Every finding on record at Wesley Manor Health Center

Based on observation, interview and record review, the facility failed to ensure a physician's order for the administration of oxygen was followed for 1 of 2 residents reviewed for respiratory care. (Resident 7)Findings include:During an observation, on 5/14/26 at 10:30 a.m., Resident 7 was receiving oxygen via nasal cannula at 3.5 liters per minute (lpm). Resident 7 was observed resting in bed with her eyes closed.During an observation, on 5/18/26 at 9:31 a.m., Resident 7 was receiving oxygen via nasal cannula at 3.5 lpm. Resident 7 was observed resting in bed.During an observation, on 5/18/26 at 12:27 p.m., Resident 7 was receiving oxygen via nasal cannula at 3.5 lpm. Resident 7 was observed resting in bed.The clinical record for Resident 7 was reviewed on 5/18/26 at 8:59 a.m. The diagnoses included, but were not limited to, respiratory failure with hypoxia, emphysema, and hypertension.A care plan, initiated on 6/30/25, indicated Resident 7 had emphysema and chronic obstructive pulmonary disease and oxygen settings were to be according to the physician's order.A care plan, initiated on 7/2/25, indicated Resident 7 had an altered cardiovascular status and oxygen settings were to be according to the physician's order.A care plan, initiated on 7/2/25, indicated Resident 7 had oxygen therapy due to chronic respiratory failure with hypoxia and emphysema and oxygen settings were to be according to the physician's order.A physician's order, dated 7/1/25, indicated to provide oxygen via nasal cannula at 2 lpm while at rest and 5 lpm with exertion.During an interview, on 5/18/26 at 9:33 a.m., CNA 3 indicated the resident was on 3 lpm of oxygen.During an interview, on 5/18/26 at 12:29 p.m., the Director of Nursing indicated she did not know what amount of oxygen the resident was to be receiving.A current facility policy, titled Oxygen Administration, dated as last reviewed on 11/12/25 and received from the Executive Director on 5/19/26 at 12:46 a.m., indicated .Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences 410 IAC (Indiana Administrative Code) 3.1-47(a)(6)

Based on observation, interview and record review, the facility failed to ensure an Interdisciplinary Team (IDT) assessment, physician's order, and care plan related to the self-administration of medications was obtained prior to the self-administration of medications for 1 of 1 resident reviewed for self-medication administration. (Resident 7)Findings include: During an observation, on 5/14/26 at 10:30 a.m., Resident 7 was observed resting in bed with her eyes closed. A cup, containing six (6) pills, was observed on the bedside table. There were no staff present in the room at the time of the observation. The clinical record for Resident 7 was reviewed on 5/18/26 at 8:59 a.m. The diagnoses included, but were not limited to, chronic respiratory failure with hypoxia, emphysema, and hypertension. The clinical record did not contain an IDT assessment, physician's order, or a care plan related to the self-administration of medications. During an interview, on 5/14/26 at 10:35 a.m., LPN 2 indicated there were six pills left at the bedside and she was not aware if Resident 7 was able to self-administer her medications.During an interview, on 5/14/26 at 3:05 p.m., the Director of Nursing indicated she was aware of the concern.A current facility policy, titled Resident Self-Administration of Medication, dated as last reviewed on 11/25/25 and received from the Executive Director on 5/19/26 at 12:46 p.m., indicated .It is the policy of this facility to support each resident's right to self- administer medications after the facility's Nurse has determined which medications may be self-administered safely .The results of the assessment are recorded on the Medication Self-Administration Assessment Form, which is place in the resident's medical record .The care plan must reflect resident self-administration for such medications 410 IAC (Indiana Administrative Code) 16.2-3.1-11(a)

Based on interview and record review, the facility failed to ensure a foley catheter placement was documented and follow-up assessments were completed after a change in urine characteristics were observed for 1 of 3 residents reviewed for catheters. (Resident B) This deficient practice resulted in Resident B being admitted to the hospital with urethral trauma.Findings include:During an interview, on 12/11/25 at 3:04 p.m., Resident B's family indicated the physician in the emergency room had indicated Resident B's catheter was inserted at the facility incorrectly. She was told a nursing student placed the catheter; the balloon was in his urethra and damaged it.The clinical record for Resident B was completed on 12/11/25 at 10:32 a.m. The diagnoses included, but were not limited to, cerebral infarction, cognitive communication deficit, benign prostatic hyperplasia with lower urinary tract symptoms, and dysuria. A care plan, dated 10/24/25, indicated Resident B had a foley catheter with a goal to remain free from catheter-related trauma. An intervention, added 12/5/25 (after the catheter was changed on 11/24/25), indicated the resident was visualized picking up the catheter bag and holding onto it or setting it up on the table. The care plan did not indicate Resident B had a history of pulling on his catheter or any interventions staff should initiate to ensure the catheter tubing was secured to prevent pulling on the catheter. A physician's order, dated 11/24/25, indicated to change the urinary catheter. The Treatment Administration Record (TAR) indicated RN 6 had changed the indwelling catheter. The physician's orders did not include the type or the size of the urinary catheter or the amount of fluid which should have been used in the balloon to anchor the catheter. A physician's order, dated 10/30/25, indicated to measure the urinary catheter output three (3) times a day in the early morning, midday, and at bedtime. On 11/24/25 at bedtime, the amount of urine documented was 175 ml (milliliters) or cc (cubic centimeters). The color of urine documented was red. There was no documentation the physician was notified on 11/24/25 at bedtime Resident B had low urine output or discolored urine. A nursing progress note, dated 11/25/25 at 1:49 a.m., indicated Resident B had complaints of abdominal pain at 12:50 a.m. Blood was noted in his catheter bag. His abdomen was tender. The physician was called at 1:07 a.m., and an order was received to send Resident B to the emergency room for an evaluation. Resident B left the facility at 1:12 a.m. The progress notes did not include documentation of the indwelling catheter change or the time the procedure occurred on 11/24/25. There was no documentation to indicate how Resident B tolerated the procedure, if there was urine return and the color of the urine, the type and size of the catheter used, and the amount of fluid used in the balloon to anchor the catheter.A hospital document, dated 11/25/25 at 1:57 a.m., indicated Resident B's chief complaint was abdominal pain. He was brought to the emergency room by emergency medical services. His foley catheter placement was exchanged at the nursing home, on 11/24/25, and presented with hematuria (blood in the urine) and blood clots. The resident reported persistent bladder pain, tenderness on both left and right sides, and a sensation of abdominal distension. The resident's exam indicated he had abdominal tenderness and mild abdominal distension. His foley catheter was in the penis and was not draining with some blood at the penile meatus (external opening at the tip of the penis). The foley catheter placed at the nursing home, on 11/24/25, was found to be very shallow, likely in the penile meatus and not in the bladder which resulted in urinary obstruction. The foley catheter was removed and a three-way catheter was placed without difficulty. There was immediate drainage of approximately 1500 cc of urine with blood. The foley catheter was found to be malpositioned which resulted in urinary obstruction and a large blood clot. A hospital discharge document, dated 11/27/25 at 8:53 a.m., indicated Resident B had a traumatic injury of the urethra (tube which carries urine from the bladder out of the body), present on admit, and suspected to be due to a urinary catheter injury. The resident's meatus had a small tear, with active oozing and bleeding from the site and a suspected higher urethral injury from improper placement/inflation of the urinary catheter balloon. During a telephone interview, on 12/10/25 at 4:01 p.m., RN 1 (a nursing student instructor from an outside entity) indicated a student nurse under her immediate supervision inserted the indwelling foley catheter into Resident B. She indicated the student prepped the area, inserted the indwelling catheter until urine was returned, advanced the catheter slightly, then blew up the balloon with the provided syringe in the sterile package. The urine returned after the catheter was inserted was a pink tinged with sediment. Resident B voiced complaints of pain in his urethral area during the procedure until the procedure was completed. She indicated neither her nor her student went back after the catheter was inserted to check on the color of the urine. She reported the procedure to the facility's dayshift nurse who was caring for Resident B. Neither her nor her student documented the procedure in Resident B's medical record prior to leaving the facility for the day. During an interview, on 12/11/25 at 10:45 a.m., the Associate Executive Director (ED) indicated RN 1 told her pink tinged urine drained into the foley catheter tubing after the catheter was inserted. RN 1 had passed the information related to the catheter insertion onto the facility's staff nurse. RN 1 and the student did not go back and follow-up after inserting the catheter as it was time for the students to leave clinical for the day. During a telephone interview, on 12/11/25 at 11:00 a.m., Urologist 9 indicated urethral trauma could be possible if the balloon of an indwelling catheter was not blown up in the bladder. If the balloon was partially or completely blown up in the urethra, there would have been a urine return, not a significant amount of urine drained after the insertion, and there would be urinary retention. There could be trauma to the urethra from a catheter being pulled on if it was not secured at the time of the insertion. During an interview, on 12/11/25 at 2:45 p.m., Resident B indicated he was admitted to the hospital and the emergency room doctor told me and my daughter that the catheter was put in the wrong place and damaged my penis. Prevention of Inappropriate Self-Extraction of Foley Catheters (May 30, 2023) was retrieved on 12/12/2025 from the National Library of Medicine (NLM) website and indicated .early identification of catheter malpositioning can minimize pain, urinary tract infections, discomfort, and hematuria as well as eliminate long-term complications.Traumatic, unintended Foley catheter extractions, whether patient-initiated or accidental, can cause permanent urologic complications.Every patient with a Foley catheter who has delirium or dementia is potentially at risk of a traumatic Foley catheter removal.Other patients at risk include.an elderly nursing home patient with a recently placed Foley catheter or one who has a prior history of traumatic self-extraction of catheters. Patients who are constantly pulling or tugging on their Foley catheters.Patients with a history of prior Foley catheter self-extractions. Be Suspicious of a Possible Malpositioned Catheter.Be aware that, occasionally, usually with urethral strictures, the catheter can double back on itself, or a male patient's urethra may be exceptionally long, giving a false impression of normalcy. Use Standard Preventive Measures.All patients with Foley catheters should include a properly placed Foley stabilization device as well as additional observation by staff if patients appear confused or agitated. Reposition the Foley Catheter Under the Thigh, Tape and Cover it. In higher-risk patients, reposition the catheter by directing it under the thigh and then taping it directly to the skin without a gap.The catheter needs to be completely secured with tape, starting almost at the level of the meatus and continuing as the catheter is secured underneath the thigh. Then wrap a large, wide elastic bandage around the patient's thigh, completely covering the tape and Foley catheter. TED hose or similar anti-edema leg wraps may also be used to cover the Foley catheter and tubing.A current facility policy, titled Catheter Usage: Rationale For Foley Catheter Insertion/Removal, dated as revised 12/29/14 and provided by the Associate ED on 12/11/25 at 2:04 p.m., indicated .Physician's order must state supporting diagnosis, size of catheter, bulb size, frequency of changes and irrigation order, if warranted.Documentation of above will be in nurses' notes and treatment record, including tolerance/acceptance of procedure.issues related to catheter care/tolerance must be addressed in the resident's plan of care.assessment needs to be included in any communication with the resident's physician This citation relates to Intake 2684620.3.1-41(a)(1)

