Every finding on record at Waters of Wabash Skilled Nursing Facility West

Based on interview and record review, the facility failed to promote resident dignity during transportation following a shower in the shower room for 1 of 3 residents reviewed for dignity. (Resident F) Findings include:Resident F's clinical record was reviewed on 10/15/25 at 9:55 a.m. Diagnoses included stroke affecting right non dominant side, mild intellectual disability, weakness, unsteadiness on feet, and cognitive communication deficit. An 8/11/25, admission, Minimum Data Set (MDS) assessment indicated she used a walker and wheelchair. She had upper extremity impairment on one side of her body. She was substantial/ maximal staff assistance for showering, upper and lower body dressing, toileting hygiene and tub/shower transfer.A progress note, on 8/6/25 at 10:40 p.m., indicated Resident F had fallen forward from the shower chair while coming out of the shower. The right front wheel fell off the shower chair causing Resident F to fall forward. Resident F hit her head on the floor causing a laceration above her right eye. Resident F did not lose consciousness and remained alert. She was sent to the emergency room (ER) for evaluation. The resident's representative and NP were notified.A progress note, on 8/30/25 at 11:15 p.m., indicated Resident F returned from the ER via emergency medical service (EMS). Resident F was assisted to bed, alert and oriented. She had seven sutures placed above her right eye brow area.During an interview, on 10/15/25 at 11:47 a.m., RN 6 indicated a staff member propelled Resident F out of the shower room into the hallway, when the front right wheel fell off the shower chair causing Resident F to fall forward onto the floor. Resident F had a laceration to her forehead. Pressure was applied and Resident F was sent to the ER for evaluation. Resident F was not transferred via mechanical lift. After this incident, they stopped transporting Resident F in the shower chair. Some staff members transferred other residents down hallway in the shower chairs.During an interview, on 10/15/25 at 1:53 p.m., the Administrator and DON indicated residents who did not require a mechanical lift for transfers should not be transported down the hallway in a shower chair.During an interview, on 10/15/25 at 2:49 p.m., QMA 7 indicated she assisted Resident F out of the shower room in the shower chair. The shower chair's right front wheel caught a divot in the floor, which caused the wheel to fall off and Resident F to fall forward onto the floor. She felt that it was fine to transfer Resident F down the hallway in a shower chair. She now knew she shouldn't transport residents down the hallway in a shower chair unless the resident transferred by a mechanical lift. Resident F required two-person staff assist and didn't need to be transferred by a mechanical lift.During an interview, on 10/15/25 at 3:02 p.m., the Administrator indicated residents should not be transported in a shower chair down the hallway unless the resident required a mechanical lift.On 10/15/25 at 3:10 p.m., the Administrator was unable to provide a policy in regard to transporting residents in a shower chair down the hallways.The Indiana Nurse Aide Training Program Core Curriculum accessed on 10/15/25 at https://www.in.gov/health/ltc/aide-training-and-certification/cna/nurse-aide-training-program-core-curriculum/, indicated the following: .PROCEDURE #32: SHOWER/SHAMPOO STEP RATIONALE 1. Do initial steps. 2. Clean/disinfect shower area and shower chair as per facility policy. Prep the bathing area per facility policy. Gather supplies and take them into the shower area. 2. Reduces pathogens and prevents spread of infection. Have the supplies ready when you bring the resident in the shower room to ensure resident safety. 3. Help resident remove clothing. Provide resident privacy 3. Maintains resident's dignity and right to privacy by not exposing body. Keeps resident warm. 4. Turn on water and have resident check water temperature for comfort, if able. 4. Resident's sense of touch may be different than yours, therefore, resident is best able to identify a comfortable water temperature. 5. Assist resident into shower via wheelchair. Lock wheels of shower chair and transfer resident to shower chair. Use safety belt to secure resident stability, if indicated. Never take your eyes off the resident or turn your back to the resident while in the shower 5. Chair may slide if resident attempts to get up. Ensure resident safety at all times. Never transport resident in shower chair.This citation relates to Intake 2633792.3.1-45(2)

Based on observation and interview, the facility failed to ensure staff performed hand hygiene during 3 of 3 medication administration observations. (Resident 13, Resident 3, and Resident 12)Findings include:During a medication administration observation on 8/6/25 at 11:09 a.m., Qualified Medication Aide (QMA) 4 removed one medication for Resident 13 from the [NAME] Hall medication cart. Prior to removing the medication, the QMA did not perform hand hygiene. She popped one pill from a blister pack into a medication cup and poured water into a plastic drinking cup. QMA 3 entered Resident 13's room and administered the medication. The QMA did not perform hand hygiene during the observation.During a medication administration observation on 8/6/25 at 11:13 a.m., QMA 4 removed one medication for Resident 3 from the [NAME] Hall medication cart. Prior to removing the medication, the QMA did not perform hand hygiene. She popped one pill from a blister pack into a medication cup and poured water into a plastic drinking cup. QMA 4 entered Resident 3's room, administered the medication, then exited the room. The QMA did not perform hand hygiene during the observation.During a medication administration observation on 8/6/25, at 11:19 a.m., QMA 4 removed one medication for Resident 12 from the [NAME] Hall medication cart. Prior to removing the medication, the QMA did not perform hand hygiene. She popped one pill from a blister pack into a medication cup and poured water into a plastic drinking cup. QMA 4 entered Resident 12's room, administered the medication, then exited the room. The QMA did not perform hand hygiene during the observation.During an interview with QMA 4 on 8/6/25, at 11:27 a.m., she indicated she forgot to use hand sanitizer before passing medications.During an interview with the Director of Nursing (DON) on 8/7/25 at 3:47 p.m., she indicated staff should perform hand hygiene before and after administering medications to residents.A current facility policy, titled Medication Administration, provided by the Administrator on 8/6/25 at 1:45 p.m., indicated the following: .Purpose: To administer all medications safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms, and help in diagnosis .Before the medication pass .2) Cleanse your hands before beginning and before contact with each resident 3.1-18(a)(l)

Based on observation, interview, and record review, the facility failed to provide assistance with eating for 1 of 1 reviewed for ADLs. (Resident B) Finding includes: During a dining observation, beginning on 7/16/24 at 11:57 a.m., Resident B had not eaten any of her lunch as of 12:41 p.m. Her eyes were closed, and she had a utensil in her hand. At 12:45 p.m., QMA 6 picked up the resident's spoon and offered the resident green beans. During an interview following the observation, QMA 6 indicated Resident B was able to feed herself, but had insomnia and fell asleep frequently during the day and required reminders to eat. QMA 6 first prompted her to eat at 12:45 p.m. During an observation, on 7/17/24 at 8:41 a.m., four residents were in the dining room. No staff were present. Resident B was talking incoherently and fidgeting with her glasses. She had eaten a few bites of eggs. Housekeeper 4 entered the dining room at 8:46 a.m. and indicated that at least one nursing staff was required to be in the dining room until all the residents were done eating. She indicated staff was instructed to leave Resident B in the dining room until she was done eating. Eventually they will just take her tray. Nursing staff entered at 8:54 a.m. and escorted individual residents out of the dining room. Resident B was alone in the dining room, with a tray in front of her from 8:55 a.m. until 8:58 a.m. During an interview on 7/17/24 at 2:55 p.m., Dining Staff 3 indicated Resident B had been in the dining room alone several times. A few weeks prior, Dining Staff 3 reported to work at 11:00 a.m. and Resident B was sitting in the dining room with her breakfast tray still in front of her. During an interview, on 7/18/24 at 2:50 p.m., QMA 6 indicated Resident B was left in the dining room after dinner unattended on more than one occasion. Staff knew they were not allowed to leave residents unattended in the dining room while they were still eating. Dinner routinely ended at 6:00 p.m. and Resident B was left alone in the dining room until 8:00 p.m. The resident was not routinely prompted to eat or assisted with meals. The resident frequently picked at her food and fell asleep. Resident B's medical record was reviewed on 7/18/24 at 12:03 p.m. Diagnoses included unspecified psychosis not due to a substance or known physiological condition; unspecified lack of coordination; unspecified insomnia; need for assistance with personal care; Alzheimer's disease; muscle wasting and atrophy of bilateral upper extremities, not elsewhere classified; generalized muscle weakness and lack of coordination. A quarterly Minimum Data Set (MDS) dated [DATE], indicated the resident had moderate cognitive impairment and required partial to moderate assistance to eat. Resident B's current care plan, dated 4/6/22, indicated the following: ADLs (Activities of Daily Living) fluctuate and amount of assist required fluctuates . I need set-up/supervision assist with eating/drinking .assist at meals with tray set-up and meals/eating as needed .give verbal cues and encourage to eat as needed (interventions dated 11/5/19) .I am at risk for aspiration. History of CVA (cerebral vascular accident or stroke) in 2014; Swallowing difficulties; history of pocketing food, long history of choking on foods/spitting . monitor for coughing or choking with meals A review of Resident B's documentation of her percentage of meals eaten, dated 6/19/24 through 7/18/24, indicated she consumed 0-25% of her food during 30 meals, 26-50% of her food during 18 meals, 51-75% of her food during 30 meals, and more than 76% of her meals during 9 of a total of 88 meals consumed. She refused one meal. Resident B's Self Performance for eating evaluation, for the same dates, indicated at a minimum, she required supervision including oversight, encouragement or cueing for 82 of 88 meals. A current, undated policy, provided by the Director of Nursing (DON) on 7/18/24 at 5:05 p.m., titled Mealtime Observation indicated: .Guideline: Residents shall be observed during mealtimes to monitor .intake of food and beverage items. Appropriate replacements/substitutions will be offered when needed. Procedure: 1. The dining room shall be monitored by the Dining Services Manager or designee at all mealtimes . 3. Nursing staff will be readily available during mealtimes, in the dining room . 5. Substitutions shall be provided for all residents when poor food/fluid intake is noted The Federal tag relates to Complaint IN00434626. 3.1-38(a)(2)(D)

