Based on observation, interviews, and record review the facility failed to ensure facial hair was trimmed for 2 of 2 residents reviewed. (Resident 2 and Resident 11) Findings include: 1)During an observation, on 06/27/25 at 10:10 AM, Resident 2 had 3 chin hairs over an inch long, greyish white in color. During an observation, on 06/30/25 at 11:44 AM, Resident 2 had not been shaved and the chin hairs were still seen. During an observation, on 7/1/25 at 8:38 AM, Resident 2 had not been shaved and the chin hairs were still seen. Resident 2's record review, on 6/30/25 at 1:16PM, indicated diagnoses included macular degeneration, osteoporosis, and weakness. Resident 2's care plan had a focus on Activities of Daily Living (ADL) need for assistance. An intervention was Resident 2 would have all ADLs met by staff. In the care plan under skin at risk for breakdown an intervention was that her skin would be monitored daily during care. The care plan did not specifically address female facial hair. 2) During an observation. on 06/27/25 at 10:09 AM, Resident 11 had a full beard on her chin approximately an inch in length and an obvious mustache, dark in color. During an observation, on 06/30/25 at 11:32 AM, Resident 11 had not been shaved, the beard and mustache were still seen. During an observation, on 7/1/25 at 10:00AM, Resident 2 had not been shaved, beard and mustache were still seen. Resident 11's record review, on 6/30/25 at 1:48PM, indicated diagnoses of blindness of right eye, macular degeneration, stroke, diabetes, anxiety, and dementia. Resident 11's care plan under preferences ndicated an intervention was to honor her wishes to not be shaved daily. In an interview, on 07/01/25 at 10:02 AM, Resident 11 was unaware of when her shower days were or when she was last shaved. She then touched her full beard and indicated she was overdue. She indicated she refused to be shaved with a regular razor, and she had an electric razor around there someplace. In an interview, on 07/01/25 at 08:38 AM, Certified Nurse Aid (CNA) 5 indicated residents should be shaved on their shower days and whenever you can tell they need shaved in between. CNA 5 indicated women should not have facial hair including chin hairs, mustache, and beards. A current policy, titled Guidelines for Activities of Daily Living undated, provided by the Administrator on 7/1/25 at 12:35PM indicated .A resident who is unable to carry out activities of daily living must receive the necessary services to maintain good grooming, and personal and oral hygiene . 3.1-38(a)3

Based on observation, interview, and record review the tacitly failed to ensure a resident maintained their weight for 1 of 4 residents reviewed. (Resident 2). Findings include: Resident 2's record review was on 06/30/25 at 08:48 AM. Resident 2's diagnoses included Anxiety, osteoarthritis, depression, glaucoma, anemia, cataracts, macular degeneration, neuropathy, and pacemaker. Resident 2's height was 5 ft 5 inches. Resident 2's weights were as follows December 141 January 2025 130 February 2025 130 March 2025 125 April 2025 123.4 May 2025 124 June 2025 123 a 6 month loss of 12.77% Nurtition at Risk notes indicated the facility had Resident 2 on weight monitoring and Nutrition at Risk between January 10, 2025 through March 18, 2025 because she had a wound. In March, the facility stopped Nutrition at risk because the note indicated there was no change in monthly weights between February and January therefore weights were stabilized. Resident 2's physician orders showed an order for Boost twice a day started on 2/28/25. Resident 2's weight on 7/1/25 was 121.5 lbs. Resident 2 lost a total of 3.5lbs after starting the Boost twice daily. Resident 2's Nutrition at Risk Quarterly Review dated 6/21/25 summary indicated to continue to monitor with no further recommendations. A review of Resident 2's progress notes from December to June 30 indicated the physician wrote Resident 2 had no weight loss. A review of Resident 2's consumption records for June indicated she ate less than 50% for 35 of 90 meals recorded In an interview, on 07/01/25 at 11:32 AM, Nurse Practioner (NP) 6 indicated he was unaware of Resident 2's continued weight loss. NP 6 ordered the Boost supplement in February. NP 6 indicated he was not made aware and it was his expectation for the DON or the computer program would alert him of any weight loss of 10% in 6 months and this did not happen for Resident 2. NP 6 indicated he would be looking over Resident 2's chart, talking to staff, and assessing the resident on 7/2/25 to determine next steps since he was aware. In an interview, on 07/01/25 at 12:44 PM, thr Registered Dietician (RD) indicated she felt the weight loss was following a pattern and therefore was not alarmed. The (RD) indicated the DON or ADON reported to the providers the outcome of nutrition at risk meetings and outcomes of residents' follow up needs. In an interview, on 07/02/25 at 09:47 AM, Certified Nursing Assistant (CNA) 8 indicated Resident 2 was able and does ask for a sandwich if she doesn't like the meal. CNA 8 indicated the documented consumptions included those substitutions. CNA 5 was in agreement with CNA 8's assessment and documentation explanation. A review of Resident 2's care plan, dated 2/2025, indicated Resident 2 required assistance with ADL's and staff were to assist with eating as needed. An focus on a Self-Care Deficit with her ability to feed herself had interventions including use task segmentation and verbal cues as needed as well as staff will encourage her to participate to the fullest extent possible to promote independence. In a focus of Resident 2 was at risk for compromise in nutrition and hydration status with the interventions of assess for significant changes in weight, monitor for adverse medication side effects, offer meal substitutes if resident consumes less than 50% of meal, and provide supplements as ordered. During an observation, on 06/30/25 at 11:49 AM, Resident 2 was not redirected or assisted with eating. ice cream was eaten without any special utensils or support visual aids. The plate was served with no special instructions given. no special plate. plain white same as others. no special mat or other assistive devices. No redirections were given throughout meal. 80% of the meal was eaten. A policy and procedure titled Skin Weight Assessment Team program dated 10/9/23 was provided by the Administrator on 7/1/25 at 12:25PM. The policy indicated .indications determining implementation of SWAT monitoring 10% or more of (undesirable) weight change in 180 days . 3.1-46

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure medications were labeled with opened dates. For 1 of 2 medications carts observed. (Resident 2, Resident 10, Resident 9, Resident 3, Resident 1, and Resident 7) Findings include:, During an observation, on 6/27/25 at 1:30PM, on 200 hall medication cart with Registered Nurse 4 (RN) and Assistant Director of Nursing (ADON), the following was observed: At 1:33 PM in the top-drawer, Resident 2's Albuterol AER HFA had no open date. At 1:35 PM in the top drawer, Resident 10's Breo Ellipta INH 100-25 mcg was dated 5/21/25 with 0 puffs left. At 1:36 PM in the top drawer, Resident 9's Breo Ellipta INH 100-25 mcg was dated 5/21/25 with 1 puff left. In an interview, on 6/27/25 at 1:37 PM, the ADON indicated she thought inhalers are good for 30 days. The ADON was observed to be adding open dates to medications that had been pulled out of cart with no dates. During an observation on 6/27/25 at 1:39 PM, in the 3rd drawer down the middle, there was an un-opened vial of Lidocaine with no name label. Next to it was a single lubricant eye drops un-opened with no name labeled. At 1:42 PM Resident 3's opened Atropine Sulfate drops had no open date. At 1:46 PM in the 3rd side drawer Resident 1's Sucralfate [NAME] 1 gm/10ml had no open date. At 1:47 PM in the same drawer, an opened bottle of Pro Heal Liquid Protein had no open date or name label. Resident 7's opened bottle of Milk of Magnesia had no open date. Resident 2's open bottle of Stomach Relief liquid had no open date. An opened 0.9% Sodium chloride irrigation USP had no open date and no name label. 1. A record review, on 6/30/25 at 10:30 AM, indicated Resident 2's diagnosis included Chronic Obstructive Pulmonary Disease, unspecified. A physician order for Proventil HFA Aerosol Solution 108 (90 Base) MCG/ACT (Albuterol Sulfate HFA), indicated to give 2 puff inhale orally every 4 hours as needed for SOB/Dyspnea. The nedication had a start date of 9/10/2024. A physician order for Pink Bismuth Suspension 262 MG/15ML (Bismuth Subsalicylate) indicated to give 30 milliliter by mouth every 4 hours as needed for indigestion. The medication had a start date of 5/20/2025. 2. A record review, on 6/30/25 at 10:35 AM, indicated Resident 10's diagnosis included unspecified Asthma, uncomplicated. A physician order for Breo Ellipta Inhalation Aerosol Powder Breath Activated 100-25 MCG/ACT (Fluticasone Furoate-Vilanterol) indicated to give 1 puff inhale orally one time a day for SOB. The medication had a start date of 7/12/2023. 3. A record review, on 6/30/25 at 10:40 AM, indicated Resident 9's diagnosis included Chronic Obstructive Pulmonary Disease, unspecified. A physician order for Breo Ellipta Aerosol Powder Breath Activated 100-25 MCG/INH (Fluticasone Furoate-Vilanterol) indicated to give 1 puff inhale orally one time a day for COPD. The medication had a start date of 8/3/2024. 4. A record review, on 6/30/25 at 10:45 AM, indicated Resident 3's diagnosis included Myotonic Muscular Dystrophy. A physician order for Atropine Sulfate Ophthalmic Solution 1 % (Atropine Sulfate (Ophthalmic) indicated to give 5 drops by mouth every 2 hours for excessive oral secretions. The medication had a start date of 2/12/2025. 5. A record review, on 6/30/25 at 11:00 AM, indicated Resident 1's diagnosis included Hemiplegia and Hemiparesis following cerebral infarction affecting right dominant side. A physician order for Carafate Oral Suspension 1 GM/10ML (Sucralfate) indicated to give 10 ml by mouth two times a day for Heartburn. The medication had a start date of 12/27/2024. 6. A record review, on 6/30/25 at 11:15AM, indicated Resident 7's diagnosis included Chronic Obstructive Pulmonary Disease, unspecified. A physician order for Milk of Magnesia Oral Suspension 400 MG/5ML (Magnesium Hydroxide)indicated to give 30 ml by mouth as needed for constipation daily. The medication had a start date of 5/6/2025. On 06/30/25 11:45 AM, an interview with Director of Nursing (DON) indicated RN 4 was new to that medication cart, the usual nurse was on vacation, but the usual nurse educated RN 4 on labeling medications when opened. A current facility policy, titled Prescription labels, was provided by the DON on 6/30/25 at 12:59 PM. The policy indicated .Medications are labeled in accordance with State and Federal Laws as well as facility requirements 3.1-25(j)(m) and (n)

