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

Based on interview and record review, the facility failed to ensure behaviors were accurately recorded and managed for 1 of 3 residents reviewed (Resident B).Findings include:Resident B's record was reviewed on 1/27/25 at 10:52 AM. Diagnoses included dementia, moderate, with behavioral disturbance.Resident B's current quarterly Minimum Data Set (MDS) assessment, dated 12/26/2025, indicated their Basic Interview for Mental Status (BIMS) score was 14 (cognitively intact). The MDS indicated Resident B did not have any behavior occurrences in the last 7 days of the review period.Resident B's current care plan, titled sexually inappropriate behavior indicated the resident had a problem of sexually inappropriate touching and verbal remarks, with a goal date of 4/3/2026. Interventions included offering distraction techniques, evaluation of what the resident was trying to communicate with the behavior, redirection, assertive communication to cease behavior, and referrals for psychiatric evaluation.A behavior tracking form, dated 9/19/2025 at 7:00 AM, indicated Resident B had touched staff members in a sexual manner on their chests and buttocks during care. The form did not indicate any possible triggers. The form indicated redirection was provided. The form did not indicate whether the redirection had been effective.A progress note, dated 9/19/2025 at 5:50 AM, indicated no behavior issues had occurred. A Social Determinants of Health assessment, dated 9/19/2025 at 2:33 pm, did not address any behavioral issues.No additional progress notes dated around or on 9/19/2025 were available for review.A behavior tracking form, dated 9/25/2025 at 10:08 AM, indicated Resident B had a behavioral issue in his room. The form indicated a possible trigger was touching. The type and purpose of touching was not documented. The form did not indicate the behavior that had occurred. The form indicated the behavior was redirected and the resident was repositioned with improvement noted.A progress note, dated 9/25/2025 at 9:28 PM, indicated Resident B had not exhibited any behavior issues. No further progress notes dated 9/25/2025 were available for review.Treatment administration records (TAR), dated 9/2025, did not include shift monitoring for behavior issues.Behavior tracking on the TAR indicated a behavior had occurred on 10/25/2026, but no interventions were provided. The outcome recorded was ineffective.A progress note, dated 10/25/2025 at 10:56 AM, indicated no behavior issues had occurred. No other progress notes dated around or on 10/25/2025 were available for review.A behavior tracking form, dated 11/26/2025, indicated Resident B made sexually inappropriate remarks to a staff member with a trigger of getting up for breakfast. The form indicated toileting, redirection and a quiet environment were provided. The form did not indicate whether the interventions were successful.No progress notes for 11/26/2025 were available for review.Behavior monitoring tracking on the TAR indicated there were no behavior issues on 11/26/2025 on any shift. Behavior monitoring tracking on the TAR indicated a behavior issue occurred on the evening shift on 11/7/2025 with interventions and effectiveness recorded as not applicable. No progress notes, dated 11/7/2025, were available for review.The TAR indicated a behavior issue occurred on 11/30/2025 with zeros recorded in the interventions and effectiveness categories.No progress notes dated 11/30/2025 were available for review.A behavior monitoring form, dated 12/22/2025, indicated Resident B made inappropriate sexual remarks. Triggers were listed as unknown. The form indicated food, fluids and redirection were offered. Effectiveness was not addressed on the form.No progress notes, dated on or around 12/22/2025 were available for review.Behavior monitoring tracking in the TAR indicated no behaviors occurred on 12/22/2025.In an interview, on 1/282026 10:30 AM, Licensed Practical Nurse (LPN) 2 indicated upon the occurrence of a behavior, staff should intervene and record the behavior, interventions and their effectiveness and present the completed form to the Social Services Director (SSD). LPN 2 indicated nursing staff should record whether behavior issues occurred, interventions and effectiveness when applicable on the TAR each shift. She indicated progress notes were also used to record behaviors.In an interview, on 01/28/2026 10:33 AM, the SSD indicated when a behavior occurred, staff should intervene, fill out a tracking tool and submit it to the Director of Nursing (DON) or the Assistant Director of Nursing (ADON). The SSD indicated she would upload the form into the computer after the team reviewed it. The SSD indicated the behavior forms should have all areas completed to ensure effective care plan interventions could be identified and communicated to staff. She indicated she did not know why the behavior forms were not fully completed. She indicated incomplete areas on the behavior forms did not allow staff to determine effective behavior interventions. The SSD indicated all paper and electronic records should contain consistent and matching information.A current policy, titled Guidelines for Behavior Management Meetings, undated, provided by the Administrator on 1/28/2026 at 2:01 PM indicated behavior management forms should be completed by nursing staff. The policy indicated the facility should use behavior documentation to determine the root cause of behaviors and provide appropriate interventions, The policy indicated nursing, social services, and mental health providers should participate in care plan development.A current policy, titled Guidelines for Behavior Management Meetings, undated, provided by the Administrator on 1/28/2026 at 2:01 PM indicated behavior management forms should be completed by nursing staff. The policy indicated the facility should use behavior documentation to determine the root cause of behaviors and provide appropriate interventions. The policy indicated nursing, social services and mental health providers should participate in care plan development. This citation is related to Intake 2721458.3.1-43(a)(1)

Based on observation, interview and record review, the facility failed to ensure a comprehensive plan of care was completed to address limited range of motion for 1 of 1 resident reviewed. (Resident 26) Findings include: During an observation, on 01/27/2026 at 8:56 AM with Assistant Director of Nursing (ADON), Resident 26 was sitting in common area in a Broda chair. Resident 26 had her eyes closed and had her head and chin tucked down and bent into her right shoulder without any support. Resident 26 denied any pain. Resident 26 was willing to shake her head yes or no. When asked to bring her head to her left shoulder, she was unable to bring her head to midline. During an observation, on 01/28/2026 at 8:45 AM, Resident 26 was sitting in a Broda chair in the common area with a pillow under her right side. Resident 26's chin and face were tucked into her right shoulder. Resident 26's record review began on 1/27/26 at 9:10AM. There was no documentation of decreased range of motion in her care plan. A discharge therapy note and evaluation, dated 3/25/25, indicated Resident 26 could straighten her neck to midline with assistance but was resistant. In an interview, on 01/27/2026 at 11:55AM, the Director of Nursing (DON) indicated the limited range of motion should have been in the care plan and the MDS coordinator would be contacted to address it. A current policy and procedure titled, Baseline Care Plan Assessment/Comprehensive Care Plans undated was provided by DON on 1/28/26 at 2:18PM. The policy indicated.the comprehensive Care Plan will further expand on the resident's risks, goals and interventions using the person-centered Plan of Care approach for each resident that includes measurable objectives and timelines to meet the resident's medical, nursing, physical functioning, mental, and psychosocial needs.the Comprehensive Care Plan will include any specialized services or specialized rehab Services recommended to be provided. 3.1-35(a)

Based on observation, interview, and record review, the facility failed to ensure food items were closed to air and contaminants, expired food was disposed of timely, and label food containers with the date opened and discard dates with the potential to affect 19 of 19 residents residing at the facility. Findings include: The facility kitchen was observed with the Kitchen [NAME] (KC) on [DATE] at 10:30 a.m. The dry storage area contained a bag of sugar in a box. The bag of sugar was open to air. There was an undated loaf of cinnamon bread, with mold visible through the packaging, present on the bread rack. The KC indicated the bag of sugar should not have been open to air and cinnamon bread had mold present and had been on the rack for around two weeks. The kitchen refrigerator was observed to have a container of cottage cheese with a use by date of [DATE], a large plastic bucket of hard-boiled eggs with no open date present, and three large bags of pre-mixed salad. One of the bags of pre-mixed salad was opened and half gone. The bags were dated as best by [DATE]. A box of prune juice had a date opened of [DATE]. A pitcher of unsweet tea had a preparation date of ,d+[DATE]. A box of pasteurized eggs had a best by date of [DATE]. A bowel of chopped cucumbers was without a lid and no date and/or label. There were two containers of half and half, one was approximately half full, with a package date of [DATE] and there was no open date on the containers. A silver serving container covered in plastic wrap was dated ,d+[DATE] and discard by ,d+[DATE]. During an interview on [DATE] at 10:50 a.m., the KC indicated the outdated items in the refrigerator should have been discarded. All items should have an open date when put into the refrigerator. All items put into the refrigerator should have lids and/or be sealed from air and dated. The items found to be outdated or undated should be thrown away. On [DATE] at 12:22 p.m., the Executive Director provided the Labeling and Dating policy, dated [DATE], which read, .Leftovers and open foods shall be clearly labeled with date food item is to be discarded. Food items to be labeled and dated include items prepared in house and food items that are opened and stored for later use .7-day self-life including date of preparation- label includes: a. Name of food item b. discard date .30-day shelf life, usually applies to items that are shelf stable until opened- label includes: a. name of food item if not clearly identified on container b. Discard date . Discard date cannot exceed use by date stamped on product by manufacturer This citation relates to Complaint IN00441092. 3XXX,d+[DATE](i)(2) 3XXX,d+[DATE](i)(3)

