Every finding on record at Serenity Spring Senior Living at Jasonville

Based on record review and interview, the facility failed to ensure residents were provided informed consent prior to an increase in psychotropic medications for 2 of 5 residents reviewed for unnecessary medications. (Resident 34, Resident 33)Findings include:1. On 1/28/26 at 9:04 a.m., Resident 34's clinical record was reviewed. The diagnoses included, but were not limited to, major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), generalized anxiety (a mental condition characterized by excessive or unrealistic anxiety), and Alzheimer's disease (a brain condition that slowly damages your memory, thinking, learning and organizing skills).A review of the physician's orders indicated the following:On 10/10/25 an order for Sertraline (brand name Zoloft, medication used to treat depression) 100 mg, two tablets daily, was prescribed for major depressive disorder and generalized anxiety.A review of a progress note, dated 10/9/25, indicated Zoloft was increased to 200 mg daily by the psychiatry Nurse Practitioner.The clinical record lacked documentation that indicated informed consent was provided to the resident and/or the resident representative, regarding treatment options, risks, and benefits of psychotropic medication prior to the increase in the psychotropic medications.During an interview with the DON (Director of Nursing) on 1/28/26 at 1:30 p.m., she indicated there was not an informed consent obtained prior to the increase of the psychotropic medications. 2. On 1/28/26 at 11:26 a.m., Resident 33's clinical record was reviewed. The diagnoses included, but were not limited to, schizophrenia (a serious mental health condition that affects how people think, feel and behave), vascular dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain), and bipolar disorder (a chronic mental illness characterized by extreme mood swings, ranging from high-energy mania to deep, hopeless depression).A review of the physician's orders indicated the following:On 4/8/25, an order for Clozaril (an antipsychotic medication used to treat treatment-resistant schizophrenia and to reduce suicide risk in schizophrenia/schizoaffective disorder) 50 mg (milligram) twice daily was prescribed for bipolar disorder and schizophrenia.On 10/10/25, an order for Clozaril 25 mg twice daily, to be taken with Clozaril 50 mg to equal 75 mg, was prescribed.A review of a progress note, dated 10/9/25, indicated Clozaril was increased to 75 mg twice daily by the psychiatry Nurse Practitioner.The clinical record lacked documentation that indicated informed consent was provided to the resident and/or the resident representative, regarding treatment options, risks, and benefits of psychotropic medication prior to the increase in psychotropic medications.During an interview with the DON (Director of Nursing) on 1/28/26 at 1:30 p.m., she indicated there was not an informed consent obtained prior to the increase of psychotropic medications. On 1/28/26 at 3:23 p.m., the DON provided a copy of the facility policy named, Psychotropic Medication Use, dated July 2022, she indicated this was a current policy used by the facility. A review of the policy indicated, .3. Residents, families and/or the representative are involved in the medication management process. Psychotropic medication management includes: a. indications for use; b. dose (including duplicate therapy); c. duration; d. adequate monitoring for efficacy and adverse consequences; and e. preventing, identifying and responding to adverse consequences . Residents (and/or representatives) have the right to decline treatment with psychotropic mediations. a. The staff and physician will review with the resident/representative the risks related to not taking the medication as well as appropriate alternatives .3.1-3(n)(2)

Based on observation, interview, and record review, the facility failed to implement the Gradual Dose Reduction (the tapering of psychotropic drugs) (GDR) recommendation and failed to have the physician limit the use of as needed antianxiety medication to 14 days for 2 of 5 residents reviewed for unnecessary medications. (Resident 1 and Resident 24) Findings include: 1. On 1/28/26 at 9:05 a.m., Resident 1 was observed to be on her bed watching the television. On 1/28/26 at 9:36 a.m., Resident 1's clinical record was reviewed. The diagnoses included, but were not limited to, atrial fibrillation, major depressive disorder, generalized anxiety disorder, and shortness of breath. The January 2026 Medication Administration Record (MAR) indicated Resident 1 was administered the following:- Mirtazapine (antidepressant) 15 mg (milligrams) at bedtime for depression and for appetite stimulant, initiated 10/23/25. - Lorazepam (antianxiety) 0.5 mg every 12 hours as needed for anxiety, initiated 1/8/26. The medication order lacked a stop date of 14 days. The Progress notes indicated the following: - On 1/8/26 at 12:34 p.m., Resident 1's medications were discussed during the Gradual Dose Reduction/Behavior meeting. The recommendation from the meeting was to discontinue the mirtazapine. - On 1/8/26 at 12:50 p.m., Resident 1 was seen by the physician. The physician ordered lorazepam 0.5 mg twice daily as needed. The progress notes lacked documentation of Resident 1 declining the gradual dose reduction of mirtazapine. The psychiatry progress note, dated 1/8/26, indicated to discontinue mirtazapine 15 mg due to weight gain. The physician visit note, dated 1/8/26, indicated Resident 1 had complaints of shortness of breath on exertion with minimal activity. The physician ordered lorazepam 0.5 mg twice a day as needed for anxiety. The stop date was 3 months. The care plan indicated Resident 1 was on an antidepressant medication therapy related to depression. The intervention was to consult with the pharmacy, health care provider to consider dosage reduction when clinically appropriate. During an interview on 1/28/26 at 2:22 p.m., the Director of Nursing (DON) indicated Resident 1 did not want the mirtazapine discontinued. The clinical record lacked documentation of Resident 1 refusal of the gradual dose reduction or the 14 days stop date of the lorazepam. 2. On 1/28/26 at 11:37 a.m., Resident 24 was observed to be ambulating in the hallway. On 1/28/26 at 11:40 a.m., Resident 24's clinical record was reviewed. The diagnoses included, but were not limited to, schizophrenia, generalized anxiety disorder, and major depressive disorder. The January 2026 Medication Administration Record (MAR) indicated the following:- Clozapine (antipsychotic medication) 150 mg once a day for schizophrenia, initiated 8/6/25. - Clozapine 200 mg once a day for schizophrenia, initiated 8/5/25. - Risperidone (antipsychotic medication) 2 mg twice a day, initiated 8/5/25. The Progress notes, dated 1/8/26 at 12:45 p.m., indicated Resident 24's medications were discussed during the Gradual Dose Reduction/Behavior meeting. The recommendation from the meeting was to start Zoloft (antidepressant) 50 mg and to decrease risperidone to 1.5 mg twice a day. The clinical record lacked documentation of implementation of the gradual dose reduction or the discussion with the Resident 24's family. The psychiatry progress note, dated 1/8/26, indicated an attempt to gradual dose reduction of risperidone. Resident 24 was on 2 antipsychotic medications. The care plan indicated Resident 24 used psychopharmacological medication related to schizophrenia. The intervention was to consult with the pharmacy, health care provider to consider dosage reduction when clinically appropriate. During an interview on 1/28/26 at 2:22 p.m., the DON indicated Resident 24's gradual dose reduction was not implemented. Resident 24's family was in the hospital and could not notify him of the gradual dose reduction. The clinical record lacked documentation of the attempt to notify the family of the gradual dose reduction. On 1/28/26 at 3:23 p.m., the DON provided the facility policy, Psychotropic Medication Use, dated 7/2022, and indicated it was the policy currently being used by the facility. A review of the policy indicated, .11. Residents on psychotropic medications receive gradual dose reductions (coupled with non-pharmacological interventions), unless clinically contraindicated, in an effort to discontinue these medications 12. Psychotropic medications are not prescribed or given on a PRN [as needed] basis unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. a. PRN orders for psychotropic medications are limited to 14 days . 3.1-48(a)(2)

Based on record review and interview, the facility failed to ensure MDS (Minimum Data Set) assessments were completed within the allotted timeframes for 2 of 6 residents reviewed for resident assessments. (Resident 3, Resident 34)Findings include:1. On 1/22/26 at 10:21 a.m., Resident 3's clinical record was reviewed. The diagnoses included, but were not limited to, depression and alcoholic cirrhosis of the liver (irreversible scarring of the liver caused by long-term, excessive alcohol consumption, which replaces healthy tissue and causes liver failure).Resident 3 was admitted to the facility on [DATE].The resident's MDS assessments indicated the admission MDS assessment dated , 10/19/25, was not completed or signed until 11/5/25.During an interview with the MDS nurse and the DON (Director of Nursing) on 1/28/26 at 1:30 p.m., it was indicated the admission MDS assessment was not completed within 14 calendar days of the admission date. The DON indicated the facility did not have a resident assessment policy and they used the RAI tool criteria for timeframe of completion.On 1/28/26 at 2:00 p.m., the Resident Assessment Instrument (RAI), Version 3.0 User's Manual, dated 10/2025, was reviewed. The RAI indicated the admission MDS assessment must be completed within 14 calendar days after the admission date.2. On 1/28/26 at 9:04 a.m., Resident 34's clinical record was reviewed. The diagnoses included, but were not limited to, Alzheimer's disease (is a brain condition that slowly damages your memory, thinking, learning and organizing skills), pain and generalized anxiety disorder (a mental condition characterized by excessive or unrealistic anxiety).A review of Resident 3's MDS assessments indicated the Annual MDS assessment with an Assessment Reference Date (ARD) of 10/30/25 was not completed or signed until 1/2/26.During an interview with the MDS nurse and the DON (Director of Nursing) on 1/28/26 at 1:30 p.m., they indicated the Annual MDS assessment was not completed within 14 calendar days of the ARD. The DON indicated the facility did not have a resident assessment policy and they use the RAI tool criteria for timeframe of completion.On 1/28/26 at 2:00 p.m., the Resident Assessment Instrument (RAI), Version 3.0 User's Manual, dated 10/2025, was reviewed. The RAI indicated the Annual MDS Assessment was to be completed within 14 calendar days after the ARD.