Based on observation, interview, and record review the facility failed to maintain temperature logs for cooked foods, refrigerators, freezers, and the dishwasher throughout the month of June 2025. 38 of 39 residents residing in the facility ate food prepared in the facility kitchen. Findings include: During an observation, on 6/27/25 at 9:10AM, there was incomplete documentation on the food temperature logs and 2 of 3 refrigerators, no logs for 1 of 3 refrigerators, and no temperature monitoring logs for the freezer and the dishwasher. The food temperature logs were missing the following information: Food temperature logs were dated June 1, 2025, through June 10, 2025. There were no logs available for June 11, 2025-June 27, 2025, for any of the three meals served. In an interview, on 6/27/25 at 9:12AM, [NAME] 9 indicated the only temp logs for the refrigerators, freezers, and dishwasher were the ones on the manager's desk. [NAME] 9 indicated the food temp logs should have been on the desk as well. In an interview, on 6/27/25 at 1:36PM, the Regional Dietary Manager indicated there were only the food temperature logs and refrigerator, freezer, and dishwasher logs to be found on the manager's desk. No others for the other months or missing days were found during a thorough search. The regional manager confirmed the facility had 1 incomplete log for 3 freezers. The facility had 3 refrigerators, but only 2 incomplete logs were available. One for a reach in and one for a walk in. The refrigerators were checked twice daily at 6am and 2pm. The following dates/times were missing a temperature for the reach in refrigerator: 6/19 2pm, 6/21 2pm, 6/22 2pm, 6/23 6am, 6/24 2pm, 6/25 8am, 6/25 2pm, 6/26 6am, 6/26 2pm, and 6/27 6am. The following dates/times were missing a temperature for the walk-in refrigerator; 6/7 2pm, 6/21 2pm, 6/22 2pm, 6/23 6am, 6/24 6am, 6/24 2pm, 6/25 6am, 6/25 2pm, 6/26 6am,6/26 2pm, and 6/27 6am. There was no temperature log sheet available for the third refrigerator. The facility had 3 freezers, but only 1 log was available. The freezer was checked twice daily at 6am and 2pm. The following dates/times were missing a temperature documented; 6/21 2pm, 6/22 2pm, 6/23 6am, 6/24 6am, 6/24 2pm, 6/25 6am, 6/25 2pm, 6/26 6am, 6/26 2pm, and 6/27 6am. There were no temperature log sheets for the other 2 freezers used by the facility. The dishwasher temperature log was not dated with month or year. The temperature log was kept for Breakfast/Lunch/Dinner. The following dates/meals were not recorded; 15th dinner, 21st breakfast, lunch, and dinner, 22nd breakfast, lunch, and dinner, 23rd breakfast and lunch, 24th breakfast, lunch and dinner, 25th breakfast, lunch and dinner, 26th breakfast, lunch and dinner, and 27th breakfast. A current policy and procedure titled Sanitation and Safety was undated, provided by the Administrator on 7/1/25 at 12:35PM indicated .3. Dish machine temperatures are logged after each meal on the dish machine temperature log. Completed temperature log sheets are kept on file for one year. A current policy and procedure titled Food Storage (Dry, Refrigerated, and Frozen) dated 8/12/23, provided by the Administrator on 7/1/25 at 12:35PM indicated .Refrigerator foods: b. internal air temperature of refrigerator was checked and recorded twice daily and logged .Frozen foods. a. internal air temperature of the freezer was checked and recorded twice daily and logged. A current policy and procedure titled Food Temperature Tray Line Recording was undated, provided by the Administrator on 7/1/25 at 12:35PM indicated .Temperatures of foods shall be recorded before being served for steam table. Food temperatures shall be checked at the end of cooking and only recorded once in steam table on the food temperature log . 3.1-21(i)1

Based on interview and record review, the facility failed to follow physician orders regarding weight monitoring for 2 of 16 residents reviewed (Resident 10 and Resident 6). Findings include: 1) Resident 10's record was reviewed 8/29/24 at 12:28 PM. Her diagnoses included cellulitis of left lower limb, diabetes, speech difficulties, dementia, acquired absence of left toes, acquired absence of right great toe, and heart failure. Resident 10's MDS (Minimum Data Set) Section C -Cognitive Patterns indicated a score on the Brief Interview of Mental Status (BIMS ) of 10. A score of 10 indicated moderate cognitive decline. Resident 10's current care plan indicated a focus on nutrition with a goal of not having signs or symptoms of dehydration through next review. An intervention was monitoring weights and intakes dated 7/1/2021. Resident 10's physician orders, dated 5/20/22, included an order specific for heart failure; to obtian a daily weight after voiding and before breakfast/medications with same clothes each day. The order indicated to notify the doctor any of 2 lb weight gain within 1 day and/or 4 lb weight gain in 5 days. The MAR, dated July 2024, indicated no weights were documented on the following dates: 2, 3, 7, 9, 13, 18, and 19. 7 of 24 weights ordered for July 2024 had not been completed. Progress notes indicated Resident 10 went to the hospital on 7/24/24 where she was admitted until 8/10/24. Resident 10's vitals sheets, dated August 2024, indicated the following: On 7/12/24 a weight of 203 lbs was recorded. The next weight of 210.3 lbs (a 7.3 lbs weight gain in 2 days) was recorded on 7/14/24. No physician notification was completed as ordered. On 7/15/24 a weight of 209 lbs was recorded. The next weight of 215 lbs (a 6 lbs weight gain in 2 days) was recorded on 7/17/24. A Physician Progress Note, dated 7/16/24 at 4:55 PM, indicated Resident 10's vital signs were stable. No concerns were voiced by nursing staff. Nurse Practioner (NP) 9 did not address the weight gain of 7.3lbs on 7/14/24 or lack of weight taken on this date. A Nurse Progress Note, dated 7/17/24 at 9:25 AM, indicated the floor nurse notified the Nurse Practioner of Resident 10's weight gain, rhonchi (Low pitched snore like sounds that can be heard with a stethoscope. Their presence means an obstruction, or an increased number of secretions is in the airway) noted on posterior lobes throughout and informed the NP Resident 10 was short of breath at times. A Physician Progress Note, dated 7/18/24 at 7:24 PM, indicated Resident 10 was seen for weight gain. The resident had gained roughly 12 lbs in the last 4 days. Nurse Practioner 9 increased diuretics. A Nurses Note, dated 7/18/24 at 4:18 PM, indicated new fluid restrictions due to water weight gain were begun. The resident weighed 215lbs this week. Lung sounds were rhonchi. A Nurse Note, dated 7/23/24 at 2:47 PM, indicated the staff reported a 7.5 weight gain in 1 day to the NP and had received orders for Lasix 80mg. A Nurse Note, dated 7/23/24 at 6:57 AM, indicated Lasix 80mg for edema had been given. A Nurse Note, dated 7/24/24 indicated the edema remained to bilateral lower extremities. Her legs felt hard and had pitting. Resident 10 reported discomfort to bilateral lower extremities often and pain medications were given as needed. A Nurse Note, dated 7/24/24 indicated Resident 10 had red hard edema in right abdominal area, bilateral thigh edema presented as tight and hard. The nurse received an order to send Resident 10 to the emergency room for evaluation and treatment. A Nurse Note, dated 7/24/24 at 8:10 AM, indicated two emergency medical transport picked up Resident 10 for transport to the hospital where she was admitted . In an interview, on 8/30/24 at 9:42 AM, the DON (Director of Nursing) indicated when a weight was was off from a previous weight the resident would require a reweigh. When a resident refused, a note was expected in the progress notes to indicate the refusal. The DON indicated residents had weigh daily physician orders for heart failure, edema, fluid restriction, and other diagnosis or cases deemed medically necessary. The DON indicated the weights done as prescribed by the provider was important because it was one of the first signs something acute was happening with the resident. 2. A record review for Resident 6 began on 9/30/2024 at 9:56 AM. Diagnosis included, Paraplegia, other chronic ostemyelitis. A review of physician orders, dated 7/11/2024, indicated to record weekly weight every day shift every Thursday for monitoring. A current care plan indicated a focus dated 2/9/23 related to care declines. Resident 6 often prefered to decline care/ treatment/ recommendations offered .Interventions dated 6/14/2019 indicated to inform the physician as needed regarding refusals. A review of vital signs indicated the following weights: 7/18/24- no weight was documented 7/25/24 104.6 lbs 8/3/24 104.6 lbs 8/4/24 104.6 lbs 8/8/24- no weight was documented 8/15/24- no weight was documented 8/22/24- no weight was documented 8/29/24 104.2 lbs A review of the Medication Administration Record (MAR), dated August 2024, indicated to record a weekly weight every day shift every Thursday for monitoring start date 7/11/2024. For the dates August 1, 8, 15, and 22 there were no indications of refusal or if the weight had been attempted. A review of the progress notes, dated August 2024, indicated there was no documentation Resident 6 refused weights or the physician was informed the weights were not completed or had been refused. The following policies were provided by the Regional Nurse consultant on 9/3/2024 at 10:13 AM: A policy, titled Clinical Nutrition, Weights, dated 4/2017, indicated .the facility will have a systematic and interdisciplinary approach for obtaining and monitoring weights .the facility will designated a trained staff member to obtain all weights .Weights will be obtained upon admission, readmission to facility, then weekly x 4 weeks, then monthly unless otherwise ordered .Monthly weights are to be obtained no later than the 5th of each month with re-weights obtained by the 7th .Nursing will notify the dietitian or designees of any significant weight changes .Significant weight change refers to percentage of body weight not related to an explainable event such as resolution of edema, paracentesis, etc .A reweighs will be obtained and recorded for all significant weight changes .A facility designee will promptly record the weights and any re-weights in to the MAR . A policy titled Guidelines for Physician orders-following physician orders, dated 6/18/23, indicated: it is the policy of the facility follow the orders of the physician 3.1-37

Based on interview and record review, the facility failed to monitor side effects of antipsychotic medication for 1 of 5 residents reviewed. (Resident 20). Findings include: A Record review began on 8/29/2024 at 12:30 PM. Resident 20's diagnosis included, unspecified dementia, bipolar disorder and anxiety. A review of the physician orders indicated to give a medication of Abilify (aripiprazole) tablet 5 milligrams (mg), 5 mg by mouth one time a day for bipolar disorder with a start date of 5/21/2024. There were no physician orders to monitor side effects for this medication. A review of care plans indicated the following: A focus dated 6/23/2024, indicated Resident 20 had depression related to bipolar depression, anxiety and had orders for psychotropic medications to treat mental illness. The interventions dated 6/23/2024 indicated to administered medications as ordered, monitor for adverse side effects and effectiveness A review of the Medication Administration Record (MAR ), dated August 2024, indicated Resident 20 received the medication Abilify tablet 5 mg, one time a day each day for the dates 1 through 30. There was no documentation to indicate the side effects were monitored for this medication in the MAR or progress notes. In an interview on 8/30/2024 at 1:12 PM, the Director of Nursing (DON) indicated there should have been a physician order to monitor side effects. A current facility policy, Guidelines for Psychotropic medication, was provided by the DON on 8/30/2024 at 9:49 AM. The policy indicated . based upon each individual resident's comprehensive assessment, the facility will ensure that residents who have not previously been on a psychotropic drug(s) are not given theses med's unless the medication is necessary to treat a specific condition/diagnosis, that is documented in the medical record by the physician. Residents will not receive psychotropic medications unless other types of interventions have been attempted to meet the resident's targeted behavioral goals and have failed. These include behavioral programming, by a trained behavioral therapist, environment changes, and/or other non-pharmacological interventions. The facility will monitor any ordered and administered psychotropic medication for the following: d) evidence that the efficacy/effectiveness of the drug is being monitored .e) adverse consequences/reactions .f) identifying and addressing any adverse consequence/reactions 3.1-48(a)(1)-(6)