Based on observation, interview, and record review, the facility failed to ensure infection control was maintained during medication administrations by not utilizing hand hygiene, glove usage, and touching pill medication with bare hands for 5 of 5 residents reviewed for medication administrations. (Residents' 8, 11, 12, D, and 19) Findings include: 1. The clinical record for Resident D was reviewed on 12/4/24 at 2:00 p.m. The diagnoses included, but were not limited to, stroke. An observation was made of Resident D's medication administration with Registered Nurse (RN) 3 on 12/5/24 at 9:00 a.m. RN 3 was observed finishing up with administering medications to another resident. After the administration, RN 3 hugged the resident. She then went back to the medication cart and pulled and prepared Resident D's medication. During that time, RN 3 pulled medication packages from the cart. After review, she then removed the pill medications from the packets and dropped them in two mediation cups. One medication cup was for tablets and the other medication cup was for three capsule pill medications. She then crushed the tablet medications. After, RN 3 using her bare hands, removed the three capsule medications in the other medication cup and emptied two of the three capsules into the crushed medications cup. The third capsule was unable to opened. So, RN 3 grabbed a pair of scissors in the medication cart drawer and cut the capsule using the scissors. RN 3 indicated at that time, she always had to cut the third capsule with scissors. There was no observation of disinfecting the scissors prior to cutting the capsule. After preparing the medications, she went into Resident D's room and administered the medications. RN 3 had picked up a straw and removed the paper covering with her bare hands, touching the mouth portion of the straw, and placed in a cup of water for resident to use. There were no observations of hand hygiene prior, during, or after medication administration of Resident D's medications. 2. The clinical record for Resident 11 was reviewed on 12/4/24 at 2:30 p.m. The diagnoses included, but were not limited to, diabetes mellitus. An observation was conducted of medication administration for Resident 11 with RN 3 on 12/5/24 at 9:15 a.m. RN 3 was observed preparing Resident 11's medications. During that time, she pulled pill medications from medication packets and eye drops. She then entered the resident's room and administered the pill medications. After, she administered the resident's eye drops. RN 3 was not observed utilizing hand hygiene prior or after administering the pill mediations and/or the resident's eye drops. 3. The clinical record for Resident 8 was reviewed on 12/4/24 at 2:45 p.m. The diagnoses included, but were not limited to, depression. A medication administration was observed for Resident 8 with RN 3 on 12/5/24 at 9:25 a.m. RN 3 was observed pulling and preparing the resident's medication. During that time, RN 3 had touched her nose and then utilized hand sanitizer on the wall. After, she returned to the medication cart and continued to pull and prepare Resident 8's pill medications. Prior to entering the resident's room, RN 3 had dropped an empty pill medication packet on the floor. She picked up the empty medication package and discarded it in the trash. She then went into the resident's room and administered the pill medication to Resident 8. There was no observation of hand hygiene after picking up the pill package off the floor. 4. The clinical record for Resident 12 was reviewed on 12/4/24 at 2:55 p.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD). An observation was made of medication administration for Resident 12 with RN 3 on 12/5/24 at 9:36 a.m. After administering Resident 8's medications, RN 3 immediately went to Resident 12's bedside. At that time, she obtained Resident 12's vital signs utilizing a Dinamap machine (a mobile monitor to electronically measure blood pressure, pulse, oxygen saturations and temperature). During that time, she removed the protective sleeve on the thermometer that was in the resident's mouth and discarded it on the Dinamap. After, she then went to the medication cart and pulled and prepared Resident 12's medication. RN 3 was observed pulling apart a capsule pill medication with her bare hands and emptying the contents in a medication cup. After, she then returned to Resident 12's room and administered the medications. There was no hand hygiene after the administration of medications to Resident 8 and/or prior to obtaining vitals for Resident 12. 5. The clinical record for Resident 19 was reviewed on 12/4/24 at 3:10 p.m. The diagnoses included, but were not limited to, stroke. An observation was made of an insulin medication administration for Resident 19 with RN 3 on 12/5/24 at 11:33 a.m. RN 3 was observed gathering supplies that included: glucometer, lancet, insulin flexpen medication, alcohol wipes, needle, and gloves for Resident 19 at the medication cart. After, she entered Resident 19's room and donned on gloves. There was no hand hygiene prior to donning on the gloves. She then obtained the resident's blood sugar reading utilizing the glucometer and administered the insulin in the resident's abdomen. After, she left the room and returned to the medication cart with her gloved hands. There was no observation of hand hygiene prior to donning on the gloves or prior to leaving the resident's room. An interview was conducted with RN 3 on 12/5/24 at 11:35 a.m. She indicated she had washed her hands prior to gathering the resident's supplies in the medication cart. An interview was conducted with Nurse Consultant (NC) 8 on 12/5/24 at 3:05 p.m. She indicated hand hygiene should be utilized between residents. RN 3 should have donned on gloves prior to eye drop administration and should not be touching pill medications with her bare hands. A medication administration policy was provided by the Director of Nursing (DON) on 12/6/24 at 9:57 a.m. It indicated the following, .Purpose: To administer all medications safely and appropriately to aid residents to over illness, relieve and prevent symptoms, and help in diagnosis .Procedure . 1. Wash hands before beginning, whenever you contaminate your hands, and if contact is made with the medication An eye drops administration policy was provided by the DON on 12/6/24 at 9:57 a.m. It indicated the following, .Purpose: The appropriate and safe administration of liquid ophthalmic medication (eye drops) as a local anesthesia to facilitate eye examination, for therapeutic treatment, or for help in the production of tears. Procedure: 1. Follow general medication administration policy and procedures. 2. Proper hand washing before and after administration . 3.1-18(b)(1) 3.1-18(l)