Based on record review and interview, the facility failed to ensure an accurate MDS (Minimum Data Set) assessment for 2 of 5 residents reviewed for unnecessary medications. (Resident 34, Resident 33)Findings include:1. On 1/28/26 at 9:04 a.m., Resident 34's clinical record was reviewed. The diagnoses included, but were not limited to, major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), generalized anxiety (a mental condition characterized by excessive or unrealistic anxiety), and Alzheimer's disease (a brain condition that slowly damages your memory, thinking, learning and organizing skills).A review of the physician's orders indicated, on 5/29/25, Depakote Sprinkles (an anticonvulsant medication used to treat seizure disorders, mental/mood conditions) capsule 125 MG (milligrams) 1 capsule by mouth two times a day was discontinued.A review of a psychiatry progress note, dated 1/8/26, indicated Depakote was discontinued on 5/29/25 and was not a current medication. A review of the Annual MDS assessment, dated 10/30/25, section N0415K1: Anticonvulsants indicated, yes, the resident was taking an anticonvulsant medication.During an interview with the MDS Coordinator and DON (Director of Nursing) on 1/28/26 at 1:35 p.m., they indicated the resident was not on an anticonvulsant medication during the observation period for the Annual MDS assessment, dated 10/30/25. The DON indicated the section for Anticonvulsant medication use should have been marked no. The DON indicated the facility did not have a MDS policy, they utilized the RAI (Resident Assessment Instrument) tool to complete MDS assessments.On 1/28/26 at 2:00 p.m., the RAI, Version 3.0 User's Manual, dated 10/2025, was reviewed. The RAI indicated for section N0415, High-Risk Drug Classes: Use and Indication, .Anticonvulsant: Check if an anticonvulsant medication was taken by the resident at any time during the 7-day observation period . 2. On 1/28/26 at 11:26 a.m., Resident 33's clinical record was reviewed. The diagnoses included, but were not limited to, schizophrenia (a serious mental health condition that affects how people think, feel and behave), vascular dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain), and bipolar disorder (a chronic mental illness characterized by extreme mood swings, ranging from high-energy mania to deep, hopeless depression).A review of the Quarterly MDS Assessment, dated 11/20/25, Section I: Active Diagnoses, the diagnoses of Non-Alzheimer's Dementia, Bipolar Disorder, and Schizophrenia were marked no.A review of the physician orders indicated the following:- Depakote Tablet Extended Release (a medication used to manage manic episodes associated with bipolar disorder) 500 mg (milligrams), give three tablets by mouth in the evening for diagnosis of Bipolar disorder, initiated 2/27/25.- Clozaril (antipsychotic used to treat treatment-resistant schizophrenia) tablet 50 mg, give one tablet two times a day for diagnoses of bipolar disorder and Schizophrenia, initiated 4/8/25. - Trazodone HCl (antidepressant medication) tablet 100 mg, give one tablet by mouth at bedtime for diagnosis of Schizophrenia, initiated 5/9/25.- Namenda (a medication to treat moderate to severe dementia) tablet 10 mg, give one tablet by mouth two times daily for diagnosis of Vascular Dementia, initiated 5/29/25. A review of the psychiatry progress note, dated 10/9/25, indicated the resident had active diagnoses of Schizophrenia, Vascular Dementia, and bipolar disorder.During an interview with the MDS Coordinator and DON on 1/28/26 at 1:35 p.m., they indicated the resident did have active diagnoses of Non-Alzheimer's Dementia, Bipolar disorder, and Schizophrenia during the assessment period for the Quarterly MDS Assessment, dated 11/20/25. The DON indicated Section I: Active Diagnoses should have been marked yes. She indicated the facility did not have a MDS policy, they utilized the RAI tool to complete MDS assessments.On 1/28/26 at 2:00 p.m., the RAI, Version 3.0 User's Manual, dated 10/2025, was reviewed. The RAI indicated for section I0100-I8000: Active Diagnoses in the Last 7 Days , .Active diagnoses are diagnoses that have a direct relationship to the resident's current functional, cognitive, or mood or behavior status, medical treatments, nursing monitoring, or risk of death during the 7-day look-back period .3.1-31(d)

Based on observation and interview, the facility failed to ensure a medication was labeled properly with an open date and a discard date in 1 of 1 medication rooms observed. Finding includes:On 1/23/26 at 1:30 p.m., the medication room refrigerator was observed to have a vial of tuberculin PPD (medication used to test for tuberculosis) without an open date or discard date. The DON (Director of Nursing) indicated there was no dates written on the open vial. She indicated that all open multidose medication vials should be labeled with an open date and discard date of 28 days after opening. On 1/28/26 at 3:20 p.m., the DON provided the facility's policy, Labeling of Medication Containers, dated April 2019 and indicated it was a current policy being used by the facility. A review of the policy indicated .All medications maintained in the facility are properly labeled in accordance with current state and federal guidelines and regulations .4. Labels for stock medications include all necessary information, such as .c. the expiration date when applicable . 3.1-25(k)(6)

Based on observation, interview, and record review, the facility failed to implement infection control practices for 1 of 1 resident reviewed for urinary catheters. Urinary catheter tubing and drainage bag was observed on the floor. (Resident 5) Findings include: On 1/21/26 at 1:43 p.m., Resident 5 was observed in the resident's room. Resident 5's urinary catheter tubing and drainage bag were observed lying on the floor. On 1/22/26 at 2:55 p.m., Resident 5 was observed propelling in the wheelchair in the hallway in the hallway. Resident 5's urinary catheter tubing and drainage bag were observed lying on the floor.On 1/23/26 at 10:20 a.m., Resident 5 was observed propelling in the wheelchair into the chapel. Resident 5's urinary catheter tubing and drainage bag were observed lying on the floor.On 1/28/26 at 12:45 p.m., Resident 5's clinical record was reviewed. The diagnoses included, but were not limited to, urinary tract infection, neuromuscular dysfunction of bladder (nerve damage that disrupts signals between the brain and bladder, causing retention or incontinence), and chronic kidney disease (common disease that means your kidneys are losing their ability to filter waste products from your blood). A physician's order, dated 1/8/26, indicated the resident had a urinary catheter for neurogenic bladder (a condition that causes loss of bladder control because of brain, spinal cord, or nerve problems).During an interview on 1/28/26 at 2:30 p.m., the Director of Nursing (DON) indicated the resident's urinary catheter tubing and drainage bag should not be touching the floor. On 1/28/26 at 3:20 p.m., the DON provided the facility's policy, Catheter Care, Urinary, dated August 2022 and indicated it was the policy being used by the facility. The policy indicated .The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections .Infection Control .2. Be sure the catheter tubing and drainage bag are kept off the floor .3.1-18(b)(1)

Based on observation, interview, and record review, the facility failed to ensure food was stored in a sanitary manner for 1 of 2 kitchen observations. Expired foods were not discarded and food was not labeled. Findings include: On [DATE] at 10:17 a.m., during the initial tour of kitchen with the Dietary Manager (DM), the following was observed: - The refrigerator by the serving line had a pitcher of red liquid. The pitcher lacked a date on it. At that time, the DM removed the pitcher and indicated it should have had a date on it. - The walk-in refrigerator had two cartons of sour cream with an expiration date of [DATE]. The DM indicated the sour cream was expired and should have been discarded. - The walk-in refrigerator had seven half gallons of buttermilk with an expiration date of [DATE]. The DM indicated the buttermilk was expired and should have been discarded. The DM indicated staff checked for expired food every day. On [DATE] at 1:50 p.m., the Director of Nursing (DON) provided the facility's policy, Food Receiving and Storage, undated, and indicated it was the policy currently being used by the facility. A review of the policy indicated 1. All foods stored in the refrigerator or freezer are covered, labeled and dated (use by date) 7. Refrigerated foods are labeled, dated and monitored so they are used by their use by date, frozen, or discarded . 3XXX,d+[DATE](i)(2) 3XXX,d+[DATE](i)(3)

Based on interview and record review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for 2 of 13 residents reviewed for accuracy of the MDS assessments. (Resident 4, Resident 21) Findings include: 1. On 2/10/25 at 9:44 a.m., Resident 4's clinical record was reviewed. The diagnoses included, but were not limited to, UTI (urinary tract infection) and congested heart failure. Resident 4's February 2025 Physician Orders indicated Macrobid (antibiotic) 50 milligrams (mg) by mouth at bedtime for UTI with a start date of 8/28/24. The Medication Administration Record (MAR), dated 11/28/24 through 12/4/24, indicated Macrobid 50 mg was administered at bedtime for UTI prevention. The quarterly MDS (Minimum Data Set) assessment, dated 12/4/24, lacked documentation of antibiotic use in the last seven days. During an interview on 2/10/25 at 11:45 a.m., the MDS nurse indicated antibiotic use was not coded on the quarterly MDS assessment, dated 12/4/24, and it should have been. 50647 2. On 2/5/25 at 2:56 p.m., Resident 21's clinical record was reviewed. The diagnoses included, but were not limited to, compression fracture, adult failure to thrive, and urinary tract infection (UTI). A review of the resident medical record indicated, on 11/27/24, the resident returned from the hospital, due to unrelated condition, and an order for Cefdinir oral capsule (antibiotic) was received related to UTI. Review of the emergency room triage note, dated 11/26/24, urine culture results, collected on 11/26/24, and discharge medications, dated 11/27/24, indicated resident was diagnosed with an UTI. A review of the Significant Change MDS assessment, dated 12/12/24, lacked documentation of UTI diagnosis. During an interview with MDS nurse on 2/10/25 at 11:45 a.m., she indicated on the Significant Change MDS assessment, dated 12/12/24, a diagnosis of UTI was not coded and according to RAI (Resident Assessment Instrument) tool criteria it should have been. A review of the RAI User's Manual (v.1.19.1, effective 10/1/24) on 2/10/25 at 11:55 a.m., indicated for diagnosis of UTI, a look-back period of 30 days for active disease instead of 7 days . physician diagnosis of UTI prior to admission is acceptable. This information may be included in the hospital transfer summary or other paperwork. During an interview with the MDS nurse on 2/10/25 at 1:50 p.m., she indicated the facility did not have a MDS assessment coding policy. She indicated the facility followed the RAI manual for coding MDS assessments. 3.1-31(d)