Based on interview and record review, the facility failed to ensure identification, assessment and follow up for acute changes in resident's condition following 2 falls for 1 resident reviewed (Resident B). Findings include: On 4/18/24 at 10:38 A.M., Resident B's record was reviewed. Diagnoses included congestive heart failure, dementia, diabetes, and repeated falls. The resident had recently been hospitalized following a fall resulting in fractured ribs and large hemothorax (condition where blood collects in the space between the lungs and rib cage usually as a result of injury/trauma to the chest). A hospital note, dated 3/31/24 at 11:51 a.m. by a hospital trauma doctor, indicated the resident had been sent to the hospital from the nursing home due to shortness of breath and concern for acute medical problem. Initially, there had been no report of history/mechanism of trauma however, trauma staff were concerned when the resident was found to have fractured ribs and large hemothorax which required insertion of a chest tube to drain the blood. The resident had a small area of bruising over one cheek, scattered abrasions, and significant bruising to his right lateral chest wall, right flank, and right knee. The nursing home was contacted who indicated the resident had fallen 2 times in the past 7-10 days. A quarterly MDS (Minimum Data Set) assessment, dated 3/8/24, indicated Resident B had a BIMS (Brief Interview Mental Status) score of 14-no cognitive impairment. He had no mood or behavior issues; no functional impairments; and used a walker and wheelchair for mobility. He required supervision with toileting hygiene, upper body dressing, and personal hygiene. He was independent with bed mobility, sit to stand transfers, toilet transfers, and chair to chair transfers. He was able to walk short distances with his walker and supervision. A care plan for falls, revised on 4/6/2020, indicated the resident was at risk for falls due to dementia, forgetfulness, impaired vision, unsteady gait, impaired balance and history of falls. The goal, revised on 8/14/23, was to reduce his fall risk factors to avoid significant injury related to falls. Interventions and dates initiated were: 8/19/2019-call light in reach, monitor for changes in gait, and notify doctor of change in condition. 9/16/2019-provide reacher/grabber to have by him when doing puzzles/crafts. 3/25/24-analyze previous falls to determine pattern, do no leave in bathroom unattended, encourage him to use handrails and assistive devices properly, evaluate/assess psychotropic medications, keep most used items in arms length to prevent bending/reaching, notify therapy of changes in condition, re-inforce need to call for assistance, and move resident closer to nurse station until IDT (Interdisciplinary Team) can evaluate. A weekly nurse progress note, dated 3/19/24 at 9:07 a.m., indicated the resident was alert and oriented x3; needed cueing on date/time. He was able to make his needs known and answer appropriately. His skin was pink, warm, and intact with 2+ pitting edema to both lower extremities and he wore compression socks as ordered. He was independent with transfers and ADL (activities of daily living) care at most times. He ate and drank adequately. His lung sounds were clear on both sides and respirations even and unlabored without shortness of breath. He was calm, pleasant, cooperative and denied pain. A Change in Condition report, dated 3/19/24 at 10:32 p.m., indicated a CNA (Certified Nurse Aid) reported the resident had fallen. His range of motion was assessed and he was checked for injuries and placed back into his recliner chair. His wheelchair had been observed folded up and lying on the floor next to him on side. Resident B indicated he'd needed to use the restroom. He indicated to the nurse, he had hit the right side of his head. The nurse obtained vital signs and neurological checks were initiated. There was no visible injury observed on his head. He was given a dose of Tylenol for a headache with no further complaints. A Late Entry note-dated 3/20/24 at 10:19 a.m., indicated the IDT recommended continuing fall follow up per facility protocol including completing of neurological checks per orders. The resident remained on therapy services, who were updated on the incident and need to review transfer and safety precautions with the resident during sessions. Dycem was placed in the recliner chair in his room and signage placed on whiteboard to aid in cueing the resident to call for assistance. An NP (Nurse Practitioner) note, dated 3/20/24 at 10:30 a.m., indicated the resident had been seen following a fall without injury. The resident reported a mild headache and soreness to the back of right side of his head. Resident B indicated the wheelchair had slipped out from underneath him as he transferred on the previous evening and he fell to the floor hitting the back of his head. Staff were to monitor him per facility protocol and notify the NP of any changes. A recommendation was made to consider moving the resident closer to the nurses station and obtaining labs if he continued to fall. An Incident Note, dated 3/24/24 at 5:25 a.m., indicated the resident was observed on the floor laying on his right side. He had a 1 cm (centimeter) laceration to the left side of his nose, a 2 cm laceration to the left side of his forehead, and an abrasion to his right lower back. He was assisted up off the floor and given Tylenol for pain. Neurological checks were initiated without abnormal findings observed. The resident was to be moved to a room closer to the nurses station. A MAR (Medication Administration Record) Administration note, dated 3/24/24 at 9:26 p.m., indicated the resident had been given Tylenol for facial grimacing after being re-positioned. A Late Entry note-dated 3/25/24 at 1:41 p.m., indicated the IDT met regarding the resident's unwitnessed fall. The resident had been moved immediately following the fall to a room closer to the nurses station for increased and frequent monitoring. He was observed with small healing lacerations to his forehead and nose with scabs. He had bruising to both upper extremities and an abrasion to his right lower back. An NP note, dated 3/25/24 at 7:24 p.m., indicated the resident was seen following a fall. He had lacerations to the left side of his nose and left side of forehead and large abrasion to his right posterior mid back. He was seen sitting in his recliner chair in his room which had been moved closer to the nurses station. He was slightly short of breath. He had a large superficial abrasion to his right posterolateral mid side with bruising and tenderness when touched. He complained of pain all over with deep inspiration. He had bruising to his outer right thigh and swelling and bruising to his right knee. Labs and x-rays of chest, right hip and right knee was ordered. A nurse note, dated 3/26/24 at 3:30 a.m., indicated the resident continued with neurological checks and vital signs which were normal. Bruising and abrasions continued with no new injuries observed or reported. -At 9:37 a.m., X-ray results received and no fractures or acute issues were noted. -At 4:11 p.m., the resident continued with bruises from his fall in various stages of healing. No new injuries. A nurse note, dated 3/27/24 at 1:27 a.m., indicated the resident continued on fall follow up. He had no new injuries and continued with bruising to his face, forehead and back. A nurse note, dated 3/28/24 at 4:08 a.m., indicated the resident continued on fall follow up. He continued with scratches to left side of his nose and left side of forehead. No new injuries. An NP note, dated 3/29/24 at 9:57 a.m., indicated the resident had been seen eating breakfast in the dining hall with no acute concerns. The bruising was healing to his right knee, right hip, and right thoracic region with associated abrasion. He had scabbed superficial abrasions to his left eyebrow and nose which were healing well. The swelling in his legs was decreasing and had 1+ pitting edema. Staff were to notify the NP of any acute concerns. MAR notes, dated 3/29 and 3/30/24, indicated the resident's blood pressure was low and anti-hypertensive medications held. A nurse note, dated 3/31/24 at 6:11 a.m., during rounds, the resident was observed with shortness of breath, moist skin, left upper extremity swollen with 2-3+ edema, blood sugar elevated, respirations elevated and heart rate at 134 per minute (normal 60-80). His oxygen saturation (blood level of oxygen) was 71% (normal >90%) and he was administered 4 liters of oxygen. New orders received to send the resident to the ER for evaluation and treatment. On 4/18/24 at 11:54 A.M., the Rehabilitation Director was interviewed. She indicated Resident B had been on their caseload until he was sent to the hospital on 3/31/24. She indicated the resident was receiving services from both physical and occupational therapies. He was walking with physical therapy and working on balance and exercises for his upper extremities with occupational therapy. The Rehabilitation Director indicated after the resident's fall on 3/24/24, the resident hadn't been able to participate in therapy due to pain/discomfort, fatigue, and not feeling well. She indicated the resident status was discussed during morning meetings. She provided therapy treatment notes which indicated: -3/25/24: Physical therapy note: the resident had fallen yesterday, on 3/24/24, causing injury to his face. He seems more confused and had a decline in tolerance for gait and transfers. Occupational therapy note: treatment held due to resident not feeling well. -3/26 and 3/27/24: Occupational therapy notes: the resident was unable to participate due to fatigue and not feeling well. Range of motion exercises were completed in his room. -3/27/24: Physical therapy note: The resident complained of feeling fatigued and sore on this day and required much encouragement to try and complete exercises. The Rehabilitation Director indicated no therapy was attempted on 3/28, 3/29, or 3/30/24. On 4/18/24 at 1:29 P.M., RN 5 (Registered Nurse) was interviewed. She indicated when a resident had a fall, a complete head to toe assessment was to be completed and documented in the Risk Management section of the medical record. 4 assessments were to be completed at the time of the fall-pain assessment, skin assessment, fall risk assessment, change in condition assessment, and neurological checks initiated for head injuries or un-witnessed falls. After the initial assessments and incident report were completed, staff were to document every shift for 72 hours, for pain, injuries, changes in condition, and neurological checks. She indicated this charting was done in the nurse progress notes. ADL documentation, dated 3/1 to 3/24/24, indicated the resident required limited assistance of 1 staff member for transfers and bed mobility. On 3/25-3/31/24, the resident was requiring extensive assistance from 1-2 staff members for transfers and bed mobility. At times, he hadn't gotten out of his recliner chair and into bed following the fall on 3/24/24. A MAR, dated March 2024, indicated Resident B had been assessed and given pain medication on 3/19/24 following his first fall and once on 3/24/24 after his 2nd fall. On 4/19/24 at 2:18 P.M., the Director of Nursing (DON) was interviewed. She indicated after the resident's first fall on 3/19/24, the fall was reviewed by therapy and the resident was to be reminded to ask for assistance. After the resident's 2nd fall on 3/24/24, the resident had been moved closer to the nurses station but she was unable to provide further information on what room he'd been placed into or what further evaluations the IDT had completed for root cause analysis of his falls. The census report for the resident hadn't indicated he had moved rooms. She indicated following a fall, nurses were to document on every shift, the resident's condition including known and new injuries, change in range of motion, pain, etc. for 72 hours and document in the progress notes. A current policy, titled Guidelines for Incident/Accidents/Fall was provided by the DON on 4/19/24 at 2:30 P.M., which stated: Procedure: 1. If a resident is involved in an incident/accident an immediate assessment of the resident will be completed by the nurse .2. In the case of a fall, the resident will have a head to toe assessment to include a pain assessment and assessment as to any changes in their ROM ability/function .8. Documentation of the physical and mental status of the resident involved will be completed each shift (every 8 hours minimally) over at least the next 72 hours or until the resident's condition improves .11. All falls will have a site investigation by appropriate staff in an effort to define the root cause of the fall. This will help provide information to enable staff to roll out interventions to prevent another similar occurrence. Each fall needs a new care plan intervention rolled out. Therapy should be involved to some degree in all post fall reviews to offer any input or to determine if a screen or being added to therapy case load is appropriate This tag relates to Complaint IN00431619. 3.1-45(a)

