Every finding on record at West River Health Campus

Based on the interview and record review, the facility failed to complete a physician's order to obtain a urine sample timely for 1 of 3 residents reviewed for urinary tract infections (UTIs). A urine sample was not obtained for five (5) days, with two documented attempts to obtain the sample before the physician was notified, and an order to obtain the sample via catheterization was received. (Resident C)Findings include:On 12/29/25 at 10:35 A.M., Resident C's clinical record indicated the resident's diagnoses included, but were not limited to, Alzheimer's disease, dementia, and a disorder of the kidney and ureter. Resident C's most recent Significant Change Minimal Data Set (MDS) assessment, dated 6/25/25, indicated the resident had severe cognitive impairment, was frequently incontinent of bladder and bowel, and required partial to moderate assistance with activities of daily living (ADL's). Resident C's physician orders included but were not limited to: culture, urine; urinalysis one time (started and discontinued 7/25/25) and urinalysis with culture and sensitivity due to signs and symptoms of infection, may in-and-out catheter to obtain (started and discontinued 7/30/25). Resident C's nurse's progress notes included, but were not limited to:7/25/25 at 11:51 A.M. - Resident initially had difficulty urinating. The hospice nurse suspected the resident had a UTI. 7/25/25 at 4:26 P.M. - Hospice nurse spoke to the physician and wanted to get a urinalysis and culture for the resident due to increased urgency. Order placed. 7/28/25 at 10:30 A.M. - Resident toileted at this time. Urine sample collection hat was placed in the toilet to collect urine for urinalysis; however, the resident missed the hat. Will attempt at the next void. Spoke with hospice nurse who stated she will be in on Tuesday for a visit and will obtain an order for an in-and-out catheter if needed.7/30/25 at 11:54 A.M. - New order, may in-and-out catheterize to obtain a urine sample for urinalysis with culture & sensitivity for possible UTI.7/31/25 at 7:57 A.M. - Urinalysis results faxed, awaiting response.07/31/25 at 12:27 P.M. - New orders to start Keflex 250 milligrams (mg) three times a day for seven (7) days UTI Urine was cloudy and odorous. Resident C's MAR/TAR from 7/25/25 to 7/31/25 indicated that an order to obtain a urine sample on 7/25/25 was attempted, and Resident C had refused. No other documented attempts were included in the MAR/TAR until the new order on 7/31/25 for the in-and-out catheter was obtained and completed successfully. Resident C's urinalysis dated 7/30/25 indicated a trace (abnormal) amount of blood in the urine, a high amount of white blood cells, many bacteria, and had a turbid appearance. During an interview on 12/30/25 at 9:15 A.M., the Assistant Director of Nursing (ADON) indicated that when an order to obtain a urine sample is received, staff should document when an attempt is made, and if unsuccessful, should document that an attempt was made the following shift, until the sample is obtained. If a urine sample cannot be obtained or if symptoms worsen, staff should notify the physician. During an interview on 12/30/25 at 9:50 A.M., RN 8 indicated the facility did not have a policy for following physician orders, but when an order to obtain a urinalysis was received, and the urine could not be obtained, the physician should be notified, and typically, an in-and-out catheter order would be obtained. This citation relates to intake 2696361.3.1-41(a)(2)

Based on observation, interview, and record review, the facility failed to ensure that a resident with medications observed at bedside during 2 random observations had a self-administration of medication assessment, physician orders, and a care plan for self-administration of medication. (Resident 27)Findings include On 8/12/25 at 11:32 A.M., during a random observation of Resident 27's room the following was observed over the bedside table:1 tube of Volteran Cream1 bottle of Dry Eye drops with no name1 bottle of Saline Drops with no name1 bottle of Vicks Vapor Rub with no name1 large, white pill with the number 196 On 8/13/25 at 9:15 A.M., during a random observation, the following was observed on Resident 27's over the bed table:1 tube of Volteran Cream1 bottle of Dry Eye drops with no name1 bottle of Saline Drops with no name On 8/13/25 at 8:56 A.M., Resident 27's clinical record was reviewed. Diagnoses included, but were not limited to, diabetes mellitus type 2 with diabetic kidney disease and hypertensive heart and chronic kidney disease with heart failure. The Current admission Minimum Data Set (MDS) dated [DATE] indicated Resident 27 was cognitively intact. Resident 27 is a set up for eating and needs moderate help with hygiene and dressing. The clinical record lacked an order for self-administration and assessment. A care conference was conducted on 7/9/25 and there was no care plan for self-administration of medications.During an interview on 8/14/25 at 8:24 A.M., the Director of Nursing (DON) indicated there should be no medications at the resident's bedside unless there was an order and a self-medication assessment completed.On 8/13/25 at 11:36 A.M., the Administrator provided a current policy Guidelines for Self-Administration of Medications dated 5/22/18. The policy indicated residents will have an .Trilogy- Self Administration of Medication within the electronic health record. Results of the assessment will be presented to the physician for evaluation and an order for self-medication . the order should include the type of medication(s) the resident is able to self- medicate .3.1-11(a)

Based on interview and record review, the facility failed to ensure a resident's plan of care was followed by providing assistance during transfers for 1 of 1 residents reviewed for falls. (Resident F) Finding includes: On 8/13/25 at 10:38 A.M., Resident F's clinical record was reviewed. Resident F was admitted on [DATE]. Diagnoses included, but were not limited to, dementia. The most recent Significant Change Minimum Data Set (MDS) Assessment, dated 6/25/25, indicated Resident F was severely cognitively impaired, required partial assistance from staff for bathing and toileting (staff do half of the work), and required supervision from staff for transfers. During an anonymous interview on 8/12/25 at 8:15 A.M., it was indicated that Resident F had fallen on 8/2/25 where family viewed the fall through a camera and called the facility to notify staff of the fall, and staff were not assisting the resident during toileting or transfers. Physician orders included, but were not limited to: Macrobid (antibiotic medication) capsule; 100 mg (milligrams) oral, take one capsule by mouth twice a day for seven days for urinary tract infection (UTI); start date 8/1/25 Current care plan included, but was not limited to: Resident is at risk for falling related to weakness and immobility, staff to assist resident with transfers as needed; start date 6/22/24 A nursing progress note, dated 7/25/25 at 10:28 A.M., indicated Resident F had trouble transferring out of bed. After several minutes resident was transferred to wheelchair with assistance from two staff members. An event report, dated 7/31/25, indicated Resident F experienced confusion and falling as symptoms of a UTI. Point of care (POC) responses in the medical record were reviewed. The following indicated staff's responses to assisting Resident F with toileting and transfers the day of the fall: 8/2/25 at 10:41 A.M.: How did resident use the toilet? Independent; Staff support provided for toileting? No setup or physical help from staff 8/2/25 at 10:41 A.M. How did the resident transfer? Independent; Staff support provided for transferring? No setup or physical help from staff;What appliances or assistive devices were used for transferring? None During an interview on 8/14/24 at 11:15 A.M., Certified Nurses Aide 4 (CNA) indicated that Resident F required assistance of one for transfer and toileting. During an interview on 8/15/25 at 9:13 A.M., The Director of Nursing (DON) indicated Resident F was typically independent, only required staff assistance while having a UTI, and the care plan level of assistance was accurate in stating Resident F needed assistance with transfers. On 8/15/25 at 11:55 A.M., the Administrator provided a policy titled Comprehensive Care Plan Guidelines, dated 5/18, that indicated Goals should be measurable and attainable, interventions should be reflective of the individual's needs; Comprehensive care plans need to remain current and accurate 3.1-35(a)

Based on observation, record review, and interview, the facility failed to provide a safe environment free of pests based on 2 random observations of ants in the resident bathroom and air conditioner during the survey. (Resident 27)Findings include:1. On 8/12 at 11:27 A.M., during a random observation, a moderate amount of small, black ants were observed in Resident 27 rest room along the base of the toilet, bathroom wall, and air conditioner. Resident indicated that facility was to spray for the ants. 2. On 8/13/25 at 8:31 A.M., during a random observation a moderate amount of small, black ants were observed in Resident 27's restroom. The ants were noted to be around the base of the toilet and along the wall. Resident 27 indicated that her son killed a larger cricket last night. The resident had food in drawers and each were indivually sealed. During an interview on 8/15/25 at 9:42 A.M., with Licensed Practical Nurse (LPN) 15 there should be no bugs in resident rooms. On 8/15/25 at 10:46 A.M., the Administrator provided a current policy Pest Control dated 8/8/18. The policy indicated . the facility maintains an ongoing pest control program to ensure the building is kept pes free . 3.1-19(f)(4)

Based on interview and record review, the facility failed to complete the required discharge documentation. Transfer/Discharge documentation was left blank and incomplete. (Resident B) Finding includes: On 6/4/25 at 1:04 p.m., Resident B's clinical record was reviewed. Diagnoses included, but were not limited to, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, aphasia, dysphagia, oropharyngeal phase. An admission Minimum Data Set (MDS) assessment dated [DATE], indicated Resident B's cognition was intact. Resident B admitted to the facility on [DATE] and discharged on 5/7/27. Care plans were reviewed and included but were not limited to: Resident plans to return to previous living environment after successful completion of his rehab program, start date 4/24/25, goal target date 7/3/25. Approaches included but were not limited to: Discharge planning upon admission and prn (as needed) thereafter, start date 4/24/25. A Notice of Transfer or discharge date d 5/7/25, was reviewed. The form included but was not limited to: Reason for Transfer or Discharge (Must select one of the reasons below.) No reason was selected from the menu. The facility had written on the form Resident Request. A physicians order was reviewed with a received date of 5/6/25, start date 5/7/25. The order description indicated - Ok to discharge. The discharge reason indicated- discharged . A documentation provided by the facility dated 5/6/25 nurse triage call center, included but was not limited to: Reason for Disposition - orders to transfer received Affirmative: MD order Disposition of Nursing Home Care Advice suggested. Note: Ok to discharge - please be sure they send records Visit diagnoses- none Anticipated discharge date : [DATE] Anticipated discharge to : [name of nursing home facility] The clinical record did not contain other information by the physician related to Resident B's discharge. On 6/4/25 at 12:38 p.m., the Clinical Support Nurse indicated the reason on the Transfer or Discharge form was not selected due to none of the reasons listed seemed to fit, so one was written in. On 6/4/25 at 12:59 p.m., the Clinical Support Nurse provided the current policy for transfer and discharge with a revision date of 5/3/17. The policy included but was not limited to: .b. Record the reasons for, the effective date of transfer or discharge, and the location to which the resident is being transferred in the medical record and on a discharge form or a letter. Give a copy of the discharge notice to the resident and his/her family legal representative . g. The physician should document medical reasons for transfer or discharge in the medical record when the reason for transfer is for any reason other than nonpayment of the stay or the facility ceasing to operate. A copy of the physicians's order for discharge should be attached to the discharge notice . This citation relates to Complaint IN00459530. 3.1-36(a)(2)

