploitation, neglect, or misappropriation to local or state agencies. ii. Ensure that all alleged violations involving abuse neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property,, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse and do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the state Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. This Federal tag relates to Complaint IN 887. 3.1-28(c)

Based on observations, interviews and record reviews, the facility failed to properly implement an infection control program to prevent the possible spread of COVID-19 relating to social distancing of residents and resident mask use for 14 of 17 residents reviewed for infection control (Residents 2, 3, 4, 5, 6, 7, 8, 9,10, 11, 12, 13, 14 and 15). Findings include: During an interview on 2/1/22 at 10:30 a.m., the Director of Nursing indicated the facility currently had two (2) residents who had tested positive for the COVID-19 virus and were currently in isolation. During observations on 2/1/22 at 12:05 p.m., and 2/2/22 at 11:45 a.m., in the health care main dining room, there were 12 tables in the dining room. Tables were not placed to ensure 6 feet spacing of residents. Tables had either 2 or 4 chairs. The placement of chairs resulted in residents sitting 2 to 3 feet from each other. During the observations, residents were observed eating their meals. Residents were seated at tables of 2, 3, and 4. During an interview on 2/2/22 at 11:53 a.m., the Administrator indicated an average if 32 residents eat meals in the main dining room daily. During an observation on 2/1/22 at 3:24 p.m., four (4) residents were escorted by activity personal to the lounge for an activity. The residents were seated by active staff. The residents were seated in a position that was side by side and closer than 6 feet one another. The activity group included Residents 8, 6 and 5. The residents were not wearing masks. The activity personal did not ensure these residents without masks were assisted to sit in a 6 foot socially distance position for activities. On 2/2/22 at 1:30 p.m., a list of residents who did not comply with mask use was provided by the Corporate Nurse Consultant. Residents 8, 6, and 5 were on the list. During an observation of a Pioneer Lounge activity on 2/2/22 from 9:33 a.m. to 9:48 a.m., eight (8) residents were present. Residents 2, 3, 4, 5, 7, 8 were included in this activity group. All eight (8) residents were not wearing masks. The residents were seated by staff members less than six (6) feet apart. At no time during the activity did any staff member offer or encourage mask use nor move resident chairs and/or wheelchairs 6 feet apart to ensure social distancing of the eight residents without masks. On 2/2/22 at 1:30 p.m., a list of residents who did not comply with mask use was provided by the Corporate Nurse Consultant. Residents 4, 5, 8 During an interview on 2/2/22 at 9:48 a.m. Activity Assistant 2 indicated that all of the residents were not wearing masks nor were they six feet apart. She also indicated she did not encourage mask use before the activity began. During an observation of Bingo on 2/2/22 from 9:57 a.m. to 10:41 a.m., residents were not encouraged or assisted to sit 6 feet apart nor was the room large enough to ensure such spacing. Bingo was offered in the lounge located in the center of the facility. The lounge was paced off at this time and measured 18 to 20 feet by 18 to 20 feet. The activity staff escorted in dependent residents and began to set up folding tables. The lounge contained one table prior to the folding table placement. Three folding tables were set up in this lounge. Seventeen (17) residents from both the healthcare and residential areas of the facility were in attendance for Bingo. Residents were seated side by side and across the table at a distance of less than 1 foot to three feet from one another. The staff members escorted residents into the lounge at 9:58 a.m. and sat them side by side. At 9:58 a.m., Activity Assistant 3 told the residents the activity would begin at 10:30 a.m. (32 minutes after she seated residents side by side). From 9:58 a.m. to 10:10 a.m.,(12 minutes), no resident in attendance was offered or wearing masks. Residents 7, 8, 9, 10, 11, 12. 13, 14 and 15 were in attendance during the Bingo activity. During an interview on 2/2/22 at 10:41 a.m., the Activity Director indicated the facility believed after the COVID-19 vaccine had been introduced into the facility and residents were vaccinated the 6 foot social distancing requirement had been loosened for vaccinated residents, During an interview on 2/2/22 at 11:53 a.m., the Administrator indicated the facility had believed after residents were fully vaccinated they could be in areas closure than 6 feet apart for activities and dining. A current, undated, facility policy, titled COVID-19 Guidelines for PPE [Personal Protective Equipment], which was provided by the DON on 2/2/22 at 10:59 a.m., indicated the following: All residents, staff, vendors, students, and visitors must wear masks at all times unless actively eating or drinking, regardless of their vaccination status. A current, 11/15/21, facility policy, titled Health Center COVID-19 Activities, which was provided by the DON on 2/2/22 at 10:59 a.m., indicated the following: All residents, visitors, vendors, essential volunteers, and staff must wear masks indoors regardless of vaccination status and following infection prevention principles. 3.1-18(b)

