Every finding on record at Waters of Huntington Skilled Nursing Facility, The

Based on observation, interview, and record review, the facility failed to ensure infection control practices were maintained for shared bathroom space, including toilets and bed pans, for 1 of 3 residents reviewed for infection control. (Resident B)Findings include:During an observation, on 7/28/26 at 9:38 a.m., Resident B's shared bathroom had a bedpan stored directly on the floor between the sink and the wall. A rolled-up, wet pair of underwear was on the left sink ledge. Three non-skid white strips in front of the toilet had numerous small areas of dark brown dried stains. A dried dark yellow substance was present to the toilet seat riser. Inside Resident B's armoire, located behind her door, an uncovered bedpan was stored directly on the second shelf.During an interview, on 7/28/26 at 9:45 a.m., QMA 3 indicated bedpans should not be stored directly on the floor and should be covered with a bag. The three non-skid strips appeared to have dried feces on them.During an interview, on 7/28/26 at 9:47 a.m., LPN 4 indicated the bedpan was directly on the floor. Bedpans should always be placed in a bag and the non-skid strips needed to be removed and replaced.During an interview, on 7/28/26 at 9:50 a.m., Housekeeping Aid 5 indicated there was a pair of wet underwear on the sink ledge next to the faucet handle, a bedpan located on the floor between the sink and the wall, and dried urine was on the toilet seat riser.During an interview, on 7/28/26 at 9:55 a.m., CNA 6 indicated bedpans should not be placed directly on the floor or dressers. They should be covered with a plastic bag. Dark brown spots were on the non-skid strips in front of the toilet.During an interview, on 7/29/26 at 9:00 a.m., the ADON indicated bedpans should be stored in plastic bags.A current facility policy, dated 12/21/23, titled Guidelines for Washing/Cleaning Bedpans and Urinals, provided by the Corporate Nurse Consultant, on 7/28/26 at 2:28 p.m., indicated the following: .12. Bedpans, or urinals should be stored in a clean, disposable bag of some type between uses 410 Indiana Administrative Code 16.2-3.1-18(a)

Based on interview and record review, the facility failed to ensure a resident with a known full code status (cardiopulmonary resuscitation [CPR] to be performed) received the appropriate emergency services as evidenced by a nurse (LPN 1) with an expired CPR certification starting CPR without a physical assessment, ceasing CPR without a medical evaluation, and failing to notify emergency services when the resident was found not breathing and without a heart rate for 1 of 3 residents reviewed for death. (Resident B). This deficient practice resulted in the facility's failure to provide CPR for Resident B during a medical event that resulted in death.The immediate jeopardy began on [DATE] when the facility failed to provide CPR as indicated by professional standards to a resident with a full code status who experienced a medical event resulting in death. The Administrator, Regional Operations Consultant, and Regional Nursing Consultant were present when informed of the immediate jeopardy on [DATE]. The immediate jeopardy was removed on [DATE], but noncompliance remained at the lower scope and severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include:Residents B's clinical record was reviewed on [DATE] at 11:59 a.m. Diagnoses included abdominal aortic aneurysm, chronic obstructive pulmonary disease, emphysema, hypertension, anorexia, vascular implants and chronic kidney disease.A physician order, dated [DATE], indicated an order for full code status.Review of the most current admission Minimal Data Set (MDS) assessment, dated [DATE], indicated the resident was cognitively intact.A care plan, dated [DATE], indicated the resident elected to be a full code.A progress note, dated [DATE] at 1:47 a.m. and written by LPN 1, indicated Resident B's oxygen saturation levels were 82%. A breathing treatment was started to see if it would help, but it did not. The resident's oxygen saturation dropped to 75% while on the breathing treatment. The resident's mouth was open, and they were very pale. The resident stopped breathing, and a heartbeat could not be heard. Chest compressions were started while the QMA was lowering the head of bed. Time of death was 1:55 a.m. on [DATE], after two rounds of chest compressions.The clinical record lacked documentation of notification to the physician/nurse practitioner of the resident's change in condition.The clinical record lacked documentation of emergency services being notified.An Event Note, dated [DATE] at 5:14 a.m. and written by LPN 1, indicated three rounds of compressions were completed, not two. The funeral home was called and arrived at 4:30 a.m. The nurse practitioner and Director of Nursing (DON) were notified. Per the resident's request, no family was called. During an interview on [DATE] at 6:08 p.m., LPN 1 indicated, on [DATE] during the night shift, she received a call from QMA 2, who was working on the secured unit, stating Resident B was not doing well. The secured unit had one CNA and one QMA working at the time. LPN 1 was the only nurse working, and was scheduled for the other units. LPN 1 indicated the resident had labored breathing and was pale. LPN 1 started a breathing treatment because that is what the Nurse Practitioner (NP) usually did, then she called the NP. QMA 2 stayed with the resident while LPN 1 went to prepare paperwork to send the resident out to the hospital. About halfway through the breathing treatment, the resident stopped breathing. LPN 1 indicated the resident was gone. She did three rounds of CPR, each consisting of 30 compressions. LPN 1 checked the resident again and found no breathing and no heart rate. LPN 1 indicated she thought the incident had lasted 20 minutes. She called the NP from the room using her personal phone and told her what she had done. The NP told her to stop the compressions/CPR. LPN 1 indicated she had a current CPR certification at the time of the incident. LPN 1 then indicated she would take the CPR class next week and was not sure if her certification had been current at the time of the incident. LPN 1 indicated she should have called for emergency services.During an interview on [DATE] at 9:30 a.m., the Nurse Practitioner (NP) indicated she had received three text messages from LPN 1 on [DATE]. The first message was at 1:23 a.m., and indicated Resident B was not doing well and the nurse was going to send the resident to the hospital. She was told QMA 2 was administering a breathing treatment. The resident's oxygen level was 86%. Staff were unable to get a blood pressure, even manually. The second message was at 1:38 a.m., indicating LPN 1 was sending the resident to the hospital. The third message was at 1:56 a.m., with LPN 1 indicating the chest compressions did not work and the resident had expired. The resident was not being sent to the hospital. During the interview, the NP indicated a breathing treatment is what she would have usually ordered in that situation. However, she was unaware the resident did not already have an order for breathing treatments. The NP did give an order for breathing treatments. The NP did not give an order to stop CPR.During an interview on [DATE] at 10:06 a.m. QMA 2 indicated she usually worked the night shift on the secured unit. She had gone to Resident B at around 10:30 p.m. and provided colostomy care. The QMA left the resident to get the supplies. When she returned, the resident was not really responding in his normal manner. CNA 4 was present and they were trying to get the resident to respond. LPN 1 was notified. The resident started to respond, and the QMA and CNA completed the care. Two hours later, the resident was not acting like his normal self and told the QMA repeatedly to sit him up. The resident denied difficulty breathing. QMA 2 called for LPN 1 again, gave her the resident's vital signs, and told her she thought the resident should be sent out. LPN 1 came to look at the resident and asked if the resident had a breathing treatment order. QMA 2 indicated she did not know if the resident had a breathing treatment order or not. LPN 1 indicated she was going to call the NP to see what she wanted them to do and told the QMA to go ahead and get a breathing treatment for the resident. QMA 2 indicated she got a nebulizer machine and an albuterol (bronchodilator) ampule. The resident did not have an order for albuterol, so QMA 2 took the medication from another resident. QMA 2 was unable to remember the name of the other resident. The QMA administered the medication. CNA 4 brought the vital signs machine and the QMA took vital signs while the breathing treatment was being administered. Approximately five minutes into the breathing treatment, QMA 2 noticed there was no rise or fall to the resident's chest. QMA 2 left the resident alone to find LPN 1and told her they needed to start CPR. The QMA adjusted the bed. LPN 1 started compressions. LPN 1 indicated she felt and heard a rib crack. LPN 1 asked QMA 2 if she thought that was resident's last breath. QMA 2 said probably. LPN 1indicated she was going to call it (end the code). LPN 1 stopped the compressions and said she was going to start making phone calls. QMA 2 indicated LPN 1 did not call the NP from the resident's room. QMA 2 indicated she had a current CPR certification. QMA 2 indicated she gave the albuterol breathing treatment because the nurse told her to.CNA 4 was unable to be reached for interview during the survey.During an interview on [DATE] at 1:29 p.m., the ADON indicated, in an emergency situation, she would call the health care provider on the phone. She would not text the provider. The resident would be assessed, and CPR would be initiated if appropriate until Emergency Medical Services (EMS) arrived to take over.During an interview on [DATE] at 1:36 p.m. LPN 5 indicated, in an emergency, she would first make sure the resident was alright. If the resident was not breathing, the code status would be confirmed. If they were a full code, someone would call 911 while CPR was initiated. They would never stop CPR until the EMS could take over. The medical provider should not be contacted via text message, but should be called on the telephone.Review of LPN 1's CPR certification on [DATE] at 8:36 a.m., from the American Heart Association Basic Life Support (CPR and AED) program was dated [DATE], with an expiration date of [DATE]. A new Certificate of Completion for Standard - CPR/AED, dated [DATE], lacked a hands-on component consistent with American Heart Association guidance.Review of QMA 2's CPR certification on [DATE] at 8:36 a.m., dated [DATE], lacked a hands-on component consistent with American Heart Association guidance.A current facility policy, dated [DATE] and titled Medical Emergencies That Require Immediate Response/Assessment was provided by the Corporate Clinical Consultant on [DATE] at 2:47 p.m. and indicated the following: . These symptoms must be reported immediately to the nurse in charge for evaluation and assessment. The nurse responds immediately and will determine if the resident requires further evaluation and treatment in an acute care setting. The nurse will notify the doctor and the resident's responsible party of the onset of these medical conditions for direction. If there is an emergent situation, the nurse will call 911 for EMS transport unless clearly defined by order and responsible party's direction not to do so --- such as in an actively dying resident.Review of American Heart Association's Resuscitation Education Science guidance, retrieved from https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines/executive-summary indicated the following: .Part 12 of the 2025 Guidelines, Resuscitation Education Science, includes recommendations about various instructional design features in resuscitation training, including CPR feedback devices, rapid-cycle deliberate practice, scripted debriefing, gamified learning, spaced learning and booster training, teamwork and leadership training, manikin fidelity, virtual and augmented reality, and the use of cognitive aids. Recommendations for these instructional design elements have been split into those for health care professionals and those for lay rescuers. The immediate jeopardy that began on [DATE] was removed on [DATE] when the facility completed education with nursing staff regarding emergency response protocols and policies, but the noncompliance remained at the lower scope and severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because LPN 1 and QMA 2 remained without current CPR certification according to professional standards. This citation relates to Intake 2671519.

Based on interview and record review, the facility failed to ensure nursing staff provided care within their scope of practice as evidenced by LPN 1 giving medication orders for a nebulizer (breathing) treatment to QMA 2 without a physician order, QMA 2 administered the nebulizer treatment, staff failed to initiate emergency medical services, and LPN 1 made the determination to end CPR activities without indication. (Resident B) This deficient practice resulted in a delay in emergency medical treatment for a resident experiencing a change in condition that resulted in death. Findings include:Residents B's clinical record was reviewed on [DATE] at 11:59 a.m. Diagnoses included abdominal aortic aneurysm, chronic obstructive pulmonary disease, emphysema, hypertension, anorexia, vascular implants and chronic kidney disease.A physician order, dated [DATE], indicated an order for full code status.Review of the most current admission Minimal Data Set (MDS) assessment, dated [DATE], indicated the resident was cognitively intact.A care plan, dated [DATE], indicated the resident elected to be a full code.The clinical record lacked documentation of notification to the physician/nurse practitioner of the resident's change in condition.The clinical record lacked documentation of emergency services being notified.A progress note, dated [DATE] at 1:47 a.m. and written by LPN 1, indicated Resident B's oxygen saturation levels were 82%. A breathing treatment was started to see if it would help, but it did not. The resident's oxygen saturation dropped to 75% while on the breathing treatment. The resident's mouth was open, and they were very pale. The resident stopped breathing, and a heartbeat could not be heard. Chest compressions were started while the QMA was lowering the head of bed. Time of death was 1:55 a.m. on [DATE], after two rounds of chest compressions.An Event Note, dated [DATE] at 5:14 a.m. and written by LPN 1, indicated three rounds of compressions were completed, not two. The funeral home was called and arrived at 4:30 a.m. The nurse practitioner and Director of Nursing (DON) were notified. Per the resident's request, no family was called. During an interview on [DATE] at 6:08 p.m., LPN 1 indicated, on [DATE] during the night shift, she received a call from QMA 2, who was working on the secured unit, stating Resident B was not doing well. The secured unit had one CNA and one QMA working at the time. LPN 1 was the only nurse working, and was scheduled for the other units. LPN 1 indicated the resident had labored breathing and was pale. LPN 1 started a breathing treatment because that is what the Nurse Practitioner (NP) usually did, then she called the NP. QMA 2 stayed with the resident while LPN 1 went to prepare paperwork to send the resident out to the hospital. About halfway through the breathing treatment, the resident stopped breathing. LPN 1 indicated the resident was gone. She did three rounds of CPR, each consisting of 30 compressions. LPN 1 checked the resident again and found no breathing and no heart rate. LPN 1 indicated she thought the incident had lasted 20 minutes. She called the NP from the room using her personal phone and told her what she had done. The NP told her to stop the compressions/CPR. LPN 1 indicated she had a current CPR certification at the time of the incident. LPN 1 then indicated she would take the CPR class next week and was not sure if her certification had been current at the time of the incident. LPN 1 indicated she should have called for emergency services.During an interview on [DATE] at 9:30 a.m., the Nurse Practitioner (NP) indicated she had received three text messages from LPN 1 on [DATE]. The first message was at 1:23 a.m., and indicated Resident B was not doing well and the nurse was going to send the resident to the hospital. She was told QMA 2 was administering a breathing treatment. The resident's oxygen level was 86%. Staff were unable to get a blood pressure, even manually. The second message was at 1:38 a.m., indicating LPN 1 was sending the resident to the hospital. The third message was at 1:56 a.m., with LPN 1 indicating the chest compressions did not work and the resident had expired. The resident was not being sent to the hospital. During the interview, the NP indicated a breathing treatment is what she would have usually ordered in that situation. However, she was unaware the resident did not already have an order for breathing treatments. The NP did give an order for breathing treatments. The NP did not give an order to stop CPR.During an interview on [DATE] at 10:06 a.m. QMA 2 indicated she usually worked the night shift on the secured unit. She had gone to Resident B at around 10:30 p.m. and provided colostomy care. The QMA left the resident to get the supplies. When she returned, the resident was not really responding in his normal manner. CNA 4 was present and they were trying to get the resident to respond. LPN 1 was notified. The resident started to respond, and the QMA and CNA completed the care. Two hours later, the resident was not acting like his normal self and told the QMA repeatedly to sit him up. The resident denied difficulty breathing. QMA 2 called for LPN 1 again, gave her the resident's vital signs, and told her she thought the resident should be sent out. LPN 1 came to look at the resident and asked if the resident had a breathing treatment order. QMA 2 indicated she did not know if the resident had a breathing treatment order or not. LPN 1 indicated she was going to call the NP to see what she wanted them to do and told the QMA to go ahead and get a breathing treatment for the resident. QMA 2 indicated she got a nebulizer machine and an albuterol (bronchodilator) ampule. The resident did not have an order for albuterol, so QMA 2 took the medication from another resident. QMA 2 was unable to remember the name of the other resident. The QMA administered the medication. CNA 4 brought the vital signs machine and the QMA took vital signs while the breathing treatment was being administered. Approximately five minutes into the breathing treatment, QMA 2 noticed there was no rise or fall to the resident's chest. QMA 2 left the resident alone to find LPN 1and told her they needed to start CPR. The QMA adjusted the bed. LPN 1 started compressions. LPN 1 indicated she felt and heard a rib crack. LPN 1 asked QMA 2 if she thought that was resident's last breath. QMA 2 said probably. LPN 1indicated she was going to call it (end the code). LPN 1 stopped the compressions and said she was going to start making phone calls. QMA 2 indicated LPN 1 did not call the NP from the resident's room. QMA 2 indicated she had a current CPR certification. QMA 2 indicated she gave the albuterol breathing treatment because the nurse told her to.CNA 4 was unable to be reached for interview during the survey.During an interview on[DATE] at 1:29 p.m., the ADON indicated, in an emergency situation, she would call the health care provider on the phone. She would not text the provider. The resident would be assessed, and CPR would be initiated if appropriate until Emergency Medical Services (EMS) arrived to take over.During an interview on [DATE] at 1:36 p.m. LPN 5 indicated, in an emergency, she would first make sure the resident was alright. If the resident was not breathing, the code status would be confirmed. If they were a full code, someone would call 911 while CPR was initiated. They would never stop CPR until the EMS could take over. The medical provider should not be contacted via text message, but should be called on the telephone.Review of LPN 1's CPR certification on [DATE] at 8:36 a.m., from the American Heart Association Basic Life Support (CPR and AED) program was dated [DATE], with an expiration date of [DATE]. A new Certificate of Completion for Standard - CPR/AED, dated [DATE], lacked a hands-on component consistent with American Heart Association guidance.Review of QMA 2's CPR certification on [DATE] at 8:36 a.m., dated [DATE], lacked a hands-on component consistent with American Heart Association guidance.Review of the Indiana Nurse Practice Act, retrieved from https://www.in.gov.doe.files, indicated the following: . 3. Nursing behaviors (acts, knowledge, and practices) failing to meet the minimal standards of acceptable and prevailing nursing practice, which could jeopardize the health, safety, and welfare of the public, shall constitute unprofessional conduct. These behaviors shall include, but are not limited to, the following: (1) Using unsafe judgment, technical skills, or inappropriate interpersonal behaviors in providing nursing care. (2) Performing any nursing technique or procedure for which the nurse is unprepared by education or experience. (11) Diverting prescription drugs for own or another person's use.Review of the current Indiana QMA Scope of Practice, retrieved from https://www.in.gov/health/ltc/aide-training-and-certification/qma/ indicated the following: .The following tasks shall NOT be included in the QMA scope of practice:. (2) Administer medication used for intermittent positive pressure breathing (IPPD) treatments or any form of medication inhalation treatments, such as nebulizers. A current facility policy, dated [DATE] and titled Medical Emergencies That Require Immediate Response/Assessment, provided by the Corporate Clinical Consultant on [DATE] at 2:47 p.m., indicated the following: . These symptoms must be reported immediately to the nurse in charge for evaluation and assessment. The nurse respond immediately and will determine if the resident requires further evaluation and treatment in an acute care setting. The nurse will notify the doctor and the resident's responsible party of the onset of these medical conditions for direction. If there is an emergent situation, the nurse will call 911 for EMS transport unless clearly defined by order and responsible party's direction not to do so --- such as in an actively dying resident.This citation relates to Intake 2671519.3.1-14(i)

