Every finding on record at Timbercrest Church of the Brethren Home

Based on observation, interview, and record review the facility failed to ensure dietary employees were competent in both dishwasher and three compartment sink sanitation testing. This deficient practice had the potential to impact 60 of 60 residents who received meals prepared in the facility kitchen.Findings include:1.During an observation of dishwasher operations in the main kitchen, on 8/19/25 at 11:24 a.m., the following was observed:The dishwasher ran through the wash and rinse cycles three times. The temperature gauges did not fluctuate before, during, or after the cycles were completed. The Executive Chef indicated that she was unsure if the temperature gauges were working and she did not know if the dishwasher was a low or high temperature machine. She was unsure of the specifics of the dishwasher, including what the desired temperatures should be and what, if any, chemicals were used.2.During an observation of dishwasher operations in the main kitchen, on 8/20/25 at 10:15 a.m., the following was observed:The dishwasher ran through the wash and rinse cycles three times. The gauges had minimal fluctuation before, during, and after the cycles were completed. Dietary Aide 8 indicated the dishwasher had just been turned on at 10:00 a.m. and was not up to temperature. He indicated he was unsure if the dishwasher was a high or low temperature machine and the final cycles gauge did not move much due to the final rinse cycle had been converted to a chemical sanitizer.The Executive Chef took the blender blades that had been used for pureeing food to the three-compartment sink. She placed the blades in the first compartment and washed the blade off, dipped the blade in the second bin to rinse it off, and then dipped the blade in the third bin to sanitize. She placed the blender blade in the drying rack. She placed a test strip into the sanitizer bin and threw it away. She indicated she was unsure what test strips to use and retrieved another brand and style and placed the strip into the sanitation bin. Both strips did not register any parts per million of sanitizing agent was in the bin. She requested assistance from Dietary Aide 8. Dietary Aide 8 identified the correct test strips to used for the brand of sanitizer that was used at that time. The sanitizer used was pink in color and located in a plastic jug. The other strips had been used for another sanitizing agent that was located in the dispenser hanging over the sink, however the dispenser was empty, and the agent was on back order. Dietary Aide 8 placed a test strip into the sanitation bin. The strip did not register any parts per million of sanitizing agent was in the bin. Dietary Aide 8 drained the sanitation bin and poured some of the pink sanitizer into the bottom of the sink. He did not measure and indicated he wasn't sure of the exact amount used, but normally added sanitizer to the top of the drain and then filled it with water. When the water in the sanitation bin was at the desired height, Dietary Aide 8 placed a test strip in the sanitation bin. The test strip indicated 400 parts per million of sanitizer was present. The Executive Chef was uncertain what the desired range was for the sanitizer but thought it should be around 200 parts per million. Dietary Aide 8 indicated 400 parts per million was a good range. At 10:50 a.m., the blender blades remained in the drying rack and had not been rewashed.During an interview, on 8/20/25 at 12:15 p.m., Regional Support indicated the dishwasher was in place from the previously contracted dietary company and he did not know much about that type of dishwasher. He was unsure if it was normal or not to have the gauges fluctuate much before, during, or after the wash cycles.3.During an observation of dish washing operations in the main kitchen, on 8/26/25 at 11:20 a.m., the following was observed:Dietary Aide 8 was washing dishes in the three-compartment sink. He indicated that the dishwasher had not been used since the previous Sunday due to lack of detergent and all dishes were washed in the three-compartment sink. Several kitchen items were washed and placed in drying rack. All items used to prepare resident meals were washed in the main kitchen. Dietary Aide 8 placed a test strip in the sanitation bin. The test strip did not indicate any sanitizer was in the bin. Dietary Aide 8 placed a second strip in the sanitizer bin. The second strip did not indicate any sanitizer was in the bin. Dietary Aide 8 indicated he was not the staff member that filled the sink, and the sinks were to be drained and changed on average two or three times a day, but sometimes it occurred less. Dietary Aide 8 pushed a cart of dishes, that were located beside the drying rack, over to shelves and started to put the dishes away. The dishes had been washed prior to identifying the lack of sanitizer in the bin. Dietary Aide 8 considered the dishes on the cart clean and sanitized because he assumed there had been sanitizer in the bin earlier in the day. A second dietary aide walked over to the three-compartment sink and washed a couple of items and dipped them in the sanitizer bin, which had not been drained, and placed items in the drying rack.During an interview, on 8/26/25 at 11:30 a.m., the Dietary Manager indicated the parts per million were not correct in the sanitizer bin due to the calibration being off on the automatic dispenser that hung above the sink. Staff were not using the pink sanitizer in the plastic jug. The pink chemicals in the plastic jug were only to be used in the dishwasher. The dishwasher was rented, and he did not know much about the dishwasher and could not identify if it was a low or high temperature machine. The water in the three-compartment sink was changed three times a day, between meals.During an interview, on 8/26/25 at 2:23 p.m., the Dietary Manager indicated all residents that reside in the facility were served from the kitchen. Each meal was batch cooked in the main kitchen and then sent to the small facility kitchens.During an interview, on 8/26/25 at 4:19 p.m., Regional Support indicated he was unsure dishwasher was a low or high temperature machine, but thought it to be a high temperature. He was not aware the dishwasher was not in use since 8/25/25. He thought staff would have taken dishes to other facility kitchens to wash.During an interview, on 8/26/25 at 4:46 p.m., Regional Support indicated the Dishwasher was a low temperature machine. Arrangements were made to have the dishwasher sanitizer switched to another product soon. He was unsure if there were logs for the dishwasher and the three-compartment sink and will provide if found. The product used in the dispenser above the three-compartment sink ran out and was not being used and staff should have used the alternate sanitizer.A main kitchen log, dated August 2025, titled, DISHMACHINE TEMPERATURE LOG (Low Temperature), provided by Regional Support, on 8/26/25 at 5:00 p.m., indicated the dishwasher temperatures and sanitizer was checked at lunch and dinner. There was no temperature or sanitizer recordings entered for 8/7, 8/8, 8/9, 8/13, 8/14, 8/21, 8/22, 8/25, 8/26/25.A three-compartment sink log, dated August 2025, provided by Regional Support, on 8/26/25 at 5:00 p.m., indicated the following: Instructions: 1. Record three times a day (e.g. open, mid-day, close).Standard: Food-grade sanitizing solution must be a quaternary ammonium sanitizer with an effective range of 200-400 parts per million. Corrective action: Check supply lines, retest. If retest fails, notify manager, take equipment out of service, and notify chemical representative. The log recorded the time and parts per million at lunch and dinner. No time or parts per million recordings were entered for 8/8, 8/9, 8/13, 8/14, 8/21, or 8/22/25.A current facility policy, dated 9/7/22, titled, THREE COMPARTMENT SINK QUALITY ASSURANCE 6.028, provided by Regional Support, on 8/26/25 at 4:18 p.m., indicated the following: .Method/Procedure: The pot sink must have three compartments.The sanitizer sink must contain a chemical sanitizer at 200 PPM (parts per million).The water in the pot sink should be changed every two hours minimum. Titration of sanitizer and temperatures must be checked and logged three times daily.1.3-20(h)

Based on observation, interview, and record review the facility failed to ensure food was prepared and served in a safe and sanitary manner regarding food handling and hand hygiene. This deficient practice had the potential to impact 60 of 60 residents who received their meals from the kitchen.Findings include:During a continuous lunch service observation, on 8/22/25 from 12:12 p.m. to 1:05p.m., the following food handling and food service concerns were observed: After preparing meal trays, [NAME] 5 exited the kitchen, walked into the dining area, turned around, and approached the meal window where the prepared meal trays sat. He removed his gloves and placed the used gloves in his front right pant pocket. [NAME] 5 delivered three resident meal trays. [NAME] 5 re-entered the kitchen and applied a new pair of gloves without performing hand hygiene. DC 5 touched several dietary meal tickets that were placed on meal trays. After he reviewed the meal tickets, he picked up the telephone and made a call. Wearing the same gloves, DC 5 reached into a plastic bag and retrieved a hotdog bun. With his gloved hands, he opened the hotdog bun, set the bun on a plate, and placed a hotdog in the bun. He grabbed the serving utensil handle and dished food onto the plate. He continued to dish two additional meal trays. DC 5 turned around to another countertop and handled the meal trays and dietary slips. After he looked at the meal tickets, he picked up the phone and made a phone call. He removed his gloves and retrieved a food container. Without performing hand hygiene, DC 5 applied new pair of gloves, and dished meal trays. He reached into a plastic bag and removed a hotdog bun, opened the bun, placed a hot dog in the bun, and returned to dishing food items. He left the serving area and retrieved a stack of meal trays on the opposite side of the kitchen. DC 5 sat the meal trays on the countertop behind the serving countertop. DC 5 returned to the serving countertop and dished out several plates. Dietary Server 6 assisted [NAME] 5 with dishing meals. She retrieved two bowls and set the bowls on a meal tray. She reached into plastic bag and retrieved a hotdog bun, opened the bun, and set it on the plate. She sat the plastic bag that contained the hotdog buns on a stack of clean meal trays. Without changing gloves, DC 5 diced cooked chicken breast by holding the chicken with his left hand and holding the knife in his right hand. DC 5 wiped his gloved hands on his apron. He walked around the kitchen and retrieved a stack of plates and placed them on the serving counter. He walked over and retrieved a hotdog bun from a plastic bag. He used his gloved hands to open the bun and place it on a plate. He cut the chicken and used his hands to pull the chicken apart and placed it on a plate. He rearranged the chicken pieces on the plate and returned to dishing the remaining food items for the meal tray. During an interview, on 8/22/25 at 1:19 p.m., DC 5 indicated he was to change his gloves after any object not used during serving, such as knobs, phone, and refrigerator and freezer handles were touched. He was to change his gloves after food was touched. He was aware he missed multiple opportunities to change his gloves and perform hand hygiene during the meal service. During an interview, on 8/22/25 at 1:23 p.m., the Executive Chef indicated staff was expected to change gloves after items not used for serving were handled or touched, especially a phone or cooked chicken. During an interview, on 8/26/25 at 2:23 p.m., the Dietary Manager indicated staff members who were dishing items for the meal trays were expected to change gloves anytime they touched an item not used to serve meal items. Staff could intermittently change between handles of serving utensils without changing gloves but should not touch any other objects. All dietary employees had previously received handwashing and glove use education. A current facility policy, dated 9/7/22, titled, DISPOSABLE GLOVES FOOD SAFETY & INFECTION CONTROL 6.009 , provided by the Executive Chef, on 8/26/ 25 at 2:240 p.m., indicated the following: .Method/Procedure: Hands must be washed before putting on and after removing disposable gloves when working in the kitchen .Hands must be leaned before outing on the gloves, and after removing the gloves.Disposable gloves must be changed, and hands washed when the gloves are dirty or ripped and when moving from one task to another, such as moving from handling dirty dishes to handling clean dishes. Hands must be washed with soap and water before putting on or after use of gloves for plating on the resident units. Hand sanitizer may be used for tray delivery process only. 3.1-21(i)(3)

Based on observation, interview, and record review, the facility failed to ensure residents received a dignified dining experience for 2 of 16 residents during random dining observations. (Residents 54 and 45)Findings include:1.Resident 54's clinical record was reviewed on 8/21/25 at 2:03 p.m. Diagnoses included unspecified dementia (severe, with psychotic disturbance), generalized anxiety disorder, insomnia, impulse disorder, chronic kidney disease, and benign prostatic hyperplasia (enlarged prostate).Current physician orders included buspirone 10 milligrams (mg) three times a day for anxiety, donepezil 10 mg once a day for dementia, sertraline 25 mg once a day for anxiety, and trazodone 50 mg at bedtime for insomnia. A quarterly Minimum Data Set (MDS) assessment, dated 7/8/25, indicated Resident 54 was severely cognitively impaired, able to eat independently, and required substantial/maximal assistance for oral hygiene, toileting hygiene, showering/bathing, and dressing. A current care plan, initiated on 10/14/24 and revised on 8/21/25, indicated Resident 54 was at nutritional risk related to dementia and anxiety. He required supervision, cueing, and redirection at meals because he would wander. He was at risk of eating non-food items. Interventions included meal set-up, supervision, cueing, and redirection at meals.During a lunch observation, on 8/19/25 at 12:13 p.m., CNA 2 assisted Resident 54 with his meal and CNA 3, at the other end of the table, assisted Resident 45 with her meal. The two CNAs carried on a conversation about CNA 2's cat while intermittently assisting the residents with their meals. Neither CNA conversed with the residents. They continued their personal conversation and did not include the residents in the conversation about cats. During a lunch observation, on 8/21/25 at 12:13 p.m., CNA 3 was sitting to the right of Resident 54. CNA 3 reached in front of Resident 54's body, quickly removed something from the resident's left hand (which was resting on the table), and placed the item on the table to the CNA's right side. As the CNA was placing the item on the table, she said We don't do that! to Resident 54.During a lunch observation, on 8/22/25 at 11:36 a.m., Resident 54 was asleep at the dining table. The resident was startled awake when CNA 2 placed a drink in front of him and said, I've got your Pepsi! At 11:41 a.m., CNA 2 placed Resident 54's soup in front of him. The resident unwrapped his silverware and proceeded to try to eat the soup with his fork. CNA 2 got some oyster crackers and put them in Resident 54's soup. Resident 54 continued to attempt to eat his soup with the fork. At 11:44 a.m., CNA 2 moved the soup bowl closer to the resident. The resident continued to attempt to eat the soup with the fork. A spoon was sticking out of the resident's applesauce cup. At 11:55 a.m., Resident 54 was eating, when CNA 2 abruptly placed a drink in front of his face. The resident's head jerked backwards, and the CNA said Here, something to wash that down with. CNA 2 did not speak with Resident 54 except when offering food or drink. At 12:09 p.m., CNA 2 abruptly placed the drink back in front of Resident 54's face and said Here.that cornbread is dry. Resident 54 startled and his head jerked backwards. CNA 2 then moved the applesauce cup closer to the resident, got a spoonful of the applesauce, lifted it to Resident 54's lips and said, Try this! The resident accepted the bite, then moved the applesauce away. CNA 2 moved it back in front of the resident and continued to offer him bites of the applesauce. At 12:15 p.m., CNA 2 offered Resident 54 another drink, and the resident indicated he did not want anymore. The CNA proceeded to offer another drink, saying One more little drink. At 12:18 p.m., the resident reached for his meal ticket. CNA 2 said No, leave that there. and moved the ticket out of his reach.During an interview with CNA 2, on 8/22/25 at 12:36 p.m., she indicated Resident 54 often fell asleep during meals. Whenever she saw him eating with the wrong utensil(s), she would give him the correct utensil. She provided help with his drinks because, without assistance, he would pour the drink into his food, mix it with the food, and then try to eat the mixture with a fork.During an interview with RN 4 on 8/22/25 at 3:19 p.m., she indicated Resident 54 could be difficult to redirect and wandered around the unit much of the time. His dementia caused him to be more childlike, and he required a lot of redirection.During a lunch observation, on 8/25/25 at 12:05 p.m., CNA 3 placed a drink in front of Resident 54 and said [Resident 54]! Take a drink! She did not lift the cup to Resident 54's lips, but waited for him to respond. The resident looked confused and did not attempt to take a drink. The CNA continued to tell Resident 54 to take a drink. When he did not respond, she lifted the drink to his lips and he took a drink.During an interview with RN 7, on 8/25/25 at 12:15 p.m., she agreed CNA 3's manner could be abrupt at times.During an interview with CNA 3, on 8/25/25 at 1:11 p.m., she indicated Resident 54 would often sleep during a meal. Staff had to keep an eye on him. Resident 54 would forget what he was supposed to do. Because of his dementia, he had the mind of a five-year-old and required a lot of help. Staff were supposed to encourage him by offering drinks. If it were another resident, she would ask them if they wanted a drink, but with Resident 54, she had to tell him what to do. Some days, he would respond when asked to do something. Other days, he had to be told what to do. It just depended on the day.2. Resident 45's clinical record was reviewed on 8/25/25 at 12:39 p.m. Diagnoses included Alzheimer's disease, generalized anxiety disorder, hypertension, and age-related osteoporosis.Current physician orders included buspirone 15 mg three times a day for anxiety, gabapentin 100 mg once a day for anxiety, memantine 5 mg twice a day for Alzheimer's disease, and mirtazapine 15 mg at bedtime for insomnia.A quarterly MDS assessment, dated 8/21/25, indicated Resident 45 was severely cognitively impaired, did not exhibit hallucination, delusions, or behaviors, used a walker to ambulate, could eat independently, required supervision/touch for oral hygiene, and substantial/maximal assistance with toileting hygiene.A current care plan, initiated on 6/20/25, indicated Resident 45 talked very loudly to herself at times, for long periods of time, sometimes in a chanting manner. Interventions included assessment of Resident 54's needs, i.e., toileting, pain, thirst, or hunger, engage Resident 45 in conversations about baking or cooking because she enjoyed talking about baking pies, cookies, and cakes, and encourage Resident 45 to vent her feelings and emotions by providing supportive listening and encouragement.A current care plan, initiated on 3/14/25, indicated Resident 45 often believed she was going somewhere with family. She stated she believed there are boys here who need something. She had exhibited exit seeking behaviors. Interventions included engagement of the resident in self-care and physical activities to channel energy, and encourage ventilation of feelings, fears, and anxiety.During a lunch observation, on 8/19/25 at 11:43 a.m., Resident 45 used a dining chair to ambulate from her walker to the dining table. CNA 2 observed the resident with the dining chair but did not intervene. At 12:07 p.m., Resident 45 pushed her chair away from the dining table. CNA 2 asked the resident where she was going. Resident 45 wanted to know why staff was asking her where she was going, but got no response from staff. She stayed in her chair and continued to talk about why everybody was so concerned about her going somewhere. As she continued to talk, CNA 2 and CNA 3 talked over Resident 45's head about CNA 2's cat. Neither CNA responded to Resident 45's question(s). They did not engage Resident 45 in conversation. CNA 2 interrupted Resident 45 by speaking over her and said [Resident 45]! Here's your soup! A second interruption occurred when CNA 2 said Here's your crackers!During an interview with the Director of Nursing (DON), on 8/25/25 at 4:48 p.m., she indicated CNA 3's manner was not as soft as some. CNA 3 had a hearing deficit. CNA 3 came across as gruff at times. Staff should not have personal conversations when assisting residents during mealtimes.A current facility policy, titled Dementia Care, provided by the ADON on 8/26/25 at 2:59 p.m., indicated the following: .4. Care and services will be person-centered and reflect each resident's individual goals while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety.9. All staff will be trained on dementia care practices upon hire, annually, and as needed to ensure they have the appropriate competencies and skill sets to ensure residents' safety and help residents attain or maintain the highest physical, mental, and psychosocial well-being. 3.1-3(a)

