Every finding on record at Salem Crossing

Based on observation, record review, and interview, the facility failed to ensure residents medication administration records accuretly refleted the administration of narcotics at the time of administration for 2 of 39 residents observed for pharmacy service procedures. (Residents 35 and 8) Findings include: 1. During an observation, on 6/3/25 at 11:20 a.m., of the 300 Hall Medication Cart 2, Resident 35's hydrocodone-acetaminophen 7.5 milligrams (mg)-325 mg medication card indicated 11 tablets were left. The Controlled Substances Record indicated 12 tablets were left. The last documented administration of the hydrocodone-acetaminophen was on 6/2/25 at 8:00 p.m., by Qualified Medication Aide (QMA) 6. The record for Resident 35 was reviewed on 6/6/25 at 11:33 a.m. The resident's diagnoses included, but were not limited to, osteoarthritis of the right shoulder and right wrist, hereditary and idiopathic neuropathy, incomplete rotator cuff tear or rupture of the right shoulder, calcific tendinitis of the right shoulder, sciatica to the right side, and cramp and spasms of the lower extremities. The Annual Minimum Data Set (MDS) assessment, dated 5/13/25, indicated the resident was moderately cognitively impaired. The resident was unable to answer the level of pain, frequency of pain, or location of pain. The care plan, revised 5/27/25, indicated the resident was at risk for pain related to acute cystitis, hypokalemia, dementia, hypertension, urinary incontinence, and left humerus fracture. The interventions, dated 9/23/22, included, but were not limited to, administer medications as ordered, document effectiveness of as needed (prn) medications, and notify the physician if pain was unrelieved and or worsening. The physician's order, dated 4/10/25, indicated to administer hydrocodone-acetaminophen 7.5 mg-325 mg twice daily for moderate pain, not to exceed 4 grams of acetaminophen from all sources in 24 hours. The June 2025 Medication Administration Record (MAR) indicated the resident last received hydrocodone-acetaminophen on 6/3/25 at 8:00 a.m. The medication was administered by Licensed Practical Nurse (LPN) 5. During an interview, on 6/3/25 at 11:32 a.m., LPN 5, indicated she had forgotten to sign out the narcotic after administering it. 2. During an observation, on 6/3/25 at 11:34 a.m., of the 100 Hall Medication Cart 1, the following narcotic counts were identified for Resident 8: - Resident 8's hydrocodone-acetaminophen 10 mg-325 mg medication card indicated 11 tablets were left. The Controlled Substances Record indicated 12 tablets were left. The last documented administration of the hydrocodone-acetaminophen was on 6/2/25 at 9:00 p.m., by LPN 4. - Resident 8's Pregabalin 75 mg medication card indicated 3 capsules were left. The Controlled Substances Record indicated 4 capsules were left. The last documented administration of the pregabalin was on 6/2/25 at 8:00 a.m., by LPN 3. The record for Resident 8 was reviewed on 6/6/25 at 9:22 a.m. The resident's diagnoses included, but were not limited to, right knee replacement surgery, dorsalgia, osteoarthritis, degenerative joint disease, muscle spasm, migraines, cervical disc displacement, spondylosis with radiculopathy to the cervical region, and cervical disc degeneration. The admission MDS assessment, dated 5/15/25, indicated the resident was moderately cognitively impaired. The resident had experienced occasional moderate pain in the last 5 days, which rarely affected his sleep or day to day activities. The care plan, revised on 5/20/25, indicated the resident was at risk for pain, related to being status post right knee replacement surgery. He had an implanted pain pump to the right thigh, dorsalgia, cervical disc degeneration and displacement, degenerative joint disease, and migraines. The interventions, dated 5/10/25, included, but were not limited to, administer medications as ordered, document effectiveness of the prn pain medications, and notify the physician if pain was unrelieved and or worsening. The physician's order, dated 5/9/25, indicated to administer 10 mg-325 mg of hydrocodone-acetaminophen every 6 hours prn for moderate pain, not to exceed 4 grams of acetaminophen in a 24 hour period. The June 2025 MAR indicated the resident last received the hydrocodone-acetaminophen on 6/3/25 at 7:33 a.m. The pain level was documented as a 4 out of 10 (A little more pain) on the Wong-Baker facial pain scale to the right knee. The medication was administered by LPN 3. The physician's order, dated 5/12/25, indicated to administer 75 mg of pregabalin daily for spondylosis with radiculopathy of the cervical region. The June 2025 MAR indicated the resident last received the pregabalin on 6/3/25 at 8:00 a.m. The medication was administered by LPN 3. During an interview on 6/3/25 at 11:38 a.m., LPN 3 indicated she should have signed out the narcotics after she gave them. The policy was to sign the narcotics out upon administration of the medication. The Controlled Substances: Storage, Documentation, Inventory and Destruction (Includes Fentanyl Patch Removal and Destruction) policy, dated November 2024, included, but was not limited to, .Purpose of Policy: To prevent diversion, improper use and accidents related to controlled substances . Documentation 1. When a controlled substance is administered to a resident, it must be recorded in the resident's Medication Administration Record (MAR) as well as in the resident's Controlled Substances Inventory Record at the time of administration . 3.1-25(b)(3)

Based on interview and record review, the facility failed to follow procedures, adequately supervise, and ensure a resident's safety while on an outing related to a resident falling and rolling into a lake (Resident B) for 1 of 3 residents reviewed for accident hazards. Findings include: During a telephone interview on 12/03/24 at 11:39 A.M., Certified Nurse Aide (CNA) 3 indicated she worked in the Activities Department and she and Bus Driver (BD) 4 took seven residents from the Memory Care Unit on the facility bus for an outing in October. They drove to a local donut shop and then went to a local lake/park area. They arrived at the lake, got the residents off the bus, and sat them down at some picnic tables. There were residents that were in wheelchairs and residents that were able to walk without assistive devices. While the other residents were sitting at the tables, CNA 3 and BD 4 were walking with Resident B near the water, about 10 feet away from the residents at the table. CNA 3 asked BD 4 to watch Resident B while she walked back towards the other residents. A couple minutes later, BD 4 yelled Help! CNA 3 looked back and saw Resident B in the lake sitting in the water. CNA 3 jumped into the lake. The water was only a couple of feet deep. CNA 3 eased Resident B towards the shore but she couldn't get him out of the water, so she stayed in with him. Someone called 911 and the police and an ambulance came to the park. CNA 3 and a police officer were able to get the resident out of the water. They wrapped a blanket around the resident. The resident refused to go in the ambulance but was assessed by the Emergency Medical Technician (EMT) and was not injured. CNA 3 called the facility and the EMT spoke with Resident B's nurse. CNA 3 was told to bring the residents back, so they loaded everyone up and went back to the facility. CNA 3 indicated she thought BD 4 would watch the resident. CNA 3 turned her back on the resident at the time of him entering the lake. During an interview on 12/03/24 at 11:51 A.M., the Director of Nursing (DON) indicated she was not sure how the incident occurred, and she was not at the facility when it happened. They were just supposed to just go on a bus trip to the bakery and get donuts and take a drive around the lake. She thought BD 4 and CNA 3 took it upon themselves to decide to stop and get the residents off the bus. CNA 3 received disciplinary action for the incident. During a telephone interview on 12/03/24 at 11:59 A.M., CNA 3 indicated before they left for the outing, she told the Memory Care Unit Coordinator she was going to take the residents off the bus. The Unit Coordinator said okay and if she had any problems give her a call. CNA 3 realized after talking with the DON that she shouldn't have had that many residents on the outing. She was thankful that Resident B was okay. During an interview on 12/03/24 at 11:11 A.M., RN 2 indicated Resident B exhibited a lot of behaviors. The resident had been physically and verbally aggressive, and in the past had cursed and slapped at staff and refused care. The resident had recently declined and was using a wheelchair now, but back in October he was up walking without any assistive devices. He wandered a lot; He used to do laps around the unit but was really unsteady. The clinical record for Resident B was reviewed on 12/03/24 at 12:30 P.M. A Quarterly MDS (Minimum Data Set) assessment, dated 08/23/24, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, non-Alzheimer's dementia and anxiety. During an interview on 12/03/24 at 1:09 P.M., the Administrator indicated CNA 3 and BD 4 were just supposed to take the residents on a bus ride. They were instructed to contact the Memory Care Unit Coordinator if the stopped anywhere. They did not call the Memory Care Unit Coordinator when they stopped the bus at the park/lake. A document, titled Employee Communication Form was provided by the Administrator on 12/03/24 at 1:13 P.M. The form indicated CNA 3 violated the Activity Outing Policy on 10/08/24 when she was instructed not to take the residents off the bus unless she contacted the Memory Care Unit Coordinator first so that the Unit Coordinator could drive to the location to be present for supervision. The bus stopped at a local lake and there was an occurrence with a resident falling and rolling into the lake. The employee not only put that resident in a situation where there was inadequate supervision and assistance, but the other six residents that were on the outing as well. An undated document signed by BD 4 was provided by the Administrator on 12/03/24 at 1:40 P.M. The document indicated BD 4 was walking with Resident B on an outing at the lake. She turned away from the resident and looked towards CNA 3 to be sure the CNA was with the other residents. BD 4 turned back around to walk with Resident B and realized the resident was getting ready to fall. The resident fell to the ground and started rolling towards the water. BD 4 ran towards him, and they both got to the edge of the shallow water. BD 4 called out for help while she held on to the resident so he wouldn't panic. With help, they got the resident's hips out of the water and onto the bank of the lake and called 911. The police and an ambulance came. An EMT assessed the resident and said he looked okay. She got a wheelchair off the bus, assisted the resident into the wheelchair, and covered him with a blanket. They loaded all the residents onto the bus and returned to the facility. The current, undated facility policy, titled Outing Checklist was provided by the Administrator on 12/03/24 at 1:13 P.M. The policy indicated, .Supervision always required on an outing .No resident should be left unattended . The current facility policy, titled Activity Outing Policy, dated 07/15, was provided by the Administrator on 12/03/24 at 1:13 P.M. The policy indicated, .it is the policy .to offer both enjoyment and safety during outings coordinated by the facility .Residents will be supervised during the outing at all times . The Past noncompliance began on 10/8/24. The deficient practice was corrected by 10/11/24 after the facility implemented a systemic plan that included the following actions: IDT members met on 10/9/24 and implemented new care plan intervention for resident to ambulate with one assist when outdoors. MD/Responsible Party/ED/DNS were notified of incident; Outing Checklist created by Executive Director; and Activity Department, Memory Care Activity Department and IDT in-serviced on the Activity Outing Policy and Outing Checklist on 10/11/24. This citation relates to Complaint IN00448365. 3.1-45(a)(2)

Based on record review and interview, the facility failed to schedule 8-hour consecutive RN coverage for 4 of 4 months reviewed. (March, April, May, and June, 2024). This had the potential to affect all 84 residents currently residing in the facility. Findings include: The review of the March to June 2024 licensed nursing schedule indicated the following days were short of 8 consecutive hours in a 24 hour day of RN coverage: March - On March 9 no RN coverage for 6a to 6p and 6p to 6a - On March 24 no RN coverage for 6a to 6p and 6p to 6a - On March 31 no RN coverage for 6a to 6p and only 6 hours of RN coverage for 6p to 6a April - On April 27 no RN coverage for 6a to 6p and only 6 hours of RN coverage for 6p to 6a - On April 28 no RN coverage for 6a to 6p and only 6 hours of RN coverage for 6p to 6a May - On May 12 no RN coverage for 6a to 6p and only 6 hours of RN coverage for 6p to 6a - On May 18 no RN coverage for 6a to 6p and only 6 hours of RN coverage for 6p to 6a - On May 25 no RN coverage for 6a to 6p and only 6 hours of RN coverage for 6p to 6a June - On June 1 no RN coverage for 6a to 6p and 6 hours of RN coverage for 6p to 6a - On June 2 no RN coverage for 6a to 6p and 6 hours of RN coverage for 6p to 6a During an interview on 6/4/24 at 9:15 a.m., the Scheduler indicated she agreed there were some days that did not have RN consecutive coverage. During an interview on 6/5/24 at 8:30 a.m., the ED (Executive Director) indicated she thought she had 8 hours of consecutive RN coverage. She was unaware the coverage started at midnight and ended at midnight. The ED agreed the nursing schedule lacked RN coverage on some days. 3.1-17(b)(3)

Based on observation, record review, and interview, the facility failed to ensure appropriate pharmacy labeling for 4 of 13 insulin flexpens observed for medication storage. (Residents 19, 31, 85, and 42) Findings include: 1. During an observation of one of the two 100 Hall medication carts on 6/4/24 at 9:55 a.m., Resident 19's lispro flexpen was in a bag marked with her name and the flexpen's open date. There was no pharmacy label. The medication room refrigerator was reviewed with no other lispro flexpens with pharmacy labels for Resident 19. The record for Resident 19 was reviewed on 6/4/24 at 11:00 a.m. The resident's diagnosis included, but was not limited to, type 2 diabetes mellitus with diabetic chronic kidney disease. The physician's order, dated 3/6/24, indicated staff were to administer the resident's lispro per sliding scale subcutaneously three times daily. The Quarterly MDS (Minimum Data Set) assessment, dated 4/24/24, indicated the resident was moderately cognitively impaired. The resident had received 1 injection of insulin during the previous 7 days prior to the assessment. 2. During an observation of one of the two 300 Hall medication carts on 6/4/24 at 10:06 a.m., Resident 31's lispro was in a bag marked with her name and the flexpens' open date. There was no pharmacy label. The medication room refrigerator was reviewed with no other lispro flexpens with pharmacy labels for Resident 31. The record for Resident 31 was reviewed on 6/4/24 at 11:08 a.m. The resident's diagnosis included, but was not limited to, type 2 diabetes mellitus. The physician's order, dated 2/5/24, indicated staff were to administer the resident's lispro per sliding scale subcutaneously three times daily. The Quarterly MDS assessment, dated 3/26/24, indicated the resident was cognitively intact. She received 7 injections of insulin during the 7 previous days prior to the assessment. 3. During an observation of one of the two 300 Hall medication carts on 6/4/24 at 10:07 a.m., Resident 85's glargine flexpen was in a bag marked with her name and the flexpen's open date. There was no pharmacy label. The medication room refrigerator was reviewed with no other glargine flexpens with a pharmacy label for Resident 85. The record for Resident 85 was reviewed on 6/4/24 at 11:10 a.m. The resident's diagnosis included, but was not limited to, type 2 diabetes mellitus. The physician's orders, dated 4/22/24, indicated the staff were to administer the resident's glargine insulin pen 5 units subcutaneously at bedtime. The Admission MDS assessment, dated 4/29/24, indicated the resident was severely cognitively impaired. She received 6 injections of insulin during the 7 previous days prior to the assessment. 4. During an observation of one of the two 400 Hall medication carts on 6/04/24 at 10:30 a.m., Resident 42's Levemir flexpen was in a bag marked with his name the flexpen's open date. There was no pharmacy label. The medication room refrigerator was reviewed with no other Levemir flexpens with a pharmacy label for Resident 42. The record for Resident 42 was reviewed on 6/4/24 at 11:16 a.m. The diagnosis included, but was not limited to, type 2 diabetes mellitus. The physician's order, dated 9/26/22, indicated staff were to administer the resident's Levemir U-100 insulin 10 units subcutaneously for type 2 diabetes mellitus daily. The Quarterly MDS assessment, dated 5/16/24, indicated the resident was moderately cognitively impaired. He received 7 injections of insulin during the 7 previous days prior to the assessment. During an interview on 6/4/24 at 10:26 a.m., LPN (Licensed Practical Nurse) 2 indicated the pharmacy label needed to be with the flexpens for cases of power outages, so that the instructions were present. During an interview on 6/5/24 at 9:57 a.m., the DON (Director of Nursing) indicated they could not locate another policy for pharmacy labeling requirements of medications. The LTC [Long Term Care] Facility's Pharmacy Services and Procedures Manual 5.3 Storage and Expiration Dating of Medications, Biologicals LTC Facilities Receiving Pharmacy Products and Services form Pharmacy, revised on 8/7/23, included, but was not limited to, . 6. Facility should destroy and reorder medications and biologicals with soiled, illegible, worn, makeshift, incomplete, damaged or missing labels or cautionary instructions . 4/5/19. 19. Facility should request that Pharmacy perform a routine nursing unit inspection for each nursing station in Facility to assist Facility in complying with its obligations pursuant to Applicable Law relating to the proper storage, labeling, security and accountability of medications and biologicals . 3.1-25(j)

Based on observation and interview, the facility failed to ensure staff provided the necessary care and services in a timely manner for 2 of 4 residents observed for Activities of Daily care. (Residents D and E) Findings include: 1. During an observation on 5/30/24 at 9:40 a.m., Resident D's bed sheet had a 2-foot diameter area of urine with a brown ring around the edges that appeared wet. There were multiple brown dotted areas within the ring. During an observation on 5/30/24 at 10:00 a.m., Resident D's bed sheet still had a circular 2-foot diameter area of urine with a brown ring that appeared to be wet. There were multiple brown spots dotted within the ring. During an observation and interview on 5/30/24 at 12:47 p.m., Resident D indicated she changed her own brief and once weekly the bedding was changed by staff. The bedding still had a 2-foot diameter area with a brown ring around the edges. The area appeared drier. During an observation on 05/31/24 at 9:05 a.m., Resident D was lying in bed with a bedspread pulled up over her body. There was a strong smell of urine in her area of the room. The resident indicated she was not wet. During an observation on 5/31/24 at 9:07 a.m., the MDS (Minimum Data Set) Coordinator entered Resident D's room. The MDS Coordinator asked the resident if she wanted to be changed and dressed. The resident indicated she did not want to be dressed and pulled the bedspread up tighter to her body. The MDS Coordinator indicated the resident was supposed to receive assistance to be checked and changed. The MDS Coordinator left the room to get assistance from a CNA (Certified Nurse Aide). During an observation and interview on 5/31/24 at 9:15 a.m., CNA 4 joined the MDS Coordinator in Resident D's room to check and change the resident. The resident indicated she had already been dressed. The MDS Coordinator asked the resident if she could check her brief to see if it was wet. The brief and sheets were dry, but the odor of urine was still observed. The resident was wearing a night gown. CNA 4 indicated she checked and changed the resident every 2 hours. The last time she had checked Resident D was around 6:30 a.m. It was maybe a little longer than the 2 hours then. The resident was not a heavy wetter, but resident would have some days that were worse than others. The record for Resident D was reviewed on 6/3/24 at 2:09 p.m. The diagnoses included, but were not limited to, acute cystitis without hematuria, severe dementia with psychotic disturbance, delusions, hallucinations, functional urinary incontinence, unsteadiness on feet, abnormalities of gait and mobility, and muscle weakness. The care plan, dated 9/23/22, indicated the resident required assistance with toileting and incontinence care due to acute cystitis, dementia, and urinary incontinence. The interventions, dated 9/23/22, included but were not limited to, assess and document skin condition weekly and as needed, assist with incontinent care as needed, and check every 2 hours for incontinence. The Quarterly MDS assessment, dated 3/18/24, indicated the resident was severely cognitively impaired. She required supervision for toileting and hygiene and was frequently incontinent of bladder and bowel. The resident required limited assistance of one staff for transfer, bed mobility, and walking in her room. The nurse's note, dated 3/21/24 at 5:38 p.m., indicated the resident was alert and oriented to self and room environment. The resident was incontinent and continent at times. Staff were to check and change the resident every 2 hours and PRN (as needed), with perineal care completed at this time also. Provide one person assistance with the use of a gait belt for the resident. During an interview on 6/4/24 at 9:30 am., NA (Nurse Aide) 5 indicated she provided perineal care, feeding, bathing, and interactions with residents when she was rounding. She rounded every 2 hours. A heavy wetter would be checked hourly. When a resident took diuretics, staff would check the resident every 30 minutes. Resident D would be checked, and the NA would ask the resident for permission to provide one person assistance to the bathroom. Staff typically wouldn't let the resident go by herself, due to her falls. The resident's bedding was changed at shower time, if it was dirty or if a resident was a heavy wetter. If she smelled the odor of urine on the resident, she would make sure the resident didn't have a wet bed, and if not, she would let the nurse know because the resident most likely had a UTI (urinary tract infection). During an interview on 6/4/24 at 11:09 a.m., CNA 6 indicated when she entered the building for her shift, she would do walking rounds with the outgoing CNA from the night shift. The walking rounds consisted of checking the residents to see if they were wet and doing bed checks. She would then check the residents' briefs every 2 hours. If she observed an odor of urine in a resident room, she would check the resident's brief to see if they were wet. If they were, she would change them. If they weren't wet, she would check back later and leave them be. During an interview on 6/4/24 at 1:15 p.m., CNA 7 indicated she had on occasion found the draw sheets to be wet on heavy wetting residents' beds when she entered for her shift. She would check the residents every 2 hours for the need to change their briefs. During an interview on 6/4/24 at 1:16 p.m., CNA 8 indicated when she entered the building for the start of her shift, she would get a report from the night shift CNA. She would start with bed checks and change the residents if they needed it. 35732 2. During an observation, on 5/30/24 at 12:10 p.m., Resident E was laying in her bed. The CNA took her lunch tray to her and explained to the resident her lunch was ready. The resident was in a wet brief and her bed was wet with urine. The resident's top sheet was wet, and the resident was uncovered. The CNA did not check the resident for bladder incontinence, and she did not cover the resident up. The CNA rolled up the head of the resident's bed and sat her lunch tray in front of her. She proceeded to pass the other residents' trays without providing incontinent care. The record for Resident E was reviewed on 6/5/24 at 10:24 a.m. The resident's diagnoses included, but were not limited to, weakness, kidney failure, arthritis and dementia. The Quarterly MDS (Minimum Data Set) assessment, dated 2/29/24, indicated the resident's cognition was severely impaired. The resident required substantial or maximal staff assistance with her ADL's (activities of daily living). The care plan, dated 5/31/24, indicated Resident E needed assistance with her ADLs including bed mobility, transfers, eating and toilet use. The interventions included, but were not limited to, the resident would participate in ADLs to her maximum potential, a touchpad call light, the resident attempted to self transfer without staff assistance, a Hoyer lift with the assistance of 2 staff for transfers to a wheelchair, assistance with toileting and/or incontinent care as needed. The resident was on a toileting plan program. The nurses note, dated 9/25/23 at 10:14 p.m., indicated the resident was alert to self with staff to anticipate the resident's needs. The resident was incontinent of bowel and bladder and staff were to provide perineal care after each episode. The IDT (Interdisciplinary Team) note, dated 5/30/24 at 12:10 p.m., indicated the resident currently had an intervention to be up in her wheelchair for lunch, however the resident preferred to stay in bed at times for lunch. During an interview on 6/4/24 at 9:50 a.m., CNA 9 indicated the residents were checked and changed every 2 hours. If a resident was incontinent when she took a tray in, she would stop and provide incontinent care before she gave the resident their food tray. The most current Certified Nursing Assistant (CNA) position description, included, but was not limited to, .Provides direct care to residents to improve maintain the resident's abilities according to the resident's plan of care. Assist in activities of daily living including bathing, grooming, dressing, mobility, transferring and feeding of assigned residents by providing set-up assistance, verbal prompts, physical support, or more extensive assistance as more fully described below . Elimination/toileting - Promptly assist resident to bathroom according to toileting schedule or promptly brings clean bedpan or urinal. Opens, removes clothing in preparation, cleans a resident if resident is unable to clean self, adjusts clothing, cleans resident's and own hands. Measures and records output as directed by Unit Charge Nurse and plan of care. Provide catheter care according to facility procedures and infection control policies . This citation relates to Complaint IN00434385. 3.1-38(a)(3)

