Based on observation, interview, and record review, the facility failed to provide daily grooming assistance for 1 of 3 residents reviewed for Activities of Daily Living (ADLs). (Resident 3) Findings include: During a random observation, on 12/26/24 at 12:40 p.m., Resident 3 was sitting in a wheelchair in front of her television. Her fingernails were long and had a brown substance under the tips. Resident 3 indicated staff normally kept up on her nails, but they had been busy lately. During an interview, on 12/27/24 at 9:50 a.m., Resident 3 indicated she had received a shower yesterday. Resident 3's fingernails were observed to be long and had a brown substance under the tips. During an interview, on 12/30/24 at 9:51 a.m., Resident 3 indicated she would get a shower that night and she wanted her nails cut. Her nails remained long and had a brown substance underneath the tips. Resident 3's clinical record was reviewed on 12/30/24 at 10:01 a.m. Diagnoses included major depressive disorder, bipolar disorder, chronic kidney disease stage 3, emphysema, dyspnea, and borderline intellectual functioning. An annual Minimum Data Set (MDS) assessment, dated 9/29/24, indicated Resident 3 was cognitively intact. No behaviors were identified during the assessment period. She required partial/ moderate assistance of staff for showering/bathing self, upper and lower body dressing and personal hygiene. Rejection of care was not present during the assessment period. The Point of Care notes for nail care indicated Resident 3 had accepted complete nail care (clean, cut, and file) on 12/2/24, 12/9/24, 12/16/24, 12/23/24, and 12/30/24. During an interview, on 12/31/24 at 8:39 a.m., Resident 3 indicated she had asked staff to cut her nails the night before. Her nails remained long and had a brown substance underneath the tips. During an interview, on 12/31/24 at 8:47 a.m., CNA 10 indicated activities staff trimmed residents' nails once a week. During an interview, on 12/31/24 at 8:48 a.m., Activities Staff 45 indicated the nurse, or the CNAs trimmed the residents' nails. During an interview, on 12/31/24 at 9:00 a.m., CNA 12 indicated the nurse trimmed Resident 3's nails on shower days. During an interview, on 12/31/24 at 9:04 a.m., the ADON indicated the facility did monthly nail checks on all the residents. If a resident refused nail care, it would be documented in the progress notes. Nail care meant the nails would be cleaned, but not necessarily cut. She indicated she would speak with Resident 3 about receiving nail care. During an interview, on 12/31/24 at 1:40 p.m., the DON indicated CNAs trimmed non-diabetic residents' nails on their shower days. It would be documented under their point of care charting tab. During a random observation, on 1/2/25 at 2:26 p.m., Resident 3's nails were short and had a brown substance underneath the tips. During an interview, on 1/2/25 at 1:59 p.m., CNA 14 indicated Resident 3's nails were not that long and didn't feel they were too dirty. She did not try to cut the residents' nails as the resident liked them mid-length but did clean them. Nails should be trimmed on the first shower day of the week. During an interview, on 1/2/25 at 2:05 p.m., CNA 15 indicated she cleaned Resident 3's nails during her shower. The resident's nails were mid-length, but not that dirty. It was normal for Resident 3 to have her nails clean and by the next morning have debris under her nails. Resident 3 didn't normally ask for her nails to be trimmed. A current facility policy, provided by the Administrator on 1/2/25 at 2:10 p.m. and titled Activities of Daily Living, indicated . A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene 3.1-38(3)(E)

Based on interview and record review, the facility failed to provide supervision to prevent repeated falls for 1 of 3 residents reviewed for falls. (Resident 30) Findings include: Resident 30's clinical record was reviewed on 12/30/24 at 9:11 a.m. Diagnoses included Alzheimer's disease with late onset, dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, essential hypertension, and anxiety disorder. Current physician orders, on 12/30/24, included amlodipine besylate (anti-hypertensive) 2.5 milligram (mg), Celexa (antidepressant) 10 mg, buspirone (antianxiety) 10 mg, and Rozerem (sedative) 8 mg. Ordered fall interventions included the following: non-skid strips next to bed, chair and toilet, red non-slip placemat to bedside table, touch pad call light, leave bathroom light on at night, Dycem (anti-slip mat) to recliner, bed height marked at 24 inches top of mattress per therapy, keep walker within reach at all times, Every one hour safety checks, stop sign to bathroom door (keep door shut with sign up, do not leave on toilet unsupervised, keep call light on left side when in bed, door chime to bathroom door, concave mattress, offer bedtime snack, call light wrapped in glow in the dark tape, floor mat at bathroom side of bed, weighted blanket while in bed, encourage to sit in lounge during the day, bed against well, and frequent verbal cues to utilize call light. A quarterly Minimum Data Set (MDS) indicated Resident 30 was moderately cognitively impaired. She had no impairment on her upper and lower extremities. She needed moderate assistance from staff for upper and lower body dressing, and toileting. She required substantial/ maximal assistance from staff for personal hygiene. She required supervision or touching assistance from staff for sit-to-stand transfers, toilet transfers and shower transfers. Resident 30 experienced two or more falls since the prior assessment. A care plan, initiated on 11/11/21 and revised on 10/28/24 , indicated Resident 30 would be free from falls with significant injury thru the next review. Interventions included: assess fall risk potential at admit, quarterly and with significant changes, assist with transfers, toileting, and ambulation as needed, bed against the wall, bed height marked at 24 inches top of mattress per therapy, call light cord wrapped in glow in the dark tape, concave mattress to bed, do not leave the resident on the toilet unsupervised, door chime to bathroom door, Dycem to recliner, encourage resident to sit in the lounge during the day, floor mat on bathroom side of bed, frequent verbal cues to utilize call light, keep call light and personal belongings within reach, keep call light on left side of bed when in bed, keep walker within reach at all times, leave bathroom light on at night, monitor blood pressure per order, monitor for medication side effects, monitor in fall risk meeting for four weeks after admit or fall, motion alarm sensor to the bathroom door, non-skid strips next to bed and chair and in front of the toilet, offer a bedtime snack, orient to room, bathroom and call light, Every one hour safety checks 3P's, red non-slip placemat on bedside table, restorative nursing program six times per week, stop sign to bathroom door, touch pad call light, vitamin D per orders and weighted blanket while in bed. A nursing progress note, dated 10/12/24 at 5:32 p.m., indicated Resident 30 was sitting on the floor directly in front of her recliner. She was sitting up on her buttocks with her legs bent up in front of her. The resident indicated she was going to the bathroom and lost her balance causing her to fall. Resident 30's walker was within reach; she was wearing socks and shoes. A head-to-toe assessment was completed. No injuries, redness, or bruising was noted due to the fall. The resident was assisted off the floor and into a standing position by two staff members. The resident denied any pain or discomfort and she was ambulating per her usual. A nursing progress note, dated 10/13/24 at 2:15 p.m., indicated Resident 30 had complaints of left wrist pain and was requesting Tylenol. Resident 30's left wrist was slightly discolored and appeared to be turning into a bruise, although the discoloration wasn't quite purple in color. Her left wrist was slightly swollen. A suspected cause was from the resident being found on the floor around midnight last night. A new order was received for a left wrist x-ray. A nursing progress note, dated 10/14/24 at 3:21 a.m., indicated Resident 