Based on observation, record review, and interview, the facility failed to provide respiratory care for 1 of 1 residents reviewed for oxygen therapy. Oxygen tubing was not labeled with a date or documented oxygen tubing was changed. (Resident 30). Finding includes: On 2/4/25 at 2:44 p.m., Resident 30 was observed lying in bed with the O2 (Oxygen) nasal cannula (NC) not in nares (nose). There was no date observed on the NC tubing. On 2/6/25 at 9:30 a.m., Resident 30 was observed lying in bed with O2 in place at 2 L (liters) via NC. There was no date observed on the NC tubing. On 2/7/25 at 9:01 a.m., Resident 30 was observed lying in bed with O2 being administered at 2 L via NC. No date was observed on the NC tubing. During an interview on 2/7/25 at 10:50 a.m., LPN 1 indicated there was no date on the oxygen tubing. During an interview on 2/7/25 at 11:04 a.m., the DON indicated that the oxygen tubing was changed every Friday. The DON indicated tubing changes should be documented on the Treatment Administration Record (TAR). On 2/6/25 at 9:31 a.m., Resident 30's clinical record was reviewed. The diagnoses included, but were not limited to, Chronic Obstructive Pulmonary Disease (COPD), respiratory failure with hypoxia (low level of oxygen in the blood), and dementia. The Admission Minimum Data Set (MDS) assessment, dated 1/13/25, indicated oxygen therapy. A review of resident's care plan, initiated on 1/7/25, indicated the resident had oxygen therapy. A physician's order, dated 1/7/25, indicated oxygen at 2 LPM (liters per minute) per nasal cannula via O2 concentrator and/or tank continuously. The physician's orders lacked an order to change to oxygen tubing. The clinical record lacked documentation the oxygen tubing had been changed. During an interview on 2/10/25 at 10:17 a.m., the DON indicated an order was placed on 2/10/25 for Resident 30's oxygen tubing to be changed. 3.1-47(a)(6)

Based on observation, interview, and record review, the facility failed to ensure food was stored and prepared in a sanitary manner for 3 of 3 observations of the kitchen. Pre-prepared beverages and foods were uncovered, unlabeled, and undated and staff hair was not covered by a hair covering. (Dietary Manager, Dietary Manager In Training, Dietary Aide 1) Findings include: 1. On 1/9/24 from 9:55 a.m. to 10:42 a.m., during the initial kitchen tour with the DM (Dietary Manager) the following was observed: - The standing glass refrigerator in the facility kitchen was observed to contain 3 trays of uncovered, unlabeled, and undated individually pre-poured cups of a white, brown, orange, and red liquid and additionally one tray of individual bowls of red gelatin with white topping. - The walk-in refrigerator unit at the end of the serving station was observed to have 2 trays of uncovered, unlabeled, and undated individual pre-poured cups of white, brown, orange, and red liquid, as well as red gelatin with white topping. - The main dining hall had one unlabeled and undated pitcher of pink liquid on a self-service drink counter. - The Dietary Manager In Training (DM-IT) was observed walking through out the kitchen area while the noon meal was being prepared. The DM-IT was observed to have hair, approximately 1 inch in length, at the nape of the neck, and around the front of face that was not covered by hair covering. - The DM was observed walking through out the kitchen while the noon meal was being prepared. The DM was observed to have hair, approximately 1 inch in length, at the nape of the neck. The hair was observed to not be covered by hair covering. - Dietary Aide (DA) 1 was observed walking through out the kitchen while the noon meal was being prepared. DA 1 was observed delivering clean plates, bowls, and utensils to the steam table in anticipation of the noon meal. DA 1 was observed to have hair, approximately 1 inch in length, at the nape of the neck, and around front of face to not be covered by hair covering. - Cook 2 was observed taking the noon meal starting temperatures. Cook 2 was observed to have approximately 1/2 inch in length of facial hair not covered by facial hair covering. 2. On 1/10/24 from 11:10 a.m. to 11:50 a.m., during a follow-up visit to the kitchen, the following was observed: - The standing glass refrigerator in the facility kitchen was observed to contain one tray of premade cups of white and red liquid and half of a tray of yellow pudding with white topping. The items were observed to be uncovered, unlabeled, and undated. - The walk-in refrigerator contained one deep metal baking dish with standing liquid at the bottom, 4 empty cups laying on the side at the bottom of baking dish, and 12 uncovered beverages upright containing white, brown, and red liquid. - DA 1 was observed walking around the kitchen area where the noon meal was being prepared. DA 1 was observed to be bringing dirty dishes to the dishwasher area. DA 1 was observed to have hair, approximately 1 inch in length, at the nape of the neck, and around front of face that was not covered by hair covering. - The DM was observed walking throughout the kitchen while the noon meal was being prepared. The DM was observed to have hair, approximately 1 inch in length, at the nape of the neck that was not covered by a hair covering. 3. On 1/11/24 from 11:10 a.m. to 11:50 a.m., during a follow-up visit to kitchen, the following was observed: - The standing glass refrigerator in the facility kitchen was observed to contain one tray of premade cups of white liquid that was uncovered, unlabeled and undated. - The walk-in refrigerator contained one tray of premade cups of white, and brown liquid with aluminum foil covering one fourth of the tray, the remainder of the tray was uncovered with aluminum foil creased and folded over. - The DM-IT was observed walking throughout the kitchen area while the noon meal was being prepared. The DM-IT was observed to have hair, approximately 1 inch in length, at the nape of the neck that was not covered by hair covering. During an interview with the DM on 1/9/24 at 10:20 a.m., she indicated that foods and drinks were to be kept covered, dated, and labeled and all staff hair was to be completely covered while in the kitchen. During an interview with DA 1 on 1/9/24 at 10:30 a.m., she indicated that any remaining foods or drinks, or premade food or drinks should be covered, labeled, and dated. During an interview on with DM-IT on 1/11/24 at 10:15 a.m., she indicated the cups of liquid, bowls of dessert should have been covered, labeled, and dated to ensure freshness and to identify the beverages and dessert. She further indicated that all hair must be covered with a hair covering. On 1/16/24 at 11:25 a.m., the Clinical Coordinator provided the Food-Supply Storage-Food and Nutrition Services policy revised 5/11/23, and indicated it was the policy currently being used by the facility. A review of the policy indicated, . refrigerated items shall be covered, labeled indicating product name, and dated [month/day/year] product was received or prepared . all pre-dished items must be covered, labeled, and dated. On 1/16/24 at 11:25 a.m., the Clinical Coordinator provided the facility policy, Food and Nutrition Employee hygiene and dress code - Food and Nutrition Services policy with a revised date of 6/13/23, and indicated it was the policy currently used by the facility. A review of the policy indicated, . all food preparation and serving areas shall be maintained in accordance with state and local sanitation standards, food handling, food preparation, and meal service .everyone entering the kitchen shall wear hair nets . On 1/16/23 at 1:55 p.m., a review of the Retail Food Establishment Sanitation Requirements Title 10 IAC 7-24, effective November 13, 2004, indicated: . refrigerated, ready to eat, potentially hazardous food prepared . shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises . discarded . covered containers, or wrappings . wrap food tightly to prevent cross contamination . food employees shall wear hair restraints . hair coverings or nets, beard restraints . that are designed and worn to wear effectively keep their hair from contacting . exposed food . 3.1-21(i)(2) 3.1-21(i)(3)

Based on interview and record review, the facility failed to ensure the written notification required for a transfer and discharge was given to the resident and the resident representative for 1 of 1 resident reviewed for hospitalization . (Resident 25) Findings include: On 1/11/24 at 10:00 a.m., Resident 25's clinical record was reviewed. The diagnosis included, but was not limited to malignant neoplasm (abnormal growth of cells) of the brain. Resident 25's progress notes indicated the resident was sent to the hospital on 11/16/23 and 11/23/23. The clinical record lacked documentation of written notification of the Transfer and Discharge forms being provided to the resident and the resident representative. During an interview on 1/12/24 at 11:52 a.m., the Director of Nursing indicated the Notice of Transfer or Discharge forms were not sent to the resident representative in writing and they had not kept a copy of the forms that would have went with the resident to the hospital. On 1/16/24 at 1:07 p.m., the Clinical Care Coordinator provided the facility policy, Admission, Transfer and Discharge Team-Rehab/Skilled, with a revised date of 7/26/23, and indicated this was the policy currently being used by the facility. A review of the policy did not indicate sending a notice of Transfer and Discharge form with the resident and resident representative when the resident was transferred to the hospital. 3.1-12(a)(6)(A)(i) 3.1-12(a)(6)(A)(ii)

Based on interview and record review, the facility failed to ensure the notification of the bed-hold policy required for a resident who transferred to the hospital was provided in writing to the resident or the resident representative for 1 of 1 resident reviewed for hospitalization . (Resident 25) Findings include: On 1/11/24 at 10:00 a.m., Resident 25's clinical record was reviewed. The diagnosis included, but was not limited to, malignant neoplasm (abnormal growth of cells) of the brain. Resident 25's progress notes indicated the resident was sent to the hospital on 11/16/23 and 11/23/23. The clinical record lacked documentation of the written notification that specified the facility's bed-hold policy had been provided to the resident or the resident representative. During an interview on 1/12/24 at 11:52 a.m., the Director of Nursing indicated the bed-hold policy forms were not sent to the resident representative in writing and they had not kept a copy of the forms that would have went with the resident to the hospital. On 1/16/24 at 12:39 p.m., the Clinical Care Coordinator provided the facility policy, Bed-Hold-Rehab/Skilled, with a revised date of 12/18/22, and indicated this was the policy currently being used by the facility. A review of the policy indicated, . POLICY: At the time of . transfer . the location will provide written information to the resident or resident representative that specifies: 1. The duration of the state bed-hold policy . 2. The reserve bed payment policy in the state plan . 3. The location's policies regarding bed-hold periods permitting a resident to return . 3.1-12(a)(25) 3.1-12(a)(26)

