Every finding on record at Wellbrooke of Crawfordsville

Based on observation, interview, and record review, the facility failed to provide effective individualized person-centered care for a resident who exhibiting dementia-related behaviors, including repeated attempts to undress, restlessness, and signs of discomfort for 1 of 3 resident reviewed for dementia care (Resident 46). Findings include:On 11/18/25 from 9:40 until 10:30 a.m., Resident 46 was observed. She was seated in a reclined Broda wheelchair, pulled up close to a common table a the nurses station, and the chair was locked in place. Resident 46 was slouched down in her seat, and leaned to the far left of the chair. During this continuous observation, Resident 46 attempted to undress herself, at one point she pulled her shirt up and over her head, which exposed her breasts as she was not wearing a bra. She was not redirected or offered activities/interventions. Staff, residents, and visitors were coming and going through the common area able to observed Resident 46.On 11/18/25 from 1:30 p.m., until 2:30 p.m., Resident 46 was observed. She was seated in her reclined Broda wheelchair, pulled up close to the nurses' station. During this continuous observation, she repeatedly pulled at her pants legs to pull the material up past her knees. She also continue to try unbutton and pull at her shirt which exposed her stomach and breasts. She was not redirected or offered activities/interventions. Staff, residents, and visitors were coming and going through the common area able to observed Resident 46.During a continuous observation on 11/19/25 from 9:20 a.m., until 11:00 a.m., the following was observed:At 9:20 a.m., Resident 46 was observed, as above, at the common table nurses' station. She was observed to be restless and exhibited signs of restlessness/anxiety as she continually sat up, leaned forward, sighed deeply, grunted, pulled her sweater over her head which exposed both breasts as she was not observed to have a bra on. She pulled her legs up to her chest and wiggled in her chair.At 9:23 a.m., she repeatedly fidgeted with the edge of her sweater and pulled it over her head.At 9:26 a.m., Staff briefly pulled the sweater back on, but no follow-up intervention or assessment (e.g., discomfort, heat, pain, toileting need, anxiety) was performed.At 9:31 a.m., Resident 46 again removed her sweater entirely; staff replaced it but did not address the cause or offer meaningful engagement or comfort measures.At 9:40 a.m., Resident 46 was taken to a volunteer-led Bible Study activity where she was seated 1:1 with an activity aide for engagement.At 10:00 a.m., the Activity Aide brought Resident 46 back to the common area nurses station. Around this time, a volunteer came to the nurse's station with a Therapy Pet Dog. Staff did not ensure that the Therapy Pet got to visit with Resident 46.During an interview on 11/19/25 at 10:20 a.m. the previous Administrator who was visiting stopped to say hello to Resident 46, who was fidgeting with a blanket on het lap and indicated the resident loved to fold clothes.From 10:26-10:46 a.m., Resident 46 fidgeted and repositioned herself so that she got both her legs out from under the table and rested them on top of the common table. She pulled her pants legs and pulled her socks off.Until 11:00 a.m., when she was taken to the main dining room for lunch, Resident 46 continued to exhibit signs of restlessness/anxiety/discomfort; constantly pulling at her clothing, pinching/pulling the edges of her blanket, pulling the blanket up and down the table, aggressively scratching the back of her head, deep sighs, occasional grunts and undirected speech, what is this? I don't know. What now?During a continuous observation on 11/21/25 from 9:05 a.m., until 11:30 a.m., Resident 46 was observed. She was seated in her reclined Broda chair, locked in place at the common area nurses station table. She appeared less anxious and less hyperactive, but exhibited signs of discomfort and tiredness as she repeatedly scootched in her chair. She sighed deeply. Moved from side to side in her chair. Leaned forward and rested her head on the table in front of her. At some times her eyes were closed and she appeared to be asleep. Then she would open her eyes and sign deeply, occasionally grunt, or loosely pick at her clothes/blanket. No activities or interventions were observed/offered until she was taken to the main dining room for lunch.Throughout the survey period, Resident 46 was repeatedly parked at the nurses' station table with only a blanket. Although there was a laundry basket of various folding items on the bench of the common area, those items, magazines, or a fidget blanket were never offered to the resident.She was only observed in one activity, which lasted less than 30 minutes (as described above).She was not given the opportunity to visit with the Therapy Pet.On 11/21/25 at 9:13 a.m., a Visiting Activity Director from a sister facility stopped at the common table to visit with Resident 46 and three other residents seated at the table. She visited with the group 1:1 for less than 3 minutes.On 11/21/25 at 9:51 a.m., Resident 46's record was reviewed. She was a long-term care resident with diagnose which included, but were not limited to, unspecified dementia, adult failure to thrive and anxiety.On 7/28/25 at 10:26 p.m., Resident has been restless this evening. She is grabbing at anything she can reach and repeats please without being able to verbalize what is wrong. She continues to deny pain but says please and reaches out grabbing nurses hair, quickly letting go, then grabs name badge and continues to reach out for anything she can grab. She stops periodically, answering questions. She replies no when asking if she is in pain and if she would like to get out of bed.On 7/29/25 at 1:08 p.m., Resident had some anxiousness this morning moving around in her geri chair and grunting while doing so.On 10/18/25 at 6:12 p.m., Resident has been antsy this shift. She attempts to pull shirt off while sitting at nurses station and when assisted by nurse in calming manor, she grabs nurses arm, digging nails into it says stop it through gritted teeth. She then starts to hit arm but it is not with much force. She is difficult to redirect at that time. PRN Ativan utilized at this time. Activities attempted to distract and effective at this time.On 10/18/25 9:18 p.m., During rounds, resident is seen stripping clothing off in bed, including brief. When CNA [certified nursing assistant] turns the corner the resident says razzle dazzled. She is assisted out of bed at this and sitting at the nurses station. She continues to fidget with clothing and blanket.On 10/21/25 at 10:27 a.m., Resident continues to present with increased anxiety, resident yelling out, taking socks off, messing with stuff on table, pushing common area table over with BLE [bilateral lower extremities], putting BLE on top of table.On 10/24/25 at 2:54 a.m., Majority of evening, resident rested in her broda chair, awake, messing with clothing and blanket.On 10/24/25 at 8:28 p.m., Resident has remained very active in her broda chair this evening. Constantly fidgeting with her blanket or clothes.She had a comprehensive care plan, initiated 11/26/24 with a target goal of 2/28/26, which indicated, my ability to make decisions regarding my daily activity engagement may be altered due to my diagnosis of dementia. I have a history of enjoying: being read to, animal therapy, and practicing my Christian religion. Interventions for this plan of care included, but were not limited to: It is important to me to be around animals. I have 2 cats of my own but please include me in visits involving pet therapy. Provide one-to-one assistance to promote success as needed. I have a sensitivity to loud noises, such as music. Please provide me with calming, individualized activities for me either in my room, at the nurse's station, or near the campus fireplace.She had one care plan, initiated on 8/14/25 with a target goal date of 2/28/26, which indicated, Resident presents with a diagnosis of Anxiety Disorder and remains on anti-anxiety medication, and a second care plan imitated on 11/2/24 with the same target goal date which indicated, Resident has a dx of anxiety disorder by s/s are well controlled.Resident 46's full care plan set lacked implementation and/or revision to address her behaviors of unsafe positioning in her Broda chair, pulling her clothes off, and constant fidgeting with her clothes or scratching her head.A Significant Change Life Enrichment Assessment, dated 8/13/25, indicated one of her favorite activities was to watch TV but was also very hyper sensitive to noise.On 11/21/25 at 10:44 a.m., a Visiting Activity Director (AD) provided a copy of Resident 46's activity participation log. The AD indicated the there was a dot beside the activity, it indicated the Resident had participated.Resident 46's activity logs was reviewed for the survey week and revealed the following:On 11/18 at 10:26 a.m. - she was coded as having participated in - sensory basket. During a continuous observation on 11/18/25 from 9:40 until 10:30 a.m., (as indicated above) Resident 46 was not offered a Sensory Basket.On 11/19 at 9:00 a.m. - she was coded as having participated int - Bible Study with Pat. During a continuous observation on 11/19/25 as indicated above, Resident 46 was not taken to the activity until 9:40 a.m., and was brought back at 10:00 a.m. She was not observed to do any Bible reading, or have anyone read the Bible to her.On 11/19 at 10:26 a.m., she was coded for participation in - Sensory Basket. During a continuous observation, as indicated above, Resident 46 was not observed to be offered a sensory basket.On 11/19 at 10:22 a.m. - she was coded for participation in - Listening to music, however at this time, as indicated during a continuous observation listed above, Resident 46 was seated at the common area nurses station and no music was playing.On 11/20 at 10:22 a.m., she was coded for participation in - Listening to Music, however at that time she was observed to be seated in her broda chair at the common area nurses station table, and no music was playing.On 11/21 at 10:00 a.m., she was coded for participation in - Crafty Creations - Turkey Coasters. During a continuous observation, as indicated above, Resident 46 was not observed to be offered or taken to the craft activity as she remained at the nurses station common table.On 11/21 at 10:31 a.m., she was coded for participation in - Listening to Music, however at that time she was observed to be seated in her broda chair at the common area nurses station table, and no music was playing.On 11/19/25 at 3:00 p.m., the Executive Director (ED) provided a copy of current facility policy titled, Program Standards, Life Enrichment, reviewed 4/14/25. The policy indicated, The purpose of this policy is to design and implement programs that provide opportunities for residents to meet their social, physical, cognitive, and emotional needs, as well as their recreational interests, ensuring programs are meaningful, diverse, stimulating, and consistent with individual needs, preferences, and abilities . Dementia Programs: (Mindful Moments) Programs for individuals with dementia are adapted to their assessed level of functioning and ability and are task-segmented to promote independent functioning and success. Programs that stimulate the five senses help to promote resident connection for those in later stages. Programs for individuals with dementia may be provided in an environment with decreased environmental stimulation. Old roles may be re-established in determining the daily routine for the resident.3.1-37(a)