Based on observation, interview, and record review, the facility failed to ensure the high-temperature dishwasher functioned at a level to maintain proper sanitization requirements. This deficient practice had the potential to impact 58 of 58 residents who received meals from the facility kitchen. Findings include:During the initial kitchen tour, on 7/21/25 at 9:30 a.m., the following concerns regarding inaccurate high temperature dishwashing were observed:The high temperature dishwashers washing temperature was 126 degrees Fahrenheit (F) instead of the requirement of 160 degrees F or higher.During an interview, on 7/21/25 at 9:50 a.m., the Dietary Manager indicated the thermostat was replaced on Friday. Even though the wash temperature was below the indicated temperature, she felt it was safe to use as she was pouring sanitizing chemical into the dishwasher. She poured a small cup of pink chemical sanitizer into the dishwasher before running the machine. After it ran, she tested the water with a chemical strip that indicated improper sanitization was completed.On 7/21/25 at 9:57 a.m., the Maintenance Director indicated he replaced the thermostat on Friday 7/19/25. He thought the thermostat was preset and did not run the dishwasher to verify the dishwasher reached the appropriate temperature.A current facility policy, dated 2017, titled, Dishwashing: Machine, provided by the administrator, on 7/25/25 at 4:24 p.m., indicated the following: .2. Check to ensure that the wash and rinse cycles are achieving proper temperature per manufacture guidelines. If a chemical sanitizer is used, check the concentration using the correct strip. Refer to the guidelines on the dish machine log for acceptable temperatures for hot water temperature, or the proper sanitizing concentration, do not proceed to wash dishes. Corrective action must be taken.3.1-21(i)(3)

A. Based on observation and interview, the facility failed to ensure narcotic medication was appropriately identified, labeled and stored. This deficient practice had the potential to affect 1 of 58 residents who resided in the facility.B. Based on observation, record review, and interview, the facility failed to ensure medications were labeled for 1 of 2 medication carts observed. This deficient practice had the potential to affect 15 of 15 residents who received medications from the secured unit medication cart Findings include:A. During a medication storage observation of the South medication cart, on 7/22/25 at 11:35 a.m., accompanied by QMA 7, the following was observed: Four white pills were in a plastic medication sleeve labeled with Resident 32's name, a.m. and p.m. The pills were oblong; the medication was scored and had markings M365. The name of the medication was not marked on the plastic sleeve. QMA 7 indicated Resident 32 had gone out for a leave of absence (LOA) with her representative. The facility dispensed 10 hydrocodone- acetaminophen (opiate pain medication) 5/325 milligram pills into the plastic mediation sleeve for her to take during her LOA. On 7/22/25 at 12:20 p.m., the DON indicated Resident 32 went on a LOA for five days accompanied by her representative. When Resident 32 returned from her leave, there were four pills remining in the plastic sleeve. The facility accepted the remaining pills, filled out a Controlled Substance Record report and placed the medications into the narcotic lock box. The Controlled Substance Record report was missing the resident identification. The DON indicated the paper should have been filled out accurately with the resident's name on the form and the medication should have been destroyed. On 7/23/25 at 2:18 p.m., LPN 8 indicated she did not place a resident identifier on the Controlled Substance Report form. She did not verify the medication before accepting the medication and placing it in the narcotic lock box. When loose medication were brought back into the facility, they should be destroyed. B. During an observation, on 7/25/25 at 9:38 a.m., the medication cart on the secured unit contained two unlabeled medications in Resident 27's section in the second drawer. The medications were a bottle of extra strength acetaminophen (Tylenol) tablets and a bottle of acidophilus probiotic tablets. Resident 43's section contained an unlabeled bottle with Vitamin D3 2000 IU (50 mcg). An opened bottle of nystatin (antifungal) powder approximately one half full without a resident identifier was in the treatment drawer. During an interview, at the same time of the observation, QMA 17 indicated the bottles should be labeled with the resident's name, an expiration date, and when opened. She did not know to whom the bottle of nystatin belonged. Resident 27's clinical record was reviewed on 7/28/25 at 2:38 p.m. The current orders included acetaminophen 325 mg – two tablets every day (5/30/25). The record lacked an order for an acidophilus probiotic. Resident 43's clinical record was reviewed on 7/28/25 at 2:39 p.m. The current orders included cholecalciferol 50 mcg daily (7/11/25). During an interview, on 7/28/25 at 9:44 a.m., LPN 6 indicated medications should be labeled with the resident's name, the physician, the name of the medication, the open date, and the directions (order). During an interview, on 7/28/25 at 9:48 a.m., the ADON indicated medications should be labeled with the resident's name, the physician's name, the date opened, the actual order and if the medication is an as needed medication (PRN). A current facility policy, titled Medication Storage in The Facility, provided by the DON, on 7/22/25 at 3:31 p.m., indicated the following: .Policy: Medications and biologicals are stored safely, securely, and properly following the manufacture or supplier recommendations. A current facility policy, dated 3/2023, provided by the DON on 7/23/25 at 2:16 p.m., titled 1.10:NONCONTRACTED PHARMACY FACILITY AGREEMENT, indicated the following: .Nonprescription medications without a prescription label are in the manufacturer's original container and labeled with the resident's name. 3.1-25(j) 3.1-25(k)

Based on interview and record review, the facility failed to promote residents' rights to make choices regarding taking leave of absence within the local community and failed to assess residents for their ability to make such determinations before restricting leave of absence for 2 of 2 residents reviewed for self-determination. (Residents 1 and 34). During a Resident Council group interview, on 7/24/25 at 1:33 p.m., Resident 34 indicated she had concerns and questions about why she and another resident were no longer allowed to leave the facility property on their motorized scooters.During an interview with the Administrator on 7/24/25 at 2:15 p.m., she indicated there was an incident with a resident on a motorized scooter. The resident(s) had done something they should not have and caused an incident. The incident happened before the Administrator was employed by the facility. She did not know more about what happened.During an interview with the Social Services Director (SSD) on 7/24/25 at 2:47 p.m., she indicated motorized scooters were owned by Residents 1 and 34. There were two incidents where Resident 1 went to a nearby Dairy Queen and a gas station. The sidewalks were uneven, and she almost tipped over. Resident 1 was educated about not taking the scooter to unsafe areas. The SSD received calls from people in the community saying the residents on the scooters were almost hit by cars. Both Resident 1 and 34 were cognitively intact. The SSD lacked documentation about the incidents and/or interviews with community members.During an interview with the DON on 7/24/25 at 3:02 p.m., she indicated she did not have documentation of where or when the incidents on the motorized scooters occurred. Both residents were cognitively intact.A review of Resident Council minutes, provided by the Activities Director (AD) on 7/28/25 at 11:04 a.m., indicated both Resident 1 and 34 were educated on 6/4/25 about the safety of going to the gas station or leaving the property without supervision. Education was again provided on 7/2/25 about safety and motorized scooters and the importance of safety in the community. Effective 7/2/25, motorized scooters were no longer allowed off of the facility property.Resident 1's clinical record was reviewed on 7/23/25 at 4:02 p.m. Diagnoses included type 2 diabetes mellitus, anxiety disorder, hypertension, overactive bladder, osteoarthritis, GERD, and muscle weakness.A quarterly Minimum Data Set (MDS) assessment, dated 7/10/25, indicated the resident was cognitively intact and used a wheelchair due to impairment on one side of both her upper and lower extremities.A current care plan, dated 7/2/25, indicated the resident had been educated on motorized wheelchair not to be used on the road(s). She was educated that she could go outside but not leave the property without supervision. Interventions included: Educate (the resident) on the importance of maintaining a safe environment free of potential fall hazards, let the resident know the facility can transport to where she wanted to go, or family could be contacted to transport the resident if needed.A Social Services note, dated 6/4/25, provided by the SSD on 7/25/25 at 4:02 p.m., indicated the following: .(Resident 1) was educated on motorized wheelchair not for on- the-road use. Resident (1) educated that she may go outside but not leave property without supervision in case battery may die or uneven sidewalks, safety, uneven road surface. Resident agreed and verbalized understanding.During an interview with Resident 1 on 7/25/25 at 9:32 a.m., she indicated she was unable to leave the facility property anymore on her motorized scooter. The resident had trouble with the sidewalk on one occasion and got stuck. She did not remember when it happened, but it had been awhile. Local police helped her get unstuck. She did not ride the scooter on the roads, but crossed the road to go to Dairy Queen. She was asked to sign a form provided by the SSD, who told her she could no longer leave the property. Resident 1 was told she would have to have supervision in order to leave the property on her scooter.Resident 34's clinical record was reviewed on 7/28/25 at 9:38 a.m. Diagnoses included hypertension, hypernatremia (high sodium levels), COPD, and anemia.A quarterly MDS assessment, dated 5/19/24, indicated Resident 34 was cognitively intact and used a wheelchair for mobility.A current care plan, dated 7/2/25, indicated the resident had been educated on motorized wheelchair not to be used on the road(s). She was educated that she could go outside but not leave the property without supervision. Interventions included: Educate on the importance of maintaining a safe environment free of potential fall hazards, let the resident know the facility can transport to where she wants to go, or family can be contacted to transport the resident if needed.During an interview with Resident 34, on 7/25/25 at 3:05 p.m., she indicated the reason she bought the motorized scooter was so she could leave the premises and go to nearby restaurants or stores. She was her own person and made her own health decisions. She took a class about how to operate the motorized scooter and was given instructions to sign in and out of the facility whenever she left the property. She did not remember when, but at some point, she was told she could no longer take her scooter off the property because it was not allowed by the State. She only left the premises one time, got stuck on an uneven section of sidewalk, and a bystander helped her get the scooter off of the uneven sidewalk. She once got stuck just outside the facility, on the premises, and had to wait for an indeterminate amount of time until someone helped her get unstuck. She had never tipped the scooter. She was recently told taking her scooter off the premises was a liability and she was no longer allowed to go off the property. She was provided with information about the restriction and signed the agreement, but she was too mad to know what she actually signed.A Social Services note, dated 6/4/25, provided by the SSD on 7/25/25 at 4:02 p.m., indicated the following: .(Resident 34) was educated on motorized wheelchair is not made for road use. Resident (34) educated that she may go outside but not leave property in case battery may die or uneven sidewalks, unsafe and uneven road surface. Resident agreed and verbalized understanding.A current facility policy, titled Guidelines for the Use of Motorized Vehicles in the Facility, provided by the Administrator on 7/28/25 at 3:16 p.m., indicated the following: .It is the intent of the facility to promote each resident's quality of life to the optimal level to include independence with mobility. Residents who are cognitively intact and who have a documented medical reason to support the use of a motorized vehicle (such as a wheel chair, scooter, or cart) will be allowed to use the vehicle as long as they 1) adhere to the related safe guards that are in place in the facility.Procedure: 2) Residents who desire to use a motorized vehicle will be assessed by therapy for safe operation ability of the device. This assessment will be done prior to the first time the resident uses the device upon admission, re-admission, when there is a change of condition in the resident, and following any incident related to the resident's use of the device. The resident will have the use of the device placed on hold if there are any safety concerns as a result of any assessment.7) When outside, the vehicle should be kept on the sidewalk.18) At any time and for any reason if the physician, therapist, DON, or Administrator feels that the resident's operating capacity poses a safety risk to the resident or others, the Administrator will remove the vehicle from the resident's possess until a decision can be made.related to the use of the vehicle going forward.3.1-3(a)