Based on observation, interview, and record review, the facility failed to provide respiratory care in accordance with professional standards and the plan of care for 5 of 6 residents reviewed. Oxygen was not administered and oxygen tubing was not labeled and dated. (Resident 15, Resident 189, Resident 2, Resident 23, Resident 26) Findings include: 1. On the following dates and times, Resident 15 was observed in bed with oxygen being delivered through tubing which was not labeled and dated: - 11/14/22 at 11:10 A.M. - 11/15/22 at 10:55 A.M. - 11/17/22 at 2:10 P.M. On 11/15/22 at 2:00 P.M., Resident 15's clinical record was reviewed. The diagnoses included, but were not limited to, heart failure and muscle weakness. A physician's order with a start date of 8/27/22 indicated the resident was to receive continuous oxygen through a nasal cannula. 2. On the following dates and times, Resident 2 was observed in bed with oxygen being delivered through tubing which was not labeled and dated: - 11/14/22 at 11:20 A.M. - 11/15/22 at 11:00 A.M. - 11/17/22 at 2:15 P.M. On 11/16/22 at 10:05 A.M., Resident 2 was observed lying in bed asleep with no oxygen nasal cannula (N/C) in his nostrils. The oxygen tubing was rolled up and sitting on the oxygen tank. On 11/16/22 at 10:06 A.M., Licensed Practical Nurse (LPN) 1 and Registered Nurse (RN) 2 were notified that Resident 2 was not wearing oxygen. LPN 1 and RN 1 were observed to immediately enter the room. Resident 2's oxygen saturation was 90% on room air. LPN 1 put the N/C in Resident 2's nostrils. After a few minutes the oxygen saturation was back up to 98%. On 11/16/22 at 10:19 A.M., Resident 2's clinical record was reviewed. The diagnoses included, but were not limited to, hypertensive heart disease, chronic kidney disease with heart failure, and dyspnea (shortness of breath). Physician orders, dated 9/18/2022 through 11/18/2022, for Resident 2 indicated, . Oxygen via nasal cannula 1-4 liters per minute every shift for dyspnea and hypoxia . The Quarterly Minimum Data Set (MDS) assessment, dated 9/19/22, indicated Resident 2 was not interviewable and wore oxygen while a resident. A care plan, initiated on 12/28/20, and current through target date 12/26/22, for Resident 2 indicated, . Focus: The resident is at risk for altered cardiovascular status R/T [related to] HHD with HF [hypertensive heart disease with heart failure] . Oxygen for SOB [shortness of breath] . Goal: Resident will be free from s/s [signs and symptoms] of complications of cardiac problems through the review date . Interventions: . Administer oxygen as ordered . During an interview on 11/16/22 at 10:07 a.m., LPN 1 indicated Resident 2 had just been put back to bed after being up for breakfast and the Certified Nursing Assistants (CNA's) forgot to put his oxygen back on. 3. On the following dates and times, Resident 189 was observed in a wheelchair in his room with oxygen being delivered through tubing which was not labeled and dated: - 11/14/22 at 11:30 A.M. - 11/15/22 at 11:05 A.M. - 11/17/22 at 2:20 P.M. On 11/15/22 at 2:10 P.M., Resident 189's clinical record was reviewed. The diagnoses included, but were not limited to, respiratory failure and kidney failure. A physician's order with a start date of 11/15/22 indicated the resident was to receive continuous oxygen through a nasal cannula. 4. On the following dates and times, Resident 23 was observed in bed with oxygen being delivered through tubing which was not labeled and dated: - 11/14/22 at 11:25 A.M. - 11/15/22 at 11:05 A.M. - 11/17/22 at 2:25 P.M. On 11/15/22 at 2:20 P.M., Resident 23's clinical record was reviewed. The diagnoses included, but were not limited to, respiratory failure and depressive episodes. A physician's order with a start date of 10/14/22 indicated the resident was to receive continuous oxygen through a nasal cannula. 5. On the following dates and times, Resident 26 was observed in bed with oxygen being delivered through tubing which was not labeled and dated: - 11/14/22 at 11:35 A.M. - 11/15/22 at 11:10 A.M. - 11/17/22 at 2:30 P.M. On 11/15/22 at 2:30 P.M., Resident 26's clinical record was reviewed. The diagnoses included, but were not limited to, pneumonia and weakness. A physician's order with a start date of 11/22/21 indicated the resident was to receive oxygen through a nasal cannula as needed to maintain oxygen levels at or above 92%. On 11/17/22 at 2:58 P.M., the Director of Nursing indicated the oxygen tubing for Resident 15, Resident 189, Resident 2, Resident 23, and Resident 26 were not labeled and dated. Oxygen tubing was to be changed and labeled with the date it was changed once weekly. On 11/18/22 at 2:30 P.M., the Director of Nursing provided the facility policy, Oxygen Administration, Safety, Mask Types-R/S, LTC, Therapy and Rehab with a revised date of 6/29/22, and indicated it was the policy currently being used by the facility. A review of the policy indicated, verify physician order, attach nasal cannula, equipment should be changed weekly and marked with date and initials. 3.1-47(a)(6)

Based on observation, interview, and record review, the facility failed to ensure staff implemented a fall care plan intervention for a resident with a history of falls for 1 of 2 residents reviewed for accidents.(Resident 15) Findings include: On 11/17/22 at 10:55 a.m., Resident 15 was observed sitting in bed wearing a long oxygen tube connected to the oxygen concentrator at her bedside. The tubing was approximately 20 feet long and was tangled underneath her bed and walker. The resident stated how the floor was very slippery and demonstrated how her feet slipped with her slippers on by sliding her feet back and forth while sitting upright in her bed. On 11/18/22 at 11:48 a.m., Resident 15 was observed in bed shuffling her oxygen tubing around in an attempt to detangle the long tube. On 11/17/22 at 2:29 p.m., Resident 15's clinical record was reviewed. The diagnoses included, but were not limited to, COPD (Chronic Obstructive Pulmonary Disease), chronic respiratory failure, difficulty in walking, heart failure, muscle weakness, and unsteadiness on feet. A review of Resident 15's care plans indicated a fall care plan, revised on 9/15/22 with a target dated of 2/15/23, had a fall intervention for staff to ensure oxygen tubing was shortened. On 11/17/22 at 2:58 p.m., the DON indicated that hospice staff were responsible for changing the oxygen tubing. She indicated she was not aware of the resident being care planned for needing short oxygen tubing. On 11/18/22 at 2:30 p.m., the DON provided the facility policy, Fall Prevention And Management- Rehab/Skilled Therapy & Rehab, revised on 3/30/22, and indicated it was the policy currently being used by the facility. A review of the policy indicated, .[post fall] 18. Continue to monitor condition and the effectiveness of the interventions . 3.1-35(g)(2)