Based on observations, interviews, and record review, the facility failed to continue nutritional and pharmaceutical supplements for a malnourished resident who was not yet at her goal of achieving and maintaining an ideal body weight resulting in continued weight loss for 1 of 2 residents reviewed for weight loss and nutrition (Resident 46). Findings include:On 11/20/25 at 11:33 a.m. Resident 46's medical record was reviewed. She was a long-term care resident whose diagnoses included, but were not limited to, dementia, malnourishment, and adult failure to thrive.Resident 46 was admitted to the facility on [DATE], the first recorded weight was on 11/4/25 and it was 98.4 pounds. At the time of her admission the resident was put on a mechanical soft diet (a texture-modified diet for people who have difficulty chewing or swallowing) and she had an active order to be weighed weekly.An admission nutrition assessment note, dated 10/31/24, indicated Resident 46 had a Body Mass Index (BMI) of 20, her nutrition goal was a BMI of 22 and to maintain a stable weight. The Dietician recommended to add Ensure once a day between breakfast and lunch, with the direction to increase the amount to twice a day if intake was good.On 11/1/24 an order for the resident to receive Ensure once a day was added.Resident 46 had recorded weights on 11/10/24, 11/17/24 and 11/24/24 which were all low 100-pound weights.On 11/27/24 the order for weekly weights was discontinued and an order for monthly weights was added.On 12/5/24 there was a recorded weight of 94 pounds. This was a 4.5% decrease in weight in one month.A Nurse Practitioners (NP) note, dated 12/6/24, indicated she wanted Resident 46 to be reevaluated by the Dietitian.On 12/12/24 an order for Mirtazapine (an antidepressant that can be used in low doses to increase appetite.) 7.5 milligrams daily was added.A Critical at Risk (CAR) note, dated 12/12/24, indicated Resident 46 had an 8.7-pound weight loss in twelve days. The new intervention was to put the resident on fortified foods.A progress note, dated 12/13/24, indicated the order for the Dietician to reevaluate Resident 46 had been discontinued and needed to be reordered.A progress note, dated 12/18/24, indicated the Assistant Director of Nursing Services (ADNS) added the order for the Dietician to reevaluate Resident 46.A nutrition note, dated 12/18/24, indicated Resident 46 had a BMI of 19 and variable intakes at meals, on average she would eat 26-50%. She would drink, on average, 51-75% of her Ensure. The weight history in the note indicated the resident had a 4-pound weight loss in the last thirty days, which was a 4.2% loss, deeming it not a significant loss. There were no new recommendations at this time.A nutrition follow-up note, dated 1/2/25, indicated Resident 46's current weight was 94.4, this weight was taken 12/6/25. She had a BMI of 19, poor intakes at meals, averaging 1-25% per meal and was averaging 76-100% of her ensure. The new intervention was to increase the order for Ensure to three times a day.On 1/3/25 the order for Ensure once a day was discontinued and a new order for Ensure three times a day was added. On 1/5/25 there was a recorded weight of 94.6 pounds. This was the only weight recorded for the month of January.The weight history in a nutrition note, dated 1/15/25, indicated Resident 46 had an 8.5-pound weight loss in the last forty-five days which was a 9% loss, deeming it a significant loss. The note indicated the new goal for Resident 46 was to get weight up to at least admission weight, if not weight prior to the loss.An NP note, dated 1/21/25, indicated Resident 46's weights had been stable over the last month. No new recommendations were given at this time.On 1/25/25 an order for Resident 46 to receive a shake made of ice cream and cranberry juice at every meal was added.A nutrition note, dated 2/4/25, indicated the Dietician spoke with several dietary staff members to ensure Resident 46 was getting the ice cream and cranberry juice shake at every meal. The note indicated the Assistant Director of Food Services (ADFS) would speak to all dietary staff about the importance of the resident receiving this supplement at every meal.On 2/5/25 there was a recorded weight of 84.4 pounds. This was a 10.8% decrease in weight in one month.A nutrition note on 2/12/25 indicated Resident 46's current weight was 84.4 pounds, and her BMI was 17. The weight history in the note indicated the Resident had a 10.2-pound weight loss in the last thirty days, which was a 12.1% loss, deeming it a significant loss. The Resident also had a 14-pound weight loss in the last ninety days, which was a 16.6% loss, deeming it a significant loss. The note indicated the Resident had poor intake at meals, averaging 1-25% and her supplement intakes averaged 26-50%.On 3/5/25 there was a recorded weight of 89.9 pounds.On 3/7/25 there was an order of 90 milliliters of MedPass supplement (a high-calorie, high-protein nutritional shake given to individuals with malnutrition or other conditions requiring extra nutrition) three times a day added.On 3/21/25 there was an order for weekly weights added.On 3/23/25 there was a recorded weight of 82.8 pounds. Compared to Resident 46's weight on 2/5/25, this was a 2% decrease.On 3/24/25 there was a recorded weight of 81.2 pounds. Compared to Resident 46's weight on 2/5/25, this was a 3.8% decrease.On 3/30/25 there was a recorded weight of 80.2 pounds. Compared to Resident 46's weight on 2/5/25, this was a 5% decrease.On 4/5/25 there was a recorded weight of 77.6 pounds. This was a 13.7% decrease in weight in one month.An NP note dated 4/8/25 indicated Resident 46 was not at goal, and her weights were trending down. The note indicated Mirtazapine had been discontinued at some point, and she indicated it would be restarted at 7.5 milligramsOn 4/8/25 the order for Mirtazapine 7.5 milligrams daily was discontinued and an order for Mirtazapine 15 milligrams daily was added.On 4/13/25 and 4/20/25 there was a recorded weight of 80.6A Dietician note dated 4/18/25 indicated her current weight was 80.6 which was a significant loss of 9.3 pounds in one month, 14 pounds in three months and 19 pounds in 6 months. The recommendation was to add 60 milliliters of MedPass supplement to the current ordered amount of 90 milliliters.On 4/20/25 the order for weekly weights was discontinued and the order for monthly weights resumed.On 4/25/25 there was an order for 60 milliliters of MedPass supplement three times a day added. This was a separate order from the 90-milliliter dose. In total at this time the Resident was ordered to receive 150 milliliters of MedPass supplement three times a day.On 5/5/25 there was a recorded weight of 80.2 pounds.An NP note, dated 6/4/25, indicated Resident 46's weights had been stable in the 80s for one month and she wanted the current interventions to continue.On 6/5/25 there was a recorded weight of 82 pounds.At this time the nutritional supplements Resident 46 had ordered were 150 milliliters of MedPass three times a day, Ensure three times a day, an ice cream and cranberry juice shake at meals, fortified foods and 15 milligrams of Mirtazapine daily.On 6/7/25 the order for 60 milliliters of MedPass supplement three times a day was discontinued.A weight note, dated 6/18/25, indicated Resident 46 was receiving Ensure and 60 milliliters of MedPass supplement three times a day. She had varied intakes at meals averaging 45-50%. The new recommendation was to discontinue the order for Ensure three times a day.At this time the ordered amount of MedPass supplement was 90 milliliters three times a day.On 6/19/25 the order for Ensure three times a day was discontinued.On 7/5/25 there was a recorded weight of 84.2 pounds.A weight note dated 7/18/25 indicated Resident 46 was receiving 60 milliliters of MedPass supplement three times a day, averaging 51-75% intake. She had varied intakes at meals averaging 25-75% intake.At this time the ordered amount of MedPass supplement was 90 milliliters three times a day.A Guidestar psychiatric note, dated 7/25/25, indicated the plan of care was to discontinue Mirtazapine because a decrease in this antidepressant can affect oral meal consumption.On 7/25/25 the order for Mirtazapine 15 milligrams daily was discontinued.At this time the nutritional supplements Resident 46 had ordered were 90 milliliters of MedPass three times a day, an ice cream and cranberry juice shake at meals and fortified foods.On 8/5/25 there was a recorded weight of 80 pounds. This was a 5% decrease in weight in one month.A nutrition note, dated 8/7/25, indicated Resident 46 had a significant weight loss of 5% in the last thirty-one days and she was receiving 60 milliliters of MedPass supplement three times a day, averaging 51-75% intake. The new recommendation was to increase MedPass supplement to 90 milliliters three times a day.At this time the ordered amount of MedPass supplement was 90 milliliters three times a day.A Interdisciplinary Team (IDT) note indicated Resident 46's family was concerned about her difficulty with eating meals, so they requested to downgrade her diet to pureed.A significant change life enrichment assessment dated [DATE] indicated Resident 46's favorite activities were watching tv, but she was very hypersensitive to noise.On 8/18/25 the order for a mechanical soft diet was discontinued and a new order for a pureed diet was added.On 8/21/25 an order for weekly weights was added.On 8/24/25 there was a recorded weight of 79 pounds.On 8/31/25 there was a recorded weight of 77.2 pounds. Compared to Resident 46's weight on 8/5/25 this was a 3.5% decrease in weight.On 9/4/25 there was a recorded weight of 78.2 pounds.On 9/7/25 there was a recorded weight of 77 pounds. Compared to Resident 46's weight on 8/5/25 this was a 3.8% decrease in weight.A CAR note, dated 9/10/25, indicated Resident 46 had a 1.2-pound weight loss in the last three days. The note indicated the current interventions were not effective, and the new intervention was to offer chocolate Ensure because that flavor was the Residents preference.On 9/10/25 the order for 90 milliliters of MedPass three times a day was discontinued and an order for Resident 46 to receive chocolate Ensure three times a day was added.On 9/14/25 there was a recorded weight of 78 pounds.On 9/15/25 there was a recorded weight of 78.8 pounds.An NP note dated 9/22/25 indicated Resident 46's weight loss and poor appetite had improved, and to continue the current ordered interventions.On 10/7/25 there was a recorded weight of 82.8 pounds.On 10/15/25 there was a recorded weight of 79.8 pounds.On 10/19/25 there was a recorded weight of 82.6 pounds.On 10/26/25 there was a recorded weight of 79.6 poundsA CAR note, dated 10/31/25, indicated Resident 46 had a 3-pound weight loss. The new intervention was a medication review.On 11/2/25 there was a recorded weight of 76.8 pounds. This is a 7.3% decrease in weight in one month.On 11/4/25 an order for Mirtazapine 7.5 milligrams daily was added. A CAR note dated 11/5/25 indicated Resident 46 had a 2.8-pound weight loss. The new intervention was to add Mirtazapine 7.5 milligrams daily.At this time the nutritional supplements Resident 46 had ordered were chocolate Ensure three times a day, ice cream and cranberry juice shake at meals, fortified foods and Mirtazapine 7.5 milligrams daily.On 11/9/25 there was a recorded weight of 78.2 pounds.On 11/16/25 there was a recorded weight of 79.4 pounds.A care plan dated 11/3/25 and last revised 11/19/25 indicated the Resident had a significant weight loss. The approaches to this problem included, but were not limited to, providing supplements as ordered.A care plan, dated 10/31/24, indicated the Resident was malnourished or was at risk of malnutrition. The goal for this problem included but was not limited to achieving and maintaining an optimal weight by 1/31/26.On 11/17/25 at 11:42 a.m. approximately 35 Residents were observed eating lunch in the dining room. Resident 46 was observed sitting at a table with other residents who also needed help eating. Resident 46 appeared restless and uninterested in eating her meal.On 11/18/25 at 11:35 a.m. approximately 30 residents, including Resident 46, were observed as they were served lunch.On 11/21/25 at 12:13 p.m. Registered Nurse (RN) 11 was observed as she helped Resident 46 drink her ice cream and cranberry juice shake. The resident appeared agitated, constantly moving and having a hard time concentrating on drinking the shake. RN 11 indicated the resident had just come back from lunch in the dining room. She indicated Resident 46 ate in the dining room for most of her meals, but she wouldn't eat much.During an interview on 11/21/25 at 2:38 p.m. Resident 46's regular NP indicated if the resident was gaining weight she would have been ok to trial coming off of Mirtazapine, but she would have wanted to see that medication restarted if the resident was consistently losing weight, or if she was staying under 80 pounds after being off of the medication for a month or two. She was unsure when she was notified of the consistent weight loss but that's when she would have restarted the medication. During an interview on 11/21/25 at 2:57 p.m. the psych NP from Guidestar indicated the NP who discontinued the Mirtazapine is no longer with Guidestar, so she looked through Resident 46's notes to try and help figure things out. She indicated she wasn't sure why the NP chose to discontinue the medication as opposed to decreasing it. The psych NP indicated the NPs are taught to monitor the residents' weights and she would have done so if it had been her overseeing Resident 46's care. She indicated she would expect to restart the medication if the resident's weight was consistently trending down over a month or two. During an interview on 11/21/2025 at 3:12 p.m. the Registered Dietician (RD) Director indicated she didn't see Resident 46 regularly but was familiar with her and her condition. She indicated she would have been ok with discontinuing the Mirtazapine when they did because the therapeutic dose was 7.5 milligrams and the resident was ordered 15 milligrams. She could not say why they chose to discontinue the medication as opposed to decreasing it to the therapeutic dose. The RD Director indicated they probably discontinued the Ensure due to low acceptance rates when it was offered. She indicated the resident didn't trigger for significant weight loss during the time of discontinuing both the medication and Ensures, and with the ice cream and cranberry juice shakes and MedPass supplement the resident was taking, she believed those made up for the Ensure being discontinued. After the order for Ensure three times a day was discontinued on 6/19/25, Resident 46 triggered for significant weight loss once 8/7/25 before it was reordered on 9/10/25. After the order for Mirtazapine 15 milligrams daily was discontinued on 7/25/25 Resident 46 was weighed twelve times before it was restarted on 11/4/25. Of those twelve weights nine of them were under 80 pounds. 3.1-46

