Every finding on record at Riverside Village

Based on observations, interviews, and record reviews, the facility failed to assess skin related to a blackened toe for 1 of 3 residents (Resident G) and failed to sign for medications immediately after administration for 2 of 3 residents reviewed for changes in condition. (Residents E and F) Findings include: 1. A records review was completed on 6/25/2026 at 9:33 A.M. for Resident G. Diagnoses included, but were not limited to, hemiplegia/hemiparesis following cerebral infarction left non-dominant side, chronic kidney disease stage 3, unspecified chronic obstructive reflux uropathy, unspecified severe protein calorie malnutrition, and adult failure to thrive. A Quarterly Minimum Data Set (MDS) assessment, dated 4/21/2026, indicated the resident exhibited a moderate cognitive deficit, had not exhibited behaviors of refusal of care, had impaired range of motion on his upper and lower extremities on one side, was dependent on staff for transfer needs, required moderate assistance for eating and had an indwelling urinary catheter and a colostomy. A current Care Plan, initiated on 8/11/2022 indicated Resident was at risk for skin breakdown due to the following: rare moist skin, chair fast, slightly limited ability to change or control body position, probable inadequate nutrition, requires assist with mobility, potential problem for friction and shear. In addition, Resident G had a history of an abrasion on his left 2nd toe and skin impairment on the left tip of the great toe. Interventions included, but were not limited to: Assess and document skin condition weekly and as needed. Notify physician of abnormal findings. A history and physical assessment, completed on 6/10/2026 for Resident G did not indicated the resident had any skin or integumentary system issues. Review of wound management notes indicated the resident had no wounds between 1/1/2026 and 6/23/2026. Review of the most recent weekly skin and vital sign assessment, dated 6/16/2023, indicated there were no skin issues. Shower documents, dated 6/22/2026 at 2:45 P.M., indicated Resident G had a bed bath with no concerns noted to skin Review of a transfer form dated 6/23/2026 for Resident G upon his transfer to an acute care facility indicated his skin condition was intact cool clammy. Resident G was transferred to a local acute care facility on 6/23/2026 at 11:45 A.M. An emergency room note, entered by an RN at the local acute care facility, on 6/24/2026 at 9:15 A.M. indicated Resident G's left great toe was oozing pus from the nail bed and his left third toe had a large black callous that was removed at the acute care center. The resident was referred to the acute care wound care specialist and photos of Resident G's wounds were sent on 6/24/2026 at 2:05 P.M. A wound care assessment, dated 6/24/2026, from the acute care hospital indicated Resident G's left 3rd toe had a black callous that was removed without incident revealing clean, new skin growth that was pink underneath the callous. In addition, the left great toe's nail bed was peeling off and there was purulent drainage coming out from underneath the nail. The great toe was covered with a moisture-wicking gauze, and a podiatry consult was recommended for removal of the nail. On 6/26/2026 at 1:31 P.M. a current policy, dated 5/2022 and titled, Skin Management Program was provided by the ED. The policy indicated, .Any skin alterations noted by direct caregivers during daily care and/or shower days must be reported to the licensed nurse for further assessment. 2. A record review was completed on 6/26/2026 at 9:22 A.M. for Resident E. Diagnoses included, but were not limited to, hydronephrosis with ureteral calculous obstruction (swelling of the kidney caused by urine back up due to obstruction by stones), bipolar disorder, and acute respiratory failure with hypoxia (the inability of the lungs to get enough oxygen into the bloodstream. A Discharge Minimum Data Set assessment, dated 6/4/2026, indicated Resident E was cognitively intact, had no issues with rejection of care and received an antipsychotic, antidepressant, and an opioid medication. The Care Plan did not indicate any issue with Resident E refusing medications. The May 2025 Medication Administration Record for Resident E indicated 3 instances of medications that had been given but was charted late on 5/12, 5/16, and 5/18/2026. During an interview on 6/26/2026 at 8:45 A.M., LPN 2 indicated she sometimes documented medication administration late but knew she should have documented the medication administration immediately after the medication had been administered. She indicated she was usually able to get medications passed in the allowable timeframe. 3. A record review was completed on 6/26/2026 at 10:00 A.M. for Resident F. Diagnoses included, but were not limited to, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, neuralgia and neuritis, and major depressive disorder. A Quarterly Minimum Data Set assessment, dated 4/29/2026, indicated Resident F had a moderate cognitive deficit, had no issues with refusal of care and received antidepressant and anticoagulant medications. Review of the May Medication Administration Record (MAR) indicated medications had been documented as administered late on two occasions. 4. A record review was completed on 6/26/2026 at 10:27 A.M. for Resident G. Diagnoses included, but were not limited to, congestive heart failure, malignant neoplasm of retroperitoneum and peritoneum, and chronic kidney disease. A Quarterly Minimum Data Set assessment, dated 5/28/2026, indicated Resident G had a moderate cognitive deficit. She had no issues with refusal of care and received antipsychotic and antidepressant medications. The June Medication Administration Record (MAR) indicated medications were documented as having been administered late nearly every day. During an interview on 6/26/2026 at 12:55 A.M., Resident G indicated sometimes her medications were late, but she was unable to recall how often it happened or when it had last happened. During an observation of medication administration on 6/26/2026 at 8:54 A.M. there were no concerns. LPN 2 signed for medications immediately after administering them. However, during an interview on 6/26/2026 at 1:06 P.M. with LPN 3 she refused to answer questions regarding administering medications timely and not signing out the medications as given timely. During an interview on 6/26/2026 at 1:21 P.M., the Regional Director of Clinical Services indicated medications should have been signed for directly after they were administered. On 6/26/2026 at 1:30 P.M. a current Procedure, dated 4/2025 and titled, Medication Administration (Medication Pass Procedure) was provided by the ED. The procedure indicated, .Medication administration will be recorded on the EMAR (Electronic Medication Administration Record) after given On 6/26/2026 at 1:31 P.M. a current policy, dated 5/2022 and titled, Skin Management Program was provided by the ED. The policy indicated, .Any skin alterations noted by direct caregivers during daily care and/or shower days must be reported to the licensed nurse for further assessment. This citation relates to Intakes 3026355 and 3053196 410 IAC (Indiana Administrative Code) 3.1-37

Based on observation, interview and record review, the facility failed to prepare, store and serve food in a sanitary manner in 1 of 1 kitchen and 1 of 2 dining halls. (Main Dining Hall) This had the potential to affect 62 of 64 residents who receive meals from the kitchen and 18 of 18 residents who ate in the Main Dining Hall. Findings include:1 An initial tour of the kitchen with the Dietary Manager (DM) was completed on 2/18/2026 at 9:39 A.M. During the tour, the following was observed:-A two door upright freezer had a thick black substance on the rubber seal and the stainless steel portion where the seal met the stainless steel. -The walk-in cooler had a container of concentrated beef broth base with a best by date of 12/2025.-The freezer had four unlabeled house made shakes without a date indicating when the shakes had been made or needed to be used by or discarded.- A large area of a dark brown substance was observed on the side of the stovetop and the side of the oven.During an interview on 2/18/2026 at 9:54 A.M., the DM indicated the thick black substance was mildew. He threw out the beef concentrate and indicated it should have been disposed of in January. He indicated the label for the shakes must have fallen off in the freezer and indicated they should have been labeled and dated. He indicated he had a company coming to clean the kitchen equipment and the brown build-up was grease. During an interview on 2/18/2026 at 2:38 P.M., the DM indicated he had scrubbed the freezer seals, but continued scrubbing would cause the seals to rip, so new ones were ordered on 2/18/2026. 2. During the lunch meal observation in the Main Dining Hall on 2/18/2026 at 12:03 P.M. until 12:12 P.M., the following was observed:-CNA 6 cupped her hand over the plastic cup of water, touching the rim of the drinking area of the cup with her fingers, and served the cup to a resident. CNA 6 also placed her fingers on the drinking area of a coffee cup and served the coffee to the same resident. -CNA 6 put her fingers inside a resident's coffee cup before pouring the coffee into the cup and serving the resident. -CNA 6 placed her hands on rim of a cup of water while serving the cup to a resident. During an interview on 2/24/2026 at 1:21 P., the DM indicated the correct way to serve a resident a drink was to always hold the bottom of the cup, keeping fingers away from the drinking surface of the cup. On 2/24/2026 at 9:45 AM, the Executive Director (ED) provided a policy dated 5/2025, and titled, Food Storage, and identified the policy as the one currently used by the facility. The policy indicated, .8. Refrigerated, ready-to-eat, potentially hazardous food purchased from approved vendors shall be clearly marked with the date the original container is opened and the date by which the food shall be consumed or discarded. This opened food can be held at 41 degrees Fahrenheit or less for no more than 7 days and the date marked may not exceed the manufacturer's use-by date .12 .c. Foods should be covered or wrapped tightly, labeled and dated with the date the item is being placed in the freezer On 2/24/2026 at 9:45 AM, the ED provided a policy dated 6/2025, and titled, Kitchen Cleanliness, and identified the policy as the one currently used by the facility. The policy indicated, .A clean, sanitary, and safe kitchen environment will be maintained at all times to ensure the health and well-being of our residents, staff, and visitors. All kitchen areas, including food preparation surfaces, equipment, storage areas, walls, and floors must be cleaned regularly and kept free of debris, spills, and potential contaminants On 2/24/2026 at 9:45 AM, the ED provided a policy dated 5/2024, and titled, Meal Service and Distribution, and identified the policy as the one currently used by the facility. The policy indicated, .6. Utensils, cups, glasses and dishes will be handled in such a way as to avoid touching any food contact surface .3.1-(i)(l)(3)

Based on observation and interview, the facility failed to readily provide grievance forms for residents to place an anonymous grievance for 65 of 65 residents.Finding includes:During a Resident Council meeting, on 2/19/2026 at 2:30 P.M., 12 of 12 residents in attendance indicated grievance forms were located behind the nursing station and they had to ask a staff member for a grievance form if they wanted to file a grievance. The residents indicated they were unable to file a grievance anonymously.During an observation and interview, on 2/19/2026 at 3:13 P.M., the Executive Director indicated grievance forms were located behind the nurse's station, but were not available for residents to obtain anonymously without asking for staff assistance. The Executive Director looked at one of the nurse's stations and there were no forms available in the plastic wall hanger behind the nurse's station. The Executive Director indicated the residents needed to ask for a grievance form.A policy was provided, on 2/24/2026 at 9:45 A.M., by the Executive Director. The policy titled, Resident Concerns and Grievances, indicated, .Resident, representative or family concerns/grievances occurring during the resident's stay shall be responded to promptly and without fear of reprisal or discrimination. Each resident has the right to: file grievances orally or in writing; file a grievance anonymously, and to obtain a written decision regarding his or her grievance. Grievances can be submitted anonymously as preferred by a resident, representative and/or family member. Anonymity will be maintained by the Grievance Official throughout the resolution process.

Based on interview and record review, the facility failed to ensure required blood monitoring was completed timely for 1 of 5 residents reviewed for unnecessary medications. (Resident 29)Finding includes: The clinical record for Resident 29 was reviewed on 2/19/2026 at 2:00 P.M. The resident's diagnoses included, but were not limited to: dementia, psychosis, anxiety, anemia, atherosclerotic heart disease, severe protein-calorie malnutrition, spondylosis, hypertension, dysphagia, hydronephrosis, hypotension, obstructive and reflux uropathy and atrophy of the kidney.A Quarterly Minimum Data Set (MDS) assessment, dated 1/19/2026, indicated the resident received antianxiety, antidepressant, anticonvulsant and hypnotic medications.A current Care Plan, initiated 11/14/2025, indicated Resident 29 was at risk for adverse side effects related to use of anticonvulsant or antiseizure medication and interventions included but were not limited to: labs as ordered.Current Physician's orders included Divalproex (a prescription medication used to treat epilepsy (seizures), manic episodes associated with bipolar disorder, and to prevent migraine headaches) capsule, delayed-release sprinkles; 125 milligrams (mg), give 2 capsules twice a day. This order was initiated on 11/14/2025.The November 2025 Medication Administration Record (MAR) indicated Resident 29 began receiving the Divalproex (Brand name of Depakote) on 11/15/2025. The December 2025 MAR, January 2026 MAR and February 2026 MAR indicated Resident 29 had received Divalproex from 11/15/2025 through 2/23/2026.A Physician's Order, dated 11/13/2025, indicated Resident 29 was to have a one-time blood draw for an Ammonia and Valproic Acid (Depakote is specifically formulated to be gentler on the stomach, often causing fewer GI side effects than valproic acid) levels. This order was discontinued on 11/25/2025 without having been completed. During an interview, on 2/23/2026 at 2:05 P.M., the Director of Nursing (DON) indicated the Valproic level was intended to have been drawn for Resident 29 and indicated she could not locate the lab results in the chart.During an interview, on 2/23/2026 at 3:00 P.M., the DON indicated the lab was discontinued on 11/28/2025 after being ordered on 11/15/2025. During an interview, on 2/24/2026 at 9:45 A.M., the Regional Director of Clinical Services (RDCS) indicated the Resident 29 had not had any Valproic or Ammonia levels monitored at all. A new Physician's Order, dated 2/23/2026, indicated for Resident 29 was to have an Ammonia and Valproic acid level drawn the next lab day and then drawn every 6 months.On 3/23/2026 at 3:00 P.M., the DON provided a policy titled, Guidelines for Lab and Radiology Tracking, dated 4/2024 and indicated the policy was the one currently used by the facility. The policy indicated .Confirm that each lab.due has been obtained.If any lab.ordered are not resulted as expected, investigate and take the necessary steps to obtain results.3.1 - 25 (h)3.1 - 25 (j)