Based on observation, record review, and interview, the facility failed to ensure the development and implementation of person-centered interventions to prevent falls for 2 of 8 residents reviewed for accidents. (Residents 65 and 45) Findings include: 1. The clinical record for Resident 65 was reviewed on 5/9/23 at 1:58 p.m. The resident's diagnoses included, but were not limited to, fracture of part of the neck of the right femur, fracture of part of the neck of the left femur, unsteadiness on feet, weakness, abnormalities of gait and mobility, osteopenia, and dementia with behavioral disturbance. The care plan, dated 9/10/22 and last revised 5/8/23 at 11:53 a.m., indicated the resident was at risk for falls due to history of falls, age, urgency/frequency/incontinence, high risk medications, requiring assistance or supervision for mobility, transfer or ambulation, unsteady gait, visual impairment affecting mobility, altered awareness of immediate physical environment, impulsive, lack of understanding of one's physical and cognitive limitations, encephalopathy, anxiety, insomnia, Alzheimer's disease, benign neoplasm of cerebral meninges, dementia, hypertension, atherosclerosis, endocarditis, atrial fibrillation, major depressive disorder, urinary tract infection, pacemaker, vitamin deficiency, aftercare following right hip arthroplasty, and left hip fracture with prosthesis. The resident's goal was to have fall risk factors reduced in an attempt to avoid significant fall related injury. The interventions included, but were not limited to, staff to ensure resident has something to drink while sitting at the dining room table (dated 5/6/23), offer/assist to bed after lunch (dated 4/8/23), assist with toileting every 2 hours (dated 2/11/23), hipsters to be worn at all times (dated 1/26/23), neon tape to wheelchair brakes as a visual cue (dated 1/13/23), non-skid strips on floor next to open side of bed (dated 1/13/23), neon tape to call light as visual cue (dated 1/12/23), reminder sign, Don't get up, call for assistance (dated 1/12/23), staff to assist to dining room for meals (dated 12/27/23), assist resident with toileting prior to meals (dated 12/25/23), scoop mattress at all [NAME] (dated 11/9/22), anti-rollbacks to wheelchair (dated 11/7/22) offer/assist to lie down after supper (dated 11/6/22), bed against the wall to allow open floor plan (dated 10/27/22), bed in lowest position, call light in reach, keep pathways free of clutter, non-skid footwear, and therapy to screen (dated 9/10/22). The nurse's note, dated 9/10/22 at 3:26 p.m., indicated the resident arrived to the facility and required assistance of 2 staff members to stand and pivot from her wheelchair. The nurse's note, dated 10/6/22 at 2:45 p.m., indicated the resident was found lying on the floor in the dining room. Her right leg was rotated outward and had pain with movement. A STAT (immediate) x-ray was ordered. The nurse's note, dated 10/6/22 at 5:59 p.m., indicated the x-ray results showed an acute right femoral fracture. The resident was sent to the emergency room . The IDT (Interdisciplinary Team) note, dated 10/7/22 at 2:45 p.m., indicated the new intervention was to provide the resident with activities of interest when in the dining room. The nurse's note, dated 10/26/22 at 7:38 a.m., indicated the resident was found sitting on the bathroom floor with no injuries. The IDT note, dated 10/27/22 at 10:20 a.m., indicated the root cause of the resident's fall on 10/26/22 was the resident attempting to transfer herself to the restroom. The new interventions were to toilet the resident every 2 hours, bed in the lowest position, and bed against the wall to allow for an open floor plan. The nurse's note, dated 11/9/22 at 3:55 a.m., indicated staff heard a noise from the resident's room and found she had fallen from bed onto her left side, striking her left elbow on the bedside dresser. Her left leg was bent at knee, and the resident stated she could not straighten her leg. Orders were received for a STAT left hip/pelvic x-ray and the resident was placed on hourly checks for her safety. The nurse's note, dated 11/9/22 at 4:04 p.m., indicated the x-ray results showed a fracture of the resident's left hip. The resident was sent to the emergency room . The IDT note, dated 11/10/22 at 9:49 a.m., indicated the root cause of the resident's fall on 11/9/22 was the resident rolling out of her bed. The new interventions were to offer and assist the resident to the toilet every 1 hour and a scoop mattress to the bed at all times. The Quarterly MDS (Minimum Data Set) assessment, indicated the resident was severely cognitively impaired, required extensive assistance of 2 staff with toileting, bed mobility, and transfers, was always incontinent of bladder, and frequently incontinent of bowel. The nurse's note, dated 12/25/22 at 5:58 p.m., indicated the nurse was called to the resident's room. The resident was sitting on the floor in the bathroom. The resident was unable to voice what had happened. She had gotten herself up and walked to the bathroom. The IDT note, dated 12/27/22 at 11:01 a.m., indicated the root cause of the resident's fall on 12/25/22 was the resident ambulating unassisted to the restroom. A new intervention to toilet the resident prior to meals and assist the resident to the dining room for meals was implemented. The nurse's note, dated 1/12/23 at 11:45 p.m., indicated the resident was found lying on her back by her bed. The resident indicated she wet the bed and didn't want to be wet. A sign was placed in the room to remind the resident to call for assistance prior to attempting to get out of bed. The IDT note, dated 1/13/23 at 10:45 a.m., indicated the root cause of the resident's fall on 1/12/23 was the resident not using her call light and attempting to get out of bed without assistance. The new intervention was to place a reminder sign in the room. The nurse's note, dated 1/26/23 at 8:00 p.m., indicated the nurse heard the resident yell for help and found her sitting on her bottom in front of her recliner. She indicated she was trying to get up to use the bathroom and couldn't remember the rest. She was last checked at 6:30 p.m., and last seen at 7:00 p.m. lying in bed. The IDT note, dated 1/27/23 at 11:33 a.m., indicated the root cause of the resident's fall was the resident attempting to toilet herself. The new intervention was for hipsters to be worn at all times. The nurse's note, dated 2/11/23 at 4:06 p.m., indicated the resident was found sitting on her bathroom floor with no injury. She was unable to verbalize how or why she got there. The resident was in her wheelchair, coming out of the main dining area just minutes prior to finding her on her bathroom floor. The IDT note, dated 2/13/23 at 2:47 p.m., indicated the root cause of the resident's fall on 2/11/23 was the resident attempting to toilet herself. The intervention put into place was to assist the resident with toileting every 2 hours. During an interview, on 5/11/23 at 1:23 p.m., CNA (Certified Nurse Aide) 2 indicated the resident had several interventions. She had hipsters on, her bed was low to the ground, and she had the papers that said to put the call light on. She was checked and changed every 2 hours. She didn't think they had any residents who were more frequent, every resident was on an every 2 hours check and change. The resident tried to get up and walk on her own and go to the bathroom on her own. She did try to use the restroom frequently. She was incontinent at times. Usually whenever they first came in she would be wet. So she would be incontinent at night. The resident's care profile sheet indicated to check her every 2 hours. During an interview, on 5/11/23 at 1:57 p.m., LPN (Licensed Practical Nurse) 3 indicated the resident was very impulsive. They toileted her every 2 hours, before and after meals. During an interview, on 5/11/23 at 2:56 p.m., the DON (Director of Nursing) indicated on 10/26/22 they had implemented every 2 hour toileting on the resident as a new fall intervention because she had been trying to go to the restroom. On 11/9/22 they did the every 1 hour because she was trying to go to the restroom again. Then on 1/27/23, they looked at her interventions and discontinued the every hour intervention because she had a decline and was a 2 person assist with transfers and she was a check and change. The intervention to toilet her every 2 hours was not put back into place on her care plan until 2/11/23. She wrote a note saying she should have been on every 2 hours check and change, but did not add the intervention to the care plan. 2. The clinical record for Resident 45 was reviewed on 5/10/23 at 9:04 a.m. The resident's diagnoses included, but were not limited to, Alzheimer's disease, vascular dementia, Parkinson's disease, cognitive communication deficit, lack of coordination, abnormalities of gait and mobility, muscle weakness, age-related physical debility, unsteadiness on feet, hemiplegia and hemiparesis following cerebrovascular event affecting right dominant side, and repeated falls. The care plan, dated 12/21/17 and last revised on 5/1/23, indicated the resident was at risk for falls related to benign prostatic hyperplasia with urgency, incontinence, dementia, right sided hemiplegia, age, two or more high risk medications, history of falls, decreased mobility, Parkinson's, weakness, unsteady gait, requiring assistance with ambulation/transfers/ambulation, altered awareness of immediate physical environment, impulsive, and lack of understanding of one's physical and cognitive limitation. The interventions included, but were not limited to, urinal in reach while in bed (dated 5/3/23), ensure bedside table within reach while up in chair (dated 4/17/23), high back wheelchair with lateral supports while out of bed (dated 4/9/23), bed in lowest position (dated 4/3/23), hospice notified to exchange bedframe for a low bed (dated 4/3/22), mat on floor next to the open side of the bed (dated 3/21/23), wheelchair to be parked and locked at bedside at all times when not in use (dated 1/19/23), bed against the wall to allow an open floor plan (dated 3/3/22), offer to assist to bed after all meals (dated 12/28/20), dycem to wheelchair at all times (9/22/20), remind resident to carry phone in pocket while up to wheelchair (dated 12/11/19), neon tape to wheelchair brakes as visual cue (dated 11/1/19), neon tape to call light as visual cue (dated 5/20/19), scoop mattress to bed (dated 1/16/19), encourage resident to wear non-skid footwear (dated 3/27/18), and call light in reach (dated 12/21/17). The fall event, dated 10/24/22, indicated the resident had a witnessed fall. He was sitting on the edge of the bed and before staff could intervene, he slid to the floor. The IDT note, dated 10/25/22 at 11:26 a.m., indicated the resident had a fall on 10/24/22. The resident was sitting on the edge of his bed in preparation of transfer and before staff could intervene he slid from the bedside into floor. The root cause of fall was the resident sliding from the bed. The IDT reviewed previous fall interventions, and found the fall mat to no longer be appropriate. The fall mat was removed and non-skid strips were placed to open side of bed. The nurse's note, dated 1/19/23 at 3:45 a.m., indicated the nurse heard a noise from the resident room and found him lying on his side on the fall mat. He indicated he was trying to get his shoes on and get ready for work and slipped out of bed. He had ripped his brief off and urinated on the bed. He was assisted onto the bed and changed into clean clothes. Staff informed the resident of the time and that it was too early to get up per his preference. The resident indicated he thought it was later in the morning. The IDT note, dated 1/19/23 at 3:45 a.m., indicated the root cause of the resident's fall was the resident attempting to transfer himself from bed to his wheelchair to go to work. The new intervention was for his wheelchair to be parked and locked at bedside at all times when not in use and fall mat to open side of the bed. The IDT note, dated 1/19/23 at 10:48 a.m., indicated the resident now had a fall mat to his bedside and his non-skid strips were removed. The nurse's note, dated 2/24/23 at 3:32 p.m., indicated the resident was in the floor on his bottom with his back against his bed. The IDT note, dated 2/27/23 at 12:46 p.m., indicated the root cause of the fall was the resident sliding from bed. The new intervention was to remove the fall mat and place down nonskid strips to the resident's bedside. The fall event, dated 3/14/23 at 9:08 p.m., indicated the resident had an unwitnessed fall where he slid from the bed trying to transfer himself. He indicated . I was going to go get that tractor with [Name of family member] . The IDT note, dated 3/15/23 at 11:!4 a.m., indicated the root cause of the resident's fall was the resident's confusion and attempt to transfer himself from his bed to the wheelchair. The new intervention was to obtain a complete blood count to rule out infection. The nurse's note, dated 3/21/23 at 12:10 a.m., indicated the resident was sitting on his bottom on the floor. He indicated he had to go to town to get the tractor. He was assisted back to bed with call light and fluids in place. The IDT note, dated 3/21/23 at 10:10 a.m., indicated the root cause of the fall was the resident's attempt to self transfer without staff assistance. The new intervention was to place a mat to the floor next to the open side of the bed. The nurse's note, dated 4/3/23 at 9:49 p.m., indicated the resident was on the fall mat. He was found lying on his left side with gripper socks and hipsters on and stated he had to go to town as there was too much work to do. The IDT note, dated 4/4/23 at 3:21 p.m., indicated the root cause of the resident's fall was the resident being confused, having dementia, and attempting to transfer himself. His hospice provider was notified and requested to exchange his bed for one with a low bed frame. The Quarterly MDS assessment, dated 4/4/23, indicated the resident was severely cognitively impaired, required extensive assistance of 2 staff with toileting, bed mobility, and transfers, was always incontinent of bladder, and always incontinent of bowel. The nurse's note, dated 5/2/23 at 9:40 p.m., indicated the resident was found in the floor on his fall mat. He indicated he needed to go very badly . Staff checked and changed the resident every 2 hours. The IDT note, dated 5/3/23 at 10:59 a.m., indicated the root cause of the resident's fall was the resident attempting to get out of bed for the bathroom. The new intervention was to place a urinal within reach while in bed. During an observation, on 5/11/23 at 10:30 a.m., Resident 45 was resting in bed. His fall mat was in place and the bed was in the low position, however there was no urinal within reach. During an observation, on 5/11/23 at 2:08 p.m., Resident 45 was resting in bed. His fall mat was in place and the bed was in the low position. There was no urinal observed in the room. During an interview, on 5/11/23 at 1:26 p.m., CNA 2 indicated the resident was to have a floor mat in place. Having the urinal in reach was one of his interventions, but he was not able to use it by himself. He was usually wet when they got to him. He used to be able to use it but could not any longer. They helped him use a urinal when he told them he needed to pee, and they put him on the toilet throughout the day. They assisted him to toilet every 2 hours. During an interview on 5/11/23 at 1:44 p.m., LPN 3 indicated his falls were mainly in the evenings. He was having delusions that prompted him to get up. He was trying to get a tractor. They tried to redirect him with the delusions. He had the strips, then he was still having falls so they went to the mat. He did not transfer himself, but he thought he could. When there was a fall, she would assess the situation to see what was going on as to why they were getting up. She would investigate what happened and then that would be the intervention she put into place. She would go by her investigation of what's happened, to keep that particular incident from happening again. During an interview on 5/11/23 at 3:21 p.m., the DON indicated on 10/25/22 they discontinued the fall mat and did non-skid strips. Then on 1/19/23 he had another fall and they were using a fall mat that night so the IDT met and added it to the care plan. Then on 2/27/23 he slid from his bed, so they removed the floor mat and did non skid strips again because they thought he may have slid from the floor mat. Then on 3/21/23 they added the mat back to the floor because she didn't want a fracture. Non-skid strips were not going to help with that, so she put the fall mat back down. She was aware they had an issue with falls as they were her weakness. The resident's urinal was not in his room. During an interview on 5/12/23 at 9:20 a.m., the DON indicated the resident now had a urinal in his room and they were doing a 3 day bowel and bladder assessment. The resident kept falling at night. She needed to see if they were putting him to bed too early. She had not thought of interventions to address the hallucinations the resident was having at night. The Fall Management Policy, last revised 8/22, provided on 5/11/23 at 2:23 p.m., by the Executive Director, included, but was not limited to, . Facilities must implement comprehensive, resident-centered fall prevention plans for each resident at risk for falls or with a history of falls . Procedure . Post fall . 5. A fall event will be initiated as soon as the resident has been assessed and cared for . The report must be completed in full in order to identify possible root causes of the fall and provide immediate interventions . 6. All falls will be discussed by the interdisciplinary team at the 1st IDT meeting after the fall to determine root cause and other possible interventions to prevent future falls . The care plan will be reviewed and updated as necessary . 3.1-45(a)(1)

Based on observation, record review, and interview, the facility failed to ensure accurate documentation in the Controlled Substances Record sheet of the administered narcotics and appropriate storage and labeling of medications for 1 of 4 medications carts and 1 of 2 medication storage rooms observed. (100 Hall Cart and 100/200/300 Hall Storage Room) Findings include: 1. During an observation on 5/9/23 at 9:12 a.m., of the 100 Hall Medication Cart with LPN (Licensed Practical Nurse) 8 the following concerns were observed: a. Resident 26's lorazepam 2 mg/mL (milligrams per milliliter) bottle was stored in the unrefrigerated narcotic drawer on the medication cart. The medication labeling indicated to store the medication in the refrigerator at a temperature of 36 to 46 degrees Fahrenheit (F). There was approximately 25 mL of the medication in the bottle. The Controlled Substances Record sheet indicated the resident should have 26.25 mL of the medication remaining, with the last dose signed out on 5/9/23 at 4:03 a.m. During an interview on 5/9/23 at 9:14 a.m., LPN 8 indicated the medication was in the drawer because they had been giving it to the resident. It had been in the drawer for at least 2 hours. She had not given it to him, and she had not counted when she took the cart. The Infection Preventionist had counted the cart for her. She had not put the medication in the refrigerator when she took the cart. The medication frequently spilled because of the dropper style lid it had. The clinical record for Resident 26 was reviewed on 5/9/23 at 2:00 p.m. The resident's diagnoses included, but were not limited to, intermittent explosive disorder, bipolar disorder, and major depressive disorder. The physician's order, dated 5/8/23, indicated to administer 0.25 mL of lorazepam intensol 2 mg/mL solution every 2 hours as needed for anxiety. The resident's MAR (Medication Administration Record), indicated the last dose of the medication was administered on 5/9/23 at 4:03 a.m. b. Resident 4's Tramadol 50 mg Controlled Substance Record Sheet, indicated the resident had a count of 8 tablets left. The last dose signed out on the sheet was on 5/9/23 at 7:34 a.m., by LPN 8. There were 9 tablets of the medication on the card. During an interview on 5/9/23 at 9:17 a.m., LPN 8 indicated she had given the medication to the resident that morning. She did not know why the count was not correct. The clinical record for Resident 4 was reviewed on 5/9/23 at 11:10 a.m. The diagnoses included, but were not limited to, spinal stenosis, carpal tunnel syndrome, and chronic pain syndrome. The physician's order, dated 5/5/23, indicated to administer tramadol 50 mg every 8 hours as needed. The resident's MAR indicated the medication had last been given on 5/9/23 at 7:34 a.m. by LPN 8. c. Resident 2's clonazepam 0.5 mg Controlled Substance Record sheet, indicated the resident had a count of 18 tablets remaining, with the last dose signed out on 5/9/23 at 2:00 p.m. The medication card contained a count of 19 tablets. During an interview on 5/9/23 at 9:18 a.m., LPN 8 indicated there were 19 tablets left on the card because she had signed out both the resident's 8:00 a.m. and 2:00 p.m. doses of the medication in advance. She had not yet given the 2:00 p.m. dose. Sometimes she forgot to sign medications out so she signed them out in advance. The clinical record for Resident 2 was reviewed on 5/9/23 at 11:05 a.m. The resident's diagnoses included, but were not limited to, major depressive disorder and generalized anxiety disorder. The physician's order, dated 1/6/23, indicated the resident received clonazepam 0.5 mg three times daily. The resident's MAR indicated the last dose was administered on 5/9/23 at 8:00 a.m. 2. During an observation on 5/9/23 at 9:28 a.m. of the 100/200/300 Hall Medication Storage room, there was an opened bottle of lorazepam 2 mg/mL in the narcotic box in the refrigerator with no pharmacy labeling. The medication lacked any identifying information for whom it belonged to, any prescriptive orders, or directions for use. During an interview on 5/9/23 at 9:30 a.m., LPN 8 indicated she believed the medication belonged to Resident 52 but she was not certain since it did not have a name. It looked to her that it had been pulled from the Pyxis system. When they pulled a medication from the Pyxis, they were supposed to put the name of the resident as well as the date the medication was opened. The clinical record for Resident 52 was reviewed on 5/9/23 at 11:25 a.m. The diagnoses included, but were not limited to, dementia, Alzheimer's disease, major depressive disorder, and anxiety disorder. The physician's order, dated 12/8/22, indicated the resident received 0.5 mL of lorazepam intensol 2 mg/mL every 4 hours as needed for seizure activity, restlessness, anxiety, and agitation. The resident's Controlled Substance Record sheet, indicated the resident had received doses of lorazepam 2 mg/mL on 11/3/22 at 3:03 p.m., and 2/9/23 at 1:23 a.m. The resident's MAR indicated the last dose of lorazepam 2 mg/mL she had received, was on 2/9/23 at 1:23 a.m. During an interview on 5/9/23 at 9:54 a.m., The Infection Preventionist indicated two other nurses had conducted the count on the 100 hall cart that morning and she had taken the keys from one of those nurses until LPN 8 arrived. There had been no count from the hand off from the other nurse, to herself, or herself to LPN 8. She had not opened the medication cart or counted it. During an interview on 5/12/23 at 10:55 a.m., the Infection Preventionist indicated they typically conducted a count when staff handed off the keys. LPN 8 was running late that morning, so she had told the off-going nurse she would take the cart until she got there. She got the keys from the nurse and handed the keys to LPN 8 when she got there. There should have been a count between the night shift nurse and LPN 8. Staff were always to give report and always count the narcotics and sign them off on the book. They always counted any time it changed hands. The Storage and Expiration Dating of Medications, Biologicals policy, last revised 7/21/22, provided on 5/9/23 at 2:10 p.m. by the DON (Director of Nursing), included but was not limited to, . Facility should destroy and reorder medications and biologicals with soiled, illegible, worn, makeshift, incomplete, damaged or missing labels or cautionary instructions . 10. Facility should ensure that medications and biologicals are stored at their appropriate temperatures according to the United states Pharmacopeia guidelines for temperature ranges . 10.2 Refrigeration: 36 - 46 F . 12.3 Facility should ensure that all controlled substances are stored in a manner that maintains their integrity and security . The Inventory Control of Controlled Substances policy, last revised on 1/1/22, provided on 5/9/23 at 2:10 p.m. by the DON, included, but was not limited to, .Procedure .1.1 Facility should maintain separate individual controlled substance records on all Schedule II medications and any medication with a potential for abuse or diversion in the form of a declining inventory using the 'Controlled Substances Declining Inventory Record'. These records should include . Date and time of administration . Quantity remaining .Name and signature of person administering the medication . Facility should ensure that the incoming and outgoing nurses count all Schedule II controlled substances and other medications with a risk of abuse or diversion at the change of each shift or at least daily and document the results on a 'Controlled Substance Count Verification/Shift Count Sheet' . 3.1-25(b)(3)