Based on observation, interview, and record review, the facility failed to timely inform the physician of changes in a resident's pain for 1 of 2 residents reviewed for pain. (Resident 13) Findings include: The clinical record for Resident 13 was reviewed on 12/4/24 at 2:41 p.m. The diagnoses included, but were not limited to, hypertension and heart failure. A physician's order, dated 6/16/23, indicated he could receive hydrocodone-acetaminophen (narcotic pain medication) 5-325 milligrams (MG); one tablet every six hours as needed for pain. A care plan, last revised on 10/23/24, indicated he was at risk for pain related to weakness and impaired mobility. The goal was for him to be free of pain with interventions as needed. The interventions included, but were not limited to, give medications as ordered, notify physician of uncontrolled pain, observe for effectiveness of interventions, and observe for signs and symptoms of pain. A Quarterly Minimum Data Set (MDS) assessment, completed 11/10/24, indicated he had moderately impaired cognition. He received scheduled and as needed pain medications. He experienced pain occasionally, which did not interfere with sleep or daily activities. His pain was rated as a 5 on a pain scale of 1 to 10 (10 being severe pain). A physician's order, dated 11/12/24, indicated he was to receive acetaminophen extra strength 500 mg: two tablets three times daily for pain. A Nurse Practitioner progress note, dated 11/12/24, indicated Resident 13 had been complaining of quite a bit more pain lately. His Norco (hydrocodone- acetaminophen) was refilled. He reported pain in his knees. A Nurse Practitioner progress note, dated 11/19/24, indicated Resident 13 had osteoarthritis, managed with Tylenol 1000 MG three times daily and had Norco for as needed (PRN) use. A new script had been sent recently. The assessment and plan indicated he had pain and to continue Tylenol 1000 mg three times daily and to continue Norco PRN. The clinical record contained Nurse Practitioner Progress notes, dated 11/21/24 and 11/26/24, which did not contain information about increased pain or discomfort. The November and December Medication Administration Records (MAR) indicated Resident 13 had received hydrocodone- acetaminophen 5-325 mg on the following days: 11/1/24 - once for pain level of 7. 11/2/24 - once for pain level of 7, 11/3/24 - twice for pain level of 5 and for pain level of 6, 11/5/24 - twice for pain level of 5 and pain level of 6, 11/6/24 - once for pain level of 5, 11/9/24 - twice for pain level of 5 and pain level of 5, 11/11/24 - twice for pain level of 5 and pain level of 7, 11/12/24 - once for pain level of 6, 11/16/24 - once for pain level of 6, 11/28/24 - twice for pain level of 5 and pain level of 5, 11/29/24 - twice for pain level of 8 and pain level of 6, 11/30/24 - three times for pain level of 6, pain level of 5, and pain level of 4, 12/1/24 - twice for pain level of 8 and pain level of 7, 12/2/24 - three times for pain level of 7, pain level of 8 and pain level of 8, 12/3/24 - twice for pain level of 6 and pain level of 8, and 12/4/24- twice for pain level of 5 and pain level of 8. On 12/4/24 at 2:41 p.m., Resident 13 was observed lying in bed in his room. He was grimacing and moaning out. Family Member (FM) 1 was at bedside and indicated Resident 13 was in a lot of pain and was being evaluated by hospice so he could receive stronger pain medications. During an interview on 12/5/24 at 2:25 p.m., FM 1, FM 2, and FM 3 indicated Resident 13 had been in a lot of pain off and on for several weeks. They had just enrolled him in hospice so he could have his pain managed better. During an interview on 12/5/24 at 2:40 p.m., Certified Nursing Assistant (CNA) 12 indicated Resident 13 had been experiencing more pain in the last few weeks. She had informed the nurses of his increased pain. During an interview on 12/5/24 at 2:41 p.m., Registered Nurse (RN) 3 indicated the Nurse Practitioner had been informed Resident 13 was having a lot of pain, and the Norco was not effectively treating the pain. He had been out of Norco for a while, but it had been refilled and the nursing staff were trying to administer it every six hours to assist with his pain control. Resident 13 had been experiencing pain in his groin area. During an interview on 12/6/24 at 10:17 a.m., Registered Pharmacist 15 indicated a refill of 24 tablets of hydrocodone- acetaminophen 5-325 mg had been sent to the facility on [DATE]. The next refill of hydrocodone- acetaminophen 5-325 mg had been sent on 11/26/24. A controlled drug form, dated 10/27/24, indicated 24 tablets of hydrocodone- acetaminophen had been delivered to the facility on [DATE]. The last dose had been administered on 11/12/24. A controlled drug form, dated 11/26/24, indicated 30 tablets of hydrocodone- acetaminophen had been delivered to the facility on [DATE]. The clinical record did not contain any other controlled drug forms indicating any hydrocodone- acetaminophen had been delivered to the facility from 11/12/24 through 11/26/24. The clinical record did not contain documentation that the physician and/or nurse practitioner had been informed of Resident 13 not having any hydrocodone in the facility from 11/12/24 through 11/26/24. The clinical record did not contain documentation the physician and/or nurse practitioner had been informed of Resident 13's increased pain. On 12/6/24 at 10:39 a.m., the Director of Nursing provided the Guidelines for Pain Management policy, dated 9/1/23, which read, .It is the intent of the facility to promote resident independency, comfort, and to preserve resident dignity in the ongoing effort to promote the highest level of quality for their lives. One aspect of this commitment is to maintain an effective pain management plan . Physician Communication and Involvement Pain will be assessed and managed in a timely manner, to include pain that is 'new' and of a recent onset. The physician will be notified of a resident's onset of 'new' pain and also of pain not being relieved by the interventions .PRN Pain Medications .If a resident requests prn pain medications 3-4 times a day for 3-4 days in a row- the physician should be notified for directions/ orders to include the possibility of regularly scheduled pain medications or a change in the current order for pain medications 3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure a homelike environment with residents' rooms that were not in good repair for 3 of 20 residents' rooms observed. (Residents' F, C and B) Findings include: 1. The clinical record for Resident B was reviewed on 12/4/24 at 11:30 a.m. The diagnoses included, but were not limited to, dementia. A Quarterly Minimum Data Set (MDS) assessment, dated 11/10/24, indicated Resident B was cognitively impaired. An observation was made of Resident B's room on 12/5/24 at 12:38 p.m. The windowsill was observed gouged and chipped. An interview was conducted with Resident B's Representative on 12/5/24 at 12:40 p.m. He indicated the room needed repairs. The windowsill had a gouge. 2. The clinical record for Resident F was reviewed on 12/4/24 at 3:19 p.m. The diagnoses included, but were not limited to, dementia. A Quarterly MDS assessment, dated 10/14/24, indicated Resident F was cognitively intact. 3. The clinical record for Resident C was reviewed on 12/4/24 at 3:25 p.m. The diagnoses included, but were not limited to, hypertension. An observation was made of Resident C and Resident F's room on 12/4/24 at 3:19 p.m. Resident C's side of room had scrapes and missing paint on back and side wall by an electrical outlet that was pulling away from the wall. Resident F's side of the room had a missing trim piece and a large yellow in color oblong shaped ring on the white ceiling. An environmental tour was conducted with the Executive Director (ED) on 12/9/24 at 1:53 p.m. Resident B's room was observed with gouged windowsill. Resident F and Resident C's room was observed with scrapes and missing paint on back and side walls by the electrical outlet of Resident C's side of the room. Resident F's side of the room was observed with a large oblong shaped yellow in color ring on the white ceiling and the trim was missing on the chair rail. An interview was conducted with Resident F on 12/9/24 at 1:55 p.m. She indicated the yellow ring on the ceiling had been there ever since she had been in the facility. She had been in the facility for approximately a year. An interview was conducted with the ED on 12/9/24 at 2:00 p.m. The ED indicated the facility was currently going through remodeling of the building. She had spoken with the maintenance director and Residents' F, B and C's rooms were on his list for repairs, but he had not gotten to them yet. A homelike environment policy was provided by the ED on 12/9/24 2:15 p.m. It indicated the following, .Policy: It is the policy of the facility to ensure that the environment provided by the facility is safe, sanitary, functional and comfortable .23) All room contents to include clothes, furniture, devices, linens, bedspreads, privacy curtains, window coverings, wall hangings, wall paper and floors should be clean and in good repair. This citation relates to Complaint IN00440964. 3.1-19(f)(5)

Based on interview and record review, the facility failed to ensure a resident was treated with dignity and respect for 1 of 1 resident reviewed for dignity. (Resident 11) Findings include: The clinical record for Resident 11 was reviewed on 12/4/24 at 12:07 p.m. The diagnoses included, but were not limited to, diabetes and depression. A Quarterly Minimum Data Set (MDS) assessment, completed 11/10/24, indicated she was cognitively intact and dependent on staff for toileting. During an interview on 12/4/24 at 12:07 p.m., Resident 11 indicated a staff member had spoken to her disrespectfully while performing incontinent care. Resident 11 had put her call light on, around 10:00 p.m., and the staff member had come into the room to answer the call light. Resident 11 had told the staff member she needed to be cleaned up after having a bowel movement. The staff member asked her if she waited till 10:00 p.m. to (expletive). There was another staff member present when the incident happened. The incident happened the night before and she had informed the management staff that morning. On 12/4/24 at 12:22 p.m., the Executive Director (ED) provided a reportable incident form, dated 12/4/24 at 7:30 a.m., which indicated Resident 11 had notified the ED of a concern related to care involving Qualified Medication Aide (QMA) 6. The immediate action taken was to suspend QMA 6 immediately pending an investigation. The physician and Director of Nursing (DON) were notified. During an interview on 12/9/24 at 12:02 p.m., Certified Nursing Assistant (CNA) 7 indicated she had been present during the incident between Resident 11 and QMA 6. QMA 6 had asked Resident 11 why she always turned the call light on, at 10:00 p.m., to be changed. QMA 6 had begun to provide incontinent care and Resident 11 indicated QMA 6 was being too rough. QMA 6 told Resident 11 she had to get the (expletive) off. Resident 11 had made another comment to QMA 6 and QMA 6 asked CNA 7 to finish the incontinent care for Resident 11 and exited the room. Resident 11 asked if she had done something wrong, and if QMA 6 was having a bad night. QMA 6 was unavailable for interview. On 12/9/24 at 3:39 p.m., the Director of Nursing provided the Guidelines for Observing and Implementing Resident Rights, dated 7/12/24, which read, .Each resident has the right to be treated with dignity and respect. Any interaction between a resident and a staff member .must be conducted in such a way as to enhance the residents' self- esteem and self-worth while meeting the resident's needs. The preferences and goals of the resident should be honored as much as possible and the resident's comfort, safety and overall welfare must be promoted, protected, and enhanced at all times . 3.1-3(t)