Based on observation, interview and record review, the facility failed to ensure triggers were identified and resident specific approaches initiated in providing trauma informed care for 1 of 1 resident reviewed (Resident C). Findings include: On 4/18/24 at 2:15 P.M., Resident C was interviewed. She was observed sitting in a wheelchair covered by several blankets with only her head and hands visible. She indicated she was tired of talking about her issues with the facility staff and felt helpless. She indicated she'd had some trauma with abuse in her past and was very modest. She hadn't wanted staff to completely uncover her when assisting her with personal care and dressing which she alleged, staff did often on the first shift. She alleged an incident had occurred on 4/10/24 where 2 CNA's (Certified Nurse Aide) had come into her room to assist her up from bed. The CNA's threw back her covers and removed her gown, exposing her. She told them to cover her up but alleged the CNA's just laughed at her and told her it wasn't a big deal and they were all girls. Resident C indicated she felt exposed and vulnerable and believed staff were ridiculing her because of her need for modesty. When asked, she indicated she had told staff repeatedly, being covered up and not exposed/being modest was very important to her but believed staff thought it was a joke and staff laughed about her. On 4/18/24 at 3:01 P.M., Resident C's record was reviewed. Diagnoses included paraplegia, diabetes, and post-traumatic stress disorder (PTSD). A level II PASRR (Pre-admission Screening and Resident Review), indicated the resident had diagnoses of depression, anxiety disorder and PTSD with symptoms of increased worry, irritability, difficulty focusing and choosing not to eat, receive care, or take medications. An admission MDS (Minimum Data Set) assessment, dated 3/12/24, indicated Resident C's BIMS (Brief Interview Mental Status) score was 14 indicating she had no cognitive impairment. She had several mood indicators including: little interest or pleasure in doing things and poor appetite nearly every day; trouble falling asleep and feeling tired with little energy 7-11 days. She rejected care 1-3 days during the assessment. Resident C was dependent on staff for bathing, dressing, hygiene, toileting, transfers and bed mobility. A Trauma Screening form, dated 3/7/24 at 2:47 p.m., indicated the resident denied abuse but had depressive illness. A Social Services Evaluation, dated 3/8/24, indicated the resident would not open up about her situations or feelings prior to admission which had included an incident upsetting to her and one which she refused to speak about. She indicated she had family but they were not supportive of her. Care plans, reviewed on 4/18/24 at 3:04 P.M., indicated the following: -3/8/24: The resident triggered a level II PASRR screening due to depression, anxiety and PTSD. Interventions were to encourage family support; provide support for therapies to promote independence, and refer to psych providers. -3/8/24: The resident had a need for adjustment to the facility. She presented with a sad mood and was treated for depression. She had issues with trusting others. This affected her ability and desire to communicate. Interventions included: encourage her to participate in conversations; provide her with situations which gave her control; learn to recognize/help the resident to identify stressors and intervene/remove stressors where possible. On 4/18/24 at 3:30 P.M., the Administrator and Regional Nurse Consultant were interviewed. Both indicated Resident C should've had a care plan put into place to address the resident's PTSD, triggers to avoid re-traumatization, and resident specific interventions to ensure her feelings of emotional/physical safety. The plan should have included maintaining her modesty and privacy during care. On 4/19/24 at 1:30 P.M., CNA 3 was interviewed. She indicated, on 4/10/24 in the morning, she and another staff member went to Resident C's room to provide care. They attempted to help the resident change her gown when the resident got upset. She told them she hadn't wanted to be exposed so they kept the old gown up over her while she put her arms in the new gown and then pulled out the old gown. CNA 3 tried to laugh it off so the resident wouldn't feel embarrassed but the resident was angry. The CNA indicated it was the first day she had cared for the resident. She hadn't been aware the resident wanted kept covered at all times as modesty and privacy were extremely important to her. CNA 3 indicated the resident's care plan hadn't indicated her wishes. On 4/19/24 at 2:34 P.M., the Administrator provided a current copy of the facility policy, titled Trauma Informed Care which stated: This policy and procedure describes expectations for the implementation of trauma-informed and trauma-sensitive services .Trauma is defined as an event or ongoing situation that results in extreme stress that overwhelms a person's ability to cope .that subsequently causes intense physical and psychological stress reactions .it is the intention of this facility to deliver trauma informed services which include .establishing a safe environment that feels physically and emotionally safe and minimizes re-traumatization .using an empowerment mode of care that promotes and respects individual's choice and control .supports the development of healthy relationships .building healthy coping skills .providing access to trauma specific services .ensuring holistic service delivery of trauma services and programs This tag relates to Complaint IN00432307.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were free from abuse for 1 of 3 residents reviewed. (Residents B). Findings include: 1. An Indiana report, dated 1/16/24, provided by the facility indicated a staff member had spoken to Resident B in inappropriate words and tone. Resident B's record was reviewed on 2/6/24 at 10:05 AM. Diagnoses included cognitive communication deficit, assault by unspecified means, contracture right knee, contracture left knee, generalized muscle weakness, and other reduced mobility. Resident B's current quarterly Minimum Data Set (MDS), dated [DATE], indicated their Basic Interview for Mental Status (BIMS) score was 14 (cognitively intact). The MDS indicated Resident B had adequate hearing and does not wear hearing aids. The MDS indicated the resident understood others and made himself understood. The MDS indicated the resident used a wheelchair, required supervision to light touch assistance to transfer from a chair/bed, and required partial to moderate assistance with his bathing needs and dressing his lower body. Resident B's current Care plan, revised 7/13/23, indicated the resident had experienced serious trauma during his lifetime related to childhood abuse/mistreatment, neglect, and verbal abuse with a goal the staff would avoid inadvertently acting insensitively towards the resident. Interventions included providing culturally competent, sensitive, trauma informed care in accordance with professional standards accounting for the person's experiences and preferences to eliminate or migrate triggers that may cause re-traumatization in the resident. Certified Nursing Assistant (CNA) 3's statement, dated 1/8/24, indicated she was providing care to Resident B's roommate with CNA 2. Resident B was upset because the room's heat had been turned down and began yelling and arguing with CNA 2. CNA 3 indicated she heard CNA 2 curse at Resident B and felt the interaction was inappropriate and reported the interaction. Resident B's statement dated 1/8/24, indicated CNA 2 walked in his room, started swearing how hot his room was, and turned down his heat. The resident indicated he asked that his heat be turned backed up when CNA 2 called him a ret**d, made fun of him that he could not walk, and left the room. Resident B indicated he turned on his call light twice for a staff member to turn the heat back up. CNA 2 returned to the room twice and turned off the call light without acknowledging him. Resident B indicated felt he was being disrespected. In an interview, on 2/6/24 at 10:40 AM, the Administrator indicated CNA 2 was terminated following the completion of the investigation and a CNA Referral Form was sent to the appropriate agency. 2. An Indiana report, dated 1/18/24, provided by the facility indicated a staff member had spoken to the Resident B in inappropriate words and tone. Resident C's statement dated 1/12/24 indicated she had an audio recording of CNA 4 speaking inappropriately to Resident B on 12/19/23, but did not report it to the DON until 1/12/24. The Administrator, DON, Assistant Director of Nursing (ADON), and SSD listened to the audio recording. The audio recording confirmed CNA 4 said f**k you to Resident B and urged him to argue with her. In an interview, on 2/6/24 at 10:40 AM, the Administrator indicated CNA 4 was terminated following the completion of the investigation and a CNA Referral Form was sent to the appropriate agency. A current policy titled Abuse Prevention Program, undated, provided the Administrator ,on 2/6/24 at 1:22 PM ,indicated the facility would not tolerate resident abuse or treatment by anyone including staff. Abuse included mental abuse defined as, but not limited to, demeaning, humiliating, or harassing residents. The policy indicated all new employees and as well as all staff on a yearly basis would receive education on the sensitivity of resident rights and needs and what constitutes physical, mental, sexual, and verbal abuse. This citation is related to complaint IN00425818 and IN00426133. 3.1-27(a)(b)