30 had a left distal radial fracture (a break in the radius bone near the wrist). A progress note, dated 10/14/24 at 9:51 a.m., indicated the nurse practitioner ordered that the resident be seen in the orthopedics' walk in clinic that day. A nursing progress note, dated 10/14/24 at 11:00 a.m., indicated Resident 30 returned for the orthopedic walk- in clinic with a cast placed on her left wrist. The resident was able to move all her fingers and thumb. She was to follow up with the orthopedics walk-in clinic in three weeks for x-rays and to ensure proper healing. A nursing progress note, dated 10/14/24 at 3:12 p.m., indicated Resident 30's code blue alarm was sounding. Resident 30 was sitting on her buttocks on the bathroom floor directly in front of the toilet. Staff were with the resident at the time of the fall and stated the resident left go of the railing and started to fall backwards. The staff member were able to lower the resident down to the floor. The resident did not hit her head. A head to toe assessment did not indicate injuries. A Morse Fall Scale report, dated 10/21/24, indicated Resident 30 was at a high risk of falling. A nursing progress note, dated 11/7/24 at 1:28 p.m., indicated Resident 30 was found sitting on the floor on the far side of the bed. The resident stated she slid/ lowered herself to the floor. She was assessed for injuries and denied hitting her head. The resident was assisted off the floor by staff members and her bed was moved against the wall. A nursing progress note, dated 11/17/24 at 11:26 p.m., indicated Resident 30 was found sitting beside her bed on the protective floor mat. A walker was beside the resident. Resident 30 indicated she was not trying to go to the bathroom. The resident denied bumping her head or having any pain/ discomfort. The resident was assisted back to bed by staff members. No apparent physical injuries were noted after the resident was assessed for injuries. A Fall Risk Evaluation, dated 11/17/24, indicated Resident 30 had three or more falls in the past three months, intermittent confusion, she was ambulatory, had poor vision, balance problems with walking, and decreased muscular coordination. A nursing progress note, dated 11/30/24 at 7: 45 p.m., indicated Resident 30 was found on the floor in her bathroom. The resident's walker was in the bathroom with the resident. The resident was wearing her tennis shoes. She indicated she was trying to go to the bathroom and missed the toilet. No injuries were noted after assessing the resident. A nursing progress note, dated 12/5/24 at 10:29 p.m., indicated staff heard a crash and found Resident 30 sitting on the floor mat by her bed. The nurse assessed the resident for injuries. The resident denied hitting her head and denied any pain. The resident's left elbow was pink and had a superficial scratch without any drainage. The resident was assisted to her feet by staff members and ambulated to the restroom. A progress note, dated 12/9/24 at 11:37 a.m., indicated a Fall Risk sign was placed in the resident's room. Point of Care documentation for every hour safety checks for the month of December 2024 were not completed as ordered. During an interview, on 1/2/25 at 9:42 a.m., CNA 17 indicated Resident 30 was on fall interventions including multiple motion censors and every hour safety checks which included checking for pain, potty, and position. Documentation was under the task tab in the computer. During an interview, on 1/2/25 at 9:43 a.m., the ADON indicated Resident 30 had numerous fall interventions in place, including hourly safety checks. Those safety checks included making sure the resident's needs were met. Documentation was listed under the task tab on the computer. Staff members checked it off once they have completed the checks. It should be checked off every hour. During an interview, on 1/2/25 at 10:31 a.m., CNA 18 indicated Resident 30 was on hourly rounding. Hourly rounding documentation was listed under the task tab. During an interview, on 1/2/25 at 1:53 p.m., the Administrator indicated the CNAs generally charted at the end of their shift and it would take time to back time all of their rounding's throughout their shift. A current policy, titled Fall Program, provided by the Administrator, on 1/2/25 at 2:10 p.m., indicated the following: .Interventions will be put in place based upon the assessment and as prevention for all new residents along with care plan review 3.1-45(a)(2)

Based on observation, record review, and interview, the facility failed to ensure appropriate clinical indications for the use of an antipsychotic medication for 1 of 5 residents reviewed for unnecessary medications. (Resident 2) Findings include: During an observation, on 12/26/24 at 12:42 p.m., Resident 2 sat in a recliner with her feet elevated. The television was on. During an observation, on 12/30/24 at 9:44 a.m., the resident sat in a recliner with her feet elevated. The television was on. During an observation, on 1/3/25 at 2:35 p.m., the resident sat in a recliner and looked at a book. Resident 2's record was reviewed on 12/30/24 at 10:24 a.m. Diagnoses included other recurrent depressive disorders, anxiety disorder, unspecified dementia, moderate with mood disturbance, unspecified dementia, moderate, with anxiety, and major depressive disorder, single episode, severe with psychotic features. Physician's orders included donepezil (for Alzheimer's) 10 milligrams (mg) - daily at bedtime (12/16/24), citalopram (antidepressant) 20 mg daily (5/2/24), risperidone (antipsychotic) 0.25 mg daily at bedtime (11/6/24), and tramadol (for pain) 50 mg two times a day (11/19/24). A 12/20/24 Minimum Data Set (MDS) assessment indicated the resident was cognitively intact. The resident felt down, depressed, or hopeless two to six days of the assessment period. She sometimes felt lonely or isolated from those around her. The resident exhibited verbal behavioral symptoms directed toward others one to three days of the assessment period. The resident wandered one to three days of the assessment period. The wandering did not put the resident at significant risk at getting into a potentially dangerous place. The resident's current behavior status, care rejection, and wandering had worsened since the prior assessment completed on 11/6/24. The resident required partial/moderate assistance with eating, oral hygiene, toileting, showering /bathing self, upper and lower body dressing, putting on /taking off footwear, and personal hygiene. Resident 2's current care plan for anxiety indicated episodes of anxiety and was to be observed for repetitive questions or statements, irritability, shortness of breath, and difficulty finding words she desired to use in conversation (initiated 11/24/23 and revised 12/28/24). The interventions included allow the resident time to answer questions and to express her feelings and/or fears, play calming music or a television program of interest, and redirect to meaningful activities of potential interest or activities of preference (all initiated 11/24/23). A current care plan for depression indicated she had stated she was experiencing episodes of depression and was to be observed for a decrease in socialization, a decrease in participation in activities of interest, irritability, and episodes of tearfulness. She had diagnoses of other recurrent depressive disorder and depressive disorder with psychotic features and took risperidone (initiated 11/24/23 and revised on 12/28/24). The interventions included allow the resident time to vent feelings and validate, encourage the resident to reminisce/share life stories, observe and report moods and behaviors, offer activities of preference or past enjoyment, and offer emotional support and reassurance (all initiated 11/24/23). A current care plan for resistance to care related to dementia indicated the resident could become verbally and physically combative with staff during care (initiated 12/26/24 and revised 12/28/24). Interventions included allow the resident to make choices, allow the resident to talk about feelings, assume a non-threatening posture: smile and talk with the resident in a pleasant, cheerful