Every finding on record at Wellbrooke of South Bend

Based on observation, record review and interview, the facility failed to ensure infection control guidelines were followed related to a nurse touching a resident's medications with ungloved hands during a medication pass observation for 1 of 5 residents observed during medication pass. (Resident 59, LPN 1)Finding includes: On 4/16/26 at 10:09 a.m., LPN 1 was observed preparing Resident 59's medications. She indicated the spironolactone (a diuretic) was going to be held because the resident's blood pressure was below the ordered parameters. She tore open the plastic pouch that contained four tablets and poured them into her ungloved hands. She picked up each pill and placed it in a medicine cup, then she picked up the spironolactone and disposed of it. She then gave the resident his pills. During an interview immediately following, the LPN was made aware she had handled the resident's pills with ungloved hands. There was no additional information provided.During an interview on 4/16/26 at 11:50 a.m., the Clinical Support Nurse and Director of Nursing were made aware of the observation. They indicated the nurse should have worn gloves if touching the pills. The policy, Specific Medication Administration Procedures, revised 11/18, indicated, .Procedures .C. For Solid medications: 1) Pour or push the correct number of tablets or capsules into the souffle cup, taking care to avoid touching the tablet or capsule, unless wearing gloves 410 IAC (Indiana Administrative Code) 16.2-3.1-18(a)

Based on observation, record review and interview, the facility failed to ensure fall interventions were care planned for and/ or in place for a resident with a history of falls for 1 of 1 resident reviewed for accidents. (Resident 34)Finding includes: Resident 34's record was reviewed on 4/15/26 at 10:00 a.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, vascular dementia with behavioral disturbance, disorientation and fracture of the femur neck.The admission Minimum Data Set assessment, dated 2/10/26, indicated the resident had significant cognitive impairment, a history of falls and required partial to moderate assistance for bed mobility, toileting and transfers.An IDOH (Indiana Department of Health) Facility Reported Incident (FRI), dated 2/27/26, indicated the resident was attempting to ambulate in her room and sustained a fall. The resident was transported to the hospital for evaluation and found to have a fracture of her left femoral neck. Upon return, care plans were updated. The Fall Care Plan, dated 2/5/26, indicated the resident was at risk for falls. Interventions included, but were not limited to, do not transfer to recliner chair. The care plan was updated on 3/9/26 to include a ghost alarm to the wheelchair and mattress (an alarm that signals at nurse's station). There was no intervention that included use of a floor mat. On 4/14/26 at 11:30 a.m., Resident 34 was observed seated in her wheelchair near the nurse's station. The resident was talking to herself, leaning over in her chair and fidgeting. A staff member was seated at the nurse's station and CNA 2 was standing a few feet away. The resident continued to fidget, it was then observed the resident's buttocks were coming over the edge of the wheelchair seat. The CNA was immediately notified, she ran to the resident and caught her as she slipped out of the wheelchair. The resident said she was trying to go to the bathroom. The CNA took her to her room at that time. No alarm had sounded at any time during the observation. On 4/14/26 at 3:32 p.m., the resident was observed in her recliner in her room. Her feet were elevated and her eyes were closed. There was a floor mat in the room propped up against the dresser. During an interview on 4/15/26 at 3:04 p.m., CNA 1 indicated fall interventions for the resident included bed and chair alarms, keep the bed in low position and keeping her in sight. Also, put a mat on the floor or next to the recliner when she was sleeping. During an interview on 4/15/26 at 3:33 p.m., the Director of Nursing and Nurse Consultant were made aware of the near fall and that the alarm had not activated. They were also made aware the floor mats had not been care planned and the resident was not to be put in the recliner. They indicated they would look into the issues. No further informaton was received. During an interview on 4/17/26 at 11:47 a.m., CNA 2 indicated the ghost alarm had been on the wheelchair when the resident had a near fall on 4/14 but did not know why the alarm didn't activate. 410 IAC (Indiana Administrative Code) 16.2-3.1-45(a)

Based on record review and interview, the facility failed to ensure a resident's dignity was maintained related to a staff member making a disrespectful comment to a resident for 1 of 1 resident reviewed for dignity. The deficient practice was corrected on 2/21/26, prior to the start of the survey, and was therefore past noncompliance. (Resident 34)Finding includes: An IDOH (Indiana Department of Health) Facility Reported Incident (FRI), dated 2/14/26, indicated a family member of Resident 34 came to visit, and as he was walking up to the resident, he overheard CNA 5 telling her to shut up. The resident was moved to a safe place, and the CNA was suspended and escorted out of the building pending an investigation. On 4/14/26 at 11:30 a.m., Resident 34 was observed seated in her wheelchair near the nurse's station. The resident was talking to herself, leaning over in her chair and fidgeting. On 4/14/26 at 3:32 p.m., the resident was observed in her recliner in her room. Her feet were elevated and her eyes were closed. The resident was confused and unable to understand or answer questions during the survey. Resident 34's record was reviewed on 4/15/26 at 10:00 a.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, vascular dementia with behavioral disturbance, disorientation and fracture of the femur neck.The admission Minimum Data Set assessment, dated 2/10/26, indicated the resident had significant cognitive impairment, a history of falls and required partial to moderate assistance for bed mobility, toileting and transfers.The facility investigation into the allegaton included interviews with staff, the family member and employee. The allegation of inappropriate language was substantiated, and the CNA was terminated and reported to the Nurse Aide Registry. All staff were in-serviced on Abuse, Neglect, and Exploitation Guidelines and Preventing, Recognizing and Reporting Abuse and Neglect between 2/16/26 and 2/21/26. During an interview on 4/17/26 at 10:35 a.m., the Administrator indicated following an allegation, the resident's safety is maintained and the accused employee is immediately suspended pending the investigation. All parties are notified and the incident is reported to the State. In this case, the son had called to report the incident to the Administrator, and the employee had ultimately been terminated. The resident had no effects related to the incident. All staff had been in-serviced on abuse and reporting. 410 IAC (Indiana Administrative Code) 16.2-3.1-3(a)

Based on record review and interview, the facility failed to ensure a resident's legal guardian was informed of a change in treatment related to psychotropic medication for 1 of 5 residents reviewed for unnecessary medications. (Resident 7) Finding includes: Resident 7's record was reviewed on 4/14/26 at 3:53 p.m. Diagnoses included, but were not limited to, schizophrenia and dementia.The Quarterly Minimum Data Set assessment, dated 3/5/26, indicated the resident was cognitively intact. She received antipsychotic medications.A Guardianship Form, dated 2/17/21, indicated Resident 7 was adjudicated as an incapacitated person and was appointed a guardian by the court.A Physician's Order, dated 10/2/25, indicated Haldol (an antipsychotic medication) 1 milligram (mg) daily and 1 mg at bedtime.A Physician's Order, dated 3/4/26, indicated Haldol 2 mg in the morning and 3 mg at bedtime.A Psychotropic Medication Informed Consent Observation, dated 3/5/26 at 12:27 p.m., indicated the resident had an increase in psychotropic medication dose, the medication class was an antipsychotic. The increased medication was Haldol 2 milligrams (mg) every morning and 3 mg every evening. The consent was signed by the resident.The record lacked any documentation the resident's legal guardian was informed or consent obtained when the antipsychotic medication had been increased.During an interview on 4/17/26 at 11:50 a.m., the Director of Nursing indicated the guardian should have been notified and signed the consent. The resident had a BIMS score of 14 and the guardian was aware she was taking antipsychotic medications. Both the guardian and the resident had agreed about taking the antipsychotic medication.A facility policy titled, Psychotropic medication use and gradual dose reduction guidelines, indicated, .2. A consent must be obtained by the Resident/Responsible Party prior to initiating a new psychotropic medication, increasing the dose of a psychotropic medication, or changing a current psychotropic medication to an alternate psychotropic medication . 410 IAC (Indiana Administrative Code) 16.2-3.1-3(n)(2)