Based on interview and record review, the facility failed to assess and monitor neurological assessments and vital signs for a resident after an unwitnessed fall with a [CONDITION(S)] on [DATE] at 2:45 p.m., which resulted in the resident becoming unresponsive and transferred to the emergency roiagnom on [DATE] at 7:20 a.m., (Resident C) and complete neurological assessments for 3 of 7 residents reviewed for Quality of Care. (Residents C, D, and K) The Immediate Jeopardy began on [DATE], when the facility failed to assess vital signs (V/S) and neurological (neuro) checks for a resident who was found lying face down on the floor from an unwitnessed fall. The Certified Nursing Assistant (CNA) 1 found the resident on the floor in his room. The Licensed Practical Nurse (LPN) 1 was called to the resident's room and found the resident on the floor face down. The resident was found unresponsive on [DATE], and sent to the emergency room (ER) at 7:45 a.m. The resident was diagnosed in the ER with a large, acute, traumatic right subdural hematoma, diffuse traumatic [CONDITION(S)], parietal bone fracture and temporal bone fracture (unknown whether a loss of consciousness occurred) and, altered mental status. The unresponsive resident was returned to the facility and his advance directives were changed to Do Not Resuscitate with comfort measures only. The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy on [DATE] at 5:30 p.m. Findings include: 1. On [DATE] at 10:45 a.m., Resident C's clinical record was reviewed. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) assessment, dated [DATE], indicated Resident C had moderately impaired cognition; required extensive assistance of 2 or more staff members with transfers, required limited assistance of one staff member with ambulation in room; was not steady only able to stabilize with human assistance when moving to standing position and walking; and had one fall with no injury. A review of the Fall Risk Assessments for the resident indicated the following: -On [DATE] at 4:00 p.m., Resident C was assessed as a high risk for falls. -On [DATE] at 5:04 p.m., Resident C was assessed as a high risk for falls after having been found on the floor. -On [DATE] at 3:49 p.m., Resident C was assessed as a high risk for falls after having been found on the floor. -On [DATE] at 6:40 a.m., Resident C was assessed as a high risk for falls. -On [DATE] at 2:40 p.m., Resident C was assessed as a high risk for falls after having been found on the floor. A care plan, initiated on [DATE] and current through target date [DATE], for Resident C indicated, . The resident has had an actual fall with [specify: no injury, evidenced by history of falls, poor balance, unsteady gait and poor vision . Resident will resume usual activities without further incident through by review date . soft touch call light within reach, ensure that resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair, environment: modify to maximize safety, recliner with easy recline lever in place . A progress note, dated [DATE] at 6:09 p.m., indicated the nurse found the resident lying on left side of the bed. The nurse completed a full head to toe assessment; vital signs included ,d+[DATE] blood pressure, 63 pulse, 98.1 temperature, 99% oxygen, and 20 respirations. The resident noted to have intermitted confusion and no complaints of pain. The resident had active range of motion present to his upper and lower extremities. The nurse was unable to assess pupils due to resident [CONDITION(S)] A progress note, dated [DATE] at 6:56 p.m., indicated the resident fell on the floor while trying to get out of his recliner. He was found with his head lying on the floor. The nurse assessed the resident with no injuries. A progress note, dated [DATE] at 2:45 p.m., indicated while answering his call light, the staff noticed the resident on the floor. The nurse assessed the resident for injuries. He had a small laceration on his right forehead. A progress note, dated [DATE] at 6:40 p.m., indicated the resident had no neuro changes or any new signs of injuries. He had no complaints of pain or discomfort. His vital signs were ,d+[DATE] blood pressure, 86 pulse, 98 oxygen, 20 respirations, and 98.2 temperature. A progress note, dated [DATE] at 7:20 a.m., indicated when the nurse was called into his room, the nurse tried to arouse the resident. The nurse said his name loudly. She did a sternal rub with no response noted. The nurse completed a neuro exam. The resident was nonresponsive; had no movement of extremities; had no pain noted; and had no verbal response. A progress note, dated [DATE] at 7:45 a.m., indicated the resident was sent to the hospital for altered mental status. A progress note, dated [DATE] at 11:26 a.m., indicated the resident came back to the nursing facility via ambulance. The resident was still in a nonresponsive state. The resident was a DNR with comfort measure only. A progress note, dated [DATE] at 10:17 p.m., indicated the nurse returned to the resident's room periodically to assess him. At 8:48 p.m., the nurse entered his room, and resident had expired. The clinical record lacked documentation of V/S and neurological checks completed for the resident on [DATE] at 3:15 p.m., 3:45 p.m., 4:15 p.m., and 4:45 p.m. On [DATE] at 12:45 a.m., after the resident's fall on [DATE] at 2:45 p.m. Resident C's Neuro Check form, dated [DATE] at 7:20 a.m., indicated vital signs (dated [DATE] at 9:56 a.m.) and 0 pain level; coma, unresponsive and cannot be aroused; 2 mm pupil size left; left and right pupil was not reactive to light; right arm and leg, and left arm and leg had no hand grasp or movement; no spontaneous movement to command; nonverbal, and Resident C was unresponsive. During an interview on [DATE] at 2:41 p.m., the Administrator indicated the facility did not have any further neurological checks from the fall on [DATE] for Resident C, because he was immediately sent out to the ER the next morning. During an interview on [DATE] at 3:00 p.m., Licensed Practical Nurse (LPN) 1 indicated on [DATE] at approximately 2:00 p.m., Resident C fell out of this recliner chair in the room. He was called to the room by a CNA who found the resident on the floor. When he arrived in the resident's room, the resident was lying face down on the floor. They turned him over, holding his head. He does not remember seeing any injuries to the head. They checked his V/S and looked for other injuries. He did neuro checks every 15 minutes x (times) 4 then every 30 minutes x 1 hours. His shift was over by the time the next neuro checks were due and he reported off to the night nurse. The resident was blind, and it was not possible to check his pupil status. He charted the neuro checks in the resident's clinical record on the fall follow up form. The resident was talking and was not acting any different than he previously acted. During an interview, on [DATE] at 4:16 p.m., the Director of Nursing indicated the neuro checks dated [DATE], on the User Defined Assessment (UDA) form was dated for [DATE], because the form populated the last time the V/S were taken, and the V/S must have been the same each time they were taken after each fall. The neuro checks from the previous falls on [DATE], [DATE], and [DATE] would have been erased after the resident discharged . During an interview on [DATE] at 11:25 a.m., Registered Nurse (RN) 2 indicated he worked night shift on [DATE]. He could not recall if Resident C fell on [DATE]. If he received a report of a resident's fall, he would get neuro checks every hour or every four hours. During an interview on [DATE] at 12:30 p.m., CNA 1 indicated she worked night shift on [DATE]. Around 4:00 a.m., on the last bed check, she assisted another CNA with bed checks. Resident C was out of it and would not respond to verbal commands. She informed LPN 2 of Resident C being out of it and the resident not responding to verbal commands. During an interview on [DATE] at 12:48 p.m., RN 1 indicated Resident C was alert and oriented. He did have history of falls. On [DATE], she was working day shift. CNA 3 informed her Resident C was not acting right. He did not talk during am care. She went to assess Resident C. The resident would not wake up and did not respond by sternal rub (pain stimulus to assess the level of consciousness). The resident was sent to the emergency room . During an interview on [DATE] at 12:56 p.m., CNA 3 indicated she worked day shift on [DATE]. Resident C was not responding when she completed morning care. She informed RN 1 of the resident's C's condition. A confidential interview was conducted, from [DATE] through [DATE]. The interview indicated the resident had been looking forward to returning home with his wife. On [DATE], the resident was sent to the ER after being found unresponsive from the fall. The facility was asked for documentation including neuro checks and code status upon transfer and the facility indicated they did not have any information to send with the resident. 2. On [DATE] at 12:18 p.m., Resident D's clinical record was reviewed. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) assessment, dated [DATE], indicated Resident D was cognitively intact; required extensive assistance of two or more staff members with transfers, ambulation in room did not occur; resident was not steady, only able to stabilize with human assistance when moving to standing position and walking; and had no falls since admission. A review of the Fall Risk Assessments for the resident indicated the following: -On [DATE] at 3:45 p.m., Resident D was assessed as a low risk for falls on admission. -On [DATE] at 8:00 a.m., Resident D was assessed as a low risk for falls after having been found on the floor. A care plan, initiated on [DATE] and current through target date [DATE], for Resident D indicated, . The resident has had an actual fall with SPECIFY: no injury, minor injury, serious injury, related to poor balance, unsteady gait . Resident will resume usual activities without further incident through by review date . Contact PT [physical therapy] for consult for strength and mobility, Education: educate/instruct resident and family on safe use of assistive devices, ensure that resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair, Environment: modify to maximize safety. Turn residents bed longways so that one side is against the wall . A Progress Note, dated [DATE] at 8:00 a.m., indicated Resident D was found on the floor. He had been up so long he went to sleep on the rail and woke up on the floor. The resident complained of a minor headache. He was assessed for injuries and a gash was observed above his right eye. He was transported to the hospital. A Progress Note, dated [DATE] at 11:29 a.m., indicated Resident D returned from the hospital with sutures to the wound above his right eye with orders to take sutures out in one week. The clinical record lacked complete documentation of Resident D's neurological evaluations and V/S after his fall on [DATE]. During an interview on [DATE] at 2:24 p.m., the DON indicated the clinical record lacked documentation of Resident D's neurological evaluations and V/S every 30 minutes x 4 and every eight hours x 3 days after his fall on [DATE]. 3. On [DATE] at 10:13 a.m., Resident K's clinical record was reviewed. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) assessment, dated [DATE], indicated Resident K had severe cognitive impairment; required extensive assistance of one staff member with transfers, required supervision of one staff member for ambulation in room; was not steady, only able to stabilize with human assistance when moving to standing position and walking; and had no falls since admission. A review of the Fall Risk Assessments for the resident indicated the following: -On [DATE] at 11:54 p.m., Resident K was assessed as a low risk for falls on admission. A care plan, initiated on [DATE] and current through target date [DATE], for Resident K indicated, . [resident name] is at risk for falls R/T [related to] confusion, gait/balance problems, unaware of safety needs, vision/hearing problems . she will be free of minor injury through the review date . ensure that resident is wearing appropriate footwear when ambulating or mobilizing in w/c [wheelchair], Environmental: modify to maximize safety. Place motion alarm near head of bed to help alert staff when resident attempts to get out of bed without first calling for help, monitor resident for significant changes in gait, mobility, positioning device, standing/sitting balance and lower extremity joint function, monitor visual and auditory impairments, review bowel and bladder continence status and establish and/or review toileting plan based on resident's needs, resident has a door alarm on her bathroom to alarm staff when resident is up in room and/or needs to use the bathroom. Make sure alarm is on at all times, contact PT [physical therapy] for consult for strength and mobility . A Progress Note, dated [DATE] at 12:11 a.m., indicated Resident K was found on the floor in the bathroom. She had a goose egg on the back of her head. A Progress Note, dated [DATE] at 9:00 a.m., indicated Resident K was found on the floor. No injures noted. A Progress Note, dated [DATE] at 11:11 a.m., indicated a change in condition due to falls functional decline. A Progress Note, dated [DATE] at 11:22 a.m., indicated Resident K was sent to the hospital. A Progress Note, dated [DATE] at 3:50 p.m., indicated Resident K returned from the hospital. A Progress Note, dated [DATE] at 9:11 p.m., indicated Resident K was found on the floor beside her bed. The clinical record lacked complete documentation of Resident K's neurological evaluations and V/S after her falls on [DATE] and [DATE]. During an interview on [DATE] at 2:24 p.m., the DON indicated the clinical record lacked documentation of Resident K's neurological evaluations and V/S every 30 minutes x 4 and every eight hours x 3 days after her falls on [DATE] and [DATE]. On [DATE] at 12:11 p.m., the Administrator provided the facility's policy, Fall Prevention and Management - Rehab / Skilled, Therapy & Rehab with revised date of [DATE], and indicated this was the policy currently being used by the facility. A review of the policy indicated .a. obtain blood pressure, pulse, respiratory rate, pulse oximetry and temperature (if able) .b. If the fall was not witnessed, neurological checks are required and must be documented in the medical chart . On [DATE] at 10:30 a.m., the Administrator provided the facility's policy, Neurological Evaluation - Rehab/Skilled with revised date of [DATE] and indicated this was the policy currently being used by the facility. A review of the policy indicated .Following an unwitnessed fall .4. After the completion of initial neurological evaluation with vital signs continue with evaluations every 30 minutes x 4, then every eight hours x 3 days . The Immediate Jeopardy, that began on [DATE] was removed on [DATE], when the facility completed a systemic plan that included nursing staff completed a written and oral education/lecture material on how to perform a neurological assessment. Skills check off by means of return demonstrations was performed by the DON and/or his designee on currently employed nurses. Nurses would report to one another during change of shifts any on-going neurological assessment, change in condition, and V/S that are to be continued for monitoring. The noncompliance remained at the lower scope and severity level of isolated no actual harm with the potential for more than minimal harm that is not immediate jeopardy because of the facility's need for continued monitoring. This Federal tag relates to the Complaint IN 986. 3.,d+[DATE](a)

Based on observation, interview, and record review, the facility failed to ensure a resident (Resident D) was treated with respect and dignity by a staff member for 1 of 3 reviewed for dignity. Finding Includes: On 1/25/22 at 12:18 p.m., Resident D's clinical record was reviewed. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set assessment, dated 12/30/21, indicated the resident was cognitively intact. A review of Resident D's progress notes indicated the following: The progress note, dated 1/2/22 at 12:27 p.m., indicated the resident informed the nurse that he had asked to be scooted over in bed. The CNA grabbed him and moved him before he was even ready. He had been having pain in his neck whenever he moved it quickly since the CNA moved him. The physician was notified to advise on an x-ray. During an interview on 1/28/22 at 10:05 a.m., Resident D indicated that a CNA had treated him disrespectfully and he had notified the nurse on shift. He had asked to be repositioned and the CNA seemed aggravated towards him. She pulled him by his neck and shoulder instead of utilizing the draw sheet. Her movement was abrupt in her manner. Her manner was unnecessary and uncalled for. He reported pain in his neck and an x-ray was conducted which was negative. The facility checked with him, but it was some time after the occurrence. The resident could not name the exact date the incident had occurred. During an interview on 1/28/22 at 10:50 a.m., The DON indicated he investigated Resident D's concern with a CNA repositioning him in bed my moving his neck and shoulder. The resident indicated that abuse did not occur. He was reporting pain and soreness in his neck. An x-ray was performed on 1/4/22. The resident's x-ray indicated no injury. The incident occurred on 12/24/21, and the date of the investigation was on 1/3/22. 3.1-3(a)