Based on interview and record review, the facility failed to ensure the physician's orders for peritoneal dialysis were followed for 1 of 1 resident reviewed for dialysis. (Resident 50) Findings include: The clinical record for Resident 50 was reviewed on 5/29/25 at 10:17 a.m. The diagnoses included, but were not limited to, congestive heart failure, kidney failure, kidney disease, chronic obstructive pulmonary disease, type 2 diabetes mellitus, end stage renal disease, and dependence on renal dialysis. A physician's order, dated 12/10/24, indicated to take the resident's vital signs before and after dialysis and to use the morning weight and the systolic blood pressure to determine the dose for dialysis. A physician's order, dated 12/10/24, indicated the resident needed weighed every morning and when the resident's weight was greater than 216 pounds to call the dialysis clinic for further instructions. If the systolic blood pressure was less than 110, use one green (2.5% dextrose) and one yellow (1.5% dextrose) bag regardless of the weight. If the systolic blood pressure was less than 110, to use two yellow bags regardless of the weight two times a day for peritoneal dialysis. The physician's order which indicated the use of the different bags of solutions based on the same low systolic blood pressure result was not clarified by the facility. The dialysis treatment logs indicated the following: a. On 2/1/25, the systolic blood pressure was 100 and two green bags were given. The bags given were based on the resident's morning weight and the order for the low systolic blood pressure was not followed. b. On 2/6/25, the systolic blood pressure was 102 and the bag concentration used was not recorded. The bags given were based on the resident's morning weight and the order for the low systolic blood pressure was not followed. c. On 3/2/25, the systolic blood pressure was 107 and two green bags were given. The bags given were based on the resident's morning weight and the order for the low systolic blood pressure was not followed. d. On 3/3/25, the systolic blood pressure was 107 and the bag concentration used was not recorded. The bags given were based on the resident's morning weight and the order for the low systolic blood pressure was not followed. e. On 3/7/25, the systolic blood pressure was 88 and 1 green bag, and 1 red bag (4.25% dextrose) were given. The bags given were based on the resident's morning weight and the order for the low systolic blood pressure was not followed. f. On 3/28/25, the resident's weight was 219.4 pounds. There was no indication the nurse called the dialysis clinic for a treatment order. The blood pressure documented was greater than the 110 in the physician's order. g. On 4/13/25, the resident's weight was 218 pounds. There was no indication the nurse called the dialysis clinic for a treatment order. The blood pressure documented was greater than the 110 in the physician's order. h. On 4/15/25, the systolic blood pressure was 108 and one green bag, and one red bag was given. The bags given were based on the resident's morning weight and the order for the low systolic blood pressure was not followed. i. On 4/22/25, the systolic blood pressure was 105 and two green bags were given. The bags given were based on the resident's morning weight and the order for the low systolic blood pressure was not followed. j. On 5/7/25, the systolic blood pressure was 103 and one green bag, and one red bag were given. The bags given were based on the resident's morning weight and the order for the low systolic blood pressure was not followed. k. On 5/25/25, the systolic blood pressure was 108 and two green bags were given. The bags given were based on the resident's morning weight and the order for the low systolic blood pressure was not followed. A current care plan, dated 5/20/24, indicated the resident needed peritoneal dialysis related to renal failure with an approach to administer dialysis solution as ordered. During an interview, on 5/29/25 at 2:35 p.m., the physician indicated she would follow up with the dialysis provider to clarify the dialysis order for low systolic blood pressure. The resident had frequent lab work completed, and the orders had changed related to the labs. The current order was confusing, and the nurse would not know what concentration of bag to use. During an interview, on 6/2/25 at 2:21 p.m., the Director of Nursing (DON) indicated she could not find any documentation of the nurses calling the dialysis clinic for weights greater than 216 pounds on the discussed dates and they should have called to obtain guidance on the concentrations to use. During an interview, on 6/2/25 at 3:09 p.m., RN 2 indicated she would use the morning weight and the systolic blood pressure to determine which concentration of bags to use for the evening dialysis. The order was based on the weight unless the systolic blood pressure was less than 110 and then she would give 2 yellow bags no matter what the weight was. If his weight was greater than 216 pounds, then she would call the dialysis clinic for an order on which bags to use. A current facility policy, dated 11/13/22 and received from the Associate Executive Director on 6/2/25 at 2:58 p.m., indicated .The facility will maintain communication with the dialysis center per provider order and as needed 3.1-37(a)

Based on interview and record review, the facility failed to ensure there was documentation the bed hold policy was provided to a resident for 1 of 3 residents reviewed for discharge. (Resident 81) The deficient practice was corrected on 5/21/25, prior to the start of the survey, and was therefore past noncompliance. Findings include: The clinical record for Resident 81 was reviewed on 5/28/25 at 2:42 p.m. The diagnoses included, but were not limited to, weakness, Crohn's disease, and dementia. The electronic health record indicated Resident 81 was discharged from the facility to the hospital on 4/8/25. There was no documentation to indicate the bed hold policy had been given to the resident or the resident's representative at the time of the discharge. There was no documentation to indicate the bed hold policy had been emailed or sent by postal service to the resident's representative if needed. During an interview, on 6/2/25 at 11:47 a.m., the Executive Director indicated in May of 2025, the facility started emailing copies of the bed hold policy to the resident's representative when a resident was discharged . If the resident's representative did not have an email, a copy would be mailed to them through the postal service. A current facility policy, titled discharge: Bed Hold, dated as last revised 12/12/19 and received from the Associate Executive Director on 5/29/25 at 11:42 a.m., indicated .Residents or their designated representative shall be informed of this policy in writing at admission, at the time of transfer to a hospital (unless an emergency), or at the time of therapeutic leave which extends beyond twenty-four [(24)] hours. Written notification at the time of transfer shall include the Notice of Transfer and Discharge and a copy of this policy .In the event of an emergency hospitalization, the resident and a family member or legal representative shall be notified by written notice, within 24 hours, and asked to provide the facility with their decision regarding the resident's return. The staff member making the call or explaining the policy may accept verbal determination as to whether the resident desires bed hold or having their name placed on the reservation/waiting list and shall document this in the medical record A current facility policy, titled Notice of Transfer or Discharge, dated as last revised on 5/21/25 and received from the Associate Executive Director on 6/2/25 at 2:58 p.m., indicated .The Notice of Transfer or Discharge and Notice of Transfer or Discharge Request for Hearing will be utilized and will be provided in the transfer paperwork, [(where applicable)], given to the resident, resident representative, and a copy maintained in the clinical record .When the Notice of Transfer or Discharge and Notice of Transfer or Discharge Request for Hearing form is provided within transfer paperwork, [(resident going to the hospital)], the resident or resident representative will be provided a copy of the notices via hand-delivery, email, or sent through the postal service .Nursing will contact the resident and/or legal representative and discuss the proposed transfer and document all such communication in the resident's clinical record The deficient practice was corrected by 5/21/25 after the facility implemented a systemic plan which included education, audits and updates to the facility policy and procedures. 3.1-12(a)(6)(A)(ii) 3.1-12(a)(6)(A)(iii) 3.1-12(25)(A) 3.1-12(25)(B) 3.1-12(a)(26)

Based on observation, interview and record review, the facility failed to ensure a consent with the identified medical reason for the use of a restraint was completed at the initiation of the restraint, to establish a time frame for continuing the use of the restraint and to establish how the restraint would be decreased and discontinued for 1 of 1 resident reviewed for restraints. (Resident 70) This deficient practice resulted in Resident C having three (3) falls with major injuries while using the restraint, had 3 emergency room evaluations and was diagnosed with nasal fractures, lacerations to her face which required sutures, and a laceration to her upper lip which required sutures. Finding includes: During an observation, on 6/13/24 at 11:48 a.m., the resident was observed to be walking in a merry walker (a walker made of plastic PVC type tubing which enclosed the resident in the tubing frame and had a seat at the back of the frame). During an interview, on 6/17/24 at 11:09 a.m., the Director of Nursing (DON) indicated the resident was not able to get out of the Merry [NAME] on her own and it was considered a restraint. The clinical record for Resident 70 was reviewed on 6/14/24 at 9:59 a.m. The diagnoses included, but were not limited to, dementia with agitation, repeated falls, restlessness and agitation, anxiety, a psychotic disorder with delusions due to a known physiological condition, dementia with a behavioral disturbance, and major depressive disorder. A Quarterly Minimum Data Set (MDS) assessment, dated 3/12/24, indicated the resident utilized a physical restraint daily and the resident was severely impaired cognitively. A care plan, which was initiated on 10/24/22, indicated the resident was at risk for falls related to confusion, decreased mobility, and decreased safety awareness secondary to dementia. The goal was for the resident to be free of falls through the next review date. The interventions included, but were not limited to, assessing for injury when the resident sits on the floor, engaging in activities which improve strength, balance and posture, and keep areas free of obstructions to reduce the risk of falls or injury. A care plan, initiated on 11/2/22 and last revised on 6/19/23, indicated the resident was an elopement risk and would wander throughout the facility. The resident had a history of attempts to leave the facility unattended and had impaired safety awareness. The resident wandered aimlessly and significantly intruded on the privacy of others. The interventions included, but were not limited to, assessing for fall risk and distracting from wandering. A physician's order, dated 7/10/23, indicated for the resident to use a merry walker every 2 hours for gait release and to release the resident from the merry walker every 2 hours for toileting, hygiene, rest, food, and fluids. The resident was to be out of the merry walker at mealtimes and to attempt for the resident to sit in the dining room chair. There were no diagnoses or clinical indication for use documented on the physician's order. A progress note, dated 7/10/23, indicated the resident's daughter was called to discuss the use of a merry walker for the resident's mobility. The daughter was instructed that the resident would be released every 2 hours from the walker for 10 minutes. The safety of the resident while in the merry walker was discussed and the daughter agreed to the use of the Merry Walker. The progress note did not indicate the clinical rational for the use of the device, a plan to ensure the device was the least restrictive alternative for the least amount of time, when the ongoing need for the device would be re-evaluated and did not include the risks of using the device. There was no written consent signed by the daughter when the device was initiated. A progress note, dated 7/13/23 at 8:15 p.m., indicated the resident had a witnessed fall while using the device. The CNA had observed the resident's merry walker tipping over a chair as the resident ran into it. The resident was lying face down in the merry walker. The resident had moderate bleeding from her nasal cavity. An Emergency Department discharge note, dated 7/13/23, indicated the resident had a fall and received a non-displaced fracture of the nasal bone, a facial hematoma, and a periorbital hematoma. A progress note, dated 7/13/23 at 10:30 p.m., indicated the resident returned to the facility from the Emergency Department and had bruising and swelling to her left eye lid, rug burns circling her left eye, and her nose was swollen. A facility fall note, dated 7/13/23, indicated the resident had a nasal bone fracture which occurred while in the merry walker. The walker tipped over a chair as the resident ran into the chair. The CNA was unable to reach the resident in time. The resident had a moderate sized hematoma above the left orbital cavity. The resident went to the Emergency Department and was diagnosed with a nasal bone fracture. A progress note, dated 7/14/23 at 10:06 a.m., indicated the fall was discussed with the resident's daughter. The anti-tippers for the merry walker were discussed. The progress note did not indicate the clinical rational for the use of the device, a plan to ensure the device was the least restrictive alternative for the least amount of time, when the ongoing need for the device would be re-evaluated and did not include the risks of using the device. There was no written consent signed by the daughter when the device was initiated. There was no documentation in the medical record to show the facility reassessed the resident for the appropriateness of the merry walker after her fall with injuries. A progress note, dated 7/26/23 at 9:00 a.m., indicated the staff talked to the resident's daughter about the safety and potential risks of the merry walker. The daughter was concerned a wheel would get stuck and tip the merry walker over. The staff reinforced to the daughter the anti-tippers were on each side and not the front or back of the merry walker. The resident was still a fall risk and still had the potential to tip the walker over. The resident would have staff supervision while in the merry walker and would be out of the merry walker every 2 hours at a minimum. A facility fall note, dated 1/23/24 at 11:10 a.m., indicated the resident had a fall at 10:40 a.m. The resident was face down on the floor in the merry walker. The CNA reported the resident's merry walker got caught on the corner of the wall by the nurse's station. The merry walker was laying on its side and the resident was laying on her right side. The resident was sent to the Emergency Department and returned at 3:40 p.m. The resident had three sutures on the bridge of her nose and two sutures to the upper lip. The daughter indicated she understood the risks of the merry walker. A hospital Emergency Department note, dated 1/23/24, indicated the resident presented to the Emergency Department after a fall. The resident was in her merry walker, and it flipped over causing her to fall face forward on the ground. The resident's injuries included mildly displaced bilateral nasal bone fractures, a small left frontal scalp contusion, a 0.5-centimeter (cm) laceration to the superior lip closed with two sutures and a 1.5 cm laceration on the nose closed with 3 sutures. There was no documentation in the medical record to show the facility reassessed the resident for the appropriateness of the merry walker after her second fall with injuries. A restraint informed consent, dated 3/4/24, was signed by the physician and the daughter. There was no written informed consent for the use of the merry walker located in the resident's medical record prior to the one dated 3/4/24. A facility fall note, dated 4/10/24 at 5:05 p.m., indicated the CNA reported the resident yelled for help and when she went to the resident, the resident was face down on the carpet, pushing herself up and rolling to her right side. There was blood coming from the resident's nose and mouth. The resident's merry walker was laying on its side by the resident. The resident had a laceration on her upper lip, facial abrasions to her forehead, chin and nose. The resident was sent to the Emergency Department and returned at 7:40 p.m., with 12 dissolvable sutures to her upper lip laceration. She also had an abrasion above her eyebrow, an abrasion to the bridge of her nose, and swelling to her nose. This was the third documented fall with injury to the resident while the merry walker was in use. A progress note, dated 4/11/24 at 10:46 a.m., indicated the daughter agreed the resident was only to be in the merry walker if the staff were able to be with the resident 1:1 or if the family was present. A physician's order, dated 4/11/24, indicated to use the merry walker with 1:1 or when family was present. Must release every 2 hours and as needed if still using 1:1 or with family for toileting, food, fluids and rest. The intervention of staff to be with the resident 1:1 did not occur until the third fall with injuries. During an interview, on 6/13/24 at 11:49 a.m., RN 3 indicated the resident was placed in the merry walker twice a shift. The Certified Nursing Assistants (CNAs) or the activity staff could help with the walker. The resident used the merry walker until she was tired and then the staff would remove the resident from the merry walker. During an interview, on 6/14/24 at 3:06 p.m., the Director of Nursing (DON) indicated the original consent for the merry walker was the verbal discussion with the daughter. The DON had verbal conversations with the daughter about the risks of the merry walker use. During an interview, on 6/17/24 at 10:09 a.m., the Assistant Executive Director (AED) indicated the physical therapist was in the quality assurance meetings when the merry walker was discussed but there were no assessments from the physical therapist (PT) for the use of the merry walker. During an interview, on 6/17/24 at 11:09 a.m., the Director of Nursing (DON) indicated the resident was not able to get out of the Merry [NAME] on her own and it was considered a restraint. There was no plan to stop using the merry walker which was considered a restraint. The first time the resident fell on [DATE] while using the merry walker, the anti-tippers were added to the walker. The resident was not supervised 1:1 until after the fall, on 4/10/24, and the intervention was put in place. During an interview, on 6/18/24 at 9:06 a.m., the daughter indicated she was not aware of the product the merry walker until the staff told her about it. Her mom would walk a few steps and then decide to sit down. At first, she was glad for the independence the merry walker gave her mom. After the first fall, anti-tippers were put on the walker, but they didn't work to keep her from falling. After the fall in April when her mom's tooth went through her mouth and she needed sutures, the daughter decided this was not working and her mom could only use the walker if someone was right with her to keep her from falling. Her mom did not understand she could not get into tight spaces, and this caused the falls. During an interview, on 6/18/24 at 2:33 p.m., the AED indicated the merry walker was a restraint and the facility thought this was the least restrictive device to be used to enhance the resident's life. The resident had zero safety awareness and was able to stand up and ambulate and was able to sit down in the seat of the merry walker. Without the merry walker, the resident would decline in her ability. There was no documentation in the electronic health record (EHR) to show this was the least restrictive device and there was no plan in the EHR to show a decrease or discontinuation of the restraint. The verbal plan would be to stop the restraint when the resident could no longer walk or bear weight since there would be a time in her disease process when she could not walk. During an interview, on 6/18/24 at 3:57 p.m., the AED indicated there was no written consent for the merry walker prior to 3/4/24. She was not able to provide documentation to show how often the use of the merry walker as a restraint was reviewed. A current policy, titled Restraints Use, dated as last revised on 4/2/2009 and received from the AED on 6/17/24 at 11:00 a.m., indicated .To ensure residents are provided a safe environment and that the use of restraints is carefully monitored to protect resident rights, personal comfort, and safety, assuring the least restrictive means are used .To use protective devices only when all other means of keeping a resident safe have been exhausted. The use of protective devices must be monitored in such a way as to minimize the impact on resident quality of life and functional status .To use protective devices or confinements only to treat medical symptoms in accordance with a physician's order and informed consent from the resident or responsible party .Initial assessment for the use of protective devices shall be followed by a monthly assessment for the first three [3] months and then quarterly assessments thereafter .Definition .Physical protective devices or restraints are any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot easily remove and that restricts freedom of movement or normal access to one's body .least restrictive measures .together with appropriate exercises and restorative nursing programs, shall be considered prior to the use of restraints .Care plan team participation in evaluation of restraint use and progress related to interventions and goals will be documented in the individual disciplinary progress notes .The interdisciplinary team, including specialized therapy staff, is responsible to participate in care planning interventions which may reduce or eliminate restraint use .Each physician's order for restraint shall be complete and specifically define the type, reason, duration, circumstances of restraint .If after a trial of alternative measures has been attempted and a determination that a physical restraint would enable and promote greater functional independence, or is necessary to provide lifesaving treatments, then the use of the restraint must first be explained to the resident, family member, or legal representative and written consent for use obtained .The care plan will reflect specific circumstances and medical symptoms for restraint use, time frames, and identify activities to occur during release periods .a licensed nurse is responsible for documenting, at least quarterly, in the nursed notes or on a physical restraint assessment the resident's response to the use of the restraint and goals identified in the plan of care and well as any attempt to reduce the use of restraints 3.1-26(a) 3.1-26(n) 3.1-26(o)