Based on interview and record review, the facility failed to ensure services were provided to a resident with an indwelling urinary catheter to prevent the development of infection for 1 of 1 resident reviewed for a catheter-associated urinary tract infection (CAUTI). (Resident 32) This deficient practice resulted in Resident 32 developing a CAUTI with septic shock and pneumonia. Resident 32 required artificial ventilation and treatment at a hospital-based intensive care unit. (Resident 32) Finding includes: On 8/13/24 at 11:20 A.M., Resident 32's clinical record was reviewed. Resident 32 was admitted on [DATE]. Diagnoses included, but were not limited to, Parkinson's disease, obstructive uropathy, dementia. An Admission MDS (Minimum Data Set) Assessment, dated 3/20/24, indicated Resident 32 was moderately cognitively impaired, was completely dependent on staff for bathing, toileting, and transfers, and had an indwelling catheter. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 7/26/24, indicated Resident 32 was significantly cognitively impaired, was completely dependent on staff for bathing, toileting, and transfers, and had an indwelling catheter. The clinical record lacked current orders related to indwelling catheter care or documentation of physician notification for clarification of indwelling catheter use. Current comprehensive care plan included, but was not limited to: Resident uses a Foley (brand of indwelling) catheter for diagnosis of obstructive uropathy; Observe for any signs of complication such as UTI, urethral trauma, strictures, bladder calculi or silent hydronephrosis notify my doctor. Date initiated: 4/27/24. Resident is at risk for excessive bleeding and bruising related to medications; Notify MD (doctor) of abnormal bruising and or bleeding. Date initiated: 4/27/24. A progress note, dated 7/28/24 at 1:30 A.M., indicated Resident 32 had blood in his urine. The clinical record lacked any further urinary or catheter assessment or notification to the physician related to any abnormal urinary symptoms. A progress note, dated 7/30/24 at 12:39 A.M., indicated Resident 32 was experiencing blood in his urine and a catheter flush was performed. Documentation did not include specific information to determine technique used to perform the catheter flush, further assessment after the catheter flush, or notification to the physician prior to flush the catheter, of findings during the catheter flush. A progress note, dated 7/30/24 at 1:31 A.M., indicated Resident 32 was found with abnormal vitals: labored wheezing respirations at 22 per minute, an oxygen saturation of 86%, a pulse of 139 beats per minute, a blood pressure of 94/54, and temperature of 101.3 degrees Fahrenheit. Resident 32 had thick and clotted blood noted in his indwelling catheter tubing and decreased urinary output. The physician was notified through triage and Resident 32 was sent to the hospital. A hospital document titled Patient Summary Report, dated 7/30/24 at 4:48 A.M., indicated Resident 32 was admitted to the hospital with septic shock secondary to a urinary tract infection and pneumonia. Resident 32 was intubated and placed in intensive care. A late entry progress note, entered by nursing staff at the facility dated 8/2/24 at 7:16 P.M. for 7/28/24 at 7:06 P.M, indicated Resident 32 had passed a blood clot, urine was clear and non-odorous, and vital signs were in normal range. The clinical record lacked notification to the physician the resident had passed a blood clot. A progress note dated 8/7/24 at 3:15 P.M., indicated Resident 32 had returned to the facility from the hospital. During an interview on 8/16/24 at 10:16 A.M., the Clinical Support 5 indicated there was no catheter assessment tool to monitor indwelling catheters but Resident 32 should have had an indwelling catheter order set entered upon return from the hospital stay and did not, and that if a nurse noticed abnormalities with an indwelling catheter such as bleeding, the physician should be notified. On 8/16/24 at 11:30 A.M., Clinical Support 5 provided a policy titled Guidelines for the Use of Indwelling Catheter, dated 12/31/23, that indicated Each resident who is incontinent of urine is identified, assessed and provided appropriate treatment and services to achieve or maintain as much normal urinary function as possible; A resident with or without a catheter, receives the appropriate care and services to prevent infections to the extent possible. The policy did not address indwelling catheter flushing or indwelling catheter associated urinary tract infections. 3.1-41(a)(2)

Based on interview, record review, and observation, the facility failed to ensure residents dependent on staff for ADL (activities of daily living) were bathed for 4 of 4 residents reviewed for ADL care. (Resident 11, Resident 32, Resident 148, Resident 6) Findings include: 1. During an interview on 8/12/24 at 11:01 A.M., Resident 32's family indicated Resident 32 was not receiving showers as often as he should be. On 8/13/24 at 11:20 A.M., Resident 32's clinical record was reviewed. Resident 32 was admitted on [DATE]. Diagnoses included, but were not limited to, Parkinson's disease, dementia, and dysphagia. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 7/26/24, indicated Resident 32 was significantly cognitively impaired and was completely dependent on staff for bathing, toileting, and transfers. Current care plans included, but were not limited to: Resident requires staff assistance to complete self-care and mobility functional tasks completely and safely; Showers: per shower schedule. Dated 4/27/24. On 8/16/24 at 10:59 A.M., Clinical Support 5 provided bathing performed from 7/1/24 through 8/16/24; Resident 32 received a shower or complete bed bath four times in July and one time in August. No shower schedule was available for review when requested. 2. On 8/14/24 at 12:02 P.M., Resident 11's clinical record was reviewed. Resident 11 was admitted on [DATE]. Diagnoses included, but were not limited to, dementia and hemiplegia. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 7/23/24, indicated Resident 11 was moderately cognitively impaired and was completely dependent on staff for bathing and transfers. Current care plans included, but were not limited to: Showers: per shower schedule. Dated 3/13/22. On 8/16/24 at 10:59 A.M., Clinical Support 5 provided bathing performed from 7/1/24 through 8/16/24; Resident 11 received a shower or complete bed bath two times in July and had not received a shower or complete bed bath in August. No shower schedule was available for review when requested. 3. On 8/13/24 at 8:44 A.M., Resident 148's clinical record was reviewed. Resident 148 was admitted on [DATE]. Resident 148's clinical record lacked diagnoses and a completed MDS Assessment. Current care plans included, but were not limited to: Showers: per shower schedule. Dated 8/12/24. On 8/16/24 at 10:59 A.M., Clinical Support 5 provided bathing performed from 8/7/24 through 8/16/24; Resident 148 had not received a shower or complete bed bath since admission to the facility. No shower schedule was available for review when requested. 48147 4. On 8/12/24 at 11:21 A.M., Resident 6 indicated she was supposed to get showers every other day but didn't get them very often. She indicated if she refused a shower, she was not offered a bed bath as an alternative. At that time, white flakes of skin were observed on Resident 6's blanket and chair. On 8/13/24 at 1:04 P.M., Resident 6's clinical record was reviewed. Resident 6 was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, hypertensive heart disease, major depressive disorder, and urge incontinence. The most current Admission Minimal Data Set (MDS) Assessment, dated 7/8/24, indicated Resident 6 was cognitively intact, required substantial to maximal assistance of staff (staff does more than half) for bathing, and had no rejection of care. A Point of Care (POC) History report indicated Resident 6 received a shower or complete bed bath two times in July and one time in August. On 8/14/24 at 11:15 A.M., the Assistant Director of Nursing (ADON) indicated CNAs (Certified Nursing Assistants) should be charting all showers and bed baths in POC Responses (a charting system for CNAs). If a resident refused a shower, staff should offer an alternative. On 8/16/24 at 11:30 A.M., Clinical Support 5 provided a current Guidelines for Bathing Preference policy, dated 12/31/23, that indicated Bathing shall occur at least twice a week . 3.1-38(a)(2)(A) 3.1-38(a)(3)(B) 3.1-38(b)(2) 3.1-38(b)(3)

Based on observation, interview, and record review, the facility failed to ensure food was served in a sanitary manner in accordance with professional standards for food service safety for 2 of 2 observations of the kitchen and 1 of 1 observations of unit refrigerators. Food was not labeled, floors were soiled, and equipment was soiled. (Kitchen, Certified Locked Dementia Unit) Findings include: On 8/12/24 at 6:58 A.M., the following was observed in the kitchen: 1. walk in cooler - 2 bags of lunch meat, one open to air, no labels. 2. walk in freezer - clear bag of cookies no label, container of individually sealed frozen pork chops, no label. 3. soiled shelves under the grill and steamer, sides of the stove soiled, floors with debris build up under equipment and storage racks, dishwasher area, around edges of walls, sides of ice machine calcium build up, dusty vents. On 8/14/24 at 9:43 A.M., the refrigerator on the locked dementia unit was observed to have a bowl of purple pureed food, no label, 3 muffins in individual bowls, no label, a tray containing 8 individual bowls of macaroni salad and two bowls of orange pureed food, no label, and an unopened can of an energy drink no label. On 8/14/24 at 12:05 P.M., the lunch meat in the walk in cooler was observed with a label. On 8/15/24 at 9:21 A.M., the same was observed for all other areas observed on 8/12/24 at 6:58 A.M. On 8/15/24 at 9:26 A.M., the Dietary Manager indicated the pork chops were delivered last week and should have been labeled, after food was opened it was put in a two gallon bag and labeled, floors were mopped nightly, usually once a week under tables, equipment, etc. There was a weekly cleaning schedule. On 8/15/24 at 12:10 p.m., the Administrator provided the current policy on food labeling and dating with a revised date of 2019. The policy included but was not limited to: Any food product removed from its original container, has a broken seal, has been processed in any way must have a label .1. Item name. 2. Date and time the food was label. 3. Use by date. 4. Initials of the person labeling the item. 4. Securely cover the food item . 3.1-21(i)(2) 3.1-21(i)(3)

Based on observation, record review, and interview, the facility failed to ensure staff performed proper hand hygiene and sanitation practices while providing care for 3 of 3 residents observed receiving care and 1 of 1 residents observed receiving blood glucose level checks. (Resident 11, Resident 19, Resident 32, Resident 9) Findings include: 1. On 8/12/24 at 9:07 A.M., LPN (Licensed Practical Nurse) 4 was observed getting supplies out of the medication cart. She knocked on Resident 11's door, entered the room, donned gloves, and obtained Resident 11's blood glucose level. LPN 4 removed her gloves, left the room, helped another staff to pull up a resident in their wheelchair by a draw sheet, went to the medication cart, and charted on the computer. No hand hygiene was observed. 2. On 8/14/24 at 9:06 A.M., CNA (Certified Nurse Aide) 6 was observed providing morning care to Resident 19. After care, CNA 6 removed her gloves, gave Resident 19 a drink from a cup, pushed the resident out of the bathroom, gave the call light to the resident, stripped the bed and pillow of linens and put them in a bag, changed the trash bag in the trash can, took personal care supplies to the bathroom, and shut the bathroom door. CNA 6 left the room carrying the bags to the dirty linen room, pushed the buttons on the door to open it, opened the lids to the containers to dispose of the bags, left the room, walked across the hall and opened the door to the bathroom, and washed her hands. 48057 3. During a wound care observation on 8/15/24 at 9:16 A.M., the RN (Registered Nurse) 11 was observed standing in the hall wearing a gown and gloves. RN 11 entered Resident 9's room, shut the door, and opened wound care supplies on Resident 9's bedside table. RN 11 reached around her gown and pulled a marker out of her pants pocket and dated the dressings. RN 11 removed her gloves, applied hand sanitizer, and put new gloves on. RN 11 assisted Resident 9 to roll to his right side. RN 11 sprayed wound cleanser in the wound on Resident 9's coccyx and applied skin prep around the wound. RN 11 used a cotton swab to apply Santyl (ointment used to promote skin healing) to the coccyx wound and covered the wound with a dressing. RN 11 removed her gloves and gown, turned the sink on, and washed her hands for nine (9) seconds. 4. During a random care observation on 8/16/24 at 2:13 P.M., CNA (Certified Nurse Aide) 2 and CNA 6 used a sit to stand lift to transfer Resident 32 from the bed to the wheelchair. The footplate of the sit to stand lift was observed to have dirty build up and the grip mat of the footplate was peeling off and sticking up on all sides. On 8/16/24 at 8:44 A.M., CNA 2 indicated hand hygiene should be done before and after glove use and before and after providing care to a resident. On 8/16/24 at 11:29 A.M., LPN 3 indicated hand hygiene needed done when hands were visibly soiled and when passing medications. In between residents, staff could use alcohol gel, and after every couple of residents, staff should wash their hands. On 8/16/24 at 11:30 A.M., the Clinical Support 5 provided the current policy on hand washing/hand hygiene with a revision date of 2/9/17. The policy included but was not limited to: All health care workers shall utilize hand hygiene frequently and appropriately .3. Health care workers (HCW) shall use hand hygiene at times such as: .c. before/after having direct physical contact with residents. d. After removing gloves, worn per standard precautions for direct contact with excretions or secretions, mucous membranes, specimens, resident equipment, grossly soiled linen, etc.Hand Washing . b) wet hands with running water. Apply liquid soap and work into a lather. c) wash for at least 20 seconds, using rotary motion and friction . On 8/16/24 at 11:30 A.M., the Clinical Support 5 provided the current policy on standard precautions guidelines with a revision date of 5/11/16. The policy included but was not limited to: 1. Standard precautions include, but are not limited to hand hygiene, safe injection practice, the proper use of PPE (e.g.; gloves, gowns, and masks), resident placement, and care of the environment, textiles, and laundry. Also equipment or items in the resident's room environment likely to have been contaminated with infectious fluids or other potentially infectious matter must be handled in a manner so as to prevent transmission of infectious agents, (e.g.; wear gloves for handling soiled equipment, and properly clean and disinfect or sterilize equipment before use on another resident) . 3.1-18(b) 3.1-18(l)