Based on observation, record review, and interview, the facility failed to ensure proper indwelling urinary catheter care, and handling of the catheter was provided during care for 2 of 4 residents catheter care reviewed. (Residents 79 and 52) Findings include: 1. The clinical record for Resident 79 was reviewed on 5/9/23 at 10:24 a.m. The diagnoses included, but were not limited to, acute infarction of spinal cord, hematuria, anemia, proteus mirabilis morganii UTIs (urinary tract infections), personal history of urinary tract infections, chronic retention of the urine, neuromuscular dysfunction of bladder. The nurse's note, dated 10/4/22 at 3:52 p.m., indicated a new order was received to place the catheter related to the resident's wounds. The care plan, dated 10/5/22 and last revised on 2/26/23, indicated the resident required an indwelling urinary catheter due to the neuromuscular dysfunction of his bladder, extensive wounds, paraplegia. The interventions, dated 11/3/22, indicated the resident was at risk for infection related to indwelling catheter; dated 10/5/22, keep the position of the bag below the level of the bladder, and to provide assistance for catheter care. The physician's order, dated 10/5/22, indicated to provide catheter care three times daily and the nurse was to record the output every shift. The order was discontinued on 11/14/22. The Admission MDS (Minimum Data Set) assessment, dated 10/6/22, indicated the resident was cognitively intact. The nurse's note, dated 10/6/22 at 6:45 p.m., indicated a CNA (Certified Nurse Aide) notified this nurse to come assess the resident's catheter related to the resident indicating there had not been any urine in the catheter bag since Thursday morning, but his brief was noticeably wet. The catheter was assessed by the nurse, who tried to deflate the balloon to reposition the catheter. The balloon had no fluid in it. Supplies were collected to change the catheter. The old catheter was removed without issue, and the resident urinated. Using sterile technique, the nurse cleaned the head of the penis with 3 iodine swabs. Lubricant was applied to the 16 French catheter. The catheter was inserted with ease with slight resistance met. The catheter tubing was pushed through without incident. Pink urine came out of the catheter. 20 mL (milliliters) of sterile water was applied to balloon. The nurse was unable to push the other 10 mL of fluid in. The catheter was secure at this time and the catheter bag was applied. 800 mL of pink, yellow urine was present. The ADL (Activities of Daily Living) note, dated 10/11/22 at 1:14 p.m., indicated the resident required maximum assistance for ADLs and bed mobility. He required maximum assistance of 2 staff with a lift for transfers. The resident was incontinent of bowel. The physician's order, dated 11/21/22, indicated to provide catheter care three times a day with the nurse to record the output every shift. The order was discontinued on 1/23/23. The nurse's note, dated 11/26/22 at 8:39 p.m., indicated the catheter was changed per sterile procedure, related to urine leakage. The nurse's note, dated 11/27/22 at 10:46 p.m., indicated the catheter was changed once again related to leaking. The nurse's note, dated 11/29/22 at 1:39 p.m., indicated sediment and dark amber colored urine were present. The NP (Nurse Practitioner) was notified, and an order was received to send a specimen over to a local hospital for a urinalysis. The urinalysis report, dated 11/29/22, indicated large occult blood, 100 mg/dL (milligrams per deciliter) of protein, nitrite positive, small leukocytes, 21-50 per HPF (high powered field) of white blood cells, slight bacteria, and 4-10 per HPF of red blood cells. The nurse's note, dated 11/29/22 at 9:27 p.m., indicated a culture was pending on the urinalysis results. The NP was made aware with a new order for Bactrim DS (double strength) twice daily for 7 days. The urine culture and sensitivity results, dated 12/2/22, indicated greater than 100,000 CFU/mL (colony forming units per milliliters) ESBL (Extended Spectrum Beta-Lactamase) E-coli (Escherichia coli). The results were sent to the NP and no new orders were obtained. The nurse's note, dated 12/3/22 at 9:00 a.m., indicated the NP called with new orders for Ciprofloxacin 500 mg (milligrams) twice daily for 14 Days. The nurse's note, dated 12/19/22 at 1:39 a.m., indicated the catheter was leaking. The catheter was irrigated, however, continued to leak. The catheter was removed and an 18 French catheter was placed with no resistance. There was no urine output upon insertion, however, urine was observed a few minutes after insertion. The nurse's note, dated 12/22/22 at 12:44 a.m., indicated the catheter had clear yellow urine with an odor. The resident was incontinent of bowel with peri-care given as needed. The nurse's note, dated 12/23/22 at 1:38 p.m., indicated the catheter was draining dark yellow urine. The nurse's note, dated 12/29/22 at 3:01 p.m., indicated the resident had decreased urine output, which was amber in color. The catheter was irrigated without difficulty. The urine culture results, dated 1/3/23 at 11:33 a.m., indicated the presence of rare streptococci, beta hemolytic group B beta hemolytic streptococci, which were predictably susceptible to penicillin and other beta lactams. The nurse's note, dated 1/18/23 at 5:49 a.m., indicated the catheter was changed related to it leaking urine with green and red discharge. After removing the catheter, a moderate amount of blood was observed coming out of the penis opening. The re-insertion of a new catheter produced a moderate amount of blood into the catheter tubing and bag. The NP was notified and indicated she would look at resident when she entered the facility. The nurse's note, dated 1/18/23 at 10:11 p.m., indicated the resident had been shaky this shift. The catheter had an output of 400 mL of dark tinted bloody urine. The nurse's note, dated 1/18/23 at 12:57 p.m., indicated an appointment was made per the request of the NP with a urologist. An appointment was made for 1/31/23 at 11:20 a.m. The nurse's note, dated 1/21/23 at 10:29 p.m., indicated the resident had a large amount of dark red bloody urine. The NP was called and an order to get a CBC (complete blood cell count) with differential was given. The nurse's note, dated 1/22/23 at 3:21 a.m., indicated the resident continued to have a large amount of dark red blood in the urine. The nurse's note, dated 1/22/23 at 3:53 a.m., indicated the resident was passing a large amount of dark red blood clots. The NP was called and gave an order to send the resident to the ER (emergency room ) to evaluate and treat. The hospital records, dated 1/22/23, indicated the discharge diagnosis was gross hematuria due to traumatic catheter pull, morganella morganii UTI, and acute blood anemia due to hematuria. The resident received bladder irrigation. The nurse's note, dated 1/26/23 at 12:55 p.m., indicated the resident returned from the hospital. The physician's order, dated 1/26/23, indicated to provide catheter care three times a day with the nurse to record the output every shift. The physician's order, dated 1/26/23, indicated to administer cefdinir 300 mg every 12 hours for a urinary tract infection. The discontinuation date was 2/2/23. The nurse's note, dated 1/30/23 at 10:53 p.m., indicated the resident continued to receive an antibiotic related to the UTI. The catheter was draining clear yellow urine. The nurse's note, dated 2/2/23 at 11:28 a.m. indicated the resident continued to receive an antibiotic related to the UTI. The catheter was patent and draining dark amber urine. The nurse's note, dated 2/3/23 at 10:30 a.m., indicated a new order to irrigate the catheter with 100 mL of NS (normal saline) as needed was received. The nurse's note, dated 3/10/23 at 12:53 a.m., indicated the catheter was changed related to it leaking. The nurse's note, dated 4/17/23 at 1:26 a.m., indicated the catheter was leaking and had only a 50 mL output. The catheter was changed using a sterile procedure. There was good urine return which was yellow in color. During an interview on 5/9/23 at 8:47 a.m., the resident indicated the staff just emptied the catheter bag, they didn't do catheter care. During an observation of incontinence and catheter care for Resident 79 on 5/9/23 at 1:03 p.m., NA (Nurse Aide) 4 and LPN (Licensed Practical Nurse) 5, entered the room and applied gloves. The resident indicated the catheter bag was just emptied. The NA obtained wipes and the brief was pulled down. The brief was wet with urine. The tubing was cleaned first, with the NA holding the tubing at the junction, but not at the tip of the penis. She removed her gloves and applied hand sanitizer. Clean gloves were applied. She obtained a wipe, and the right crease was cleaned in an upward direction. She obtained a fresh wipe for each swipe, cleaning from the tip down the shaft of the penis. The right and left creases were cleaned downward. She removed her gloves and applied hand sanitizer. Clean gloves were applied. The resident was rolled onto his right side. The NA indicated catheter care was provided daily, but it depended on the day. Depending on the day, different things were done. One time daily or twice. She lifted the catheter bag above the bladder to check it and held it in place ten seconds. She asked the resident if the staff said anything about the odor or color. She lowered the catheter bag onto the bed. She lifted the catheter bag up above the bladder again. The LPN requested for her to lower the catheter bag below the bladder. During an interview on 5/9/23 at 1:24 p.m., LPN 5 indicated the catheter bag should not be lifted above the bladder, so that it wouldn't drain urine back into the bladder. During an interview on 5/9/23 at 1:26 p.m., NA 4 indicated she should hold the catheter tubing at the end and at the penis itself to clean the tubing. The tubing should be held to prevent from being pulled out or it could cause leakage. The catheter tubing had been leaking. During a second observation of catheter care for Resident 79 on 5/11/23 at 8:53 a.m., CNA 6 performed hand hygiene and applied gloves. The urine in tubing was amber to bloody colored. The catheter tubing was cleaned, holding four inches away from the penis. She obtained a wipe and with the same area of the wipe, she swiped 2 times from the tip of the penis down the shaft. She did not dry the penis or the creases. The resident was helped to roll onto his right side. The resident had stool on his bottom. The stool had a dry ring around the edges. The CNA obtained a wipe and with 5 swipes of the same area of the wipe, she cleaned anal area, front to back. She obtained a wipe and with one swipe in a back to front direction, she cleaned the anal area. She obtained a wipe and with 2 swipes of the same area of the wipe, in a back to front direction, the stool was wipes off. She obtained another wipe and with 2 swipes with the same area of the wipe cleaned the anal area, front to back. She obtained another wipe and with 4 swipes with the same area of the wipe, folding and with 2 swipes with the same area of the wipe, cleaned the anal area. She did not pat the anal area dry. The resident was rolled onto his back. She obtained a wipe and in a back to front direction, she cleaned the scrotum. She did not pat the area dry. She removed her gloves and performed hand hygiene. She wasn't sure when the catheter bag was emptied last. The catheter bag was half full of urine. The urine in the catheter bag was emptied and it was amber to bloody colored. During an interview on 5/11/23 at 9:05 a.m., CNA 6 indicated the catheter bag was emptied at the beginning, middle and again at the end of the shift. For catheter perineal care, she would clean the tubing first, cleaning the tube a little way down, and pat it dry after cleaning. She should hold the tubing at the penis because it could pull out, and his tended to pull out easily. She patted the area dry with the wipe. His catheter tended to leak. She checked the resident every 2 hours for stool. He could tell them when he needed changed. His stool was usually dry around the edges of the stool. She should clean his bottom from the top downward and she should not repeat the same area of the wipe to clean. 2. The clinical record for Resident 52 was reviewed on 5/11/23 at 10:37 a.m. The diagnoses included, but was not limited to, Parkinson's disease, dementia, Alzheimer's disease, neuromuscular dysfunction of the bladder, neurogenic bladder, hydronephrosis with a right ureteral stent, and cystitis without hematuria pyocystis. The care plan, dated 1/31/19, indicated the resident required an indwelling catheter related to a neurogenic bladder and obstructive uropathy. The interventions, dated 1/31/19, indicated to manipulate the tubing as little as possible during care, position the bag below the level of the bladder, and provide assistance for catheter care. The nurse's note, dated 5/31/22 at 10:58 p.m., indicated the catheter was draining at the bedside and had milky yellow urine with a foul smell. The physician's order, dated 6/7/22 indicated to provide catheter care three times daily at 5:00 a.m., 1:00 p.m., and 9:00 p.m. The nurse was to record the output every shift. The nurse's note, dated 6/14/22 at 1:38 a.m., indicated the catheter was draining cloudy yellow urine. The nurse's note, dated 6/16/22 at 11:35 p.m., indicated the catheter was draining cloudy yellow urine. The nurse's note, dated 6/25/22 at 3:55 a.m., indicated the urine was obtained for the urinalysis per the MD (medical doctor's) order and taken to the local hospital. The Urinalysis report, completed on 6/25/22, indicated the resident's urine was yellow and turbid, had moderate occult blood, 100 mg/dL, was positive for nitrites, had a large number of leukocytes, greater than 100 per hpf white blood cells, and marked red blood cells. No culture was indicated. The nurse's note, dated 7/7/22 at 10:09 a.m., indicated new orders were received to flush the catheter with 100 ml of normal saline every 8 hours as needed for blockage or a change in urine, color, or clarity. The physician's order, dated 7/8/22, indicated to flush the catheter with 100 ml of normal saline every 8 hours as needed for blockage or a change in urine color or clarity. The nurse's note, dated 8/7/22 at 2:51 a.m., indicated a CNA reported to the nurse that the catheter was leaking. The catheter bag was assessed and was leaking from the bag, but also at the insertion site. The catheter was removed. An 18 French catheter was inserted using sterile technique. A small flash of yellow urine was observed. The Quarterly MDS assessment, dated 8/24/22, indicated the resident was severely cognitively impaired. She required substantial assistance from staff for toileting hygiene. The nurse's note, dated 12/8/22 at 12:03 a.m., indicated the catheter was changed per order. A 18 French 10 mL catheter was anchored via sterile technique. The catheter was patent, draining yellow colored urine. The nurse's note, dated 12/25/22 at 2:17 a.m., indicated the catheter was changed related to leaking. The nurse's note, dated 1/8/23 at 1:53 a.m., indicated a new catheter was anchored via sterile technique. A 16 French 20 mL balloon with immediate urine return was provided. The nurse's note, dated 3/10/23 at 11:54 p.m., indicated the resident required assistance of one staff for ADL's. The catheter was anchored and patent with cloudy yellow urine flowing in line. She was incontinent of bowel and did not make wants and needs known to staff most often. Staff were to anticipate all of the resident's wants and needs. The nurse's note, dated 4/7/23 at 10:50 p.m., indicated the catheter was anchored and patent with amber yellow and somewhat cloudy urine. During an observation of catheter care for Resident 52 on 5/11/23 at 8:38 a.m., by CNA 7 with LPN 5, present, the CNA applied hand sanitizer and gloves. She obtained a wipe and with 3 swipes of the same area of the wipe, she cleaned the crease to the left of the labia. The catheter tubing was not cleaned. As the CNA swiped down the labial area toward the catheter tubing, stool could be seen on the wipe, with each swipe. The CNA removed her gloves and applied hand sanitizer. She applied clean gloves. The resident was rolled onto her left side. The CNA obtained a wipe and with 2 swipes of the same area of the wipe she cleaned the anal area. She folded the wipe and with 2 swipes of the same area of the wipe, cleaned the anal area. She obtained a wipe and with 2 swipes of the same area of the wipe she cleaned the anal area. She folded the wipe and with 2 swipes of the same area of the wipe, cleaned the anal area. She did not dry the anal area. The clean brief was applied. The catheter tubing was still not cleaned. She removed her gloves and applied hand sanitizer. During an interview on 5/11/23 at 8:50 a.m., CNA 7, indicated she had cleaned the tubing before the perineal care, and it was just not in view. She indicated if stool was present, it could have brought the stool back onto the tubing while cleaning. She indicated she cleaned the tubing every 2 hours. The catheter bag was emptied at the end of her shift. The resident was good at drinking fluids. The CNA indicated she pat the resident's perineal area dry after she cleaned with the wipes. She then admitted she didn't do that during the care. During an interview on 5/11/23 at 12:41 p.m., the DON (Director of Nursing) indicated the nurse was supposed to let the CNA know the orders for catheter care. They should clean the resident from front to back, folding the cloth or changing to a new one with each swipe. They should dry the area from front to back when doing perineal care. They should not lift the catheter bag above the bladder and should hold the catheter tubing at the entry site while cleaning. She later indicated she found the area on the policy for drying the resident after cleaning the perineal area. The Perineal Care Skills Competency procedure steps, last reviewed on March 2023, was provided by the DON on 5/11/23 at 12:38 p.m., included, but was not limited to, . 10 . Gently wipe catheter from meatus downward approximately four inches. Do not rewipe catheter. Discard used wash cloth in plastic bag . 12. Separate labia and wash urethral area first . 14. Alternate from side to side wipe from front to back and from center of perineum outward. 15. Use a clean area of the washcloth with each wipe. Do not rewipe area unless using a clean area of the washcloth . 17. Wash and rinse tip of penis in circular motion, starting at urethra moving outward . 19. Continue washing down the penis to the scrotum outward . 21. Gently pat dry area in same direction as washing . 24. Clean anal area from front to back, using a clean area of washcloth with each wipe. Do not rewipe area, unless using a clean area of the washcloth . 26. Gently pat area dry in same direction as when washing . The Indwelling Urinary Catheter Care, Emptying Drainage Bag and Catheter Removal policy, last reviewed December 2012, was provided by the IP (Infection Preventionist) on 5/11/23 at 2:00 p.m. The policy included, but was not limited to, Catheter care and emptying of urinary drainage bag may be done by a licensed nurse or certified nurse aide . 6. Using the non-dominant hand grasp the catheter tubing where it enters the meatus. 7. Using the dominant hand retrieve a wet soaped washcloth, cleanse the catheter in circular motion for about 10 cm [centimeters] (4 inches) . 3.1-41(a)(2)