Based on interview and record review, the facility failed to update the care plan and to provide interventions to prevent falls for residents with recent falls for 3 of 7 residents reviewed for accidents. (Residents B, D, and K). Findings include: 1. On 1/25/2022 at 11:40 a.m., Resident B's clinical record was reviewed. The diagnoses included, but were not limited to, dementia, multiple fractures of the ribs and difficulty in walking. The Quarterly Minimum Data Set (MDS) assessment, dated 10/29/2021, indicated Resident B had severe cognitive impairment; required limited assistance of one staff member with transfers, required limited assistance of one staff member with ambulation in room; was not steady, only able to stabilize with human assistance when moving to standing position and walking; and had one fall with no injury and one fall with injury since admission. A review of the Fall Risk Assessments for the resident indicated the following: -On 12/19/2021 at 12:28 a.m., Resident B was assessed as a high risk for falls after having been found on the floor. A care plan, initiated on 2/21/2019 and current through target date 4/27/2022, for Resident B indicated, . [resident name] is an unavoidable fall risk R/T [related to] dementia with advanced cognitive impairment, impulsivity, forgetfulness, decreased mobility, muscle weakness, history of falls, unsteadiness on feet and impaired safety awareness . Resident will be free of falls through review date . Cognitive: encourage participation and plan diversional activities that are of resident's interest, educate resident/family about safety reminders and what to do if a fall occurs, educate resident/family/IDT [Interdisciplinary Team] as to causes of fall, resident frequently toilets self and does not request assistance, encourage to be in common area near nursing office after meals as tolerated to enhance oversight of resident, ensure resident is wearing appropriate footwear shoes or gripper socks when ambulating or mobilizing in wheelchair, check bathroom door alarm to assure it is turned on and working properly every shift for safety, Environmental: daughter was requested to de-clutter resident room and bring some unused items home, monitor resident for significant changes in gait, mobility, positioning device, standing/sitting balance and lower extremity joint function, offer toileting after dinner, ensure batteries are functional in bathroom door alarm, review and modify environmental hazards that could cause or contribute to fall, ensure wheelchair is within reach of resident when assisting resident in bed, ensure a safe environment: call light within reach, adequate low glare light, bed at appropriate height, motion sensor alarm to bathroom door, non-skid strips to bathroom floor in front of toilet, anti-rollback wheelchair, review as indicated for significant changes, safety awareness and decision making capacity, review bowel and bladder continence status and establish and/or review toileting plan based on resident's needs, monitor for falls when in room, motion alarm in place at head of bed that will alert staff when patient is attempting to get out of bed without asking for assistance, review residents medical record for medications or combinations of medications that could predispose to falls/increase fall risk, review status of any medical conditions that predispose to falls or that could increase the risk of injury from falls, sign in room [ask for help to stand] as a reminder to ask for help before getting up, staff to stay with resident when assisted to bathroom for toileting, keep door open when resident is in her room alone for safety, make sure Alyssum [sic] cushion is in wheelchair at all times when resident up in wheelchair . A Progress Note, dated 12/19/2021 at 12:49 a.m., indicated, resident found on floor calling out help me! Presents sitting on floor with small 2 cm (centimeter) cut to right forehead. Pain at left forehead, right hip, left shoulder, left knee. Doctor notified and states send to ER (emergency room ) for evaluation and treatment. A Fall Scene Huddle Worksheet, dated 12/19/2021 and untimed, indicated the resident was found in her room on the floor from an unwitnessed fall. The resident indicated she had been ambulating. The resident did not have an injury from the fall. The worksheet was signed by staff indicating it had been reviewed on 1/10/2022. The clinical record lacked documentation of an intervention having been put into place after the fall on 12/19/2021, to prevent further falls from reoccurring for Resident B. During an interview on 1/28/2022 at 2:15 p.m., the Director of Nursing indicated he had been on vacation when the resident fell on [DATE], and there had been no interventions put into place nor was the care plan updated. 2. On 1/25/2022 at 12:18 p.m., Resident D's clinical record was reviewed. The diagnoses included, but were not limited to, [CONDITION(S)], [CONDITION(S)] of the right lower limb and acute kidney failure. The Admission Minimum Data Set (MDS) assessment, dated 12/30/2021, indicated Resident D was cognitively intact; required extensive assistance of two or more staff member with transfers, ambulation in room did not occur; was not steady, only able to stabilize with human assistance when moving to standing position and walking; and, had no falls since admission. A review of the Fall Risk Assessments for the resident indicated the following: -On 12/23/2021 at 3:45 p.m., Resident D was assessed as a low risk for falls on admission. -On 1/15/2022 at 8:00 a.m., Resident D was assessed as a low risk for falls after having been found on the floor. A care plan, initiated on 1/7/2022 and current through target date 4/8/2022, for Resident D indicated, . The resident has had an actual fall with SPECIFY: no injury, minor injury, serious injury, related to poor balance, unsteady gait . Resident will resume usual activities without further incident through by review date . Contact PT [physical therapy] for consult for strength and mobility, Education: educate/instruct resident and family on safe use of assistive devices, ensure that resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair, Environment: modify to maximize safety. Turn residents bed long ways so that one side is against the wall . A Progress Note, dated 1/15/2022 at 8:00 a.m., indicated the resident was found on the floor. The resident indicated he had been up so long he went to sleep on the rail and woke up on the floor. Resident complained of a minor headache. He was assessed for injuries and gash noted above right eye. The resident was transported to hospital. A Progress Note, dated 1/15/2022 at 11:29 a.m., indicated Resident D returned from the hospital with sutures to the wound above right eye with orders to take sutures out in one week. A Fall Scene Huddle Worksheet, dated 1/4/2022 at 5:00 a.m., indicated the resident was found in his room from a witnessed fall after sliding out or rolling out of bed. The resident did not receive any injuries. The intervention was for staff to assist the resident with the bed rails. A Fall Scene Huddle Worksheet, dated 1/15/2022 at 8:00 a.m., indicated the resident was found in his room on the floor from an unwitnessed fall. The resident indicated he had been sleeping. The resident had pain with movement to head. The intervention was to turn bed sideways with one side against the wall. The care plan for Resident D lacked documentation of an intervention for the fall on 1/4/2022. The care plan intervention of turning the bed sideways with one side against the wall for the fall on 1/15/2022 was updated on 1/27/2022, which was 12 days after the fall on 1/15/2022. During an interview on 1/28/2022 at 2:15 p.m., the Director of Nursing indicated the care plan for Resident D had not been updated after the fall on 1/4/2022 and should have been updated immediately after the fall on 1/15/2022. 3. On 1/26/2022 at 10:13 a.m., Resident K's clinical record was reviewed. The diagnoses included, but were not limited to, Alzheimer's disease and type II diabetes mellitus. The Admission Minimum Data Set (MDS) assessment, dated 11/21/2021, indicated Resident K had severe cognitive impairment; required extensive assistance of one staff member with transfers, required supervision of one staff member for ambulation in room; was not steady, only able to stabilize with human assistance when moving to standing position and walking; and had no falls since admission. A review of the Fall Risk Assessments for the resident indicated the following: -On 12/22/2021 at 11:54 p.m., Resident K was assessed as a low risk for falls on admission. A care plan, initiated on 11/18/2021 and current through target date 3/16/2022, for Resident K indicated, . [resident name] is at risk for falls R/T [related to] confusion, gait/balance problems, unaware of safety needs, vision/hearing problems . she will be free of minor injury through the review date . ensure that resident is wearing appropriate footwear when ambulating or mobilizing in w/c [wheelchair], Environmental: modify to maximize safety. Place motion alarm near head of bed to help alert staff when resident attempts to get out of bed without first calling for help, monitor resident for significant changes in gait, mobility, positioning device, standing/sitting balance and lower extremity joint function, monitor visual and auditory impairments, review bowel and bladder continence status and establish and/or review toileting plan based on resident's needs, resident has a door alarm on her bathroom to alarm staff when resident is up in room and/or needs to use the bathroom. Make sure alarm is on at all times, contact PT [physical therapy] for consult for strength and mobility . A Progress Note, dated 12/23/2021 at 12:11 a.m., indicated resident found on floor in bathroom. The resident had a goose egg on the back of her head, no bleeding noted, no other injuries noted. A Progress Note, dated 1/6/2022 at 9:00 a.m., indicated the resident was found on the floor. No injures noted. A Progress Note, dated 1/6/2022 at 11:11 a.m., indicated a change in condition due to Falls Functional decline. A Progress Note, dated 1/6/2022 at 11:22 a.m., indicated the resident was sent to the hospital. A Progress Note, dated 1/6/2022 at 3:50 p.m., indicated the resident returned from the hospital. A Progress Note, dated 1/6/2022 at 9:11 p.m., indicated the resident was found on the floor beside the bed. No injuries were observed. A Progress Note, dated 1/10/2022 at 12:49 p.m., indicated the resident was sent to the hospital due to extreme pain of her back and to her right side of abdomen. The resident was yelling out that it hurt. A Progress Note, dated 1/10/2022 at 5:48 p.m., indicated resident had a mildly displaced fracture of 11-12 rib. A Fall Scene Huddle Worksheet, dated 12/23/2021 at 12:11 a.m., indicated the resident was found in her room on the floor from an unwitnessed fall. The resident indicated she had slipped. Urine was found on the floor. The intervention was to put a personal alarm on the bathroom door. The worksheet was signed by staff indicating it had been reviewed on 1/7/2022. A Fall Scene Huddle Worksheet, dated 1/6/2022 at 5:30 a.m., indicated the resident was found in her room on the floor from an unwitnessed fall. The resident was attempting to self-transfer. The worksheet was signed by staff indicating it had been reviewed on 1/7/2022. A Fall Scene Huddle Worksheet, dated 1/6/2022 at 9:00 a.m., indicated the resident was found in her room on the floor from an unwitnessed fall. No injuries noted. The intervention was to put a motion alarm near the head of bed. A Fall Scene Huddle Worksheet, dated 1/6/2022 at 9:15 p.m., indicated the resident was found in her room on the floor from an unwitnessed fall. No injuries noted. The intervention was to update care plan, motion alarm in place. The care plan for Resident K lacked documentation of an intervention after the fall on 1/6/2022 at 5:30 a.m., no new intervention for the fall on 1/6/2022 at 9:15 p.m., and the intervention to include a personal alarm on the bathroom door for the fall on 12/23/2022 at 12:11 a.m., was updated on 1/7/2022, which was 15 days after the fall on 12/23/2022. The facility was asked during the survey period for an X-ray report for the resident's visit on 1/6/2022 and an x-ray was not provided for Resident K. During an interview on 1/28/2022 at 2:15 p.m., the Director of Nursing indicated he had been on vacation when the fall for Resident K occurred on 12/23/2021, and the intervention was not put on the care plan until after he returned on 1/7/2022. The intervention of motion alarm was for all 3 falls on 1/6/2022. They had provided an intervention of 1 on 1 for the resident but he had not documented it anywhere. On 1/25/2022 at 12:11 p.m., the Administrator provided the facility's policy, Fall Prevention and Management - Rehab / Skilled, Therapy & Rehab with revised date of 9/17/2021, and indicated this was the policy currently being used by the facility. A review of the policy indicated, . Purpose: . To identify risk factors and implement interventions before a fall occurs . 3. Care Plan the appropriate interventions, including personalizing all areas 4. Communicate fall risks and interventions to prevent a fall before it occurs per the 24-Hour Report, care plan and Kardex, daily stand-up meeting, and/or Fall Committee meetings . This Federal tag relates to the Complaint IN 986. 3.1-45(a)(2)