Based on interview and record review, the facility failed to ensure orthostatic blood pressures were properly obtained and to obtain blood pressure and pulse, as ordered by the physician, prior to administering medication for 1 of 1 resident reviewed for death and 1 of 1 resident reviewed for behaviors. (Resident 17 and Resident 20) Findings include: 1. The clinical record for Resident 17 was reviewed on [DATE] at 11:19 a.m. The diagnoses included, but were not limited to, atrial fibrillation (abnormal heartbeat), and hypertension. She died at the facility on [DATE]. A care plan, last revised [DATE], indicated Resident 17 was at risk for falls related to dementia, atrial fibrillation, and history of falls. The goal was for her to have no injuries due to falls. The interventions included, but were not limited to, attempt to keep areas free of clutter and to notify and update physician as needed. A Quarterly Minimum Data Set (MDS) assessment, completed [DATE], indicated she was cognitively intact, needed moderate assistance of staff with walking in her room, and had one fall without injury since the prior assessment. An incident note, dated [DATE] at 11:29 a.m., indicated a nursing assistant had called the nurse to the shower room because Resident 17 had fallen. Resident 17 was assessed for injuries. Resident 17 indicated she was fine and not hurt. Resident 17 was assisted up and walked back to her room. Resident 17 was sitting in her recliner relaxing. An Interdisciplinary Team (IDT) Post Fall Review, dated [DATE], indicated that Resident 17 had become dizzy when reaching for her walker, slipped and fell in the shower room. The IDT recommended orthostatic blood pressures should be completed for 72 hours. A physician's order, dated [DATE], indicated to measure orthostatic blood pressure every shift for dizziness for three days. Check blood pressure after laying down for five minutes. A physician's order, dated [DATE], indicated to measure orthostatic blood pressure every shift for dizziness for three days. Check blood pressure after standing up for one minute from a lying position. A physician's order, dated [DATE], indicated to measure orthostatic blood pressure every shift for dizziness for three days. Check blood pressure after standing up for three minutes from a lying position. The [DATE] Medication Administration Record (MAR) indicated the orthostatic blood pressure, obtained on day shift of [DATE] by Registered Nurse (RN) 3, was documented as being ,d+[DATE] after lying for five minutes, after standing from a lying position of one minute, and after standing from a lying position for three minutes. The November MAR did not contain orthostatic blood pressure readings, on [DATE], during the day shift. A physician's order, dated [DATE], indicated she was to receive metoprolol tartrate (heart medication) tablet 50 milligram (MG) by mouth twice a day for hypertension. Instructions were to hold if systolic blood pressure (upper reading of blood pressure) (SBP) was less than 100 or if heart rate was less than 60. The [DATE] MAR did not contain documentation of a pulse rate being obtained prior to administering the Metoprolol in the evening, on [DATE], or prior to the morning and/or evening administrations on [DATE]. During an interview on [DATE] at 1:56 p.m., Registered Nurse (RN) 3 indicated she took the orthostatic blood pressure when the resident was standing, sitting, and lying down. 2. The clinical record for Resident 20 was reviewed on [DATE] at 2:15 p.m. The diagnoses included, but were not limited to, hypertension and anemia. A Quarterly MDS assessment, completed [DATE], indicated he was moderately cognitively impaired. A care plan, last revised [DATE], indicated he was at risk for elevated blood pressure related to hypertension. The goal was for his blood pressure to remain within normal limits. The interventions included, but were not limited to, administer medication as ordered by the physician, check for blood pressure parameters, and monitor blood pressure prior to administering, if indicated. A physician's order, dated [DATE], indicated he was to receive metoprolol succinate ER (extended-release heart medication) 25 MG twice daily for hypertension. The instructions were to hold the medication for SBP less than 100 or heart rate less than 60. The November and December MAR did not contain documentation of the blood pressure and/or heart rate readings prior to administering the metoprolol twice daily from [DATE] through [DATE]. During an interview on [DATE] at 2:38 p.m., the Director of Nursing indicated the directions for obtaining the orthostatic blood pressures were specified in the physician's order, and if an order contains parameters, the vitals should be taken and documented prior to administration and held as ordered. 3XXX,d+[DATE](a)

Based on observation, interview and record review, the facility failed to post the facility's nursing staffing for five (5) consecutive dates. This deficient practice has the potential to adversely affect all residents. Findings include: On 4-24-24 at 9:55 a.m., the facility's posted staffing was observed to be located by the nursing station. The posted staffing dates were for 4-18-24 and 4-19-24. This posting was unchanged at an observation conducted on 4-24-24 at 1:35 p.m. This posting was updated as of an observation on 4-25-24 at 1:56 p.m., to the current date of 4-25-24. In an interview with the Executive Director on 4-25-24 at 4:30 p.m., she indicated she has been conducting the nursing work schedules for some time at the facility. In an interview with the Executive Director on 4-25-24 at 4:45 p.m., she indicated had not noticed the daily posted nursing staffing sheets were not current. This Federal tag relates to Complaints IN00430719 and IN00432008. 3.1-17(a)

Based on interview and record review, the facility failed to protect the resident's right to be free from verbal and physical abuse of a staff member towards a resident for 1 of 3 residents reviewed for abuse. (Resident D, CNA 6) Findings include: The clinical record of Resident D was reviewed on 4-26-24 at 9:43 a.m. Her diagnoses included, but were not limited to cerebral infarction due to occlusion or stenosis of MCA (middle cerebral artery) affecting the non-dominant left side with hemiplegia and hemiparesis. A review of Resident D's most recent Minimum Data Set assessment, dated 2-6-24, indicated her cognitive status was moderately impaired, she was non-ambulatory, used a wheelchair with assistance of 1 person for wheelchair mobility, required substantial assistance with bed mobility and was dependent for toileting needs and bathing assistance. In an interview with the Executive Director (ED) on 4-24-24 at 10:35 a.m., she indicated the facility recently had a new employee, CNA 6. She further explained the facility had received a report of rough treatment during care of a resident by a staff member, CNA 6. The ED summarized CNA 6 was was terminated due to inappropriate language and intimidation and with her being on orientation, or just off of orientation, she was terminated due to the facility's zero tolerance policy towards abuse. The ED indicated she had submitted a report of the incident to the Indiana Department of Health's Long-Term Care Division on the same date the facility received the allegation of abuse. In an interview on 4-24-24 at 2:20 p.m., with Resident D, she indicated she is generally speaking, treated very well and very professionally, with one exception. She explained, recently, a new aide got upset with me when she was trying to roll me over [for incontinence care] and I told her it was hurting me. Sometimes, my joints just hurt and she just kept going on. She just didn't listen to me. Just kind of hurrying things along. So, I spoke with the administrator about it. I told her that I didn't want the girl punished, just talk to her about not rushing so much and listen to what people tell her. Well, later that day, she came back to me and told me, kind of hateful like, that she thought it awful that I told on her and now she was in trouble. She just stood in the doorway and kind of hollered at me, she definitely raised her voice to me. Later, when I was talking to somebody, I found out they let her go. I hate that, but you can't treat people that way. She added, due to the Administrator taking care of issues so quickly, she has no further concerns related abuse or neglect. By the administrator taking care of things so quick, it shows me they mean business and take care of things like they should. A review of CNA 6's employee file indicated she was hired on 4-10-24. Her employee file indicated she had completed education regarding resident rights, abuse prohibition and six hours of dementia care training on or before her hire date. A Personnel Change Form, dated 4-19-24 and 4-20-24, indicated CNA 6 was terminated, effective 4-19-24, by the facility for Violation of company policy. The investigative file of the allegation of abuse indicated the state reportable was faxed to the, Indiana Department of Health's Long-Term Care Division on 4-19-24, follow-up interviews with other residents regarding abuse were conducted, staff education was conducted with facility staff on 4-22-24, pre-employment screening for certification validity, criminal background check and reference checks, and Resident D was monitored for a minimum of 72 hours for any negative effects after this incident. On 4-25-24 at 1:20 p.m., the ED provided an undated copy of a policy entitled, Abuse Prevention Program. This policy indicated, to prevent resident abuse, neglect .Each resident receives care and services in a person-centered environment in which all individuals are treated as human beings .Staff members who are suspected of abuse or misconduct shall immediately (regardless of time left on shift) be barred from any further contact with residents of the facility and be suspended from duty, pending the outcome of the investigation, prosecution or disciplinary action against the employee. 3.1-27(a) 3.1-27(b)