Based on interview and record review, the facility failed to ensure the physician reviewed and addressed pharmacy recommendations in a timely manner for 1 of 5 residents reviewed for unnecessary medications (Resident 1). Finding includes:Resident 1's clinical record was reviewed on 8/21/25 at 12:26 p.m. Diagnoses included gastro-esophageal reflux disease (GERD) without esophagitis, folate deficiency, Vitamin D deficiency, constipation, chronic kidney disease, hypo-osmolality (lower-than-normal concentration of dissolved particles, such as sodium, in blood), hyponatremia (having too little sodium in the blood), and type 2 diabetes mellitus with polyneuropathy (damage to peripheral nerves). Current orders included famotidine 40 milligrams (mg) daily (7/25/24). Pharmacy recommendations on 11/11/24, 1/13/25, and 3/10/25, provided by the DON on 8/22/25 at 9:30 a.m., indicated the pharmacist indicated the resident received a proton pump inhibitor (PPI - treats disorders of the stomach), omeprazole 40 mg once daily, in addition to another gastroprotective therapy famotidine 40 mg once daily. Both therapies may not have been necessary. The discontinuation of one of the medications was recommended. A nursing progress note, dated 4/18/25 at 11:09 a.m., indicated a new order to discontinue omeprazole had been received due to multiple therapies. The resident's clinical record lacked physician notification and rationale for declination of the pharmacist's recommendations for 11/11/24, 1/13/25, and 3/12/25 prior to 4/18/25. During an interview, on 8/26/25 at 9:33 a.m., the ADON indicated the pharmacy sent the recommendations to the facility. The Social Services Designee printed them off. The ADON sent them to the physician or gave them to the nurses to send to the physician. The pharmacy usually notified the facility when a recommendation had not been addressed. An office visit note from the allergist, dated 7/24/24, provided by the ADON on 8/26/25 at 10:16 a.m., indicated the resident likely had uncontrolled GERD which contributed to her symptoms. Omeprazole 40 mg daily was added for reflux induced asthma. A pharmacy recommendation for 8/2024, provided by the ADON on 8/26/25 at 10:16 a.m., indicated the physician had declined discontinuing either omeprazole or famotidine because the resident had been symptomatic with the famotidine alone, and a trial of the omeprazole was being attempted to see if the resident improved. During an interview, on 8/26/25 at 10:40 a.m., the ADON indicated the resident had seen an allergist in July of 2024 who had ordered the omeprazole, and the primary care physician had declined to discontinue the medication. The resident had been seen by the allergist again in December of 2024. While the medications had been listed as ordered medications, the allergist had not specifically provided a rationale for continued use of both omeprazole and famotidine. She believed the resident was scheduled to go back to the allergist in March of 2025. During an interview, on 8/26/25 at 4:12 p.m., the ADON indicated she had been unable to locate additional information on the pharmacy recommendations for 11/11/24 and 1/13/25 that had been communicated to the physician and the rationale for declination. During an interview, on 8/26/25 at 4:18 p.m., the DON indicated pharmacy recommendations were sent to the physician and then tracked for being returned by the physician. She did not have additional information on communication with the physician about the pharmacy recommendations on 11/11/24 and 1/13/25. An undated, current policy, provided by the ADON on 8/26/25 at 2:59 p.m., titled Medication Regimen Review, indicated the following: .The Consultant Pharmacist performs a Medication Regimen Review (MRR) which is a comprehensive review of each resident's medication. This is also known as a Drug Regimen Review (DRR) and is completed at least monthly.Findings and recommendations are reported to the Director of Nursing, the attending physician, and the Medical Director.Recommendations are acted upon and documented by the facility staff and/or the prescriber. The Medical Director and attending physician must be notified of all recommendations/findings/irregularities involving medications. The physician accepts and acts upon suggestions, or rejects and provides an explanation for disagreeing. An undated, current policy, provided by the ADON on 8/26/25 at 2:59 p.m., titled Documentation and Communication of Recommendations, indicated the following: .The Consultant Pharmacist works with the facility to establish a system whereby the Consultant Pharmacist's observations and recommendations regarding residents' medication therapy are communicated and responded to by those with authority, and/or responsibility to implement the recommendations in an appropriate and timely fashion.2. Comments and recommendations concerning medication therapy are communicated in a timely fashion. The timing of these recommendations should enable a response prior to the next medication regimen review. In the event of a problem requiring the immediate attention of the prescriber, the responsible physician or physician's designee is contacted by the Consultant Pharmacist or the facility, and the prescriber's response is documented on the Consultant Pharmacist review record or elsewhere in the resident's medical record. 3. Recommendations are acted upon and documented by the facility staff and/or prescriber. If the prescriber does not respond to recommendation directed to him/her within a reasonable timeframe, the Director of Nursing and/or Consultant Pharmacist may contact the Medical Director. 3.1-25(i)

Based on interview and record review, the facility failed to follow an Indiana Physician Order for Scope of Treatment (POST) form indicating do not attempt resuscitation/DNR for a resident that received cardiopulmonary resuscitation (CPR) for 1 of 3 residents reviewed for Advanced Directives. (Resident 61) Findings include: Resident 61's clinical record was reviewed on [DATE] at 11:49 a.m. Diagnoses included unspecified systolic (congestive) heart failure, obstructive sleep apnea, dysphagia, oropharyngeal phase, and other pneumonia, unspecified organism. Current orders indicated the resident was a full code, pending POST form completion, dated [DATE]. An Indiana Physician Order for Scope of Treatment (POST) form dated [DATE], and signed [DATE], indicated in section A that Resident 61 requested a do not attempt resuscitation (DNR) if he had no pulse and was not breathing. A progress note, dated [DATE] at 3:30 a.m., indicated resident had no pulse, was not breathing, and had no chest rising. Code status was verified by staff as a full code. CPR was initiated and 911 emergency services were called. A progress note, dated [DATE] at 3:38 a.m., indicated the resident's representative was notified that staff started chest compressions. Once EMS arrived, they administered medications, but the emergency medical technician (EMT) spoke with the resident representative, who indicated Resident 61 would not want chest compressions if he didn't have a heartbeat. Since there was no heartbeat, the decision was made to stop medications and ventilation. During an interview, on [DATE] at 12:19 p.m., the DON and Social Services indicated it wasn't a clear cut and dry DNR. The resident wanted to be a DNR, but with full interventions. The resident voiced that if he was found with no heartbeat and not breathing, he did not want CPR performed. During an interview, on [DATE] at 1:46 p.m., the DON indicated there was a note stating the resident still had respirations, but they were unable to provide those documents. She didn't know why his code status was not updated. Once a POST form was completed and in the chart, the order should be updated. Staff members verify a resident's code in the banner of their face sheet within the electronic clinical record. A printed resident face sheet, provided by the DON on [DATE] at 2:15 p.m., indicated Resident 61's status was DNR, but had a note attached stating full interventions. The alerts indicated full interventions including life support measures in the intensive care unit. In addition to care described in Comfort Measures and Limited Additional Interventions above, use intubation, advanced airway interventions, and mechanical ventilation as indicated. Transfer to hospital and/or intensive care unit if indicated to meet medical needs. During an interview, on [DATE] at 2:37 p.m., RN 11 indicated she found a resident's code status on the face sheet under the tab continuance of care. During an interview, on [DATE] at 2:38 p.m., RN 12 indicated she looked at the banner for a resident's code status. A current policy titled Advanced Directive Policy, provided by the ADON on [DATE] at 2:48 p.m., indicated the following: .Changes to the residents choices for advanced directives will be documented, included in the residents plan of care, state specific documents will be updated as necessary, physician orders will be obtained to reflect new choices as applicable and all items will be communicated to staff providing resident care

Based on observation, record review, and interview, the facility failed to allow a resident with the ability to make their own decisions to formulate an advance directive. (Resident 50) Findings include: On 9/26/24 at 8:55 a.m., Resident 50's clinical record was reviewed. Diagnoses included essential hypertension, heart failure, acute kidney failure, and Type 2 diabetes mellitus. A Minimum Data Set (MDS) assessment, dated 6/30/24, did not include a BIMS (Brief Interview for Mental Status) assessment to evaluate cognition. On 6/27/24, Resident 50's family member signed a Do Not Resuscitate (DNR) form. A progress note, on 6/27/24 at 8:47 p.m., indicated Resident 50 was alert and oriented. A POST form (a physician's order for scope of treatment based on the resident's medical conditions and preferences),dated 7/5/24, indicated the resident had a DNR code status. During an interview with the Admissions Coordinator (AC) on 9/27/24 at 9:45 a.m., she indicated the resident's family member had completed the admission paperwork. At the time of admission, Resident 50 had come from the hospital and was tired. Each admission was different, dependent upon her assessment of a person's ability to sign advance directives at that time. When she visited residents at the hospital, before they were admitted to the facility, she would also assess family dynamics to determine if the resident could sign the advance directives. On 9/25/24, at 10:24 a.m., Resident 50's clinical record indicated a BIMS score of 14, which indicated she was cognitively intact and capable of making reasonable and consistent decisions. During an interview with the Administrator on 9/30/24 at 2:42 p.m., she indicated the resident would have been competent enough to sign the Advance Directive at admission. A current facility policy, titled Advance Directive Policy, with a revision date of 6/23/23, was provided by the Director of Nursing (DON) on 9/25/24 at 2:48 p.m. The policy indicated the following: It is the policy of (the facility) to establish, implement and maintain written policies and procedures for advance directives. The resident has the right and the facility will assist the resident to formulate an advance directive .a) Upon admission, identify if the resident has an advance directive and if not, determine if the resident wishes to formulate an advance directive .c) .The facility will identify the primary decision maker (e.g., assess the resident's decision-making capacity ) 3.1-4 (f)(1)(A)(ii)

Based on observation and interview, the facility failed to ensure medications stored in the medication carts were labeled with resident identifiers and directions for 2 of 3 medication carts reviewed. (Hall 100 Medication Cart and Hall 400 Medication Cart). Findings include: During an observation of the Hall 100 medication cart on 9/26/24 at 3:30 p.m., accompanied by QMA 6, the bottom drawer contained an unlabeled bottle of Vanadium Complex (a supplement used to support blood glucose levels), an unlabeled bottle of Stasis Liver Detox (a liver supplement), and an unlabeled bottle of Thytrophin PMG (a thyroid supplement). QMA 6 indicated all supplements belonged to one resident and each should have a label with resident identifiers. During an observation of the Hall 400 medication cart on 9/26/24 at 3:42 p.m., accompanied by QMA 8, an unlabeled bottle of acetaminophen 500 mg tablets and an unlabeled bottle of Juice Plus Fruit & Vegetable Blend supplement were in the cart. QMA 8 indicated both should be labeled. During an interview with RN 9 on 9/26/24 at 3:57 p.m., she indicated all bottles and containers in the medication carts should have a label containing the name of the resident, their date of birth, instructions for use, and the name of a provider. On 9/26/24, at 4:00 p.m., the Assistant Director of Nursing (ADON) indicated medications in the medication carts should have a resident name, physician name, an open date, and directions for use on the bottle. The DON provided a current facility policy, titled Storage and Expiration Dating of Medications and Biologicals on 9/27/24 at 12:34. This policy did not contain information regarding labeling of medications. 3.1-25(j)(k)

Based on observation, interview, and record review, the facility failed to properly prevent and/or contain COVID-19 by not wearing appropriate personal protective equipment (PPE) in areas requiring transmission-based precautions (TBP) during random observations on the 300 Hall. Findings include: During a random observation, on 9/24/24 at 10:59 a.m., CNA 14 entered room [ROOM NUMBER] while wearing gloves, an N95 mask placed over a surgical mask, and a gown. No face shield and/or eye protection was worn before entering the resident's room. Signage on the door indicated the resident was in transmission-based precautions, and required a gown, gloves, N95 mask and a face shield/goggles before entering the room. During a random observation, on 9/24/24 at 11:05 a.m., CNA 14 was wearing a gown, gloves, and an N95 mask overtop of a surgical mask while entering room [ROOM NUMBER]. During an interview, on 9/24/24 at 12:12 p.m., CNA 14 indicated she only wore gloves, a gown, and placed an N95 mask over a surgical mask. No face shield/ goggles were worn before entering the resident's room. During a random observation, on 9/26/24 at 9:11 a.m., CNA 3 entered room [ROOM NUMBER] while wearing gloves, a gown, goggles, and an N95 mask over a surgical mask. During an interview, on 9/26/24 at 9:15 a.m., CNA 3 indicated she wore a gown, gloves, face shield and placed an N95 mask overtop a surgical mask before entering the resident's room. During an interview, on 9/26/24 at 11:44 a.m., the ADON indicated staff should not be wearing both a surgical mask and N95 before entering a resident's room who was on transmission-based precautions. A current facility policy titled COVID-19 PREVENTION AND RESPONSE and REPORTING, provided in the entrance survey binder on 9/25/24 at 10:45 a.m., indicated the following: .16. HCP who enter the room of a resident with suspected or confirmed SARS-CoV-2 infection should adhere to standard precautions and use a NIOSH-approved particulate respirator with N95 filers or higher, gown, gloves, and eye protection 3.1-18(a)

Based on interview and record review, the facility failed to follow physician orders to call the physician for low blood pressure readings for 1 of 3 residents reviewed at risk for falls. (Resident B) Findings include: Resident B's clinical record was reviewed on 3/13/24 at 10:35 a.m. Diagnoses included hypertension, amnesia (memory loss), unsteadiness on feet, muscle weakness, and other lack of coordination. Current physician orders included calling the physician when the resident's blood pressure was below 80/50 and with signs/symptoms of hypotension (low blood pressure). A progress note, dated 2/18/24 at 5:50 p.m., indicated the resident had a low blood pressure of 71/53 with symptoms including shortness of breath and lethargy (lack of energy/ motivation). He was reclined to 30 degrees in his recliner. The resident representative was notified and was to be called if he experienced further symptoms. A note was sent to the physician. A progress note, dated 2/24/24 at 10:33 a.m., indicated the resident had a low blood pressure of 77/47 with symptoms of shortness of breath. He was encouraged to drink fluids to help increase his blood pressure. A note was sent to the physician. During an interview, on 3/14/24 at 11:45 a.m., LPN 5 indicated resident had parameters if his blood pressure was 80/50 or below to notify the physician. She didn't think she called the physician regarding his last low blood pressure reading. During an interview, on 3/14/24 at 11:51 a.m., RN 4 indicated there was a physician order to notify the physician if his blood pressure was below 80/50. If his symptoms don't improve with interventions, she would call the physician. If he improved without showing signs of symptoms, she would send a note to the physician through inner office mail. During an interview, on 3/14/24 at 2:07 p.m., the ADON indicated she would expect the nurses to call the physician regarding a low blood pressure unless the physician has said not to call them. Some physicians are notified Monday through Friday through inner office mail. During an interview, on 3/14/24 at 2:56 p.m., the DON indicated that pushing fluids and elevating feet were a nursing intervention for low blood pressure. Since resident B's blood pressure improved with interventions, it wasn't emergent to call the physician. Review of a current policy, dated 5/14/19, provided by the ADON on 3/14/24 at 2:09 p.m., titled Guidelines for Physician Notification, indicated the following: .Purpose: To ensure the resident's physician is aware of all diagnostic testing results or change in condition in a timely manner to evaluate condition for the need of provision of appropriate intervention for care This citation relates to complaint IN00424450. 3.1-37(a)