Based on record review and interview, the facility failed to ensure the resident and the resident's representative were notified in writing of the transfer/discharge appeal rights and the bed hold policy when a resident was transferred to the hospital for 1 of 3 residents reviewed for hospitalization (Resident 58). Finding includes:Resident 58's clinical record was reviewed on 7/28/25 at 12:09 p.m. His diagnoses included type 2 diabetes with other diabetic kidney complications, paroxysmal atrial fibrillation (rapid irregular heart rhythm), abnormal findings on diagnostic imaging of heart and circulation, and cerebral infarction (stroke) due to occlusion or stenosis of the small artery. A progress note, dated 4/25/25 at 10:30 a.m., indicated the facility spoke with the resident's representative to send the resident to the hospital after the latest labs indicated the resident's hemoglobin continued to decrease. Emergency Medical Services would take the resident to the local hospital. The resident's representative indicated the family would transport the resident to the regional hospital. An e-Interact SBAR (Situation, Background, Assessment, Recommendation) summary for providers note, dated 4/25/25 at 3:40 p.m., indicated the resident was sent to the hospital. The clinical record lacked indication the resident and the resident's representative were notified of the transfer/discharge appeal rights and bed hold policy in writing for the resident's transfer to the hospital. During an interview, on 7/28/25 at 12:59 p.m., LPN 6 indicated, when a resident was transferred, a face sheet was sent, the code status was sent, a medication list was sent, and a bed hold form was sent. She was uncertain of what else was sent and indicated she was going to ask the ADON. During an interview, on 7/28/25 at 1:02 p.m., LPN 6 and the ADON indicated all the required paperwork such as the bed hold and the transfer/discharge forms were now on a pathway on the computer and popped up to complete when a resident was transferred or discharged . During an interview on 7/28/25 at 1:25 p.m., the DON indicated the required forms for transfer/discharge and bed hold were on the computer and popped up when a resident was transferred or discharged . When Resident 58 was transferred, paper copies were used. She indicated the resident's transfer to the hospital had been unusual. The resident's clinical record did not contain the transfer/discharge appeal rights or the bed hold policy provided to the resident and/or the resident representative with the resident's transfer to the hospital. A current facility policy, dated 1/1/17, provided by the DON on 7/28/25 at 2:22 p.m., titled Transfer and Discharge Policy and Procedure, indicated the following: .Before a facility transfers a resident to a hospital or a therapeutic leave, the nursing facility will provide information to the resident/responsible party that specifies the duration of the bed-hold policy and the facility's policies regarding bed-holds.Emergency Transfer:.Explain transfer and reason to the resident and/or representative if applicable send the original State Transfer/Discharge/Bedhold notice with the resident and/or representative or person(s) responsible for care. Place the facility copy in the health record. 3.1-12(a)(6)(A)(i)3.1-12(a)(6)(A)(ii)3.1-12(a)(6)(A)(iii)3.1-12(a)(25)

Based on interview and record review, the facility failed to ensure vision services were provided for 1 of 3 residents reviewed for ancillary services. (Resident 33) Finding Includes:During an interview, on 7/21/25 at 10:00 a.m., Resident 33 indicated he had not been seen by the facility's eye doctor. He spoke with the Social Service Director two weeks ago and she was to schedule an eye appointment at the local supermarket. He had not heard anything regarding an appointment. He was blind in his left eye and had poor vision in right eye.Resident 33's clinical record was reviewed on 7/25/25 at 1:59 p.m. Diagnoses included benign prostatic hyperplasia (enlarged prostate), neuropathy (nerve damage), major depressive disorder, and anxiety. Current orders included Resident 33 may receive services including eye care, audiology, podiatry, and dental. (9/19/24). A quarterly Minimum Data Set (MDS) assessment, dated 4/27/25, indicated Resident 33's cognitive status was moderately impaired. He required corrective lenses and his vision was adequate. A current care plan for being at risk for dental, vision, hearing and podiatry issues, dated 1/1/25, indicated Resident 33 asked to be put on the list to be seen by ancillary services, and it would be his choice if he would be seen when ancillary providers were in the building. The goal included Resident 33 would be encouraged to participate in ancillary services quarterly while ancillary providers were in the facility if he allowed them to treat him. A physician progress note, dated 12/23/24, indicated Resident 33 needed an eye doctor appointment scheduled for visual disturbances. A physician progress note, dated 2/17/25, indicated Resident 33 complained of worsening vision and required an eye exam. A follow up was needed to check if Resident 33 was on the list to be seen by the eye doctor during next visit to the facility. A physician progress note, dated 7/7/25, indicated Resident 33 would like an eye exam. A 9/29/24 document, scanned into Resident 33's electronic record, had the wrong last name entered on it. The first name and date of birth were accurate. The form was signed by Resident 33 and indicated that he wanted audiology, eye care, and podiatry ancillary services. A 7/15/25 document, scanned into Resident 33's electronic record, was signed by Resident 33 and indicated that he wanted audiology, eye care, and podiatry ancillary services. During an interview, on 7/28/25 at 10:44 a.m., Resident 33 indicated he felt that his vision in his right eye had worsened and was blurrier than it had been. He wanted to see an eye doctor as soon as possible. During an interview, on 07/28/2025 at 11:42 a.m., the Social Services Director (SSD) indicated she was unable to locate documentation regarding an eye appointment for Resident 33. She recalled discussing an eye appointment with Resident 33 approximately two weeks ago. She reached out to the optometry company via email on 7/14/25 and questioned why Resident 33 had not been seen by their provider. They indicated that Resident 33 was not on their caseload. She had Resident 33 sign a release for ancillary services on 7/15/25. She informed Resident 33 he could be seen in-house during the optometrist's next visit, or he could be seen in the community. She felt Resident 33 opted to wait to be seen by the facility optometrist, so no appointment was scheduled. She was not aware the physician notes indicated the need for an eye exam. She was not aware Resident 33's initial optometry election form had the wrong last name on it. She confirmed the forms had matching first names and date of birth s. She verified the form was in her handwriting and she may have made a mistake. She did not feel optometry services were delayed on her behalf as she acted promptly when finding out Resident 33 wanted to see an eye doctor but did feel the facility optometry services did not see him timely. She verified that both ancillary services documents indicated Resident 33 wanted to receive ancillary services for audiology, eye care, and podiatry. During an interview, on 7/28/2025 at 3:19 p.m., the DON indicated there was a female resident admitted within the same time frame of Resident 33, who had the last name that was listed on Resident 33's initial ancillary services authorization document. The initial consent form was filled out in error. She and the ADON reviewed physician progress notes and anything that occurred within a 24-hour basis. The practitioner did not inform staff of Resident 33 needing an eye exam. She felt the ancillary services provider did not notify the management team of having an unidentifiable resident on their facility list. She did not feel that there was a delay in vision services due to Resident 33 had not been vocal about wanting to see an eye doctor. During an interview, on 7/28/2025 at 3:29 p.m., the Administrator indicated the ancillary services provider should have informed the facility of the inability to locate an unidentified resident. If the facility staff had been notified of the wrong name on the initial ancillary services form, the staff would have identified the problem, and it would not have caused a delay of vision services During an interview, on 7/28/2025 at 3:36 p.m., Resident 33 indicated he was frustrated because he was informed earlier in the day that he had an eye doctor appointment at the local supermarket at 1:30 pm. The facility transported him and when he arrived it was noted the eye doctor office did not open until 2:00 p.m. He waited until 2:00 p.m. and then was informed by the local supermarket's vision department staff that the eye doctor was not in until Thursday. The facility transport took him to a local office of an optometry chain. No eye appointments were available at that provider. He did not receive any eye care services today. During an interview, on 7/28/25 at 3:43 p.m., the SSD indicated that she had transportation take Resident 33 to the supermarket's optometry office at 1:30 p.m. for an eye appointment. She had not actually called that office to set up an appointment because she knew they took walk-ins. Resident 33 was on the transportation log to take to the supermarket's optometrist on Thursday, however the optometrist's staff indicated to the facility staff that Thursdays were first come, first serve, so Resident 33 may not be seen on that day either. An eye appointment was made for Monday, August 4 at 3:40 p.m. An admission Agreement, updated 2/6/23, provided by the Administrator on 7/28/25 at 12:48 p.m., indicated the following .ANCILLARY SUPPLIES AND SERVICES: Resident may utilize a variety of ancillary supplies and services during his or her stay in the facility. ancillary supplies and services or supplies and services indirectly related to residents stay in the facility and include, but are not limited to,.certain support services, certain medical equipment, and transportation. 3.1-39(a)

Based on observation, interview, and record review, the facility failed to develop and implement effective interventions for and monitoring of behavior expressions of known wandering and physical aggression for 1 of 1 residents reviewed for dementia care. (Resident 53)Findings include:Resident 53's clinical record was reviewed on 7/25/25 at 9:38 a.m. Diagnoses included dementia with other behavioral disturbance(s), major depressive disorder, anxiety disorder, need for assistance with personal care, and insomnia.Current physician's orders included sertraline hydrochloride (HCL) 25 milligrams (mg) one tablet by mouth daily for depression, donepezil HCl 10 mg one tablet by mouth at bedtime for dementia, check function of WanderGuard (a wearable device used to monitor residents who are at risk for elopement) to left ankle every shift for elopement risk, behavior monitoring each shift for depressive mood, anxiety, resident to resident altercations, agitation, and non-compliance/aggressive physical contact, and may admit to a secured unit related to diagnosis of Alzheimer's/dementia.A quarterly Minimum Data Set (MDS) assessment, dated 7/8/25, indicated Resident 53 was severely cognitively impaired, had difficulty focusing attention and was easily distracted, had disorganized thinking, incoherent (rambling or irrelevant) conversation, was unpredictable, and wandered daily.A current care plan, initiated 6/30/25, indicated the resident was at risk for elopement from the facility based on the elopement risk assessment and secondary to confusion, disorientation, and other cognitive deficits affecting decision making and general awareness. Interventions included: Assess for unmet needs that might be masked by wandering behavior (i.e., pain, hunger, thirst, toileting, positional needs, companionship, etc.), assess the resident for wandering and elopement risks upon admission, quarterly, and in the event of a significant change in condition, divert attention to safe and meaningful activities, meet needs as determined by assessment, notify the physician or social worker of changes in mood, behavior, or cognition as necessary, provide therapeutic interventions to distract from wandering, and WanderGuard placed on left ankle.A current care plan, initiated 12/13/23, indicated Resident 53 was at risk for elopement due to a diagnosis of dementia. Interventions included: Personalized - I like to be left alone, I like to wander around, I like to be offered food and drinks (9/20/24), if the resident leaves the building, goes into a peer's room, or becomes aggressive, redirect (the resident) by limiting the number of staff who redirect the resident, if another person is needed for safety, the second person should remain out of sight, in the background, or behind the primary caregiver. Do not overwhelm the resident (12/13/23).A current care plan, initiated 8/10/24, indicated the resident was aware that, according to his diagnoses, depression, and cognitive status, he might be at risk for occasional episodes of physical and/or verbal aggression, aggressive physical contact with staff and other residents, inappropriate sexual talk and touch with staff and other residents, wandering hallways, elopement, exit seeking, non-compliance with care and medications, and made false accusations. Interventions included: Allow the resident to vent, refer to psychiatric nurse practitioner if needed, offer the resident his favorite snack, and redirect him to a quiet area to self-regulate.A current care plan, initiated 1/1/25, indicated the resident had episodes of wandering, as evidenced by roaming the halls all day, forgetting where his room was, and wandering into the rooms of other residents. Interventions included: Attempt to redirect the resident from wandering activity, and provide the resident with food, drink, offer toileting, walk with the resident, and offer other activities.A current care plan, initiated 8/9/24, indicated Resident 53 had a depressive mood, anxiety, agitation, and aggressive physical contact. He was at risk for resident-to-resident aggressive physical contact due to his diagnoses and history of aggression. Interventions included: Listen to concerns and follow up on (these) promptly as needed, and provide support and encouragement as needed.A Wandering Risk Scale assessment, dated 7/5/25, indicated the following: The resident was able to follow instructions, was ambulatory, could not communicate, had a history of wandering, medical diagnoses of dementia/cognitive impairment, and was a high risk to wander.A review of Resident 53's census indicated from 3/30/22 to 8/19/24, he resided on the secured memory unit of the facility. On 8/19/25, the resident was transferred to an unsecured unit.A progress note, dated 8/16/24 at 1:50 p.m., indicated Resident 53 was arguing with another resident, became agitated, and lunged at the other resident. Resident 53 was offered a snack and an activity, but the agitation continued. The psychiatric nurse practitioner was notified and gave an order for valproic acid (a seizure drug used off-label to treat bipolar disorder)125 mg to be given three times daily.A progress note, dated 8/18/24 at 4:26 p.m., indicated Resident 53 saw a female resident attempt to take a ball from another male resident. Resident 53 shoved the (other) male resident to the ground and caused the other resident to hit his hip on the way to the floor. The men were immediately separated. Resident 53 appeared to forget the incident and returned to his previous activities.A progress note, dated 8/29/24 at 5:46 a.m., indicated Resident 53 was combative with staff and raised his fists to them.A progress note, dated 10/6/24 at 9:55 p.m., indicated Resident 53 was combative with certified nurse aids (CNA), used foul language, and pushed one of the CNAs against the wall. Prior to the incident, the resident walked around the hallways and did not want to get ready for bed. His brief was soiled, and he walked into the hallway half naked. The CNAs tried to calm him down, reassured him, explained why his brief needed to be changed, and eventually was able to get the brief changed. He would not allow his clothing to be changed.A social service progress note, dated 10/11/24 at 9:46 p.m., indicated the resident refused care and was combative when staff tried to assist him. Several attempts of personalized interventions did not work. He was left alone and reapproached later.A progress note, dated 11/8/24 at 8:53 p.m., indicated the resident became agitated during a clothing change. Resident 53 attempted to choke the CNA providing care, but the CNA was able to get away before the resident caused harm.During an observation, on 7/25/25 at 2:31 p.m., Resident 53 wandered up and down the Center hallway, turned right at the nurse's station and walked to the exit door at the end of the South hallway. He turned around, walked back towards the nurse's station, looked in several rooms as he passed them, and headed down the North hallway. At 2:37 p.m., the resident stood at the exit door of the North hallway, then turned left into a hallway leading to the memory unit. Resident 53 was not visible to staff at that point. At 2:43 p.m., he wandered back into the North hallway and made his way to the lounge area next to the nurse's station. No staff approached Resident 53 or offered a snack, activity, or diversion.During an interview with LPN 8, on 7/25/25 at 2:35 p.m., she indicated Stop Sign Banners were secured across the doorways of residents who have complained about Resident 53 entering their rooms unannounced and/or uninvited. She thought the banners helped to keep Resident 53 out of other residents' rooms, but not always. Resident 53 would often stand in doorways and stare at the other residents. He would sometimes go in, uninvited, and the other residents would turn on their call lights for assistance. CNAs and/or nurses would retrieve Resident 53 and try to redirect him.During an interview with CNA 9, on 7/25/25 at 2:42 p.m., she indicated the banners across the doorways were to help keep Resident 53 out of other residents' rooms. Resident 53 would sometimes pull the banner away, go into a room, and lay down on a bed. The other residents would turn on their call lights for assistance and some would yell at him to get out. Yelling at him did not deter him and he would just stare at the other residents. Nurses or CNAs would remove him from the rooms. He could become aggressive and push others. During an interview with LPN 10, on 7/25/25 at 2:46 p.m., she indicated the banners were used to keep wanderers out of other residents' rooms. There were a few wanderers, but Resident 53 was the primary one. Sometimes he would pull the banner(s) off the doors and go inside. He was more likely to go into a room without the banner than one with the banner. He could become combative with staff, especially during personal care or toileting. He would sometimes participate in activities, but most times would not.During an observation, on 7/25/25 at 2:50 p.m., Resident 53 was leaning on the medication cart at the nurse's station. He listened to others talking and looked around aimlessly. At 2:55 p.m., he remained at the nurse's station. No staff made eye contact with or talked to him.During an observation, on 7/28/25 at 1:41 p.m., Resident 53 was at the exit door of the South hallway. He moved from the South exit door, past the nurse's station, and down to the exit door of the North hallway. He placed his hands on the handle of the door but did not push to open it. He moved into the hallway leading to the memory unit and was not visible for four minutes. At 1:45 p.m., he returned to the North hallway exit door. As he walked down the hallway, he stopped at the doors and peered inside. A CNA passed him but did not make eye contact. He smiled at two staff members, but neither responded to him. He continued down the South hallway, went into the physical therapy room, came back out, and crossed the hallway into another resident's room at 1:49 p.m. He wandered around the room, picked up a bag of potato chips, looked at them, and sat them back down. At 1:50 p.m., he straightened the sheets on the other resident's bed, sat down, put his feet up, and settled into the bed. A physical therapy assistant (PTA) returned an item to the therapy room and on her way out noticed Resident 53 in the bed. She addressed him by name and made several attempts to get Resident 53 out of bed. She offered her hand, but he would not comply. She eventually offered him a cookie which resulted in him getting out of bed. He accompanied her to the hallway where she replaced the banner across the door. He tried to pull the banner away again. At approximately 2:00 p.m., the resident went with the PTA down the hall towards the nurse's station.During an interview with the DON, on 7/28/25 at 2:22 p.m., she indicated approximately one year ago, Resident 53 was the only male on the memory unit. He was very protective of the women on the unit, particularly one woman. When another male was admitted to the memory unit, Resident 53 got aggressive with him. An incident occurred involving the female resident(s) and a ball. Resident 53 shoved the other male resident, causing the other male to fall and hit his hip on the way down to the floor. When another incident almost occurred, the facility decided to place Resident 53 on the unsecured unit. Some residents complained about Resident 53 entering their rooms unannounced and uninvited, but he was harmless.During an interview with the DON, on 7/28/25 at 2:25 p.m., she indicated the facility did not have a policy specifically addressing wandering.3.1-37(a)