Based on observation, record review and interview, the facility failed to provide behavioral interventions for 1 of 2 residents reviewed for behavioral-emotional issues. (Resident 19) Finding includes:During an observation, on 2/18/2026 at 10:22 A.M., Resident 19 had a very strong odor of urine in her room.During an observation, on 2/18/2026 at 11:43 A.M., Resident 19 was observed to be hoarding paper towels from the dispenser in the dining room. Resident 19 was pulling paper towels, folding them and placing them under her arm. The stack was approximately three inches thick. Staff observing the behavior had not intervened with this behavior.During an observation, on 2/18/2026 at 1:32 P.M., Resident 19 was observed in dining room with a very strong smell of urine.During an observation, on 2/18/2026 at 3:26 P.M., Resident 19 was sitting in the dining room, and a strong scent of urine could be smelled.During an observation, on 2/19/2026 at 12:49 P.M., Resident 19's room had a strong smell of urine.During an observation, on 2/18/2026 at 12:11 P.M., Resident 19 was observed wearing ill-fitting clothing that were too big with her pants dragging on the ground, drooping off of her buttock to her mid-thigh and a shirt two sizes too big.During an observation, on 2/19/2026 at 11:56 A.M., Resident 19 was observed to be wearing the same clothing from 2/18/2026.During an observation, on 2/20/2026 at 8:32 A.M., Resident 19 was observed to be wearing the same clothing from 2/18/2026.During an observation, on 2/23/2026 at 11:54 A.M., Resident 19 was observed to be wearing the same clothing from 2/18/2026. The shirt had many visible stains. A very strong sent of urine could be smelled from six feet away from the resident.A record review for Resident 19 was completed on 2/23/2026 at 12:59 P.M. Diagnoses included, but were not limited to: Alzheimer's disease, dementia, generalized anxiety and schizophrenia.A Quarterly Minimum Data Set (MDS) assessment, dated 2/20/2026, indicated Resident 19 had moderate cognitive impairment, had no documented behaviors during the 7-day look back period, required partial/moderate assistance with toileting before hygiene and showering, required supervision for personal hygiene and dressing and was occasionally incontinent of bladder.A Nurse Practitioner Progress Note, on 2/2/2026 at 5:12 P.M., indicated Resident 19 was co-managed with psychiatry and currently not taking any medications for her schizophrenia. The note indicated Resident 19 received supportive care only due to non-compliance related to unspecified psychosis.Resident 19 had care plans that addressed not adjusting well to changes, hitting herself while talking to an imaginary person or sitting without talking, refusing shower and facial hair trimming, rummaging through roommates belongings and taking items, refusing nursing assessments, refusing to wear incontinent briefs and using textured bath towels in place of traditional incontinent briefs, carrying around plastic bags with personal belongings, displaying verbal and combative agitation towards staff and thumping another resident after being provoked, However, there were no personalized interventions to prevent behavioral issues.A Care Plan, initiated on 9/5/2017 and updated on 4/2/2025, indicated Resident 19 required assistance with ADLs (activities of daily living) including toilet use. Resident 19 often refuses ADL care/assistance and could become combative during care at times. Interventions included, but were not limited to: offer toilet upon rising, before or after meals, prior to bed and as needed throughout the night, encourage Resident 19 to make choices in care such as clothing, shower time preference, etc., Resident 19 prefers to wash herself and not shower, and encourage resident to do as much for self as possible and praise efforts for self-care. However, there were no personalized interventions to prevent behavioral issues.During an interview, on 2/23/2026 at 8:22 P.M., Resident 19's guardian indicated Resident 19's hygiene was atrocious as she would not use the toilet, but would stack towels under herself and urinate on the towels. She indicated the facility had let these behaviors happen and was not doing anything for Resident 19 or her situation. She indicated the facility did not talk about her behavioral health, nor had the psychiatric nurse practitioner spoken to her about Resident 19's behavioral issues. She indicated she had been told Resident 19 would not take any medication, so there was nothing they could do for her regarding her behaviors and lack of hygiene.During an interview and observation, on 2/24/2026 at 11:57 A.M., the floating Social Service director (SSD) indicated the psychiatric nurse practitioner checked on Resident 19 to ensure she was not having any increased behaviors and was doing well. She indicated any observed behaviors should have been documented in the nursing progress notes. She indicated Resident 19 refused weekly assessments, vital signs and skin assessments and only had had one recent nursing progress note of refusing a shower. She indicated refusing to change clothing and showering should have been charted as a behavior. The SSD went to the room of Resident 19 and indicated the room smelled badly of urine. She indicated after leaving the room, This makes me want to cry, and the SSD became tearful.During an interview, on 2/24/2026 at 12:24 P.M., LPN 3 indicated staff attempted to offer services to Resident 19 by talking and by different staff approaching her at different times. She indicated staff had to be careful not to upset Resident 19.During an interview, on 2/24/2026 at 12:30 P.M., LPN 2 indicated the clothing Resident 19 had been wearing was the only clothing she would wear. She indicated resident interventions on the care plan were not specific to her care as Resident 19 was in her own world with delusions She indicated staff approached Resident 19 with different staff and times to offer services.During an interview, on 2/24/2026 at 12:49 P.M., the facility psychiatric nurse practitioner indicated she had not been advised of any complaints about behaviors that would need medicated. She indicated staff had not advised her of any refusals of care or documented any behaviors. She indicated the staff should have been trialing different times and ways to approach Resident 19 regarding care and showering to have a positive response.During an interview, on 2/24/2026 at 12:40 P.M., the Executive Director indicated Resident 19 had rights and the facility staff had asked her to change her clothing, but she had refused. He indicated Resident 19 was content, happy and at her baseline.A policy was requested for a behavioral health program, on 2/24/2026 at 1:33 P.M. A policy was not provided by the facility prior to the survey exit.3.1-43(a)(1)

Based on observation, interview and record review, the facility failed to ensure showers were provided for 1 of 6 residents reviewed for ADL (Activities of Daily Living) care. (Resident 21)Finding includes:On 2/18/2026, at 2:39 P.M., Resident 21 was observed in the Memory Care unit dayroom with greasy, unkempt hair. On 2/20/2026, at 11:30 A.M., Resident 21 was observed in the dayroom of the Memory Care unit with her hair still unkempt and greasy.On 2/23/2026 at 10:06 A.M. Resident 21 was observed in the Memory Care unit while exiting her room; her hair appeared disheveled and greasy.The clinical record of Resident 21 was reviewed on 2/19/2026 at 12:54 P.M. The resident's diagnoses included, but were not limited to: Alzheimer's disease, a displaced fracture of the base of the neck of the left femur, paranoid schizophrenia, diabetes mellitus, osteoporosis, personal history of intraductal carcinoma in situ of the left breast, anemia, severe protein-calorie malnutrition, retention of urine, cognitive or emotional deficit following cerebral infarction, depression, dysphagia, anorexia, vascular dementia and acquired absence of both breasts and nipples.A Quarterly Minimum Data Set (MDS) assessment, dated 2/10/2026, indicated the resident had both short-term and long-term memory problems and moderately impaired cognitive skills for daily decision making and required partial assistance with bathing and/or showering.A current Care Plan, revised on 2/11/2026, indicated Resident 21 had a problem of refusing showers and interventions included but were not limited to: explain tasks in detail and allow resident time to process, staff will continue to encourage resident to allow care as resident tolerates. Resident 21's current Care Plan included a problem of needing assistance with ADLs. Interventions included but were not limited to: assist with bathing as needed per resident preference, offer showers two times per week and resident prefers two showers in the morning or early afternoon weekly.Documentation from the Electronic Medical Record (EMR) and shower sheets (written documentation of a resident's hygiene care) were both reviewed for 1/20/2026 through 2/20/2026. Resident 21 had a shower on 1/21/2026; there was only one attempt documented to shower the resident on 1/28/2026 and the resident refused. There were no further attempts documented to shower the resident. Resident 21 received a shower on 1/31/2026. There was only one attempt to shower the resident documented on 2/7/2026 and Resident 21 refused, there were no further attempts documented to shower the resident. There were 3 documented attempts to aide Resident 21 to shower on 2/11/2026. Resident 21 received a shower on 2/14/2026 and there were 3 documented attempts to shower the resident on 2/18/2026 and the resident refused the shower all 3 times.The nursing notes failed to evidence any documentation of the resident's refusal to shower between 1/20/2026 through 2/20/2026. During an interview, on 2/20/2026 at 1:30 P.M., QMA 7 indicated showers were completed according to the Memory Care unit schedule, which was found in the shower book. The QMA indicated the aide should have completed a shower sheet for each resident shower they completed. The QMA indicated a resident shower included a hair shampoo, bilateral fingernail care and a facial shave. QMA 7 indicated if a resident had refused their shower, the aide would have re-approached and tried to get the resident to shower later. The QMA indicated the aide would have attempted to help the resident shower 3 times. QMA 7 indicated if the resident refused 3 times, the aide would have notified the nurse and the nurse would have documented the resident's refusal. During an interview, on 2/20/2026 at 2:20 P.M., the Unit Manager indicated a resident should have been offered a shower at least 3 times and then the aide should have notified the nurse. The Unit Manager indicated the nurse should have documented the resident's refusal in the Electronic Medical Record (EMR).There was no explanation given as to why Resident 21 had only been offered and/or showered once in the week of 1/20/2026 and once for the week of 2/1/2026. In addition, it was unclear why there were no nursing notes regarding the resident's repeated refusals to shower. During an interview, on 2/23/2026 at 11:26 A.M., the Regional Director of Clinical Services (RDCS) indicated the facility did not have a policy for providing ADLs, including showers and/or baths.3.1 - 38(a)(1)

Based on record review and interview, the facility failed to follow a physician's order to notify the provider of a 3 pound weight gain in 1 day for 1 of 3 residents reviewed for edema. (Resident 33) Finding includes: A record review for Resident 33 was completed on 2/19/2026 at 12:52 P.M. Diagnoses included, but were not limited to, chronic congestive heart failure (CHF). A Quarterly Minimum Data Set (MDS) assessment, dated 1/12/2026, indicated Resident 33 received a diuretic daily for CHF. A Physician's Order, dated 1/14/2026, indicated Resident 33 was to be weighed daily and the physician was to be called for a gain of 3 pounds in one day or 5 pounds in one week. On 2/8/2026 the Medication Administration Record (MAR) indicated the resident's weight was 197 pounds and on 2/9/2026 it was 200.1 pounds, a gain of 3.1 pounds in one day. The MAR indicated the physician was not notified of the 3.1 pound gain. During an interview on 2/24/2026 at 10:09 A.M. the DON indicated the physician should have been notified of the weight gain. She further indicated the facility did not have a policy regarding following physician orders as they followed the standards of practice. 3.1-37(a)