Based on interview and record review, the facility failed to ensure a thorough investigation was completed to include staff interviews after an injury of unknown source was identifed for 1 of 5 residents reviewed for accidents. (Resident 34) Finding includes: The clinical record for Resident 34 was reviewed on 6/14/24 at 11:12 a.m. The diagnoses included, but were not limited to Alzheimer's disease, dementia, unspecified intellectual disability, cognitive communication deficit, and other reduced mobility. A facility incident report indicated, on 4/7/24, there was bruising noted to Resident 34's right knee with swelling. The on-call nurse practitioner (NP) gave orders to do an x-ray as a precaution. X-ray results showed an acute fracture to the right hip and the bone was diffusely demineralized. A facility incident report with a follow-up added on 4/10/24, indicated on 4/6/24 at 10:00 a.m., the resident was observed to have swelling and her right leg appeared to be turned to the right. On 4/7/24, x-ray results came back and showed an acute right hip fracture. On 4/10/24, the Assistant Executive Director (AED) and Director of Nursing (DON) continued the investigation and demonstrated on the Maxi lift (a battery powered lift) where the placement of the sling landed, how it applied pressure when lifting a resident, and indicated this could have caused a pathological fracture. A physician's history and physical note, dated 4/11/24, indicated the resident was seen for medical necessity for a right hip fracture. The injury was most likely an osteoporosis fracture due to a maxi lift used and no documentation of a recent fall. During an interview, on 6/18/24 at 9:19 a.m., the Executive Director (ED) indicated she could not say for certain if the maxi lift being used instead of the Hoyer lift was the cause of the fracture. During an interview, on 6/18/24 at 9:54 a.m., the ED indicated there were no staff interviews the facility had conducted for the night shift staff who worked before the incident was noticed in the morning. The facility did not conduct interviews about how the resident was transferred with the staff who worked on the shift prior to when the injury was noticed. A current policy, titled Fall Risk Identification/Fall Investigation, dated as last revised 12/6/19 and received from the AED on 6/8/24 at 3:50 p.m., indicated .All falls and reports of potential risks shall be investigated and fall intervention implemented, as needed The facility did not provide a policy about investigating injuries by the time of exit. 3.1-28(d)

Based on observation, interview and record review, the facility failed to cue and assist a resident during lunch according to the plan of care and to assess/reweigh a resident for a significant weight change for 1 of 4 residents reviewed for nutrition. (Resident 45) Finding includes: During an observation, on 6/12/24 at 12:13 p.m., Resident 45 was sitting up in a pedal Broda (chair for positioning) at the dining table with his eyes closed. His plate still had most of his food. The staff were not cueing or assisting him to eat. Most of the other residents in the dining room had already finished eating. During an observation, on 6/12/24 at 12:24 p.m., a female staff asked Resident 45 if he was hungry, and the resident shook his head for no. The resident was very thin. During an observation, on 6/13/24 at 12:05 p.m., Resident 45 was sitting in his pedal Broda at the dining table. The resident was not eating on his own and the staff were not encouraging or assisting the resident to eat. The staff were helping other residents to eat their lunch. During on observation on 6/14/24 at 12:07 p.m., Resident 45 was in his pedal Broda at the dining table, he was not eating. His silverware was still rolled up in the napkin and no staff was cueing or assisting the resident to eat. The staff were assisting residents at other tables. During an observation, on 6/14/24 at 12:37 p.m., Resident 45 was still sitting at the dining room table. The silverware was still wrapped up in a napkin and there was no staff assisting or encouraging the resident to eat. During an observation, on 6/17/24 at 11:39 a.m., Resident 45 was sitting up in his pedal Broda at the dining room table, his silverware was wrapped up in the napkin and his food was not touched. A female staff pushed the resident in his pedal Broda away from the table. The clinical record for Resident 45 was reviewed on 6/14/24 at 4:07 p.m. The diagnoses included, but were not limited to, unspecified dementia, type 2 diabetes mellitus, osteoarthritis, and cerebral infarction. A care plan, dated 2/22/24, indicated the resident had an activities of daily living (ADL) self-care performance deficit related to dementia. The interventions included, but were not limited to, the resident required supervision by the staff to eat and may require limited to extensive assistance at times. A care plan, dated 2/27/24 and last revised on 5/28/24, indicated the resident had a nutritional or potential nutritional problem related to dementia, depression, underweight for age, and gluten intolerance. The goal included the resident would consume greater than or equal to 75% of his meals and the resident would have a gradual weight gain of 1-3 pounds each month. The interventions included, but were not limited to, observe/document/report signs of difficulty swallowing, choking, refusing to eat, monitor intake, and to observe/record/report significant weight loss of 3 pounds in one week, greater than 5% in one month, 7.5% in 3 months or greater than 10% in 6 months. An occupational therapy (OT) evaluation, dated 3/1/24, indicated the resident had a swan neck deformity (a bending of the base of the finger, a straightening of the middle joint and a bending of the outermost joint) in his right hand and his self-feeding may be impaired at times pending the food item. The resident presented with impairments in dexterity, strength and follow-through resulting in limitations and/or participation restrictions in self-care and general tasks. A physician's order, dated 5/27/24, indicated to give a regular diet, regular texture. The resident had a gluten sensitivity. A Registered Dietitian (RD) note, dated 5/27/24, indicated the quarterly nutrition assessment was completed. The resident had no significant weight change. The resident was referred to speech therapy and was referred to occupational therapy to assess the need for adaptive equipment. The resident had the following weights: 1. On 5/27/24, the weight was 133.6 pounds. 2. On 6/1/24, the weight was 126.2 pounds which was a 5.54% significant weight loss in 4 days. There was no documentation in the electronic health record (EHR) of a re-weight or assessment for the significant weight loss. During an interview, on 6/17/24 at 11:33 a.m., the Assistant Executive Director (AED) indicated the Nutrition at Risk (NAR) notes were not in the progress notes. The RD should have requested a re-weight on 6/1/24 and it might have gotten missed. The resident was not on the NAR although any re-weights would have been entered into the computer. During an interview, on 6/17/24 at 11:54 a.m., the RD indicated the resident did not trigger for a significant weight loss on 6/1/24 since it had not been 30 days. The RD had ordered a supplement of a magic cup on 5/27/24 since the resident's weight was not where she wanted it to be. The resident could usually feed himself with some cueing and sometimes his plate needed to be rotated so he could have better access to his food. A current policy, titled Nutrition/Weight Loss/Gain, dated as last revised on 4/8/2010 and received from the AED on 6/17/24 at 3:56 p.m., indicated .To establish methods for identifying concerns with residents' nutritional or hydration status and to guide facility staff to intervene as necessary to address any identified concerns .It is the policy of this facility to intervene when a resident has been identified as being at-risk for unplanned weight loss, and/or dehydration .Prevention .Care Planning/intervention will be established as appropriate .Monitoring .Staff will make observations regarding each resident's intake after meals .Intervention .When significant weight loss or significant weight gain has been observed, the following steps must be taken .Physician and family notification .Notification of the RD and/or Dietary Supervisor .Assessment of potential causes for the change .Interventions will be addressed on the resident's plan of care A current policy, titled Nutrition Risk, dated as last revised on 1/24 and received from the AED on 6/17/24 at 3:56 p.m., indicated .A Nutrition Risk team uses a systematic and interdisciplinary approach to identify, track, intervene, monitor, and follow-up with residents at high risk for significant weight changes, malnutrition, dehydration and pressure injuries, and any other nutrition-related concerns .Residents at nutrition risk will be reviewed the Interdisciplinary team [IDT] .The following criteria may be used to determine if a resident qualifies for Nutrition Risk .Unplanned significant weight loss/gain .5% in one month, 7.5% in 3 months, or 10% in 6 months .Significant change in appetite and/or decrease in usual oral intake in last 7 days 3.1-46(a)(1)