tone of voice, encourage as much participation/interaction by the resident as possible during care activities, establish a routine that is comfortable for the resident, maintain routine/minimize changes, give clear explanation of all care activities prior to and as they occur during each contact, give positive feedback, and if irritated, reapproach (all initiated 12/26/24). A current care plan for behaviors of getting up without assistance, not wanting/refusing assistance to use the bathroom, or using the walker indicated the resident could become irritated when staff attempted to assist the resident (initiated and revised 12/26/24). Interventions included anticipate and meet the resident's needs, assist the resident to a quiet area, reduce noise and stimulation around her, consider psych evaluation if appropriate, encourage participation in activities of enjoyment or previous interest, evaluate antecedents, such as noise levels, time of day, being tired, etcetera, evaluate the resident for items such as a recent medication change, an infection, etcetera, explain all procedures to the resident before starting and allow the resident time to adjust to changes, if the resident continues to be agitated but safe, leave the area and reapproach later, offer opportunities for physical exercise, snacks/nutrition and fresh air, provide opportunity for positive interactions, attention, for example, stop and talk with the resident as passing by, provide positive feedback to the resident, and talk with the resident in a calm voice (all initiated 12/26/24). A current care plan for the potential to be physically aggressive indicated the resident had a history of being physically aggressive with staff (initiated and revised on 12/26/24). Interventions included one on one with the Social Services Director (SSD), administer medications as ordered and monitor/document for side effects and effectiveness, allow the resident time to express herself and her feelings about the situation, anticipate and meet the resident's needs, consider counseling if appropriate, encourage as much participation/interaction by the resident as possible during care activities, give the resident as many choices as possible about care and activities, identify potential antecedents to physical aggression, if the resident continues to be agitated but safe, leave the area and reapproach later, and when resident becomes agitated, intervene before agitation escalates: guide away from source of distress; engage calmly in conversation (all initiated 12/26/24). A current care plan for being verbally aggressive indicated the resident had a history of yelling and cursing at staff (initiated and revised on 12/26/24). Interventions included one on one with the SSD, observe and document behavior, including attempted interventions, provide positive feedback to the resident, and redirect/distract with activities of interest (all initiated 12/26/24). A 9/6/24 at 10:01 a.m. progress note by the psychological services Nurse Practitioner (NP), indicated the resident was seen to follow up on a request by the pharmacy to attempt a gradual dose reduction of her psychotropic (drugs that affect a person's mental state) medications. The risperidone was discontinued. A gradual dose reduction attempt for the citalopram, lorazepam (antianxiety), and trazodone (antidepressant) was clinically contraindicated due to the discontinuation trial of the risperidone. A Nurses' Note, dated 9/18/24 at 1:40 p.m., indicated the resident told the CNA she was cold. When the CNA explained, they were going to go to the bathroom and get some clothes on, the resident called her a bitch. The room temperature was 73 degrees according to the room thermometer. A Nurses' Note, dated 9/21/24 at 11:08 a.m., indicated the resident had a knot and bruise on the right side of her upper forehead. The resident indicated she had hit her head on her bedside table when she fell asleep in her chair and denied pain or discomfort. Neurological checks were initiated. The medical provider was notified. A Nurses' Note, dated 9/25/24 at 11:30 p.m., indicated the resident kept getting out of bed by herself, would not leave her gown on, or leave or bed pad on her bed. She continued to transfer herself without her walker or wheelchair and did not use her call light. She urinated on the floor. A Nurses' Note, dated 9/25/24 at 11:41 p.m., indicated the resident was lying naked in her bed. Her hospital gown and bed pad were on the floor in her bathroom. She did not have a brief on. She indicated to the nurse she did not wear gowns at night, and she got them in the morning. The resident refused to put a gown on and got agitated. A Nurses' Note, dated 9/26/24 at 7:59 p.m., indicated the resident was in the hallway without clothes on. The resident was assisted to the bathroom, and morning care was given. The resident ambulated to the dining room with a scowl on her face. The resident yelled she wanted cold tea when asked if she would like hot tea. Iced tea was prepared. The resident yelled she wanted it in a mug. The resident refused to speak anymore. She fed herself in the dining room. A Progress Note, dated 9/26/24 at 11:40 a.m. by the psychological services NP, indicated the resident was seen to follow up on the recent discontinuation of the risperidone. The resident was visited in her room with no distress noted. Medications and behaviors were reviewed. The current psychiatric plan of care was continued. A Nurses' Note, dated 9/26/24 at 1:05 p.m., indicated the resident had removed all her clothing and refused to get dressed. She eventually agreed to get dressed. A Nurses' Note, dated 9/27/24 at 12:28 p.m., indicated the resident had a behavior and did not listen to suggestions to go to the recliner and rest. The resident did not want to take her UTI stat medication. She was encouraged to transfer and move but was not amenable. She seemed to understand, but did not seem to want to follow instructions. An assessment for stroke was performed, and no signs or symptoms of stroke were observed. The resident moved her tongue out of mouth involuntarily multiple times. A Nurses' Note, dated 9/27/24 at 5:55 p.m., indicated the resident did not act appropriately. She was found walking in the room with no clothes or shoes on. The resident was assisted with dressing and assisted to chair. She was found again with no shirt or shoes on. The resident indicated she did not want to be dressed because her back hurt. The resident declined to put hard sole shoes on but did accept slippers. A Nurses' Note, dated 9/28/24 at 1:07 a.m., indicated the resident got up from bed twice through the shift and walked beside her bed using the wheelchair as a walker. She told the staff she went to the bathroom, but no output was seen in the toilet bowl. A Nurses' Note, dated 9/28/24 at 7:22 a.m., indicated the resident was resting in bed and declined to get dressed and come down to breakfast. She complained of back pain. Acetaminophen (oral pain med) and trolamine salicylate (topical cream for pain) were administered. A Nurses' Note, dated 9/28/24 at 9:24 a.m., indicated the resident was up ambulating in her room completely dressed with her walker. She denied pain or urgency with urination. Her urine was clear amber color with no foul odor. A Nurses' Note, dated 9/28/24 at 11:26 a.m., indicated the resident had removed her clothing and sat in her chair. She refused to eat lunch in the dining room. A Nurses' Note, dated 9/28/24 at 1:12 p.m., indicated the resident wore a gown and sat in her recliner. She had a large bowel movement in her chair. A Nurses' Note, dated 9/28/24 at 1:41 p.m., indicated the primary care NP was notified. New orders were received for a stat urinalysis with a culture and sensitivity, vital signs every shift for 48 hours, initiate hypodermoclysis (administration of fluids into the subcutaneous tissue to provide hydration) to the abdomen of normal saline 1000 milliliters (ml) at 50 ml/hour and ceftriaxone (antibiotic) 1 gram intramuscularly on 9/28/24 and 9/29/24. A Nurses' Note, dated 9/29/24 at 5:04 a.m., indicated a urine specimen was collected and sent to the lab. A Nurses' Note, dated 9/29/24 