**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow an Indiana Physician Order for Scope of Treatment (POST) form indicating do not attempt resuscitation/DNR for a resident that received cardiopulmonary resuscitation (CPR) for 1 of 3 residents reviewed for Advanced Directives. (Resident 61) Findings include: Resident 61's clinical record was reviewed on [DATE] at 11:49 a.m. Diagnoses included unspecified systolic (congestive) heart failure, obstructive sleep apnea, dysphagia, oropharyngeal phase, and other pneumonia, unspecified organism. Current orders indicated the resident was a full code, pending POST form completion, dated [DATE]. An Indiana Physician Order for Scope of Treatment (POST) form dated [DATE], and signed [DATE], indicated in section A that Resident 61 requested a do not attempt resuscitation (DNR) if he had no pulse and was not breathing. A progress note, dated [DATE] at 3:30 a.m., indicated resident had no pulse, was not breathing, and had no chest rising. Code status was verified by staff as a full code. CPR was initiated and 911 emergency services were called. A progress note, dated [DATE] at 3:38 a.m., indicated the resident's representative was notified that staff started chest compressions. Once EMS arrived, they administered medications, but the emergency medical technician (EMT) spoke with the resident representative, who indicated Resident 61 would not want chest compressions if he didn't have a heartbeat. Since there was no heartbeat, the decision was made to stop medications and ventilation. During an interview, on [DATE] at 12:19 p.m., the DON and Social Services indicated it wasn't a clear cut and dry DNR. The resident wanted to be a DNR, but with full interventions. The resident voiced that if he was found with no heartbeat and not breathing, he did not want CPR performed. During an interview, on [DATE] at 1:46 p.m., the DON indicated there was a note stating the resident still had respirations, but they were unable to provide those documents. She didn't know why his code status was not updated. Once a POST form was completed and in the chart, the order should be updated. Staff members verify a resident's code in the banner of their face sheet within the electronic clinical record. A printed resident face sheet, provided by the DON on [DATE] at 2:15 p.m., indicated Resident 61's status was DNR, but had a note attached stating full interventions. The alerts indicated full interventions including life support measures in the intensive care unit. In addition to care described in Comfort Measures and Limited Additional Interventions above, use intubation, advanced airway interventions, and mechanical ventilation as indicated. Transfer to hospital and/or intensive care unit if indicated to meet medical needs. During an interview, on [DATE] at 2:37 p.m., RN 11 indicated she found a resident's code status on the face sheet under the tab continuance of care. During an interview, on [DATE] at 2:38 p.m., RN 12 indicated she looked at the banner for a resident's code status. A current policy titled Advanced Directive Policy, provided by the ADON on [DATE] at 2:48 p.m., indicated the following: .Changes to the residents choices for advanced directives will be documented, included in the residents plan of care, state specific documents will be updated as necessary, physician orders will be obtained to reflect new choices as applicable and all items will be communicated to staff providing resident care

Based on observation, record review, and interview, the facility failed to allow a resident with the ability to make their own decisions to formulate an advance directive. (Resident 50) Findings include: On 9/26/24 at 8:55 a.m., Resident 50's clinical record was reviewed. Diagnoses included essential hypertension, heart failure, acute kidney failure, and Type 2 diabetes mellitus. A Minimum Data Set (MDS) assessment, dated 6/30/24, did not include a BIMS (Brief Interview for Mental Status) assessment to evaluate cognition. On 6/27/24, Resident 50's family member signed a Do Not Resuscitate (DNR) form. A progress note, on 6/27/24 at 8:47 p.m., indicated Resident 50 was alert and oriented. A POST form (a physician's order for scope of treatment based on the resident's medical conditions and preferences),dated 7/5/24, indicated the resident had a DNR code status. During an interview with the Admissions Coordinator (AC) on 9/27/24 at 9:45 a.m., she indicated the resident's family member had completed the admission paperwork. At the time of admission, Resident 50 had come from the hospital and was tired. Each admission was different, dependent upon her assessment of a person's ability to sign advance directives at that time. When she visited residents at the hospital, before they were admitted to the facility, she would also assess family dynamics to determine if the resident could sign the advance directives. On 9/25/24, at 10:24 a.m., Resident 50's clinical record indicated a BIMS score of 14, which indicated she was cognitively intact and capable of making reasonable and consistent decisions. During an interview with the Administrator on 9/30/24 at 2:42 p.m., she indicated the resident would have been competent enough to sign the Advance Directive at admission. A current facility policy, titled Advance Directive Policy, with a revision date of 6/23/23, was provided by the Director of Nursing (DON) on 9/25/24 at 2:48 p.m. The policy indicated the following: It is the policy of (the facility) to establish, implement and maintain written policies and procedures for advance directives. The resident has the right and the facility will assist the resident to formulate an advance directive .a) Upon admission, identify if the resident has an advance directive and if not, determine if the resident wishes to formulate an advance directive .c) .The facility will identify the primary decision maker (e.g., assess the resident's decision-making capacity ) 3.1-4 (f)(1)(A)(ii)