Based on observation, record review, and interview, the facility failed to ensure residents received the necessary treatment and services related to medications not administered as ordered for 1 of 5 residents reviewed for unnecessary medications. (Resident 30) The facility also failed to ensure physician's orders were followed related to a resident's compression wraps for 1 of 2 residents reviewed for edema. (Resident 7) Findings include:1. Record review for Resident 30 was completed on 4/14/26 at 3:26 p.m. Diagnoses included, but were not limited to, heart failure, hypertension, and orthostatic hypotension. A Physician's Order, dated 3/26/26, indicated to give midodrine (medication to increase your blood pressure) 10 milligrams (mg) three times a day. Hold for systolic blood pressure (SBP, top number of blood pressure reading) greater than 130. The April 2026 Medication Administration Record (MAR) indicated the midodrine was not administered when the blood pressure (BP) was in parameters or administered when the BP was out of parameters on the following dates and times:-4/1/26 at 6:00-8:00 a.m., the BP was 102/51 and the midodrine was not administered -4/1/26 at 12:00-1:00 p.m., the BP was 122/74 and the midodrine was not administered-4/6/26 at 6:00-8:00 a.m., the BP was 116/72 and the midodrine was not administered-4/6/26 at 12:00-1:00 p.m., the BP was 138/77 and the midodrine was administered During an interview on 4/16/26 at 10:17 a.m., the Director of Nursing (DON) indicated the nurse had read the order wrong and should have administered the medication when the BP was below 130 and held the medication when the BP was over 130. 2. During a random observation on 4/17/26 at 9:44 a.m., Resident 7 was in bed. Her legs were uncovered. She did not have any type of compression wraps or socks on at the time. Her legs appeared to be swollen. The resident indicated she had not been helped with getting up and out of bed yet. On 4/17/26 at 11:00 a.m., Resident 7 was observed being propelled down the hallway. She was wearing non-slip socks on both feet. On 4/17/26 at 3:34 p.m., Resident 7 was sitting in a wheelchair in the main lobby/gathering area during activities. She was wearing non-slip socks on both feet. Resident 7's record was reviewed on 4/14/26 at 3:53 p.m. Diagnoses included, but were not limited to, chronic kidney disease and localized edema. A Care Plan, dated 8/19/21, indicated the resident received diuretic medications related to edema (swelling) and hypertension. An intervention was to apply Tubigrips (compression bandage) to bilateral lower extremities as ordered. A Physician's Order, dated 10/1/24, indicated apply compression wrap (Tubigrip) from mid-foot to knee, covering the heel. Apply in the morning and remove at bedtime. The April 2026 Medication and Treatment Administration Record indicated the Tubigrips were marked as administered on 4/17/26. The Quarterly Minimum Data Set assessment, dated 3/5/26, indicated the resident was cognitively intact. During an interview on 4/17/26 at 3:34 p.m., the Assistant Director of Nursing was notified and had no further information to provide. 410 IAC (Indiana Administrative Code) 3.1-16.2-37(a)

Based on observation, record review and interview, the facility failed to ensure pressure ulcer treatment was provided as ordered for 1 of 2 residents reviewed for pressure. (Resident 9)Finding includes: Resident 9's record was reviewed on 4/14/26 at 2:14 p.m. Diagnoses included, but were not limited to, Sezary disease (a blood cancer affecting the skin) and severe protein calorie malnutrition. The admission Minimum Data Set assessment, dated 4/11/26, indicated the resident had moderate cognitive deficits and received hospice care.A wound assessment, dated 3/26/26, indicated the resident had a deep tissue injury (DTI, pressure injury) to his right heel. A Physician's Order, dated 4/11/26, indicated to gently cleanse and dry the right heel, apply skin prep to the surrounding wound. Collagen to the wound bed, Xeroform to the wound and wrap with Kerlix every Monday, Wednesday, and Friday. On 4/15/26 at 3:10 p.m., the Wound Nurse was observed performing the wound treatment to the resident. She washed the wound with wound cleanser and patted dry, she then applied the collagen and Xeroform to the wound bed and wrapped the heel with Kerlix. She did not apply skin prep to the surrounding skin. During an interview on 4/15/26 at 3:56 p.m., the Wound Nurse indicated she did not apply the skin prep as ordered. 410 IAC (Indiana Administrative Code) 16.2-3.1-40

Based on interviews, and record review, the facility failed to notify a resident's responsible party when a urinary catheter had become dislodged and was replaced, for 1 of 3 residents reviewed for hospice care, (Resident B). Finding Includes:On 12/10/25 at 10:00 A.M., Resident B's clinical record was reviewed. The resident was admitted to the facility from home under hospice services for 6 days of respite care. Diagnoses included but were not limited to degenerative disease of the nervous system, senile degeneration of the brain, dementia, Alzheimer's disease, hypertension, and chronic kidney disease. Resident B's MDS (Minimum Data Set) assessment dated [DATE] for Discharge Assessment, indicated the resident had severe cognitive impairment. The resident had a catheter and was frequently incontinent of bowel. A Nursing Progress Note, dated 11/21/25 at 6:50 P.M., indicated Resident B had stood up from her wheelchair and pulled her urinary catheter out. The Hospice company was called and indicated they would send a nurse to the facility to reinsert the catheter.A Nursing Progress Note, dated 11/21/25 at 9:41 P.M., indicated the hospice nurse had reinserted the catheter without difficulty. Review of the hospice visit note, dated 11/21/25 from 8:25 P.M. to 9:19 P.M., indicated upon their arrival to the facility, Resident B had been awake lying in bed, and had denied any pain or discomfort. A new urinary catheter had been inserted without discomfort. It was noted that the dislodged catheter balloon had not been fully inflated having only 10ccs of fluid in it rather than 30ccs as required. On 12/10/25 at 10:20 A.M., an interview with the Administrator indicated on the day of admission, 11/21/25, Resident B had stood up unassisted from her wheelchair and had caused her urinary catheter to pull out. The Administrator indicated the facility nursing staff had immediately notified hospice services, who then came to the facility and reinserted a new catheter. The Administrator indicated he believed hospice services had notified the family at that time, so the facility had not attempted to notify the family again. On 12/11/25 at 9:16 A.M., an interview with the Hospice Executive Director, indicated she did not believe her staff nurse had notified the family that the urinary catheter had come out and a new catheter had been placed. The Hospice Executive Director indicated that the nurse who placed the catheter on Friday night should have notified the residents' responsible party. On 12/11/25 at 2:05 P.M., the facility Administrator provided a policy titled, Notification of Change in Condition, dated 12/8/25. The policy indicated, .To ensure appropriate individuals are notified of change in condition. The facility must inform the.resident's legal representative when.A need to alter treatment significantly.Documentation of notification or notification attempts should be recorded in the resident Electronic health record.This citation relates to complaint 2686804. 3.1-5(a)(2)