Based on record review and interview, the facility failed to ensure residents were treated with dignity and respect for 3 of 5 residents reviewed for resident rights. ( Residents B, D, and C) Findings include: 1. The clinical record for Resident B was reviewed on 3/21/23 at 9:00 a.m. The diagnoses included, but were not limited to, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and major depressive disorder. The Quarterly MDS (Minimum Data Set) assessment, dated 2/15/23, indicated the resident was moderately cognitively intact. He required extensive assistance of two staff members for ADL's (activities of daily living). The review of the in-services education completed on 4/8/22 and 1/6/23, indicated the CNA (Certified Nursing Aide) 1 was educated on Essential of Resident Rights, Nondiscrimination in Healthcare, Elder Justice Act and Abuse Recognition, Prohibition, and Reporting. The incident report, dated 2/13/23, indicated Hospice aide 3 walked into the resident's room and CNA 1 was already in the room. Resident B had his light on and indicated his feet were cold. She heard the CNAs say, well you have socks on. She ask what was going on and CNA 1 indicated the resident was just being an ass, then she walked out of the room mad. The Incident Report, dated 2/23/23, indicated the CNA 1 called Resident B an ass. During an interview on 3/21/23 at 11:27 a.m., CNA 1 indicated on 2/23/23 she was going in to do care on him and the hospice aide was present. Resident B was yelling out and being just a little aggravating. She called him a name and the hospice aide heard her. She got pulled off the hall. She didn't know of him saying anything. She was walking out of the room as she said it. CNA 2 heard CNA 1 call the resident a name. She indicated she was very stressed because there was a lot going on. She was taking care of a lot of people and there was a lot of call lights on. She then went into the resident's room and said it. She wasn't thinking at the time, it just came out. She didn't say it to him, but she said it to the hospice aide. She was in the residents doorway and then she walked out. She said the resident was being an ass. She was telling it to the hospice aide. The hospice aide didn't say anything, she just looked at her. The resident was screaming, yelling out, and he was pressing his call light a lot. His roommate was also pushing his call light a lot. Staff had been in there multiple times that morning. He was yelling out for breakfast and staff asked him if he wanted anything, but he said he didn't want anything else. She should have not said what she said. She should have went into the room more politely and asked him what he needed. She told the other CNA to go in and help the resident. During an interview on 3/21/23 at 11:41 a.m., CNA 2 indicated she was in the resident's room with CNA 1 and getting ready to leave the room They were to the doorway and Hospice Aide 3 was entering. CNA 1 told Hospice Aide 3 the resident was being an ass today. She did not think the resident heard her call him a name. The resident was safe and then she went to the DON (Director of Nursing). When a resident had behaviors, she would inform the resident's nurse, and ask Social Services to talk to the resident. She would be nice to the resident and continue with resident care. During an interview on 3/21/23 at 12:16 p.m., the DON indicated on 2/23/23 she recalled the incident. It was right after morning meeting. Hospice Aide 3 informed her that an aide had come into the resident's room. The resident didn't want to get up for the day and CNA 1 indicated he's being an ass. CNA 1 called the resident a butt. The DON informed CNA 1 she couldn't call the residents names. The resident recalled the incident immediately and could not recall it later. He heard it initially. He wasn't upset. The resident said he heard her say it. He didn't want to get out of bed and was upset about that, but not about her calling him a name. CNA 1 should have stepped away. CNA 1 told her she was frustrated. She educated CNA 1 and told her she should have had another caregiver come in and to walk away. CNA 1 indicated she had a bad weekend and she brought her bad weekend in to work. The resident did not have any issue with either of them providing care. 34309 2. The clinical record for Resident D was reviewed on 3/21/23 at 12:53 p.m. The diagnoses included, but were not limited to, heart failure, anxiety disorder, atrial fibrillation, and chest pain. The incident report, dated 4/25/22, indicated Resident D notified a nurse that NA (Nurse Aide) 4 was verbally abusive during care. The NA was suspended pending the investigation. The care plan, dated 4/25/22 and last revised on 2/14/23, indicated the resident may have an increase in psychosocial distress related to an increase in anxiety symptoms, agitation, and being withdrawn from others. The interventions, dated 4/25/22, indicated the staff was to monitor for psychosocial distress and offer one on one (one staff to one resident) conversation and active listening. The DON interviewed the resident on 4/25/22. The resident indicated NA 4 told the resident that she was mean to her roommate and the resident asked her to repeat what she said. The NA couldn't tell her anything. The resident indicated she informed the NA 4, on 4/25/22, that she felt she had a UTI (urinary tract infection). NA 4 indicated to her that she knew the resident was mean, angry, and very irritable with everyone. The resident indicated she felt degraded by NA 4 and the way she responded to her. NA 4's written report of the incident, dated 4/25/22, indicated she took the resident to the bathroom and the resident wanted to know how someone with a UTI behaved. NA 4 indicated she seemed a little grumpy and irritated. Resident D notified LPN (Licensed Practical Nurse) 5, on 4/25/22, of the incident with the NA 4. The resident indicated the NA told her she was mean to her roommate and she had been mean for a while. The resident abuse questionnaire, dated 4/25/22, indicated the resident was degraded by the staff member by saying she had been grouchy and mean. The resident indicated this occurred on 4/24/22 and 4/25/22. The NA received an in-service on the abuse policy on 4/23/22, 4/24/22, and 4/28/22. Her signature was documented, indicating her attendance on one of these dates. The Social Service Director interviewed the resident on 4/29/22. The resident indicated NA 4 was definitively insensitive. She felt it was teetering on abuse. She felt staff would benefit from additional training. The Quarterly MDS assessment, dated 4/30/22, indicated Resident D was cognitively intact. During an interview on 3/21/23 at 11:45 a.m., CNA 2 indicated Resident D knew what was going on with her care. She seemed fine cognitively to her. She had not declined mentally. She could provide information. She had never complained to her that anything had happened with any other staff. During an interview on 3/21/23 at 12:30 p.m., Resident D indicated NA 4 was suspended and she couldn't come back to her room. She mouthed off at her and said some rude things. The NA told her she was rude to her roommate. It upset her completely. 3. The clinical record for Resident C was reviewed on 3/21/23 at 10:30 a.m. The diagnoses included, but were not limited to, overactive bladder, weakness, repeated falls, and irritable bowel syndrome with diarrhea. The Quarterly MDS assessment, dated 12/30/22, indicated Resident C was moderately cognitively impaired. The incident report, dated 1/4/23, indicated Resident C reported to the Social Service Director that, on 1/3/23, NA 4 was rude, hateful, and cursed at her. The NA was suspended pending the investigation. On the resident abuse questionnaire completed by the Social Service Director. on 1/4/23, indicated the resident indicated she had her call light on and NA 4 entered her room. NA 4 indicated she would no longer come into her room and take care of the resident because she had taken enough sh** off of her. The resident indicated NA 4 was in a bad mood upon entry and she was hateful. During the resident abuse questionnaire conducted by the Social Service Director, on 1/6/23, the resident indicated she could not remember the NA's exact words, but the NA would not come back to see her or her roommate for over an hour. She could tell the NA 4 did not want to be there. The NA's written report, dated 1/5/23, indicated she walked into the resident's room to turn the call light off and was frustrated. The resident indicated she was wet and NA 4 checked her brief and indicated to the resident, the brief was dry. The resident indicated to NA 4 her brief was wet, so NA 4 changed her brief and left the room. The care plan, dated 1/13/23, indicated the resident had urinary tract infections. The interventions, dated 1/13/23, indicated to assist the resident with incontinence care and to observe for continued or worsening symptoms of UTI (worsening incontinence, urgency, frequency). During an interview on 3/21/23 at 10:38 a.m., the Social Service Director indicated Resident C reported the incident to her on 1/4/23. She could not remember the details of the incident, but later indicated that her interview with the resident was documented in the incident report. During an interview on 3/21/23 at 11:19 a.m., the ED (Executive Director) indicated NA 4 was no longer on the schedule. She felt NA 4 had quit, because the documentation showed she was terminated, which could mean she was fired or quit. During an interview on 3/21/23 at 11:52 a.m., the resident indicated she could not remember what happened in January with NA 4. During an interview on 3/21/23 at 12:02 p.m., CNA, QMA (qualified medication assistant), and the Scheduler indicated NA 4 did what was asked of her, but she had been terminated. The employee records, reviewed on 3/21/23 at 12:06 p.m., for NA 4 indicated the NA received resident rights training on 10/18/21, 4/1/22 and 10/1/22. The NA received the facility's Vision, Mission, Values handbook, which indicated . Unacceptable Conduct . 1. Violation of resident rights . 5. Discourteous treatment, horseplay, disruptive or unruly behavior, creation of unreasonable noise, or use of profane language . During an interview on 3/21/23 at 12:21 p.m., the DON indicated NA 4 was a young and she was terminated because there had been other allegations from residents, and it seemed recurring. She was not found to be abusive, but it was time to let her go. The NA had not reported what the resident indicated. Resident C had not made allegations about any other staff. Resident D indicated the NA said something that Resident D, thought was rude and not very nice. She was just terminated recently, no education was provided, but she was lectured. Resident D was alert and oriented. The Resident Rights policy, revised on December, 2022, was provided by the ED (Executive Director) on 3/21/23 at 12:38 p.m. The policy included, but was not limited to, . Respect and Dignity. The resident has the right to be treated with respect and dignity . Freedom from Abuse, Neglect, and Exploitation. The resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation . This Federal tag relates to Complaint IN00401566 3.1-3(t)

Based on observation, record review, and interview, the facility failed to ensure residents' physicians were notified related to a significant change in condition, which resulted in a continued decline and worsening of the resident's condition (Resident 67) for 2 of 24 residents reviewed for notification. (Residents 67 and 49) Findings include: 1. During an observation on 6/29/22 at 9:30 a.m., the resident was observed in the dining room during snack time. A staff member was assisting the resident with holding her cup and taking a drink. The clinical record for Resident 67 was reviewed on 6/28/22 at 12:38 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual MDS (Minimum Data Set) assessment, dated 3/18/22, indicated the resident was severely cognitively impaired. The resident required limited assistance of one staff member with eating. The Quarterly MDS assessment, dated 6/6/22, indicated the resident was severely cognitively impaired. The resident required extensive assistance of one to two staff members with all ADL's (Activities of Daily Living). The resident required extensive assistance of one staff member with eating. The care plan, dated 6/19/21 and revised on 6/7/22, indicated the resident required assistance with ADL's including bed mobility, transfers, eating and toileting. The interventions included, but were not limited to, the resident prefers to go to bed just after dinner, assist with ambulation as needed, assist with 2 person assistance to the wheelchair, assist with bathing as needed per resident preference, offer showers two times per week, and a partial bath in between. Assist the resident with bed mobility as needed, assist with bed mobility as needed, assist with dressing, grooming, and hygiene as needed, encourage resident to do as much for herself as possible, assist with eating and drinking as needed, assist with oral care at least two times daily, and assist with transfers as needed, with an assist of 2 to the wheelchair. The nurse's note, dated 5/29/22 at 4:49 p.m., indicated the resident was observed when assisting her to get up for the day, she was not easily aroused, was not vocalizing, and her eyes were in a fixed stare. The resident was given a sternal rub with little response. Cold water was used to her face and the resident yelled out. She was assisted up to the wheelchair. She was not vocalizing, and her eyes had a continued stare. She was assisted with her dinner time meal. The resident was holding food and fluids in mouth for several minutes before swallowing. Her intake was poor. She was unable to take her morning medications. The resident's family member was in the building and updated on her change of condition. The NP (Nurse Practitioner) was updated. She was assisted back to bed with the assistance of two staff, continued to have difficulty swallowing, and her speech was impaired. They would continue to monitor and treatment per plan of care. The nurse's note, dated 5/30/22 at 2:10 p.m., indicated Resident 67 was assisted to the dining room in her wheelchair with a one person assistance. After several bites she was noted chewing food for much longer and not swallowing. The NP was updated with new orders to change her diet to puree related to longer periods of chewing and swallowing. The resident's emergency contact was in the facility and updated on the new order. He stated that he understood the new order as he fed resident one meal yesterday and observed the decline in meal intake. The nurse's note, dated 5/30/22 at 11:48 a.m., indicated the resident was observed having a hard time feeding herself this am. Staff attempted to assist to dine with the resident and resident refused any assistance. Her appetite and fluid intake was poor. She could answer questions appropriately, however, she was having a hard time finding words so it took a little while for her to answer. The IDT (Interdisciplinary Team) note, dated 5/31/22 at 10:29 a.m., indicated the team met and reviewed the resident's recent change in condition. She was observed pocketing food and fluids several minutes before she was able to swallow. She was also not responding to commands per her usual. She was not speaking and was not easily aroused at times. The NP was notified and a new order was received to downgrade her diet to pureed and speech therapy to evaluate and treat as indicated. Will continue to observe. The nurse's note, dated 6/1/22 at 2:35 p.m., indicated the resident was observed up in her wheelchair and continued to have much difficulty speaking. Her appetite and fluid intake was poor with staff assistance. She screamed out when staff would encourage food and fluids. The nurse's note, dated 6/2/22 at 3:27 p.m., indicated the resident was up in her wheelchair. She was observed to continue to have difficulty with speech. Her appetite and fluid intake were poor. She was observed with increased agitation when staff would encourage food and fluids. Her family was at her bedside. During an interview on 6/28/22 at 1:50 p.m., LPN 5 indicated the resident had a decline in her condition in the past few weeks. The resident was able to feed herself with cueing and encouragement, but now the staff would feed her. She required extensive assistance with her ADL's. When the resident had a change in condition she notified the NP (Nurse Practitioner) and the NP did not give any new orders. She indicated she thought the resident had a stroke. During an interview on 6/29/22 at 10:20 a.m., LPN 11 indicated they thought the resident might have had a TIA ([CONDITION(S)]). She had a change in condition in the past few weeks. She still had difficulty with her speech and the staff had to feed her now. The documentation indicated the NP was updated. She would have documented what the NP had said about the resident and if there were any orders given. Their policy was to assess and treat the resident when there was a change in condition. She would call the NP and get an order to send the resident to the hospital. She did not know why 911 wasn't called for the resident. She was not on duty when the resident had a change in condition. During an interview on 6/29/22 at 11:22 a.m., NP 6 indicated on 5/29/22 the facility would have called the on call nurse practitioner. She was not aware of the resident's symptoms, if she had been she would have made a note and followed up on it when she came in. She should have been updated on the condition of the resident when she came in, it should have been written in the book they used for notification. She would have thought the on call NP would have done some labs or something. If someone called the on call NP, the nurse's note should document NP notified and new orders received. She did not recall being told anything else about the resident. She was not aware of the resident not being able to speak, or not being able to be aroused on 5/31/22. She would rely on the staff to notify her of changes from the resident's baseline. She did not have any communication from the nurse in her phone on 5/29/22, 5/30/22 or 5/31/22 regarding the resident. She would have guaranteed one of her partners would have ordered some labs or something if one of the partners were notified. She identified the on call NP as NP 16 and called her to verify if she was notified of the change in condition. During an interview on 6/29/22 at 11:44 a.m., NP 16 indicated she did not recall taking a call on the resident. She checked her phone for the dates and did not see any record of calls from any of the facilities numbers. She had no calls around the timeframe of 4:30 p.m. She did not have any calls from the facility or the nurse at all for that entire day. If she had received a phone call about a resident in the condition described on 5/29/22, she would have given orders for them to send him or her out, especially if it was a big change. During an interview on 6/29/22 at 12:05 p.m., the NP 6 indicated there was no documentation in the book for communication with her regarding the resident's change in condition. During an interview on 6/29/22 at 12:10 p.m., LPN 5 indicated the resident had a change in condition around dinner time. She called the NP on call for that weekend, but could not remember which NP she talked to. During an interview on 6/29/22 at 12:20 p.m., the DON indicated when a resident had a change in condition, she expected the nurse to open an event and call the nurse practitioner, however a lot of times the on call NP would not give them anything. If the resident was not a DNR (do not resuscitate), she would expect her to be sent to the hospital, if they're a DNR she would leave it up to the family if they wanted them sent or not sent to the hospital. She would have wanted to see the NP notified of whatever the change was and would have expected documentation of the physician's response. She would expect the nurse to advocate for the resident. During an interview on 6/29/22 at 12:21 p.m., the Executive Director indicated she would expect staff to do whatever was best for the resident. 2. The clinical record for Resident 49 was reviewed on 6/24/22 at 9:10 a.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The significant change MDS assessment, dated 5/25/22, indicated the resident was severely cognitively impaired. The nurse's note, dated 5/26/2022 at 8:30 a.m., indicated the nurse was called into the resident's room by the CNA (Certified Nurse Aide) and upon arrival the resident was observed in a grand mal [CONDITION(S)] involving the upper body. The [CONDITION(S)] lasted 5 minutes, with the resident going into post-ictal state, The resident's vitals were within normal limits, with easy respirations, however she was unresponsive. The clinical record lacked documentation of any notification to the physician, hospice, or the resident's family of the [CONDITION(S)] on 5/26/2022 The nurse's note, dated 5/27/22 at 5:08 a.m., indicated while the nurse was in the resident's room the resident began to have a [CONDITION(S)] [MEDICATION(S)] approximately 5 minutes. The hospice nurse was contacted and gave orders to start an as needed [MEDICATION(S)]. He would contact the doctor to see about an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurse's note, dated 5/29/22 at 12:01 a.m., indicated the resident was observed to be having a [CONDITION(S)] when the CNA entered the room. An as needed [MEDICATION(S)] was administered to the resident. The IDT note, dated 5/31/22 at 9:39 a.m., indicated the resident had 2 seizures over the weekend and received orders for an as needed [MEDICATION(S)]. Since the medication was administered the resident had no further [CONDITION(S)] activity. A diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 6/28/22 at 10:54 a.m., LPN 10 indicated if a resident had [CONDITION(S)] like activity she would stay and monitor the activity, make sure they were free of hurting their self, and time the [CONDITION(S)] activity. After the activity was over she would go ahead and take vitals, make sure they're not biting their tongue. She would notify the DON (Director of Nursing), the doctor, and the family. She would notify the physician for any kind of a [CONDITION(S)]. She was not aware of the resident having a grand mal [CONDITION(S)]. She would have notified the doctor and seen if they wanted her sent out, or any new orders at all. The physician notification would be documented in the notes. There would be an event or an observation for [CONDITION(S)] activity. During an interview on 6/28/22 at 11:03 a.m., the DON indicated when a resident had a [CONDITION(S)], staff needed to wait in the room, document how long it lasted, call the NP or hospice. They should notify them of the [CONDITION(S)] and how long it lasted. There should be notes and there should be an event opened for [CONDITION(S)] activity. She did not know about the resident's [CONDITION(S)] on 5/26/22. The nurse texted her about the [CONDITION(S)] on 5/27/22, but she didn't know about the prior day. She was not aware of the [CONDITION(S)] on the 5/26/22 until she came back to work after the weekend. She reviewed the resident's clinical record when she came in the next work day and made sure she had the medications. The nurse should have notified the physician and opened the events on 5/26/22. During an interview on 6/29/22 at 11:50 a.m., NP 6 indicated she had seen Resident 49 multiple times, she had ran labs and urinalysis, she was aware of some odd behavior that staff stated was seizures, but she had not witnessed one herself. She was not on call on 5/26/22. She would have expected a physician notification and orders to send out the resident to the hospital. Five minutes was an extremely long time to have a [CONDITION(S)]. The Resident Change of Condition Policy, last revised 11/2018, was provided on 6/29/22 at 11:13 a.m. by the DON, included, but was not limited to, . It is the policy of this facility that all changes in resident condition will be communicated to the physician and family/responsible party, and that appropriate, timely, and effective intervention takes place. Procedure 1. Life Threatening Change a. The licensed nurse will initiate appropriate first aide measures until emergency response personnel arrive on the scene. b. The licensed nurse will inform the attending physician, alternate physician, or Medical Director of resident status as soon as possible before, during, or after the change of condition occurs or when the resident crisis has been managed, and document the notification. c. The licensed nurse will notify the family/responsible party of resident change of condition and document notification. d. All nursing actions, physician contacts, and resident assessment information will be documented in the medical record. e. The nursing supervisor (or licensed nurse) will notify the Director of Nursing Services or Executive Director, as appropriate. 2. Acute Medical Change a. Any sudden or serious change in a resident's condition manifested by a marked change in physical or mental behavior will be communicated to the physician. b. If unable to contact the attending physician or alternate physician in a timely manner, notify the Medical Director for medical intervention. c. The responsible party will be notified that there has been a change in the resident's condition and what steps are being taken. d. All nursing actions/interventions will be documented in the medical record as soon as possible after resident needs have been met . 3.1-5(a)(2)

