Every finding on record at Stonebridge Health Campus

Based on interview and record review, the facility failed to ensure the Notice of Transfer or Discharge and Bed hold Policy was provided to the residents or the resident's representative when transferred to the hospital for 2 of 4 residents reviewed for hospitalization. (Resident 11, Resident 68) Findings include: On 7/13/26 at 9:55 a.m., Resident 11's clinical record was reviewed. The diagnoses included, but were not limited to, stroke and anxiety. A progress note, dated 4/13/26 at 10:51 p.m., indicated Resident 11 fell while sitting in the wheelchair. Resident 11 was transferred to the emergency room for evaluation. The Notice of Transfer or Discharge lacked documentation of Resident 11's responsible party being notified of the Notice of Transfer or Discharge and the Bed Hold Policy. During an interview on 7/14/26 at 9:45 a.m., the Director of Health Services (DHS) indicated the clinical record lacked documentation of the family being provided the Notice of Transfer or Discharge and the Bed Hold Policy. 2. On 7/9/26 at 11:00 a.m., Resident 68's clinical record was reviewed. The diagnoses included, but were not limited to, diabetes mellitus, convulsions (rapid, involuntary muscle contractions), and chronic kidney disease (your kidneys are damaged and cannot filter blood properly). A review of the progress notes indicated the resident was transferred to the hospital on 5/23/26 and returned to the facility on 5/25/26. The clinical record lacked documentation that a written copy of the Notice of Transfer or Discharge and Bed Hold policy were provided to the resident and the resident representative. During an interview with the DHS (Director of Health Services) on 7/13/26 at 11:50 a.m., she indicated she could not find any documentation that the resident and/or the resident representative were notified in writing. On 7/14/26 at 11:35 a.m., the Executive Director provided a policy labeled Guidelines for Transfer and discharge date d 12/8/25, she indicated this was a current policy used by the facility. A review of the policy indicated, .c. In cases of emergency transfers, the notice of the bed hold policy under the State plan and the facility's bed hold policy should be provided to the resident or resident's representative within 24 hours of the transfer. This may be sent with other papers accompanying the resident to the hospital. d. Social Service should review the documentation in CCM the following business day to assure written information was provided to the resident and a family member or legal representative of the bed hold and admission policies. Notification of Bed Hold Policy and readmission should be provided via certified mail in the event notification was not provided as part of the discharge process . 410 IAC (Indiana Administrative Code) 16.2-3.1-12(a)(6)(A)(i)410 IAC 16.2-3.1-12(a)(6)(A)(ii)410 IAC 16.2-3.1-12(a)(6)(A)(iii)410 IAC 16.2-3.1-12(a)(25)(A)410 IAC 16.2-3.1-12(a)(25)(B)410 IAC 16.2-3.1-12(a)(26)

Based on interview and record review, the facility failed to complete a comprehensive assessment of a resident within 14 calendar days after admission to the facility for 1 of 1 residents reviewed for assessments. (Resident 59)Findings include:On 9/17/25 at 10:27 a.m., Resident 59's clinical record was reviewed. The diagnoses included, but were not limited to, chronic kidney disease, COPD (chronic obstructive disease), and chronic respiratory failure. The resident was admitted on [DATE]. A 9/4/25 admission Minimum Data Set (MDS) assessment was completed on 9/14/25. This was 4 days after day 14. During an interview on 9/17/25 at 11:36 a.m., the Corporate Nurse Consultant indicated the MDS assessment was completed late. During an interview on 9/18/25 at 12:56 p.m., the Director of Health Services indicated the facility lacked a policy for completing MDS assessments, and the staff followed the Resident Assessment Instrument (RAI) manual. On 9/19/25 at 10:02 a.m., a review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument, dated 10/1/24, indicated, . admission Assessment . The admission assessment is a comprehensive assessment for a new resident and, under some circumstances, a returning resident that must be completed by the end of day 14, counting the date of admission to the nursing home as day 1 . 3.1-31(d)(1)

Based on interview and record review, the facility failed to ensure a PASARR (preadmission screening and resident review) was completed when a new mental health diagnosis was added for 1 of 5 residents reviewed for unnecessary medications. (Resident 7)Findings include:On 9/17/25 at 11:30 a.m., Resident 7's clinical record was reviewed. The diagnoses included, but were not limited to, new diagnosis on 4/12/25 of schizoaffective disorder (a mental health condition that combines symptoms of schizophrenia and a mood disorder), dementia (loss of memory, language, problem-solving and other thinking abilities), brief psychotic disorder (mental health condition characterized by sudden, short-lived psychotic symptoms, that last for at least one day but less than one month), major depressive disorder, and anxiety disorder.A PASARR Level I screen, dated 10/2/23, indicated the resident's mental health conditions were major depressive disorder, without psychotic features and anxiety disorder, it did not include schizoaffective disorder as a mental health diagnosis. The Level I screen indicated a PASARR Level II evaluation was not required at this time. The Level I screen indicated, .If a status change occurred or other information suggested a potential serious mental illness, then an updated Level I must be submitted to report the change to reevaluate the need for a PASARR Level II behavioral health evaluation.During an interview with the Director of Health Services (DHS), on 9/18/25 11:27 a.m., she indicated the clinical record lacked an updated PASARR Level II, for a new diagnosis of schizoaffective disorder on 4/12/25.During an interview with the DHS, on 9/18/25 at 12:56 p.m., she indicated the facility did not have a PASARR Level II policy. She indicated they follow the RAI (Resident Assessment Instrument) manual.A review of the RAI 3.0 User's Manual Version 1.19.1, October 2024, indicated the following: .If a Significant Change in Status Assessment occurs for an individual known or suspected to have a mental illness, intellectual disability, or related condition (as defined by 42 CFR 483.102), a referral to the State Mental Health or Intellectual Disability/Developmental Disabilities Administration authority (SMH/ID/DDA) for a possible Level II PASRR evaluation must promptly occur as required by Section 1919(e)(7)(B)(iii) of the Social Security Act.3.1-16(d)(1)(A)3.1-16(d)(1)(B)