Based on interview and record review, the facility failed to ensure a resident was assessed, monitored and treated for pain, which resulted in the resident calling 911 and going to the hospital due to her pain, for 1 of 3 residents reviewed for pain management, (Resident B). Finding includes: On 6/23/25 at 9:14 A.M., Resident B's clinical record was reviewed. The resident was admitted to the facility for one day, following an eight day hospital admission from home. The resident diagnoses included, but were not limited to, left shoulder and left arm pain, multiple sclerosis, spastic hemiplegia to the right side, polyneuropathy, chronic pain, venous insufficiency, overactive bladder, and spinal enthesopathy of the cervical region. Review of the Resident B's hospital records indicated the resident had been admitted for complaints of left shoulder, neck and left arm pain. The physician's assessment following testing indicated the resident had . a less that 50% partial-thickness partial width articular surface tear of the supraspinatus and infraspinatus tendons (a significant injury to the rotator cuff where the tear extends halfway through the thickness of the tendon on the joint surface, and also fraying on the outer surface of the tendons, which are part of the rotator cuff) . The Hospital medication orders, dated 6/3/25, included but were not limited to acteaminophen-oxycodon 325 mg-7.5mgon e tablet by mouth, every 4 hours as needed for pain. The facility physician's admission orders, dated 6/11/25, included, but were not limited to the instruction to administer oxycodone acetaminophen 7.5-3.5 mg, 1 tablet by mouth , every 4 hours as needed for pain. Resident B's admission Observation assessment form, dated 6/11/25, indicated at the time of admission (approximately 12:32 P.M., per nursing progress notes), the resident reported that she had had a new onset of pain that was not a chronic condition. There were no further documentation of pain, pain assessments or treatments to address the residents pain on admission. Review of the resident's medication administration record (MAR) indicated the resident had not received any medications for pain relief on 6/11/25. A Nursing Progress Note, dated 6/11/25 at 11:05 P.M., indicated .Resident used her personal cell phone in room and called 911 stating she has increased left shoulder pain and wants relief. Resident insists that she return back to hospital and will not be returning back to our facility. Resident informed of risks of leaving AMA [against medical advice]. Resident states she id leaving anyway. AMA form printed and signed by resident. DNS [Director of Nursing Services] .notified. Resident left with EMT [Emergency Medical Technician] via stretcher . The emergency room (ER) documentation, dated 6/12/25 at 12:40 A.M., indicated Resident B told the ER physician that when the facility staff had cleaned her up, they had rolled her to her left side and she protested because it had hurt her arm badly. Consequently, she had signed herself out of the facility and was brought to the ER. The x-ray of the left shoulder, indicated there was no fracture and no acute findings. The resident was admitted to the local hospital for a recurring urinary tract infection and pain. During an interview, on 6/23/25 at 12:00 P.M., Certified Nursing Assistant (CNA) 3, indicated she and CNA 6 were in Resident B's room at about 9:00 P.M., to change and reposition the resident. She indicated they had rolled the resident to her side to clean her and the resident had complained of pain, so they rolled her back to her back and completed her care. During an interview, on 6/23/25 at 12:45 P.M., CNA 6 indicated she had helped CNA 3 with Resident B's evening care when they properly rolled the resident with a draw-sheet to clean her, the resident had screamed out in pain, so they had rolled her back to her back to continue care. During an interview on 6/23/25 at 1:26 P.M., the Administrator indicated the resident had complained of pain, but had not requested pain medication. The Administrator indicated the resident should have been assessed for pain and her pain should have been addressed through intervention and/or medication. During an interview, on 6/23/25 at 3:02 P.M., the Director of Nursing indicated Resident B should have been assessed for pain every shift for 72 hours following her admission, but was not. The Director of Nursing indicated the nurse on duty, Licence Practical Nurse (LPN) 7 should have assessed the resident for pain and offered pain medication when the resident had yelled out in pain, but had not. During an interview with LPN 7, she indicated she went to the resident's room after CNA 6 and CNA 7 completed her evening care, to administer evening medications, and the resident had been tearful. LPN 7 indicated the resident was in a lot of pain from positioning with evening care. LPN indicated she had not completed a pain assessment, nor had she offered the resident pain medication. Finally, LPN 7 indicated she did not know when the resident had last had pain medication. LPN 7 indicated if the resident had wanted pain medications, she should have asked for them. On 6/24/25 at 12:15 P.M., the Administrator provided a policy titled, Pain Management Policy, dated 7/24 and indicated it was the current pain management policy. The policy indicated, .Residents are assessed for pain upon admission, and during medication administration .Interview Resident-Pain medications will be prescribed and given based upon the intensity of pain .MILD =(1-2) MODERATE = (3-5) SEVERE = (6-8) VERY SEVERE, HORRIBLE = (9-10) .Pain [using faces indicated tears = 10 worst pain] . This citation relates to Complaints IN00461459 and IN00461410. 3.1-37(a)

Based on interview and record review, the facility failed to ensure discharge documentation was obtained and/or complete upon discharge for 5 of 6 residents reviewed for transfer/discharge. (Residents F, H, J, K and L) Finding include: 1. The record for Resident F was reviewed on 3/5/2025 at 10:48 A.M. Diagnoses included, but were not limited to low back pain, Cerebral palsy, obesity and contracture to the right upper arm. A Social Service Progress Note, dated 2/11/2025 at 10:20 A.M., indicated the following: Discharge to preferred address. Resident was alert and oriented. All personal possessions sent with the resident. Resident F's physician orders lacked an order to discharge the resident. During an interview, on 3/6/2025 at 9:56 A.M., the Regional Director of Clinical Services (RDCS) indicated there should have been a physician's order to discharge the resident home. 2. The record for Resident H was reviewed on 3/5/2025 at 2:34 P.M. Diagnoses included, but were not limited to anemia, diabetes, and cellulitis of the lower left leg. A Nurse's Progress Note dated 9/26/2025, indicated Resident H had been discharged home with their belongings along with discharge papers. There was no physician order to discharge Resident H to their home. A Transfer of Care/Discharge summary, dated [DATE], located in the Clinical Discharge and Narrative section of the electronic record was incomplete. There were blank sections for the following areas: transportation; customary routine; continence; cognitive patterns; dental; communication; nutritional status, vision; pressure ulcer/injury; mood and behavior patterns; activity pursuits; psychosocial well-being; physical functioning and structural problems- mobility devices, self-care and mobility. Resident H's current medications were also not listed on the Discharge Summary and the summary lacked a signature from the resident and/or the resident's representative. During an interview, on 3/6/2025 at 9:56 A.M., the RDCS indicated there should have been a physician's order to discharge the resident home. During an interview, on 3/6/2025 at 1:47 P.M., the RDCS indicated the Clinical Discharge and Narrative sections should have been completed based off the information in the most recent Minimum Data Set Assessment (MDS) assessment and should not have been left blank. During an interview, on 3/6/2025 at 1:49 P.M., the RDCS indicated a copy of the physician orders report for medications, from the electronic medical record, should have been printed and attached to the discharge summary and a copy should have been sent home with the resident. 3. The record for Resident J was reviewed on 3/5/2025 at 2:38 P.M. Diagnoses included, but were not limited to diabetes, hypertension, obesity and congestive heart failure. Resident J's payer source was private pay as of 7/22/2024. A Physician's Order, dated 8/29/2025, indicated an order to discharge the resident home with three (3) days of medications. A Transfer of Care/Discharge summary, dated [DATE], located in the Clinical Discharge and Narrative section of the electronic record had the following areas left blank: transportation; customary routine; continence; cognitive patterns; dental; communication; nutritional status, vision; pressure ulcer/injury; mood and behavior patterns; activity pursuits; psychosocial well-being; physical functioning and structural problems- mobility devices, self-care and mobility. The care plan goals and the medications to be taken at home were also not documented. A Receipt for Returned Products from [Name of Pharmacy], dated 8/30/2024, indicated the following medications were returned to the pharmacy: 2 Levofloxacin (antibiotic), 73 metformin (anti diabetes), 35 Lisinopril (blood pressure), 22 acetaminophen (pain), 4 multivitamins, 4 aspirin, 5 carvedilol (heart), 4 furosemide (water retention) and 39 atorvastatin (cholesterol). The reason for the return of all the medications was documented as discharged . During an interview, on 3/6/2025 at 1:19 P.M., the RDCS indicated the medications for Resident J should have been sent home with him. A Quarterly Minimum Data Set (MDS) assessment for Resident J was completed, on 8/27/2024, 2 days prior to the discharge date of 8/29/2024. During an interview, on 3/6/2025 at 1:47 P.M., the RDCS indicated the Clinical Discharge and Narrative sections should have been completed based off the information in the most recent Minimum Data Set (MDS) Assessment and not left blank. During an interview, on 3/6/2025 at 1:49 P.M., the RDCS indicated a copy of the physician's orders report from the electronic medical record should have been printed and attached to the discharge summary. 4. The record for Resident K was reviewed on 3/5/2025 at 2:30 P.M. Diagnoses included, but were not limited to anxiety, hypertension, pancreatitis, and alcoholic cirrhosis of the liver. There was no physician's order to discharge Resident J on 10/20/2025. A Transition of Care/Discharge summary, dated [DATE], indicated Resident J had been discharged home. The Clinical Discharge and Narrative section lacked any documentation in the following areas: transportation; customary routine; continence; cognitive patterns; dental; communication; nutritional status, vision; pressure ulcer/injury; mood and behavior patterns; activity pursuits; psychosocial well-being; physical functioning and structural problems- mobility devices, self-care and mobility. There was also no home medications listed on the summary and the summary was not signed by Resident J and/or Resident J's representative. During an interview, on 3/6/2025 at 9:56 A.M., the RDCS indicated there should have been a physician's order to discharge Resident J home. During an interview, on 3/6/2025 at 1:47 P.M., the RDCS indicated the Clinical Discharge and Narrative sections should have been completed based off the information in the most recent Minimum Data Set Assessment (MDS) and not left blank. An admission MDS had been completed, on 10/1/2025, nineteen (19) days prior to his discharge. During an interview, on 3/6/2025 at 1:49 P.M., the RDCS indicated a copy of the physician's orders report from the electronic medical record, which would have included a list of medications, should have been printed and attached to the discharge summary. 5. A record review for Resident L was completed on 3/5/2025 at 1:33 P.M. Diagnoses included, but were not limited to Diabetes Type 2, staphylococcal arthritis to the right knee, rheumatoid arthritis and anemia. Resident L's Physician's orders included the following medications: atorvastatin 80 milligrams (mg) daily, duloxetine 20 mg daily, Flomax 0.4 mg daily, rifampin 300 mg twice daily, and pantoprazole 40 mg daily. Resident L's medical record did not include a Physician's Order to be discharged to the community. In addition, there was no physician's order regarding if medications could be sent with the resident when he was discharged . A Transition of Care/Discharge summary, dated [DATE], indicated Resident L had been discharged home. The summary did not include a discharge medication list and the clinical discharge/narrative was incomplete. During an interview on 3/6/2025 at 1:49 P.M., the Regional Director of Clinical Services (RDCS) indicated a Physician's [NAME] should have been written for Resident L to discharge home, and a copy of the physician orders report from the electronic medical record should have been printed and attached to the discharge summary. The RDCS indicated the section for clinical discharge and narrative should have been completed based off the information in the most recent Minimum Data Set Assessment (MDS) and not left blank. On 3/6/2025 at 9:22 A.M., the RDCS provided the policy titled, Discharging Planning, dated 3/2023, and indicated the policy in the one currently used by the facility. The policy included the following: . Appropriate IDT members will participate in formulating a comprehensive discharge plan . 6. A physician's order for discharge including related medications, equipment, treatments, and home health will be obtained as applicable . 8. The instructions will be reviewed and signed by the resident/representative in a manner they are able to understand; a copy of the instructions will be given to the resident/representative On 3/6/2025 at 1:15 P.M., the RDCS provided the policy titled, Discharging a Resident with Medications, with a revision date of 8/1/2024, and indicated the policy was the one currently used by the facility. The policy included the following: . 1. Facility nurse shall review the medication list with the prescriber to determine which medication orders will be continued upon discharge. 1.1 A reconciliation of all discharge orders against medications taken during the resident stay shall be completed per facility policy. 2. Resident's physician/prescriber shall provide an order indicating that the resident may take medications with them upon discharge On 3/6/2025 at 1:47 P.M., the RDCS provided the Transition of Care/Discharge Summary Guidelines, undated, and indicated the guidelines were the ones currently used by the facility. The guidelines indicated the following: .Clinical Discharge and Narrative- MDS ARD: select the most recent MDS (if no MDS available leave blank) .Discharge Medications- Please print out home discharge medication instructions from [name of charting program], using the Physician Orders Report, with the discharge date as the Start date and end 30 days later This citation relates to complaint IN00453560. 3.1-12(a)(3)

Based on observation, interview and record review, the facility failed to store food in a safe and sanitary manner in 1 of 1 kitchen observed. The deficient practice had the potential to affect 70 of 71 residents who consumed food prepared in the kitchen. Findings include: During an observation of the kitchen conducted on 11/21/2024 at 9:39 A.M. with the Culinary Nutrition Manager the following was observed in the reach-in freezer: -an open, unsealed, bag of frozen peas -an open, unsealed, bag of frozen mixed vegetables were found in the reach in freezer. During an interview on 11/21/2024 at 9:40 A.M., the Culinary Nutrition Manager indicated the bags of opened, frozen food should have been sealed after use. 3.1-21(i)(3)

