Every finding on record at Serenity Spring Senior Living at Northwood

Based on observation, interview, and record review, the facility failed to ensure a safe, sanitary, and homelike environment in 3 of 6 unit halls and common resident spaces. The 100 unit hall temperature was 70 degrees Fahrenheit (F), the Garden Ridge unit hall was 64 degrees F, and the Cedar point unit hall was 69 degrees F. (100 unit, Garden Ridge unit, Cedar Pointe unit, Resident B, Resident D). Finding includes:During a record review on 4/6/26 at 11:30 A.M., minutes from a Resident Council meeting on 2/17/26 mentioned facility temperature levels as a topic of concern. During an interview on 4/6/26 at 2:50 P.M., Resident B indicted the Garden Ridge unit temperature was cool.During an observation on 4/6/26 at 3:00 P.M., the Garden Ridge unit hallway thermostat read 65 degrees F. During an observation on 4/7/26 at 9:25 A.M., the Gardent Ridge unit hallways thermostat read 64 degrees F. On 4/7/26 at 9:30 A.M., the 100 unit hallway thermostat read 70 degrees F. on 4/7/26 at 10:50 A.M., the Cedar Ponite unit hallway thermostat read 68 degrees F. On 4/7/26 at 11:20 A.M. Resident D indicated she was cold when coming out of her room into the Cedar Pointe unit hallway. During an interview on 4/7/26 at 11:25 A.M., Maintenance 4 indicated the facility tried to keep the temperature between 72 - 74 degrees F. On 4/7/26 at 12:30 P.M., the Facility Administrator supplied a facility policy titled, Homelike evironment, dated 02/202. The policy included, .2. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. The characteristics include: .h. comfortable and safe temperatures (71 - 81 [degrees Fahrenheit]) .This citation relates to intake 2637477. 410 IAC (Indiana Administrative Code) 16.2-3.1-19(f)(5)410 IAC (Indiana Administrative Code) 16.2-3.1-19(h)410 IAC (Indiana Administrative Code) 16.2-3.1-19(j)

Based on observation, interview, and record review, the facility failed to ensure care plan interventions to prevent falls were in place for 1 of 3 residents reviewed for quality of care. A resident with a history of falls did not have specific interventions to prevent further falls in place according to the plan of care. (Resident C) Finding includes:During record review on 4/6/26 at 11:00 A.M., Resident C's diagnoses included, but were not limited to, lack of coordination, muscle weakness, and repeated falls. Resident C's most recent quarterly Minimum Data Set (MDS) assessment, dated 1/27/26, indicated the resident was alert and oriented, had upper and lower extremity impairments to both sides, utilized a wheelchair for mobility, and had two or more falls since the previous assessment. Resident C's care plan included, but was not limited to, resident is at risk for falls (last revised 1/12/26). Interventions included but were not limited to park wheelchair outside of room to maximize space and safety (initiated 8/25/25) and fall mat to be place beside left side of bed when resident is in bed. Do not leave on floor when resident is up in wheelchair (initiated 6/11/24). During an observation on 4/6/26 at 3:00 P.M., Resident C was observed up in the dining room in her wheelchair. Resident C's room contained a fall matt on the floor next to the resident's bed. During an observation on 4/7/26 at 9:30 A.M., Resident C was in bed sleeping. The resident's wheelchair was in her room parked near the head of the resident's bed. During an interview on 4/7/26 at 11:00 A.M., RN 6 indicated Resident C's fall matt should be removed from the floor when resident is not in bed and her wheelchair should be parked outside of her room while she is in bed to create more space in the room and provide a safer environment. RN 6 indicated the CNA's may need to be reminded of the Resident's fall interventions to ensure they are in place. On 4/7/26 at 12:30 P.M., the Facility Administrator supplied a facility policy titled, Care Plans, Comprehensive Person-Centered, dated 03/2022. The policy included, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . 3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment . 8. Services provided for or arranged by the facility and outlined in the comprehensive care plan are: a. provided by qualified persons .This citation relates to intakes 2637477, 2685770, and 2692710. 410 IAC (Indiana Administrative Code) 16.2-3.1-35(a)410 IAC (Indiana Administrative Code) 16.2-3.1-35(g)(2)

Based on observation, interview, and record review, the facility failed to ensure care plan conferences were held for 4 of 5 residents reviewed for unnecessary medications. (Resident 6, Resident 7, Resident 11, Resident 44) Findings include: 1. On 6/11/25 at 8:20 A.M., Resident 6's clinical record was reviewed. Diagnoses included, but were not limited to anxiety, osteoporosis, depression, and early-onset cerebellar ataxia (a neurological disorder that primarily affects the cerebellum, a part of the brain responsible for coordinating movement and balance). The most recent quarterly Minimum Data Set (MDS) assessment, dated 5/20/25, indicated Resident 6 was cognitively intact. Resident 6's clinical record was reviewed for care plan conferences in the last year and lacked documentation of a care plan conference between 5/10/24 and 2/7/25. 2. On 6/11/25 at 11:30 A.M., Resident 7's clinical record was reviewed. Diagnoses included, but were not limited to, anxiety, depression, and dementia with behaviors. The most recent quarterly MDS assessment, dated 5/19/25, indicated Resident 7 was cognitively intact. Resident 7's clinical record was reviewed for care plan conferences in the last year and lacked documentation of a care plan conference between 8/1/24 and 5/22/25. 3. On 6/11/25 at 2:22 P.M., Resident 11's clinical record was reviewed. Diagnoses included, but were not limited to, dementia without behaviors, depression, epilepsy, and anxiety. The most recent quarterly MDS assessment, dated 4/15/25, indicated Resident 11's cognition was severely impaired. Resident 11's clinical record was reviewed for care plan conferences in the last year and lacked documentation of a care plan conference after 9/25/24. 4. On 6/12/25 at 9:12 A.M., Resident 44's clinical record was reviewed. Diagnoses included, but were not limited to, psychotic disorder with hallucinations, vascular dementia with behaviors, and stroke. The most recent quarterly MDS assessment, dated 3/12/25, indicated Resident 44 was cognitively intact. Resident 44's clinical record was reviewed for care plan conferences in the last year and lacked documentation of a care plan conference after 8/8/24. During an interview on 6/12/25 at 12:00 P.M., the Social Services Director (SSD) indicated residents should have care plan conferences quarterly and as needed and should be documented in the clinical record. On 6/13/25 at 9:53 A.M., a current Comprehensive Care Plan Policy, revised March 2022, was provided by the Director of Nursing (DON) and indicated, . care plan meeting/care conferences are to take place per state specific regulations (admissions, change of condition, quarterly, annual or as requested by resident/POA or facility). 3.1-3(n)(3)

Based on interview and record review, the facility failed to ensure notification to family/resident representative with a change in resident condition for 4 of 5 residents reviewed for falls. Family/resident representatives were not notified following falls. (Resident 39, Resident 43, Resident 52, Resident 56) Findings include: 1. On 6/11/25 at 2:33 P.M., Resident 39's clinical record was reviewed. Diagnoses included, but were not limited to, Parkinson's disease, dementia, anxiety, and depression. The most recent quarterly Minimum Data Set (MDS) assessment, dated 4/9/25, indicated a severe cognitive impairment and two or more falls since the previous assessment. A Health Status note, dated 3/27/25 at 3:04 P.M., indicated Resident 39 stood up from a wheelchair on his own, lost his balance, and fell on the right shoulder. The note lacked documentation that the family or resident representative was notified of the fall. An Interdisciplinary Team (IDT) note, dated 3/28/25 at 10:06 A.M., indicated they reviewed the fall and interventions, but lacked documentation that the family or resident representative was notified of the fall. 2. On 6/11/25 at 1:51 P.M., Resident 43's clinical record was reviewed. Diagnoses included, but were not limited to, seizure disorder and depression. The most recent quarterly MDS assessment, dated 5/19/25, indicated a severe cognitive impairment. Resident 43 had no falls since the previous assessment. A Health Status note, dated 5/1/25 at 11:18 P.M., indicated Resident 43 was found on the floor on his right side. The resident could not recall what had happened, but did indicate he hit his head. The note lacked documentation that the family or resident representative was notified of the fall. An IDT note, dated 5/2/25 at 10:02 A.M., indicated they reviewed the fall and interventions, but lacked documentation that the family or resident representative was notified of the fall. 3. On 6/11/25 at 10:18 A.M., Resident 52's clinical record was reviewed. Diagnoses included, but were not limited to, Alzheimer's disease, dementia, and schizophrenia. The most recent quarterly MDS assessment, dated 3/6/25, indicated cognition could not be assessed, and had two or more falls since the previous assessment. A Health Status note, dated 12/3/24 at 4:27 A.M., indicated Resident 52 had fallen. The note lacked documentation that the family/resident representative was notified of the fall. A progress note, dated 1/31/25 at 9:19 A.M., indicated Resident 52 fell while ambulating in the hallway. The note lacked documentation that the family/resident representative was notified of the fall. 4. On 6/12/25 at 7:36 A.M., Resident 56's clinical record was reviewed. Diagnosis included, but was not limited to, dementia. The most recent quarterly MDS assessment, dated 5/28/25, indicated a severe cognitive impairment, and a fall with injury since the previous assessment. An IDT note, dated 3/4/25 at 10:08 A.M., indicated Resident 56 was found on the floor in his room. The note lacked documentation that the family/resident representative was notified of the fall. On 6/12/25 at 2:20 P.M., the Assistant Director of Nursing (ADON) indicated all information that had been provided was part of the resident's clinical record. She indicated the facility had other internal documents that may have more information, but they were not part of the clinical record. On 6/13/25 at 9:53 A.M., the Director of Nursing (DON) provided a current Assessing Falls and Their Causes policy, last revised 3/2018, that indicated When a resident falls, the following information should be recorded in the resident's medical record . Notification of the physician and family, as indicated . Notify the following individuals when a resident falls . The resident's family 3.1-5(a)