Based on observation, interview, and record review, the facility failed to provide supporting documentation for a new diagnosis of schizoaffective disorder for 1 of 5 residents reviewed for unnecessary medication. (Resident 7)Findings include: On 9/15/25 at 11:34 a.m., Resident 7 was observed to be ambulating with a walker in the hallway. On 9/15/25 at 2:13 p.m., Resident 7 was observed to be sitting on her bed looking at books.On 9/17/25 at 10:26 a.m., Resident 7 was observed to be ambulating with a walker in the hallway.On 9/17/25 at 11:30 a.m., Resident 7's clinical record was reviewed. The diagnoses included, but were not limited to, dementia with psychotic disturbance, schizoaffective disorder, major depression, and anxiety.Resident 7's admission date was 12/1/23. A PASARR Level One (assessment to determine if the resident has a serious mental illness) indicated the following:- On 9/5/23, indicated the current mental health diagnoses were major depression and depression.- On 10/2/23, indicated the current mental health diagnoses were major depression, anxiety, and depression.The admission paperwork, dated 12/1/23, lacked documentation of a diagnosis of schizoaffective disorder.The psychiatric hospital Discharge Medication Reconciliation, dated 4/14/24, indicated discharge medications of lithium carbonate 450 milligrams (mg) every day at 6:00 p.m. for mood disorder and Seroquel 25 mg three times a day for bipolar disorder. The discharge diagnoses lacked documentation of a diagnosis of schizoaffective disorder.A progress note, dated 4/11/25 at 6:34 a.m., indicated past medical history of schizoaffective disorder.During an interview on 9/17/25 at 1:20 p.m., the Corporate Nurse Consultant presented Resident 7's progress notes and indicated they had no supporting documentation for diagnosing schizoaffective disorder prior to 4/11/25. During an interview on 9/17/25 at 3:06 p.m., the Director of Health Services (DHS) indicated they did not have a policy for supporting documentation for a new diagnosis of schizoaffective disorder. 3.1-35(g)(1)

Based on observation, interview, and record review, the facility failed to ensure the posted nurse staffing information was accurate and current for 1 of 6 days during the survey. Findings include: During an observation on Tuesday, 10/16/24 at 10:10 a.m., the staff posting sheet was dated for Friday, 10/10/24. During an interview on 10/16/24 at 10:11 a.m., the Executive Director (ED) indicated the staffing sheets was posted by the nursing station. An observation at that time, indicated the staff posting sheet was posted for 10/10/24. The ED indicated the staffing sheet was not current and she would get an updated one posted to reflect that day. During an interview on 10/16/24 at 10:15 a.m., the Clinical Support Nurse indicated the scheduler was responsible for posting the daily staffing sheet. On 10/16/24 at 11:13 a.m., the ED provided the facility policy, Guidelines for Staff Posting, reviewed on 12/31/23, and indicated it was the policy currently being used. A review of the policy indicated, . 1. At the beginning of the day the number and amount of licensed nurses (RN and LPN) and the number and hours of nursing personnel, per shift, who provide direct care to residents will be posted .

Based on observation, interview, and record review, the facility failed to ensure implementation of a blue bunny boot (used to prevent and heal pressure ulcers) was utilized for 1 of 4 residents reviewed for pressure ulcers. (Resident 27) Findings include: On 10/4/23 at 11:00 a.m., Resident 27 was observed to be sitting in a positioning wheelchair in his room. He had a white dressing on his left foot. The blue bunny boots were not observed to be on his left or right heel. No bunny boots were observed to be on the floor near his positioning wheelchair. On 10/4/23 at 2:39 p.m., Resident 27 was observed to be sitting in a positioning wheelchair in his room. He had a white dressing on his left foot. The blue bunny boots were not observed to be on his left or right heel. No bunny boots were observed to be on the floor near his positioning wheelchair. On 10/5/23 at 10:08 a.m., Resident 27 was observed to be sitting in a positioning wheelchair in the day room on the unit. He had a white dressing on his left foot. The blue bunny boots were not observed to be on his left or right heel. No bunny boots were observed to be on the floor near his positioning wheelchair. On 10/5/23 at 12:32 p.m., Resident 27 was observed to be sitting in a positioning wheelchair in the restorative dining room. He had a white dressing on his left foot. The blue bunny boots were not observed to be on his left or right heel. No bunny boots were observed to be on the floor near his positioning wheelchair. On 10/6/23 at 9:56 a.m., Resident 27 was observed to be sitting in a positioning wheelchair in the day room on the unit. He had a white dressing on his left foot. The blue bunny boots were not observed to be on his left or right heel. No bunny boots were observed to be on the floor near his positioning wheelchair. On 10/5/23 at 11:08 a.m., Resident 27's clinical record was reviewed. The diagnoses included, but were not limited to cerebrovascular disease, dementia, anxiety, and hemiplegia (paralysis of one side of the body). A care plan, initiated on 6/1/23 and current through target date 10/31/23, indicated Resident 27 had a pressure ulcer to left heel. The staff would observe for healing/non-healing; signs of infections; and apply treatment as ordered. The care plan lacked documentation of how to relieve pressure on his left heel if Resident 27 removed the bunny boots or crossing his legs and causing additional pressure on his heels. A Physician's Order, dated 9/6/23 through 10/6/23, indicated resident to wear blue bunny boots at all times for wound and prevention (start date 6/5/23). Wound Management Report, dated 10/3/23 at 11:22 a.m., indicated Resident 27 had a Stage 3 ulcer to left heel. The Clinically at Risk Individual Monitoring lacked documentation of how to relieve pressure on his left heel if Resident 27 removed the bunny boots or crossing his legs and causing additional pressure on his heels. During an interview on 10/6/23 at 11:09 a.m., Certified Nursing Assistant (CNA) 1 indicated Resident 27 had a pressure ulcer to his left ankle. His interventions were to wear blue bunny boots to his left foot. He would not remove them. During an interview on 10/6/23 at 11:48 a.m., the Assistant Director of Nursing (ADON) indicated Resident 27 had a pressure ulcer to his left heel. His interventions were to wear blue bunny boots to his left heel. He did not remove them. On 10/10/23 at 12:24 p.m., the Minimum Data Set Consultant provided the facility's policy, Pressure/Stasis/Arterial/Diabetic Wound Guidelines, dated 12/31/22, and indicated it was the policy being used by the facility. A review of the policy did not address ensuring implementation of pressure ulcer interventions. 3.1-40(a)(2)

Based on observation, interview, and record review, the facility failed to ensure a medication was stored in a locked compartment for 1 out of 1 medications observed during a random observations while observing medication administration. (Resident 155) Findings include: On 10/6/23 at 12:50 p.m., during medication administration with Registered Nurse (RN) 1, a round, pink pill was observed to be lying on the medication cart behind the computer. RN 1 was observed to look the pill up using a pill identifier website and identified the pill as citalopram (an antidepressant). RN 1 indicated at that time she did not have any residents on citalopram and did not know why the pill was on the medication cart. During an interview on 10/10/23 at 11:22 a.m., the Assistant Director of Nursing (ADON) indicated they had done some research and they had a resident who had been taking citalopram. The resident was identified as Resident 155. On 10/10/23 at 11:30 a.m., Resident 155's clinical record was reviewed. The diagnosis included, but were not limited to depression. Current physician orders, dated 10/10/23, indicated Resident 155's orders included, but were not limited to: citalopram tablet 20 mg (milligram) once a day for depression. On 10/6/23 at 2:33 p.m., the Corporate Support Nurse provided the facility policy titled, Medication Storage in the Facility with a revised date of January 2019, and indicated it was the policy currently being used by the facility. A review of the policy indicated, Storage of Medications: Policy: Medications and biologicals are stored safely, securely and properly . A. The provider pharmacy dispenses medications in containers . Medications are kept in these containers . 3.1-25(m)