Based on record review and interview, the facility failed to implement pharmacy recommendations and follow physician orders to discontinue medications for 1 of 5 residents reviewed for pharmacy recommendations. (Resident 24)Finding includes: Resident 24's clinical record was reviewed on 7/23/25 at 9:38 a.m. Diagnoses included major depressive disorder, dementia, and hypertension (high blood pressure). Current orders included ondansetron HCL (for nausea) 4 milligram every six hours as needed for nausea or vomiting.A quarterly Minimum Data Set (MDS) assessment, dated 5/27/25, indicated Resident 24's cognitive status was severely impaired.A pharmacy medication regimen review, dated 1/1/25, indicated the provider agreed to discontinue Resident 24's PRN ondansetron and PRN Imodium (for diarrhea).The clinical record indicated Resident 24's ondansetron was not discontinued.During an interview, on 7/28/25 at 1:48 p.m., the ADON indicated Resident 24's ondansetron had never been discontinued.During an interview, on 7/28/25 at 2:03 p.m., the DON indicated based on the 1/1/25 pharmacy recommendation, Resident 24's ondansetron and Imodium order should have been discontinued. Upon receiving pharmacy recommendations, they were given to the provider to review and sign, and then the provider returned the signed recommendation to the ADON or DON. The ADON reviewed the recommendations and changed orders accordingly.3.1-25(b)3.1-25(o)

Based on record review and interview, the facility failed to ensure a resident did not receive an excessive dosage than ordered of an antidepressant when physician orders were not followed for a gradual dose reduction for 1 of 5 residents reviewed for unnecessary medications. (Resident 24)Finding includes: Resident 24's clinical record was reviewed on 7/23/25 at 9:38 a.m. Diagnoses included major depressive disorder, dementia, and hypertension (high blood pressure). Current orders included escitalopram oxalate (for depression) 5 milligram daily.A quarterly Minimum Data Set (MDS) assessment, dated 5/27/25, indicated Resident 24's cognitive status was severely impaired.A pharmacy medication regimen review, dated 5/7/25, indicated Resident 24 had a gradual dose reduction approved for escitalopram to go from 10 milligrams to 5 milligrams daily. The 5-milligram order was added but the 10-milligram order did not get discontinued. Recommendation was to discontinue the 10-milligram order to comply with the gradual dose reduction.The clinical record indicated an escitalopram 5 milligram order was entered by the ADON on 5/1/25 to start on 5/2/25. The DON acknowledged the order on 5/13/25 The 10-milligram order did not get discontinued until 5/12/25 at 2:38 p.m. by the ADON. The DON acknowledged the order on 5/13/25 at 8:38 a.m. This resulted in the orders for both 5 mg and 10 mg to be active at the same time. The electronic medication administration record (EMAR) indicated that escitalopram 5 milligram and escitalopram 10 milligram were both administered on 5/2/25 through 5/12/25.During an interview, on 7/28/25 at 2:03 p.m., the DON indicated the escitalopram dose was discussed at the 5/1/25 behavior meeting and it was determined to decrease the dosage to 5 milligrams. Orders were usually entered during the behavior meeting by the ADON. Upon receiving pharmacy recommendations, they were given to the provider to review and sign, and then the provider returned the signed recommendation to the ADON or DON. The ADON reviewed the recommendations and changed orders accordingly.During an interview, on 7/28/2025 at 2:31 p.m., the DON indicated that Resident 24's EMAR indicated an escitalopram 5 milligram tablet, and an escitalopram 10 milligram table was administered daily from 5/2/25 through 5/12/25. She was made aware of the error after the pharmacy notified her of the duplicate medication administration. The 10-milligram tablet was discontinued at that time.3.1-48(a)(1)3.1-48(b)(2)

Based on observation, interview, and record review the facility failed to assess residents for self-administration of medications for 3 of 3 residents reviewed for self-administration of medication. (Resident 8, Resident 12, and Resident 42)Findings Include: 1.During an observation and interview with Resident 12, on 7/21/25 at 10:51 a.m., the resident indicated his morning medications were left with him each day because he did not like to take his medications before he ate breakfast. On his bedside table was a medication cup which contained one medium round peach pill, one medium round beige pill, one small round pink pill, and half of a small oblong white pill. Nurses left his morning medications with him daily because they were aware he waited for breakfast to be served before he took the pills. During an observation, on 7/23/25 at 9:05 a.m., Resident 12's medications were sitting on his bedside table in a medication cup. The medication cup contained one oblong white pill, one medium round peach pill, one medium round dark pink/purple pill, and half of a small oblong white pill. Resident 12 indicated he had just finished breakfast and had not yet taken his pills. He could not identify the pills or what condition(s) they treated. During an interview with LPN 6, on 7/23/25 at 9:10 a.m., she indicated Resident 12 was not care-planned to self-administer medications. He did not like to take his medications before breakfast. Since he was alert and oriented, she felt comfortable leaving his pills with him. Resident 12's clinical record was reviewed on 7/23/25 at 9:25 a.m. Diagnoses included type 2 diabetes mellitus, major depressive disorder, benign prostatic hyperplasia, and cardiomyopathy. Current physician's orders included nicotine transdermal patch 24-hour apply 14 milligrams (mg) transdermal one time a day for tobacco use, metoprolol tartrate 25 mg 0.5 tablet by mouth two times a day for hypertension (hold for heart rate less than 60 beats per minute, hydralazine hydrochloride 50 mg give one tablet by mouth two times a day for hypertension, lisinopril 5 mg give one tablet by mouth one time a day for hypertension, fluoxetine hydrochloride 60 mg give one tablet by mouth one time a day for depression, and clopidogrel bisulfate 75 mg give one tablet by mouth one time a day for heart attack/stroke prophylaxis. A quarterly Minimum Data Set (MDS) assessment, dated 7/3/25, indicated Resident 12 was cognitively intact, with no hallucinations, delusions, or behaviors, had impairment to his lower extremities bilaterally, used a manual wheelchair, required partial to moderate assistance for activities of daily living, and substantial/maximum assistance for lying to sitting and transfers to shower. The clinical record lacked a physician's order to self-administer medication and self-administration of medication assessment. During an interview with the DON on 7/23/25 at 3:37 p.m., she indicated staff are not supposed to leave medications in residents' rooms. None of the residents in the facility were to self-administer medications and the facility policy says not leave medications in residents' rooms. 2. During an observation, on 7/22/25 at 10:57 a.m., a medication administration cup, containing eight pills, sat beside a plastic cup of water, on Resident 49's table. The medications were, one grey and yellow capsule, one pink tinge, round pill, two small, round, white pills, one medium, round, white pill, one large, red, gel capsule, one large, oblong, white pill, and one large, oblong, pink-tinge pill. During an interview, on 7/22/25 at 11:16 a.m., Resident 49 indicated he had gotten side-tracked and had forgotten to take his medication. He self-propelled his wheelchair to the table, picked up the medication administration cup, and emptied the cup of medications into his mouth. After taking a drink from the plastic cup of water, which sat by the medication administration cup, he swallowed the pills. He was unsure of what medications he had taken, except there was a water pill and an eye pill, but he did not know which pills those were. He took whatever medications the staff gave him. During an observation, on 7/23/25 at 10:27 a.m., Resident 49 sat in his recliner. Across the room, a medication administration cup which contained medication, sat beside a plastic cup of water, on Resident 49's table. During an interview, on 7/23/25 at 3:37 p.m., the DON indicated medications were not to be left in any resident rooms by staff. The facility had a policy which addressed not leaving medications in rooms. There were no residents at the facility who self-administered their medications. During an observation on 7/25/25 at 10:18 a.m., Resident 49 was sleeping in his recliner. Across the room, a medication administration cup containing ten pills sat beside a plastic cup of water on Resident 49's table. The medications included one pink and tan capsule, one small, pink, round pill, two small, round, white pills, one medium, round, white pill, one large, red, gel capsule, one large, oblong, white pill, and one large, oblong, pink-tinge pill, one small, oval, off-white pill, one medium, round pink pill. During an observation, on 7/25/25 at 12:07 p.m., Resident 49 was sitting in his wheelchair in his room. The medication administration cup, with medications, remained sitting on the table. Resident 49's clinical record was reviewed on 7/25/24 at 4:05 p.m. Diagnoses included hypertension (high blood pressure), diabetes (high blood sugar), and atrial fibrillation (fast, irregular heartbeat). A quarterly Minimum Data Set (MDS) assessment, dated 6/4/25, indicated Resident 49's cognitive status was moderately impaired. The clinical record lacked a physician's order to self-administer medication and a self-administration of medication assessment. 3. During observation, on 7/25/25 at 10:24 a.m., Resident 8 was asleep in her bed. A medication administration cup, containing nine pills, sat beside a plastic cup of water, on Resident 8's bedside table. The bedside table was across the room, in front of Resident 8's recliner. The medications were, one small, red gel capsule, one small, green, gel capsule, one yellow oval pill, one large maroon capsule, two small, round, white pills, one medium, round, white pill, one white oval pill, 1/2 of a white oval pill, and one Trelegy inhaler. During an interview, on 7/25/2025 at 2:30 p.m., Resident 8 indicated the facility staff would leave medications in her room for her to take when she woke up. She did not know what medications she took. She took whatever medication the staff brought to her. Resident 8's clinical record was reviewed on 7/25/24 at 11:36 a.m. Diagnoses included bipolar disorder, dysphagia (difficulty swallowing), and cognitive communication deficit. A quarterly Minimum Data Set (MDS) assessment, dated 6/29/25, indicated Resident 8's cognitive status was moderately impaired. The record lacked a physician's order to self-administer medication and a self-administration of medication assessment. During an interview, on 7/28/2025 at 12:51 p.m., LPN 6 indicated she left medications in both Resident 42 and Resident 8's rooms. Both residents were alert and oriented and they liked their medications available for when they were ready to take them. Resident 42 liked his medications to be placed on the table under the TV, and he took his medications after he ate breakfast. Resident 8 took her medications around breakfast time. Resident 8 sometimes needed an extra reminder due to illness or confusion. She went back to check all the medications left in the resident's rooms were taken. A current facility policy, dated March 2023, titled Medication Administration, provided by the DON on 7/22/25 at 3:31 p.m., indicated the following: Purpose: To administer all medications safely and appropriately.Procedure: 17. Remain with the resident to ensure that the medication is swallowed. 3.1-11(a)