Based on observation, interview, and record review, the facility failed to ensure adequate supervision and assistive devices were provided to prevent accidents for 4 of 5 residents reviewed for falls. Complete and thorough assessments were lacking after each fall, care plans were not updated with each fall, current interventions were not in place to at times of falls and a comprehensive review of all falls was not completed. (Resident 39, Resident 43, Resident 52, Resident 56) Findings include: 1. On 6/11/25 at 2:33 P.M., Resident 39's clinical record was reviewed. Diagnoses included, but were not limited to, Parkinson's disease, dementia, anxiety, and depression. The most recent quarterly Minimum Data Set (MDS) assessment, dated 4/9/25, indicated a severe cognitive impairment, and two or more falls since the previous assessment. Resident 39 required supervision or touching assistance with eating and bed mobility, substantial to maximum assistance (helper does more than half the effort) with transfers, and was totally dependent on staff for toileting and bathing. Current physician orders included, but were not limited to: Assist of one staff with transfers and ambulation, dated 5/1/25 A current Risk for Falls Care Plan, last revised 3/7/25, included, but was not limited to, the following interventions: staff to walk with the resident when he was agitated to reduce behaviors and promote overall safety, dated 2/11/25. Occupational Therapy for wheelchair assessment, dated 4/10/25. Educate and remind staff to utilize gait belt for all transfers for safety, dated 4/29/25. Fall risk assessments were completed on the following dates (for the previous 12 months): 1/8/25 High risk for falls 3/12/25 Moderate risk for falls 4/5/25 Medium risk for falls From 12/1/24 through current, Resident 39 experienced the following falls: Fall 1 12/3/24 at 2:40 A.M. Certified Nurse Aide (CNA) alerted nursing staff resident was on the floor. The upper body was on the fall mattress and the lower half on the floor. The resident had been given a Haldol (antipsychotic) injection three hours prior to fall (no current order for the Haldol). The resident indicated he was going to the restroom and had moved the floor mattress trying to walk between the mattress and air unit causing the fall. An Interdisciplinary Team (IDT) note, dated 12/3/24 at 10:08 A.M., indicated the resident was noted to have behaviors and agitation, and was moved to the common area to be observed by staff. The resident's current orders were to be reviewed for medication changes and the care plan was updated on 12/3/24 to reflect the review. A Post Fall Vitals form was completed following fall, but lacked neurological (neuro) checks. (A neurological assessment for falls prevention aims to identify underlying neurological conditions that may increase a person's risk of falling and to guide interventions that can reduce that risk of additional falls.) The record lacked a falls assessment following the fall. Fall 2 2/5/25 at 9:15 A.M., Resident fell forward out of the wheelchair and experienced a hematoma with swelling that was decreased with an ice pack. An IDT note, dated 2/6/25 at 10:13 A.M., indicated the resident was probably sleeping in the wheelchair and fell forward out of it. The new intervention was to have anti-rollbacks on the wheelchair, and to remind staff to encourage resident to sit in recliner or lay down after meals. The falls care plan was not updated with anti-rollbacks until 2/14/25 (after Fall 4), and offer to lay down between meals was added on 3/17/25 (after Fall 5). The following neuro checks were documented following the fall: 2/5/25 at 9:15 A.M. 2/5/25 at 10:15 A.M. 2/5/25 at 10:45 A.M. 2/5/25 at 6:13 P.M. 2/5/25 at 11:30 P.M. 2/6/25 at 6:22 A.M. 2/6/25 at 2:32 P.M. 2/6/25 at 11:20 P.M. 2/7/25 at 9:15 A.M. 2/7/25 at 5:21 P.M. 2/8/25 at 9:00 A.M. The record lacked a falls assessment following the fall. Fall 3 2/10/25 at 6:56 P.M., Resident was wheeling self in the hall, stood up and fell when walking on his own. Fall was witnessed by staff. An IDT note, dated 2/11/25 at 9:54 A.M., indicated resident would benefit from walking with staff throughout the day when agitated to reduce behaviors. The care plan was updated on 2/11/25 to include walking with resident when agitated. The record lacked a falls assessment following the fall. Fall 4 2/14/25 at 1:44 P.M. Resident was found lying on the left side in the dining area. An IDT note, dated 2/14/25 at 3:47 P.M., indicated resident was found on the floor with the wheelchair behind him. Staff believed resident was propelling self in wheelchair with feet and slid out of it. The new intervention was to place a Dycem in the wheelchair. The care plan was updated on 2/14/25 to include an intervention for anti-rollbacks to wheelchair and Dycem in the wheelchair. The following neuro checks were completed following the fall: 2/14/25 at 1:25 P.M. 2/14/25 at 1:56 P.M. 2/14/25 at 2:31 P.M. 2/14/25 at 2:55 P.M. 2/14/25 at 3:25 P.M. 2/15/25 at 2:07 A.M. No neuro checks were documented after 2/15/25 at 2:07 A.M. The record lacked a falls assessment following the fall. Fall 5 3/12/25 at 7:25 A.M. Resident wheeling self to room, stood and fell to the floor. An IDT note, dated 3/14/25 at 10:06 A.M., indicated staff would offer to lay down after meals. The care plan was updated 3/17/25 to include an intervention to offer to lay down between meals. The following neurological checks were completed following the fall: 3/12/25 at 7:25 P.M. 3/12/25 at 7:55 P.M. 3/12/25 at 8:25 P.M. 3/12/25 at 8:55 P.M. 3/13/25 at 4:47 P.M. 3/13/25 at 4:50 P.M. 3/13/25 at 4:51 P.M. 3/13/25 at 9:12 P.M. 3/14/25 at 6:38 A.M. 3/14/25 at 1:18 P.M. No neuro checks were documented after 3/14/25 at 1:18 P.M. Fall 6 3/27/25 at 3:04 P.M. Resident stood up from wheelchair, and fell to right side. Fall was witnessed and did not hit head. An IDT note, dated 3/28/25 at 10:06 A.M., indicated the new intervention was to assist resident to a regular chair during meals. The care plan was updated 3/28/25 with new intervention, and resolved 5/12/25. The record lacked a falls assessment following the fall. Fall 7 4/9/25 at 8:31 P.M. Resident fell out of wheelchair while sitting in the hall resulting in a 2-inch laceration above the left eyebrow. Fall was witnessed. An IDT note, dated 4/10/25 at 10:16 A.M., indicated a new intervention for therapy to do a wheelchair assessment. The care plan was updated on 4/10/25 for Occupational Therapy to do a wheelchair assessment. The record lacked a falls assessment following the fall. Fall 8 4/28/25 at 4:43 P.M. Resident stood from the wheelchair at the dining room table. The resident's hands slipped from the table and the resident fell. Fall was witnessed and did not hit head. An IDT note, dated 4/29/25 at 10:07 A.M., indicated a new intervention to remind staff to use gait belt for transfers. The care plan was updated 4/29/25 to remind staff to use gait belt. The record lacked a falls assessment following the fall. On 6/12/25 at 11:09 A.M., the Director of Therapy Services indicated they did a screen for Resident 39's wheelchair on 2/14/25 when anti-rollbacks were placed on the wheelchair. At that time, the wheelchair was appropriate for the resident and nothing further was done. On 6/12/25 at 11:22 A.M., Resident 39 was observed sitting in a wheelchair in the dining room. At that time, the resident's room was observed with a dark red colored tape around both call lights. 2. On 6/11/25 at 1:51 P.M., Resident 43's clinical record was reviewed. Diagnoses included, but were not limited to, legally blind, seizure disorder, and depression. The most recent quarterly MDS assessment, dated 5/19/25, indicated a severe cognitive impairment. Resident 43 had no falls since the previous assessment. Resident required partial to moderate assistance (helper does less than half the effort) with eating and transfers, and substantial to maximum assistance (helper does more than half the effort) with toileting, bathing, and bed mobility. Current physician orders included, but were not limited to: extensive assist of one to two staff with gait belt, pivot to wheelchair, dated 4/10/25. A current Risk for Falls Care Plan, last revised 4/21/25, included, but was not limited to, the following interventions: Clip call light to resident's clothing for safety due to poor vision, dated 5/2/25. Transfer to recliner after meals with call light in reach for safety, dated 5/25/25. A current Activities of Daily Living (ADL) Care Plan, last revised 4/21/25, included, but was not limited to, the following interventions: Resident requires 2pgbs (2 person gait belt assist) and walker for transfers, dated 4/14/25. Falls risk assessments included the following (for the previous 12 months): 4/13/25 Medium risk. Resident 43 experienced the following falls from 12/1/24 through current: Fall 1 5/1/25 at 11:18 P.M., a progress note indicated resident was found on the floor lying on the right side. A walker was observed turned over. Resident could not recall what had happened, but did indicate he hit his head. An IDT note, dated 5/2/25 at 10:02 A.M. indicated a new intervention to clip call light onto resident's clothing for safety due to poor vision. The care plan was updated 5/2/25. The following neurological checks were completed following the fall: 5/1/25 at 10:00 P.M. 5/1/25 at 10:30 P.M. 5/1/25 at 11:00 P.M. 5/1/25 at 11:30 P.M. 5/2/25 at 12:00 A.M. 5/2/25 at 12:43 P.M. No neurological checks were documented after 5/2/25 at 12:43 P.M. The record lacked a falls assessment following the fall. Fall 2 5/4/25 at 8:23 A.M. a progress note indicated resident was found lying on the left side with head against the siding by the wall at 7:30 A.M. in the dining room. Resident had a red raised area on the back of the head measuring 3 cm (centimeters) x 3 cm. Also a 3 inch abrasion to the left shoulder blade. An IDT note, dated 5/5/25 at 10:00 A.M. indicated staff believed resident stood up and wheelchair rolled out from under him causing him to lose his balance and fall. New intervention was to place anti-rollbacks on the wheelchair. The care plan was updated 5/5/25 to include anti-rollbacks. One neurological check was documented on 5/6/25 at 1:30 A.M. The record lacked a falls assessment following the fall. Fall 3 5/22/25 at 6:28 P.M. a progress note indicated an unwitnessed fall at 6:00 P.M. Resident was found lying on the floor on his right side in the middle of the room. An IDT note, dated 5/23/25 at 9:43 A.M., indicated a new intervention to offer resident to sit in recliner after meals. The care plan was updated 5/25/25 to include recliner after meals. The clinical record lacked documentation of neuro check on 5/23/25 at 4:45 P.M. The record lacked a falls assessment following the fall. On 6/10/25 at 9:56 A.M., Resident 43 was observed sitting in his room in a recliner with eyes closed. A call light was observed clipped to the left arm of the recliner. On 6/12/25 at 8:04 A.M., Certified Nurse Aide (CNA) 9 was observed to bring Resident 43 back to his room from the main dining room and transferred the resident from the wheelchair to the recliner by herself. The resident was then observed sitting in the recliner with a call light clipped to the left arm of the recliner. On 6/12/25 at 11:14 A.M., Resident 43 was observed sitting in his room in a recliner. A call light was observed clipped to the left arm of the recliner. 3. On 6/11/25 at 10:18 A.M., Resident 52's clinical record was reviewed. Diagnoses included, but were not limited to, Alzheimer's disease, dementia, and schizophrenia. The most recent quarterly MDS assessment, dated 3/6/25, indicated cognition could not be assessed, and two or more falls since the previous assessment. Resident was dependent on staff with eating, toileting, bathing, and bed mobility, and required substantial to maximum assistance (helper does more than half the effort) with transfers. Falls assessments for the previous 12 months were completed on the following dates: 8/9/24 High risk 11/14/24 Moderate risk 11/29/24 High risk 12/1/24 Medium risk 12/1/24 Medium risk 1/10/25 High risk 3/1/25 High risk 5/30/25 High risk From 12/1/24 through current, Resident 52 experienced the following falls: Fall 1 12/1/24 at 10:20 P.M. a progress note indicated resident was standing at the treatment cart, closed eyes, and fell backward hitting head on the floor resulting in a hematoma on the back of the head. Resident was sent to the emergency room where a scan of the head was negative for any acute findings. The clinical record lacked documentation that an IDT review was completed following fall. The falls care plan was not updated with a new intervention following fall. Fall 2 12/3/24 at 4:57 A.M. a progress note indicated resident had a witnessed fall. Resident came around the corner hitting door frame with left shoulder. The note did not indicate if the resident hit her head or not. The clinical record lacked documentation that an IDT review was completed following fall. The falls care plan was not updated with a new intervention following fall. Neuro checks were not completed following fall. Fall 3 12/11/24 at 2:42 P.M. a Health Status note indicated resident was walking on unit wearing new house shoes that family had brought. While walking by nurses' station, resident got feet tangled and fell on her bottom. An IDT note, dated 12/12/24 at 10:26 A.M., indicated it was believed the new shoes were what caused the fall. Family was asked to take house shoes home on next visit. The falls care plan was not updated with a new intervention following fall. A falls risk assessment was not completed following fall. Fall 4 12/20/24 at 1:48 P.M. a Health Status note indicated resident was found sitting on the floor unable to state what happened. An IDT note, dated 12/23/24 at 10:59 A.M., indicated the care plan would indicate resident would sit on the floor intentionally. The care plan was updated 12/23/24 to include resident sits on the floor at times, resolved 3/17/25. The care plan was not updated at that time to include an actual intervention for staff to follow to prevent falls. Neuro checks were not completed following fall. A falls risk assessment was not completed following fall. Fall 5 1/10/25 at 6:31 P.M. a progress note indicated resident was standing at the medication cart and fell backwards from a standing position. Resident hit head on the floor resulting in bleeding and swelling. An IDT note, dated 1/13/25 at 10:22 A.M., indicated it was believed the resident's blood pressure was dropping causing her to fall. The new intervention was request a medication review. The falls care plan was not updated with a new intervention following fall. The clinical record lacked documentation of neuro checks following fall. Fall 6 1/18/25 at 4:20 A.M. a Health Status note indicated the resident fell onto left side of body and did not hit head. Fall was witnessed. The clinical record lacked documentation that an IDT review was completed following fall. The falls care plan was not updated with a new intervention following fall. A falls risk assessment was not completed following fall. Fall 7 1/18/25 at 7:20 P.M. a Health Status note indicated the resident had a witnessed fall at 4:20 P.M. The resident fell onto her left side and did not hit her head. An IDT note, dated 1/21/25 at 10:48 A.M., indicated a new intervention was for Physical Therapy to evaluate and treat for a walker. The falls care plan was not updated following the fall. A falls risk assessment was not completed following fall. Fall 8 1/31/25 at 9:19 A.M., a progress note indicated resident fell while ambulating in the hall. An IDT note, dated 1/31/25 at 10:28 A.M., indicated resident had a walker but due to low cognition was unable to remember to use it. Bright colored tape to be applied to the walker. The falls care plan was updated with new intervention on 1/31/25 and resolved 2/24/25. A falls risk assessment was not completed following fall. Fall 9 2/2/25 at 2:15 P.M. a Health Status note indicated resident fell in another resident's room resulting in a minor cut to the back of the head measuring 1 cm x 2 cm and scant bruising to the right eyelid. An IDT note, dated 2/3/25 at 10:22 A.M., indicated staff would encourage resident to participate in activities. The falls care plan was not updated following fall. The clinical record lacked documentation of neuro checks following fall. A falls risk assessment was not completed following fall. Fall 10 2/22/25 at 1:54 A.M. a Health Status note indicated resident was found lying on the right side next to the bed. A hematoma was observed above the right eyebrow. An IDT note, dated 2/24/25 at 9:50 A.M., indicated a new intervention for a scoop mattress. The falls care plan was updated to include a scoop mattress on 2/24/25. A falls risk assessment was completed on 3/1/25. The following neuro checks were completed following fall: 2/22/25 at 11:33 A.M. 2/22/25 at 7:30 P.M. 2/23/25 at 3:30 A.M. The clinical record lacked documentation of neuro checks after that. Fall 11 4/27/25 at 4:27 P.M. a progress note indicated resident was found on the floor lying on her back to the left side of the bed with a 1 cm laceration to the bridge of the nose with a moderate amount of bleeding. An IDT note, dated 4/28/25 at 10:23 A.M., indicated an intervention to move the left side of the bed against the wall and move the bedside table away from the bed. The falls care plan was updated on 4/28/25. The following neuro checks were completed following fall: 4/27/25 at 3:30 P.M. 4/27/25 at 3:40 P.M. 4/27/25 at 4:01 P.M. 4/27/25 at 4:30 P.M. 4/27/25 at 5:01 P.M. The clinical record lacked documentation of neuro checks after that. Fall 12 4/30/25 at 5:18 A.M., a Nurses Note indicated resident tried to transfer herself and flipped from the bed to the floor resulting in three bumps: two on the left side of the face and one on the head. Fall was unwitnessed. An IDT note, dated 4/30/25 at 10:11 A.M., indicated pain and anxiety medication would be increased and mattress would be placed to the floor for safety. The falls care plan was updated on 4/30/25. The following neuro checks were completed following fall: 4/30/25 at 1:30 A.M. 4/30/25 at 4:30 A.M. 4/30/25 at 5:00 A.M. 4/30/25 at 6:00 A.M. 4/30/25 at 6:30 A.M. 4/30/25 at 7:00 A.M. 4/30/25 at 3:00 P.M. 4/30/25 at 11:00 P.M. The clinical record lacked documentation of neuro checks after that. 4. On 6/12/25 at 7:36 A.M., Resident 56's clinical record was notified. Diagnosis included, but was not limited to, dementia. The most recent quarterly MDS assessment, dated 5/28/25, indicated a severe cognitive impairment, and a fall with injury since the previous assessment. Resident required setup or cleanup assistance with eating, toileting, and transfers, supervision or touching assistance with bed mobility, and partial to moderate assistance (helper does less than half the effort) with bathing. Current physician orders included, but were not limited to: activity level: assist of one staff with walker, dated 3/7/25. A current Risk for Falls Care Plan, last revised 3/5/25, included, but was not limited to, an intervention to clip call light to resident's clothing for safety, dated 10/8/24. Falls risk assessments included the following (for the previous 12 months): 8/26/24 Medium risk 10/4/24 High risk 3/4/25 Moderate risk 5/28/25 Moderate risk Since 12/1/24, Resident 56 had experienced the following falls: Fall 1 3/3/25 at 2:41 P.M. a Nurses Note indicated resident was found on the floor lying on the right side. An IDT note, dated 3/4/25 at 10:09 A.M., indicated a fall had occurred at 2:41 P.M. A new intervention placed for bed stoppers under all four wheels of the bed, locked wheels on bed, and non skid strips to right side of the bed. The falls care plan was updated the following day (after Fall 2). The clinical record lacked documentation that neuro checks were completed following fall. A falls risk assessment was completed the next day, 3/4/25. Fall 2 3/4/25 at 10:08 A.M. An IDT note indicated resident was found on the floor. Resident stated he was trying to transfer self from the bed to the recliner, tripped and fell. Head of bed to be elevated, staff to check on resident more frequently through the night, and toilet resident upon rising, after meals, at night and as needed. The falls care plan was updated 3/4/25 to include bed stoppers, bed in lowest position, and wheels locked, also anti-rollbacks on wheelchair. On 3/5/35 the care plan was updated to include administration of medication for dizziness. The following neuro checks were completed following fall: 3/4/25 at 5:28 P.M. 3/5/25 at 1:09 A.M. 3/5/25 at 7:12 P.M. 3/5/25 at 9:18 A.M. 3/6/25 at 3:21 A.M. 3/6/25 at 11:02 A.M. 3/6/25 at 10:28 P.M. 3/7/25 at 7:14 A.M. Fall 3 4/21/25 at 1:30 P.M. a progress note indicated resident reported to staff that he fell out of bed and got up on his own. A skin tear was noted to the right hand and elbow, and a bump to the back of the head. An IDT note, dated 4/23/25 at 10:13 A.M., indicated a new intervention for a scoop mattress to bed. The falls care plan was updated with the new intervention on 4/23/25. The following neuro checks were completed following fall: 4/21/25 at 7:00 A.M. 4/21/25 at 7:30 A.M. 4/21/25 at 8:00 A.M. 4/21/25 at 9:00 A.M. 4/22/25 at 1:00 A.M. 4/23/25 at 1:00 A.M. The clinical record lacked documentation that neuro checks were completed after that. On 6/11/25 at 8:51 A.M., Qualified Medication Aide (QMA) 7 was observed to assist Resident 56 to the toilet and then back to bed. After situating the resident in bed, a call light was observed coiled on the floor under the head of the bed. QMA 7 left the room without providing the call light to the resident. On 6/12/25 at 11:18 A.M., Resident 56 was observed lying in bed with the lights out and television on. Two call lights were observed lying over the bedside table with dark red tape around them. Neither call light was clipped to the resident's clothing. On 6/12/25 at 9:10 A.M., the Assistant Director of Nursing (ADON) indicated prior to the current neuro check form, the Post Fall Neuros/Vitals form was the only one that was being used and only included vital signs, not neurological checks. She indicated staff was educated on using the new form, as well as charting directly in the clinical record. At that time, the new neuro check form was provided and indicated neuro checks needed to be completed at the following times following a fall: Every 15 minutes x 1 hour Every 30 minutes x 2 hours Every hour x 4 hours Every 8 hours x 72 hours On 6/12/25 at 2:20 P.M., the ADON indicated everything that was provided was included in the clinical record. She indicated the facility had internal documents with additional information, but none of that information was included in the resident's clinical record. On 6/13/25 at 10:32 A.M., the Director of Nursing (DON) provided a current Falls policy, last revised 3/2018, that indicated .the nurse shall assess and document/report the following . Neurological status . Falls should also be identified as witnessed or unwitnessed events . the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling . On 6/13/25 at 10:32 A.M., the DON provided a current Neurological Assessment policy, last revised 10/2010, that indicated Neurological assessments are indicated . Following an unwitnessed fall . Following a fall or other accident/injury involving head trauma On 6/13/25 at 9:53 A.M., the DON provided a current Care Plans policy, last revised 3/2022, that indicated Assessments of residents are ongoing and care plans are revised as information about the resident and the residents' conditions change . The interdisciplinary team reviews and updates the care plan . when there has been a significant change in the resident's condition . when the desired outcome is not met 3.1-45(a)

Based on interview and record review, the facility failed to provide a required notice to a resident being discharged from Medicare services for 1 of 3 residents reviewed. No record of a SNF-ABN (Skilled Nursing Facility-Advanced Beneficiary Notification) notice was available that indicated the resident was notified of a discharge from Medicare services with days remaining prior to the resident's discharge from the facility. (Resident 75) Finding includes: On 6/9/25 at 10:00 A.M., Resident 75's discharge from Medicare services was reviewed. Resident 75 was discharged from Medicare services on 2/24/25 when benefit days were not exhausted. Resident 75 discharged from the facility on 2/24/25. A copy of the Notice of Medicare Non-Coverage (NOMNC) notice was not provided. On 6/9/25 at 11:30 A.M., the Social Service Director (SSD) indicated a Notice of Medicare Non-Coverage (NOMNC) notice was provided to Resident 75, but the facility lacked documentation in the clinical record that the resident was notified. On 6/9/25 at 11:35 A.M., the SSD supplied a copy of a SNF Beneficiary Notice Scenarios guideline dated 04/2018. The guideline indicated a NOMNC notification form should have been issued when a .Resident is being discharged from Part A (Medicare) and is leaving the SNF immediately following the last covered skilled day, with skilled benefit days remaining/available. 3.1-4(f)(2)

Based on observation, interview, and record review, the facility failed to ensure resident's drug regimens were free from unnecessary drugs for 2 of 5 residents reviewed for falls. A resident was given an antipsychotic without a physician's order and a gradual dose reduction (GDR) wasn't done for a resident taking an antipsychotic and antianxiety medication. (Resident 39, Resident 6) Findings include: 1. On 6/11/25 at 2:33 P.M., Resident 39's clinical record was reviewed. Diagnoses included, but were not limited to, Parkinson's disease, dementia, anxiety, depression, and psychotic disorder. The most recent quarterly Minimum Data Set (MDS) assessment, dated 4/9/25, indicated a severe cognitive impairment, and use of an antipsychotic medication. Physician orders included, but were not limited to, the following: Haldol (an antipsychotic medication) Injection Solution 5 MG (milligram)/ML (milliliter) Inject 5 mg intramuscularly every 6 hours as needed, ordered 11/25/24 and discontinued 12/2/24 at 3:18 P.M. Haloperidol Lactate (Haldol) Oral Concentrate 2 MG/ML Give 0.25 ml by mouth two times a day, ordered 12/27/24 and discontinued 1/10/25. A Nurses Note, dated 12/2/24 at 11:22 P.M., indicated Resident 39 was given a 5 mg injection of Haldol. At that time, there was no current physician's order for Haldol. The physician's order for Haldol had been discontinued previously that day at 3:18 P.M. A Health Status note, dated 12/3/24 at 2:40 A.M., indicated Resident 39 had fallen in his room, and that a Haldol injection had been administered earlier in the shift. Resident 39's Medication Administration Record (MAR) for December 2024 lacked documentation that Haldol was given on 12/2/24. On 6/13/25 at 9:23 A.M., The MDS Coordinator (previously the Dementia Director) indicated Resident 39 had been given Haldol on 12/1/24 and was not followed up on in a timely manner. She indicated that was the reason it had been discontinued on 12/2/24 after she had discussed the issue with the prescribing provider. On 6/13/25 at 10:42 A.M., the Assistant Director of Nursing (ADON) indicated she spoke with the nurse that gave Resident 39 Haldol on 12/2/24, but he did not remember the incident or giving the medication. 2. On 6/11/25 at 8:20 A.M., Resident 6's clinical record was reviewed. Diagnoses included, but were not limited to anxiety, osteoporosis, depression, and early-onset cerebellar ataxia (a neurological disorder that primarily affects the cerebellum, a part of the brain responsible for coordinating movement and balance). The most recent quarterly MDS assessment, dated 5/20/25, indicated Resident 6 was cognitively intact, substantial to maximum assist (staff perform over half the effort) for bed mobility, transfers, and toileting. She received an antipyschotic and an antianxiety medication. Physician's Orders, included, but were not limited to, the following: Klonopin (antianxiety) 0.5 milligram (mg) tablet, give 0.5 mg by mouth in the morning for early-onset cerebellar ataxia, ordered 6/11/24 (continued from previous order) Klonopin 1 mg tablet, give 1 mg by mouth at bedtime for early-onset cerebellar ataxia, ordered 6/11/24 (continued from previous order) Abilify (antipyschotic) 5 mg tablet, give 5 mg by mouth at bedtime for adjustment disorder with depressed mood, ordered 9/24/24 discontinued 10/3/24 Abilify (antipyschotic) 10 mg tablet, give 10 mg by mouth at bedtime for adjustment disorder with depressed mood, ordered 10/3/24 and discontinued 11/7/24 Abilify (antipyschotic) 15 mg tablet, give 15 mg by mouth at bedtime for adjustment disorder with depressed mood, ordered 11/7/24 and discontinued 5/15/25 Abilify (antipyschotic) 20 mg tablet, give 20 mg by mouth at bedtime for adjustment disorder with depressed mood, ordered 5/15/25 A current Antianxiety Care Plan, last revised 11/27/24, included, but was not limited to, an intervention to consult with the health care provider to consider dosage reduction when clinically appropriate, initiated 6/18/19. A current Antipyschotic Care Plan, last revised 11/15/24, included, but was not limited to, an intervention to consult with the health care provider to consider dosage reduction when clinically appropriate, initiated 9/25/24. The clinical record lacked documentation of a contraindication for a GDR or a rationale to continue the medications from a prescribing practitioner. During an interview on 6/12/25 at 11:33 A.M., the Assistant Director of Nursing (ADON) indicated she could not provide documentation signed by the prescribing physician or nurse practitioner for the contraindication from the resident's clinical record. On 6/13/25 at 9:22 A.M., Licensed Practical Nurse (LPN) 16 indicated if a resident was having behaviors that warranted an antipsychotic, the nurse would need to call the doctor and get an order. The order would then be documented in the clinical record. On 6/13/25 at 10:32 A.M., a current Tapering Medications/Gradual Drug Dose Reduction Policy, revised July 2022, was provided by the Director of Nursing (DON) and indicated, After medications are ordered for a resident, the staff and practitioner shall seek an appropriate dose and duration for each medication . within the first year after a resident is admitted on a psychotropic medication or after the resident has been started on a psychotropic medication, the staff and practitioner shall attempt a GDR in two separate quarters (with at least one month between the attempts) . After the first year, the facility shall attempt a GDR at least annually, unless clinically contraindicated . and the physician has documented the clinical rationale for why any additional attempted dose reduction at that time would be likely to impair the resident's function or increase distressed behavior . On 6/13/25 at 11:00 A.M., the Director of Nursing (DON) provided a current Intramuscular Injections policy, last revised 3/2011, that indicated Verify that there is a physician's medication order for this procedure 3.1-48(a) 3.1-48(b)(2)