Based on observation, interview and record review, the facility failed to ensure infection control practices were carried out appropriately for 1 of 1 staff observed providing high contact care in an Enhanced Barrier Precautions (EBP) room for 1 of 1 residents observed in isolation (Resident 23). Finding includes: During an observation on 11/22/2024 at 9:10 A.M., Resident 23 had an Enhanced Barrier Precautions sign above her bed and an isolation cart in the room. During an observation on 11/22/2024 at 9:14 A.M., CNA 8 was observed changing the bed linens in Resident 23's room. The CNA did not have on a pair of gloves or a gown while changing the resident's bed linens. During an interview on 11/22/2024 at 9:15 A.M., CNA 8 indicated she was unaware that Resident 23 was on Enhanced Barrier Precautions. She indicated she had not seen the sign on the resident's door. During an interview on 11/22/2024 at 9:20 A.M., CNA 8 indicated, after checking with the licensed nurse, she was informed Resident 23 was on EBP due to wounds on the bottoms of both of her feet. She indicated she should have been wearing a gown and gloves prior to providing care to Resident 23. On 11/25/2024 at 9:15 A.M., a record review was completed for Resident 23. Diagnoses included, but were not limited to: type 2 diabetes with foot ulcer. A current Care Plan, initiated on 8/16/2024 indicated Resident 23 was at risk for becoming colonized with a Multi-drug Resistant Organism (MDRO) and required enhanced barrier precautions due to chronic wounds. Interventions included, but were not limited to: identify resident as needing EBP through signage and medical record, use standard precautions including hand hygiene in addition to EBP, and wear a gown and gloves prior to high contact resident care activities. On 11/27/2024 at 8:57 A.M., the Regional Nurse provided the policy titled, Enhanced Barrier Precautions, undated, and indicated it was the policy currently being used by the facility. The policy indicated .Enhanced barrier precautions are used for: Resident's with chronic wounds and/or indwelling medical devices, regardless of their MDRO status. Examples of chronic wounds include, but are not limited to, pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers. Use of personal protective equipment - gown and gloves: During high contact resident care activities and changing linens 3.1-18(a)

Based on interview and record review, the facility failed to address pharmacy recommendations timely for 1 of 5 residents reviewed for unnecessary medications. (Resident 38) Finding includes: A record review was completed on 11/25/2024 at 1:40 P.M. for Resident 38. Diagnoses included but were not limited to: generalized anxiety, radiculopathy (pinched nerve), hemiparesis/hemiplegia and repeated falls. A Significant Change Minimum Data Set (MDS) assessment, dated 11/14/2024, indicated Resident 38's cognition was intact, he had no behavior issues, had pain and took antianxiety and antidepressant medications daily. Physician Orders for Resident 38 included, but were not limited to: -11/7/2024 buspirone 10 milligrams (mg) by mouth twice a day. -11/8/2024 diazepam 5 mg by mouth twice a day -11/7/2024 trazodone 75 mg by mouth at bedtime -11/14/2024 fluoxetine 20 mg by mouth once a day -11/7/2024 gabapentin 600 mg by mouth three times a day A Pharmacy Review for Resident 38, completed on August 5, 2024 and September 10, 2024 regarding decreasing the resident's gabapentin dose were not addressed by the physician until after the pharmacist review and recommendations were completed in October 2024. On October 8, 2024 the recommendation was to decrease the gabapentin from 300 mg three times a day to 200 mg three times a day due to the potential for an increased risk for falls. The physician addressed the October recommendation and indicated the gabapentin was unrelated to falls. During an interview on 11/26/24 at 1:44 P.M., the DON indicated Pharmacy recommendations should be addressed when received or at least within 30 days. A current policy provided on 11/26/2024 at 1:56 P.M. by the Regional Nurse, dated October 2018 and titled, Medication Regimen Reviews and Pharmacy Recommendation, indicated the following, .Pharmacy recommendations should be reviewed with follow up the the physician within 30 days of the facility receiving 3.1-48(3)

Based on observation, record review and interview, the facility failed to provide Activities of Daily Living (ADLs) for dependent residents timely related to nail care, shaving, and turning and repositioning for 3 of 5 dependent residents who were reviewed for ADLs. (Residents 15, 38 & 14) Findings include: 1. During an observation on 11/21/2024 at 11:28 A.M., Resident 15 had long fingernails with a brown substance under them on his left hand. During an interview on 11/22/2024 at 2:15 P.M., Resident 15 indicated he had requested his nails be trimmed twice in the last week. He indicated he was unable to trim his own nails because he was blind. Resident 15 had a scab under his left eye and he indicated it was from scratching himself with his long nails. During an observation on 11/22/2024 at 2:15 P.M., Resident 15's fingernails were long and there was a brown substance under most of his nails. Resident 15's record review was completed on 11/25/2024 at 1:50 P.M. Diagnoses included, but were not limited to: Parkinson's disease, congestive heart failure, Type 2 diabetes mellitus, Major depressive disorder, legal blindness, delusional disorder and psychotic disorder. A Significant Change Minimum Data Set (MDS) assessment, dated 11/8/2024, indicated Resident 15 had intact cognition, had not rejected care, had severely impaired vision, was able to understand others and make himself understood and required substantial assistance for showering. A current Care Plan, dated 11/2/2024, indicated Resident 15 required assistance with ADLs. His goal was to have ADL needs met. His interventions included, but were not limited to: AM and PM Care. During an interview on 11/25/2024 at 11:00 A.M., CNA 3 indicated AM Care were the tasks done in the morning when a resident woke up and PM Care were the tasks performed when the resident was getting ready for bed. The tasks for AM and PM Care included face washing, oral care, hair brushing, applying lotion and deodorant, shaving, and nail trimming. During a follow-up interview on 11/25/2024 at 2:00 P.M., Resident 15 indicated his nails had not been trimmed and asked, Who is going to cut my nails? During an interview on 11/25/2024 at 2:04 P.M., CNA 11 indicated Resident 15's fingernails were long and dirty and should not be long or dirty. CNA 11 indicated nail care was part of a resident's shower routine or done during AM or PM Care. 2. During an interview on 11/21/2024 at 2:12 P.M., Resident 38 indicated he did not like having facial hair or long fingernails and had requested to be shaved and have his nails trimmed. He indicated he had asked multiple times in the last two weeks and was told someone would do it tomorrow, but staff had not shaved his face or trimmed his nails. During an observation on 11/22/2024 at 11:06 A.M., Resident 38 had long nails and facial hair on his face. During an interview on 11/25/2024 at 9:05 A.M., Resident 38 indicated his roommate had shaved him on 11/22/2024 after he had asked staff twice to shave his facial hair and staff had not shaved him. Resident 38's record review was completed on 11/25/24 at 1:40 P.M. Diagnoses included, but were not limited to: radiculopathy (pinched nerve), generalized anxiety, hemiparesis/hemiplegia and muscle weakness. A Significant Change MDS assessment, dated 11/14/2024, indicated Resident 38 had intact cognition, had not rejected care, required substantial assistance with showering and supervision for personal hygiene tasks. A current Care Plan, initiated on 5/31/2024, indicated Resident 38 required assistance with ADLs. Resident 38 had a goal to improve his current functional status. Interventions included, but were not limited to: assist with dressing, grooming and hygiene as needed. During an interview on 11/25/2024 at 1:56 P.M., CNA 3 indicated AM and PM Care included partial bedbath, oral care, perineal care, deodorant applied to under arms and shaving was to be offered. During an interview on 11/26/2024 at 9:22 A.M., Resident 38 indicated he had requested his nails trimmed on 11/22/2024 by staff, but they had not been trimmed. He indicated he had not been shaved since his roommate had shaved him on 11/22/2024. During an interview on 11/26/2024 at 9:38 A.M., the Executive Director (ED) indicated she had spoken to staff about shaving Resident 38 on 11/22/2024 and was not aware Resident 38 had not had his face shaved by staff. The ED indicated residents should be shaved and have their nails trimmed when they requested to be shaved or have their nails trimmed. 3. During observations on 11/21/2024 at 10:02 A.M.,11:26 A.M., and 2:09 P.M., Resident 14 was supine in bed with a soft triangular wedge lying next to the left upper body. During observations on 11/22/2024 at 9:27 A.M. and 3:32 P.M. Resident 14 was supine in bed with a soft triangular wedge lying next to the upper body. During observations on 11/25/2024 at 8:36 A.M., 10:14 A.M., 11:21 A.M., 2:31 P.M., Resident 14 was supine in bed with a triangular wedge next to the left upper body. During an observation on 11/25/2024 at 11:47 A.M. CNA 3 entered Resident 14's room and exited with the roommate. During observations on 11/26/2024 at 9:12 A.M., 10:19 A.M., 11:40 A.M., and 2:21 P.M., Resident 14 was supine with a triangular wedge next to his body. During an observation on 11/26/2024 at 10:52 A.M. two staff went into Resident 14's room and exited at 11:36 A.M. with Resident 14's roommate. At 11:40 A.M. Resident 14's bed was in low position, and he was supine with a triangular wedge lying next to the left upper body. A record review was completed on 11/25/2024 at 3:07 P.M. Diagnoses included, but were not limited to: hemiplegia and hemiparesis following other cerebrovascular diseases affecting right dominant side, other vascular syndromes of brain in cerebrovascular diseases cadasil syndrome, dysphagia following cerebral infarction, aphasia following cerebral infarction. A Care Plan dated 4/16/2018, for impaired mobility included an intervention to turn and reposition the resident every 2 hours and as needed. A Care Plan dated 8/27/2015, for at risk for skin breakdown included an intervention dated 5/7/2022 indicated to turn and reposition the resident at least every 2 hours. During an interview on 11/25/2024 at 1:23 P.M., CNA 3 indicated she provided care to Resident 14 around 10:15 A.M. with a check and change so far twice during the shift. She indicated she had checked Resident 14 for incontinence and changed him twice during her shift. She indicated he was not on a rotation position schedule, but she was aware there was something wrong with his left side and he could not be left on his left side. She indicated Resident 14 had had a stroke. During an interview on 11/25/2024 at 2:14 P.M., CNA 4 indicated when she took care of a dependent resident, she provided the following care: she washed them, checked and changed them for incontinence every two hours, fed them, applied lotion, cut their nails and combed their hair. During an interview on 11/25/2024 at 2:22 A.M., CNA 6 indicated when she took care of a dependent resident she provided the following care: she did everything for them, checked and changed them for incontinence, assisted them with meals, transferred and emptied Foley catheter if they had one. During an interview on 11/25/2024 at 2:25 P.M., CNA 7 indicated when she took care of a dependent resident, she provided the following care: oral care, if incontinent bed and brief changed, washed their face and made sure they were comfortable in the right position and safe. During an interview on 11/26/2024 at 10:43 A.M. CNA 2 indicated when she took care of a dependent resident, she provided the following care: oral and nail care, peri- care, toileted, showered, combed hair, transferred, and foot care. During an interview on 11/26/2024 at 1:10 P.M., CNA 2 indicated she had taken care of Resident 14 and provided the following care: before bed bath, oral and nail care, changed his brief three times, and applied lotion. He was turned on his side briefly when she was washed him and provided incontinence care. She indicated his right side was his affected side and the wedge cushion was placed next to his upper body to prevent him from leaning to the left. She indicated he was on his back all the time and was only on his side when he was turned to do peri- care. On 11/25/2024 at 2:30 P.M. the Regional Nurse indicated the facility did not have a policy for providing ADLs to dependent residents. The Regional Nurse provided a checklist, dated 9/2023, and titled, Fingernail Care, and identified it as the checklist currently by used the facility to provide fingernail care. The checklist did not indicate when fingernail care was to be performed, but listed the steps used by the facility to perform nailcare. The checklist indicated, .9. Clean under nails with orange stick. 10. Clip fingernails straight across, then file in a curve On 11/26/2024 at 11:30 A.M. the ED indicated the facility did not have a policy for providing ADLs to dependent residents. The ED provided a checklist dated, 4/2012, and titled, AM Care, and identified it as the checklist currently used by the facility. The checklist indicated, . 8. Shave resident, if needed or requested On 11/26/2024 at 2:13 P.M. the DON indicated they did not have a policy on turning and repositioning but indicated it was the standard of care. 3.1-38 (a)(1)