Based on interview and record review, the facility failed to ensure radiological services were provided immediately, as indicated by the physician's order, to a resident who sustained a fall with injury for 1 of 1 resident reviewed for radiological services. (Resident 31) Findings include: During an interview with Resident 31's Power of Attorney (POA) on 10/4/23 at 10:09 a.m., they were informed she fell while going to the bathroom around 8:00 p.m., on a Wednesday (7/26/23), and the facility would get an x-ray because she had complained of right hip pain. The POA was not informed of the x-ray results so they called the facility on Friday (7/28/23) around 9:00 a.m., and was told the resident did not have a fracture. Around 3:00 p.m. that same day, the POA received a phone call from the facility stating their mother had a broken hip and she was sent to the hospital. The POA did not know what caused the confusion nor the delay in the x-ray results. On 10/5/23 at 2:05 p.m., Resident 31's clinical record was reviewed. The diagnoses included, but were not limited to, dementia, abnormalities of gait and mobility, and muscle weakness. Resident 31's Event Report, dated 7/26/23 at 6:40 p.m., indicated the resident sustained an unwitnessed fall in her bathroom. Resident 31's progress notes indicated the following: - On 7/26/23 at 8:05 p.m., the resident started to complain of right hip pain related to the fall. - On 7/26/23 at 8:21 p.m., the nurse received an order for a STAT (immediate) x-ray for the resident's right hip. - On 7/26/23 at 8:33 p.m., the resident complained of right hip pain when getting up from her wheelchair. - On 7/26/23 at 9:38 p.m., the radiological services company called the facility and stated there was no technician working so the STAT x-ray was delayed to the next day. - On 7/28/23 at 8:48 a.m., an IDT (interdisciplinary team) note indicated the resident sustained a skin tear to her right elbow. There was no mention of the x-ray results. - On 7/28/23 at 3:01 p.m., the x-ray results were received and indicated the resident had an impacted fracture of the right femoral neck. - On 7/28/23 at 3:27 p.m., the resident was sent to the hospital. Resident 31's Radiology Report, dated 7/27/23 at 8:42 p.m., indicated acute impacted fracture of the right femoral neck. During an interview on 10/6/23 at 12:42 p.m., Licensed Practical Nurse 1 indicated she was working the night the resident fell . The resident initially did not complain of pain, but as the evening went on she began to show limitations in range in motion to her right hip and complained of pain. She obtained an order for a STAT x-ray but she could not remember when the x-ray was taken, however, the company was known to not come on time. During an interview on 10/6/23 at 12:58 p.m., Certified Medication Aide 1 indicated she was working the 7/28/23 shift when the resident was sent out the the hospital for her hip fracture. She indicated she did not know why the radiological services company did not call with the x-ray results because that was the standard practice. The facility had two fax machines and it was likely the company faxed over the results and did not call. On 10/10/23 12:30 p.m., the Clinical Support Nurse provided the [Radiology Services Name] PORTABLE IMAGING AND DIAGNOSTIC TESTING SERVICES AGREEMENT, dated 4/19/23, and indicated it was the contract currently being used by the facility. A review of the contract indicated no specific time frames in regard to service response time. 3.1-49(g)

Based on observation, interview and record review, the facility failed to ensure residents were free from significant medication errors for 1 of 3 residents reviewed for medication administration. This resulted in the resident requiring admission to the hospital intensive care unit. (Resident 45). Finding includes: During an interview on 11/30/22 at 1:42 p.m., Resident 45 indicated over a month ago, she had received Resident 46's medication. A nurse came into her room with two medication cups which had their names on them. The nurse administered her (Resident 45) Resident 46's medication. Later that evening, the facility rushed her to the hospital. On 12/2/22 at 11:19 a.m., Resident 45's clinical record was reviewed. The diagnoses included, but were not limited to, atrial fibrillation (irregular heartbeat), hypotension (low blood pressure), diabetes mellitus, accidental poisoning by unspecified drugs. The Admission Minimum Data Set (MDS) assessment, dated 10/18/22, indicated Resident 45 had moderately impaired cognition. The Progress Notes indicated the following: - On 11/4/22 at 7:00 p.m., Resident 45's every one hour vital signs (body temperature, pulse rate, respiration rate, and blood pressure) were initiated. The vitals check were within normal limits. She was answering questions appropriately. - On 11/4/22 at 9:29 p.m., Resident 45 was assisted to bed. Her blood pressure was slightly lower than baseline. She was answering questions appropriately. -On 11/5/22 at 12:21 a.m., Resident 45 was given the incorrect medication at approximately 6:50 p.m. The nurse practitioner indicated to observe resident's vital signs every hour times 24 hours; to send resident to the hospital if mean arterial pressure (MAP, a calculation that doctors use to check whether there's enough blood flow to major organs) falls below 65; and had a decreased level of consciousness. At 11:00 p.m., her blood pressure was 81/49; her pulse was varying between 80-116 with rapid changes; and she was drowsy. Her MAP had decreased to 60. The nurse called 911, and Resident 45 was transferred to the hospital. - On 11/5/22 at 12:31 a.m., the emergency room nurse called to verify Resident 45's vital signs while at the facility. The emergency room nurse indicated she was in atrial fibrillation and the Poison Control Center had been contacted. - On 11/22/22 at 10:27 a.m., the physician indicated Resident 45 was seen for readmission after a hospitalization following a medication error. The Vitals Report dated 11/1/22 through 11/30/22 indicated the following: - On 11/1/22 at 8:33 a.m., Resident 45's pulse was 79 and her blood pressure was 107/75. - On 11/2/22 at 7:50 a.m., Resident 45's pulse was 119 and her blood pressure was 103/68. - On 11/3/22 at 8:21 a.m., Resident 45's pulse was 114 and her blood pressure was 119/62. - On 11/3/22 at 7:50 p.m., Resident 45's pulse was 86. - On 11/4/22 at 7:55 a.m., Resident 45's pulse was 105 and her blood pressure was 115/75. - On 11/4/22 at 7:15 p.m., Resident 45's pulse was 128 and her blood pressure was 132/70. - On 11/4/22 at 7:37 p.m., Resident 45's pulse was 116 and her blood pressure was 89/51. - On 11/4/22 at 7:50 p.m., Resident 45's pulse was 128 and her blood pressure was 132/70. - On 11/4/22 at 7:51 p.m., Resident 45's pulse was 116 and her blood pressure was 89/51. - On 11/4/22 at 8:54 p.m., Resident 45's pulse was 77 and her blood pressure was 85/54. - On 11/4/22 at 10:02 p.m., Resident 45's pulse was 84 and her blood pressure was 81/56. - On 11/4/22 at 11:24 p.m., Resident 45's pulse was 96 and her blood pressure was 81/49. Resident 45's Inpatient Discharge Instructions, dated 11/5/22, indicated her reason for visit was for hypotension and new onset atrial fibrillation. She was admitted after accidentally taking extra blood pressure medications which caused her blood pressure to be extremely low requiring intensive care unit (ICU) level of care. During an interview on 12/5/22 at 11:47 a.m., the Nurse Practitioner (NP) indicated Licensed Practical Nurse (LPN) 1 carried in two cups of medication into Resident 45 and Resident 46's room. Resident 45 was administered Resident 46's medication of cilostazol (medication to treat peripheral vascular disease) 50 milligrams (mg); aripiprazole (antipsychotic medication) 2 mg; buspirone (medication to treat anxiety) 7.5 mg; carvedilol (medication to treat high blood pressure) 6.25 mg; and hydrocodone/acetaminophen (pain medication) 7.5 mg. He started her on a central nervous system assessment (assessment to assess mental status and vital signs) every hour because of the administration of ariprazole, buspirone, and hydrocodone/acetaminophen could decrease her vital signs and level of consciousness. At her midnight central nervous system assessment, her blood pressure had decreased and ordered her to be sent to the emergency room . During the interview on 12/5/22 at 2:54 p.m., LPN 1 indicated on 11/4/22, Resident 45 liked her medications early and Resident 46 also wanted her medications. She prepped and took Resident 45 and Resident 46's medications into the room and placed a medication cup on each of their table. Resident 45 took the medication in the cup which was on her table. Resident 46 looked in the medication cup and asked where her pain pill was. At that time, LPN 1 realized she had give Resident 45 the medications for Resident 46. She indicated she was only to prep and take one resident's medication into the room at a time. On 12/6/22 at 12:05 p.m., the Director of Health Services (DHS) provided the facility's policy, Medication Administration General Guidelines, with a revised date of 1/2018, and indicated this was the policy currently being used by the facility. A review of the policy indicated .4) FIVE RIGHTS-Right resident, right drug, right dose, right route and right time, are applied for each medication being administer. A triple check of these 5 Rights is recommended at three steps in the process of preparation of a medication for administration: (1) when the medication is selected, (2) when the dose is removed from the container, and finally (3) just after the dose is prepared and the medication put away Medications are not pre-prepared either in advance of the med pass or for more than one resident at a time. 3.1-48(c)(2)