Based on observation, interview and record review, the facility failed to ensure a CNA (Certified Nursing Aide) followed the resident's comprehensive care plan regarding fall prevention for 1 of 3 residents reviewed for falls. (Resident B) This resulted in the resident falling to the floor, fracturing both femurs (thigh bones) and required surgical repair of the fractures and hospitalization after the staff member left the resident seated on the side of their bed, without supervision. (Resident B) Finding includes: A facility self-reported incident #300, dated 5/30/25 at 10:39 A.M., indicated Resident B was .sitting on bed and attempted to transfer unassisted and fell on her side. Resident was immediately assessed by nurse and pain in torso was reported .order received to send to ED [Emergency Department] X-rays show acute displaced longitudinal oblique fracture of the distal diaphysis and distal metaphysis of the femur with a mild amount of hemorrhage at the fracture site On 6/26/25 at 10:22 A.M., Resident B was not observed in her room, the bed had been made, and a mat was folded up against the wall. A bolster/perimeter mattress ( a mattress with elevated sides) was observed with bilateral bolsters on the sides of the bed. The resident was observed in the hallway, near the nurses station, in a high back wheelchair. She did not respond to her name or other questions. She was observed to stare but made no vocal sounds. On 6/24/25 at 10:46 A.M., a review of the clinical record for Resident B was conducted. The resident's diagnoses included, but were not limited to: dementia, unsteadiness on feet, muscle weakness, abnormalities of gait/mobility and depression. The Annual Minimum Data Set (MDS) Assessment, dated 4/15/25, indicated the resident had inattention with disorganized thinking, required substantial/maximal assistance from a staff member when she went from a lying to a standing position and when she went from a seated to standing position. The resident's current care plan, initiated on 11/18/24, indicated the resident had .impaired cognition with associated short term memory impairment and risk for confusion, disorientation, altered mood, impaired or reduced safety awareness & communication r/t [related to] Dementia. Sometimes understood/understands The interventions included, but were not limited to: pay attention to basic needs, provide cues and supervision for decision making. A current fall care plan, initiated on 10/4/23, indicated Resident B was at risk for falls related to a history of falls, poor safety awareness due to a diagnosis of dementia and decreased mobility. The interventions included, but were not limited to: fall mat next to bed, bed in the low position, staff to assist with transfers and a perimeter mattress to define edges of the bed. A facility Profile Care Guide ( information that directed resident care for CNA's), dated 9/18/24, indicated the resident required one staff member for transfer assistance. A Nursing Progress Note, dated 5/30/25 at 10:39 A.M., indicated CNA 3 had called LPN 2 into Resident B's room to have the resident assessed after a fall. CNA 3 indicated the resident had been seated at the side of her bed and CNA 3 had walked away from the resident to grab something. CNA 3 had heard a thump and found the resident lying on her left side, in a seated position. The resident had complained of bilateral hip and knee pain, but was unable to verbalize the severity of pain per a pain scale. An emergency room Report, dated 5/30/25 at 12:32 P.M., indicated the resident had presented to the emergency room with a left leg deformity after a fall from the edge of the bed. .She was reportedly at the edge of the bed and fell to the ground, sustained an injury to the left leg and has some swelling above the knee along with some deformity and tenderness An X-ray indicated the resident had a comminuted distal femur fracture. The report indicated at 2:54 P.M., a re-examination was conducted due to the resident's pain and swelling of the right knee area. Another x-ray was obtained which revealed a fracture of the right distal femur. The Assessment/Plan from the emergency room indicated the following: fall from ground level, left femur fracture, periprosthetic (fracture associated with an orthopedic implant-history of femur fracture with internal fixation) and acute traumatic fracture right distal femur. admitted to the hospital in stable condition. The hospital Computerized Tomography (CT) results indicated the following: .right acute displaced oblique fracture of the distal femur. (The long bone in the thigh area, when it breaks in a diagonal pattern it could be related to traumatic injury-forceful blow or twisting of the leg) . The hospital CT results of the left leg revealed an old proximal femur fracture with an internal fixation (previous fracture repair) with a .left comminuted, obliquely oriented fracture of the distal femur. The distal fracture fragment is medially displaced by 1 full shaft width at time of the CT. Bones severely demineralized (When a fracture is displaced, it means that the broken ends of the bone are not aligned correctly and have shifted our of their normal pattern) A form titled, Statement of Witness Form, dated 6/1/25, indicated the Administrator and the Director of Nursing (DON) had spoken to CNA 3 regarding the incident. The statement indicated CNA 3 had moved the floor mats to position the wheelchair next to the resident's bed, for a transfer. There were no other statements regarding the investigation of the fall. CNA 3 was terminated due to misconduct and policy violation, unrelated to incident, on 6/11/25. A form titled, Disservice/Training Log, dated 6/1/25, indicated CNA 3 had been in-serviced on transfer training. Resident B returned from the hospital, on 6/4/25 at 9:44 P.M. An Interdisciplinary Team (IDT) Progress Note, dated 6/2/25 at 9:41 A.M., indicated Resident B had a fall. .Resident was sitting on the edge of bed, aide was getting ready to transfer resident to w/c [wheelchair] while getting a washcloth resident attempted to transfer self and fell to the floor. Resident has severe cognitive deficits r/t [related to] dx [diagnosis] of dementia and does not remember that she requires assistance with transfers .Immediate intervention resident sent to ER [Emergency Room] for eval [evaluation] and treat, ghost alarm place to bed During an interview, on 6/24/25 at 12:02 PM. the Administrator indicated when he had documented, on the incident report, he had only observed one of the CT results and was unaware there were actually two femur fractures when he reported the incident. On 6/24/25 at 2:17 P.M., the Administrator provided a policy titled, Fall Management Program Guidelines, dated 5/31/17 and last reviewed on 12/17/24 and indicated the policy was the one currently used by the facility. The policy indicated .[Name of Corporation] strives to maintain a hazard free environment, mitigate fall risk factors and implement preventative measures. [Name of Corporation] 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 This citation relates to Complaint IN00460706. 3.1-45(a)(2)

Based an observation, interview and record review, the facility failed to ensure 3 of 5 staff members (CNA 4, 5 and 6) reviewed followed fall protocols after a resident experienced a fall for 1 of 3 residents reviewed for falls. (Resident C) Finding includes: A facility self-reported incident, #301, dated 6/4/25 at 6:57 A.M., indicated Resident C was .lowered to the floor after sitting on edge of the wheelchair and not able to sit back .Nurse immediately made the resident comfortable and assessed resident she had complaint of left knee pain .Dr [doctor] ordered x rays in house and they were inconclusive. Facility sent to local ED [Emergency Department] for x rays to confirm or deny a fracture Under the portion of the form, titled Type of injury, added on 6/6/25 was acute fracture of the femoral metaphysis [wide part of the thigh bone) with displacement. (When a fracture is displaced, it means that the broken ends of the bone are not aligned correctly and have shifted our of their normal pattern) A form titled, Statement of Witness Form, dated 6/4/25 and documented by CNA 4 indicated .she [Resident C] was done using the bathroom and I got her up and she was standing up so I told her we were going in the chair so I got her in the chair but for some reason she didn't sit all the way back so she told me to wait and she leaned forward because she was on the edge and couldn't push herself back, she ended up going forward mind you her chair was right beside her before she sat down but instead of her going back she went forward and barely hit the wall, it wasn't like she just fell her knees went forward and hit the wall. I tried to get her up but she was too heavy for me, so I moved the wheelchair back as I'm standing over her and lowered her to the ground and went and got help. I went and got [name of CNA 5] because I knew the nurse had to assess her and I also got [CNA 6] come and help us. [Name of CNA 5] went and got a blanket and put it under her [the resident] and all three of us picked her up and put her in bed (sic) There were no written statements from CNA 5 or CNA 6. A form titled, Statement of Witness Form, dated 6/4/25 and documented by LPN 7, indicated he had been notified, on 6/4/25 at approximately 4:00 A.M. that CNA 4 had been looking for him because Resident C had been lowered to the floor while being transferred from the toilet to her wheelchair. On 6/24/25 at 12:42 P.M., a review of the clinical record for Resident C was conducted. The resident's diagnoses included, but were not limited to: Hemiplegia (severe paralysis) following cerebral infarction (stroke) affecting right non-dominant side, osteoarthritis and altered mental status. The Quarterly Minimum Data Set (MDS) Assessment, dated 5/24/25, indicated the resident required substantial/maximal assistance from a staff member when she went from a lying to a standing position and when she went from a seated to a standing position. The resident was documented as having used a wheelchair and had had no falls since their admission nor since the last assessment. A Fall care plan, dated 8/20/20 and last reviewed 6/23/25, indicated Resident B was at risk for a fall related to right hemiplegia, balance deficits, confusion, impulsivity, a history of falls and non-compliance with call light. The interventions included, but were not limited to: encourage resident to assume standing position slowly, provide non-skid footwear, staff to assist resident with transfers, as needed and staff to use gait belt for transfers. A Nursing Progress Note, written by LPN 7, dated 6/04/25 6:57 A.M., indicated the resident had been lowered to the floor by a CNA after transferring her from the toilet to the wheelchair, at 4:00 A.M. Resident C had been seated on the edge of the wheelchair and while she had been attempting to sit back further (in the wheelchair), her knees had hit the wall and she was not able to stand properly, so the resident had been lowered to the floor. The Resident had been assisted from the floor, to the wheelchair with the assistance of 2 persons and then placed back in bed. There were no injuries documented. A Nursing Progress Note, dated 6/5/25 at 12:22 P.M., indicated the resident had complained of increased pain. Tylenol had not helped much and she wanted something stronger,. The note indicated the nurse had called the physician. At 2:32 P.M., the resident's daughter had requested her mother be sent to a local Emergency Room. An emergency room Physician Note, dated 6/5/25, indicated the resident had fallen at the facility while she was being transferred from the toilet to a wheelchair. The patient had a history of left-sided stroke and had not bore weight on that leg previously. During the exam, the patient had positive tenderness to the left distal femur region and metatarsals of left foot. An Assessment/Plan: indicated the resident had a fracture of left femur, a fracture of the metatarsal of left foot and a prescription had been written for pain medication. The Patient had been placed in a splint and released back to the facility and was to follow up with an orthopedic physician. The Resident's family had been in agreement for the resident to return to the facility. During an observation/interview, on 6/24/25 at 1:56 P.M., Resident C had no memory of the fall, was unable to recall who the president was and thought it was June 7th. The call light was observed within reach. The resident indicated she was very tired and had been at therapy and needed a rest. During an interview, on 6/25/25 at 1:20 P.M., the DON indicated the facility had no policy, except for the Indiana State Department of Health Nurse Aide Curriculum, that would have indicated what a nurse aide was required to do if a resident fell. During an interview, on 6/25/25 at 1:30 P.M., CNA 5 indicated she had assisted Resident C off of the floor and onto her bed, with the assistance of 2 other staff members, CNA 4 and CNA 6. She indicated they had been waiting on the nurse but the resident was screaming she wanted to get her off of the floor, so they had assisted the resident to get off of the floor and back into her bed. The Indiana State Department of Health Nurse Aide Curriculum, dated 7/1998, revised on 11/19/15, indicated on page 27, .II. Falls - the consequences of falls can range from minor bruises to fractures and life-threatening injuries .C Intervention 1. If a resident begins to fall, never try to stop the fall. Gently ease the resident to the floor and: a. Call for help immediately, and b. Keep the resident in the same position until the nurse examines the resident 3.1-14(i)