Based on observation, record review and interview, the facility failed to evaluate residents for self-administration of medications for 2 or 2 residents observed to have medications at bedside. (Residents 9 and 18) Finding includes: 1. During initial tour of facility on 8/24/21 at 10:45 a.m., Resident 18 had a cup of medicine located on her over the bed table. The resident indicated she tells the nurse to leave the medicine and she would take her medication when she wants. Resident 18's baseline care plan dated 6/17/21, included, but was not limited to: administer medication per Medical Doctor (MD) order, observe for side effects of medication and notify MD of any noted. Cognition goal indicated resident was not alert and oriented and included a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Resident 18's Care Area Assessment (CAA) dated 6/30/21, included but was not limited to: Cognitive Loss/Dementia, Brief Interview for Mental Status (BIMS) indicated the resident had moderate cognitive loss. The resident requires skilled nursing care for medical management and medication oversite. Review of the residents physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] 2. During a hall-tray, meal observation on 8/25/21 at 9:15 a.m., Resident 9 was observed to be seated in his room, in a wheelchair with his bedside table in front of him. There was a medication cup with several pills in the cup on the bedside table. During an interview, the resident indicated he had not taken his medication yet, but would be taking them when breakfast was served. Qualified Medication Aide (QMA) 1 entered the room and indicated to the resident that he needed to take his medication and then left the room. The medication cup containing the pills remained on his bedside table. During an interview on 8/25/21 at 9:25 a.m., QMA 1 indicated Resident 9 prefers to take his morning medications after he had a few bites of his breakfast and that it was okay to leave his medications on his bedside table. The clinical record for Resident 9 was reviewed on 8/25/21 at 10:00 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly Minimum Data Set (MDS) assessment, dated 8/11/21, indicated the resident was moderately cognitively impaired. A review of the resident's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A care area assessment (CAA) for Cognitive Loss/Dementia, included a conclusion statement dated 5/11/21, that included, but was not limited to, He requires skilled nursing care for medical management and medication oversight. During an interview on 8/25/21 at 10:30 a.m., the Nurse Consultant indicated the medications should not be left at bedside unless a resident had a self-administration assessment. Resident 9 did not have an assessment for self-administration of medications. A current facility policy, dated March 2015, titled Inservice Manual, provided by the Director of Nursing (DON) on 8/25/21 at 11:15 a.m., included, but was not limited to, II. DURING THE MEDICATION PASS .Monitor resident, make sure medication is taken, leaving NO medications at bedside. 3.1-11(a)

Based on observation, record review and interview, the facility failed to provide adequate supervision and failed to implement effective care plan interventions to prevent falls for 2 of 4 residents reviewed for accidents (Residents B and D). This deficient practice resulted in Resident B falling, hitting his head and receiving 11 staples. Findings include: 1. During an observation on 7/7/21 at 11:05 a.m., Resident B was lying in his bed. The bed was in low position and a floor mat was placed next to the bed. The resident's call light was lying on the floor next to the top of his bed and was out of his reach. During an observation on 7/7/21 at 1:05 p.m., Resident B was seated in his wheelchair positioned away from a table in the main dining room after eating his meal. There was no regular dining chair at the table and no facility staff present in the dining room. Resident B appeared restless with frequent adjustments to his legs. At 1:15 p.m., staff entered the dining room and began clearing table cloths from the tables. Resident B remained in his wheelchair and was observed frequently closing his eyes and then awakening to readjust himself in his wheelchair. At 1:23 p.m., the business office manager entered the dining room and woke Resident B and asked if he would like to return to his room. She removed resident from the dining room at 1:25 p.m. During an observation on 7/8/21 at 9:43 a.m., Resident B was seated in a wheelchair in his room, fidgeting in his chair. Observation of room lacked the presence of a busy blanket. The clinical record for Resident B was reviewed on 7/7/21 at 10:23 a.m. Diagnoses included, but were not limited to, fracture of left ulna, [CONDITION(S)], muscle weakness, and repeated falls. The resident admitted to the facility on [DATE]. The resident had an admission minimum data set (MDS) assessment, dated 4/10/21, which indicated the resident was severely cognitively impaired, was a limited assist of one staff for bed mobility, transfer and bathing. He was an extensive assist of 1 staff for dressing and toileting. The resident used a wheelchair and was not steady when or upon standing. A care plan for Falls, dated 4/7/21 with the problem: Resident at risk for falling related to history of falls, dementia, weakness, depression, anxiety, stroke, and [CONDITION(S)]. Interventions included, but were not limited to, staff to assist resident with transfers as needed, keep personal items and frequently used items within reach, keep call light in reach, and provide non-skid footwear. The resident's Event Report's, included the