Based on observation, interview, and record review, the facility failed to ensure residents had supervision and interventions in place to prevent accidents for 2 of 2 residents reviewed for Accidents. A resident's fall intervention was out of place, care plans were not updated with new interventions, and a resident's diet orders were not followed or supervised during a group activity. (Resident 30 and Resident 32) Findings include: 1. On 8/13/24 at 11:25 A.M., nonskid strips were observed in the shower and in front of sink in Resident 30's bathroom. Nonskid strips were not observed in front of the toilet. On 8/13/24 at 9:25 A.M., Resident 30's clinical record was reviewed. Resident 30 was admitted to the facility on [DATE] following left hip surgery. Diagnoses included, but were not limited to, Alzheimer's disease, muscle weakness, and unspecified fall. The most current Quarterly Minimum Data Set (MDS) Assessment, dated 6/21/24, indicated Resident 30 had severe cognitive impairment, required partial to moderate assistance of staff (staff does less than half) for transferring and toileting, and had one fall without injury and one fall with injury since the prior assessment on 3/28/24. A fall risk assessment, dated 8/2/24, indicated Resident 30 was at high risk for falls. The admission comprehensive falls care plan, dated 11/2/23, included the following interventions: Assure the floor is free of liquids and foreign objects Encourage/assist resident to assume a standing position slowly Keep call light in reach Keep personal items and frequently used items within reach Provide nonskid footwear Staff to assist resident with transfers as needed Therapy evaluation and treatment as needed The clinical record indicated Resident 30 had fallen 10 times since admission to the facility. Fall 1 On 11/1/23 at 11:20 P.M., Resident 30 had an unwitnessed fall while attempting to self toilet. The resident complained of pain in his left hip and was sent to the emergency room (ER) for evaluation and treatment. Hospital discharge papers indicated the x-rays were negative for a hip fracture. The intervention Staff to assist resident with toileting prior to bed and then throughout the night was added to the care plan on 11/2/23. Fall 2 On 11/13/23 at 4:57 A.M., Resident 30 had an unwitnessed fall while attempting to self toilet. The resident had a laceration to his left elbow and was sent to the ER for evaluation and treatment. Hospital discharge papers, dated 11/13/24, indicated x-rays were negative for an elbow fracture. The intervention Nursing staff to offer and assist with toileting upon rounds was added to the care plan on 11/22/23. Fall 3 On 11/24/23 at 4:53 A.M., Resident 30 had an unwitnessed fall while attempting to self toilet. The intervention antiroll back to wheelchair was added to the care plan on 11/27/23. Fall 4 On 11/25/23 at 3:00 A.M., Resident 30 had an unwitnessed fall while attempting to self toilet. The resident's previous laceration on the left elbow had reopened and his eye was dark pink and swollen. The resident was sent to the ER for evaluation and treatment. Hospital discharge paperwork, dated 11/27/23, indicated x-rays were negative for facial and elbow fractures. The intervention Wake frequently at night and assist with toileting needs was added to the care plan on 11/27/23. Fall 5 On 12/8/23 at 7:00 A.M., Resident 30 had a witnessed fall while attempting to self transfer out of bed. The intervention Encourage resident to wear non skid socks in bed was added to the care plan on 12/11/23. Fall 6 On 12/21/23 at 3:06 A.M., Resident 30 had an unwitnessed fall while sitting on the couch in the day room. The intervention Dycem to couch was added to the care plan on 12/21/23. Fall 7 On 1/25/24 at 1:32 A.M., Resident 30 had an unwitnessed fall while attempting to self toilet. The intervention Therapy referral for trunk control was added to the care plan on 1/26/24. Fall 8 On 5/7/24 at 2:46 A.M., Resident 30 had an unwitnessed fall while attempting to self toilet. The resident sustained abrasions to his right knee and right elbow and a knot to the back of his head. The interventions Bed in lowest position and Offer resident to toilet between 1am-2am was added to the care plan on 5/7/24. Fall 9 On 5/18/24 at 9:06 P.M., Resident 30 had an unwitnessed fall while attempting to self toilet. The intervention non skid strips in front of toilet was added to the care plan on 5/20/24. Fall 10 On 7/28/24 at 8:00 P.M., Resident 30 had an unwitnessed fall while attempting to self toilet. A nursing progress note, dated 7/28/24 at 8:45 P.M., indicated the floor in the bathroom was very slick. An x-ray on the resident's left hip and left ankle was ordered. Results indicated the left ankle and left hip were negative for fracture and dislocation. The intervention assist to toilet with each round was added to the care plan on 7/29/24. On 8/14/24 at 9:10 A.M., the Assistant Director of Nursing (ADON) indicated that maintenance placed nonskid strips in front of Resident 30's toilet on 8/13/24 around noon. On 8/16/24 at 9:10 A.M., Clinical Support 5 indicated after a resident sustained a fall, the IDT (Interdisciplinary Team) would meet to determine a root cause for the fall and a new intervention related to the fall would be placed in the care plan and implemented that day. 48057 2. On 08/13/24 at 11:20 A.M., Resident 32's clinical record was reviewed. Resident 32 was admitted on [DATE]. Diagnoses included, but were not limited to, Parkinson's disease, dementia, and dysphagia. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 7/26/24, indicated Resident 32 was significantly cognitively impaired, required moderate assistance from staff with eating, and required a modified diet due to choking, coughing, and difficulty swallowing. Physician orders included, but were not limited to: Diet: Fortified foods/puree/thin liquids Special Instructions: Built up utensils and divided plate. Start date 8/8/24. Diet: Puree, Thin liquids, Resident to be feed all meals. Go to dining room for all meals. Date 5/15/24 - 6/20/24. Care plan included, but was not limited to: Resident has potential for complications, functional and cognitive status decline. Diet as ordered. Date initiated: 4/27/24. A progress note, dated 6/2/24 at 11:26 A.M., indicated Resident 32 had choked on banana bread while in activities. The progress note indicated by the time staff saw Resident 32 choking, he was blue/purple and the nurse performed the Heimlich maneuver to dislodge food stuck in Resident 32's throat. Resident 32 was sent to the emergency department. A chest X-ray report obtained in the hospital emergency department, dated 6/2/24 at 1:33 P.M., indicated resident 32 was admitted for aspiration and the X-ray indicated infiltrates in the lungs. A progress note, dated 6/2/24 at 6:09 P.M., indicated Resident 32 returned to the facility from the hospital with an order for Augmentin (antibiotic) with a diagnosis of pneumonia. During an interview on 8/16/24 at 2:22 P.M., Clinical Support 5 indicated Resident 32 was in the activities room when staff were making banana bread and provided it to residents, Resident 32 was given banana bread by another resident, and that Resident 32 was on a puree diet at the time he choked in activities. On 8/16/24 at 11:30 A.M., Clinical Support 5 indicated there was no facility policy on resident supervision or following diet orders, but staff were expected to follow all physician orders. On 8/16/24 at 11:30 A.M., Clinical Support 5 provided a current Falls Management Program Guidelines policy, dated 12/31/23, that indicated Should the resident experience a fall the attending nurse shall complete the Fall Event This includes an investigation of the circumstances surrounding the fall to determine the cause of the episode, a reassessment to identify possibly contributing factors, interventions to reduce risk of repeat episode and a review by the IDT to evaluate thoroughness of the investigation and appropriateness of the interventions . The resident care plan should be updated to reflect any new or change in interventions. On 8/16/24 at 11:30 A.M., Clinical Support 5 provided a current Comprehensive Care Plans policy, dated 12/31/23, that indicated Comprehensive care plans need to remain accurate and current. New interventions will be added and updated during or directly following CCM [continuity of care meeting] meeting. 3.1-25(a)(1) 3.1-45(a)(2)

Based on interview, record review, and observation, the facility failed to ensure a resident's decline in nutritional status was addressed and recommendations were followed for 1 of 1 residents reviewed for significant weight loss. (Resident 32) Finding includes: On 8/13/24 at 11:20 A.M., Resident 32's clinical record was reviewed. Resident 32 was admitted on [DATE]. Diagnoses included, but were not limited to, Parkinson's disease, dementia, and dysphagia. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 7/26/24, indicated Resident 32 was significantly cognitively impaired, required moderate assistance from staff with eating, was completely dependent on staff for bathing, toileting, and transfers, and required a modified diet due to choking, coughing, and difficulty swallowing. Physician orders included, but were not limited to: Diet: Fortified foods/puree/thin liquids Special Instructions: Built up utensils and divided plate. Start date 8/8/24. Order Set Admission - Weekly Weight. Start date 3/16/24. Dietary supplement: Ensure may substitute if available. Dated 5/5/24 - 6/11/24. Dietary supplement: Medpass 120 mL (milliliters) TID (three times a day). Dated 6/11/24 - 7/9/24. Care plan included, but was not limited to: Resident is malnourished/at risk for malnutrition related to diagnoses, inadequate nutrient/energy intakes, and/or metabolic demands. Date initiated 3/18/24. Resident has experienced a significant weight loss. Date initiated 7/8/24. Obtain a dietary consult as needed. Follow recommendations as required. Date initiated 5/14/24 Hospital discharge documents, dated 3/15/24, indicated Resident 32 had a weight recorded of 218 pounds. The following vitals indicated date taken by nursing staff in the facility: 3/19/24 (admission) 230 lbs (pounds) Height: 5 feet 11 inches No weekly weight taken the week of 3/24/24-3/30/24 No weekly weight taken the week of 3/31/24-4/6/24 4/12/24 (11:25 AM) 231 lbs 4/15/24 (10:54 AM) 231 lbs No weekly weight taken the week of 4/21/24-4/27/24 No weekly weight taken the week of 5/5/24-5/11/24 No weekly weight taken the week of 5/12/24-5/18/24 5/20/24 (2:51 PM) 253.8 lbs 5/27/24 (3:54 PM) 175.4 lbs 6/3/24 (3:08 PM) 184.6 lbs 6/6/24 (2:54 AM) 183 lbs No weekly weight taken the week of 6/9/24-6/15/24 6/18/24 (12:07 PM) 183.5 lbs 6/24/24 (1:36 PM) 185.8 lbs 7/1/24 (8:39 AM) 181.6 lbs 7/5/24 (12:07 PM) 181.6 lbs No weekly weight taken the week of 7/7/24-7/13/24 No weekly weight taken the week of 7/14/24-7/20/24 No weekly weight taken the week of 7/21/24-7/27/24 8/7/24 (3:30 PM) 177 lbs 8/12/24 (1:42 PM) 178 lbs A progress note, dated 5/13/24 at 9:26 A.M., indicated Resident 32 had no edema noted. A progress note, dated 5/22/24 at 5:22 P.M., indicated Resident 32 had a weight gain in the last 30 days, weekly weights should continue, and no increased edema was noted. A weight monitoring nutrition assessment progress note created by the registered dietitian on 5/30/24 at 4:13 P.M. indicated Resident 32's weight of 175.4 lbs on 5/27/24 was likely an error and Resident 32 should be re-weighed. A weight was not recorded until the next weekly weight was due. A weight monitoring nutrition assessment progress note created by the registered dietitian, dated 6/10/24 at 10:43 A.M., indicated Resident 32's weight Inconsistencies were likely how inconsistently Resident 32 was being weighed by staff; staff to ensure resident is weighed the exact same every time day, continue weekly weights. During an observation on 8/16/24 at 2:09 P.M., CNA 6 weighed Resident 32's wheelchair by itself (52.8 lbs), then weighed Resident 32 while sitting in the wheelchair (235.6 lbs), for a final weight for Resident 32 of 182.8 lbs. During an interview on 8/15/24 at 9:28 A.M., the ADON (assistant director of nursing) indicated the large fluctuation in Resident 32's weight was due to staff not weighing Resident 32 correctly, and was unsure where the actual weight loss occurred because residents clothes still fit the same. The ADON indicated Resident 32 was put on nutritional supplement and fortified foods after the significant weight loss. The ADON indicated the weight machine was not reading right and needed to be calibrated and that may have caused the significant weight differences, and was unsure if Resident 32 was reweighed after the weight machine was recalibrated. During an interview on 8/16/24 at 10:16 A.M. the Regional Clinical indicated weekly weights documented in physician orders and POC (point of care) responses populate in vitals, if weekly weights were not there, they were not completed, and that the order for weekly weights order is a nurse task to be completed but sometimes CNA (certified nurses aide) may take the weight and give the weight to the nurse to enter. The Regional Clinical indicated she believed Resident 32's weight entered on 5/20/24 and 5/27/24 should have been marked invalid, and the 46.4 pound weight loss from 4/15/24 to 6/3/24 was due to Resident 32 having diarrhea and edema. Documents indicating diarrhea and edema during this time was requested but not provided. The clinical record lacked documentation in medical record of thorough assessment of resident 32's condition for recorded weight loss. A document provided by Clinical Support 5 on 8/16/24 at 1:52 P.M., titled Work History Report indicated the weight scale had been calibrated weekly from 8/5/23 through 8/17/24. On 8/16/24 at 11:30 A.M., Clinical Support 5 provided a document titled Guidelines for Weight Tracking, dated 12/31/23, that indicated Scales shall be properly maintained and calibrated to ensure accuracy of weight. Residents who have a weight that seems out of normal range shall be re-weighed to determine the accuracy of the original weight. The physician, resident representative and dietitian shall be notified of a weight variance of 5% in 30 days, 7.5% in 90 days, and 10% in 180 days. 3.1-46(a)(1)