Based on observation and interview, the facility failed to ensure medications stored in the medication carts were labeled with resident identifiers and directions for 2 of 3 medication carts reviewed. (Hall 100 Medication Cart and Hall 400 Medication Cart). Findings include: During an observation of the Hall 100 medication cart on 9/26/24 at 3:30 p.m., accompanied by QMA 6, the bottom drawer contained an unlabeled bottle of Vanadium Complex (a supplement used to support blood glucose levels), an unlabeled bottle of Stasis Liver Detox (a liver supplement), and an unlabeled bottle of Thytrophin PMG (a thyroid supplement). QMA 6 indicated all supplements belonged to one resident and each should have a label with resident identifiers. During an observation of the Hall 400 medication cart on 9/26/24 at 3:42 p.m., accompanied by QMA 8, an unlabeled bottle of acetaminophen 500 mg tablets and an unlabeled bottle of Juice Plus Fruit & Vegetable Blend supplement were in the cart. QMA 8 indicated both should be labeled. During an interview with RN 9 on 9/26/24 at 3:57 p.m., she indicated all bottles and containers in the medication carts should have a label containing the name of the resident, their date of birth , instructions for use, and the name of a provider. On 9/26/24, at 4:00 p.m., the Assistant Director of Nursing (ADON) indicated medications in the medication carts should have a resident name, physician name, an open date, and directions for use on the bottle. The DON provided a current facility policy, titled Storage and Expiration Dating of Medications and Biologicals on 9/27/24 at 12:34. This policy did not contain information regarding labeling of medications. 3.1-25(j)(k)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to properly prevent and/or contain COVID-19 by not wearing appropriate personal protective equipment (PPE) in areas requiring transmission-based precautions (TBP) during random observations on the 300 Hall. Findings include: During a random observation, on 9/24/24 at 10:59 a.m., CNA 14 entered room [ROOM NUMBER] while wearing gloves, an N95 mask placed over a surgical mask, and a gown. No face shield and/or eye protection was worn before entering the resident's room. Signage on the door indicated the resident was in transmission-based precautions, and required a gown, gloves, N95 mask and a face shield/goggles before entering the room. During a random observation, on 9/24/24 at 11:05 a.m., CNA 14 was wearing a gown, gloves, and an N95 mask overtop of a surgical mask while entering room [ROOM NUMBER]. During an interview, on 9/24/24 at 12:12 p.m., CNA 14 indicated she only wore gloves, a gown, and placed an N95 mask over a surgical mask. No face shield/ goggles were worn before entering the resident's room. During a random observation, on 9/26/24 at 9:11 a.m., CNA 3 entered room [ROOM NUMBER] while wearing gloves, a gown, goggles, and an N95 mask over a surgical mask. During an interview, on 9/26/24 at 9:15 a.m., CNA 3 indicated she wore a gown, gloves, face shield and placed an N95 mask overtop a surgical mask before entering the resident's room. During an interview, on 9/26/24 at 11:44 a.m., the ADON indicated staff should not be wearing both a surgical mask and N95 before entering a resident's room who was on transmission-based precautions. A current facility policy titled COVID-19 PREVENTION AND RESPONSE and REPORTING, provided in the entrance survey binder on 9/25/24 at 10:45 a.m., indicated the following: .16. HCP who enter the room of a resident with suspected or confirmed SARS-CoV-2 infection should adhere to standard precautions and use a NIOSH-approved particulate respirator with N95 filers or higher, gown, gloves, and eye protection 3.1-18(a)

Based on interview and record review, the facility failed to follow physician orders to call the physician for low blood pressure readings for 1 of 3 residents reviewed at risk for falls. (Resident B) Findings include: Resident B's clinical record was reviewed on 3/13/24 at 10:35 a.m. Diagnoses included hypertension, amnesia (memory loss), unsteadiness on feet, muscle weakness, and other lack of coordination. Current physician orders included calling the physician when the resident's blood pressure was below 80/50 and with signs/symptoms of hypotension (low blood pressure). A progress note, dated 2/18/24 at 5:50 p.m., indicated the resident had a low blood pressure of 71/53 with symptoms including shortness of breath and lethargy (lack of energy/ motivation). He was reclined to 30 degrees in his recliner. The resident representative was notified and was to be called if he experienced further symptoms. A note was sent to the physician. A progress note, dated 2/24/24 at 10:33 a.m., indicated the resident had a low blood pressure of 77/47 with symptoms of shortness of breath. He was encouraged to drink fluids to help increase his blood pressure. A note was sent to the physician. During an interview, on 3/14/24 at 11:45 a.m., LPN 5 indicated resident had parameters if his blood pressure was 80/50 or below to notify the physician. She didn't think she called the physician regarding his last low blood pressure reading. During an interview, on 3/14/24 at 11:51 a.m., RN 4 indicated there was a physician order to notify the physician if his blood pressure was below 80/50. If his symptoms don't improve with interventions, she would call the physician. If he improved without showing signs of symptoms, she would send a note to the physician through inner office mail. During an interview, on 3/14/24 at 2:07 p.m., the ADON indicated she would expect the nurses to call the physician regarding a low blood pressure unless the physician has said not to call them. Some physicians are notified Monday through Friday through inner office mail. During an interview, on 3/14/24 at 2:56 p.m., the DON indicated that pushing fluids and elevating feet were a nursing intervention for low blood pressure. Since resident B's blood pressure improved with interventions, it wasn't emergent to call the physician. Review of a current policy, dated 5/14/19, provided by the ADON on 3/14/24 at 2:09 p.m., titled Guidelines for Physician Notification, indicated the following: .Purpose: To ensure the resident's physician is aware of all diagnostic testing results or change in condition in a timely manner to evaluate condition for the need of provision of appropriate intervention for care This citation relates to complaint IN00424450. 3.1-37(a)