Based on interview and record review, the facility failed to ensure a resident's fall interventions were followed to prevent the potential for accidents when she was left alone in the bathroom and transferred with only one staff member on three separate occasions for 1 of 5 residents reviewed for falls (Resident 32). Findings include:On 11/19/25 at 9:52 a.m., Resident 32's record was reviewed. She was a long-term care resident with diagnoses which included, but were not limited to, dementia, hemiplegia and hemiparesis (muscle weakness/paralysis) following cerebral infarction (stroke) affecting left non-dominant side, and anxiety.Resident 32's nursing progress notes were reviewed.1. From 1/1/25 until 4/17/25, Resident 32 had already experienced three falls in her bathroom. She had a witnessed fall on 3/8/25 and 3/16/25, then an unwitnessed fall on 3/29/25 in which she sustained a skin tear injury.A nursing progress note, date 4/17/25 at 1:28 p.m., indicated Resident 32 had been assisted to the toilet and then attempted to get up without calling for assistance. She was found laying on the bathroom floor face down and sustained a 1.1 centimeter (cm) skin tear to her right first finger and a 4 cm abrasion to her left upper cheek.An Interdisciplinary Team (IDT) progress note, dated 4/18/25 at 9:22 a.m., indicated the new intervention put in place was for staff not to leave the resident in the bathroom unattended.After the fall on 4/17/25 and new intervention not to be left unattended in the bathroom, there were three more instances where she was left alone.On 6/2/25 at 10:02 p.m., Resident 32 was upset with an aide for not coming back to assist her, while she was in the bathroom, having been left alone for an indeterminable amount of time.On 6/13/25 at 3:16 a.m., Resident 32 had not been feeling well and requested to use the bathroom for a bowel movement, and the not indicated, did use call light for assistance back to her chair, having been left alone in the bathroom for an indeterminable amount of time.On 8/21/25 at 7:43 p.m., Resident 32 put her bathroom light on after she had been assisted to the toilet. She was found on the floor with no staff present.2. From 1/1/25 until 7/22/25, Resident 32 was lowered to the floor on 8 separate occasions, (2/4/25, 3/16/25, 4/26/25, 5/10/25, 5/14/25, 6/18/25, 6/25/25, 7/22/25).An IDT progress note, dated 5/14/25 at 8:50 a.m., indicated Resident 32 had a witnessed fall during a transfer when her knees buckled and she needed to be lowered to the floor. The new intervention put into place at that time was for her to be a 2-person assist with transfers until therapy can assess for safe transfers.On 6/18/25 at 7:31 a.m., Resident 32 was being assisted by only one aide when she let go of the grab bar and her wheelchair was too far away, so the aide had to lower the resident to the floor. The aide who transferred the resident alone, was given a teachable moment, on 6/19/25.On 6/25/25 at 11:44 a.m., Resident 32 was again, being assisted by only one aide during a transfer when she was lowered to the floor. The aide who transferred the resident alone was given a teachable moment on 6/26/25.On 7/22/25 at 2:16 a.m., Resident 32 was being transferred by only one aide in the bathroom when her legs gave out and the aide had to lower her to the floor. Resident 32 sustained a small, raised area to the left side of her head. The aide who transferred the Resident alone, was given a teachable moment, on 7/24/25.During an interview on 11/20/25 at 1:23 p.m. with the Executive Director (ED) and Director of Nursing (DON) present, the DON indicated Resident 32 was impulsive and often transferred without staff knowledge, but that when new interventions were placed, it was her expectation for all staff to implement those interventions which could be found on the Resident's Care Profile.On 11/19/25 at 3:00 p.m., the ED provided a copy of current facility policy titled, Fall Management Program Guidelines, reviewed 11/19/25. The policy indicated, The purpose of this policy is to. maintain a hazard free environment, mitigate fall risk factors and implement preventative measures. THS recognizes even the most vigilant efforts may not prevent all falls and injuries. In those cases, intensive efforts will be directed toward minimizing or preventing injury. Nursing staff will monitor and document continued resident response and effectiveness of interventions for 72 hours. Discuss risks and interventions with resident and/or responsible party and communicate Interventions during shift report.3.1-45(a)

Based on record review and interview, the facility failed to ensure a medication was withheld based upon the physician ordered parameter set for that medication. This deficient practice had the potential to effect 1 of 5 residents reviewed for unnecessary medications, (Resident 12). Findings include:On 11/19/25 at 10:54 a.m., Resident 12's record was reviewed. She had the following diagnoses aphasia (a language disorder that affects the ability to communicate), dysphagia (difficulty swallowing), supraventricular tachycardia (rapid regular heartbeat caused by faulty electrical signals in the heart's upper chamber), muscle weakness, and history of falling.She had an order, dated 7/16/25 for metoprolol tartrate tablet (an immediate-release selective beta-blocker medication primarily used to treat high blood pressure, chest pain, and to reduce the risk of death or heart attack after an acute myocardial infarction) , 25 milligrams (mg) amount 1/2 tablet, oral. Special instructions indicated to hold for systolic blood pressure (SBP- top BP reading) less than 100 or pulse less than 60 two times daily.On 11/11/25 metoprolol was administered for a blood pressure of 99/61.On 10/18/25 metoprolol was administered for a blood pressure of 98/62.On 11/20/25 at 1:39 p.m., the Director of Nursing Services (DNS) indicated the medication was given outside of the ordered parameters. A policy titled, Guideline for Medication Orders was provided by the DNS on 11/20/25 at 2:00 p.m. It indicated, .Telephone or verbal order for drugs must include: the name and strength of the drug, the quantity or specific duration of the drug, the dosage and frequency of administration, route of administration, diagnosis for use, dated and time order received.3.1-37