at 9:42 a.m., indicated the urinalysis results indicated a culture was not indicated. The resident's morning care was completed without difficulty and she fed herself breakfast in her room. A Nurses' Note, dated 9/29/24 at 1:02 p.m., indicated the resident had no abnormal behaviors that shift. A Nurses' Note, dated 9/29/24 at 9:03 p.m., indicated the resident was found standing up using her walker without assistance twice. She was found once after taking herself to the toilet. A Nurses' Note, dated 9/30/24 at 9:49 a.m., indicated the psychological services NP was notified of the increase in behaviors. The NP indicated she would like the resident to be monitored for sleep patterns to ensure the resident was getting adequate sleep. A Nurses' Note, dated 9/29/24 at 10:23 p.m., indicated the resident was found on the floor in her room lying on her left side. Her gown was wet. A Nurses' Note, dated 9/30/24 at 12:11 p.m., indicated the resident refused to get up in the morning. She lay in bed until 11:00 a.m. She was incontinent of bowel and bladder and used the call light multiple times saying she did not get her medications. A Nurses' Note, dated 9/30/24 at 1:05 p.m., indicated the resident was thrusting her tongue out of her mouth constantly. A Nurses' Note, dated 9/30/24 at 7:06 p.m., indicated the resident was found lying in front of the window. The resident indicated she was trying to close the blinds for the evening and tripped on her call light cord. She hit her elbow on the air conditioning unit. A Nurses' Note, dated 9/30/24 at 10:13 p.m., indicated the resident was reminded to call for help. She was brought out to the lounge area to sit after supper. She was assisted to the bathroom and brought back out to the lounge. She asked to get ready for bed at 8:45 p.m. She was assisted with bedtime care, assisted to her recliner, and reminded to call when she was ready to go to bed. She was checked on at 9:30 p.m. She had transferred herself to her bed. A Nurses' Note, dated 10/1/24 at 5:03 p.m., indicated the resident was checked on throughout the night. The resident was awake each time. The resident indicated she had not slept at all. A Nurses' Note, dated 10/1/24 at 12:13 p.m., indicated the resident stated she was up all night. She had not been seen napping throughout the shift, which was a change, as the resident normally napped some throughout the day. A Nurses' Note, dated 10/1/24 at 11:30 p.m., indicated the resident was upset and wanted a bed pad on her bed, but wanted a white one not a blue one. She scooted to the bottom of the bed and curled up in a ball. She repeatedly said she needed a white bed pad on her pad. Staff attempted various things to help her, and resident refused. A Nurses' Note, dated 10/2/24 at 3:00 a.m., indicated the resident was found on the floor sitting by her room chair with her walker overturned. The resident had a bruise on her left foot. The resident indicated she was going to the bathroom when she fell. A Nurses' Note, dated 10/2/24 at 9:12 a.m., indicated the resident was in the hallway repeatedly stating she was ready for dinner and ready to go up. The resident became agitated with the foot pedals on her wheelchair, When the foot pedals were removed to get the wheelchair closer to the table the resident insisted on having foot pedals on and under her feet. The foot pedals were moved back. The resident continued to request the foot pedals be moved back and forth. She leaned forward as far as she could nearly falling several times. She repeatedly put her finger in her hot water in her tea cup and stated it was cold. The resident's brow was furrowed with facial grimacing. The hot water had steam. A Nurses' Note, dated 10/2/24 at 10:45 a.m., indicated the resident's neck and back were massaged with a topical menthol analgesic. The resident smacked her lips and fixated on a bracelet. A Nurses' Note, dated 10/2/24 at 11:34 a.m., indicated the psychological services NP was notified of the staff's report of the resident being restless and agitated. The resident sat at the table for lunch. The resident was smiling and talkative. She indicated she had fallen last night and was looking for her blanket. The resident had some difficulty finding her words and smacked her lips repeatedly throughout the conversation. A Nurses' Note, dated 10/2/24 at 12:33 p.m., indicated the psychological services NP gave a new order for risperidone 0.25 mg every bedtime for dementia with behavioral disturbance. A Nurses' Note, dated 10/3/24 at 9:55 p.m., indicated the resident refused morning care. She indicated it was only 5:15 a.m., and she would get up at 9:00 a.m. The resident was told it was 10:00 a.m. She yelled it was not. The resident had not been sleeping all morning. She had been awake and refused to get out of bed with all staff attempts. A Nurses' Note, dated 10/3/24 at 1:11 p.m., indicated the resident continued to lie in bed and refused morning care. She refused to go to the bathroom for toileting. She allowed the CNA to reposition her in bed twice during the shift. A Progress Note, by the psychological services NP, dated 10/4/24 at 11:06 a.m., indicated the resident was seen to follow up on a failed attempt to discontinue risperidone. The notable events were agitation and uncontrolled tongue thrusts. The staff reported that the resident experienced irritable moods and a worsening of symptoms of insomnia. The staff reported the resident had been hyper fixated on multiple issues. The resident was visited in the dining room with no distress noted. A Nurses' Note, dated 10/7/24 at 12:20 a.m., indicated the resident was restless and complained the room was too hot. She was offered a fan, and she said it would get too cold. She was assisted to the bathroom and a sheet was obtained for her to use instead of a blanket. A Nurses' Note, dated 10/7/24 at 6:21 a.m., indicated the resident was restless throughout the night and had the call light gripped in both hands. She turned on the call light frequently to let staff know she was awake, she was in bed, or she wished the staff would leave her alone so that she could get some sleep. A Nurses' Note, dated 11/1/24 at 4:32 p.m., indicated the resident tried to walk with a wheelchair. The CNA encouraged the resident to use her walker. A Nurses' Note, dated 12/4/24 at 4:05 p.m., indicated the resident continued to attempt to use a wheelchair as a walker. During an interview on 1/3/25 at 12:41 p.m., the SSD indicated the resident had been on the risperidone for a long time. She had a gradual dose reduction and experienced all kinds of behaviors. She provided pink behavior sheets filled out by the CNAs for the behaviors during the gradual dose reduction trial. A behavior sheet, dated 9/21, provided by the SSD on 1/3/25 at 12:41 p.m., indicated the resident had been denying the time, when she was told breakfast was over soon. She said she was not ready to get up. When the CNA left, the resident got herself dressed and started walking down to breakfast. The resident said the staff did not get her up or it was too late. She complained of not sleeping. A behavior sheet, dated 9/28/24 at 1:53 p.m., provided by the SSD on 1/3/25 at 12:41 p.m., indicated the resident refused to keep her clothes on and removed them three times. She removed her brief and had a trail of feces from her chair to the toilet. A behavior sheet, dated 9/29/24 at 8:00 p.m., provided by the SSD on 1/3/25 at 12:41 p.m., indicated the resident pushed her call button repeatedly. She was mean and aggressive. A behavior sheet, dated 9/30/24 at 9:00 p.m., provided by the SSD on 1/3/25 at 12:41 p.m., indicated the resident yelled at the CNA because the resident's wheelchair was not in the right place. When the CNA fixed the wheelchair location, the resident screamed at the CNA to get out. A behavior sheet, dated 9/30/24 at 4:00 p.m., provided by the SSD on 1/3/25 at 12:41 p.m., indicated the resident kept getting up on her own. She then fell. She wanted to get up on her own all the time. During an interview, on 1/3/25 at 2:20 p.m., the SSD indicated the resident had previously gone to a mental health center and had been diagnosed with other specified