Based on interview and record review, the facility failed to provide documentation to show the resident specific psychosis/behaviors which were used as the rationale for declining a gradual dose reduction (GDR) of an antipsychotic for 1 of 5 residents reviewed for unnecessary medications. (Resident 38) Finding includes: The clinical record for Resident 38 was reviewed on 6/14/24 at 10:40 a.m. The diagnoses included, but were not limited to, unspecified dementia with psychotic disturbance, psychotic disorder with delusions due to a known physiological condition, severe major depressive disorder without psychotic features, and dementia with anxiety. A physician's order, dated 9/22/23, indicated to give risperidone (an antipsychotic) 0.25 milligrams (mg) three tablets one time a day for the psychotic disorder with delusions. A pharmacy GDR request, dated 3/1/24, indicated the resident received risperidone 0.75 mg daily and to please attempt a GDR of the risperidone to 0.5 mg daily. The physician response indicated the GDR was declined. The clinical rationale included the resident had intermittent episodes of delusional thinking and could be distressing. See the progress note dated 3/19/24. The progress notes were reviewed from 2/1/24 through 3/18/24 and no resident delusions, behaviors or distress were documented in the progress notes. A psychiatric progress note documented by the Nurse Practitioner, dated 3/19/24, indicated the staff reported the resident continued with intermittent delusions which could be distressing. The resident had no evidence of delusional thinking or paranoia during her visit. A Care Tracker Behavior Monitoring and Interventions report, dated March of 2024, showed the Certified Nursing Assistants (CNAs) documented the following resident behaviors: 1. On 3/11/24 at 1:15 p.m., the resident was accusing of others. 2. On 3/11/24 at 1:16 p.m., the resident expressed frustration/anger at others. 3. On 3/19/24 at 1:37 p.m., the resident expressed frustration/anger at others. 4. On 3/19/24 at 1:38 p.m., the resident was agitated. The Behavior Monitoring and Interventions report did not include the interventions used, how long the behaviors lasted, if there were any delusions or the level of distress by the resident. It also did not include if a licensed nurse had to be involved with the resident's behaviors. There were no progress notes in the electronic health record to match the dates and times of the behaviors listed in the Care Tracker Behavior Monitoring and Interventions report. A care plan, dated 9/14/23, indicated the resident displayed delusional thoughts and told stories which were not factual. The interventions included, but were not limited to, attempt to redirect, don't argue, and ensure the resident's safety. During an interview, on 6/18/24 at 10:12 a.m., the psychiatric Nurse Practitioner (NP) indicated there was a behavior note on 3/19/24 which indicated the resident was sitting at the dining table waiting for an activity to start and she was upset and talking about her mom and dad. There were no other notes of behaviors on 3/19/24. There were no other progress notes with behaviors/delusions documented for February or March 2024. The resident could get easily upset at times although none of these behaviors were documented in the electronic health record. The staff had reported the delusions to her although the staff did not indicate how often or how the resident was distressed. A current policy, titled Medications: Psychotropic Drug Policy, dated as last reviewed on 4/22/22 and received from the Assistant Executive Director on 6/17/24 at 3:56 p.m., indicated .To develop/implement an interdisciplinary system to limit the use of psychotropic medications .to limit the use of psychotropic medications to only residents who have an appropriate supporting diagnosis and/or are exhibiting behavioral symptoms that indicate psychosocial distress and/or make the resident a danger to their self or others .remains committed to identifying the least restrictive intervention in order to treat the behavioral symptoms, which may include making changes in the environment, restructuring the resident's schedule, assessing the resident for acute causes for the behavior, or changing our approach to the resident .This policy includes a specific system for monitoring the use of psychotropic medications and reviewing the use of these medications periodically in attempt to reduce or discontinue our use of them if appropriate .When a resident exhibits a pattern of behavioral symptoms that indicate they are suffering psychological-related distress and/or are considered to be a danger to their self or others, staff must first ensure the safety of the resident and other residents .If psychotropic medications have been used to manage a resident's behavior, a plan must be developed to reduce or eliminate the use of this medication. This will include a behavioral intervention care plan. Attempts to redirect the behavior with less restrictive interventions must be documented in the resident's medical record .If a psychotropic medication [PRN or routine] is being used to treat a resident's behavior, then the specific behaviors for which the mediation is being used will be monitored daily and documented in the resident's treatment record .Anti-psychotic medications are approved for the following DSM indications .Medical illnesses or delirium with manic or psychotic symptoms and/or treatment related psychosis or mania .Diagnosis alone cannot warrant the use of anti-psychotic medication. Clinical condition must also meet the following .Symptoms are due to mania or psychosis .Behavioral symptoms present a danger to the resident or others .Symptoms are causing one or more of the following: inconsolable or persistent distress, a significant decline in function, and/or major difficulty in receiving needed care 3.1-48(a)(3) 3.1-48(a)(4)

Based on observation, interview and record review, the facility failed to ensure employee meals were not stored in the nutrition refrigerator, failed to ensure items were dated with open dates and labeled with a name, and failed to ensure thermometers were in the refrigerator/freezers for 3 of 10 nutritional and unit refrigerators observed for safe and sanitary conditions. Findings include: 1. During an observation, on 6/13/24 at 8:23 a.m., the First Floor Unit nutrition refrigerator, located in the medication room, was found to contain a lunch bag. At that time, LPN 1 indicated it was her lunch in the bag. Also found in the refrigerator was a 16-ounce open bottle of strawberry poppy seed salad dressing. The bottle had been opened and was found without an open date or a label indicating who was the owner of the salad dressing. A sign found on the front of the refrigerator indicated .This fridge is for ensures, pudding, applesauce's only. All Staff and resident food/drink items to be put in the fridges at either end of the hallway per state guidance During an interview, on 6/13/24 at 8:23 a.m., LPN 1 indicated the food storage policy, in the medication room nutrition refrigerator, was confusing. They posted the sign on the refrigerator, but the facility still allowed the storage of the items. During an interview, on 6/13/24 at 8:31 a.m., the Director of Nursing indicated the facility had an employee breakroom and the employee food items were to be stored in that refrigerator. 2. During an observation, on 6/13/24 at 8:33 a.m., the refrigerator found at the end of the hall, close to the elevator, on the first-floor unit was found to have 1-gallon of vanilla ice cream and a clear plastic zip lock bag containing frozen pastries. Both items were found without an open date or label to indicate who was the owner of the items. There was also no thermometer found in the freezer. The refrigerator contained an open 8-ounce bag of shredded taco cheese which had been opened and contained approximately 1-ounce of shredded cheese. There was no label to indicate the date the item had been opened or the owner of the items. There was no thermometer found in the refrigerator. During an interview, on 6/13/24 at 8:33 a.m., LPN 1 indicated there was no log to show the temperatures of the freezer or refrigerator had been monitored. During an interview, on 6/13/24 at 8:35 a.m., the Assistant Director of Dining indicated the dining staff did not know the refrigerator was on the unit/hall. The items should have been labeled/dated and the refrigerator and freezers should have had thermometers. During an observation, on 6/14/24, the refrigerator had been removed from the area. 3. During an observation, on 6/17/24 at 2:09 p.m., the refrigerator/freezer found in the common area in front of the nursing station was found to have a Styrofoam container of ice cream, with a plastic spoon upright in the ice cream, uncovered and without a date or label to indicated who was the owner of the ice cream. During an interview, on 6/17/24 at 2:12 p.m., RN 2 indicated the owner was unknown and the item should have been covered. A facility policy, titled RESIDENT FOOD SERVICES, dated as last revised 1/24 and received from the Health Care Administrator on 6/13/24 at 10:30 a.m., indicated .The outside food must be .clearly labeled with the resident's name, the date the food was brought to the resident, and the use-by date A facility policy, titled RESIDENT FOOD SERVICES, dated as last reviewed 1/24 and received from the Health Care Administrator on 6/13/24 at 10:30 a.m., indicated .Subject .UNIT PANTRY STOCK .Staff food .items are not stored in resident pantry refrigerators .All opened items must be labeled with opened and use-by-dates A facility policy, titled Refrigerator Temperature Checks, dated as last revised 11/21/14 and received from the Health Care Administrator on 6/13/24 at 10:30 a.m., indicated .Refrigerator .temperature checks should be documented on the form located on the front of the refrigerator .Temperatures should be documented at least daily .All open bottles and containers must have a date opened date on them .If no date is found on an open bottle or container, it must be discarded when found 3.1-21(i)(3)

Based on observation, interview and record review, the facility failed to protect a resident from injury while walking with the resident from the bathroom to the resident's recliner without using a gait belt for 1 of 3 residents reviewed for accidents. (Resident B) Resident B fell and hit their head resulting in a laceration which was treated with staples and an interval development of a right frontoparietal convexity subdural hematoma (a blood vessel in the space between the skull and the brain was damaged). Finding includes: During an observation, on 9/28/23 at 9:41 a.m., Resident B was observed sitting in a recliner with her feet elevated. She appeared clean and dry and was wearing nonskid socks. There was a walker with a gait belt lying across the top and the room was free of obstacles. Resident B did not verbalize responses to questions, instead she nodded for yes and shook her head for no. She denied pain at the time. An Incident Report to the Indiana State Department of Health, dated 9/21/23, indicated the resident was being assisted by staff from the bathroom after bedtime care. The resident fell , hitting their head on the doorway. The type of injury sustained was a laceration to the head and an interval development of a right frontoparietal convexity subdural hematoma (a blood vessel in the space between the skull and the brain, the subdural space, was damaged). The record for Resident B was reviewed on 9/28/23 at 2:30 p.m. Diagnoses included, but were not limited to, traumatic subdural hemorrhage without loss of consciousness, metabolic encephalopathy, and Parkinson's disease. A care plan, initiated on 9/17/23 and in effect on the day of the resident's fall, indicated .Transfer: extensive assistance with 1-2 staff, GB [gait belt], and walker to w/c [wheelchair] A nursing note, dated 9/22/23 at 8:05 a.m., indicated RN 4 was called to the resident's room to find, upon entering, the resident lying on her back in front of the entry door. She had hit her head on the door during the fall and sustained a laceration to the back of her head. At 7:40 p.m., the family and management staff were notified. A nursing note, dated 9/22/23 at 5:16 a.m., indicated the resident was admitted to the hospital with a diagnosis of a traumatic subdural hematoma. Resident B also had a laceration on her scalp and four (4) staples were placed. A Computed Tomography report (CT report), dated 9/21/23, indicated the resident had an internal development of a right frontoparietal convexity subdural hematoma, a mild increase in the size of the left subdural hematoma, and a scalp laceration with staples. A facility document, titled INVESTIGATION, dated 9/22/23, indicated .CNA was assisting resident from BR [bathroom] to recliner after hs [hour of sleep/bedtime] care. Per CNA resident got feet tripped up and fell backwards while ambulating hitting her head on door frame. Resident wearing non-skid footwear, using walker, staff s [without] gait belt During an interview, on 9/28/23 at 9:44 a.m., CNA 1 indicated the information related to how a resident transferred could be found in the computer system. She went into the computer system every morning for resident information. During an interview, on 9/28/23 at 9:45 a.m., CNA 2 indicated the information for transfers was in the Kardex found in the computer system. She checked it every morning. During an interview, on 9/28/23 at 9:57 a.m., the Director of Nursing indicted staff were educated on gait belt use in July. They were not re-educated after Resident B's fall in September. During an interview, on 9/28/23 at 10:18 a.m., the Assistant Executive Director indicated audits for gait belt use were being completed. The staff member who did the audits was off on Friday, 9/22/23, and this was why the audit was not completed after the incident on 9/21/23. When the employee returned on Monday, 9/25/23, she was busy auditing other things. During an interview, on 9/28/23 at 11:30 a.m., the Assistant Executive Director indicated the policy, of the facility, was to use a gait belt. During a telephone interview, on 9/28/23 at 1:48 p.m., CNA 3 indicated on the day of the fall, she and RN 4 transferred the resident to the bathroom and then the nurse left the room. After assisting Resident B with toileting, they (CNA 3 and Resident B) were walking from the bathroom and Resident B's feet slipped out from under her. CNA 3 was not using a gait belt. She indicated my hand was on her back. She did not think about using a gait belt; she had been educated on the facility policy to use a gait belt. She indicated when the nurse came in to initially assist her with getting the resident up, they did not use a gait belt. She did have access to the Kardex and information on how the resident was to transfer, and checked the information when she charted at about 7-8 p.m. She did not look at the Kardex for transfer information. During an interview, on 9/28/23 at 2:10 p.m., RN 4 indicated she was called to Resident B's room around 7:30 p.m. The resident was observed lying on the floor with her legs extended. Resident B had hit her head. RN 4 did an assessment to include neurochecks and vital signs. The resident did sustain a laceration to the back of her head measuring 1.2 centimeters (cm). She had the CNA get an ice pack. She assessed the resident to make sure Resident B had no hip, neck, or back pain, and then they transferred her to her recliner. RN 4 indicated she did assist the CNA to get the resident up before and they did use a gait belt as well as when they got her off the floor and to her recliner. She did a teachable moment with the CNA after the incident and indicated the Director of Nursing educated/reminded the staff on the Ground Floor Unit, the next day, to use gaits belts. Information related to how to transfer the resident was in the care profile and the physician's orders. During an interview, on 9/28/23 at 2:22 p.m., the Director of Nursing indicated care plan and mobility/transfer information was in the Kardex in the computer system. The CNAs had access to the information. All CNAs had access to the system, and they should always get their orders from that area. When the orders were updated by the nurse, they populate to the Kardex when the care plan was updated. They should not be using a paper sheet. They could use the paper sheet throughout their shift, but if someone was new to the unit or if questioning mobility orders, they should check the Kardex. CNAs did give report and information was passed on from shift to shift. A facility document, titled 7/24/2023, was received from the Assistant Executive Director on 9/28/23 at 9:00 a.m., indicated Please review the information in your mailboxes regarding the gait belt policy and mechanical lift use. It is imperative not only for your own safety, but also for the safety of the residents we care for that we follow the appropriate transfer orders .Please sign and return the sheet in your mailbox acknowledging that you received the information The document was dated 7/24/23 and signed by CNA 3. At the bottom, it indicated .9-22-23 Re-educated on gait belt policy . and was signed by the Director of Nursing and CNA 3. A facility document, titled [NAME] Manor Weekly Audit 2020, was received from the Assistant Executive Director on 9/28/23 at 10:22 a.m. The gait belt audits were dated 9/2/23, 9/9/23 and 9/15/23. There were no further audits completed at the time the documents were provided. A current policy, titled Nursing Services Policy, dated as last reviewed on 12/2/19 and received from the Assistant Executive Director on 9/28/23 at 9:00 a.m., indicated .Nursing care is provided to meet resident needs by .Receiving appropriate nursing interventions .Residents will be protected from accidental injury using the proper equipment in a safe manner. Assistance is provided for transfers, including mobility devices as needed A current policy, titled Gait Belts, dated as last revised on 12/14/14 and received from the Assistant Executive Director on 9/28/23 at 2:59 p.m., indicated .Gait belt availability and use is required at all times This Federal Tag relates to Complaint IN00418063. 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to store food, and wash and dry dishes in a sanitary manner resulting in the potential for all residents who consume food from the kitchen to become ill from food borne illness. Findings include: During a kitchen tour, on 03/30/23 at 10:00 a.m., with the Director of Dining Services (DDS) the following was observed: 1. The clean and dry storage rack was observed to have: a) A small metal tong with a brown particle on the tong. b) A metal 1/2 (half) cup with a brown substance on the inside of the cup. c) A large sheet pan with a clear liquid in inside of the pan. d) A 2-inch side pan with a yellow substance scattered throughout the inside of the pan. e) A 2-inch pan with a clear liquid in the bottom of the pan and a light gray substance on the bottom of pan. f) A pizza cutter was noted with brown bits on the blade. 2. The walk-in cooler was observed to have: a) An open carton of heavy whipping cream with the top open to air (not re-sealed after opening). b) A 4-inch pan of white whipped potatoes was observed, and the pan was warm to the touch. 3. In the walk-in freezer, an open plastic container of cut carrots was noted with ice crystals on the frozen carrots. During an interview, on 03/30/23 at 10:10 a.m., the DDS indicated there was debris and liquid on the cooking utensils and pans and they needed to be rewashed and dried because the dishware was not clean. The open whipping cream should have been covered in plastic, frozen carrots needed to be covered and a cooling was necessary for the mashed potatoes. During an interview, on 03/30/23 at 10:19 a.m., the Kitchen Supervisor (KS) 4 indicated there was no cooling log for the mashed potatoes in the walk-in cooler. A current policy, titled Sanitation and Infection Prevention/Control, dated as last reviewed on 01/2023 and received from the DDS on 3/30/23 at 12:17 p.m., indicated .Pots, dishes, and flatware are stored in such a way as to prevent contamination by splash, dust, pests, or other means .air dry all food contact surfaces, including pots, dishes, flatware and utensils before storage A current policy, titled Food Handling Guidelines, dated as last reviewed on 12/2009 and received from the DDS on 3/30/23 at 12:17 p.m., indicated .Cooling of potentially hazardous cooked foods: Food shall be cooled .Use the Cooling Log form at the end of this policy to document the temperature of the food 3.1-21(i)(3)