Based on record review and interview, the facility failed to ensure that a resident's code status matched the comprehensive care plan for 1 of 5 residents reviewed for advance directives (Resident 12). Findings include: On 11/19/25 at 10:54 a.m., Resident 12's record was reviewed. She had the following diagnoses which included, but were not limited to, asphasia (difficulty speaking), dysphagia (difficulty swallowing), cystitis (bladder infection), Parkinson's disease, muscle weakness, and history of falling.Resident 12 had a physician's order for do not resuscitate (DNR) dated 7/22/25.Her comprehensive care plan indicated she desired a full code status dated 7/16/25.On 10/19/25 at 2:00 p.m., the Director of Nursing Services (DNS) provided a copy of the full code care plan.A policy titled, Comprehensive Care Plan Guideline, was provided by the Executive Director on 11/18/25 at 5:04 p.m. It indicated, .A comprehensive care plan will be developed within 7 days of completion of the comprehensive assessment (MDS 3.0).3.1-35(c)(2)

Based on record review and interview, the facility failed to ensure a resident had their predetermined advance directive preference of Do Not Resuscitate (DNR) when she was changed to a full code status upon admission for 1 of 3 residents reviewed for advanced directives (Resident 69). Findings include:On 11/18/25 at 12:02 p.m., Resident 69's record was reviewed. She admitted to the facility on [DATE]. Her comprehensive care plan indicated she had diagnoses which included, but was not limited to, Parkinson's disease (a progressive, incurable neurological disorder that affects movement, causing symptoms like tremors, slowness of movement and rigidity caused by loss of brain cells).Upon her admission she had a living will, dated 2/27/1992, which indicated, she did not want her life to be artificially prolonged.If at any time I have an incurable injury, disease, or illness certified in writing to be a terminal condition by my attending physician has determined that my death will occur within a short period of time, and the use of life-prolonging procedures would serve only to artificially prolong the dying process, I direct that such procedures be withheld or withdrawn, and that I be permitted to die naturally with only the provision of appropriate nutrition and hydration and the administration of medication and the performance of any medical procedures necessary to provide me with comfort care or to alleviate pain. The document was scanned into her record on 11/17/25.A comprehensive care plan was initiated on 11/18/25 which indicated she desired to be a full code.SA physician's order was added to her record on 11/17/25 for a Full Code. During an interview on 11/20/25 at 1:29 p.m., the Director Nursing Services (DNS) indicated all resident were admitted with a full code status unless they had signed physician's order such as an Out of Hospital (OOH) or Physician's Order for Scope of Treatment (POST). The DNS indicated there could be a phone call made to the physician for a code status and witnessed by two nurses as needed. She indicated she was not aware the resident had a living will. The clinical team did not get the Living Wills in the admission packets. They got them from the family at the time of admission.A policy titled Guidelines for Advanced Directives was provided by the DNS on 11/19/25 at 2:30 p.m. It indicated, Advanced Directives will be reviewed with the resident and/or resident representative by the Admissions Representative or designee at the time of admission 3.1-4(d)3.1-4(e)3.1-38(f)3.1-4(I)(4)

Based on observation, interview, and record review, the facility failed to ensure proper handwashing for 2 of 2 dining observations. This had the potential to affect 53 of 53 residents who ate meals from the kitchen. Findings include: During a dining observation on 7/31/24 the following was observed: a. At 11:41 a.m., [NAME] 5 was observed washing his hands at the sink in the dining room, he turned off the faucet with his bare hands, without using a paper towel to turn off the water. He then proceeded back into the kitchen. b. At 11:43 a.m., [NAME] 5 was observed washing his hands at the sink in the dining room, he turned off the faucet with his bare hands, without using a paper towel to turn off the water. He then grabbed paper towels to dry off his hands and dropped the paper towel on the floor. [NAME] 5 picked up the paper towels from the floor and continued to finish drying his hands. The paper towels were then disposed of, and he obtained a plate of food from the steam table and served a resident their lunch plate. c. At 11:45 a.m., Dietary Services Assistant 6 was observed to wash his hands for less than 20 seconds and touched the faucet handle with bare hands, without using a paper towel to turn off the water. He then proceeded back into the kitchen. d. At 11:49 a.m., Dietary Services Assistant 6 was observed to have soap on his hands at the sink, he was lathering his hands with the soap and then proceeded to turn on the faucet handle with soapy hands, he touched the touched the faucet handle with bare hands without using a paper towel to turn off the water. He entered the kitchen and returned with a bowl of food that he served to a resident. e. At 11:51 a.m., [NAME] 5 was observed washing his hands at the sink in the dining room, he turned off the faucet with his bare hands, without using a paper towel to turn off the water. He then proceeded to steam table and obtained a plate a food to serve to a resident. f. At 11:53 a.m., Dietary Services Assistant 3 was observed to wash his hands for less than 20 seconds and touched the faucet handle with bare hands, without using a paper towel to turn off the water. He then proceeded back into the kitchen and returned with a bowl of food and served it to a resident. During a second dining observation on 8/5/24 the following was observed: g. At 11:44 a.m., Activity Associate 17 was observed to wash his hands for less than 20 seconds and touched the faucet with bare hands, without using a paper towel to turn off the water. He then proceeded to steam table and obtained a plate a food to serve to a resident. h. At 11:47 a.m., Dietary Services Assistant 6 was observed to have soap on his hands at the sink, he was lathering his hands with the soap and then proceeded to turn on the faucet handle with soapy hands, he touched the faucet handles with bare hands without using a paper towel to turn off the water. He went into a cabinet and obtained a glass to prepare a drink for a resident. During an interview, on 8/5/24 at 11:54 a.m., Certified Residential Medication Aide (CRMA) 16 indicated staff were to wash their hands with soap and water and they were to turn off the faucet handle by using a paper towel. Staff were not to touch the faucet handle with their bare hands. During an interview, on 8/5/24 at 11:57 a.m., Registered Nurse (RN) 18 indicated staff were to wash their hands with soap and water, make sure to scrub well, and they were to turn off the faucet handle by using a paper towel. Staff were not to touch the faucet handle with their bare hands. On 8/5/24 at 1:15 p.m., the Director of Nursing (DON) provided a document, with a revised date of 2/9/17, titled, Guideline for Handwashing/Hand Hygiene, and indicated it was the policy currently being used by the facility. The policy indicated, .1. Hand Washing a) turn water on to a comfortable temperature b) Wet hands with running water. Appy liquid soap and work into a lather c) Wash well for at least 20 seconds .d) Rinse hands well under running water .e) Dry hands with paper towels f) Turn off faucet with paper towels to avoid recontamination hands from faucet 3.1-21(i)(3)

Based on observation, interview, and record review, the facility failed to ensure medications were labeled properly for 1 of 2 medication carts observed for medication storage (Residents 254, 255, and 18). Findings include: During a medication storage observation with the Director of Nursing (DON) and Licensed Practical Nurse (LPN) 20, on 8/5/24 at 1:45 p.m., the 200-hall medication cart contained the following items: a. An undated and opened Humalog (medication used to lower blood sugar) insulin medication, it contained a label that indicated it was for Resident 254. b. An undated and opened Lantus (medication used to lower blood sugar) insulin medication, it contained a label that indicated it was for Resident 255. c. An opened and undated Lantus insulin pen that contained an incomplete sticker label. The label name and room number lines were blank, directions line indicated to see the medication administration record (MAR), and the date line was blank. At the bottom of the label was a residents handwritten first name only. During an interview, on 8/5/24 at 1:47 p.m., LPN 20 indicated all insulins should be dated when opened, and the reason the insulin pen had a different label was because it was pulled from their MedBank tower (automated medication dispensing unit). She did not know when the insulin pen was pulled or opened. At first, she was unable to determine the resident's last name, but after looking she was able to determine the insulin pen belonged to Resident 18. During an interview, on 8/5/24 at 1:48 p.m., the DON indicated she tried to access the system to find out when the medication was pulled from the MedBank tower but was unable to determine when it was retrieved. The only time they pulled medications from the tower was if it was a new medication, change in medication, or a new admission. She was unsure why it had been pulled and was going to contact the pharmacy. During an interview on 8/5/24 at 3:20 p.m., Employee 25 indicated he was the Account Manager, he had tried, but was unable to locate any documentation in the MedBank of any insulin pen being pulled for Resident 18, and that sometimes, if not stocked properly, it would not log it when it was removed. On 8/6/24 at 11:06 a.m., Resident 254's record was reviewed. The profile indicated the resident's diagnoses included, but were not limited to, type 2 diabetes mellitus with hyperglycemia (a chronic condition that affects the way the body processes blood sugar, where the person has high blood sugar levels). A physician's order, dated 7/31/24, indicated to administer Humalog U-100 insulin solution subcutaneously (into the deepest layer of the skin) per sliding scale (a method of calculating insulin dosages based on blood glucose levels and mealtime) before meals. On 8/6/24 at 11:10 a.m., Resident 255's record was reviewed. The profile indicated the resident's diagnoses included, but were not limited to, type 2 diabetes mellitus with hyperglycemia A physician's order, dated 8/2/24, indicated to administer Lantus U-100 insulin, 10 units subcutaneously at bedtime. On 8/5/24 at 11:20 a.m., Resident 18's record was reviewed. The profile indicated the resident's diagnoses included, but were not limited to, type 2 diabetes mellitus with hyperglycemia. A physician's order, dated 6/30/24, indicated to administer Lantus SoloStar U-100 insulin; 100 units/milliliter (ml); 14 units subcutaneously once a day. On 8/5/24 at 2:00 p.m., the DON provided and identified a document as a current facility policy, titled, MEDICATION STORAGE IN THE FACILITY, revised date 11/18. The policy indicated, .D. When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. 1) A date opened sticker shall be placed on the medication .E. The medication administration personnel will check the expiration date of each medication before administering it 3.1-25(j) 3.1-25(k)