disruptive, impulse control, and conduct disorder. During an interview, on 1/3/24 at 2:35 p.m., CNA 7 indicated if any residents have any behaviors a pink behavior slip is filled out. She had not provided care often for the resident, but had not had any problems with her when she did provide care. She was uncertain where to look for the interventions to provide for a resident's care such as behaviors and falls but would speak to her supervisor to ensure she had the right answer. During an interview, on 1/3/25 at 2:38 p.m., RN 8 indicated the last time the resident's medication was changed, she had an increase in confusion. The resident had a lot of tongue movements too. RN 8 had performed multiple assessments on the resident checking for stroke and other possible causes for her change in behavior. The NP had been notified at that time. The resident was sometimes alert and oriented to person, place, and time. The resident was offered snacks and activities to help her mood. She had always been compliant taking her medications for RN 8. During an interview, on 1/3/25 at 2:45 p.m., CNA 7 indicated when they charted, they could see some of the interventions, but not all of them. She would check with the nurse to find out what the interventions were for the residents to make sure she was using all of them. During an interview, on 1/3/25 at 2:48 p.m., LPN 9 indicated she had been providing care for the resident for about a month. She had been trying to use her wheelchair instead of her walker for ambulation. She went to therapy, and they worked with her and got her a different walker. She did not use her wheelchair anymore. The psychological services NP had recently discontinued the resident's antianxiety medication and increased her pain medication. LPN 9 believed the resident was having more pain than anxiety. The change had helped her. The resident had no other behaviors of which she was aware. During an interview, on 1/3/25 at 3:13 p.m., CNA 7 indicated she was not sure what the resident's behaviors were other than trying to walk with her wheelchair instead of her walker. Her mood changes could also go into psychosis, she thought as the resident thought she was more capable than she really was. During an interview, on 1/3/25 at 3:16 p.m. LPN 9 indicated she believed the resident's psychosis was exhibited by her not being able to be redirected, and it was difficult to explain. For example, the resident insisted on using a wheelchair for walking instead of the walker because she believed therapy had told her to use the wheelchair for a walker. The resident did not hit or yell, she just argued. She had difficulty understanding concepts when she was experiencing her psychosis. During an interview, on 1/3/25 at 3:20 p.m., RN 8 indicated when she took care of the resident during her episodes of tongue movements and her ability to understand and comprehend was impaired that was when the resident was exhibiting her symptoms of psychosis. She believed the psychosis mimicked a stroke. During an interview, on 1/3/25 at 3:24 p.m., the SSD indicated for the resident's psychosis the staff told her the resident can be very delusional. The staff told her a couple of months ago the resident was not making sense. She thought the resident's psychosis presented as the resident told the staff one day her resident representative took her remote control. The SSD found the remote and did not put a progress note in. The resident representative had taken the remote to the staff and asked them to turn on happy shows and not sad as he believed sad shows worked her up. Another example was when the resident sat on her walker and wheeled herself backwards. The SSD tried to talk to the resident. The resident told the SSD she was done. Then, she ignored the SSD. The resident was just different. The SSD indicated she did not really know how to explain what the resident's psychosis symptoms looked like. During an interview, on 1/3/25 at 3:46 p.m., the DON indicated the resident's psychosis was the behaviors she had. When she was experiencing psychosis, they had her at the nurses' station to keep her occupied. She did not respond to redirection at all. The resident was not herself. She did not believe the resident was self-aware of any of the behaviors she demonstrated. The Risperdal (risperidone) manufacturer's label, accessed 1/3/25 at 2:25 p.m. at the accessdata.fda,gov website, had a black box warning which indicated WARNING: INCREASED MORTALITY IN ELDERLY PATIENTS WITH DEMENTIA-RELATED PSYCHOSIS .Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Risperdal is not approved for use in patients with dementia-related psychosis. Risperdal's indications for use included only the treatment of schizophrenia, for short-term treatment of acute manic or mixed episodes associated with Bipolar I disorder, and the treatment of irritability associated with autistic disorders. A current facility policy, revised 11/2016, titled PSYCHOTROPIC MEDICATIONS, provided by the DON on 1/3/25 at 4:32 p.m., indicated .Psychotropic medications shall only be used when there is adequate indication for their use. The facility will not allow psychotropic medications of any type for the purpose of resident discipline of staff convenience 3.1-48(a)(4)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to dispose of unlabeled and unused medications for 2 of 3 medication carts reviewed for medication storage and labeling. (Medication Cart B and Medication Cart C) Findings include: During a medication storage observation of Medication Cart B, accompanied by RN 8 on [DATE] at 9:45 a.m., a pill in an unlabeled medication cup was in the second drawer, towards the back of the cart. RN 8 indicated the medication had been pulled from the drawer prior to checking a resident's blood pressure. Since the blood pressure was not within range, the medication was not administered. Two additional pills were found loose on the bottom of the drawer. RN 8 indicated the pills should be disposed of. During an interview with the ADON, on [DATE] at 9:48 a.m., she indicated the loose medications should be disposed of immediately. During a medication storage observation of Medication Cart C, accompanied by QMA 16 and the ADON on [DATE] at 10:03 a.m., a pill in an unlabeled medication cup was in the top drawer. QMA 16 indicated the medication had been there for a long time. An additional pill was loose at the bottom of the drawer. The ADON indicated the pills should be disposed of. During an interview with the Administrator, on [DATE] at 11:22 a.m., she indicated the medication carts had just been gone through a week prior. During an interview with RN 8 on [DATE] at 9:51 a.m., she indicated loose pills should be placed in the drug buster solution for disposal. A current, undated facility policy, titled Destruction of Medications, provided by the Administrator on [DATE] at 3:52 p.m., indicated the following: .All unused, contaminated, or expired prescription drugs shall be disposed of in accordance with state laws and regulations .1) Drugs will be destroyed in a manner that renders the drugs unfit for human consumption and disposed of in compliance with all current and applicable state and federal requirements. 2) Unused, unwanted and non-returnable medications should be removed from their storage area and secured until destroyed 3.1-25(j)