Based on record review and interview, the facility failed to ensure COVID-19 testing was completed for residents experiencing COVID-19 symptoms for 4 of 5 residents reviewed. (Resident 10, 233, 1 and 7) Findings include: 1. The clinical record for Resident 10 was reviewed on 6/29/22 at 9:02 a.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Significant Change in Status MDS (Minimum Data Set) assessment, dated 6/16/22, indicated the resident was severely cognitively impaired. She was dependent on staff for care. The care plan, dated 6/9/22 and revised on 6/22/22 at 11:28 a.m., indicated the resident was at risk for impaired gas exchange related to sleep apnea. The interventions, dated 6/9/22, indicated to administer medications as ordered, administer oxygen as ordered at 2 liters by nasal cannula, assess vital signs and lung sounds as needed, elevate head of bed as needed, monitor oxygen saturation rates as needed, and nebulizer treatments as ordered. The resident received the Moderna COVID-19 vaccinations on 2/4/21, 3/22/22, and 6/24/22. The Surveillance Log of Resident Infections and Antibiotic Use indicated the resident had symptoms of bilateral wheezing on 4/1/22. The chest x-ray indicated negative results. The resident was started on [MEDICATION(S)] 750 mg (milligrams) daily, with a start date of 4/1/22 and a stop date of 4/5/22. She was not placed in isolation. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . If the resident had any of these symptoms, place the resident in droplet plus precautions, notify the MD (Medical Doctor) and obtain orders for COVID-19 testing. The nurse's note, dated 4/2/22 at 9:22 a.m., indicated the resident's respirations were even and unlabored with diminished lung sounds. The clinical record lacked documentation of COVID-19 testing upon the start of respiratory symptoms. The nurse's note, dated 4/3/22 at 10:33 p.m., indicated the antibiotic therapy was continued as ordered. The resident was void of coughing thus far but continued with diminished lung sounds. The nurse's note, dated 4/5/22 at 11:17 p.m., indicated the resident received an oral antibiotic for a possible upper respiratory infection. The nurse's note, dated 4/14/22 at 10:42 p.m., indicated a new order for 2 liters of oxygen at night as needed for low O2 (oxygen) saturations. The O2 saturations were at 96% on room air. During an interview on 6/29/22 at 9:59 a.m., the Infection Preventionist indicated she would monitor residents for COVID with symptoms of fever, new or worsening cough, sore throat, nausea, vomiting, body aches, chills, congestion, and decreased O2 saturations. Resident 10 would have had a cough, if an x-ray showed pneumonia, but normally she would have poc tested residents anyway. If residents showed the same respiratory symptoms at the same time, she would test. The nurses would sometimes COVID test residents and not document the testing. She would sometimes not catch them to document it. Upon looking in her computer system, she found that Resident 10 was not COVID tested on or around April 3. The staff did not understand infection control. Resident 10 was put on antibiotics weekly by the hospice doctor. On April 16, 2022 LPN 13 tested positive for COVID-19. On April 23, 2022 Receptionist 14 tested positive for COVID-19. Both were symptomatic. 2. The clinical record for Resident 233 was reviewed on 6/29/22 at 12:46 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS (Minimum Data Set) assessment, dated 3/24/22, indicated the resident was cognitively intact. The care plan, dated 12/14/21 and revised on 4/5/22, indicated the resident was at risk for impaired gas exchange related to: [CONDITION(S)] (Chronic Obstructive Pulmonary Disease) with shortness of breath while lying flat. The interventions included, but were not limited to, administer medications as ordered, administer oxygen as ordered, assess vital signs and lung sounds as needed, chest x-ray as ordered, elevate the head of the bed as needed, encourage diversion activities, monitor oxygen saturation rates as needed, nebulizer treatments as ordered, observe for non verbal signs of anxiety such as furrowed brows, pacing, a change in mental status or behaviors, and observe for verbal signs of stress and anxiety. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 250 mg (milligram) oral, once a day starting 4/21/22 and ending on 4/24/22. COVID-19 testing as needed via POC/Antigen or PCR test per facility policy and CDC (Center for Disease Control) Guidance as needed. COVID-19 testing as needed via POC/Antigen or PCR test per facility policy and CDC Guidance as needed, with a start date of 1/2/22 and a discontinue date of 5/7/22. The nurse's note, dated 4/20/22 at 3:23 p.m.,indicated the NP (Nurse Practitioner) was in to see the resident. A new order was received for a Z-pak related to complaints of nasal congestion and facial discomfort. The nurse's note, dated 4/22/22 at 2:27 p.m., indicated the resident continues with antibiotic therapy for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] The nurse's note, dated 5/2/22 at 5:28 p.m., indicated the resident complained of chest congestion. Auscultation of the left upper lobe was noted with rales. The NP was notified and new orders were obtain for a chest x-ray. The nurse's note, dated 5/3/22 at 3:52 p.m., indicated PRN (as needed) Tylenol was given once this shift for generalized aches and pains. The clinical record lacked documentation indicating the resident was COVID-19 tested for respiratory symptoms. During an interview on 6/29/22 at 10:15 a.m., RN 15 indicated for any resident having respiratory symptoms they would do a Covid-19 test first. During an interview on 6/29/22 at 9:59 a.m., the Infection Preventionist indicated Resident 233 had no COVID testing documented. She had sinus congestion and was started on [MEDICATION(S)]. 3. The clinical record for Resident 1 was reviewed on 6/29/22 at 12:35 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS assessment, dated 3/21/22, indicated the resident was cognitively intact. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . If the resident had any of these symptoms, place resident in droplet plus precautions, notify MD and obtain orders for COVID-19 testing. The vaccination record for Resident 1 indicated the resident received her first COVID-19 vaccine on 1/10/21 at the facility. She received her second vaccine on 2/8/21. She refused her booster vaccine on 11/11/21 and 5/31/22, however did accept the booster on 6/24/22. The respiratory surveillance line list indicated the resident had pneumonia/central [CONDITION(S)] on 4/4/22. Her symptoms included diaphoretic and wheezes, culture/test results indicated n/a(not applicable), antibiotic order was [MEDICATION(S)] 100 mg every 12 hours from 4/4/22 to 4/13/22 for a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Nurse Practitioner's note, dated 4/4/22 at 12:31 p.m., indicated the resident was seen for complaints of not feeling well. Her lungs were clear, but she appeared diaphoretic. The NP ordered a CBC (Complete Blood Count), CMP (Complete Metabolic Panel), and chest xray. The nurse's note, dated 4/4/22 at 2:37 p.m., indicated the resident had complaints of weakness, diaphoresis, and aches. New orders were received and the NP was aware. The nurse's note, dated 4/4/22 at 11:34 p.m., indicated the resident's chest xray conclusion was consistent with central [CONDITION(S)] or perihilar patchy infiltrates. The NP was notified and new orders were given for [MEDICATION(S)] 100 mg every 12 hours for ten days and a [MEDICATION(S)] dose pack. The nurse's note, dated 4/5/22 at 1:07 a.m., indicated the resident's lung sounds were observed with wheezes. The nurse's note, dated 4/15/22 at 1:31 a.m., indicated the resident's antibiotic therapy was completed. She had no cough, congestion, or shortness of air. The clinical record lacked documentation of any testing for COVID-19 at or after the onset of of new symptoms. During an interview on 6/29/22 at 9:59 a.m., the Infection Preventionist indicated Resident 1 had no COVID testing documented. She ended up on [MEDICATION(S)] and [MEDICATION(S)]. She had a chest x-ray that same day as the symptoms and it showed [CONDITION(S)]. 4. The clinical record for Resident 7 was reviewed on 6/29/22 at 12:30 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan, dated 3/3/20, indicated the resident was at risk for impaired gas exchange related to a history of pneumonia, allergic rhinitis, other disease of respiratory tract, and history of COVID-19. The interventions included, but were not limited to, administer medications as ordered, administer oxygen as ordered, assess vital signs, lung sounds as needed, chest xray as ordered, elevate head of bed as needed, and monitor oxygen saturation rates as needed. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . If the resident had any of these symptoms, place the resident in droplet plus precautions, notify the MD and obtain orders for COVID-19 testing. The Surveillance log indicated the resident had a [CONDITION(S)] infection on 4/27/22. The symptoms included a cough, congestion, and a runny nose. The X-ray results indicated the resident had [CONDITION(S)]. The antibiotic orders included [MEDICATION(S)] 250 mg from 4/20/22 to 4/24/22 for a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The vaccination record indicated the resident received his first covid-19 vaccination on 1/10/21. He received his second vaccination on 2/8/21. He received his third vaccination on 11/12/21. He received his fourth vaccination on 6/24/22. The SBAR Physician Communication Tool, dated 4/27/22 at 3:32 p.m., indicated the resident had a cough and congestion, the problem seemed to be respiratory. The recommendation was a chest xray. The evaluation notes indicated the chest x-ray showed [CONDITION(S)]. The infection event for [CONDITION(S)], dated 4/29/22 at 2:26 p.m., indicated the resident had a lower respiratory tract infection with a new or increased cough, and a dry cough. The nurse's note, dated 4/28/22 at 12:21 a.m., indicated the resident had a chest x-ray. The results had indicated a slight increase central markings, question [CONDITION(S)]. The NP was made aware. The nurse's note, dated 4/28/22 at 4:37 p.m., indicated a new order was received from the NP for a [MEDICATION(S)] dose pack as directed for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurse's note, dated 4/29/22 at 11:31 p.m., indicated the resident continued on the [MEDICATION(S)] dose pack with minimal coughing. The nurse's note, dated 5/3/22 at 3:54 p.m., indicated the resident had an occasional non-productive cough observed. The nurse's note, dated 5/6/22 at 11:56 p.m., indicated the resident had a sporadic non productive cough. The clinical record lacked documentation of any testing for COVID-19 at or after the onset of of new symptoms. During an interview on 6/29/22 at 9:59 a.m., the Infection Preventionist indicated Resident 7 had no covid testing documented and received a [MEDICATION(S)] dose pack. His chest x-ray showed [CONDITION(S)] on the same day as the symptoms. During an interview on 6/29/22 at 11:38 a.m., NP 6 indicated when nursing staff would call with a resident's symptoms of covid she would always ask if they had completed a covid test. The COVID cases in the last two months have been minimal. She would expect a covid test for fever, congestion, coughing, diarrhea. She did not get called on every single runny nose. She would expect a covid test for a runny nose and congestion. If a resident had [CONDITION(S)] and orders for antibiotics she would have expected they'd been COVID tested . The COVID Support Center policy, dated 4/30/20, was provided on 6/23/22 at 1:20 p.m. by the ED (Executive Director). The policy included, but was not limited to, . How and When Testing Occurs . The first determination of testing involves residents or employees exhibiting symptoms of the illness. Both residents and employees area monitored daily for an elevated temperature and respiratory issues like coughing and shortness of breath . 3.1-18(b)

Based on observation, record review, and interview, the facility failed to ensure proper catheter care and handling of the indwelling urinary catheter bag and tubing for 2 of 3 residents reviewed for indwelling urinary catheters. (Residents 10 and 6) Findings include: 1. During an observation on 6/23/22 at 8:55 a.m., Resident 10's indwelling urinary catheter bag and tubing was directly on the floor with the bed in it's lowest position. During an observation on 6/24/22 at 9:02 a.m., the resident was sitting in her wheelchair in the dining room. Her catheter bag was in a dignity pouch hanging under the wheelchair. The catheter tubing was resting directly on the floor. During an observation on 6/27/22 at 10:53 a.m., the resident was sitting in her wheelchair in the dining room. The indwelling urinary catheter bag was in a dignity pouch and the tubing was lying on the floor. During an observation on 6/28/22 at 11:12 a.m., CNA (Certified Nursing Aide) 12 and LPN Licensed Practical Nurse) 4 were performing catheter care on Resident 10. CNA 12 obtained a wipe and cleaned the catheter tubing from the exterior labia down the tubing without holding the tubing at the meatus. She removed her gloves and applied hand sanitizer. The clinical record for Resident 10 was reviewed on 6/28/22 at 9:32 a.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Significant Change in Status MDS (Minimum Data Set) assessment, dated 6/16/22, indicated the resident was severely cognitively impaired. She was dependent on staff for toileting hygiene. The care plan, dated 6/8/22 and last revised on 6/22/22, indicated the resident required an indwelling urinary catheter due to [CONDITION(S)] ([CONDITION(S)]) in the urine and [CONDITION(S)] bladder. The interventions, dated 6/8/22, indicated do not allow tubing or any part of the drainage system to touch the floor. Manipulate the tubing as little as possible during care. Position the bag below the level of the bladder. Provide assistance for catheter care. The nurse's note, dated 3/23/22 at 1:41 p.m., indicated the NP (Nurse Practitioner) was in the facility to see the resident. The labwork was received with abnormal results of a BUN (Blood Urea Nitrogen) high at 43 and a creatinine high at 1.9. The nurse's note, dated 6/01/22 at 11:30 p.m., indicated orders received previously this day for labwork as well as a urinalysis with culture and sensitivity if indicated. An in and out catheter procedure was performed using a sterile technique. There was an immediate return of 400 mL (milliliters) of dark, cloudy, and foul smelling urine. A urinalysis with culture and sensitivity was conducted on 6/2/22. The urine was amber in color and turbid. There was 1 plus bacteria, 2 plus protein 3 plus leukocytes and 21 to 50 red blood cells in the urine. There was greater than 50 white blood cells and greater than 100,000 CFU (Colony Forming Units) per mL [CONDITION(S)] present. The resident was prescribed [MEDICATION(S)] (antibiotic) 100 mg twice daily. The nurse's note, dated 6/3/22 at 6:38 p.m., indicated a Foley catheter was placed. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] The nurse's note, dated 6/3/22 at 9:19 p.m., indicated the resident was tolerating the indwelling Foley catheter this evening. The resident was re-educated as to why the catheter was in place (to aid in fully emptying bladder). The collection bag had 550 mL of amber colored urine. The urinalysis with culture and sensitivity was pending. The nurse's note, dated 6/4/22 at 11:55 p.m., indicated the culture and sensitivity was received from the laboratory. It was positive for a [CONDITION(S)] (urinary tract infection) with 100,000 plus bacteria. A new order was received for [MEDICATION(S)] 100 mg (milligrams) by mouth twice a day for 7 days to treat the [CONDITION(S)]. The nurse's note, dated 6/6/22 at 11:20 p.m., indicated the resident was diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurse's note, dated 6/7/22 at 2:34 p.m., indicated an order to discontinue the [MEDICATION(S)] and start [MEDICATION(S)] 100 mg BID (twice daily) for 10 Days due to the culture and sensitivity results. The nurse's note, dated 6/10/22 at 9:18 p.m., indicated the resident remained on contact isolation related to [CONDITION(S)] in the urine. During an interview on 6/28/22 at 11:30 a.m., CNA 12 indicated to perform catheter care, she would undo the brief, obtain one wipe, starting close to the vagina and swiping up about 4 inches. During an interview on 6/28/22 at 11:42 a.m., the DON (Director of Nursing) indicated the staff should be performing pericare when they do catheter care. She then indicated they would complete perineal care at least once per shift. 2. During an observation, on 6/28/22 at 10:07 a.m., CNA 18 and CNA 17 entered Resident 6's room to perform catheter care. After washing their hands and donning gloves, CNA 17 performed catheter care by cleansing the catheter from the external labia outward with one disposable wipe. They did not cleanse the complete catheter by separating the labia and cleansing from the insertion site, and they did not cleanse the resident's perineal area. The resident's brief was replaced and the CNAs indicated the care was completed. The clinical record for Resident 6 was reviewed on 6/24/22 at 1:51 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The Annual MDS assessment, dated 3/31/22, indicated the resident was severely cognitively impaired and required extensive staff assistance with personal care and hygiene. The care plan, dated 6/10/22, indicated the resident required an indwelling urinary catheter related to urinary retention. The interventions included, but were not limited to, provide assistance for catheter care. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurse was to record output every shift. The nurse's note, dated 6/9/22 at 5:16 p.m., indicated the resident had no urine output after 8 hours and had blood tinged discharge and complaints of abdominal pain and tenderness. The NP was notified with new orders to insert a Foley catheter and obtain a urinalysis with culture and sensitivity. The nurse's note, dated 6/9/22 at 5:17 p.m., indicated the Foley catheter was inserted per sterile technique and the urine was obtained with amber cloudy urine observed. The specimen was sent to the lab. The urinalysis report, dated 6/11/22, indicated the resident had a large amount of occult blood, protein was 30, positive for nitrates, large amount of leukocytes, appearance was turbid, white blood cells were greater than 100, epithelial cells were 11 to 20, red blood cells were 4 to 10, [MEDICATION(S)] was present, bacteria was marked, amorphous crystals were present. There was not culture and sensitivity attached. The Nurse Practitioner's comment on the report indicated to repeat the test as the hospital did not culture. The nurse's note, dated 6/13/22 at 10:23 a.m., indicated the resident had a urinalysis done, but the culture was not done. New orders were obtained to get a new urinalysis with culture and sensitivity. The nurse's note, dated 6/13/22 at 1:11 p.m., indicated the urinalysis results indicated the resident had moderate occult blood, moderate leukocytes, cloudy appearance, moderate bacteria. The culture was pending. The urinalysis report, dated 6/16/22, indicated the resident had three or more organisms present, each greater than 10,000 CFU/mL (colony forming units per milliliter). The organisms were commonly found on external and internal genitalia, and were considered colonizers. No further testing was performed. The nurse's note, dated 6/16/22 at 11:40 p.m., indicated urine was obtained for a urinalysis and culture and sensitivity. The nurse's note, dated 6/18/22 at 4:52 p.m., indicated the urinalysis results were received, the culture was pending. The NP was notified. The nurse's note, dated 6/21/22 at 3:31 p.m., indicated an order was received for a urinalysis with culture and sensitivity. The nurse's note, dated 6/22/22 at 6:21 p.m., indicated the resident's urine was cloudy, with positive (+)1 blood, +1 protein, positive for nitrates, 3+ for leukocytes, 21 to 50 red blood cells, greater than 50 white blood cells, epithelial cells, bacteria, hyaline casts, amorphous, [MEDICATION(S)], budding yeast, and white blood cell clumps present. The urine culture report, dated 6/22/22, indicated the specimen showed proteus mirabilis with greater than 100,000 CFU/mL and providencia Stuartii, which was an organism known to possess inducible beta-lactamase, at greater than 100,000 CFU/mL. The nurse's note, dated 6/25/22 at 4:43 p.m., indicated the urine culture results were received and the NP was notified with new orders for the resident to receive [MEDICATION(S)] 1 gram daily for seven days. During an interview, on 6/28/22 at 10:12 a.m., CNA 17 indicated catheter care was short and sweet, they just cleaned the catheter, that was all the skill said to do. During an interview, on 6/28/22 at 11:48 a.m., the Regional Director of Clinical Services, indicated staff had been told to do catheter care and that was what they did. When the residents had catheter care ordered every shift it would be done with perineal care. She thought staff were so focused on the task that was all they did. They were to start at the insertion site and go out. They would clean both sides if it was a female. Staff knew to do that. The Indwelling Urinary Catheter Care, Emptying Drainage Bag & Catheter Removal policy and procedure dated January 2012, was provided on 6/28/22 at 12:08 p.m. by the DON. The policy included, . 6. Using the non-dominant hand grasp the catheter tubing where it enters the meatus. 7. Using the dominant hand retrieve a wet soaped washcloth, cleanse the catheter in circular motion for about 10 cm [centimeters] (4 inches). Start cleansing where the catheter enters the meatus and down toward the drainage tube . 3.1-41(a)(2)

Based on record review and interview, the facility failed to provide assistance and guidance for residents to be involved with the care planning process for 2 of 24 resident care plan revision reviewed. (Residents 79 and 65) Findings include: 1. The clinical record for Resident 79 was reviewed on 6/24/22 at 9:32 a.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS (Minimum Data Set) assessment, dated 6/9/22, indicated the resident was cognitively intact. The Care Plan Summary, dated 3/15/22 at 3:36 p.m., indicated the resident was invited to attend the care plan meeting but chose not to attend. The box indicating to explain why the resident chose not to attend was left blank. The Care Plan Summary, dated 6/15/22, indicated the resident again was invited and chose not to attend. The box indicating to explain why the resident chose not to attend was left blank. The clinical record lacked documentation of any explanation of why the resident did not choose to attend, or any efforts further to attempt to involve the resident in care planning. During an interview on 6/27/22 at 2:06 p.m., Resident 79 indicated she did not recall talking about care plan meetings with staff. She knew who the SSD (Social Services Director) was, but she did not recall ever being asked about a care plan meeting. She thought those were only done when a resident was ready to go home. During an interview on 6/28/22 at 10:38 a.m., the SSD indicated she sent out care plan invitations every 3 months, typically a week ahead of time. She would ask a resident if they were interested in being involved, but she had several who were not interested in being involved. If they didn't want to be involved they reviewed the care plans with herself, the MDS coordinator, and a nurse manager. She would document in the care plan meeting observation if they had chosen not to attend but not why they chose not to attend. If a resident told her they did not want to attend she just continue to give them the care plan invitation every time they were due. She had not asked them why they didn't want to attend. She should have completed the box that indicated why they did not attend. Other than the initial invitation she did not take any steps to encourage resident participation. 2. The clinical record for Resident 65 was reviewed on 6/28/22 at 10:35 a.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS assessment, dated 6/2/22, indicated the resident was cognitively intact with good recall and orientation. The Care Plan Summary, dated 6/7/22, was completed by the Social Worker and indicated the resident was invited but chose not to attend the meeting. The box indicating to explain why the resident chose not to attend was left blank. The clinical record lacked documentation of any explanation of why the resident did not choose to attend, or any efforts further to attempt to involve the resident in care planning. During an interview on 6/28/22 at 10:15 a.m., the resident indicated she was not invited to the care plan meetings. She did not even know what a care plan meeting was about. She would like to attend a meeting to have a say in how she was cared for and about her goal to go home. During an interview on 6/28/22 at 10:38 a.m., the Social Worker indicated the resident did attend her Road to Recovery meeting on 6/15/22. The meeting was just her and the resident. No other disciplines were involved. The resident did not attend any other care plan meetings since admission on 2/24/22. 3.1-35(a)(2)(C) 3.1-35(2)(B)

Based on observation, interview, and record review, the facility failed to ensure staff to resident abuse did not occur for 1 of 3 residents reviewed for abuse. (Resident C) The clinical record for Resident C was reviewed on 4/21/22 at 12:23 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/21/22 at 11:53 a.m., the resident was observed sitting in the dining/activity room with her eyes closed. Staff approached and spoke with the resident; she showed no fearfulness towards staff or other residents. There were no signs of any psychosocial distress. The incident report, dated 4/15/22 at 7:37 p.m., indicated staff witnessed CNA (Certified Nursing Assistant) 4 push Resident C. During an interview on 4/21/22 at 1:08 p.m., Activity Assistant 5 indicated on 4/15/22, CNA 4 was exiting the nursing supply room. Resident C told CNA 4 she was going to go into the supply room and CNA 4 told the resident no. Resident C then pushed CNA 4. CNA 4 pushed the resident back and stated, how would you like it if you were pushed. During an interview on 4/21/22 at 1:12 p.m., Activity Assistant 6 indicated on 4/15/22, she was behind the nurse's desk, heard raised voices, looked up, and witnessed CNA 4 place both hands on Resident C's chest and push her. She immediately went to the resident and removed her from the situation. The resident began to cry but calmed down very easily. On 4/21/22 at 12:07 p.m , the Executive Director provided a current copy of the document titled Abuse Prohibition, Reporting, and Investigation dated 2/2010. It included, but was not limited to, Policy .It is the policy .to provide each resident with an environment that is free from abuse .This includes .verbal abuse .physical abuse .will not permit residents to be subjected to abuse by anyone, including employees .Willful .means the individual must have acted deliberately .intimidation .Physical Abuse .pulling .rough treatment .Verbal Abuse .The use of oral .language The Past noncompliance began on 4/15/22 and the deficient practice corrected by 4/18/22 after the facility implemented a systemic plan that included the following actions: The facility completed staff education on abuse (4/18/22), facility wide resident interviews completed related to abuse (4/15/22), skin assessments completed on all residents (4/15/22), psychosocial follow-up 3 day follow-up completed by Social Services (4/18/22), and all employee files audited to ensure 100% compliance of abuse and dementia training. This Federal tag relates to Complaint IN 810 3.1-27(a)(1)