Based on observation, interview, and record review, the facility failed to provide a sanitary environment to help prevent the development and transmission of communicable diseases and infections for 3 of 3 residents observed for incontinence care. Hand hygiene was not completed between glove changes, staff washed hands with less then 15 second lather, an incontinence pad was held between the bed and the staff's knees (with the inside of the incontinence pad against her scrub pants), staff left a visibly soiled incontinence pad on a resident after toileting him, and residents were not offered to wash their hands after toileting. (Resident 7, Resident 45, Resident 6) Findings include: 1. On 6/11/25 at 8:51 A.M., Qualified Medication Aide (QMA) 7 was observed to provide toileting assistance to Resident 56. Prior to assisting the resident on the toilet, QMA 7 washed her hands for 9 seconds, then put on gloves. The resident was assisted to sit on the toilet. The inside of the resident's brief was visibly wet and bulging with brown spots on the inside of it. When the resident was finished and stood up, QMA 7 wiped him, removed her gloves and washed her hands for 7 seconds. QMA 7 told the resident to pull up his brief and pants which he did, then exited the bathroom. QMA 7 did not touch the brief or assess that it was soiled. At that time, QMA 7 indicated Resident 56 did not have any cream ordered for incontinence care. On 6/12/25 at 8:04 A.M., Certified Nurse Aide (CNA) 9 indicated briefs would bulge when wet, and would be flat if dry. She indicated when taking a resident to the toilet, it was good practice to just change the brief whether they appeared to be soiled or not just in case. 3. On 6/11/25 at 8:53 A.M., QMA 46 and Licensed Practical Nurse (LPN) 21 were observed toileting Resident 45. QMA 46 failed to perform hand hygiene after he cleaned Resident 45's buttocks and perineal area. QMA 46 removed gloves and performed a 13 second hand lather. QMA 46 and LPN 21 failed to offer for Resident 45 to perform hand hygiene after he used the bathroom. During an interview on 6/11/25 at 10:00 A.M., the Infection Preventionist indicated when washing hands, staff should wash or scrub their hands for at least 20 seconds with soap. Staff should change gloves if they were visibly soiled or when going from a dirty to clean task and perform hand hygiene between glove changes. If a resident's incontinence pad was soiled, staff should put on a clean one. Staff should offer to wash the resident's hands after toileting and they should not hold resident belongings, clothing, or incontinence pads against themselves or their scrubs. On 6/13/25 at 10:32 A.M., the Director of Nursing (DON) provided a current Handwashing/Hand Hygiene policy, revised August 2019, that indicated, .Hand hygiene is the final step after removing and disposing of personal protective equipment .The use of gloves does not replace handwashing .Rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers . 3.1-18(b) 3.1-18(l) 2. On 6/11/25 at 9:21 A.M., incontinence care was observed on Resident 6 performed by CNA 34 and QMA 46. Resident 6 was laying on her back in bed. QMA 46 got a clean incontinence pad from the package and laid it across the footboard of the bed. QMA 46 unfastened the soiled brief, performed incontinence care of the groin area, took off gloves, and put a new pair of gloves on without performing hand hygiene between. CNA 34 assisted resident to roll on her right side. She placed the clean incontinence pad between her knees and the side of the bed (with the inside of the incontinence pad against her scrub pants), wiped the resident's buttocks, and laid the new incontinence pad under the resident. CNA 34 took off gloves and put a new pair of gloves on without performing hand hygiene between. QMA 46 fastened the incontinence pad and both QMA 46 and CNA 34 proceeded to help Resident 6 get dressed.

Based on interview and record review, the facility failed to ensure a notice of transfer or discharge was given to residents or resident representatives for 5 of 5 residents reviewed for hospitalization s. The transfer or discharge notice was not completed and clinical records lacked documentation of residents/representatives receiving a notice of transfer or discharge at the time of the hospitalization s. (Resident 38, Resident 52, Resident 46, Resident 43, Resident 15) Findings include: 1. On 5/14/24 at 2:49 P.M., Resident 38's clinical record was reviewed. Diagnoses included, but were not limited to, dementia. The most recent Annual MDS (Minimum Data Set) Assessment, dated 4/23/24, indicated Resident 38's cognition was severely impaired and she was an extensive assist of 1 staff for bed mobility, transfers, and toileting. Progress notes included, but were not limited to, the following: On 1/30/24 at 3:31 A.M., Nurse's Note: At 0300 [3:00 A.M.] this nurse and CNA [certified nurse aide] heard a thump and got up to check what sound was and found res. [resident] setting [sic] on floor in front of bedroom door. Res. was setting [sic] on bottom with legs straight out in front of her, walker was behind resident facing the bedroom room . sending to ER [emergency room ] for further eval [evaluation] at this time per MD [Medical Doctor] . The clinical record lacked documentation of the representative receiving a notice of transfer or discharge due to residents severe cognitive impairment at the time of hospitalization . During an interview on 5/16/24 at 9:55 A.M., the Administrator indicated she thinks staff are filling out transfer or discharge forms, sending them with the residents, but are not making copies to keep in the residents clinical record. 2. On 5/14/24 at 3:21 P.M., Resident 52's clinical record was reviewed. Diagnoses included, but were not limited to unspecified intellectual disabilities and senile degeneration of brain. The most recent Admission MDS Assessment, dated 2/28/24, indicated Resident 52's cognition was unable to be assessed and was an extensive assist of 2 staff for bed mobility, transfers, and toileting. Progress notes included, but were not limited to, the following: On 4/25/24 at 1:40 A.M., Nurse's Note: CNA witnessed resident up et [and] walking in lounge, as CNA was walking toward resident to help resident back to W/C [wheelchair], resident fell hitting his head . Per NP [Nurse Practitioner] order to send resident to [name of hospital] for eval & treat . The clinical record lacked documentation of the representative receiving a notice of transfer and discharge due to residents intellectual disability at the time of hospitalization . 45933 3. On 5/14/24 at 1:54 P.M., Resident 43's clinical record was reviewed. Current diagnosis included, but was not limited to, diabetes mellitus. The most recent Quarterly and State Optional MDS, dated [DATE], indicated Resident 43 was cognitively intact, and he was an extensive assist of 2 for bed mobility, transfers, and toileting. Progress notes included, but were not limited to, the following: 1/13/2024 13:14 [1:14 P.M] .Resident continues to throw up and states he does not feel well. This nurse contacted NP [Nurse Practitioner] who noted order to send res [resident] to ER [emergency room ] for eval [evaluation] and treat. Daughter notified . The clinical record lacked documentation of the resident and representative receiving a notice of transfer or discharge at the time of hospitalization . During an interview on 5/16/24 at 9:55 A.M., the Administrator indicated she thinks staff are filling out transfer or discharge forms, sending them with the residents, but are not making copies to keep in the residents clinical record. 38770 4. On 5/17/24 at 1:25 P.M., Resident 15's clinical record was reviewed. Resident 15 had moderate cognitive impairment and was discharged to the hospital due to hypotension (low blood pressure) and lethargy on 5/11/24 and returned to the facility 5/15/24. Resident 15's clinical record lacked a notice of transfer or discharge, and lacked documentation that it was sent with the resident or given to the resident's representative. On 5/20/24 at 8:57 A.M., a copy of a transfer form, dated 5/11/24, was provided. The form lacked a reason for the discharge, ombudsman information, and appeal rights. 5. On 5/13/24 at 2:36 P.M., Resident 46's clinical record was reviewed. Resident 46 was discharged to the hospital on 1/28/24 and returned to the facility 1/29/24. Resident 46's clinical record lacked a notice of transfer or discharge, and lacked documentation that it was sent with the resident or given to the resident's representative. On 5/16/24 at 9:55 A.M., the Administrator indicated the transfer forms that were provided were what was sent with the residents at the time of discharge. She further indicated the ombudsman was notified of the discharge if he/she was already involved with that resident, but not otherwise. On 5/16/24 at 4:10 P.M., a current Transfer Form policy, dated 3/2017 was provided and indicated This facility provides a completed and accurate Transfer Form to a resident transferred or discharged from our facility 3.1-12(a)(6)(A)

Based on interview and record review, the facility failed to ensure a bed hold form and policy was given to residents or resident representatives for 5 of 5 residents reviewed for hospitalization s. The bed hold form was not completed and clinical records lacked documentation of residents/representatives receiving a bed hold form and policy at the time of the hospitalization s. (Resident 38, Resident 52, Resident 46, Resident 43) Findings include: 1. On 5/14/24 at 2:49 P.M., Resident 38's clinical record was reviewed. Diagnoses included, but were not limited to dementia. The most recent Annual MDS (Minimum Data Set) Assessment, dated 4/23/24, indicated Resident 38's cognition was severely impaired and she was an extensive assist of 1 staff for bed mobility, transfers, and toileting. Progress notes included, but were not limited to, the following: On 1/30/24, Nurse's Note: At 0300 [3:00 A.M.] this nurse and CNA [certified nurse aide] heard a thump and got up to check what sound was and found res. [resident] setting [sic] on floor in front of bedroom door. Res. was setting [sic] on bottom with legs straight out in front of her, walker was behind resident facing the bedroom room . sending to ER [emergency room ] for further eval [evaluation] at this time per MD [Medical Doctor] . On 2/5/24, Nurse's Notes: resident very lethargic, arms flaccid, will not open eyes, will not respond to nail bed press or sternal rub . Primary Care Provider responded with the following feedback: A. Recommendations: send to ER . The clinical record lacked documentation of the representative receiving a bed hold form and policy at the time of hospitalization due to severe cognitive impairment. 2. On 5/14/24 at 3:21 P.M., Resident 52's clinical record was reviewed. Diagnoses included, but were not limited to unspecified intellectual disabilities and senile degeneration of brain. The most recent Admission MDS Assessment, dated 2/28/24, indicated Resident 52's cognition was unable to be assessed and was an extensive assist of 2 staff for bed mobility, transfers, and toileting. Progress notes included, but were not limited to, the following: On 4/25/24, Nurse's Note: CNA witnessed resident up et [and] walking in lounge, as CNA was walking toward resident to help resident back to W/C [wheelchair], resident fell hitting his head . Per NP [Nurse Practitioner] order to send resident to [name of hospital] for eval [evaluation] & treat . On 4/29/24, Nurse's Note: Resident was found on floor next to his chair in the 200 hall lounge . MD notified and gave order to send out to [name of hospital] ER to eval [evaluation] and treat . The clinical record lacked documentation of the representative receiving a bed hold form and policy at the time of hospitalization due to severe intellectual disability. 45933 3. On 5/14/24 at 1:54 P.M., Resident 43's clinical record was reviewed. Current diagnosis included, but was not limited to, diabetes mellitus. The most recent Quarterly and State Optional MDS, dated [DATE], indicated Resident 43 was cognitively intact, and he was an extensive assist of 2 for bed mobility, transfers, and toileting. Progress notes included, but were not limited to, the following: 1/13/2024 13:14 [1:14 P.M] .Resident continues to throw up and states he does not feel well. This nurse contacted NP [Nurse Practitioner] who noted order to send res [resident] to ER [emergency room ] for eval [evaluation] and treat. Daughter notified . The clinical record lacked documentation of the resident and representative receiving a bed hold form and policy at the time of hospitalization . 38770 4. On 5/13/24 at 2:36 P.M., Resident 46's clinical record was reviewed. Resident 46 was discharged to the hospital on 1/28/24 and returned to the facility 1/29/24. Resident 46's clinical record lacked documentation that bed hold information was sent with the resident or given to the resident's representative. During an interview on 5/16/24 at 9:55 A.M., the Administrator indicated she thinks staff are filling out bed hold forms and giving it with the policy to the residents, but were not making copies to keep in the resident's clinical record. On 5/16/24 at 4:10 P.M., the DON provided a current Bed-Holds and Returns policy, dated 3/2022, that indicated All residents/representatives are provided written information regarding the facility bed-hold policies, which address holding or reserving a resident's bed during periods of absence . Residents are provided written information about these policies at least twice . well in advance of any transfer . at the time of transfer 3.1-12(a)(25) 3.1-12(a)26