following incidents: a. On 4/14/21 at 7:30 a.m., Resident B was found sitting on the floor by the door to his room during staff rounds. Resident was assessed to have no injuries and was assisted back to bed. A fall care plan intervention was added on 4/14/21 to increase purposeful rounding. b. On 4/14/21 at 2:10 p.m., Resident B was found on the bathroom floor in his room in front of the toilet. Resident reported one of his shoes had fallen off and was assessed to have no injuries. A fall care plan intervention was added on 4/15/21, to assess for appropriate fitting footwear. c. 4/19/21 at 11:35 a.m., the resident was observed by staff standing in the hallway outside of his room and reaching for the door handle to his bathroom when he fell to the floor onto his buttocks. Resident was assessed to have no injuries. A fall care plan intervention was added on 4/20/21, to offer to toilet before lunch. d. 4/27/21 at 11:12 a.m., staff observed resident seated in his wheelchair in his room. He was then observed standing up from his wheelchair and loosing his balance, falling to the floor on his buttocks. The resident was assessed to have no injuries and was assisted back into his wheelchair. A fall care plan intervention was added on 4/27/21, to provide busy/activity blanket for resident. e. 5/9/21 at 2:17 p.m., resident was observed sitting on the floor in his room with his head against the wall. He was assessed and found to have an abrasion to the right side of his head requiring first aide and an island dressing was to be applied. A fall care plan intervention was added on 5/12/21, to toilet resident after lunch. f. 6/5/21 at 6:24 p.m., resident was found on the floor in his room after being laid down for a nap. The resident was assessed and found to have a skin tear to his left hand which required first aide. The resident was assisted into his wheelchair and seated in a common area for observation. A fall care plan intervention was added on 6/7/21, to place floor mats at the bedside. g. 6/6/21 at 5:37 p.m., the resident was seated in his wheelchair at a table in the main dining room. Staff went to obtain another plate of food for another resident and upon return, observed Resident B seated on the floor in front of his wheelchair with his plate beside him. He was assessed to have no injuries and assisted into his wheelchair. A fall care plan intervention was added on 6/7/21, to transfer resident into a regular chair when in the dining room. h. 6/14/21 at 10:16 p.m., the resident was being transferred into his wheelchair to go to the bathroom and tripped, falling forward and hitting his head above the left eye. Resident was assessed to have a 1 cm laceration above his left eye. He received first aide and a application of a bandaid. A fall care plan intervention was added on 6/15/21, for two people for all transfers i. 6/19/21 at 6:59 p.m., resident was observed seated in his wheelchair, eating dinner in his room. Staff later observed resident on the floor in his room, seated on his buttocks, leaning against a dresser and unclothed. Resident was assessed to have a skin tear to his left elbow with moderate bleeding. First aide was performed and steri-strips applied to wound. A fall care plan intervention was added on 6/19/21, for resident to be offered early rise get up. j. 6/20/21 at 5:15 a.m., the resident was found by staff on the floor of his room in front of a dresser. He was assessed to have a large bump with an open area noted to the back of his head. The resident indicated he hit his head on the wall and a large blood spot was noted on the wall. He was sent to the emergency room and received 11 staples to the back of his head. A fall care plan intervention was added on 6/21/21, to assist resident with getting ready for bed after dinner. k. 6/30/21 at 12:47 a.m., resident was found seated on the floor next to his bed. Resident was assessed to have a 2 centimeter (cm) by 0.5 cm laceration above his left eye and a 0.5 cm by 0.5 cm laceration on the bridge of his nose. First aide and cold compress applied to wounds. Steri-strips applied to both lacerations. The fall care plan lacked an added intervention. During an interview on 7/8/21 at 11:29 a.m., the Corporate Nurse Consultant indicated the resident's intervention to transfer to a regular dining chair should have been discontinued due to the resident frequently refusing to transfer. During an interview on 7/8/21 at 12: 13 p.m., the Activity Director indicated the busy blankets provided to residents were kept in a closet on Noble hall. The blankets were not resident specific, but were accessed as needed. 2. During an observation on 7/8/21 at 11:15 a.m., Resident D was in her bed. Her call light was on the floor between the bed and the wall to her right side, out of reach. The room lacked a posted reminder to call for assistance. Resident's glasses were placed on a low shelf to the left of her bed, out of reach. The clinical record for Resident D was reviewed on 7/8/21 at 10:32 a.m. Diagnoses included, but were not limited to, acute [CONDITION(S)], [CONDITION(S)], scoliosis, and intervertebral disc degeneration. The resident admitted to the facility on [DATE]. The resident had a quarterly MDS assessment, dated 5/25/21, which indicated the resident was cognitively intact, was an extensive assist of one staff for bed mobility, transfer, dressing and toileting. A care plan for Falls, dated 2/21/21 with the problem: Resident at risk for falling related to assist with ADL's, [CONDITION(S)], urinary tract infections, protein-calorie malnutrition, congestive heart