Based on observation, record review, and interview, the facility failed to ensure appropriate interventions to prevent accidents were implemented for 6 of 10 residents reviewed for accidents. (Residents 27, 44, 57, 53, 55, and 181) 1. The clinical record for Resident 27 was reviewed on 4/20/21 at 10:06 a.m. Diagnoses included, but were not limited to, weakness and dementia. The Quarterly MDS (Minimum Data Set) Assessment, dated 1/30/21, indicated the resident was moderately cognitively impaired, required extensive assistance of two plus staff members with transfers, and had two or more falls since the last assessment. During an observation, on 4/19/21 at 11:53 a.m., CNA (Certified Nursing Aide) 7 and CNA 8 went to assist Resident 27 from his bed to the wheelchair. They sat the resident up in bed and applied a gait belt to his waist before lifting the resident out of bed. The resident appeared to be asleep, with eyes closed, and was not assisting to stand throughout the transfer. His knees were buckled from the time he was lifted, until he was placed in the chair. There was no MP3 player (portable music player) at his bedside. During an observation, on 4/22/21 at 8:24 a.m., Resident 27 was resting [NAME], there was no MP3 player at his bedside. During an observation, on 4/22/21 at 2:38 p.m., LPN (Licensed Practical Nurse) 6 and LPN 9 brought the resident to his room in his Broda chair. They applied a gait belt, stood the resident and kicked the wheelchair back out of the way as they transferred the resident to the bed. The resident did not appear to bare weight as they pivoted him into the bed. There was no MP3 player observed at the residents bedside at this time. During an observation, on 4/23/21 at 3:30 p.m., CNA 3 and CNA 10 assisted the resident to bed. They wheeled the chair to the bedside and applied a gait belt to the resident, who was observed to be very drowsy. They informed him they were going to stand him up They lifted the resident and his knees were buckled. It did not appear as though the resident was baring any weight. They pivoted the resident into bed, during which his feet were sliding out from under him. CNA 3 indicated at the time, they had laid the resident down once already and they had gotten him back up, and decided to lay him down once again because he was just so tired. While in the room, CNA 3 and CNA 10 both commented about an MP3 player laying on the resident's bedside table. What's this [Name of Resident 27]? Is this new? They both indicated this was the first time they had seen an MP3 player in the resident's room. He had one on the 300 hall but since he had been on the 400 hall they hadn't seen one. The care plan, initiated on 6/19/19 and last revised on 4/20/21, indicated the resident was at risk for falls due to a history of falls and incontinence. Interventions included, but were not limited to, portable MP3 player at bedside with headphones with favorite music which started on 12/7/20; mechanical lift for transfers which started on 3/1/21 and ended on 4/20/21. The IDT (Inter-disciplinary Team) note, dated 5/28/20 at 12:20 p.m., indicated the resident had a fall due to rocking back and forth in his chair. The fall was witnessed by the nurse, housekeeping, and activities. An intervention to place dycem in the wheelchair was put into place. The nurse's note, dated 8/15/20 at 12:50 p.m., indicated the resident was being assisted from the toilet to the wheelchair by one staff member. Upon grabbing the bar and standing up, the resident was stronger with left arm and shifted all his weight to his left side. The CNA was unable to compensate the transferred weight and CNA assisted resident to floor. Resident was assessed with no new injuries noted. The IDT note, dated 8/15/20 at 12:50 p.m., indicated the IDT had reviewed the fall and a new intervention of gait belt to always be used with transfers was put into place. The IDT note, dated 11/25/2020 at 1:18 p.m., indicated the IDT met to review an assisted fall on 11/24/20 at 8:05 p.m. A CNA was toileting Resident 27 and when placing him back in wheelchair the chair moved related to not being locked and the resident slid to floor with CNA assist. No injuries were noted. An intervention to educate staff to ensure wheelchair brakes are locked when assisting resident to sit in wheelchair was implemented The IDT note dated, 12/7/20 at 11:25 a.m., indicated the IDT met to review unwitnessed fall on 12/6/20 at 10:00 a.m. Resident 27 was in the TV lounge in the floor and had appeared to have leaned out of his wheelchair. A new intervention for the resident to have a portable CD player at bedside with headphones with favorite music was put into place. The IDT note, dated 12/28/20 at 12:33 p.m., indicated the IDT met to review an unwitnessed fall on 12/28/20 at 1:33 a.m. Resident 27 was found to be sitting on the floor, upright on buttock at foot of roommate's bed and indicated he was trying to put on a pair of jeans. An intervention to check on the resident every hour while [NAME] was put into place. The IDT note, dated 1/11/21 at 3:55 p.m., indicated the IDT had met to review an unwitnessed fall on 1/11/21 at 6:30 am. Resident 27 was found in his room, laying on his left side with upper body on mattress, legs on the floor. No injuries noted. An intervention for a peddling Broda chair to maintain positioning and allow mobility was implemented. The IDT note, dated 3/1/21 at 1:49 p.m., indicated the IDT met to review a fall that occurred, on 2/28/21 at 10:57 a.m. Staff were attempting to transfer Resident 27 from his chair to the bed and the resident was not able to help turn or stand per his norm, so staff had to lower resident to the floor. No injuries noted. A new intervention to change the resident to a sit to stand lift for transfers was implemented. The IDT note, dated 3/3/21 at 11:56 a.m., indicated the IDT met to review fall that occurred on 3/2/21 at 12:55 p.m. Resident 27 was found sitting straight up on his buttocks in front of his bedroom door with his legs straight out in front of him, had removed his shirt because he was hot. No injuries noted. An intervention to offer snack between meals was implemented. The Therapy and Wellness Screen, completed on 3/3/21, indicated the resident was screened due to a fall. The question, . Is there a functional change or increased risk noted . was answered as not applicable, because the fall was related to the residents behavior. A therapy evaluation was not indicated. The IDT note, dated 4/19/21 at 10:29 a.m., indicated the IDT had reviewed the residents's fall precautions and discontinued the mechanical lift because the resident was able to bare weight and and was changed to an assist of two for transfers. The members in attendance did not include anyone from the therapy department. The clinical record lacked documentation of any therapy screening to assess the resident's ability to bare weight and transfer with assistance of two staff members. During an interview on 4/23/21 at 8:15 a.m., the RSM (Rehab Services Manager) indicated they did not currently have Resident 27 on caseload, and had not since January. They did a therapy screen if they were notified the resident had falls. He screened a fall in March, because the resident had two falls right in a row. When they looked at falls, they looked at position, the level of assist, was the resident now requiring a mechanical lift. He wasn't aware that he had been moved to a mechanical lift and he thought the staff were still transferring the resident physically. He was not aware that he had changed. Usually it would be discussed in IDT meetings, and he could not recall that he was in them. Nurses had the ability to downgrade a resident typically, but if they said they were doing better they may talk to the Therapy Department to see if that's an opportunity for involvement. He would typically expect to be involved in decisions with functional decline. The staff did not voice to him that there was any change in the resident's status that was requiring him to be seen for therapy. During an interview on 4/23/21 at 8:59 a.m., CNA 10 and CNA 11 indicated they both were familiar with Resident 27, and as far as they knew he had always been an assist of two staff members. They had never used a mechanical lift on him at all, at least not in the couple months since he had been back on the dementia unit. CNA 10 indicated most of the time they transferred him he was not helping to stand. CNA 11 indicated most of the time they transferred him he was asleep and was not baring weight or helping to stand. During an interview, on 4/23/21 at 9:04 a.m., the MCSS (Memory Care Support Specialist) indicated she was present for the discussion to discontinue the mechanical lift. She didn't feel like it was appropriate because the resident could be transferred with 2 people. The RSM wasn't at the meeting. She did not know if therapy evaluated to see if he could be upgraded to an assist of two staff for transfers. To her knowledge she didn't know if they had used a lift on him. He came back to the dementia unit on 3/17/21 and to her knowledge she could not ever recall seeing anyone use a mechanical lift to transfer the resident. During an interview, on 4/23/21 at 9:08 a.m., LPN 6 indicated she sometimes helped get the residents up and down, she did not ever recall using a mechanical lift on Resident 27. She saw when the order was put in, but she had still transferred him without a mechanical lift because he could bare his own weight. 2. The clinical record for Resident 44 was reviewed, on 4/21/21 at 9:05 a.m. Diagnoses included, but were not limited to, vascular dementia with behavioral disturbance, anxiety disorder, major depressive disorder, and pain in right hip. The MDS Quarterly review assessment, dated 3/5/21, indicated the resident was severely impaired cognitively. The care plan, dated 9/25/20 and last revised on 4/26/21, indicated the resident was at risk for falls due to a history of falls, advanced age, incontinence, and the use of high risk medication. The resident required assistance with ADL's (Activities of Daily Living) /transfers, had unsteady gait,was impulsive, had altered awareness of immediate environments, lack of unsteady of cognitive/physical limitations, dementia, weakness, poor safety awareness, and increased need for assistance with Covid-19. Interventions for Environmental changes indicated the following: dated 4/1/21, resident should have personal items in reach and a therapy screen; dated 3/6/21, indicated staff were to offer to assist resident to toilet following meals; dated 1/2/21, Two staff members to offer to assist resident with short distance ambulation as able when resident need arose; dated 12/23/20, Hipsters (roll protectors) on at all times; dated 12/14/20, bright colored tape to wheelchair brakes as visual cue; dated 12/13/20 Encourage resident to remain in common areas while awake; dated 9/25/20, Call light in reach and non skid footwear. During an observation, on 4/21/21 at 9:24 a.m., Resident 44 was observed in the Cottage Dining Room sitting at a table, in her wheelchair, with a doll and playing with pieces of tubing. During an observation, on 4/2,1/21 at 11:11 a.m., the resident was in the Cottage Dining Room folding washcloths. During an observation, on 4/21/21 at 2:15 p.m., the resident was sitting in the Cottage Dining Room folding towels. The Fall Event, dated 12/12/20, indicated the resident was sitting in her recliner and was found sitting in front of her recliner on the floor across from the nurse's station. This was unwitnessed. She had no visible injuries. The fall intervention was to remove all linens from the common area. The Fall Event, dated 12/29/20, indicated the resident was sitting in her wheelchair. Position after fall was on her right side against wall. The resident had clothes on, gripper socks on. the fall occurred outside of dining room in hallway. Unwitnessed- Resident stated she was trying to get up to walk because she wanted to walk. The resident was no longer able to ambulate without assist, unable to educate related to cognition. Medication changes-[MEDICATION(S)] 1 milligrams every day discontinued 12/28/20. New Intervention-Two staff members to offer to assist resident with short distance ambulation as able when resident need arises. 3. The clinical record for Resident 57 was reviewed on 4/22/21 at 10:05 a.m. The resident's diagnoses included, but were not limited to, vascular dementia, Alzheimer's disease, [CONDITION(S)] disease, peripheral vascular disease, hypertension, communication deficit, lack of coordination, abnormalities of gait and mobility, [CONDITION(S)], mood disorder due to known physiological condition with mixed features, repeated falls, and personal history of [CONDITION(S)] (TIA), and cerebral infarction without residual deficits. The care plan, dated 12/18/17, indicated the resident was non compliant with safety issues related to falls. He disregarded safety interventions. Interventions included, but were not limited to, 12/18/19 Staff would remind resident of safety interventions as needed. The care plan dated, 12/21/17 and last revised on 4/19/21, indicated the resident was at risk for falls due to: BPH (benign prostatic hyperplasia) with urgency, frequency of urine, dementia, age, medications, vision impairment, history of falls, decreased mobility, [CONDITION(S)] weakness, unsteady gait, altered awareness of immediate physical environment, impulsive, lack of understanding of one's physical and cognitive limitation. Interventions included, but were not limited to, the following: dated 4/5/21, offer to toilet before and after meals; dated 2/19/21, toilet riser applied to bathroom toilet; dated 12/28/20, offer to Assist resident to bed after all meals; Green tape to call light as reminder; and dated 12/21/17, Call light in reach. During an observation, on 4/21/21 at 11:08 a.m., Resident 57 was being taken to the back Cottage Dining Room from his family member to await the lunch delivery. During an observation, on 4/21/21 at 12:55 p.m., the resident was sitting in his wheelchair. He waited behind his family member in the Main Cottage Dining Room for her to finish being fed. She was then taken to her room for care and he was wheeling his wheelchair into the hallway alone. The Fall Event, dated 4/28/20, indicated the resident had a fall which occurred in front of his family member's closet. He sustained 3 scrapes to the right knee. The new intervention was for a motion sensor at bedside at night until bed alarm arrives. The Fall Event, dated 9/21/20, indicated the resident had a fall in the resident's bedroom. He slid out of his wheelchair while picking up frosting from the floor. The new intervention was for a dycem to the wheelchair at all times. The Fall Event, dated 11/3/20, indicated the resident had a fall in the resident's bedroom. He was trying to obtain cookies for his family member and himself. His legs went out from under him. The new intervention was for snacks to be available within reach. The Fall Event, dated 11/29/20, indicated the resident had a fall onto his bedroom floor. He was transferring himself to bed. The new intervention was for staff to assist the resident to bed after dinner. The Fall Event, dated 12/28/20, indicated the resident had a fall onto the bedroom floor. The resident was transferring himself to bed from the wheelchair. The new intervention was for staff to assist the resident to bed after all meals. The Fall Event, dated 2/6/21, indicated the resident had a fall in bedroom against the closet door. The resident was attempting to get a cookie. The new intervention was for snacks to be placed on the bedside table and be in reach. The Fall Event, dated 2/19/21, indicated the resident had a fall self transferring to the toilet. He hit his left side on the bathtub. The new intervention was to ensure fall interventions were in place. The New Order, dated 4/30/20, indicated the resident had a motion sensor at bedside to be used at night until bed alarm arrives. Repeated falls. The goal was the resident would be free of falls/injury. Approach-Motion sensor at bedside until bed alarm arrives. The physician's order for April 2021 indicated the resident's activity level was to wheelchair with assistance. During an interview, on 4/23/21 at 10:48 a.m., LPN 12 indicated the facility got rid of motion sensors and bed/chair alarms years ago. She was not aware of any motion sensors and alarms on the unit. During an interview on 4/22/21 at 2:08 p.m., LPN 6 indicated the resident was non-compliant and told them he wasn't going to do what he was told to do and and would laugh at them. Having his family talk to him didn't help either. He had experienced a decline in the last 6 months. He couldn't get up and take off like he used to. The staff performed hourly checks through the night. There was 1 nurse and 1 CNA on the night shift. The resident had both day and night falls. Mostly when going to the bathroom without using his call light. During an interview, on 4/22/21 at 9:56 a.m., the Rehab Services Manager indicated he was called to screen the resident with the falls he had on 11/16/20, 11/30/20, 12/21/21, 2/8/21, 2/22/21, and 4/5/21. He screened the residents who fell prior to going to the morning meetings to discuss the fall interventions he suggested. The resident was in physical therapy from 11/6/20 through 3/29/21. He required assistance for walking and transfer, and partial assistance for sit to stand and ambulation. An intervention would be to keep the resident with his family member in the common area for activities and offer assistance when needed. 4. The clinical record for Resident 181 was reviewed on 4/23/21 at 9:28 a.m. The resident's diagnoses included, but were not limited to, fracture of unspecified part of neck of left femur, subsequent encounter for closed fracture with routine healing, unspecified dementia with behavioral disturbance, muscle weakness aftercare following explanation of hip joint prosthesis, sleep disorders, lack of coordination, and abnormalities of gait and mobility. The current care plan, dated 11/1/19 and revised on 4/23/21, indicated the resident was at risk for falls. Interventions include but were not limited to, neon tape to call light, assist with transfers as needed, call light in reach, resident requires assistance with ADL's including bed mobility, transfers, eating and toileting, assist with ambulation as needed. Up ad lib with assistive device of choice; Walker/ Wheelchair as needed. During an observation, on 4/23/21 at 9:00 a.m., the resident was at the medication cart. When the nurse left the cart the resident picked up the picture of ice water and started walking away with it. A staff member took the water pitcher and went to put the ice pitcher back. While the nurse was away from the desk the resident went to the nurses desk and started picking up the shower sheets and looking at them. The staff member walked over after a few minutes and took the papers, and the resident started going into the nurses station. During an observation on 4/22/21 at 2:00 p.m., the resident was observed walking down the hallway. Her gait was unsteady, she was wobling back and forth as she was walking. During an observation on 4/23/21 at 3:15 p.m., the resident was coming out of room 413 and shutting the door. Room 413 was a male resident's room. Five staff members were observed at the nurses station talking and did not observe the resident. During multiple observations on 4/19/21 to 4/26/21 the resident was observed walking without the assistance of a staff member, a walker, or a wheelchair. The resident was walking with an unsteady gait of wobling back and forth as she walked. The nurse's note, dated 3/20/21 at 8:50 a.m., indicated staff was cleaning up after breakfast when the resident was noted to have gotten up out of recliner near the nurses station and walked to back the dining room. A resident yelled out Someone needs help. When staff entered the back dining room to find resident 181 was sitting on ground on her buttocks with both legs out in front of her. The resident was noted to have grabbed a bedside table and was using it as a walker and got tripped up on the legs and fell to the ground. A new fall intervention was put into place to have staff assist the resident when up ambulating. The nurse's note dated 2/04/2021 at 9:26 a.m., The nurse heard a thump. A CNA and the nurse entered the room and the resident was noted sitting on buttocks with legs straight out in front of her and sitting in front of bedside commode. Resident assisted up via three staff members. Full head to toe assessment completed at that time and resident noted with purple discoloration to left hip. During an interview, on 4/23/21 at 2:10 p.m., CNA 3 indicated the resident was up ad lib (as tolerated). She moved a little slower since her hip fracture. She did wander into other residents rooms. Interventions included gait belts, folding clothes, redirection, and activities. She indicated the facility did not use motion sensory monitors on the doors. She indicated the resident had a decrease in appetite and needed assist with eating at times since she fractured her hip. Resident 181 was unable to use a call light to call for assist. During an interview, on 4/26/21 at 9:15 a.m., LPN 5 indicated the resident had several falls. She did fracture her hip with one of the falls. The resident was unable to be educated and use her call light. They did not use the sensory door alarms. The resident had covid and she was very sick. She was still weak. She liked to push people around in their wheelchair. She had to be monitored like all dementia patients. She would go into another residents room and use the bathroom. She would wander into other resident's rooms and take things. 5. The clinical record for Resident 55 was reviewed, on 4/22/21, at 1:33 p.m. The MDS assessment dated [DATE], indicated the resident was severely cognitively impaired. Diagnoses included, but were not limited to, unspecified fracture of left femur, anxiety disorder, [CONDITION(S)], dementia, lack of coordination, repeated falls, weakness, abnormalities of gait and mobility, age-related [CONDITION(S)], displaced spiral fracture of shaft of left femur, [CONDITION(S)], and difficulty in walking. During multiple observations, from 4/19/21 to 4/26/21, Resident 55 was observed to be wheelchair bound. The current care plan, dated 10/5/20 and revised on 4/20/21, indicated Resident 55 was at risk for falls. Interventions included, but were not limited to, assist with transfers as needed, non skid footwear,resident required assistance with ADL's including bed mobility, transfers, eating and toileting, 50% weight bearing to left lower extremity. The nurse's note, dated, 3/15/21 at 12:59 a.m., indicated CNA was passing a nearby lunch tray when walking by and patient was sitting on buttocks. Resident stated that she was trying to sit over there and pointed at her wheelchair. Patient suffered from dementia and could not relay recent information. Resident was last seen in wheelchair prior to being found on bedroom floor between the wheelchair and bed. The new intervention of placing bright colored tape was placed on the wheelchair brakes. The nurse's note, dated 2/9/21 at 10:39 a.m., indicated the resident had an unwitnessed fall on 2/8/21 at 11:46 am. At roughly 11:45 a.m., the NP (Nurse Practitoner) went in to the resident room. She was found sitting straight up in the floor, on her buttocks with legs straight out in front of her, in front of the bathroom on roommates side of the room. Resident 55 had complaints of left hip/leg pain. The NP in house give orders for Xray. A mobile radiology company came in to perform an xray. Results received indicated the resident had a fracture of the proximal shaft of the left femur just superior to the fixation plate. NP notified with orders to send resident to ER for eval and treat. EMS arrived to facility at 5:40 p.m. to transport. The new intervention of plaving green tape on her call light to help remind her to use call light before getting up out of bed. The nurse's note, dated 12/31/20 at 11:24 a.m., indicated the IDT reviewed the unwitnessed fall on 12/31/20 at 3:25 a.m. Resident 55 had been resting [NAME]. Nurse found resident sitting on buttocks with left leg crossed underneath right leg in floor near foot of bed. The resident was dressed in her gown with bare feet. She had removed her pull up. The resident stated that she attempted to ambulate to the bathroom and began to urinate during transfer and slipped in urine on the floor. No open wounds noted. No med changes in previous seven days. The resident was transferred to ER via ambulance without issue. The new intervention of Intervention of [NAME] non skid strips to the open side of the bed. The nurse's note, dated 11/21/20 at 12:40 p.m., indicated the nurse was alerted by the CNA that the resident was sitting on the floor in hallway. Upon reaching resident, resident was noted sitting on floor with legs out straight and sitting next to the wall. She had a hematoma to right side of scalp. Intervention was for staff to assist the residnet when going to and from the dining room. During an interview, on 4/23/21 at 2:10 p.m., CNA 3 indicated the resident was up with assist to the wheelchair. She was up ad lib and walked all the time before her hip fractures. She was in a wheelchair for her mobility. She indicated the resident had a decline since her femur fractures. The Therapy and Wellness Screen, completed on 2/15/21, indicated the resident was screened due being newly admitted . The question, . Is there a functional change or increased risk noted . was answered as not applicable, because the fall was related to the residents behavior. A therapy evaluation was not indicated. During an interview on 4/26/21, at 9:50 a.m., LPN 5 indicated Resident 55 used to be up as tolerated before she fractured her hip twice. She has to use a wheelchair for mobility now. She is able to use her call light but she doesn't always do that. The residents with dementia are hard to educate. 6. The clinical record for Resident 53 was reviewed on 4/23/21 at 9:28 a.m. Diagnoses included, but were not limited to, fracture of unspecified part of neck of left femur, subsequent encounter for closed fracture with routine healing, unspecified dementia with behavioral disturbance, muscle weakness aftercare following explanation of hip joint prosthesis, sleep disorders, lack of coordination, and abnormalities of gait and mobility. The resident had 12 falls from 4/27/20 through 3/30/21. The current care plan, dated 11/1/19 and last revised on 4/23/21, indicated the resident was at risk for falls. Interventions included, but were not limited to, neon tape to call light, assist with transfers as needed, call light in reach, resident required assistance with ADL's including bed mobility, transfers, eating and toileting, and assist with ambulation as needed. During an observation, on 4/23/21 at 10:55 a.m., Resident 53 was observed walking with her walker. She attempted to sit down 2 times before getting to the dining room. Her shoes were observed on improperly. They were not on the heels of her feet and she was shuffling her feet. During an observation, on 4/23/21 at 11:05 a.m., the resident was getting up from the table indicating she had to pee. The resident's shoes were coming off of her feet. She walked on her tip toes at times. During an observation, on 4/21/21 at 1:35 p.m., the resident was observed getting up from her chair in the dining room. Her shoes were not properly on her feet. She walked to the sink to get paper towels, sit down for a few minutes and then walked back to her room without assist from staff. Six staff members were observed standing at the nurses station talking and did not observe the resident. The nurse's noted, dated 4/27/20 at 5:30 p.m., indicated IDT Review of unwitnessed fall on 4/27/20 at 5:30 p.m The Resident had been sitting in dining room chair. She was found lying on back beside chair. The resident stated I was trying to go to my bathroom and got my foot caught in the chair and fell . The new intervention of staff to assist the resident to a standard chair upon entering the dining room. The nurse's note, dated 5/24/20 at 6:10 p.m., indicated staff heard the resident screaming from her room. Staff ran to her room and found her lying on her back holding her head up in her bathroom doorway; facing her toilet. The nurse asked her what happened to her and she said she didn't know. The new intervention of staff to remain in restroom while toileting. The nurse's note dated 6/7/20 at 11:28 a.m., the resident continued with decrease in mobility. The nurse's note, dated 7/18/20 at 11:30 a.m. indicated, the nurse was assisting activity assistant with passing out snacks. The nurse heard the resident yell and turned around to see why resident was yelling. Just as she turned around the resident was in the process of sitting down, however no chair was present behind resident and the resident landed on her buttocks sitting up straight. The new intervention of discontinued for staff to assist the resident to the dining room each day at 11:15 am and assist to a stationary for morning snack. The nurse's note, dated 8/23/20 at 1:14 p.m., a review of unwitnessed fall on 8/23/20 at 8:00 a.m. The resident was resting [NAME] prior to breakfast. Staff heard the resident yell out; upon entering found the resident sitting on buttocks next to bed and bedside table. An abrasion was noted to the right eyebrow with discoloration. The nurse's note dated 8/30/20 at 6:29 p.m., indicated a review of the witnessed fall on 8/30/20 at 11:45 a.m. The resident was walking through common area and attempted to sit in stationary chair. The resident missed chair and fell on back. The new intervention of psychiatric group to review medications and bright colored tape to designated stationary chair. The nurse's note dated 1/28/21 at 12:30 p.m., Staff heard resident yelling help from her room. CNA came and got this nurse and stated the resident was on the floor in her bathroom. This nurse entered bathroom and the resident was lying on left side with left arm under her and holding her head up from the floor and the wall. During an interview, on 4/21/21 at 8:30 p.m., LPN 6 indicated the resident used a walker with the assistance of staff. Her activity was up with assist. She also used a wheelchair for mobility. During an interview, on 4/23/21 at 2:23 p.m., CNA 3 indicated the resident probably needed stand by assist with staff. The resident was impulsive and jumped up to walk. She always wore her shoes. During an interview, on 4/23/21 at 2:26 p.m., the RSM indicated due to the way the resident walked her balance was in front of her. She would not be able to walk with the walker close to her. He indicated she was not educatable, staff had to use cueing. During an interview, on 4/26/21, at 9:50 a.m., LPN 5 (Licensed Practical Nurse) indicated Resident 53 ws up ad lib with a walker. Sometimes she got weak and used a wheelchair, but she did not like to. Some times her knees would buckle and she would sit down in the floor. They encouraged her to use a wheelchair. She was able to use the call light, but she didn't always use it. She indicated the resident wore her shoes over her nonskid socks. She acknowledged the resident probably needed shoes with the backs out due to her shoes not fitting properly. The LPN indicated they did not use sensory door alarms for the residents. The Fall management Program policy, last revised on November 2017, provided on 4/23/21 at 10:17 a.m., included, but was not limited to, . Facilities must implement comprehensive, resident-centered fall prevention plans for each resident at risk for falls or with a history of falls . 5. Residents [TRUNCATED]