Based on interview and record review, the facility failed to implement policies and procedures protecting the resident's right to be free from verbal and physical abuse of a staff member towards a resident for 1 of 3 residents reviewed for abuse. (Resident D, CNA 6) Findings include: The clinical record of Resident D was reviewed on 4-26-24 at 9:43 a.m. Her diagnoses included, but were not limited to cerebral infarction due to occlusion or stenosis of MCA (middle cerebral artery) affecting the non-dominant left side with hemiplegia and hemiparesis. A review of Resident D's most recent Minimum Data Set assessment, dated 2-6-24, indicated her cognitive status was moderately impaired, she was non-ambulatory, used a wheelchair with assistance of 1 person for wheelchair mobility, required substantial assistance with bed mobility and was dependent for toileting needs and bathing assistance. In an interview with the Executive Director (ED) on 4-24-24 at 10:35 a.m., she indicated the facility recently had a new employee, CNA 6. She further explained the facility had received a report of rough treatment during care of a resident by a staff member. The ED summarized CNA 6 was was terminated due to inappropriate language and intimidation and with her being on orientation, or just off of orientation, she was terminated due to the facility's zero tolerance policy towards abuse. The ED indicated she had submitted a report of the incident to the Indiana Department of Health's Long-Term Care Division on the same date as discovery of the allegation of abuse. In an interview on 4-24-24 at 2:20 p.m., with Resident D, she indicated she is generally speaking, treated very well and very professionally, with one exception. She explained, recently, a new aide got upset with me when she was trying to roll me over [for incontinence care] and I told her it was hurting me. Sometimes, my joints just hurt and she just kept going on. She just didn't listen to me. Just kind of hurrying things along. So, I spoke with the administrator about it. I told her that I didn't want the girl punished, just talk to her about not rushing so much and listen to what people tell her. Well, later that day, she came back to me and told me, kind of hateful like, that she thought it awful that I told on her and now she was in trouble. She just stood in the doorway and kind of hollered at me, she definitely raised her voice to me. Later, when I was talking to somebody, I found out they let her go. I hate that, but you can't treat people that way. She added, due to the Administrator taking care of issues so quickly, she has no further concerns related abuse or neglect. By the administrator taking care of things so quick, it shows me they mean business and take care of things like they should. The investigative file of the allegation of abuse indicated the state reportable was faxed to the, Indiana Department of Health's Long-Term Care Division on 4-19-24, follow-up interviews with other residents regarding abuse were conducted, staff education was conducted with facility staff on 4-22-24, pre-employment screening for certification validity, criminal background check and reference checks, and Resident D was monitored for a minimum of 72 hours for any negative effects after this incident. A review of CNA 6's employee file indicated she was hired on 4-10-24. Her employee file indicated she had completed education regarding resident rights, abuse prohibition and six hours of dementia care training on or before her hire date. A Personnel Change Form, dated 4-19-24 and 4-20-24, indicated CNA 6 was terminated, effective 4-19-24, by the facility for Violation of company policy. On 4-25-24 at 1:20 p.m., the ED provided an undated copy of a policy entitled, Abuse Prevention Program. This policy indicated, to prevent resident abuse, neglect .Each resident receives care and services in a person-centered environment in which all individuals are treated as human beings .Staff members who are suspected of abuse or misconduct shall immediately (regardless of time left on shift) be barred from any further contact with residents of the facility and be suspended from duty, pending the outcome of the investigation, prosecution or disciplinary action against the employee. 3.1-27(a)(1) 3.1-27(b)

Based on interview and record review, the facility failed to ensure adequate nursing staff coverage for the long-term care portion of the facility, as well as for the secured dementia care unit of the facility for 1 of 1 night shift and for the 17 residents of the long-term care portion of the building and for 7 residents of the facility's secured dementia care unit of the facility. Findings include: In an interview with the Executive Director (ED) on 4-25-24 at 2:50 p.m., she indicated around the end of March and beginning of April of 2024, only one RN 4 and one CNA 3 were on duty for the night shift. She shared that on that particular night, CNA 3 called her around 11:00 p.m., to discuss some concerns she had regarding the facility. During the conversation, she mentioned that the memory care unit wasn't staffed and there was only a nurse and aide in the building and the door of the memory care unit was open and unlocked. I immediately came into the building. When I got here, I found the memory care unit door open to the long term care unit and obviously unlocked. [Names of RN 4 and CNA 3] were both on the long term care unit at that time. They explained that since they were the only two staff here, that was the best way to handle the situation. I immediately sent the nurse to the memory care unit and the memory care unit door was closed and locked. I had no idea any of this was going on until that moment. I have no idea how long this had been going on. Our census on that date was 22. She indicated she remained in the building for the rest of that shift and she noted none of memory care unit residents were up or wandering about. In a confidential interview, they indicated, It's not happened often, but there have been a few times where the locked unit has not had a staff person for night shift .I couldn't give you a date, but I am aware of a time or two when the locked unit was left unlocked when I have checked it when I come in at 6 am. They indicated they did not report the memory care unit being unlocked to management as they thought management would be aware of this since management puts together the schedules. On 4-26-24 at 10:42 a.m., the ED provided an updated Midnight Census Report, for 3-20-24, indicating the facility's census included 7, memory care unit residents and 17, long-term care unit residents, for a total census of 24 residents. In an interview with the ED on 4-25-24 at 4:30 p.m., she clarified the night shift was the date of 3-20-24 into 3-21-24. The ED indicated shortly thereafter [date unspecified], education with the licensed nurses was conducted regarding notification to management of any changes in the schedule and the memory care unit is to staffed at all times and the door is to be secured/locked at all times. 4-30-24 at 4:30 p.m., the ED indicated, My expectations for the memory care unit is that it be locked/secured at all times and there be a nurse or aide present at all times. On 4-25-24 at 5:06 p.m., the ED provided a copy of a document entitled, Facility Assessment Tool, with a revision date of 10-17-23. This document indicated the facility's staffing plan as, based on your resident population and their needs for care and support, describe your general approach to staffing to ensure that you have sufficient staff to meet the needs of the residents at any given time, includes, but does not limit the nursing staffing to, 1 Nurse Nights .and 1 [nurse aide] nights, with staffing ratios of 1.25 licensed nurse and 1.25 certified nursing assistant for every 25 residents. [Name of the memory care unit] will always have a minimum of: Nurse or QMA on days/evenings [and] Night staff aide on-site related to census. This Federal tag relates to Complaint IN00431980. 3.1-17(b)(1) 3.1-17(c)(2)

Based on observation, interview and record review, the facility failed to develop a care plan for 1 of 3 residents reviewed for incontinence care related to urinating in inappropriate locations of the facility. (Resident B) Findings include: The clinical record of Resident B was reviewed on 10-10-23 at 10:46 a.m. His diagnoses included, but are not limited to, unspecified encephalopathy, nontraumatic subdural hematoma, hydrocephalus, Alzheimer's disease, anoxic brain damage, repeated falls, dementia and incontinence. His most recent Minimum Data Set assessment, dated 8-16-23, indicated he is severely cognitively impaired, he is ambulatory, he wanders about the facility and is incontinent of bowel and bladder. Observations of Resident B and his room was conducted on 10-10-23 at 12:15 p.m., 10-10-23 at 1:55 p.m., 10-11-23 at 3:50 p.m., 10-12-23 at 9:15 a.m., 10-12-23 at 10:08 a.m., and 10-12-23 at 11:30 a.m., which indicated a urine odor was present. In an interview with the Activity Director on 10-11-23 at 3:50 p.m., she indicated the facility was aware of the urine odor in the room. She added Resident B is frequently incontinent of urine. In an interview on 10-12-23 at 11:50 a.m., with the Administrator and DON, the Administrator indicated the facility's expectations are if an odor is noticed, the facility tries to get it addressed. We have cleaned the room at least twice a day, usually morning and afternoon. We have changed out the mattress, cleaned the PTAC (heating and air conditioning unit), as well as conducting additional cleaning & mopping. The DON shared she keeps a container of a odor remover in her office, located across from Resident B's room in which she sprays his room several times a day when he is not in the room. I would guess it's been about 2 weeks ago that we began to notice a urine odor in his room and it has progressively gotten worse. She added the facility has identified Resident B has urinated in his bathroom and behind the bathroom door and in the trash can; has even urinated in the business office. The business office manager was present at the time and he did not seem to notice she was present. He had been sitting in her office, then got up and urinated behind her and she happened to look over her shoulder and saw him urinating .He has urinated in the resident common area, has urinated in the east hall down by the doors and in the main copy room .Since he came in [admitted to the facility], he has urinated in inappropriate places at times. A review of the clinical record failed to locate a care plan related to Resident B urinating in inappropriate locations. In an interview with the DON on 10-12-23 at 12:12 p.m., she indicated she could not locate a care plan for this issue. On 10-12-23 at 12:58 p.m., the Administrator provided a copy of a policy entitle, Baseline Care Plan Assessment/Comprehensive Care Plans, with a revision date of 11-25-2017. This policy indicated, It is the policy of the facility to ensure that every resident has a Baseline Care Plan completed and implemented within 48 hours of Admission .The Baseline Care Plan will continue to be updated with changes in risk factors, goals and interventions until the Comprehensive Care Plan is completed .The Comprehensive Care Plan will further expand on the resident's risks, goals and interventions using the 'Person-Centered' Plan of Care approach for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, physical functioning, mental and psychosocial needs. These needs will be defined from observation, interviews, clinical medical record review and through assessments and CAA's. The facility interdisciplinary team in conjunction with the resident, resident's family, surrogate or representative as appropriate along with a 'hands on caregiver, such as a Certified Nursing Assistant will discuss and develop quantifiable objectives along with appropriate interventions in an effort to achieve the highest level of functioning and the greatest degree of comfort/safety and overall well-being attainable for the resident. This Federal tag relates to Complaint IN00417042. 3.1-35(a) 3.1-35(b)(1)