Based on observation, interview and record review, the facility failed to develop and implement individualized interventions for dementia care to support psychosocial well-being and address aggressive behaviors for 2 of 3 residents reviewed (Resident B and Resident C). Findings include: 1. On 9/26/23 at 11:49 A.M., Resident B's family member was interviewed. They indicated several concerns with the resident's care and condition including multiple falls, bruising, lack of activities, multiple medication changes, swelling in legs, and an alleged physical altercation with another resident who had been aggressive towards her. They believed the facility thought Resident B had been the aggressor, but the other resident had been the one to strike her. The family member indicated they had offered suggestions to the facility on how to care for the resident, including information about her favorite activities and likes/dislikes, but believed the facility hadn't tried to incorporate any of these suggestions into her plan of care. When family visited, the resident was alleged to usually be sleepy and not engaged in activities, which they believed contributed to her depression and behaviors. Resident B had a passion for playing solitaire and had kept score of how many games she'd won, which was over a thousand games. She enjoyed crocheting, cooking, prepping for meals, and house work although she hated folding clothes/towels. The family member indicated she could only do these activities for short periods of time due to her dementia, but they had been things that had been important to her and part of her daily life. On 9/26/23 at 1:34 P.M., Resident B's clinical record was reviewed. Diagnoses included dementia with behavioral disturbances, anxiety disorder, depression, delusions, and sleep disorder. Her clinical record indicated she had been sent to the hospital on 7/24/23 for a psychiatric evaluation, but was found to have COVID-19 pneumonia. She remained hospitalized with pneumonia until 8/1/23, when she returned to the facility. On 8/4/23, she was transported to a psychiatric hospital for a medication washout (psychotropic medications are stopped and re-evaluated for need or change in medications). She returned to the facility on 8/15/23 with physician orders for Mellaril (antipsychotic) 10 mg (milligrams) by mouth 4 times per day and Celexa (anti-depressant) 10 mg by mouth 1 time per day for behavior management. A quarterly MDS (Minimum Data Set) assessment, dated 6/7/23, indicated the resident had severely impaired cognition, understood others and was able to be understood when communicating, and had disorganized thinking which fluctuated in severity. She had several mood indicators which included feeling tired or having little energy; feeling bad about herself; and trouble concentrating 7-11 days. She had verbal behaviors directed toward others 4-6 days but had no rejection of care or wandering. Her behaviors were managed with antipsychotic, anti-anxiety and anti-depressant medications. Current care plans indicated the following: Initiated 1/13/23: the resident had impaired cognition. Interventions, dated 1/13/23 included: allow resident time to respond, anticipate her needs when able, encourage activities, and offer support and reassurance. Initiated 12/22/22: elopement. Interventions, dated 12/22/22, included: provide resident with diversional task when exit seeking such as snack or drink. Initiated 1/3/23 and revised 8/28/23: the resident was at risk for behavioral disturbances related to dementia with behaviors, psychosis and mood disorder; currently receiving anti-depressant and anti-anxiety medications. The goal was for the resident to have no episodes of behaviors. Interventions, dated 1/3/23, included: 1 to 1 as needed, anti-psychotic medications per orders, monitor effectiveness of medications, observe for behaviors, let resident know what you are doing during care, approach her calmly and quietly, offer activity of choice, and psychiatric services per orders. Initiated 2/9/23: the resident had a diagnosis of insomnia. The goal was for the resident to be restful at night. Interventions, dated 2/9/23, were encourage her to avoid caffeinated foods prior to bedtime, encourage her to do more activities, medications as ordered; observe for effectiveness, and notify physician as needed. An Activity admission Evaluation form, dated 9/15/23 at 12:39 p.m., indicated the assessment was for re-admission to the facility, collected from the staff and was as follows: The resident had no religion type and had not practiced. She was oriented to person only. Poor short term/long term memory with short attentions span. She could read but not write. Her current recreational interests were art/crafts projects; spiritual programs/religious services; gardening; fitness/exercise; listening to music; social parties/group activities; talking/conversing; and enjoyed folding blankets and clothes. There was no information collected from the family regarding her activities preferences. The evaluation was summarized as the resident having a hard time participating in group activities due to anxiety and behaviors. She enjoyed independent activities such as folding laundry, but was unable to stay focused on a single task for extended periods of time. There was no care plan developed for activities or dementia programming. On 9/26/23 from 10:30 A.M. to 10:55 A.M., during a tour of the memory care unit (MCU), 5 residents were observed seated on the couch and in wheelchairs of the living room, watching a movie on the TV. Resident B was observed seated in a chair, which sat in back of the living room area. She had purple bruising beneath her left eye. CNA 5 (Certified Nurse Aide) was observed to assist the resident in putting on her jacket. CNA 5 moved away and the resident was observed to slowly and unsteadily rise up from the chair. She stood and fidgeted with her jacket and kept repeating she didn't know what was going on. She wore tennis shoes and had both legs visible beneath her pant legs, which showed ace wraps around her calves. She started to take off her jacket, let it fall to the ground, and started to remove her shirt. CNA 5 intervened and was overheard to tell the resident we are not gonna do this today and assisted the resident to put her arm back in the sleeve of her shirt and put back on her jacket. She slowly wandered around the living room area, into the hall towards the dining room, and back into the living room. The dining room/activity room was located across from the living room area and was dark with no lights on. Resident B had a frown on her face, furrowed eyebrows, grimacing at times, and tearfulness. She kept repeating she hadn't known where she was or what was going on and was very difficult to re-direct from her obvious anxiety. CNA 5 was interviewed and indicated they just let Resident B alone because she was non-redirectable. On 9/26/23 at 12:14 P.M., Resident B was observed in the dining room, seated at a table with other female residents and drinking lemonade. The dining room was quiet with no music or interactions occurring between residents or staff. On 9/26/23 from 3:35 P.M. to 3:55 P.M., the MCU was observed. There were 5 residents in the living room area playing balloon toss with an activities staff member. Resident B was observed slowly walking around the dining room. She went to the sink and turned on the water and rinsed her fingers, fiddled with the door to the refrigerator and walked slowly around the tables. She appeared sleepy, with her eyes half open and mouth drooping, and supported herself against the wall between the dining and living room. She indicated she was exhausted. She had worked all day helping her mother by doing all the dusting and laundry and was ready to rest. On 9/27/23 at 9:30 A.M., the MCU was observed. There were 3 residents sitting in the living room, all with their eyes closed and appearing to sleep. An activity staff member was in the corner of the dining room with 2 male residents and was painting their fingernails. Resident B was observed walking around the dining room and hall area. She appeared tired and confused. A review of progress notes indicated the following: On 8/15/23 at 7:18 p.m., the resident was readmitted to the facility. She was agitated and indicated she hadn't understood what was happening, needed to get out of here, and needed her purse. She was exit seeking and tried to push open the door to the unit. The behavior had occurred since 4 p.m. and attempts to redirect her with snacks, attention and TV were ineffective. On 8/16/23 at 2:25 a.m., the resident awoke at 2:00 a.m. and reported anxiety and being scared. She asked the nurse to prayer with her, which was effective and the resident returned to bed. At 11:15 a.m., the resident was seen by the psychiatric NP (Nurse Practitioner) and new orders were given for Xanax (anti-anxiety) 0.5 mg by mouth 3 times per day as needed x 14 days for anxiety. At 4:12 p.m., the resident was given Xanax 0.5 mg for anxiety/distress and exit seeking, which was ineffective. The note lacked non-pharmacological interventions attempted. On 8/17/23 at 5:23 a.m., RN 8 indicated the resident woke up briefly around 2 a.m., but was pleasant and allowed the nurse to complete her assessment. She had no reports of the resident having anxiety. At 5:35 a.m., the QMA (Qualified Medication Aide) administered Xanax 0.5 mg by mouth to the resident. There was no documentation to indicate symptoms or behaviors the resident was having. At 11:30 a.m., the resident had been observed walking the hallway when she reached for something on a room door, lost her balance, stumbled and fell onto her knees. She had no apparent injury. On 8/21/23 at 1:53 a.m. and 3:15 a.m., the resident had wandering/exit seeking behaviors, entered other resident rooms and took their personal belongings, wanted to call her mom and dad and indicated she needed to get out of here. Redirection was ineffective. At 9:50 p.m., the resident continued with anxiety and was combative with staff and used profanity. Xanax 0.5 mg was given and ineffective. The note lacked non-pharmacological interventions attempted. On 8/25/23, at unknown time, a behavioral health note, written by the therapist, indicated the resident had been seen for services related to specific behavioral and mood symptoms noted by staff including sundowning, anxiety, depression, pacing, exit seeking and delusions. During the visit, the resident was anxious, searching for her mother, and difficult to redirect. On 8/25/23 at 6:01 p.m., the resident was sitting in the dining room, sobbing and asking where are they. 1:1, redirection, and snacks were all ineffective. On 8/26/23 at 4:57 a.m. and 6:14 p.m., the resident paced the floor, was exit seeking, crying and made negative comments towards herself. On 9/4/23 at 3:15 a.m., the resident had broken sleep all night. She had been up and down from her bed and recliner and her behaviors were disruptive to her roommate. Redirection, multiple staff approach, food/drink, toileting, 1:1 and change of environment provided but ineffective. On 9/5/23 at 9:34 p.m., per shift report, the resident had been given Xanax at 3 p.m. due to tearfulness, exit-seeking, and hitting doors and tables. This shift, she continued to pace. She was encouraged to elevate her legs and rest but would only do so for very short periods of time (5-10 minutes). She paced the hallway and asked repeated unintelligible questions with expressions of worry about getting things done. 1:1 and calming talk with reassurance was effective for only brief periods of time. An Incident Note, dated 9/6/23 at 2:02 a.m., indicated Resident B had been smacked by Resident C in the face, and knocked off her glasses. The QMA separated them and notified the nurse. Resident B was crying and reported severe pain. She had a raised purple area to the corner of her left outer eye that measured 2 cm (centimeters) by 2.5 cm. An all over skin check was done and a large dark purple bruise was observed on her right breast that measured 9 cm by 11 cm and a smaller purple bruise measuring 2.5 cm by 3.5 cm to her outer right breast. Resident B was given some pain medication and offered ice for her left eye. Both were started on 15 minute safety checks. An IDT (Interdisciplinary Team) note indicated there had been an altercation between the resident and a peer. Resident B resided on the MCU with advancing dementia and periods of anxiety, sundowning, exit seeking and aggression towards others. She had a small hematoma/bruising to her outer left eye with no vision changes. She hadn't appeared to remember the incident and couldn't provide any details. She had poor sleeping patterns and had not slept much during the night in the last 72 hours. She paced the unit, often going/in and out of other rooms, banging on