Based on observation, interview, and record review the facility failed to provide supervision and implement personalized interventions to prevent falls for 1 of 3 residents reviewed for falls (Resident C). Findings include: During an observation, on 3/13/24 at 3:07 p.m., Resident C sat in a recliner in her room. She wore stockings, with her shoes laying beside her feet. During an observation, on 3/14/24 at 11:41 a.m., the resident was assisted out of her room in a wheelchair. The resident's clinical record was reviewed on 3/13/24 at 11:30 a.m. Diagnoses included heart failure, hypertension (high blood pressure), repeated falls, pain, disorientation, syncope (fainting) and collapse, difficulty in walking, generalized muscle weakness, history of falling, unsteadiness on feet, and fatigue. Current physician orders included diltiazem (for blood pressure) 240 mg extended release daily started 9/28/23, tramadol (opiate for pain) 50 mg three times a day started 12/29/23, and oxygen at 2-5 liters per minute per nasal cannula for dyspnea (difficulty breathing) started 11/27/23. A significant change Minimum Data Set (MDS) assessment on 12/6/23 indicated the resident was moderately cognitively impaired. She required substantial to maximal assistance with putting on and taking off footwear. She required partial to moderate assistance with walking. A quarterly MDS assessment on 3/6/24 indicated the resident was severely cognitively impaired. She required partial to moderate assistance with putting on and taking off footwear and walking. An activities of daily living (ADLs) functional status/rehabilitation potential care plan, initiated on 8/18/22 and last revised on 2/25/24, indicated the resident was limited in ability to doing her own ADLs related to left sided weakness. Her goal was to be able to do her own ADLs with set up assistance through the next review on 3/30/24. Current interventions included walking: walks with walker, gait belt, and one assist but is noncompliant (5/18/23). A current fall care plan, initiated on 8/5/22 and last revised on 3/6/24, for falls indicated the resident was at risk for falling. Her goal was to remain free from injury through the next review (3/30/24). Current interventions included purposeful routine rounding 4P's - 1. Pain 2. Personal needs (bathroom) 3. Personal items (everything within easy reach - call light, water, phone, tissue, remote) (8/5/22), keep personal items and frequently used items within reach (11/1/22), frequent checks (12/6/23), leave door open to see resident, she may not be compliant with this as she likes the door to be closed (12/25/23), place excess oxygen tubing in oxygen tubing bag to void a trip hazard (1/10/24), encourage resident to be in supervised area with meaningful activities if without companion between 12 noon and 8 p.m. or whenever awake and restless (2/7/24), reeducate staff to make sure that frequently used items like TV remote control are within reach (2/14/24), clean and keep resident's dentures and its storage within her reach (2/20/24), and gait belt with one assist during transfers and ambulation (walking) (2/22/24). Fall risk assessments completed on 12/6/23 and 3/6/24 indicated the resident was a high risk for falls A progress note, dated 12/4/23 at 10:38 p.m., indicated the resident was found on the floor. She was lying on her back with her head supported by a QMA on duty. The resident indicated she was trying to get clothes from her dresser to change. A falls care plan intervention, started 12/4/23, indicated the resident was to be provided with assistance with clothing change between 8 p.m. and 9 p.m. The intervention was discontinued on 12/5/23. A progress note, dated 1/2/24 at 9:55 a.m., indicated the resident was found on the floor in her room near her recliner. The falls care plan lacked a new intervention for the 1/2/24 fall. A progress note, dated 1/3/24 at 12:27 p.m., indicated the resident was found sitting on her bottom in her room calling for help. The resident indicated her legs felt weak, and she collapsed to the floor. A falls care plan intervention, started 1/3/24, indicated make sure TV remote turns on both TV and mediacom box so that resident does not have to get up and push ok on mediacom box. The intervention was discontinued on 1/4/24. A progress note, dated 1/8/24 at 1:50 p.m., indicated the resident was found lying on her back alongside her bed in her room. Resident indicated she had gotten her crackers and cream-filled sponge cakes out of her closet, walked back to her recliner, lost her balance on the way, and fell . A fall care plan intervention, started 1/8/24, indicated keep resident's snack supply up within easy reach of the resident. The intervention was discontinued on 1/9/24. A progress note, dated 1/15/24 at 10:26 p.m., indicated the resident was found on the floor. She indicated she was trying to go to the bathroom but lost her balance. A fall care plan intervention, started 1/15/24, indicated the resident usually went to the toilet early in the evening. Toileting assistance was to be provided between 6 p.m. and 8 p.m. The intervention was discontinued on 1/16/24. A progress note, dated 2/2/24 at 3:40 p.m., indicated the resident was found lying on her back on the floor in her room. The resident indicated she had walked to the restroom, lost her balance, and fell backward. A fall care plan intervention, started 2/2/24, indicated the resident should be offered assistance to the restroom between 3 p.m. and 4 p.m. The intervention was discontinued 2/3/24. A progress note, dated 2/19/24 at 6:31 p.m., indicated the resident was walking down the hall at 4:55 p.m. accompanied by a certified nurse aide (CNA). She started to reach something on her right side and fell over. She fell on her right side hitting her head on the wall. An ADLs care plan intervention, started on 5/18/23, indicated the resident walked with walker, gait belt, and one assist but was noncompliant. A fall care plan intervention, started on 2/22/24, indicated the resident required a gait belt and assistance of one staff member for ambulation and transfers. A progress note, dated 3/6/24 at 2:30 p.m., indicated the resident was found on the floor in a sitting position shouting for help. Her feet were bare. An abrasion was found to her upper left back and measured 1 cm by 1.5 cm. She indicated she had to use the restroom and did not have time to use her call button. A fall care plan intervention, started on 3/7/24, indicated the resident usually ambulated all the way to the bathroom by herself when unattended. A bedside commode was to be provided and offered to the resident for toileting use to minimize fall risk from long distance ambulation. The intervention was discontinued on 3/8/24 Review of the progress notes indicated the resident fell 17 times from 12/4/23 through 3/6/24. During an interview, on 3/13/24 at 11:06 a.m., CNA 7 indicated the facility had a quick reference guide for fall preventions for all residents by the charting kiosk. Fall interventions could also be found on the electronic medical record. During an interview, on 3/14/24 at 12:26 p.m., RN 8 indicated when devising interventions for the residents, they would look at what was causing the falls. Resident C, specifically, would require long term goals and interventions due to her multiple falls. During an interview, on 3/14/24 at 2:08 p.m., the ADON indicated the nurse on shift for the fall would put in place a new intervention a fall. The intervention was generally long term, or a new one would be put in its place if it was discontinued. She was uncertain why interventions were being discontinued after one day. The nurse would have had to put in an end date. During an interview, on 3/14/24 at 2:23 p.m., CNA 9 indicated she utilized the care plan with the interventions for fall prevention on the computer software. During an interview, on 3/14/24 at 2:30 p.m., QMA 10 indicated he utilized the electronic medical record (EMR) to find the interventions for falls to be used for the residents. During an interview, on 3/14/24 at 2:41 p.m., RN 11 indicated she had a paper which provided instructions on updating care plans after a fall. An intervention was added with a fall and stayed active until the condition or problem resolved. The intervention should be continued as long as necessary. During an interview, on 3/14/24 at 3:05 p.m., the DON was uncertain why Resident C's interventions for falls would have been discontinued after one day. During an interview, on 3/14/24 at 3:07 p.m., the ADON indicated fall care plan interventions should not have been discontinued unless the problem was resolved. Review of a current, undated facility policy, titled Falls, Prevention and Follow up, provided by the DON on 3/13/24 at 2:47 p.m., indicated .It is the goal of the nursing staff to prevent as many falls as possible This citation relates to complaint IN00424450. 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure a resident did not receive psychotropic medications when continuation of the medication was not indicated for 1 of 5 residents reviewed for unnecessary medications (Resident 5). Findings include: During an observation on 8/7/23 at 10:25 a.m., Resident 5 was observed sleeping in a recliner near the nurses station. On 8/8/23 at 9:50 a.m., the resident was observed sleeping in his wheelchair sitting at the nurses station. On 8/8/2023 at 3:38 p.m., the resident was observed sleeping in a recliner near the nurses station. On 8/10/2023 at 11:00 a.m., the resident was observed to be sleeping intermittently during the resident council meeting. When awake, the resident appeared confused. On 8/10/23 at 4:08 p.m., the resident was asleep in the recliner near the nurses station. On 8/11/23 at 9:00 a.m., the resident was asleep in his wheelchair in the television room. Resident 5's clinical record was reviewed, on 8/9/2023 at 10:19 a.m., and indicated an active, 10/22/20, diagnosis of major depressive disorder, single episode, mild. A current physician's order indicated sertraline (anti-depressant) 50 mg (milligram) once a day at 9:00 a.m., with a start date of 6/12/2023. A review of the resident's medication history indicated the following: Sertraline tablet; 25 mg; amt: 1 tab; oral, special instructions: to be administered with 50 mg tab for total dose of 75 mg once a day at 8:00 p.m., starting on 2/28/2023 and ending on 3/6/2023. On 3/6/2023, the sertraline was discontinued and documented as ineffective by the prescribing NP (Nurse Practitioner). An order for buspirone (anti-anxiety) 10 mg three times a day was started on 3/7/2023 and stopped on 6/3/2023. On 6/5/2023, buspirone 10 mg three times a day was reordered. A progress note, dated 4/2/23, indicated the NP followed up on the discontinuation of sertraline and the start of buspirone. The resident was pleasant and very engaging today. Mood is baseline .Staff reports his buspirone has been very helpful with his anxiety and he is tolerating medication without any adverse side effects .no hallucinations, paranoid, homicidal, or suicidal statements .continue buspirone 10 mg three times daily as prescribed. Progress notes from April 2023 and May 2023 indicated the following: On 4/4/23 at 10:11 p.m. the resident was reportedly angry and could not be consoled. He cussed at the CNA (certified nursing assistant) and threw his walker. He was angry because he did not want to be at the facility. On 4/5/2023 at 6:27 a.m., the resident was reported as being in a good mood and pleasant with staff. On 4/5/2023 at 9:47 p.m., the nurse documented .Mood fair with outbursts of restlessness and confusion around supper time. On 4/10/2023 at 12:02 p.m., the NP's progress note indicated: .Staff reports he has had some delusional behavior but is being treated for a UTI (urinary tract infection) . The resident continues buspirone 10 mg 3 times a day and is tolerating without any adverse side effects. Sertraline was discontinued after staff reports it was ineffective On 4/12/2023 at 9:24 p.m., a progress note indicated the resident was in a good disposition with no noted confusion and restlessness for the shift. April 2023 progress notes did not include any documentation of depression. A progress note dated 5/8/23 at 3:26 p.m. indicated the NP's progress note indicated staff reported Resident 5 had eight episodes of delusional behavior in regards to going to Ohio. The resident was redirectable, mood was appropriate with no hallucinations or paranoid, homicidal, or suicidal statements. The buspirone was to be continued as ordered. Progress notes from May 2023 contained no mention of depression or related behaviors. Progress notes from June 2023 indicated the following: On 6/2/2023 at 9:00 a.m., a progress note indicated the resident remained in his room on droplet/airborne isolation precautions and had to be returned to his room twice. On 6/2/2023, Resident 5 was discharged to the hospital for signs and symptoms of COVID-19. On 6/4/2023 he returned from the hospital and was returned to isolation in his room. On 6/04/2023 at 2:23 p.m., Resident 5 was in good spirits and joking with the staff. He was confused about why he was at the facility. He was in contact isolation. On 6/5/2023 at 2:53 p.m., a progress note indicated Resident 5 had a restless day and believed he needed to be at school, teaching. He kept leaving his room without assistance to the school. He was on isolation precautions for COVID-19. Staff had to keep returning him to his room. On 6/5/2023 at 8:40 p.m., the resident remained on isolation for COVID-19. He had attempted to exit his room once this shift but was directed back inside his room. On 6/5/2023, Resident 5 restarted sertraline 50 mg once a day at 9:00 a.m. On 6/9/2023 at 12:10 a.m., a note indicated he was taken out of isolation on 6/12/23. On 6/12/2023 at 11:09 a.m., a new order to restart sertraline 50 mg daily was documented in the progress note. On 6/12/2023 at 9:47 p.m., the NP's progress note indicated after returning from the hospital, they discontinued his sertraline and staff is requesting to restart this medication. Upon assessment he was showing signs and symptoms of increased depression and it appeared the sertraline may prove beneficial at this time. The clinical record lacked additional indication of depression. On 7/24/2023 at 1:06 p.m., the NP's progress note indicated the resident was pleasant and engaging. The staff reported no behaviors and no signs or symptoms of depression. The plan was to continue buspirone as ordered. The resident's care plan dated 2/25/21 with a revised date of 8/2/23 at 5:31 p.m. indicated a problem of major depression and signs and symptoms of anxiety. He received buspirone. Signs and symptoms of depression and anxiety included increased irritability (yelling at spouse and others), tearfulness related to wanting to go home and be with his wife, and/or wanting to go home to the farm where he grew up as a child. He would often say that he was packing up to go to Ohio. An intervention dated 2/24/2021 indicated staff should observe moods, affect, and behaviors with hands on care. A significant change in status on the 6/25/2023 MDS indicated the cognitive status of the resident was severely impaired and depression was minimal. During an interview with RN 7 on 8/14/2023 at 12:19 p.m., she indicated the resident could be very adamant about what he wanted. He could get fixated on something and was difficult to redirect. The RN was unaware of the restart of sertraline. The hospital had the resident on sertraline when he returned. She had not observed any signs of depression, but the resident could be agitated and anxious. She indicated his agitation and anxiety were often related to his desire to see his wife or his desire to return home. A document titled Use of Psychotropic Drugs, provided by the DON on 8/11/2023 at 5:33 p.m., indicated the following: .Policy - Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s) . 4) The indications for use of any psychotropic drug will be documented in the medical record . b) For psychotropic drugs that are initiated after admission to the facility, documentation shall include the specific condition as diagnosed by the physician . i) Psychotropic medications shall be initiated only after medical, physical, functional, psychosocial, and environmental causes have been identified and addressed . ii) Non-pharmacological interventions that have been attempted, and the target symptoms for monitoring shall be included in the documentation . 6) Residents who use psychotropic drugs shall receive gradual dose reductions, unless clinically contraindicated, in an effort to discontinue these drugs . 11(b)(ii) An evaluation shall be documented to determine that the resident's expression or indications of distress are 1) Not due to a medical condition or problems that can be expected to improve or resolve as the underlying condition is treated or the offending medication(s) are discontinued .2) Not due to environmental stressors alone, that can be addressed to improve the symptoms or maintain safety 3.1-48(4) 3.1-48(b)(2)