Based on observation, record review, and interview, the facility failed to implement appropriate supervision for residents with dementia related to behaviors for 1 of 30 residents reviewed for dementia care (Resident 181) Findings include: The clinical record for Resident 181 was reviewed on 4/23/21 at 9:28 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] aftercare following explanation of hip joint prosthesis, sleep disorders, lack of coordination, and abnormalities of gait and mobility. The Significant Change MDS assessment dated [DATE], indicated the resident was severely cognitively impaired. During an observation on 4/19/21 at 2:10 p.m., Resident 181 was observed in another resident's room. She was attempting to sit in the resident's wheelchair. Two staff members were outside of room. The staff were unaware the resident was in another residents room. During an observation, on 4/21/21 at 12:45 p.m., the resident was observed in the dining room walking around. She proceeded to take hold of another resident and push him out of the dining room down the hall. The staff were unaware of the resident pushing another resident's chair. During an observation, on 4/23/21 at 9:00 a.m., the resident was at the medication cart. When the nurse left the cart the resident picked up the picture of ice water and started walking away with it. A staff member took the water pitcher and went to put the ice pitcher back. While the nurse was away from the desk the resident went to the nurses desk and started picking up the shower sheets and looking at them. After a few minutes a staff member walked around the room and took the papers from the resident. During an observation, on 4/23/21 at 3:15 p.m., the resident was coming out of room [ROOM NUMBER] and shutting the door. room [ROOM NUMBER] was another male residents room. Five staff members were observed at the nurses station talking and did not observe the resident. The current care plan, dated 10/26/20 and revised on 3/11/21, indicated Resident 181 was at risk for intrusive wandering. Interventions included, but were not limited to, motion sensory alarm on the bedroom door to alert staff when the resident is out of her room so she can be directed to a common area, dated 10/26/20. Offer clothing for resident to fold if the resident was wandering and looking for something, dated 10/26/20. Redirect the resident to activities-magazines, TV, cleaning, folding baby clothes, coloring, music, devotional and religious, going outside (weather permitting), pet visits, and crafts, dated 10/26/20. Rule out pain, thirst, hunger, toileting needs and boredom, dated 10/26/20. The nurse's note, dated 4/20/21 on 1:00 a.m., indicated the nurse was called to the resident's room per CNA. The resident was found sitting in floor at bedside. Resident 181 was questioned if she was ok and what she was doing sitting in floor. The resident responded with garbled, soft spoken speech (per norm). The resident was assisted to a standing position, and then back into bed. Would place colored tape on call light as intervention. During an interview, on 4/23/21 at 2:10 p.m., CNA 3 indicated the resident was up ad lib. She moved a little slower since her hip fracture. She did wander into other residents rooms. Interventions included gait belts, folding clothes, redirection, and activities. She indicated the facility did not use motion sensory monitors on the doors. She indicated the resident had a decrease in appetite and needed assist with eating at times since she fractured her hip. Resident 181 was unable to use a call light to call for assist. 4.1-37(a)

Based on record review and interview, the facility failed to ensure an allegation of misappropriation was thoroughly investigated for 1 of 3 residents reviewed for allegation investigation. (Resident 25) Findings include: The clinical record for Resident 25 was reviewed on 4/20/21 at 11:00 a.m. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS (Minimum Data Set) Assessment, dated 1/28/21, indicated the resident was moderately cognitively impaired. During an interview, on 4/19/21 at 10:33 a.m., the resident indicated he kept his money in a lock box the facility had provided to him. When he was sent to the hospital about 2 weeks ago, someone took his key and took fifty dollars from the box. He told the ED (Executive Director), but she would not replace his money. The review of the clinical record, reportable incidents, and grievances for the last 60 days lacked documentation of any report or investigation for the allegation of misappropriation of resident funds for Resident 25. During an interview on 4/20/21 at 1:35 p.m., the ED indicated the resident had reported missing money more than once. She replaced it the first time and gave him a lock box. When he went to the hospital he reported his money had been stolen, however they could not verify that he ever had the money. She couldn't talk to him because he refused to talk to her, he just yelled at her. Until she could talk to him without him yelling at her she couldn't resolve the issue. She was waiting to have an opportunity to speak to him without him screaming at her. On 4/20/21 at 1:40 p.m., the ED provided copy of grievance form, which she indicated she had found in another location, dated 4/2/21 at 3:10 p.m. The grievance indicated the SSD (Social Services Director) had received a complaint from the resident that he was missing $50 from his drawer. The money had last been seen on 3/26/21, and the resident stated when he went out to the hospital on 3/21/21 and returned, staff returned his key to him and he noticed he was missing a fifty dollar bill. The SSD reviewed the grievance with the ED. The key was returned from laundry, however they were unable to replace the money as the resident had a locked drawer that he monitored. SSD had educated previously on resident trust and keeping minimal money in facility. The SSD educated on responsibility of locked drawer. The SSD discussed keeping minimal money in facility drawer and/or utilizing resident trust. Resident voiced understanding. The report lacked documentation of any additional staff or resident interviews related to the allegation of misappropriation or any further action taken to investigate the allegation. During an interview, on 4/20/21 at 2:02 p.m., the SSD indicated the report she got was the resident believed fifty dollars had been missing. His key had went to laundry and was brought back to his room and he felt like that money was missing. They told him they were unable to replace it, and at the time he was ok with that, but he brought it up a week later and was yelling about it and very upset. She brought the concern to the administrator, but she did not do anything else beyond that point. She did not verify anything with the laundry services. During the interview, on 4/20/21 at 2:13 p.m., Resident 25 indicated he talked to the SSD, and she indicated she would talk to the ED. The ED came back and said she didn't think he should be reimbursed. He always kept the key in his possession, he wore it on a lanyard around his neck. The ED and SSD would not talk to him about it anymore and he still felt they were responsible because it was locked in the box they provided to him. During an interview, on 4/26/21 at 10:22 a.m., the ED indicated everything she had related to the incident was on the grievance form. The Housekeeping Supervisor had the key the entire time, and nobody was ever in it. During an interview, on 4/26/21 at 10:27 a.m., the Housekeeping Supervisor indicated she did not recall Resident 25's key ever coming down to laundry and did not recall anyone discussing it with her. She had not discussed with the ED any concerns of the resident's key being in laundry. No one had asked her about it. During an interview, on 4/26/21 at 10:30 a.m., Housekeeper 4 indicated she did not recall ever seeing a key in the laundry, and no one had asked her if she had seen a key. The Abuse Prohibition, Reporting, and Investigation policy and procedure, last revised June 2018, provided on 4/19/21 at 8:30 a.m., included, but was not limited to, . Definitions/Examples of Abuse . Misappropriation of Resident Funds . Investigation . The Executive Director is the designated individual responsible for coordinating all efforts in the investigation of abuse allegations . Resident Abuse - Staff member . 4. The Executive Director and/or Director of Nursing will be immediately notified of the report and the initiation of the investigation . 8. An incident report will be initiated within 2 hours of the allegation, following the guidelines for Unusual Occurrence Reporting . 9. Residents will be questioned (if alert) about the nature of the incident and their statement will be put into writing . 10. An investigation will be completed to assure other residents have not been affected by the incident . and the results documented . 11. The investigation will include: Facts and observations by involved employees . Facts and observations by witnessing employees . Facts and observations by non-witnessing employees . Facts and observations from others who might have pertinent information . Facts and observation by the supervisor or individual whom the initial report was made . Analyze the occurrence to determine root cause, and what changes are needed to prevent further occurrence . 16. A comprehensive record of the abuse investigation will be kept by the Executive Director and/or Director of Nursing Services . 3.1-28(d)

Based on observation, record review, and interview, the facility failed to ensure care plans were initiated for areas of concern for 2 of 30 residents reviewed for care plans. (Residents 27 and 25) Findings include: 1. During an observation, on 4/19/21 at 12:07 p.m., Resident 27 was sitting in the Cottage Dining Room in his Broda (a wheelchair for positioning and tilting) chair. He was leaning forward with his eyes closed and slowly falling forward toward the table. During an observation, on 4/20/21 at 8:35 a.m., the resident was sitting in the doorway into the Cottage Dining Room. He was leaning on the armrest on his left armpit and below the bilateral cushions on the Broda chair. During an observation, on 4/22/21 at 11:29 a.m., the resident was sitting in his Broda chair in the Cottage Dining Room. The resident's head was down toward his lap. At 12:45 p.m., he was still asleep with his head down toward his lap. During an observation, on 4/23/21 at 10:52 a.m., the resident was observed with pillows to the left side and under the left arm of the resident. This was the first observation of the pillows being present. During an observation, on 4/23/21 at 1:02 p.m., the resident was observed sitting in his Broda chair in the dining room. 2 pillows had been placed on the left side and under the left arm of the resident. During an observation, on 4/26/21 at 10:15 a.m., the resident was observed leaning over onto pillows, asleep, in his Broda chair, in the Cottage Dining Room. The clinical record for Resident 27 was reviewed on 4/20/21 at 3:24 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The clinical record lacked documentation of a care plan or physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurse's note, dated 4/26/21 at 12:37 a.m., indicated the resident was leaning to the left in his Broda chair and had excessive secretions. The nurse's note, dated 4/25/21 at 3:05 p.m., indicated the resident continued to lean towards the left when up in his chair, and staff were providing a pillow for the resident to lean on to avoid skin breakdown. The nurse's note, dated 4/25/21 at 12:52 a.m., indicated the resident was in his Broda chair prior to bed and continued to lean towards the left. The nurse's note, dated 4/24/21 at 5:26 p.m., indicated the resident continued to lean towards the left when up in his Broda chair. The nurse's note, dated 4/24/21 at 12:16 a.m., indicated the resident was sitting in his Broda chair in the dining room. The resident was leaning in his chair. The resident was cued to sit up and aided into upright position, but would immediately return to leaning off side of chair. The nurse's note, dated 4/23/21 at 12:35 a.m., indicated the resident continued to lean forward and to the left in his chair, despite repositioning and encouragement to try to sit back in chair to prevent falling. During an interview, on 4/22/21 at 2:08 p.m., LPN (Licensed Practical Nurse) 6 indicated there was a pillow next to the resident's left side to prevent him from leaning over the arm of the chair. The resident was reminded to sit up to eat meals, but he would work his way back down. He had been drowsy during meals. During an interview, on 4/26/21 at 10:15 a.m., LPN 5 indicated the resident had been leaning in his chair since he was brought into the unit. She could not locate a care plan or orders for interventions to prevent leaning. Both LPN 6 and the Memory Care Support Specialist looked for the care plan for leaning at this time and could not locate one. 2. The clinical record for Resident 25 was reviewed on 4/20/21 at 11:00 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS (Minimum Data Set) Assessment, dated 1/28/21, indicated the resident had two unhealed stage 2 pressure ulcers. The Wound Management Detail report indicated the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] - A stage II pressure ulcer to the right gluteal fold upon admission on 8/3/20, which healed on 8/26/20. - A pressure ulcer, identified as a blood filled blister, to the left lower back, which was identified on 3/18/21, and healed on 4/1/21. - A stage II pressure ulcer to the left hip which was identified on 1/20/21 and healed on 2/1/21. - A pressure ulcer, identified as a scab like area to the coccyx, identified on 11/29/20, and healed on 2/18/20. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurse's note, dated 12/12/20 at 10:35 a.m., indicated the resident was encouraged to offload and return to bed after meal, The resident indicated he understood but did not want out of his wheelchair until he wanted to. The nurse's note, dated 12/14/20 at 10:44 p.m., indicated the resident was encouraged to not sit in his wheelchair all day to allow his coccyx to heal, however he was non-compliant and would sit in his wheelchair all day until bedtime. The nurse's note, dated 1/30/2021 at 10:00 a.m., indicated the resident would not get out of his wheelchair to offload before meals. He was educated and returned verbal understanding, but stated he would do what he wanted to. The nurse's note, dated 4/9/21 at 1:24 p.m., indicated the resident was educated on the importance of offloading, with his correct understanding obtain, however he said he wasn't going to get out of the wheelchair unless he d*** well wants to. The clinical record lacked documentation of a care plan to address the resident's continual non-compliance with offloading pressure. During an interview on 4/26/21 at 1:42 p.m., the Wound Nurse indicated the resident had been non-compliant with offloading since before she was working at the facility. Some days he was a little bit more compliant with others, but he did still have days where he was noncompliant with offloading. During an interview, on 4/26/21 at 2:22 p.m., the RDCO (Regional Director of Clinical Operations) indicated when a resident was non-compliant, they would try to work with the resident and come up with a compromise. It would have to be care planned somewhere, and she would expect the non-compliance to be addressed. During an interview, on 4/26/21 at 2:42 p.m., the DON (Director of Nursing) indicated she was not sure why the resident did not have a care plan for non-compliance and he should have one. The Skin Management Program policy, last revised October 2020, provided on 4/23/21 by the Executive Director, included, but was not limited to, . When a resident declines treatments or interventions . The facility is expected to address the resident concerns and offer relevant alternatives if there resident has declined the specific treatments . Please see refusal of care/intervention care plan . The IDT (Interdisciplinary Team) Comprehensive Care Plan Policy, last revised on 10/2019, provided on 4/26/21 at 3:13 p.m. by the Unit Manager, included, but was not limited to, Policy .The care plan will include measurable goals and resident specific interventions based on resident needs and preferences to promote the resident's highest level of functioning including medical, nursing, mental, and psychosocial needs .Care plan problems, goals, and interventions will be updated based on changes in resident assessment/condition, resident preferences or family input . 3.1-35(a)