Based on interview and record review, the facility failed to submit a discharge Minimum Data Set (MDS) assessment in a timely manner for 1 of 1 resident reviewed for Resident Assessment. (Resident 41) Findings include: Resident 41's closed clinical record was reviewed on 12/5/22 at 3:30 p.m. The diagnoses included, but were not limited to, unspecified injury of the head and Type II diabetes mellitus. The discharge Minimum Data Set (MDS), dated [DATE], for Resident 41 indicated, Finalized but had not been submitted to the Centers for Medicare and Medicaid (CMS). The MDS was over 120 days old. During an interview on 12/6/22 at 10:30 a.m., the corporate MDS consultant indicated the discharge MDS, dated [DATE], for Resident 41 was inadvertently marked not for submission. During an interview on 12/6/22 at 11:33 a.m., the MDS Coordinator indicated the facility did not have a policy related to timely submission of the MDS but the facility utilized the Resident Assessment Instrument (RAI) manual.

Based on interview and record review, the facility failed to accurately complete an Admission Minimum Data Set (MDS) assessment for 1 of 2 residents reviewed for a decline in Activities of Daily Living. (Resident 29) Findings include: Resident 29's clinical record was reviewed on 12/5/22 at 11:27 a.m. The diagnoses included, but were not limited to, dysphagia (difficulty swallowing) following nontraumatic intracerebral hemorrhage and unspecified protein-calorie malnutrition. The Admission Minimum Data Set (MDS) assessment, dated 9/7/22, indicated Resident 29 required the supervision of one person with eating during the look back period of 9/2/22 through 9/7/22. The physician orders, dated 9/1/22 through 9/6/22, for Resident 29 indicated, . Enteral feeding: Formula: Boost Plus or Ensure Plus 1 can [237 milliliters] per G-tube BID [twice a day] 1 bolus feeding [type of feeding where a syringe is used to send formula through the feeding tube] . The Medication Administration Record (MAR), dated 9/2/22 through 9/7/22, for Resident 29 indicated the resident received a bolus feeding per G-tube twice a day. During an interview on 12/6/22 at 10:30 a.m., the corporate MDS consultant indicated the Admission MDS assessment for Resident 29 was coded incorrectly. The resident was receiving a bolus feeding and the MDS assessment should have been coded as extensive assistance of one for eating. During an interview on 12/6/22 at 11:33 a.m., they MDS Coordinator indicated the facility did not have a policy on coding MDS's correctly but used the Resident Assessment Instrument (RAI) manual. 3.1-31(d)

Based on observation, interview, and record review, the facility failed to place a sign on the door or wall outside a residents room who was on Transmission Based Precautions for 1 of 1 resident reviewed during a random observation. (Resident 11) Findings include: On 11/29/22 at 10:44 a.m., during an initial tour of the facility, a bin with gowns and gloves was observed outside of Resident 11's room and the door was closed. There was no sign on the door or wall to indicate if the resident was on transmission based precautions (TBP). On 12/5/22 at 10:15 a.m., Resident 11's clinical record was reviewed. The diagnoses included, but were not limited to, chronic myeloid leukemia and rheumatoid arthritis. Physician orders, dated 11/9/22 through 11/29/22, for Resident 11 indicated, . Contact/Droplet Precautions three times a day; 7:00 a.m. through 2:00 p.m., 2:00 p.m. through 10:00 p.m., and 11:00 p.m. through 6:00 a.m. Nursing Progress Notes, dated 11/29/22 at 3:56 p.m., for Resident 11 indicated, . [doctor name] infection disease was called this shift to ask about isolation precautions r/t [related to] res [resident] dx [diagnosis]. [doctor name] is treating res for mycobacterium chelonae [a rapidly growing mycobacteria that commonly affects the skin] with clarithamyocin [an antibiotic] and no isolation precautions are required. Res taken off contact/droplet precautions. During an interview on 11/29/22 at 10:45 a.m., the Director of Social Services indicated Resident 11 was on TBP for a skin disorder but she was not aware of what type of precautions. During an interview on 12/5/22 at 2:54 p.m., Care Resident Care Associated (CRCA) 1 indicated Resident 11 had been on TBP the prior week but she was not sure what type. She remembered having to wear gowns and gloves. On 12/6/22 at 3:57 p.m., the Interim Executive Director provided the facility policy, Guidelines for Droplet Precautions with a revised date of 3/19/20, and indicated it was the policy currently being used by the facility. A review of the policy indicated, . Procedures: e. Isolation signs . 1. Place a sign [preferably yellow] at the doorway instructing visitors to report to the nursing station before entering the room . 3.1-18(b)(1)