Based on observation, interview, and record review, the facility failed to ensure accuracy of assessments for 14 of 26 resident records reviewed during the survey. MDS (Minimum Data Set) Assessments did not accurately reflect resident status. (Resident 52, Resident 38, Resident 12, Resident 35, Resident 36, Resident 41, Resident 19, Resident 17, Resident 19, Resident 43, Resident 48, Resident 5, Resident 53) Findings include: 1. On 5/14/24 at 10:49 A.M., Resident 36's room was observed. The bed was observed equipped with small grab bars. On 5/16/24 at 1:52 P.M., Resident 36's clinical record was reviewed. Diagnosis included, but were not limited to, Parkinson's Disease. The most recent Annual MDS Assessment, dated 3/14/24, indicated use of physical restraints in the form of bed rails. Resident 36's clinical record lacked a current physician order for bed rails. Resident 36's clinical record lacked a current care plan related to bed rails. A Physical Device and/or Restraint Evaluation and Review form, dated 3/7/24, indicated assist/grab bars were being reviewed for the resident, and were not being used as a restraint. 2. On 5/16/24 at 1:59 P.M. Resident 14's clinical record was reviewed. Diagnosis included, but were not limited to, dementia, anxiety, and psychotic disorder. The most recent Quarterly MDS Assessment, dated 5/7/24, indicated Resident 14 had taken an anticoagulant medication. The MDS also indicated the Resident did not take an antiplatelet medication. Current physician orders included, but were not limited to: Clopidogrel Bisulfate (an antiplatelet medication) Oral Tablet 75 mg (milligrams) by mouth one time a day, dated 12/27/23. Aspirin (an antiplatelet medication) 81 mg by mouth one time a day, dated 12/27/23. Resident 14's clinical record lacked a current physician's order for an anticoagulant medication. 45933 3. During an observation on 5/14/24 at 10:39 A.M., Resident 48's bed was observed with small grab bars. On 5/15/24 at 8:59 A.M., Resident 48's clinical record was reviewed. Current diagnoses included, but were not limited to, dysphagia and muscle weakness. The most recent Quarterly and State Optional Minimum Data Set (MDS) Assessment, dated 3/26/24, indicated resident 48 used bed rails daily. No other assessment for use of bed rails was documented. Resident 48's clinical record lacked an order related to a bed rails. Resident 48's clinical record lacked a care plan related to a bed rails. 4. On 5/14/24 at 1:54 P.M., Resident 43's clinical record was reviewed. Current diagnosis included, but was not limited to, diabetes mellitus. The most recent Quarterly and State Optional MDS, dated [DATE], indicated Resident 43 was cognitively intact and received an anticoagulant. Resident 43's record lacked an order for an anticoagulant during the look back period. Current care plans included, but were not limited to, The resident is on anticoagulant therapy, revised 2/19/24 and interventions included, but were not limited to, .Monitor resident condition based on clinical practice guidelines or clinical standards of practice r/t [related to] use of Plavix [antiplatelet] . revised 2/19/24. 46416 5. On 5/14/24 at 9:58 A.M., Resident 19's bed was observed without bed rails. On 5/14/24 at 1:41 P.M., Resident 19's clinical record was reviewed. Diagnoses included, but were not limited to, anxiety and atherosclerotic heart disease The most recent Quarterly MDS Assessment, dated 4/10/24, indicated resident was cognitively intact, an extensive assist of 1 staff for bed mobility, transfers, toileting, had pneumonia, and used a restraint (bed rail) daily. During an interview on 5/17/24 at 11:00 A.M., the MDS Coordinator indicated pneumonia was marked in error and should have been taken off the MDS Assessment, dated 4/10/24. 6. On 5/14/24 at 9:50 A.M., Resident 17 was observed asleep in her bed without bed rails. On 5/16/24 at 2:47 P.M., Resident 17's clinical record was reviewed. Diagnoses included, but were not limited to, dementia and bipolar. The most recent Annual MDS Assessment, dated 4/23/24, indicated Resident 17's cognition was mildly impaired, supervised with set up from staff for bed mobility, transfers, toileting, and used a restraint (bed rail) daily. 7. On 5/13/24 at 10:32 A.M., Resident 52's bed was observed pushed up to the wall on the left side and without bed rails. On 5/14/24 at 3:21 P.M. Resident Resident 52's clinical record was reviewed. Diagnoses included, but were not limited to unspecified intellectual disabilities and senile degeneration of brain. The most recent Admission MDS Assessment, dated 2/28/24, indicated Resident 52's cognition was unable to be assessed, was an extensive assist of 2 staff for bed mobility, transfers, toileting, and used a restraint (bed rail) daily. 8. On 5/13/24 at 10:00 A.M., Resident 38's bed was observed without bed rails. On 5/14/24 at 2:49 P.M., Resident 38's clinical record was reviewed. Diagnoses included, but were not limited to dementia. The most recent Annual MDS Assessment, dated 4/23/24, indicated Resident 38's cognition was severely impaired and she was an extensive assist of 1 staff for bed mobility, transfers, toileting, and used a restraint (bed rail) daily. 9. On 5/14/24 at 9:54 A.M., Resident 41's bed was observed without bed rails. On 5/16/24 at 3:22 P.M., Resident 41's clinical record was reviewed. Diagnoses included, but were not limited to, dementia. The most recent Quarterly MDS Assessment, dated 4/24/24, indicated Resident 41's cognition was unable to be assessed, she was an extensive assist of 2 staff for bed mobility and transfers, totally dependent on 2 staff for transfers, and used a restraint (bed rail) daily. 46882 10. On 5/14/24 at 1:54 P.M., Resident 45's clinical records were reviewed. Diagnosis included, but were not limited to, macular degeneration, chronic combined systolic and diastolic heart failure, Sjogren syndrome. The most current Quarterly MDS (Minimum Data Set) Assessment and State Optional MDS, dated [DATE], indicated Resident 45 was cognitively intact and required extensive assistance of two for bed mobility, transfers and toilet use, used oxygen and was on hospice, and had physical restraints, bed rails used daily. Review of the Physical Device and/or Restraint Evaluation and Review, dated 5/1/24, indicated: Which device(s) are you recommending and/or reviewing for this resident? (check all that apply) a. Assist/Grab bar(s) Assist bars increase resident independence with bed mobility. Assist bars increase resident's independence with bed mobility, such as turning side to side in bed, from lying to sitting position on side of bed with transfers. Care planning for use of physical devices Focus: The resident uses physical devices assist bars to bed R/T (related to) increases resident's independence with bed mobility, turning side to side and from lying to sitting on side of bed for transfers. Goal: Resident will demonstrate the appropriate use of assist bars to bed to increase her independence with bed mobility. Intervention: Monitor/document/report to health care provider PRN any changes regarding use of assist bars to bed. 11. On 5/14/24 at 3:18 P.M., Resident 3's clinical records were reviewed. Diagnosis included but was not limited to, cerebral ischemia, depression, cerebral infarction, occlusion and stenosis of bilateral carotid arteries. The most current Quarterly MDS (Minimum Data Set) Assessment and State Optional MDS, dated [DATE], indicated Resident 3 was mildly impaired cognitively, required extensive assistance of two for bed mobility, transfers, and toilet use, had physical restraints, bedrail used daily. Review of Physical Device and/or Restraint Evaluation and Review, dated 4/28/24, indicated: Which device(s) are you recommending and/or reviewing for this resident? (check all that apply) a. Assist/Grab bar(s) Potential resident safety risks have been evaluated for this device/restraint (e.g., potential entrapment, accident hazards, potential negative outcome, physical restraint, potential negative psychosocial outcome, etc.). How will the assist/grab bar(s) benefit and/or allow the resident to reach their highest level of independence? grab bars helps res.(resident), help staff in positioning Would the assist/grab bar(s) be a restraint for this resident? (Refer to Definition of Restraint above.) no Care planning for use of physical devices Focus: The resident uses physical devices bilateral assist bars R/T weakness Goal: Resident will demonstrate the appropriate use of physical device(s) by review date Device assist bars Intervention: Monitor/document/report to health care provider PRN any changes regarding use of assist bars Intervention: Educate and discuss with resident & family the risks and benefits of the assist bars regarding its use. 12. On 5/16/24 at 3:19 P.M., Resident 53's clinical records were reviewed. Diagnosis included, but were not limited to, Type II diabetes mellitus with hyperglycemia, amputation at level between knee and ankle of left lower leg, and difficulty in walking. The most current Admission MDS assessment, dated 3/13/24, indicated Resident 53 was cognitively intact, required partial assistance with bed mobility, substantial maximal assistance for transfer and toilet use, and had physical restraints, bed rails used daily. Resident 53's clinical record lacked a Physical Device and/or Restraint Evaluation and Review. Current care plan for The resident uses physical devices bilateral assist bars related to weakness, dated 3/9/24 indicated the following interventions: Monitor/document/report to health care provider PRN (as needed) any changes regarding use of bilateral assist bars, dated 3/9/24. Educate and discuss with resident the risks and benefits of the bilateral assist bars regarding its use, dated 3/9/24. Resident 53's clinical record did contain a signed Consent for bed rail use, dated 3/9/24. During an interview on 5/17/24 at 11:00 A.M., the MDS Coordinator indicated bedrails were not restraints and when she was trained she was told to mark that. She indicated that was an error in coding and training and no one in the building was on physical restraints. 13. On 5/14/24 at 2:44 P.M., Resident 35's clinical records were reviewed. Diagnosis included, but were not limited to, Type II diabetes mellitus with diabetic polyneuropathy, non-pressure chronic ulcer of right foot, acute osteomyelitis of right ankle and foot. The most current Quarterly MDS (Minimum Data Set) Assessment and State Optional MDS, dated [DATE], indicated Resident 35 was cognitively intact, required supervision of one for bed mobility, transfers and toilet use, had no pressure ulcers, no venous ulcers, no diabetic foot ulcers and no other open lesions of the foot. Wound notes dated 5/15/24 indicated: Date wound 1st noted 4/1/24 Diabetic ulcer left heel 1 cm (centimeter) x 1 cm x 0.2 cm 100% granulation No drainage Seen by wound specialist Debridement on 5/15/24 Right heel drsg (dressing) present yes Drsg intact yes Resident goes to WCC (Wound Care Clinic) During an interview on 5/17/24 at 11:00 A.M., the MDS Coordinator indicated diabetic foot ulcers should have been marked yes on Resident 35's MDS. On 5/17/24 at 9:35 A.M., a current non dated Physical Device and/or Restraint Evaluation and Review Form was provided by the Director of Nursing (DON) and indicated . Definition of Restraint: A device is considered a restraint if it restricts the resident's freedom of movement, or normal access to one's body . If it does restrict the resident's freedom of movement . you must obtain (1) provider order with justification for medical necessity (2) signed permission from Power of Attorney (POA) or responsible party if required . Restraints must be removed at least every 2 hours to allow for repositioning and checking for areas of skin irritation . During an interview on 5/17/24 at 11:00 A.M., the MDS Coordinator indicated bed rails were not used as physical restraints and that most residents only use the mobility bars, which do not restrict movement, and not bed rails. The MDS Assessments were marked as use of restraints in error she believed because that's how she was taught in training. No one in the building uses a physical restraint. At that time, she indicated there was not a policy for MDS Assessments but it was their policy to use the RAI (Resident Assessment Instrument) Manual. 3.1-31(c)(13)

Based on observation, interview, and record review, the facility failed to develop a comprehensive person-centered care plan with resident specific needs for 4 of 22 residents reviewed for care plan development and implementation. Resident on hospice did not have a care plan for hospice, resident did not have a care plan for eating meals at a bedside table in the main dining room, residents that were taking an antianxiety, diuretic, and antidepressant did not have care plans for use. (Resident 19, Resident 5, Resident 48, Resident 45) Findings include: 1. On 5/14/24 at 1:41 P.M., Resident 19's clinical record was reviewed. Diagnoses included, but were not limited to, anxiety and atherosclerotic heart disease The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 4/10/24, indicated Resident 19 was cognitively intact, an extensive assist of 1 staff for bed mobility, transfers, toileting, and was on hospice. Current Physician's Orders included, but were not limited to, the following: Admit to [name of hospice company] with diagnosis of atherosclerotic heart disease (ASHD), ordered 4/4/24 Progress notes included, but were not limited to, the following: On 4/4/24 at 2:00 P.M., Note Text: Resident admitted to [name of hospice company] with diagnosis of ASHD. Comfort meds [medications] ordered. Resident 19's clinical record lacked a care plan related to hospice. During an interview on 5/17/24 at 11:00 A.M., the MDS (Minimum Data Set) Coordinator indicated residents on hospice should have a hospice care plan in their clinical record and nurses on the floor should be putting it in when they get the order for hospice. During an interview on 5/20/24 at 3:15 P.M., the Director of Nursing (DON) indicated Resident 19 was on hospice he should have a hospice care plan. 45933 2. On 5/15/24 at 8:59 A.M., Resident 48's clinical record was reviewed. Current diagnoses included, but were not limited to, dysphagia and muscle weakness. The most recent Quarterly and State Optional Minimum Data Set (MDS) Assessment, dated 3/26/24, indicated resident 48 received an antianxiety and antidepressant medication. Current Physician Order's included, but were not limited to, Ativan 0.5MG [milligrams] . by mouth three times a day for anxiety/agitation, start date 2/3/24 and traZODone .[sic]50MG .Give q tablet by mouth at bedtime, start date 1/3/24. The clinical record lacked a care plan related to Resident 48 receiving an antianxiety medication (Ativan). The clinical record lacked a care plan related to Resident 48 receiving an antidepressant medication (Trazodone). During an interview on 5/16/24 at 4:16 P.M., the DON indicated the MDS Coordinator should have developed a care plan specific to the antianxiety medication and antidepressant medication. 46882 3. On 5/14/24 at 3:55 P.M., Resident 5's clinical records were reviewed. Diagnosis included, but were not limited to, Alzheimer's disease, bipolar disorder, atherosclerosis of native arteries of bilateral legs, and fracture of shaft of humerus. The most current Quarterly MDS (Minimum Data Set) and State Optional MDS Assessment, dated 5/8/24 indicated Resident 5 was mildly impaired cognitively, required supervision of one for bed mobility and transfers and extensive assist of one for toilet use. She had the following medications: antipsychotic, antianxiety, hypnotic, anticoagulant, antibiotic and diuretic. Current physician orders included, but were not limited to the following: olanzapine oral tablet 20 MG (milligrams) Give 1 tablet by mouth one time a day for bipolar disorder, dated 2/7/2024 lorazepam oral tablet 0.5 MG Give 0.5 mg by mouth three times a day for anxiety, dated 2/6/2024 Lasix oral tablet 40 MG Give 40 mg by mouth one time a day for edema, dated 2/21/2024 apixaban oral tablet 5 MG Give 5 mg by mouth two times a day for pulmonary embolism, dated 2/6/2024 amoxicillin-pot (potassium) clavulanate oral tablet 875-125 MG Give 1 tablet by mouth two times a day for bone/joint infection until 05/20/2024, dated 11/20/2023 doxycycline hyclate oral tablet 100 MG Give 100 mg by mouth two times a day for infection until 05/20/2024, dated 11/20/2023 Belsomra oral tablet 5 MG Give 5 mg by mouth one time a day related to insomnia, dated 2/29/2024 Resident 5's clinical records lacked a care plan for diuretic and anticoagulant use. During an interview on 5/17/24 at 11:00 A.M., the MDS Coordinator indicated she started the care plans and there should be one in the records for medications, especially black box warnings like anticoagulants. 4. On 5/13/24 at 11:27 A.M., Resident 45 was observed in the dining room seated off to the side by self eating off bedside table. On 5/14/24 at 11:09 A.M., Resident 45 was observed with a bedside table sitting in front of her in the dining room during lunch. On 5/14/24 at 1:54 P.M., Resident 45's clinical records were reviewed. Diagnosis included, but were not limited to, macular degeneration, chronic combined systolic and diastolic heart failure, Sjogren syndrome. The most current Quarterly MDS (Minimum Data Set) and State Optional MDS Assessment, dated 4/17/2024, indicated Resident 45 was cognitively intact and required extensive assistance of two for bed mobility, transfers and toilet use, used oxygen and was on hospice, and had physical restraints, bed rails used daily. Current physician orders included, but were not limited to the following: (Name of Hospice Company) to eval. (evaluate), dated 2/29/2024 Resident 45's clinical records lacked a care plan for hospice and use of a bedside table in the dining room. During an interview on 5/15/24 at 11:00 A.M., Resident 45 indicated she had no idea why they have her sitting in the dining room at a bedside table. During an interview on 5/16/24 at 11:06 A.M., CNA 33 indicated Resident 45 used a bedside table in the dining room because she preferred to sit alone, did not see well, and the tables were not low enough for her to reach her plate. During an interview on 5/17/24 at 11:00 A.M., the MDS Coordinator indicated residents on hospice should have hospice care plans. Nurses on the floor should put a care plan in when they get an order for hospice. On 5/17/24 at 9:52 A.M., the Dementia Care Coordinator provided a current Care Plans, Comprehensive Person-Centered policy, revised March 2022, which indicated A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. On 5/17/24 at 10:00 A.M., the DON (Director of Nursing) indicated it was the policy of the facility to follow the physician's orders and care plan interventions. 3.1-35(a)

Based on observation, interview, and record review, the facility failed to ensure residents had care plan conferences and care plans were revised for 1 of 2 residents reviewed for accidents and 3 of 5 residents reviewed for unnecessary medications. A resident moved out of the locked dementia unit and a resident's sleep medication was changed but the care plans were not revised. Residents did not have care plan conferences timely. (Resident 38, Resident 12, Resident 5, Resident 48) Findings include: 1. On 5/13/24 at 11:27 A.M., Resident 38 was observed waiting for lunch in the main dining room. On 5/14/24 at 2:49 P.M., Resident 38's clinical record was reviewed. Diagnoses included, but were not limited to, dementia without behaviors. The most recent Annual MDS (Minimum Data Set) Assessment, dated 4/23/24 indicated Resident 38's cognition was severely impaired and she was an extensive assist of 1 staff for bed mobility, transfers, and toileting. A current Dementia Care Plan, revised 10/13/23, included, but was not limited to, the following interventions: Resident resides on the locked dementia unit and is participating in dementia care activities, initiated 1/28/24 Progress notes indicated Resident 38 was moved from the locked dementia unit onto the 300 Hall 2/22/24. During an interview on 5/17/24 at 1:48 P.M., the Director of Nursing (DON) indicated the care plan intervention that she was on the locked dementia unit should have been revised because she was no longer on the locked dementia unit. 45933 2. On 5/15/24 at 2:28 P.M., Resident 12's clinical record was reviewed. Current diagnoses included, but were not limited to hypertension, diabetes mellitus, anxiety, and depression. The most recent Quarterly and State Optional Minimum Data Set (MDS) Assessment, dated 4/30/24 indicated Resident 12 had moderate cognitive impairment. Resident 12 failed to receive a care plan conference after 12/1/23. 3. On 5/15/24 at 8:59 A.M., Resident 48's clinical record was reviewed. Current diagnoses included, but were not limited to, dysphagia and muscle weakness. The most recent Quarterly and State Option Minimum Data Set (MDS) Assessment, dated 3/26/24, indicated Resident 48's cognition was unable to be assessed. Resident 48 failed to receive a care plan conference after 1/15/24. During an interview on 5/16/24 at 9:10 A.M., the SSD indicated care plan conferences should be completed every 90 days. During an interview on 5/20/24 at 10:30 A.M., the SSD indicated it is the facility's policy to complete care plan conferences every quarter. 46882 4. On 5/14/24 at 3:55 P.M., Resident 5's clinical records were reviewed. Diagnosis included, but were not limited to, Alzheimer's disease, bipolar disorder, atherosclerosis of native arteries of bilateral legs, and fracture of shaft of humerus. The most current Quarterly MDS (Minimum Data Set) Assessment and State Optional MDS, dated [DATE] indicated Resident 5 was mildly impaired cognitively, required supervision of one for bed mobility and transfers and extensive assist of one for toilet use. She had the following medications: antipsychotic, antianxiety, hypnotic, anticoagulant, antibiotic and diuretic. Current physician orders included, but were not limited to the following: Belsomra oral tablet 5 MG Give 5 mg by mouth one time a day related to insomnia, dated 2/29/2024 A current care plan for The resident has sleep disturbance and utilizes Ambien for insomnia, dated 2/6/2024. The care plan was not revised when the Ambien was discontinued and Belsomra was ordered. Progress Notes included, but was not limited to the following: 2/29/2024 10:47 A.M. Psychopharmacological Med/Physical Restraint Note Text: Pharmacy rec [recommends] at this time to d/c [discontinue] ambien [sic] and start belsomra [sic] 5 mg PO [by mouth] QHS [every bedtime] for insomnia. Psych [Psychiatric] NP [Nurse Practitioner] accepted this change, orders updated at this time. During an interview on 5/17/24 at 1:48 P.M., the Director of Nursing (DON) indicated floor nurses and/or the DON should be revising care plans immediately after a change occurs. On 5/17/24 at 9:52 A.M., The Dementia Care Coordinator provided a Care Plans, Comprehensive Person-Centered policy, revised March 2022, which indicated, .11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change . 3.1-35(a) 3.1-35(c)(2)(C) 3.1-35(d)(2)(B) 3.1-35(e)