Based on interview and record review, the facility failed to have a process for residents to file a grievance anonymously. This had the potential to affect 54 of 54 residents who resided in the facility. Finding includes: During a Resident Council meeting on 1/30/2025 at 10:29 A.M., 8 out of 8 residents did not know how to file a grievance anonymously. On 1/30/2025 at 11:01 A.M., the Executive Director (ED) indicated the facility used an application (app) to allow residents to file a grievance. The app to file a grievance was only accessible on facility computers and tablets. If a resident wanted to file a grievance, the resident had to tell a staff member so the staff member could open the app and give the resident the electronic device. The grievance app did allow, once accessed online, residents to submit anonymously. During an interview on 1/31/2025 at 2:21 P.M., the Life Enrichment Director (LED) indicated she helped residents file grievances. If a resident wanted to file a grievance, the LED opened the grievance app and gave the resident the device. She indicated if only one resident asked to file a grievance in a day, and the grievance was submitted anonymously, she would know who filed the grievance and the grievance was not anonymous. During an interview on 1/31/2025 at 2:30 P.M., the Social Services Director (SSD) indicated he helped residents file grievances by giving the resident a device that had access to the grievance app. If a resident asked to file a grievance, and the facility only received one grievance that day that was submitted anonymously, the SSD would know who filed the grievance and the grievance was not anonymous. On 1/31/2025 at 3:02 P.M., the ED supplied a policy dated, 12/16/2024, and titled, Resident Concern Process. The ED identified the policy as the one currently used by the facility. The policy indicated, . 14. Resident rights for filling a grievance: . Grievances or concerns can be filed verbally, in writing or anonymously Although the facility had an electronic system to allow residents to file anonymous grievances, the system required direct staff assistance to open the system, thus allowing staff to know whom had filed a grievance and potentially removing autonomy. 3.1-3(a)

Based on observation and interview, the facility failed to serve food in a sanitary manner for 1 of 3 dining rooms observed. This had the potential to affect 9 of 9 residents ate in the dining room. Finding includes: During an observation and interview, on 1/30/2025 at 11:29 A.M., Dietary Aide 4 carried two different residents' plates with her thumb on the eating surface of plate. The dietary aide indicated the residents' plates should have been carried from the bottom surface. During an observation, on 1/30/2025 at 12:05 P.M., Dietary Aides 5 and 6 were observed touching the eating surface of two different residents' plates with their thumbs while serving meals. During an interview, on 1/30/2025 at 12:10 P.M., the Director of Food Service indicated the food servers should have handled the plates from the bottom and not have touched the eating surface of the plate. On 1/30/2025 at 12:48 P.M., the Executive Director (ED) provided a policy titled, Food Production Guidelines - Sanitation and Safety, dated 2009 and indicated the policy was the one currently used by the facility. The policy indicated .plates .are handled so hands do not touch the areas where the food or mouth will be placed . 3.1-21(i)(3)

Based on observations, interviews and record review, the facility failed to proved Activities of Daily Living (ADLs) for a a dependent resident related to shaving for 1 of 4 residents reviewed for ADLs. (Resident 4) Finding includes: During an observation, on 1/31/2025 at 10:15 A.M., Resident 4 had multiple white hairs present on her chin that were approximately a half inch in length. During an observation, on 2/3/2025 at 1:40 P.M. Resident 4 still had multiple white hairs present on her chin over the length of a half an inch. During an observation, on 2/4/2025 at 1:55 P.M., Resident 4 had multiple white hairs on her chin over the length of a half an inch. The clinical record of Resident 4 was reviewed on 2/3/2025 at 12:50 P.M. The resident's diagnoses included, but were no limited to: emphysema, traumatic pneumothorax, wedge compression fracture of thoracic vertebrae, acute on chronic heart failure, paroxysmal atrial fibrillation, pleural effusion, left bundle branch block, presence of automatic cardiac defibrillator, depression and dementia. A Quarterly Minimum Data Set (MDS) assessment, dated 11/21/2024, indicated Resident 4 was severely cognitively impaired and required supervision with oral hygiene, toileting, showering and bathing, upper body dressing and personal hygiene. A current Care Plan, revised 1/30/2025, indicated the resident required staff assistance to complete ADL tasks completely and safely. Interventions included, but were not limited to: offer facial shaving on shower days, as needed, or as requested and to notify nursing of refusals. The medical record for Resident 4 indicated the resident had received showers on the following dates: 2/3/2025, 1/30/2025, 1/27/2025, 1/26/2025, 1/22/2025, 1/20/2025, 1/16/2025, 1/13/2025, 1/9/2025, 1/6/2025 and 1/2/2025. The progress notes did not include any documentation of Resident 4 refusing to have her face shaved. During an interview, on 2/4/2025 at 1:56 P.M., CNA 8 indicated shaving for residents should be provided every day. CNA indicated facial shaving should be provided to both male and female residents if the resident has facial hair unless their preference was to have facial hair. CNA 8 was not aware of any female residents who preferred to have facial hair. During an interview, on 2/4/2025 at 2:13 P.M., CNA 9 indicated the residents were given a shower two times a week according to a provided shower schedule. CNA 9 indicated she shaved the male residents' faces with every shower and if needed, she shaved the female residents' faces during shower days, too. During an interview, on 2/4/2025 at 3:07 P.M., LPN 10 indicated Resident 4 had visible chin hairs and should have been shaved. On 2/5/2025 at 8:30 A.M., the DON provided a paper titled, Lesson #11 Activities of Daily Living (Oral Care, Grooming, Nail Care), undated and indicated this paper was currently used by the facility as a policy. The policy indicated .be able to explain the importance of .grooming, including hair and facial hair . 3.1-38 (a)(2)(A)-(E)

Based on observation, interview, and record review the facility failed to follow standard precautions during the performance of routine testing of blood glucose and the administration of insulin for 1 of 1 reviewed for infection control. (Resident 21) Finding includes: During an observation of a medication administration pass on 2/4/2025 at 11:06 A.M., LPN 3 gathered her supplies from the medication cart and entered Resident 21's room. LPN 3 then donned gloves and proceeded to take the Resident's blood sugar. When she had completed the task, she exited the room with her gloves on, disposed of the supplies and removed the gloves, donned new gloves and cleaned the glucometer. Next, she removed those gloves, opened up the computer and prepared the insulin. LPN 3 then entered Resident 21's room, donned gloves and administered the insulin. At no point did LPN 3 wash her hands or use alcohol based hand rub. During an interview on 2/4/2025 at 11:12 A.M., LPN 3 indicated she should have used alcohol- based hand rub before and after taking the blood sugar and prior to the administration of the insulin. On 2/4/2025 at 11:47 A.M., the Regional Clinical Support provided, Specific Medication Administration Procedures and Blood Sugar Monitoring, and indicated the procedures are the one currently used by the facility. The procedures included the following . 2. Perform hand hygiene and done (Sic) gloves. And for medication administration from a syringe to sanitize hands with approved sanitizer and remove and discard gloves. Clean hands by washing or using sanitizer On 2/5/2025 at 8:20 A.M., the Administrator provided a policy titled, Guidelines for Handwashing/Hand Hygiene, revised 2/9/17, and indicated the policy was the one currently used by the facility. The policy indicated .3. Health Care Workers (HCW) shall use hand hygiene at times such as: c. Before/after having direct physical contact with residents. d. After removing gloves, worn per Standard Precautions for direct contact with excretions or secretions, mucous membranes, specimens, resident equipment, grossly soiled linen, etc . 3.1-18(l)

Based on observation, interview, and record review the facility failed to ensure coordination of Hospice care and documentation of care provided was maintained in the facility for 1 of 1 residents reviewed for Hospice care. (Resident 21) Finding includes: A record review was completed for Resident 21 on 2/3/2025 at 8:57 A.M. Diagnoses included, but were not limited to: diabetes mellitus with neuropathy and senile degeneration of the brain. A Physician order, dated 1/9/2025, indicated Resident 21 had been admitted to Hospice. During a review of the Hospice communication book on 2/5/2025 at 11:30 A.M., for Resident 21, the following sections of the binder were blank: comprehensive care plan, physician orders, medication list, narcotic count and visit notes. During an interview on 2/5/2025 at 1:00 P.M., the DON indicated the Hospice book for Resident 21 was missing the medication list, physician orders, comprehensive care plans, narcotic count and assessments. She indicated the book should have had those documents. On 2/6/2025 at 8:50 A.M., the Clinical Support Nurse indicated the facility did not have a policy for maintaining a Hospice book for communication between the facility and the Hospice team. On 1/30/2025 a contract for Hospice services was provided by the Administrator. The contract for Hospice services was a requested and provided. The contract, dated 10/4/2021 included the following .1.03 Information/Documentation provided to Facility on admission and on-going: * most recent hospice plan of care; *Hospice medication information specific to each patient; * Hospice physician and attending physician orders specific to each patient; *copies of clinical notes after each visit. 1.04 Coordination/Continuity of Care: *Communicating with Facility representatives and other Hospice to ensure quality of care for the patient/family. *Maintain communication with facility staff, patient/family and physician with appropriate documentation. 1.07 Hospice RN Case Manger will coordinate and supervise all services provided to the hospice patient residing within the Facility, through written communication, to ensure the patient/family needs are met 24 hours a day. The communication will be documented on nurse visit notes. 2. Responsibilities of Facility: 2.07 Maintain an accurate medical record that includes all services and events provided. All services will be furnished according to agreement. Required documentation provided by Hospice will be included in a designated area/section. Facility will ensure that these forms are not removed. Facility will provide a copy of patients's medical record to Hospice, if requested after discharge .