Based on observation, interview, and record review the facility failed to provide supervision and implement personalized interventions to prevent falls for 1 of 3 residents reviewed for falls (Resident C). Findings include: During an observation, on 3/13/24 at 3:07 p.m., Resident C sat in a recliner in her room. She wore stockings, with her shoes laying beside her feet. During an observation, on 3/14/24 at 11:41 a.m., the resident was assisted out of her room in a wheelchair. The resident's clinical record was reviewed on 3/13/24 at 11:30 a.m. Diagnoses included heart failure, hypertension (high blood pressure), repeated falls, pain, disorientation, syncope (fainting) and collapse, difficulty in walking, generalized muscle weakness, history of falling, unsteadiness on feet, and fatigue. Current physician orders included diltiazem (for blood pressure) 240 mg extended release daily started 9/28/23, tramadol (opiate for pain) 50 mg three times a day started 12/29/23, and oxygen at 2-5 liters per minute per nasal cannula for dyspnea (difficulty breathing) started 11/27/23. A significant change Minimum Data Set (MDS) assessment on 12/6/23 indicated the resident was moderately cognitively impaired. She required substantial to maximal assistance with putting on and taking off footwear. She required partial to moderate assistance with walking. A quarterly MDS assessment on 3/6/24 indicated the resident was severely cognitively impaired. She required partial to moderate assistance with putting on and taking off footwear and walking. An activities of daily living (ADLs) functional status/rehabilitation potential care plan, initiated on 8/18/22 and last revised on 2/25/24, indicated the resident was limited in ability to doing her own ADLs related to left sided weakness. Her goal was to be able to do her own ADLs with set up assistance through the next review on 3/30/24. Current interventions included walking: walks with walker, gait belt, and one assist but is noncompliant (5/18/23). A current fall care plan, initiated on 8/5/22 and last revised on 3/6/24, for falls indicated the resident was at risk for falling. Her goal was to remain free from injury through the next review (3/30/24). Current interventions included purposeful routine rounding 4P's - 1. Pain 2. Personal needs (bathroom) 3. Personal items (everything within easy reach - call light, water, phone, tissue, remote) (8/5/22), keep personal items and frequently used items within reach (11/1/22), frequent checks (12/6/23), leave door open to see resident, she may not be compliant with this as she likes the door to be closed (12/25/23), place excess oxygen tubing in oxygen tubing bag to void a trip hazard (1/10/24), encourage resident to be in supervised area with meaningful activities if without companion between 12 noon and 8 p.m. or whenever awake and restless (2/7/24), reeducate staff to make sure that frequently used items like TV remote control are within reach (2/14/24), clean and keep resident's dentures and its storage within her reach (2/20/24), and gait belt with one assist during transfers and ambulation (walking) (2/22/24). Fall risk assessments completed on 12/6/23 and 3/6/24 indicated the resident was a high risk for falls A progress note, dated 12/4/23 at 10:38 p.m., indicated the resident was found on the floor. She was lying on her back with her head supported by a QMA on duty. The resident indicated she was trying to get clothes from her dresser to change. A falls care plan intervention, started 12/4/23, indicated the resident was to be provided with assistance with clothing change between 8 p.m. and 9 p.m. The intervention was discontinued on 12/5/23. A progress note, dated 1/2/24 at 9:55 a.m., indicated the resident was found on the floor in her room near her recliner. The falls care plan lacked a new intervention for the 1/2/24 fall. A progress note, dated 1/3/24 at 12:27 p.m., indicated the resident was found sitting on her bottom in her room calling for help. The resident indicated her legs felt weak, and she collapsed to the floor. A falls care plan intervention, started 1/3/24, indicated make sure TV remote turns on both TV and mediacom box so that resident does not have to get up and push ok on mediacom box. The intervention was discontinued on 1/4/24. A progress note, dated 1/8/24 at 1:50 p.m., indicated the resident was found lying on her back alongside her bed in her room. Resident indicated she had gotten her crackers and cream-filled sponge cakes out of her closet, walked back to her recliner, lost her balance on the way, and fell. A fall care plan intervention, started 1/8/24, indicated keep resident's snack supply up within easy reach of the resident. The intervention was discontinued on 1/9/24. A progress note, dated 1/15/24 at 10:26 p.m., indicated the resident was found on the floor. She indicated she was trying to go to the bathroom but lost her balance. A fall care plan intervention, started 1/15/24, indicated the resident usually went to the toilet early in the evening. Toileting assistance was to be provided between 6 p.m. and 8 p.m. The intervention was discontinued on 1/16/24. A progress note, dated 2/2/24 at 3:40 p.m., indicated the resident was found lying on her back on the floor in her room. The resident indicated she had walked to the restroom, lost her balance, and fell backward. A fall care plan intervention, started 2/2/24, indicated the resident should be offered assistance to the restroom between 3 p.m. and 4 p.m. The intervention was discontinued 2/3/24. A progress note, dated 2/19/24 at 6:31 p.m., indicated the resident was walking down the hall at 4:55 p.m. accompanied by a certified nurse aide (CNA). She started to reach something on her right side and fell over. She fell on her right side hitting her head on the wall. An ADLs care plan intervention, started on 5/18/23, indicated the resident walked with walker, gait belt, and one assist but was noncompliant. A fall care plan intervention, started on 2/22/24, indicated the resident required a gait belt and assistance of one staff member for ambulation and transfers. A progress note, dated 3/6/24 at 2:30 p.m., indicated the resident was found on the floor in a sitting position shouting for help. Her feet were bare. An abrasion was found to her upper left back and measured 1 cm by 1.5 cm. She indicated she had to use the restroom and did not have time to use her call button. A fall care plan intervention, started on 3/7/24, indicated the resident usually ambulated all the way to the bathroom by herself when unattended. A bedside commode was to be provided and offered to