Based on observation and interview, the facility failed to ensure a sit to stand lift was clean for 3 of 6 days during the survey. Findings include: On the following dates, times, and locations, a sit to stand lift was observed with the foot platform containing food crumbs and debris: - On 11/29/22 at 10:00 a.m., in the hallway by room [ROOM NUMBER]. - On 11/29/22 at 2:20 p.m., in the hallway by room [ROOM NUMBER]. - On 11/30/22 at 10:55 a.m., in the hallway by the main nurse's station. - On 11/30/22 at 2:00 p.m., in the hallway by room [ROOM NUMBER]. - On 12/1/22 at 10:10 a.m., in the hallway by room [ROOM NUMBER]. During an interview on 12/1/22 at 10:19 a.m., the Director of Health Services indicated the foot platform of the sit to stand lift was dirty and in need of cleaning before use. On 12/6/22 at 12:12 p.m., the Director of Health Services provided a list of residents who used the sit to stand lift which indicated two residents used the sit to stand lift for transfers. 3.1-19(f)

Based on observation, interview, and record review, the facility failed to ensure residents' transfer equipment was free from disrepair for 14 of 54 residents reviewed for transfer equipment status (Residents 8, 32, 40, 102, 44, 21, 103, 15, 10, 7, 17, 43, 36, and 4) and failed to ensure residents' bedroom furniture was free from disrepair for 2 of 24 residents reviewed environment (Residents 6 and 20). Findings include: During a facility tour, on 12/20/21 at 11:00 a.m., the following was observed: 1a.) Resident 8's wheelchair back and bottom cushion were observed to have multiple cracks in the outer layer. 1b.) Resident 32's left armrest was observed to have multiple cracks. 1c.) Resident 40's wheelchair back was observed with multiple cracks. 1d.) Resident 102's right wheelchair armrest was observed with multiple cracks. 1e.) Resident 44's left wheelchair armrest was observed with multiple cracks. 1f.) Resident 21's left and right wheelchair armrest were observed with multiple cracks. The right armrest holder was observed to be broken with a sharp plastic edge exposed to the resident. 1g.) Resident 103's right wheelchair armrest was observed with multiple cracks. 1h.) Resident 15's left wheelchair armrest was observed with multiple cracks. 1i.) Resident 10's wheelchair back and bottom were observed with multiple cracks. 1j.) Resident 7's left and right wheelchair armrests were observed with multiple cracks. 1k.) Resident 17's left wheelchair armrest was observed with multiple cracks. 1l.) Resident 43's left and right wheelchair armrests were observed with multiple cracks. 1m.) Resident 36's left and right wheelchair armrests were observed with multiple cracks. 1n.) Resident 4's left and right wheelchair armrests were observed with multiple cracks. 2a.) Resident 6's bedside table was observed missing two large areas of veneer exposing the compressed wood underneath. 2b.) Resident 20's bedside table was observed missing a large area of veneer exposing the compressed wood underneath. On 12/20/21 at 2:30 p.m., an environmental tour was completed with the Maintenance Director and the Administrator present. Both staff members indicated the wheelchairs and bedside tables were in disrepair and needed fixed. On 12/20/21 at 3:50 p.m., the Director of Nursing Services provided the facility policy, Resident Rights Guidelines, revised 5/11/21, and indicated it was the policy currently being used by the facility. A review of the policy indicated the policy did not address the residents' environment. 3.1-19(f)(5)

Based on interview and record review, the facility failed to accurately complete an admission Minimum Data Set (MDS) assessment for 1 of 21 residents reviewed for Minimum Data Set Assessment. (Resident 47) Findings include: Resident 47's clinical record was reviewed on 12/20/2021 at 2:00 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS), dated [DATE], assessed Resident 47 as having one unstageable pressure ulcers/injuries due to non-removable dressing/device. During an interview, on 12/20/2021 at 3:02 p.m., the corporate MDS consultant indicated the admission MDS for Resident 47 was coded incorrectly. The resident did not have an unstageable pressure ulcers/injury. The facility did not have a policy related to the MDS. They use the Resident Assessment Instrument (RAI) manual. A review of the Resident Assessment Instrument (RAI) Version 3.0 Manual, Section M0300E indicated, . Enter 0 if no unstageable pressure ulcers/injuries related to non-removable dressing/device are present . 3.1-31(d)

Based on interview and record review, the facility failed to ensure adequate physical support to prevent a fall for a resident who required physical support while toileting for 1 of 3 residents reviewed for falls (Resident B). Findings include: On 2/25/21 at 2:00 P.M., Resident B's closed clinical record was reviewed. [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Admission Assessment, dated 11/27/20, indicated the resident required extensive physical assistance of 2 or more staff for toilet use and support and was not steady, only able to stabilize with staff assistance. The Brief Interview for Mental Status assessment indicated the resident was severely cognitively impaired. The MDS Interim Payment Assessment, dated 12/17/20, indicated for toilet transfer the resident did none of the effort, and the helper did all the effort. The MDS Discharge Assessment, dated 12/30/20, indicated the resident required extensive assistance for toilet use and support, and the resident required substantial/maximal assistance to transfer on and off of the toilet. The resident care plan with a problem start date of 12/9/20, through discharge date of [DATE], indicated, Resident has impairment in functional status in regards to .transfers, toileting .related to: weakness, cancer, [MEDICAL CONDITIONS](hypertension), [MEDICAL CONDITION] .Problem Approach: Resident requires .extensive assist with transfers .extensive assist with toileting (keeping in mind that ADL's (activities of daily living) could fluctuate frequently). A nursing progress note, dated 11/26/20 at 9:44 P.M., indicated, Resident appears shaky with transfers, slow to follow command/instructions, and states dizzy upon rising . A nursing progress note, dated 12/6/20 at 2:08 P.M., indicated, .resident complaining of extreme dizziness . A nursing progress note, dated 12/13/20 at 1:54 P.M., indicated, .administered PRN (as needed) [MEDICATION NAME] (a medication used to prevent and treat nausea, vomiting, and dizziness caused by motion sickness) d/t (due to) c/o (complaint of) [MEDICAL CONDITION] . Occupational Therapy Therapist Progress Notes, dated 12/21/20, indicated, The patient performs toileting hygiene .helper lifts, holds, or supports trunk or limbs . The patient is able to safely transition from sit to stand requiring CG (contact guard-contact with patient due to unsteadiness)/minA (minimal assist). A Fall Event, dated 12/22/20 at 2:37 P.M., indicated, res (resident) sitting on toilet and staff turned to get equipment and res (resident) impulsively attempted to get up and slid to floor in front of stool. staff witnessed res (resident) slide and scrapped (sic scraped) her back on toilet. bruise noted. During an interview, on 2/26/21 at 10:30 A.M., the Director of Health Services indicated the resident would at times appear to be physically independent, but was also impulsive and could suddenly require physical assistance. During an interview, on 2/26/20 at 12:15 P.M., Certified Nursing Aid 1 indicated, on 12/22/20 he had helped Resident B onto the toilet and turned his back to gather her shower items and the resident slid off of the toilet and got an abrasion on her back. He was the only staff with her at that time. This Federal tag relates to Complaint IN 073. 3.1-45(a)(2)