failure, chronic pulmonary disease, [CONDITION(S)], [CONDITION(S)], disc degeneration and scoliosis.Interventions included, but were not limited to, staff to assist resident with transfers as needed, keep personal items and frequently used items within reach, keep call light in reach, and provide non-skid footwear. The resident's Event Report's, included the following incidents: a. On 2/21/21 at 1:00 p.m., Resident D was found sitting on the floor in front of her wheelchair, next to her bed. She indicated she had tried to get into bed without asking for assistance. Resident was assessed to have no injuries and was assisted back to bed with assistance of two staff. A fall care plan intervention was added on 2/21/21 to provide education to use call light for assistance. b. On 2/23/21 at 4:54 p.m., the resident was found on the bathroom floor in her room. The resident indicated she was trying to transfer to the toilet and fell . Resident was assessed to have no injuries. A fall care plan intervention was added on 2/24/21 to add visual reminders in resident's room to use call light to ask for assistance. c. On 2/26/21 at 10:56 p.m., resident was found on the bathroom floor in her room. She indicated she crawled from her bed to the bathroom. Resident was assessed to have no injuries. A fall care plan intervention was added on 2/26/21, to perform purposeful rounding. d. On 3/2/21 at 7:55 p.m., resident was found on the floor next to her bed. She indicated she put herself on the floor in order to plug in her phone charger. Resident was assessed to have no injuries. A fall care plan intervention was added on 3/2/21, to ensure resident's cell phone charger was plugged in. e. On 5/10/21 at 10:32 p.m., the resident was found on the floor laying face down with the call light in her hand. She indicated she was trying to walk over to her bed. Resident was assess to have no injuries. A fall intervention, dated 5/11/21, to post a visual reminder to call for assistance was duplicated for this incident. f. On 5/18/21 at 8:13 a.m., the resident was found on the floor in the bathroom, lying on her side. Resident was assessed to have no injuries and was assisted back to bed. A fall care plan intervention was added on 5/18/21, to toilet resident after breakfast. g. On 6/7/21 at 6:43 p.m., the resident was found in her room on the floor next to her lift-recliner. Her lift-recliner was observed in high position. Resident was assessed to have no injuries. A fall care intervention was added on 6/8/21, to Velcro the lift-recliner remote control to an area in reach of the resident. h. On 6/23/21 at 3:32 p.m., the resident was found on the floor under her bed. She indicated she was trying to reach her cell phone that had dropped on the floor. Resident was assessed with no initial injuries. She developed some pain to her chest and a chest X-ray was completed; negative exam. A fall care plan intervention was added on 6/24/21 to provide a mechanical reacher/grabber. i. On 7/4/21 at 12:43 a.m., the resident was observed on the floor between her lift-recliner and her bed with the chair in high position. She indicated she was trying to get up. Resident was assessed to have no injuries. A fall care plan intervention was created 7/6/21, to toilet resident before and after meals. j. On 7/6/21 at 7:47 p.m., the resident was found on the floor between her lift-recliner and the bed. She indicated she was trying to get up to call her son. Resident assessed to have no injuries. A fall care plan intervention was added 7/7/21, to place cell phone within reach. During an interview on 7/8/21 at 11:15 a.m., Resident D indicated she was not provided a reacher and had no idea where it might be. During an interview on 7/8/21 at 11:17 a.m., RN 4 indicated there was not posted reminder to call for assistance on the wall. During an interview on 7/8/21 at 11:31 a.m., the Corporate Nurse Consultant indicated the care plan for Resident D had not been followed entirely. A current facility policy, revised 5/22/18, titled, Fall Management Program Guidelines, provided by the Administrator on 7/8/21 at 10:53 a.m., included, but was not limited to, PROCEDURES .5. The resident care plan should be updated to reflect any new or changed interventions. A current facility policy, dated 6/2015, titled, Interdisciplinary Team Care Guideline, provided by the Administrator on 7/8/21 at 10:53 a.m., included but was not limited to,PROCEDURES .g. Nurse managers shall communicate pertinent care plan approaches to the nursing staff. This Federal Tag relates to Complaint IN 495. 3.1-45(a)(2)

Based on record review and interview, the facility failed to appropriately assess, notify the physician or family and update the care plan after falls for 1 of 3 residents reviewed for accidents. (Resident G) Findings include: The clinical record for Resident G was reviewed on 1/20/21 at 2:49 p.m. [DIAGNOSES REDACTED]. Resident G's recent significant change Minimum Data Set (MDS), dated [DATE], indicated she had severe cognitive impairment and required extensive assistance for locomotion, transfer, dressing, toilet use, bed mobility and hygiene. The resident's clinical record included the following: a. A nursing progress note, dated 9/13/20 at 3:57 p.m., indicated the nurse was called to Resident G's room and was found seated on the floor in front of her recliner. The clinical record lacked an investigation, entry of a Fall Event assessment or documented notification of MD and family. The resident's care plan lacked an intervention for the 9/13/20 unwitnessed fall. b. A nursing progress note, dated 1/13/21 at 4:57 p.m., indicated Resident G was found in her room, scooting across the floor from her recliner. The clinical record lacked an investigation, entry of a Fall Event assessment or documented notification of MD and family. The resident's care plan lacked an intervention for the 1/13/21 unwitnessed fall. During an interview on 1/21/21 at 11:29 a.m., the DON indicated a Fall Event and investigation should have been completed and the resident assessed after any fall. The resident's physician and family should have been notified and the care plan reviewed and updated. A current facility policy, dated 5/22/18, titled, Fall Management Program Guidelines, provided by the DON on 1/21/21/ at 9:25 a.m., included the following: PROCEDURES DEFINITION: .Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred. .2. Should the resident experience a fall the attending nurse shall complete the Fall Event {SIC} This includes an investigation of the circumstances surrounding the fall to determine the cause of the episode, a reassessment to identify possible contributing factors, interventions to reduce risk of repeat episode and a review by the IDT to evaluate thoroughness of the investigation and appropriateness of the interventions. 3. The attending physician or medical director in the absence of the attending physician and the responsible part should be notified 5. The resident care plan should be updated to reflect any new or change in interventions. This Federal Tag relates to Complaint IN 327. 3.1-45(a)

Based on record review and interview, the facility failed to assure staff completed required health screening of employees to reduce possible exposure of residents with an illness, such as COVID 19. Findings include: A review of the staff COVID-19 screening documentation, on 1/20/21 at 1:21 p.m., indicated the following: a. Of the 26 direct healthcare staff who had entered the building on 1/17/21, two staff members had failed to complete a COVID 19 screen. b. Of the 29 direct healthcare staff who had entered the building on 1/18/21, two staff members had failed to complete a COVID 19 screen. c. Of the 27 direct healthcare staff who had entered the building on 1/19/21, one staff member had failed to complete a COVID 19 screen. During an interview on 1/20/21 at 2:46 p.m., the Administrator indicated the staff should always screen for COVID 19 upon entering the facility and she was unsure why these employees failed to do so. She indicated she was responsible for assuring compliance. A current facility policy, titled, COVID-19 Screening, provided by the Administrator on 1/21/21 at 9:25 a.m., included, but was not limited to, the following: Overview .In response to the COVID19 global pandemic, Trilogy is enacting procedures to address employee and/or visitors that could cause risk to residents by having COVID-19 by screening each person as mandated by federal and state requirements. 3.1-18(b)

Based on interview and record review, the facility failed to ensure respiratory assessments were completed for 1 resident who returned from the hospital for a respiratory condition; and failed to ensure that skin assessments, care and treatment of [REDACTED]. This impacted 1 of 6 residents reviewed for assessments and skin issues. (Resident #B) Findings include: The record for Resident #B was reviewed on 10/8/13 at 9:50 A.M. [DIAGNOSES REDACTED]. The admission physician orders [REDACTED]. 9/12/13--[MEDICATION NAME] nebulizer solution one vial every six hours as needed for wheezing. 9/12/13--Chopped soft diet, Nectar thick liquids. 9/12/13--Skilled charting upon admission every eight hours times three days then discontinue. 9/12/13--Weekly skin assessment every ____ (the blank was not filled in) based on resident preferred bathing schedule. Record: 0=No area skin impairment; 1= New area impairment; 2=Existing skin impairment (See wound sheets) 9/12/13--[MEDICATION NAME] 500 milligrams give one tablet by mouth daily times 10 days upon rising. 9/12/13--Keflex 250 milligrams give one capsule by mouth daily upon rising. Start on 9/23/13 when [MEDICATION NAME] treatment is complete. A. Acute care hospital progress notes, dated 9/9/13 through 9/12/13, indicated the resident was admitted to the hospital for pneumonia on 9/9/13 after a choking episode with loss of consciousness while eating, and which was resolved with the [MEDICATION NAME] maneuver. The notes indicated the resident was discharged on [DATE] to the facility on antibiotics, a dysphagia diet, and thickened liquids. The facility document titled "Nursing Admission Assessment and Data Collection" was completed on 9/12/13 at 1:50 P.M. This document indicated there was a current infection present on admission, which was pneumonia. The respiratory portion indicated the resident's lung sounds were diminished bilaterally and she had a cough, and had a temperature of 99.1 Fahrenheit (F) when she was admitted to the facility. An assessment of the resident's lung sounds were not documented on the "Skilled Nursing Assessment and Data Collection" for 9/19/13. There were no temperatures found to monitor for infection on the following dates of 9/13/13 through 9/16/13, 9/20/13, and 9/21/13. There were no nurses notes with vital signs on 9/23/13 after 10:15 A.M., the day the resident was sent to the hospital for evaluation and treatment and admitted to the hospital. During an interview on 10/9/13 at 1:37 P.M., the DON indicated he could not find any vital signs for the dates of 9/13/13 through 9/16/13, 9/20/13, and 9/21/13 to indicate temperatures were monitored. He indicated he was unable to