Based on observation, record review, and interview, the facility failed to ensure staff information was posted in a prominent place, was readily accessible to residents and visitors, and was in a clear and readable format. Findings include: On 7/15/24, at 11:32 a.m., staffing information was not readily available at the nurses station towards the front doors of the facility. No information was available on the walls at the front of the facility. The front of the building was the main entrance into the facility. On 7/15/24, at 11:41, during an interview with the Administrator (Adm), she indicated the staff posting was on the wall outside of the Director of Nursing's (DON) door. The DON's office was located in the west hall of the facility, past the nurses desk, through a doorway, and on the left side of the hallway. On 7/16/24, at 12:05 p.m., nurse staffing was posted outside the DON's door. There were two plastic sleeves that contained two 8.5 x 11 sheets of paper with staffing information. The two documents were positioned on their sides. In order to view the documents, they had to be removed from the eye-level hooks where they were hung, and repositioned to an upright orientation in order to be read. The font was small, approximately a 10 or 12 font size. During an interview with the DON, on 7/18/24 at 12:39 p.m., she indicated she thought the posting location was fine. She had been instructed by the Administrator to move the postings to a publicly accessible location at the front of the facility. A document titled Guidelines for BIPA Staffing Posting Requirement, revised on 7/24/23, and provided by the DON on 7/18/24 at 5:05 p.m., included the following information: .4) Posting Requirements: a) Data must be posted in a clear, readable format with a font of 14 or above. b) Data must be in a conspicuous prominent location, accessible to residents/visitors

Based on observation, interview, and record review, the facility failed to provide food that was attractive and palatable. (Residents 5, 15, 18, and 21) Findings include: During an interview on 7/15/24 at 11:08 a.m., Resident 18 indicated she was not feeling well. She thought her blood glucose might be low. She had not eaten any breakfast that morning because she .could not face another peanut butter and jelly sandwich She described the food as awful. She complained repeatedly to the administrator and other staff about the palatability of the food. She finally resorted to eating peanut butter and jelly sandwiches because that was the only thing she could tolerate. Carbohydrates were too many and there was not enough protein provided. The food was not properly seasoned and not appealing in appearance. During an interview on 7/18/24 at 10:42 a.m., Resident 5 indicated the food palatability varied. Sometimes the food was not bad, but other times it was not edible. It all depended on who was working in the kitchen. During an interview on 7/15/24 at 11:23 a.m., Resident 21 indicated the food was not good, sometimes not hot, and unappealing. During an interview on 07/15/24 at 3:12 p.m., Resident 15 indicated the food was sometimes bad . sometimes good, depending on who was working in the kitchen. Information gathered at a Resident Council Meeting on 7/17/24 at 3:04 p.m. included the following: Resident 21 indicated improperly cooked shrimp had been served twice. Resident 15 indicated she would taste what was being served for eating breakfast - eggs were often cold and the oatmeal was too thick. During an observation of dining on 07/16/24 at 12:26 p.m. a resident was overheard saying the chicken was actually soft, that she could actually eat it. At 12:43 p.m., another resident was observed sending her hamburger back to the kitchen because it was cold. A test lunch tray was provided on 7/16/24 at 1:10 p.m. The menu for the day included Dijon chicken, rosemary roasted potatoes, green beans, and chocolate pudding. The chicken was appropriately cooked, was warm (not hot), and was seasoned slightly. There was no Dijon taste to the chicken. The rosemary roasted potatoes, light gray to dark gray in color, were grease soaked and mushy. They tasted like grease. The rosemary could be detected but there were no other seasonings. The green beans were from a can and no salt or any other seasoning had been added. They were flavorless and mushy. The chocolate pudding was lumpy and not thoroughly mixed. During an interview with the Administrator on 7/17/24 at 4:02 p.m., she indicated one resident complained frequently about too much pepper on the food. Another resident had complained about a curry soup. She was not aware of other residents complaining about the look and taste of the food. She did not encourage the kitchen staff to taste the food before serving it because she wanted to avoid cross-contamination. No policy addressing food attractiveness or palatability was provided. 3.1-21 (a)(1)(2)

Based on observation, interview, and record review, the facility failed to provide a nourishing snack at bedtime when there was more than fourteen (14) hours between the evening meal and breakfast the next day. This had the potential to affect twenty four (24) out of twenty four (24) residents. (Residents 3, 16, 15, 18, 21, and 22) Findings include: During a resident council meeting on 7/17/24 at 3:04 p.m., Resident 15 indicated the facility used to provide snacks in the evening. Eventually, the snacks provided were only oatmeal pies. The night before the meeting, there were no snacks available at all. Resident 21 indicated the facility sometimes provided goldfish, oatmeal pies, or a sandwich. If the facility would run out of snacks, the residents did not get an evening snack. Resident 15 indicated residents would sometimes ask a kitchen staff member to hold food items for them. The staff member would do so. All residents present at the council meeting indicated snacks were not offered in the evenings. They could get snacks only when they asked for them and often, no snacks were available. During an interview with CNA 5 on 7/18/24 at 2:50 p.m. she indicated residents could get a snack at bedtime if they asked. The problem was there were no snacks to pass out to the residents. The residents used to get chips and cookies. Now, they could barely get cookies. She had, on occasion, gone to the grocery store to buy granola bars because there were no snacks available. The facility did not provide peanut butter crackers or even oatmeal cookies. They did sometimes have sandwichest, but those could be up to four (4) days old. The sandwiches were soggy and mushy. Most of the residents on the [NAME] hall wanted snacks. When they were available, snacks could be found in the therapy room refrigerator or cabinets. An untitled document, provided by the Business Office Manager (BOM), on 7/15/24 at 3:36 p.m., indicated mealtimes at the facility were as follows: Breakfast - 7:30 a.m., Lunch - 12:00 p.m., and Dinner - 5:00 p.m. The time between dinner and breakfast the next day was fourteen and a half (14.5) hours. During an interview with the Administrator on 7/17/24 at 4:02 p.m., she indicated snacks were provided to the residents and kept in the refrigerator in the therapy room. Snacks were passed with medications at night. Residents could have a snack any time of day they wanted. In addition to sandwiches in the refrigerator, residents could have crackers and cookies. To tell a resident snacks were unavailable was not acceptable. No policy referencing evening or bedtime snacks was provided by the facility. 3.1-21(d) and (e)

Based on observation, interview, and record review, the facility failed to implement Enhanced Barrier Precautions (EBP) for 1 of 5 residents reviewed for EBP (Resident 21) Findings include: Resident 21's clinical record was reviewed on 7/16/24 at 3:25 p.m. Diagnoses for the resident included, but were not limited to, type 2 diabetes mellitus with diabetic neuropathy, morbid (severe) obesity due to excess calories, and non-pressure chronic ulcer of other part of left foot with unspecified severity. Current physician orders included, but were not limited to: 6/7/24 - An external ointment, mupirocin 2%, was to be applied to the left great toe topically every day and night shift. The wound was to be covered with dry, sterile gauze. 5/14/24 - A weight bearing as tolerated (WBAT) surgical shoe to be worn on the left foot. 5/6/24 - Monitor the left great toe each shift for signs and symptoms of infection, dressing placement, and surrounding tissue until healed. 2/8/24 - Notify the physician of any foul-smelling odor, red streaking up the leg, discolored drainage, and watch for infection, every shift. During an observation, on 5/17/24 at 11:23 a.m., Resident 21 was in her room. She was wearing disposable booties over her socks. Drainage was observed on the disposable bootie. The resident indicated she had a diabetic ulcer on the bottom of her toe. She could see the drainage on the bootie. The room had no signage, inside or outside, to indicate the resident required EBP. No personal protective equipment (PPE) was available inside or outside the room. During an observation on 5/17/24, at 1:42 p.m., Resident 21 indicated the nurse had put on a new bootie but did not change the dressing. She indicated the nurses providing dressing changes to her foot did not wear gowns when providing care. During an observation on 7/16/24, at 9:30 a.m., the wound care nurse and the DON performed a dressing change on Resident 21's left great toe. The DON provided hands-on care while the wound care nurse measured the wound. Both nurses donned gloves before providing care. No gowns were donned before or during the procedure. The wound care nurse indicated the wound was a full-thickness, diabetic foot ulcer. During an interview with the corporate nurse consultant, on 7/17/24 at 11:15 a.m., she indicated EBP should be used for residents with catheters and wounds. She was not aware of any residents with wounds in the facility. She was not aware EBP was not being followed for Resident 21. PPE should be available in the resident's room. During an interview with the Director of Nursing (DON) on 7/18/24 at 12:38 p.m., she indicated Resident 21 should be on EBP. A document, titled Guidelines for Enhanced Barrier Precautions (EBP) - An extension of Personal Protective Equipment (PPE), with a revision date of 12/2022, was provided by the Administrator on 7/17/24 at 4:02 p.m. The document indicated it was the policy of the facility to ensure that additional and appropriate PPE is utilized, when indicated, to prevent the spread of Multidrug-resistant Organisms, also known as MDROs. Enhanced Barrier Precautions (EBP) are defined as the use of PPE (gowns and gloves) during high-contact resident care activities that generate opportunities for transfer of MDROs in the form of blood or body fluids, onto the hands and/or clothing of the rendering caregiver. EBP is to be used when Contact Precautions do not otherwise apply and where there is a diagnosis of a MDRO or a colonized MDRO. These precautions are generally in place for the duration of the resident's stay, or until there is a resolution of the wound or discontinuation of the device that placed the resident at 'higher risk' .Examples of 'high contact' resident care activities at which time EBP is to be practiced are: a) dressing care/changes/management of dressings .Procedure: .3) Ensure that proper signage is posted on the resident's room door instructing those who plan to enter the room to check first at the nurses' station for education/instructions. 4) Ensure that all necessary supplies are available in an enclosed clean labeled container outside thee resident's room 3.1-18(a)