Based on observation, interview and record review, the facility failed to ensure an odor-free room environment for 1 of 3 residents reviewed for a home-like and clean environment. (Resident B) Findings include: An observation of Resident B and his room was conducted on 10-10-23 at 12:15 p.m. A strong urine odor was present in his room at that time. A second observation of Resident B and his room was conducted on 10-10-23 at 1:55 p.m. A strong urine odor remained at that time. In an observation of Resident B and his room on 10-11-23 at 3:50 p.m., the room remained with a strong urine odor present. In an interview at this time with the Activity Director, she indicated the facility was aware of the urine odor in the room and questioned if his bed mattress might be causing the odor as Resident B is frequently incontinent of urine. The Activity Director indicated the housekeeping staff mop Resident B's floor at least twice daily to minimize odor. In an interview on 10-11-23 at 4:10 p.m., with the Director of Nursing (DON), she indicated the facility just received a new mattress for Resident B and were waiting for him to wake up, in order to replace the mattress. In an observation on 10-12-23 at 9:15 a.m., Resident B was seated in dining room with the Activity Director present with him. There was no unpleasant odor present at this time. During an observation of Resident B's room on 10-12-23 at 10:08 a.m., a Wet Floor sign was located at the room entrance with the room's floor obviously wet. Resident B was walking in the hallway with a male employee. This employee indicated Resident B's room's floor had been cleaned [mopped] twice that morning. A faint urine odor remained in the room with an obvious cleaning solution odor present. During an observation at 10-12-23 at 11:30 a.m., Resident B was in his room with a male employee present. The Wet Floor sign was no longer present and the floor was dry. A strong urine odor remained. In an interview with the Assistant Director of Nursing (ADON) on 10-12-23 at 10:20 a.m. She indicated Resident B's bed mattress was replaced yesterday afternoon. In an interview on 10-12-23 at 11:10 a.m., with the Administrator and DON, the DON indicated at that time, the facility will more than likely have to take up the current laminate flooring and remove it in order to get rid of the odor. The DON shared the facility recently had a similar situation in another resident room in which a resident urinated on the floor and the urine had seeped under the laminate, requiring the facility to remove the flooring in that room, clean the underlayment and replace the flooring in order to accomplish getting rid of the urine odor. In an interview on 10-12-23 at 11:50 a.m., with the Administrator and DON, the Administrator indicated the facility's expectations are if an odor is noticed, the facility tries to get it addressed. She added the facility has Resident B's room cleaned at least twice a day, usually morning and afternoon. and interventions have included, but not limited to, changing out the mattress, cleaning the PTAC (heating and air conditioning unit), as well as conducting additional cleaning and mopping. The DON shared she keeps a container of a odor remover in her office, located across from Resident B's room, in which she sprays his room several times a day when he is not in the room. I would guess it's been about 2 weeks ago that we began to notice a urine odor in his room and it has progressively gotten worse. She added the facility has identified Resident B has urinated in his bathroom and behind the bathroom door and in the trash can; has even urinated in the business office. The business office manager was present at the time and he did not seem to notice she was present. He had been sitting in her office, then got up and urinated behind her and she happened to look over her shoulder and saw him urinating .He has urinated in the resident common area, has urinated in the East hall down by the doors and in the main copy room .Since he came in, he has urinated in inappropriate places at times. The clinical record of Resident B was reviewed on 10-10-23 at 10:46 a.m. His diagnoses included, but are not limited to, unspecified encephalopathy, nontraumatic subdural hematoma, hydrocephalus, Alzheimer's disease, anoxic brain damage, repeated falls, dementia and incontinence. His most recent Minimum Data Set assessment, dated 8-16-23, indicated he is severely cognitively impaired, he wanders about the facility and is incontinent of bowel and bladder. On 10-12-23 at 11:32 a.m., the Administrator provided a copy of a procedure entitled, General Cleaning Policies and Procedures [for] Resident Room - Clean. This procedure outlined the steps to provide a clean, attractive and safe environment for residents, visitors and staff. The procedure included step-by-step instructions on how to clean a resident's room and bathroom. In an interview on 10-12-23 at 11:50 a.m., with the Administrator and DON, the Administrator indicated the facility's expectations are if odors are noticed, the facility will attempt to address the odors. This Federal tag relates to Complaint IN00417042. 3.1-19(f)(5) 3.1-19(m)2)

Based on observation, interview, and record review, the facility failed to ensure a foley catheter drainage bag was covered, to provide dignity, for a resident with a foley catheter for 1 of 1 residents reviewed for catheters. (Resident 75) Findings include: Resident 75's record was reviewed on 8/30/23, at 1:23 p.m. The record indicated Resident 75 had diagnoses that included, but were not limited to, bone infection of the lower vertebra, protein-calorie malnutrition, type 2 diabetes mellitus, heart disease, pressure ulcer of the sacral region, chronic kidney disease, heart disease and high blood pressure. A care plan, dated 8/24/23, indicated a focus for at risk for complications related to foley catheter use, and included, but was not limited to interventions of monitor position of drainage bag and keep below waist to ensure proper drainage. Current physician's orders included: Catheter care every shift and ensure catheter drainage bag is below the waist and covered every shift. With a start date of 8/23/2023 On 8/31/23, at 10:08 a.m., the catheter drainage bag was observed uncovered, and hung on the bed frame on the side of the bed that faced the door. On 8/31/23, at 11:46 a.m., the catheter drainage bag was observed uncovered on the side of the bed that faced the door. On 8/31/23, at 11:49 a.m., LPN 1 indicated they usually have a bag covering the catheter bag. LPN 1 checked the resident's catheter drainage bag, removed a dignity cover that was attached to the bed frame on the window side of the bed, and placed the catheter bag in it. A policy for catheter use was provided by the Administrator on 9/1/23 at 1:57 p.m. The policy included, but was not limited to: .4. Insertion, ongoing care and catheter removal protocols that adhere to professional standards of practice and facility policy and procedure with adherence to infection prevention and control techniques 3.1-3(v)(1)

Based on interview and record review, the facility failed to assess and document bruising on a cognitively impaired resident for 1 of 2 residents reviewed. (Resident 74) Findings include: During an interview, on 8/29/23, at 1:36 p.m., Resident 74 indicated he had a bruise on his left wrist and doesn't know how he got it. The left wrist was observed to have a purple bruise that was slightly larger than a half dollar. Resident 74's record was reviewed on 8/30/23 at 2:23 p.m. The record indicated Resident 74 had been admitted on [DATE] and had diagnoses that included, but were not limited to, low back pain, permanent atrial fibrillation, heart disease, Alzheimer's disease, high blood pressure and presence of a cardiac pacemaker. Review of Daily Skilled Nursing Notes dated 8/26/23, 8/27/23, 8/28/23, 8/29/23, and 8/30/23, indicated no skin issues were assessed or documented, including bruising. There was no documentation in the progress notes of the bruising. On 9/01/23, at 1:05 p.m., Resident 74's left wrist was observed with the Director of Nurses and the Administrator. Resident 74 had two bruises; the bruise on his wrist and another bruise on the back of his hand/wrist area. The Director of Nurses indicated the newer bruise was from a blood draw and the bruise had a needle puncture wound. The bruise that had been observed earlier had dark purple undertones with reddened areas on top. Resident 74 indicated he didn't know how it happened. A policy for Skin Observation/Assessment, was provided by the Administrator on 9/1/23 at 1:57 p.m. The policy included, but was not limited to: It is the policy of the facility to ensure that each resident is provided with showers and or baths to maintain proper hygiene as well as comfort. During the shower/bath, the care giver will observe the resident's skin. Conditions that will be observed for include but are not limited to what appear to the care giver to be cruises, red areas, open areas, scratches, abrasions, blisters, discoloration, dry flaky skin, pressure ulcers, scars as well as any other conditions of the skin. Note: Only licensed nurses can assess the skin. If the care giver is not a nurse and they observe a change in the resident's skin, the care giver will notify the nurse immediately so that the nurse can perform a skin assessment and notify the physician/family as appropriate and also obtain any needed orders for treatment. Appropriate documentation and care planning will be completed as per policy .4.) Other times that will resident will have a skin assessment will be upon admission, readmission, after a fall or an injury, upon discovery (by a care giver) of a skin change, prior to discharge or as indicated with a condition change 3.1-37(a)

Based on observation, interview and record review, the facility failed to ensure a resident had a physician's order for a foley catheter for 1 of 1 residents reviewed for foley catheter use. (Resident 75) Findings include: During an interview, on 8/30/23, at 10:34 a.m., Resident 75 indicated she has a catheter because she can't go, and will have to have it for the rest of her life. A urinary catheter drainage bag was observed attached to the bed frame. Resident 75's record was reviewed on 8/30/23 at 1:23 p.m. The record indicated Resident 75 had diagnoses that included, but were not limited to, bone infection of the lower vertebra, protein-calorie malnutrition, type 2 diabetes mellitus, heart disease, pressure ulcer of the sacral region, chronic kidney disease, heart disease, and high blood pressure. A Care Plan, dated, 8/24/23, indicated a focus for at risk for complications related to foley catheter use, and included, but were not limited to interventions to Monitor position of drainage bag and keep below waist to ensure proper drainage .Monitor indwelling catheter and change foley bag as needed. Change foley every month as ordered Current physician's orders included: Catheter care every shift and ensure catheter drainage bag is below the waist and covered every shift, with a start date of 8/23/2023. Monitor Foley Catheter output every shift every 8 hours started 8/23/23. Physician's orders failed to include the size of the Foley catheter and how many cubic centimeters of water would be used to inflate the balloon to anchor the catheter in place in the bladder. On 9/01/23, at 1:34 p.m., the Administrator indicated the order for the catheter was not in the record, but they put it in. A policy for catheter use was provided by the Administrator on 9/1/23 at 1:57 p.m. The policy included, but was not limited to: It is the policy of the facility to ensure that a resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that Catheterization was necessary .4. Insertion, ongoing care and catheter removal protocols that adhere to professional standards of practice and facility policy and procedure with adherence to infection prevention and control techniques 3.1-41(a)