Based on observation, interview, and record review, the facility failed to provide supervision for a resident with known fall risk and ensure the implementation of fall interventions to prevent repeated falls for 2 of 3 residents reviewed for falls. (Resident B and Resident D) This deficient practice resulted in Resident B sustaining a left ankle fracture during a fall. Findings include: 1. Resident B's clinical record was reviewed on 4/10/25 at 9:30 a.m. Diagnoses included fracture of the left tibia (shin bone), a sprain of the left wrist, type 2 diabetes, muscle weakness, hypertension (high blood pressure), dementia, visual hallucinations, and repeated falls. Current physician orders included escitalopram (antidepressant), 10 milligrams (mg), metoprolol succinate (antihypertensive) 50 mg, hydrocodone-acetaminophen (for pain) 5-325 mg, and safety checks every 30 minutes for fall interventions. A quarterly Minimum Data Set (MDS) assessment, dated 1/21/25, indicated Resident B was severely cognitively impaired. He had no upper or lower extremity impairment. He required supervision/ touching assistance with toileting hygiene, upper and lower body dressing, rolling to the left and right, sitting to lying, lying to sitting, sitting to stand, chair/bed to chair transfers, toilet transfers, and walking 10 feet. A current care plan, initiated on 10/26/22 and revised on 3/10/25, indicated Resident B was at risk for falls related to his condition and risk factors. His falls would be reduced in an attempt to avoid significant injury related to falls. Interventions included 60 minute checks for fall safety/prevention/interventions, anti-rollbacks to the wheelchair, anti-tippers applied to the wheelchair, resident's call light within reach, Dycem (a non-slip pad) on the wheelchair, encourage and assist with wearing non-skid foot wear, encourage resident to use handrails or assistive devices properly, encourage to use a grabber tool to retrieve items out of reach, non-skid strips in front of toilet, notify physician of changes in condition, nurse practitioner to do medication review, use overnight briefs to reduce wake times, reinforce need to call for assistance, smart audio monitor to help with falls, grab bars on the left side of the bed for safety, a mat on the floor next to the bed, and anti-tippers to the front of the wheelchair. A progress note, dated 3/6/25 at 9:39 p.m., indicated Resident B was sitting on the floor in front of his recliner. The resident was laughing and appeared to have slipped out of his chair. Staff assessed the resident for any head injury. The resident was smiling, laughing, and playful. Fall precautions and 24-hour neurological checks were in place. Staff were to continue to monitor. A progress note, dated 3/7/25 at 9:20 a.m., indicated Resident B was found lying on his right side, unclothed and under a blanket. Staff attempted to assist resident getting dressed but the resident began screaming and stated, Don't do that, that hurts, feel it? Staff assessed the residents left shoulder and the resident screamed. The resident also complained of left hip pain. The nurse contacted the Nurse Practitioner (NP), who ordered the resident sent to the emergency room (ER) for better imaging. No immediate interventions were implemented to prevent further falls. The clinical record lacked indication of the outcome of the ER visit. A progress note, dated 3/10/25 at 4:38 a.m., indicated Resident B was noted on the floor in front of his recliner. Resident B had been sitting in his recliner. The resident was lying on his left side. He was wearing pants, a shirt, and shoes. The resident was assessed without any injuries noted. The resident was assisted onto his feet, then placed into his recliner. No immediate interventions were implemented to prevent further falls A progress note, dated 3/10/25 at 1:30 p.m., indicated the Interdisciplinary Team (IDT) met to review a fall from 3/10/25 at 3:30 a.m. Resident B was found next to his recliner on his left side. Neurological checks continued from a previous fall. The NP, DON, and the resident's representative were notified. The IDT recommended 60-minute safety checks to ensure the resident was safe and not on the floor. A progress note, dated 3/15/25 at 8:42 a.m., indicated Resident B was found on the floor scooting to the bathroom. The resident was wearing non-skid footwear. Neurological checks and vital signs were within normal limits. The resident was not incontinent at the time of the fall. A head-to-toe assessment was performed without any injury noted. No immediate interventions were implemented to prevent further falls. A progress note, dated 3/17/25 at 9:50 a.m., indicated the IDT met to review an unwitnessed fall on 3/15/25 at 8:30 a.m. Resident B was found scooting on the floor in his room. The resident could not relay how the fall occurred. The resident was assessed without any injuries noted. The IDT recommended nonskid strips by his bed. The NP, DON, and the resident's representative were notified. A progress note, dated 3/21/25 at 5:43 p.m., indicated Resident B was in front of his wheelchair on his knees. Resident B had his left hand on the bed and his right hand on the bedside table. The resident was assisted up and into his wheelchair by two staff members. No immediate interventions were implemented to prevent further falls. A fall risk assessment, dated 3/23/25, indicated Resident B was at high risk for falls. A progress note, dated 3/22/25 at 4:07 a.m., indicated Resident B was found on the floor with no brief, pants, or shoes on. The side of his bed was wet. There was blood on the floor. The resident was assessed, and his vital signs were within normal limits. Resident B had a cut on the tip of his left middle finger. No immediate interventions were implemented to prevent further falls. A progress note, dated 3/24/25 at 11:11 a.m., indicated the IDT met to review a fall on 3/22/25 at 3:15 a.m. The staff responded to the resident's room after hearing the resident talking and found the resident sitting on the floor in the restroom with blood on his finger. Resident B was unable to give a description of the incident. The resident was unaware if he hit his head. Neurological checks were initiated. Staff assisted Resident B to his feet, helped him get dressed, and placed him into his wheelchair. All the resident's needs were met at that time. The NP, ADON, Administrator, DON, and the resident's representative were notified. The IDT recommended staff offer the use of overnight briefs to reduce wake times. A progress note, dated 3/31/25 at 11:00 p.m., indicated Resident B was standing at the foot of his bed. He lost his balance and sat on the floor. The resident denied any complaints of pain. A skin tear was noted to his left forearm. Resident B was dressed in clothes and shoes and had been toileted. The resident did not hit his head during the fall. Resident B was assisted to his feet by two staff members and placed in his wheelchair. No immediate interventions were implemented to prevent further falls. A progress note, dated 4/1/25 at 11:17 a.m., indicated staff were called to Resident B's room due to Resident B being on the floor in front of his recliner. Upon entering the room, Resident B was sitting on the floor in front of his recliner with blood on the left side of his face. Resident B was dressed in a shift, his pants were half down his leg, wearing a brief and socks. The resident was not wearing shoes. His wheelchair and walker were within reach. Staff assessed Resident B and obtained his vital signs. Resident B was noted with a gash to his left eyebrow and a small skin tear to his left thumb near his palm. The resident was continent at the time of the fall. Swelling was noted to his left wrist and an x-ray was ordered. No immediate interventions were implemented to prevent further falls. A progress note, dated 4/1/25 at 2:41 p.m., indicated Resident B was noted to have left wrist swelling with the resident moaning and holding his left wrist with his right hand. The NP ordered an x-ray. A fall risk assessment, dated 4/1/25, indicated Resident B was at high risk for falls. A progress note, dated 4/2/25 at 9:56 a.m., indicated the IDT met to review Resident B's fall from 3/31/25 at 11:00 p.m. Resident B was standing at the foot of his bed, lost his balance and sat on the floor. The resident had no complaints of pain. A skin tear was noted to his left forearm. The resident was dressed in clothes and was wearing shoes. Resident B had been previously toileted. He did not hit his head during the fall. Resident B was assisted to his feet by two staff members and seated in his wheelchair. The IDT recommended a baby monitor so staff would hear when the resident was moving around in his room. The ADON, NP, and the resident's representative were made aware. A progress note, dated 4/2/25 at 6:53 a.m., indicated x-ray results showed a fracture to his left wrist. The NP and the resident's representative were notified. A progress note, dated 4/2/25 at 8:33 a.m., indicated a new order was received to send Resident B to the emergency room (ER) for evaluation and treatment of the wrist fracture. A progress note, dated 4/2/25 at 10:01 a.m., indicated the IDT met to review Resident B's fall from 4/1/25 at 11:00 a.m. Staff were called to the resident's room due to the resident being on the floor in front of his recliner. Upon entering the room, the resident was sitting on the floor in front of his recliner with blood on the left side of his face. The resident was dressed in a shirt, was wearing a brief with his pants halfway down his legs and had socks on. Resident B was without shoes and his wheelchair and walker were within reach. Staff assessed the resident and obtained his vital signs. The resident was noted with a gash to his left eyebrow and a small tear to his left thumb by his palm. The resident was continent at the time of the fall. Swelling was noted to his left wrist and a stat x-ray was ordered. The IDT recommended staff offer diversional activities when the resident was noted alone in his room. NP, ADON, and resident's representative were made aware. A left ankle x-ray, performed at the local hospital, on 4/2/25 at 10:38 a.m., indicated irregularity of remote injury or acute nondisplaced fracture. A progress note, dated 4/2/25 at 12:49 p.m., indicated the emergency room staff found Resident B had a left ankle fracture and would be returning to the facility with a boot. The resident's left wrist did not show signs of a fracture. A fall risk assessment, dated 4/4/25, indicated Resident B was at high risk for falls. A progress note, dated 4/7/25 at 8:32 a.m., indicated the IDT met to review Resident B's fall on 4/4/25 at 5:00 p.m. Resident B was sitting in his wheelchair at the nurse's station. Resident B was seen trying to get out of his chair and fell out before staff could stop him. The wheelchair tipped over along with the resident. No injury was noted. The ADON, NP, and the resident's representative were notified. The IDT recommended anti-tippers to the front of his wheelchair, which was added to the care plan. No immediate interventions were implemented to prevent further falls on 4/4/25. A progress note, dated 4/8/25 at 22:45 p.m., indicated Resident B was in the recliner at the nurse's station. Staff saw him try to get up and ran toward the resident to prevent a fall. Resident B slid against the recliner onto the floor. Resident B was assessed for injuries, but none were found. No redness, swelling, or bleeding was present. A pain scale for the cognitively impaired was used. No sign of distress was noted. His vital signs were stable. Fall precautions were in place. The DON and NP were notified. No immediate interventions were implemented to prevent further falls. A fall risk assessment, dated 4/8/25, indicated Resident B was at high risk of falls. During an interview, on 4/10/25 at 11:15 a.m., LPN 5 indicated resident fall assessments should be documented under the risk management tab. As soon as the DON was notified, the DON would inform the nurse of the new intervention. The DON or the nurse updated the care plan. During an interview, on 4/10/25 at 11:25 a.m., LPN 6 indicated the nurse or management came up with the new fall intervention after a fall occurred. Some interventions were placed right away, other times it took a while. Management would update the care plan with the new interventions. Resident B was on 30-minute safety checks. The facility tried to keep him out of his room as much as possible. When agitated, he would be a one on one. During an interview, on 4/10/25 at 11:35 a.m., LPN 7 indicated after a fall occurred, the assessment was completed under the risk management tab. Staff needed to fill out the residents fall risk, change of condition, and pain assessments. The ADON or DON tried to come up with new interventions as soon as possible. During an interview, on 4/10/25 at 11:36 a.m., CNA 8 indicated she was unsure what Resident B's fall interventions were. She needed to check with the nurse. During an observation, on 4/10/25 at 11:36 a.m., Resident B was sitting in the main dining room. He did not have anti-tippers on the front of his wheelchair. During an interview, on 4/10/25 at 11:45 a.m., CNA 8 indicated she was unsure if the CNAs had access to the resident's care plan. They would be notified during shift change of any interventions or changes to the resident's care. During an interview, on 4/10/25 at 11:43 a.m., Housekeeper 9 indicated she was unaware of Resident B's fall interventions. He usually propelled himself up and down the hallway or preferred to color. During an observation, on 4/10/25 at 12:03 p.m., Resident B was propelling himself down the hallway. He propelled himself up to the nurse's station and asked the CNA to give him a report. He did not have anti-tippers on the front of his wheelchair. During an interview, on 4/10/25 at 12:03 p.m., CNAs 10 and 11 indicated Resident B was on 30-minute safety checks, had fall strips in his room, and a monitor. They were unsure of other fall interventions. There was a communication book at the nurse's station but was unsure if it was directly used for Resident B. CNA 9 left to speak with the DON, and after returning, CNA 9 indicated anything new with any of the residents was discussed during shift change. During an interview, on 4/10/25 at 2:00 p.m., the DON indicated the nurse wrote the intervention under the immediate action taken. Resident B's fall interventions include 30-minute safety checks and a monitor in his room. CNAs normally had a huddle at the end of their shifts where everything was discussed. During an observation, on 4/10/25 at 2:15 p.m., Resident B was sitting at a small table near the nurse's station while a staff member sat beside him in a chair. The small table had coloring books, colored pencils, and a puzzle activity for the resident. He did not have anti-tippers on the front of his wheelchair. During an observation, on 4/11/25 at 9:36 a.m., Resident B's room was located at the end of the hallway. Resident B did not have a floor mat at his bedside. During an interview, on 4/11/25 at 9:40 a.m., the ADON indicated she felt the 30-minute safety checks were sufficient in preventing Resident B from falling. The facility had been able to provide enough staff for Resident B to receive one-on-one staff assistance twice a week. Resident B needed to be one on one when he was agitated. The anti- tippers to the front of his wheelchair were on backorder. At the time of the interview, with the ADON present, Resident B's room was measured 102 feet away from the nurse's station using therapy's walking stick. During an interview, on 4/11/25 at 10:08 a.m., the DON indicated 30-minute safety checks were not sufficient in preventing Resident B from falling. Staff tried to keep Resident B in eyesight. The DON felt the resident receiving one-on-one staff assistance would prevent future falls. She was unaware he was supposed to have anti-tippers on the front of his wheelchair. 2. Resident D's clinical record review was completed on 4/11/25 at 9:30 a.m. Diagnoses included dementia, anxiety, opioid dependence, chronic kidney disease, hypertension, psychotic disturbance and mood disturbance. Current physician orders included hydrocodone-acetaminophen (opiate pain medication) 5-325 mg, mirtazapine (antidepressant) 7.5 mg, and sertraline (antidepressant) 25 mg. A quarterly MDS assessment, dated 3/15/25, indicated Resident B was severely cognitively impaired. He required partial/ moderate assistance with toileting hygiene, lower body dressing, rolling to the left and right, sitting to lying, lying to sitting, sitting to stand, chair/bed to chair transfers, toilet transfers, and walking 10 feet. He required substantial/ maximal assistance with upper body dressing. A current care plan, initiated on 1/2/24 and revised on 12/30/24, indicated Resident D was at risk for falls related to his condition and risk factors. His fall risk factors would be reduced in an attempt to avoid significant injury related to falls. Interventions included, anti-rollbacks to his wheelchair, the bed in lowest position, call light within reach, do not leave resident in the bathroom unattended, encourage and assist resident with wearing non-skid footwear, ensure Dycem (anti-skid mat) is in his wheelchair, keep most used items in arm's length to prevent bending/reaching, monitor for changes in gait/positioning, non-skid strips to floor in front of toilet, place mat on floor beside bed, reassess fall risk factors annually and PRN, and reinforce the need to call for assistance. A progress note, dated 4/9/25 at 1:08 p.m., indicated staff found the resident on the floor beside his bed next to his wheelchair. The resident stated he was trying to get into his wheelchair, but he unlocked his wheelchair and fell to the floor. Resident D was wearing regular socks without shoes. Anti-slip strips were in place. Resident D had no complaints of pain in his legs, back, hips or arms. The DON, ADON, and the resident's representative were notified. No immediate interventions were implemented to prevent further falls. A progress note, dated 3/17/25 at 9:27 a.m., indicated Resident D was found on the floor at the foot of his bed. He was next to his shoes, but only had socks on. Resident D's shoes were wet. The resident stated he was trying to get up to go to the bank. Resident D did not have any complaints of pain or discomfort at the time of assessment. No redness or bruising was noted. The resident was assisted off the floor and into his wheelchair. The DON, ADON and the resident's representative were notified. No immediate interventions were implemented to prevent further falls. A progress note, dated 2/11/25 at 2:48 p.m., indicated Resident D was found on the floor next to his wheelchair by his bathroom. The resident appeared to have slid out of his wheelchair. The resident denied any pain. No bruising or redness was noted. Resident D stated he was trying to stand up out of his wheelchair and used the bathroom door for support. The resident lost his balance and slid out of his chair. The resident's vital signs were stable, 24-hour neurological checks were in place. NP, DON, and the resident's representative were notified. No immediate interventions were implemented to prevent further falls. During an observation, on 4/11/25 at 11:07 a.m., Resident D's room did not have a floor mat observed in the room or non-skid strips on the floor in front of his toilet. During an observation, on 4/11/25 at 11:11 a.m., Resident D was sitting in his wheelchair in the main dining room. No anti-rollbacks were attached to his wheelchair. During an interview, on 4/11/25 at 11:20 a.m., CNA 12 indicated there was a communications binder at the nurse's station for residents that had fall interventions in place. Floor mats were not used in Resident D's room, as he got up on his own and it was a trip hazard. During an interview, on 4/11/25 at 12:44 p.m., the ADON indicated no one in particular was responsible for implementing new fall interventions. The MDS Coordinator was responsible for updating the resident care plan. During an observation, on 4/11/25 at 12:45 p.m., Resident D propelled himself backwards out of his bathroom and had his pants pulled down to his knees. The resident indicated he needed his pants pulled up. A CNA entered Resident D's room and assisted the resident with pulling up his pants. When Resident D stood up, a Dycem pad was not observed on his wheelchair seat. During an interview, on 4/11/25 at 12:52 p.m., LPN 7 indicated she needed to look at Resident D's care plan for his fall interventions. LPN 7 asked the ADON to help her navigate the resident's care plan to find his fall interventions. At the same time as the interview, LPN 7 did not observe a fall mat in Resident D's room and indicated his anti-rollbacks were on backorder. During an interview, on 4/11/25 at 1:01 p.m., CNA 13 indicated she was made aware of fall interventions during the nurse's report and the CNA communication binder between shifts. She did not recall seeing a floor mat in the resident's room. She adjusted the bed so Resident D's knees were at a 90-degree angle. During an interview, on 4/11/25 at 1:08 p.m., LPN 7 indicated maintenance was putting Resident D's anti-rollbacks on his wheelchair at this time. During an interview, on 4/11/25 at 1:40 p.m., the DON, ADON, and MDS Coordinator indicated maintenance was responsible for implementing any new fall interventions. After maintenance was notified, nurses and CNAs were notified of the new interventions during their daily huddles. A current policy, titled Guidelines for Incident/Accidents/Falls, provided by the DON, on 4/11/25 at 1:15 p.m., indicated the following: .Based on the results of the incident/accident/fall, the resident's care plan will be addressed to ensure that any needed points of focus have measurable goals with appropriate interventions in place This citation is related to complaint IN00456781. 3.1-45(a)(2)