Based on, record review, and interview, the facility failed to accommodate visitation rights for 1 of 3 residents reviewed for resident rights. (Resident B) Finding includes: During an interview, on 2/1/24 at 11:18 a.m., Resident B indicated she wasn't allowed to have a friend enter the building for visitation. Outside visitation with her friend was allowed. Inside visitation was not permitted until documentation was provided to the facility of bedbug infestation treatment at his place of residence. Her friend was unable to afford treatment. During an interview, on 2/1/24 at 12:00 p.m., LPN 10 indicated the facility had limitations with one of Resident B's visitors. During an interview, on 2/1/24 at 12:17 p.m., the Administrator indicated that one specific visitor of Resident B was found to have brought bedbugs into the facility. They had the restricted visits to outside only. On 2/1/23 at 12:35 p.m., a facility document of a conversation between the resident and the Administrator, dated 11/6/23, was provided by the Administrator. The document indicated the Administrator spoke with Resident B regarding her visitation being outside the facility with her friend. Resident B indicated she felt there was discrimination against her friend. During an interview, on 2/1/24 at 12:54 p.m., the Social Services designee indicated Resident B's visitor was not allowed to enter the facility until he provided documentation of bedbug treatment at his place of residence. During an interview, on 2/1/24 at 2:18 p.m., the DON indicated Resident B's visitor was unable to enter the facility. The clinical record for Resident B was reviewed on 2/1/24 at 2:27 p.m. The diagnoses included anxiety. A 12/21/23 quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively intact. During an interview, on 2/1/24 at 3:20 p.m., CNA 11 indicated the facility was requiring outside visitation with one of Resident B's visitors. During an interview, on 2/1/24 at 3:27 p.m., QMA 12 indicated Resident B's visitor was unable to enter facility, as they felt he had bedbugs. Visits must take place outdoors, even when it was cold outside. Bedbugs were still found in the facility after her friend was restricted from entering. Pest control invoices for bedbug treatments, provided by the Administrator, on 2/1/24 at 10:30 a.m., indicated treatment dates for bedbugs included 12/1/23 and 1/22/24. An undated facility policy provided by the Administrator on 2/1/24 at 2:35 p.m., titled Policy/Procedure: Visitation Rights of Residents, indicated .Residents have the right to receive visitors of their choosing at the preferred time that the resident chooses as long as the visit does not impose on the rights of other residents .Ensure that all residents enjoy full and equal visiting privileges consistent with resident preference This visit relates to Complaint IN00424644. 3.1-8(a)

Based on interview and record review, the facility failed to report resident-to-resident abuse for 1 of 2 resident altercations reviewed for State Agency reporting (Resident 6 and Resident 17). Findings include: During an interview on 7/27/23 at 10:15 a.m., Resident 6 indicated her previous roommate (Resident 17) and she argued periodically. The last time they argued, it became physical. Resident 6 was in bed when Resident 17 came over to her bed, grabbed Resident 6's face, and said Don't you ignore me. Resident 6's clinical record was reviewed on 7/27/23 at 1:27 p.m. Her diagnoses included multiple sclerosis, generalized anxiety disorder, bipolar disorder, major depressive disorder, and delusional disorder. Her medications included aripiprazole (antipsychotic) 2.5 mg (milligrams) daily and sertraline (antidepressant) 75 mg daily. A quarterly Minimum Data Set (MDS) assessment, dated 6/14/23, indicated the resident was cognitively intact. She was totally dependent on the assistance of two staff members for bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing. She was totally dependent on assistance of one staff member for eating, and locomotion off and on the unit. Her upper and lower extremities range of motion was impaired on both sides. A care plan initiated on 3/23/23 and revised on 6/27/23 indicated she had made accusations (which had been investigated and determined to be unsubstantiated) against unidentified people. The goal initiated on 3/23/23 with a target date of 9/5/23 indicated the resident will feel safe. Interventions included all resident accusations will be investigated (initiated 3/23/23) and listen to resident, gather as much information as possible (initiated 3/23/23). A General Progress Note, dated 6/18/23 at 11:19 p.m., indicated the resident had put on her call light and reported her roommate was being mean and yelling at her. The roommate became upset and indicated the resident was lying and to shut up. Three times, the staff were called to intervene in the argument. The roommate became physical with the resident and they were separated. Review of Resident 17's clinical record was completed on 8/1/23 at 3:12 p.m. Diagnoses included dementia and psychotic disorder with hallucinations due to known physiological conditions. Her medications included risperidone (antipsychotic) 0.25 mg two times a day. A significant change MDS assessment, dated 6/20/23, indicated the resident was moderately cognitively impaired. She required supervision with assistance of one staff member for walking in room and corridor. A Progress Note, dated 6/18/23 at 10:30 p.m., indicated the resident yelled at her roommate (Resident 6). Staff responded three times between 6:00 p.m. and 7:00 p.m. to calm the residents. The Director of Nursing (DON) and Administrator were notified and they both advised to separate the residents. When the nurse went to separate the residents, they seemed to be settled. Near 8:00 p.m., Resident 17 went and shook her roommate (Resident 6) to wake her up. Resident 17 indicated Resident 6 touched her first. Then Resident 17 indicated she did not touch her roommate (Resident 6). The residents were separated. An investigation of the resident-to-resident altercation, provided by the Administrator, was received and reviewed on 7/28/23 at 10:01 a.m. The concern description of the Concern/Grievance record indicated Resident 6 expressed concern over an incident with her previous roommate (Resident 17). She indicated Resident 17 was mean to her and yelled at her. Her roommate was upset over who paid more money for the room. An interview on 6/19/23 with Resident 6, by the Social Services Designee (SSD), indicated Resident 6 said Resident 17 was mean to her and accused her of lying. She indicated Resident 17 did not hit her or become physical. She was worried Resident 17 would get too close to her and could get physical. An interview on 6/19/23 with Resident 17, by the SSD, indicated Resident 17 said she yelled at Resident 6 and hurt her feelings. She indicated the nurse took Resident 6's side and believed Resident 6's lies. She was not physical with Resident 6 and only yelled at her. During an interview, on 7/28/23 at 2:26 p.m., the Administrator indicated she did not report to the State Agency the allegation of abuse because after the investigation, she determined during the resident-to-resident altercation nothing physical happened, and no cussing or threats were involved. During an interview, on 7/28/23 at 3:03 p.m., LPN 51 indicated she was the nurse on duty during the resident-to-resident altercation. She was uncertain if Resident 17 touched Resident 6 or not. Resident 6 initially reported Resident 17 grabbed her face and whipped her head around. A CNA on duty at the time had reported to the nurse she saw Resident 17 near Resident 6's bed. She did not see Resident 6 touch Resident 17 at any time. The residents were immediately separated. Later, after the residents were separated, Resident 6 indicated Resident 17 did not touch her. A current, undated policy, titled Abuse Prevention Program, provided by the Administrator on 7/27/23 with the entrance conference paperwork, indicated the following: .When an alleged or suspected case of abuse or neglect is reported to the Administrator, the Administrator, or person in charge of the facility, will notify the following persons or agencies of such incident immediately. State Licensing and Certification Agency (i.e. ISDH) .Abuse involving one resident upon another resident will be reported to ISDH 3.1-28(e)