Based on observation, interview, and record review, the facility failed to ensure oxygen equipment was properly labeled and oxygen services were provided according to physician order for 1 of 3 residents reviewed for respiratory care. (Resident 6) Finding includes: On 8/12/24 at 11:30 A.M., Resident 6 was observed to receive 5 Liters (L) of oxygen via nasal cannula. The humidification bottle was empty and not dated and the tubing was not dated. At that time, Resident 6 indicated she was supposed to be getting 3L of oxygen but was not sure why. On 8/13/24 at 1:04 P.M., Resident 6's clinical record was reviewed. Diagnoses included, but were not limited to, non-ST elevation (NSTEMI) myocardial infarction and shortness of breath. The most current Admission Minimum Data Set (MDS) Assessment, dated 7/8/24, indicated Resident 6 was cognitively intact, received partial to moderate assistance of staff (staff does less than half) for transfers, and was not receiving oxygen. Physician orders included, but were not limited to: Oxygen at 3L per nasal canula continuous, dated 7/30/24 Change oxygen tubing monthly once a day on the 1st of the month, dated 7/30/24 A Profile Care Guide care plan, dated 7/16/24, indicated Resident 6 received 3L of continuous oxygen. On 8/14/24 at 11:10 A.M., Licensed Practical Nurse (LPN) 12 indicated she was unsure who was supposed to change oxygen tubing and humidification bottles. On 8/14/24 at 11:15 AM., the Assistant Director of Nursing (ADON) indicated tubing and humidification bottles were changed out according to physician's order or as needed by the night shift nursing staff. On 8/16/24 at 11:39 A.M., Clinical Support 5 indicated the facility did not have a policy for following physician orders, but staff were expected to follow orders. On 8/16/24 at 11:30 A.M., Clinical Support 5 provided a Respiratory Equipment policy, dated 12/31/23 that indicated Use sterile distilled water for humidification over 4LPM [liters per minute] . Change prefilled humidifier when water level becomes low . Change oxygen cannula and tubing monthly and as necessary. 3.1-47(a)(6)

Based on observation, interview, and record review, the facility failed to ensure effective supervision was provided to a cognitively impaired, dependent resident to prevent falls and failed to ensure the bed was in low position with a fall mat in accordance with the plan of care to prevent injury for 1 of 3 residents reviewed for falls. This deficient practice resulted in Resident B experiencing an unwitnessed fall from the bed, landing on the floor, and sustaining a left clavicle fracture. (Resident B) Finding includes: On 5/8/24 at 8:41 a.m., Resident B was observed sitting in a wheelchair in his room. On 5/8/24 at 9:39 a.m., Resident B's clinical record was reviewed. The diagnoses included, but were not limited to, fracture of unspecified part of left clavicle, subsequent encounter for fracture with routine healing, unspecified fall, subsequent encounter, dysphagia following cerebral infarction, contracture, left hip, contracture left knee, contracture right knee, vascular dementia. A Quarterly MDS (Minimum Data Set) assessment, dated 1/12/24, indicated Resident B's cognition was severely impaired, the resident required substantial assistance of staff to roll left and right for bed mobility and was dependent on staff for moving from lying to sitting on side of bed. The Care Plans included, but were not limited to: Resident is at risk for falls related to a history of falls, CVA (cerebral vascular accident), weakness, unsteady, cognitive impairment, dementia. The interventions included, but were not limited to, low bed with fall mat next to bed, initiated 6/20/22. A Fall Risk Review, dated 10/31/23, indicated a fall risk score of 20, indicating a high risk for falls. A Progress Note, dated 2/8/24 at 3:29 p.m., indicated CNA called a nurse to resident's room. The resident was noted on the floor beside bed lying on his right side with a skin tear to left elbow. There were no signs or symptoms of pain noted. POA (Power of Attorney) was called and a message was left to the return call. Neurological checks initiated. Nursing Home Triage (NHT) notified. A Progress Note, dated 2/9/24 at 1:30 p.m., indicated staff reported dark bruising on residents left shoulder area. Resident yelling out a lot during ADL's (Activities of Daily Living) this morning during care. NHT called to obtain order for left shoulder x-ray. Area has some swelling, pulses present, circulation normal, able to move hands. A Progress Note, dated 2/9/24 at 5:24 p.m., indicated the nurse called POA to report the results of the x-ray. No answer, had to leave a message to return call to facility. A Progress Note, dated 2/9/24 at 8:00 p.m., indicated NHT called with orders from Nurse Practitioner. Ok to order x-ray of shoulder and clavicle (collar bone) left arm. If family wants to can send to ED (Emergency Department) or be seen by orthopedic partners on Monday. Family calling other family at this time to discuss what they want to do. A Progress Note, dated 2/9/24 at 8:13 a.m., indicated the family has decided to have resident go to the ED for assessment and treatment. A Progress Note, dated 2/14/24 at 3:24 a.m., indicated the Interdisciplinary Team (IDT) note on 2/8/24 resident had a fall from bed. Root cause: Resident rolled out of bed and noted on floor. Intervention: Nurse to ensure residents placement in bed. On 2/9/24 resident was sent to ER per family request related to pain. Resident returned with new order for Lortab (pain medication). On 5/8/24 at 12:36 p.m., a State Reportable incident was reviewed for Resident B. The report indicated Resident B had rolled out of bed and sustained a clavicle fracture. During an interview, on 5/9/24 at 9:04 a.m., the DON (Director of Nursing) indicated she observed the resident's bed to not be in low position with a fall mat immediately after the fall. The DON indicated the post-fall investigation identified that CNA 1 exited the resident's room without ensuring the bed was in the low position with a fall mat next to it and the resident experienced an unwitnessed fall. On 5/9/24 at 9:20 a.m., the DON provided typed statement forms for CNA 1 and CNA 2. The statements included, but were not limited to: Date of interview - 2/9/24 CNA 1 I started working 100/300 hall mid shift. Around 3pm [sic] I went in and helped [CNA 2 ] do a check and change on [Resident B ] due to him having BM [bowel movement]. We cleaned him up and got everything out of his room. When we left room, he was in the middle of the bed and his knees were facing the tv. [CNA 2 ] went over to Skilled Legacy. When we left the room bed was how I originally walked in, bed was in highest position and no mat was put down. It was about 20-30 min [minutes] later and I was walking back down the 300 hall, and I overheard [Resident B] yell help. I went into the room and seen he was on the floor by the bed. I turned on the call light and got the nurse [DON]. The nurse came in and did an assessment. Date of interview 2/13/24 CNA 2 [CNA 2] states she went into [Resident B] room with [CNA 1] to check and change him. [Resident B] was in a wheelchair at the time, and we used the Hoyer lift. After checking and changing him I took out the trash. [CNA 1] was still in the room finishing up cleaning. Then I went to skilled legacy to finish out my shift. I thought [CNA 1] knew that his bed was to be in the lowest position and mat on floor. On 5/8/24 at 11:18 a.m., CNA 3 indicated resident fall interventions are found on assignment sheets, if there was a change, the nurse lets them know. On 5/9/24 at 11:38 a.m., the Clinical Support Nurse provided the current policy for fall management program guidelines with a review date of 12/31/23. The policy included, but was not limited to, care plan interventions should be implemented that address the resident's risk factors. On 5/9/24 at 11:38 a.m., the Clinical Support Nurse provided the current policy for Comprehensive Care Plan Guideline with a revision date of 5/22/18. The policy included, but was not limited to, pertinent care plan approaches are communicated to the nursing staff per the 24-hour CRCA (CNA) assignment or the care tracker profile depending on campus preference. The deficient practice was corrected on 2/13/24 after the facility implemented a systemic plan that included the following actions: the facility inserviced the staff on ensuring fall interventions were implemented and ongoing monitoring of ensuring fall interventions were in place. This citation relates to Complaints IN00432902, IN00433296, IN00431331. 3.1-45(a)(1)

Based on interview and record review, the facility failed to ensure physician medication orders were put in place for 1 of 3 residents reviewed. A medication dosage increase was not done. (Resident E) Finding includes: On 9/7/23 at 10:51 a.m., Resident E's clinical record was reviewed. They had diagnoses that included, but were not limited to, dehydration, nausea and vomiting. Resident E admitted to the facility on [DATE] and discharged on [DATE]. A discharge MDS (Minimum Data Set) assessment indicated Resident E's cognition was intact. Physicians orders for August 2023 were reviewed and included but were not limited to: ondansetron( nausea medication) tablet, disintegrating; 4 mg (milligram) amt: 4 mg; oral special instructions: prn (as needed) for N/V (nausea and vomiting), every 6 hours - PRN ; PRN 1, PRN 2, PRN 3, PRN 4, order start date 8/22/23. Basic metabolic panel; CBC w/differential; other test (magnesium level) special instructions: night shift to prepare documents and day shift to await lab results and process any new orders given. Twice a day; 02:00 AM-06:00 AM; -02:00 PM, order start date 8/28/23. Resident documents were reviewed and included but were not limited to: Physicians progress notes : date: 8/24/23- Zofran (nausea medication) 8 mg 1 Q (every) 8 hours prn-N/V CBC (complete blood count) & BMP (basic metabolic panel) on Monday (or next lab day). Encourage fluids. * add mag (magnesium) level also. Resident E did not have an active order for Zofran 8 mg prn for August 2023 physician orders. Progress notes were reviewed and included, but were not limited to 8/29/23 at 12:55 p.m., Therapy was in with resident and noted resident blood pressure when sitting up was significantly higher than when she was laying down. Also resident would have vertigo and throw up. Resident has been throwing up whenever sitting up each time therapy has sat her up. Call placed to (name of Dr. office) and order received for resident to go to (name of hospital) ER to be evaluated and treated per request by family and facility therapy manager. The August 2023 EMAR (Electronic Medication Administration Record) was reviewed and ondansetron 4 mg was given to Resident E on the following dates: 8/22 x 1 8/23 x 1 8/25 x 1 8/26 x 1 8/27 x 1 8/28 x 1 On 9/8/23 at 10:25 a.m., the NP ( Nurse Practitioner) indicated she visited Resident E at the facility on 8/24/23, Resident H was extremely nauseated, she did not want her to get dehydrated, the dose of medication she was on for N/V was not enough so she wrote an order to increase the dose. The NP indicated she could not remember if she gave the nurse on the unit the order or laid it down on the desk or medication cart, she may have verbally told the nurse the order also. On 9/8/23 at 11:40 a.m., LPN 1 indicated if the physician comes in the morning to see residents he dictates orders to triage, triage will call the facility nurse with the orders, when the nurse practitioner comes they do the same, everything goes thorough nursing triage on a recorded line. On 9/8/23 at 1:25 p.m., the Clinical Support Nurse indicated there are 3 ways the physician or nurse practitioner gives orders to the licensed nurse, verbal, leave written orders, or triage can give to the licensed facility nurse. It is the licensed nurses responsibility to ensure orders are put into Matrix Care. On 9/8/23 at 1:20 p.m., the Clinical Support Nurse provided the policy on guidelines for medication orders with a review date of 12/31/22. The policy included, but was not limited to: .telephone or verbal orders shall be recorded in Matrix when received by the nurse receiving the order . This Federal tag relates to Complaint IN00416986. 3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure proper storage of medications for 2 of 2 medication carts and 2 of 2 medication storage rooms observed. Loose pills were observed in the medication cart drawers, and temperature logs were not completely filled out for the refrigerator in the medication rooms (200 Hall, 300 Hall). Findings include: 1. On 5/12/23 at 9:42 A.M., the 200 Hall medication cart was reviewed. The following loose pills were observed in the bottom of the drawers: 1 pink oblong pill with marking 894/5 1/2 white rectangle pill with marking B 2 yellow oblong pills with marking 80/A 1 pink circle pill with marking C/74 2 white circle pills with marking AN/44 1 yellow oblong pill with marking A/18 1 dark red circle pill with marking 421/U 1 blue circle pill with marking L/24 1 white rectangle pill with marking B15 1 pink oval pill with marking 29/1 1 peach circle pill with marking 318/93 1 white circle pill with marking 099 1 yellow oval pill with marking 152 1/2 blue circle pill with no marking visible (2) 1/2 green oblong pills with no marking visible 1/2 dark red circle pill with no marking visible 1 white capsule with marking FL/72 At that time, LPN 3 indicated when staff observed loose pills in the medication carts, they should dispose of them. LPN 3 indicated he was unsure who was responsible for cleaning the medication carts. On 5/12/23 at 9:55 A.M., the 300 Hall medication cart was observed. The following loose pills were observed in the bottom of the drawers: 1 white circle pill with marking HP/24 1 yellow oval pill with marking 152 1/2 dark red circle pill with no marking visible 1 white oval pill with marking APO/A10 At that time, RN 7 indicated night shift was responsible for cleaning out the medication carts. 2. On 5/12/23 at 9:42 A.M., the 200 Hall medication storage room was observed. The May 2023 temperature log posted on the refrigerator lacked temperatures for the following days: 5/1/23 5/2/23 5/5/23 5/6/23 5/7/23 5/8/23 5/10/23 5/11/23 At that time, LPN 3 indicated night shift was responsible for filling out the refrigerator temperature logs in the medication storage rooms. 3. On 5/12/23 at 9:55 A.M., the 300 Hall medication storage room was observed. The April 2023 temperature log was blank with no temperatures filled in. The May 2023 temperature log posted on the refrigerator lacked temperatures for the following days: 5/3/23 5/10/23 In the 300 Hall medication storage room, two green circle pills with marking RP101 were observed sitting loose on a cabinet shelf. At that time, RN 7 indicated night shift was responsible for filling out the refrigerator temperature logs in the medication storage rooms, and pills should not be loose in the medication storage room cabinets. On 5/12/23 at 11:30 A.M., a current medication storage policy, revised 11/18, was provided and indicated Medication storage areas are kept clean, well-lit, and free of clutter and extreme temperatures and humidity . The Facility should check the refrigerator or freezer in which vaccines are stored, at least two times a day, per CDC Guidelines. 3.1-25(m)