Based on record review and interview, the facility failed to ensure a Minimum Data Set (MDS) assessment was accurately coded for 2 of 3 residents' MDS assessments reviewed. (Resident B and D) Findings include: 1. Resident B's clinical record was reviewed on 4/10/25 at 9:30 a.m. A progress note, dated 12/25/24 at 2:18 p.m., indicated Resident B was observed sitting on the floor in the doorway of his room. A head-to-toe assessment was completed with redness noted to the residents' left elbow. A progress note, dated 12/21/24 at 6:15 a.m., indicated Resident B was on the floor in front of his recliner. Resident B was fully clothed and had socks and shoes on. The resident's vital signs were slightly elevated but came back down to normal range after a few minutes. No injuries were noted, and the resident denied any pain. A progress note, dated 12/9/24 at 7:36 p.m., indicated Resident B was noted lying on the floor in his room. Resident B was fully dressed and had socks and shoes on. The resident's wheelchair was beside him. The resident was assessed without any injuries noted. Neurological assessments were initiated, and the resident was assisted into his wheelchair. A quarterly Minimum Data Set (MDS) assessment, dated 1/21/25, indicated Resident B had no falls since his prior assessment. 2. Resident D's record review was completed on 4/11/25 at 9:30 a.m. A progress note, dated 2/11/25 at 2:48 p.m., indicated Resident D was found on the floor next to his wheelchair by his bathroom. The resident appeared to have slid out of his wheelchair. The resident denied any pain. No bruising or redness was noted. Resident D stated he was trying to stand up out of his wheelchair and used the bathroom door for support. The resident lost his balance and slid out of his chair. The resident's vital signs were stable, 24-hour neurological checks were in place. NP, DON, and the resident's representative were notified. A progress note, dated 1/12/25 at 2:58 a.m., indicated Resident D was heard yelling. Resident D was noted to be lying on the floor in his room. Resident D indicated he needed to urinate. The resident had regular socks on without shoes. Resident D's wheelchair was several feet away from him and the wheels were not locked. Resident D was assisted by three staff members onto his feet and placed him in his wheelchair. A quarterly MDS assessment, dated 3/15/25, indicated Resident D had no falls since his prior assessment. During an interview, on 4/11/25 at 12:05 p.m., the MDS Coordinator indicated she reviewed the risk management section of the clinical record to see when the resident's last fall was. If the resident fell before the assessment date was due, she would mark it on the MDS assessment. If the risk management assessment had been locked and signed, she was unable to see the report. She was only able to see active reports. During an interview, on 4/11/25 at 12:18 p.m., the DON indicated prior risk management reports were under the historical tab. Even if the assessment was locked and signed, it would still show up under the historical tab. During an interview, on 4/11/25 at 1:15 p.m., the Administrator indicated the facility did not have a specific MDS assessment policy. 3.1-31(d)(3)

Based on interview and record review the facility failed to ensure assessments were completed for 3 of 4 residents reviewed with respiratory illness and falls. (Resident J, Resident C and Resident D). Findings include: 1.) Resident J's record was reviewed on 3/4/25 at 12:24 PM. Diagnoses included chronic obstructive pulmonary disease (COPD), anemia and hypertension. A review of Resident J's current quarterly Minimum Data Set (MDS), dated [DATE], indicated their Basic Interview for Mental Status (BIMS) score was 14 (cognitively intact). Resident J declined an interview. A review of Resident J's current care plan titled chronic respiratory illness indicated the resident had a problem of asthma, with a goal date of 5/7/25. Interventions included observing for shortness of breath, cough, increased secretions and notifying the physician when necessary. A review of physician orders dated 2/25/25, indicated prednisone 40 mg was ordered to be given for 4 days, then reduced to 20 mg for 3 days, then 10 mg for 3 days for an upper respiratory infection with wheezing. A review of progress notes, dated 2/14/25 at 7:00 PM, indicated Resident J had a cough and clear breath sounds. Progress notes, dated 2/18/25 at 7:30 PM, indicated Resident J was seen by Nurse Practitioner 8 for a harsh cough with dark, yellow sputum production. The note indicated Resident J had reported symptoms started at the end of the previous week. The Nurse Practitioner indicated Resident J had acute bronchitis and prescribed Augmentin (antibiotic) and prednisone (steroid). Progress note,s dated 2/25/25 at 7:36 PM, indicated Resident J had continued respiratory symptoms, including respiratory wheezes. The Nurse Practitioner recommended completing her course of antibiotics, steroids, and breathing treatments would be increased in frequency. A review of progress notes between 2/14/25 to 3/4/25 did not include any further recording of assessments or vital signs for Resident J. A review of vital sign records indicated Resident J's temperature was 97.5 on 2/13/25 at 10:00 PM and 97.4 on 2/15/25 at 11:55 AM. No additional temperature readings after 2/15/25 were available for review. In an interview, on 3/4/25 at 12:53 PM, Registered Nurse 7 indicated a resident receiving antibiotics for respiratory symptoms should have their breath sounds and temperature checked every shift. A current policy titled Physical Respiratory Evaluation Guidelines, dated 10/24/24, provided by the Director of Nursing on 3/4/25 at 1:55 PM indicated staff should observe the resident's respiratory rate, assess lung sounds, obtain oxygen saturation levels and observe for a cough. The policy did not address documentation guidelines. 2) Resident C's record was reviewed on 3/4/25 at 10:18AM. Diagnoses included non-traumatic brain dysfunction, abnormalities of gait, and weakness. Resident C's last annual, Minimum Data Set (MDS), dated [DATE], indicated their Basic Interview for Mental Status (BIMS) score was 5 (cognitively impaired). The MDS indicated Resident C required physical assistance to perform activities of daily living and the use of a walker. Resident C's progress notes were reviewed with unwitnessed falls documented on the following dates and times; 12/22/24 at 11:20 AM, 1/01/25 at 6:38 AM, 1/6/25 at 3:34 AM, 1/13/25 at 8:51 AM, and 2/8/25 at 2:14 AM. There was no documentation of refusal of neurological checks or reason for missed neurological checks. A neurological checklist started after the fall on 12/22/24. The checklost started at 11:40 AM, The last check was at 1200 noon. No other checks were recorded. There was a note on the form Resident C returned from the hospital on 12/26/24 without a time noted. The form indicated neuro checks should have continued until 12/30/24 but were not completed. A neurological checklist started after the fall on 1/13/25. The checklist started at 8:51 AM, was completed through 5:15 AM, then the following times were not documented. There was an entry at 11:15 PM. Then three non consecutive entries were completed. Three non consecutive entries were one blank. A neurological checklist started after the fall on 2/7/25. The checklist was completed through 2/9/25. A missed entry on 2/10/25 at 7:45AM followed by 2 completed entries. None of the entries dated 2/11/25, 2/12/25, and 2/15/25 were completed. 3) Resident D's record was reviewed on 3/4/25 at 10:30 AM. Diagnoses included Parkinson's disease. Resident D's last comprehensive, Minimum Data Set (MDS), dated [DATE], indicated their Basic Interview for Mental Status (BIMS) score was 4 (cognitively impaired). The MDS indicated Resident D required physical assistance to perform activities of daily living and the use of a walker. Resident D's progress notes were reviewed with unwitnessed falls documented on the following dates and times; 10/24/24 at 1:06 AM, 10/24/24 at 9:20 AM, 10/24/24 at 2:01 PM, and 10/28/24 at 6:30 PM. There was no documentation for refusal of neurological checks or reason for missed neurological checks. A neurological checklist started after the fall on 10/24/24 at 12:30 AM. The checklist was completed until 1:15 PM then 3 entries were left blank, and it was resumed at 9:15 PM that evening. Three entries were made, then a missed entry on 10/27/24 at 1:15 PM. There were 2 completed entrees, then the form was marked off as it was indicated Resident D fell [DATE]. There was no restarting or stopping of the form for the subsequent falls on 10/24/24. A neurological checklist started after the fall on 10/28/24 at 6:30 PM. The form was mislabeled with dates, had 5 blank entries, illegible times and dates the checklist should have been completed. In an interview, on 3/4/25 at 11:14 AM, Licensed Practical Nurse (LPN) 2 indicated neurological checks should be completed on all residents who have an unwitnessed fall or strike their head during a fall. LPN 2 presented a neurological check form and reviewed the neurological check schedule. She reviewed in detail the expected intervals of neurological assessments. She indicated the neurological check form should be completely filled out with no blank spaces at the end of the monitoring period. She indicated any refusals or missed assessments should be explained in the progress notes. In an interview, on 3/4/25 at 1:06 PM, the Director of Nursing (DON) indicated the neurological checks form should be completed entirely, and any missed assessments should be explained in the Resident's progress notes. The DON acknowledged there was missing documentation in Resident C, and Resident D's neurological check forms presented. A current policy titled Guidelines for Incidents/Accidents/Falls was received by the DON on 3/4/25 at 11:11AM. The policy indicated .2. In the case of a fall, the resident will have a head to toe assessment to include a pain assessment as to any change in their range of motion ability or function. Further, residents who have an unwitnessed fall must have neuro checks started and continued per policy . This citation is related to complaints IN00450770 and IN00454234. 3.1-37

Based on observation and interview, the facility failed to ensure the facility was maintained in a clean, homelike manner for random observations of resident rooms, bathrooms, and common area hallways. Findings include: During a facility tour on 11/1/24 beginning at 10:42 a.m. and accompanied by the Administrator, the following was observed: a. The carpeting in the hallways was stained. b. Unclean floors with dark/ brown black debris in rooms 50-61. The bathrooms had brown matter around the base of the toilets, with yellowish-brown stains on the outside surfaces of the toilets. c. The carpet in the hallways outside of rooms 63-75 were stained, with worn areas throughout. The bathrooms had scattered debris on the floors. d. The carpeting in the hallway outside of rooms 76-93 was stained, with worn areas throughout. During the tour, the Administrator indicated housekeeping was in the process of mopping the floors and cleaning resident rooms. During a facility tour, on 11/1/24 at 1:11 p.m. and accompanied by the Administrator, the following was observed: a. The bathroom floor in room [ROOM NUMBER] was sticky and the baseboard around the room and bathroom was discolored with a yellow/brown substance. The toilet had dried brown matter inside of toilet and discoloration on the outside. b. The floor in room [ROOM NUMBER] had a thick substance and scattered debris on it and the baseboards had a yellow/brown discoloration. There were dark reddish/brown stains on the bathroom floor behind the toilet. c. The toilet in room [ROOM NUMBER] had dried brown matter inside the bowl and around the rim. The floors in the bathroom and room had stains and dried spills on them. d. The floor in room [ROOM NUMBER] had debris and a thick, dark brown/black substance on it. The toilet had a yellowish/brown discoloration at the base. e. The floor in room [ROOM NUMBER] had a black/brown matter on the floor. The baseboards were stained and discolored. The bathroom wall tiles had visible stains around the toilet and under the sink. During the tour, the Administrator indicated the rooms did not appear to be clean and he did not know the last time the floors had been stripped. The housekeeping supervisor had been in the position for approximately four days. During an interview on 11/1/24 at 1:38 p.m., the Housekeeping Director indicated he was developing a new cleaning plan for the facility. Review of a Deep Cleaning Schedule for October 2024, provided by the Administrator on 11/1/24 at 12:46 p.m., indicated at a minimum, one room was to be deep cleaned per day, in addition to normal daily task. A current, undated facility policy, titled Daily Cleaning/Electrostatic Spraying was provided by the Administrator on 11/1/24 at 12:33 p.m. The policy indicated the following: Purpose: To provide a clean and safe environment for residents, visitors and staff. Daily Cleaning Procedure: 17. Resident Bathroom a. Wipe down all surfaces starting with mirrors, grab bars, sinks, toilet. A current, undated facility policy, titled General Cleaning Policies and Procedures Resident Room-Discharge Clean was provided by the Administrator on 11/1/24 at 12:33 p.m. The policy indicated the following: Purpose: To provide a clean, attractive and safe environment for residents, visitors and staff. Procedure: 7. Clean the Resident's Sink: a. Apply disinfectant or bathroom cleaner to the interior of the sink. b. Clean the inside of the sink, the exterior surfaces of the sink and all metal handles and faucets using a clean cloth dampened with the disinfectant or bathroom cleaner. e. Clean the plumbing underneath the sink. 8. Clean Toilets: a. Scrub the inside of the toilet and urinals with the bowl brush and disinfectant cleaner. Flush the toilets and urinals. Use the flush water to rinse your bowl mop and brush. Spray disinfectant cleaner onto a cloth and clean all toilet seats, flush handles, exposed pipes and outside surfaces of the toilets and urinals. clean base also where urine may be. When gum or sticky residue form the floor by gently prying it loose with a putty knife. This citation relates to Complaint IN00446015. 3.1-19(f)(5)

Based on record review and interview, the facility failed to provide weekly skin assessments for a resident identified at risk for skin breakdown according to their plan of care for 1 of 3 residents assessed for pressure injury. (Resident D) Findings include: The clinical record for Resident D was reviewed on 10/4/24 at 7:47 a.m. Diagnoses included depression, dementia, anxiety, hypothyroidism, delusions, hypertension, insomnia, and hypoglycemia. Review of the clinical record indicated Resident D had not received a skin assessment since 3/10/24. The most recent quarterly Minimum Data Set (MDS) assessment, dated 7/3/24, indicated the resident was at risk for pressure ulcers, required a wheelchair; required partial to moderate assistance for transfers and repositioning. A current care plan, dated 11/10/23, indicated the resident was at risk for skin breakdown due to incontinence, requiring help with bed mobility and toileting hygiene. Interventions included, but were not limited to skin assessments at least weekly by a nurse, dated 11/10/23. During an interview on 10/4/24 at 9:23 a.m., the Assistant Director of Nursing and the MDS Coordinator both indicated Resident D should of had weekly skin assessments as part of standard care and facility policy. A recent policy, dated 5/28/23, titled Guidelines for Skin Observation/Assessment (Shower/Baths) was provided by the ADON on 10/4/24 at 9:46 a.m. The policy indicated the following: Procedure: 3.) Nurses will do skin assessments at least weekly (or as indicated). Oftentimes, this can be done more efficiently and to the benefit of the resident if skin assessments done during the shower/bath time. This citation relates to Complaints IN00443645 and IN00442048. 3.1-40 (a)(2)