Based on interview and record review, the facility failed to ensure PASARR (preadmission screening and resident review) were completed when a new mental health diagnoses and a new antipsychotic medication were added for 2 of 2 residents reviewed for PASARR. (Resident 73 and 70) Findings include: 1. The record for Resident 73 was reviewed on 3/31/23 at 4:19 p.m. Diagnoses included, but were not limited to, dementia with behavioral disturbance, anxiety disorder, unspecified psychosis not due to a substance or known physiological condition, and dementia with agitation. A PASARR level I, dated 10/7/22, indicated the resident's mental health conditions were major depression and anxiety disorder. The Level I screen indicated a PASARR disability was not present. If a status change occurred or other information suggested a potential serious mental illness, then an updated Level I must be submitted to report the change to reevaluate the need for a PASARR level II behavioral health evaluation. The PASARR Level I did not include an unspecified psychosis not due to a substance or known physiological condition. During an interview, on 4/4/23 at 11:25 a.m., the Associate Executive Director indicated a new PASARR should have been completed with the addition of the diagnosis of unspecified psychosis not due to a substance or known physiological condition. 44598 2. The record for Resident 70 was reviewed on 3/31/23 at 2:12 p.m. Diagnoses included, but were not limited to, dementia without behavioral disturbance, psychotic disturbance and mood disturbance, anxiety disorder, and depression. A PASARR level II, dated 2/7/23, indicated the resident's mental health conditions were dementia and anxiety disorder. The Level II screen indicated a PASARR disability was not present. If a status change occurred or other information suggested a potential serious mental illness, then an updated Level I must be submitted to report the change to reevaluate the need for a PASARR level II behavioral health evaluation. A physician's order, dated 3/21/23, indicated Risperdal (an antipsychotic medication) 0.5 mg (milligram) 1 tablet at bedtime. A new PASARR level I was not completed when Resident 70 was ordered Risperdal Oral Tablet 0.5 mg. During an interview, on 4/4/23 at 4:52 p.m., the Associate Executive Director indicated the resident most likely did not have a new PASARR completed when Risperdal was added. A new PASARR level I should have been completed. The facility did not have a PASARR policy. 3.1-16(d)(1)(A) 3.1-16(d)(1)(B)

Based on observation, interview and record review, the facility failed to label and date medications for 2 of 4 medication carts reviewed during medication storage. (G wing and H wing medication carts) Findings include: 1. During an observation, on 03/29/23 at 2:48 p.m., the 2nd floor G wing medication cart A was observed with Licensed Practical Nurse (LPN) 2. Observed in the top drawer was: a) Basaglar (brand name insulin) insulin pen with no open date on the used insulin. b) Lispro (band name insulin) insulin pen with no open date on the used insulin. c) Toujeo (brand name insulin) insulin pen with no open date on the insulin. d) Aspart (brand name insulin) insulin pen with no open date. During an interview, on 03/29/23 at 2:48 p.m., LPN 2 indicated none of the insulin pens observed in G wing medication cart A had open dates on the insulin pens. 2. During an observation, on 03/29/23 at 3:24 p.m., the 2nd floor H wing medication cart B was observed with LPN 3, and in the top drawer was a Levemir (brand name insulin) insulin pen with no open date on the pen or package. During an interview, on 03/29/23 at 3:24 p.m., LPN 3 indicated the insulin pen observed in the H wing medication cart B did not have an open date on the insulin. During an interview, on 03/30/23 at 2:19 p.m., the Director of Nursing (DON) indicated staff were to label all insulin pens with a date first used. A current policy, titled Vials and Ampules of Injectable Medications, dated as last reviewed on 05/2016 and received from the Assistant Associate Director on 3/30/23 at 2:49 p.m., indicated .Vials and ampules of injectable medications are used in accordance with the manufacturer's recommendations .and vials and ampules will have .The date opened and the initials of the first person to use the vial are recorded on multidose vials on an accessory label affixed for that purpose 3.1-25(k)(6)

Based on interview and record review, the facility failed to ensure the prophylactic antibiotic was reviewed and monitored for 1 of 1 resident reviewed for antibiotic use. (Resident 43) Finding includes: The record for Resident 43 was reviewed on 03/31/23 at 10:02 a.m. Diagnoses included, but were not limited to, urinary tract infections. A physician's order, dated 1/26/23, indicated cephalexin (an antibiotic) 250 mg (milligrams) daily as a prophylactic medication. A progress note, dated 2/27/23 at 4:17 p.m., indicated the hospice nurse was in the facility and the Foley catheter was changed with a 16 French 10 ml (milliliter) bulb. The resident's prophylactic antibiotic was reordered from the pharmacy. The hospice nurse was aware of the antibiotic issue. A progress note, dated 2/27/23 at 4:24 p.m., indicated the hospice nurse called the facility nurse and gave a verbal order for Macrobid (an antibiotic) 100 mg twice a day for ten days then to resume the Keflex (cephalexin) order due to dark urine color was noted with sediment. A surveillance log reviewed on 04/03/23 at 4:26 p.m., indicated the prophylactic antibiotic was not listed to be monitored. During an interview, on 4/3/23 at 3:37 p.m., the Infection Preventionist indicated the facility was not monitoring the prophylactic cephalexin. During an interview, on 4/3/23 at 3:45 p.m., the Director of Nursing indicated the resident was admitted to the facility with the prophylactic dose of cephalexin due to a history of multiple urinary tract infections. There was no surveillance for the prophylactic cephalexin. She was not aware of alternatives tried prior to the prophylactic cephalexin. A current policy, titled Antibiotic Stewardship, dated 2/27/20 and received from the Administrator on 4/4/23 at 4:30 p.m., indicated .The purpose of the program is to reduce inappropriate use of antibiotics, improve resident outcomes and lessen adverse events. Antibiotic Stewardship is a part of our Infection Control Program. The facility will track antibiotic use daily. The facility will communicate with the physicians(s) prescribing antibiotics with an Antibiotic Report Card on a monthly basis and as needed .The facility will ensure the pharmacy reviews all antibiotic usage for appropriateness. Antibiotics use will be calculated on a monthly basis for QAPI purposes. The facility will monitor for all adverse reactions/outcomes related to antibiotic therapy 3.1-18(b)(1)(A)

Based on observation, interview and record review, the facility failed to ensure a resident had been assessed for self-administration of medications before leaving medications unattended with a resident for 1 of 1 resident randomly reviewed for self-administration of medications. (Resident 45) Finding includes: During a random observation, on 03/30/23 at 9:28 a.m., a medication cup containing 11 pills was found on Resident 45's breakfast tray, on the bedside table, in the resident's room. The resident was in the restroom, her roommate was up in a recliner in the room, and there were no staff present. The record for Resident 45 was reviewed on 03/30/23 at 9:31 a.m. Diagnoses included, but were not limited to, chronic pain, type 2 diabetes, and atrial fibrillation. A self-administration of medication assessment was not found in the record. An order to self-administer medications was not found in the record. During an interview, on 03/30/23 at 9:31 a.m., LPN 5 indicated she left the medications in the room unattended. The resident usually took the medications when she got up, but she went to the restroom first. LPN 5 indicated she was not supposed to leave the medications with the residents, the resident needed to have an assessment to self-administer and an order to self-administer medications. During an interview, on 03/30/23 at 12:40 a.m., the Director of Nursing indicated the facility did not have an assessment to self-administer medications for Resident 45. A current policy, titled Medication: Self-Administration and Bedside Storage, last revised on June 01, 2011, and received from the Assistant Executive Director on 03/30/23 at 12:40 p.m., indicated .Residents who request to self-administer drugs will be assessed to determine if the practice is safe 3.1-11(a)

Based on observation, interview and record review, the facility failed to obtain a physician's order for routine Suprapubic catheter care (a flexible tube inserted through the stomach into the bladder to drain urine) for 1 of 1 resident reviewed for catheter care. (Resident 41) Finding includes: On 04/07/22 at 1:22 p.m., the resident was observed sitting in her electric wheelchair, with the television on, in her room. She had a suprapubic catheter in place which was attached to a drainage bag secured to the back of her wheelchair. The record for Resident 41 was reviewed on 04/08/22 at 11:52 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's order, dated 04/21/21 and discontinued on 07/15/21, indicated to provide care to the resident's catheter site two times daily. A current care plan, created on 3/11/21, indicated to provide catheter site care as ordered. During an interview, on 04/11/22 at 11:41 a.m., LPN 1 indicated the resident had an order to provide catheter care but it was discontinued and a new order was not put into place. A current facility policy, titled Nursing Services dated 03/02/21 and provided by the Director of Health Services (DHS) on 04/11/22 at 2:30 p.m., indicated .It is the policy of Wesley Manor, Inc. that each resident shall receive nursing care and supervision to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessments, standards of nursing practice A current facility policy, titled Catheter Care dated 03/02/21 and provided by the DHS on 04/11/22 at 2:30 p.m., indicated .Supra Pubic catheter care will be performed at least twice daily or more often if necessary 3.1-41(a)(2)