find where an assessment or vital signs were completed before the resident was discharged to the hospital. A policy titled "VITAL SIGNS GUIDELINES," with a revised date of 12/07, was provided on 10/10/13 at 11:58 A.M., by the DON and deemed current. The policy included the following: "PURPOSE: To document and track vital signs to monitor changes in condition of residents in relation to vital sign results. PROCEDURE: 1. Vital signs will be taken at the following times: a. Upon admission... c. Change in condition d. Following an incident or accident...h. To monitor infections..." B. A discharge summary from the hospital dated 9/12/13 indicated the resident's coccyx was pink with no skin breakage and a barrier cream had been used for protection of skin breakdown while the resident was admitted to the hospital. A facility document titled "Hospital Discharge Report," which did not have a signature from the nurse receiving the report or the date the report was taken from the hospital, indicated the nurse giving the report to the facility reported the resident had a skin issue, which was a red sacral area, and the treatment was barrier cream every shift and as needed. The facility document titled "Nursing Admission Assessment and Data Collection" was completed on 9/12/13 at 1:50 P.M. The skin assessment portion indicated the resident had bruises located in the following areas, one bruise to the right anticubital area, one bruise to the left posterior hand, and 4 bruises to the abdomen. A facility document titled, "CNA Bath/Shower Skin Check Sheet" completed on 9/13/13 indicated the resident was given a shower and the CNA circled the entire buttocks area on the diagram of the person on the sheet with an arrow from the buttocks area and stated, "Sore and pink, cream on bottom." This form was signed by the CNA, but there was no charge nurse signature. On 10/10/13 at 12:17 P.M., the Director of Nursing (DON) provided a document dated 10/10/13 titled, "CORP-CNA Skin Assessment Detail Report." The report indicated on 9/13/13 at 11:18 A.M., the CNA had documented the resident had a new skin problem, it was on her bottom, the area was pink in color, and she did notify the nurse of the skin problem. The report indicated on 9/15/13 at 9:43 A.M., the CNA had documented the resident had a new skin problem, but did not explain the location. She indicated she did notify the nurse about the new skin problem. During an interview on 10/10/13 at 10:28 A.M., CNA #3 indicated on the resident's shower days, the CNA's would look for new skin issues and would document them on the shower sheets or would document no skin issues on the shower sheets. She indicated the nurses would visually inspect the resident's skin on the shower days, then they would sign their name on the shower sheets. She indicated if she found a new skin condition she would alert the nurse of the new skin issue and chart the skin condition in the kiosk (computer). She indicated the CNA's must document daily on the resident's skin to indicate if there is a new skin issue. A facility document titled "Skin Impairment Assessment," dated 9/22/13, indicated the resident had excoriation between her buttocks which was red in color and measured 5.0 x 3.0 centimeters. A pictograph on the document indicated an "X" mark on the area of the inner buttocks with a line and stated, "between buttocks." The physician was called and ordered antifungal powder for the excoriation. A facility document titled "Accident/Incident Report" dated 9/22/13 with time of occurrence at 11:00 A.M., indicated the resident had excoriation between buttocks that was red in color. The report indicated the measures taken to prevent this from happening again was the resident was cleaned and dried, the treatment was applied, and the staff was reminded to check resident's skin when toileting them and make nurses aware of any skin issues. The report indicated the resident was last toileted by the CNA at 10:00 A.M. A nurses note, dated 10/1/13 at 2:00 P.M., written as a late entry for 9/22/13, indicated the resident's skin was reddened around the labia folds, up to the pubis and up to the area around the anus. During an interview on 10/10/13 at 9:30 A.M., LPN #4, who wrote the late entry note, indicated she had assessed the resident's skin on the day she was sent to the hospital, and had applied the powder twice. She indicated her late entry should have been for 9/23/13, not 9/22/13. Facility documents titled "Skilled Nursing Assessment and Data Collection" were not found for the following dates of 9/13/13 through 9/16/13 and 9/20/13 through 9/23/13, this included any skin assessments. There were no skin assessments found on the facility document titled "Skilled Nursing Assessment and Data Collection" for 9/19/13. There were no nurses notes with assessments on 9/23/13 after 10:15 A.M., the day the resident was sent to the hospital for evaluation and treatment and admitted to the hospital. During an interview on 10/9/13 at 1:37 P.M., the DON indicated he could not find any facility documents titled "Skilled Nursing Assessments or Data Collection" for the following dates of 9/13/13 through 9/16/13 and 9/16/13 through 9/23/13 to indicate skin assessments were completed on these dates. He indicated he was unable to find where an assessment or vital signs were completed before the resident was discharged to the hospital. During an interview on 10/8/13 at 1:35 P.M., the Unit Manager of the Conner and Pioneer Units indicated she thought the resident was discharged to the hospital around supper time. On 10/10/13 at 8:54 