Based on observation, record review, and interview, the facility failed to store food under sanitary conditions, related to foods not tightly sealed, outdated foods, and dirty kitchen equipment, for 1 of 1 kitchen observed. This had the potential to affect all residents who resided in the facility and received food from this dietary kitchen. Findings include: On 2/13/2023 at 9:45 A.M., a kitchen tour was conducted with the Dietary Manager (DM). The following was observed in the walk-in cooler: - A bag of carrots in the walk-in cooler with a use by date of 2/9/2024. - A bag of chopped onions with a use by date of 2/11/2024. - A block of cream cheese not sealed tightly. - A bag of mashed sweet potatoes not sealed tightly. - A tray of salad bar items: olives, eggs, onions, cheese, tomatoes, and bacon not sealed appropriately. The following was observed in the walk-in freezer: - A bag of diced meat unlabeled and not sealed. - An opened bag of sliced pepperoni not sealed appropriately. - An opened box of bread sticks not sealed appropriately. - 2 Boxes on the floor. In the dry storage area, the following was observed: - Numerous boxes and items not 18 inches below the ceiling. - An opened bag of cookie pieces not sealed or dated. - Two (2) large and 10 small skillets with the Teflon coating completely off and or chipped. A microwave on a shelf was observed with splattered food on the inside of the door and a reddish stain on the glass tray. During an interview, on 2/13/2024 at 9:55 A.M., the DM indicated the food should have been thrown out, sealed appropriately and labeled. The items in the dry storage were not 18 inches below the ceiling and should have been. The skillets should have not been used and the microwave should have been cleaned. On 2/15/2024 at 9:20 A.M., the Corporate Nurse provided the policy titled, Storage Procedures, dated 5/31/2016, and indicated the policy was the one currently used by the facility. The policy indicated Dry Storage of Food .4. Items are stored at least 18 inches from the ceiling on clean racks or other clean surfaces and away from sprinkler heads and pipes . 4. Open packages are labeled, dated and stored in closed containers . Refrigerated Storage: .5. Food is covered, dated and stored loosely to permit air circulation . 7. Prepared perishables such as salads, puddings, milk, etc., are stored in a refrigerator and covered, labeled, and dated until used . Frozen Storage: .3. All foods in the freezer are wrapped in moisture proof wrapping or placed in suitable containers, to prevent freezer burn. Items are labeled and dated . Storage of Non-Food Supplies: . 2. Items are stored at least six (6) inches off the floor and 18 inches from the ceiling On 2/15/2024 at 9:20 A.M., the Corporate Nurse, provided the policy titled,Food Labeling and Dating Policy, dated 1/2023, and indicated the policy was the one currently used by the facility. The policy indicated, Any food product removed from its original container, has a broken seal, has been processed in any way must have a label that contains the following: 1. Item name 2. Date and Time the food was labeled. 3. Use by date. 4. Initials of the person labeling the item. 5 Securely cover the food item On 2/15/2024 at 9:20 A.M., the Corporate Nurse provided the policy titled, Food Production Guidelines: Sanitation and Safety, dated 5/31/2016, and indicated the policy was the one currently use by the facility. The policy indicated . 15. All preparation and serving equipment and surfaces that have been in contact with raw meat and other raw foods, especially poultry, will be cleaned and sanitized to avoid cross contamination pots pans, .etc 3.1-21(i)(3)

Based on observation, interview, and record review, the facility failed to ensure medications were kept in a locked cart when unattended, failed to ensure a medication cart was clean and free from loose medications, failed to put an opened-on date on opened medications, and failed to ensure over the counter medications had resident identifiers, for 2 of 2 medication carts observed. (110 & 100 Hall Medication Carts) Findings include: 1. During a random observation, on 02/15/2024 at 8:27 A.M., the medication cart on the 110 hall was unlocked and unattended. An interview was completed, on 02/15/24 at 8:31 A.M. LPN 3 indicated the medication cart should be locked when unattended. 2. During a medication storage observation of the 110-hall medication cart with LPN 3, on 2/15/2024 at 9:22 A.M., the following was observed: a. A drawer containing resident medications had a large amount of a sticky solution spilled on the sides and bottom of the drawer. b. Five loose pills were sitting on the bottom of a medication drawer. c. The following medications were open but did not contain an opened-on date: one bottle of Tums (antacid), one bottle of Milk of Magnesia (laxative), one bottle of Alive Women's Gummies (supplement), one bottle of Pro-Stat (supplement), and one bottle of Peg 3350 (laxative). d. The following over the counter medications were unopened and did not contain any resident identifiers: one box of extra strength acetaminophen/diphenhydramine, one box of aspirin, one box of caffeine tablets, and one box of ibuprofen tablets. An interview was completed, on 2/15/2024 at 9:38 A.M. LPN 3 indicated the drawer containing residents' medications should not have sticky solution on the sides and bottom of the drawer and the medication cart should not contain loose pills. LPN 3 indicated residents' over the counter medications should have an opened on date, and contain a label with the resident's name, drug name and dosage amount. 3. During a medication storage observation of the 100-hall medication cart with LPN 2, on 2/15/2024 at 9:42 A.M., the following was observed: a. One opened box of Tylenol with no opened-on date. b. Two unopened boxes of Lidocaine patches with no resident identifiers. c. One opened box of Afrin (nasal spray) with no resident identifiers and no opened-on date. An interview was completed, on 2/15/2024 at 9:48 A.M. LPN 2 indicated the resident's over the counter medication should have an opened on date, and a label containing resident's name, dosage amounts and dosage times. On 2/15/2024 at 10:15 A.M., the DON (Director of Nursing) provided a policy titled, Medication Ordering And Receiving From Pharmacy, and dated January 2018. The DON indicated the policy was the current policy used by the facility. The policy indicated, .A. Use of medications brought to the facility by a resident or responsible party is allowed only when the following conditions are met . 3) The medication container is clearly labeled in accordance with facility procedures for medication labeling and packaged in a manner consistent with facility guidelines for medications On 2/15/2024 at 2:45 P.M., the Corporate Nurse provided a policy titled, Medication Storage in The Facility, and dated January 2018. The Corporate Nurse indicated the policy was the current policy used by the facility. The policy indicated, .Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access . Medication storage areas are kept clean .When the original seal of a manufacturer's container or vial is initially broken, the container or vial with be dated. 1) A dated opened sticker shall be placed on the medication 3.1-25(j) 3.1-25(l) 3.1-25(m)

Based on observation and interview, the facility failed to ensure proper infection control practices were implemented, related to lack of changing gloves and handwashing during peri-care for 1 of 1 resident observed for peri-care and failed to ensure that a blood glucose was completed in a sanitary manner for 1 of 1 resident observed for glucometer use. (Residents 31 and 30) Findings include: 1. On 2/16/2024 at 10:46 A.M., a peri care observation for Resident 31 was conducted with CNA 4 and CNA 6. Resident 31 was observed on the toilet. Both CNA 4 and CNA 6 were properly gloved during care. CNA 4 wiped the resident after having a bowel movement, and pulled up his brief. CNA 4 preceded to position the resident in his wheelchair and fix his clothing, all while still wearing the same gloves. CNA 4 removed her gloves and disposed of them in the bathroom trash and wheeled the resident out of his room to the common area. During an interview, on 2/26/2024 at 10:56 A.M., CNA 4 indicated she should have removed her gloves and washed her hands before interacting with the resident. 38845 2. During an observation on 2/15/2024 at 10:57 A.M., LPN 3 completed a blood glucose check on Resident 30. LPN 3 applied gloves, placed the glucometer device on a barrier and cleansed the finger with an alcohol pad. With an opened hand, LPN 3 fanned the area she had just cleansed. During an interview, on 2/15/2024 at 10:58 A.M., LPN 3 indicated she should not have fanned the area. On 2/16/2024 at 11:30 A.M., the Director of Nursing provided the policy titled,Guideline for Handwashing/Hand Hygiene, dated 12/31/2023, and indicated the policy was the one currently used by the facility. The policy indicated . 1. All health care workers shall utilize hand hygiene frequently and appropriately .3. Health Care Workers (HCW) shall uses hand hygiene at times such as: .c. Before/after having direct physical contact with residents. d. After removing gloves, worn per Standard Precautions for direct contact with excretions or secretions, mucous membranes On 2/15/2024 at 1:46 P.M., the Corporate Clinical Nurse provided the policy titled,Guidelines for performance of blood glucose monitoring and glucometer maintenance, dated 12/31/2023, and indicated the policy was the one currently used by the facility. The policy indicated . 2. Appropriate infection control technique shall be followed during testing procedures 3.1-18(a)