the resident for toileting use to minimize fall risk from long distance ambulation. The intervention was discontinued on 3/8/24 Review of the progress notes indicated the resident fell 17 times from 12/4/23 through 3/6/24. During an interview, on 3/13/24 at 11:06 a.m., CNA 7 indicated the facility had a quick reference guide for fall preventions for all residents by the charting kiosk. Fall interventions could also be found on the electronic medical record. During an interview, on 3/14/24 at 12:26 p.m., RN 8 indicated when devising interventions for the residents, they would look at what was causing the falls. Resident C, specifically, would require long term goals and interventions due to her multiple falls. During an interview, on 3/14/24 at 2:08 p.m., the ADON indicated the nurse on shift for the fall would put in place a new intervention a fall. The intervention was generally long term, or a new one would be put in its place if it was discontinued. She was uncertain why interventions were being discontinued after one day. The nurse would have had to put in an end date. During an interview, on 3/14/24 at 2:23 p.m., CNA 9 indicated she utilized the care plan with the interventions for fall prevention on the computer software. During an interview, on 3/14/24 at 2:30 p.m., QMA 10 indicated he utilized the electronic medical record (EMR) to find the interventions for falls to be used for the residents. During an interview, on 3/14/24 at 2:41 p.m., RN 11 indicated she had a paper which provided instructions on updating care plans after a fall. An intervention was added with a fall and stayed active until the condition or problem resolved. The intervention should be continued as long as necessary. During an interview, on 3/14/24 at 3:05 p.m., the DON was uncertain why Resident C's interventions for falls would have been discontinued after one day. During an interview, on 3/14/24 at 3:07 p.m., the ADON indicated fall care plan interventions should not have been discontinued unless the problem was resolved. Review of a current, undated facility policy, titled Falls, Prevention and Follow up, provided by the DON on 3/13/24 at 2:47 p.m., indicated .It is the goal of the nursing staff to prevent as many falls as possible This citation relates to complaint IN00424450. 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure a resident did not receive psychotropic medications when continuation of the medication was not indicated for 1 of 5 residents reviewed for unnecessary medications (Resident 5). Findings include: During an observation on 8/7/23 at 10:25 a.m., Resident 5 was observed sleeping in a recliner near the nurses station. On 8/8/23 at 9:50 a.m., the resident was observed sleeping in his wheelchair sitting at the nurses station. On 8/8/2023 at 3:38 p.m., the resident was observed sleeping in a recliner near the nurses station. On 8/10/2023 at 11:00 a.m., the resident was observed to be sleeping intermittently during the resident council meeting. When awake, the resident appeared confused. On 8/10/23 at 4:08 p.m., the resident was asleep in the recliner near the nurses station. On 8/11/23 at 9:00 a.m., the resident was asleep in his wheelchair in the television room. Resident 5's clinical record was reviewed, on 8/9/2023 at 10:19 a.m., and indicated an active, 10/22/20, diagnosis of major depressive disorder, single episode, mild. A current physician's order indicated sertraline (anti-depressant) 50 mg (milligram) once a day at 9:00 a.m., with a start date of 6/12/2023. A review of the resident's medication history indicated the following: Sertraline tablet; 25 mg; amt: 1 tab; oral, special instructions: to be administered with 50 mg tab for total dose of 75 mg once a day at 8:00 p.m., starting on 2/28/2023 and ending on 3/6/2023. On 3/6/2023, the sertraline was discontinued and documented as ineffective by the prescribing NP (Nurse Practitioner). An order for buspirone (anti-anxiety) 10 mg three times a day was started on 3/7/2023 and stopped on 6/3/2023. On 6/5/2023, buspirone 10 mg three times a day was reordered. A progress note, dated 4/2/23, indicated the NP followed up on the discontinuation of sertraline and the start of buspirone. The resident was pleasant and very engaging today. Mood is baseline .Staff reports his buspirone has been very helpful with his anxiety and he is tolerating medication without any adverse side effects .no hallucinations, paranoid, homicidal, or suicidal statements .continue buspirone 10 mg three times daily as prescribed. Progress notes from April 2023 and May 2023 indicated the following: On 4/4/23 at 10:11 p.m. the resident was reportedly angry and could not be consoled. He cussed at the CNA (certified nursing assistant) and threw his walker. He was angry because he did not want to be at the facility. On 4/5/2023 at 6:27 a.m., the resident was reported as being in a good mood and pleasant with staff. On 4/5/2023 at 9:47 p.m., the nurse documented .Mood fair with outbursts of restlessness and confusion around supper time. On 4/10/2023 at 12:02 p.m., the NP's progress note indicated: .Staff reports he has had some delusional behavior but is being treated for a UTI (urinary tract infection) . The resident continues buspirone 10 mg 3 times a day and is tolerating without any adverse side effects. Sertraline was discontinued after staff reports it was ineffective On 4/12/2023 at 9:24 p.m., a progress note indicated the resident was in a good disposition with no noted confusion and restlessness for the shift. April 2023 progress notes did not include any documentation of depression. A progress note dated 5/8/23 at 3:26 p.m. indicated the NP's progress note indicated staff reported Resident 5 had eight episodes of delusional behavior in regards to going to Ohio. The resident was redirectable, mood was appropriate with no hallucinations or paranoid, homicidal, or suicidal statements. The buspirone was to be continued as ordered. Progress notes from May 2023 contained no mention of depression or related behaviors. Progress notes from June 2023 indicated the following: On 6/2/2023 at 9:00 a.m., a progress note indicated the resident remained in his room on droplet/airborne isolation precautions and had to be returned to his room twice. On 6/2/2023, Resident 5 was discharged to the hospital for signs and symptoms of COVID-19. On 