Based on interview and record review, the facility failed to ensure residents were free from unnecessary medications for 5 of 6 residents reviewed for unnecessary medications. Resident's as needed anti-anxiety medication was ordered for greater than 14 days. A resident had a Physician's Order for an antipsychotic with an unacceptable diagnosis. (Resident 45, Resident 3, Resident 14, Resident 19, Resident 48) Findings include: 1. On 5/15/24 at 8:59 A.M., Resident 48's clinical record was reviewed. Current diagnoses included, but were not limited to, dysphagia and muscle weakness. The most recent Quarterly and State Option Minimum Data Set (MDS) Assessment, dated 3/26/24, indicated Resident 48's cognition was unable to be assessed, and she received an antipsychotic. Current Physician Order's included, but were not limited to, SEROquel [antipsychotic] Oral Tablet 25 MG [milligrams] .Give 25 mg by mouth one time a day related to DEMENTIA IN OTHER DISEASES CLASSIFIED ELSEWHERE, UNSPECIFIED SEVERITY, WITHOUT BEHAVIORAL DISTURBANCE, PSYCHOTIC DISTURBANCE, MOOD DISTURBANCE, AND ANXIETY. Current care plans included, but were not limited to, The resident is on antipsychotic medication therapy R/T [related to] trouble sleeping and dementia. During an interview on 5/16/24 at 10:31 A.M., the Director of Nursing (DON) indicated dementia is not an acceptable diagnosis for an antipsychotic. 2. On 5/15/24 at 2:28 P.M., Resident 12's clinical record was reviewed. Current diagnoses included, but were not limited to hypertension, diabetes mellitus, anxiety, and depression. The most recent Quarterly and State Optional Minimum Data Set (MDS) Assessment, dated 4/30/24 indicated Resident 12 had moderate cognitive impairment and received an antianxiety medication. Current Physician Orders included, but were not limited to, LORazepam [sic] [antianxiety] Tablet 0.5 MG. Give 1 tablet by mouth every 4 hours as needed for Restlessness . start date, 11/29/22. A review of the April and May Medication Administration Record (MAR) indicated Resident 12 received Lorazepam on 4/21/24 and 5/5/24. 38770 3. On 5/14/24 at 2:49 P.M., Resident 14's clinical record was reviewed. Diagnosis included, but were not limited to, dementia, anxiety, and psychotic disorder. The most recent Quarterly MDS Assessment, dated 5/7/24, indicated a severe cognitive impairment, and resident was taking an antianxiety medication. Current physician orders included, but were not limited to: Ativan Oral Tablet 0.5 MG (milligrams) Give 0.5 mg by mouth every 12 hours as needed for increased anxiety, dated 3/25/24. No stop date was documented for the medication. 46882 4. On 5/14/24 at 3:18 P.M., Resident 3's clinical records were reviewed. Diagnosis included, but were not limited to cerebral ischemia, depression, cerebral infarction, and occlusion and stenosis of bilateral carotid arteries. The most current Quarterly MDS (Minimum Data Set) Assessment and State Optional MDS, dated [DATE], indicated Resident 3 was cognitively moderately impaired, and required extensive assistance of two for bed mobility, transfers, and toilet use. Current physician's orders included, but were not limited to the following: lorazepam oral tablet 0.5 MG (milligram) Give 0.5 mg by mouth every 2 hours as needed for anxiety, dated 2/7/2024 Admit to [name of company] hospice with Dx (diagnosis) of I67.82 (cerebral ischemia), dated 2/7/2024 5. On 5/14/24 at 1:54 P.M., Resident 45's clinical records were reviewed. Diagnosis included, but were not limited to, macular degeneration, chronic combined systolic and diastolic heart failure, Sjogren's Syndrome. The most current Quarterly MDS (Minimum Data Set) Assessment and State Optional MDS, dated [DATE], indicated Resident 45 was cognitively intact and required extensive assistance of two for bed mobility, transfers and toilet use, used oxygen and was on hospice, and had physical restraints, bed rails used daily. Current physician orders included, but were not limited to the following: [name of company] hospice to eval. (evaluate), dated 2/29/2024 lorazepam oral tablet 0.5 MG Give 0.5 mg by mouth every 30 minutes as needed for pain/restlessness, dated 3/1/2024 46416 6. On 5/14/24 at 1:41 P.M., Resident 19's clinical record was reviewed. Diagnoses included, but were not limited to, anxiety and atherosclerotic heart disease. The most recent Quarterly MDS Assessment, dated 4/10/24, indicated resident was cognitively intact, an extensive assist of 1 staff for bed mobility, transfers, toileting, and taking an antianxiety medication. Current Physician's Orders included, but were not limited to, the following: lorazepam (antianxiety) 0.5 mg (milligram), Give 1 tablet by mouth every 2 hours as needed for anxiety , ordered 4/4/24 A current Black Box Warning (the highest safety- related warning that medications can have assigned by the Food and Drug Administration) Care Plan, dated 1/13/24, included, but was not limited to, the following intervention: Black box warning: Lorazepam, initiated 1/13/24 The MAR for April 2024 was reviewed and indicated Resident 19 was administered lorazepam from the as needed order on 4/11/24, 4/17/24, and 4/24/24. The May 2024 MAR was reviewed and indicated Resident 19 was administered lorazepam from the as needed order on 5/15/24. During an interview on 5/16/24 9:52 A.M., the DON indicated PRN (as needed anti-anxieties should only be scheduled for 14 days. On 5/17/24 at 1:27 P.M., a current Psychotropic Medication Use Policy, revised July 2022, was provided by the Administrator and indicated . 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 . If the prescriber or attending physician believes it is appropriate to extend the PRN order beyond 14 days, he or she will document the rationale for extending the use and include the duration for the PRN order . 3.1-48(a)(2) 3.1-48(a)(4)(6)

Based on observation, interview and record review, the facility failed to maintain safe and secure storage of medications for 3 of 4 medication carts observed and 1 of 3 medication storage rooms observed. Loose pills were observed in the medication carts, and refrigerator temperature logs were not filled out completely in the medication room. Findings include: 1. On 5/17/24 at 8:44 A.M., the medication cart on the PARF (Therapy to Home) Hall was reviewed. The medication cart was observed with the following loose pills in the drawers: 1 small oval white pill At that time, LPN (Licensed Practical Nurse) 19 indicated nurses on nights were supposed to go through the medication cart to make sure it was clean. She indicated she did it when she was here also. Pharmacy came once a month to review the carts. On 5/17/24 at 9:50 A.M., 300 Hall medication cart was reviewed. The medication cart was observed with the following loose pills in the drawers: 1 oblong white pill with L484 on one side 1 small oval white pill with 15 on one side 1 small oval white pill with 316g on one side At that time, LPN 37 indicated she only worked weekends and was not sure when medication carts were cleaned. She indicated she did clean paper out of the medication cart. On 5/17/24 at 9:59 A.M., the 200 Hall medication cart was reviewed. The medication cart was observed with the following loose pills in the drawers: 1 round red pill with ph32 on one side 1 rectangular white pill with 10 on one side CTN on other side At that time, LPN 18 indicated pharmacy came at least once a month and checked medication carts. She indicated she checked the carts when she worked. 2. On 5/17/24 at 10:15 A.M., the Med room [ROOM NUMBER]-300 Hall on Crossroads was reviewed. The temperature log for the supplement fridge was missing a temperature for 5/14/24 P.M., 5/15/24, 5/16/24, and 5/17/24. The temperature log for the medication fridge was missing a temperature for 5/15/24 P.M., 5/16/24, and 5/17/24 A.M. At that time, LPN 18 indicated night shift usually checked temperatures. The following medications were observed sitting on the counter in the medication room: 2 bottles of Miralax and 2 bottles of geri-tussin DM (dextromethorphan and guaifenesin) for a resident discharged on [DATE]. At that time, LPN 18 indicated she was not sure why the medications were sitting there. She indicated they could not be sent back to pharmacy and had to be destroyed. On 5/17/24 at 11:47 A.M., the DON (Director of Nursing) provided at Storage of Medications policy, revised November 2020, that indicated .2. Drugs and biologicals are stored in the packaging, containers or other dispensing systems in which they are received. 3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner . On 5/20/24 at 9:29 A.M., the Clinical Care Leader provided a Refrigerator and Freezer policy, revised December 2014, which indicated . 2. Monthly tracking sheets for all refrigerators and freezers will be posted to record temperatures . 3.1-25(m) 3.1-25(r)

Based on observation, interview, and record review, the facility failed to ensure distribution and food service was provided in accordance with professional standards for food service safety for 2 of 2 meals observed, and 1 of 1 meal services observed in the kitchen. (Main Kitchen, Locked Unit Dining Room) Findings include: During a lunch observation on 5/13/24 from 11:56 A.M. through 12:02 P.M., Qualified Medication Aide (QMA) 3 was observed taking cookies out of the packaging with bare hands, and placing on the food trays to serve to the residents. Certified Nurse Aide (CNA) 5 was observed to also touch cookies with bare hands before serving to residents. On 5/16/24 at 10:36 A.M., a meal service was being observed in the kitchen. While preparing the cups and utensils, Dietary Aide 21 was observed transferring coffee mugs with bare hands to the trays touching the insides of the mugs. Dietary Aide 21 was also observed touching the inside lids of the handled cups with bare hands before filling them with drinks. On 5/16/24 at 2:49 P.M., the Kitchen Manager indicated staff was not supposed to handle cups by the inside or underside of lids, and should not have been handling food with bare hands during meal service. During a breakfast observation on 5/20/24 at 7:50 A.M., QMA 3 was observed to touch toast with bare hands while applying jelly to them before serving to the residents. On 5/17/24 at 10:30 A.M., a current Food Preparation and Service policy, dated 4/2019, was provided and indicated Food preparation staff adhere to proper hygiene and sanitary practices to prevent the spread of food-borne illness . Bare hand contact with food is prohibited. Gloves are worn when handling food directly and changed between tasks 3.1-21(i)(2) 3.1-21(i)(3)

Based on interview, and record review, the facility failed to properly document influenza and pneumococcal vaccines being offered to residents for 3 of 5 residents reviewed for influenza and pneumococcal vaccination. Clinical records lacked the vaccine consent/refusal date, the reason why it was refused, and a date education was provided to the resident and/or resident representative. (Resident 19, Resident 4, Resident 36) Findings include: 1. On 5/14/24 at 1:41 P.M., Resident 19's clinical record was reviewed. Diagnoses included, but were not limited to, anxiety and atherosclerotic heart disease. The most recent Quarterly MDS Assessment, dated 4/10/24, indicated resident was cognitively intact. Resident 19 was [AGE] years old and was admitted to the facility on [DATE]. Resident 19's immunization history was reviewed for his influenza and pneumonia vaccination status. The following vaccination lacked documentation of a refusal date, the reason why it was refused, and a date education was provided to the resident and/or resident representative: Influenza 2. On 5/13/24 at 2:30 P.M., Resident 4's clinical record was reviewed. Diagnoses included, but were not limited to, anxiety and depression. The most recent Quarterly MDS Assessment, dated 2/14/24, indicated Resident 4 was cognitively intact. Resident 4 was [AGE] years old and was admitted to the facility on [DATE]. Resident 4's immunization history was reviewed for her influenza and pneumonia vaccination status. The following vaccinations lacked documentation of a consent/refusal date, the reason why it was refused, and a date education was provided to the resident and/or resident representative: Pneumococcal Polysaccharide (PPSV23)-Refused Pneumococcal Conjugated (PCV13)-no record of consent to administer or refusal 3. On 5/14/24 at 2:38 P.M., Resident 36's clinical record was reviewed. Diagnoses included, but were not limited to, Parkinson's disease. The most recent Annual MDS Assessment, dated 3/14/24 indicated Resident 36 was cognitively intact. Resident 36 was [AGE] years old and admitted to the facility on [DATE]. Resident 36's immunization history was reviewed for her influenza and pneumonia vaccination status. The following vaccinations lacked documentation of a consent/refusal date, the reason why it was refused, and a date education was provided to the resident and/or resident representative: Influenza-no record of consent to administer or refusal Pneumococcal Conjugated (PCV13)-no record of consent to administer or refusal During an interview on 5/20/24 at 2:49 P.M., the Infection Preventionist (IP) indicated that newly admitted residents should have the influenza and pneumococcal vaccines offered to them at admission and the other residents were usually offered prior to the influenza season annually. The pharmacy they use, would usually tell her if a resident was due for a pneumococcal vaccine and they would even come into the facility and give the vaccine if needed. During an interview on 5/21/24 at 9:30 A.M., the IP indicated all 4 of the residents refused vaccines but the reason and education given was not clearly documented. She indicated the consent/refusal forms should have been completed and scanned into the clinical record. On 5/13/24 at 11:50 A.M., a current Resident Immunizations Policy, revised 3/8/22, was provided by the Administrator and indicated . Purpose [is] to provide residents and clients the opportunity to receive immunizations as they fit into their healthcare goals [and] to provide guidance for the location's immunization program including recommended vaccinations. Upon admission, each client, resident and/or resident representative will receive the Vaccination Information Statements (VIS) for influenza and pneumococcal vaccines . review current vaccinations and provide and document education on the benefits and potential side effects of the vaccinations for which the client/resident is eligible . If the client, resident and/or resident representative consent to vaccination, obtain written consent if required by state regulation or if written consent is not required, obtain and document verbal consent .complete screening questions prior to administering vaccination . administer vaccination or refer to Provider or Pharmacy for vaccine administration . if the resident and/or resident representative chooses not to be vaccinated after discussion of benefits, document declination . residents will be reviewed for vaccine eligibility annually or when the Adult Immunization Schedule changes . education, consent, and screening are required prior to administration of each dose of any vaccine given . 3.1-13(a)

Based on observation, interview, and record review, the facility failed to ensure a safe, functional, sanitary, and comfortable environment for residents for 2 of 5 halls observed, and 1 of 1 common area observed. (Locked Unit, room [ROOM NUMBER] ) Findings include: 1. On 5/14/24 at 11:02 A.M., the bathroom vent in room [ROOM NUMBER] was observed caked with dust. On 5/20/24 at 8:07 A.M., the same was observed. 2. On 5/14/24 at 11:12 A.M., the bathroom vent in room [ROOM NUMBER] was observed caked with dust, and an unlabeled tube of zinc oxide was observed on the back of the toilet. The back of the room door was observed with a metal strip coming away from the door. On 5/20/24 at 8:15 A.M., the same was observed. 3. On 5/14/24 at 11:06 A.M., the bathroom door of room [ROOM NUMBER] was observed with scuff marks, chipping away at the door, and the room floor was sticky. On 5/20/24 at 8:14 A.M., the bathroom in room [ROOM NUMBER] was the same. The floor was not sticky. 4. On 5/14/24 at 10:49 A.M., the grab bar behind the toilet in room [ROOM NUMBER] was observed with a loose fastener on the right side not attached to the wall. The vent in the bathroom was caked with dust. On 5/20/24 at 8:12 A.M., the same was observed in room [ROOM NUMBER]. A stack of uncovered briefs was observed sitting on the back of the toilet. 5. On 5/14/24 at 10:57 A.M., two unlabeled and uncovered toothbrushes were observed on the shared bathroom sink in room [ROOM NUMBER] in a cup. A denture cream tube and two tubes of toothpaste were observed on the sink unlabeled. Scuff marks were observed on the bottom of the bathroom door. On 5/20/24 at 8:11 A.M., the same was observed, but the denture cream tube and toothpaste had been put up in the cabinet. 6. On 5/14/24 at 11:08 A.M., room [ROOM NUMBER] was observed to be shared by two residents. The call light box had one call light attached to it, and the cord was observed wrapped on one of the beds. No call light was observed for the other side of the room. The bathroom was observed with clean briefs on the back of the toilet, uncovered. On 5/20/24 at 8:13 A.M., the same was observed. 7. On 5/13/24 at 11:30 A.M., the common area in the locked unit was observed with a register under the window that was missing the cover on the bottom with exposed wires. On 5/20/24 at 8:23 A.M., the same was observed. 8. On 5/20/24 at 8:23 A.M., a chair seat in the common are of the locked unit was observed not attached to the legs. 45933 9. During an observation on 5/13/24 at 2:06 P.M., room [ROOM NUMBER] had paint chipped off in multiple areas around the door frame to the bathroom, and the inside of the bathroom door had a large chipped area on the bottom. On 5/20/24 at 11:50 A.M., the same was observer in room [ROOM NUMBER]. During an interview on 5/20/24 at 2:22 P.M., the Maintenance Director indicated staff should tell him when there is an issue with the environment or put in a work order. On 5/20/24 at 1:35 P.M., the Administrator provided a current Homelike Environment policy, revised February 2021 that indicated, Residents are provided with a safe, clean, comfortable environment .2. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting . 3.1-19(f)(5)

Based on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity for 2 of 2 random observations. A staff member was observed standing while assisting to feed a resident, and a staff member walked away from a resident with visible urine under her chair. (Resident 27, Resident 48) Findings include: 1. On 5/13/24 at 12:02 P.M., Certified Nurse Aide (CNA) 5 was observed standing next to Resident 27 while assisting to feed the resident. 45933 2. During an observation on 5/13/24 at 11:19 A.M., Resident 48 was observed eating in the dining room with a large wet spot under her wheelchair. On 5/13/24 at 11:28 A.M., Licensed Practical Nurse (LPN) 14 sat Resident 48's meal tray in front of her and walked away. During an interview on 5/13/24 at 11:34 A.M., LPN 14 indicated the wet spot was urine. During an interview on 5/16/24 at 4:14 P.M., the Director of Nursing (DON) indicated if a resident was observed with a wet spot under their wheelchair that she would expect staff to bring the resident back to their room and provide care, and then the wet spot and the chair should be cleaned. On 5/16/24 at 2:49 P.M., the Kitchen Manager indicated staff was supposed to sit next to residents while assisting to feed them. On 5/17/24 at 10:30 A.M., a current Assistance with Meals policy, dated 3/2022, was provided and indicated Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example: a. not standing over residents while assisting them with meals On 5/20/24 at 1:35 P.M., the Administrator provided an undated Dignity policy that indicated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem .5. When assisting with care, residents are supported in exercising their rights. For example, residents are: e. provided with a dignified dining experience. 3.1-3(t)

Based on observation and interview the facility failed to provide services based on resident preferences for 1 of 5 residents reviewed. The facility failed to provide ice water to one resident when requested. (Resident 45) Findings include: During an interview on 5/14/24 at 9:39 A.M., Resident 45 indicated she didn't get water unless she asked. During an observation on 5/15/24 at 1:37 P.M., CNA (Certified Nurse Aide) 38 assisted Resident 45 from the commode to her recliner. CNA 38 put the bedside table in front of Resident 45 explaining where her cup of lemonade and box of Kleenex were located. She told Resident 45 her water cup only had a small amount of water in it and asked if she would like the cup filled up. Resident 45 told her yes. During an observation on 5/15/24 at 3:16 P.M., Resident 45's water cup had not been filled up. On 5/14/24 at 1:54 P.M., Resident 45's clinical records were reviewed. Diagnosis included, but were not limited to macular degeneration, chronic combined systolic and diastolic heart failure, Sjogren's Syndrome. The most current Quarterly, State Optional MDS (Minimum Data Set) Assessment, dated 4/17/2024, indicated Resident 45 was cognitively intact and required extensive assistance of two for bed mobility, transfers and toilet use, used oxygen and was on hospice. During an interview on 5/17/24 at 1:27 P.M., LPN 19 indicated ice water was not routinely passed, the residents have to ask for it. When she went into a resident's room and saw an empty cup, she would fill it up. On 5/20/24 at 8:57 A.M., the DON (Director of Nursing) provided a current Resident Hydration and Prevention of Dehydration policy, revised October 2017, which indicated This facility will strive to provide adequate hydration and to prevent and treat dehydration . On 5/20/24 at 8:57 A.M., the DON provided a current Accommodation of Needs policy, revised March 2021, which indicated .1. The resident's individual needs and preferences are accommodated to the extent possible, except when the health and safety of the individual or other residents would be endangered . 3.1-3(v)(1) 3.1-46(b)