Based on observation, record review, and interview, the facility failed to report weight gains of 2 lbs (pounds) or greater for heart failure protocol, as ordered by the physician, for 2 of 5 residents reviewed for unnecessary medications (Resident 5 and 16). Findings include: 1. During a random observation, on 7/26/23 at 10:12 a.m., Resident 16 was was sitting in a recliner with feet elevated, her eyes were closed, connected to oxygen via nasal cannula, and was opened-mouth breathing. During an interview, on 7/26/23 at 1:17 p.m., Resident 16 indicated she retained fluids, had trouble breathing for last couple of weeks, had started on oxygen the day prior, and had also had an X-ray taken. Her clinical record was reviewed on 7/28/23 at 1:27 p.m. Diagnoses included combined systolic and diastolic congestive heart failure, chronic atrial fibrillation, and shortness of breath. Current physician orders included the following; a. Heart failure: daily weight-after voiding and before breakfast and medications with same clothes every day. Notify physician of 2 lb gain in one day and 4 lb gain in 5 days, the order date was 3/29/23. b. Heart failure: edema assessment, check for edema at all extremities each shift and document amount of pitting 0, 1+, 2+, 3+, 4+, the order date was 3/30/23. c. Levofloxacin (antibiotic) 500 mg (milligram), one tablet daily for seven days for infection, the order date was 7/25/23. d. Bumetanide (diuretic) 2 mg, one tablet twice a day for fluid retention, the order date was 7/26/23. e. Oxygen at 2 L/M (Liters per Minute) per nasal cannula continuously, the order date was 7/26/23. f. Oxygen saturation checks daily, the order date was 7/27/23. A 7/5/23 quarterly MDS (Minimum Data Set) assessment indicated she was cognitively intact and had received a diuretic every day. She had a current care plan, dated 4/6/23, for heart failure. The goal, with a target date of 9/27/23, indicated she would not have an acute exacerbation of heart failure symptoms. Interventions, dated 4/6/23, indicated continued resident education on heart failure protocol and disease management, follow heart failure protocol that was listed on MAR (Medication Administration Record) and TAR (Treatment Administration Record), changes monitored, and physician notified as needed. An intervention, revised on 7/26/23, indicated medications would be administered as ordered. She had a current care plan, dated 7/26/23, for displayed complications with gas exchange due to pneumonia and received oxygen therapy. The goal, with a target date of 9/27/23, indicated she would not exhibit signs or symptoms of respiratory distress through next review. Interventions, dated 7/26/23, indicated oxygen was administered as ordered, lung sounds monitored as needed, head of bed elevated to facilitate breathing, oxygen saturations monitored as ordered and as needed, and physician notified of any changes. She had a current care plan, dated 7/26/23, for an infection and taking an antibiotic for seven days for pneumonia. The goal, with a target date of 9/27/23, indicated she would be free of signs and symptoms of infection through next review date. Interventions, dated 7/26/23, indicated enhanced barrier precautions, physician kept updated on un-resolving symptoms, lab work and medications as ordered, and adverse affects of antibiotic would be reported to the physician. Review of Resident 16's daily weights indicated the following: Weight on 6/11/23 was 282.4 lbs and her weight on 6/12/23 was 285.0 lbs. This was a 2.6 lb weight gain in one day. Weight on 6/12/23 was 285.0 lbs and her weight on 6/13/23 was 287.6 lbs. This was a 2.6 lb weight gain in one day. Weight on 6/19/23 was 286.0 lbs and her weight on 6/20/23 was 288.4 lbs. This was a 2.4 lb weight gain in one day. Weight on 6/24/23 was 290 lbs and her weight on 6/25/23 was 292.0 lbs. This was a 2.0 weight gain in one day. Weight on 7/12/23 was 284.4 lbs and her weight on 7/13/23 was 287.8 lbs. This was a 3.4 lb weight gain in one day. Weight on 7/18/23 was 287.2 lbs and her weight on 7/19/23 was 289.5 lbs. This was a 2.3 lb weight gain in one day. The clinical record lacked physician notification of daily weight gains. A Dietary Progress Note, dated 7/5/23 at 2:27 p.m., indicated weights showed significant fluctuations, 250 lbs - 285 lbs, over the past three months, and diuretic treatment with fluid shifts gains and losses. A progress note, dated 7/24/23 at 10:51 p.m., indicated the resident complained of feeling short of breath earlier that evening, and her oxygen saturation was 95% on room air. A breathing treatment had been given with some relief. Her left lower lobe was more diminished than her normal and she complained of pain to her lungs when she inhaled. Staff offered to send her to the emergency room and she declined. Her vital signs were within normal limits. Oxygen was started at 3 L/M for comfort and nitroglycerine had been given. A progress note, dated 7/25/23 at 11:26 a.m., indicated new orders for a chest X-ray, anterior, posterior, and lateral view, and CBC (Complete Blood Count) and CMP (Comprehensive Metabolic Panel) labs to be drawn had been obtained. A progress note, dated 7/25/23 at 12:17 p.m., indicated she continued to complain of shortness of breath, oxygen saturation was 95% on room air, and lung sounds were clear to upper lobes and diminished in lower lobes. Oxygen at 3 L/M via nasal cannula per resident's request. A progress note, dated 7/25/23 at 4:06 p.m., indicated the Nurse Practitioner had been notified of lab and X-ray results. The chest X-ray indicated enlarged cardiac size with bilateral hilar congestion and mild pulmonary edematous changes. The possibility of underlying infiltrates could not be ruled out. A progress note, dated 7/25/23 at 5:31 p.m., indicated an new order had been received to increase the bumetanide from 1 mg to 2 mg twice a day and added Levoquin 500 mg for seven days. A progress note, dated 7/26/23 at 10:05 p.m., indicated she continued to complain of shortness of breath, oxygen saturation was 85%, lung sounds clear to upper lobes, diminished in lower lobes, and remained on 3 L/M of oxygen. 2. During an observation, on 7/27/23 at 1:42 p.m., Resident 5 was ambulating with a walker in the hall, with edema (swelling) visible to bilateral lower extremities from below her knees to the tops of her feet. Her clinical record was reviewed on 7/27/23 at 1:12 p.m. Diagnoses included acute on chronic diastolic congestive heart failure. Current physician orders included the following; a. Heart failure: edema assessment, check for edema at all extremities each shift and document amount of pitting 0, 1+, 2+, 3+, 4+, the order date was 2/13/23. b. Heart failure: daily weight-after voiding and before breakfast and medications with same clothes every day. Notify physician of 2 lb gain in one day and 4 lb gain in 5 days, the order date was 2/13/23. c. Torsemide (diuretic) 60 mg, one tablet daily for congestive heart failure, the order date was 4/20/23. A 6/15/23 quarterly MDS assessment indicated she was cognitively intact and received a diuretic every day. She had a current care plan, dated 1/7/23, for heart failure. The goal, with a target date on 8/21/23, indicated shoe would not have an acute exacerbation of heart failure symptoms, The interventions, dated 1/7/23, indicated medications administered as ordered, head of bed elevated when in bed at all times due to shortness of breath when lying flat, changes monitored and physician notified as needed, and oxygen provided as ordered. Review of Resident 5's daily weights indicated the following: a. Weight on 7/4/23 was 258.2 lbs and her weight on 7/5/23 was 260.8 lbs. This was a 2.6 lb weight gain in one day. b. Weight on 7/23/23 was 259.8 lbs and her weight on 7/24/23 was 262.4 lbs. This was a 2.6 lb weight gain in one day. The clinical record lacked physician notification of daily weight gains. During an interview, on 8/1/23 at 10:20 a.m., LPN 5 indicated daily weights were documented on the MAR. If physician notification was required, it was documented in progress notes or on the MAR. During an interview, on 8/1/23 at 10:30 a.m., the DON indicated the physician notifications for daily weight gains were documented in progress notes or with the MAR or TAR. During an interview, on 8/1/23 at 2:08 p.m., the Nurse Consultant indicated their heart failure protocol was the physician orders. They did not have a policy for this, they just followed the physician orders. Review of a current, undated, facility policy titled PHYSICIAN ORDERS-(FOLLOWING PHYSICIAN ORDERS), provided by the DON on 8/1/23 at 1:53 p.m., indicated the following: .Policy: It is the policy of the facility to follow the orders of the physician 3.1-37(a)

Based on record review and interview, the facility to failed to provide adequate supervision for a resident with a history of falls and failed to develop and implement person-centered, individualized interventions to reduce the risk of falls, for 1 of 4 residents reviewed for accidents (Resident 23). Findings include: Resident 23's clinical record was reviewed on 7/28/23 at 3:07 p.m. He had admitted to the facility on [DATE] and transferred to an acute hospital on 6/24/23. Diagnoses included pathological hip fracture, weakness, unsteadiness on feet, abnormalities of gait and mobility, and dementia. Physician orders included the following: a. Monitor incision to left hip each shift for signs/symptoms of infection or worsening, dressing placement, and surrounding tissue until healed, the order date was 6/1/23. b. Weight bearing as tolerated to left hip/leg, the order date was 6/1/23. c. Oxycodone (opioid)-acetaminophen 7.5-325 mg (milligram), one tablet every eight hours as needed for chronic pain, the order date was 6/2/23. d. Apply skin prep daily to left elbow, order date was 6/20/23. e. Levaquin (antibiotic) 750 mg, one tablet daily for infection for five days, the order date was 6/20/23. A Fall Risk Review, dated 6/1/23 at 11:48 p.m., indicated he was at a high risk for a fall. He had a history of falls within the last three months, required assistance with ambulation, had a balance problem while standing/walking, and required use of assistive devices. A baseline care plan, dated 6/7/23, indicated the resident required two person physical assistance with bed mobility and one person physical assistance with transfers, to walk in his room, and with locomotion on the unit. He had a history of falls, had a fall at home that resulted in a fracture, and had pain to his left left hip related to post-operative repair of the fracture. The baseline care plan did not include personalized interventions to reduce his risk for falls. An admission MDS (Minimum Data Set) assessment, dated 6/8//23, indicated he was cognitively intact. He required extensive assistance with bed mobility, transfers, dressing, toilet use, personal hygiene, and with locomotion on and off the unit. Walking in room or corridor had not occurred. He had a fracture related to a fall in the last month, prior to admission. A Nurse Practitioner Skin and Wound Note, dated 6/13/23 at 11:40 a.m., indicated he had admitted to the facility for physical and occupational therapy after surgical repair of left hip fracture secondary to fall at his home. He had limited ambulation ability and was confused. A progress note, dated 6/14/23 at 5:22 a.m., indicated he had several episodes of yelling out and had episodes of hallucinations such as did you see that airplane in here and do you see where I cleaned up all that oil that spilled. He complained of pain throughout the night, received an oxycodone, and had rested in his chair afterwards. A progress note, dated 6/17/23 at 9:47 a.m., indicated antibiotic therapy was ordered for urinary tract infection. A Care Plan Summary note, dated 6/19/23 at 12:58 p.m., indicated the interdisciplinary team met with the resident and his daughter to discuss his progress in therapy, goals of care, and discharge plan. Therapy indicated he had made functional progress but his cognition impeded his making further progress, and they were primarily working on rebuilding strength, safety awareness, and endurance. A progress note, dated 6/21/23 at 6:59 p.m., indicated the resident ambulated to the dining room with a walker and one staff assist for breakfast. A progress note, dated 6/23/23 at 1:53 p.m., indicated he was oriented to self only at that time, and had previously been oriented to time and place. His gait was unsteady and transferred with one assist. A progress note, dated 6/24/23 at 12:25 a.m., indicated he had an unwitnessed fall in his room. He was assessed, then assisted up with two staff. He had hit his head on the closet door, had a large raised area to back of his head, and a reddened area on mid/left back. He complained the left side of his buttocks hurt. Active range of motion was per his normal. A progress note, dated 6/24/23 at 12:56 p.m., indicated he had been up several times without assistance and forgot he was unsteady on his feet. He had no complaints of pain from fall the night before. An SBAR (Situation, Background, Assessment, Recommendation) Summary for Providers, dated 6/24/23 at 7:50 p.m., indicated a change in condition related to altered mental status and a fall. He had an increased level of confusion, was on follow up from a fall the previous night, and was reluctant to rest or stay off his feet. An order was received to send resident to the emergency room for evaluation and treatment. A progress note, dated 6/25/23 at 11:06 a.m., indicated the resident's daughter went to the facility to pick up his belongings and told them he wouldn't be back. He had a current care plan, dated 6/27/23, for risk of falls related to history of falls with injuries. The goal, with a target date of 9/6/23, indicated he would not have any injuries due to falls through next quarterly review. The interventions, all initiated 6/27/23, included areas kept clutter free, call light kept in reach in room, encouraged resident to use call light to seek assistance, offer scheduled toileting as needed, notify and update physician and family as needed, and evaluate possible causes of falls and address to the extent possible. The clinical record did not include person-centered, individualized interventions to reduce the resident's risk for falls prior to his fall on 6/24/23. During an interview, on 8/1/23 at 11:13 a.m., the DON indicated he had been sent to the hospital due to altered mental status related to a fall. The hospital indicated he had sustained a dislocation of his right elbow from the fall. Review of a Facility Report Incident, provided by the DON on 8/1/23 at 11:15 a.m., indicated the incident date was 6/27/23 at 10:01 a.m. He had an unwitnessed fall in his room, assessment indicated a raised area to the back of his head, and he complained of pain to his right elbow. The physician had been notified and an order to send the resident to the emergency room for evaluation and treatment had been received. The preventive measures taken indicated immediate fall interventions in place and care plan updated, neurological checks had been initiated, resident representative had been notified and no concerns. The follow up, added 7/4/23, indicated a report from the hospital had been received and indicated a dislocation of his right elbow. Contributing factors to resident's fall were determined to be a diagnosis of dementia, unsteadiness on feet, weakness, and abnormalities of gait and mobility. He had not returned to the facility. Review of a current, undated, facility policy titled INCIDENTS/ACCIDENTS/FALLS, provided by the DON on 8/1/23 at 1:53 p.m., indicated the following: .11. All falls will have a site investigation by appropriate staff 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. Note: Each fall needs a new intervention rolled out 3.1-45(a)(2)