Based on interview and record review, the facility failed to ensure bed hold policies were provided to the resident and/or responsible parties at the time of the hospital transfer for 2 of 3 residents reviewed for hospitalization (Residents 21 & 48). Findings include: 1. During an interview on 11/21/2024 at 10:22 A.M., Resident 21 indicated she had been to the hospital in the last 4 months and did not recall receiving any paperwork prior to leaving the facility. On 11/25/2024 at 11:25 A.M., a record review was completed for Resident 21. A Quarterly Minimum Data Set assessment (MDS), dated [DATE] indicated the resident had mild cognitive impairment. A review of Resident 21's census record indicated the resident was hospitalized on [DATE] and returned to the facility on [DATE]. A Nursing Progress Note, dated 4/19/2024 at 4:50 P.M., indicated after assessing the resident, the nurse called Emergency Services and the resident was transported to the hospital. A Nursing Progress Note, dated 4/23/2024 at 4:30 P.M., indicated Resident 21 was readmitted to the facility from the hospital. During an interview on 11/25/2024 1:07 P.M., LPN 12 indicated the process for sending a resident to the hospital included filling out paperwork prior to the resident leaving the facility. The paperwork included the bed hold policy and a transfer/discharge assessment. During an interview on 11/25/2024 at 1:14 P.M., the Infection Prevention Nurse indicated the bed hold policies would either be in the miscellaneous tab in the resident's chart or possibly in the paperwork waiting to be scanned into the resident's record. During an interview on 11/25/2024 at 1:30 P.M., the Infection Prevention Nurse indicated she was unable to find a bed hold policy for Resident 21. She indicated a bed hold policy should have been sent with the resident prior to leaving the facility. The record lacked the documentation that a bed hold policy was provided to Resident 21 prior to leaving for the hospital. 44111 2. A record review was completed on 11/25/2024 at 9:02 A.M. for Resident 48. Diagnoses included, but was not limited to: unspecified dementia, unspecified severity, with other behavioral disturbance, unspecified psychosis not due to a substance or known physiological condition, and generalized anxiety disorder. A Nursing Progress Note, dated 1/11/2024 at 1:05 P.M., indicated there was an order for Resident 48 to be sent to the psychiatric hospital for an evaluation and treatment related to behaviors. A Nursing Progress Note, dated 1/18/2024 at 12:20 P.M., indicated Resident 48 returned to the facility. A record of hospital transfer forms to the hospital was not found in the electronic medical record. During an interview on 11/25/2024 at 10:51 A.M., LPN 10 indicated that when a resident was sent to the hospital the following papers would be sent with the resident: emergency transfer observation, CCD (Continuity of Care Document), and a bed hold policy. LPN 10 could not locate the transfer paperwork for 1/11/2024 and indicated it should have been filled out. On 11/25/2024 at 2:50 P.M., the Regional Nurse provided a policy titled, Hospital Discharge/Transfer, revised 2/2019, and indicated the policy was the one currently used by the facility. The policy indicated .Nursing will complete an Emergency transfer observation and attach copies of the following information from the resident medical record: Face Sheet, H&P Physician Notes, Current orders, CCD, Advance directives, Comprehensive Care Plan, Pertinent labs, Notice of Transfer/Discharge, Bed hold policy, Nursing Notes . On 11/26/2024 at 8:40 A.M., the Regional Nurse provided a policy titled, Bed Hold, revised 1/2019, and indicated the policy was the one currently used by the facility. The policy indicated .2. The residents will be provided the bed hold policy at the time of the hospital transfer or therapeutic leave . 3.1-12(25)(A)(B)

Based on interview and record review, the facility failed to provide the resident and/or the resident's representative with a notice of transfer for 2 of 2 residents reviewed for hospitalization (Residents 21 & 48). 1. During an interview on 11/21/2024 at 10:22 A.M., Resident 21 indicated she had been to the hospital in the last 4 months. On 11/25/2024 at 11:25 A.M., a record review was completed for Resident 21. A Quarterly Minimum Data Set assessment (MDS), dated [DATE] indicated the resident had mild cognitive impairment. A review of Resident 21's census record indicated the resident was hospitalized on [DATE] and returned to the facility on [DATE]. A Nursing Progress Note, dated 4/19/2024 at 4:50 P.M., indicated after assessing the resident, the nurse called Emergency Services and the resident was transported to the hospital. During an interview on 11/25/2024 at 1:07 P.M., LPN 12 indicated the process for sending a resident to the hospital included filling out paperwork prior to the resident leaving the facility and completing a transfer/discharge assessment in the resident's chart. During an interview on 11/25/2024 at 1:14 P.M., the Infection Prevention Nurse indicated the transfer/discharge assessment could be found in the observations tab in the resident's chart. She indicated the transfer/discharge paperwork was uploaded to the chart with the resident's discharge paperwork from the hospital. The record lacked the documentation that a transfer/discharge assessment was completed in conjunction with Resident 21's transfer to the hospital on 4/19/2024. During an interview on 11/25/2024 at 1:30 P.M., the Infection Prevention Nurse indicated she was unable to find a transfer/discharge assessment for Resident 21. She indicated one was not completed and should have been. 44111 2. A record review was completed on 11/25/2024 at 9:02 A.M. for Resident 48. Diagnoses included, but was not limited to: unspecified dementia, unspecified severity, with other behavioral disturbance, unspecified psychosis not due to a substance or known physiological condition, and generalized anxiety disorder. A Nursing Progress Note, dated 1/11/2024 at 1:05 P.M., indicated there was an order for Resident 48 to be sent to the psychiatric hospital for an evaluation and treatment related to behaviors. A Nursing Progress Note, dated 1/18/2024 at 12:20 P.M., indicated Resident 48 returned to the facility. A record of hospital transfer forms to the hospital was not found in the electronic medical record. During an interview on 11/25/2024 at 10:51 A.M., LPN 10 indicated that when a resident was sent to the hospital the following papers would be sent with the resident: emergency transfer observation, CCD (Continuity of Care Document), and a bed hold policy. LPN 10 could not locate the transfer paperwork for 1/11/2024 and indicated it should have been filled out. On 11/25/2024 at 2:50 P.M., the Regional Nurse provided a policy titled, Hospital Discharge/Transfer, revised 2/2019, and indicated the policy was the one currently used by the facility. The policy indicated .Nursing will complete an Emergency transfer observation and attach copies of the following information from the resident medical record: Face Sheet, H&P Physician Notes, Current orders, CCD, Advance directives, Comprehensive Care Plan, Pertinent labs, Notice of Transfer/Discharge, Bed hold policy, Nursing Notes . 3.1-12(3)

Based on interview and record review, the facility failed to ensure 1 of 3 residents reviewed for medication administration, had medications available from the pharmacy in a timely manor, (Resident C). Finding includes: The clinical record for Resident C was reviewed on 10/9/24 at 3:37 P.M. Diagnosis included Bipolar II disorder, borderline personality, anxiety, obsessive-compulsive disorder, and chronic low back pain. The Physician's Orders, dated 6/10/24 to 7/2/24, indicated Resident C's prescribed orders included the following: Caplyta one 42 mg capsule once a day in the evenings between 7:00 P.M. and 10:00 P.M., for Bipolar II disorder, with a start date of 6/10/24 and end date of 8/12/24. Pregabalin one 100 mg capsule two times a day in the morning between 7:00 A.M. and 10:00 A.M. and again between 7:00 P.M. and 10:00 P.M., for chronic back pain with a start date of 6/10/24 and end date 6/20/24. A review of Resident C's Medication Administration Record (MAR) from 6/10/24 to 7/2/24, indicated the resident did not receive the Caplyta medication on 6/11/24 at 6/11/24, 6/12/24, 6/18/24, 6/19/24, and 6/23/24 for the 7:00 P.M. - 10:00 P.M dose. The nursing comment on the MAR indicated, Not Administer: Drug/Item Unavailable, each time the medication was not administered. Pregabalin on 6/11/24 at 7:00 A.M. to 11:00 A.M. and 7:00 P.M. - 11:00 P.M., 6/12/24 at 7:00 A.M. to 11:00 A.M. and 7:00 P.M. - 11:00 P.M. The nursing comment on the MAR indicated Not Administer: Drug/Item Unavailable, each time the medication was not administered. Review of the pharmacy Proof of Delivery statement indicated the resident's Caplyta was shipped from the pharmacy on 6/12/24 and received by the facility on 6/13/24 at 12:47 A.M. and Pregabalin was shipped from the pharmacy on 6/12/24 and received by the facility on 6/13/24 at 12:47 A.M. During an interview on 10/10/24 at 10:39 A.M., the Director of Nursing indicated an order was sent to the pharmacy for Resident C's Caplyta medication in a timely manor, but the medication did not come immediately. The Director of Nursing indicated if medications were not immediately available for administration, the physician should be notified for for further instructions and the MAR should reflect the reason the medication was not administered. During an interview on 10/10/24 at 1:44 P.M., the Regional Nurse Consultant indicated the facility did not carry Caplyta in the emergency medication supply and the physician should have been notified when the resident did not receive medications per physician orders. On 10/10/24 at 1:30 P.M., the Regional Nurse Consultant provided a policy titled, Medication Shortages/Unavailable Medications, dated 12/1/10 and revised on 1/01/22, and again on 8/1/24, indicating it was the current facility policy. The policy indicated the following: . Upon discovery that Facility has an inadequate supply of a medication to administer to a resident, Facility staff should immediately initiate action to obtain the medication from Pharmacy. If the available delivery causes delay or a missed dose in the resident's medication schedule, Facility nurse should obtain the medication from the Emergency Medication Supply to administer the dose, and if the medication is not available in the Emergency Medication Supply, Facility staff should notify Pharmacy and arrange for a STAT immediate delivery if medically necessary. If an emergency delivery is unavailable, Facility nurse should contact the attending physician to obtain new orders or directions for alternate administration. This citation relates to Complaint IN00438192. 3.1-25(a)

Based on interview and record review, the facility failed to ensure 1 of 3 residents reviewed for medication administration, received medications as ordered by the resident's physician, (Resident C). Finding includes: The clinical record for Resident C was reviewed on 10/9/24 at 3:37 P.M. Diagnosis included Bipolar II disorder, borderline personality, anxiety, obsessive-compulsive disorder and chronic low back pain. Physician's Orders dated 6/10/24 to 7/2/24 indicated Resident C's prescribed orders included the following medications: Baclophen one 10 mg tablet four times a day with meals and at bedtime at 8:00 A.M., 12:00 P.M., 5:00 P.M., and 9:00 P.M., for chronic back pain, with a start date of 6/10/24 and end date of 8/12/24. Caplyta one 42 mg capsule once a day in the evenings between 7:00 P.M. and 10:00 P.M., for Bipolar II disorder, with a start date of 6/10/24 and end date of 8/12/24. Pregabalin one 100 mg capsule two times a day in the morning between 7:00 A.M. and 10:00 A.M. and again between 7:00 P.M. and 10:00 P.M., for chronic back pain with a start date of 6/10/24 and end date 6/20/24. A review of Resident C's Medication Administration Record (MAR) from 6/10/24 to 7/2/24, indicated the resident did not receive medications on the following dates and times: Baclophen one 10 mg tablet four times a day with meals and at bedtime on 6/11/24 at 5:00 P.M., 6/17/24 at 8:00 A.M., 6/28, 19, 23, 2024 at 5:00 P.M., and 6/27/24 at 9:00 P.M. There were no nursing comments to indicated why the resident had not receive the medication. Caplyta on 6/11/24 at 6/11/24, 6/12/24, 6/18/24, 6/19/24, and 6/23/24 at 7:00 P.M. - 10:00 P.M. The nursing comment on the MAR indicated, Not Administer: Drug/Item Unavailable, each time the medication was not administered. Pregabalin on 6/11/24 at 7:00 A.M. to 11:00 A.M. and 7:00 P.M. - 11:00 P.M., 6/12/24 at 7:00 A.M. to 11:00 A.M. and 7:00 P.M. - 11:00 P.M. The nursing comment on the MAR indicated Not Administer: Drug/Item Unavailable, each time the medication was not administered. Review of the pharmacy Proof of Delivery statement indicated the resident's Baclophen was shipped from the pharmacy on 6/10/24 and received by the facility on 6/11/24 at 1:23 A.M., Caplyta was shipped from the pharmacy on 6/12/24 and received by the facility on 6/13/24 at 12:47 A.M., and Pregabalin was shipped from the pharmacy on 6/12/24 and received by the facility on 6/13/24 at 12:47 A.M. During an interview on 10/10/24 at 10:39 A.M., the Director of Nursing indicated an order was sent to the pharmacy for Resident C's Caplyta in a timely manor, but the medication did not come immediately. The Director of Nursing indicated if medications were not immediately available for administration, the physician should be notified for further instructions and the MAR should reflect the reason the medication was not administered. During an interview on 10/10/24 at 1:44 P.M., the Regional Nurse Consultant indicated the facility did not carry Caplyta in the emergency medication supply and the physician should have been notified when the resident did not receive medications per physician orders. On 10/10/24 at 1:30 P.M., the Regional Nurse Consultant provided a policy titled, Medication Shortages/Unavailable Medications, dated 12/1/10 and revised on 1/01/22, and again on 8/1/24, indicating it was the current facility policy. The policy indicated the following: Upon discovery that Facility has an inadequate supply of a medication to administer to a resident, Facility staff should immediately initiate action to obtain the medication from Pharmacy. If the available delivery causes delay or a missed dose in the resident's medication schedule, Facility nurse should obtain the medication from the Emergency Medication Supply to administer the dose, and if the medication is not available in the Emergency Medication Supply, Facility staff should notify Pharmacy and arrange for a STAT immediate delivery if medically necessary. If an emergency delivery is unavailable, Facility nurse should contact the attending physician to obtain new orders or directions for alternate administration. The National Library of Medicine indicated in Nursing Rights of Medication Administration dated 9/4/23, indicated, It was a standard during nursing education to receive instruction on a guide to clinical medication administration and upholding patient safety known as the ' five rights ' or ' five R ' s ' of medication administration, Right Patient, Right Drug, Right Route, Right Dose and Right time. The right time meaning administering medications at a time that was intended by the prescriber. Often, certain drugs have specific intervals or window periods during which another dose should be given to maintain a therapeutic effect or level. This citation relates to Complaint IN00438192. 3.1-37(a)