Based on interview and record review, the facility failed to ensure staff informed a resident's representative following a fall that had to potential to require physician intervention for 1 of 1 resident reviewed for notification of changes (Resident B). Findings include: Interview, on 7/18/19 at 2:37 p.m., Resident B's family member indicated, (Resident B) fell and didn't notify us of of her fall for over 10 hours. On 7/18/19 at 3:00 p.m., Resident B's clinical record was reviewed. [DIAGNOSES REDACTED]. Resident B's progress notes indicated the following: -6/28/19 at 6:54 a.m., Res (resident) was sitting on the floor in her room, states she was coming back from the bathroom and fell . Res states she hurts but she hurt before the fall as well . Resident requested Tylenol at that time and was put back in her bed where she slept the remainder of the morning . Family does need notified today . -6/28/19 at 2:49 p.m., Therapy reports to res c/o (complaining of) pain when stand to rt (right) hip. Tyl (tylenol) admin (administered) prn (as needed) with some effect. New order recd (received) for stat (immediate) xray . Spouse update on fall and new orders. -6/29/19 at 9:00 a.m., Resident husband approached nurses station and to discuss resident's care, he is disgruntled regarding resident's recent fall and manner in which it was handled . states that he was not notified of wife's fall until nearly 10 hours after the incident occurred . -7/1/19 at 12:30 p.m., . New order recd (received) to send to ER (emergency room ) for eval (evaluation) of rle (right lower extremity)/hip due to pain and swelling . Resident B's fall Event Report, dated 6/28/19 at 3:10 a.m., indicated on a pain scale of 0-10 the resident's pain intensity was an 8, with 0 being no pain, and a 10 being excruciating pain. Resident Representative Notified: Yes. Date/Time: 6/28/19 at 1:58 p.m. Resident B's emergency room radiology report, dated 7/1/19 at 3:15 p.m., indicated, IMPRESSION: . There is a subtrochanteric femur fracture that was not visualized on the (MONTH) 18 study (at that time, there was only an intertrochanteric fracture). Therefore, one should consider the possibility that the subtrochanteric fracture is acute. (Hospital Name) IP (inpatient) Orthopedic Staff consult, dated 7/1/19 at 5:12 p.m., indicated, (Resident's Name) . recently had a . fx (fractured) right hip on 6/19/19. Did well initially but appears to have a fall or two around 6/28/19 . Had xray at that time that was negative but symptoms worsened so brought to ED (emergency department). Xrays in ED appear to show new subtrochanteric fracture . Interview, on 7/22/19 at 12:01 p.m., the Director of Health Services (DHS) indicated there is no way to go back and change the time the resident's representative was notified once the nurse completed the fall report and the facility had contacted the resident's representative before 1:58 p.m. A written statement from LPN 1 was provided by the facility on 7/22/19 at 3:25 p.m. The statement, dated 6/18/19, indicated, . 9:30 a.m. Call placed to spouse to update on orders. Spouse notified of fall @ (at) this time . Interview, on 7/22/19 at 3:30 p.m., Resident B's husband indicated the facility did not call him until around noon and he would have wanted a call before then. Interview, on 7/22/19 at 3:45 p.m., LPN 1 indicated the written statement was a couple of hours off and the 9:30 a.m. time would have been closer to 11:30 a.m. Interview, on 7/22/19 at 4:30 p.m., the DHS indicated there was no further documentation in regard to contacting Resident B's representative of the fall. On 7/19/18 at 3:00 p.m., the DHS provided the facility policy, Notification of Change in Condition, dated 5/23/18, and indicated it was the policy currently being used. A review of the policy indicated, . The facility must inform the . representative when: 1. An accident involving the resident which results in an injury and has the potential for requiring physician intervention . This Federal tag relates to Complaint IN 566. 3.1-5(a)(1)

Based on observation, interview, and record review, the facility failed to ensure the cleanliness of mobility devices for 3 of 24 residents reviewed for environment (Resident 4, Resident 15, and Resident 30). Findings include: 1.) On 7/17/19 at 11:40 A.M., Resident 15 was observed in her room in a chair. She indicated the wheelchair beside her was hers. The wheelchair spokes, metal frame, and brake levers were observed to have on them a dried, brown and tan substance, dust, and food crumbs. On 7/18/19 at 11:29 A.M., Resident 15 was observed in her room, sitting in her wheelchair. The wheelchair spokes, metal frame, and brake levers were observed to have on them a dried, brown and tan substance, dust, and food crumbs. 2.) On 7/17/19 at 12:15 P.M., Resident 30 was observed in his room, sitting in his wheelchair. The wheelchair spokes, metal frame, and brake levers were observed to have on them a dried, brown and tan substance, dust, and food crumbs. On 7/18/19 at 12:05 P.M., Resident 30 was observed in his room, sitting in his wheelchair. The wheelchair spokes, metal frame, and brake levers were observed to have on them a dried, brown and tan substance, dust, and food crumbs. Interview, 7/18/19 at 12:07 P.M., the resident indicated the wheelchair was often in a dirty condition, and he was unsure if anyone ever cleaned the chair. On 7/18/19 at 3:00 P.M., the resident's clinical record was reviewed. The quarterly Minimum Data Set assessment (MDS), dated [DATE], indicated the resident was severely cognitively impaired. 3.) On 7/18/19 at 10:44 A.M., Resident 4 was observed in her room, sitting in her wheelchair. The wheelchair spokes, metal frame, and brake levers were observed to have on them a dried, brown and tan substance, dust, and food crumbs. Interview, 7/18/19 at 10:45 A.M., the resident indicated, I don't think they ever clean this wheelchair. I wish they would, because it's so filthy. On 7/18/19 at 3:10 P.M., the resident's clinical record was reviewed. The admission Minimum Data Set assessment (MDS), dated [DATE], indicated the resident was cognitively intact. Interview, 7/19/19 at 2:40 P.M., the Director of Health Services indicated the wheelchairs were in need of cleaning. They were supposed to be cleaned once a week on night shift. On 7/22/19 at 11:15 A.M., the Director of Admissions Services provided the Resident Rights, undated, and indicated these were the Resident Rights currently used by the facility. A review of the Resident Rights indicated, .the resident has a right to a safe, clean, comfortable homelike environment . 3.1-19(f)(5)