A. Based on observation, interview and record review, the facility failed to prevent falls with major injury and fall with injury for 2 of 7 (Resident 39 and Resident 22) and the facility failed to follow care plan interventions for 2 of 7 residents reviewed for falls (Resident 46 and Resident 47). Findings include: 1. On 6/22/22 at 12:59 p.m., the door to Resident 39's room was closed. On 6/23/22 at 9:20 a.m., he sat in his recliner in his room with his walker in front of him. On 6/23/22 at 1:09 p.m., his door was closed. On 6/24/22 at 11:15 a.m., he ambulated independently to common area outside of dining room with a rollator walker. On 6/24/22 at 2:31 p.m., he sat in his recliner in his room with a visitor in his room. On 6/27/22 at 3:06 p.m., he was in his recliner in his room with visitors. Resident 39's clinical record was reviewed on 6/23/22 at 10:17 a.m. Diagnoses included, but were not limited to, wedge compression fracture of third lumbar vertebra, subsequent encounter for fracture with routine healing, need for assistance with personal care, history of falling, difficulty in walking, not elsewhere classified, unsteadiness on feet, cognitive communication deficit, low back pain, age-related [CONDITION(S)] without current pathological fracture, other malaise and vitamin D deficiency. His medications included, but were not limited to, [MEDICATION(S)] (blood pressure) 25 mg (milligram) daily and [MEDICATION(S)] ([CONDITION(S)]) 100 mg daily. An admission MDS (Minimum Data Set), dated 3/3/22, indicated he was moderately cognitively impaired. He required supervision of one staff member for bed mobility, walking in his room and the corridor and locomotion off the unit. He required supervision for locomotion on the unit. He required limited assistance of one staff member for transfers. He required extensive assistance of one staff member for dressing, toilet use, personal hygiene. He used a walker. He had a fall in the last month prior to admission/entry or reentry. He had problem care plan for falls, dated 2/24/22, that indicated he was at risk for falling related to new admission and environment intrinsic factors; 1. Over Age 80 2. Lower extremity and core weakness as evidenced by unable to complete even one on a 30 second Chair Stand Assessment 3. Balance deficit - could not complete 10 seconds on tandem 4-Stage Balance Test 4. Cognitive impairments with ACL ([NAME] Cognitive Level) score 3.6 - 3.8 5. Urinary incontinence 6. History of falls in residential with compression fracture 7. Chronic disorders - Severe [CONDITION(S)] and Arthritis extrinsic factors - 1. Use of assistive device - rollator 2. Four or more medications. His most recent fall was 4/14/22. His goal was he would remain free from injury through next review. His interventions included, but were not limited to, keep call light in reach, provide proper, well-maintained, individualized, non-skid footwear, provide resident with safety device/appliance: rollator, routine rounding 4P's- 1.) Pain 2.) Position 3.) Personal Needs (Bathroom) 4.) Personal Items (everything within easy reach - call light, water, phone, Kleenex, remote) started on 2/24/22 and encourage use of non-skid shoes, gripper socks at all times started on 3/11/22. His nurses notes indicated, but was not limited to, the following: On 3/11/22 at 8:45 p.m., he was found on the floor in his room by the CNA. Upon arrival he was laying on his left side in between his recliner and his bed. He attempted to self-transfer, his walker appeared to be in use as it was tipped over next to him. Approximately 30 minutes prior to the fall, he rested comfortably in his chair, CNA asked him if he was ready to go to bed, since that was his preferred bedtime and he denied at that time that he was not ready. When nurse asked him what he was trying to do he stated he was walking over to get in bed. His call light was not on. He did not have slipper socks on as he changed clothing without assistance. He was educated on asking for assistance when transferring and he verbalized understanding. 15-minute checks were initiated. A fall risk assessment, dated 3/31/22, indicated he was at a high risk for falls. On 4/14/22 at 6:39 a.m., he was found on the floor in a sitting position. He said he was getting dressed and slid off the bed. He had no complaints of pain when first assessed. At that time, he complained that his back was sore and that the concrete floor caused it. PRN (as needed) medication to be given and back pain monitored. On 4/14/22 at 9:38 a.m., an IDT (Interdisplinary) note, indicated he had a fall that morning with complaints of back pain now. His preferred time to get up was 7:00 a.m. - 7:30 a.m., but was getting up and getting dressed at 5:30 a.m. The SSD (Social Service Director) would meet to re-evaluate preferred time for waking. He was barefoot at time of fall, SSD would also address non-skid slippers/gripper socks. He currently had his own personal bed. Care plans were reviewed and updated. On 4/14/22 at 11:11 a.m., he complained of back pain and stated it hurt to move. New order received for an x-ray STAT (immediately). On 4/14/22 at 8:09 p.m., Lumbar spine anteroposterior (AP) and lateral (LAT) conclusion indicated there was a compression deformity at the L2 (Lumbar vertebrae), and L5 level, age indeterminate. Otherwise, [CONDITION(S)] changes. Sacrum/coccyx x-ray conclusion indicated no acute findings. [CONDITION(S)] changes and consider a repeat study if symptoms continued to persist or progress. On 4/15/22 at 1:12 p.m., x-ray results from 4/14/22 and previous MRI (Magnetic Resonance Imaging) to orthopedic doctor as he had performed kyphoplasty procedure on 12/28/21. On 4/21/22 at 3:43 p.m., MRI results were received, a new compression fracture at L2 with approximately 25% vertebral body height loss. Fluid is seen within the fracture. A prior vertebroplasty to T12 (Thoracic vertebrae), L1, L3 and L4. [CONDITION(S)] changes as above. On 5/3/22 at 6:17 p.m., he returned from orthopedic appointment. He was scheduled for L2 kyphoplasty on 5/9/22. On 5/4/22 at 6:45 p.m., small multiple white, macerated [CONDITION(S)] to right and left side of gluteal fold. Skin breakdown is a mirrored image. He was incontinent of bladder and bowel. Denied pain related to area of skin breakdown. He had moderate amount of pain and awaited surgery next week and kept him from being active and mostly wanted to stay sitting in his recliner. He was medicated with [MEDICATION(S)] (narcotic pain reliever) for pain. A new order was received for foam dressings. On 5/9/22 at 7:36 a.m., he left the facility for surgical procedure. On 5/9/22 at 1:56 p.m., he returned from surgical procedure. His dressing was to remain clean, dry, and in place for two days, may remove dressing on day three and shower and was to keep head elevated while lying for the first 48 hours, no lifting over 10 pounds until instructed after follow up. On 5/26/22 at 2:10 p.m., he was admitted to hospice, for diagnosis of cerebral atherosclerosis effective 5/26/22. On 6/1/22 at 8:34 a.m., he had a stage 2 pressure injury to his right gluteus 0.8 cm (centimeter) x 0.8 cm x 0.1 cm. A new order was received for [MEDICATION(S)] dressing change every three days and PRN dislodgement/soilage. He was started on magic cup and two cal 60 cc (cubic centimeter) three times daily due to weight loss. He would be encouraged to lay down after breakfast and lunch to relieve pressure to area. He had his own mattress and would discuss with hospice nurse for airloss mattress to replace personal bed. During an interview with RN 33, on 6/22/22 at 9:03 a.m., she indicated he had a fracture to his back and sat up a lot and he didn't like to lay down, essentially that's how he developed the stage 2 pressure ulcer. During an interview with CNA 38, on 6/27/22 at 9:24 a.m., she indicated she assisted him with walks and used a gait belt, he was encouraged to use the call light. He got up unassisted and that was how he fell , she did frequent checks on him. When she walked by his room, she offered him to use the bathroom, he was a more independent kind of guy, he came from residential. If his door was closed, she cracked it opened and peeked in on him. If you did not shut his door he would get up and shut it. During an interview with the DON and ADON, on 6/27/22 at 10:41 a.m., the ADON indicated his initial intervention was an x-ray and his preferred bedtime was 7:00 a.m. - 7:30 a.m., he was re-approached to his preferred get up time. He got up earlier now. He did not use his call light. They checked on him and tried to keep him busy. They did purposeful rounding, he did use his call light some but, on the whole, did not use it every time. Mobility wise, he was getting back to his baseline from when he came over from residential. The DON indicated he was [AGE] years old, family did not want him to move to healthcare. He had a history of compression fracture and vertebroplasties/kyphoplasties. ADON indicated he fell a lot in residential and went through therapy. The DON indicated he had fallen in residential on 10/18/21, 10/31/21, 11/4/21, 1/1/22, 1/9/22, 1/15/22 and 1/19/22. The fall on 4/14/22, he was bare foot, he had his own personal bed and now had a hospital bed. Family wanted to wait to move him to healthcare, they had even stayed with him in residential and didn't want him to move. 2. On 6/22/22 at 12:55 p.m., Resident 22 was in his recliner with his feet elevated. On 6/23/22 at 9:17 a.m., his door was slightly ajar but unable to observe him from the doorway. On 6/24/22 at 11:11 a.m., his door was slightly ajar but unable to observe him from the doorway. On 6/24/22 at 1:10 p.m., he ambulated to his room with his walker and a staff member On 6/27/22 at 3:27 p.m., he was riding the Nustep (exercise bike) across from the nurse's station. Resident 22's clinical record was reviewed on 6/22/22 at 2:43 p.m. Diagnoses included, but were not limited to, unsteadiness on feet, repeated falls, [CONDITION(S)] without behavioral disturbance, personal history of other drug therapy on [MEDICATION(S)] (blood thinner), frequency of micturition, cognitive communication deficit and chronic fatigue. His medications included, but were not limited to, [MEDICATION(S)] (blood thinner) 5 mg twice daily, insulin [MEDICATION(S)] (insulin) pen 100 unit/mL (milliliter) (3 ml)12 units subcutaneous twice daily, [MEDICATION(S)] (diuretic) 20 mg daily, [MEDICATION(S)] (blood pressure) 5 mg daily and [MEDICATION(S)] (blood pressure) 12.5 mg daily. A quarterly MDS, dated [DATE], indicated he was moderately cognitively impaired. He required extensive assistant of one staff member for bed mobility, transfers, walking in his room and the corridor, locomotion on the unit, dressing, toilet use and personal hygiene. He used a walker. He had one fall with no injuries and one fall with injury since admission/entry or reentry or the prior assessment. He had a problem care plan for falls, dated 10/7/21, that indicated he was at risk for falling related out-toeing gait, [CONDITION(S)], incontinent of bladder, poor balance while standing, history of falls in residential, high-risk medications - antihypertensives, diuretics, antidepressants and his most recent fall was on 4/7/22. His goal was he would remain free from injury through next review. Interventions included, but were not limited to, routine rounding 4P's- 1.) Pain 2.) Position 3.) Personal Needs (Bathroom) 4.) Personal Items (everything within easy reach - call light, water, phone, Kleenex, remote) started on 12/1/21, reminder sign to be placed on his stand-up rollator with his permission started on 12/28/21, turn off his television before assisting him out of his recliner for transfers and ambulation to prevent distractions while walking started on 1/9/22. A fall risk assessment, dated 2/9/22, indicated he was at a high risk for falls. His nurses notes indicated, but were not limited to, the following: On 2/27/22 at 4:09 p.m., the nurse was called to his room, by the CNA assigned to him, due to him being found floor. Nurse and the QMA went to assist and observed him on floor in front of the recliner laying toward his left side with his arm under him and faced towards the floor. He was assisted to his recliner and assessed for injuries. No injuries were noted. He stated he dropped a flashlight on floor in front of him and reached to grab it and slid from his chair to his knees and continued forward and fell to the floor. He was reminded to call for help when needed. On 2/28/22 at 8:35 a.m., an IDT note indicated his most recent fall was discussed and root cause of fall was he reached for his flashlight from his recliner. Questioned if he would be able to use a reacher/grabber appropriately. He did have a lift recliner as well. His care plan intervention was keep reacher close to him while he sat in his recliner so that he could safely pick items off floor if needed started on 2/27/22. A nurses note, dated 4/8/22 at 12:32 a.m., indicated the writer was informed by CNA that he was on the floor. Writer and went to his room. He talked and was able to answer questions. There was a moderate amount of blood from a head laceration. He denied pain related to range of motion. His pupils were equal and round, his handgrips were equal and firm. He was assisted up to the edge of the bed. The CNA and the writer applied pressure to his head laceration and 911 was called. He stated he had gotten up out of bed and attempted to go to the bathroom when he lost his balance. There was blood on the nightstand. He had grippy socks on. The CNA stated that his call light had just come on and she answered it right away. When she went in he was on his buttocks with his head leaned back against the corner of the arm of his recliner and his walker was nearby within reach and not overturned. On 4/8/22 at 5:08 a.m., he returned to the facility at 3:00 a.m., his bandage was redressed to his head. Seven Staples in place to his head laceration. Paperwork reviewed and laceration to be kept dry for 24-48 hours and then he may shower patting cut dry. Do not soak the cut. Wash around cut with clean water two times daily. May cover laceration with thin layer of petroleum jelly or Vaseline and nonstick bandage. Staples were usually removed in 7 to 14 days depending on how incision was healing and to follow up with primary physician for suture removal. Emergency department documentation, dated 4/8/22, indicated he fell striking the back of his head and nursing home personnel stated they found him lying on the floor and there may had been a brief loss of consciousness. He received a 5 cm laceration over the occipital area and required 8 staples. On 4/8/22 at 8:44 p.m. (Recorded as late entry on 4/11/22 at 2:42 p.m.) his primary physician stated to go to emergency department if the bleeding from his scalp laceration got worse or had neurological changes. On 4/8/22 at 10:17 a.m., a call was received from the local physician's office with new order to hold the [MEDICATION(S)] for 24 hours and let cardiologist know. On 4/9/22 at 1:45 a.m., he continued to bleed through bandages this evening. Writer applied pressure, and used an ice pack on the area, he continued to bleed through the bandage. The CNA went in to assist resident to the restroom and found that he had once again bled through his bandage. Writer called on call doctor and informed him of need to send resident to the hospital due to considerable amounts of blood on present bandage. On 4/9/22 at 5:47 a.m., he returned from local hospital with four staples that were added to the pre-existing ones. Paperwork advised removal in 7-14 days. On 4/9/22 at 12:33 p.m., fall follow up, no latent injury were noted. The dressing to his head was dislodged with no bleeding noted from laceration. He had 12 staples. During an interview with CNA 38 on 6/27/22 at 9:27 a.m., she indicated he was on frequent checks to go to the bathroom, he was a one assist at all times, and he was encouraged to use his call light. He liked to get up and take himself to the bathroom, she offered him every two hours or so to use the bathroom. During an interview with RN 33, on 6/27/22 at 10:25 a.m., she indicated they walk with him everywhere. He was able to use a wheelchair when his blood sugars were low, he was a fragile diabetic. He normally walked with a stand-up walker. She read his interventions from his care plan and indicated he wore shoes most of the time. During an interview with the ADON and DON, on 6/27/22 at 10:51 a.m., the DON indicated he fell on [DATE] at 11:20 p.m., and was sent out on 4/8/22 at 12:30 a.m. The ADON indicated he did use his call light some, he was assisted with walking. The immediate interventions were therapy due to falls and lab work. The DON indicated he had the fall on 6/24 where he was lowered to the floor. The ADON indicated he had an odd gait, therapy called it out-toeing. 3. On 6/23/22 at 1:10 p.m., CNA 36 indicated to Resident 46 that she was going to take her to the bathroom but needed to get the stand-up lift. On 6/23/22 at 1:11 p.m., CNA 36 was observed pushing the stand-up lift up to Resident 46 in her room and indicated to her to put her feet up. Resident 46 leaned forward, and CNA 36 placed the lift pad behind her and snapped the lift pad strap around her torso and indicated to her to hang on. Resident 46 place her hands onto hand bars and CNA 36 lifted her from her wheelchair located in her room and pushed her to the bathroom while she stood on the mechanical lift. CNA 36 placed Resident 46 in front of the toilet on the stand up lift with her back side to the toilet, she pulled her pants down and took soiled brief off and lowered her to the toilet. Resident 46 indicated she was done CNA resituated the lift pad and strap then lifted her in a standing position, provided incontinent care and placed brief on her and pulled up her pants. Resident 46 held onto the handlebars while CNA 36 pushed her while she stood on the mechanical lift and lowered her to sitting in her wheelchair. She unhooked her and indicated to put her feet up, she pulled the mechanical lift from in front of her and placed her foot pedals on her wheelchair. CNA 36 indicated she always lifted her with the stand-up lift by herself except for in the mornings when she first gets up due to her arms and her being sleepy. Resident 46's clinical record was reviewed on 6/22/22 at 2:31 p.m. Diagnoses included, but were not limited to, need for assistance with personal care and unspecified dementia without behavioral disturbance. A significant change MDS, dated [DATE], indicated she was severely cognitively impaired. She required extensive assistance of two staff members for bed mobility and transfers. She required extensive assistance of one staff member for dressing, toilet use and personal hygiene. She used a wheelchair. A quarterly MDS, dated [DATE], indicated she was severely cognitively impaired. She required extensive assistance of two staff members for bed mobility, transfers and toilet use. She required extensive assistance of one staff member for dressing and personal hygiene. She used a wheelchair. A problem care plan for falls, dated 1/22/20, indicated she was at risk for falling related to impaired mobility - wheelchair bound, [CONDITION(S)], use of [CONDITION(S)] medications, knees gave out during transfer with staff, reaches for items from wheelchair, her most recent fall was 11/19/21. Her goal was she would remain free from injury through next review. Her interventions included, but were not limited to, transfers: mechanical stand-up with two assist started on 11/19/21. She had a problem care plan for ADL Functional / Rehabilitation Potential, dated 1/22/20, indicated she was limited in ability to own ADL's related to Dementia. Her goal was to assist as much as possible with cues and prompts through next review. Her interventions included, but were not limited to, transfers: mechanical stand-up with two assist started 9/28/21 and toilet use: extensive assist with stand lift started on 1/22/20. A 10/14/21 fall risk assessment indicated she was not at risk for falls. A nurses note, dated 11/19/21 at 9:30 p.m., indicated the CNA was transferring Resident 46 to bed and the CNA voiced she decided to clean and to change her brief from the stand-up lift. She was unable to hold anymore and was slowly letting go, the CNA helped lower her slowly to the floor. No injury was noted at that time. It took three staff members with extensive assistance and gait belt to transfer her to bed. She was to be two assist with all transfers via stand up lift. A 6/8/22 fall risk assessment indicated she was not at risk for falls. During an interview with the DON, on 6/23/22 at 1:46 p.m., she indicated according to the care plan and CNA assignment sheets she was to be a two person assist with stand up lift. Although she felt like she was a one person assist, she would have restorative evaluate her to see if she needs to be a one or a two assist. 4. During an interview, on 6/21/22 at 1:26 p.m., Resident 47 indicated he had recently moved to the healthcare center, as he no longer met criteria for assisted living and had fallen a few times. He had a walker next to his chair with a storage pocket hanging from the handlebar. There was a plastic caddy on the floor next to the chair. On 6/23/22 at 8:45 a.m., he was seated in the main dining room for breakfast. His walker was on his right side with a storage pocket on the handlebar. On 6/23/22 at 1:10 p.m., he was in his room. The plastic caddy was on the floor next to his recliner chair. On 6/24/22 at 3:23 p.m., he was near the nurses station using the exercise machine. His walker was on his right side with a storage pocket on the handlebar. On 6/27/22 at 8:49 a.m., he was seated in the main dining room for breakfast. His walker was on his right side with a storage pocket on the handlebar. Resident 47's clinical record was reviewed on 6/22/22 at 2:24 p.m. Diagnoses included, but were not limited to, compression fracture of lumbar and thoracic vertebra, repeated falls, low back pain, [CONDITION(S)], [CONDITION(S)], chronic kidney disease, and chronic pain. Current physician orders included, but were not limited to, [MEDICATION(S)] (water pill) 20 mg daily, [MEDICATION(S)] 20 mg daily with routine dosage from 6/21/22-6/23/22 for [CONDITION(S)] exacerbation, and weekly weight on Monday. A 6/1/22, quarterly, Minimum Data Set assessment indicated he was moderately cognitively impaired and required extensive assistance with walking in his room and for transfers. He had a current, 3/3/22 (revised 6/21/22), care plan problem of risk for falls. Interventions included, but were not limited to, raise plastic caddy next to recliner to higher level, change personal bed to hospital bed, assure he is wearing eyeglasses, keep cinnamon candies in drawer of bedside stand for easy access, sign to remind to use call light on walker, and frequent safety checks. A 3/3/22 event note indicated at 9:30 p.m., the resident was found sitting on the floor with his back against the bed, his right hand holding his left arm, rocking back and forth. He indicated he had hit his head, and an abrasion was found to his posterior scalp. He gave various explanations as to what he had been doing. He had been in bed at 9:20 p.m. for a bladder scan. He had been restless and anxious, as he had just moved into healthcare the same day. New immediate interventions of an assistive device and personal care items, including candy, kept within reach was added, as he had been looking for his candy earlier in the evening. He was sent to the emergency department for evaluation. Review of a 3/3/22 emergency department report indicated no acute injury. A 3/23/22 event note indicated at 11:00 a.m., he had a witnessed fall and was found sitting on the floor parallel to the bed with one shoe on and one off. He was not injured. He had stood to give a visitor a hug, when his shoe fell off and he lost his balance. A witness confirmed this and stated the resident did bump his head on the floor. His shoes were noted to not be tied properly. An intervention of corrective footwear was to be implemented. A 3/26/22 progress note indicated increasing back pain, and an x-ray was ordered. A 3/28/22 report indicated compression deformities at L1-L2 (lumbar spine) and T11 (thoracic spine) compression deformities. A 3/29/22 Social Service note indicated a message was left with the resident's family for his need of a new pair of shoes and he could also benefit from a small table or stand to put next to his chair to keep his papers and phone off of the floor. Staff encouraged him to place items on the bedside table, but he often refused. A 4/11/22 CT scan of his lumbar spine indicated compression fractures of T11 and L1 were favored to be acute or subacute. A 4/14/22 progress note indicated his new shoes were brought in by his family. There was no indication in the clinical record of his family being contacted further about his new shoes since 3/29/22. A 4/23/22 event note at 1:20 p.m. indicated he was found on the floor beside his recliner. He complained of pain to lower back. He had lost his balance and would continue to ambulate without asking for assistance. He had been standing and bent over to get something out of the container next to his chair. A new intervention was added to use his call light at all times for assistance. A root cause analysis note indicated he had likely lost his balance as he was bending over, reaching for something out of plastic container next to recliner. He had been sent to the emergency department for evaluation and an intervention would be added to raise his container from the floor. Review of a 4/23/22 emergency department note indicated probable acute T2, T11, and L5 compression fractures and age-indeterminate, likely chronic, L1, L3, and L4 compression fractures. A 6/13/22 event note indicated at 10:56 a.m., he had an unwitnessed fall in front of his recliner. He had abrasions to his right back, each measuring 23 centimeters (cm) length (L) x 1.3 cm width (W), and 28.5 cm L x 2 cm (W). He had been trying to sit in his recliner and lost his balance. A new intervention was added for a Call for Assistance sign on his walker. During an interview, on 6/27/22 at 9:36 a.m., the ADON indicated the delay on receiving the resident's new shoes in April was due to his family having difficulty finding wide-width shoes. The facility had tried to place a table near his chair, but he hadn't liked it. The sign had been on his walker as of the previous week. During an interview, on 6/27/22 at 9:15 a.m., CNA 52 indicated the resident's fall interventions included assistance to walk to and from the dining room and 15-minute checks. He had kept taking the reminder sign off of his walker. During an interview, on 6/27/22 at 9:22 a.m., CNA 53 indicated the resident's fall interventions included using a gilt belt for transfers, and frequent rounding to ensure his needs were met. He was also supposed to have a sign on his walker to remind him to call for assistance. Review of a current, undated, facility policy titled, FALLS, PREVENTION AND FOLLOW UP, provided by the DON on 6/27/22 at 11:22 a.m., indicated the following: .Anyone with a history of falls within the past 30 days is likely to fall again A current facility policy titled, TRANSFER ASSESSMENT TOOL, provided by the DON, on 6/27/22 at 11:22 a.m., indicated the following: All residents in the Healthcare and Crestwood should be given on of the following transfer designations. This code should represent the resident's weakest time of the day for transferring. Amount of assistance required will be determined by the nurse .STAND UP LIFT requires weight bearing support of 25 pounds and is able to tolerate weight bearing on lower extremities during transfer. An additional dot will be posted identifying one or two person assist with stand up lift 3.1-45(2)