Based on interview, observation, and record review, the facility failed to ensure oxygen tubing was dated for 1 of 1 residents reviewed for oxygen therapy. (Resident 7) Findings include: The clinical record for Resident 7 was reviewed on 8/30/2023 at 1:35 p.m. The medical diagnoses included weakness, stroke, and chronic obstructive pulmonary disease. A Quarterly Minimum Data Set Assessment, dated for 8/2/2023, indicated Resident 7 was cognitively intact, utilized oxygen therapy, and needed assistance from staff members for activities of daily living. A physician order, dated 4/25/2023, indicated for Resident 7 to utilize oxygen at 1 liter per minute continuously. During an observation and interview on 8/29/2023 at 11:07 a.m., Resident 7 was laying in bed at this time with her oxygen nasal cannula on the floor. The oxygen tubing and humidification bottle did not have a date of initiation on it. Resident 7 reported she did not know the last time her oxygen tubing was changed, but it was on the floor because it falls off when she sleeps. During an observation on 8/29/2023 at 2:24 p.m., Resident 7 was laying in bed with her oxygen nasal cannula on the floor. The oxygen tubing and humidification bottle did not have a date of initiation on it. Resident 7 reported she put her oxygen back in when she was eating lunch, but it had fallen off again. A policy entitled, Oxygen Administration, was provided by the Administrator on 8/31/2023 at 12:00 p.m. The policy indicated, .Tubing, humidifier bottle and filters will be changed, cleaned and maintained no less than weekly and PRN [as needed]. Each will be labeled with the date, time, and initialed by staff completing this service to equipment . 3.1-47(a)(6)

Based on interview and record review the facility failed to implement an activity program care plan for 1 of 2 residents reviewed for activities (Resident 18). Finding include: Review of the record of Resident 18 on 7/14/22 at 1:42 p.m., Alzheimer's disease, dementia with behavioral disturbance, [CONDITION(S)] and chronic obstructive pulmonary disease. Interview with the Director Of Nursing (DON) on 7/14/22 at 2:31 p.m., verified Resident 18 did not have a care plan implemented for activities. The DON indicated it was the Social Service Director responsibility to implement the activity care plan for Resident 18. The activity care plan policy provided by the DON on 7/14/22 at 4:46 p.m., indicated life enrichment staff as members of the interdisciplinary care plan team would participate in the development of a comprehensive care plan for each resident. The care plan team is a group of healthcare professionals established to identify the resident's needs and preferences with care, and to evaluate progress towards established goals through routine documentation. Activity care plan goals would be developed to aid the resident in pursuing meaningful leisure activities and enhancing functional, mental and spiritual well-being. 3.1-35(a)

Based on observation, interview and record review the facility failed to assist a dependent resident with eating and failed to supervise and cue a resident with eating who required supervision at meals for 2 of 3 residents reviewed for nutrition (Resident 6 and Resident 14). Findings include: 1.) During an observation on 7/11/22 at 2:13 p.m., Resident 6 was laying in bed with her eyes closed. The resident's lunch tray was sitting on the bedside table. The resident had puree meat, green vegetable, mashed potatoes and ice cream. The resident's silverware was wrapped in a napkin clean and there were no indentation in the food indicated there was an attempt to feed the resident. QMA 4 came in the resident's room and took her lunch tray. During an observation on 7/12/22 12:41 p.m., Resident 6 was laying in bed with her eyes closed. The resident's lunch tray was sitting on her bedside table. The resident had puree meat, orange vegetable and mashed potatoes. There were no indentation in her food indicating she had not attempted to eat or was assisted with eating. CNA 3 came in the resident's room and indicated the resident usually only drank her health shake. CNA 3 took the resident's lunch tray. Review of the record of Resident 6 on 7/13/22 at 11:30 a.m., indicated the resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) assessment, dated 5/5/22, indicated the resident was severely impaired for daily decision making. The resident required extensive assistance of one person for eating. During an observation on 7/13/22 at 12:30 p.m., Resident 6 was laying in bed with her meal tray on her bedside table. The resident is drinking fluid in a cup with a lid and a straw. The resident had puree spaghetti with meat sauce, puree Italian blend vegetable, puree garlic bread and ice cream. The resident took a small bite of her ice cream at 12:45 p.m., and then took the bottom of the cup and put it in each bowl of food she had. The resident did not talk and had confusion. QMA 4 came in the resident's room and took the resident's lunch tray. During an interview with the Director Of Nursing (DON) on 7/13/22 at 3:08 p.m., indicated the CNA's were responsible to assist resident 6 with her meals. 2. The clinical record for Resident 14 was reviewed on 7/13/2022 at 11:21 a.m. The medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly Minimum Data Set Assessment, dated 6/9/2022, indicated that Resident 14 needed limited assistance for eating tasks and utilized a mechanically altered diet. The assessment indicated limited assistance as the staff provide guiding maneuvers of limbs. An activities of daily living care plan, dated 3/4/2021, indicated that Resident 14 needed assistance with meal tray set-up and meals/eating as needed. A nutritional risk care plan, dated 3/3/2021, indicated Resident 14 was at nutritional risk with an interventions of finger foods per request. A speech therapy progress and discharge summary, dated 7/5/2022, indicated for Resident 14 to discharge from speech therapy with staff to assist/supervise during meals to cue for swallowing strategies. An observation on 7/13/2022 indicated Resident 14 was served a sandwich, peaches, broccoli, and ice cream for lunch at 12:09 p.m. by QMA 4. Silverware was set to the right of Resident 14 with two cups of liquid. Resident 14 began to eat her sandwich with her left hand. She would scoop ice cream onto the fingers of her left hand then feed herself, she did not attempt to use her silverware nor was she able to reach her drinks. The dining hall staff did not provide verbal cueing. She utilized her left hand to eat her broccoli and a few peaches. At 12:42 p.m., DON sat down and asked Resident 14 if she would like help. Resident 14 smiled in response to the question. DON then fed Resident 14 a peach then placed a cup within Resident 14's hand which she was then able to take a drink of. At 12:46 p.m. DON got up to get drinks for Resident 12 then returned to Resident 14 at 12:50 p.m. At 12:57 p.m., Resident 14 was finished eating and was assisted to the common area after lunch. An interview with DON on 7/13/2022 at 1:04 p.m., indicated that Resident 14 was eating her sandwich while the staff were assisting other residents. Due to Resident 14 having her diet downgraded to mechanical soft, they attempted to supply her with as many finger foods as possible. She indicated when Resident 14 first admitted to the facility in 2021, she would use her right hand to eat, but recently has been using her left hand. A policy entitled, Activities of Daily Living, was provided by the Administrator on 7/14/2022 at 10:30 a.m. The policy indicated, .Moderate ADL assistance .Assistance with eating utensils; needs prompting at meals .Dependent ADL assistance .Total assistance with eating . 3.1-38(a)(2)(D)