Based on record review and interview, the facility failed to ensure a resident with a weight loss of greater than 5% in a 30-day period, had been addressed at the time the weight loss occurred for 1 of 1 residents reviewed for nutrition (Resident 34). Findings include: Resident 34's record was reviewed on 8/5/24 at 9:56 a.m. The profile indicated the resident's diagnoses included, but were not limited to, unspecified dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities) and dysphasia oropharyngeal phase (swallowing problems occurring in the mouth and/or the throat). A quarterly Minimum Data Set (MDS) assessment, dated 5/3/24, indicated the resident had severe cognitive deficit, required supervision with eating, had no documented weight loss, and had no swallowing or nutritional concerns. A care plan, dated 4/6/23, indicated the resident was malnourished and was at risk for malnutrition. Interventions included, but were not limited to, dietician to re-evaluate as indicated and weight as ordered. A care plan, dated 2/6/24, indicated the resident had impaired swallowing related to dysphasia. Interventions included, but were not limited to, monitored record weight. Notify physician and family of significant weight loss. A care plan, dated 7/31/24, indicated the resident had experienced a significant weight loss. Interventions included, but were not limited to, weight as ordered. Review of the resident's weight from 2/1/24 to 8/5/24, indicated on 5/5/24 the resident weighed 129.8 pounds (lbs). Her weight on 6/5/24 was 121 lbs. The weight review indicated the resident had lost 8.8 lbs or 9.3% in 30 days. The record lacked documentation of the weight loss being identified and acted upon. A quarterly nutrition note, dated 5/17/24 at 9:17 a.m., indicated the resident's average intake was 13.63%. The note lacked documentation of any weight loss for the resident. A nutrition note, dated 6/20/24 at 3:09 p.m., indicated the resident was being followed by the interdisciplinary team (IDT-brings together knowledge from different health care disciplines to help people receive the care they need) for weight loss. The IDT recorded the resident average intake at 13.63%. The note lacked documentation of any weight loss by the resident. A dietician's note, dated 7/31/24 at 4:02 p.m., indicated the resident had a significant weight loss for the period of 3 and 6 months from the weight recorded on 7/28/24. A physician's order, dated 8/1/24, indicated to administer 120 milliliters (ml) of MedPass 2.0 (a dietary supplement to help people to gain weight and/or recover from illness) between meals two times a day. A physician's order, dated 8/1/24, indicated to provide a diet to include fortified foods (foods that have extra nutrients added to it or has nutrients added that are not normally there), under a mechanical soft consistency (soft-textured foods that could be pureed, mashed, or blended), and thin liquids, at each meal. During an interview, on 8/5/24 at 2:54 p.m., the Regional MDS Support indicated she was unsure why the resident's weight loss had not been addressed. She believed the resident was being treated for a UTI (urinary tract infection) during the time of the weight loss. During an interview, on 8/5/24 at 2:58 p.m., the Regional Clinical Support indicated she was unsure why the 30-day weight loss had not been addressed. She had reviewed the resident's actual intakes, and they did not correlate with the documentation found in the dietician assessment, which indicated 13.63% of meals. On 8/5/24 at 3:03 p.m., the Regional MDS Support provided a document, with a revised date of 5/10/24, titled, Guidelines for Weight Tracking, and indicated it was the policy currently being used by the facility. The policy indicated, .Procedures .3. The Registered Dietician (RD) or the Nutrition & Dietetics Technician, Registered (NDTR) will review the resident's nutritional status, usual body weight and current weight .8. The physician, resident representative, and Registered Dietician (RD) or the Nutritional & Dietetics Technician, Registered (NDTR) shall be notified of a weight variance of 5% in 30 days, 7.5% in 90 days, and 10% in 180 days .9. The facility may open and complete a .Weight/Nutrition Event for a significant weight variance of 5% in 30 days, 7.5% in 90 days, or 10% in 180 days 3.1-46(a)(1)

Based on interview and record review, the facility failed to ensure care plan meetings were conducted at least quarterly for 3 of 24 resident's reviewed for care plan meetings (Residents 34, 23, and 1). Findings include: 1. During a family interview, on 8/1/24 at 11:14 a.m., Resident 34's daughter-in-law indicated she could not recall having a care plan meetings quarterly over the past year. Resident 34's record was reviewed on 8/5/24 at 9:56 a.m. The census indicated the resident had been admitted to the facility on [DATE]. A quarterly Minimum Data Set (MDS) assessment, dated 5/3/24, indicated the resident had severe cognitive deficit. A Resident First Meeting (care plan meeting) notes, dated 7/1/23 to 8/5/24, indicated the following: a. A Resident First Meeting was held on 5/2/24. The resident's representative had attended the meeting via telephone. The resident declined to attend. b. A Resident First Meeting was held on 8/1/24. The resident's representative had attended the meeting via telephone. The resident declined to attend. The record lacked documentation of a Resident First Meeting being conducted between the dates of 7/1/23 and 5/3 2/24. 35317 2. During an interview, on 7/31/24 at 12:21 p.m., Resident 23 indicated she did not remember being invited to or attending a care plan meeting recently. She could not recall when the last one was. Resident 23's record was reviewed on 8/2/24 at 10:59 a.m. A quarterly Minimum Data Set (MDS) assessment, dated 7/3/23, indicated the resident was cognitively intact. Census information indicated the resident was admitted to the facility on [DATE]. A Resident First [NAME] note, dated 5/3/24 at 2:51 p.m., indicated a care plan meeting was conducted on this day for Resident 23. A Resident First Meeting note, dated 8/3/23 at 10:08 a.m., indicated a care plan meeting was conducted on this day for Resident 23. Resident 23's record lacked documentation of a quarterly care plan meeting being conducted between the months of August 3, 2023 - May 3, 2024. 3. During an interview, on 8/1/24 at 1:42 p.m., Resident 1 indicated he did not remember being invited to or attending a care plan meeting recently. He could not recall when the last one was. Resident 1's record was reviewed on 8/2/24 at 10:22 a.m. A quarterly Minimum Data Set (MDS) assessment, dated 7/16/24, indicated the resident was cognitively intact. Census information indicated the resident was admitted to the facility on [DATE]. A Resident First Meeting note, dated 5/7/24 at 9:47 a.m., indicated a care plan meeting was conducted on this day for Resident 1. Resident 1's record lacked documentation of a quarterly care plan meeting being conducted between the months of July 4, 2023 through May 7, 2024. During an interview, on 8/5/24 at 1:42 p.m., the Social Service Director (SSD) indicated she was aware that they were behind on the quarterly care plan meetings. She indicated the care plan meetings should be conducted quarterly. She indicated Resident 23 and 1 did not have the quarterly care plan meetings conducted. She was hired at the facility in November of 2023, and she had been trying to get caught up on them since then. During an interview, on 8/5/24 at 2:51 p.m., the Regional MDS Support indicated she was aware that some of the residents had missed their quarterly care plan meetings. She indicated the facility identified they were behind in January of 2024 and began an audit action plan. She indicated the audit was ongoing and they were getting close to being caught up. On 8/5/24 at 2:05 p.m., the Director of Nursing provided a document, dated 12/31/23, titled, Resident's First Meeting Guidelines, and indicated it was the current policy being used by the facility. The policy indicated, .2. Subsequent meeting for non-Medicare residents should be conducted at a minimum of quarterly and with a significant change 3.1-35(e)

Based on interview and record review, the facility failed to ensure resolutions to the concerns voiced by the Resident Council were communicated back to the Resident Council for 1 of 3 months of Resident Council minutes reviewed (Resident 35). Findings include: During an interview with the Resident Council, on 8/5/24 at 1:20 p.m., Resident 35 indicated she could not recall ever having any of the department managers or anyone else coming in to meet with the Resident Council to discuss the resident council's grievances. Review of the Resident Council Meeting Minutes, dated 5/13/24, indicated the following: a. A form related to nursing concerns of call light wait times and staffing number concerns, lacked documentation of any response from the nursing department. b. A form related to a maintenance concern of a missing bathroom door, lacked documentation of any response from the maintenance department. c. A form related to a request for more variety in menu options, lacked documentation of any response from the dietary department. During an interview, on 8/5/24 at 1:30 p.m., the Activity Director indicated she would document the Resident Councils concerns on the Resident Council response forms. She then would put the form in the mailbox of the appropriate department directors. The department directors were responsible to address the concern. She rarely received any response from the directors. During an interview, on 8/5/24 at 2:19 p.m., the Executive Director (ED) indicated no staff would ever attend one of the Resident Council meetings unless they had been invited. Any grievance from the Resident Council would be documented on the facility grievance forms and given to the appropriate department director for a resolution. The resolution would then be communicated to the Resident Council by the staff who was invited to attend the meeting. The information would be documented under old business on the Resident Council meeting minutes. On 8/5/24 at 3:18 p.m., the ED provided a document, dated January 1, 2017, titled, Resident Council, and indicated it was the policy currently being used by the facility. The policy indicated, .Procedures: .8. The group's grievances and recommendations will be brought to the attention of the Executive Director who will forward the concerns to the appropriate department leader for attention and response. 8.1 Responses regarding resolutions will be documented, reviewed by the Executive Director, and kept with the Resident Council minutes .9. Actions taken and/or considerations given to issues will be reported back to the Resident Council at the next meeting 3.1-3(l)