Based on observation, interview and record review, the facility failed to ensure documentation included the specific hallucinations and delusions for a resident with dementia who was prescribed an antipsychotic, to ensure antipsychotics were not prescribed for behaviors and to ensure appropriate labs were obtained when prescribed mood stabilizing medications for 3 of 5 residents reviewed for unnecessary medications. (Resident 14, 68 and 56) Findings include: 1. The record for Resident 14 was reviewed on 4/8/22 at 3:46 p.m. Diagnoses included, but were not limited to, dementia with Lewy bodies, [CONDITION(S)], anxiety disorder and restlessness and agitation. a. A physician's order, dated 9/22/21, indicated to give [MEDICATION(S)] (an antipsychotic) 0.5 mg (milligram) two times daily for delusional disorder. A care plan, dated 4/17/2018, indicated the resident had physical behavioral symptoms directed at others and at times became resistive to care and would hit the staff. The goal was the resident would not cause harm or injury to herself or others over the next 90 days. The interventions included, but were limited to, provide medication as ordered, record behaviors on the Behavior tracking form, remind the resident the behavior was not appropriate and remove from the situation. A care plan, dated 4/27/18, indicated the resident was taking antipsychotic medications due to a [CONDITION(S)] with delusions/hallucinations and personality changes. The interventions included, but were not limited to, prescription as ordered, psych services as warranted and to observe mood and behavior as well as attempt to determine precipitating factors in fluctuations of mood. The care plans did not include the resident specific hallucinations/delusions. A psychiatry progress note, dated 1/16/21, indicated the resident had a past medical history of dementia with Lewy bodies and a [CONDITION(S)] with hallucinations and anxiety. The mental status exam included there were no delusions or hallucinations, the resident was calm and oriented to person. The plan included to continue [MEDICATION(S)] due to Lewy body dementia with behavioral disturbance with delusions and hallucinations. A psychiatry progress note, dated 3/2/22, indicated the resident had a history of dementia with Lewy bodies and a [CONDITION(S)] with hallucinations. The mental status exam included the resident was oriented to person, had poor short and long term memory, had severe impairment in judgement and no delusions or hallucinations. The plan included the [MEDICATION(S)] would be continued for the Lewy body dementia. A psychiatry progress note, dated 3/30/22, indicated the resident had a history of dementia with Lewy bodies and a [CONDITION(S)] with hallucinations. The mental status exam included no delusions and no hallucinations. The plan was to continue the [MEDICATION(S)] for the Lewy body dementia. The psychiatry notes did not include a description of the past hallucinations. During an interview, on 4/11/22 at 11:39 a.m., LPN 4 did not know what the delusions were being monitored for Resident 14. The resident was nonverbal and wandered although was easily redirected. Sometimes she was combative with care and they monitored the resident for the combativeness. During an interview, on 4/11/22 at 11:51 a.m., the dementia UM (unit manager) indicated she did not have the specific delusions or hallucinations documented for Resident 14. b. A physician's order, dated 4/1/21, indicated to give [MEDICATION(S)] sprinkles (an anticonvulsant used as a mood stabilizer) 125 mg two times daily for dementia with Lewy bodies. During an interview, on 4/13/22 at 10:23 a.m., the Director of Health Services (DHS) indicated there was no ammonia level or [MEDICATION(S)] level completed for Resident 14. 2. During an observation, on 4/8/22 at 10:46 a.m., Resident 68 was lying, in bed, in her room while other residents were sitting up in the common area and watching television. During an observation, on 4/11/22 at 11:13 a.m., the resident was lying, in bed, in her room and the room was darkened. During an observation, on 4/12/22 at 9:52 a.m., the resident was lying, in bed, in her room. During an observation, on 4/12/22 at 10:58 a.m., the resident was still lying in bed and a male visitor was in the room. The record for Resident 68 was reviewed on 4/11/22 at 9:54 a.m. The diagnoses included, but were not limited to, [CONDITION(S)], major depressive disorder and dementia. A physician's order, dated 1/5/22, indicated to give [MEDICATION(S)] (generic for the antipsychotic [MEDICATION(S)]) 0.25 mg two times daily for Alzheimer dementia with behavioral disturbances. A care plan, dated 9/13/21, indicated the resident rejected or resisted care such as getting out of bed, eating meals and ADL (activities of daily living care). The interventions included, but were not limited to, identify time/approaches/staff which would result in the least resistance, know the resident preferred to sleep late some mornings, respect her decision to sleep late, provide a meal upon rising as the resident desired and respect the resident's right to refuse care. A clinical note, dated 12/23/21 at 12:48 p.m., indicated the resident refused morning medications and yelled at the nurse to get out. Staff allowed the resident to continue resting in the morning. At lunch time, staff tried to wake the resident and she swung her arms at staff and told them to get out. A clinical note, dated 12/26/21 at 1:45 p.m., indicated the resident refused several attempts to get up for breakfast and lunch. The daughter and her son were able to get the resident up. A clinical note, dated 1/1/22 at 12:32 p.m., indicated the resident had refused to get out of bed for a.m. ADL care. No symptoms of distress or pain noted. A clinical note, dated 1/05/22 at 12:14 p.m., indicated the resident was lying in bed, this a.m., with her eyes closed. Refused to get up for breakfast. The resident was up for lunch. A clinical note, dated 1/5/22 at 12:19 p.m., indicated the resident refused to get up, in the a.m., on the first attempt and on the second attempt got out of bed. A psychiatric progress note, dated 1/5/22, indicated the resident had increased behaviors of resisting care, refusing medications and nursing reported the resident had been more hateful. The mental status exam included the resident had no delusions and no hallucinations, was oriented to person and was not a danger to herself or others. The plan included Alzheimer's disease and to start [MEDICATION(S)] 0.25 mg twice a day for behaviors. The psychiatric progress note did not include the care planned preference for the resident to sleep late. A psychiatric progress note, dated 2/16/22, indicated the staff reported the resident would not get out of bed most of the time and would only get up to eat and then go back to bed. The plan included the [MEDICATION(S)] (an antidepressant) would be increased to 50 mg daily due to increased isolation and sleep. The [MEDICATION(S)] would be continued at 0.25 mg twice daily. During an interview, on 4/12/22 at 9:52 a.m., LPN 4 indicated the resident's daughter said Resident 68 was never much of a morning person. During an interview, on 4/12/22 at 11:05 a.m., CNA 5 indicated the resident did not like to get up for breakfast, preferred coffee first when she did wake up and was generally cooperative with care and only refused when the staff got her up too early. During an interview, on 4/12/22 at 4:55 p.m., the DHS indicated she had just reviewed the psychiatric note on 1/5/22 and saw the [MEDICATION(S)] was prescribed for behaviors and was disappointed when she reviewed the records. 3. The record for Resident 56 was reviewed on 4/8/22 at 2:40 p.m. Diagnoses included, but were not limited to, Alzheimer's disease, type 2 diabetes mellitus, somatoform disorders, depressive disorder, [CONDITION(S)] of the left eye, hypertension, [CONDITION(S)] and anxiety disorder. A physician's order, dated 3/31/21, indicated to give 1 capsule of [MEDICATION(S)] Sprinkles 125 mg by mouth two times a day. During a record review, on 4/13/22 at 10:49 a.m., Resident 56 had no documentation of labs being drawn for an Ammonia or [MEDICATION(S)] level. During an interview, on 4/13/22 at 10:53 a.m., the DHS indicated anyone on [MEDICATION(S)] should have an Ammonia and [MEDICATION(S)] ([MEDICATION(S)]) levels. The Nurse Practioner indicated if the Ammonia level was rising most likely the [MEDICATION(S)] level would also. The labs should have been drawn every 6 months. During an interview, on 4/13/22 at 11:23 a.m., the DHS indicated they could not find Ammonia or [MEDICATION(S)] levels for Resident 56. A current facility policy, titled [CONDITION(S)] Drug Policy, dated as revised 12/2/2019 and received from the DHS on 4/11/22 at 3:05 p.m., indicated .It is the policy of Wesley Manor to limit the use of [CONDITION(S)] medications to only resident who have an appropriate supporting diagnosis and/or are exhibiting behavioral symptoms that indicate psychosocial distress and/or make the resident a danger to their self or others .Wesley Manor remains committed to identifying the least restrictive intervention in order to treat the behavioral symptoms, which may include making changes in the environment, restructuring the resident's schedule, assessing the resident for acute causes for the behavior, or changing our approach to the resident .This policy included a specific system for monitoring the use of [CONDITION(S)] medications and reviewing the use of these medications periodically in attempt to reduce or discontinue our use of them if appropriate .If [CONDITION(S)] medications have been used to manage a resident's behavior, a plan must be developed to reduce or eliminate the use of this medication. This will include a behavioral intervention care plan. Attempts to redirect the behavior with less restrictive interventions must be documented in the resident's medical records .If a [CONDITION(S)] medication [PRN or routine] is being used to treat a resident's behavior, then the specific behaviors for which the medication is being used will be monitored daily and documented in the resident's treatment record .Diagnosis alone cannot warrant the use of anti-psychotic medications. Clinical condition must also meet the following .Symptoms are due to [CONDITION(S)] or [CONDITION(S)] .Behavioral symptoms present a danger to the resident or others .Symptoms are causing one or more of the following .inconsolable or persistent distress, a significant decline in function, and/or major difficulty in receiving needed care .Prior to determining that anti-psychotic medication will be used, we must first have ruled out the effectiveness of other non-pharmacological interventions, such as .Treatment of [CONDITION(S)] or other acute infection .pain management .Correcting environmental factors that may contribute to behavior .Person-centered scheduling .Identification and elimination of stimuli known to trigger the behavior .Addressing poor lab values .Bowel and bladder discomfort .Addressing an unmet need [hunger, thirst, boredom .] .IDT must be notified of any behavior that may possibly need an anti-psychotic medication The Nursing Drug Handbook, indicated [MEDICATION(S)] had an adverse reaction of increasing ammonia levels (elevated ammonia levels occurs when the kidneys or liver are not working properly allowing waste to remain in the bloodstream) and liver toxicity. The nursing assessment included to monitor for liver function studies before starting the medication and periodically thereafter. 3.1-48(a)(3) 3.1-48(a)(4)

Based on observation, interview and record review, the facility failed to ensure staff members wore a surgical or N95 respirator (medical grade) face mask on 3 of 4 units (FG unit , F unit and G unit) and failed to ensure 2 newly admitted residents were placed in an isolation unit (Resident 1 and Resident 2). These deficient practices had the potential to spread infections, including COVID-19, to 61 of 85 residents in the health care facility. Findings include: 1. During a walk through observation of the facility, on 10/15/20 beginning at 9:40 a.m., of the staff on the FG unit, all nursing staff and one housekeeper were observed wearing cloth masks. There was also no isolation rooms at the time of the observation. During an observation, of the F unit at 10:18 a.m., all staff were observed wearing cloth masks. During an observation, of the G unit at 10:42 a.m., all staff on the unit were wearing cloth masks. During an interview, on 10/15/20 at 10:10 a.m., Medical Records Employee 1 indicated the staff was allowed to wear cloth masks in the facility. During an interview, on 10/15/20 at 10:14 a.m., Housekeeper 2 indicated staff was allowed to wear cloth masks in the facility. During an interview, on 10/15/20 at 11:15 a.m., the Director of Nursing indicated there was no policy about staff needing to wear surgical masks while in the facility, all staff was allowed to use cloth masks, since there were no COVID-19 cases in the facility and she was unaware the facility was suppose to have been using surgical masks. 2. During a walk through observation of the facility, on 10/15/20 beginning at 9:40 a.m., there were no isolation rooms at the time of the observation and no signage on the rooms of the newly admitted resident's rooms to indicate isolation precautions had been put in place. During an interview, on 10/15/20 at 12:16 p.m., the Director of Nursing indicated new residents had 1 negative Covid test prior to being admitted , so they did not need to be isolated. The record for Resident 1 was reviewed on 10/15/20 at 12:36 p.m. [DIAGNOSES REDACTED]. Resident 1 was admitted on [DATE]. There were no physician orders for isolation precautions. The record for Resident 2 was reviewed on 10/15/20 at 12:38 p.m. [DIAGNOSES REDACTED]. Resident 2 admitted on [DATE]. There were no physicians order for isolation precautions. Preparing for COVID-19 in Nursing Homes (updated June 25, 2020) retrieved on 10/16/20 from the Centers of Disease Control (CDC) website indicated .Core Practices .Implement Source Control Measures .HCP (Health Care Providers) should wear a face mask at all times while they are in the facility .Cloth face coverings should NOT be worn by HCP Responding to Coronavirus (COVID-19) in Nursing Homes (updated April 30,2020) retrieved on 10/16/20 from the Centers of Disease Control (CDC) website indicated .Create a plan for managing new admissions and readmissions whose COVID-19 status is unknown . placement in a single room or in a separate observation area so the resident can be monitored for evidence of COVID-19. All recommended COVID-19 PPE should be worn during care of residents under observation, which includes use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown. Testing residents upon admission could identify those who are infected but otherwise without symptoms and might help direct placement of asymptomatic [DIAGNOSES REDACTED]-CoV-2-infected residents into the COVID-19 care unit. However, a single negative test upon admission does not mean that the resident was not exposed or will not become infected in the future. Newly admitted or readmitted residents should still be monitored for evidence of COVID-19 for 14 days after admission and cared for using all recommended COVID-19 PPE 3.1-18(a)