Based on observation and interview, the facility failed to ensure food was stored appropriately and dishwasher temperatures were within range and completed for 1 of 1 kitchen observations. Food was not labeled correctly, left open to air, and expired food was not disposed of from the refrigerator and the freezer. Dishwasher final wash temperatures documented in logs were not at an appropriate level. (Kitchen) Findings include: On [DATE] at 8:49 A.M., the following was observed in the kitchen: Dry storage: An opened bag of pasta without a label and open to air Boxes containing food on the floor Freezer: An opened bag of peas with a prep (preparation/open) date of [DATE] and open to air An opened bag of broccoli with handwritten date of ,d+[DATE] (no year) 7 small bowls of vanilla ice cream on a tray without a label An open bag of onion rings without a label and open to air Unknown food item in brown bag without label and open to air Boxes containing food items on the floor Refrigerator: Poppy seed dressing out of original container with a use by date of [DATE] White dressing out of original container without a label Honey mustard dressing out of original container with a use by date of [DATE] Tub of sour cream with manufacturer's use by date of [DATE] Diced potatoes in a bag open to air Shredded potatoes in a bag labeled pot [DATE] and open to air Ground meat without a label and open to air Strawberries in a container with fuzzy white substance covering them An opened bag of Swiss cheese slices with a use by date of ,d+[DATE] (no year indicated) An opened bag of American cheese slices with received date of [DATE] Walk in refrigerator (HCR3): A drink pitcher containing brown liquid without a label A box of nectar cranberry juice with a use by date of [DATE] and manufacturer's expiration date of [DATE] A box of nectar cranberry juice with a use by date of [DATE] and manufacturer's expiration date of [DATE] A drink pitcher of sweet tea with use by date of [DATE] A drink pitcher containing clear liquid without a label A drink pitcher of root beer with a use by date of [DATE] During an interview on [DATE] at 9:34 A.M., Kitchen Staff 2 indicated they did the dishes that morning and at that time indicated they were not sure if the black lines drawn on the gauges were to indicate what temperature the dishwasher must reach for the rinse and final wash. On [DATE] at 9:35 A.M., the dishwasher temperature gauges were observed to be at a high level and filled with water splotches which made the gauges hard to read. At that time, the Kitchen Manager indicated the wash temperature should be at least 160 degrees Fahrenheit and the final rinse should be at least 180 degrees Fahrenheit, the gauges were hard to read, they did not have another method to check the temperatures, and they may need to call [company name] that does maintenance on the machine to have them come look at it. On [DATE] at 10:05 A.M., the log book with dishwasher temperatures was provided by the Kitchen Manager and they indicated kitchen staff should be documenting the dishwasher temperatures for the rinse and final wash three times every day. The dishwasher temperature log was reviewed from [DATE] to [DATE] and indicated the following: [DATE] breakfast final rinse temperature was 170 [DATE] noon meal final rinse temperature was 175 [DATE] evening meal final rinse temperature was 175 [DATE] breakfast final rinse temperature was 170 [DATE] noon meal final rinse temperature was 171 The wash and final rinse temperatures were not filled in for the evening meal on [DATE]. [DATE] breakfast final rinse temperature was 170 [DATE] noon meal final rinse temperature was 175 The wash and final rinse temperatures were not filled in for the evening meal on [DATE]. [DATE] breakfast final rinse temperature was 170 [DATE] noon meal final rinse temperature was 175 [DATE] evening meal final rinse temperature was 172 [DATE] breakfast final rinse temperature was 170 [DATE] noon meal final rinse temperature was 170 The wash and final rinse temperatures were not filled in for the evening meal on [DATE]. [DATE] breakfast final rinse temperature was 170 [DATE] noon meal final rinse temperature was 175 The wash and final rinse temperatures were not filled in for the evening meal on [DATE]. [DATE] breakfast final rinse temperature was 170 [DATE] noon meal final rinse temperature was 175 [DATE] evening meal final rinse temperature was 170 [DATE] breakfast final rinse temperature was 170 [DATE] noon meal final rinse temperature was 175 The wash and final rinse temperatures were not filled in for the evening meal on [DATE]. There was not a log included for the date of [DATE] [DATE] breakfast final rinse temperature was 170 [DATE] noon meal final rinse temperature was 175 The wash and final rinse temperatures were not filled in for the evening meal on [DATE]. [DATE] breakfast final rinse temperature was 170 [DATE] noon meal final rinse temperature was 172 [DATE] evening meal final rinse temperature was 180 The wash and final rinse temperatures were not filled in for breakfast or noon meals on [DATE]. [DATE] evening meal final rinse temperature was 190 [DATE] breakfast final rinse temperature was 175 [DATE] noon meal final rinse temperature was 175 [DATE] evening meal final rinse temperature was 175 The wash and final rinse temperatures were not filled in for breakfast or noon meals on [DATE]. [DATE] evening meal final rinse temperature was 170 [DATE] breakfast final rinse temperature was 170 [DATE] noon meal final rinse temperature was 171 The wash and final rinse temperatures were not legible for the evening meal on [DATE]. [DATE] breakfast final rinse temperature was 170 [DATE] noon meal final rinse temperature was 175 [DATE] evening meal final rinse temperature was 175 [DATE] breakfast final rinse temperature was 175 [DATE] noon meal final rinse temperature was 175 [DATE] evening meal final rinse temperature was 180 [DATE] breakfast final rinse temperature was 175 [DATE] noon meal final rinse temperature was 175 [DATE] evening meal final rinse temperature was 180 [DATE] breakfast final rinse temperature was 170 [DATE] noon meal final rinse temperature was 173 The wash and final rinse temperatures were not legible for the evening meal on [DATE]. The wash and final rinse temperatures were not filled in for breakfast, noon meal, or evening meal on [DATE]. [DATE] breakfast final rinse temperature was 170 [DATE] noon meal final rinse temperature was 175 [DATE] evening meal final rinse temperature was 170 [DATE] breakfast final rinse temperature was 170 [DATE] noon meal final rinse temperature was 175 The wash and final rinse temperatures were not legible for the evening meal on [DATE]. [DATE] breakfast final rinse temperature was 170 [DATE] noon meal final rinse temperature was 172 The wash and final rinse temperatures were not legible for the evening meal on [DATE]. [DATE] breakfast final rinse temperature was 170 [DATE] noon meal final rinse temperature was 175 The wash and final rinse temperatures were not filled in for the evening meal on [DATE]. [DATE] breakfast final rinse temperature was 170 [DATE] noon meal final rinse temperature was 175 The wash and final rinse temperatures were not filled in for the evening meal on [DATE]. There was not a log included for the date of [DATE] [DATE] breakfast final rinse temperature was 170 [DATE] noon meal final rinse temperature was 175 The wash and final rinse temperatures were not legible for the evening meal on [DATE]. [DATE] breakfast final rinse temperature was 170 [DATE] noon meal final rinse temperature was 175 The wash and final rinse temperatures were not legible for the evening meal on [DATE]. [DATE] breakfast final rinse temperature was 170 [DATE] noon meal final rinse temperature was 175 The wash and final rinse temperatures were not filled in for the evening meal on [DATE]. [DATE] breakfast final rinse temperature was 175 [DATE] noon meal final rinse temperature was 175 [DATE] evening meal final rinse temperature was 180 [DATE] breakfast final rinse temperature was 172 [DATE] noon meal final rinse temperature was 175 [DATE] evening meal final rinse temperature was 180 There was not a log included for the date of [DATE] [DATE] breakfast final rinse temperature was 171 [DATE] noon meal final rinse temperature was 170 [DATE] evening meal final rinse temperature was 180 [DATE] breakfast final rinse temperature was 170 The wash and final rinse temperatures were not filled in for the noon and evening meals on [DATE]. [DATE] breakfast final rinse temperature was 172 During an interview on [DATE] at 10:14 A.M., the Regional Consultant indicated there were not any residents in the facility with communicable diseases or gastrointestinal upset. On [DATE] at 11:15 A.M., the following was observed in the kitchen: Freezer: An opened bag of peas with a prep (preparation/open) date of [DATE] and open to air Refrigerator: Strawberries in a container with fuzzy white substance covering them During an interview on [DATE] at 8:37 A.M., the Kitchen Manager indicated there should be a received label placed on items when they are received. Once the item is opened, it should have a label placed on it that includes the item description, date opened, and expiration date but the labels are confusing and it's such a waste of product. They further indicated that staff should check at the end of their shift for sealed bags and they should check twice daily for labels that may have fallen off and expired products. Moldy foods should be discarded. They further indicated in regards to the dishwasher temperature logs, they do not feel like they need to be filled out as the form indicates because while staff is doing dishes, they should be monitoring the temperatures to make sure they are high enough while the dishwasher is going. There was not an investigation into the lower recorded temperatures. The gauges on the machine have been changed by [company name] because they were so difficult to read. A current Food Labeling policy, revised [DATE], provided by the Regional Consultant on [DATE] at 10:30 A.M., indicated . When a food item enters the facility, the item needs to be labeled with a received-on label before it is put away . Foods in production need BOTH a production date AND a use by date. Foods are considered to be in production when they have been taken out of the original container AND the seal has been broken . handwritten labels must include: item name, date and time the food was labeled, use by date, initials of staff member .all food items must be properly covered (not exposed to air) prior to being labeled and dated . The [name of dishwasher] manual, Rev 2.01A, was reviewed and indicated . After the machine has warmed up for five to ten minutes (5 - 10 min.), observe the wash and rinse temperatures. The wash temperature must be 155 degrees F (Fahrenheit) minimum. The rinse temperature must be 180 degrees F minimum. A current Dish Machine policy, revised [DATE], provided by the Regional Consultant on [DATE] at 10:30 A.M., indicated . High-Temperature Dishwasher (heat sanitization) recommended guideline: wash ,d+[DATE] degrees F, final rinse 180 degrees F . On [DATE] at 10:41 A.M., a current Dishwasher Temperature Log policy was asked for from the Regional Consultant; however, they indicated they were not sure there was one and one was not provided. 3XXX,d+[DATE](i)(2) 3XXX,d+[DATE](i)(3)