Based on interview and record review, the facility failed to ensure staff reported a resident-to-resident altercation to the Administrator immediately, delaying the submission of the incident within the required timeframe to the Indiana Department of Health for 1 of 3 incidents reviewed. (Resident B and Resident C) Findings include: The clinical record for Resident C was reviewed on 8/8/24 at 10:54 a.m. Diagnoses included anxiety, major depressive disorder, and dementia. A late entry progress note, dated 8/1/24 at 11:45 p.m., indicated on 7/9/24 at 11:42 p.m., Resident C was in an altercation with another resident. Resident C was in no distress and did not have any memory of the incident happening. Staff would continue to monitor the resident. Review of a facility self-reportable, dated 7/29/24, indicated on 7/29/24 Resident B was standing close to Resident C and Resident C then pressed his hands onto Resident B's chest. The administrator submitted the reportable to the Indiana Department of Health (IDOH) on 7/29/24 at 12:39 p.m. The clinical record for Resident B was reviewed on 8/8/24 at 10:50 a.m. Diagnoses included anxiety, depression, and dementia. During an interview, on 8/8/24 at 12:21 p.m., the Psychiatric NP indicated she was notified that there had been some animosity between Resident B and Resident C. Resident B was agitated walking up and down the hallway, after she left, the facility notified her that Resident B had punched another resident, and she gave an order to administer Haldol and send out to the hospital if ineffective. During an interview, on 8/8/24 at 12:44 p.m., LPN 3 indicated Resident B was very agitated and was up in another resident's face on 7/9/24. During an interview, on 8/8/24 at 3:21 p.m., QMA 1 indicated, on 7/9/24, Resident B was wandering down the hall and entered Resident C's room. Resident C was coming out of the bathroom when Resident B swung and struck Resident C on the shoulder or chest area. Resident C then grabbed Resident B by the shoulder and slammed him on the bed. Resident B and Resident C were separated. Resident C was yelling that Resident B attacked him, they were able to get Resident C calmed down and separated from Resident B. LPN 3 came to the dementia unit after receiving the call and notified the Social Services Director regarding the incident. During an interview, on 8/9/24 at 9:01 a.m., the Administrator indicated the facility needed to report any abuse, accidents, resident to resident altercations, falls with injury and unusual occurrences to IDOH. He did investigate the resident-to-resident altercation when he was made aware, which was on 7/29/24. QMA 1 would have been interviewed, but no longer worked at the facility. The Administrator listed the date of 7/29/24 on the facility self-reportable as the date of occurrence because that was the day he was made aware of the altercation. During an interview, on 8/9/24 at 9:28 a.m., CNA 2 indicated Resident B pushed resident C down to the ground. Resident C got back up and pushed Resident B back. LPN 3 was notified about the physical altercation between Resident B and Resident C. During an interview, on 8/9/24 at 9:45 a.m., LPN 3 indicated she would not report anything that she did not physically see herself. If she saw any type of altercation or abuse, she would notify the DON. During an interview, on 8/9/24 at 10:06 a.m., CNA 20 indicated she followed the chain of command, and the nurse reported any incidents to the Administrator or DON. During an interview, on 8/9/24 at 10:30 a.m., LPN 2 indicated any type of resident-to-resident altercation was reported immediately to the Administrator, Social Services Director, and DON. During employee record review, on 8/9/24 at 11:26 a.m., CNA 20 and LPN 3 attended abuse in-service training on 7/25/24. QMA 1 and CNA 2 attended abuse in-service training on 10/26/23. A current facility policy, titled Abuse Reporting Policy, provided by the Administrator on 8/9/24 at 11:24 a.m., indicated the following: .All alleged violations involving mistreatment, abuse, neglect, misappropriation of resident property and any injuries of an unknown origin MUST be reported to the Administrator and Director of Nursing. The Administrator is the Abuse Coordinator of the facility. Additionally, the person(s) observing an incident of resident abuse or suspecting resident abuse must IMMEDIATELY report such incidents to the Charge Nurse, regardless of the time lapse since the incident occurred. The Charge Nurse will immediately report the incident to the Administrator or to the individual in charge of the facility during the Administrator's absence The Charge Nurse must complete an incident report and obtain a written, signed and dated statement from the person reporting the incident. A completed copy of the incident report and written statements from the witnesses, if any, will be provided to the Administrator or individual in charge of the facility within 24 hours of the occurrence of such incident This citation relates to Complaint IN00440436. 3.1-28(c)

Based on observation, interview, and record review, the facility failed to develop and implement individualized non- pharmacological interventions for behaviors for residents with dementia for 1 or 3 residents reviewed for dementia care (Resident B and Resident C). Findings include: During a random observation, on 8/8/24 at 10:54 a.m., Resident B was sitting in the main dining room. On 8/8/24 at 11:07 a.m., Resident B was wandering around the unit and he went behind where Resident C was sitting in the common area. Resident C started to get up out of his chair but LPN 2 told him to sit back down. Resident B then went around and started touching another resident's walker. Resident C got out of his chair to go over to where Resident B was located. LPN 2 got in between Resident B and Resident C. LPN 2 was able to get Resident C to sit back down in his chair. Resident C stated, he is a pain in the a--. On 8/8/24 at 9:57 a.m., Resident B was fidgeting with things at the nurse's station before walking independently up and down the hallway. Review of Resident B's clinical record was completed on 8/8/24 at 10:50 a.m. Diagnoses included depression, dementia, anxiety and seizures. Current medication orders included, but were not limited to, sertraline (antidepressant) 100 mg (milligrams) one tablet daily, memantine (dementia) 10 mg one tablet twice daily, Vimpat (anti-epileptic) 100 mg one table twice daily, lorazepam (antianxiety) 1 mg one table twice daily, and donepezil (memory loss and confusion) 10 mg one table daily at bedtime. He had physician ordered behavior monitoring for target behaviors of intrusive wondering, anxiety, non-compliant with care and redirection, pacing. A 6/6/24, admission, Minimum Data Set (MDS) assessment indicated he wandered daily. A progress note, dated 6/20/24 at 8:38 p.m., indicated Resident C was having aggression towards him (Resident B). A progress note, dated 7/9/24 at 10:21 a.m., indicated Resident B was given an injection of 2.5 milliliters (mL) of Haldol (antipsychotic). The Psychiatric Nurse Practitioner (NP) observed Resident B's behavior after writer assisted the QMA in getting the resident dressed. Resident B continued having behaviors and had gotten a pencil and appeared to be holding it as if wanting to stab someone with it. The Psychiatric NP ordered another injection of Haldol at that time. A physician's note, dated 7/9/24 at 9:20 a.m., indicated Resident B was agitated and restless. Staff reported agitation over putting on his socks. He was pacing and staff witnessed him going back and forth to the exit doors and shaking them in an attempt to open the doors. An order was given for Haldol 2.5 milligram (mg) IM (intramuscularly). After the NP left the facility, she was notified that Resident B was still agitated, punched another resident, and had a pencil in his pocket. An order was given to administer a second dose of Haldol and to send to the hospital if ineffective. Resident B's care plan lacked interventions related to increased agitation and aggression with another resident. Review of Resident C's clinical record was completed on 8/8/24 at 10:54 a.m. Diagnoses included dementia with other behavioral disturbances, major depressive disorder and anxiety. Current medication orders included, but were not limited to, sertraline (antidepressant) 50 mg (milligrams) one tablet daily, lisinopril (hypertension) 10 mg one tablet daily and donepezil (memory loss and confusion) 10 mg one table daily at bedtime. He had physician ordered behavior monitoring for target behaviors of depressive mood, anxiety, agitation and non-compliance. A 6/27/24, quarterly, Minimum Data Set (MDS) assessment indicated he was not having any physical, verbal, or other behavioral symptoms toward others. A progress note, dated 6/20/24 at 8:38 p.m., indicated he was aggressive towards Resident B. A progress note, dated 7/9/24 11:42 p.m., indicated the resident was in an altercation with another resident. There was no distress or memory of the incident. Staff would continue to follow up. Resident C's care plan lacked interventions related to behavior. No behaviors were documented under the Behavior Monitoring order for July 2024. During an interview, on 8/8/24 at 11:07 a.m., LPN 1 indicated that Resident B walked from the time he got up until the time he went to bed. He wandered into other resident rooms if their doors were left open. He was easily redirected. Resident C did not have any behaviors. He was overly protective of the female residents on the unit. The nurse had previously had to get between Resident B and Resident C five times already today. During an interview, on 8/8/24 2:29 p.m., the Social Services Director indicated the residents care plan should match the orders for behavior monitoring. The care plan should have been updated with a new intervention. They would add physical contact with another resident and that would be updated on his behavior monitoring order. During an interview, on 8/9/24 at 9:01 a.m., the Administrator indicated there should have been a summarization in the progress notes regarding their behaviors and the interventions that were used. During an interview, on 8/9/24 at 9:11 a.m., the DON indicated staff was unsure who should be documenting behaviors under the behavior monitoring. The care plan should have been updated with new interventions on their behaviors the next day. During an interview, on 8/9/24 at 9:28 a.m., CNA 2 indicated that Resident B was always wandering around walking and getting into things. He was normally easily redirected. He liked to talk about work and tinker with little toys. During an interview, on 8/9/24 at 9:45 a.m., LPN 3 indicated she was unsure who was to document residents' behavior monitoring. She would not chart something that she was told, she must physically see it herself before she would chart it. A current policy, titled Behavior Management Program, provided by the Administrator on 8/9/24 at 9:10 a.m., indicated the following: .Each resident of the facility identified as exhibiting problematic behavior will be observed in a manner to identify the casual factor, if possible, of the behavior as well as seek approaches/interventions appropriate for the same. When a resident exhibits problematic behavior, the same is addressed on the 24-hour report and in the resident's medical record This citation relates to Complaint IN00440436. 3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure adequate supervision to prevent falls for a cognitively impaired resident, 1 of 3 residents reviewed for accidents. (Resident C) Finding includes: During an observation on 6/3/24 at 9:52 a.m., Resident C's door was completely closed. During a continuous observation on 6/3/24 at 11:08 a.m., the resident was in her room with the door slightly ajar (door opened a crack with curtain blocking any view) and unable to visualize the resident. The resident was saying Hello repetitively in a manner to summon assistance. Her summons for assistance was faintly audible two doors down from the resident's room due to the door being slightly ajar. At 11:11 a.m., an unknown staff member passing by, entered the room while the resident summoned for assistance. During an observation on 6/3/24 at 12:49 p.m., the resident's door was completely shut. During an interview at the time of observation on 6/4/24 09:17 a.m., the resident indicated she had been at the facility approximately one week and had not used her call light yet. During a continuous observation on 6/5/24 at 10:12 a.m., the resident activated her call light. The door was ajar but unable to visualize inside resident's room. An unknown staff member entered the room at 10:18 a.m. to answer the call light. Resident C's clinical record was reviewed on 6/5/24 at 12:49 p.m. The resident admitted to the facility on [DATE]. Diagnoses included the following: unspecified dementia, unspecified polyneuropathy, weakness, other abnormalities of gait and mobility, delusional disorder, restless leg syndrome, maxillary fracture of left side, fracture of nasal bones, and adjustment disorder with mixed anxiety and depressed mood. Current physician's orders included the following: quetiapine fumarate (delusional disorder)-administer 25 mg (milligrams) by mouth once daily, dated 5/2/24; escitalopram (depression)-administer 10 mg by mouth once daily, dated 5/3/24; lorazepam (anxiety)-administer 0.5 mg by mouth twice daily, dated 3/7/24; buspirone (depression)-administer 10 mg by mouth three times daily, dated 3/7/24; and hydrocodone-acetaminophen (pain) 5-325 mg-administer every 8 hours by mouth, dated 2/2/24. An order, dated 4/24/24 included the following: Apply hipsters on as resident allows every shift for fall intervention. Review of a Fall Risk Assessment, dated 2/2/24, indicated the resident was at high risk for falls. A quarterly Minimum Data Set (MDS) assessment, dated 5/11/24, indicated the resident's cognition was severely impaired. The resident exhibited delusions and wandering. She required moderate to maximum assistance for transfers, toileting, and walking. The resident was dependent on staff for putting on and taking off footwear. A wheelchair was used for mobility. The resident was frequently incontinent of bowel and bladder. Falls since the prior assessment included two or more without injury. The MDS lacked falls with injury. This was inconsistent with the fall event notes. A care plan for falls, dated 2/5/24, indicated the resident was at risk for falls related to confusion/forgetfulness, functional impairment, impaired balance with transfers, incontinence, lower extremity weakness, unsteady gait, and use of high risk medications. Interventions included the following: Bring resident to nurses station when trying to get out of bed all night long (2/5/24), Encourage and assist with wearing non-skid footwear (2/5/24), Encourage staff to put the resident in bed after dinner meal instead of recliner (5/20/24), floor mat beside bed (4/30/24), reassess fall risk factors annually and as needed (2/5/24), when trying to get up unassisted, offer diversional activities such as a busy box (2/5/24), and tilted wheelchair seat (6/4/24). Review of fall event notes indicated the following unwitnessed falls: On 3/9/24 at 2:38 a.m., the resident was found sitting on the floor beside her lowered bed. The resident was incontinent. No injury was noted. The care plan was not updated with any new interventions. On 3/10/24 at 9:03 a.m., the resident was found on the floor outside of the bathroom door. The resident was yelling out, Get me up. No injury was noted. Resident lacked non-skid footwear. The care plan was not updated with any new interventions. On 3/11/24 at 6:20 p.m., the resident was found sitting on the floor between her bed and the recliner. Her wheelchair wheels were unlocked. No injury was noted. The care plan was not updated with any new interventions.The care plan was not updated with any new interventions. On 3/24/24 at 6:02 p.m., the resident was found sitting on the floor beside her recliner. The resident was confused. No injury was noted. A fall on 3/24/24 at 11:24 p.m.lacked an event note. The care plan was not updated with any new interventions. On 4/2/24 at 4:15 p.m., the resident was observed sitting on the floor inside of the door with blood all over her head, face, hands, and the floor. The resident indicated she was working in the garden and fell over. Wheelchair was unlocked. Injuries included an abrasion to the top of the scalp and a laceration to the left forehead.The care plan was not updated with any new interventions. On 4/18/24 at 9:00 p.m., the resident was found in her room on her buttocks in front of the recliner while transferring herself-lacked an event note. No injury noted. The care plan was not updated with any new interventions. On 4/21/24 at 11:12 p.m., the resident was found sitting on the floor beside her bed. Her wheelchair was unlocked. No injury noted. The care plan was not updated with any new interventions. On 4/23/24 at 9:31 p.m., the resident was found sitting on the floor and yelling out for help and stated she had dropped the papers she was carrying and went to get them. Her wheelchair was unlocked. No injury noted. The care plan was not updated with any new interventions. On 5/19/24 at 2:00 a.m., the resident was found sitting on the floor in front of the recliner with the foot rest still elevated. No injuries were noted. On 6/3/24 at 5: 26 p.m., the resident was found on her knees beside the bed. The resident indicated she had slipped out of her wheelchair. The wheelchair was unlocked. No injury was noted. Review of Post Fall 72-Hour Monitoring Reports lacked specific times for monitoring the resident and assessments every 8 hours for the 24 hour, 48 hour, and 72 hour time frames for the following fall dates: 3/24/24, 4/2/24, 4/18/24, 4/21/24, 4/23/24, 5/19/24, and 6/3/24. A Nurse's Note, dated 3/24/2024 at 6:08 p.m., indicated the resident was noted on the floor beside her recliner. She was assisted by two staff into her wheelchair. A Nurse's Note, dated 3/24/24 at 6:30 p.m., indicated the resident was agitated. Orders for Haldol 2.5 ml (milliliters) intramuscularly (for agitation) and repeat in one hour if no improvement and urine dipstick (test for urinary tract infection). The urine dipstick test was negative. A Nurse's Note, dated 3/24/2024 at 11:24 p.m., indicated the resident was found sitting on the floor beside her recliner. No injury noted. Staff assisted the resident into he wheelchair. An emergency room visit note, dated 4/2/24, indicated the resident had a cut on her forehead, nose fracture, and a facial fracture related to a head injury. Radiology reports were not provided upon request. An Interdisciplinary Team (IDT) Note, dated 4/19/24, indicated the root cause of the fall on 4/18/24 was due to the resident transferring herself. An IDT Note, dated 4/24/24, indicated the resident did not use the call light for assistance. Confidential interviews were conducted during the course of the survey and indicated the following: -The resident was known to have falls upon admission. The resident preferred her door be left open to watch the traffic up and down the hall. -It was not appropriate for staff to keep residents's doors closed when residents were at high risk for falls to keep their door closed. The door kept closed impaired the inability to see in the room and provide good supervision. -During an interview on 6/5/24 at 3:06 p.m., the resident was in her bed and indicated she did not want her door closed. During an observation on 6/6/24 at 2:25 p.m., RN 5 asked permission to perform treatment to pressure ulcer and the resident indicated the staff was not going to do anything with her. She instructed staff to leave the room. Upon exiting room, RN 5 stated she would close the door. Resident yelled, Get your hands off my door. The resident's door was left open. During an interview on 06/7/24 at 9:55 a.m., CNA 9 indicated she was familiar with the resident's care and was aware the resident had frequent falls. She believed the resident last fell approximately one and one half months ago. During an interview on 6/7/24 at 10:24 a.m., LPN 7 indicated she was familiar with the resident's care. The resident had fallen as a result of waking up and attempting to self transfer without asking for assistance by activating her call light. Due to cognitive impairment, the resident attempted to ambulate on her own. During an interview on 6/7/24 at 12:33 p.m., the DON indicated the following interventions were included to decrease falls: therapy inclusion, using non-skid footwear, and non-skid strips on the floor. The resident seemed disoriented prior to falls. During interview on 6/7/24 at 12:36 p.m., CNA 9 indicated she had worked Monday, Wednesday, Thursday and Friday this week and had not been told in report from other staff members that the resident had fallen this week on Monday. She was not aware of the interventions for the resident to have hipsters or a tilted seat on her wheelchair. During an observation on 6/7/24 at 12:37 p.m., the resident was in her bed and the ADON entered the room to answer the call light. She completely closed the door upon exiting the resident's room. During a continuous observation on 6/7/24 at 2:33 p.m., the resident was yelling, Hello. Administrator walked by the room without looking into the resident's room. At 2:42 p.m., the resident was sitting in her wheelchair beside her bed not yelling out. At 2:45 p.m., the administrator walked by and after rounding the corner, the resident started yelling out, Help. Help. Help. Help please. At 2:48 p.m., the Business Office Manager, BOM walked down the hallway and heard resident yelling out, knocked on the door, and offered assistance. She exited the room at 2:49 p.m. The door was left open. At 2:51p.m., the resident began yelling, Please make my bed. Please make my bed. At 2:52 p.m., the SSD was in hallway and did not acknowledge the resident as she passed by the resident's room while she was yelling out, Please fix my eyeglasses so I can see out of them. Please do it. Resident's room is the fourth door from nurses station and is more than halfway down the hall from nurses station. Continuous observation until 2:59 p.m. During interview on 6/7/24 at 3:37 p.m., DON indicated the resident's door was frequently closed because I think she likes it that way. She was unable to provide additional monitoring documentation other than the post fall 72-hour monitoring reports. No specific times were indicated on the forms for monitoring beyond the hourly checks up to completion of the freuquet monitoring. As a result, there was no way to tell how far apart monitoring was completed. She did not like the post fall monitoring forms, but that was the form staff used. A current facility policy, dated 6/30/23, titled GUIDELINES FOR INCIDENTS/ACCIDENTS/FALLS, provided by the Administrator on 6/7/24 at 10:51 a.m., indicated the following: Policy: .This information will be used to implement corrective actions to include any needed training to prevent reoccurrences when possible .2.residents who have an unwitnessed fall must have neuro checks started and continued per policy. Neuro checks will be initiated even if the resident states they did not hit their head in an unwitnessed [by staff], fall.9. Documentation of the physical and mental status of the resident[s] involved will be completed each shift [every 8 hours minimally] over the next 72 hours .10. The occurrence is to be communicated shift to shift as part of the report until the resident is stabilized and at least 72 hours post fall.11. All falls will have a site investigation .in an effort to define the root cause of the fall. This will help provide information to enable staff to roll out interventions to prevent another similar occurrence This citation relates to complaint IN00432578. 3.1-45(a)(2)