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 2 of 2 residents reviewed for accidents. Care plan interventions were not followed or updated after falls, and one random observation of a treatment cart containing prescription medication was observed left unlocked and unattended. This deficient practice resulted in Resident 44 having 9 falls in 11 months resulting in three fractures. (Resident 44, Resident 28, Treatment Cart) Findings include: 1. During an interview on 2/1/23 at 9:21 A.M., CNA (Certified Nurse Aide) 73 indicated Resident 44 falls a lot. Resident's bed was observed in low position against the wall, with padded mat rolled up and stacked against the head of the bed. Resident was out of her room. On 2/2/23, Resident 44's clinical record was reviewed. Diagnoses included, but were not limited to, fracture of unspecified part of neck of right femur, type 2 diabetes, cognitive communication deficit, unspecified abnormalities of gait and mobility, and vascular dementia. The most recent significant change MDS (Minimum Data Set) assessment, dated 12/27/22, indicated resident has severe cognitive impairment and requires extensive assistance with bed mobility, transfers, toileting, limited assistance with eating, and is totally dependent for bathing. Resident is frequently incontinent of bowel and bladder but is not on a toileting plan. Care plan included, but were not limited to, the following: Resident is at risk for falls related to impaired mobility, weakness, dementia, decreased safety awareness, history of CVA (cardiovascular accident), osteoarthritis, and osteoporosis. Interventions included, but were not limited to, the following: Encourage use of grabber or ask for assistance (revised 3/4/22) Review bowel and bladder continence status and establish and/or review toileting plan based on resident's needs (revised 10/4/22) Fall events from 2/17/22 (admitted ) through 1/14/23 indicated Resident 44 experienced the following 9 (nine) falls: Fall 1 On 3/19/22 at 4:10 A.M., resident was found lying on her back in the middle of the floor in her room. Resident was confused and unable to tell staff what happened, just said, there's a girl over there but she's gone now. Full body assessment completed. Resident was assisted into bed with the assistance of 2 staff using a lift. Neurochecks were conducted: 3/19/22 at 4:10 A.M., 4:40 A.M., 5:10 A.M., 5:40 A.M., 2:15 P.M., 8:32 P.M. 3/20/22 1:01 A.M., 1:45 P.M., 7:36 P.M. 3/21/22 2:23 A.M., 10:06 A.M. No new intervention to care plan. Fall 2 On 5/17/22 at 6:47 A.M., the resident was found on the floor of her room. Resident stated, I was trying to go to the bathroom. and stated it hurt while her hand was resting on her left hip. Resident was oriented to person. Physician was notified and order was received to send resident to emergency room for evaluation. Resident was sent to the hospital, where she was diagnosed with a displaced intertrochanteric fracture of left femur and underwent surgery for a Gamma nail fixation of the fracture. She was discharged from the hospital back to the facility on [DATE] at 12:51 P.M. One new intervention was added to care plan:ensure that resident is wearing appropriate footwear (fully-enclosed slip-resistant shoes, footwear color contrast with floor) when mobilizing in wheelchair (revised 5/19/22). No documentation neurochecks was found. Fall 3 On 6/22/22 at 9:45 P.M., Resident 44 had an unwitnessed fall; staff member observed resident on floor lying prone on her left side. Hematoma noted on forehead and bruise on left arm. Vital signs were assessed. Resident was oriented to person. Resident was assisted to bed with assistance of 2 staff. Physician was notified, no new orders. Neurochecks were conducted: 6/22/22 9:45 P.M. 6/23/22 10:45 A.M., 4:15 P.M. 6/24/22 2:30 A.M., 9:55 A.M., 5:00 P.M. 6/25/22 midnight, 8:56 A.M., 4:31 P.M. 6/26 at 9:46 A.M., 9:46 P.M. No new interventions to care plan. Fall 4 On 7/5/22 at 2:20 P.M., Resident 44's motion sensor alarmed, and resident was found lying on left side on the floor, talking about a man and a baby. Resident complained of pain in left shoulder. Resident was oriented to person and incontinent. Physician was in the building and ordered X-ray. (Results of X-ray were documented after another fall later that same night). Resident was placed back in bed using lift. Neurochecks were conducted; 7/5/22 2:20 P.M., 2:50 P.M., 3:20 P.M., 3:50 P.M., 4:20 P.M. No new interventions were added to care plan. Fall 5 On 7/5/22 at 10:35 P.M., Resident 44 was standing in the hallway outside her room. Staff attempted to assist her back to bed; however, resident fell forward, then sideways, and landed on her right side, then rolled over to her back. Resident was oriented to person. Physical assessment was done. The record lacked documentation of physician notification or x-ray results. No orders. Neurochecks were conducted: 7/5/22 10:35 P.M., 11:00 P.M., and 11:30 P.M. 7/6/22 midnight, 12:30 A.M., 8:00 A.M., 3:34 P.M. 7/7/22 5:11 A.M., 1:15 P.M., 7:00 P.M. 7/8/22 1:12 P.M., 8:27 P.M. Resident had previous non-displaced fx [fracture] of left clavicle from previous fall earlier in day. Resident was assisted back to bed by nursing staff with lift. No new interventions were added to care plan. A new order for occupational therapy was initiated on 7/26/22; a new order for physical therapy was initiated on 7/27/22. Fall 6 On 8/30/22 at 12:45 A.M. CNA heard thud and entered Resident 44's room. Resident was found resident sitting between the headboard of the bed and wall of the closet, upper back/head/neck against the wall and lower back and buttocks flat against the floor, knees folded up and feet flat on the floor. Head struck wall and left crater in plaster on the wall. Resident did not land on floor mat. Red spot on scalp where head struck the wall. Resident was oriented to person and incontinent. The record lacked record of MD notification following fall. Resident was sent to emergency room due to potential for head injury. Neurochecks conducted prior to hospital visit: 8/30/22 12:45 A.M.,1:15 A.M. Resident was transferred via ambulance to emergency room due to potential head injury. Resident had physical assessment by physician, urinalysis, CT scan of the head and cervical spine, X-ray and CT scan of lumbar spine, all of which showed no acute fractures. Resident was discharged from the emergency room at 4:53 A.M. Neurochecks were conducted after return to the nursing home: 8/30/22 10:45 A.M. 8/31/22 1:16 A.M. No new interventions were added to the care plan. Fall 7 On 10/20/22 at 4:30 A.M., Resident 44 had an unwitnessed fall. A staff member found the resident lying on her right side on the floor pad next to bed. Resident was assisted back to bed with assistance of 2 staff. Bruising was noted on right arm, vital signs were within normal limits. Resident was oriented to person and incontinent. Resident was assisted back to bed with assistance of 2 staff. Neuro checks were conducted: 10/20/22 4:30 A.M. and 12:09 P.M. 10/21/22 3:40 A.M., 4:10 A.M., 4:40 A.M., 7:00 P.M. 10/22/22 3:00 A.M., 11:00 A.M. No new interventions were added to care plan. Fall 8 On 12/10/22 at 6:00 A.M., Resident 44 was found by a CNA on the floor beside her bed. Bed was in low position and floor mat in place. Resident denied pain or discomfort, no signs or symptoms of pain noted. Resident was transferred to a wheelchair and was assessed for injuries. Resident was confused. Neuro checks were conducted: 12/10/22 6:00 A.M., 6:30 A.M., 7:00 A.M., 7:30 A.M., 8:00 A.M., 2:00 P.M. 12/12/22 12:31 A.M., 8:31 A.M. A new order for occupational therapy and physical therapy were put into place the day prior to the fall, on 12/9/22. No new interventions were added to resident's care plan. Fall 9 Progess notes indicated that Resident 44 fell on [DATE]. At that time, she was given pain medication and assisted back to to bed. Resident 44 continued to complain of pain and an X-Ray was ordered on 1/16/23. The resident was sent to the hospital on 1/16/23, where she was found to have a fracture of unspecified part of neck of right femur, which was surgically repaired at the hospital. Documentation of neuro checks were requested from DON (Director of Nursing) and not received. No new interventions were added to care plan. During an interview on 2/3/23 at 1:47 P.M., the SSD (Social Services Director) indicated no knowledge of what staff were doing to keep Resident 44 from falling. She described the resident as very impulsive and capable of things you wouldn't think she would be capable of. During an interview on 2/3/23 at 1:39 P.M. with the DON (Director of Nursing), she indicated no knowledge of what staff were doing to keep Resident 44 from falling. She pulled up the resident's care plan on the computer and indicated that the interventions were going well until the incident on 12/10/22. During an observation of Resident 44's room on 2/6/23 at 2:12 P.M. with CNA 6, no grabber was observed in the room. At that time, CNA 6 indicated she was not sure Resident 44 would know how to use a grabber. 2. On 2/1/23 at 2:01 P.M., Resident 28's clinical record was reviewed. Diagnosis included, but were not limited to, Alzheimer's, dementia, anxiety, and depression. The most recent significant change MDS (minimum data set) Assessment, dated 12/4/22, indicated Resident 28 had a severe cognitive impairment, required extensive assistance of 1 (one) staff for eating, and extensive assistance of 2 (two) staff for bed mobility, transfers, and toileting. The MDS indicated Resident 28 had 2 (two) or more falls since admission or prior assessment with no injury. Care plans included, but were not limited to the following: Risk for falls related to confusion and history of falls, dated and last revised 10/24/22. Resident has had an actual fall with no injuries related to history of falls and poor balance, dated 11/8/22, and last revised 11/9/22. Interventions included, but were not limited to: Ensure resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair (revised 11/9/22), dycem in wheelchair (revised 11/9/22). Fall Events from 10/21/22 (admitted ) through 1/22/23, indicated Resident 28 experienced the following 8 (eight) falls: Fall 1 10/22/22 12:30 P.M. Resident was attempting to get out of a recliner in the dining room, lost balance and fell on her bottom. A CNA (certified nursing aide) witnessed the fall, but was not able to get to the resident in time to prevent the fall. The nurse was not on the floor at the time of the fall. The record lacked documentation of whether the resident hit her head or not. Neuro checks were not initiated at the time of the fall. Resident 28 had neuro checks performed on 10/23/22 at 3:09 P.M., and again on 10/24/22 at 5:43 P.M. A falls care plan was not in place at the time of the fall. Fall 2 10/24/22 7:05 P.M. Resident fell into a heater getting up out of her chair and landed on knees. A CNA witnessed the fall and indicated resident did not hit her head. A risk for falls care plan was initiated that day. Fall 3 10/25/22 7:50 P.M. Resident observed sitting on the floor in front of recliner. Fall was unwitnessed. Neuro checks were initiated and completed at the following times: 10/25/22 7:50 P.M., 8:20 P.M., 9:20 P.M., 9:50 P.M. 10/26/22 3:00 A.M., 9:30 A.M. 10/27/22 1:00 P.M., 8:00 P.M. 10/28/22 3:00 A.M, 9:48 A.M. The risk for falls care plan lacked an updated intervention following fall. Fall 4 11/7/22 6:33 P.M. Resident slipped out of wheelchair while staff assisting to the bathroom. The record lacked documentation of whether the resident hit her head or not. A neuro check was completed 10/7/22 at 6:41 P.M. The clinical record lacked documentation of any other neuro checks following fall. A care plan for falls was initiated 11/8/22 that included, but was not limited to an intervention for dycem to be placed in the wheelchair. Fall 5 11/12/22 6:15 P.M. Resident was found sitting in the floor next to wheelchair in the dining room. The falls note indicated It looks like the resident slipped out of her chair Neuro checks were initiated and completed at the following times: 11/12/22 6:15 P.M., 6:45 P.M. 11/13/22 1:35 A.M., 12:30 P.M., 5:01 P.M. 11/14/22 6:00 A.M. 11/15/22 1:20 A.M., 9:00 A.M., 6:00 P.M. The falls care plan lacked an updated intervention following fall. Fall 6 11/18/22 10:30 A.M. While in therapy, resident fell forward out of wheelchair, and landed on the floor hitting the right side of her head. Neuro checks performed after the fall revealed uneven pupils and nonreactive to light. Resident was sent to the ER (emergency room ), and discharged same day at 3:48 P.M. Scans performed at the hospital revealed no injury. Neuro checks after the fall were completed at the following times: 11/18/22 10:30 A.M., 4:15 P.M. 11/19/22 9:07 A.M. 11/20/22 12:15 A.M., 9:56 A.M. 11/21/22 12:12 A.M., 10:04 A.M., 5:32 P.M. The falls care plan lacked an updated intervention following fall. Fall 7 12/21/22 4:40 P.M. Resident found sitting on the dining room floor in front of wheelchair. Resident indicated at that time she had to go to the bathroom. Neuro checks were initiated and completed at the following times: 12/21/22 4:40 P.M., 5:40 P.M., 6:10 P.M. 12/22/22 6:32 A.M. The falls care plan lacked an updated intervention following fall. Fall 8 1/22/23 7:24 P.M. Resident found lying on the floor in the hallway. Resident was sitting on buttocks up against the hallway double doors. Resident had no walker nearby. Neuro checks were initiated and completed at the following times: 1/22/23 7:24 P.M., 7:54 P.M., 8:24 P.M., 8:54 P.M., 9:24 P.M. 1/23/23 4:51 A.M., 1:17 P.M. 1/24/23 2:21 A.M., 10:30 A.M. 1/25/23 4:30 A.M., 10:28 A.M. An IDT (Interdisciplinary Team) note, dated 1/23/23 indicated the fall was reviewed and new intervention was to keep walker within reach. The falls care plan lacked an updated intervention following fall. On 2/2/23 at 9:03 A.M., Resident 28 was observed sitting at the dining room table in a wheelchair. Resident 28 had nonskid socks on that were upside down with the slick portion of the sock on the bottom on the feet. On 2/2/23 at 1:54 P.M., CNA 3 and RN (registered nurse) 5 were observed to assist Resident 28 from a wheelchair to the recliner. After transferring, the wheelchair was observed with no dycem. At that time, RN 5 indicated she was unaware of Resident 28 having dycem in her wheelchair, and that it wouldn't help the resident if it was in the wheelchair. On 2/3/23 at 10:46 A.M., Resident 28 was observed sitting in the common area in a recliner with her feet up. A walker was not in reach, and her wheelchair was observed across the room at the opening of the hallway across from the shower room. On 2/3/23 at 11:48 A.M., CNA 7 and CNA 9 were observed to transfer Resident 28 from a recliner to a wheelchair. There was no dycem observed in the wheelchair. Resident 28's socks were observed twisted with the slick side down during the transfer. On 2/6/23 at 9:11 A.M., Resident 28 was observed sitting at a table in the dining room. A walker was not observed within reach of the resident. 3. On 2/7/23 from 1:41 P.M. until 2:35 P.M., a treatment cart was observed sitting in the hallway just before the 200 Hall across from the nurses station. During that time, the following was observed: LPN (Licensed Practical Nurse) 25 walked past the treatment cart and into the nurses station Resident 25 was observed sitting in a wheelchair by the nurses station with no other staff present by the treatment cart CNA 27 walked past the treatment cart and onto the 200 Hall LPN 25 walked past the treatment cart and onto the 200 Hall to the medication cart 2 (two) doors down Housekeeper 64 walked past the treatment cart CNA 27 walked past the treatment cart leaving the 200 Hall The activities director was observed to push Resident 44 past the treatment cart and onto the 200 Hall, then was observed walking past the treatment cart to leave the 200 Hall Housekeeper 64 and Housekeeper 71 walked past the treatment cart The staffing coordinator walked past the treatment cart entering the 200 Hall and again leaving the 200 Hall Resident 17 walked past the treatment cart using a walker Resident 35 wheeled self past the treatment cart in a wheelchair CNA 27 walked past the treatment cart On 2/7/23 at 2:35 P.M., the treatment cart was observed with RN (Registered Nurse) 55. The treatment cart contained the following: Dressings (for treatments), plastic vials of normal saline, swabs, bandages, alcohol pads, fingernail clippers, 2 (two) lotion bottles with prescription labels on them with resident information, and 21 containers of creams all with prescription labels on them with resident information. At that time, RN 55 indicated the treatment cart was supposed to be locked at all times when not in use. During an interview on 2/6/23 at 12:54 P.M., the Administrator indicated the policy of the facility was to follow interventions listed in the resident care plan, and the staff was expected to do so. On 2/6/23 at 11:28 A.M., a current Falls Resource policy, dated 3/30/22, was provided and indicated Fall reduction efforts include: . implement interventions to reduce falls. Education regarding: . Safe and proper use of any assistive device (wheelchair, walker, etc.) The policy indicated after a fall, complete neuro checks, and to check the care plan to determine if the cause of the fall was addressed and if not effective, revise the care plan with a new goal. On 2/7/23 at 3:27 P.M., a current Medications: Acquisition Receiving Dispensing and Storage policy, dated 2/8/22, was provided and indicated Medications will be stored in a locked medication cart, drawer or cupboard At that time, the Administrator indicated the policy was for medication carts as well as treatment carts. 3.1-45(a) 38770