Based on observation, interview and record review, the facility failed to ensure residents were free from unnecessary medications for 1 of 5 residents reviewed for unnecessary medications. A resident's as needed anti-anxiety medication was ordered for greater than 14 days (Resident 10). Finding includes: On 5/10/23 at 11:53 A.M., Resident 10 was observed sitting up in reclining wheelchair, legs covered, call light in reach, eyes closed, snoring, bedside table next to resident. On 5/11/23 at 10:05 A.M., Resident 10 was observed sitting in reclining wheelchair, eyes closed, blanket over her legs with call light in reach. On 5/12/23 at 10:36 A.M., Resident 10 was observed sitting in reclining wheelchair, call light in reach, and bedside table next to resident. On 5/15/23 at 10:48 A.M., Resident 10 was observed sitting in reclining wheelchair, call light in reach, bedside table next to resident. Resident 10 was yelling out Hey. On 5/11/23 at 10:07 A.M., Resident 10's clinical record was reviewed. Diagnosis included, but was not limited to, dementia, with other behavioral disturbance, anxiety disorder, and depression. The current quarterly MDS (Minimum Data Set) assessment, dated 2/3/23, indicated Resident 10 was moderately impaired, was currently on hospice, and received an anti-anxiety medication 7 of 7 days of the assessment look back period. Current physician's orders included, but were not limited to, lorazepam - Schedule IV tablet; 0.5 mg [milligram]; amt: 0.5 MG; oral Special Instructions: dx [diagnosis]: Anxiety or agitation. To give sublingual, crush and mix with 0.5 ml [milliliter] h20 [water] Every 30 Minutes - PRN [as needed] dated 9/30/22. There was no extension of the medication ordered by the physician. Review of the MAR (medication administration record) indicated Resident 10 received lorazepam 0.5 mg prn on the following dates: 10/2/22 8:14 A.M. behavior 10/4/22 8:33 P.M. yelling out 10/8/22 9:43 A.M. yelling out 10/16/22 8:11 A.M. yelling into hallway 10/18/22 8:20 A.M. behavior 11/7/22 10:35 A.M. very anxious and crying 11/8/22 10:09 A.M. behavior issues 11/9/22 10:14 A.M. behavior issues 11/10/22 9:58 A.M. behavior issues 11/12/22 10:37 A.M. anxiety 11/13/22 8:56 A.M. anxiety 12/7/22 6:25 P.M. anxious 12/12/22 8:49 P.M. anxiety 12/16/22 6:31 P.M. restlessness 12/31/22 3:41 P.M. pain 1/4/23 2:24 A.M. anxiety 2/11/23 12:10 A.M. behavior issues 2/19/23 11:03 A.M. behavior issues 3/1/23 8:07 P.M. anxious 3/26/23 6:38 P.M. behavior issues, crying unconditionally 4/25/23 3:24 P.M. pain 5/9/23 2:34 P.M. anxiety 5/11/23 8:54 P.M. restlessness Review of the nurses notes indicated the following: 11/14/2022 11:03 A.M. Spoke with (Name of Hospice) nurse (Name of Nurse) regarding resident increase in anxiety and restless behavior also that resident is yelling out more to have nursing staff come in room, and attempting to climb out of bed. Orders given to make Lorazepam 0.5 mg TID [three times a day] routinely due to resident behaviors. Started routine Lorazepam this am, will monitor resident for effectiveness and any other side effects. Nursing (Name of Nurse) During an interview on 5/15/23 at 11:40 A.M., the Regional Consultant indicated the ordering physician had not done an assessment every 14 days since the lorazepam prn was ordered on 9/30/22. On 5/15/23 at 11:52 A.M., a current Psychotropic Medication Usage and Gradual Dose Reductions policy, dated 10/9/17, was provided and indicated PRN order for psychotropic drugs are limited to 14 days. Except as provided if the attending physician or prescriber believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluated the resident for the appropriateness of that medication. 3.1-48(a)(6)

Based on observation, interview, and record review, the facility failed to ensure it was free of a medication error rate of greater than 5 percent (%) for 2 of 6 residents (Resident 14, Resident 238)observed during medication pass. 2 medication errors were observed during 25 opportunities for error in medication administration. This resulted in a medication error rate of 8%. A resident choked and was unable to swallow large portion of unidentified partially crushed medication and the incorrect dose of an ordered medication was given to a resident. Findings include: 1. On 5/10/23 at 8:18 A.M., LPN (Licensed Practical Nurse) 3 was observed to crush and administer the following 10 medications to Resident 14: amlodipine 5 mg (milligram) (for blood pressure) Buspar 7.5 mg (for mood) calcium 600 mg (for osteoporosis) Carbidopa/Levodopa 25/100 mg (for Parkinson's disease) vitamin D3 1000 IU (international unit) (vitamin to help with calcium absorption) docusate sodium 100 mg (stool softener) lisinopril 5 mg (for blood pressure) omeprazole 20 mg (for stomach) UTI stat liquid 30 mL (milliliter) in a cup (UTI prevention) venlafaxine 37.5 mg (for mood) While the resident was drinking a liquid after the spoonful of crushed medications mixed with applesauce, Resident 14 started coughing. Resident 14 took a piece of a white pill the size of a pencil eraser from her mouth and put it in a Kleenex held by LPN 3. LPN 3 disposed of the pill. At that time, LPN 3 indicated he did not know what pill it was. During an interview on 5/15/23 at 11:00 A.M., the Regional Consultant indicated a medication spit out by a resident was treated as a refusal and staff should have documented in the EHR the circumstances as to why the resident refused it. 2. On 5/10/23 at 8:44 A.M., LPN 3 was observed to administer 1 pill of Senexon-S 8.6-50mg for constipation to Resident 238. The current physician's orders included, but were not limited to, the following medication: Senexon-S (sennosides-docusate sodium) tablet; 8.6-50 mg 2 tablets by mouth twice a day During an interview on 5/15/23 at 11:50 A.M., the Regional Consultant indicated physician's orders should be followed when administering medications. A current Medication Administration policy, revised 11/2018, was provided by the Regional Consultant and indicated . Medications are administered in accordance with written orders of the prescriber . If a dose of regularly scheduled medication is withheld, refused . it is documented on MAR (medication administration record) or in the EHR. An explanatory note is also entered . 3.1-48(c)(1)

Based on observation, interview, and record review, the facility failed to ensure the plan of care was followed for 1 of 3 residents reviewed. A fall intervention was not in place. (Resident D) Finding includes: On 4/21/23 at 7:35 a.m., Resident D was observed lying in bed. Resident D was not interviewable. On 4/21/23 at 7:56 a.m., Resident D's clinical record was reviewed. Resident D diagnoses included, but were not limited to, unspecified dementia and other lack of coordination. A Quarterly MDS (Minimum Data Set) assessment, dated 2/8/23, indicated Resident D's was not cognitively intact, required extensive assistance of 2 persons for bed mobility, and was dependent on 2 staff for transfers. Care plans were reviewed and included, but were not limited to: Resident is at risk for falling related to a history of falls, cognitive impairment, weakness, unsteadiness/balance issues, poor eyesight, and adult failure to thrive. The interventions included, but were not limited to, dycem to air mattress, approach start date 2/6/23. The current April physicians orders were reviewed and included, but were not limited to: fall intervention: dycem to air mattress below draw sheet, frequency 3 three times a day: 6:00 AM - 2:00 PM, 2:00 PM - 10:00 PM, 10:00 PM - 6:00 AM. Start date 2/4/23. An IDT (Interdisciplinary Team) progress note, dated 2/6/23 at 11:16 a.m., indicated Met to discuss fall on 2/3/23 Root cause: Self transferring from bed Intervention: Dycem to air mattress Will continue to monitor. On 4/21/23 at 9:18 a.m., a treatment to Resident D's skin was observed. The dycem was not observed to be on Resident D's mattress. On 4/21/23 at 9:53 a.m., CNA 1 was observed to make Resident D's bed. A draw sheet, incontinence pad, and top sheet were observed to be put on the mattress. The dycem was not observed to be placed on the mattress. CNA 1 indicated the linens that had been taken off the bed before new linens were applied were, a draw sheet, incontinence pad, and Resident D's blanket. CNA 1 indicated Resident D's fall interventions in place in his room were bed in lowest position, fall mat beside bed, and call light in reach. On 4/21/23 at 9:56 a.m., CNA 2 indicated a draw sheet, incontinence pad, blanket and pillows were applied when making Resident D's bed. The fall interventions in his room were bed in low position and a fall mat. On 4/21/23 at 2:00 p.m., the Clinical Support Nurse provided the current policy titled, Fall Management Program Guidelines, reviewed 3/16/22. The policy included, but was not limited to, care plan interventions should be implemented that address the resident's factors. Any orders received from the physician should be noted and carried out. Discuss risks and interventions with resident and/or responsible party and communicate interventions during shift report. This Federal tag relates to Complaint IN00405930. 3.1-35(g)(2)

Based on observation, interview, and record review, the facility failed to ensure physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . (Resident B) Finding includes: On 9/8/22 at 11:45 a.m., QMA 1 and CNA 1 were observed to transfer Resident B from bed to a wheelchair, using a gait belt and two assist. On 9/9/22 at 11:20 a.m., Resident B indicated staff get them up with two person assist and do not use a lift. On 9/8/22 at 9:44 a.m., Resident B's clinical record was reviewed. Resident B's current September 2022 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Hoyer lift for all transfers, three times a day 10:00 p.m. - 6:00 a.m., 6:00 a.m. - 2:00 p.m., 2:00 p.m. - 10:00 p.m., order date 8/29/22. Care plans were reviewed and included, not limited to: Resident requires staff assistance to complete ADL (activities of daily living) tasks completely and safely. Interventions included, not limited to: Hoyer lift for transfers, approach start date 8/30/22. On 9/9/22 at 2:38 p.m., QMA 2 indicated Resident B was a max assist of two with a gait belt and not a mechanical lift. On 9/9/22 at 12: 26 p.m., the Infection Preventionist provided the current policy on utilizing a lift with an effective date of 5/11/17. The policy included, not limited to: If the resident requires the use of a lift device, this will need to be added to the residents plan of care that will be communicated to the caregiver. 3.1-35(g)(2)