Based on interview and record review, the facility failed to notify the physician of multiple missed medication administrations for 1 of 3 residents reviewed for notification. (Resident C) Finding includes: The clinical record for Resident C was reviewed on 10/9/24 at 3:37 P.M. Diagnosis included, but were not limited to, Bipolar II disorder, borderline personality, anxiety, obsessive-compulsive disorder and chronic low back pain. Physician's Orders dated 6/10/24 to 7/2/24, indicated Resident C's prescribed orders included: Baclophen one 10 mg tablet four times a day with meals and at bedtime at 8:00 A.M., 12:00 P.M., 5:00 P.M., and 9:00 P.M., for chronic back pain, with a start date of 6/10/24 and end date of 8/12/24. Caplyta one 42 mg capsule once a day in the evenings between 7:00 P.M. and 10:00 P.M., for Bipolar II disorder, with a start date of 6/10/24 and end date of 8/12/24. Pregabalin one 100 mg capsule two times a day in the morning between 7:00 A.M. and 10:00 A.M. and again between 7:00 P.M. and 10:00 P.M., for chronic back pain with a start date of 6/10/24 and end date 6/20/24. A review of Resident C's Medication Administration Record (MAR) from 6/10/24 to 7/2/24, indicated the resident did not receive the prescribed medications on the following dates and times: Baclophen one 10 mg tablet four times a day with meals and at bedtime on 6/11/24 at 5:00 P.M., 6/17/24 at 8:00 A.M., 6/28, 19, 23, 2024 at 5:00 P.M., and 6/27/24 at 9:00 P.M. There were no nursing comments to indicated why the resident had not received the medication. Caplyta on 6/11/24 at 6/11/24, 6/12/24, 6/18/24, 6/19/24, and 6/23/24 at 7:00 P.M. - 10:00 P.M. The nursing comment on the MAR indicated, Not Administer: Drug/Item Unavailable, each time the medication was not administered. Pregabalin on 6/11/24 at 7:00 A.M. to 11:00 A.M. and 7:00 P.M. - 11:00 P.M., 6/12/24 at 7:00 A.M. to 11:00 A.M. and 7:00 P.M. - 11:00 P.M. The nursing comment on the MAR indicated Not Administer: Drug/Item Unavailable, each time the medication was not administered. Review of the pharmacy Proof of Delivery statement indicated the resident's Baclophen was shipped from the pharmacy on 6/10/24 and received by the facility on 6/11/24 at 1:23 A.M., The Caplyta medication was shipped from the pharmacy on 6/12/24 and received by the facility on 6/13/24 at 12:47 A.M., and Pregabalin medication was shipped from the pharmacy on 6/12/24 and received by the facility on 6/13/24 at 12:47 A.M. During an interview on 10/10/24 at 10:39 A.M., the Director of Nursing indicated an order was sent to the pharmacy for Resident C's Caplyta in a timely manor, but the medication did not come immediately. The Director of Nursing indicated if medications were not immediately available for administration, the physician should be notified for further instructions and the MAR should reflect the reason the medication was not administered. The Director of Nursing indicated the physician should have been notified when Resident C did not receive medication administrations as ordered. During an interview on 10/10/24 at 1:44 P.M., the Regional Nurse Consultant indicated the physician should have been notified when the resident did not receive medications per physician orders. On 10/10/24 at 1:30 P.M., the Regional Nurse Consultant provided a policy titled, Medication Shortages/Unavailable Medications, dated 12/1/10 and revised on 1/01/22, and again on 8/1/24, indicating it was the current facility policy. The policy indicated if the available delivery of a medication causes delay or a missed dose in the resident's medication schedule, the facility nurse should obtain the medication from the Emergency Medication Supply to administer the dose, If an emergency delivery was unavailable, The facility nurse was to contact the attending physician to obtain new orders or directions for alternate administration. This citation relates to Complaint IN00438192. 3.1-5(a)(3)

Based on observation, interview, and record review, the facility failed to ensure residents' environment was safe, functional, sanitary, and comfortable, related to restroom flooring not intact in 1 of 3 rooms observed. (room [ROOM NUMBER]) Findings include: On 1/29/24 at 2:42 P.M., an observation of the bathroom in room [ROOM NUMBER] was conducted. The bathroom floor was missing parts of the vinyl flooring, located on both the sides of the toilet and in front of the toilet. On 1/29/24 at 3:27 P.M., an observation of room [ROOM NUMBER]'s bathroom flooring was conducted with the Maintenance Director. He indicated the floor should not be in that condition and it looked bad. He indicated he was unaware of the flooring and indicated it was not good. He was filling in for the facility and was unaware of the floors condition. He would check to see if there had been a work order for it's repair. During an interview, on 1/29/24 at 3:32 P.M., one resident in room [ROOM NUMBER] indicated she used the bathroom daily, and the floor had been messed up for a long time, maybe since fall. She was then observed going into the restroom and shutting the door. During an interview, on 1/29/24 at 3:36 P.M., CNA 1 indicated she started working at the facility in October, and the floor was broken and missing pieces around the toilet back then. During an interview, on 1/29/24 at 3:42 P.M., the Housekeeping Manager indicated her staff reported the broken flooring, and the last two Maintenance Directors were supposed to have it replaced. She indicated there had been a plumbing problem and they had to have the pipes cleared out in room [ROOM NUMBER]. On 1/29/24 at 3:50 P.M., the Maintenance Director indicated he had not found a work order from the previous Maintenance Director. On 1/30/24 at 9:57 A.M., the Administrator provided a current policy, titled, Maintenance Work Order, dated 10/2002, with revision on 4/2018. The policy indicated .Our Community provides routine maintenance for tenants and is responsible for the overall management of the physical plant. Work orders for maintenance needs shall be used to maintain effective communication and tracking .Maintenance Director will update the General Manager during each morning meeting on the status of open work orders. Maintenance Director is responsible to keep person requesting maintenance and the General Manager updated regularly on the progress being made until each work order has been completed This citation relates to Complaint IN00424179. 3.1-19(e)

Based on interview and record review, the facility failed to prevent verbal abuse from occurring for 2 of 3 residents reviewed for abuse. (Residents 32 and 45) Finding includes: During an interview on 12/5/2023 at 9:38 A.M., Resident 32 indicated that the facility was allowing Resident 45 to engage in verbal violence. She indicated the last occurrence was 3 days ago on 12/2/2023. Resident 45 called her a pig and other names while in the dining room at an adjacent table when the incident occurred. Resident 32 indicated the facility allowed the verbally aggressive resident to sit at the table next to her. She shouldn't have to feel afraid, and feels bad about Resident 45 laughing at her. Resident 32 indicated the guy in the office won't do anything about the issue. During an interview on 12/6/2023 at 9:45 A.M., Resident 53 indicated that two ladies got into an argument in the dining room, and he intervened verbally. Residents 32 and 45 were involved. He indicated these verbal issues happened frequently between the two residents and no staff intervened in this incident until he became verbal. On 12/6/2023 at 11:52 A.M., a conversation could be heard with Resident 32 and the Administrator in the hallway, with Resident 32 asking the administrator about the incident that occurred on 12/2/2023 in the dining room. A record review for Resident 32 was completed on 12/07/2023 at 2:08 P.M. Diagnoses included, but were not limited to: schizoaffective disorder, delusional disorder, and intellectual disabilities. A Significant Change Minimum Data Set (MDS) assessment, dated 10/27/2023, indicated Resident 32 was cognitively intact, and had no behaviors during the assessment period. A Progress Note for Resident 32, dated 12/6/2023 at 12:01 P.M., indicated, .Notified that resident reported hearing co-resident yelling in main dining area, not at her, but in general vicinity, and did not like statements yelled. Resident reports no psychosocial distress at this time with writer. Will continue to observe. Notified guardian, no questions or concerns at this time A Care Plan, initiated 6/14/2021 and revised on 10/31/2023, indicated Resident 32 had been observed yelling at another resident after being yelled at by that resident. A record review for Resident 45 was completed on 12/11/2023 at 1:54 P.M. Diagnoses included, but were not limited to: cerebral infarction, vascular dementia, adjustment disorder with mixed anxiety and depressed mood. A Quarterly MDS assessment, dated 12/5/2023, indicated Resident 45 had moderate cognitive impairment and had verbal behavioral symptoms direct towards others for 2-6 days of the assessment period. A Nurse's Note, dated 12/2/2023 at 6:00 P.M., indicated Resident 45 was sitting at a table in the dining room talking to another resident. Resident 45 started yelling and swearing at a second resident (Resident 32) sitting at another table, and then at a third resident (Resident 53) sitting at a different table after a comment was made by the third Resident to staff. Resident 45 was assisted out of the dining room and put on 15-minute safety checks. On 12/4/2023 at 10:17 A.M., an Interdisciplinary Team Behavior Note indicated Resident 45 started swearing and yelling at two residents. A Care plan, initiated on 7/9/2023 and updated 12/6/2023, indicated Resident 45 would make comments that may become offensive to others, and may make threatening statements towards staff and other residents. A Psychiatry Progress Note, dated 11/9/2023, indicated, .Patient with continued episodes of antagonizing other residents and staff. She continues to get into verbal alterations. She is somewhat redirectable During an interview on 12/11/2023 at 10:00 A.M., LPN 5 indicated she didn't witness the interaction, but QMA 7 informed her of the incident and separated Residents 32 and 45. LPN 5 indicated she was aware of the verbal altercation, and believed the incident was verbal abuse. She indicated LPN 6 notified the Director of Nursing and Administrator of the abuse. On 12/11/2023 at 2:44 P.M., QMA 7 indicated she was standing in the doorway of the dining room watching everyone, and heard Resident 45 say something, then Resident 32 said something back to Resident 45. She indicated she knew the residents were arguing and Resident 45 called Resident 32 a fat b*tch. QMA 7 indicated she felt this was verbal abuse. On 12/12/2023 at 10:15 A.M., LPN 6 indicated she was not in the dining room at the time of the incident, but Resident 45 called Resident 32 a stupid b*tch. Resident 53 made a comment about getting the two residents out of the dining room. The Director of Nursing and Administrator were informed of the incident, and the Administrator talked to Resident 45. On 12/12/2023 at 11:55 A.M., the Administrator indicated Resident 32 came to him and told him of statements that made her uncomfortable, but didn't indicate which resident made the comments. He remembers the staff contacting him about Resident 45 being upset at the nurse's station, but no mention of the incident in the dining room. On 12/12/2023 at 12:01 P.M., the Director of Nursing indicated Resident 32 reported that Resident 45 was yelling at her, and she informed the Administrator about the incident. She remembered getting a telephone call about Resident 45 being upset with staff and other residents, but could not recall being informed of the dining room incident. A policy titled, Abuse Prohibition, Reporting, and Investigating was provided by the Administrator after the entrance conference. The policy indicated, .Policy: It is the policy of [Facility Corporation Name] to provide each resident with an environment that is free from abuse, neglect, misappropriation of property, and exploitation. This includes, but is not limited to verbal abuse, sexual abuse, physical abuse, mental abuse, corporal punishment, and involuntary seclusion .[Facility Corporation Name] will not permit residents to be subjected to abuse by anyone including employees, home office staff, other residents, consultants, volunteers, staff, or personnel of other agencies serving the resident, family members, legal guardians, sponsors, friends, or other individuals .Definitions/Examples of Abuse: .Verbal Abuse - The use of oral, written, and/or gestured language that willfully includes disparaging and derogatory terms to residents or their families or within hearing distance, regardless of their age, ability to comprehend, or disability. This includes any episode of staff to resident, and verbal threats of harm by resident to resident. This does not include random statements of a cognitively impaired resident such as repetitive name calling or nonsensical language 3.1-27(b)