Based on observation and interview, the facility failed to ensure kitchen utensils, pots, colanders and dishes were covered and inverted, extra powder thickener was not poured back into its origional container, and clean thermometers were stored in a sanitary [NAME] until reuse after cleaning with probe wipe, this effected 44 of 44 residents who received their meals from the kitchen. Findings include: 1. During an observation, on 12/9/2022 at 10:43 A.M., Cook 4 over filled the measuring cup with thickener and poured some of it back into the container. During an interview, on 12/9/2022 at 10:49 A.M., Cook 4 indicated she should not have poured it back in the container. 2. During an observation, on 12/9/2022 at 11:01 A.M., observed Cook 5 temp the rice then clean the thermometer with a probe wipe and set the thermometer on the countertop behind him, he removed his gloves, washed his hands donned gloves picked the meter up and temped the vegetables. He continued the same steps after temping the vegetable and the fish. During an interview, on 12/9/2022 at 11:08 A.M., the Cook 5 indicated that they do sanitize the counter several times a day, but should have put it on a plate. 3. During the tour of the kitchen on 12/9/2022 at 11:10 A.M., observed the dishes on shelves on the side of the steam table facing up, uncovered with dust and crumbs on the shelf. The bottom shelf was approximately 12 inches from the floor. During an interview, on 12/9/2022 at 11:12 A.M., the Dietary Manager indicated that the dishes should have been turned over. On 12/13/2022 at 9:26 A.M., the Administrator provided a policy titled, Food Temperatures-Serving Line, revised 7/2013, and indicated the policy was the one currently used by the facility. The policy indicated .5. Proper procedures are used so that measured temperatures are accurate and contamination is prevented: B. Thermometers are clean, rinsed, and santized before, after, and in between use. An alcohol swab may be used to sanitize according to the manufactures instructions. And she provided a policy titled, Safety Guidelines, revised 3/2013, and indicated the policy was the one currently used by the facility. The policy indicated .J. 5. China or glasses will not be mixed with pots and pans when washing or stored in food preparation areas. K. Work Areas 3. Keep cupboard, closet doors and drawers closed 3.1-21(i)3

Based on observation, interview and record review, the facility failed to provide assistance for removal of facial hair for 1 of 4 residents reviewed for activities of daily living. (Resident 34) Finding includes: A clinical record review was completed, on 12/9/2022 at 10:26 A.M., diagnoses included but not limited to: encephalopathy, unspecified, nontraumatic intracranial hemorrhage, contusion and laceration of cerebrum, unspecified, with loss of consciousness, acute embolism and thrombosis of unspecified deep veins of unspecified lower extremity, other pulmonary embolism without acute cor pulmonale, hemiplegia, unspecified affecting left nondominant side, and aphasia. During an observation, on 12/12/2022 at 10:21 A.M., Resident 34 was sitting up in bed, he had hair growth on his cheeks, chin, and neck. During an observation, on 12/13/2022 at 9:55 A.M., resident was unshaved sitting up in bed. During an observation, on 12/14/2022 at 8:39 A.M., resident was sitting up in bed a staff member was assisting him with his breakfast, and he was unshaved. During an interview, on 12/13/22 at 10:45 A.M., the resident indicated, if they had time he would like to be shaved, he shaved at home, does not recall if he received a shower last night. During an interview, on 12/13/2022 at 3:40 P.M., CNA 2 indicated that they tried to give him a shower before, he refuses, he prefers a bed bath. Shower protocol is to make sure peri area is clean, nail care and to shave him. Since he is an evening shower they are always usually shaved. He would shave them if they were not. During an interview, on 12/14/2022 at 11:36 A.M., CNA 1 (certified nurse aide) indicated activity of daily living care that she provides in the morning: clean the peri-area, get ready for the day, make the bed, shut blinds and doors, check skin for hot spots, make room nice and clean and organized, make sure they are comfortable and give them a shower or if they want one. She does not do anything differently for a male's care compared to a female except to wipe from front to back. When asked if she offered to shave Resident 34 she indicated she did not, and she should have. On 12/14/2022 at 11:55 A.M., a policy was requested, and one was not provided. 3.1-38(a)(3)(D)

Based on observation and interview, the facility failed to ensure resident rooms and 1 kitchenette were maintained in a clean safe environment (room [ROOM NUMBER], 116, 127, 129, 230 and unit 200 kitchenette) Findings include: 1.During a tour of the facility with the Maintenance Director and Housekeeping Supervisor, conducted on 12/13/2022 between 10:30 A.M. and 12:15 P.M., the following was noted: room [ROOM NUMBER] had exposed plaster on the walls and loose vinyl baseboards at the corners. room [ROOM NUMBER] has exposed plaster on the walls. room [ROOM NUMBER] had exposed plaster on the walls and loose baseboards. room [ROOM NUMBER] had exposed plaster on the walls. room [ROOM NUMBER] had exposed plaster on the walls. 2. 200 Hall Kitchenette had a drawer that was missing a face plate that was housed inside the cabinet. During an interview, conducted with the Housekeeping Supervisor, at that time, she indicated she would tell the housekeepers to put in a work order for exposed plaster or loose baseboards when they are cleaning resident rooms. During an interview, conducted with the Maintenance Director, at that time, he indicated he is the only person to maintain the building and if staff doesn't put in a work order he is unaware of what needs fixed as these items would have been corrected. A current policy, titled Walls Preventative Maintenance and Furniture Maintenance was provided by the Regional Nurse on 12/14/22 at 3:44 P.M. The policy states it is the facilities policy to inspect common areas and corridor walls monthly, .resident room walls are inspected during routine semi-annual preventative maintenance . The furniture maintenance policy states .Furniture is to be cleaned and organized daily, purpose is to provide guidelines for cleaning and caring for furniture .Procedure: generate work orders for furniture in need of repairs or touch up painting 3.1-18(a)