Based on observation, record review, and interview, the facility failed to adequately supervise and implement effective interventions for 1 of 3 residents who were fall risks. Resident C acquired a fractured fibula related to a fall, after having had multiple falls with interventions that were not effective with his cognitive status, and increased confusion and impulsivity. ( Resident C) Finding includes: During the initial tour on 5/26/21 at 8:30 a.m., Resident C was observed in his room lying in bed. The MDS Coordinator indicated Resident C had a recent fall that had resulted in a fracture. On 5/27/21 at 12:24 p.m., Resident C was observed in dining room for lunch, conversing with other residents. Alarm noted on wheelchair. On 5/27/21 at 12:32 p.m., Resident C's room was noted to be 6 rooms from the nurses' station down the 300 hall. A perimeter mattress was on his low bed, and his reacher was on top of his bed. During a review of Resident C's clinical record on 5/26/21 at 11:12 a.m., it indicated Resident C was severely cognitively impaired. Resident C's diagnoses included, but were not limited to, [CONDITION(S)], DVT (deep vein thrombosis), hypertension, end stage [CONDITION(S)], CVA, fracture of right fibula, spinal stenosis. A significant change in status MDS, dated [DATE], indicated Resident C required extensive assistance of 2 with ADLs and total dependence with bathing. Resident C had one fall without injury and one fall with major injury since his admitted [DATE]. Resident C's care plans included, but were not limited to, Resident has potential for experiencing symptoms of fatigue, weakness, and confusion related to [CONDITION(S)]. Interventions included, but were not limited to, administer medications as ordered, encourage resident to take rest period during episodes of fatigue, labs as ordered, observe for signs and symptoms of [CONDITION(S)] and report to physician. Start date 4/17/21. At risk for pain related to fracture right distal fibula. Start date 4/12/21. Resident requires staff assistance to complete ADL tasks completely and safely. Interventions included, but were not limited to, allow resident sufficient time to complete all or parts of tasks, encourage resident to do as much as safely possible for self, observe for deterioration in ADL abilities and report, therapy evaluate and treat as ordered. Start date 3/19/21. Resident is at risk for falling related to weakness, unsteady, history of CVA with right sided weakness, history of falls, cognitive impairment, medications, right fibula fracture, non weight bearing right leg. He is also non-compliant with asking for assistance with transfers. Interventions included, but were not limited to, check and change every 2 hours and with routine rounding at night, offer and assist with urinal as needed, Hoyer (mechanical) lift with transfers, bed and chair alarm, check placement and function every shift, defined perimeter mattress, ensure floor is free of liquids and foreign objects. Start date 3/12/21, revised 4/28/21. Resident C's admission assessment, completed on 3/11/21 at 2:33 p.m., indicated Resident C had a history of falls in the last year and had a fall within the last month prior to admission. The Baseline Care Plan, completed on 3/11/21 at 3:32 p.m., indicated Resident C was at risk of falls. A review of Resident C's clinical record indicated 4 unwitnessed falls since admission on 3/10/21: 3/11/21, 4/1/21, 4/3/21, and 4/13/21. Resident C's progress notes indicated, 3/11/21 at 5:26 p.m.- The nurse was alerted to the resident's room around 4:45 p.m. Resident found to be lying on the floor partially on his right side. Resident stated, leaned forward for something and kept going. No internal or external rotation of the hips or bilateral lower extremities. No complaints of pain. Had small abrasion to forehead above the right eye and a small abrasion to the bridge of his nose. Denied hitting head, but due to cognitive status initiated neuro checks for safety. Notified family of fall. Resident broke glasses, family to pick them up. Physician notified. Monitored per facility protocol. 3/11/21 at 6:34 p.m.- Received order to apply [MEDICATION(S)] (antibacterial cream) to forehead abrasion and bridge of nose twice daily x 7 days. . 3/11/21 at 9:39 p.m.- Fall follow up. Oriented x 2-3. Neuro checks continued. Denies pain or discomfort. Extensive assist with transfers. 3/13/21 at 3:53 p.m.- IDT note: Resident had fall in room reaching for item. Root cause- resident unable to lean forward and obtain item. New intervention: therapy to give resident a reacher and assist with use. 3/16/21 at 7:22 a.m.- CAR NOTE- resident added to CAR for fall, resident had fall in room reaching for item, resident is currently on therapy caseload, therapy to give resident a reacher and work with resident on use. 3/18/21 at 3:48 p.m.- Resident followed on CAR due to fall. Resident has had no further falls at this time. Interventions are appropriate and effective. 4/01/21 at 4:00 p.m.- Around 4 p.m., call light alerted staff of needing assistance. When aide went to answer the light, noted the resident sitting on floor in front of wheelchair. Resident stated I got in a hurry and my feet got tangled up, I was going to help you all out. Resident was assessed for immediate injury and was negative on findings. Assisted to straighten out lower extremities. No shortening, internal, or external rotation noted to hips or lower extremities. Assisted to standing position with 2 assist and a gait belt. Assisted back to wheelchair. Vitals obtained and documented. Physician and family updated. Call don't fall signs placed in room. 4/01/21 at 6:43 p.m.- CAR NOTE-Resident followed on CAR due to fall. Resident had no further falls at this time. Interventions are appropriate and effective. Physician, POA, and IDT team are in agreement with plan of care. Will continue to follow. 4/02/21 at 9:58 p.m.- Recorded as a late entry on 4/3/21 at 3:00 a.m.- Resident remains on fall follow up. Vital signs stable. Resident denied pain or discomfort. No injuries noted related to fall. Call don't fall signs present. Call light and fluids in reach. Resident reminded of need to use call light for assist with transfers. 4/03/21 at 8:02 a.m.- IDT NOTE- resident had fall in room during unassisted transfer, resident does not remember to ask for assistance, perimeter mattress placed to bed, will continue to monitor. 4/03/21 at 9:00 a.m.- While walking down hall, the nurse heard resident call for help. Resident was found to be lying on left side (shoulder and hip) on carpet floor next to bed. He was assisted to sitting position and then to bed side with assistance of two and gait belt. Resident able to move all extremities without pain. Resident denied hitting head and voiced he was trying to get into chair to watch movie. Call light was in reach, however not in use. Resident agreeable to sit near nurses' station and watch movie on big screen TV. 4/03/21 3:30 p.m.- Phone call placed to triage to inform of fall earlier this shift and request x-ray of right ankle/foot due to swelling. Resident voiced he, sprained ankle when he fell the other day. Daughter here and verified that she was notified of fall yesterday and noted that his right foot has old fracture from years ago. Outer aspect of right ankle has slight bruising and swollen with tenderness to touch. Daughter aware of sliding out of bed earlier this shift and encouraged her father to call when needing to get up. Resident voiced agreement. Order noted and will await x-ray arrival. 4/03/21 at 6:57 p.m.- Here to obtain x-ray to right ankle and foot. 4/03/21 at 8:53 p.m.- Received result from X-ray to right ankle/foot. (1) no fracture to right foot (2). Acute spiral fracture distal fibula Daughter notified of results,and wants him to be sent out in morning hours due to it will confuse him this late at night and she had already taken her medication for the evening. Tylenol prn was given at med pass. Triage notified of results. 4/03/21 at 10:54 p.m.- Received order from physician/Triage may send to hospital/emergency room of family choice related to fractured ankle. 4/04/21 at 4:21 a.m.- Fall follow up: pad alarm under resident while in bed, related to not compliant with using call light and waiting for assistance. Speech clear. Call light in reach. Denied pain or discomfort. encouraged to use call light and not stand on right ankle due to it being fractured. 4/04/21 at 9:13 a.m.- Resident's daughter in facility to accompany resident to emergency room for evaluation and treatment of right ankle fracture. Ambulance called for transport. Report called to hospital. 4/04/21 at 2:26 PM- Resident returned to facility via stretcher by ambulance with daughter at side. Resident denied pain. Splint on right leg from toes to knee and orders to elevate leg above level of heart next three days, keep splint on and non weight bearing until follow up with ortho. 4/12/21 at 2:58 p.m.- IDT NOTE- resident had fall on 4/3/2021, due to unassisted transfer. Resident very impulsive and has decreased safety awareness, new intervention is for pad alarm to be placed to bed and chair. 4/12/21 at 3:01 p.m.- CAR NOTE- Resident followed on CAR due to falls, resident had a fall on 4/01/2021, due to unassisted transfer, new intervention was a perimeter mattress, resident had fall on 4/3/2021, due to unassisted transfer. Resident's very impulsive and has decreased safety awareness. New intervention was for pad alarm to be placed to bed and chair. Physician and POA are agreeable to plan of care. 4/13/21 at 4:40 a.m.- Recorded as late entry on 4/20/21 at 7:02 a.m.- CNA went to answer bathroom light and observed patient on the floor. Nurse observed patient on the floor laying on his right side. He stated that he went to transfer himself to the toilet and fell forward out of the wheelchair, patient denied hitting his head. He denied any pain. He does have an abrasion to right outer thigh area, he stated that he scraped it on the wheelchair pedal, the markings are concurrent with that. Patient has no obvious deformities. No obvious bleeding. His ROM is within normal limits for this patient. He had soiled underwear and was placed back in the wheelchair and taken to the bed, changed and washed. Son was in the room at this time and was notified of fall, his daughter was called. Reminded resident that he could not transfer and to call for assistance, he verbalized understanding but will require reeducation on this. 04/20/21 at 8:29 a.m.- IDT NOTE- resident had fall in bathroom, root cause was need to utilize toilet and unassisted transfer, new intervention was to check and change every 2 hours and with routine rounding at night. Offer and assist with urinal as needed, will continue to monitor. 4/23/21 at 8:19 a.m.- CAR NOTE-Resident followed on CAR due to falls. Resident had no further falls at this time. Interventions are appropriate and effective. Physician, POA, and IDT are in agreement with plan of care. 4/30/2021 at 4:25 p.m.- Recorded as late entry on 5/7/21 at 4:26 p.m.- CAR NOTE-Resident followed on CAR due to falls. Resident has had no further falls at this time. Interventions are appropriate and effective. Physician, POA, and IDT team are in agreement with treatment plan. 5/07/21 at 4:26 p.m.- CAR NOTE-Resident followed on CAR due to falls. Resident has had no further falls at this time. Interventions are appropriate and effective. Continues on therapy caseload. Physician, POA, and IDT team are in agreement with plan of care. Continues on therapy caseload. 5/12/21 at 1:37 p.m.- Falls reviewed. Resident continues to be at risk for falls related to CVA with right sided weakness, history of falls, cognitive impairment, non weight bearing status to right leg due to fibula fracture, non compliance with call light and asking for assistance. Fall interventions reviewed and continue to be appropriate. Call Don't Fall sign in resident's line of vision as a visual reminder. Resident on scheduled toileting plan as staff check and change resident every 2 hours and as needed for toileting needs. Resident continues with pressure reducing defined parameter mattress to bed to help resident identify mattress edges, alarms continue to bed and chair. Alarms do not prevent resident from doing anything he could other wise do. Alarms assist staff to know when resident has needs and forgets to call. Resident has severe cognitive impairment and has history of non-compliance. Staff to continue with frequent rounding and assisting with all needs. 5/14/21 at 8:37 p.m.- Recorded as late entry on 5/17/21 at 8:38 p.m.- CAR NOTE-Resident followed on CAR due to falls. Resident has had no further falls at this time. Resident last fall was on 4/03/2021. Interventions appropriate and effective. On therapy caseload. Physician, POA, and IDT team are in agreement with plan of care. 5/20/21 11:10 p.m.- Resident had appointment with ortho on 5/19/21. Came back with orders: wear ASO brace to right ankle at all times except for hygiene, start PT for right ankle strengthening and ROM, and use assistive device or assist for transfers or ambulation. The clinical record lacked specific interventions that were effective for Resident C. Call light education and reminders to use his reacher were ineffective to prevent falls since he was cognitively impaired and was frequently confused and had memory loss. The facility failed to ensure increased supervision related to Resident C's impulsive behavior and lack of safety awareness was provided to the resident. The care plan to check on the resident more often than every two hours had not been changed or increased since 3/12/21 when care plan was implemented. During an interview on 5/27/21 at 11:42 a.m. with the Director of Nursing, she indicated a nurse should immediately implement an intervention at the time of a fall. The IDT team then meets and discusses the root cause and if the current interventions need to be changed. She indicated she does not believe in alarms, as evidenced-based practice shows they do not prevent falls, but, tell staff, when the resident is on the floor. She will be educating staff on expectations next week. For residents with severe cognition impairments she feels that moving them to a common area for supervision or near the nurses' station is more effective. Next week will be implementing a new procedure with the IDT team, the MDS Coordinator will meet with the team immediately after a fall with the resident to determine root cause and the interventions and care plans will be updated immediately at that time. During an interview on 5/27/21 at 11:46 a.m., the MDS Coordinator indicated she updates care plans with interventions. The nurse is supposed to call the Director of Nursing immediately after a fall and immediately put a new intervention in place. Acknowledged that no intervention was actually put in place for Resident C's first fall until several days later. Further indicated sometimes the IDT team may not meet until a few days after a fall before an appropriate intervention is put in place. Resident C was severely impaired and not able to be educated on use of the call light, as he would not remember to use it, or would use it and still get up unassisted anyway. The perimeter mattress should have been implemented sooner, and he should have either been moved out to the nurses' station for supervision, or had his room moved closer to the nurses' station. Also, she normally implements the check and change every 2 hrs upon admission. During an interview on 5/27/21 at 12:37 p.m., RN 1 indicated Resident C was very impulsive and, when he wants to get up, he just goes. He needs constant reminders to call for assistance with transfers. His balance if off and he requires 1-2 staff assistance. He forgets his limitations and forgets he cannot walk. He does have a low bed and a perimeter mattress. He, also, has a reacher, but requires reminders to use it instead of reaching on his own. During a review of the current policy, Fall Management Program Guidelines, dated 5/31/17, indicated, .A fall is considered to be: an unintentionally coming to rest on ground, floor, or other lower level, but not as a result of an overwhelming external force .A fall without injury is still a fall .The fall risk assessment is included as part of the Admission and Quarterly Nursing Observation and other Events/Observations .Identified risk factors should be evaluated for the contribution they may have to the resident's likelihood of falling. Care plan interventions should be implemented that address the resident's risk factors .An investigation of the circumstances surrounding the fall to determine the cause of the episode, a reassessment to identify possible contributing factors, interventions to reduce risk of repeat episode and a review by the IDT to evaluate thoroughness of the investigation and appropriateness of the interventions .The resident care plan should be updated to reflect any new or change in interventions. Nursing staff will monitor and document continued resident response and effectiveness of interventions for 72 hours. Discuss risks and interventions with resident and/or responsible party and communicate interventions during shift report. This Federal tag relates to Complaint IN 979. 3.1-45(a)