A. Based on interview, observation, and record review, the facility failed to ensure that staff used the assistance of two people when providing care and staff had the proper knowledge of the use of a low air loss mattress to prevent a resident's fall out of bed, which resulted in harm when the resident obtained a fractured femur (thigh bone) that required surgery for 1 of 14 residents reviewed for accidents (Resident 27). B. Based on interview, observation, and record review, the facility failed to ensure hot water temperatures were maintained within safe range for 3 of 14 residents reviewed for accidents (Residents 11, 40, and 26). Findings include: A. During an interview, on 7/11/23 at 10:06 a.m., Resident 27 indicated on 5/2/23 Certified Resident Care Aide (CRCA) 18 was providing incontinence care while she was in bed. CRCA 18 rolled her over to the right side of the bed and just kept rolling until she rolled her out of bed. She fractured her femur and had to have surgery. There was only one staff member who provided incontinence care at that time. Resident 27's record was reviewed on 7/13/23 at 1:31 p.m. The profile indicated the resident diagnoses included, but were not limited to, nondisplaced spiral fracture (fracture due to torsion or twisting force that produces a fracture that circles or spirals around the shaft) of shaft of left femur (thigh bone, the longest strongest bone in the body) and multiple sclerosis (a disease in which the immune system eats away at the protecting covering of nerves). An annual Minimum Data Set (MDS) assessment, dated 1/6/23, indicated the resident was cognitively intact and required assistance of two persons for bed mobility, transfers, and toileting. The MDS indicated she was dependent on the assistance of 2 or more staff for lower body dressing. A quarterly MDS assessment, dated 4/8/23, indicated the resident was cognitively intact and required assistance of two persons for bed mobility, transfers, toileting, and lower body dressing. A care plan, dated 7/1/2020 and revised 5/3/23, indicated the resident was at risk for falls related to weakness to all extremities, use of anti-depressant medication, and impaired mobility. Interventions included but were not limited to provide two caregivers to give assistance while providing care. Review of the Occupational Therapy (OT) plan of treatment note, dated 1/2/23, indicated the resident was referred to therapy due to a decline of active range of motion (AROM) to her left upper extremity (arm). The therapy note indicated, Resident 27 was dependent for toileting hygiene, lower body dressing, and transfers. A progress note, dated 5/2/23 at 12:52 p.m., indicated Resident 27 was lying on her side when staff was changing her brief. Staff was standing behind the resident providing peri-care when the resident began to slide out of the bed, legs first, away from staff. Staff were able to grab the resident around her torso and assisted to her to the floor with the resident's left knee bent. A progress note, dated 5/2/23 at 3:00 p.m., indicated Resident 27 had a stat (immediately) x-ray and had an acute fracture of distal femur with a small lipohemarthrosis (mixture of fat and blood in a joint cavity following trauma). The Nurse Practitioner was notified, and the resident transported to the emergency room . An Interdisciplinary Team (IDT) note, dated 5/3/23 at 8:43 a.m., indicated Resident 27 was lying on her side while staff was changing her brief. The staff person was standing behind the resident providing peri-care when the resident began to slide out of bed, legs first, away from the caregiver. The intervention was to provide two caregivers while care was provided to the resident. An episodic event form, dated 5/3/23, indicated a root cause of the fall to be the air mattress. A plan of action was to ensure that the air mattress was to be firm during care and to have two staff members when care was provided while resident was in bed. The facility was to ensure the safety of all residents who receive care while in bed on an air mattress. An in-service sheet, dated 5/3/23 and 5/4/23, indicated staff attended an in-service on bed mobility, transfer, and care. There were 29 staff members in attendance. A hospital discharge report, dated 5/8/23, indicated Resident 27 had surgery, on 5/3/23, on the intramedullary retrograde nail femur (surgeon will make two small incisions near the knee joint to insert two flexible titanium rods through the femur). An undated investigation summary, indicated the resident was holding on to the mobility bar during incontinence care and was not strong enough to prevent herself from sliding off the bed. During an interview, on 7/14/23 at 10:17 a.m., Resident 27 indicated she had required the use of a mechanical lift for a long time, and she needed the assistance of two persons for incontinence care, transfers, showers, and turning side to side while in bed, and had been that way for a long time prior to the fall. During an interview, on 7/14/23 at 10:19 a.m., Registered Nurse (RN) 11 indicated Resident 27 required a mechanical lift for transfers and was two person assist for turning and repositioning. During interview, on 7/14/23 at 11:21 a.m., Qualified Medication Aide (QMA) 14 indicated Resident 27 had a low air loss mattress, and the low air loss mattress had a machine that contained a button and could be pushed to firm the mattress while staff was providing care. During an interview, on 7/14/23 at 11:59 a.m., CRCA 18 indicated that when Resident 27 had her fall, incontinence care was being provided. She indicated the resident was turned onto her side and began to slide off her mattress. The CRCA 18 was able to help assist the resident as she fell to the floor with her left leg bent. She was unable to explain what a low air loss mattress was and was not aware there was a firm button that could be used while providing care when the resident was in bed. Review of the low air loss mattress manufacturer guidelines indicated a mode of operation was an auto firm mode and provided maximum air inflation designed to assist both resident and caregivers during resident transfer and treatment. On 7/14/23 at 1:29 p.m., the Regional Clinical Support provided a document, dated 5/10/16, titled, Nursing ADL Documentation Guidelines, and indicated it was the policy currently being used by the facility. The policy indicated, .Procedures: .2. ADL services will be conducted and documented by the Certified Nurses Aide (CNA) each shift 6 .The paper format shall be submitted to the MDS Coordinator On 7/14/23 at 1:46 p.m., the Executive Director (Ed) provided a document, dated 5/31/17, titled, Fall Management Program Guidelines, and indicated it was the policy currently being used by the facility. The policy indicated, .Procedure: .a. Identified risk factors should be evaluated for the contribution they may to the resident's likelihood of falling 34129 B1. During an observation, on 7/10/23 at 11:23 a.m., Resident 11's bathroom sink hot water was too hot to hold hands under the water for more than a few seconds without burning the skin. The Director of Plant Operations (DPO) checked the hot water temperature, on 7/10/23 at 12:08 p.m., and indicated Resident 11's bathroom sink hot water temperature was too warm, at 127.4 degrees Fahrenheit (F), per the facility's thermometer and the hot water temperature should be between 100 F to 120 F. Resident 11's record was reviewed, on 7/13/23 at 10:15 a.m., with diagnoses included, but were not limited to, hypertension (high blood pressure), cognitive communication deficit, and difficulty in walking. An admission Minimum Data Set (MDS) assessment, dated 6/20/23, indicated the resident was cognitively intact, required extensive assistance of two persons for bed mobility, transfer, and toilet use, and was a total dependence of one person for personal hygiene. B2. During an observation with the DPO, on 7/10/23 at 12:11 p.m., the hot water temperature in Resident 40's bathroom sink was 122.0 F per the facility's thermometer. The DPO indicated, the hot water temperature in Resident 40's bathroom was too warm and the facility had recently purchased a new hot water boiler. Resident 40's record was reviewed, on 7/11/23 at 3:06 p.m., with diagnoses included, but were not limited to, dementia (the loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities) and malignant neoplasm of unspecified part of unspecified bronchus or lung (lung cancer). An admission MDS assessment, dated 5/8/23, indicated the resident had a severe cognitive impairment and required extensive assistance of one person for bed mobility, transfer, toilet use, and personal hygiene. B3. During an observation with the DPO, on 7/10/23 at 12:15 p.m., the hot water temperature in Resident 26's bathroom sink was 125.6 F per the facility's thermometer. The DPO indicated the hot water temperature in Resident 26's bathroom was too warm, and he checked random resident bathrooms water temperatures daily, kept a temperature log, and had not had any water temperatures in the facility more than 120 degrees Fahrenheit. Resident 26's record was reviewed, on 7/14/23 at 10:07 a.m., with diagnoses included, but were not limited to, hypertension (high blood pressure) and altered mental status. An annual MDS assessment, dated 6/24/23, indicated the resident was cognitively intact, required extensive assistance of two persons for bed mobility, transfer, and toilet use, and was an extensive assistance of one person for personal hygiene. On 7/11/23 at 9:05 a.m., the Executive Director (ED) indicated, all the hot water temperatures in the residents' rooms should be between 100 F to 120 F, the DPO had turned down the hot water temperature in the boiler because the hot water temperature was too warm, and the DPO was checking the water temperatures throughout the day to make sure that the water was not too hot in any of the residents' rooms. The ED indicated, there had been no reported burns or scalding's as a result of the hot water temperatures. On 7/13/23 at 8:55 a.m., the ED indicated the mixing valve had been changed out in the hot water system and the DPO had been checking the hot water temperatures in the facility to ensure the hot water temperature was maintained between 100 F to 120 F. The ED, on 7/10/23 at 12:29 p.m., provided and identified a document as a current facility policy, titled Water Temperature Testing Life Safety, dated 8/20/2018. The policy indicated, .It is Trilogy policy to test water temperatures daily .Required Water Temperatures .Patient room temperatures are specified by state requirements .Indiana 100 F-120 F 3.1-45(a)

Based on record review and interview, the facility failed to ensure a pharmacy recommendation was addressed timely for 1 of 5 residents reviewed for unnecessary medications (Resident 5). Finding includes: Resident 5's record was reviewed on 7/12/23 at 10:57 a.m. The profile indicated the resident's diagnoses included, but were not limited to, unspecified atrial fibrillation (AFIB-the heart's upper chambers beat chaotically and irregularly - out of sync with the lower chambers of the heart) and hypertension (high blood pressure). A physician's order, dated 1/14/22, indicated digoxin (a drug used to treat irregular heartbeat and some types of heart failure) tablet 0.125 milligrams (mg) once daily. A care plan, dated 1/26/22, indicated the resident had potential for cardiovascular distress related to diagnoses of hypertension and AFIB. Interventions included, but were not limited to, labs per physician's order. A pharmacy recommendation, dated 3/14/23, indicated to consider monitoring digoxin trough level (a lab drawn just before the next dose of digoxin medication to determine the level of the medication in the blood) and BMP (a test that measures eight different substances in the blood) on the next lab day and every 6 months. A handwritten note at the bottom of the recommendation form indicated BMP done 3/8/23 and had someone's initials next to it. The record lacked documentation of the digoxin trough level having been ordered or completed. A pharmacy recommendation, dated 5/24/23, indicated to consider monitoring digoxin trough level and BMP on the next lab day and every 6 months. The form indicated the lab had been ordered. A physician's order document, attached to the pharmacy recommendation, dated 5/17/23, indicated digoxin level, once a day on 2nd Wednesday of May and November. The record lacked documentation of the digoxin trough level having been completed. A pharmacy recommendation, dated 6/14/23, indicated a digoxin level had been ordered, but no results were in the chart for level ordered 5/17/23. The record indicated the lab had not been drawn until 6/23/23. A lab report document, dated 6/26/23 at 5:26 a.m., indicated the digoxin level had been completed. The document indicated the level was low. During an interview, on 7/12/23 at 3:13 p.m., the Regional Clinical Support indicated she had investigated the recommendation for the resident's digoxin level. The lab had not been drawn in a timely manner. During an interview, on 7/14/23 at 9:34 a.m., the Executive Director (ED) indicated not addressing the digoxin level for 3 months was not good practice and did not conform to the facility policy. On 7/14/23 at 9:24 a.m., the ED provided a document, with a revision dated of 11/18, titled, Consultant Pharmacist Reports, and indicated it was the policy currently used by the facility. The policy indicated, .Procedures: .E. Recommendations are acted upon and commented on by the facility personnel and/or the prescriber. 1) Prescriber accepts and acts upon the upon suggestion or rejects and provides an explanation for disagreeing 3.1-48(a)(3)