Based on interview and record review, the facility failed to ensure staff (Employee 1, Employee 2 and Employee 3) reported suspicions of resident mistreatment (Resident F) to the Administrator, when a staff member (CNA 4) reportedly used inappropriate language and refused to meet the needs of a resident for 1 of 3 residents reviewed for abuse. Findings include: During an interview on 4/4/2023 at 12:21 p.m., Employee 1 indicated they had been told about CNA 4 using inappropriate language with Resident F. The employee did not report what they heard to the Administrator (or designee). During an interview on 4/4/2023 at 12:46 p.m., Employee 2 indicated the facility had recently had an inservice on abuse and abuse reporting. The employee had heard CNA 4 had used inappropriate language with Resident F. The employee was told CNA 4 had said I am not going to change your brief every g _ _ d _ _ _ 15 minutes. Employee 2 did not report this to the Administrator (or designee). During an interview on 4/4/2023 at 2:37 p.m., Employee 3 indicated they had been told CNA 4 made inappropriate remarks to Resident F. It was reported to the employee CNA 4 stated they would not come to her room every 25 minutes to put the resident on the bed pan. The employee did not report this to the Administrator. During an interview on 4/5/2023 at 9:25 a.m., the Administrator indicated staff should report all suspicion of abuse or mistreatment immediately to him. The facility had provided several inservices on abuse and reporting. During an interview on 4/5/2023 at 10:38 a.m., CNA 4 denied allegations of abuse or mistreatment of Resident F. A current, undated, facility policy titled Abuse Prevention Program was provided by the Administrator on 4/4/2023 at 9:27 a.m. The policy indicated the following: . IV. Identification .Employees are required to report any incident, allegation or suspicion of potential abuse, neglect or mistreatment they observe, hear about or suspect to the Administrator or an immediate supervisor who will immediately report the allegation to the Administrator This Federal Tag relates to Complaint IN00399395. 3.1-28(c)

Based on observation, interview, and record review, the facility failed to ensure the facility kitchen was maintained in a hygienic and sanitary manner. 18 of 18 residents ate food prepared in the facility kitchen. Findings include: During a tour of the facility kitchen, on 1/5/23 at 8:43 a.m., accompanied by the Dietary Manager, the following was observed: The gas stove had dark grime and debris containing oatmeal and egg shells, on and around the burners. Beneath the burners, on a piece of foil, there was a thick amount of yellowed greasy debris containing discarded egg shells, a shriveled bread roll, macaroni noodles, two breaded meat nuggets, and oatmeal. The shelf above the cooktop, holding two open and uncovered packages of pastries, was covered with greasy and sticky grime. The stove knobs and oven door handles were covered with a sticky, greasy grime substance. During an interview, at the time of the observation, the Dietary Manager indicated the staff was to clean the stove weekly. The storage shelves next to the stove contained muffin tins, skillets, and mixing bowls on pieces of parchment. The muffin tins had black debris and crumbs on them. The parchment papers had dark debris, crumbs, and areas of a sticky red/pink substance on them. The toaster on the prep table was covered with a sticky, yellowed grime. The microwave oven had a thick, white substance running down the inside of the door. The top of the inner part of the oven had debris on it. The stacked crates of drinking glasses beneath the prep table had crumbs, debris, and grime on them and on the wheeled base holding the crates. A wheeled cart with shelves next to the crates had debris and crumbs on the shelves. The kitchen floor had scattered debris on it. The floor underneath the appliances had a moderate amount of debris and food-stuff on it. The corners of the floor had a collection of debris and food-stuff debris. The floor beneath the dishwasher area had a moderate amount of debris and food-stuff debris. The ceiling vent above the steam table was covered with a thick, gray grime. The refrigerator next to the steam table contained a tray with an assortment of cups of thinned, mushy, and transparent appearing cole slaw, pudding, and cooked fruits. The cups were partially covered with an undated piece of plastic wrap. Clear drink pitchers containing lemonade, fruit punch, iced tea, and milk had a streaked, white film covering the bottoms of the inside of the pitchers. A bag of cole slaw dressing was open, dated 12/8/22, and laying on the shelf. A pitcher labeled as containing ketchup had a thick, dried clog of ketchup on the spout. A pitcher labeled as containing tomato soup, dated 12/27/22, had separated contents. The bottom of the refrigerator had a creamy yellow liquid with black debris covering it. During an interview, at the time of the observation, the Dietary Manager indicated the white substance on the pitchers was lime build-up from the facility's water. The food should be dated when stored. She thought the refrigerator had a leak of some kind. The kitchen staff used a cleaning schedule. She indicated all 18 residents residing in the facility [NAME] food prepared in the kitchen. Review of facility December 2022 and January 2023 Cleaning Schedule documents, provided by the Dietary Manager on 1/4/23 at 9:19 a.m., indicated the following had been completed daily: .Wipe down stove and shelf above .Wipe down any carts used Wipe down toaster .Sweep & Mop any spills .Clean & Sanitize microwave Review of a facility December 2022 Special Weekly Cleaning document, provided by the Dietary Manager on 1/4/23 at 9:19 a.m., indicated the floor had last been deep cleaned, with items pulled out and cleaned underneath, on 12/17/22. The oven and range top had been cleaned last on 12/18/22. Review of a current facility policy titled Cleaning Rotation, dated 2017 and provided by the DON on 1/4/23 at 9:55 a.m., indicated the following: .Items cleaned daily: Stove top .Kitchen and dining room floors .Toaster .Microwave oven .Items cleaned weekly: .Shelves This Federal Tag relates to Complaint IN00398423. 3.1-21(i)(3)