Based on observation, record review, and interview, the facility failed to ensure transmission-based precautions were implemented to prevent the spread of infectious gastroenteritis for 1 of 9 residents with gastroenteritis (Resident 15). This deficient practice resulted in the development of gastroenteritis for 8 of the remaining 16 residents who resided on the secured unit (Resident 20, 41, 61, 25, 50, 32, 52, and 38). Findings include: During an interview, on 12/27/24 at 9:02 a.m., the Administrator indicated the secured unit had experienced an outbreak. Five residents began experiencing nausea, vomiting, and diarrhea through the night. The residents had been tested for COVID-19, respiratory syncytial virus (RSV), and influenza. The facility was awaiting the results to determine what type of infection the residents had contracted. 1. During an observation, on 12/26/24 at 12:11 p.m., Resident 15 sat in the dining room, eating lunch. Resident 15's clinical record was reviewed on 12/30/24 at 4:09 p.m. Diagnoses included Alzheimer's disease with late onset. Physicians' orders included loperamide (antidiarrheal) 4 milligrams (mg) one time for loose stools (12/25/24), loperamide 2 mg as needed every 24 hours for loose stools for 10 days (12/25/24), ondansetron (for nausea and vomiting) 4 mg every 6 hours as needed for nausea and vomiting for 10 days. A Nurses' Note, dated 12/25/24 at 1:15 p.m., indicated the resident had vomited five to six times and had diarrhea during the shift. A Nurses' Note, dated 12/25/24 at 1:32 p.m., indicated the Nurse Practitioner (NP) was notified. New orders were received for loperamide and ondansetron. A Nurses' Note dated 12/25/24 at 2:49 p.m., indicated the resident's representative was notified of the resident's new orders related to the intestinal flu. The resident's clinical record lacked testing and indication the resident was placed in transmission-based precautions for her symptoms of vomiting and diarrhea. During an interview, on 12/30/24 at 10:02 a.m., the Infection Preventionist (IP) indicated the residents who experienced nausea, vomiting, and/or diarrhea on 12/27/24 had tested negative for COVID-19. The droplet/contact precautions were changed to contact isolation to continue until 48 hours after the resolution of symptoms. She was uncertain who had the first case of gastroenteritis with this outbreak. She had indicated review of the dietary staffing and other staffing had shown no staff had been ill with similar symptoms. She had not worked the week prior to 12/26/24. The DON monitored the infections when she (the IP) had time off. During an interview, on 12/31/24 at 9:08 a.m., RN 5 indicated when a resident experienced vomiting or diarrhea, she would check to see if the symptoms were normal for the resident, then call the physician, check for COVID-19, and put the resident in transmission-based precautions for COVID-19. If the results were negative for COVID-19, then the isolation would be changed from the isolation for COVID-19 to contact isolation for the nausea, vomiting, and diarrhea. During an interview, on 12/31/24 at 11:33 a.m., RN 6 indicated if a resident experienced nausea, vomiting, and/or diarrhea, a rapid COVID-19 test would be performed. If the test was negative, then another COVID-19 test would be taken and sent to the hospital. The resident would be placed in transmission-based precautions for COVID-19. If the COVID-19 test sent to the hospital was negative, the precautions would be changed to contact isolation until 48 hours after the resolution of the symptoms. During an interview, on 12/31/24 at 1:33 p.m., the DON indicated when a resident experienced nausea, vomiting, and/or diarrhea, a COVID test was performed and sent to the hospital if the rapid COVID-19 test was negative. The resident was placed in precautions for COVID-19. If the COVID-19 test sent to the hospital was negative, then the resident's precautions were changed to contact isolation for gastroenteritis. An infection screener was to be filled out whenever an infection was suspected. She was unaware Resident 15 had experienced multiple episodes of vomiting prior to the outbreak of eight other residents with gastroenteritis. She was uncertain if Resident 15 had been tested for COVID-19 or had been put in transmission-based precautions. During an interview, on 1/3/25 at 3:45 p.m., the DON indicated Resident 15 had not been tested for COVID-19 or been put on transmission-based precautions as she would have expected to be done. 2. During an observation, on 12/26/24 at 12:10 p.m., Resident 41 sat in a chair in the dining room, eating lunch. Resident 41's record was reviewed on 12/31/24 at 10:01 a.m. She shared a room with Resident 15. Diagnoses included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. A Nurses' Note, dated 12/27/24 at 10:49 a.m., indicated the resident had vomiting and diarrhea. An Infection Report, dated 12/27/24 at 11:28 a.m., indicated McGeer's criteria (used to define infections for long-term care) was met for gastroenteritis (inflammation of the stomach and intestines). 3. During an observation, on 12/26/24 at 12:18 p.m., Resident 20 sat in her wheelchair in the dining room. During an observation, on 12/27/24 at 9:07 a.m., Resident 20's door had an isolation sign on it and was closed. Resident 20's clinical record was reviewed on 12/30/24 at 11:11 a.m. Diagnoses included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. A Nurses' Note, dated 12/27/24 at 5:41 a.m., indicated the resident vomited. The rapid COVID-19 test was negative. An Infection Report, dated 12/27/24 at 11:31 a.m., indicated McGeer's criteria was met for gastroenteritis. 4. During an observation on 12/26/24 at 12:09 p.m., Resident 61 sat in a chair in the dining room eating her lunch with the assistance of her resident representative. During an observation on 12/27/24 at 9:07 a.m., Resident 61's door was closed with an isolation sign on it. Resident 61's clinical record was reviewed on 12/30/24 at 3:03 p.m. Diagnoses included Alzheimer's disease with early onset. A Nurses' Note, dated 12/27/24 at 3:00 a.m., indicated the resident wandered into the hallway holding feces in her hand. She was assisted back into her room and began vomiting into her bathroom sink. She continued to vomit. An Infection Report, dated 12/27/24 at 11:21 a.m., indicated McGeer's criteria was met for gastroenteritis. 5. During an observation, on 12/26/24 at 12:12 p.m., Resident 25 sat at a table in the dining area, eating lunch. Resident 25's clinical record was reviewed on 12/31/24 at 10:04 a.m. Diagnoses included unspecified dementia, unspecified severity, with anxiety. A Nurses' Note, dated 12/27/24 at 11:08 a.m., indicated the resident vomited and had diarrhea. An Infection Report, dated 12/27/24 at 11:27 a.m., indicated McGeer's criteria was met for gastroenteritis. 6. During an observation, on 12/26/24 at 12:19 p.m., Resident 50 sat at a table in the dining room and fed herself lunch. During an observation, dated 12/27/24 at 9:07 a.m., Resident 50's door was closed with an isolation sign on it. Resident 50's clinical record was reviewed on 12/31/24 at 10:05 a.m. Diagnoses included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. A Nurses' Note dated, 12/27/24 at 11:21 a.m., indicated the resident experienced nausea, vomiting, and diarrhea. An Infection Report, dated 12/27/24 at 11:30 a.m., indicated McGeer's criteria was met for gastroenteritis. 7. During an observation, on 12/26/24 at 12:18 p.m., Resident 32 sat in the dining room, eating lunch. During an observation, on 12/27/24 at 9:09 a.m., Resident 32's door was closed with an isolation sign on it. Resident 32's clinical record was reviewed on 12/31/24 at 12:25 p.m. Diagnoses included unspecified dementia, severe, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. A Nurses' Note, dated 12/27/24 at 2:27 a.m., indicated the resident had vomited all over himself, his bed, and his floor. He was also covered in feces. A Nurses' Note, dated 12/27/24 at 2:59 a.m., indicated the resident vomited again and had more diarrhea. An Infection Report, dated 12/27/24 at 11:32 a.m., indicated McGeer's criteria was met for gastroenteritis. 8. During an observation, on 12/26/24 at 12:18 p.m., Resident 52 sat in a wheelchair at a table in the dining room. Resident 52's clinical record was reviewed on 12/31/24 at 10:06 a.m. Diagnoses included Alzheimer's disease, unspecified. A Nurses' Note, dated 12/28/24 at 8:05 a.m., indicated Resident 52 was covered in emesis and diarrhea. She was placed in COVID-19 transmission-based precautions. A Nurses' Note, dated 12/29/24 at 6:46 a.m., indicated the resident's COVID-19 results were negative, and the resident was put on contact isolation. 