Based on observation, interview, and record review, the facility failed to ensure a privacy curtain was installed for 1 of 1 resident reviewed for privacy (Resident 29). Findings include: During an observation on 7/11/23 at 10:36 a.m., Resident 29 was lying on her bed and there was no privacy curtain on the resident's side of the room. During an observation on 7/12/23 at 10:32 a.m., the resident was lying on her bed and no privacy curtain for the resident's side of the room. The resident indicated she asked for a curtain when she was moved into the room, but none had been provided. She would go into the bathroom for care from the staff, whenever she needed privacy. The privacy curtain for the other resident was pushed aside against the far wall next to the other resident's bed. During an observation on 7/12/23 at 10:35 a.m., the resident was lying on her bed. The roommate's privacy curtain was pulled out and around the roommate. The curtain did not provide privacy for Resident 29. On 7/13/23 at 9:34 a.m., the Director of Nursing (DON) indicated all residents in a double occupancy room should have their own privacy curtain. On 7/13/23 at 9:39 a.m., Licensed Practical Nurse (LPN) 8 indicated all residents in double occupancy rooms should have their own privacy curtain. LPN 8 indicated she would close the door when providing care for a resident, if a person walked in, she would cover the resident with a blanket. On 7/13/23 at 9:53 a.m., during the room observation no privacy curtain was on the resident's side of the room. On 7/13/23 at 10:00 a.m., the Executive Director (ED) indicated the privacy curtain had been removed due to it being soiled by the previous roommate and the housekeepers had not replaced it yet. During the room observation on 7/13/23 at 3:00 p.m., the resident was lying on her bed, a privacy curtain was hanging on Resident 29's side of the room. The roommate's privacy curtain was pushed back against the far wall against the roommate's bed. Resident 29's record was reviewed on 7/13/23 at 10:24 a.m. A quarterly Minimum Data Set (MDS) assessment (a standardized assessment tool that measures health status in nursing home residents), dated 6/16/23, indicated the resident was cognitively intact and required limited assistance of one person for toileting and dressing. The resident's care plan, dated 12/8/22, indicated the resident was at risk for incontinence and needed assistance of one person with toileting as needed. On 7/12/23 at 9:50 a.m., the DON provided a document, with a revised date of 5/11/17, titled, Resident Rights Guidelines, and indicated it was the policy currently being used by the facility. The policy indicated, .2. Our residents have a right to .a. be treated with dignity and respect .d. privacy 3.1-3(o)

Based on observation, interview, and record review, the facility failed to ensure that contracted staff completed a resident assessment and vital signs in privacy for 1 of 1 resident randomly observed (Resident 32). Finding includes: During a dining observation, on 7/10/23 at 11:43 a.m., Resident 32 was sitting at a table in his Geri chair (large, padded chair with wheeled bases) waiting for lunch to be served. Two contracted hospice nurses entered the dining room and went to where Resident 32 was sitting. Registered Nurse (RN) 4 obtained vital signs on the resident. The RN obtained a temporal (forehead) temperature, pulse oximeter reading, heart rate, manual blood pressure, and auscultated (listened) his lungs with her stethoscope. There were several other residents in the dining room at that time along with dietary staff and other facility staff. During an interview, on 7/10/23 at 11:48 a.m., RN 4 indicated she was not told that she could not obtain a resident's vital signs while they were in the dining room. Resident 32's record was reviewed on 7/11/23 at 9:42 a.m. The profile indicated the resident diagnoses included, but were not limited to, Rhabdomyolysis (a breakdown of muscle tissue that releases damaging protein in the blood), unspecified dementia (group of conditions characterized by impairment of at least two brain functions such as memory and judgment), and cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it). A quarterly Minimum Data Set (MDS) assessment, dated 5/17/23, indicated the resident was severely impaired cognitively and was on hospice services. During an interview, on 7/12/23 at 9:39 a.m., the Executive Director (ED) indicated that staff should not be performing assessments and/or vital signs in the dining room on any resident. During an interview, on 7/12/23 at 9:53 a.m., the ED indicated that hospice staff had been told before not to do assessments and vital signs in the dining room. On 7/12/23 at 9:50 a.m., the ED provided a document, with a revised date of 5/11/17, titled, Resident Rights Guidelines, and indicated it was the policy currently being used by the facility. The policy indicated, .2. Our residents have a right to: a. Be treated with dignity and respect .d. Privacy 3.1-3(t)

Based on observation, record review, and interview, the facility failed to ensure a resident's indwelling urinary catheter (a catheter which is inserted into the bladder and remains in to drain urine) tubing was kept from contact with the floor for 1 of 2 residents reviewed for urinary catheters (Resident 198). Finding includes: During a random observation, on 7/10/23 at 11:36 a.m., Certified Occupational Therapist Assistant (COTA) 9 was pushing Resident 198 in the hallway, in his wheelchair. The resident's indwelling catheter tubing was observed dragging the floor. During the initial pool observation, on 7/10/23 at 11:54 a.m., Resident 198 was observed in his room sitting in front of his television. His indwelling urinary catheter tubing was in contact with the floor. During a random observation, on 7/11/23 at 10:33 a.m., Resident 198 was sitting next to his bed in his room. His indwelling catheter tubing was in contact with the floor. During a random observation, on 7/11/23 at 10:55 a.m., Resident 198 was observed in therapy. His indwelling catheter tubing was in contact with the floor. Resident 198's record was reviewed on 7/13/23 at 2:37 p.m. The profile indicated the resident's diagnoses included, but were not limited to, obstructive and reflux uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow and can be either structural or functional) and benign prostatic hyperplasia with lower urinary tract symptoms (needing to urinate frequently [during the day and night], a weak urine stream, and leaking or dribbling of urine). A care plan, dated 7/10/2023, indicated the resident used a catheter for the diagnosis of obstructive and reflux uropathy. Interventions included, but were not limited to, observe tubing. During an interview, on 7/12/23 at 2:57 p.m., the Director of Nursing (DON) indicated catheter tubing should never come into contact with the floor, as it could create and infection risk. On 7/12/23 at 3:12 p.m., the Regional Clinical Support provided a document, dated 5/11/2016, titled, Preserving Dignity with Indwelling Catheter, and indicated it was the policy currently being used by the facility. The policy indicated, .1. General guidelines: .e) Urinary drainage bags and catheter tubing should be kept from touching the floor surface. 3.1-41(a)(2)

Based on record review and interview, the facility failed to ensure stat ordered radiology services were timely provided to ensure immediate assessment for infection of a surgical wound for 1 of 3 residents reviewed for radiology services. (Resident C) Findings include: Resident C's clinical records were reviewed on May 09, 2022 at 1:30 p.m. Resident C's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A nursing progress note, dated January 06, 2022 at 1:35 p.m., indicated Resident C had arrived from the hospital following a right hip surgical repair. The surgical incision wound was assessed to measure 26 centimeters long by 0.1 centimeters wide and with 51 staples in place for wound closure. The wound showed no signs or symptoms of infection. A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Impression: commuted intertrochanteric femoral fracture [thigh bone that had been broken into two or more pieces] and medial inferior pubic ramus with near complete pathologic fracture [pelvic bone]. The surgical wound incision was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] Clinical record documentation indicated Resident C's wound continued to heal without concern. The staples were removed on January 17, 2022 and steri-strips were applied. Dressings were discontinued and monitoring for signs and/or symptoms of infection continued daily each shift. A nursing progress note, dated January 24, 2022 at 12:04 p.m., indicated Resident C had a moderate amount of clear yellow drainage from the right hip incision. CBC (complete blood count) completed on January 24, 2022; indicated white blood cells were within normal range at 6.6 (no infection indicated). A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . A stat right hip X-ray was ordered to assess for infection. Taber's Cyclopedic Medical Dictionary 22 Edition indicated stat as immediately, without delay. On May 10, 2022 at 2:15 p.m., Resident C's Nurse Practitioner (NP) was interviewed. During the interview, the NP indicated she had come to the nursing home and assessed Resident C in the early that morning on January 27, 2022. A stat X-ray of the right hip order was written to rule out or diagnose an infection. If an infection, gas in the hip, had been diagnosed this would have warranted implementation of antibiotic therapy to treat the infection. Review of X-ray orders indicated the following: January 27, 2022 at 10:00 a.m. stat right hip, unilateral with pelvis when performed, 2 - 3 views. January 27, 2022 at 2:30 p.m. reorder stat right hip, unilateral with pelvis when performed 2 - 3 views. The right hip X-ray report (date completed not indicated) indicated Report Review completed on January 28, 2022 at 5:25 a.m. There is a fluid collection seen in the lateral thigh measuring at least 10 x 6 x 16 cm. There are tiny punctate areas of gas within this region. Impression 1. Large fluid collection seen in the lateral aspect of the thigh. There is a small amount gas seen within this area. This may be related to hematoma from recent surgery although infection is not entirely excluded. Progress notes, dated January 27, 2022 at 9:30 p.m., indicated Resident C was transferred to a local acute care hospital and admitted for treatment. Resident C's family were interviewed on May 10, 2022 at 10:40 a.m. and 11:40 a.m. Each family member indicated Resident C had been admitted to the hospital on January 27, 2022 due to an infection in the resident's right hip. On May 11, 2022 at 11:10 a.m. the Clinical Support Nurse was interviewed. During the interview the Nurse indicated Resident C's stat right hip X-ray; that had been ordered on January 27, 2022; had not been completed within a stat time frame, 4 or less hours. The Past Noncompliance isolated deficiency began on January 27, 2022 and was removed and corrected on February 28, 2022 after the facility implemented a systemic plan that included the following actions: -Training and Competency Checklist for all Licensed Nurses on stat orders -On going monitoring for completion of stat orders This Federal tag relates to Complaint IN 836. 3.1-49(g)