doors/tables and yelling throughout the hall. 15 minute safety and neurological checks would be done for the next 72 hours. The note hadn't indicated the resident had extensive bruising on her breast and there was no documentation about cause of the bruise. No new non-pharmacological interventions were addressed. A psych NP note, dated 9/6/23, indicated the resident's mood was fragile and she was verbally and physically aggressive. She was tearful with frequent mood swings and was difficult to redirect. She would be started on Xanax 1 mg tablet by mouth, 2 times per day and continue with Xanax 0.5 mg 3 times per day as needed. On 9/7/23 at 12:19 p.m., the resident was redirected numerous times throughout the day to take a rest from walking which she had been doing with her eyes closed. She was offered alternative activities. She sat down and ate her lunch with the other residents. On 9/8/23 at 2:37 p.m., the resident had been attempting to sit back into her wheelchair, but missed and landed on the carpet in front of her wheelchair in the lounge. New orders were received to discontinue the Xanax 1 mg 2 times per day but continue with the as needed Xanax 0.5 mg every 8 hours. On 9/9/23 at 5:31 a.m., Resident B had been able to go to sleep until 1:00 a.m. and woke up at 4:00 a.m. Upon awakening, she was uncooperative with care, paced the hallways, banged on the walls and begged to go to God and heaven and was upset staff couldn't take her there. She was toileted, given food and drink and given Xanax. On 9/10/23 at 3:19 p.m., the resident had a small bluish bruise to her left buttock most likely from fall on 9/8/23. She complained of discomfort and started to strip her clothes off saying I probably have a lot of bruises, do you want to see? On 9/13/23 at 3:21 p.m., a care plan meeting was held with the resident's daughter. Staff shared that the resident had been doing well with behaviors when they kept her busy doing house related activities such as folding laundry and helping with fake money. They requested the family bring in a purse for her to carry the fake money in. A behavior health note, dated 9/15/23 by the therapist, indicated the resident's mood was anxious/worried. Staff reported that the resident finally slept last night after 3 days with very little sleep. Her anxiety medications were decreased due to falling recently. There was no evidence of significant emotional distress but continued with much confusion. Therapist tried different music for her to listen to and she indicated she hadn't liked any of them. She relaxed when she was played sounds of the ocean-she actually had fallen asleep but had awoken startled and wanted to know if it was time to leave. The resident may benefit from some type of white noise in her room to sleep and may benefit from a weighted blanket. These interventions were not included in the resident's care plans. An Incident Note, dated 9/19/23 at 5:59 a.m., indicated the resident was observed to fall from the couch onto her bottom. She was assisted back into her chair. She reported pain in her chest where she had an old bruise. Bruising also remained to her buttocks, left eye and other scattered old bruises. On 9/21/23 at 5:21 a.m., the resident had slept from 9 p.m. until 3:30 a.m. and then got up and began pacing the halls, banging on the walls, and yelling out for help. She was crying and pushing the medication and treatment carts around. She was provided a snack, which helped. At 10:32 a.m., a weekly progress note indicated as needed Xanax had been effective for outbursts of yelling and self hurt (punching the wall with her fist). She participated in a coloring activity this a.m. On 9/23/23 at 5:27 a.m., the resident was anxious, pacing, and pounding on the walls. She had been given Xanax at 12:09 a.m. and had slept in the recliner chair until 4 a.m. When she got up, she began pulling on the couch, pounding on the doors, pulling on the railing, yelling for help, urinated in a wheelchair and trash can after being toileted. At 5:00 p.m., she had increased anxiety and abrupt behaviors; constant pacing; stated she wanted to die and hadn't wanted to be here. Xanax was administered per orders. The note lacked non-pharmacological interventions attempted. On 9/24/23 at 5:11 a.m., resident had been up all night exit seeking, banging on doors, screaming and going into other resident rooms. Redirection was unsuccessful. On 9/26/23 at 2:10 a.m., resident was screaming for help and disrobed 3 times. She declined to go to bed until 2 a.m. At 4:00 a.m., the QMA observed the resident fall from the recliner onto the floor. She had a small skin tear to her left lateral pinky finger which was cleansed and bandaged. At 1:18 p.m., new orders were gotten for extra strength Tylenol and Ibuprofen for pain. The note lacked non-pharmacological interventions attempted. On 9/26/23 at 2:08 P.M., the Director of Nursing (DON) was interviewed. She indicated staff had tried several interventions that were unsuccessful in managing her behaviors. The resident had previous inpatient psychiatric visits, prior to admission to the facility for dementia related behaviors. She would be prescribed medications and they would only work for short periods of time and then her behaviors would escalate. The extensive bruising to the resident's breast was reported to her, and she was told the resident would injure herself by running into the walls, furniture, and medication carts and would hit the walls with her fist. It had been assumed the extensive bruising and continued observation of new bruises was due to these episodes in addition to the falls. There was all new administrative staff, including the activities department. There was not a designated activities person for the MCU, or structured dementia programming at this time, but LPN 3 (Licensed Practical Nurse) was the newly designated MCU Director and would be working on activities for the unit. On 9/26/23 at 3:36 P.M., LPN 9 was interviewed. She indicated Resident B's behaviors were resistant to interventions and she would become angry and hit the wall with her hands but hadn't seen her purposefully run into objects to hurt herself. At times, the resident would swing her arms out at staff if she was upset and didn't want to be cared for at the time. On 9/26/23 at 3:38 P.M., CNA 12 was interviewed. She indicated activity staff would come down and do an activity with residents, usually once a day. Staff would play movies or music before supper. When Resident B had behaviors and was anxious, she would be comforted by staff sitting right next to her and touching her leg to leg however, when staff had to get up and move away, she would get anxious again. She had witnessed the resident hitting the wall before in frustration and anger. 2. On 9/26/23 at 3:45 P.M., Resident C was observed lying in her room in bed. Her eyes were open and she smiled. She was holding a stuffed dog. She had not been observed during the day to be up in her wheelchair. On 9/27/23 at 12:33 P.M., Resident C's record was reviewed. Diagnoses included Alzheimer's disease with late onset, dementia with behavioral disturbances, depression and delusional disorder. A quarterly MDS assessment, dated 8/17/23, indicated the resident had severely impaired cognition. She had no mood indicators or behaviors. Current care plans included the following: Revised on 9/14/23: the resident had mood issues exhibited by delusions such as looking for children and people in her house; entering others rooms to look for them, yelling at staff to get out and becoming agitated and aggressive at times. Goals included: Her verbal aggression and anger towards other would not result in injury to self or others. Interventions included: provide support with skills to de-escalate, cope, and manage stress, provide pet therapy or animal visitors, take outside for sunshine and fresh air, listen to her concerns and follow up on these promptly, provide support and encouragement, and psych services to follow as needed. Initiated on 11/11/19: Resident had insomnia and was prescribed routine medication for sleep. Interventions included: assess for pain. Initiated on 10/22/19: the resident had depression due to losses and decline in health. Her depressive symptoms were crying, tearfulness, and irritability. Interventions included: provide support and encouragement as needed. A psych NP note, dated 8/30/23, indicated the resident was seen for having episodes of tearfulness and expressions of pain from recent hip fracture. Her pain medication had been increased, which helped, and she did well when her pain was under control. She was described as doing better after being transferred back to memory care. She did become teary in the evening hours with increased dementia symptoms. She was observed on this day resting in bed and pleasantly confused. Staff were to monitor and document any new or worsening behaviors. She was to continue on her anti-depressant and medication for her sleep disorder. A review of progress notes indicated the following: On 9/2/23 at 5:17 a.m., the resident had intermittent crying and anxiety during the evening. She was consoled by talking and back rub. She was assisted to bed and asleep at 9:30 p.m. These successful interventions were not added to the care plan. On 9/3/23 at 4:30 a.m., the resident slept for about 1-2 hours tonight and had 2 episodes of crying. The note lacked non-pharmacological interventions attempted. On 9/6/23 at 1:54 a.m., the QMA reported that Resident C smacked another resident in the face, knocking off her glasses. The residents were immediately separated. The resident declined vitals and assessment. The resident was started on 15 minute safety checks. An IDT note, dated 9/6/23 at 9:58 a.m., indicated the resident had a physical altercation with another resident. She had a history of aggression towards others and had fluctuating moods at times. She was often up during the night hours and would nap during the day. Investigation indicated the resident was attempting to convince Resident B to sit down and when Resident B yelled, she struck her with an open hand, in her face and knocked her glasses off. The residents were separated and the resident was redirected and left alone. Staff had reported an increase in frequency of aggressive behaviors which had become worse in the evening/night hours. The note lacked non-pharmacological interventions to be added to the plan of care. A psych NP note, dated 9/6/23, indicated the resident had behaviors that were aggressive and occurred mostly at nighttime with tearfulness. Her antipsychotic medication was re-ordered after having been discontinued in April 2023. An Incident Note, dated 9/8/23 at 4:54 a.m., indicated the resident continued on 15 minute safety checks. She had denied having any pain, but was observed to be limping. She was not aggressive but had anxiety, depressive symptoms, restlessness and insomnia. She declined to lay in bed until 1:20 a.m. but was up again at 1:45 a.m., crying, indicating she needed to go home. She was assisted home, toileted and back to bed at 1:50 a.m. but was back up 10 minutes later crying and unable to indicate what was wrong. She laid back down and fell asleep after 3 a.m. The note lacked non-pharmacological interventions attempted. On 9/10/23 at 3:00 a.m., the resident had increased agitation, resistance to care and physical aggression toward staff and other residents on shift. She finally calmed after multiple interventions, 1:1, calm approach by multiple different staff, change of environment, food and drink. At 9:23 p.m., the resident had been tearful for the past hour and was now showing aggressive behavior towards staff and another resident. She was cursing and swinging and hit the nurse in the jaw and CNA in the arm. The note lacked non-pharmacological interventions attempted. On 9/11/23 at 10:15 p.m., resident was combative with staff after