Based on observation, interview, and record review, the facility failed to ensure 2 staff members were present during the transfer of a dependent resident with a mechanical lift, resulting in a fall with multiple fractures of bilateral feet, for 1 of 4 residents reviewed for falls. (Resident B) Findings include: On 1/20/22 at 9:50 A.M., RN 1 indicated Resident B had recently fallen. On 1/20/22 at 9:55 A.M., Resident B was observed lying in bed. Staff were providing care. The resident was non-verbal. On 1/20/22 at 12:00 P.M., the clinical record of Resident B was reviewed. Diagnoses included, but were not limited to, Alzheimer's disease. A care plan, dated 4/10/19 and updated 10/6/21, indicated, The resident has an ADL [activities of daily living] self care performance deficit R/T [related to] loss of mobility, weakness, OA [[CONDITION(S)]], dementia .E/B [evidenced by] requires assist of staff with ADL care tasks. The Interventions included: Transfer: Resident transfers with Ultra lift [mechanical lift] and two assist. An additional care plan, initially dated 4/22/19 and updated 10/6/21, indicated, The resident has limited physical mobility R/T OA, pain, overall physical condition E/B transfers per Ultra lift, does not walk, wheelchair for locomotion. The Interventions included, Weight Bearing: Resident does not walk, transfers per Ultra lift. A quarterly Minimum Data Set (MDS) assessment, dated 10/12/21, indicated Resident B had moderately impaired cognition, and required extensive assistance of two or more staff to transfer. The resident did not ambulate. Nurses notes included the following notations: 12/25/21 at 8:40 P.M.: CNA [certified nurse aide] came to this nurse and stated resident fell on the floor. This nurse went into residents [sic] room and found her lying on her right side and c/o [complained of] right leg and right arm pain. Cna stated resident slid out of mechanical lift using a full pad during transferring .Resident alert and crying at this time The resident was transferred to the hospital on 12/25/21 at 9:00 P.M. A hospital emergency room report, dated 12/25/21 at 9:36 P.M., included: The patient presents to the emergency department with concerns for injury after a fall. Patient reportedly fell 4 ft from a Hoyer [mechanical] lift. She has pain in her bilateral lower legs. She complains of pain in her neck because of her positioning .Patient arrives by way of [ambulance service] for evaluation after fall at [name of facility]. Long term care facility. Facility nurse reports patient fell from Hoyer lift to the floor today just prior to arrival. Nurse reports patient is pleasantly confused at baseline. Reports patient fell on her right side. Patient complains she is unable to move her legs . X-ray results indicated the resident received fractures of the right foot at the 3rd metatarsal [foot bone], 4th metatarsal and 5th metatarsal; and fractures of the left foot at the 1st metatarsal, 2nd metatarsal, and 3rd metatarsal. On 1/20/22 at 2:10 P.M., a family member of Resident B was interviewed. The family member indicated she received a call from the facility on 12/25/21, and was informed that Resident B had fallen out of the lift. When she asked how that happened, the staff member informed her there was supposed to be 2 people transferring her, and there was only 1. On 1/20/22 at 2:40 P.M., LPN 1 was interviewed. LPN 1 indicated she was working on 12/25/21. CNA 1 informed her that Resident B had fallen out of the lift. LPN 1 found Resident B lying on the floor under the lift. She asked CNA 1 if she was alone, and CNA 1 responded yes. LPN 1 indicated she was worried, and sent the resident to to the hospital as soon as she could. On 1/20/22 at 3:00 P.M., CNA 1 was interviewed. CNA 1 indicated she was transferring Resident B from the wheelchair to the bed with a hoyer lift. She checked all of the loops. The resident was up in the air, and CNA 1 had to move the wheelchair from under the lift. CNA 1 indicated she observed the resident slide out of the lift. She did not know how it happened. She usually transferred residents with mechanical lifts by herself. There were so many residents requiring mechanical lift transfers, so in order to get their work done, the staff had to do it by themselves. On 1/21/22 at 8:55 A.M., the Administrator provided staff Competency Validation Checklists regarding mechanical lift transfers. The Administrator indicated that following Resident B's fall, nursing staff were inserviced and were checked off on mechanical lift transfers. The Safe Resident Handling Equipment Competency Validation Checklist included, Stop, check and verbalize all sling hooks and loops are secure. Check each side of sling, and then have partner cross check opposite side and verbally confirm that all straps are checked and OK At that time, the Administrator provided audit forms, and indicated random audits were performed to ensure 2 staff were present during mechanical lift transfers. On 1/21/22 at 12:04 P.M., the Administrator provided the current facility policy, Safe Resident Handling Program, undated. The policy included, To help ensure that all employees who have contact with lifts are trained and competent in the use of mobility devices .validation checklist is a required competency used to determine competency in the use of mobility equipment .The Care Plan is part of the communication process to the caregiver The Administrator indicated at that time that if a resident requires a mechanical lift, it is documented in the care plan to use the lift with 2 staff members. This Federal tag relates to Complaint IN 694. 3.1-45(a)(2)

Based on interview and record review, the facility failed to ensure a resident was transferred correctly, a staff member grabbed a resident's arm and it resulted in a shoulder fracture, for 1 of 3 residents reviewed requiring assistive devices with transfers, in a sample of 4. Resident A Findings include: The closed clinical record of Resident A was reviewed on 7/25/16 at 10:45 A.M. The resident was admitted to the facility with [DIAGNOSES REDACTED]. An admission assessment, dated 3/15/16, indicated: .Level of Consciousness Alert. The resident is oriented to Person, Place, Time .Mobility Devices, Wheelchair .Balance, Poor trunk control. Gait disturbance/unsteady gait An admission Minimum Data Set (MDS) assessment, dated 3/21/16, indicated Resident A scored a 15 out of 15 for cognition, indicating no memory impairment. The resident required extensive assistance of two+ staff for transfer and toilet use. A test for balance during transitions and walking indicated, Not steady, only able to stabilize with staff assistance while moving from seated to standing position, moving on and off of the toilet, and surface-to-surface transfer. The resident had fallen in the 2-6 months prior to admission, and had a fracture related to a fall. The resident had 1 fall since her admission. A Physical Therapy Progress Note, dated 5/5/16, indicated, .Plan to try some coordination techniques while standing over next week, to improve wt (weight) shift and balance deficits .Pt (patient) noted to have occ lob (loss of balance) posteriorly once standing. Bathroom active with standing tolerance with balance deficits 40% of the time with one UE (upper extremity) support at times, today Nurses Notes included the following notations: 5/8/16 at 4:30 A.M.: Resident alert. Voices all wants et (and) needs. Conts (continues) inhouse PT (physical therapy)/OT (occupational therapy)/ST (speech therapy) services R/T (related to) pelvic fx (fracture) et Parkinsons. Monitoring et assessing gait with slightly unsteady (sic( this shift .Ext (extensive) x 1 assist with gait belt via w/c (wheelchair). Has left sided weakness. Denies pain 5/9/16 at 5:56 P.M.: .Extensive 2 assist for transfers and ADL's (activities of daily living). Unsteady gait. Locomotion by W/C propelled by staff 5/10/16 at 12:02 A.M.: Tramadol HCL tablet 50 mg .c/o (complaints of) left shoulder pain. 5/10/16 at 1:24 A.M.: Resident alert. Voices all wants et needs. Conts inhouse PT/OT/ST therapies as ordered per MD for weakness .Monitoring et assessing gait .Ext x 1 assist with gait belt via w/c with gait unsteady. Left sided weakness. PRN (as needed) Tramadol administered earlier in shift with 0 effectiveness noted thus far in shift 5/10/16 at 2:24 A.M.: Tramadol .PRN Administration was: Ineffective. Resident's left shoulder swollen will administer Tylenol for pain. 5/10/16 at 4:00 A.M.: Acetaminophen .PRN Administration was: Effective. An Occupational Therapy note, dated 5/10/16 at 11:43 A.M., indicated, Upon tx (treatment) initiation pt was being seen by PT. PTA (physical therapist assistant) informed therapist that pt L shoulder has noted edema with pt reporting significant pain of 10/10 stating that she lost balance previous evening during transfer and CNA caught pt by arm to prevent fall A Physical Therapy note, dated 5/10/16 at 12:43 P.M., indicated, Pt. c/o (complains of) 10/10 L (left) shoulder pain this am. Did not use rw (rolling walker) this date due to pain. Assessed L shoulder noting edema (swelling). NS (nurse) notified. Fax sent out to dr. Ice to L shoulder per ns, Tramadol did not help pain pt stated. Last evening pt stated CNA transferring wc to recliner, pt had lob (loss of balance) and CNA caught her with pt's arm Nurses Notes continued: 5/10/16 at 2:17 P.M.: Faxed (name of physician's) office with health status update. Left shoulder pain with swelling unrelieved with Tramadol and Tylenol. 5/10/16 at 4:20 P.M.: New Orders: Ice left shoulder 3x/day 5/10/16 at 7:25 P.M.: (Name of physician) called about x-ray to left shoulder. Tech stated that arm is broken. Dr. recommended to send resident to the ER to have resident evaluated. Family aware of recommendations. The resident was transferred to theER on [DATE] at 8:03 P.M. An emergency room Physician Documentation note, dated 5/10/16 at 8:23 P.M., indicated, Chief Complaint: Injury to left shoulder. The injury happened yesterday. Occurred at at nursing home (Worsening pain when staff member was attempting to lift her by that arm). Patient is experiencing severe pain .Patient was recently in a sling for quiet a while for injury to her left shoulder from a fall out of bed. Patient had been doing better and was doing rehabilitation in a nursing home. The nurse that was unfamiliar with her history attempted to help lift her last night by her left arm and the patient had sudden severe pain in the arm. She was placed back in her immobilizer . Course of Care: patient was found not to have a dislocated shoulder but rather a humeral head (shoulder) fracture on the left. This appears to be spontaneous from the lifting injury Progress Notes continued: 5/10/16 at 10:27 P.M.: Resident returned from ER with immobilizer on lt (left) shoulder. Fx to neck of left humerus A Care Plan, initially dated 3/15/16 and revised 5/16/16 (after the resident's discharge), indicated: The resident has an ADL self care performance deficit R/T (related to) impaired mobility, hx (history) of fall with pelvic fracture, left humeral fracture, Parkinson's disease .E/B (evidenced by) requires assist of staff with ADL care. The Interventions included: Ambulation: 2 assist gait belt and walker, Resolved 3/25/2016; Resident requires extensive assistance of two staff to transfer to/from commode; Resident transfers with 1 pgbs and walker An additional Care Plan, initially dated and revised 5/16/16, indicated: The resident is at risk for falls R/T pelvic fracture, Parkinson's disease, impaired mobility .difficulty in walking E/B requires 1 pgbs and walker with transfers, wheelchair for locomotion. The Approaches included: Monitor resident for significant changes in gait, mobility positioning device On 7/25/16 at 11:45 A.M., during an interview with CNA # 1, she indicated she was the CNA who took care of Resident A on 5/9/16 during the evening shift. She indicated she did not usually work that unit, and did not feel comfortable on that unit. She indicated she helped transfer Resident A from the recliner to the wheelchair, from the wheelchair to the toilet, and then from the toilet to the wheelchair and to bed. She indicated she did not remember the resident falling. She indicated she used a gait belt and a walker during the transfers. On 7/25/16 at 1:50 P.M., during an interview with the Certified Occupational Therapist Assistant (COTA), she indicated she was working with Resident A on 5/10/16. She indicated Resident A was alert. She indicated the resident told her that someone transferred me without a belt and grabbed my arm. On 7/25/16 at 3:00 P.M., during an interview with the RN # 1, he indicated he was working the evening of 5/9/16. He indicated the resident did not complain to him on 5/9/16, and CNA # 1 did not report anything unusual to him. He indicated the resident did wear a sling, so the CNA should have known which arm to avoid. He indicated he was unsure if CNA # 1 utilized a gait belt, or used it correctly, during transfers, as he was not in the room with the resident. He indicated he attempted to speak with the resident the next day, and the resident wouldn't give any names. He indicated the resident did not want to get anyone in trouble. On 7/26/16 at 10:05 A.M., during an interview with PTA # 1, she indicated she had been working with Resident A, including working on exercises to improve her balance, because the resident had balance issues. She indicated on 5/10/16, the resident was complaining of severe pain, rated 10 out of 10, which was worse than she had previously complained of. PTA # 1 indicated she asked the resident, What happened? The resident told her it occurred during a transfer the previous evening. She indicated the resident told her that she had lost her balance, and the CNA caught her by her bad arm as she went down. She indicated she was unsure if the resident mentioned a gait belt. She indicated she reported the incident to the safety nurse. On 7/26/16 at 11:15 A.M., during an interview with the Quality Assurance Nurse, she indicated she was the staff member responsible for investigating falls. She indicated that PTA # 1 approached her on 5/10/16, and told her that Resident A's shoulder was swollen, and that something happened last evening. She indicated she looked at the documentation, and there was nothing documented regarding an incident. She indicated she then spoke to the staff and looked at the video camera tapes. She indicated the camera did not allow her to see in the resident room, but that she didn't observe anything unusual. She indicated when she spoke to the resident, the resident told her that The CNA was helping me from the wheelchair to the recliner and she fell on me. She indicated the resident told her, We hit the floor then we helped each other up. She indicated that CNA # 1 told her there was not a fall, and she had no reason not to believe her. She indicated she educated staff to always report anything unusual to the nurse immediately. On 7/26/16 at 2:05 P.M., the Administrator provided the current facility policy on Gait (Transfer) Belt, revised 5/16. The policy included: Purpose: To safely stabilize a transfer or with ambulation of a resident. To aid in maintaining balance. To avoid injury to both residents and staff member. To avoid injury to both residents and staff member. Note: Gait belts used unless medically contraindicated. This Federal tag relates to Complaint IN 018. 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure care was provided, in that, a dependent resident admitted without a pressure ulcer on the right heel, developed a pressure ulcer on the right heel (Resident #116) and/or a dependent resident admitted with a pressure blister on the right heel developed a pressure ulcer on the right heel (Resident #76) for 2 of 3 residents who met the criteria for review of pressure. This deficient practice resulted in Resident #116 experiencing an Unstageable pressure ulcer on the right heel and/or Resident #76 experiencing a Stage 3 pressure ulcer to the right heel. Findings include: 1. During an observation on 2/27/15 at 8:55 A.M., Resident #116 was observed being transferred from her wheelchair to her recliner. At that time she wore blue heel protectors. The clinical record of Resident #116 was reviewed on 3/2/15 at 9:30 A.M. The clinical record indicated Resident #116 was admitted to the facility on [DATE] with no skin impairment noted to the right heel and [DIAGNOSES REDACTED]. The Admission MDS (Minimum Data Set) assessment dated [DATE] indicated Resident #116 was at risk for developing a pressure ulcer, was cognitive intact and needed the extensive assistance of 2 people for bed mobility and transfers. The Nursing Admission assessment dated [DATE] indicated Resident #116 had skin impairments including, but not limited to, right buttock upon admission. No skin impairment to the right heel was documented. A Care Plan dated 10/3/14 noted: "...The resident has potential for pressure ulcer development R/T decreased mobility, weakness, H/O (history of) pressure ulcer Stage 2 to left (right) buttock...Turning/repositioning program every shift per facility protocol. Reposition with (2 people)..." The care plan dated 10/3/14 lacked documentation related to providing pressure relief to Resident #116's heels. A "Braden Scale for Predicting Pressure Sore Risk" assessment for Resident #116 dated 9/30/14 was provided by the Wound Care Nurse (WCN) on 3/3/15 at 4:45 P.M. Resident #116's Braden score was 17. The Intervention Guide on the form read as follows: "...Score 17...Mild Risk (Score of 15-18)...Intervention Guide...Protect Heels..." A physician's orders [REDACTED]. A physician's orders [REDACTED]. A "Wound Data Collection" form for Resident #116 dated 10/27/14 read as follows: "...Right heel...Suspected Deep Tissue Injury...Length...cm 3.0...width...cm 2.9...Depth...cm 0.1...Minimum Drainage...Serosanguineous..." A "Wound Data Collection" form for Resident #116 dated 11/10/14 read as follows: "...Right heel...unstageable d/t (due to) eschar present over 80% ...Length...cm 2.5...width...cm 2.1..." A "Wound Data Collection" form for Resident #116 dated 3/2/15 read as follows: "...Right heel...Stage 3 pressure ulcer...Length...cm 0.8...width...0.8...Depth...cm 0.2...Minimum Drainage...Granulation % 60...Slough % 40..." A copy of the Clinical Practice Guideline was provided by the Wound Care Nurse (WCN) on 3/3/15 at 3:10 P.M., and on page 8, Stages of Pressure Ulcers read as follows: Stages of Pressure Ulcers "...Suspected deep tissue injury Purple or maroon area of discolored intact skin...due to damage of underlying soft tissue from pressure and/or shear..." "Unstageable Full thickness tissue loss in which the base of the ulcer is covered by...eschar (tan, brown or black) in the ulcer bed..." "...Stage 3 Full thickness loss..." During an observation of a dressing change to Resident #116's right foot on 3/3/15 at 11:20 A.M., the WCN indicated the Stage 3 pressure ulcer measured the same as it did on 3/2/15 and had 60% granulation and 40% slough. At that time, the WCN indicated she did not know what had caused the pressure ulcer. During an interview on 3/4/15 at 10:50 A.M., PT #1 indicated Resident #116 was very weak on admission and needed the assistance of 2 people for transfers and bed mobility. During an interview on 3/4/15 at 9:45 A.M., the Wound Care Nurse (WCN) indicated Resident #116 was at high risk for developing a pressure ulcer and should have had pressure relief provided to her feet, due to a history of a pressure ulcer, and the [DIAGNOSES REDACTED]. The WCN further indicated she was unable to provide documentation that Resident #116 was provided pressure relief to her heels from admission on 9/23/14 to 10/27/14 when the deep tissue injury occurred. A Policy and Procedure titled "Lower Extremity Ulcers" was provided by the Heath Care Administrator on 3/4/15 at 10:52 A.M., and it read as follows: "...6. Interventions will be documented, implemented and added to the care plan..." A Policy and Procedure titled "Pressure Ulcer Practice Guidelines" was provided by the Heath Care Administrator on 3/4/15 at 10:52 A.M., and it read as follows: "...INITIAL RISK ASSESSMENT...Prevention strategies should be developed and implemented at the time of admission based upon the initial assessment of the causative factors that contribute to the resident's risk for skin breakdown...Include these prevention strategies on the resident's care plan. Inform caregivers of prevention strategies..." 2. During an observation on 3/2/15 at 9:48 A.M., Resident #76 was observed in her room sitting in her wheelchair. At that time she wore a blue air boot to the right lower leg and foot. The clinical record of Resident #76 was reviewed on 3/2/15 at 9:30 A.M. The clinical record indicated Resident #76 was initially admitted to the facility on [DATE]. Resident #76 was readmitted to the facility from the hospital on [DATE]. Resident #76's [DIAGNOSES REDACTED]. The Admission MDS (Minimum Data Set) assessment dated [DATE] indicated Resident #76 was at risk for developing a pressure ulcer, experienced moderate cognitive impairment and needed the extensive assistance of 2 people for bed mobility and transfers. A Nursing Admit Re-admit Data Collections form dated 1/8/15 indicated Resident #76 had a Stage 2 pressure ulcer to the right medial heel. A Care Plan initiated on 10/3/14 read as follows: "...The resident has potential for pressure ulcer development R/T lower extremity [MEDICAL CONDITION], weakness, loss of mobility and dementia...Interventions...Monitor nutritional status..." A Lab Specimen Report for Resident #116 dated 1/21/15 read as follows: "...Total Protein 5.7 L (low) 6.3 -8.2 g/dl (normal range)" "[MEDICATION NAME] 2.8 L 3.5 -5.0 g/dl (normal range)" A "Wound Data Collection" form for Resident #76 dated 1/8/15 read as follows: "...Right heel...medial heel - serous filled blister. Stage 2 pressure ulcer...Length...cm 3.0...width...cm 3.3..." A "Wound Data Collection" form for Resident #76 dated 1/26/15 read as follows: "...Right heel...Stage 2 pressure ulcer-blister remains intact...Length...cm 4.0...width...cm 3.4...tx (treatment) changed from skin prep to [MEDICATION NAME]" A "Wound Data Collection" form for Resident #76 dated 2/9/15 read as follows: "...Right heel...unstageable pressure ulcer d/t (due/to) eschar present... Length...2.3...width...cm 1.5..." A copy of the Clinical Practice Guideline was provided by the WCN on 3/3/15 at 3:10 P.M., and on page 8, Stages of Pressure Ulcers, read as follows: ...Stage 2 Partial thickness loss of dermis...May also present as an intact ...blister "...Unstageable Full thickness tissue loss in which the base of the ulcer is covered by...eschar (tan, brown or black) in the ulcer bed..." A Policy and Procedure titled "Pressure Ulcer Practice Guidelines" was provided by the Heath Care Administrator on 3/4/15 at 10:52 A.M., and it read as follows: "...Staff should monitor lab studies as ordered for signs of undernutrition or malnutrition..." During an interview on 3/3/15 at 2:23 P.M., the Wound Care Nurse (WCN) indicated Resident #116's lab report dated 1/21/15 showed a low protein level of 5.7 g/dl (normal range 6.3 -8.2 g/dl ) and a low [MEDICATION NAME] level of 2.8 g/dl (normal range 3.5 -5.0 g/dl), but no intervention had been implemented. A protein supplement had not been provided for Resident #116 to promote healing. A Policy and Procedure titled "Pressure Ulcer Practice Guidelines" was provided by the Heath Care Administrator on 3/4/15 at 10:52 A.M., and it read as follows: "...Staff should monitor lab studies as ordered for signs of undernutrition or malnutrition..." 3.1-40(a)(1) 3.1-40(a)(2)