6/4/2023 he returned from the hospital and was returned to isolation in his room. On 6/04/2023 at 2:23 p.m., Resident 5 was in good spirits and joking with the staff. He was confused about why he was at the facility. He was in contact isolation. On 6/5/2023 at 2:53 p.m., a progress note indicated Resident 5 had a restless day and believed he needed to be at school, teaching. He kept leaving his room without assistance to the school. He was on isolation precautions for COVID-19. Staff had to keep returning him to his room. On 6/5/2023 at 8:40 p.m., the resident remained on isolation for COVID-19. He had attempted to exit his room once this shift but was directed back inside his room. On 6/5/2023, Resident 5 restarted sertraline 50 mg once a day at 9:00 a.m. On 6/9/2023 at 12:10 a.m., a note indicated he was taken out of isolation on 6/12/23. On 6/12/2023 at 11:09 a.m., a new order to restart sertraline 50 mg daily was documented in the progress note. On 6/12/2023 at 9:47 p.m., the NP's progress note indicated after returning from the hospital, they discontinued his sertraline and staff is requesting to restart this medication. Upon assessment he was showing signs and symptoms of increased depression and it appeared the sertraline may prove beneficial at this time. The clinical record lacked additional indication of depression. On 7/24/2023 at 1:06 p.m., the NP's progress note indicated the resident was pleasant and engaging. The staff reported no behaviors and no signs or symptoms of depression. The plan was to continue buspirone as ordered. The resident's care plan dated 2/25/21 with a revised date of 8/2/23 at 5:31 p.m. indicated a problem of major depression and signs and symptoms of anxiety. He received buspirone. Signs and symptoms of depression and anxiety included increased irritability (yelling at spouse and others), tearfulness related to wanting to go home and be with his wife, and/or wanting to go home to the farm where he grew up as a child. He would often say that he was packing up to go to Ohio. An intervention dated 2/24/2021 indicated staff should observe moods, affect, and behaviors with hands on care. A significant change in status on the 6/25/2023 MDS indicated the cognitive status of the resident was severely impaired and depression was minimal. During an interview with RN 7 on 8/14/2023 at 12:19 p.m., she indicated the resident could be very adamant about what he wanted. He could get fixated on something and was difficult to redirect. The RN was unaware of the restart of sertraline. The hospital had the resident on sertraline when he returned. She had not observed any signs of depression, but the resident could be agitated and anxious. She indicated his agitation and anxiety were often related to his desire to see his wife or his desire to return home. A document titled Use of Psychotropic Drugs, provided by the DON on 8/11/2023 at 5:33 p.m., indicated the following: .Policy - Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s) . 4) The indications for use of any psychotropic drug will be documented in the medical record . b) For psychotropic drugs that are initiated after admission to the facility, documentation shall include the specific condition as diagnosed by the physician . i) Psychotropic medications shall be initiated only after medical, physical, functional, psychosocial, and environmental causes have been identified and addressed . ii) Non-pharmacological interventions that have been attempted, and the target symptoms for monitoring shall be included in the documentation . 6) Residents who use psychotropic drugs shall receive gradual dose reductions, unless clinically contraindicated, in an effort to discontinue these drugs . 11(b)(ii) An evaluation shall be documented to determine that the resident's expression or indications of distress are 1) Not due to a medical condition or problems that can be expected to improve or resolve as the underlying condition is treated or the offending medication(s) are discontinued .2) Not due to environmental stressors alone, that can be addressed to improve the symptoms or maintain safety 3.1-48(4) 3.1-48(b)(2)

Based on observation, interview, and record review, the facility failed to ensure the physician was notified of weight fluctuations for 1 of 3 residents reviewed for nutrition (Resident 47) and failed to ensure the physician was notified of abnormal blood pressure and pulse readings for 1 of 19 residents reviewed for the investigation sample (Resident 53). Findings include: 1. During an interview, on 6/21/22 at 1:26 p.m., Resident 47 indicated he had recently moved to the healthcare center, as he no longer met criteria for assisted living. Resident 47's clinical record was reviewed on 6/22/22 at 2:24 p.m. Diagnoses included, but were not limited to, compression fracture of lumbar and thoracic vertebra, repeated falls, low back pain, edema, congestive heart failure, chronic kidney disease, and chronic pain. Current physician orders included, but were not limited to, furosemide (water pill) 20 mg daily, furosemide 20 mg daily with routine dosage from 6/21/22-6/23/22 for congestive heart failure exacerbation, and weekly weight on Monday. A 6/1/22, quarterly, Minimum Data Set assessment indicated he was moderately cognitively impaired and had weight loss. A 3/4/22 Nutrition Note indicated he was on a regular no added salt (NAS) diet and was able to feed himself. He weighed 186 pounds and had gained 13 pounds in 3 months when he was in assisted living, and the weight gain was not quite significant. He had edema to his bilateral lower extremities, which may have been part of his weight gain. He had a good appetite. On 3/7/22, he received a new order for Lasix 20 mg daily. On 3/10/22, he was diagnosed with a respiratory infection and started on an antibiotic. On 3/14/22, he weighed 190 pounds. On 3/21/22, he weighed 174 pounds. He was re-weighed on the same day and weighed 173. The medical provider was not notified of the weight loss. On 4/8/22, he received an order for a daily frozen/pudding supplement. A 4/11/22 Registered Dietician (RD) note indicated his weight was 174 pounds, which was a 16 pound weight loss in 30 days. The weight loss was likely due to NAS restriction, diuretic therapy, and reduced edema to his lower extremities. On 4/25/22, he weighed 168 pounds. The medical provider was