Based on interview and record review, the facility failed to provide wound care for a resident with a surgical incision for 1 of 3 residents reviewed for hospitalization . This resulted in the incision reopening requiring an additional surgery and hospital stay for the resident. (Resident 72). Finding includes: During an interview, on 11/12/19 at 1:54 p.m., Resident 72 indicated she was admitted to the facility for rehabilitation following surgery to her right ankle after a fall. She reported concerns to facility staff about her surgical incision being irritated by the orthopedic boot she was wearing. She further indicated she had not received regular dressing changes to her surgical incision and the nurses did not remove the boot daily to assess her skin. The record for Resident 72 was reviewed on 11/12/19 at 3:38 p.m. [DIAGNOSES REDACTED]. An admission assessment, dated 09/01/19, indicated the resident had a surgical wound to her right ankle which was covered with a bandage and an ace wrap. There was no physician's order for care of the surgical incision and no wound assessment in the record at admission. A physician's order, dated 09/01/19, indicated the resident had a surgical follow up appointment with an orthopedic NP (nurse practitioner) on 09/13/19. An NP progress note, dated 09/13/19, indicated, .The patient's staples were removed today and Steri-strips (sterile pieces of medical tape used to keep a wound closed) were placed over the incisions. A tall cam boot was placed on the right lower extremity for protection and immobilization .Steri-strip care instructions- (MONTH) shower in 24 hours, pat the incisions dry and gently remove the steri-strips if still intact in 7-10 days. Keep the steri-strips clean and dry. Wear the right cam walker boot at all times during ambulation. You may take off the boot for hygiene purposes only .Call/return to the office .for signs or symptoms of infection (such as redness, purulent drainage, fever, chills, ect) The NP orders were not added to the resident's physician's orders on 09/13/19. A nurse's note, dated 10/09/2019, indicated, .Splint in place to RLE (right lower extremity.) Res (resident) reported that splint was rubbing on her outer ankle. [MEDICATION NAME] pad (a foam dressing) placed and ace wrap to hold in place. Ankle reddened The record did not contain a wound assessment, a physician's order for dressing or documentation to indicate the doctor had been notified. An NP progress note, dated 10/11/19, indicated, .The patient reports that her cam walker boot has been rubbing against the outside of her ankle .she recently noticed a wound to the outside of her right ankle at the end of her incision .There is a 1 CM (centimeter) by 1 CM superficial wound noted to .incision, with scant serosanguinous (blood tinged) drainage, wound bed is pink and clean, no .signs of infection .x-rays of the ankle show stable anatomic bone and hardware alignment .There is no evidence of interval complications involving the hardware .plan: start daily wet to dry dressing changes to the right lateral ankle wound .wear the cam walker boot during ambulation (walking) only A facility nurse's note, dated 10/11/2019, indicated, .Returned from ortho visit with new orders. Daughter aware. States of wound requiring wet to dry dressing. Writer and DHS assessed wound so writer could make wound sheet and follow up. Daughter states ortho says area is superficial and will need to return on 10/15 Tuesday for re eval (evaluation.) Dressing removed and writer and DHS observed what appears as metal hardware from fx (fracture) repair. Area measure 1.0 X 1.0. Unable to obtain depth safely. Daughter call back to ortho and orders to sent to ER immediately for repair An emergency room x-ray report, dated 10/11/19, indicated, .The orthopedic screw in question .does not project beyond the outline of the overlying skin .view of the right ankle demonstrate previously seen .hardware which appears unchanged in alignment A hospital physician's note, dated 10/11/19, indicated, .She (Resident 72) reports post op that her wound completely healed .approximately 1 week ago she began noting drainage from the wound .she went to the clinic today where [MEDICATION NAME] tissue was noted over the wound .Assessment/Plan .now with dehiscence (opening) of . wound. A screw is visible in the wound .I recommend surgery to remove the screw, irrigate, and debride (remove dead tissue) the wound Hospital records indicated Resident 72 was discharged back to the facility on [DATE]. During an interview, on 11/12/19 at 4:02 p.m., LPN 24 indicated weekly skin assessments were signed off on the MAR (Medication Administration Record) and if there was an open area on admission or after admission a wound assessment should have been filled out. During an interview, on 11/15/19 at 10:19 a.m., the DHS (Director of Health Services) indicated it was her expectation for the nurse to remove the resident's cam (controlled ankle movement) boot each day to assess the underlying skin integrity unless contraindicated by physician's orders. During an interview, on 11/15/19 at 10:44 a.m., the DHS indicated they should have obtained physician's orders for the treatment of [REDACTED]. During an interview, on 11/15/19 at 2:32 p.m., the NP indicated it was her expectation the facility would have provided wound care as ordered by her on 9/13/19 and she considered daily skin assessments and wound care to be a part of hygiene. The NP indicated the resident still had steri-strips on the incision when she was seen on 10/11/19. This concerned her because on 9/13/19 she had ordered they should be removed in 7-10 days. A current facility policy, titled Skin: Preventionof and Care for Pressure Ulcers provided by the DHS on 11/13/19 at 2:14 p.m., indicated .prevent pressure from external sources, such as clothing, casts, braces or adaptive devices 3.1-37(a)

Based on record review and interview, the facility failed to ensure the safety of a resident while being transferred for 1 of 3 residents reviewed for accidents. (Resident B) Resident B was inappropriately transferred manually when the careplan indicated a mechanical lift. The resident sustained [REDACTED]. Findings include: During record review on 7/9/2019 at 3:00 p.m., Resident B [DIAGNOSES REDACTED]. Resident B was on the hospice program since 4/10/2019 for [MEDICAL CONDITION]. A Physician order, dated 6/10/2019, indicated status change to maxi lift (mechanical lift device) for transfers. A CNA plan of care, dated 6/10/2019, indicated resident was a maxi lift for transfers. A CNA plan of care, dated 6/18/2019,indicated resident was a maxi lift for transfers. A care plan report for falls risk, dated 7/27/2018, indicated a change in resident transfers on 6/10/2019 to maxi lift for transfers. An investigation report, dated 6/18/2019, indicated Resident B was transferred utilizing a 2 person pivot transfer and a [MEDICAL CONDITION] knee occurred. The resident had been changed to a maxi lift for transfers on 6/10/2019. An investigation report, dated 6/29/2019, indicated the Director of Heath Services (DHS) informed the family it appeared 2 aides utilized a 2 person assist with pivot transfer. The report indicated .It also appeared that when the transfer happened, (Name of Resident B)'s right knee did not move with the pivot and it was twisted. We believe this may have caused the fracture. An incident report to the Indiana State Department of Health dated 6/19/2019, indicated Resident B was transferred using a 2 person pivot transfer after lunch. She was laid down and her right knee was swollen and bruised. An x-ray was taken and the results indicated a distal [MEDICAL CONDITION] femur. A physician order [REDACTED]. The resident was on hospice and they family decided not to send resident to the ER and to treat the resident at the facility. An orthopedic consult was arranged. A rules of conduct report indicated CNA 5 and CNA 6 were transferring Resident B using a 2 person pivot assist instead of the mechanical lift and the event was suspected to cause a fracture to the resident's right femur just above the knee. CNA 5 and CNA 6 failed to look at the CNA plan of care. During an interview, on 7/9/2019 at 1:55 p.m., with LPN 7, she indicated she changed the care plan for Resident B on 6/10/2019 to reflect the resident's decline, from a 2 per assist to a maxi lift for transfers. She indicated staff were aware of change in transfer and it was noted on the CNA plan of care. During an interview, on 7/9/2019 at 12:30 p.m., with CNA 5, she indicated she was not aware of the resident plan of care was changed to a maxi lift and proceeded to transfer Resident B with a 2 person assist in the morning and after lunch. She indicated she reported to the nursing staff the resident had a bruise and swollen knee after her transfer to bed after lunch. She indicated she was not aware the resident hit her knee during the day. During an interview. on 7/9/2019 at 1:05 p.m., with CNA 6, she indicated she was not aware of the resident plan of care change to a maxi lift and proceeded to transfer Resident B with a 2 person assist in the morning and after lunch. She indicated she was not told in report the resident needed a maxi lift for her transfers. She indicated she reported to the nursing staff that the resident had a bruise and swollen knee after her transfer to bed after lunch. She indicated the resident did not hit her knee on anything before or during lunch. During an interview, on 7/10/2019 at 10:16 a.m., with CNA 8, he indicated during the change of shift the CNA leaving the shift would give the incoming CNA a report which included how to transfer each resident. The CNA care plan, which was on the computer board, was reviewed and if the computer was not working, the nursed would be questioned regarding how to transfer a resident. If a resident has a bruise or swollen knee, it is reported to the nurse to check out the resident. During an interview, on 7/10/2019 at 10:19 a.m., with CNA 9, she indicated during the change of shift the CNA leaving would give her a report which included how to transfer each resident. The CNA care plan, which was on the computer board was reviewed before caring for a resident and if the computer was not working, you would ask a nurse how the resident transferred. During an interview, on 7/9/2019 at 1:59 p.m., with the DNS, she indicated CNA 5 and CNA 6 should have reviewed the CNA care plan prior to caring for Resident B. CNA 5 and CNA 6 received written warnings and were retrained prior to returning to work at the facility. The current facility policy, Resident Handling/ Limited Lift, revised 8/19/2014, received from the DNS on on 7/9/2019 at 2:10 p.m., indicated .1. Initial screening will be performed on all residents to assess transfer and ambulating status. 2. Resident transfer status will be reviewed via care plan time frame and on an as needed basis This Federal tag relates to Complaint IN 719. 3.1-45(a)