Based on interview and record review, the facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) to 1 of 3 residents reviewed for SNF Beneficiary Protection Notification (Resident 44). Findings include: On 8/14/18 at 1:52 p.m., Resident 44's clinical record was reviewed. The [DIAGNOSES REDACTED]. The Physician Medicare Cert/Recert Report, dated 5/3/18, indicated Resident 44 was readmitted to the facility on [DATE], from the hospital with [DIAGNOSES REDACTED]. The SNF Beneficiary Protection Notification form indicated, Last covered day of Part A Service: 5/6/18 .The facility/provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted .1. Was an SNF ABN provided to the resident? No .Other: Explained: Resident admitted with Medicaid as payer source in 2013. Resident and family previously voiced concerns about owing money. Since we were aware there would be no additional charges, we did not issue ABN to avoid causing distress to the family and resident . On 8/14/18 at 2:07 p.m., the Business Office Manager (BOM) indicated Resident 44 was not provided a SNF ABN form. She knew a SNF ABN form should have been done, but it was not done. On 8/15/18 at 9:15 a.m., the Executive Director (ED) provided the facility's policy, How to Implement SNF ABNs, undated, and indicated it was the policy currently being used by the facility. A review of the policy indicated, Continued Stay Determination 1. The team determines the resident no longer qualifies for skilled Part A services due to medical necessity or custodial care. 1. The resident will continue in the NF (nursing facility) under a different payer source. a. Issue current SNF ABN (CMS ) letter on or before the last covered day . 3.1-4(f)(2)

Based on interview and record review, the facility failed to ensure the accuracy of a resident's prognosis for a Minimum Data Set (MDS) assessment for 1 of 1 resident reviewed for hospice. (Resident 1) Findings include: Resident 1's clinical record was reviewed on 8/15/2018 at 2:30 p.m. [DIAGNOSES REDACTED]. Nursing Progress Notes, dated 5/4/2018 at 7:14 p.m., indicated . On-call MD verbalized ok to have hospice eval (evaluate) and admit . A Facility Notification form, dated 5/5/2018, indicated Resident 1 was admitted to hospice on 5/5/2018. Resident 1's Admission Minimum Data Set (MDS) assessment, dated 5/10/2018, indicated, . Health Conditions . Prognosis . Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months? . No . During an interview, on 8/15/2018 at 2:55 p.m., with the MDS Coordinator, she indicated the MDS should have been coded, Yes. During an interview, on 8/15/2018 at 3:10 p.m., with the Regional MDS Coordinator, she indicated the MDS was coded No because the facility did not have the Hospice Physician Certification/Recertification of Terminal Illness form on file however, they probably should have it. On 8/15/2018 at 3:00 p.m., The Regional MDS Coordinator indicated the facility did not have a policy related to coding of the MDS for residents who have a life expectancy of less than 6 months. They follow the Resident Assessment Instrument (RAI) Manual. A review of the Resident Assessment Instrument (RAI) Version 3.0 Manual, Section J1400 indicated, . Code 1, yes: if the medical record includes physician documentation: 1). that the resident is terminally ill; or 2). the resident is receiving hospice services. 3.1-31(d)

Based on observation, interview, and record review, the facility failed to ensure acceptable parameters of nutritional status were maintained for 2 of 4 residents reviewed for nutritional status during stage II in that residents had been identified with severe weight loss and decreased protein levels with no change in treatment interventions. (Resident #70 and Resident #113) Findings include: 1.) On 6/23/16 at 1:38 P.M., the clinical record for Resident #113 was reviewed. [DIAGNOSES REDACTED]. The Minimum Data Set Assessment ((MDS) dated [DATE], indicated a Brief Interview of Mental Status (BIMS) score of 15, which indicated the resident to be cognitively able to be interviewed. The MDS indicated the resident had no dental abnormalities or swallowing difficulties and required meal set up only. Diet orders with a start date of 5/22/16 and current through 6/28/16, were for regular diet. The admission weight for Resident #113 was recorded on 5/23/16, as 175 pounds. The recorded weight for 6/15/16, was 163 pounds. The recorded weight for 6/22/16 was 163 pounds. This indicated a weight loss of 6.85%. Weight loss greater than 5% in 30 days is severe. Lab Results dated 6/13/16, for Resident#113 indicated a protein (compounds which provide the amino acids necessary for human metabolism and tissue growth and repair) level of 5.0 grams per deciliter (GM/dl), which is below the reference range of 6.4-8.0 GM/dl and albumen (simple proteins) level of 2.7 GM/dl, which is below the reference range of 3.5-5.0 GM/dl. The 6/22/16 Monthly Nutrition Note indicated, significant weight loss with normal BMI of 26.3, no new recommendations, will followup per protocol . The care plan for the category of Nutrition with a problem start date of 5/26/16 and current through 6/28/16, indicated a long term goal of, Maintain my weight at a healthy range for me without any unwarranted significant weight changes . The care plan included no revisions to address the severe weight change experienced by Resident #113. The clinical record lacked documentation to indicate Resident #113 had poor food intake. Observation on June 23, 2016 at 2:43 p.m.; Resident #113 was observed in her room, with family present, eating an apple. Resident #113 indicated she has, had a better appetite lately and finds the food here agreeable. The family member did not disagree. On 6/27/16 at 10:11 A.M., an interview with the Director of Nursing (DON) was conducted. The DON indicated tracking weights is important for ensuring the maintenance of optimal nutritional status. The DON indicated significant weight losses and gains are immediately reported to the DON. The dietician reviews the information on a weekly basis and makes recommendations to the physician. Care plan interventions are made as soon as possible, usually by the MDS coordinator and are also addressed in the daily clinical care meetings. The DON indicated there is no written facility policy regarding weight changes. 2.) On 6/24/16 at 10:18 A.M., the closed clinical record for Resident #70 was reviewed. [DIAGNOSES REDACTED]. The Minimum Data Set Assessment ((MDS) dated [DATE], indicated a Brief Interview of Mental Status (BIMS) score of 14, which indicated the resident to be cognitively able to be interviewed. The MDS indicated the resident had no dental abnormalities or swallowing difficulties and required meal set up only. Diet order dated 1/2/16 and current through the discharge date of [DATE], were for controlled carbohydrate diet (CCHO). The admission weight for Resident #70 was recorded on 1/1/16, as 185 pounds. The recorded weight for 1/18/16 was 175 pounds. This is a weight loss of 5.4%. Weight loss of greater than 5% in 30 days is severe. No nutritional notations are indicated in the progress notes. The care plan for the category of Nutrition with a problem start date of 1/7/16 and current through the long term goal target date of 4/8/16 indicated a long term goal of, Maintain my weight at a healthy range for me without any unwarranted significant weight changes . The care plan included no revisions to address the significant weight change experienced by Resident #70. On 6/27/16 at 10:11 A.M., an interview with the Director of Nursing (DON) was conducted. The DON indicated tracking weights is important for ensuring the maintenance of optimal nutritional status. The DON indicated significant weight losses and gains are immediately reported to the DON. The dietician reviews the information on a weekly basis and makes recommendations to the physician. Care plan interventions are made as soon as possible, usually by the MDS coordinator and are also addressed in the daily clinical care meetings. The DON indicated there is no written facility policy regarding weight changes. 3.1-46(a)(1)