Based on observation, record review and interview, the facility failed to prevent the development of pressure ulcers for 2 of 5 residents reviewed who met the criteria for pressure ulcers. In addition, the facility failed to maintain infection control while providing the treatment of [REDACTED].#14 for 1 of 3 pressure ulcer treatment observations. The deficit practice resulted in the worsening of Resident #14's pressure ulcers in size. (Resident #13 and #14). Findings include: 1a. The clinical record for Resident #14 was reviewed on 9/17/15 at 11:05 a.m. Resident #14 had [DIAGNOSES REDACTED]. A review of Resident #14's clinical record indicated the resident currently had three pressure ulcers, which were labeled as A, B, and C by the Director of Nursing and the Wound Nurse/ADON (Assistant Director of Nursing) on the Wound: Pressure ulcer assessment w/ Braden, completed on 9/17/15 at 5:15 p.m. A review of the .Wound: Pressure ulcer assessment w/ Braden (wound nurse only), dated 8/14/15, indicated the following for Wound A: A new, stage II ('Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister ') pressure ulcer was located on the right inner thigh and had an origin date of 8/14/15. The pressure ulcer measurements were 3.0 centimeters length by 0.2 centimeters width by 0.1 centimeters depth. The treatment was .[MEDICATION NAME] 3x (times) daily til healed. Ensure (Foley) catheter tubing is not under leg when up in w/c . .ACTIVITY .degree of physical activity . Chairfast: Ability to walk severely limited or non-existent. Cannot bear own weight and/or must be assisted into chair or wheelchair .Mobility .ability to change and control body position .Very Limited: Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently A review of the .Wound: Pressure ulcer assessment w/ Braden (wound nurse only), dated 8/20/15, indicated the following for Wound C: A new, stage II pressure ulcer was located on the right inner thigh and had an origin date of 8/20/15. The pressure ulcer measurements were 1.0 centimeters length by 0.8 centimeters width by 0.2 centimeters depth. The treatment was .[MEDICATION NAME] 3x (times) daily til healed. Ensure (Foley) catheter tubing is not under leg when up in w/c (wheelchair) A review of the .Wound: Pressure ulcer assessment w/ Braden (wound nurse only), dated 9/11/15, indicated the following for Wound B: A new, stage II pressure ulcer was located on the right inner thigh (just under buttock fold) and had an origin date of 9/11/15. The pressure ulcer measurements were 0.4 centimeters length by 0.9 centimeters width by 0.1 centimeters depth. The treatment was .Wash with soap and water, apply xeroform gauze and cover with [MEDICATION NAME] foam dressing; change every 3 days and prn (as needed) for loosening/soilage. Ensure (Foley)catheter tubing is not under leg when up in w/c (wheelchair); (Foley) catheter tubing strap is applied; encourage to use cushion in power chair at all times Resident #14 had current physician orders [REDACTED]. .Check that resident is not sitting on catheter tubing.every shift .Start date - 8/24/2015 .Wash posterior upper thigh with soap and water, cover with xeroform gauze and [MEDICATION NAME] foam dressing change every days (day) and prn (as needed) for loosening/soilage every evening shift Start date - 09/11/2015 1b. An observation of Resident #14's pressure ulcer treatments by the Wound Nurse/ADON and LPN #7 on 9/17/15 at 1:41 p.m. indicated the following: LPN #7 had unfastened the left side of Resident #14's brief and had asked the Wound Nurse if she wanted Resident #14's incontinent brief removed and the Wound Nurse indicated no. The Wound Nurse washed her hands and picked up a pair of gloves that had been sitting on the resident's bed and then began adjusting resident's brown throw that was on his bed with her bare hands. She then donned the gloves and began cutting the xeroform dressing with a pair of scissors she pulled from her front pant pocket that also held two visible ink pens. The Wound Nurse indicated the pressure ulcer treatments for Resident #14 were not a sterile procedure but should be clean. LPN #7 was attempting to hold back Resident #14's incontinent brief from the pressure ulcers, but when the resident moved, the brief would contaminate the pressure ulcers, even after the Wound Nurse would clean the pressure ulcers. The Wound Nurse, on 9/17/15 at 2:06 p.m., during the pressure ulcer treatments, indicated Resident #14's brief was soiled, but never removed the incontinent brief. There was a small brown smear observed on the incontinent brief. Wound A. The Wound Nurse indicated pressure ulcer A measured 1.6 centimeters length by 0.9 centimeters width by 0.1 centimeters depth with pink, dry granulation tissue and was a Stage II pressure ulcer. Wound B. The Wound Nurse indicated pressure ulcer B was 1.0 centimeters in length by 0.5 centimeters in width with no depth, yellow slough present and was an unstageable pressure ulcer. Wound C. The Wound Nurse indicated pressure ulcer C was 1.2 centimeters in length by 0.9 centimeters in width by less than 0.1 centimeters in depth with red, moist, granulation tissue. The Wound Nurse indicated the dressing for Resident #14's pressure ulcer had a moderate amount of yellow, brown, serous drainage. The Wound Nurse had placed a disposable washcloth in the bottom of Resident #14's sink where she had been washing her hands. She let the washcloth sit while it was saturated with water that was running into the sink. She then squeezed the excess water from the washcloth, applied soap and cleaned Resident #14's pressure ulcer with it. The Wound Nurse removed a pair of scissors for a second time from her front right pant pocket, which also held two ink pens. The scissors were visibly soiled with a white/yellow dried substance on them. The Wound Nurse began to cut the Xeroform dressing with the soiled scissors, but was stopped by the surveyor. The Wound Nurse, after the pressure ulcer treatments were completed on Resident #14, placed the again soiled scissors in the top drawer of a treatment cart on top of single-use Vaseline packets. The Wound Nurse/ADON, with the DON present, was interviewed on 9/17/15 at 3:32 p.m. The Wound Nurse indicated Resident #14's pressure ulcers had worsened. She also indicated there was one pressure ulcer that separated into two wounds on 9/11/15. The Wound Nurse indicated during the pressure ulcer treatments for Resident #14 on 9/17/15 at 1:41 p.m., the observation of the wound care was accurate. During an interview with the Nurse Consultant on 9/18/15 at 2:49 p.m., she indicated the accuracy of the wound nurse's wound assessment for Resident #14's pressure ulcers were in question. She further indicated she had the wound clinic assess the pressure ulcers to Resident #14's right upper thigh and right buttock for accuracy and staging of the wounds on 9/18/15. Review of the wound clinic assessment of the resident's wounds indicated the following: .Buttocks: right buttock pressure ulcer: 1x0.5x0.1cmm, clean pink base. The entire buttocks are bright red from too much pressure . .Right Lower Extremity: .ulcers on posterior thigh measure 1x0.7x0.1cm and 1x0.8x0.1cm, clean pink bases These indicated a difference in measurement. During an interview with the DON (Director of Nursing) on 9/18/15 at 3:11 p.m., she indicated Resident #14 had not previously been seen by the Wound clinic for the pressure ulcers to his right upper thigh and right buttock but only for his venous ulcers to his feet and lower legs. 2. Review of Resident #13's clinical record began on 9/18/15 at 10:12 a.m. [DIAGNOSES REDACTED]. Resident #13 had a current, 8/4/2015 comprehensive Minimum Data Set (MDS) assessment, which indicated the resident was cognitively impaired, rarely or never made decisions, did not ambulate, and was totally dependent on staff for ADLs and bed mobility. A .Wound: Pressure ulcer assessment document, dated 7/30/15, indicated Resident #13 developed a suspected deep tissue injury pressure ulcer to the inner aspect of the right foot on 7/30/15. The pressure ulcer measured 2 cm long by 2 cm wide, with no depth. The subsequent weekly assessments of the pressure ulcer were as follows: a. On 8/12/15, the pressure ulcer was staged as a suspected deep tissue injury and measured 2cm long by 1 cm wide, with no depth. b. On 8/19/15, the pressure ulcer remained a suspected deep tissue injury and measured 2 cm long by 1.7 cm wide, with no depth. c. On 8/27/15, the pressure ulcer remained a suspected deep tissue injury and measured 0.9 cm long by 0.6 cm wide, with no depth. d. On 9/4/15, the pressure ulcer became unstageable, and measured 1cm long by 1 cm wide, with no depth. e. On 9/11/15, the pressure ulcer became a stage III, and measured 1 cm long by 0.6 cm wide, with a depth of 0.1 cm. Resident #13 had current careplan problems of potential for skin breakdown related to, but not limited to, cognitive impairment, stasis [MEDICAL CONDITION], and [MEDICAL CONDITION]. An intervention to elevate Resident #13's feet was added on 8/1/15. Resident #13 had a careplan problem, dated 7/30/15, of .Deflated blood blister on the bottom of the R (right) foot underneath R (right) great toe Interventions included, but were not limited to, elevating the resident's feet on pillows while in bed. A Charts/Clinical Notes hospice document, dated 8/5/15, indicated the resident was laid down following meals to relieve pressure on the coccyx area, which had contributed to the development of the pressure ulcer to the foot. During an interview, on 9/18/15 at 11:50 a.m., the Director of Nursing (DON) indicated there were no interventions in place regarding keeping the resident's feet apart to prevent pressure. A review of the policy titled Skin Management Program, with a policy start date of 8/14/14, provided by the Nurse Consultant on 8/18/15 at 2:00 p.m., indicated the following: .1. PURPOSE: A. It is our policy to assess for and reduce risk factors that may contribute to the development of pressure ulcers and other skin alterations unless the individual's condition demonstrates that the development is clinically unavoidable 4. A review of the policy titled WOUND & NON WOUND ASSESSMENTS & DOCUMENTATION, with a policy start date of 10/5/12, provided by the Nurse Consultant on 8/18/15 at 2:00 p.m., indicated the following: .1. WOUNDS A. All wounds, as defined below, will be managed by the facility wound nurse(s) . .C. Definitions of wounds: .II. Stage II pressure ulcer - Partial Thickness - Partial thickness skin loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled or sero-sanguinous filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising . .III. Stage III pressure ulcer - Full Thickness Skin Loss - Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. .V. Unstageable Status/Unclassified - Full Thickness Skin or Tissue Loss Depth Unknown - Full Thickness tissue loss in which the actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth cannot be determined . .VI. Suspected Deep Tissue Injury Depth Unknown - Purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/or shear 3.1-40 (a)(1) 3.1-40 (a)(2)