A.M., the care Executive Director of Health Information Management of an acute hospital provided inpatient records for Resident #B. The admitting [DIAGNOSES REDACTED]. A hospital document titled "History" dated 9/23/13 at 5:59 P.M., indicated the resident's temperature in the emergency room was 99.3 F. The doctor had indicated her urine was infected and the resident's overall skin condition over the coccyx area was the reason for his decision to admit the resident to the hospital. A hospital document titled "History and Physical" dated 9/23/13 at 11:20 P.M., indicated the resident had [MEDICAL CONDITION] (skin chafing that occurs in or around skin folds. The irritation and trapped moisture results in secondary bacterial or fungal infections), and the doctor ordered an antifungal medication to treat the condition. He indicated she had skin breakdown in her perineal area. A hospital document titled "Wound Care Note" dated 9/24/13 at 3:02 P.M., indicated the initial consult was for a "sacral sore". The note indicated an extra thick antifungal would be ordered to the buttocks, medial thighs, and groin. The note indicated [DIAGNOSES REDACTED] (redness) was present related to moisture and shearing and it appeared fungal with satellite [MEDICAL CONDITION]. The note indicated a waffle mattress was applied to the bed and an antifungal medication was ordered. A undated facility policy titled "CLINICAL DOCUMENTATION SYSTEMS Skilled Nursing Assessment and Data Collection" was provided by on 10/9/13 at 11:30 A.M., by the DON and deemed current, stated: " PURPOSE: To complete and document a comprehensive assessment of the resident's current medical status and skilled nursing needs.. a. This form may be used for interim assessments for acute episodes, change in condition or episodic events... 4. The comprehensive head to toe assessment shall address each body system and skilled service. 5. The form shall be completed daily for each day the resident is receiving skilled services... 8. Staff not assigned to complete the assessment shall note on the back of the form any changes to the assessment and/or any pertinent information that occurs during their shift...." This Federal tag relates to Complaint IN 857. 3.1-37(a)

Based on observation, record review and interview, the facility failed to ensure a resident was wearing proper clothing, related to preventative measures, for a resident with a fall history, which resulted in a fracture to the right lower leg, for 1 of 9 residents reviewed for fall prevention in a sample of 15. (Resident #15) Findings include: During the initial tour of the facility on 9/24/12 at 11:20 A.M., RN #9 indicated Resident #15 had a history of [REDACTED]. The clinical record for Resident #15 was reviewed on 9/24/12 at 12:50 P.M. [DIAGNOSES REDACTED]., urinary retention, history of urinary tract infections, osteoarthritis, osteoporosis and [DIAGNOSES REDACTED]. A form titled "Clinically At Risk Individual Monitoring Sheet" dated 4/26/12, stated "Resident had fall on 4/24/12 out of elec (electric) w/c (wheelchair). Resident had slick track pants on- on top of Hoyer lift pad and resident unfastened seat belt and leaned forward......Do not use slick track pants when up in w/c (wheelchair)." A care plan titled "Falls" indicated a fall intervention was added on 4/25/12 that stated "Appropriate clothing- no slick track pants." A Fall Circumstance Assessment and Intervention form dated 7/13/12, indicated Resident #15 fell at 4:00 P.M. and was found in his room with his seat belt unfastened, wearing "slippery" pants, gait belt around both legs, with both legs underneath him. An injury box was marked with a checkmark indicating S/S (signs and symptoms) of fracture. Nursing notes dated 7/13/12 indicated the following: a.) At 4:30 P.M., Resident #15 was sent to the ER (emergency room ) for evaluation. b.) At 8:45 P.M., Resident #15 returned to the facility after receiving an x-ray confirming a "R (right) fib (fibula) fx (fracture)". A form titled "Clinically At Risk Individual Monitoring Sheet" dated 7/19/12, indicated the [DIAGNOSES REDACTED].fall from electric wc (wheelchair)" Recommended clinical intervention: "Remove slick pants from wardrobe to prevent sliding out of chair." A facsimile transmittal sheet, dated 9/18/12, notes/comments indicated "(Resident #15) slipped down in chair. No injury. Wearing slick running pants on slick Hoyer pad." An observation of Resident #15 on 9/27/12 at 10:40 A.M., noted the resident was sitting up in his wheelchair and was wearing red, shiny pants. An interview with LPN #6 on 9/27/12 at 11:30 A.M., indicated (LPN #6) was a PRN (as needed) nurse and only worked when needed, therefore (LPN #6) was not as familiar with the resident's as a full time nurse would be, and was not thoroughly aware of each resident's care plan. Additionally, LPN#6 suggested CNAs (certified nursing assistants) usually dress the resident's. 3.1-45(a)(2)