Based on observation, interview, and record review, the facility failed to ensure fall preventative interventions were implemented resulting in a fall with multiple fractures for 1 of 5 residents reviewed for falls (Resident B). Findings include: On 12/31/18 at 7:30 a.m., the Director of Health Services (DHS) provided a report, titled, Indiana State Department of Health Survey Report System, dated 11/8/18. The report indicated, Resident B had a fall while ambulating with the Certified Nursing Assistant (CNA). The CNA indicated, the resident's knees buckled and she was lowered to the floor. At the time of the fall no injury was reported. Around 9:07 a.m., while being assisted with care the resident complained of pain, was grabbing her left hip and her leg was drawn up. She also complained of pain in the right wrist when her blood pressure was being taken. Assessments were completed at the time of the fall and again when the resident began to complain of pain. Notification was made to the physician, family and nursing administration, and the resident was sent to the emergency room for evaluation. The emergency room reported Resident B had right radial and femoral head fractures. Follow up on 11/12/18 indicated, the resident required surgical repair to her hip and radial fractures. On 11/14/18 it was brought to the DHS's attention by a different nurse that at the time of the incident it took 3 people to get the resident up, Registered Nurse (RN) 8, Qualified Medication Aide (QMA) 10, and CNA 9, and that the resident had been crying out in discomfort. The investigation was re-opened. After receiving additional statements from staff working the unit on other shifts, it was determined policy was not followed by the nurse or CNA, and the nurse and CNA were terminated. On 12/31/18 at 7:30 a.m., the Director of Health Services (DHS) provided a document, titled, Complaint/Concern Tracking Log, dated 7/17/18 - 11/8/18. The log indicated, on 11/8/18 Resident B had a fall with fracture, and a care plan meeting was set with the family for 11/15/18. Record review was completed for Resident B on 12/31/18 at 9:09 a.m. The record indicted, the resident was admitted to the facility on [DATE] and had current [DIAGNOSES REDACTED]. Review of Clinical Notes, dated 11/8/18 - 12/31/18, indicated: a. On 11/8/18 at 4:59 a.m., RN 8 documented, Resident B was ambulating with a 4 wheeled walker to get a shower accompanied by CNA 9. The resident's knees buckled and she was lowered to the floor. She was wearing socks, she did not hit her head, the writer assessed, and she was assisted up by 2 staff and taken to bed. b. On 11/8/18 at 8:53 a.m. Licensed Practical Nurse (LPN) 11 documented, at 7:15 a.m. a CNA went to Residents B's room to do activities of daily living. The resident was in bed and when the CNA attempted to move the resident she started yelling out in pain. LPN 11 assessed the resident, she had her hand grabbing the left hip and her leg was drawn up. When asked if she could straighten out her leg, Resident B tried but then resumed position. There was no bruising noted. LPN 11 applied a blood pressure wrist cuff to the right wrist, and when it started to tighten, the resident yelled out that it hurt. There was no swelling or bruising noted to the right hand or wrist, and she was able to move her fingers freely. An order was received to send the resident to the emergency room for evaluation. Family was notified and the resident was taken to the emergency room . c. On 11/8/18 at 10:39 a.m., LPN 11 documented she called the emergency room for a report, and was informed the resident had a radial (wrist) and femoral head (located at the head of the femur which fits at the pelvis) fractures. d. On 11/12/18 at 9:53 p.m., documentation indicated, the resident returned to the facility with an incision to the right hip with 29 staple, and a cast on the right arm. Review of a hospital document for Resident B, titled, History and Physical, dated 11/8/18, indicated, The patient apparently early this morning had a witnessed fall where she sort of as it is described to me, and gently slipped down off the edge of the bed. She had apparently not complained of too much of pain. They put her back in bed .Extremities: Examination of her right lower extremity reveals that she is externally rotated and shortened .Right hip is painful with stress. Her right wrist is splinted at this time, but previous x-rays have showed a non-displaced [MEDICAL CONDITION] distal radius. The patient seems to be having some left wrist pain and swelling is noted as well. Radiology: Review of the patient's outside films reveal displaced right-sided femoral neck fracture .She has a nondisplaced probably intra-articular [MEDICAL CONDITION] distal radius as well . Review of a quarterly Minimum Data Set (MDS), dated [DATE], indicated, Resident B had the ability to make herself understood and to understand others. She required extensive assistance of 2 for transfers, walking in the corridor, locomotion on unit, dressing, toilet use and personal hygiene. Extensive assistance of 2 + for walking in room. Mobility devices included a walker and wheel chair. Pain medications were offered as needed (PRN), there was no pain present. No falls since admission. Review of Significant Change MDS, dated [DATE], indicated, Resident B usually had the ability to make herself understood and to understand others. Brief Interview for Mental Status (BIMS) score of 1 indicated severe cognitive impairment. She required extensive assistance of 2 for bed mobility, transfers, and locomotion on the unit, dressing, eating, toilet use, and personal hygiene. She did not walk in the room or corridor. Mobility devices included a wheelchair. The resident received scheduled and prn pain medication for pain, but was unable to verbalize the pain or if medication was effective. Resident had a fall with fracture in the last month. Review of Care Plans for Resident B, to include but not limited to: 1. Problems: (Resident name) has altered thought process, is at risk for self-care deficit and is at risk for injury, [DIAGNOSES REDACTED]. Interventions: Facilitate (resident name) use of assistive devices for ambulation as appropriate. Ensure that (resident name) wears appropriate footwear that fits properly to facilitate safe ambulation. Assess for risk for falls and initiate appropriate interventions. Provide assistive devices per therapy evaluation to steady gait and provide ambulation support .2. Problems: (Resident name) requires assistance with ambulation related to decreased strength and weakness to increased independence and maintain/improve current ability. Goal: (Resident name) will ambulate to/from meals and as desired on unit with assist x 1, rolling walker and gait belt daily through next review. Interventions: Provide roller walker and 1 minimum to moderate assist, gait belt at all time .3. Problems: (Resident name) is at high risk for falls. Goal: (Resident name) will maintain at current level of mobility without experiencing fall related injuries. Interventions: (Resident name) will wear non-slick footwear that fits Use gait belt as appropriate for all transfers and assisted ambulation .4. Problems: Locomotion on unit- (Resident name) requires extensive assistance. Goal: (Resident name will participate in unit activities/social interactions 3-5 times per week over the next 90 days. Interventions: Assist (resident name) to desired location. (Resident name) requires use of 4 wheeled walker .4. Problems: (Resident name) has a history of falls since admission or prior admission: within last month. Goal: (Resident name} will maintain current level of mobility with no increase in the incidence of falls/injuries. Interventions: Assist (resident name) to wear non-slick footwear that fits. Instruct (resident name) on safety measures to reduce the risk of falls . On 12/31/18 at 1:55 p.m., the DHS provided a document, dated 11/8/18, and indicated it was a follow-up statement from QMA 10. The statement indicated, 10 went in at 4:30 a.m. to give Resident B her medications. The resident was sitting in bed, and CNA 9 was getting ready to get her up and give her a shower. The resident took her medications and QMA 10 left. The QMA 10 was then called back to the room by CNA 9 stating the resident was face down on the floor. QMA 10 called RN 8 from G wing, and when RN 8 came she said to turn the resident over, so they did, and pick her up. The resident could not bear weight on either legs. It took 3 of us, we put her on her walker and took her to bed, put her to bed and I left, she grab her (sic) right rib. After I got medications done RN 8 was sitting at desk. I asked her how Resident B was and she said she assessed her and she was moaning, she said that CNA 9 said she does that. I gave LPN 11 report and told her that Resident B fell and left. On 12/31/18 at 1:55 p.m., the DHS provided a document, dated 11/12/18 at 10:45 p.m., and indicated it was an interview she had conducted as a follow-up with RN 8. The statement indicted, when the nurse was interviewed by the DHS she indicated the resident had been found face down on her belly with her feet toward the door. When asked why she documented in the resident medical record the resident was sitting up, she replied I don't know. When the nurse was asked what she assessed, she stated in her note she had assessed the resident, and she was able to move her legs and they rolled her over on her right hip. When asked if the resident had assisted range of motion, she said yes, when asked why she didn't chart that, indicated, I don't know. When asked for an account of what happened after the she arrived, RN 8 indicated, CNA 9 and QMA 10 were instructed to lift Resident B up. When they got her up her feet were crossed at the ankles. The resident did not yell out and showed no signs or symptoms of pain. I don't know why I told them to put her to bed. I took her blood pressure on her right wrist and there was no pain noted. CNA 9 stated to me that she was walking the resident to the bathroom and the resident's knees buckled and she lowered her to the ground, and the resident got tired of sitting so she laid down. I would not have gotten her up is she was yelling. Resident B did not have a gait belt on her. On 12/31/18 at 1:55 p.m., the DHS provided a document, dated 11/12/18 at 11:30 p.m., and indicated it was an interview she had conducted as a follow-up with CNA 9. The statement indicated, the CNA was getting Resident B up to go to the bathroom and take a shower. Resident B fell on the carpet outside the bathroom. She had been walking with her rolling walker, CNA 9 did not use the gait belt or have non-skid footwear on her. When she got to the bathroom door, she started shuffling her feet so I got behind her and put my arms around her waist. She lost her balance, and started to sway back and forth and started to fall. I lowered her to the floor and she slipped out of my hands and fell forward onto her right side. Resident B was not yelling, and stated (now look). I called for QMA 10 and when she came in, she said she was getting the RN 8. RN 8 came, assessed her, and told us to get her up. It took all 3 of us to get her up and we sat her on the seat of her walker. RN 8 said to put her back to bed, so we did. Resident B lifted her own bottom in the bed. I gave her the call light and covered her up. When asked why she did not use the gait belt, indicated, Because (resident name) does not like to use the gait belt, she does not like things tight around her. On 12/31/18 at 7:45 a.m., the Assistant Director of Nursing (ADON) indicated, the resident had been admitted to the health center after experiencing a bad fall with injury while residing on the memory care unit. On 12/31/18 at 11:52 a.m., the ADON indicated, when a resident fell , whomever found the resident was to stay with the resident and the nurse was to be notified. The nurse was then to assess the resident, call and notify the physician, family, and supervisor who was always in the facility. The ADON was notified for all falls, if emergent she was to be called, if non-emergent she would get an e-mail, phone call or text. Falls were discussed weekly during Quality Assessment/Performance Improvement (QAPI) meeting. The ADON was responsible for assuring the process was followed. On 12/31/18 at 12:06 p.m., the ADON indicated, Resident B had a fall during the night shift when on the way to her shower with an aide. The aide indicated, the residents knees gave out and she went to the floor. There was no pain at the time of the incident, later she had pain. The resident had fractures of the hip and wrist, with surgical repair. The resident will probably remain in the health center due to increase in assistance with her needs. On 12/31/18 at 12:12 p.m., the DHS indicated, QMA 10 had come to her and reported there were rumors that the DHS had not received the correct story initially regard events surrounding Resident B's fall and aftercare. QMA 10 indicated, she had been working on the floor at the time of the incident, had heard CNA 9 yell for help, and went to get RN 8. QMA 10 did not see the incident, or help other than to get her up off the floor and back to bed, and indicated the resident was in pain and was not bearing weight when they got her up to bed. The resident was put back to bed at the time of the incident, RN 8 did not call the family or physician to report the fall. With the new information, the DHS re-opened the investigation. CNA 9 as interviewed first and indicated, she was behind Resident B near the bathroom door when the resident's knees buckled. She grabbed the resident from behind to lower her to the floor, but the resident slipped out of her arms and fell sideways onto the floor (she had not told that before). RN 8 was interviewed next and originally repeated the original story. When the DHS told her she had heard different, the nurse then told another story. When the nurse was asked for the assessment of the accurate story of the resident falling, she indicated, I don't know. The nurse had no documentation of the true story. Both RN 8 and CNA 9 were terminated due to falsification of documentation, their stories were not consistent and did not match the documentation. RN 8 and CNA 9's stories did not match what was originally reported or charted, RN 8 did not call the family or physician at the time of the incident, and they both did not follow the policy for fall incidents. RN 8 should have assessed the resident, left her on the floor if there was a suspected injured, called the physician, called 911, called the family to meet her at the hospital, notified the supervisor in the facility who would have notified the ADON, then the ADON would have notified the DHS. On 12/31/18 at 12:50 p.m. the DHS provided a policy, titled, Change of Condition Notification, revised 12/13/17. The policy indicated, Purpose: To keep the resident, resident's legal representative and/or interested family member aware of the resident's status. The resident's physician and family must be informed of any change in the resident's condition. All notifications to be done within 24 hours of findings .Areas that require notification of the Physician, Resident, Resident's legal representative and/or interested family member: 1. Accidents to the resident: falls, skin tears, bruises, abrasions, choking episodes .2. Deterioration in health status that may be demonstrated by: pain, decline in activities of daily living (ADL) function .Procedure: 1. The resident, resident's legal representative and/or interested family member must be kept informed of the resident's status. 2. The resident's attending physician must be informed of any change in the resident's status. 3. Notification of the resident, resident legal representative, interested family member and physician must be documented in the resident's clinical record. 4. Notification of physician needs to have follow-up if not response initially. 5. In emergent situations, the nurse should speak with the physician directly. 6. For calls needing a physician response for appropriate care, the nurse must exercise persistence. For non-emergent situations, but those related to concerns, a return call from the physician should be expected within 4-6 hours. If there is no timely response the nurse needs to call the physician again. 7. When repeated attempts to notify the physician are unsuccessful, an alternate physician should be contacted-if no alternate-contact the Medical Director. On 12/31/18 at 1:19 p.m., the DHS provided a policy, titled, Accident, Incident & Unusual Occurrence, dated 7/16/15. The policy indicated, To outline responsibilities for the reporting and investigation of accidents and incidents in order to monitor occurrences and prevent, when possible safety hazards for residents, staff, and the public .It is the policy of (facility name) that all accidents and incidents are recorded in writing and reviewed to identify hazards to health and safety .5. All employees are responsible for promptly reporting to the nurse in charge, their immediate supervisor, or other department heads any occurrence which has or could have resulted in injury to resident Reports shall include fire, natural disasters, breakage, theft, walk-a-ways, falls 7. In the event of an incident involving a resident, all medically relevant events shall be recorded, accurately and completely, in the medical record, in addition to being recorded on the Accident/Incident report .8. Resident assessments will be performed in the event of any accident/incident resulting in injury or suspected abuse. 9. The nurse in charge shall immediately notify the resident's representative and physician of incidents when medical intervention is required . 3.1-45(a)