Based on observation, interview and record review, the facility failed to ensure choices were honored according to their daily morning wake times for 4 of 7 residents reviewed for choices (Resident C, D, F and G). Findings include: During an interview on 1/2/22 at 4:07 a.m., QMA 1 indicated staffing during the night shift was one nurse and one or two aides. She indicated during her shift, there were 7 residents who staff were to get up and ready before first shift arrived to work at 6:00 a.m. They were in the process of getting them up and most of them required a mechanical lift. During an observation and interview on 1/2/22 at 4:50 a.m., Resident F was awake, sitting in his recliner. He indicated sometimes staff wake him up in the morning and other times he was already awake. He was not sure what he was supposed to be doing since he was awake and they were not serving breakfast yet. He admitted from another facility and just didn't know what he should be doing right now since he was awake. A copy of the night shift list of residents to get up was provided by LPN 2 on 1/2/22 at 5:10 a.m. The list included seven residents, including Residents C, D, F, and G, and indicated the following: In order to keep things moving smoothly this is the new get-up list. This is to help ensure that meals run on time. When we are late to breakfast it makes everything run behind The list was dated 12/13/21 and signed by LPN 2. During a second observation on 1/2/22 at 5:50 a.m., Resident C was asleep in his recliner in his room. 1. The clinical record for Resident F was reviewed on 1/3/22 at 9:20 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent significant change Minimum Data Set (MDS) assessment, dated 10/31/21, indicated the resident was severely cognitively impaired. He required extensive assistance with bed mobility and transfers with two-person assistance. A health care plan, dated 3/18/20, indicated it was important for the resident to choose his wake up time. His preferences indicated a time between 6:00 a.m. and 7:00 a.m. 2. The clinical record for Resident C was reviewed on 1/3/22 at 10:07 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent quarterly MDS assessment, dated 11/12/21, indicated the resident was severely cognitive impaired. He was extensive assist with transfers and one-person physical assist. A health care plan, dated 2/27/19, indicated the resident required extensive assist and a mechanical lift was initiated 12/21/21. Another health care plan, dated 2/22/19, indicated it was important to choose his own wake-up time. The resident preferred natural rise wake time. 3. During an observation on 1/2/22 at 5:15 a.m., Resident D was seated in her Broda chair (positioning wheelchair) in her room, awake. The clinical record for Resident D was reviewed on 1/3/22 at 10:48 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent significant change MDS assessment, dated 11/3/21, indicated the resident was unable to complete the assessment and was rarely or never understood. She required extensive assistance with transfers with 2-person assistance. A health care plan, dated 5/19/17, indicated the resident needed extensive assistance with transfers. On 9/27/21, a mechanical lift was initiated. A health care plan, dated 7/23/14, indicated the resident preferred to get up in the morning between 6:00 a.m. and 7:00 a.m. A care plan meeting, dated 11/9/21, indicated the resident was unable to comprehend or express her wishes. Her legal guardian participated via phone. 4. The clinical record for Resident G was reviewed on 1/3/22 at 11:31 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent quarterly MDS assessment, dated 10/22/21, indicated the resident was severely cognitively impaired. She required total dependence with transfers with one-person physical assistance. A health care plan, dated 10/27/17, indicated the resident chose her morning get-up time between 6:00 a.m. and 7:00 a.m. Interventions included, but were not limited too, determine what time the resident wants to get up in the morning, approximately between 6:00 a.m. and 7:00 a.m. During an interview on 1/3/22 at 2:10 p.m., LPN 2 indicated third shift staff get some people up to help with breakfast and it also helped the nursing staff start their day. The residents on the list had been some that were early risers and others voiced the desire to get up early. The list did help, but it was not for staff convenience. If there was one aide, they do not get all seven residents up on their shift. They have three aides that work third shift, but they have had some agency help cover 3rd shift. They had been monitoring meal times and breakfast was being served late. Breakfast was served at 7:30 p.m. and management arrived to work between 8:00 a.m. and 9:00 a.m. During an interview on 1/3/22 at 3:00 p.m., LPN 3 indicated she did the care plan meetings, but the nursing department made the get-up list. She did go around ask the resident and/or their family member what time they would like to get up and will make any changes to to their care plans. During each care conference, she always asked if preferences were being met or if they want to make any changes. Review of a current facility policy, dated 5/31/06, titled Manual: ISDH Nurse Aide Training Instructor Manual, provided by the Administrator on 1/3/22 at 3:10 p.m., indicated the following: Resident's Rights: A. Policy 1. Rights are both human and privileges and legal protections. Residents have the legal rights of all United States citizens. Residents also have rights relating to their everyday lives and care in a nursing facility. A facility must inform residents of their rights 4. The resident has the right to choose. The resident has the right to refuse treatment participate in their care planning. This Federal tag relates to complaint IN 546 3.1-3(u)(1)

Based on interview and record review, the facility failed to ensure residents who were dependent on staff for showering, received those services for 3 of 8 residents reviewed for Activities of Daily Living (ADL) assistance (Residents D, F and J). Findings include: 1. During an interview 6/21/21 at 12:25 p.m., Resident J indicated he was not receiving showers like he was supposed to. He never receives a shower on Saturday and the weekends were terrible for staffing. There was nobody to oversee the staff during the weekends and they occasionally took a break together, leaving no one in the facility. He does not sleep much at night and would often see call lights going off and felt they needed more staff. The clinical record for Resident J was reviewed on 6/21/21 at 12:37 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent Minimum Data Set (MDS) assessment, dated 5/29/21, indicated the resident was cognitively intact. The resident required two-person assistance for bed mobility and transfers. The resident was admitted [DATE]. A health care plan, dated 5/26/21, indicated the resident preferred a shower three times weekly. The shower schedule indicated the resident was to receive a shower on Tuesday and Saturday during the day-shift, as well as, a shower on Thursday on evening shift. Review of the Point of Care History report, provided by the Director of Nursing (DON) on 6/21/21 at 1:40 p.m., indicated the resident did not receive a shower in May. The resident was offered and refused a shower on 5/31/21 on third-shift. During June, the resident received a shower on 6/9/21, 6/12/21, 6/16/21 and 6/19/21. 2. The clinical record for Resident D was reviewed on 6/21/21 at 10:12 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident D was admitted to the facility on [DATE]. The most recent MDS assessment, dated 5/26/21, indicated the resident had moderate cognitive impairment. He required 2-person assistance with bed mobility, transfers and toileting. A health care plan, dated 5/26/21, indicated the resident preferred a shower twice weekly. The shower schedule indicated the resident was to receive a shower on Monday and Thursday during the day-shift. Review of the Point of Care History report, provided by the DON on 6/21/21 at 1:40 p.m., indicated no shower was given during the month of May. The resident received a shower on 6/3/21, 6/7/21, 6/10/21, 6/17/21 and 6/21/21. 3. The clinical record for Resident F was reviewed on 6/21/21 at 12:10 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent quarterly MDS assessment, dated 4/16/21, indicated the resident was severely cognitively impaired. The resident required physical assistance for bathing. A health care plan, dated 5/9/18, indicated the resident preferred a shower twice weekly on evening shift. The shower schedule indicated the resident was to receive a shower on Tuesday and Friday during the evening-shift. Review of the Point of Care History report, provided by the DON on 6/21/21 at 1:40 p.m., indicated the resident did not receive a shower in May. The resident was offered and refused an evening shower on 3 occasions. She was offered a shower during the night shift on 7 occasions and refused. During June, the resident received two showers on 6/2/21. She again received a shower on 6/11/21 and 6/18/21. The resident was offered and refused an evening shower on 1 occasion. She was offered a shower during the third shift on 5 occasions and refused. During an interview 6/20/21 at 11:21 p.m., LPN 4 indicated occasionally there were 2 aides from 6:00 p.m. until 10:00 p.m., but 2nd shift could be a little rough. During an interview on 6/21/21 at 9:59 a.m., CNA 1 indicated there has been no real change in staffing, they did not have enough CNA's. During an interview on 6/21/21 at 10:31 a.m., CNA 2 indicated they did not have any 2nd shift aides. Often there was only 1 aide for 2nd and 3rd shift on the weekends. During an interview on 6/21/21 at 1:15 p.m., CNA 3 indicated they could use more staff on 2nd shift. During an interview on 6/21/21 at 1:30 p.m., the DON indicated ideally they would have 1 nurse and 2 aides 6:00 p.m. through 6:00 A.M. The care was able to be done with 1 aide. The Administrator indicated they did not have a specific shower policy, but the residents were to receive at least 2 showers per week. This Federal tag relates to Complaint IN 196 and IN 233. 3.1-38(a)(2)(A)

Based on record review and interview the facility failed to provide a cognitively impaired resident an appropriate assessment after the resident exited the facility unsupervised FOR 1 of 3 residents reviewed for accidents. (Resident B) Findings include: The clinical record for Resident B was reviewed on 5/8/2021 at 11:17 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent Quarterly Minimum Data Set (MDS) assessment, dated 4/20/21, indicated the resident was cognitively impaired. During an interview on 5/8/2021 at 11:01 a.m., Resident F (Resident B's roommate) indicated on 4/27/2021 at approximately 6:00 p.m., Certified Nursing Assistant (CNA) 2 entered their room and asked if she had seen Resident B. She indicated CNA 2 stated Resident B was gone. After CNA 2 left the room, the roommate indicated she looked out the window and saw Resident B walking alone past the window. I looked out the window and I saw her just strolling by the window. The roommate indicated she yelled for CNA 2 and said Resident B was outside. During an interview on 5/10/2021 at 11:06 a.m., the Executive Director and DON indicated the clinical record should have had an assessment documented of Resident B for after the incident. During an interview on 5/10/2021 at 11:23 a.m., LPN 1 indicated she did not document an assessment of Resident B once she returned to the building. During an interview on 5/10/2021 at 12:00 p.m., LPN 3 indicated she worked 4/17/2021. LPN 3 indicated she was told Resident B had exited the facility. LPN 3 indicated there was no documentation of any assessment of the resident after she was returned to the facility and no increased monitoring was put into place. This Federal tag relates to complaint IN 300. 3.1-37(a)