Based on observation interview and record review, the facility failed complete a root cause analysis, assess and develop appropriate interventions for 2 of 3 residents reviewed for unwitnessed falls. This deficiency resulted in a pelvic fracture for Resident #35. (Residents #35 and #65) Findings include: 1. During an interview on 11/4/2015 at 2:55 P.M., the DON (Director of Nursing) indicated that Resident #35 had 4 falls in the last 30 days and one fall had resulted in a pelvic fracture and a hospital stay of 4 days. On 11/9/15 at 10:46 A.M., Resident #35 was observed with O2 (oxygen per nasal cannula) on and communicated without difficulty. On 11/10/2015 at 11:30 A.M., a record review for Resident #35 was conducted. The resident was admitted to the facility on [DATE]. The Physician orders [REDACTED].history of falling, heart failure, hypertension A Patient Transfer Assessment Form from a local hospital, dated 8/28/2015, indicated, .gets confused .3L (liters) O2 (oxygen) The MDS (Minimum Data Set) assessment, dated 9/11/2015, indicated a BIMS (Brief Interview for Mental Status) score was 12 out of 15. The MDS assessment, dated 9/25/2015, indicated a BIMS of 9 out of 15. Both scores indicated the resident was moderately cognitively impaired. On 11/10/2015 at 11:35 A.M., a record review of 6 Fall Events for Resident #35 indicated the following: * Date 9/18/2015 at 8:08 A.M., an unwitnessed fall occurred in Resident #35's bathroom. The resident was found without supplemental oxygen. The neurological checks were partially completed during the 48 hours following the fall. The care plan, updated on 9/18/2015, indicated Remind/re-educate resident to use call light and ask for assist with transferring and toileting. * Date 9/22/2015 at 4:40 A.M., a fall occurred in Resident #35's bathroom. The fall was unwitnessed. The resident was found without supplemental oxygen. Resident #35 complained of being dizzy and the staff was unable to get a biox (oxygen level) reading. The intervention was to check placement of supplemental oxygen tubing when rounding. The neurological checks were partially completed during the 48 hours following the fall. The care plan was updated on 9/22/2015, to Please do environmental assessment on rounds for safety paying special attention to my oxygen placement and tubing. * Date 10/5/2015 at 7:20 A.M., a fall occurred in Resident #35's room, fall was unwitnessed and the resident was found without supplemental oxygen. The resident was found to be confused. The intervention was to educate and assist with every care in interaction on supplemental oxygen placement. The neurological checks were partially completed during the 48 hours after the fall. The care plan was updated on 10/5/2015 to Educate and assist with every care interaction on O2 placement (to help with placement related to increased confusion). An IDT (Intra-Disciplinary Team) note, dated 10/-12/2015 at 10:51 A.M., indicated, Resident continues to remove O2 and suffer periods of increased confusion. Resident was attempting to self transfer and became tangled in O2 tubing. Staff will observe for environmental hazards (including tubing) during rounds and remedy as necessary. * Date 10/9/2015 at 1:00 A.M., a fall occurred in Resident #35's room, fall was unwitnessed and the resident was found without supplemental oxygen and the resident complained of hitting her head during the fall. The progress note, dated 10/9/2015 at 1:00 A.M., indicated, .Found resident on back with head at the foot at the bed at 12:40 AM yelling for help .at 11:30 PM resident found with O2 on .no oxygen on and on floor .emesis occurred twice A Progress note, dated 10/9/2015 at 10:00 A.M., indicated, Report called to (local hospital) on the patient. Progress note, dated 10/9/2015 at 2:38 P.M., indicated, .Hospital called to say that they were sending patient back A Progress note, dated 10/10/2015 at 8:38 A.M., indicated, .Post fall, purple and red bruising from hematoma present. Eye has redness around right eye The neurological checks were partially completed before and after the resident's evaluation at the hospital. The care plan was updated on 10/12/2015, to Offer toileting on rounds, and observe for confusion related to O2 removal by resident. * Date 10/15/2015 at 4:50 A.M., a fall occurred in Resident #35's room, fall was unwitnessed and the resident complained of pain to her left frontal lobe. The fall circumstance indicated a lg (large) goose egg left frontal lobe. The resident was found without supplemental oxygen. The neurological checks were partially completed during the 48 hours following the fall. The care plan was updated on 10/16/2015, to Check biox (oxygen saturation)/O2 placement Q (every) 4 hrs (hours) and prn (as needed) at noc (nocturnal). * Date 10/31/2015 at 1:14 A.M. a fall occurred in Resident #35's room. The Progress note, dated 10/31/2015 at 9:55 A.M., indicated, .Resident was discovered laying on right side .on floor .Resident has complaint of tenderness and noted large goose egg on right side of head .Resident also c/o (complaint of) R (right) hip pain .I tried to assist resident to walk with both staff members on each side: resident was unable to bear down full wt (weight) on foot .O2 was not on resident .Resident transferred to ER (emergency room ) via stretcher at 0249 (2:49 A.M.) The Care plan, dated 11/4/2015, indicated. Apply alarm to chair and bed. Check for placement and function Q shift. On 11/10/2015 at 1:00 P.M., a record review of a Patient Transfer Assessment Form, dated 11/3/2015, from a local hospital, indicated, Nurse Discharge Summary/Current Problem: Pelvic Fx (fracture)-multiple The progress notes indicated the following: On 8/31/15 at 3:30 P.M., It should be noted that resident requires reminder to keep O2 N/C (oxygen per nasal cannula) in place. On 9/1/15 at 6:39 A.M., Continues to take oxygen off face. Continue to remind to put nasal cannula within nose. Resident is more alert when continuous oxygen is applied. On 9/2/15 at 6:02 P.M., Needs reminding at times not to remove O2. On 9/3/15 at 7:10 A.M., .having a hard time sleeping at night and constantly taking off nasal cannula. On 9/18/15 at 9:02 P.M., resident continues to take oxygen tube off. On 9/22/15 at 4:38 A.M., Vital signs noted WNLs (within normal limits) except O2 does not register. On 10/1/2015 at 11:02 P.M., Pt (patient) does need freq (frequent) reminders/education r/t (related to) O2 TX (treatment) and keeping N/C on. On 10/8/15 at 2:24 P.M., Resident removes oxygen and needs continued education/reminders to keep oxygen in place. Resident becomes confused when oxygen not in use. On 10/12/15 at 10:59 A.M., Resident continues to remove O2 resulting in periods of increased confusion. During an interview on 11/10/2015 at 1:42 P.M., the DON (Director of Nursing) indicated, .after a fall, the first witness needs to ask the resident questions about what they were doing right before the fall .the nurses should start neurological checks if the fall was unwitnessed or the resident was observed hitting their head in the fall .all neurological checks should be completed which include every 15 minutes times 4, then every hour times 4 and then every 4 hours for 48 hours .the nurse should always put an intervention in place that is relevant to the fall 2. On 11-6-2015 at 2:58 P.M., a record review for Resident #65 was conducted. Physician orders [REDACTED]. The MDS assessment, dated 10-8-2015, indicated the BIMS was unable to be completed by resident and the cognitive status was listed as, Moderately impaired-decisions poor; cues/supervision required. On 11-6-2015 at 2:58 P.M. a record review of the 5 Fall Events for Resident #65 indicated: * Date 9/15/2015 at 9:58 P.M., an unwitnessed fall occurred in Resident #65's room. A Progress note, dated 9/15/2015 at 11:53 P.M., indicated, .Resident was found on the floor in the middle of his room The neurological checks were partially completed for the 48 hours after the fall. The immediate interventions for this fall were Rest and Lowered bed. An IDT progress note, dated 9-16-2015 at 9:06 A.M., indicated, .will consult family regarding possible room closer to nurses station when available .move bed against wall on left side, keep in low position and fall mat at bedside There was no care plan update available for this fall. * Date 9/17/2015 at 11:40 P.M., an unwitnessed fall occurred in Resident #65's room. A Progress note, dated 9/18/2015 at 12:31 A.M., indicated, .resident observed on the floor The neurological checks were partially completed for the 48 hours after the fall. There was no care plan update was available for this fall. * Date 9/ 5 at 4:10 A.M., an unwitnessed fall occurred in Resident #65's room. A progress note, dated 9/19/2015 at 12:35 P.M., indicated, .Resident moved to room (number) this am as part of fall prevention intervention The neurological checks for this fall were partially completed for the 48 hours following this fall. The Care plan was updated, on 9/19/2015, to Move to room closer to the nursing station so that I can be more easily observed. * Date 9/30/2015 at 6:25 A.M., an unwitnessed fall occurred in Resident #65's. A Progress note, dated 9/30/2015 at 6:25 A.M., indicated, .found resident sitting on buttocks on padded mattress aside of bed The neurological checks were partially completed for the 48 hours following this fall. The Care plan was updated, on 9/30/2015, to Give resident verbal reminders not to ambulate/transfer without assistance and Observe frequently and place in supervised area when out of bed, and visualize on rounds and as often as possible when in bed at noc (night). * Date 10/9/2015 at 1:44 A.M., an unwitnessed fall occurred in Resident #65's room. The neurological checks were partially completed for the 48 hours following this fall. An update to the care plan, dated 10/6/2015, indicated Fall mat at bedside on floor when in bed. Another care plan update, dated 10/9/2015, indicated Parameter mattress to bed for safety and Tab alarm to chair and bed for safety. On 11/9/15 at 9:47 A.M., Resident #65 was observed sitting alone in his room with a clip alarm attached to his shirt. During an interview on 11/10/2015 at 1:42 P.M., the DON indicated, .after a fall, the first witness needs to ask the resident questions about what they were doing right before the fall .the nurses should start neurological checks if the fall was unwitnessed or the resident was observed hitting their head in the fall .all neurological checks should be completed which include every 15 minutes times 4, then every hour times 4 and then every 4 hours for 48 hours .the nurse should always put an intervention in place that is relevant to the fall A Falls Management Program Guidelines policy, dated as revised on 6/15, was received from the DON on 11/9/2015 at 11:30 A.M. The DON indicated this to be the current policy for falls. The policy indicated, .Procedure .7. Nursing staff will monitor and document continued resident response and effectiveness of interventions for 72 hours A Guidelines For Neurological Checks policy, dated May 2010, was received from the DON on 11/10/2015 at 11:35 A.M. The DON indicated this to be the current policy for neurological checks after an unwitnessed fall or fall with head injury. The policy indicated, .Procedure: .3 .Unwitnessed falls should have neuro-checks completed 3.1-45 (a)(2)