9. Resident 38's clinical record was reviewed on 12/30/24 at 4:07 p.m. Diagnoses included Alzheimer's disease with late onset. A Nurses' Note, dated 12/27/24 at 11:24 p.m., indicated the resident experienced nausea, vomiting, and diarrhea. A Nurses' Note, dated 12/27/24 at 3:52 p.m., indicated the resident was given an ondansetron pill for nausea and vomiting. An Infection Report, dated 12/27/24 at 11:29 p.m., indicated McGeer's criteria was met for gastroenteritis. Norovirus Facts and Stats, (May 2024) was retrieved on 1/3/25 from the Centers for Disease Control and Prevention (CDC) website. The guidance included the following: .Norovirus is the leading cause of vomiting and diarrhea from acute gastroenteritis among all people of all ages in the United States Norovirus infection, (March 2022) was retrieved on 1/3/25 from the Mayo Clinic website. The guidance included the following: .Norovirus infection can cause severe vomiting and diarrhea that starts suddenly. Noroviruses are highly contagious .Diarrhea, stomach pain, and vomiting typically begin 12 to 48 hours after exposure. Norovirus infection symptoms usually last 1 to 3 days .Norovirus infection occurs most frequently in closed and crowded environments. Examples include hospitals, nursing homes A current, undated facility policy, titled Contact Precautions/Nausea & Vomiting, provided by the Administrator on 1/2/25 at 9:05 a.m., indicated the following: .Contact precautions are used for patients who are known or suspected to be infected with microorganisms that can be transmitted by [1] Direct contact with the patient [2] Indirect contact with environmental surfaces or patient care items [3] Secretions or drainage that cannot be contained .Contact precautions for residents can be removed when resident has been free from nausea & vomiting and are showing no other signs of infection for 48 hours 3.1-18(b)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure staff reported a resident's change in condition to the nurse before proceeding with care and failed to complete a physical assessment after an unwitnessed fall with head injury for a cognitively impaired and dependent resident for 1 of 3 residents reviewed for accidents (Resident B). Findings include: The clinical record for Resident B was reviewed on [DATE] at 10:45 a.m. Diagnoses included dementia, spastic hemiplegia to non-dominant left side, hypertension, stage 3 chronic kidney disease, anxiety disorder, and osteoarthritis. The most current, quarterly, MDS (Minimum Data Set) assessment, dated [DATE], indicated Resident B was severely cognitively impaired and rarely or never understood. The resident lived on the secured unit and required extensive assistance of 2 persons for transfers and toileting. A progress note, dated [DATE] at 6:20 a.m., indicated Resident B was found lying on her left side next to the toilet, with a pool of blood running next to her head. She was unresponsive. Per the CNA, the resident was sitting on the toilet and fell off. RN 2 and two CNAs assisted Resident B off the floor and into a wheelchair. The resident was very heavy during the transfer. During the transfer into the wheelchair, the resident turned blue in color and was not responding. CPR was not initiated as she had elected a DNR (Do Not Resuscitate) order. RN 2 and three CNAs assisted the resident from her wheelchair and onto the bed. RN 2 and LPN 1 determined Resident B was deceased . A progress note, dated [DATE] at 6:20 a.m., indicated LPN 1 responded to a code blue light for Resident B. Resident B was noted to by laying on the floor with her bilateral feet near the toilet and her head pointed toward the bathroom door, with blood pooling under the left side of her head with her eyes open. The CNA indicated the resident fell off of the toilet. RN 2 stayed with the resident and 2 CNAs while LPN 1 left to call 911. Staff notified LPN 1 that the residents' respirations had ceased and she was without a pulse, and was blue in color. Her DNR status was confirmed. The clinical record lacked assessment of Resident B after the unwitnessed fall. The most current vital signs were documented on [DATE]. The Post Fall Investigation, dated [DATE] at 6:30 a.m., indicated vital signs were not within normal range, but did not indicate measurements of vital signs. In a written statement from the facility investigation, on [DATE], CNA Student 3 indicated that CNA 4 and herself assisted Resident B out of bed and placed her on the toilet. Resident B looked stable and the CNA stated they normally left the resident unattended while on the toilet. The CNAs left the restroom and started providing care to Resident B's roommate. They heard a bang and went into the restroom and found Resident B on the floor and bleeding from her head. CNA Student 3 pulled the code blue light to alert staff that assistance was needed. In a written statement from the facility investigation, on [DATE], CNA 4 indicated prior to transferring Resident B to the toilet, the resident didn't have her normal color and was almost pale, with a gray undertone. Both herself and Student CNA 3 placed a gait belt around Resident B, causing the resident to start tensing up. This caused the CNAs to have trouble getting their arms around the resident to get her up. They placed the resident on the toilet and adjusted her 2-3 times to make sure she was far enough back. After adjusting her, they both left to strip her bed. CNA 4 walked into the bathroom and saw the resident a couple inches off the ground. After CNA Student 3 pulled the code blue cord, CNA 4 left to go find help. RN 2 arrived and told them they needed to get Resident B up off the floor. They struggled to get the resident off the floor and into her wheelchair while holding a towel on her head. CNA 4 noticed the resident looked gray. They transferred the resident from her wheelchair into bed. Resident B did not make any sounds while she was falling or laying on the ground. During an interview on [DATE] at 1:03 p.m., LPN 1 indicated on [DATE], at approximately 6:20 a.m., the code blue light went off. LPN 1 and RN 2 ran to the resident's room. The resident was on the floor with their feet towards the toilet, and the left side of their forehead on the floor, with blood pooling beneath their head. The resident's eyes were open, but the resident was unresponsive. LPN 1 did not hear the resident make any noise. LPN 1 indicated the resident's color was good. LPN 1 left the room and called 911 and the physician. After making the calls, LPN 1 started to return to the room. On the way to the resident's room, LPN 1 was informed by staff the resident had died. When LPN 1 arrived at the resident's room, the resident's color was off. LPN 1 and RN 2 monitored the resident for breath sounds and heart beat, but Resident B did not have either present. During an interview on [DATE] at 1:27 p.m., Student CNA 3 indicated, on [DATE] during the morning care, she and CNA 4 were getting Resident B up for the day. The CNAs transferred the resident to the wheelchair and then to the toilet. They had to adjust the resident on the toilet 2-3 of times before leaving the resident alone in the bathroom. CNA Student 3 indicated the resident had requested privacy. CNA Student 3 had never provided care to Resident B before, and was not familiar with the resident. While providing care to the resident's roommate, they heard a big bang and went to the bathroom to investigate. Resident B was observed on the floor and her head was bleeding. The resident did not say anything. CNA Student 3, CNA 4, and RN 2 picked the resident up and placed her in a wheelchair, then transferred the resident from the wheelchair to the bed. The resident did not make a sound during any of the transfers. Once the resident was in bed, RN 2 checked for respirations and found none. During an interview on [DATE] at 2:03 p.m., RN 2 indicated, on [DATE], she had just gotten to work and received report when the code blue alarm sounded. RN 2 and LPN 1 ran to the resident's room. The resident was on the bathroom floor, with her head bleeding. RN 2 indicated their first reaction was to get the resident to safety and get help. The resident was verbally unresponsive, had a gray pallor, and the resident's eyes were open and not moving. She was not making any sounds. RN 2 told LPN 1 to call 911 and the physician. RN 2, CNA Student 3, and CNA 4 transferred the resident to the wheelchair and then from the wheelchair