Based on observation, interview, and record review, the facility failed to ensure the physician was notified of weight fluctuations for 1 of 3 residents reviewed for nutrition (Resident 47) and failed to ensure the physician was notified of abnormal blood pressure and pulse readings for 1 of 19 residents reviewed for the investigation sample (Resident 53). Findings include: 1. During an interview, on 6/21/22 at 1:26 p.m., Resident 47 indicated he had recently moved to the healthcare center, as he no longer met criteria for assisted living. Resident 47's clinical record was reviewed on 6/22/22 at 2:24 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A 6/1/22, quarterly, Minimum Data Set assessment indicated he was moderately cognitively impaired and had weight loss. A 3/4/22 Nutrition Note indicated he was on a regular no added salt (NAS) diet and was able to feed himself. He weighed 186 pounds and had gained 13 pounds in 3 months when he was in assisted living, and the weight gain was not quite significant. He had [CONDITION(S)] to his bilateral lower extremities, which may have been part of his weight gain. He had a good appetite. On 3/7/22, he received a new order for [MEDICATION(S)] 20 mg daily. On 3/10/22, he was diagnosed with a respiratory infection and started on an antibiotic. On 3/14/22, he weighed 190 pounds. On 3/21/22, he weighed 174 pounds. He was re-weighed on the same day and weighed 173. The medical provider was not notified of the weight loss. On 4/8/22, he received an order for [MEDICAL RECORD OR PHYSICIAN ORDER] A 4/11/22 Registered Dietician (RD) note indicated his weight was 174 pounds, which was a 16 pound weight loss in 30 days. The weight loss was likely due to NAS restriction, diuretic therapy, and reduced [CONDITION(S)] to his lower extremities. On 4/25/22, he weighed 168 pounds. The medical provider was not notified of the weight loss. On 5/2/22, he weighed 154 pounds. The medical provider was not notified of the weight loss. On 5/23/22, he weighed 169 pounds. The medical provider was not notified of the weight gain of 5 pounds from 5/17/22. A 5/24/22 RD note indicated his weights had been variable in the previous 30 days. A high calorie supplement was to be added twice daily. On 5/30/22, he weighed 159 pounds. The medical provider was not notified of the weight loss. On 6/6/22, he weighed 170 pounds. The medical provider was not notified of the weight gain. On 6/20/22, he weighed 169 pounds. During an interview, on 6/27/22 at 9:36 a.m., the ADON indicated the delay on receiving the resident's new shoes in April was due to his family having difficulty finding wide-width shoes. The facility had tried to place a table near his chair, but he hadn't liked it. The sign had been on his walker as of the previous week. During an interview, on 6/27/22 at 10:32 a.m., the ADON indicated the RD informed her the resident had a large weight gain due to [CONDITION(S)]. An RD email indicated on 3/4/22, his weight gain was addressed and it was likely related to [CONDITION(S)] and with diet therapy and NAS diet, a weight loss was expected. On 4/8, he was started on a supplement as he wasn't always eating lunch well, likely due to back pain and an intake decline around the same time. 2. Resident 53's closed clinical record was reviewed on 6/27/22 at 11:00 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician orders, current at the time of the resident's last day of admission at the facility, included, but were not limited to, [MEDICATION(S)] (blood pressure) 25 mg at bedtime, [MEDICATION(S)] (blood pressure) 0.1 mg as need for systolic blood pressure greater than 180 or diastolic blood pressure greater than 100, and [MEDICATION(S)] (water pill) 10 mg daily. A 3/30/22, quarterly, MDS indicated he was moderately cognitively impaired and required extensive assist for ADLs. Review of 5/3/22 vital signs indicated his blood pressure was 118/63 and his pulse was 60 beats per minute (bpm). Review of 5/10/22 vital signs indicated his blood pressure was 121/65 and his pulse was 62 bpm. A 5/12/22 at 6:17 a.m., progress note indicated the resident was very weak could not walk to the bathroom. His blood pressure was 77/65 and his pulse was 105 bpm. The medical provider was not notified of the abnormal vital signs. A 5/12/22 at 9:00 a.m., progress note indicated he was resting in bed peacefully. His blood pressure was 122/88 and his pulse was 115 bpm. He complained of being tired. The medical provider was not notified of the increased pulse rate. A 5/13/22 at 8:54 a.m., progress note indicated he continued with weakness and poor appetite. His vital signs were within normal range for the resident, with his blood pressure being 90/52 and his pulse 95 bpm. The medical provider was not notified of the abnormal vital signs. During an interview, on 6/27/22 at 11:24 a.m., RN 50 indicated she would notify the medical provider and review the resident's medications and look for trends if vital signs were found to be outside of the normal range. The notification would be documented in the progress notes. During an interview, on 6/27/22 at 9:15 a.m., CNA 52 indicated the nurses documented weights. During an interview, on 6/27/22 at 9:26 a.m., RN 59 indicated the computer system would flag discrepancies with weights and vital signs. During an interview, on 6/27/22 at 2:13 p.m., the DON indicated she could not find confirmation the medical provider had been notified about the abnormal vital signs. Review of a current facility policy, titled WEIGHT, dated 10/4/20 and provided by the DON on 6/27/22 at 11:22 a.m., indicated the following: .If there is a 5 [five] pound weight difference of 5% (whichever is higher), the resident will be re-weighed .Residents with a CHF diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of a current facility policy, titled Guidelines for Physician Notification, revised date 5/14/19 and provided by the ADON on 6/27/22 at 2:28 p.m., indicated the following: .Purpose: To ensure the resident's physician is aware of all diagnostic testing results or change in condition in a timely manner to evaluate condition for the need of provision of appropriate intervention for care .Attempts to notify the physician and their response should be documented in the resident's record 3.1-5(a)(2)

Based on observation, record review and interview, the facility failed to ensure a resident was adequately assessed for mental health services after being diagnosed with two new mental health conditions and the facility failed to develop and implement interventions on the care plan for monitoring one of the new mental health diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: During an interview on 6/21/22 at 10:31 a.m., Resident 6 was sitting in bed, she did not engage in conversation. Her clinical record was reviewed on 6/24/22 at 10:29 a.m. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An 4/13/22 admission MDS (Minimum Data Set) assessment indicated she moderate cognitive impairment. She had received an anti-psychotic medication four days and an anti-depressant seven days during the assessment period. She had not received psychological therapy. Current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1. Monitor behavior of expressions of sadness every shift, the order date was 3/2/19. 2. Monitor behavior of [CONDITION(S)] (extremely elevated and excitable mood usually associated with [CONDITION(S)] disorder) every shift, the order date was 3/2/19. 3. Monitor behavior of tearfulness every shift, the order date was 3/2/19. 4. Monitor behavior of hallucinations every shift, the order date was 10/1/20. 5. Monitor behavior of self isolation twice a day, the order date was 1/11/22. Review of a PASARR Level I pre-admission screening, dated 2/28/19, indicated the following mental health diagnoses; major depression, [CONDITION(S)] disorder and anxiety disorder. A current mood state care plan, dated 3/4/19, indicated she presented with [CONDITION(S)] and delusions and received a mood stabilizing medication. Signs and symptoms included becoming manic and presenting with increased symptoms of depression (would isolate herself, stayed in bed, refused meals, easily tearful, and resistive to care suddenly). Presented with delusions as evidenced by, believed she heard her son and needed to look for him and got up on her own to search, would say she need to find the deck and would look for the deck. She had good days and bad days, was at risk for harm to self (weight loss, skin breakdown related to refusals of meals, care and to get out of bed, and at risk for falls). The goal, with a target date of 9/3/22, indicated she would not exhibit signs of isolation (sad, dull affect, non-commutative, withdrawn, lack of eye contact, expressions of loneliness/rejection, hostile, irritable behavior, lack of awareness of surroundings and inattention to self-care). Interventions included, but were not limited to, encouraged to verbalize feelings and fears and encouraged her to become involved in activities, both with an approach start date of 3/4/19. A psychiatric progress note, dated 7/29/21 at 4:57 p.m., indicated, but was not limited to, Catatonia. During an interview on 6/24/22 at 10:17 a.m., LPN 21 indicated the resident was having a day where she wanted to remain in bed. During a follow-up interview on 6/27/22 at 9:53 a.m., LPN 21 indicated the catatonic diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of a definition of catatonia from the website WebMD, https://www.webmd.com/[CONDITION(S)]/what-is-catatonia, provided by the Social Service Director on 6/27/22 at 1:12 p.m., with the excited catatonia type high-lighted, indicated the person may move around but their movement seems pointless and impulsive. They may seem agitated, combative, or delirious, or they may mimic the movements of someone who's trying to help them. During an interview, on 6/27/22 at 1:33 p.m., the Social Service Director indicated the PASARR screening, dated 2/28/19, was the most recent one and there should have been another one done with medication changes. Review of current facility policy, titled MOOD AND BEHAVIOR POLICY, undated and provided by the Social Service Director on 6/27/22 at 2:23 p.m., indicated .The interdisciplinary team will utilize information from the PASARR process as well as to complete a comprehensive assessment of resident needs, strengths, goals, life history and preference using the resident assessment instrument (RAI) specified by CMS .The objective of the Mood and Behavior Policy and Procedure is to provide a plan of care that is individualized to the residents needs based upon the comprehensive assessment by the interdisciplinary team. This plan of care will include medically related social services to address mood and behavioral health services to attain or maintain the highest practicable well-being

Based on observation, interview, and record review, the facility failed to implement a bowel monitoring program to ensure residents were treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: 1. During an interview, on 6/21/22 at 11:00 a.m., Resident 36 indicated she had occasional constipation and had been hospitalized a few times since her recent admission to the facility. Resident 36's clinical record was completed on 6/22/22 at 12:15 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A 5/21/22, 5-day, MDS assessment indicated she was cognitively intact, required extensive assistance for transfers and toileting, was occasionally incontinent of bowel and did not have constipation. Review of BM documentation and progress notes indicated the following: She had a small BM on 5/1/22 and did not have another BM until 5/4/22, when she had a medium BM following a dose of MOM. The clinical record lacked documentation of BMs from 5/5/22 through 5/7/22, when she had a small BM. She was admitted to the hospital on 5/8/22, following a fall at the facility. Review of a 5/11/22 hospital discharge summary indicated diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . After re-admission to the facility, she was transferred back to the emergency department continued emesis and abdominal pain. She was admitted on [DATE] with a possible bowel obstruction. She readmitted to the facility on [DATE]. She had a medium bowel movement on 5/15/22. On 5/18/22, the resident's abdomen was distended and hard to touch, but had bowel sounds active to all quadrants. She hadn't been able to have bowel movement after milk of magnesia was given in the morning. She received [MEDICATION(S)] on 5/19/22 and 5/21/22 and MOM on 5/21/22 and 5/22/22. The clinical record lacked documentation of bowel movements until 5/23/22. Review of the resident's June 2022 BM record indicated no documentation from 6/1/22 through 6/5/22, when she had a medium BM. 2. On 6/22/22 at 12:55 p.m., Resident 20 was in the hallway in her wheelchair. CNA 31 assisted her to her room. Resident 20's clinical record was reviewed on 6/22/22 at 1:48 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A 4/27/22, quarterly, Minimum Data Set (MDS) assessment indicated she was cognitively intact, required extensive assistance with transfers and toileting, and was continent of bowel. She had a current, 5/3/21 care plan problem of risk for dehydration due to inadequate fluid intake, diabetes, kidney disease, constipation, and diuretic use. Review of bowel monitoring for June 2022 indicated the following: She had a medium BM on 6/7/22, and no BMs on 6/8/22, 6/9/22, and 6/10/22. The clinical record lacked documentation of BMs from 6/11 through 6/13/22, when she had a medium BM. She did not have a BM 6/16/22 through 6/19/22, and the clinical record lacked documentation of BMs until she had a medium BM on 6/21/22. Review of the resident's June MAR and progress notes indicated she had not received an intervention, up to an including a [MEDICATION(S)], for constipation. During an interview, on 6/27/22 at 9:15 a.m., CNA 52 indicated the CNAs were responsible for documenting BMs and the nurses would monitor for constipation. CNAs were able to look back for the past 48 hours to see if a resident had a BM. During an interview, on 6/27/22 at 9:22 a.m., CNA 53 indicated the nurses monitored for constipation. The CNAs could see the previous 24 hours only. During an interview, on 6/27/22 at 9:26 a.m., RN 59 indicated if a resident went 24 hours without a BM, they were to receive prune juice or it's equivalent. After 48 hours, they were to receive MOM. After three days, they were to receive a suppository, and after four days, they were to receive an enema. Night shift would pull a report daily with those who had not had a bowel movement so the interventions could be started. During an interview, on 6/27/22 at 9:52 a.m., the DON indicated a report was supposed to be pulled on night shift, then put out to day shift to initiate interventions. During an interview, on 6/27/22 at 11:22 a.m., the DON indicated she could not find a reason for the missing documentation of the resident's bowel monitoring. Review of a current facility policy, titled BOWEL INCONTINENCY MANAGEMENT, dated 4/2015 and provided by the DON on 6/27/22 at 11:22 a.m., indicated the following: .The nursing staff will identify elimination patterns by observing and recording all BMs and will establish a BM schedule based on individual patterns .make sure CNAs are accountable for consistently following through with recording the BMs .Nursing will monitor and make notes routinely until a successful pattern has been established 3.1-37(a)

Based on observation, record review and interview, the facility to ensure a resident did not receive a dosage increase of a [CONDITION(S)] medication without indication, for 1 of 5 residents reviewed for unnecessary medications (Resident 32). Findings include: During an observation on 6/23/22 at 9:37 a.m., Resident 32 was in the hallway ambulating with a walker. On 6/23/22 at 1:11 p.m., he was sitting in a chair in the common area across from the nurses' station. On 6/24/22 at 10:17 a.m., he was sitting in a chair in the common area across from the nurses' station. On 6/27/22 at 8:59 a.m., he was sitting in a chair in the common area across from the nurses' station. His clinical record was reviewed on 6/23/22 at 9:44 a.m. Diagnoses included, but were not limited to, dementia without behavioral disturbance and major depressive disorder. Current physician orders included, but were not limited to the following: 1. Observe resident closely for significant side effects to anti-depressant and report to the physician. Side effects: sedation, drowsiness, agitation, dry mouth, blurred vision, [CONDITION(S)], [CONDITION(S)], muscle tremor, weight changes and photosensitivity, the order date was 2/24/21. 2. [MEDICATION(S)] (anti-depressant), 50 mg (milligram) once a day, give with [MEDICATION(S)] 25 mg for a total of 75 mg once a day at 8:00 p.m., the order date was 2/15/22. 3. [MEDICATION(S)] (anti-depressant), 25 mg (milligram) once a day, give with [MEDICATION(S)] 50 mg for a total of 75 mg once a day at 8:00 p.m., the order date was 2/15/22. 4. Psychologist to evaluate and treat due to treatment of depression of sleep disturbance issues, the order date was 3/14/22. A 5/18/22 quarterly MDS (Minimum Data Set) assessment indicated he had moderate cognitive impairment. He had not had any moods or behaviors and he had received an anti-depressant everyday during the assessment period. A current care plan, dated 2/25/21, indicated he presented with major depression and received [MEDICATION(S)]. Signs and symptoms of depression included increased irritability (yelling at spouse and others), tearfulness related to wanting to go home and be with his wife and/or wanting to go home to the farm where he grew up as a child. Intervention included, but were not limited to, acknowledge to him that the current situation must be difficult, administer medications as ordered, allow him to express his feelings, encourage him to be involved in activities and wife visited him daily, all with a start date of 2/25/21. A Behavioral Gradual Dose Reduction (GDR) progress note, dated 1/10/22 at 1/10/22 at 10:08 a.m., indicated it was recommended, based on clinical data and symptom presentation, to reduce [MEDICATION(S)] from 75 mg to 50 mg once a day and to monitor for rebound symptoms of mood dysregulation. A Behavior Management Meeting note, dated 1/10/22 at 10:38 a.m., indicated order had been received to decrease [MEDICATION(S)] to 50 mg once a day. A progress note, dated 1/12/22 at 4:15 p.m., indicated he had walked down the hall without his walker, pushing a foot-stool with most of his belongings piled on top. He was able to be re-directed and assisted to the dining room. A progress note, dated 1/17/22 at 8:55 p.m., indicated he displayed no signs or symptoms of depression, had been pleasant and cooperative and kind to staff and other residents. A progress note, dated 1/22/22 at 9:34 p.m., indicated no signs or symptoms of depression, he did have increased confusion and thought he should pack because his wife was coming to take him home. Ate supper with his wife. After she had left he was upset because she should have stayed and slept with him, emotional support had been given. A progress note, dated 1/23/22 at 8:45 p.m., indicated he had increased confusion, wife had been there ate supper with him, after she had left he was upset and thought he needed to follow her, and he wanted to be with his wife. Emotional support had been given. A progress note, dated 1/25/22 at 9:57 p.m., indicated he displayed no signs or symptoms of depression, very happy, had supper with his wife and then back to his room and watched television. An IDT (Interdisciplinary Team) progress note, dated 1/27/22 at 8:57 a.m., indicated they had discussed his plan of care. He had behaviors of being tearful on January 22 and 23, and a behavior of packing up his belongings on January 12. A progress note, dated 1/31/22 at 9:11 p.m., indicated he had been in a pleasant mood, enjoyed having supper with his wife and then visiting in his room. Later that evening he had came to the lounge and joined in an activity. A psychiatric progress note, dated 2/9/22 at 2:19 p.m., indicated follow-up routine visit and review of the resident's response to GDR of [MEDICATION(S)]. Had met with the resident, he was awake and alert and able to carry on meaningful conversation and he reported no issues with mood, sleep and/or appetite. The plan indicated no changes to current plan of care and he appeared to be responding well to GDR of [MEDICATION(S)]. A progress note, dated 2/9/22 at 5:00 p.m., indicated he had questioned his wife where she had been during supper, his voice had been raised and agitated. Staff member visited with him and his spouse at the table and redirected the conversation. A progress note, dated 2/12/22 at 9:30 a.m., indicated he had been upset, thought he hadn't seen his wife in three or four days and was worried about her. Staff member provided reassurance that his wife visited daily. A Behavior Management Meeting note, dated 2/14/22 at 10: 42 a.m., indicated during the month of January he had presented with tearfulness, increased confusion and asking about his wife (1/22 and 1/23/22) and delusions on 1/21/22. During the month of February he had presented with tearfulness, increased confusion, agitation and asking about his wife leaving (2/5 and 2/9/22), this was an increase in mood and behaviors, the team decided this was a failed GDR and recommended to increase [MEDICATION(S)] back to 75 mg once a day. A Behavior Management Meeting note, dated 2/14/22 at 10:45 a.m., indicated an order had been received to increase [MEDICATION(S)] to 75 mg once a day. A progress note, dated 2/28/22 at 5:12 a.m., indicated he had hardly slept that night, thought his wife was coming to see him. A progress note, dated 2/28/22 at 2:03 p.m., indicated he had been confused, staff attempts to re-direct had been effective for short periods of time. A progress note, dated 3/2/22 at 6:26 a.m., indicated at 4:00 a.m. he had been frantic because he thought he was late for a meeting with his wife. He walked to the lounge, questioned staff member several times during the next hour about meeting his wife and returned to sit in the lounge. A Behavior Management Meeting note, dated 3/14/22 at 1:27 p.m., indicated during the month of February he had presented with three episodes of [CONDITION(S)], three episodes of delusions and one refusal of care. In March he had presented with three episodes of [CONDITION(S)]. No order changes had been recommended. A progress note, dated 3/25/22 at 4:31 a.m., indicated he had been trying to get hold of his wife for the past half-hour. He was able to be re-directed. A progress note, dated 4/3/22 at 9:24 p.m., indicated he had increased confusion and had tried to pack up his belongings, his wife requested assistance from staff and they were able to re-direct him. A Behavior Management Meeting note, dated 4/11/22 at 10:30 a.m., indicated his episodes of [CONDITION(S)] had been discussed. New order for blood work to be done had been received. A Behavior Management Meeting note, dated 4/11/22 at 12:30 p.m. (recorded as a late entry on 4/21/22 at 12:32 p.m.), indicated during the month of March he had presented with nine episodes of [CONDITION(S)] and one episode of delusions. In April he had presented with two episodes of [CONDITION(S)] and four episodes of delusions. A recommendation was discussed to change the time he received his [MEDICATION(S)] from 9:00 a.m. to 7:00 p.m. A Behavior Management Meeting note, dated 5/9/22 at 11:11 a.m., indicated he had presented with three episodes of increased confusion, two episodes of delusions and two episodes of [CONDITION(S)]. No recommendations had been discussed. During an interview, on 6/27/22 at 9:54 a.m., LPN 21 indicated the resident had a failed GDR attempt of his anti-depressant because he misses living with his wife. During an interview, on 6/27/222 at 11:57 a.m., the Social Service Director indicated he had failed the GDR related to episodes of crying and increased confusion. Review of a current facility policy, titled PSYCHOACTIVE MEDICATIONS OTHER THAN ANTIPSYCHOTICS AND SEDATIVES/HYPNOTICS, with a revised date of 4/2015 and provided by the Social Service Director on 6/27/22 at 2:38 p.m., indicated .7. a. During the first year in which a resident is admitted on a psychopharmacological medication (other than an antipsychotic or a sedative/hypnotic), or after the facility has initiated such medication, the facility should attempt to taper the medication during at least two separate quarters (with at least one month between the attempts), unless clinically contraindicated. After the first year, a tapering should be attempted annually, unless clinically contraindicated 3.1-48(b)(2)