Based on record review and interviews, the facility failed to provide interventions upon admission for a dependent resident with a reddened coccyx which resulted in a Stage IV pressure area for 1 of 2 residents reviewed for pressure areas in a sample of 3. (Resident "C") Finding include: The record for Resident "C" was reviewed on 02/10/14 at 1:45 p.m. Resident "C" was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The record indicated Resident "C" was admitted with a Stage 1 pressure area (defined area of persistent redness). The resident was discharged to an ACF (Acute Care Facility: Hospital), on 01/11/15, with a Stage IV pressure area (full thickness tissue loss with exposed bone, tendon or muscle). The Admission MDS (Minimum Data Set) assessment, dated 12/03/14, indicated Resident "C" was cognitively intact. The resident required extensive assist of 2 for transfers, bathing, and extensive assistance of 1 for for ambulation, dressing, hygiene and toileting. The ACF "Patient Transfer Assessment Form," dated 11/26/14 at 10:10 a.m., indicated the resident's "Skin Condition Report," with an anatomical drawing area, a circle to the coccyx area, "...2) red area (no breakdown)." The ECF (Extended Care Facility: Nursing Home) "Admission Nursing Assessment," dated 11/26/14 1300 (1:00 p.m.), indicated: "DEHYDRATION RISK ASSESSMENT:...UTI...Dry mouth/tongue" "FUNCTIONAL STATUS: Total Assist...2 person assist..." RANGE OF MOTION ASSESSMENT": Areas were checked indicating the resident had limited ROM (Range of Motion) to her lower extremities. The Admission "BRADEN PRESSURE ULCER RISK" (a scale to identify risk of skin breakdown), dated 11/26/14, indicated risk scores: Resident "C" was at "HIGH RISK: Score 10-12" with areas of concern noted: "Moisture"(skin) Constantly Moist... Mobility: Very Limited... Nutrition: Adequate... Friction & Shear: Problem..." with a score "TOTAL:11". The form's anatomical drawing corresponded with the ACF documentation area circled and indicated: "Red coccyx." A "BRADEN SCALE FOR PREDICTING PRESSURE SORE RISK" form, initiated on 12/03/14, indicated the resident was assessed every week. The form's reference risk scores indicated: "9 </=: Very High Risk" "10-12 High Risk" "13-14 Moderate Risk" "15-18 At Risk" The risk scores for Resident "C" were: 12/03/14: 16 (at risk) 12/10/14: 16 (at risk) 12/17/14: 18 (at risk) . The admission Nurse's Notes, dated 11/26/14 1300 (1:00 p.m.), did not address the reddened area. The skin area was not noted until a Nurses Note indicated: "12/09/14 2:30 p.m. During ADL's (Activities of Daily Living), CNA reported coccyx area now open, area assessed, findings documented on wound/pressure flow record. MD notified. N.O. (New Order) received...." The Nurses Notes addressed the coccyx wound as indicated: "12/15/14 11:30 a.m. Coccyx wound assess. See weekly record...asked daughter if she is OK c (with) ordering low air loss mattress for resident...." "12/18/14 10:00 a.m. Reassessed coccyx wound. Wound edges now necrotic. Wound bed covered c slough. Resident c/o (complains/of) pain discomfort during cleansing...low air loss mattress in place...." "12/22/14 10:30 a.m. Drsg (Dressing) order ^'d (changed) to coccyx wound..." "12/25/14 1;30 p.m. ...stated the only thing that hurts is her coccyx...." "12/28/14 3:30 p.m. ...Drsg on coccyx ^'d, has a lot of slough & is red around wound." "12/29/14 11:50 a.m. ...Wound to coccyx has 0 (no) change...." "12/30/14 11:00 a.m. Treatment ^'d to coccyx per order. Area stage III (full thickness tissue loss) c slough intact & very foul odor....." "01/04/15 11:00 a.m. ...Dressing changed to coccyx per order...." "01/06/15 12:00 p.m....Dressing changed per order...." "01/09/15 2:30 p.m....Treatment to coccyx wound continues with mod (moderate) - lg (large) amount serosanquineous drainage...." "01/10/15 3:50 a.m. PRN (as needed) sacral drsg ^ completed per MD order. Tolerated will. Coccyx drainage noted...." "01/11/15 11:30 a.m. Confused....At this time CNA reported to this writer that resident is in bed and unable to speak normally. Lying on right side and clutching positioning rail. Makes noises as if uncomfortable, but unable to verbalize....B/P 88/51...Phoned Dr back as resident seemed to be worsening....Acts as if in pain... Report called to (ACF name) ER for eval and treatment...Dressing to coccyx changed prior to discharge. Moderate amount slightly foul drainage noted with very little slough left in wound." A "NURSING HOME TO HOSPITAL TRANSFER FORM", dated 01/11/15, indicated: "...SKIN/WOUND CARE: Pressure Ulcers...Daily dressing change coccyx wound...Resident with stage 4 wound to coccyx which has improved. Unable to answer questions at this time." The "WEEKLY WOUND EVALUATION FLOW RECORD", for the resident's wound, indicated: "12/09/14: 2.0 cm L (Length) X (by) 0.9 cm W (Width) X 0.1 D (Depth)" "12/15/14: 3.0 cm L X 3.0 W X 0.2 D. ^ (Change) tx (treatment) order..." No other weekly wound information was provided. Review of the Physician's Progress Notes indicated the physician saw the resident and indicated: "11/28/14". No mention of a pressure area. "12/05/14...She is moving slowly, but improving in therapy...." "12/12/14 (Resident "C" name) is not doing as well this week. She is more sleepy. Nursing states she was given Tranzadone by psychiatrist for apparently due to some situational depression and some poor sleep; however, the reports (sic) she has back slid this week in therapy due to somnolence...." "12/19/14 {Resident "C" name) is doing fair....She came in with a stage 2 (sic) decubitus, now is unstageable. She is on inner mattress...." "12/24/14 ...Her main complaint is her sacral wound....Big issue is her sacral wound...." "01/09/15 ...remains confused. She still has a coccyx wound....She has been hampered some by her coccyx wound and confusion...." The Physician order [REDACTED]. 12/15/14 12/18/14 12/22/14 12/31/14 The Dietary interventions indicated: "12/31/14: 2 cal beverage 120 cc TID (3 time a day) c (with) med (medication) pass Record % (percentage) consumed in MAR (Medication Administration Record) MVI (Multivitamin) c Mineral once daily for wound healing." The "Care Conference" documentation indicated: "01/05/14 (sic) Care Conference...Members present included {Resident "C"), therapy, SS, nursing. The POA was on speaker phone...(Resident "C") then mentioned she knew she had a sore on her behind that needed to be taken care of...." The Care Conference minutes did not address the open area other than the concern expressed by Resident "C" on 01/05/14. Review of a Care Plan, initiated on admission, 11/26/14, indicated: "Problems: 11/26/14: Redness to coccyx; surgical wound 12/09/14: Pressure ulcer Stage LL (Left Lower) coccyx" "Interventions: 12/15/14: Pressure relief support surface (low air mattress) Turn & reposition every 2 hours Dressing change as ordered...." During an interview, on 2/11/15 at 10:30 a.m., the DNS (Director Nursing Services) indicated Resident "C" was admitted with a skin area. The DNS indicated Resident "C" was non-complaint with positioning and therapy. The DNS indicated the facility had undergone a change of ownership on 01/2015. The DNS provided, at the time, a copy of an undated Policy & Procedure, titled, "PRESSURE ULCER PREVENTION AND MANAGEMENT', which was in place during the previous ownership, and at the time of admission for Resident "C." A confidential interview, with a direct care staff person, during the survey, indicated Resident "C" was compliant with therapy. The "PRESSURE ULCER PREVENTION AND MANAGEMENT" Policy & Procedure indicated: "At time of Admission: 1. All residents will be assessed for pressure ulcer risk at time of admission using a Standardized Scale, i.e. Braden or Norton. 2. All risk factors are identifies.... For an Actual Pressure Ulcer: 1. Pressure Ulcers are assessed to location, stage, size, shape, depth,..., surrounding tissue, and drainage (type, color, odor, and amount),.... 2. Initial status is documented in medical record. A narrative note or a form is acceptable.... 4. The Dietary Manager is notified and a referral is made to Registered Dietician for all Stage 2 or greater pressure ulcer. The Registered Dietician will assess for nutritional interventions and develop a plan as indicated.... 7. Within one week and then weekly, the IDT Risk Team reviews all new pressure ulcers and care plans.... 10. Daily monitoring is to be in place to assess the effectiveness of the plan of care and to ensure the care plan is followed i.e.: wound status pain, s/s infection or change...." This Federal tag related to Complaint IN 273. 3.1-40(a)(2)