not notified of the weight loss. On 5/2/22, he weighed 154 pounds. The medical provider was not notified of the weight loss. On 5/23/22, he weighed 169 pounds. The medical provider was not notified of the weight gain of 5 pounds from 5/17/22. A 5/24/22 RD note indicated his weights had been variable in the previous 30 days. A high calorie supplement was to be added twice daily. On 5/30/22, he weighed 159 pounds. The medical provider was not notified of the weight loss. On 6/6/22, he weighed 170 pounds. The medical provider was not notified of the weight gain. On 6/20/22, he weighed 169 pounds. During an interview, on 6/27/22 at 9:36 a.m., the ADON indicated the delay on receiving the resident's new shoes in April was due to his family having difficulty finding wide-width shoes. The facility had tried to place a table near his chair, but he hadn't liked it. The sign had been on his walker as of the previous week. During an interview, on 6/27/22 at 10:32 a.m., the ADON indicated the RD informed her the resident had a large weight gain due to edema. An RD email indicated on 3/4/22, his weight gain was addressed and it was likely related to edema and with diet therapy and NAS diet, a weight loss was expected. On 4/8, he was started on a supplement as he wasn't always eating lunch well, likely due to back pain and an intake decline around the same time. 2. Resident 53's closed clinical record was reviewed on 6/27/22 at 11:00 a.m. Diagnoses included, but were not limited to, abnormal weight loss, age-related debility, and hemiplegia and hemiparesis non-dominant right side following CVA. Physician orders, current at the time of the resident's last day of admission at the facility, included, but were not limited to, atenolol (blood pressure) 25 mg at bedtime, clonidine (blood pressure) 0.1 mg as need for systolic blood pressure greater than 180 or diastolic blood pressure greater than 100, and torsemide (water pill) 10 mg daily. A 3/30/22, quarterly, MDS indicated he was moderately cognitively impaired and required extensive assist for ADLs. Review of 5/3/22 vital signs indicated his blood pressure was 118/63 and his pulse was 60 beats per minute (bpm). Review of 5/10/22 vital signs indicated his blood pressure was 121/65 and his pulse was 62 bpm. A 5/12/22 at 6:17 a.m., progress note indicated the resident was very weak could not walk to the bathroom. His blood pressure was 77/65 and his pulse was 105 bpm. The medical provider was not notified of the abnormal vital signs. A 5/12/22 at 9:00 a.m., progress note indicated he was resting in bed peacefully. His blood pressure was 122/88 and his pulse was 115 bpm. He complained of being tired. The medical provider was not notified of the increased pulse rate. A 5/13/22 at 8:54 a.m., progress note indicated he continued with weakness and poor appetite. His vital signs were within normal range for the resident, with his blood pressure being 90/52 and his pulse 95 bpm. The medical provider was not notified of the abnormal vital signs. During an interview, on 6/27/22 at 11:24 a.m., RN 50 indicated she would notify the medical provider and review the resident's medications and look for trends if vital signs were found to be outside of the normal range. The notification would be documented in the progress notes. During an interview, on 6/27/22 at 9:15 a.m., CNA 52 indicated the nurses documented weights. During an interview, on 6/27/22 at 9:26 a.m., RN 59 indicated the computer system would flag discrepancies with weights and vital signs. During an interview, on 6/27/22 at 2:13 p.m., the DON indicated she could not find confirmation the medical provider had been notified about the abnormal vital signs. Review of a current facility policy, titled WEIGHT, dated 10/4/20 and provided by the DON on 6/27/22 at 11:22 a.m., indicated the following: .If there is a 5 [five] pound weight difference of 5% (whichever is higher), the resident will be re-weighed .Residents with a CHF diagnosis will be weighed per MD order. Any weight changes greater than 3 [three] pounds in one day or 5 [five] pounds in one week will be reported to PCP [primary care provider] by the charge nurse Review of a current facility policy, titled Guidelines for Physician Notification, revised date 5/14/19 and provided by the ADON on 6/27/22 at 2:28 p.m., indicated the following: .Purpose: To ensure the resident's physician is aware of all diagnostic testing results or change in condition in a timely manner to evaluate condition for the need of provision of appropriate intervention for care .Attempts to notify the physician and their response should be documented in the resident's record 3.1-5(a)(2)

Based on observation, record review and interview, the facility failed to ensure a resident was adequately assessed for mental health services after being diagnosed with two new mental health conditions and the facility failed to develop and implement interventions on the care plan for monitoring one of the new mental health diagnoses for 1 of 1 residents reviewed for PASARR (Pre-admission Screening and Resident Review) (Resident 6). Findings include: During an interview on 6/21/22 at 10:31 a.m., Resident 6 was sitting in bed, she did not engage in conversation. Her clinical record was reviewed on 6/24/22 at 10:29 a.m. Her diagnoses included, but were not limited to, (4/4/15) Alzheimer's disease, (9/30/19) dementia with behavioral disturbance, (5/11/20) major depressive disorder, (3/8/21) bipolar disorder, (7/29/21) catatonic disorder and (2/14/22) delusional disorders. An 4/13/22 admission MDS (Minimum Data Set) assessment indicated she moderate cognitive impairment. She had received an anti-psychotic medication four days and an anti-depressant seven days during the assessment period. She had not received psychological therapy. Current physician orders included, but were not limited to the following; 1. Monitor behavior of expressions of sadness every shift, the order date was 3/2/19. 2. Monitor behavior of mania (extremely elevated and excitable mood usually associated with bipolar disorder) every shift, the order date was 3/2/19. 3. Monitor behavior of tearfulness every shift, the order date was 3/2/19. 4. Monitor behavior of hallucinations every shift, the order date was 10/1/20. 