Based on interview and record review, the facility failed to follow physician order's for medication administration and monitoring for 3 of 3 residents reviewed for physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Findings include: An Indiana Department of Health (IDOH) reportable was provided by the Director of Nursing (DON) 6/9/22 at 10:23 a.m. The reportable indicated the alleged event occurred on 5/31/22 when Resident B received the wrong dose of [MEDICATION(S)] (to treat neuropathic pain) on 5/25/22. The resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident demonstrated increased lethargy and her oxygen saturation dropped between 70% and 80% on room air. Oxygen was applied and deep breathing was encouraged. The oxygen saturation returned to 97% and oxygen was discontinued on 5/25/22. The follow-up included to provide increased alerts differentiating the [MEDICATION(S)] 50 mg from the [MEDICATION(S)] 150 mg on the medication cards. A Medication Error Report indicated the errors occurred on May 24, 25 and 30, 2022. The physician was notified on 5/31/22 at 8:00 p.m. after LPN 1 noted the error. Review of the controlled drug record, the evening dose of 150 mg was signed off on 5/24/22 at 8:15 a.m., and 5/25/22 at 8:15 a.m. Review of the controlled drug record for [MEDICATION(S)] 50 mg morning dose, the wrong medication was given on 5/27/22 at 9:24 p.m., and 5/30/22 at 8:00 p.m. 1. The clinical record for Resident B was reviewed on 6/9/22 at 8:41 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent Admission Minimum Data Set (MDS) assessment, dated 5/21/22, indicated the resident was cognitively intact. A health care plan, dated 5/5/22, indicated the resident was at risk for generalized pain due to chronic pain. Interventions included, but were not limited to, pain medication if distraction does not work. Another health care plan, dated 6/9/22, indicated the resident received active range of motion six days per week related to chronic pain. Interventions included, but were not limited to, observe for pain or discomfort and medicate per physician orders. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A progress note, dated 5/22/22 at 9:30 p.m., indicated the residents blood pressure was consistently low; 87/46, 86/55 and 86/54. The physician was notified and a order was received to hold [MEDICATION(S)] (treat high blood pressure) for 3 days then to report back on blood pressures. A progress note, dated 5/25/22 at 10:07 a.m., indicated a wound nurse called and reported the resident's oxygen saturation had dropped down to 74%. They were able to get the level up after removing her mask and having her take deep breaths. Oxygen was applied at 1 liter and her oxygen saturation came up to 97%. On 5/25/22 at 1:18 p.m., the physician was notified of a change in condition due to resident requiring oxygen. A progress note, dated 5/25/22 at 2:12 p.m., indicated the resident returned from wound clinic appointment and her oxygen level was 71% on room air. 1 liter of oxygen was applied and her saturation came up to 95%. The resident was alert, oriented and her speech clear, but stated she was very sleepy from her appointment. A progress note, dated 5/25/22 at 9:43 p.m., indicated the resident continued to need oxygen at 2 liters. She required frequent reminders to keep in place and when removed, dropped to 85%. The resident appeared to be sleeping more throughout the evening. A progress note, dated 5/26/22 at 6:46 p.m., indicated the resident was feeling a little weaker and her oxygen saturation without oxygen was 94%. A progress note, dated 5/31/22 at 8:12 p.m., indicated the resident received the wrong dose of [MEDICATION(S)] on 05/24/22, 05/25/22, and 05/30/22. The physician and family were notified of the medication error. During an observation with the DON on 6/9/22 at 10:58 a.m., the medication cards had A.M. and P.M. noted on each card with a corresponding controlled drug record. The times were highlighted to reflect the time the medication was to be given. During an interview on 6/9/22 at 11:02 a.m., QMA 2 indicated she gave 150 mg in the morning instead of 50 mg. The resident was lethargic and her oxygen saturation had dropped. She received education on medication administration and the 5 rights. 2. The clinical record for Resident C was reviewed on 6/9/22 at 12:51 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent quarterly MDS assessment, dated 4/20/22, indicated the resident was severely cognitively impaired. A health care plan, dated 3/7/19, indicated the resident had complications related to diabetes and hypertension. Interventions included, but were not limited to, administer medication as ordered and monitor blood pressure. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order indicated to hold the medication if her pulse was less than 50 beats per minute or systolic blood pressure less than 100. Review of the May MAR, Resident C's blood pressure included the following: a. 5/19/22 - 91/66 b. 5/31/22 - 91/51 c. 6/6/22 - 97/43 d. 6/8/22 - 96/48 Staff failed to withhold the medication ordered by the physician. 3. The clinical record for Resident D was reviewed on 6/9/22 at 12:13 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent quarterly MDS assessment, dated 3/30/22, indicated the resident was severely cognitively impaired. A health care plan, dated 3/15/19, indicated the resident had active hypertension. Interventions included, but were not limited to, administer medication as ordered and notify the physician if the blood pressure exceeds limits established by the physician. A physician order, dated 5/19/22, indicated to give [MEDICATION(S)] (to treat high blood pressure) 0.3 mg twice daily. The order indicated to hold the medication if the blood pressure was less than 130/60, recheck in 1 hour. Review of the May MAR, Resident D's blood pressure included the following: a. 5/19/22 - 114/50 b. 5/23/22 - 105/53 and 100/50. Staff failed to withhold the medication ordered by the physician. During an interview on 6/9/22 at 10:53 a.m., the DON indicated she originally reported 1 overdose, but there were actually 2. She did not report the underdose errors since the resident did not have any adverse effects. Three of the 4 staff involved worked for an outside agency, but she did provide education to QMA 2 related to the five rights. During an observation with the DON on 6/9/22 at 10:58 a.m., the medication cards had A.M. and P.M. noted on each card with a corresponding controlled drug record. The times were highlighted to reflect the time the medication was to be given. During an interview on 6/9/22 at 11:02 a.m., QMA 2 indicated she gave 150 mg in the morning instead of 50 mg. The resident was lethargic and her oxygen saturation had dropped. She received education on medication administration and the 5 rights. During the exit conference, the DON indicated LPN 1 noticed the discrepancies and she was notified on 5/31/22, but the errors occurred starting on 5/24/22. Review of a current policy effective January 2007, titled MEDICATION ORDERS provided by the Infection Control Preventionist on 6/9/22 at 3:00 p.m., indicated the following: Policy Medications are administered only upon the clear, complete, and signed order This Federal Tag relates to complaint IN 925 3.1-25(b)

Based on observation and interview, the facility failed to properly prevent and/or contain COVID-19 by staff not wearing face masks appropriately in the Crestwood Unit and in a TBP (Transmissioned Based Precaution) room on the 300 hall, staff not cleaning eye protection appropriately and not performing hand hygiene after touching PPE (Personal Protective Equipment) during random observations. Findings include: On 1/14/22 at 9:34 a.m., Activity Aide 33 was observed reading to six residents in the common area, across from the nurses station, on the Crestwood Unit. Her mask was pulled down and exposed her nose and mouth. On 1/14/22 at 11:29 a.m., CNA 13 wore a surgical mask and applied an N95 mask over the surgical mask to enter a room on the 300 hall that had signage on the door to indicate the resident was in TBP. During an interview, with the IP (Infection Prevention) nurse with the DON present, on 1/14/22 at 11:50 a.m., he indicated staff should not be applying an N95 over a surgical mask. On 1/14/22 at 12:58 p.m., CNA 17 was standing in the common area on the 300 hall, as she talked to a resident, she used her shirt to wipe off her goggles and then placed them on her face. She asked the resident if she was ready, without performing hand hygiene, she assisted the resident as she held onto her gait belt and walked her down the hall to her room. During an interview with CNA 13, on 1/14/22 at 1:00 p.m., she indicated she normally took off her surgical mask and applied an N95. During an interview with CNA 17, on 1/14/22 at 1:02 p.m., she indicated she would not normally wipe her goggles on her shirt, she was just trying to see and would normally perform hand hygiene after touching her goggles. On 1/14/22 at 1:09 p.m., Laundry Aide 21, applied an N95 over her surgical mask to enter a room on the 300 hall that had signage on the door to indicate the resident was in TBP. During an interview, with the Activity Director, on 1/14/22 at 1:20 p.m., she indicated she would not normally pull her mask down when she talked with the residents. One of the residents indicated they could not hear her and asked her to pull her mask down, it was something she would not normally do and it was a real quick thing. Signage titled Current PPE Requirements, dated 1/13/22 and provided by the Administrator, on 1/14/22 at 2:39 p.m., indicated the following: Green zones, Face masks: surgical grade or better. Eye protection: Goggles or Face Shields for all interactions within 6 feet of an individual. Yellow and Red Zones: Follow PPE instructions posted on resident door. A 7/7/21 revised policy titled, 707 FOR STAFF WORKING IN DESIGNATED CARE UNITS GREEN, YELLOW AND RED ZONES, provided by the Administrator, on 1/14/22 at 2:39 p.m., indicated the following: Procedure: . Green Zone: 1. Standard Based Precautions. 2. PPE required: Universal surgical mask issued by Timbercrest (unless instructed to wear KN95 by DON/Infection Preventionist/HR). Staff who have received both doses of the COVID vaccine and have submitted proof thereof are permitted to wear surgical grade facemasks issued by Timbercrest . Yellow zone 2. PPE required: Approved KN95 Mask or KN95 covered with cloth facemask (may be used for entire shift unless were or visibly soiled). Staff who have received both doses of the COVID vaccine and have submitted proof thereof are permitted to wear surgical grade facemasks issued by Timbercrest 3.1-18(b)(1)

Based on observation, interview, and record review, the facility failed to assess a skin impairment and implement interventions to prevent the development of a pressure injury and failed to provide treatment and interventions to prevent the worsening of a pressure injury for 1 of 1 residents reviewed for pressure injuries (Resident 30). This deficient practice resulted in Resident 30's wound progressing from a reddened area with shearing to an unstageable pressure wound. Findings include: During a wound care observation, on 7/13/21 at 2:20 p.m., accompanied by the Wound Care Nurse and LPN 33, the following was observed: Resident 30 was in bed. She had an open wound to her coccyx, approximately the diameter of a softball and irregular in shape. The wound bed was covered in a white tissue substance with a thicker darkened area across the top of the wound. The Wound Nurse indicated the wound measured 2.8 centimeters (cm) long (L) x 3.6 cm wide (W) and was unstageable (Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed). She had an additional open wound with a bright red wound bed, approximately the size of a jelly bean, adjacent to the larger wound. Resident 30's clinical record was reviewed on 7/11/21 at 2:17 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She had a current, 6/23/21, physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A 7/1/21, significant change, Minimum Data Set (MDS) Assessment indicated she was moderately cognitively impaired, required extensive assistance for ADLs and mobility, and had one stage 3 pressure injury. Review of a baseline care plan, dated 5/25/21, indicated preventative skin care of floating heels. There were no interventions related to her coccyx. She had a current care plan problem, initiated 6/2/21 and revised 7/8/21, of a stage 3 pressure injury to her sacral area, related to pressure and bowel incontinence. Interventions included monitor and record, keep skin clean and dry, and ensure her treatment was completed. She had a current, 6/24/21, care plan problem of impaired bed mobility related to right hip fracture, requiring assist bars x 2. She had a current, 7/14/21, care plan problem of risk for skin breakdown. There was no prior care plan developed for risk for skin breakdown in the clinical record. Review of a 5/24/21 admission assessment indicated her bilateral heels were pink, soft, and mushy; she had a red area to her coccyx with slight shearing noted, and a dry foam dressing was placed as a preventative measure. The clinical record lacked measurement of the reddened, sheared area to her coccyx, nor was a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of a 5/25/21 Braden skin risk assessment indicated she was at high risk for skin breakdown. A 5/31/21 progress note indicated a discussion with family of hospice services due to slow progression in therapy. A 5/31/21 Registered Dietician note indicated a reddened area to her coccyx. Review of a 6/2/21 wound assessment indicated a 2 cm L x 3 cm W x 1 cm depth stage 2 (partial-thickness loss of skin with exposed dermis; granulation tissue is not present) pressure injury to her coccyx. She was frequently incontinent of bowel, had limited movement related to her hip fracture, a poor appetite with weight loss, and an overall decline. She had been refusing therapy and not getting out of bed. A new order was obtained for antimicrobial foam dressing and a request made for a low air loss mattress. A 6/9/21 wound assessment indicated the wound measured 5.5 cm L x 6 cm W x 0.1 cm depth with 100% granulation (new connective tissue and microscopic blood vessels that form on the surfaces of a wound during the healing process). A 6/16/21 wound assessment indicated the wound measured 2 cm L x 2 cm W x 0.1 cm depth with 50% slough (dead cells adhered to the wound bed) and was a stage 3 (full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. If slough or eschar (thick, hardened dead tissue) obscures the extent of tissue loss this is an Unstageable Pressure Injury.) A 6/23/21 wound assessment indicated the wound measured 2 cm L x 2 cm W x 0.1 cm depth with 100% slough and was a stage 3. She was admitted to hospice services on 6/24/21 for [CONDITION(S)]. A 6/30/21 wound assessment indicated the wound measured 2 cm L x 1.5 cm W x 0.1 cm depth with 50/50 slough/granulation tissue. A 7/8/21 wound assessment indicated the wound measured 3.9 cm L x 1.8 cm W x 0.1 cm depth with 100% slough and remained a stage 3. During an interview, on 7/13/21 at 2:37 p.m., the Wound Nurse indicated she assessed the resident's wound on a weekly basis. The biggest factor in the development of the wound was mobility loss and having been grossly incontinent of bowel at admission. There was slough present in the wound bed, so it was a stage 3. The area was worsening, so she would call the physician for new treatment orders. During an interview, on 7/15/21 at 1:42 p.m., the ADON indicated there was no care plan in place related to prevention of skin breakdown prior to 7/14/21. Review of a current facility policy, titled PRESSURE ULCER PROTOCOL, dated 4/2019 and provided by the ADON on 7/14/21 at 9:24 a.m., indicated the following: .Pressure ulcers and skin problems will be promptly reported to the attending physician, on call nurse, and WCC [wound care nurse] .The Skin Integrity Event shall be completed: a. Wound location b. Size of reddened and/or open area .8. The resident's care plan shall include the skin problem, approaches and goals for care 3.1-40(a)