dinner. She punched staff, threw objects and attempted to be combative with other residents. She was able to be calmed down some but continued with behaviors. On 9/12/23 at 9:19 p.m., reported that resident had slept all day. She was tearful during the evening, but unable to say what was wrong. A psych NP note, dated 9/20/23, indicated the residents family had expressed concern about the resident being restarted on her antipsychotic and was requesting it be discontinued. Hospice services were meeting with the family on this day due to the resident significant change in condition and ongoing decline. Antipsychotic medication was to be weaned and discontinued in 7 days. On 9/21/23 at 1:27 a.m., the resident was admitted to hospice on 9/20/23 for Alzheimer's dementia. The QMA reported the resident had been angry and was swinging an object at staff because she hadn't wanted care. The note lacked non-pharmacological interventions attempted. On 9/22/23 at 1:41 a.m., per shift change, the resident was combative, resistant to care, aggressive and punched someone,which was reported to management. At bedtime, she had weakness and was resistant to help up from the couch into her wheelchair. On 9/27/23 at 9:25 A.M., CNA 8 was interviewed. She indicated Resident C was very sweet and used to care for herself but now was no longer eating, required assistance and could be combative with care. The previous week, there had been an altercation with another resident- not Resident B- but hadn't thought there were anymore. On 9/27/23 at 10:09 A.M., the DON was interviewed. She indicated Resident C had been upset with another resident and had yelled at her. She attempted to smack the other resident, but the QMA intervened before contact was made. The residents were separated from one another. The facility tried to staff a QMA and a CNA on night shift on the MCU, but they were having difficulty with staffing. She acknowledged there had been only a QMA working the night of 9/6/23, when the altercation occurred between Resident B and Resident C, making it difficult for 1 staff member to provide care and supervision to residents with behaviors. On 9/27/23 at 12:15 P.M., the DON provided a current copy of the facility's policy, titled A Dedicated Dementia Care Unit Philosophy which indicated the following: .We believe that the quality of life for our resident's are enriched when their days are filled with meaningful and enjoyable structured activity. We believe that this activity serves as a powerful coping mechanism in times of fear and stress .The memory care unit provides a specific and screened population, a safe and secure environment that is not overstimulating, free from unnecessary medications, provides activities structured specifically for functionally limited residents, offers rich sensory stimulation, residents are treated with dignity and respect, are provided with patience, dignity and acceptance and resident behaviors are interpreted and not challenged This Federal tag relates to Complaint IN00417508. 3.1-37(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure communication of code status for 1 of 3 residents reviewed. (Resident 37) Findings include: Resident 37's record review, began on [DATE] at 1:55PM, diagnoses included Alzheimer's disease, epilepsy, and weakness. Resident 37 had an active order of full code (to have Cardiopulmonary Resuscitation) dated [DATE]. The current quarterly comprehensive assessment indicated a BIMS (Brief Interview Mental Status) score of 99. The score of 99 indicated severe cognitive impairment. Resident 37's comprehensive care plan indicated she was a full code. Resident 37's face sheet indicated she was a full code. During an interview on [DATE] at 7:13 AM RN 6 indicated she relied on information from shift change report and electronic medical record to include: face sheet, orders, and care plan to provide person centered care to residents. During an interview, on [DATE] at 9:32 AM, the DON (Director of Nursing) indicated resident should have an order and care plan regarding current code status in the medical record. The DON indicated they refer to orders and face sheet for code status. The DON indicated she would investigate current code status of full code. On [DATE] at 10:11 AM, an order for DNR (Do not Resuscitate) was entered. On [DATE] at 9:04AM the Administrator provided a preference for DNR status signed by Resident 37's husband on [DATE]. The Administrator further provided a care plan with the focus of DNR code status. The date initiated was [DATE] with revision on [DATE]. In an interview on [DATE] at 9:28 the DON indicated she updated the previous care plan of full code to accurately reflect DNR. She indicated she possibly should have resolved the previous code status focus in the care plan and started a focus on the DNR status to make clear the resident husband's choice of code status. On [DATE] Resident 37 was a full code. Resident 37's code status should have changed when a new preference form (post) was signed by the husband on [DATE]. If Resident 37 would have had a cardiovascular event the facility would have performed CPR between the dates of [DATE] and [DATE] when the correct code status was entered. A policy titled, Directives Policy and Procedure was provided by the Administrator on [DATE] at 9:04AM, the last revision date of policy was 6/2020. The policy indicated Procedure: 5. The resident desires will be re-evaluated on an annual basis or upon a change of condition as indicated to ensure the resident's/legal representative's choices were honored timely . 3.1-4(d)

Based on observations, and interview, the facility failed to ensure kitchen sanitation was maintained for 40 of 41 residents who resided at the facility and ate their meals prepared in the kitchen. Findings included: On 8/10/2023 at 9:06 AM an observation of kitchen with [NAME] 2 was completed. The steam table had a white residue located on the lids. The steamer had a white residue coming down from the bottom of the door. Behind the steam table, the panel on the wall had multiple brown specks all over. The panel was coming down off the wall, behind the panel could be observed. In front of the coffee machine there were sticky brown substances all over. The oven toaster had build up layers of black flaky particles on top and inside. The oven had discolored particles located on the front. The stove had burnt layers, black substances located all over and food particles inside of the burner. During an interview at that time, [NAME] 2 indicated she was the only employee in the kitchen on 8/10/23. They had about 40 residents to eat out of the kitchen, and she would prep for everyone. During an observation on 8/10/2023 at 11:44 AM, [NAME] 2 was taking temperatures of the food. The lids of the steam table were pulled off and placed below the steam table, on the shelve there were several white residue spots. The lids were placed on that shelf. During lunch service, there was another staff observed putting up the shipment in the dry storage area located in the back of the kitchen. No cleaning was observed. In an interview on 8/10/2023 at 1:32 PM, [NAME] 2 indicated the kitchens didn't have a cleaning schedule. The DM and her just picked out what they were going to clean and clean it. The dishwasher, and the coffee machine should be cleaned twice a week, the stove was cleaned once a week. The steam table and the steamer were once a day. The steam table was to be cleaned and drained. The panel on the wall started to come off when they moved the steam table along the wall about a week prior. It was sideways but it just got in the way there,sto they moved it along the wall. The panel started to come off due to the steam. They told the maintenance man they needed it replaced but he was no longer here. In an observation at 2:00 PM with the Regional Operation Manager of the kitchen, all areas were observed. During an interview at that time, the Regional Operation Manager indicated the DM was off that day. So, they asked another staff member from a different facility to come and help. The Regional Operation Manager was aware they did not have a schedule for cleaning and indicated they did not have a facility policy. In an interview on 8/15/2023 at 9:52 AM, the Director of Nursing indicated there was one person in the facility that does not eat from the kitchen. The facility census was 41. 3.1-21(i)(1) and (3)

Based on interview and record review, the facility failed to ensure a process was in place to identify and correct quality deficiencies for 41 of 41 residents currently residing in the facility. Findings include: A QAPI (Quality Assurance Performance Improvement) committee list was provided by the Administrator on 08/14/23 at 10:00 AM. The member list included the Administrator, Director of Nursing, Infection Preventionist, Medical Director, Business Office Manager, Maintenance, Activities, Dietary, Pharmacy, and Medical Records. There was no policy and procedure provided prior to exit regarding QAPI. In an interview on 08/16/23 at 10:51 AM the Administrator indicated the QA committee met monthly. Issues in the facility were tracked and trended through the committee monthly. She indicated the QAPI process was utilized to improve processes within the facility. The facility had a schedule of processes to review each month to ensure improvement of operations. The Administrator indicated the performance improvement plan for Advanced Directives had begun 08/14/23. The facility annual survey completed on 09/29/22 identified noncompliance regarding Advanced Directives. The facility was also found to be noncompliant regarding Advanced Directives on 08/16/23. Refer to tag F0578. 3.1-52

Based on observation, interview and record review, the facility failed to implement fall interventions and update the care plans to prevent further falls for 2 of 3 residents reviewed (Resident U and Resident V). Findings include: 1. On 11/7/22 at 11:23 A.M., Resident U's record was reviewed. Diagnoses included heart failure, chronic obstructive pulmonary disease, and major depressive disorder. A quarterly MDS (Minimum Data Set) assessment, dated 8/24/22, indicated the resident had a BIMS (Brief Interview Mental Status) score of 8 indicating the resident had moderately impaired cognition. He required limited assistance of 1 staff member for bed mobility and transfers. He was non-ambulatory and dependent on staff for locomotion on/off the unit in his wheelchair. He required extensive assistance of 2 for toileting. A care plan, initiated 6/6/22, indicated Resident U was at risk for falls due to his condition and risk factors, history of falls, confusion, weakness, use of assistive device, balance disorder, staff support to transfer, difficulty rising from chair or toilet, and use of psychoactive medications. The goal was for his many fall risk factors to be reduced in an attempt to avoid significant injury related to falls. Interventions and dates implemented were: analyze previous falls to determine a pattern or trend (11/5/22); bed in lowest position (6/16/22); bed wheels locked at all times (6/16/22); call light in reach-explain use and reinforce as needed (5/17/22); low bed with mat next to bed (5/26/22); monitor for changes in gait/positioning (5/17/22); notify doctor of changes in condition (5/17/22); offer to lay down after meals (7/23/22); reinforce need to call for assistance (11/5/22); apply alarms for wheelchair and bed when up/laying down and check frequently for activation and proper functioning (11/5/22); when trying to get up unassisted, offer diversional activities such as a busy box (6/16/22); alarm on bed (11/5/22); alarm on wheelchair when up (11/5/22). On 11/7/22 at 11:50 A.M., Resident U was observed seated in his wheelchair in the dining room with his spouse. He was very frail appearing with an ashen color to his skin. He was very slow to respond to his spouse speaking