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO HAVE A FUNCTIONAL CHAIR ALARM FOR A RESIDENT WITH A HISTORY OF FALLS, RESULTING IN THE RESIDENT FALLING AND SUSTAINING A RIGHT HIP FRACTURE FOR 1 OF 3 RESIDENTS SAMPLED FOR FALLS IN A TOTAL SAMPLE OF 5 (RESIDENT #A). FINDING INCLUDES: REVIEW OF THE RECORD OF RESIDENT #A ON 11-9-10 AT 1:30 P.M. INDICATED THE RESIDENT'S [DIAGNOSES REDACTED]. THE FALL RISK CARE PLAN FOR RESIDENT #A WITH AN INITIATION DATE OF 4-27-10 INDICATED THE INTERVENTIONS INCLUDED, BUT WERE NOT LIMITED TO, SAFETY ALARM ON THE WHEELCHAIR. THE NURSING NOTES FOR RESIDENT #A DATED 8-7-10 AT 5:00 A.M. INDICATED THE RESIDENT WAS FOUND FACE DOWN NEXT TO THE BED. THE FLOOR ALARM PAD WAS SOUNDING. THE RESIDENT HAD A LACERATION ON THE RIGHT SIDE OF HER BOTTOM LIP, A BRUISE ON HER RIGHT ELBOW, A SKIN TEAR ON HER RIGHT ARM, HER NOSE WAS SWOLLEN AND OUT OF ALIGNMENT. THE RESIDENT COMPLAINED OF RIGHT LEG PAIN UPON MOVEMENT. THE RESIDENT WAS SENT TO THE emergency room FOR EVALUATION AND TREATMENT. THE LOCAL HOSPITAL NOTES FOR RESIDENT #A DATED 8-7-10 INDICATED THE RESIDENT HAD A ONE CENTIMETER LACERATION ON THE LIP REQUIRING THREE SUTURES, FACIAL CONTUSION, CHIPPED TOOTH AND NON- DEPRESSED NASAL FRACTURE. THE NURSES NOTES FOR RESIDENT #A DATED 8-9-10 AT 9:09 P.M. INDICATED THE RESIDENT WAS FOUND LYING ON THE FLOOR IN THE HALLWAY LYING ON HER LEFT SIDE. THE RESIDENT COMPLAINED OF A SEVERE HEAD ACHE, BACK PAIN AND LEFT HIP PAIN. THE RESIDENT HAD A LARGE HEMATOMA ON THE BACK OF HER HEAD. THE RESIDENT WAS SENT TO THE emergency room AT THE LOCAL HOSPITAL. THE FACILITY INCIDENT INVESTIGATION FOR RESIDENT #A DATED 8-9-10 INDICATED THE RESIDENT WAS IN HER WHEELCHAIR AND fell on [DATE]. THE FALL WAS WITNESSED AND THE WHEELCHAIR ALARM WAS SOUNDING. THE LOCAL HOSPITAL NOTES FOR RESIDENT #A DATED 8-9-10 INDICATED THE DIAGNOSTIC IMPRESSION WAS LEG CONTUSION AND SUPERFICIAL HEAD INJURY. THE NURSES NOTES FOR RESIDENT #A DATED 8-11-10 AT 10:15 A.M. INDICATED THE RESIDENT WAS IN A WHEELCHAIR AND ATTEMPTED TO STAND AND WALK AND fell on HER RIGHT HIP. THE RESIDENT COMPLAINED OF RIGHT HIP PAIN. THE RESIDENT'S CHAIR ALARM DID NOT SOUND WHEN THE RESIDENT GOT UP. THE LOCAL X-RAY COMPANY WAS NOTIFIED FOR AN X-RAY. THE NURSES NOTES FOR RESIDENT #A DATED 8-11-10 AT 12:01 P.M. INDICATED THE X-RAY RESULTS OF THE RIGHT HIP SHOWED NO FRACTURE. THE NURSES NOTES FOR RESIDENT #A DATED 8-12-10 AT 10:58 A.M. INDICATED THE RESIDENT CONTINUED TO COMPLAIN OF RIGHT HIP AND LEG PAIN. THE NURSES NOTES FOR RESIDENT #A DATED 8-12-10 AT 2:34 P.M. INDICATED THE RESIDENT WAS SENT TO THE LOCAL HOSPITAL FOR AN X-RAY BECAUSE OF HER LEG PAIN. THE LOCAL HOSPITAL REPORT FOR RESIDENT #A DATED 8-12-10 INDICATED THE RESIDENT WAS admitted FOLLOWING A FALL AND HAD A RIGHT FEMORAL NECK FRACTURE (RIGHT HIP FRACTURE) WHICH REQUIRED URGENT SURGICAL REPAIR. THE TREATMENT RECORD FOR RESIDENT #A DATED 8-1-10 THOUGH 8-31-10 INDICATED THE RESIDENT'S CHAIR PAD ALARM WAS TO BE CHECKED FOR FUNCTIONING AND PLACEMENT EVERY SHIFT. THE DOCUMENTATION INDICATED NO CHECK WAS DONE ON NIGHT SHIFT ON 8-9-10, 8-10-10 OR 8-11-10. THE MINIMUM DATA SET (MDS) ASSESSMENT FOR RESIDENT #A DATED 7-26-10 INDICATED THE FOLLOWING: BED MOBILITY- LIMITED ASSISTANCE OF ONE PERSON, TRANSFER- LIMITED ASSISTANCE OF ONE PERSON, WALK IN ROOM- INDEPENDENT, WALK IN CORRIDOR- SUPERVISION ONLY, DRESSING- LIMITED ASSISTANCE OF ONE PERSON, TOILET USE- LIMITED ASSISTANCE OF ONE PERSON AND FUNCTIONAL LIMITATION IN RANGE OF MOTION- NO LIMITATION. THE MDS ASSESSMENT FOR RESIDENT #A DATED 9-14-10 INDICATED THE FOLLOWING: BED MOBILITY-TOTAL DEPENDENCE OF TWO PEOPLE, TRANSFER- TOTAL DEPENDENCE OF TWO PEOPLE, WALK IN ROOM- DID NOT OCCUR, WALK IN CORRIDOR- DID NOT OCCUR, DRESSING- TOTAL DEPENDENCE OF TWO PEOPLE, TOILET USE- TOTAL DEPENDENCE OF TWO PEOPLE AND FUNCTIONAL LIMITATION IN RANGE OF MOTION- LEG (INCLUDING HIP AND KNEE)- LIMITATION ON ONE SIDE AND PARTIAL LOSS OF VOLUNTARY MOVEMENT. DURING OBSERVATION ON 11-9-10 AT 2:00 P.M., RESIDENT #A WAS LYING IN A LOW BED WITH A MAT BESIDE HER BED. RESIDENT #A'S FAMILY MEMBER WAS SITTING BESIDE THE RESIDENT. RESIDENT #A'S FAMILY MEMBER INDICATED THE RESIDENT MAKES NO EFFORT TO GET OUT OF THE BED OR THE WHEELCHAIR SINCE THE LAST FALL. INTERVIEW WITH THE DIRECTOR OF NURSING (DON) ON 11-9-10 AT 3:00 P.M. INDICATED THE NURSES WERE RESPONSIBLE TO CHECK FALL ALARMS EVERY SHIFT. INTERVIEW WITH LPN #1 ON 11-10-10 AT 11:05 A.M. INDICATED SHE WAS THE NURSE CARING FOR RESIDENT #A ON 8-11-10 WHEN SHE fell . LPN #1 INDICATED SHE AND ANOTHER NURSE WERE IN THE NURSES' STATION CHARTING. LPN #1 INDICATED RESIDENT #A WAS SITTING IN HER WHEELCHAIR OUTSIDE THE NURSING STATION BY THE TV ROOM. LPN #1 INDICATED SHE NOR THE OTHER NURSE WITNESSED THE FALL. LPN #1 INDICATED THEY BOTH HEARD THE NOISE OF RESIDENT #A'S FALL. LPN #1 INDICATED NO STAFF REPORTED TO HER THAT THEY WITNESSED THE FALL. LPN #1 INDICATED THE ALARM DID NOT SOUND ON RESIDENT #A'S WHEELCHAIR WHEN SHE fell . LPN #1 INDICATED THERE WAS NO CERTAIN TIME TO CHECK FALL ALARMS. THEY WERE TO BE CHECKED ON HER SHIFT BETWEEN 6:00 A.M. AND 2:00 P.M. LPN #1 INDICATED SHE DID NOT THINK SHE HAD CHECKED RESIDENT #A'S WHEELCHAIR ALARM THE DAY SHE fell . LPN #1 INDICATED SHE CHANGED THE BATTERY IN THE ALARM PAD AND THE ALARM BOX AFTER THE FALL AND NEITHER ONE WOULD WORK. LPN #1 INDICATED SHE GOT RESIDENT #A A NEW ALARM PAD AND ALARM BOX AFTER THE RESIDENT'S FALL. LPN #1 INDICATED ACCORDING TO THE "GET UP LIST" RESIDENT #A WAS GOTTEN UP ON NIGHT SHIFT THE DAY OF HER FALL. INTERVIEW WITH THE NURSE MANAGER ON 11-10-10 AT 11:15 A.M. INDICATED RESIDENT #A HAD ALWAYS BEEN GOTTEN UP IN THE MORNINGS BY NIGHT SHIFT. THE FALL MANAGEMENT PROCEDURE PROVIDED BY THE ADMINISTRATOR ON 11-9-10 INDICATED THE PURPOSE WAS TO ASSESS ALL RESIDENTS FOR RISK FACTORS THAT MAY CONTRIBUTE TO FALLING AND TO PROVIDED PLANNED INTERVENTIONS IDENTIFIED BY THE TEAM AS APPROPRIATE FOR RESIDENT USE IN MAINTAINING OR RETURNING TO THE HIGHEST LEVEL OF PHYSICAL, SOCIAL AND PSYCHOSOCIAL FUNCTIONING AS POSSIBLE. THIS FEDERAL TAG RELATES TO COMPLAINT NUMBER IN 344. 3.1-45(a)(2)