Based on interview and record review, the facility failed to ensure planned interventions were implemented, in that, a sit to stand mechanical lift was not used to transfer a resident, resulting in a fracture for 1 of 3 residents reviewed for accidents in a sample of 4 who met the criteria. (Resident #64) Findings include: The DHS (Director of Health Services) was interviewed on 6/2/14 at 11:22 a.m., regarding the investigation into a lower leg fracture on Resident #64. The DHS indicated, on 5/25/14 CNA #5 and CNA #6 had used the stand and pivot method to transfer Resident #64 for toileting. The DHS further indicated the resident showed no signs of pain. After the evening meal, on 5/25/14 CNA #5 and CNA #6 discovered an apple sized light blue area on the residents left knee and notified the nurse. The DHS indicated LPN #2 did not think anything was wrong with the resident's legs due to constant discoloration related to poor perfusion. The DHS indicated on 5/26/14 when the staff attempted to transfer Resident #64, the resident began complaining of pain and a large bruise was discovered. On 6/2/14 at 11:30 a.m., Resident # 64's clinical record was reviewed. Resident #64's [DIAGNOSES REDACTED]. The "Resident Lift Assessment Profile", dated 7/3/13, indicated Resident #64 required a sit to stand lift device for transfers. The "Monthly Nursing Assessment and Data Collection" tool, dated 5/19/14, indicated Resident #64 required a wheelchair and a sit to stand lift for mobility and transfers. The tool further indicated Resident #64 was non-weight bearing. The "Nurse's Notes" indicated: a. On 5/26/14 at 10:30 a.m., a large bruise was discovered to the left lower leg, just below the knee, measuring 16.0 by 10.0 cm (centimeters). A new order was obtained for an x-ray of the left lower leg. b. On 5/26/14 at 11:50 a.m., the x-ray results were received and reported to physician, DHS, and hospice. A new order was received for therapy to evaluate for possible splinting/immobilization. c. On 5/27/14 during the 6:00 a.m. to 2:00 p.m. shift, Resident #64's family requested resident to be seen by an orthopedic physician. d. On 5/27/14 at 5:20 p.m., resident sent to emergency room . The facility physician discussed with the nurse on duty that an oblique fracture, in that location, in an individual with osteoporosis, can be caused by simply bearing weight, pivot transfer, or use of sit to stand lift. The "Radiology Report", dated 5/26/14, indicated oblique fractures of the proximal tibia and fibula. The "Care Plan", dated 4/14/14, indicated " I am at risk for falls and use a sit to stand lift for transfers with staff assist to prevent any injury or fall." The "Care Plan", dated 4/18/14, indicated "I have osteoporosis and am at high risk for fractures. Please use caution when you are assisting me to turn and reposition, transfer, dress, ect. Observe me for any complaints of new onset of pain. Also observed (sic) for any unexplained swelling, tenderness, and guarding of my joints or extremities. Notify my Doctor of any significant findings. My goal is to remain free of fractures." The CNA assignment sheet, dated 5/19/14, indicated resident required a sit to stand lift for assistance with transfers. On 6/4/14 at 9:42 a.m., the "Guidelines for Resident Transfers" policy was reviewed. The policy indicated its purpose was to ensure the safety of residents and staff when performing mobility/transfer tasks. The policy further indicated, "...shall determine the type of transfer device, amount of assistance required to assist with safe mobility...." 3.1-45(a)(2)

Based on interview and record review, the facility failed to ensure a resident at risk for pressure ulcers did not develop a Stage IV pressure ulcer, for 1 of 3 residents reviewed with pressure ulcers, in a sample of 7. Resident G Findings include: 1. The closed clinical record of Resident G was reviewed on 5/3/12 at 11:25 A.M. The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Nursing Admission Assessment, undated, indicated Resident G required assistance with transfers, bathing, dressing, and toileting. The skin assessment indicated: "...Turgor fair...Does the resident have a Stage I wound or greater...? N (no)...Is resident at risk for developing pressure ulcer? N. Pressure ulcer known to be present? N...Skin is exposed to moisture/incontinence? Y (yes)...." An anatomical drawing documented an "X" on the left buttock area with the notation "abrasion." A "Skin Plan of Care," which was a part of the assessment, indicated: "Turn and reposition for comfort and with care...Provide pressure relieving device in chair, to bed, Ensure resident is clean and dry...Assist with positioning in bed and chair." A Minimum Data Set (MDS) assessment, dated 11/28/11, indicated the resident had no memory problems, and required extensive assistance of one staff for bed mobility, transfer, and toilet use. The MDS assessment indicated the resident was occasionally incontinent of bowels and bladder, was at risk of developing pressure ulcers, and did not have a pressure ulcer at that time. A Care Plan, dated 12/8/11, indicated "Potential for alteration in skin integrity R/T (related to) Immobility, Incontinence, Disease process/condition: DDD, [MEDICAL CONDITION] arthritis, [MEDICAL CONDITION]." The Interventions included: "Assess/record changes in skin status. Report pertinent changes in skin status to physician...Turn and reposition every two hours...Minimize pressure over boney (sic) prominences...." A Skilled Nursing Assessment, dated 12/11/11 at 12:30 P.M., indicated, "Abraised area noted left buttocks. (Name of physician) notified. New orders received...." A Skin Impairment Assessment, dated 12/11/11, indicated, "Initial Identification...Present on admission? Y, Type: Abrasion, Location: Left, Length 0.4, Width 0.4, Depth <.1...." A physician's orders [REDACTED]." Skilled Nursing Assessments, dated 12/12/11, 12/13/11, 12/14/11, 12/15/11, 12/16/11, and 12/17/11 each indicated, "Currently has skin impairment: N (No)...." A Nursing Note, dated 12/17/11 at 1:30 P.M., indicated, "Rec. (received) new tx (treatment) orders from (name of physician). See TO (telephone order) this date." A physician's orders [REDACTED]. D/C (discontinue) Calazyme to abraised area left buttock. 2. Cleanse area Left buttock (with) N/S (normal saline). Apply [MEDICATION NAME] AG (change) Q 3rd day." Documentation regarding the appearance of the pressure ulcer on 12/17/11 or the reason for the new treatment order was lacking in the clinical record. Nurse's Notes, dated 12/19/11 at 3:00 P.M., indicated, "Res (resident) has a wound (left) buttock - area is 4.3 length 4 cm (centimeters) width. Area is necrotic - stage IV - [MEDICATION NAME] AG applied - New orders for Zinc 220 mg daily x 1 mo and Vitamin C 500 mg x 1 mo. - Culture wound (left) buttock - cushion for w/c (wheelchair)." A "Pressure...Ulcer Assessment," indicated, "Initial Identification, Date: 12-19-11, Present on admission? Y, Location (left) buttock, Stage/Thickness: E ("E: Un-stageable)...slough/eschar...")...Exudate: S (serous), Color: necrotic...Surrounding tissue: red...." A Physician's Progress Note, dated 12/22/11, indicated: "...Patient does have a stage III wound with necrotic base to the coccyx...." A Pressure Ulcer Assessment then included the following: 12/27/11: "Pressure/Stage: II, Measurements (cm) L (length) 4.3, W (width) 4, D (depth) <0.1...Wound Bed...Color/tissue type/percent/location: Y & B (yellow and black)...Surrounding tissue: R (red)...." 1/2/12: "Pressure/stage: II, Measurements, L 7.3, W 5.3, D <0.1...Wound Bed...Color...Y/B (yellow/black)...Surrounding tissue: R (red)...." A Physician's Progress Note, dated 1/6/12, indicated, "...Decubitus Ulcer, buttock, Patient basically has unstageable/Stage IV ulcer in the sacral area which was recently debrided by therapy. I do think she needs wound VAC and expert surgical consultation at this time. We will send her to the hospital for same...." On 5/3/12 at 3:45 P.M., during interview with the Assistant Director of Nursing (ADON) and RN # 1, they each indicated they did not see Resident G's buttocks upon admission, or on 12/11/11, so they could not say what the abrasion looked like, or why there wasn't a treatment order at that time. The ADON indicated, "We were real surprised at the progression of the wound" from 12/11/11 until 12/19/11. The ADON indicated the nurses probably were checking the pressure area, but just checked "no skin impairment" as routine. RN # 1 indicated she had just started in December 2011, but had done the wound measurements weekly following the initial identification on 12/19/11. RN # 1 did not respond when queried regarding the documentation of "Stage II" areas, when the pressure ulcers had black and yellow tissue. The ADON and RN # 1 indicated they did not know why the nurse obtained a treatment order on 12/17/11, but there was not documentation of the pressure ulcer until 12/19/11. On 5/3/12 at 4:25 P.M., during interview with RN # 2, she indicated she was the nurse who performed the initial assessment of Resident G on 11/21/11. RN # 2 indicated she "really didn't remember," but indicated the area she marked as an abrasion on the left hip was "probably reddened, with no skin breakdown." RN # 2 indicated she did not think it would have been a pressure area. 2. On 5/4/12 at 11:10 A.M., the Administrator provided the current facility policies on "Pressure Prevention Guidelines," undated, and "Pressure/Stasis Wound Condition Report Guidelines," undated. The Pressure Prevention policy included: "Purpose: To maintain good skin integrity and avoid development of pressure ulcers. Procedure: Care plan interventions shall be implemented based on risk factors identified in the nursing assessment. Interventions may include but not be limited to:...Inspect the skin daily during care for signs of breakdown or changes to the skin...ROM (range of motion) with ADL's (activities of daily living), if immobile. Establish an individualized turning schedule if resident is immobile or compromised. Frequency of position change is individualized...Obtain an advanced pressure reduction cushion for wheelchair...." The Pressure/Stasis Wound Condition Report policy included: "...Initiate the form when an area of impairment, (e.g. skin tear, rash...abrasion...) is identified. 3. Complete the section titled 'Initial Identification' in its entirety...5. Document description of wound...6. Document objective information about pain...." At that same time, the Administrator provided the current facility policy on "Weekly Skin Assessment Guideline," revised 4/08. The policy included: "...In addition to the Weekly Assessment by the licensed nurse the nursing assistant shall observe the skin for areas of impairment with bathing and daily dressing and pericare and notify the nurse if an area is identified.". 3. "Stages of Pressure Ulcers," AMDA - 2008, includes the following: Stages of Pressure Ulcers: Stage I: Intact skin with nonblanchable redness of a localized area, usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. Note: This area may be painful, firm, soft, warmer or cooler compared to adjacent skin. Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink ulcer bed without slough. May also present as an intact or open/ruptured serum filled blister. Note: This stage should not be used to describe skin tears, tape burns, perineal [MEDICAL CONDITION], maceration or excoriation. Stage III: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV: Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the ulcer bed. Often includes undermining and tunneling. Note: The depth of a Stage III or IV varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. This federal tag relates to Complaint IN 337. 3.1-40(a)(1)