to the bed. Once the resident was in bed, she turned blue. The resident was found to have no pulse or heartbeat. She did not remember if the resident had any independent movement during the transfers. RN 2 did not assess the resident. During an interview, on [DATE] at 3:12 p.m., LPN 11 indicated Resident B was verbal at times, but normally would just yell. Resident B required two-person assistance with transfers and activities of daily living. During an interview, on [DATE] at 3:27 p.m., CNA 8 indicated Resident B needed complete support with her activities of daily living including transferring on and off the toilet. She did not leave the resident unattended in the bathroom, due to resident leaning toward her left side while sitting on the toilet. During an interview, on [DATE] at 4:06 p.m., ADON indicated, during an unwitnessed fall with injury for a cognitively impaired resident, she would start doing assessments and not move the resident to prevent further harm if they were unconscious. During an interview, on [DATE] at 9:46 a.m., the ADON indicated it was not appropriate to move/transfer a resident who was found unresponsive after an unwitnessed fall. The nurse should assess the resident. During an interview, on [DATE] at 12:59 p.m., the DON and ADON indicated when a resident fell, an assessment should always be completed. An assessment should contain vital signs and a head to toes assessment. After reviewing the clinical record, neither the DON nor the ADON could find an assessment of Resident B after the fall on [DATE]. The DON and ADON both indicated there should have been an assessment completed and staff should not have moved the resident from the floor. During an interview, on [DATE] at 1:34 p.m., both the DON and ADON indicated if a resident presented with a change in condition, this information should be discussed with the nurse. Review of a current policy, darted [DATE], titled Head Injury was provided by the Administrator on [DATE] at 9:15 a.m. The policy indicated the following: Procedure: 1. Assess resident following a known, suspected, or verbalized head injury. The assessment shall include, at a minimum: a. Vital Signs. b. General condition and appearance. c. Neurological evaluation for changes in: i. Physical functioning 11. Behavior iii. Cognition iv. Level of consciousness v. Dizziness vi. Nausea vii. Irritability viii. Slurred speech or slow to answer questions. d. Evaluation of the head, eyes, ears, and nose for significant changes in vision, hearing, smell, or bleeding Review of a current policy, dated 1/2015, titled Fall Assessment Policy was provided by the Administrator on [DATE] at 4:20 p.m. The policy indicated the following: Procedure: 1. Call for nurse and stay with the resident 2. Check to see if resident is breathing 3. Do not move resident 4. Reassure resident by talking to him/her in a calm and supportive manner 5. Apply direct pressure to any bleeding area 6. Check resident's pulse, respiratory rate and blood pressure; If resident is a DIABETIC-MAY check the residents blood glucose level. This citation relates to Complaint IN00432892. 3.1-37(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a current copy of the resident's advance directive was in their clinical record for 1 of 1 residents reviewed for advance directives. (Resident 54) Review of Resident 54's clinical record was completed on [DATE] at 3:08 p.m. Diagnoses included unspecified dementia, episodic paroxysmal anxiety, depressive disorder with severe psychotic symptoms, and body dysmorphic disorder. A current, [DATE], physician order indicated the following: Description - DNR Advance Directive Status: Verified With Family Only. During a review of a [DATE] care plan, on [DATE] at 3:30 p.m., it indicated the resident desired to be a DNR (do not resuscitate) and her wishes would be honored. Instructions were to get a signed DNR with a physician's signature. Code status was to be reviewed as needed. There was no advance directive document in the resident's electronic health record. During an interview on [DATE] at 9:06 a.m., the DON provided a document titled Treatment Option Declaration - Patient with Capacity, signed by Resident 54. The document indicated the resident chose supportive care with no CPR (cardiopulmonary resuscitation), had designated a health care representative, and signed and dated the document on [DATE]. The DON indicated she was unable to find the original document and had provided a new one to the resident. There was no physician's signature. A current facility policy/procedure, dated 7/2022, provided by the Administrator on [DATE] at 5:00 p.m., indicated the following: .Advance Directives & Residents' Rights - It is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an advance directive. Definitions: 'Advance Directive' is a written instruction, such as a living will or durable power of attorney for health care, recognized under state law (whether statutory or as recognized by the courts of the state), relating to the provision of health care when the individual is incapacitated. Policy Explanation and Compliance Guidelines: .1) On admission, the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident would like to formulate an advance directive .3) Upon admission, should the resident have an advance directive, copies will be made and placed on the chart as well as communicated to the staff .9) Any decision making regarding the resident's choices will be documented in the resident's medical record and communicated to the interdisciplinary team and staff responsible for the resident's care 3.1-4(ii)(5)

Based on observation, interview, and record review, the facility failed to apply a dynamic elbow brace per physician's order for 1 of 1 resident reviewed for range of motion. (Resident 50). Findings include: Resident 50 clinical record was reviewed on 2/24/24 at 9:08 a.m. Diagnoses included dementia and spastic hemiplegia affecting left nondominant side (muscle tightness and involuntary contractions in extremities on left side of body). Current orders included the resident to wear dynamic elbow splint to left upper extremity; put on at 8 a.m. and remove at 12 noon. During an observation, on 2/22/24 at 8:45 a.m., she was lying in bed and was not wearing her dynamic elbow brace. The brace was laying on the recliner. During an observation, on 2/22/24 at 10:10 a.m., she was lying in bed and was not wearing her dynamic elbow brace. The brace was laying on the recliner. During an observation, on 2/22/24 at 11:24 a.m., she was lying in bed without wearing her dynamic elbow brace. The brace was laying on the recliner. During an interview, on 2/22/24 at 11:26 a.m., the Resident representative indicated when he arrived, the resident was lying in bed and was not wearing her dynamic elbow brace. During an observation, on 2/22/24 at 11:52 a.m., she was eating lunch without wearing her dynamic elbow brace. During an interview, on 2/23/24 at 10:07 a.m., CNA 12 indicated the resident did not wear her brace while lying in bed. Her dynamic elbow brace was applied once she got into her chair. During an observation, on 2/23/24 at 1:30 p.m., she was sitting in her wheelchair wearing her dynamic elbow brace to her left arm. During an interview, on 2/23/24 at 1:31 p.m., QMA 13 indicated the resident wore her dynamic elbow splint once she was out of bed. During an interview, on 2/26/24 at 4:12 p.m., RN 14 indicated she constantly wore her dynamic elbow brace, even when she was lying in bed. During an interview, on 2/26/24 at 4:17 p.m., the DON indicated she expected the resident to be wearing her dynamic elbow brace between 8 a.m. and noon per physician order. During an interview, on 2/26/24 at 4:40 p.m., the DON indicated the resident usually refused to wear her dynamic elbow brace. During her record review, on 2/26/24 at 4:45 p.m., clinical record lacked indication of the residents refusal to wear the dynamic elbow brace. Review of the current policy, revised 1/23, titled Splinting Interventions, provided by the Administrator on 2/26/24 at 2:40 p.m., indicated the following: .1. Verify physician's order for splint; which extremity, and frequency of splinting 3.1-37(a)