A. Based on observation, interview and record review, the facility failed to ensure assistive devices for fall prevention were utilized and/or a resident received adequate supervision for safe transfer for 2 of 2 randomly selected and/or observed residents reviewed for falls. For 1 of 2 residents, the lack of usage of assistive devices by a CNA (certified nursing assistant), resulted in injury to the resident. (Resident #126) Resident # 126, Resident #118 B. Based on observation, interview and record review, the facility failed to ensure the resident environment was free of accidents and hazards related to the unlocked door of the beauty salon and the potentially hazardous materials in the unlocked cabinets. This deficiency had the potential to affect 2 of the 22 residents residing in the 100 Hall who were cognitively impaired. Resident # 29, Resident # 6 Findings include: A. 1. On 12/4/12 at 10 A.M., nurses notes of Resident #126 were reviewed and indicated the following: On 12/1/12 at 11 P.M., the "resident was assisted to the bathroom per 1 assist et (and) her walker, resident tripped over her feet and fell to her left side on ground hitting her head on either the sink or the wall...type of alleged injury: bump on her head L (left); bump/abrasion 5 cm (centimeters) circle on L buttock; abrasion 8 cm on L buttock...immediate intervention put in place...educated CNAs (certified nursing assistants) on the using of a gait belt with each transfer/ambulation on resident..." On 12/5/12 at 9 A.M., the DON (Director of Nursing) provided a copy of the facility policy and procedure for "Gait (transfer) belt." This form was dated most recently as 1/09. This policy included, but was not limited to, the following: "Purpose: to safely transfer or ambulate resident, to aid resident in maintaining balance, to avoid injury to both resident and staff member." On 12/5/12 at 9:50 A.M., the DON was interviewed. She indicated the resident should have had a gait belt on when she was being transferred by a CNA and fell on [DATE] at 11 P.M. The DON indicated the resident did not have a gait belt on during this transfer. On 12/5/12 at 10:08 A.M., the DON provided a copy of the resident's fall risk assessment. On admission, 10/30/12, the resident had a total score of 23. This form indicated a score of 12 or more equals high risk for falls. On 12/1/12, post fall, the fall risk assessment, was completed again. The total score remained at 23. This form included, but was not limited to, the following: resident was [AGE] years or older; in the last 90 days, has had 3 or more falls; ambulates with problems and devices; elimination with assistance and vision status is highly or severely impaired. At this time, the DON also provided a current copy of the resident's plan of care, dated 11/9/12, for "Potential for injury and impaired physical mobility r/t (related to) h/o (history of) CVA (cerebral vascular accident), general debility, hx (history) of falls aeb (as evidenced by) requires assist of walker and staff assist with transfers, walking..." Approaches included, but were not limited to, the following: "every shift: transfers and walks with 1 PGBS (person gait belt standby) and use of rolling walker..." A.2. On 11/26/12 at 10:15 A.M., during initial tour of the facility, Resident # 118 was observed sitting in a recliner chair near the nurses station for the 100, 200, and 300 hall. Resident #118's complete face and anterior neck was discolored/bruised which included her forehead, both cheeks, chin and anterior neck. The discoloration was a dark purple, and brown with slight yellowing discoloration along the edges of the bruising. On interview at this time, the RN coordinator of the 100, 200, and 300 unit, indicated the resident had fallen in her room and there were no fractures. On 11/29/12 at 10:48 A.M., Resident #118's clinical record was reviewed. Her admitted was 7/26/12. Her admission Minimum Data Set Assessment ((MDS) dated [DATE],indicated a cognitive summary score of 10. A score of 8-12 indicated a moderate cognition impairment. Bed mobility, transfer, and toilet use were noted as 3,3 ( extensive assistance with 2 plus persons physically assist). The current MDS dated [DATE], indicated a cognition score of 7 which indicated a severe cognition impairment. Bed mobility, transfer, and toilet use were coded as 3,3. Her admission care plan dated 7/26/12 addressed the problem of: "potential for injury and impaired physical mobility r/t (related to) decreased mobility, weakness, dementia, lung ca (lung cancer) with h/o (history of) RLL (right lower lobe) lobectomy aeb (as evidenced by) requires 1pgbs (1 person gait belt stand by) and walker for walking and transfers, prn ( when needed) 2 pgbs ( 2 person gait belt stand by ), w/ch (wheelchair) for locomotion." Interventions included: "Every shift: check bed/chair alarm for function c (with) sensor pads. Transfer and walk with 1pgbs and walker-prn 2 pgbs, wheelchair for locomotion-propels self and propelled by staff, low bed-to be in lowest position when in use, keep call light within reach when in room-encourage to call for assist for transfers/ walking, monitor for c/o (complaint) pain- have resident rate on scale of 1 to 10- administer prn analgesic as ordered, monitor effectiveness of prn analgesic, increased use- keep MD informed, and PT (physical therapy) as ordered - D/cd (discontinued on 10/18/12), and 11/19/12- put bed up against the wall and pad on floor." The care plan was revised on with a date of 10/26/12. The 10/26/12 care plan, which addressed the problem for potential for injury had the added interventions: 11/19/12- autolocking w/c (wheelchair), bed against the wall and pad on floor next to the bed, and 12/4/12- sensor pad in recliner. Nursing notes dated 7/26/12 at 4:30 P.M., indicated, resident arrived to this facility from another nursing facility in Michigan."... General condition appears pale multiple bruises et wound on head c (with) steri strips noted..." Nursing notes dated 7/26/12 at 9:00 P.M., indicated, "...Gait unsteady. Alert & oriented c (with) some confusion noted..." Nursing note dated 7/27/12 at 10:00 A.M., indicated, "... Resident has had recent fall @ (Michigan facility name). Checked @ local hosp (hospital) ER. No injury/fx (fracture). Resident has episodes of decreasing B/P (blood pressure) esp (especially) Am's and feels faint & must lay or sit down. Other dx. (diagnosis) include Lung CA (cancer)..." "...Dementia & Memory loss. Unable to answer most questions that are specific..." Nursing note dated 8/5/12 at 8:00 P.M., indicated, "Care giver walked past resident's room et saw resident standing in her room. Care giver asked why she was up et if she needed anything. Resident stated she was trying to find some pants because the ones she had on was wet. Care giver assisted c (with) care. Resident had an incont (incontinent) urine on self, got up by herself, went to bathroom, changed out of wet clothes, et was looking for dry pants. Resident was educated on using her call light for wants, et needs. Will cont (continue) to monitor." Nursing note dated 8/7/12 at 2:00 A.M., indicated, "Resident was confused et CNA was taking resident to BR (bathroom) ..." Nursing note dated 8/18/12 at 6:45 P.M., indicated, "Resident was found to be walking to MDR (main dining room) by herself et had 0 (zero) walker or assistance. Resident was educated on using call light when having any wants or needs. Resident stated she understood. This nurse found resident up in her bathroom changing her clothes for bed. Educated resident again on using call light. Resident had unclipped chair alarm et had got up out of her w/c. Resident has been non-compliant c (with) using call light. Will cont (continue) to monitor." Nursing note dated 10/18/12 at 12:45 P.M., indicated, "ST (Speech Therapy) notified of increased confusion in res (resident) during therapy on 10/17/12 eve (evening) et this am..." Nursing note dated 10/23/12 at 3:00 A.M., indicated, " Res increase confusion. Gets lost. Does not remember her Rm (room) location. Needs cueing." Physician order [REDACTED]. Nursing note dated 11/14/12 at 2:00 A.M., indicated, "Resident found sitting in her w/c in hallway when the nurse seen (sic) her et asked her if she was ok et why she was out of bed in hallway. Resident confused didn't know where she was or time of day..." Nursing note dated 11/15/12 at 2:30 P.M., indicated, "Orders to d/c (discontinue) prn (as needed) hs (at bedtime) Ativan (antianxiety medication) & start Ativan 0.5 mg po (by mouth) QID (four times a day) routinely..." Nursing note dated 11/16/12 at 12:00 P.M., indicated, " Very drowsy p (after) brkf (breakfast). Did take meds c (with) much enc. (encouragement) to swallow and to hold head up..." Nursing note dated 11/19/12 at 9:15 P.M., indicated, "Res (Resident) found lying on floor in her room. Full body assessment completed et full set of vitals obtained. Hematoma to R (right) forehead. Hospice care contacted. Nurse in route to facility." Facility incident documentation dated 11/19/12, indicated, "Res got out of bed without assistance et fell going to bathroom." Documentation indicated resident was barefoot and liquid was noted on the floor. Resident had been in a low bed and alarm sounded. Resident was observed to have hematoma on the right side of her head. Immediate interventions initiated after the fall were to put the bed against the wall and a pad on the floor. On 12/4/12 at 8:18 A.M., Resident #118 was observed sitting in her wheelchair with clip alarm visible, in the hall by the nurses station of 100, 200 and 300 hall. Resident #118 continued to have extensive bruising of purple discoloration of forehead, both cheeks, chin, and anterior neck area with some yellow discoloration also. She had her feet off the wheelchair pedals starting to stand. No staff were present at the nurses station area or visible in the 300, 200, and 100 hall. The Surveyor stood by the resident to monitor while making staff aware of the resident who was needing assistance (by waving at the CNA). CNA #1 was at the entry of the main dining room pushing another resident in a wheelchair and then proceeded to assist Resident #118. On 12/4/12 at 2:15 P.M., Resident #118 was observed in a recliner at nurses station of 100, 200, and 300 hall. The resident was holding the clip of her personal alarm and asked the surveyor what to do with it. No other staff present until RN Safety Coordinator randomly walked up the hall a few seconds later and was asked to assist the resident. On 12/4/12 at 2:43 P.M., the Director of Nursing (DON) and the RN Safety Coordinator were interviewed regarding documented incidents in the nursing notes of Resident #118 transferring without assistance in 8/2012,10/2012, and 11/2012, and incidences of increased confusion. Discussed lack of interventions initiated after the resident had been observed on several occasions transferring without assistance of staff. Also that the care plan had not been changed from 7/26/12 until 11/19/12 after the fall. The DON indicated at that time that documentation was lacking of new interventions initiated to prevent falls until after 11/19/12 fall. On 12/5/12 at 12:30 P.M., during interview with DON regarding lack of supervision and monitoring after resident noted to transfer self unassisted and when resident's prn ativan was increased to routine instead of when needed. The DON indicated she had talked to the hospice nurse after we had talked yesterday. She indicated the hospice nurse had indicated the ativan had been changed to routine to keep the resident calm and comfortable. The DON indicated at this time when the ativan was increased the facility had not increased monitoring of resident to prevent falls. The DON also indicated the resident had been put on celexa 10 mg po daily (antidepressant) and the ativan (antianxiety) dosage had been decreased to twice a day after the fall. The DON indicated no interventions to prevent falls had been initiated until after the fall of 11/19/12. B. During the initial tour of the facility on 11/26/2012 at 10:32 P.M., the door of the beauty salon, which is located across from the nurses' station on the 100 hall, was observed to be unlocked and slighty ajar. Unpon entering the beauty salon, the cabinet which stores the hair supplies was observed to be unlocked and slightly opened. Located in the unlocked cabinet was: 1. Opti Curl Permanant - Health Hazards (Acute & Chronic): Harmful if swallowed, inhaled, or absorbed through skin. This product may cause serious irritant, respiratory, and/or allergic reactions in sensitive individuals. Emergency & First Aid Procedure: If, call a physician, hospital emergency room , or poison control center immediately. Induce vomiting only if recommended by medical personnel. Get prompt medical attention. If eye or skin contact occurs, immediately flush with water and get medical attention if irritation occurs. 2. Colorfusion - Haircolor can cause an allergic reaction which in certain rare cases can be severe. This product contains ingredients which may cause skin irritation on certain individuals and a preliminary test according to accompanying directions should first be made. This product must not be used for dyeing the eyelashes or eyebrows; to do so may cause blindness. 3. Rusk Designer Collection Hairspray - Warning: Avoid spraying into eyes. Keep out of reach of children. Use only as directed. Inhaling contents can be harmful or fatal. 4. Hand - E - Foam - Warning: For external use only do not apply to eyes or over large areas of the body. Also observered in the beauty salon were 2 curling irons and 1 blowdryer that were plugged into an active electrical outlet. On 11/26/12 at 2:15 p.m., the facility's policy and procedure for supervising the beauty salon and it's inventory of potentially hazardous products was requested. The Health Care Administrator indicated there was not a specific policy or procedure for ensuring the beauty salon was supervised at all times or that the hazardous products remained in locked storage when no supervision was available. During an interview with the Director of Nursing on 11/26/12 at 10:25 A.M., upon learning the door to the beauty salon was open and that no one was in the salon supervising the chemicals and equipment, the DON said, "Someone must have left the door open." During an interview with the Health Care Administrator (HCA) on 12/4/12 at 12:31 P.M., the HCA indicated the beautician was hired by the facility for the residents and that the beautician was scheduled for her services on Tuesday thru Friday. On Monday, the facility allowed the residents' family members use the beauty salon. The HCA said, " One of the family members probably left the door open." 3.1-45(a)(2)

A. Based on interview and record review, the facility failed to ensure a CNA (certified nursing assistant) performed personal care skills within the scope of practice of a CNA, which resulted in ear trauma and the resident being sent to the emergency room for 1 of 1 randomly reviewed residents. Resident #54 B. Based on interview and record review, the facility failed to ensure a CNA performed a resident transfer without utilizing a required gait belt which resulted in physical injuries to the resident for 1 of 1 randomly reviewed residents. Resident #126 Findings include: A. The clinical record of Resident #54 was reviewed on 12/3/12 at 10 A.M. The most recent MDS (minimum data set assessment) dated 8/20/12, indicated the following: a total cognition score of 15. This score indicated the resident is cognitively intact. Nurses notes, dated 11/3/12 at 10 P.M., indicated the following: "Resident told CNA her L (left) ear felt wet. CNA told this nurse resident L ear was bleeding. Noted blood slowly coming out of resident's L ear. This nurse tried to visualize residents L ear drum but unsuccessful with the otoscope d/t (due to) the amt (amount) of blood in the canal...Resident stated during her shower this day she asked the CNA to clean out her ears with Q tips et (and) the CNA did as the resident asked. Resident stated there was some pain during the ear cleaning with the Q tips. Resident also stated she noticed a small amt of blood during the evening meal but did not tell anyone at that time." Nurses notes, dated 11/4/12 at 12:15 A.M., indicated the following: "(hospital name) ER (emergency room ) called et stated they are sending the resident back et there is trauma to the ear canal...stated they removed a blood clot et there may be a small amt of bleeding for a little while." On 12/4/12 at 3:30 P.M., the DON (Director of Nursing) was interviewed. She indicated the CNA cleaned the resident's ear out with a Q tip as the resident requested. The DON stated CNAs are not to put anything in the resident's ears. She indicated the CNA was educated on not putting anything in resident's ears after the incident. On 12/5/12 at 8:30 A.M., the DON (Director of Nursing) provided a copy of the resident's emergency room visit from 11/3/12. This form included, but was not limited to, the following: "stated complaint: bleeding from ear...primary impression: left ear canal trauma..." On 12/5/12 at 1 P.M. the Indiana State Department of Health, Nurse Aide Training Program Core Curriculum manual was reviewed. This program was most recently dated 1998 and included, but was not limited to, the following: "Standard 14: Nurse Aide Scope of Practice: The nurse aide will perform only the task in the course standards and Resident Care Procedures Manual. The nurse aide will not perform any invasive procedures..." B. On 12/4/12 at 10 A.M., nurses notes of Resident #126 were reviewed and indicated the following: On 12/1/12 at 11 P.M., the "resident was assisted to the bathroom per 1 assist et (and) her walker, resident tripped over her feet and fell to her left side on ground hitting her head on either the sink or the wall...type of alleged injury: bump on her head L (left); bump/abrasion 5 cm (centimeters) circle on L buttock; abrasion 8 cm on L buttock...immediate intervention put in place...educated CNAs (certified nursing assistants) on the using of a gait belt with each transfer/ambulation on resident..." On 12/5/12 at 9 A.M., the DON (Director of Nursing) provided a copy of the facility policy and procedure for "Gait (transfer) belt." This form was dated most recently as 1/09. This policy included, but was not limited to, the following: "Purpose: to safely transfer or ambulate resident, to aid resident in maintaining balance, to avoid injury to both resident and staff member." On 12/5/12 at 9:50 A.M., the DON was interviewed. She indicated the resident should have had a gait belt on when she was being transferred by a CNA and fell on [DATE] at 11 P.M. The DON indicated the resident did not have a gait belt on during this transfer. On 12/5/12 at 10:08 A.M., the DON provided a copy of the resident's fall risk assessment. On admission, 10/30/12, the resident had a total score of 23. This form indicated a score of 12 or more equals high risk for falls. This form included, but was not limited to, the following: resident was [AGE] years or older; in the last 90 days, has had 3 or more falls; ambulates with problems and devices; elimination with assistance and vision status is highly or severely impaired. At this time, the DON provided a current copy of the resident's plan of care, dated 11/9/12, for the "Potential for injury and impaired physical mobility r/t (related to) h/o (history of)[MEDICAL CONDITION], general debility, hx (history) of falls aeb (as evidenced by) requires assist of walker and staff assist with transfers, walking..."Approaches included, but were not limited to, the following: "every shift: transfers and walks with 1 PGBS (person gait belt standby) and use of rolling walker..." 3.1-14(i)