Based on observation, interview, and record review, the facility failed to ensure a resident was free from unnecessary [CONDITION(S)] medications related to Psych notification of increased sedation for 1 of 8 residents reviewed for unnecessary [CONDITION(S)] medications. (Resident 27) Findings include: During an observation, on 4/19/21 at 12:07 p.m., Resident 27 was sitting in his Broda chair, in the Cottage Dining Room. He was leaning forward with his eyes closed and slowly falling forward toward the table. The MCSS (Memory Care Support Specialist), was attempting to get him to hold a spoon and feed himself. She kept asking him to open his eyes and take a bite of food. He was unable to get the spoon to his mouth. She obtained the spoon from the resident and indicated she was going to feed him. During an observation on 4/20/21 at 8:35 a.m., the resident was sitting in his Broda chair in the doorway of the Cottage Dining Room. The Broda chair had cushions to both sides of his shoulders, but he was leaning onto his left armpit, below the bilateral cushions on the armrest of the chair. His eyes were closed, and he was drooling a milky substance onto the armrest and floor. During an observation, on 4/20/21 at 2:06 p.m., the resident was asleep in his Broda chair in the middle of the Cottage Dining Room at a table. His eyes were closed, and he was not responding to the activity going on with baby dolls for the female residents. During an observation, on 4/22/21 at 8:19 a.m., the resident was sitting in his Broda chair in the Cottage Dining Room doorway. He had his eyes closed. During an observation, on 4/22/21 at 8:25 a.m., the resident was asleep in bed. During an observation, on 4/22/21 from 11:29 a.m. through 12:45 p.m., the resident was sitting in his Broda chair in the Cottage Dining Room. The resident's head was falling toward his lap. LPN 6, tried to awaken the resident to sit up, but he didn't open his eyes. During an observation, on 4/23/21 at 10:52 a.m., the resident was asleep in his Broda chair in the dining room. He was being taken to his room for care. During an observation, on 4/26/21 at 10:15 a.m., the resident was observed leaning over onto two pillows, asleep in his Broda chair's armrest, in the Cottage Dining Room. The clinical record for Resident 27 was reviewed on 4/20/21 at 3:24 p.m. The diagnoses included, but were not limited to intellectual disability, [CONDITION(S)] [CONDITION(S)], intermittent explosive disorder, [CONDITION(S)], persistent mood disorders, borderline personality disorder, anxiety disorder, dementia with behavioral disturbance, and acute [CONDITION(S)] with [CONDITION(S)]. The MDS (Minimum Data Set) assessment dated [DATE] indicated Resident 27 was moderately cognitively impaired impaired. The care plan, dated 6/19/19 and last revised 2/2/21, indicated the resident was at risk for adverse side effects related to use of [CONDITION(S)] medication -antipsychotic, antidepressant, anxiolytic. Interventions included, but were not limited to, administer medications as ordered, observe for effectiveness. assessment two times a year. Document side effects as observed and notify MD (Medical Doctor). IDT (Interdisciplinary Team) to review routinely to attempt gradual dose reductions, unless contraindicated by MD. Observe for side effects: Antipsychotic medications: dizziness, dry mouth, indigestion, drowsiness, constipation, impaired balance, weight gain, tremors, abnormal involuntary movements. Observe for side effects: Non antipsychotic medications: dry mouth, drowsiness, dizziness, [CONDITION(S)], decreased appetite, nausea, depression, confusion, pain. Pharmacist to review medications routinely. The Physician's Orders included, but were not limited to, the following medications: - [MEDICATION(S)] (antipsychotic) 234 mg/1.5 ml (milliliters) syringe intramuscularly. Special Instructions: Give every 28 days Once A Day Every 28 days between 7:00 a.m. - 11:00 p.m., which started on 11/17/20 - lorazepam (sedative) - Schedule IV 0.5 mg tablet orally. Special Instructions: Indications: At bedtime with a start date of 2/12/21. - lorazepam - Schedule IV 1 mg tablet orally once a day, at 8:00 a.m., with a start dated of 2/12/21. - [MEDICATION(S)] (sleep aid) 5 mg tablet orally at bedtime with a start dated of 10/26/20. - [MEDICATION(S)] (cognition enhancing) 5 mg tablet orally once a day with a start date of 3/10/21. - [MEDICATION(S)] (antipsychotic) 15 mg tablet orally once a day with a start date of 10/24/20. - [MEDICATION(S)] (antipsychotic) 2 mg tablet orally twice a day with a start date of 10/24/20. The nurse's note, dated 3/21/21 at 2:27 p.m., indicated the resident had minimal behaviors and was more sleepy during the shift. A Social Service Director's note, dated 3/16/21 at 11:16 a.m., indicated the resident was seen on 1/19/2021 by a psychiatric medical group. Assessment and plan from 1/19/2021 visit by the Nurse Practitioner (NP) indicated staff were to monitor and document ongoing or worsening behaviors and notify the psychiatric medical group as warranted for consideration of additional medication adjustments. Facility also encouraged to document behaviors as the reported behaviors per nursing are not noted. Staff to monitor resident for efficacy of medications as well as presence of adverse side effects to include, but were not limited to, somnolence/sedation. The nurse's note, dated 3/13/21 at 1:25 a.m., indicated the resident had been sleeping soundly during the shift. No outbursts were noted. During an interview, on 4/19/21 at 11:35 a.m. CNA 7 indicated Resident 27, mostly falls asleep when we feed him. We give him a bite of his food and he's completely out of it and it falls out of his mouth. During an interview, on 4/21/21 at 12:50 p.m., LPN 6 indicated the resident ate only half of his food for lunch. It was his norm to doze off. He would [NAME] up and then be sleepy again. During an interview, on 4/22/21 at 2:05 p.m., CNA (Certified Nursing Aide) 13 indicated the resident was sleeping during the day and staff gave constant reminders to him to eat. He was awake some nights. During an interview, on 4/22/21 at 2:08 p.m., LPN 6 indicated the resident had been drowsy during meals. His intake had been less than it had been. The NP/MD were asked to decrease a psychiatric medication and the NP declined. The LPN wanted to discuss the medication with the Psych NP when she came to the facility the next day. During an interview, on 4/22/21 at 8:30 a.m., LPN 12 indicated the resident became drowsier once he moved back to the unit. He was on the healthcare side and he was not like this there. The clinical record lacked documentation to indicated the Psych NP was notified of the resident's increased sedation. The [CONDITION(S)] Management Policy, last revised on 9/2017, provided on 4/26/21 at 3:30 p.m., included, but was not limited to, Policy .to ensure that a resident's [CONDITION(S)] medication regimen helps promote the resident's highest practicable mental, physical and psychosocial well-being with person centered intervention and assessment. These medications area managed in collaboration with the attending physician, pharmacist and facility staff to include non pharmacological interventions, and reduction as applicable . 3.1-48(a)(3)

Based on observation and interview, the facility failed to ensure medications were secured during medication administration for 1 of 4 medication carts observed related to medication storage. (300 Hall) Findings include: During an observation, on 4/21/21 at 8:25 a.m., LPN (Licensed Practical Nurse) 14 obtained medications for Resident 20 and entered the resident's room. The medication cart was left unlocked while the LPN was in Resident 20's room and the medication cart was out of view of the LPN during the medication administration. During an interview, on 4/21/21 at 8:35 a.m., LPN 14 indicated she should have locked the medication cart and normally she did. During an interview, on 4/21/21 at 8:35 a.m., the Director of Nursing indicated the nurse should have locked the medication cart after obtaining the medications. The General Dose Preparation and Medication Administration policy, last revised on 1/1/13, provided on 4/22/21 at 3:25 p.m. by the Unit Manager included, but was not limited to, .7. Facility should ensure that medication carts are always locked when out of sight or unattended. 3.1-25(m)

Based on interview and record review, the facility failed to ensure the physician was notified of the unavailability of an anticonvulsant medication for a resident (Resident B) which resulted in [MEDICAL CONDITION] activity and hospitalization for stabilization for 1 of 3 residents reviewed for physician notification. Findings include: The emergency room service report, dated 12/21/19 at 7:30 a.m., indicated Resident B arrived due to [MEDICAL CONDITION] activity, had a history of [REDACTED]. The resident had 3 [MEDICAL CONDITION] this a.m. The clinical record for the resident was reviewed on 12/26/19 at 11:52 a.m. [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE] at 6:54 p.m. The hospital discharge orders, dated 12/19/19 at 4:38 p.m., indicated the resident was to receive [MEDICATION NAME] (anticonvulsant medication) 300 mg (milligrams) twice daily and was last given on 12/19/19 at 9:18 a.m. The admission order, dated 12/20/19, indicated the resident was to receive [MEDICATION NAME] 300 mg twice daily for [DIAGNOSES REDACTED]. The nurse's note, dated 12/21/19 at 6:45 a.m., indicated the resident was found actively convulsing and was sent to the emergency room for evaluation. The (MONTH) 2019 Medication Administration Record [REDACTED]. The clinical record lacked documentation of physician notification related to the unavailability of the medication. During an interview on 12/26/19 at 1:03 p.m., the Director of Nursing indicated there was no documentation that the physician was notified of the medication not given. On 12/26/19 at 4:10 p.m., the Director of Nursing provided a current copy of the document titled Medication Storage/Unavailable Medication dated 1/1/13. It included, but was not limited to, Applicability .This Policy .sets forth procedures relating to medication shortage and unavailable medications .If the medication is unavailable from Pharmacy .Facility should obtain alternate Physician/Prescriber orders This Federal tag relates to Complaint IN 244 3.1-5(a)(3)

Based on interview and record review, the facility failed to ensure a resident (Resident B) received an anticonvulsant medication, as ordered by the hospital discharge physician, which resulted in a hospitalization for 1 of 3 residents reviewed for significant medication errors. Findings include: The clinical record for Resident B was reviewed on 12/26/19 at 11:52 a.m. [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE] at 6:54 p.m. The hospital discharge orders, dated 12/19/19 at 4:38 p.m., indicated the resident was to receive [MEDICATION NAME] (anticonvulsant medication) 300 mg (milligrams) twice daily and was last given on 12/19/19 at 9:18 a.m. The admission order, dated 12/20/19, indicated the resident was to receive [MEDICATION NAME] 300 mg twice daily for [DIAGNOSES REDACTED]. The nurse's note, dated 12/21/19 at 6:45 a.m., indicated the resident was found actively convulsing. The convulsions lasted at least 50 seconds with little than 5 seconds in between convulsions. The resident was sent to the emergency room for evaluation. The (MONTH) 2019 Medication Administration Record [REDACTED] - 12/19/19 between 7:00 p.m. and 11:00 p.m. - 12/20/19 between 7:00 a.m. and 11:00 a.m. - 12/20/19 between 7:00 p.m. and 11:00 p.m. During an interview on 12/26/19 at 1:03 p.m., the Director of Nursing indicated the resident did not receive the anticonvulsant medication. The emergency room service report, dated 12/21/19 at 7:30 a.m., indicated upon arrival the resident was actively seizing with generalized tonic clonic movements with eyes rolled upwards. The resident received [MEDICATION NAME] (antianxiety) 1 mg IV (intravenous) and [MEDICATION NAME] (anticonvulsant) 1,000 mg IVPB (intravenous piggyback) which were administered in the emergency room and the patient stopped seizing after the [MEDICATION NAME] was administered. On 12/26/19 at 3:30 p.m., the Director of Nursing proved a current copy of the document titled Medication Errors dated 11/2018. It included, but was not limited to, Policy .It is the policy of the this provider to ensure residents residing in the facility are free of medication error and the facility maintains a medication error rate of less than 5% This Federal tag relates to Complaint IN 244 3.1-48(c)(2)

Based on interview and record review, the facility failed to administer pain medication to a resident (Resident B) after a fall with complaints of severe pain. This resulted in the resident yelling and moaning out in pain during movement for 1 of 4 residents reviewed for pain control. Findings include: The clinical record for Resident B was reviewed on 9/13/17 at 11:15 a.m. [DIAGNOSES REDACTED]. The initial MDS (Minimum Data Set) assessment, dated 8/16/17, indicated a BIMS (Brief Interview of Mental Status) score of 01 which signified severely impaired cognition. The nurse's note, dated 8/25/17 at 6:34 p.m., indicated the resident was found sitting on the floor in the hallway with no significant injury found. The nurse's note, dated 8/26/17 at 11:13 a.m., indicated the resident had extreme pain to the left hip and left upper leg. A new order was obtained from the physician for an x-ray. The nurse's note, dated 8/26/17 at 12:45 p.m., included, but was not limited to, the following: Resident noted with extreme pain to left hip and leg upon attempting to self ambulate. Staff assisted resident back .sitting position with resident yelling out in pain. Staff assisted resident to lay down abed to rest. Resident restless attempting to self ambulate. Staff assisted times two into recliner in common area. Resident continues to moan. MD (medical doctor) updated on resident's continuing pain .send resident to (name of hospital) The incident report, dated 8/27/17 at 3:40 p.m., indicated the resident was admitted to the hospital with [REDACTED]. The August 2017 Medication Administration Record [REDACTED]. The August 2017 Medication Administration Record [REDACTED] During an interview on 9/13/17 at 4:24 p.m., LPN (Licensed Practical Nurse) 3 indicated pain medication was not given due to the resident not having pain when he was not being moved. The clinical record lacked documentation of the administration of any as needed pain medication when the resident complained of extreme pain at 11:13 a.m. on 8/26/17 and was not transferred to the hospital until 12:45 p.m. This Federal tag relates to Complaint IN 712 3.1-37(a)

Based on interview and record review, the facility failed to ensure adequate supervision was in place for a newly admitted resident (Resident #C) with a history of violent behaviors and current escalating behaviors, which resulted in a resident to resident altercation with injury, for 1 of 3 residents reviewed for accidents. This deficient practice had the potential to affect 25 of 25 residents residing on the dementia unit. Findings include: The incident, dated 8/14/16 at 8:30 a.m., included, but was not limited to, the following: .Residents Involved .(Resident #C's name) .(Resident #D's name) .Brief Description of the Incident .(Resident #D) .yelling for staff. Upon nurse entering the room (sic) she witnessed (Resident #C) lying on .back and (Resident #D) holding (Resident #C's) arms down to keep (Resident #C) from hitting .As soon as staff entered the room, (Resident #D) got up and let staff intervene with (Resident #C) .Type of Injury .Head laceration to right posterior head of(Resident #C) Skin tear to left elbow and abrasion to right cheek of (Resident #D) .Immediate Action Taken .(Resident #C) sent to hospital for evaluation and treatment .Preventative Measures .Will reevaluate (Resident #C) upon return from hospital .Follow Up .(Resident #C) remains in behavioral hospital for treatment. IDT (Interdisciplinary Team) will review medications, care plans, and new interventions upon return and update as needed . The clinical record for Resident #C was reviewed on 9/8/16 at 2:20 p.m. [DIAGNOSES REDACTED]. The admission MDS (Minimum Data Set) assessment, dated 8/12/16, indicated Resident #C had a BIMS Brief Interview for Mental Status) score of 3, which signified severely impaired cognition. Behavioral Symptoms - Presence & Frequency .2. Behavior of this type occurred 4 to 6 days .B. Verbal behavioral symptoms directed towards others ( .hitting, kicking, pushing, scratching, grabbing .) The psychiatric hospital history and physical, dated 7/26/16 at 11:59 p.m., included, but was not limited to, the following: .(Resident #C's name) .History of Present Illness .According to the .report .was sent from (name of previous facility) to the emergency room for medical clearance .According to staff, the patient has had a violent episode today .Mental Status Exam .was seen to be very dazed, confused .moving constantly .speech quick and fast The document titled Psych (Psychiatric) Initial Assessments, dated 7/27/16 at 5:11 p.m., included, but was not limited to, the following: .(Resident #C's name) .History of Present Illness .Pt (patient) admitted through (name of hospital) ED (emergency department). Pt (patient) became agitated at (name of previous long term care facility). Report given by Pt's (patient's) (family member) was that Pt (patient) became agitated with 1:1 (one on one) staff member in his bathroom, ripped towel bar of wall and struck staff member .Pt (patient) has been getting increasingly more verbally aggressive for last month since .was attacked by .roommate .sustained several large bruises .(family member) reports Pt (patient) has had increased anxiety, paranoia, fear someone is going to hurt them (sic) .Mental Status Exam .Appearance: disheveled .Behavior: restless, agitated .Speech: pressured .Thought Process: incoherent, indecisive .Thought Content: preoccupation, blaming .Affect: angry, sad .Eye Contact: poor . The psychiatric hospital document titled SBAR (Situation, Background, Assessment, Recommendation) Handoff Communication, dated 8/3/16, included, but was not limited to, the following: .pt (patient) has been agitated, refused to change, trying to hit staff. Refused meds (medications). Wandering (plus sign) (and) hard to redirect . The hospital discharge instructions, dated 8/5/16 at 10:12 a.m., indicated Resident #C refused all morning medications. The care plan for Resident #C included, but was not limited to, the following: .Problem Start Date: 08/09/2016 .Behavior 1: Resident has bx (behavior) of intrusive wandering (Rsd (resident) wanders into others room and tends to pick up and take others personal belonging)/exit seeking . The care plan for Resident #C included, but was not limited to, the following: .Problem Start Date: 08/09/2016 .Behavior 2: Resident can be verbally aggressive towards staff . The care plan for Resident #C included, but was not limited to, the following: .Problem Start Date: 08/12/2016 .Behavior 3: Resident becomes physically aggressive with staff during care . During an interview on 9/9/16 at 12:20 p.m., when asked why interventions for Resident #C were not put into place regarding his/her explosive behaviors, the Memory Care Facilitator (MCF) indicated she was not there when he/she was admitted and did not approve Resident #C. During an interview on 9/9/16 at 12:30 p.m., the DON (Director of Nursing) indicated she was on vacation when Resident #C was admitted . The DON further indicated the facility does training with staff and they know how to handle situations. This Federal tag relates to Complaint IN 593 3.1-27(a)(1)

Based on interview and record review, the facility failed to ensure a resident received adequate fluid intake, resulting in hospitalization for dehydration, in 1 of 4 residents reviewed for hydration status, in a sample of 6. Resident D Findings include: 1. The closed clinical record of Resident D was reviewed on 1/9/12 at 1:30 P.M. The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Nursing Admission Assessment, dated 11/6/11, indicated the resident was not oriented to time or place. The resident's height and weight were left blank. A Hydration Assessment, dated 11/7/11, indicated, "Score of 10 or greater will necessitate supervision and oversight of the resident to ensure hydration needs are met." The resident's total score was 12. A Dietary Progress Note, dated 11/7/11, indicated, "Resident admitted on [DATE] to (room number) on a Reg (regular) diet. Likes and dislikes to be assessed. RD (registered dietician) to follow." A Nutrition Risk Assessment, undated, indicated, "...Assessment Type New Admit...Diagnosis...UTI (urinary tract infection) (with) [MEDICAL CONDITION] (in) 62, Weight (lb) (left blank)...Total Fluids (left blank)...Diet Order Reg...." The remainder of the assessment, including "Oral/Nutrition Intake-Fluid," "Physical and mental functioning," and "Lab Values," was blank. The reverse of the assessment indicated, "...Estimating Fluid Needs, Minimum fluid requirement is 1500cc daily...." A Resident Care Plan, dated 11/7/11, indicated: "Problem/Need/Concern, Diet-Reg...Interventions, Record meal % q (every) meal and report changes in appetite. Provide 1500 to 1800 cc fluid with meals every day. Other fluids with med (medication) pass, snacks, hydration pass, and at bedside." The resident's food/fluid intake record, dated November 2011, was reviewed. The record indicated the resident received the following fluids: 11/7/11: 840 cc, 11/8/11: 945 cc, 11/9/11: 1400 cc, 11/10: 660 cc, 11/11: 540 cc, 11/12: 570 cc. Nurses Notes included the following notations: 11/7/11 at 11:45 A.M.: "Alert to self only. Has confusion (and) forgetfulness QD (every day)...." 11/7/11 at 10:00 P.M.: "Alert to self (with) confusion and forgetfulness noted...Requires (one) assist for ADL's (activities of daily living) and transfers. Feeds self (with) set-up assist. Appetite and fluid intake fair...." 11/8/11 at 12:35 P.M.: "Alert to self...Feeds self (with) set-up. Appetite (and) fluid intake fair...." 11/8/11 at 10:00 P.M.: "Feeds self (with) set-up assist. Appetite (and) fluid intake adequate...." 11/10/11 at 10:00 P.M.: "...Alert to person (with) periods of confusion...Resident had (two) episodes of 'dry heaves' or vomitting (sic) clear/white phlegm. Refuses to eat or drink anything except for occasional sips of soft drink. C/O (complaints of) stomach pain...." 11/11/11 at 12:35 A.M.: "Alert to person (with) periods of confusion noted...Refused fluids tonight...Temp 99." 11/11/11 at 2:00 P.M.: "...Feeds self (with) set-up. C/O nausea this day. Is drinking sprite eating saltines...." 11/11/11 at 10:00 P.M.: "...Conts (continues) to sip on sprite and eat saltines...." 11/12/11 at 11:00 A.M.: "(Alert and oriented) periods of confusion...Appetite (and) fluid intake fair...." 11/12/11 at 6:30 P.M.: "Rsd (resident) lethargic...unable to bear weight @ this time. T (temperature) 99.6...Family (nurse in family) request CXR (chest x-ray). Will obtain UA (urinalysis) as well per (name of physician)." 11/12/11 at 7:20 P.M.: "(Family member) here. Wants his mother sent to (name of hospital)...." 11/12/11 at 8:10 P.M.: "EMS (emergency medical services) here. Rsd loaded on cart (and) taken to (name of hospital)." A hospital emergency room record, dated 11/12/11 at 9:40 P.M., indicated, "...Physical Exam...Skin: poor skin turgor (indicative of dehydration)...Impression: 1. Acute [MEDICAL CONDITION]/Dehydration...." Laboratory results, dated 11/12/11 at 10:10 P.M., indicated, "Sodium 134 L(low)...BUN 64 H (high), Creatinine 2.9 H (high)...." On 1/10/12 at 11:15 A.M., during interview with the Director of Nursing (DON), she assisted in deciphering some of the notations on the fluid intake record. The DON indicated the resident was not at the facility very long, and she did not remember much about the resident. On 1/10/12 at 12:15 P.M., during interview with the Dietary Manager (DM), she indicated the resident "was not here long enough" to have been seen by the Registered Dietician, and that is why the nutrition assessment form was not completed. The DM indicated "nursing would document the resident's weight." Upon search through the records, the DM discovered the resident's weight was documented on a vital sign sheet, and was 121.2 pounds upon admission. 2. On 1/10/12 at 3/10, the Director of Nursing provided the current facility policy on "Hydration Management," revised 3/10. The policy included: "...New admissions scoring 10 or more on the Hydration Assessment will be placed on Intake monitoring for 3 days. 4. The Dietary Services Manager with assistance of the Registered Dietician will determine daily fluid requirements for each resident. 5. The Dietary Services Manager with assistance of the Registered Dietician will determine likes and dislikes including usual amount of fluid intake for each resident. 6. A comprehensive care plan will be written after completion of the Hydration Assessment and 3 day intake record with specific resident needs and preferences. 7. Fluid intake will be planned to include at least 480 ml/meal for each resident...." This federal tag relates to Complaint IN 083. 3.1-46(b)