Based on interview and record review, the facility failed to ensure appropriate treatment and services were conducted to prevent catheter obstructions and urinary tract infections when catheter care orders were not updated and followed and an order to see a urologist was not completed for 1 of 2 residents reviewed for catheter care, (Resident F). Finding includes: On 6/14/22 at 10:00 A.M., Resident F's clinical record was reviewed. The resident's Admission Record indicated an initial admitted [DATE] and most recent readmission following a hospital stay on 5/15/23. Diagnoses upon admission included, cerebrovascular accident (stroke), hemiparesis, and aphasia. A review of Resident F's most recent comprehensive Minimum Data Set (MDS) was an annual assessment dated [DATE] and indicated Resident F had moderate cognitive impairment, required extensive assistance for bed mobility, transfers, dressing, eating, personal hygiene and was totally dependent on others for bathing and locomotion. The resident was dependent on a urinary catheter and ostomy for bladder and bowel care respectively. Diagnoses at the time of the assessment included stroke with hemiparesis that affected the left side, obstructive uropathy, anxiety, depression, and chronic pain. Resident F received scheduled pain medication as well as additional pain medication as needed. Review of Resident F's hospital records from 1/01/23 to 6/14/23, indicated the following hospital visits: From 1/12/23 to 1/14/23, the resident was admitted at local hospital for urinary retention and the facility's inability to change the Foley catheter. The resident was treated with Cephalexin 500 mg capsule every 8 hours for 5 days for urinary tract infection. The hospital Discharge Summary dated 1/14/23 indicated the resident's Foley catheter should be changed monthly at the facility, and if unable to change the catheter, he would be seen by urology in their office. The resident's Foley Catheter was changed during this visit. On 3/11/23 Resident F was admitted at a local hospital for catheter obstruction and released on 3/11/23. The hospital Discharge Summary dated 3/11/23 indicated the resident's old catheter was removed with only a few cc's of fluid within the balloon. The physician indicated a small amount of blood was obtained after the catheter was removed and in the future his catheter should be changed on a monthly bases and should be able to be done in the nursing facility rather than sending him to the emergency room . From 4/08/23 to 4/13/23, Resident F was admitted at local hospital for aspiration pneumonia and urinary tract infection and inflammation reaction due to indwelling Foley catheter, .chronic indwelling Foley catheter that looks like it is getting infected . The resident was treated with Doxycycline 100 mg tablet orally 2 times daily for 2 days. The hospital Discharge Summary dated 4/13/23 indicated the resident had a urinary tract infection due to urinary indwelling catheter, and the Foley catheter was last changed on 3/11/23. On 4/17/23 the resident was evaluated at local hospital and released on 4/18/23. The ER (emergency room ) Physician Report, dated 4/18/23, indicated diagnoses included urinary tract infection, bowel obstruction, dehydration, and pneumonia. The ER physician indicated the resident was placed on Omnicef (dosage unknown) for the urinary tract infection. The Foley catheter was not changed at the hospital during this visit. On 4/23/23 the resident was evaluated at local hospital for urinary tract infection and knee pain and was released on 4/23/23. Resident did not receive additional medications for the Urinary tract infection. The Foley catheter was not changed at the hospital during this visit. From 5/10/23 to 5/15/23, Resident F was admitted at local hospital for multiple concerns including a possible urinary tract infection. The ER Physician Note indicated, .cloudy urine noted in tubing, large amount of sediment . The resident was treated with Levaquin 750 mg tablet orally every 24 hours for 3 days. Foley catheter was changed during this visit. On 5/29/23 the resident was evaluated at local hospital and released on 5/29/23 for possible urinary tract infection and abdominal pain. emergency room report indicated, .urinalysis that does show signs that could potentially be a urinary tract infection .colonization .follow-up tomorrow morning in the urology clinic for exchange of his catheter .the patient was discharged in stable condition with plan for close follow-up tomorrow with urology .Please call to schedule your follow-up tomorrow as you need to have your Foley changed in the office with the urologist . The Foley catheter was not changed during this visit. Review of Resident F's progress notes indicated; On 2/16/23 at 11:17 A.M., Results of Urinalysis show presence of bacteria. MD (Medical Doctor) notified and due to the presence of indwelling catheter MD is waiting on results of Culture to address results appropriately. Nursing. On 02/17/2023 at 09:45 P.M., Contacted MD with urine culture results and new order received to begin Cipro 500mg po BID x 7 days. Nursing. On 4/14/2023 at 12:08 P.M., Spoke with Urology Associates about daughters request to have Foley catheter changed every 2 weeks. Urology Ass. states they have orders to change catheter every 3 weeks and will have the nurse discuss with dr and they will fax the order to our main fax. Nursing. On 4/19/2023 at 10:57 P.M., the physician note indicated, . He was recently hospitalized from April 8, 2023 till April 13, 2023. Patient was treated for sepsis due to aspiration pneumonia and UTI. Urine culture grew gram-negative rods. He has a chronic indwelling Foley catheter . Nursing reports that patient saw urologist who has ordered to change his Foley catheter every 2 weeks On 5/30/2023 at 12:59 A.M., .Resident returned back from emergency hospital at about 11:20 pm, with new order to follow up with urologist in the morning, Dx[diagnosis]; of UTI due long term use of Foley catheter Nursing. Review of Physician's order dated 8/13/22, indicated to change the Foley catheter and urinary drainage bag as needed for dislodgement, leakage or occlusion. The order was discontinued on 1/17/23. Physician's order dated 1/17/23, indicated to change the Foley catheter and urinary drainage bag as needed on the 14th of the month. The order was discontinued on 3/13/23. Physician's order dated for 3/13/23, indicated to change the Foley catheter and urinary drainage bag every month on the 11th of the month. The order was discontinued on 4/13/23. Physician's order dated 4/13/23, indicated to change the Foley catheter and urinary drainage bag as needed for dislodgement, leakage or occlusion, as needed. The order was discontinued on 5/16/23. Physician's order dated 5/13/23, indicated to change the Foley catheter and urinary drainage bag as needed for dislodgement, leakage or occlusion as needed. The order was open-ended with no discontinuation date. There were no orders initiated for the resident's Foley catheter to be changed every 2 weeks or every 3 weeks as per the resident's progress notes. The resident was not referred to the Urologist as directed by the emergency room physician on 5/29/23. Review of Resident F's Medication Administration and Treatment records indicated Resident F's Foley catheter was changed as follows; 1/12/23 at the hospital 3/11/23 at the hospital There were no documented Foley catheter changes for February, April, or May of 2023. Review of Resident F's Care Plans included a plan for his urinary catheter dated 8/12/22, and indicated, .Resident requires an indwelling urinary catheter .at risk for infection .Resident will have catheter care managed appropriately as evidenced by: not exhibiting signs and symptoms of urinary tract infection .Change catheter per MD order On 6/14/23 at 2:12 P.M., during an interview with the Regional Nurse Consultant, she indicated the facility did not initiate catheter change orders for the resident at any time from his hospital visits from 1/1/23 to 6/14/23. The Regional Nurse Consultant indicated the emergency room and hospital physician's orders should have been written as ordered and followed for catheter changes. The Regional Nurse Consultant also indicated the urology consults were not made as ordered by the hospital physicians and they should have been. She indicated the resident did not see his urologist as ordered. On 6/16/23 at 10:15 A.M., the Administrator provided the current facility policy titled, Bowel and Bladder Program, dated 3/10 and revised 5/19. The policy indicated, .If it is determined an indwelling catheter IS medically necessary, obtain a physician's order with .frequency of change This Federal tag is related to complaints IN00409839. 3.1-41(2)

Based on record review and interview, the facility failed to properly monitor, assess, and notify physician of complaints of pain to [MEDICAL TREATMENT] shunt site located in right groin of resident resulting in [DIAGNOSES REDACTED]. (Resident B) Finding includes: During an interview, on 7/18/17 at 10:14 A.M., Resident B indicated she had reported to staff prior to being transported to the hospital that she had not been feeling well, her appetite had decreased, and she had been vomiting. She indicated she reported to staff the pain in leg at shunt site was so bad it would wake her from a sound sleep and [MEDICAL TREATMENT] was having trouble accessing port for a few months and staff kept patting her on the head, telling her nothing was wrong. She indicated the physician had told her the infection was around her port and he indicated it had been there for a while. The clinical record for Resident B was reviewed on 7/19/17 at 9:32 A.M. The [DIAGNOSES REDACTED]. The significant change MDS (Minimum Data Set) assessment, dated 7/11/17, indicated Resident B was admitted to facility on 8/16/16, had a BIMS (Brief Interview of Mental Status) score of 13, cognitively intact, received [MEDICAL TREATMENT], and currently had a surgical wound. The Treatment Flowsheet, dated 5/1/17 through 5/31/17, indicated orders for [MEDICAL TREATMENT] at [MEDICAL TREATMENT] center, check for bruit and thrill every shift and record blood pressure upon return from [MEDICAL TREATMENT]. No order was available to monitor [MEDICAL TREATMENT] site every shift for signs and symptoms of infection. The Resident Progress Notes, dated 5/29/17 at 4:34 P.M., indicated Resident B returned from [MEDICAL TREATMENT] and started complaining of numbness on her hands, cramping on her legs, weakness, light-headedness, nausea and was sent to local emergency room . No progress notes available indicating [MEDICAL TREATMENT] site had been assessed for signs or symptoms of infection. The Resident Progress Notes, dated 5/29/17 at 8:49 P.M., indicated Resident B had returned from hospital with ordered to follow up with physician at local family practice office. The ER (emergency room ) Physician note, dated 5/29/17, indicated Resident B was to follow up in 3- 5 days with physician at local family practice office. The Resident Progress Notes, dated 5/30/17, indicated the appointment was canceled with physician of local family practice office because facility physician was her primary and resident was to be placed on physician list to be seen upon next visit. The next scheduled date to be seen was not until 6/8/17 and that fell outside the suggestion 3-5 days after release from ER. No documentation was available to indicate primary facility physician had been made aware of order to follow up with local family practice in 3-5 days from discharge from hospital. The Resident Progress Notes, dated 6/8/17 at 12:10 P.M., indicated Resident B was unable to be seen by primary facility doctor on rounds due to [MEDICAL TREATMENT] appointment. The Treatment Flowsheet, dated 6/1/17 through 6/30/17, indicated an order to check for bruit and thrill every shift. No orders were present to monitor [MEDICAL TREATMENT] site every shift for signs and symptoms. The Resident Progress Notes, dated 6/18/17 at 6:15 P.M., indicated Resident B had complained of not feeling well, was shivering, had temperature of 102.2, one episode of vomiting was noted and [MEDICAL TREATMENT] port site was hot to touch. Resident B was sent to hospital. No documentation available to indicate that [MEDICAL TREATMENT] site to right groin had been assessed since 6/16/17 when she returned from [MEDICAL TREATMENT]. The History and Physical, dated 6/18/17, indicated Resident B presented to the emergency room with fever of 103.6 and possible [MEDICAL CONDITION] of [MEDICAL TREATMENT] to right lateral thigh. The patient complain to pain all over and not feeling well, had some nausea and vomiting. Her initial lactic acid was 2.8 and she was labeled as [MEDICAL CONDITION]. Right lateral thigh [MEDICAL TREATMENT] was was diffusely tender. The assessment and plan was febrile illness, possibly right lateral thigh [MEDICAL TREATMENT] access, awaiting cultures. The ER Physician Report, dated 6/18/17, indicated Resident B presented with a bit of pain and redness over her right thigh where her [MEDICAL TREATMENT] access points were and her last [MEDICAL TREATMENT] was 2 days ago. Her admitting [DIAGNOSES REDACTED]. The Pre-Arrival Communication Form, dated 6/18/17, indicated Resident B was coming from facility and had been ill for a couple of days, that facility nurse indicated resident was shaky, nurse found her to have a temperature and [MEDICAL TREATMENT] port to right thigh was warm to touch. The Microbiology Report, dated 6/18/17 indicated blood cultures were positive [MEDICAL CONDITION]. The Consultation Note from facility physician, dated 6/19/17, indicated Resident B had complained of some malaise and nausea and vomiting, pain in the proximal portion of her right femoral AV graft as well as warmth, swelling in her right leg that was evaluated at access center but has more noted warmth recently. A temporary [MEDICAL TREATMENT] catheter was to be placed due to bacteremia with involvement of graft. The Consultation Note from infection control physician, dated 6/21/17, indicated Resident B had been having pain and swelling to right thigh [MEDICAL TREATMENT] site for the past few months, her cultures were now [MEDICAL CONDITION]. He indicated Resident B [MEDICAL CONDITION] bacteremia and likely source was infected AV fistula ([MEDICAL TREATMENT] site). The Consultation Note from the surgeon, dated 6/21/17, indicated Resident B had a tender bulging areas in the venous limb of loop graft, her white blood cell count ranged around 10,000 and 2 blood cultures were positive [MEDICAL CONDITION]. He indicated the [MEDICAL TREATMENT] site was most likely the source [MEDICAL CONDITION] blood cultures and ordered culture of fluid around [MEDICAL TREATMENT] site. The Microbiology Report, dated 6/22/17, indicated fluid around [MEDICAL TREATMENT] site was positive [MEDICAL CONDITION]. The Consultation Note from nephrologist, dated 6/22/17, indicated Resident B was noted to have strep bacteremia. The Resident Progress Notes, dated 7/4/17 at 1:03 P.M., indicated Resident B was readmitted to facility with 3 incisions to her right upper thigh with a total of 46 staples. During an interview, on 7/19/17 at 1:40 P.M., the DNS (Director of Nursing Services) indicated the facility should have contacted the facility physician when resident returned fromER on [DATE] with orders to follow up on 3-5 days with another physician. He indicated that [MEDICAL TREATMENT] sites should be monitored and documented every shift for signs and symptoms of infection. During an interview, on 7/21/17 at 10:42 P.M., LPN (Licensed Practical Nurse) #8 indicated the communication book that was sent between facility and [MEDICAL TREATMENT] center included only weights and blood pressures. She indicated the [MEDICAL TREATMENT] center would call and report any complications to the facility, and she did indicate the [MEDICAL TREATMENT] center did communicate they were having trouble accessing the port prior to resident being hospitalized for [REDACTED]. On 7/19/17 at 11:30 A.M., the ADM (Administrator) provided the [MEDICAL TREATMENT] policy, dated 1/2015, and indicated the policy was the one currently being used by the facility. The policy indicated an assessment of the resident's [MEDICAL TREATMENT] site will be completed every shift to include bruit and thrill, condition of skin at site, drainage, pain, warmth, redness, and recorded on the Medication Administration Record and/or [MEDICAL TREATMENT] flow sheet. 3.1-37(a)