Based on observation and interview, the facility failed to follow infection control guidelines during the COVID-19 pandemic related to appropriate eye protection, properly removed and disposed of used PPE (Personal Protective Equipment) after exiting a resident's room, and were not knowledgeable of the correct order for doffing PPE for 3 of 7 staff observed for Infecgtion Control. (CNA 3, RN 1, and QMA 1) Findings include: 1. On 1/27/22 at 1:00 p.m., CNA (Certified Nurse Aide) 3 was observed wearing a face shield with a large gap between the shield and forehead. 2. On 1/27/22 at 1:15 p.m., RN 1 was observed wearing googles which did form a seal around their eyes. 3. On 1/28/22 at 11:00 a.m., QMA (Qualified Medication Aide) 1 was observed working on a COVID-19 positive unit. The QMA was wearing a disposable blue gown in the hallway and was observed walking into and out of residents' rooms without donning nor doffing a new gown. During an interview on 1/28/22 at 11:15 a.m., QMA 1 indicated they removed and disposed of used gowns in the hallways after leaving each resident room. The QMA was not knowlegable of the correct sequence of PPE removal. During an interview on 1/27/22 at 11:30 a.m., the Director of Nursing indicated staff should remove their isolation gowns before exiting a resident's room. On 1/28/22 at 2:00 p.m., the Director of Nursing (DON) provided the facility's policy, Donning snd Removing Personal Protective Equipment (PPE) - Home Heath with a revised date of 11/29/20, and indicated it was the policy currently being used by the facility. A review of the policy indicated, .Remove all PPE before exiting the patient room . 3.1-18(b)

Based on observation, interview, and record review, the facility failed to ensure staff posted a contact-droplet precaution signage outside resident rooms who were on Transmission Based Precautions (TBP) for 4 of 6 residents reviewed for infection control (Resident 6, Resident 26, Resident 32, and Resident 232). Findings include: 1. On 9/13/21 at 10:07 a.m., Resident 6's room was observed to have a Personal Protective Equipment (PPE) cart in the hallway outside the resident's door. There was no signage to indicate what type of TBP the resident was on or what type of PPE was needed upon entry. Interview at that time, Certified Nursing Assistant (CNA) 1 indicated Resident 6 was moved to that room and was on contact-droplet TBP, because his roommate had Coronavirus disease 2019 (COVID-19). On 9/15/21 at 10:30 a.m., Resident 6's room was observed to have a Personal Protective Equipment (PPE) cart in the hallway outside the resident's door. There was no signage to indicate what type of TBP the resident was on nor what type of PPE was needed upon entry. On 9/14/21 at 3:15 p.m., Resident 6's clinical record was reviewed. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, indicated on 9/13/21 and current through target date 9/27/21, for Resident 6 indicated: FOCUS: [Resident name] has the potential to develop COVID infection related to exposure to positive roommate .GOAL: .The resident will be free from s/s [signs and symptoms] of infection by the review date INTERVENTIONS: .Maintain droplet precaution isolation . During an interview, on 9/15/21 at 10:35 a.m., Licensed Practical Nurse (LPN) 1 indicated when a resident was on TBP for being a new admission to the facility or had contact with a COVID-19 resident, the resident's door should have a contact-droplet TBP signage. Resident 6's door lacked a contact-droplet TBP signage. The Indiana State Department of Health COVID-19 Infection Control Guidance in Long-term Care Facilities, dated 9/7/21, indicated, .ZONES .Yellow Zone .Precautions . Add Droplet-Contact Signage .Post signage on residents' doors . On 9/12/21 at 11:00 a.m., the Administrator provided the facility's policy, Emerging Threats - Acute Respiratory Syndromes Coronavirus (COVID) - Enterprise, dated 7/12/21, and indicated it was the policy currently being used by the facility. A review of the policy indicated, Upon identification of any resident with suspected or positive COVID-19, a Contact/Droplet Precautions sign will be posted on the outside of the resident's room . 2. On 9/12/21 at 12:10 p.m., Resident 26's room was observed to have a Personal Protective Equipment (PPE) cart in the hallway outside the resident's door. Resident 26's door was observed to a have a yellow zone and airborne TBP signage. Interview at that time, Licensed Practical Nurse (LPN) 2 indicated Resident 26 was on contact-droplet TBP, because he had contact with a staff member who had Coronavirus disease 2019 (COVID-19). Resident 26's door lacked a contact-droplet TBP signage. On 9/13/21 at 10:08 a.m., Resident 26's room was observed to have a Personal Protective Equipment (PPE) cart in the hallway outside the resident's door. Resident 26's door was observed with a yellow zone and airborne TBP signage. Resident 26's door lacked a contact-droplet TBP signage. On 9/15/21 at 10:30 a.m., Resident 26's room was observed to have a Personal Protective Equipment (PPE) cart in the hallway outside the resident's door. Resident 26's door was observed with a yellow zone and airborne TBP signage. Resident 26's door lacked a contact-droplet TBP signage. On 9/14/21 at 3:15 p.m., Resident 26's clinical record was reviewed. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 26's Physician Order, dated September 2021, indicated droplet precautions related to exposure to COVID-19 positive employee for 14 days (start date 9/9/21). A care plan, indicated on 7/28/21 and current through target date 11/12/21, for Resident 26 indicated: FOCUS: .The resident has the potential for respiratory infection related to COVID-19 pandemic. Exposure to covid-positive employee on 9/9/21 .GOAL: .The resident will be free from s/s [signs and symptoms] of infection by the review date INTERVENTIONS: .Droplet precaution isolation related to exposure to covid positive person . During an interview, on 9/15/21 at 10:35 a.m., Licensed Practical Nurse (LPN) 1 indicated when a resident was on TBP for being a new admission to the facility or had contact with a COVID-19 resident or staff member, the resident's door should have a contact-droplet TBP signage. Resident 26's door lacked a contact-droplet TBP signage. The Indiana State Department of Health COVID-19 Infection Control Guidance in Long-term Care Facilities, dated 9/7/21, indicated, .ZONES .Yellow Zone .Precautions . Add Droplet-Contact Signage .Post signage on residents' doors . On 9/12/21 at 11:00 a.m., the Administrator provided the facility's policy, Emerging Threats - Acute Respiratory Syndromes Coronavirus (COVID) - Enterprise, dated 7/12/21, and indicated it was the policy currently being used by the facility. A review of the policy indicated, Upon identification of any resident with suspected or positive COVID-19, a Contact/Droplet Precautions sign will be posted on the outside of the resident's room . 3. On 9/12/21 at 12:10 p.m., Resident 32's room was observed to have a Personal Protective Equipment (PPE) cart in the hallway outside the resident's door. There was no signage to indicate what type of TBP the resident was on nor what type of PPE was needed upon entry. Interview at that time, Licensed Practical Nurse (LPN) 2 indicated Resident 32 was on contact-droplet TBP, because she was a new admission to the facility. On 9/13/21 at 10:08 a.m., Resident 32's room was observed to have a Personal Protective Equipment (PPE) cart in the hallway outside the resident's door. There was no signage to indicate what type of TBP the resident was on nor what type of PPE was needed upon entry. On 9/15/21 at 10:30 a.m., Resident 32's room was observed to have a Personal Protective Equipment (PPE) cart in the hallway outside the resident's door. Resident 32's door was observed to with an airborne TBP signage. Resident 32's door lacked a contact-droplet TBP signage. On 9/14/21 at 3:15 p.m., Resident 32's clinical record was reviewed. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, indicated on 9/16/21 and current through target date 12/10/21, for Resident 32 indicated: FOCUS: .[Resident name] admitted to the facility from the hospital and requires droplet precautions for 14 days related to Covid-19 surveillance .GOAL: .The resident will be free from s/s [signs and symptoms] of infection by the review date INTERVENTIONS: .Droplet precaution . During an interview, on 9/15/21 at 10:35 a.m., Licensed Practical Nurse (LPN) 1 indicated when a resident was on TBP for being a new admission to the facility or had contact with a COVID-19 resident or staff member, the resident's door should have a Contact-Droplet TBP signage. Resident 32's door lacked a Contact-Droplet TBP signage The Indiana State Department of Health COVID-19 Infection Control Guidance in Long-term Care Facilities, dated 9/7/21, indicated, .ZONES .Yellow Zone .Precautions . Add Droplet-Contact Signage .Post signage on residents' doors . On 9/12/21 at 11:00 a.m., the Administrator provided the facility's policy, Emerging Threats - Acute Respiratory Syndromes Coronavirus (COVID) - Enterprise, dated 7/12/21, and indicated it was the policy currently being used by the facility. A review of the policy indicated, Residents admitted from a hospital or the community will be placed into quarantine for 14 days following admission .Upon identification of any resident with suspected or positive COVID-19, a Contact/Droplet Precautions sign will be posted on the outside of the resident's room . 4. On 9/12/21 at 12:10 p.m., Resident 232's room was observed to have a Personal Protective Equipment (PPE) cart in the hallway outside the resident's door. Resident 232's door was observed with an airborne TBP signage. Interview at that time, Licensed Practical Nurse (LPN) 2 indicated Resident 232 was on contact-droplet TBP because he was a new admission to the facility. Resident 232's door lacked a contact-droplet TBP signage. On 9/13/21 at 10:08 a.m., Resident 232's room was observed to have a Personal Protective Equipment (PPE) cart in the hallway outside the resident's door. Resident 232's door was observed with an airborne TBP signage. Resident 232's door lacked a contact-droplet TBP signage. On 9/15/21 at 10:30 a.m., Resident 232's room was observed to have a Personal Protective Equipment (PPE) cart in the hallway outside the resident's door. Resident 232's door was observed with an airborne TBP signage. Resident 232's door lacked a contact-droplet TBP signage. On 9/14/21 at 3:15 p.m., Resident 232's clinical record was reviewed. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, indicated on 9/16/21 and current through target date 10/1/21, for Resident 232 indicated: FOCUS: .[Resident name] admitted to the facility from the hospital and requires droplet precautions for 14 days related to Covid-19 surveillance .GOAL: .The resident will be free from s/s [signs and symptoms] of infection by the review date INTERVENTIONS: .Droplet precaution isolation . During an interview, on 9/15/21 at 10:35 a.m., Licensed Practical Nurse (LPN) 1 indicated when a resident was on TBP for being a new admission to the facility or had contact with a COVID-19 resident or staff member, the resident's door should have a Contact-Droplet TBP signage. Resident 232's door lacked a Contact-Droplet TBP signage. The Indiana State Department of Health COVID-19 Infection Control Guidance in Long-term Care Facilities, dated 9/7/21, indicated, .ZONES .Yellow Zone .Precautions . Add Droplet-Contact Signage .Post signage on residents' doors . On 9/12/21 at 11:00 a.m., the Administrator provided the facility's policy, Emerging Threats - Acute Respiratory Syndromes Coronavirus (COVID) - Enterprise, dated 7/12/21, and indicated it was the policy currently being used by the facility. A review of the policy indicated, .Residents admitted from a hospital or the community will be placed into quarantine for 14 days following admission Upon identification of any resident with suspected or positive COVID-19, a Contact/Droplet Precautions sign will be posted on the outside of the resident's room . 3.1-18(b)