Based on observation, interview, and record review, the facility failed to provide supervision to prevent repeated falls and failed to prevent falls during staff-assisted transfers for 2 of 5 residents reviewed for falls (Residents 1 and 29). This deficiency resulted in occipital (skull bone) and hip fractures for Resident 1. Findings include: 1. On 7/12/21 at 1:27 p.m., Resident 1 was in bed. On 7/13/21 at 9:32 a.m., the resident was in bed. On 7/14/21 at 8:31 a.m., the resident was in bed. Review of Resident 1's clinical record was completed on 7/11/21 at 2:47 p.m. Diagnoses included, but were not limited to, left hip fracture, restlessness and agitation, repeated falls, [CONDITION(S)] stage 2, and type 2 diabetes. A 3/23/21, admission, Minimum Data Set (MDS) assessment indicated he was moderately cognitively impaired. A 6/23/21, significant change, MDS assessment indicated he was moderately cognitively impaired and required extensive assistance with mobility and limited assistance with locomotion in his room. He had a current, 3/16/21, care plan problem, revised 7/8/21, of risk for falling related to poor safety awareness as he did not use his call light for assistance despite written reminders and signs and bowel and bladder incontinence. Interventions included, but were not limited to, bed in lowest position (7/6/21), mattress with raised perimeter (6/25/21), larger pants (6/25/21), 15 minute checks (5/7/21), reminder in room to call for assistance (5/5/21) and fall mat next to bed (5/3/21). Review of Resident 1's fall history in his clinical record indicated the following: On 4/3/21 at 11:00 p.m., he lost his balance in his bathroom while attempting to turn with one hand on transfer bar and the other on his rollator (walker). His gripper socks were on but worn down. The initial intervention to prevent further falls were staff re-educated and the resident was educated on standing with both hands on his rollator, and his gripper socks were replaced. He sustained an 8 centimeter (cm) long (L) x 8 cm wide (W) abrasion to his left mid-back, an 8 cm L x 1 cm W skin tear to his right forearm, a 15 cm L x 8 cm W abrasion and bruising to his right upper back, and a 1.5 cm L x 2 cm W sore on his right lower lip. On 4/10/21 at 8:15 p.m., he was found on the floor in his room in front of the TV with his bed covers on; he likely was caught in the covers while attempting to get up from bed. The initial intervention to prevent further falls was to assist him to the toilet and educate him to continue to use call light for any needs. The facility was unable to determine what happened to cause the fall; he had been toileted around 7 p.m. On 4/16/21 at 9:43 a.m., he had an unwitnessed fall in his room in front of his recliner. He had lost his balance while backing up to recliner to sit down and sat too quickly. The initial intervention to prevent further falls was to assist him to the toilet and the process was started. He had been toileted last at 9:00 a.m. On 5/5/21 at 8:42 a.m., he had a witnessed fall in his bathroom, and slid down the wall. Staff witnessed him losing strength and sliding down the wall, and he was assisted to the floor. The initial intervention to prevent further falls was a reminder sign in room to use his call light for assistance. He had been toileted an hour prior. On 5/28/21 at 2:15 a.m., he had an unwitnessed fall outside of his bathroom; he had lost balance and strength while walking to his bathroom without assistance. The initial intervention to prevent further falls was to assist him to the bathroom, and added scheduled toileting between 2:00 a.m. and 2:30 a.m. On 6/8/21 at 1:00 a.m., he had a witnessed fall in front of his recliner. He had been either standing up or sitting down in his recliner and was witnessed by a CNA sliding down the recliner and sitting on the floor. He had been assisted to the bathroom at 12:00 a.m. 15 minute checks were implemented and he was to be evaluated by therapy. On 6/20/21 at 10:46 a.m., he was found beside his bed, with his pants around his knees; he had likely tripped trying to get out of bed, and his pants fell , as they were too big. He was on 15 minute checks and had just been resting in bed at 10:30 a.m. and had been assisted to the bathroom at 9:30 a.m. The immediate intervention to prevent further falls was to notify his family of a need for smaller pants. On 7/3/21 at 3:00 p.m., he had an unwitnessed fall in his bathroom. He had been incontinent of bowel and bladder and his pants were down at the time. He likely lost balance due to his pants being down and had not activated his call light for assistance. He had been resting in bed 15 minutes prior to his fall. He had an abrasion to his left knee, swelling and abrasion to his left eyebrow, a nondisplaced fracture involving the left occipital bone and subcapital fracture of the left femoral neck. Review of a 7/3/21 emergency department note indicated he had fallen and had a contusion to his left forehead and pain to his left hip. A CT scan of his spine indicated a non-displaced fracture of the left occipital bone. An x-ray indicated a left subcapital fracture of the left femoral neck. The resident and family did not wish to have surgical intervention and he was to be bed-bound going forward. During an interview, on 7/15/21 at 9:21 a.m., QMA 35 indicated the resident had liked to do things himself and didn't want to ask for help. He was receptive if staff asked something of him, but he really didn't want to ask for help. He liked to toilet himself frequently without assistance. He had been on 15 minute checks, and also the staff member on the hall was responsible for checking in on him. He would become more incontinent as the day went on and was very hard of hearing; she was not sure how much he recalled due to being so hard of hearing. He used a white board a lot. During an interview, on 7/15/21 at 10:19 a.m., the DON indicated the resident had been on a toileting program to prevent falls. During an interview, on 7/15/21 at 10:36 a.m., the ADON indicated the resident didn't want to sit out in common area. He liked activities, but wanted to be in his room when not attending activities programs. His physical therapy had ended on a Friday, and he fell the next day, on Saturday. He needed help with clothing and toileting, and was not cognitively able to use urinal. He would get up without his rollator at times. 2. Resident 29's clinical record was reviewed on 7/12/21 at 1:13 p.m. Diagnosis included, but were not limited to, recurrent moderate major depressive disorder, attention and concentration deficit, [CONDITION(S)] disorder, [CONDITION(S)], difficulty in walking, other lack of coordination, muscle weakness (generalized), history of falling, repeated falls and unspecified abnormalities of gait and mobility. His medications included, but were not limited to, acetaminophen (pain reliever) 500 mg (milligram) four times daily, [MEDICATION(S)] (high blood pressure) 3.125 mg twice daily, [MEDICATION(S)] (dementia) 10 mg daily, [MEDICATION(S)] (anti-depressant) 40 mg daily, [MEDICATION(S)] (high blood pressure)10 mg daily, [MEDICATION(S)] (dementia)10 mg twice daily and [MEDICATION(S)] (pain reliever) four times daily. A 3/9/21, quarterly, MDS (Minimum Data Set) fall assessment indicated he was a high risk for falls. A 5/26/21, quarterly, MDS indicated the resident was moderately cognitively impaired. He required extensive assistance of one staff member for bed mobility. He transferred with extensive assistance of two staff members. He used a wheelchair for mobility. He had one fall since admission or prior assessment with no injury. He had a 7/12/21 revised, fall care plan, that indicated he was at risk for falls related to unsteady balance, he required a stand-up lift for transfers, he had a history of leaning to left side and required lateral support on his left side, high-risk medication use, [CONDITION(S)] with history of fractures, back pain, urinary incontinence, poor safety awareness as evidenced by he had reached to floor to pick up papers. His most recent fall was 7/11/21. Interventions included, but were not limited to, for transfers with mechanical stand-up lift, use two staff assist to ensure safety, dated 4/15/21. A fall event form, dated 4/15/21 at 10:40 a.m., indicated the cause of the fall was the resident had removed the loop of stand lift sling. The new immediate intervention was initiated and communicated to staff, the resident required staff assistance when transferred. The initial root cause of fall was the resident removed one side of stand lift harness while being transferred. IDT (Interdisplinary Team) indicated root cause analysis of fall was the resident was lowered to floor from mechanical stand up lift due to unhooking strap of sling connected to lift. Initial intervention was he would be a two assist for transfers with mechanical standup lift to ensure safety. A nurses note, dated 4/15/21 at 11:14 a.m., indicated a staff member called the writer to report that the resident was lowered to the ground following transfer to the bathroom. The writer entered the room and found the resident on the bathroom floor in supine position, with stand lift in front of him. Once stand lift was moved, the resident then rolled to his left side and he was provided with a pillow until assessment was completed. He had no visual injuries nor complaints of pain. Intervention of two staff assist was implemented. A review of the CNA assignment sheet, dated 6/30/21, indicated the resident required staff assistance of two and the stand up lift. A nurses note, dated 7/11/21 at 10:00 p.m., indicated a CNA transferred the resident to bed using a stand up lift. The resident sat at the edge of bed, while the CNA moved the lift away, the resident lost his balance and the CNA was unable to move resident back on the bed. The resident was lowered to the ground. A skin tear to his left shoulder was noted. A fall event form, dated 7/12/21 at 7:37 a.m., indicated the resident had received a skin tear to his left shoulder, measurements were 0.3 cm (centimeters) X 0.1 cm he had slipped off the bed. To prevent the fall from happening again, the CNA was to find help during transfers. IDT root cause analysis of fall indicated the resident had lost his balance and slipped off bed when CNA assisted to bed with mechanical stand-up lift then removed stand-up lift. The initial intervention was the CNA was re-educated on the use of two staff members when transferring with mechanical stand-up lift for this resident. An IDT note, dated 7/12/21 at 9:00 a.m. indicated the residents most recent fall was reviewed, it was likely the resident lost his balance as the mechanical stand-up lift was being pulled away from the bed. Initial intervention of re-educating nursing staff, the resident required two staff members for transfers with mechanical stand-up lift. An interview with the ADON, on 7/14/21 at 2:17 p.m. she indicated with the 7/11/21 fall: the CNA had pulled the stand up lift away from the bed and the resident had lost his balance and fell . The newer CNA was re-educated and reminded the resident was a two assist with stand up lift. The CNA had used the stand up lift by himself. The fall, on 4/15/21, was when the two assist with the stand up lift was implemented. A different CNA had taken the resident to the bathroom and put the resident on the toilet, disconnected the sling from the stand up lift, got him dressed and stood him back up, pulled his brief and his pants up, he wiggled on the stand up lift and took his hand off the bar of the lift and got a hold of the loop of the sling. The resident stood himself up more on the lift and the loop came unhooked and the CNA had lowered him to the floor. A current policy, titled FALLS, PREVENTION AND FOLLOW UP, provided by the DON on 7/15/21 at 10:19 a.m. indicated the following: POLICY: It is the goal of the nursing staff to prevent as many falls as possible, but is nationally recognized through many studies that falls are a frequent occurrence in people over the age of 65 . PROCEDURE: 1. Fall Risk Factors; a. Anyone with a history of falls within the past 30 days is likely to fall again. b. Chronic disease puts people at risk for falls that involve gait disturbance, balance impairment, and sensory loss (poor eyesight or hearing). c. People who require assistive devices (canes, walkers, crutches) due to the inappropriate use of these devices. d. Weakness and chronic pain . g. cognitive impairment 3.1-45(a)

Based on record review and interview the facility failed to provide adequate supervision to prevent falls for a resident who was a high risk for falls for 1 of 2 residents reviewed for falls (Resident G). This deficient practice resulted in Resident G falling and sustaining pelvic fractures. Findings include: Resident G's clinical record was reviewed on 9/8/20 at 1:30 p.m. [DIAGNOSES REDACTED]. care, vitamin D deficiency, [MEDICAL CONDITION], chronic pain, history of falling, difficulty in walking, unsteadiness on feet and hospice. A significant change, Minimum Data Set ((MDS) dated [DATE], indicated she was moderately cognitively impaired. She required extensive assistance for bed mobility, dressing, toileting and personal hygiene. She required limited assistance with walking in room and transfers. She used a walker. She was occasionally incontinent of bladder and always continent of bowel. A significant change, Minimum Data Set (MDS), dated [DATE], indicated she was severely cognitively impaired. She required extensive assistance for bed mobility, walking in room, dressing, toileting and personal hygiene. She required limited assistance with transfers. She used a walker. She was occasionally incontinent of bladder and always continent of bowel. A significant change fall assessment, dated 7/7/20, indicated she was a high risk for falls. A problem care plan, dated 12/17/18, for falls indicated she was at risk for falling related to history of falls with serious injury, unsteadiness on feet, removes gripper socks per self at night, often walked without the use of assistive device, attempted to get up from lift recliner with footrest elevated, stood quickly and did not allow time to steady herself before briskly walking, poor insight into deficits, poor safety awareness. Her goal was to remain from injuries. Interventions/approaches included, but were not limited to, 7/7/20 place second soft touch call light pad on the bed so the resident had one on each side of her while lying in bed, 5/3/20 after assisting the resident to bed, please close her door at night as this was her preference, 4/10/20 her room to be rearranged, 4/7/20 physical therapy changed wheels on her walker to sliders, 3/30/20 removed lift recliner from room, had a loveseat to sit on, 3/29/20 start smart program, 3/27/20 gave the resident verbal reminders not to ambulate/transfer without assistance, 3/28/20 platform added to standard walker for right wrist fracture with splint, 3/21/20 provided light weight blanket for the resident when sitting in recliner that she can easily remove herself, 1/8/20 place appropriate size gripper socks on the resident, 9/30/19 place trash can and briefs closer to the toilet in the bathroom so resident did not have to make extra movements in bathroom, 2/24/20 add non-skid strips in bathroom, 8/22/19 changed personal bed to hospital bed,8/19/19 check placement of sign on walker reminding resident to use when ambulating, 8/19/19 keep soft touch call light within reach, 8/19/19 keep walker within reach at all times, 6/23/19 CNA to apply gripper socks to res feet when she laid down in bed, 5/18/19 the resident was to be toileted with assistance after every meal, three times daily, 9:00 a.m., 1:00 p.m., and 6:00 p.m., 5/11/19 if the resident chooses to eat lunch in her room encourage her to be sitting in the chair and not on the edge of the bed, 12/17/18 4 P's Hourly Rounding, 12/17/18 bed height set at correct height for the resident, create a room that most closely represents her home environment - bed, nightstand, furniture, equipment, personal items, 12/17/18 keep call light within easy reach at all times, 12/17/18 provide the resident with safety device/appliance: walker and wheelchair, provide proper, well-maintained, individualized, non-skid footwear, 12/17/18 provide slow, repeated orientation to her room. Progress notes and fall forms included, but were not limited to the following: a. 3/21/20 at 1:30 p.m., a Fall Form indicated the resident had an unwitnessed fall in her room. The initial root cause analysis of the fall indicated the resident attempted to get up without the use of an assistive device, in socks and lost her balance while trying to move a blanket off her lap. The initial intervention was she was sent to the emergency room (ER) and to apply a light weight blanket that she could easily remove from her lap, she sustained a right wrist fracture from the fall. b. 3/21/20 at 1:40 p.m., the resident was found on the floor in her room between the recliner chair and the doorway of the bathroom with a blanket around her. Walker was not close to resident. Residents call light was not on. She was yelling out and moaning that her back, right arm and hips hurt. Noted was a 0.2 centimeter (cm) laceration with hematoma to her left eyebrow. She had a scant amount of bleeding. Area was cleansed with soap and water. No further bleeding. No dressing required. Right wrist pain, 10 on scale of 1-10. Increase swelling and hand deviated from wrist. Applied ice and secured with ace wrap and elevated it on a pillow. No rotation or shortening to lower extremities. Resident would not move legs due to pain and facial grimacing when extremities touched. Pedal pulse was present. No swelling to hips. Skin was warm and dry. Vitals were completed every 15 minutes three times. Physician called with update on resident fall and for an order to transfer the resident to a local emergency room for an evaluation. CNA reported she had just left the resident three minutes before the fall. She had just finished her lunch and removed tray from her room. The resident was sitting in a recliner chair with blanket on her lap. c. 3/21/20 at 5:30 p.m., the hospital reported the resident was being released back to facility. The resident had a broken right wrist and it was in a splint, wrapped with an ace bandage. d. 3/27/20 at 6:30 p.m., a Fall Form indicated the resident had a fall in her room. Evaluation note indicated a 72 Hour Fall Follow-Up was completed the initial root cause analysis of the fall was the resident lost her balance when she got out of lift recliner with footrest still elevated, barefooted without the use of an assistive device of a walker. The initial intervention was the resident was assisted to toilet, approach added to her care plan to give resident verbal reminders not to ambulate/transfer without assistance, 15 minute checks were initiated. e. 3/27/20 at 6:37 p.m., late entry recorded on 3/28/20 at 1:42 a.m., a CNA notified the writer that she saw that the resident was on the floor when she walked down the hall past the restroom. The resident was found on her bedroom floor in front of bed laying on her right side. The resident had been in the recliner previously. The recliner feet was still in up position. The resident did not know why she was up or how she fell . No noted areas. Her vital signs were within normal limits. The resident was able to move all extremities. The resident's splint to her right forearm, wrist and hand was intact. The resident had no complaints of new pain. The resident's left pupil was slightly bigger than the right and was sluggish in reaction to light. Her right pupil was non-reactive. The daughter was notified and updated her on the fall, all questions were answered. The resident was assisted to the toilet and then assisted to recliner in the nursing area. New intervention was added to the care plan and printed out for staff to read and sign. f. 3/28/20 at 8:00 p.m., the resident was sitting on side of bed trying to stand up with her walker. The resident stated that she needed to use restroom. She helped the resident to the restroom and then back to bed. Her vital signs were taken and within normal limits. The resident pupils continued to be unequal and non-reactive. g. 3/29/20 at 6:42 p.m., the resident toileted herself again after staff was doing 15 minute checks. Staff found the resident in the bathroom, voiding in the hat. Staff assisted with as needed ADLs and assisted her to bed with walker near bed and soft touch call light was near the resident. h. 3/30/20 at 9:10 a.m., the resident had gotten up from recliner with the recliner up in front of her and fell to her right side on the floor. The resident did not feel she had hit her head but could not say for sure. No noted injury to head. Resident stated she had no pain after the fall. Pain remained in her wrist from previous fall. She had no noted injury at time of fall. Neurological checks and vital signs were within normal limits. She had active range of motion. The writer, CNA, and ADON assisted resident to her feet. No dizziness was reported upon standing. Resident was assisted to the couch. Her right arm was propped on a pillow for comfort. Resident stated she was feeling comfortable. The call light was in reach and resident was asked to call for any help. i. 3/30/20 at 10:01 a.m., a Fall Form indicated a fall follow up 3/30/20. The initial root cause analysis of the fall was the resident attempted to get up from recliner with footrest elevated after breakfast. The initial intervention was the recliner was removed from her room, the resident had a loveseat to utilize, order for right shoulder xray, order for physical and occupational therapy to evaluate and treat and a new order for as needed [MEDICATION NAME] (pain reliever) 10 mg four times daily for five days. No injuries. j. 4/9/20 at 6:50 a.m., a Fall Form indicated the resident had a fall with an injury. The initial root cause analysis was the resident lost her balance getting up from the toilet without assistance of staff. The initial intervention was orthostatic blood pressures and rearrange her room. k. 4/9/20 at 6:50 a.m., the resident's bathroom call light was on and the nurse stopped to assist the resident and observed resident on the bathroom floor with her walker over top of her lap. She was sitting up against the wall in front of the commode. She had a weak grasp to her right hand because it was currently splinted from another previous fall. No outward/inward rotation noted. There was a small skin tear was noted to her right elbow that measured approximately 1 cm x 1 cm. Her right eye had some redness above it and some swelling. Ice was to be applied to help with swelling and some redness was noted as well to her back. The resident was assisted up to her feet, onto the commode and washed and dressed for the day. Vitals obtained and neurological checks initiated. l. 4/11/20 at 12:09 p.m., staff entered residents room for an assessment and noted the resident attempted to get up by herself from her recliner. The resident stated she had to go to the wash room. The resident was assisted up per staff and ambulated with her walker to the bathroom for toileting. X-rays were negative for fracture. m. 4/11/20 at 8:15 p.m., the resident attempted to get out of bed by herself, she was assisted to the bathroom and care was completed. n. 5/3/20 at 9:55 p.m., the resident was found on the floor, she had ambulated without walker to the bathroom, changed out of her nightgown and dressed herself with the exception of one gripper sock. No injury was noted, alert to self, neurological assessment within normal limits for resident, vital signs were obtained. No injury was noted at that time. o.5/3/20 at 10:09 p.m., the Fall Form indicated on 5/3/20 the resident had an unwitnessed fall in her room with no Injuries. A fall follow-up progress note every shift through 5/6/20 3:00 p.m. -11:30 p.m. to include: 1. mobility/ROM 2. any latent injuries 3. pain 4. intervention initiated was working, or if not working, then a new intervention was to be started (CNAs were to be verbally educated of the new intervention) 5. a set of vitals into electronic health record. Interventions: 1. After assisting the resident to bed, please close her door at night as this was her preference. The root cause analysis of the fall was the resident was unsteady/weak due to fracture of wrist, lost balance attempting to shut her bedroom door. The initial intervention was after assisting the resident to bed, please close her door at night as this was her preference. No injuries. p. 7/7/20 at 1:27 p.m., the resident had unwitnessed fall, her call light was going off. Hospice nurse noticed resident sitting on the floor as she walked by. CNA entered room and then came to get writer. The resident was found sitting on her buttocks with legs out in front of her next to the bed. The walker was in an upright position to the side of her. She was going to the bathroom. She denied hitting her head. She indicated she had lost her balance. She denied pain. Active range of motion to all extremities. No bruising, swelling or redness to her head, torso or extremities. She was assisted with two to a standing position. Her gait was unsteady without walker. Resident had no safety awareness and will begin to walk briskly before stabilizing gait. Encouraged to stand and get her balance before ambulating. She followed direction. She was assisted to the bathroom. She was incontinent of bladder. Resident stood on her own will and ambulated back to bed. An assessment was completed. Her daughter and physician was notified of fall without injury. q. 7/7/20 at 1:37 p.m., a Fall Form dated 7/7/20 indicated the resident had an unwitnessed fall in her room. A fall follow-up progress note every shift through 7/10/20 7:00 a.m. - 3:30 p.m. was to include: 1. mobility/ROM 2. any latent injuries 3. pain 4. intervention initiated was working, or if not working, then a new intervention to be started (CNAs were to be verbally educated of the new intervention) 5. a set of vitals into electronic health record. Intervention - placed second soft touch call light pad on bed so the resident had one on each side of her while lying in bed. The root cause analysis of fall was the resident got up from bed and attempted to take herself to the bathroom, lost her balance, fell next to bed and landed on buttocks. Prior to fall, CNA offered to assist the resident to the bathroom twice, but the resident became agitated, said she didn't need help, she wasn't going to eat lunch and told the CNA if she didn't leave the room she would call police. The initial intervention was a second soft touch call light pad to be placed on the resident's bed so she had one on each side of her while lying in bed. No injuries. r. 7/9/20 at 3:54 a.m., the resident was found on the bathroom floor, her call light was going off, she was coming back from bathroom and fell . She had a skin tear to right elbow that measured 1.2 cm by 0.1 cm width, less 0.1 cm depth with a small amount of bleeding, it was cleaned and covered. Active range of motion to all extremities, pupils were reactive to light. She denied pain. A note to primary care provider to have foam to right elbow until healed. s. 1. 8/30/20 at 12:24 a.m., approximately 11:30 p.m. the resident was yelling out when staff entered her room, she was lying on her back on the floor. She was alert but unable to move her left leg without yelling out in pain. Physician was called and received an order to send the resident to the emergency room for evaluation and treatment. 2. A review of a CT of the Pelvis without contrast impression results dated 8/30/20 at 3:48 a.m., from the emergency department indicated the resident had fractures of inferior and superior pubic rami on the left. 3. 9/8/20 at 6:14 a.m., at 5:45 a.m. the nurse checked on the resident, she had no vital sign and no pulse. At 5:50 a.m., another nurse confirmed death. 6:00 a.m. hospice was called and waited for a call back and called back with a new order to release body to funeral home. At the time of the fall, her orders included, but were not limited to, [MEDICATION NAME]-[MEDICATION NAME] (pain reliever) 5-325 (mg) three times daily and as needed (PRN) every four hours, [MEDICATION NAME] oxalate (anti-depressant) 10 mg daily, trazadone (sedative) 50 mg at bedtime, [MEDICATION NAME] concentrate solution (pain reliever) 0.25 milliliter (ml) every two hours as needed for pain and resident should be assisted to the bathroom at 10:00 p.m., 2:00 a.m., and 5:00 a.m. During an interview with the DON on 9/9/20 at 9:19 a.m., she indicated there was documentation from the physician that it was a challenge to keep her from falling. She would get up on her own. They did checks on the resident at night time, gave her non slip socks, rearranged her room, Occupational Therapy/Physical Therapy (OT/PT), toileting plans, reviewed her medications, they did medication changes, she would take the non slip socks off herself, her room was close to the nurses station, she was very impulsive. She had been on hospice since 6/26/20, her health was declining since June, not eating well, encourage her to eat and move, she wanted to sleep a lot and stay in bed. She was [AGE] years old. She was in more pain due to the fracture, it was a challenge to keep her pain controlled, not over medicating but to medicate the pain. She was not actively dying before the fall. A current facility policy, titled FALLS, PREVENTION AND FOLLOW UP, and provided by the ADON on 9/9/20 at 2:34 p.m., indicated the following: POLICY: It is the goal of the nursing staff to prevent as many falls as possible, but is nationally recognized through man studies that falls are a frequent occurrence in people over the age of 65 .PROCEDURE: 1 Fall Risk Factors: a. Anyone with a history of falls within the past 30 days is likely to fall again. b. Chronic disease puts people at risk for falls that involve gait disturbance, balance impairment, and sensory loss (poor eyesight or hearing). c. People who require assistive devices (canes, walkers, crutches) due to the inappropriate use of these devices. d. Weakness and chronic pain .g. Cognitive impairment A START SMART: Fall Prevention Program provided by the ADON on 9/9/20 at 2:34 p.m. indicated the following: PURPOSE: To identify residents who require special precautions to prevent falls. Program is utilized in conjunction with present falls evaluations to prevent unintended falls/injury . PROCEDURE: 1. Program is placed into effect when a resident has 3 or greater falls in a month and/or has two falls with a history of at least two falls the previous month . 4. Neon orange masking tape will be placed in open view to alert employees of resident's increased fall risk. Identifiers will be placed with approval of resident/resident representative and in a way to respect the resident's dignity. The tape will be placed on the designated areas as applicable: a. Bottom or the resident's name plate, outside of the door. b. Around the front legs of residents walker. c. In front of both handles on wheelchair. d. On each side of the top bar on the back bar of the BRODA chair. 5. All staff will be responsible for checking on residents to ensure they are comfortable and do not have a need This Federal Tag relates to Complaint IN 861. 3.1-45(a)(2)