to him and was observed to have poor eye contact. His wheelchair was up to the table and his right foot rested on an empty chair under the table. He wore a nasal cannula and was receiving oxygen. He wore no alarms on him nor was a chair alarm box noted to be attached to the chair. His spouse indicated staff didn't use alarms any longer because he would take them off. She indicated she doubted staff could even hear them if they were used because his room was down the hallway and furthest from the nurses station. She would like for the resident to be moved closer to the nurse's station but was told that wasn't possible due to unavailability of male rooms. She indicated the resident believed he was still capable of doing things for himself and continued to try which resulted in falls. The resident had a long history of falls, however his spouse indicated he'd never had so many in 1 month and it was very distressing to her. Fall reports, indicated Resident U had falls on 10/2, 10/12, 10/14, 10/19, 10/28, 10/29, 10/30, and 11/3/22. Review of fall reports indicated the following: -10/2/22 at 3:45 p.m., the resident was observed on the floor in his room after attempting to get out of bed by himself. He was assisted into his wheelchair and placed at the nurse's station for closer observation until bedtime. The fall investigation form was blank and there was no root cause analysis completed nor changes made to his care plan. -10/12/22 at 5:00 p.m., the resident was observed on the floor in his room next to his bed. He had attempted to get up from bed himself and into his wheelchair. The wheelchair locks were observed to not be on at the time he attempted the transfer. An occurrence assessment indicated the resident had no apparent injury. Staff initiated 15 minute checks which were documented until 10/15/22. The fall investigation form was blank and there was no root cause analysis completed or changes made to his care plan. -10/14/22 at 4:20 p.m., Resident U attempted to reach for something in the dining room, slipped out of his chair, and hit his head on the floor which resulted in bruising to the left side of his head and a large skin tear to his left middle finger. The report hadn't indicated if the fall was witnessed or unwitnessed. The resident continued on 15 minute checks from the fall that occurred on 10/12. The resident was educated to ask for help and not reach for things unassisted due to falls. There was no fall investigation form initiated and no changes made to his care plan. -10/19/22 at 5:30 p.m., the resident was in the dining room where he was found on the floor lying on his right side. He had no apparent injuries. He was placed on 15 minute checks. The fall investigation form was blank and there was no root cause analysis completed or changes made to his care plan. -10/28/22 at 2:45 p.m., the resident had a witnessed fall from his wheelchair while in the dining room. He attempted to get bingo chips up off the floor and fell forwards out of his chair. The fall investigation form was blank and there was no root cause analysis completed or changes made to his care plan. -10/29/22 at 9:30 a.m., the resident had an unwitnessed fall. He was observed on the floor in front of his bed lying on his oxygen tank. He had attempted to get into bed from his wheelchair whose brakes were locked. Staff indicated prior to the fall, the resident had been in the hall lounge looking at the birdcage and had then propelled himself down the hallway to his room. The unsigned/undated fall report indicated interventions were to assess for a toileting program/toilet him, put call light in place, and assess proper equipment usage. He was to have frequent checks and routine scheduled care times. He was to be asked after meals if he wanted to lie down. The fall investigation form indicated the resident should not be alone in his room while up in his wheelchair. There were no changes made to the care plan. -10/30/22 at 11:00 a.m., the resident fell in his bathroom when trying to go to the toilet. He was on the floor sitting on his bottom with his wheelchair near him and whose brakes were unlocked. He indicated he was trying to get off the toilet and into his wheelchair after using the toilet. He indicated he hit his head when he fell. Immediate intervention was to provide 1:1 supervision. The fall investigation indicated he often made attempts to self transfer and forgot to call for assistance. He required frequent checks and routine care. He had alarms which he deactivated. Staff were inserviced to check his alarms frequently and provide 1:1 care when restless. There were no changes made to the care plan. -11/3/22 at 11:15 a.m., the resident was found on the floor in the doorway to his room with his wheelchair nearby. He had no apparent injuries and 15 minute checks were put into place. There was no fall investigation report available to review. A CNA care sheet, provided by the Administrator on 11/7/22 at 11:59 A.M., indicated Resident U had a low bed and mat beside, should have his call light in reach at all times, and liked to lay down after meals. The sheet did not indicate the resident used a safety alarm when in bed and in his wheelchair. On 11/7/22 at 1:45 P.M., CNA 2 (Certified Nurse Assistant) was interviewed. She indicated Resident U was supposed to have a safety alarm on when in bed and in his wheelchair. On 11/7/22 at 1:47 P.M., the Administrator was interviewed. She indicated Resident U was to wear a safety alarm when in bed and his wheelchair. She indicated there had been some confusion with staff regarding use of the alarms and he had not had it on when up in his chair but should have. 2. On 11/7/22 at 1:30 P.M., Resident V's record was reviewed. Diagnoses included dementia, deafness, atrial fibrillation, history of falls, and presence of cardiac pacemaker. An admission MDS assessment, dated 9/12/22, indicated the resident's cognitive status was unable to be assessed due to resident being deaf and inability to communicate. He required extensive assistance of 2 for bed mobility and transfers. He was non-ambulatory and was dependent on staff for locomotion on/off the unit using his wheelchair. A care plan, initiated on 9/12/22, indicated Resident V was at risk for falls due to his condition and risk factors of confusion, being deaf, incontinence, and dementia. The goal was to reduce his fall risk factors in an attempt to avoid significant injury related to falls. Interventions and dates implemented were: bed in lowest position (9/26/22); call light in reach (9/2/22); low bed with mat next to bed (9/26/22); monitor for changes in gait/positioning (9/2/22); and notify doctor of changes in condition (9/2/22). On 11/2/22 at 9:35 A.M., Resident V was observed seated in the lounge area, in a wheelchair. His head was down and he leaned to the left side. His left arm hung over the arm of the wheelchair and his hand laid on the floor. A female resident seated near him, was observed to try and motion to staff passing by to get attention and assistance for the resident. A staff member approached the resident and indicated he had been having extreme leaning in his chair and she would assist him to go lie down. On 11/7/22 at 1:50 P.M., Resident V was observed lying down in bed in his room. There was no mat lying next to the bed but one was observed folded and leaning against the wall across from his bed. Progress notes indicated the following: -9/9/22 at 11:08 a.m., the nurse went down to resident's room to assess him for slumping in his wheelchair. He was put into bed with his floor mat on the floor. Staff would continue to monitor him. -9/18/22 at 2:05 p.m., the resident was found on the floor in front of his wheelchair at 1:40 p.m. He had been in a sitting position on the floor with both hands flat on the ground. He was assisted back into his chair. -10/7/22 at 2:34 p.m., the resident's spouse called and wanted to know if the resident could get a Broda chair for positioning. She indicated he had one at his previous facility and sat up well with it. The request was passed onto the Director of Nursing (DON). Occurrence Investigations indicated: -10/3/22 at 12:20 a.m., Resident V was found on the floor next to his bed and appeared to be trying to get out of bed. He was found on the floor mat, on his bottom with his legs outstretched in front of him and his back against the bedframe. He was placed on 15 minute checks. The fall investigation form was blank and there was no root cause analysis completed or changes made to his care plan. -10/7/22 at 4:15 p.m., the resident was found in his room on the floor next to his bed. He had an injury to his right hip and knee where he had landed on it. His bed was not in the lowest position. The fall investigation form was blank and there was no root cause analysis completed or changes made to his care plan. A Care Plan Meeting note, dated 10/12/22 at 10:57 a.m., indicated a meeting had been held with the resident's spouse and his care plan reviewed. He had been slouching in his chair. His spouse indicated she wanted him to get up but didn't want him to sleep in his wheelchair. She asked about the use of a Broda chair but didn't want to try it so the resident could still wander. A CNA care sheet, provided by the Administrator on 11/7/22 at 11:59 A.M., indicated Resident V used a wheelchair but hadn't indicated he had a low bed with a mat to the floor. The sheet hadn't indicated the resident had extreme leaning when in his wheelchair which was a risk for falls. On 11/7/22 at 1:44 P.M., LPN 5 (Licensed Practical Nurse) was interviewed. She indicated Resident V was having some changes in his condition and the Nurse Practitioner had been notified. The resident had been having issues with leaning while in his wheelchair and on 10/17/22, began working with occupational therapy to assist with this. He remained a fall risk due to extreme leaning in the chair and when in bed due to previous falls. On 11/7/22 at 2:51 P.M., the Certified Occupational Therapy Assistant was interviewed. She indicated she was trying to work on positioning with the resident following his falls but he was not very cooperative. He had very little upper extremity control, weakness, and fatigue. She had considered the use of a Broda chair but that would limit his mobility. A current facility policy, titled Fall Management Procedure was provided by the Administrator on 11/7/22 at 2:25 P.M., and stated: Purpose: To assess all residents for risk factors that may contribute to falling and to provide planned interventions to help prevent falls as identified by the team and based upon root cause analysis to prevent reoccurrence .B. Immediately post fall-an intervention must be put into place to prevent reoccurrence, if no intervention can be determined to be appropriate at the time, the resident should be placed on 15 minute checks .until the IDT can review the fall circumstances and determine an appropriate fall prevention intervention/s. C. The intervention immediately implemented must be documented on the Occurrence Assessment of the fall, communicated to staff and added to the Health Care Plan. D. Update the plan of care each time there is a change in intervention and communicate it to staff .Post Fall Investigation .IV. IDT team will meet when possible and review documents related to the fall and will complete a root cause analysis to determine the root cause of the fall. Interventions will be determined by root cause analysis and may include the immediate intervention already put into place, could be added to this intervention or could replace the immediate intervention .VI. The resident's Health Care Plan will be updated/revised to include all interventions implemented by the IDT team. VII. Staff caring for the resident will be informed of care plan changes per assignment sheet, verbal report and/or huddles This Federal tag relates to Complaint IN00392499. 3.1-45(a)