Based on observation, interview, and record review the facility failed to prevent the development and worsening of pressure areas for 1 of 1 residents reviewed for pressure areas, resulting in an increased wound size and infection (Resident #24) Finding includes: The Wound Assessment Details from the wound clinic, dated 6/19/17, indicated Resident #24 had a Stage 3 pressure (extends into tissue beneath the skin) area to left heel (wound 1) that measured 2 cm (centimeters) x 3.5 cm x 1 cm, wound base slough and eschar and large amount of [MEDICAL CONDITION] (yellow or tan, cloudy and thick) drainage and maceration around the wound. A Stage 3 pressure area to right buttock (wound 2) that measured 0.7 cm x 1 cm x 1.5 cm, wound base of slough and granulation tissue and large amount of sero-sanguineous (pale red to pink, thin and watery) drainage. A Stage 3 pressure area to left posterior leg (wound 3) that measured 0.9 cm x 0.9 cm x 0.5cm, wound base with slough and eschar and moderate amount of seropurelent drainage. The assessment indicated Resident #24 indicated pain to wound areas was between 3-5 scale out 10 for worst pain. Physician orders, dated 06/19/17, indicated wound care orders for each of the three pressure areas as follows: 1. Left heel wound, cleanse with normal saline, pat dry, apply santyl, and cover with carboflex, gauze, cast padding, and [MEDICATION NAME]. 2. Sacrum wound, cleanse with wound cleanser, apply Aqualcel and cover with sorbion border. 3. Left calf wound, cleanse with normal saline, pat dry, apply santyl, and cover with carboflex, gauze, cast padding, and [MEDICATION NAME]. A clinical record review was conducted on 07/19/17 at 9:12 AM, for Resident #24 and indicated an admission date of [DATE]. Her [DIAGNOSES REDACTED]. Her medications included: [MEDICATION NAME], carvedilol, [MEDICATION NAME], [MEDICATION NAME], [MEDICATION NAME], promod protein, santyl dressing, [MEDICATION NAME], and [MEDICATION NAME]. The most recent quarterly MDS (Minimum Data Set) assessment, dated 04/27/17, indicated a BIMS (Brief Interview for Mental Status) score 13, cognitively intact. The assessment indicated two pressure areas that developed after admission were present; one unstageable and one stage three with the largest area measuring 3.8 cm (centimeters) x 4.3 cm x 0.0cm. Care plan for impaired skin integrity, dated 2/18/17, indicated Resident #24 had pressure wound to left heel, right upper mid buttock, and wound to left lateral calf. Interventions included, but were not limited to, assess wound weekly documenting measurements and description and treat as ordered. Progress notes, dated 06/11/17, indicated the onset of a new wound area to the Left Calf. No measurements were indicated in the documentation. The weekly update skin event form was completed on 06/12/17 and indicated measurements as follows: Left calf - 1.3cm x 1.2cm x 0.5cm. The Physician's Telephone Orders, dated 6/12/17, indicated an order to d/c current treatment to left calf (wound #3) and start cleanse wound to left lateral calf with normal saline, pat dry, apply Santyl and cover with [MEDICATION NAME] one daily. The wound culture results, dated 6/12/17, indicated the left heel wound contained many Proteus Mirabilis (bacteria found in soil and water) and was susceptible to [MEDICATION NAME]. The Physician's Telephone Order, dated 6/16/17 , indicated on order of [MEDICATION NAME] solution 40 mg (milligrams) per milliliters, give 100 mg intramuscularly every day for 7 days. No other documentation of assessments of left posterior wound (Wound #3) available. Wound culture documents, dated 07/10/17, indicated the presence of Providenia Stuartii (bacteria found in soil, water, and sewage), Proteus Mirabilis (bacteria found in soil and water, and many Entercococcus species. The culture indicated bacteria susceptible to [MEDICATION NAME]/tazobactam. The Physician's Telephone Order, dated 7/17/17, indicated an order for [REDACTED]. The wound management documentation, dated 07/14/17 at 11:23 A.M, indicated a Stage 3 pressure area to the left heel (wound #1) measured 1.5cm x 1.8 cm x 0.3 cm depth with undermining measuring 1.2 cm at 2 o'clock position. The drainage from the wound was a moderate amount of [MEDICAL CONDITION]. The wound base presented with 25 percent slough. The Wound Management, dated 7/14/17 at 11:40 A.M., indicated Stage 3 pressure area to sacrum (wound #2) measured 0.6cm x 0.9cm x 1 cm with moderate amount of serosanguinous drainage, wound base 100% granulation. On 07/20/2017, at 2:21 PM, wound care was observed with RN #1. She was not observed washing hands prior to setting up supplies and those supplies were set up on the bedside table with remote control, used wash cloth, box of tissues, and drink cup that remained next to the supplies. RN #1 was observed to use gloved had to pull back blankets and raise up the bed prior to removing the dressing on wound 1 and 3 and she did not change gloves. CNA #2 assisted with holding of the leg during wound care. RN #1 cut off old bandage with scissors and placed the dirty scissors on the bedside table with the supplies. She then use the same gloved hand to pick up normal saline container from the supply table; she dropped a dirty gauze to the floor and reached down to pick it up and threw it in the trash can then readjusted the trash bag before going back to touching the peri-wound area of wound 3, with the same dirty gloves. She used the same container of NS, which was previously touched with dirty glove, to cleanse the calf and heel wounds without changing gloves. CNA #2 was observed letting cleansed heel touch towel on bed without wound being cleaned again. RN #1 used dirty glove to open swab to measure and put the wrapper back on the table of supplies; both wounds were measured with dirty gloves. She then applied santyl covered gauze to the wounds without changing gloves, both wounds had carboflex applied over santyl without glove change or handwashing. The carboflex was observed to fall from the calf wound on to the bed and she picked it up and put it back on the wound, then wrapped with cast padding without glove change. When moving to change the dressing on the sacrum wound, RN #1 did not wash hands prior to setting up table and the table still contained the same items on it. After set up, she was observed to wash hands for 12 seconds and cleansed the wound with wound cleanser. She did not change gloves to measure the wound and touched the wound bed. The dirty scissors were used to cut the calcium alginate packing. The dirty swab used to measure the tunneling in the wound was used to pack the new dressing and [MEDICATION NAME] was applied, no glove change. The wounds measured as follows on 07/20/17: 1. Left Heel - 2cm x 2.8cm x 0.5cm - Stage 3 2. Sacrum - 1cm x 0.8cm x 1.1cm, with tunneling in the 9 o'clock position of 1.5cm - Stage 3 3. Left Calf - 3.2cm x 2.2cm x 1.2cm - no facility documentation to indicate assessment or staging after initially found. Wound documentation, dated 07/14/17, indicated the following measurements: 1. Left Heel - 1.5cm x 1.8cm x 0.3cm - Stage 3 2. Sacrum - 0.6cm x 0.9cm x 1cm - Stage 3 3. Left Calf - no previous facility documentation of assessment. During an interview, on 07/20/17 at 3:36 PM, the MDS nurse indicated a care plan should have been put in place for each of the wound areas. During an interview, on 07/21/17 at 12:50 PM, the DNS (Director of Nursing Services) indicated the facility did not agree with the wound clinic assessment of the Left Calf wound being a pressure area, therefore they did not treat it as such and did not measure or assess the wound specifically. A policy was provided by the Corporate Nurse on 07/21/17 at 9:00 AM, titled Skin Management Program, dated 09/2016, and indicated this was the policy currently used by the facility. The policy indicated, .3. All alterations in skin integrity will be documented with the medical record .b) All newly identified area after admission will be documented on the New Skin Event. 4. The wound nurse (licensed nurse assigned responsibility for wounds for the building or assigned unit) will be notified of alterations in skin integrity. a) The facility must have an assigned wound nurse that assess wounds on a weekly basis. b) The wound nurse is responsible for communicating to IDT on a weekly basis 3.1-40(a)(1)(2)

Based on record review and interviews, the facility failed to secure the fall mats placed next to resident beds resulting in falls with injury for 2 of 2 residents reviewed for falls. Resident "F" sustained a hip fracture and Resident "D" sustained a scraped shin, lump above the right eye and bloody nose. (Resident "D" and Resident "F") Findings include: 1. The record of Resident "D" was reviewed on 10/22/12 at 12:20 p.m. Resident "D" was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident "D" had a history of [REDACTED]. "09/14/2012 10:45 p.m. Resident found on (sic) sitting on floor next to her bed facing her bed. One end of roommates fall mat was out in middle of room. Resident appeared to possibly have tripped on mat....0.5 cm (centimeter) scape (sic) to right shin, small lump noted above right eye, bloody left nostril, 2.5 cm x 0.3 cm bruise to right index finger...." Review of the Fall Investigation indicated: "09/17/2012 10:09 a.m., IDT (Interdisciplinary Team: staff representing different departments to investigate situations/problems) Fall review: Resident experienced an unwitnessed fall on 09/14/12 at approximately 2215. staff (sic) was alerted by bed alarm sounding and observed resident sitting on her buttocks on the floor next to her bed....upon environmental assessment, staff observed that one end of the roommate's fall mat was in the middle of the room. staff (sic) state that resident may have tripped over fall mat....she sustained a a (sic) scrape to the right shin, a lump above the right eye and a nose bleed....environmental safety check completed." Review of the record of Resident"B", the roommate of Resident "D", on 10/23/12 at 12:45 p.m., indicated Resident "B" had a history of [REDACTED]. 2. The record of resident "F" was reviewed on 10/22/12 at 9:30 a.m. Resident "F" was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the record for Resident "F" indicated in the nurses progress notes: "09/30/12 8:24 a.m. Res (resident) had an un-witnessed fall at 8:15 p.m., while trying to get up on his own. Alarm was connected but did not sound, Bedside fall mat looked to have been pushed by Res while falling. No visible injuries. Res had c/o (complaint of) pain in L (left) hip....X-ray ordered for L hip. ..." "09/30/12 9:05 p.m. Went to Res's room for 9:00 neuros and found Res attempting to get up alone again..." "10/01/12 3:26 a.m. Residents image results were received, results indicated that resident has a left hip FX (fracture)....resident is being sent to ER...Resident was transported at 12/45 a.m." Review of the Fall Investigation indicated: "10/01/12 9:40 a.m. IDT (Interdisciplinary Team: staff representing different departments to investigate situations/problems) Fall review: resident (sic) experienced an unwitnessed fall on 09/30/12 at 2012 (8:15 p.m.)...staff noted that resident's fall mat appeared to have slid under his bed during the fall." LPN #4 was interviewed on 10/23/12 at 1:00 p.m. LPN #4 indicated the resident had disabled and bent the bed alarm resulting in it being broken. A review of the MARs (Medication Administration Record), at the time, for Resident "F" indicated the bed alarm had been checked and working at shift change prior to the fall. The DNS (Director Nursing Services) was interviewed on 10/22/12 at 1:00 p.m. The DNS indicated the investigations of falls for Resident "D" and Resident "F" indicated the fall mats being used in the facility were lightweight and able to be folded and moved from the resident's bedside when the residents were in wheelchairs or out of their rooms. The DNS indicated the fall mats appeared to have slid out of place which contributed to both falls. The DNS indicated the IDT identified the fall mat issue following Resident "D"'s fall on 09/14/12, but failed to implement safety measures to prevent further falls from fall mats sliding until the investigation of Resident "F"'s fall. Review of a facility Policy and Procedure, "Fall Management Program: revised 6/12", provided by the DNS on 10/23/12 at 1:30 p.m., indicated: "POLICY: It is the policy of American Senior Communities to ensure residents residing within the facility will maintain maximum physical functioning through the establishment of physical, environmental and psychosocial guidelines to prevent injury related to fall. PROCEDURE: Fall risk...Post fall... 5. All falls will be discussed by the interdisciplinary team the next business day morning after the day of the fall to determine other possible interventions to prevent future falls. * The fall event will be reviewed by the team... * The care plan will be reviewed and updated, as necessary 3.1-45(a)(2)