Based on observation, interview and record review, the facility failed to ensure a cognitively impaired resident, who was at risk for elopement, received the supervision to prevent elopement from the facility for 1 of 2 residents with exit seeking behaviors. This deficient practice resulted in the resident leaving the locked unit, going down two flights of stairs and then exiting the facility, resulting in her being outdoors, without supervision, for an hour and 15 minutes (Resident B). The immediate jeopardy began on 9/3/19, when Resident B eloped from the facility. The Administrator and ADON, were notified of the immediate jeopardy on 9/11/19 at 3:57 p.m. The immediate jeopardy was removed on 9/13/ 2019, but non-compliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: Review of a facility reported incident on 9/11/2019 at 11:30 a.m., indicated Resident B was found outside of the facility's secured (Crestwood) unit, on 9/3/19. Resident B's clinical record was reviewed on 9/11/19 at 11:45 p.m. [DIAGNOSES REDACTED]. Medications included, but were not limited to, [MEDICATION NAME] (blood pressure medication) 25 mg twice daily, [MEDICATION NAME]-[MEDICATION NAME] (blood pressure medication) 20-12.5 mg once daily, and [MEDICATION NAME] (antipsychotic medication) 0.5 mg once daily. She had current physician orders [REDACTED]. She was to reside in the Secured Unit. A 6/26/19, annual, Minimum Data Set (MDS) assessment indicated she was severely cognitively impaired, had hallucinations, and ambulated independently. She had a current, 2/18/19, care plan problem of risk for falling, with her last fall having occurred on 6/28/19. She had a current, 8/9/17, care plan problem of confusion and forgetfulness, related to dementia. She had a current, 8/9/17, care plan problem of risk for elopement due to Alzheimer's/Dementia. She would state she needed to go home, and would go up and down the hallway, looking for a way out. She would push on doors, to get them to open because she wanted to go home. Interventions included, but were not limited to, 15 minute checks (started 9/3/19), when staff was leaving Crestwood doors, ensure the doors had locked before walking away from the doors (started 2/4/19), and notify MD and family of an increase in agitation or exit seeking behavior. An 8/29/19 Weekly Summary indicated she was alert and confused, with a poor memory. A 9/1/19 progress note indicated she had been having hallucinations and delusions throughout the evening, carrying a baby and voicing she was not putting up with any nonsense. Later in the shift, she was fidgeting with a doll, and wandering in and out of other resident's rooms, and talking to unseen people between 11:07 p.m. and 11:49 p.m. A 9/3/19 progress note indicated a head to toe assessment had been completed with no injury noted. There was no indication in the clinical record the resident had been found outdoors. A 9/4/19 progress note indicated a late entry for 9/3/19 of POA and PCP being notified of being located outside of the Crestwood unit. A 9/4/19 progress note indicated at 4:57 a.m., she had been up all night, pacing up and down the hallway and talking to herself. She pushed on a door, which did not open, so she went to another door, but did not push on it. A 9/4/19 progress note indicated she had been exit seeking a large amount of the shift. During an interview, on 9/11/19 at 11:57 a.m., the ADON indicated Resident B had left the secure unit, via the east end door, had gone down the stairwell, and exited out the facility via the ground floor door. She was found outside of the fenced courtyard, weeding the plants. She had been unaccounted for, for approximately a total of 1 hour and 15 minutes. During an interview, on 9/11/19 at 1:58 p.m., with the ADON and Administrator, the Administrator indicated the east-end Crestwood door had not been operating properly at the time of the elopement. The green light would come on to indicate it was locked, but the door would not always latch shut- it had to be pulled closed to ensure it latched completely. The facility had a door check procedure in place, but they had discovered it had not been completed by the staff member responsible for it. The resident had been known to push at the doors. A door repair company had been in to look at the doors, but had not found anything major wrong with it, and only needed to make some minor adjustments to have it close better. During an interview, on 9/11/19 at 2:09 p.m., the Administrator indicated she was not sure how long the door had not been closing properly. Review of a 9/4/19 Door Repair Company Work Order document, indicated the stair well door Chexit device/power supply (door hardware to lock and alarm the door) needed checked. A new Chexit device key switch had been ordered and would be replaced when it arrived. Review of a 9/10/19 Door Repair Company Work Order indicated the electric panic device was not locking properly at the end of the Crestwood Hall. The Chexit device in the panic bar had been replaced, as well as the power supply in the ceiling. Review of statements from the facility investigation, provided by the Administrator on 9/11/19 at 2:09 p.m., indicated the following : A 9/4/19 statement, from Maintenance Assistant 4, indicated around 8:00 p.m., or a little after, on 9/3/2019 someone asked if she had seen Resident B. She had then entered the sitting area across from the nurses station, looked out the window and saw Resident B outside. She had then left the unit, entered the Healthcare unit, and ran down the 200 Hall to assist the resident back inside the facility. A 9/6/19 statement from CNA 7 indicated she had been pulled from Healthcare to Crestwood, and worked with CNA 10, until 6:30 p.m., when she had left following supper. CNA 7 had began looking for the resident after 7:00 p.m., but before 8:00 p.m. She had begun checking other rooms and let the nurse know. She mentioned to the Maintenance Assistant she had been looking for the resident, and the Maintenance Assistant saw her in the courtyard. During an interview, on 9/11/19 at 3:08 p.m., CNA 14 indicated she was aware of the door not latching in the past. It would not always securely latch, she would call maintenance, and when they looked at it, it checked out okay. During an interview, on 9/11/19 at 3:52 p.m., Maintenance Assistant 4 indicated she had not been aware of the door not latching properly. She had been on the unit in order to lock the door under the elevator. CNA 7 asked her if she had seen Resident B, she told her she hadn't seen her, and proceeded to continue working. After she was done, she looked out the windows across from the nurses station, and saw the resident outside, near the door to enter the 200 Hall, where she had been picking weeds. During an interview, on 9/11/19 at 3:58 p.m., LPN 21 indicated she was not aware the door did not latch, but one of the other staff members had told her the doors had failed to latch in the past. The resident had tried to exit before, a couple days or a week before, when she had tried several times to get out the door. On the day the resident was found outside, the Maintenance Assistant had observed her and then ran to get to her. LPN 21 and another staff member went outside to catch her attention until the Maintenance Assistant reached her. Review of a Crestwood Door Checks document indicated on 9/3/19, the doors were to be checked to make sure to close and lock the door if necessary. The door was signed off as being checked at 9:15 a.m. and 2:30 p.m., by CNA 10. An untimed notation indicated a resident got out on 2nd shift. Review of a surveillance video, on 9/12/19 at 10:20 a.m., accompanied by the Administrator, indicated CNA 10 approached the end of the hallway, in the direction of the door at 8:35 a.m., but had not physically checked the door as of 9:40 a.m. At 6:45 p.m., Resident B approached the east end door, and exited through it at 6:46 p.m. During the observation of the video, the Administrator indicated CNA 10 had not been viewed on the video as having physically checked the door in the afternoon, although she had signed off as having done it. Review of a phone statement from CNA 10, signed by the ADON on 9/4/19, indicated CNA 10 was interviewed on 9/4/19 at 2:00 p.m. She had informed the ADON and Administrator she did not remember if she had physically checked the Crestwood doors to ensure they were locked. The CNA did not report for her next scheduled shift. Observation of the east end stairwell and area outside of the Crestwood unit, at 9/12/19 at 2:15 p.m., accompanied by[NAME] Maintenance Director, indicated the following: There were eight standard steps down to the first landing, then nine more standard steps to the ground floor landing, with a small entry way and door, leading to the outside. Outside of the exit door, there was a slab landing with mulch surrounding the eastern edge of it. To the southwest (right) of the landing, a road was visible, with condominiums visible past the road and a parking lot adjacent to it. Directly in front of the landing, past a small grassy area, there was a private road, with a larger grassy area on the other side of it, then a highway, which the Maintenance Director identified as State Road 13. He indicated immediately to the left/behind the landing, it was approximately 75 feet to the bi-level retaining wall garden, with the fence visible above it, surrounding the facility courtyard. The yard outside of the retaining wall was observed with areas of dry dirt, covered with straw, grass, and sprinklers spraying the straw areas. There was a slight incline leading to the retaining wall, and an increase in the incline toward the raised ramp leading to the 200 Hall door. Review of a current, 5/8/19 policy, revised 6/19 and 9/4/19, titled CRESTWOOD DOOR POLICY, and provided by the Administrator on 9/11/19 at 2:14 p.m., indicated resident living on the secured unit would be safe from potential hazards by ensuring all essential doors and locking mechanisms were in proper working condition. All exterior doors were to be kept closed and locked at all times. All exterior doors and fire doors were to be checked daily, once each shift. Problems with doors were to be reported to maintenance staff according to CW (Crestwood) Door Check Tool, dated 6/2019. Unauthorized exits by residents would be reported to the Administrator and/or DON immediately. Review of a current facility policy, titled Health Care and Crestwood Emergency Disaster Plan, dated 11/1/17 and provided by the Administrator on 9/12/19 at 11:11 am., indicated the facility would establish effective security measures to ensure the safety of the residents and prevention of possible exit by a confused resident. Key personnel would receive sufficient training to respond to a missing resident. Prevention of a missing resident included, but was not limited to, al exit doors and stairway doors were to be equipped with alarm systems. Staff were to respond immediately when an alarm sounded. Photographs of residents who were at risk for elopement would be kept in a .Person of Interest Binder . located at the Health Care desk, Crestwood nurses station, Residential nurses station, front desk, and the offices of the Dietary Supervisor, Maintenance Director, and Director of Housekeeping and Laundry Services. Residents who have attempted to wander off their unit and/or from the building would be provided with a Wander Guard bracelet. The immediate jeopardy that began on (MONTH) 3, 2019, was removed on (MONTH) 13, 2019 when the facility began inservicing staff on the facility's elopement procedure and Crestwood door procedures and began updating their elopement binders, but non-compliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy, because the inservicing had not been completed for all staff and monitoring to ensure staff was following the plan was completed. 3.1-45(a)

Based on observation, interview and record review, the facility failed to prevent the development of an unstageable pressure ulcer for 1 of 1 residents reviewed for pressure ulcer. This deficient practice resulted in an unstageable pressure ulcer on the foot for the resident (Resident 10). Findings include: A record review, on 9/29/17 10:52 a.m., indicated Resident 10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician order, dated 4/11/14, indicated the resident was to have weekly nursing assessments on Fridays. An MDS (Minimum Data Set) assessment, dated 8/9/17, indicated the resident required extensive assistance by two staff members for bathing, dressing and mobility. There was no pressure ulcer noted in the assessment. A care plan focus dated, 9/22/17, indicated the resident acquired a deep tissue injury on the left lateral foot. Interventions included but were not limited to: apply [MEDICATION NAME]-iodine pad daily, monitor and record any complaints of pain, monitor and report any signs or symptoms of infection and no shoes. A nursing note, dated 9/22/17 at 5:08 p.m., indicated a deep tissue injury found to the left lateral foot. The pressure area was noted to be in the area where the leather of her shoe was thicker and reinforced. The spouse was in the room and he voiced the shoes were donated to the resident by the facility. The note referred to the wound as both a pressure ulcer and a deep tissue injury. A wound assessment worksheet, dated 9/22/17, indicated a wound to the left lateral foot. The wound was unstageable, 0.6cm x 0.3cm x 0, wound base was brown/black, no drainage, no odor, the peri-area was [DIAGNOSES REDACTED]tous (reddened) and [MEDICAL CONDITION] (swollen) and the area was tender to the touch. A physician order, dated 9/23/17, indicated the resident was to receive an application of [MEDICATION NAME]-iodine pad daily for the unstageable pressure injury to the left foot. This order was clarified on 9/28/17 as a treatment for [REDACTED]. A nursing note, dated 9/25/17 at 4:00 p.m., indicated the unstageable pressure was being changed to a deep tissue injury. A nursing note, dated 9/29/17 at 5:00 p.m., indicated the resident received a pair of shoes donated by the facility on 11/8/13. The SSD followed up with the Resident's husband and informed him the resident was now wearing moccasins that did not apply any pressure. A wound assessment worksheet, dated 10/2/17, indicated a wound to the left lateral foot. The wound was unstageable, 1cm x 0.5cm x 0, wound base was brown/black, no drainage, no odor and the peri area was [DIAGNOSES REDACTED]tous and [MEDICAL CONDITION]. Weekly Nursing Summary dates completed were as follows: 6/3/17, 6/16/17, 6/30/17, 7/28/17, 9/10/17 and 9/22/17. During this time period reviewed, from 6/1/17 through 10/4/17 there were 19 weekly summaries not completed. During an observation of the resident with Employee 35, on 10/2/17 at 1:30 p.m., an irregular shaped wound, approximately the size of a small kidney bean, was observed to her left lateral foot. During this observation the skin was intact (closed). The wound bed was dark purple and black in color with reddening and swelling around the area approximately the size of a half dollar coin. Employee 35 asked the resident if it was tender to the touch and the resident shook her head yes. Employee 35 indicated the area looked a little bigger and the redness had spread. An interview with the DON, on 9/29/17 at 1:50 p.m., indicated the nurses were to do a weekly skin assessment during the weekly summary. An interview with Employee 38, on 10/2/17 at 10:36 a.m., indicated the CNA's (Certified Nursing Assistant) were to do a skin check with all care and during showers. They report any concerns to the nurses and the nurses would do a skin assessment. The nurses were to do a complete skin assessment weekly and document it in the weekly summary. An interview with the DON, on 10/4/17 at 8:32 a.m., indicated there were no other weekly summaries to provide. On 10/2/17 at 10:56 a.m., the DON provided a copy of a policy titled Skin Assessment Wound Evaluation. This policy indicated 2. In addition to daily observations of the resident's skin by the nursing staff, a Licensed Nurse will be assigned to complete an assessment of every residents' skin at least weekly as completed on the Weekly Nursing Summary 3.1-40(a)