Based on record review and interview the facility failed to ensure a cognitively impaired resident did not exit the facility unsupervised for 1 of 3 resident reviewed for elopement. (Resident B) Findings include: The clinical record for Resident B was reviewed on 5/8/2021 at 11:17 a.m. Diagnoses included, but were not limited to, Alzheimer's disease, diabetes type 2, [CONDITION(S)] and dementia. The most recent Quarterly Minimum Data Set (MDS) assessment, dated 4/20/21, indicated the resident was cognitively impaired. On 5/8/2020 at 12:33 p.m., a Fall Risk Assessment, dated 4/12/2021 was reviewed. The assessment indicated Resident B was at risk for falls. On 5/8/2021 at 12:33 p.m., the most current Elopement Risk Assessment, dated 12/17/2020, was reviewed. The assessment indicated Resident B was at risk for elopement. During an interview on 5/8/2021 at 11:01 a.m., Resident F (Resident B's roommate) indicated on 4/27/2021 at approximately 6:00 p.m., Certified Nursing Assistant (CNA) 2 entered their room and asked if she had seen Resident B. She indicated CNA 2 stated Resident B was gone. Resident F stated she had not seen Resident B since before supper that evening. After CNA 2 left the room, the roommate indicated she looked out the window and saw Resident B walking alone pass the window. I looked out the window and I saw her just strolling by the window. The roommate indicated she yelled for CNA 2 and said Resident B was outside. During an interview on 5/8/2021 at 11:48 a.m., the Executive Director (ED) and the Director of Nursing (DON) indicated on 4/27/2021 the received notification from the facility that Resident B had gotten out of the building. During an interview on 5/8/2021 at 12:51 p.m., Resident E indicated on 4/27/2021 after supper he heard the door alarm sounding. Resident E indicated he looked out his window and saw Resident B walking in the yard. He indicated staff were trying to stop the sounding alarm; he yelled that Resident B was headed for the front of the building and staff ran to the front door. During an interview on 5/10/2021 at 12:00 p.m., LPN 3 indicated she worked 4/17/2021 6:00 p.m to 6:00 a.m LPN 3 indicated she was told Resident B had exited the facility unsupervised. This Federal tag relates to complaint IN 300. 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to place a resident, who was a person under investigation (PUI) with a pending COVID-19 test, under transmission based precautions (TBP) to mitigate the spread of COVID-19 for 1 of 3 residents reviewed who were PUI for COVID-19 (Resident 31). Findings include: During an interview, on 11/13/20 at 8:45 a.m., during entrance to the facility, the SSD indicated Resident 31 had tested positive for COVID-19 on 11/11/20 and was transferred to a sister facility's COVID-19 unit; her roommate was in TBP related to possible exposure and they had no positive staff at the time, but were awaiting all staff and resident test results from 11/12/20. Review of Resident 31's clinical record was completed on 11/13/20 at 10:07 a.m. [DIAGNOSES REDACTED]. Review of progress notes indicated the following: On 11/4/20, she felt shaky, foggy, and slightly nauseous. Her blood pressure was 94/40 and her temperature was 98.0. The Nurse Practitioner gave new orders for [MEDICATION NAME] (for nausea) and increased monitoring of temperature and oxygen saturation. On 11/5/20 (a late entry made on 11/12/20), indicated she had requested to be tested for COVID-19. On 11/6/20, she went to the ER for left sided abdominal pain. It had been ongoing for the last three days, and her medications were helpful. She was not currently on isolation. She returned the same day with a [DIAGNOSES REDACTED]. On 11/11/20, she went to an outside clinical appointment. On 11/11/20 at 1:18 p.m., the results of the resident's COVID-19 test had returned positive. When she was informed, the resident stated she had not been feeling bad, but had a sore throat off and on. Review of Resident 31's COVID-19 test indicated it had been collected 11/5/20, received at the laboratory on 11/10/20, and resulted as positive on 11/11/20. During an interview, on 11/12/20 at 9:43 a.m., the Administrator indicated Resident 31 had been seen at the ER for left lower quadrant pain. She was diagnosed with [REDACTED]. She continued to not feel well and requested to be tested for COVID-19 after the weekend. When the resident had been informed of testing positive, she informed the facility she had been experiencing a sore throat, but hadn't wanted to tell anyone. She was transferred to a COVID-19 unit at a sister facility. During an interview, on 11/12/20 at 10:17 a.m., the DON and Administrator indicated the facility had been using a mail-in lab for COVID-19 testing. They had previously had no problems receiving results within 48 hours. During an interview, on 11/12/20 at 11:51 a.m., with the Administrator and DON, the Administrator indicated COVID-19 tests were overnighted to the laboratory. Resident 31 had not been placed in TBP, as they did not feel she was having signs or symptoms of COVID-19. The resident went to an outside appointment weekly, and had been to the ER. The DON indicated the resident had been out of the facility more often than others and the clinical office she visited weekly had been having increased cancellations due to COVID-19, so the resident may have heard information there which caused her to want to be tested . The DON indicated there was a pod of rooms on the west hall of the facility with PUI and TBP for exposure. During an interview, with the Administrator and DON, on 11/13/20 at 10:20 a.m., the Administrator indicated the resident had been tested per her request. The facility went by the signs and symptoms listed by the CDC such as nausea, sore throat, temperature, chills, or respiratory symptoms. Resident 31 had been tested on [DATE], but the results had not come back until 11/11/20; the Administrator had called twice for the test results in that time frame. Review of a current facility policy, titled MMM Resident and Staff Testing Strategies for COVID-19, revised 11/3/20 and provided by the Administrator on 11/13/20 at 12:11 p.m., indicated the following: .The resident who displays s/s of COVID-19 will be placed in TBP until results of COVID test . Review of an August 26, 2020 CMS QSO 20-38-NH memorandum, titled Interim Final Rule (IFC), CMS-3401-IFC, Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency related to COVID-19 Focused Survey Tool, indicated the following: .Residents who have signs or symptoms of COVID-19 must be tested . While test results are pending, residents with signs or symptoms should be placed on transmission-based precautions (TBP) in accordance with CDC guidance Review of a cdc.gov/coronavirus document, dated 9/11/20, for older adults indicated the following: .In some cases, older adults and people of any age with underlying health conditions may have symptoms that are not typically seen in others, or they may take longer than others to develop fever and other symptoms .In older adults (aged 65 and older), normal body temperature can be lower than in younger adults. For this reason, fever temperatures can also be lower in older adults .If you are caring for a patient aged 65 or older, be aware that a single reading higher than 100°F (37.8°C), multiple readings above 99°F (37.2°C), or a rise in temperature greater than 2°F (1.1°C) above the patient ' s normal (baseline) temperature may be a sign of infection 3.1-18(b)

Based on record review and interview, the facility failed to ensure there was an Advanced Directive for code status on the resident's profile and an order for [REDACTED]. Findings include: 1. Resident 18's clinical record was reviewed on [DATE] at 11:21 a.m. A focused careplan, dated [DATE], for code status indicated Cardiopulmonary Resuscitation (CPR) was to be performed. Interventions included, but were not limited to, ensure code status form is signed and on the chart and code status was sent with the resident to the hospital and physician appointments. The clinical record lacked an identified code status on the profile or an order in the EHR. 2. Resident 17's clinical record was reviewed, on [DATE] at 2:30 p.m. A focused careplan, dated [DATE], for code status indicated Do Not Resuscitate. Interventions included, but were not limited to, ensure code status form is signed and on chart and code status was sent with the resident to the hospital and physician appointments. The clinical record lacked an identified code status on the profile or an order in the EHR. 3. Resident 30's clinical record was reviewed, on [DATE] at 2:37 p.m. A focused careplan, dated [DATE], for code status indicated Do Not Resuscitate. Interventions included, but were not limited to, ensure code status form is signed and on chart and code status was sent with the resident to the hospital and physician appointments. The clinical record lacked an identified code status on the profile or an order in the EHR. During an interview with RN 5, on [DATE] at 2:37 p.m. with the Quality Assurance (QA) Nurse present, she indicated she would look at the resident's profile on the EHR to know what a resident's code status was and the admitting nurse was suppose to put the code status in the EHR. The QA Nurse indicated she did not see the code status on the resident's profiles or orders for them and they should have been in the EHR. A current facility policy titled Code Status and Advanced Directive Determination, dated [DATE] and provided by the QA Nurse, on [DATE] at 3:00 p.m., indicated the following: .2. PR[NAME]EDURE: .F. After a CPR decision had been made, the form signed by the resident/family will be placed on the medical record in the appropriate location and this information will be communicated to the nurse in charge of caring for the resident 3XXX,[DATE](f)5