5. Monitor behavior of self isolation twice a day, the order date was 1/11/22. Review of a PASARR Level I pre-admission screening, dated 2/28/19, indicated the following mental health diagnoses; major depression, bipolar disorder and anxiety disorder. A current mood state care plan, dated 3/4/19, indicated she presented with bipolar and delusions and received a mood stabilizing medication. Signs and symptoms included becoming manic and presenting with increased symptoms of depression (would isolate herself, stayed in bed, refused meals, easily tearful, and resistive to care suddenly). Presented with delusions as evidenced by, believed she heard her son and needed to look for him and got up on her own to search, would say she need to find the deck and would look for the deck. She had good days and bad days, was at risk for harm to self (weight loss, skin breakdown related to refusals of meals, care and to get out of bed, and at risk for falls). The goal, with a target date of 9/3/22, indicated she would not exhibit signs of isolation (sad, dull affect, non-commutative, withdrawn, lack of eye contact, expressions of loneliness/rejection, hostile, irritable behavior, lack of awareness of surroundings and inattention to self-care). Interventions included, but were not limited to, encouraged to verbalize feelings and fears and encouraged her to become involved in activities, both with an approach start date of 3/4/19. A psychiatric progress note, dated 7/29/21 at 4:57 p.m., indicated, but was not limited to, Catatonia. During an interview on 6/24/22 at 10:17 a.m., LPN 21 indicated the resident was having a day where she wanted to remain in bed. During a follow-up interview on 6/27/22 at 9:53 a.m., LPN 21 indicated the catatonic diagnosis was probably added in July 2021 and the delusional disorder diagnosis earlier this year. Review of a definition of catatonia from the website WebMD, https://www.webmd.com/schizophrenia/what-is-catatonia, provided by the Social Service Director on 6/27/22 at 1:12 p.m., with the excited catatonia type high-lighted, indicated the person may move around but their movement seems pointless and impulsive. They may seem agitated, combative, or delirious, or they may mimic the movements of someone who's trying to help them. During an interview, on 6/27/22 at 1:33 p.m., the Social Service Director indicated the PASARR screening, dated 2/28/19, was the most recent one and there should have been another one done with medication changes. Review of current facility policy, titled MOOD AND BEHAVIOR POLICY, undated and provided by the Social Service Director on 6/27/22 at 2:23 p.m., indicated .The interdisciplinary team will utilize information from the PASARR process as well as to complete a comprehensive assessment of resident needs, strengths, goals, life history and preference using the resident assessment instrument (RAI) specified by CMS .The objective of the Mood and Behavior Policy and Procedure is to provide a plan of care that is individualized to the residents needs based upon the comprehensive assessment by the interdisciplinary team. This plan of care will include medically related social services to address mood and behavioral health services to attain or maintain the highest practicable well-being

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement a bowel monitoring program to ensure residents were treated for constipation for 2 of 5 residents reviewed for unnecessary medications (Residents 36 and 20). Findings include: 1. During an interview, on 6/21/22 at 11:00 a.m., Resident 36 indicated she had occasional constipation and had been hospitalized a few times since her recent admission to the facility. Resident 36's clinical record was completed on 6/22/22 at 12:15 p.m. Diagnoses included, but were not limited to, retention of urine, bladder neck obstruction, acute cystitis without hematuria, and constipation. Current physician orders included, but were not limited to, oxycodone-acetaminophen (opiate) 10-325 every four hours as needed, ferrous sulfate (iron) 325 mg daily on Monday, Wednesday, and Friday, polyethylene glycol (laxative) 17 grams daily as needed, and milk of magnesia (MOM) (laxative) 30 milliliters daily as needed. A 5/21/22, 5-day, MDS assessment indicated she was cognitively intact, required extensive assistance for transfers and toileting, was occasionally incontinent of bowel and did not have constipation. Review of BM documentation and progress notes indicated the following: She had a small BM on 5/1/22 and did not have another BM until 5/4/22, when she had a medium BM following a dose of MOM. The clinical record lacked documentation of BMs from 5/5/22 through 5/7/22, when she had a small BM. She was admitted to the hospital on [DATE], following a fall at the facility. Review of a 5/11/22 hospital discharge summary indicated diagnoses of, but not limited to, infection or inflammation of bladder, fall, and drug-induced constipation. After re-admission to the facility, she was transferred back to the emergency department continued emesis and abdominal pain. She was admitted on [DATE] with a possible bowel obstruction. She re-admitted to the facility on [DATE]. She had a medium bowel movement on 5/15/22. On 5/18/22, the resident's abdomen was distended and hard to touch, but had bowel sounds active to all quadrants. She hadn't been able to have bowel movement after milk of magnesia was given in the morning. She received polyethylene glycol on 5/19/22 and 5/21/22 and MOM on 5/21/22 and 5/22/22. The clinical record lacked documentation of bowel movements until 5/23/22. Review of the resident's June 2022 BM record indicated no documentation from 6/1/22 through 6/5/22, when she had a medium BM. 2. On 6/22/22 at 12:55 p.m., Resident 20 was in the hallway in her wheelchair. CNA 31 assisted her to her room. Resident 20's clinical record was reviewed on 6/22/22 at 1:48 p.m. Diagnoses included, but were not limited to, dysphagia, other signs and symptoms involving cognitive functions and awareness, heart failure, type 2 diabetes, respiratory failure with hypoxia, chronic kidney disease, and constipation. Current physician orders included, but were not limited to, furosemide (water pill) 20 mg daily, hydrocodone-APAP (opiate) 5-325 mg four times daily, and polyethylene glycol (laxative) 17 grams daily as needed. A 4/27/22, quarterly, Minimum Data Set (MDS) assessment indicated she was cognitively