Based on interview, observation and record review, the facility failed to provide adequate supervision in the bathroom for a resident who was identified as high fall risk, had a history of [REDACTED]. The resident sustained [REDACTED]. This deficient practice impacted 1 of 6 residents reviewed who had a history of [REDACTED]. (Resident #2) Findings include: On 8/1/11 at 11:00 A.M., a tour of the facility was completed with the Director of Nursing and L.P.N. #6. In an interview at that time, L.P.N. #6 indicated Resident #2 had a history of [REDACTED]. On 8/2/11 at 2:45 P.M., Resident #2 was observed while being transferred from wheelchair to reclining chair. The resident was observed to be unsteady and unable to stand without complete assistance from C.N.A. #12. The resident's lower extremities appeared weak, with the resident unable to bear most of her own weight. The resident swayed from side to side, with her knees bent, while the C.N.A. transferred the resident. In an interview on 8/5/11 at 9:30 A.M., C.N.A. #11 indicated she had been caring for Resident #2 since May 2011, and the resident had never been independent with walking, and required complete assistance with transferring. She indicated the resident was alert; however orientation to person, place, and time was questionable each day. The clinical record for Resident #2 was reviewed on 8/2/11 at 10:50 A.M.. [DIAGNOSES REDACTED]. The M.D.S. (Minimum Data Set) assessment dated [DATE] indicated the resident had a BIMS (Brief Interview for Mental Status) score of "13" (a score of 13-15=cognitively intact). The resident was also identified as requiring extensive physical assistance of 1 staff person for transfers, dressing, toileting, and hygiene. "Ambulation" was indicated as "not performed by the resident or staff at all." A "Social Service Notes" dated 6/25/10 indicated "Admission note-Res (Resident) has fallen 13 times in the past year....Res utilizes w/c (wheelchair) and walker for ambulation..." A "Nurse's Notes" dated 11/24/10 at 7:00 P.M. indicated "C.N.A. reported res. fell on floor in bathroom.... Complains of right hip and knee pain.... lost her balance causing her to fall...." A "Nurse's Notes" dated 11/24/10 at 8:30 P.M. indicated "Report received from hospital. Res. positive for right hip fracture and will be admitted to hospital...." A "Physical Therapy Daily Note" dated 2/21/11 indicated "Withheld (therapy) secondary to increased pain from falling last night and breaking her right wrist.... Patient had a recent set-back in therapy secondary to fall during the night of 2/20/11...." A "Physical Therapy Discharge Summary" dated 3/15/11, indicated Resident #2 was "high fall risk." A "Fall Circumstance Investigation" dated 6/15/11, indicated Resident #2 fell at 8:25 A.M. in the restroom. The "IDT (Interdisciplinary Team) Review" note indicated to add as a "Prevention Update" intervention to the resident's Care Plan: "Do not leave res unattended in the restroom." A "Fall Circumstance Investigation" dated 6/25/11, indicated Resident #2 fell at 7:45 A.M. in the restroom. The description of the fall indicated "Res told C.N.A. to step out while I go to the bathroom. Res stood up and fell . C.N.A. right outside bathroom door." The "IDT Review" indicated to include "Staff must stay in restroom while res toilets." On 8/3/11, L.P.N. #6 provided the "Resident Care Sheet" forms. In an interview, she indicated the forms were used to communicate with the C.N.A.s about each resident's care. The "Special Needs" area of the "Resident Care Sheet" for Resident #2 listed an intervention added on 6/15/11 of "must stay in bathroom during toileting." The "Further Preferences" included, but were not limited to, "do not leave unassisted in bathroom..." On 8/4/11, the Divisional Clinical Support Registered Nurse for Trilogy Health Services, LLC, provided documentation of Resident #2's fall history. The documentation included a paper titled "Fall Timeline." The "Fall Timeline" for Resident #2 included the following dates for falls and interventions: Falls in the bathroom: 7/12/2010, 7/16/2010, 10/18/2010, 11/4/2010, 11/24/2010 (fractured hip), 2/21/11 (fractured wrist), 4/10/11, 6/15/11 (intervention to not leave alone in the bathroom), and 6/25/11 (Nurse's note stating C.N.A. left alone per resident's request.) Other falls: 8/19/2010, 8/31/2010, 10/6/2010, 10/8/2010, 1/11/2011, 2/3/2011, 4/10/2011, 7/1/2011, 7/9/2011, and 7/28/2011. Interventions put in place from 7/12 to 11/24/10: Removal of bath mat, bed alarm, encourage bath mat, provide chair in bathroom for grooming. There were no new interventions put into place following the fall with fracture on 11/24/10 except to "continue antibiotic for urinary tract infection." A sensor alarm to the wheelchair was added on 2/3/11. No new interventions were added after the fall with a wrist fracture on 2/21/11. On 4/10/11, an intervention was added to "continue to educate family and resident on safety concerns as family and resident request resident to be left alone in the bathroom." On 6/15/11, an intervention was added to "encourage resident to ask for assistance and not to be left unattended in the bathroom." On 6/25/11, the intervention included "resident and family encouraged that staff needs to stay in bathroom with resident due to resident not using call light to ask for assist. Resident and family agree to intervention." In an interview on 8/4/11 at 2:45 P.M., the Divisional Clinical Support Registered Nurse and the Director of Nursing indicated that leaving the resident in the bathroom upon her request was a resident's right regardless of her fall outcome. A "Falls Management Program Guidelines," dated as revised 3/08, included, but was not limited to, the following information: "PURPOSE: Trilogy Health Services (THS) strives to maintain a hazard free environment, mitigate fall risk factors and implement preventative measures.... DEFINITION: A fall without injury is still a fall.... PROCEDURE: Should the resident experience a fall....a reassessment to identify possible contributing factors, interventions to reduce risk of repeat episode and a review by the IDT to evaluate thoroughness of the investigation and appropriateness of the interventions...." 3.1-45(a)(2)