Based on interview, observation and record review, the facility failed to supervise a cognitively impaired resident, Resident #26, who had multiple falls, resulting in a fractured wrist, for 1 of 8 residents reviewed with falls, in the sample of 12. Findings include: Resident #26 was identified on the initial tour of the facility, on 5/14/12 at 9:00 A.M. by LPN #1, as cognitively impaired, having had a recent fall with fracture, and utilizing a wheelchair for transfers. The resident was observed to have been sitting in a wheelchair in the hallway, with a cast to her left lower arm. The resident was observed to have an alarming seat belt on her wheelchair. Resident #26's clinical record was reviewed on 5/14/12 at 10:30 A.M. [DIAGNOSES REDACTED]. Resident #26's most recent MDS (Minimum Data Set) assessment, dated 4/27/12, indicated the resident was cognitively impaired, required extensive assistance from staff for transfers and bed mobility, had not ambulated, and had fallen since the last assessment. A care plan, for falls, dated 3/4/12, indicated interventions of "wheelchair with anti-roll back devices and anti thrust cushion," "educate/remind resident to ask for assistance prior to ambulation/transfers," "reorient to room as needed," "dycem to wheelchair," "bed against wall," " frequent used items in reach," "staff to take resident to dining room/hall not left alone in room," "recliner out of room," "phone at head of bed," "4/24/12 alarming seat belt in wheelchair." The previous fall care plan, dated 3/14/11, indicated the alarming floor mat was started 9/3/11. The care plan included a problem, dated 4/25/12, for "restraint/enabler, medical symptom-fracture left wrist from fall related to decreased safety awareness, impulsiveness-alarming seatbelt." A care plan, dated 2/7/12 to 5/7/12, indicated a problem of "impaired cognitive skills, as evidenced by memory problems, recall problems, dementia." The CNA assignment sheets, dated 3/28/12, provided by the Director of Nursing, on 5/15/12 at 1:00 P.M., indicated for Resident #26, "out of bed for all meals, no bedspread anytime, not to be alone in chair in room, bed to wall with alarming mat at bedside, alarm box out of reach." The fall circumstance, assessment and interventions forms and a time line of falls, provided by the Director of Nursing, on 5/15/12 at 12:30 P.M., indicated falls on the following dates: 3/3/12 4 p.m. fall from recliner chair in room. added alarm to recliner, obtained urine sample. The timeline indicated an added intervention of alarm to recliner and obtain UA (urinalysis). 3/4/12 6:30 A.M. fall from bed to floor mat. 3/7/12 7:45 a.m. fall in room, fall from chair to floor mat. Being treated for [REDACTED]. 3/15/12 found on floor, 7 p.m. sitting in wheelchair reaching for an object, landed on bottom. Intervention was allow up in wheelchair with objects close to her. Nurses notes, for this same time and date, indicated this occurred in the resident's room with the roommate yelling for help and alarm ringing. 4/4/12 at 6 p.m. nurses notes indicated "resident reaching for clothes that daughter had brought to donate to staff...slid out of wheelchair..." The time line indicated the intervention of clothes removed. 4/6/12 8:40 p.m. found on floor in resident's room, states rolled out of bed. Nurses notes, same date and time, indicated the alarm did sound. 4/15/12 6:40 p.m. found on floor in room by bed, root cause- just got back form hospital for treatment of [REDACTED]. The timeline indicated for interventions" does have a possible urinary tract infection." 4/18/12 8:45 P.M. found on floor in room, attempted to self ambulate, does not use call light, safety equipment was functioning at time of fall, resident was toileted by staff. Recent agitated or restlessness. The nurses notes entry for this same date and time indicated: "Received report from CNA resident was lying on the floor in front of her wheelchair. Resident stated she tried to get up to go home and she fell ." The facility lacked documentation after the last three falls, of new interventions having been implemented, except testing and treatment for [REDACTED]. 4/18/12 9:15 p.m. found on floor in resident's room, injury left wrist signs and symptoms of fracture, left wrist swelling, recent agitation or restlessness, states wants to go home. The report indicated the safety measures were in place. Nurses notes, dated 4/18/12 at 9:15 p.m. indicated: "Received report from CNA that resident got out of bed and fell in the doorway of her room. Resident was lying on her back with her knees bent. Resident was very confused and stated she wanted to go home...complains of left wrist pain, noticeable swelling..." The timeline provided by the DON indicated on 4/19/12 an antibiotic was ordered for increased confusion. Nurses notes indicated: "4/19/12 2:30 a.m. returned to facility at 1250 a.m. (sic) from hospital..found fracture to left wrist (colles fracture)...splinted left wrist..." 4/23/12 7:10 p.m. found in floor of room, bed wheels were locked. Nurse notes, dated 4/23/12 at 7:15 p.m., indicated resident pulled self to room after meal, alarm sounded and resident found sitting slumped on floor, lethargic...self releasing alarming seat belt added. During interview with the Director of Nursing, on 5/15/12 at 1:30 p.m., she indicated the resident had a decline in condition in the past few months and had repeated urinary tract infections and anxiety. 3.1-45(a)(2)