Based on interview and record review, the facility failed to ensure residents were showered as indicated by their preference for 2 of 2 residents reviewed for choices (Resident B and Resident 27). Findings include: 1. During an interview, on 9/13/2021 at 10:21 a.m., Resident B indicated she had not had a shower in several weeks. She preferred to have 2 showers a week. On 9/16/2021 at 11:00 a.m., Resident B's clinical record was reviewed. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set assessment, dated 7/23/2021, indicated Resident B was interviewable, cognitively intact and required total dependence with bathing. A care plan, initiated on 7/23/2021 and current through target date 10/15/2021, for Resident B indicated, . Focus: The resident has an ADL [activities of daily living] self care performance deficit R/T [related to] weakness, impaired mobility . Goal: Resident will maintain current level of function in . personal hygiene . Interventions: Bathing: resident is able to bath self with assist of 1 . Resident B's Follow Up Question Report dated, 9/1/2021 through 9/15/2021, indicated the resident received 1 shower on 9/6/2021 and 2 sponge baths, one on 9/10/2021 and the second one on 9/13/2021. During an interview, on 9/16/2021 at 12:50 p.m., the interim Director of Nursing (DON) indicated she would guess Resident B had not received any showers if that is what the resident had said. 2. During an interview, on 9/13/21 at 9:42 a.m., Resident 27 indicated he has not had a shower in several weeks. During an interview, on 9/16/21 at 1:05 p.m., Resident 27 indicated he had one shower in September 2021. He would like two showers a week. On 9/15/21 at 12:43 p.m., Resident 27's clinical record was reviewed. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, initiated on 12/19/19 and current through target date 11/12/21, for Resident 27 indicated: Focus The resident has an ADL [activities of daily living] self care performance deficit R/T [related to] hx [history] of stroke resulting [CONDITION(S)] .GOAL: .Resident will maintain current level of function .INTERVENTIONS: .bathing-res [resident] prefers to undress in the shower room with 1 care giver present .BATHING: Resident requires 1 staff assist . The annual Minimum Data Set (MDS) assessment, dated 11/4/20, indicated Resident 27 was cognitively intact; very important to choose between a tub bath, shower, bed bath, or sponge bath; and required one person assist with total dependence in part of bathing activity. The quarterly Minimum Data Set (MDS) assessment, dated 8/2/21, indicated Resident 27 was cognitively intact and required one person assist with total dependence in part of bathing activity. Resident 27's Follow Up Question Report, dated 9/1/21 through 9/15/21 indicated one shower on 9/9/21 at 2:03 p.m. During an interview, on 9/16/21 at 12:48 p.m., the Director of Nursing (DON) indicated Resident 27 has had one shower for the month of September, and he should of had 2 showers a week. On 9/16/2021 at 4:09 p.m., the Social Services Director provided the facility's policy, Person-Centered Care-Rehab/Skilled with a revised date of 8/19/2021, and indicated it was the policy currently being used by the facility. A review of the policy indicated, ' . Purpose: To improve resident quality of life and quality of care by honoring preferences that support individuality, independence and choice . This Federal tag relates to Complaint IN 237. 3.1-3(u)(1)

Based on observation, interview, and record review, the facility failed to provide supervision to maintain a resident's safety from an agitated resident which resulted in a resident being hit and receiving a fractured nose that required medical intervention for 1 of 1 resident reviewed for accidents (Resident C and D). Findings include: On 3/10/20 at 11:30 a.m., Resident C's clinical record was reviewed. The [DIAGNOSES REDACTED]. Resident C's quarterly Minimum Data Set (MDS) assessment, dated 1/7/20, indicated he had severe cognitive impairment, rejected care 1 to 3 days, and wandered 1 to 3 days. A care plan, initiated on 5/17/19 and current through target date 4/8/20, for Resident C indicated: FOCUS: .The resident has potential for elopement R/T (related to) Dementia .GOAL .Resident will not leave facility unattended .INTERVENTIONS .Offer to take resident for a walk outdoors . A care plan, initiated on 1/7/20 and current through target date 4/8/20, for Resident C indicated: FOCUS: .The resident has a behavior symptom R/T (related to) Dementia E/B (evidence by) wandering, aggression, and inability to anticipate ADL (activities of daily living) need GOAL .Resident will have no evidence of behavior problems entering other res (resident) rooms INTERVENTIONS .entering other res rooms: Attempt non-pharmacological interventions access regularly for toileting needs, redirect with sorting activity, encourage walking throughout the day, encourage 1:1 or group activity/socialization . Resident C's clinical record lacked documentation of monitoring of elopement or physical aggression behaviors. Resident C's progress note, dated 3/8/20 at 3:26 p.m., indicated Resident C was very agitated. He attempted to elope and hit both nurses on duty. He attempted to hit a resident, and he did hit a resident twice. Interview, on 3/10/20 at 1:50 p.m., Certified Nursing Assistant (CNA) 1 indicated she had worked day shift on 3/8/20. Resident C had a history of [REDACTED]. Resident C had not been sleeping well at night and had been agitated with staff. Resident C had tried to leave the facility. Licensed Practical Nurse (LPN) 1 was attempting to redirect Resident C, and he became combative with staff. LPN 1 was going to take Resident C to his room, but Resident C went into the Solarium. LPN 1 had been between Resident C and Resident D. LPN's arm was looped around Resident's C's right arm, and Resident C swung and hit Resident D's nose. Resident D put her hands up to her face to guard her face and Resident C hit her again. Resident C hit Resident D's hands. Resident D received a skin tear to her right hand and her nose was bleeding. CNA 1 did not indicate she offered Resident C a walk outdoors for an intervention for him wanting to leave the facility. Interview, on 3/10/20 at 2:15 p.m., LPN 2 indicated she had worked day shift on 3/8/20, on the west end. She heard a commotion at the front entrance. She observed Resident C trying to attempt to leave the facility, and LPN 1 was trying to redirect him from the front entrance. Resident C was combative with staff. Resident C got more agitated when more staff members tried to redirect him, so LPN 2 went back to the hall she was working. Interview, on 3/10/20 at 3:00 p.m., CNA 2 indicated he had worked on 3/8/20. Resident C had a history of [REDACTED]. Before and after lunch on 3/8/20, Resident C had attempted to leave the facility. CNA 2 did not indicate he offered Resident C a walk outdoors for as intervention for him wanting to leave facility. Interview, on 3/11/20 at 10:15 a.m., the Ombudsman (an advocate for residents in nursing homes) indicated Resident C's wandering and physical aggression towards staff had been going on for 1 year and 3 months. Last summer, Resident C hit his roommate and room change was made with no further known incidents. Interview, on 3/11/20 at 11:30 a.m., LPN 1 indicated she had worked day shift on 3/8/20. She was in the dining room. Resident C was in the dining room and observed a family member leave the front entrance. Resident C went to the front entrance and attempted to leave the facility. When Resident C could not leave, Resident C got agitated. He was slamming doors in the hallway. She tried to redirect Resident C. LPN 2 tried to redirect Resident C. Resident C left the main hallway and headed down the hallway to the 400 hall. On the way down the hallway, Resident C swung at another resident, but did not make contact with her. Resident C headed into the Solarium and LPN 1 was holding onto his right arm, Resident C swung at LPN 1, missed and hit hit Resident D in the nose. Resident C swung again before Resident D could move away. A CNA then moved Resident D away. Resident D had a bloody nose and was sent to the emergency room . Resident D returned from the emergency room with a fracture nose. Resident C had a history of [REDACTED]. LPN 1 did not indicate she offered Resident C a walk outdoors as an intervention for him wanting to leave the facility, nor that other residents were directed away from Resident C while he was agitated. On 3/10/20 at 10:45 a.m., Resident D was observed to be sitting in a recliner in the Solarium on the 400 hall. She was observed to have a green bruise on her nose, 2 dime size purple bruises on her left hand, and 1 dime size bruise with a skin tear (a wound caused shear and/or [MEDICATION NAME] force trauma resulting in separation of skin layers) on her right hand. Resident D's clinical record was reviewed. The [DIAGNOSES REDACTED]. Resident D's progress notes indicated the following: -On 3/8/20 at 1:00 p.m., Resident D was hit by another resident once in the face and once in the facial area with her arms crossed in front of her face. She had bruising to her nose and skin tears to her right arm and hand. Resident D was sent to the emergency room . -On 3/8/20 at 3:46 p.m., Resident D was sent to the emergency room for a possible nasal fracture. -On 3/8/20 at 3:50 p.m., Resident D's husband called. Resident D is being released from the emergency room . She had a nasal fracture. Resident D's emergency room report, dated 3/8/20 at 2:18 p.m., indicated she had a closed nasal fracture. On 3/11/20 at 2:45 p.m., the Social Service Director (SSD) provided the facility's policy, Resident's Rights for Skilled Nursing Facilities, dated October 2016, and indicated it was the policy currently being used by the facility. A review of the policy indicated, .(2) The resident has the right to be free from abuse . 3.1-45(a)(2)