Based on record review and interview, the facility failed to ensure stat ordered laboratory services were provided to ensure immediate assessment for infection of a surgical wound for 1 of 3 residents reviewed for laboratory services. (Resident C) Findings include: Resident C's clinical records were reviewed on May 09, 2022 at 1:30 p.m. Resident C's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A nursing progress note, dated January 06, 2022 at 1:35 p.m., indicated Resident C had arrived from the hospital following a right hip surgical repair. The surgical incision wound was assessed to measure 26 centimeters long by 0.1 centimeters wide and with 51 staples in place for wound closure. The wound showed no signs or symptoms of infection. A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Impression: commuted intertrochanteric femoral fracture [thigh bone that had been broken into two or more pieces] and medial inferior pubic ramus with near complete pathologic fracture [pelvic bone]. The surgical wound incision was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] Clinical record documentation indicated Resident C's wound continued to heal without concern. The staples were removed on January 17, 2022 and steri-strips were applied. Dressings were discontinued and monitoring for signs and/or symptoms of infection continued daily each shift. A nursing progress note, dated January 24, 2022 at 12:04 p.m., indicated Resident C had a moderate amount of clear yellow drainage from the right hip incision. A CBC (complete blood count) completed on January 24, 2022; indicated white blood cells were within normal range at 6.6 (no infection indicated). A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . A stat CBC was ordered to assess for infection. Taber's Cyclopedic Medical Dictionary 22 Edition defined stat as immediately, without delay. On May 10, 2022 at 2:15 p.m., Resident C's Nurse Practitioner (NP) was interviewed. During the interview, the NP indicated she had come to the nursing home and assessed Resident C in the early morning on January 27, 2022. Stat laboratory orders were written to rule out or diagnose an infection. If an infection had been diagnosed this would have warranted implementation of antibiotic therapy to treat the infection. Review of laboratory orders indicated the following: January 27, 2022 at 10:00 a.m. stat CBC with differential (measures the specifics of your white blood cell count, plus all your other blood cell levels). Level was not drawn. January 27, 2022 at 2:30 p.m. reorder for a stat CBC with differential. Level was not drawn. Progress notes, dated January 27, 2022 at 9:30 p.m., indicated Resident C was transferred to a local acute care hospital and admitted for treatment. Resident C's family were interviewed on May 10, 2022 at 10:40 a.m. and 11:40 a.m. Each family member indicated Resident C had been admitted to the hospital on January 27, 2022, due to an infection in the resident's right hip. On May 11, 2022 at 11:10 a.m. the Clinical Support Nurse was interviewed. During the interview the Nurse indicated Resident C's stat CBC that had been ordered, on January 27, 2022, had not been drawn. The Past Noncompliance isolated deficiency began on January 27, 2022 and was removed and corrected on February 28, 2022 after the facility implemented a systemic plan that included the following actions: -obtaining a new Laboratory Service Company -Phlebotomy Training and Competency Checklist for all Licensed Nurses that would enable collection of specimens -On going monitoring of completion of laboratory testing This Federal tag relates to Complaint IN 836. 3.1-49(a)

Based on record review and interview, the facility failed to ensure a copy of the baseline care plan was provided to the residents or their representatives (Residents 39, 58, 32, 49, 50, and 213), and failed to follow their facility policy for holding the resident's initial care plan (Resident First) meetings in a timely manner (Residents 39 and 58). Findings include: 1. Resident 39's record was reviewed on 4/22/22 at 2:12 p.m. The profile indicated the resident had been admitted to the facility on [DATE]. A baseline care plan had been completed on 2/28/22 and lacked documentation of a copy of the baseline care plan being provided to resident or their representative. Care plan documentation indicated the resident's initial Resident First Meeting had been held on 3/23/22. 2. Resident 58's record was reviewed on 4/25/22 at 9:54 a.m. The profile indicated the resident had been admitted to the facility on [DATE]. A baseline care plan had been completed on 3/18/22 and lacked documentation of a copy of the baseline care plan being provided to resident or their representative. Care plan documentation indicated the resident's initial Resident First Meeting had been held on 4/4/22. 3. Resident 32's record was reviewed on 4/20/22 at 2:35 p.m. The profile indicated the resident was admitted to the facility on [DATE]. A baseline care plan had been completed on 2/22/22 and lacked documentation of a copy of the baseline care plan being provided to resident or their representative. Care plan documentation indicated the resident's initial Resident First Meeting had been held on 3/25/22. 4. Resident 58's record was reviewed on 4/19/22 at 3:15 p.m. The profile indicated the resident was admitted to the facility on [DATE]. A baseline care plan had been completed on 12/14/21 and lacked documentation of a copy of the baseline care plan being provided to resident or their representative. Care plan documentation indicated there was a Resident First Meeting conducted on 3/24/22. The record lacked documentation a Resident First Meeting was conducted prior to 3/24/22. During an interview, on 4/21/22 at 9:58 a.m., the Minimum Data Set (MDS) Coordinator indicated she reviewed the resident's record and was unable to find documentation a care plan meeting was held with the resident or resident representative until the meeting on 3/24/22. 5. Resident 50's record was reviewed on 4/22/22 at 9:37 a.m. The profile indicated the resident was admitted to the facility on [DATE]. A baseline care plan had been completed on 3/11/22 and lacked documentation of a copy of the baseline care plan being provided to resident or their representative. Care plan documentation indicated the resident's initial Resident First Meeting had been held on 3/24/22. 6. Resident 213's record was reviewed on 4/25/22 at 9:36 a.m. The profile indicated the resident was admitted to the facility on [DATE]. A baseline care plan had been completed on 4/8/22 and lacked documentation of a copy of the baseline care plan being provided to resident or their representative. Care plan documentation indicated the resident's initial Resident First Meeting had been held on 4/18/22. During an interview, on 4/25/22 at 11:34 a.m., Registered Nurse (RN) Clinical Support indicated there should have been a Resident First Meeting provided for each resident within ten days of their admission. There should have been a copy of the baseline care plan provided to the resident or representative at the meeting. She thought they should have also provided a copy of the baseline care plan within 72 hours of admission but was not sure. On 4/22/22 at 10:39 a.m., the Executive Director (ED) provided a document, with a review date of 3/16/22, titled, Resident First Meeting Guidelines, and indicated it was the policy currently being used by the facility. The policy indicated, .Procedures: 1. A Resident First Meeting should be scheduled and held within 10 days of admission On 4/25/22 at 12:05 p.m., the RN Clinical Support provided a document titled, 48 Hour Baseline Care Plan Guideline, and indicated it was the policy currently being used by the facility. The policy indicated, .POLICY: 48 Hour Baseline Care Plan Guideline .3. The MDS coordinator or MDS nurse will print the 48-hour baseline care plan and provide it to the resident or resident representative during the initial resident first meeting

Based on record review and interview, the facility failed to ensure a notice of Medicare non-coverage (NOMNC) (a notice which should be provided at least 48 hours prior to services being discontinued) was provided prior to discontinuing service for 2 of 3 residents reviewed for beneficiary notification protection review (Residents 219 and 220). Findings include: 1. Resident 219's record was reviewed on 4/26/22 at 11:12 a.m. Census information indicated the resident admitted to the facility on [DATE] and discharged on [DATE]. An entrance conference worksheet, beneficiary notice, residents discharged within the last six months was completed, and provided by the Executive Director on 4/19/22 at 10:00 a.m. The worksheet indicated Resident 219 was discharged from the facility to home within the prior six months from a Medicare covered Part A stay with benefit days remaining. The resident's clinical record lacked documentation a notice of Medicare non-coverage (NOMNC) (a notice which should be provided at least 48 hours prior to services being discontinued) was provided. 2. Resident 220's record was reviewed on 4/26/22 at 11:19 a.m. Census information indicated the resident admitted to the facility on [DATE] and discharged on [DATE]. An entrance conference worksheet, beneficiary notice, residents discharged within the last six months was completed, and provided by the Executive Director on 4/19/22 at 10:00 a.m. The worksheet indicated Resident 220 was discharged from the facility to home within the prior six months from a Medicare covered Part A stay with benefit days remaining. The resident's clinical record lacked documentation a notice of Medicare non-coverage (NOMNC) (a notice which should be provided at least 48 hours prior to services being discontinued) was provided During an interview, on 4/26/22 at 10:32 a.m., the Executive Director (ED) indicated they checked the records and were unable to find documentation a NOMNC was issued to Residents 219 and 220. It should have been issued and signed by the residents or resident representatives. On 4/26/22 at 11:02 a.m., the ED provided a document titled, NOMNC Completion , and indicated it was the policy currently being used by the facility. The policy indicated, .When would we issue a NOMNC? If a resident is within their 100-day benefit period but we are notifying them that their coverage is ending (i.e., therapy or nursing can no longer skill them), the NOMNC should be issued. For residents being notified of discontinuation of their Medicare coverage, the NOMNC is required to be issued 2 calendar days prior to the actual discharge from Medicare (NOTE: just because someone is discharging from Medicare does not mean they must discharge from the campus, they need to be informed they have a right to remain and pay privately)