Based on observation, record review, and interview, the facility failed to develop and implement individualized interventions related to wandering for residents with dementia for 1 of 6 residents reviewed for dementia care, (Resident 2). Findings include: During a random observation, on 10/17/19 at 10:45 a.m., a door alarm had sounded near the front entrance of the facility, a CNA assisted Resident 2 in front of the nurses' station, she indicated we have to stay away from the door. During a medication administration observation in a female residents room, on 10/18/19 at 9:02 a.m., the resident entered the female resident's room, stood with his hands clasped behind his back, then exited. During a random observation, on 10/18/19 at 9:04 a.m., a CNA assisted the resident out of a room where two female residents were sitting. During a random observation, on 10/18/19 at 3:15 p.m., the resident was standing in front of the nurses desk, the Administrator had a vase of flowers in her hands, the resident grabbed the vase, the Administrator also had hold of the vase, the resident tilted the vase and emptied the water onto the floor. He removed the flowers from the vase, walked towards the West Hall and threw the flowers down hall. The resident's clinical record was reviewed on 10/17/19 at 1:52 p.m. [DIAGNOSES REDACTED]. Current physician orders [REDACTED]. a. Trazadone (antidepressant), 100 milligram (mg) tablet, give one tablet, at bedtime, for [MEDICAL CONDITION], order date 4/23/19. b. Wanderguard (an alarming monitor) check placement , order date 6/24/19 c. [MEDICATION NAME] antidepressant), 200 mg tablet, give one tablet, at bedtime, for depression, order date 8/31/19. d. [MEDICATION NAME] (pain reliever), 50 mg tablet, give one tablet, two times a day, for pain, order date 9/11/19. e. [MEDICATION NAME] (anticonvulsant), 100 mg tablet, give one tablet, at bedtime, for emotional lability, order date 10/8/19. An 10/3/19, quarterly, Minimum Data Set assessment indicated he had severe cognitive impairment. He required extensive assistance with bed mobility, transfers, dressing, and personal hygiene, supervision to walk in room and in corridor, with locomotion on and off the unit, and with eating. Wandering occurred daily. He had current care plans for the following: A 1/14/19 behavior with display mood issues care plan. Mood behavior #1, nervousness/anxiety: picking at skin on hands and fingers until they are raw. Interventions included, redirect with busy work for hands (silly putty), offer lotion for hands, offer snack or drink (diet Pepsi), and redirect with conversation about his dog. Mood behavior #2, hitting staff when anxious. Interventions included, move to a quiet environment when first displaying anxious symptoms, offer snack/drink, diversional activity-discuss his children, and approach later with another caregiver. Mood behavior #3, agitation such as clenching his fists, short tempered, shaking his fists at staff, and irritable facial expressions. Interventions included, provide calm surroundings, offer snack/drink, assess for unmet needs such as toileting, and diversion activity/talk about family. An 4/2/19, wandering care plan indicated he wandered related to cognitive impairments and seeking family members (his kids). Interventions included, assist the resident to and from activities, sit close to speaker to encourage involvement, check placement of wanderguard bracelet daily, place familiar objects to resident in his room, such as pictures/objects/furniture, provide assistance in locating room, and provide directional cues (pictures, name on doors). A 7/19/19, episode of resident to resident altercation care plan indicated he had thrown a pop bottle at another resident, on 8/30/19, he had hit another resident in the head with a piece of PVC pipe, on 9/21/19, he had thrown another resident's food at them. Interventions included to address any physiological needs determined from the behavior assessment, review completed behavior assessment with Interdisciplinary Team, and supervise while in the dining room and other common areas. Nurse's progress notes indicated, but were not limited to, the following: On 8/15/2019 at 4:36 p.m., the resident had been wandering up and down the halls, in and out of the dining room more so than usual. He entered staff offices, stood and looked at staff then left. He had an angry look on his face at times. He removed his shirt in the lobby and refused to put it back on. He jerked away from staff and ambulated down the hall. Given time to calm down and reapproached was helpful. Staff were monitoring for changes in mood and behaviors. On 9/21/2019 at 5:48 p.m., during the evening meal, the resident paced the dining room and stopped and stared at residents that were eating. He threw a handful of spaghetti at the floor. He wandered to another table, grabbed a handful of another resident's food and threw it at them. The resident was removed from the dining room, sat in the lobby, and offered a pop. He calmed down quickly. His granddaughter came for a visit and he was seen smiling and interacting with her. On 9/24/2019 at 2:15 p.m., the interdisciplinary team met, on 9/23/19, and discussed medications, mood, and behavior. Plan was to add [MEDICATION NAME] (anticonvulsant) to medication regimen for agitation. On 9/26/2019 at 9:59 a.m., the resident had been pacing around when he approached the entry door. The wanderguard alarm sounded and frightened him. He took off running around the corner and down the hall before the CNA caught up to him to see what was the matter. The resident stated that it scared him. On 9/27/2019 1:45 p.m., following the noon meal, the resident was wandering about the lobby and front entrance area. He was enjoying cookies a visitor had brought for him. Without provocation, the resident threw the cookie at the front door. Resident appeared agitated with increased tremors. He was unable to articulate reason for throwing the cookie. On 10/1/2019 at 5:50 p.m., the resident had an unsteady gait and balance. He was leaning strongly to his left. He was unsafe to stand on his own. His tremors had increased. He was placed in a wheelchair for his safety. The Nurse Practitioner (NP) was notified. An order was received to discontinue [MEDICATION NAME]. Daughter was notified. On 10/8/19 at 1:38 p.m., a new order for carbamazapine 100 mg, every bedtime, was received for emotional liability. There were no documented behaviors between 10/1 and 10/8/19. On 10/18/19 at 4:31 p.m., the resident was throwing items, pulling table clothes off tables, harder to direct. A new order for [MEDICATION NAME] (antipsychotic), 5 mg one time order, was received from the NP and an order to transfer to a geri-psychiatric facility for evaluation and treatment. On 10/19/19 at 12:13 a.m., the resident was transported to the geri-psychiatric unit by the Regional Administrator at 10:00 p.m. During an interview, on 10/17/19 at 10:46 a.m., QMA 7 indicated the resident would usually had behaviors in the evening, some behaviors happened when he had too much stimulation. During an interview, on 10/21/19 at 10:28 a.m., the DON indicated the resident had been transferred to a geri-psychiatric facility. During an interview, on 10/21/19 at 1:36 p.m., the DON indicated she did not have any additional information to provide to indicate individualized interventions for the resident. During an interview, on 10/21/19 at 2:56 p.m., RN 5 indicated the resident required total assistance with dressing, toileting, and shaving, if he was having a really bad day they would feed him, between lunch and dinner was when his behaviors typically occurred, she felt the caffeine may have made him agitated. During an interview, on 10/21/19 at 3:12 p.m., the Activity Director indicated the resident wouldn't sit still long enough to do activities. He wandered a lot. He participated in coffee and donuts, and he liked Pepsi. Review of a current facility policy, titled Behavior Assessment and Management, dated 9/2/18 and provided by the Administrator-In-Training, on 10/21/19 at 4:03 p.m., indicated .As identified, through unchanged behaviors and review of documentation, ongoing education of staff on approaches, utilizing effective interventions, etc should be provided 3.1-37(a)

Based on interview and record review, the facility failed to ensure a resident was provided with the necessary care following a fall for 1 of 6 residents who were reviewed for accidents. (Resident #27) Findings include: During a staff interview on 1/21/13 at 11:11 a.m., LPN #1 indicated Resident #27 had a witnessed fall within the past 30 days that resulted in a left hip fracture. During record review on 1/22/13 at 2:30 p.m., Resident #27's [DIAGNOSES REDACTED]. During record review on 1/23/13 at 2:00 p.m., the initial occurrence assessment was reviewed. The assessment indicated, on 12/24/12 at "7:45 p.m., CNA #2 was assisting Resident #27 with a transfer in her room by himself. Resident #27 fell on to the floor and landed on her back. Resident #27 received a lump to the back of her head, measuring approximately 3" long that had started to bruise. Resident #27 also complained of tenderness upon movement, and bruising to her left leg was noted. A head to toe assessment was completed with neurological assessment and vital signs obtained per facility protocol. The physician was not notified of the incident or injuries to Resident #27. The Power of Attorney (POA) for Resident #27 was notified on 12/24/12 at 9:15 p.m.," per phone message left on the answering machine. A follow-up assessment was completed on 12/25/12 at 3:00 a.m. The assessment indicated Resident #27 had bruising to the back of her head and complaints of left leg and hip pain. No bruising was seen on her leg at the time, but an abrasion to her left shoulder blade was present. The assessment indicated pain medication was given to Resident #27, which provided relief. A neurological checklist was initiated for Resident #27 at the time of the fall. Resident #27 was being assessed for every 15 minutes for 1 hour, then every 30 minutes for 2 hours, then every 2 hours for 8 hours. The assessment included vital signs, pupil response, lethargy and reflexes until the resident was found in bed with a change of condition. No abnormal pupil change, lethargy or reflex change was identified until 12/25/12 at 6:45 a.m. A nursing note dated, 12/25/12 at 6:40 a.m., indicated Resident #27 was found in bed, vomiting, pupils sluggish and the resident was lethargic. A bruise and swollen area was noted to her posterior head. The physician and POA were notified and Resident #27 was sent to the local hospital by ambulance for treatment. Resident #27 was hospitalized from [DATE]-12/30/12 for a left hip fracture. On 1/24/13 at 2:00 p.m., a care plan, dated 4/11/12, indicated Resident #27 required 1 person assistance during the day and 2 person assistance in the evening related to fatigue. A care plan, dated 1/2/13, indicated Resident #27 required a stand lift with the assistance of 2 staff related to her recent fall. On 1/24/13 at 2:10, the CNA assignment sheet was reviewed. The sheet indicated Resident #27 required a stand lift with 2 staff members to assist. During an interview on 1/24/13 at 3:25 p.m., CNA #2 indicated he was transferring Resident #27 by himself at the time of her fall on 12/24/12. He indicated no other staff member was present in her room. A fall risk assessment, dated 10/19/12, was reviewed on 1/25/13 at 10:40 a.m. The assessment indicated Resident #27 had a history of [REDACTED]. During an interview on 1/25/13 at 1:00 p.m., the Director of Nursing (DoN) indicated the staff did not follow facility policy related to a fall and assistance level as needed. Review of a current facility policy, dated 2/14/2012, titled "Incident/Accident Report Procedure & Form," which was provided by the Director of Nursing on 1/23/13 at 2:32 p.m., indicated the following: "...A. Assessment and Investigation: ... XI. After resident is thoroughly assessed and is safe for moving, assist resident up if they have fallen or assist resident to bed or chair if needed. For a resident that requires moderate transfer assistance and is on the floor, a mechanical lift (and at least two staff members) should be used to get resident up off the floor. B. Notification: I. Notify the Physician immediately for emergencies and injuries requiring emergency treatment. III. Notify the responsible party immediately for emergencies.... D. Follow-up Assessment and Documentation: II. Notify DON and Administration of incident with injury immediately so that ISDH may be notified if appropriate. 3.1-45(a)(2)