intact, required extensive assistance with transfers and toileting, and was continent of bowel. She had a current, 5/3/21 care plan problem of risk for dehydration due to inadequate fluid intake, diabetes, kidney disease, constipation, and diuretic use. Review of bowel monitoring for June 2022 indicated the following: She had a medium BM on 6/7/22, and no BMs on 6/8/22, 6/9/22, and 6/10/22. The clinical record lacked documentation of BMs from 6/11 through 6/13/22, when she had a medium BM. She did not have a BM 6/16/22 through 6/19/22, and the clinical record lacked documentation of BMs until she had a medium BM on 6/21/22. Review of the resident's June MAR and progress notes indicated she had not received an intervention, up to an including a laxative, for constipation. During an interview, on 6/27/22 at 9:15 a.m., CNA 52 indicated the CNAs were responsible for documenting BMs and the nurses would monitor for constipation. CNAs were able to look back for the past 48 hours to see if a resident had a BM. During an interview, on 6/27/22 at 9:22 a.m., CNA 53 indicated the nurses monitored for constipation. The CNAs could see the previous 24 hours only. During an interview, on 6/27/22 at 9:26 a.m., RN 59 indicated if a resident went 24 hours without a BM, they were to receive prune juice or it's equivalent. After 48 hours, they were to receive MOM. After three days, they were to receive a suppository, and after four days, they were to receive an enema. Night shift would pull a report daily with those who had not had a bowel movement so the interventions could be started. During an interview, on 6/27/22 at 9:52 a.m., the DON indicated a report was supposed to be pulled on night shift, then put out to day shift to initiate interventions. During an interview, on 6/27/22 at 11:22 a.m., the DON indicated she could not find a reason for the missing documentation of the resident's bowel monitoring. Review of a current facility policy, titled BOWEL INCONTINENCY MANAGEMENT, dated 4/2015 and provided by the DON on 6/27/22 at 11:22 a.m., indicated the following: .The nursing staff will identify elimination patterns by observing and recording all BMs and will establish a BM schedule based on individual patterns .make sure CNAs are accountable for consistently following through with recording the BMs .Nursing will monitor and make notes routinely until a successful pattern has been established 3.1-37(a)

Based on observation, record review and interview, the facility to ensure a resident did not receive a dosage increase of a psychotropic medication without indication, for 1 of 5 residents reviewed for unnecessary medications (Resident 32). Findings include: During an observation on 6/23/22 at 9:37 a.m., Resident 32 was in the hallway ambulating with a walker. On 6/23/22 at 1:11 p.m., he was sitting in a chair in the common area across from the nurses' station. On 6/24/22 at 10:17 a.m., he was sitting in a chair in the common area across from the nurses' station. On 6/27/22 at 8:59 a.m., he was sitting in a chair in the common area across from the nurses' station. His clinical record was reviewed on 6/23/22 at 9:44 a.m. Diagnoses included, but were not limited to, dementia without behavioral disturbance and major depressive disorder. Current physician orders included, but were not limited to the following: 1. Observe resident closely for significant side effects to anti-depressant and report to the physician. Side effects: sedation, drowsiness, agitation, dry mouth, blurred vision, urinary retention, tachycardia, muscle tremor, weight changes and photosensitivity, the order date was 2/24/21. 2. Zoloft (anti-depressant), 50 mg (milligram) once a day, give with Zoloft 25 mg for a total of 75 mg once a day at 8:00 p.m., the order date was 2/15/22. 3. Zoloft (anti-depressant), 25 mg (milligram) once a day, give with Zoloft 50 mg for a total of 75 mg once a day at 8:00 p.m., the order date was 2/15/22. 4. Psychologist to evaluate and treat due to treatment of depression of sleep disturbance issues, the order date was 3/14/22. A 5/18/22 quarterly MDS (Minimum Data Set) assessment indicated he had moderate cognitive impairment. He had not had any moods or behaviors and he had received an anti-depressant everyday during the assessment period. A current care plan, dated 2/25/21, indicated he presented with major depression and received Zoloft. Signs and symptoms of depression included increased irritability (yelling at spouse and others), tearfulness related to wanting to go home and be with his wife and/or wanting to go home to the farm where he grew up as a child. Intervention included, but were not limited to, acknowledge to him that the current situation must be difficult, administer medications as ordered, allow him to express his feelings, encourage him to be involved in activities and wife visited him daily, all with a start date of 2/25/21. A Behavioral Gradual Dose Reduction (GDR) progress note, dated 1/10/22 at 1/10/22 at 10:08 a.m., indicated it was recommended, based on clinical data and symptom presentation, to reduce Zoloft from 75 mg to 50 mg once a day and to monitor for rebound symptoms of mood dysregulation. A Behavior Management Meeting note, dated 1/10/22 at 10:38 a.m., indicated order had been received to decrease Zoloft to 50 mg once a day. A progress note, dated 1/12/22 at 4:15 p.m., indicated he had walked down the hall without his walker, pushing a foot-stool with most of his belongings piled on top. He was able to be re-directed and assisted to the dining room. A progress note, dated 1/17/22 at 8:55 p.m., indicated he displayed no signs or symptoms of depression, had been pleasant and cooperative and kind to staff and other residents. A progress note, dated 1/22/22 at 9:34 p.m., indicated no signs or symptoms of depression, he did have increased confusion and thought he should pack because his wife was coming to take him home. Ate supper with his wife. After she had left he was upset because she should have stayed and slept with him, emotional support had been given. A progress note, dated 1/23/22 at 8:45 p.m., indicated he had increased confusion, wife had been there ate supper with him, after she had left he was upset and thought he needed to follow her, and he wanted to be with his wife. Emotional support had been given. A progress note, dated 1/25/22 at 9:57 p.m., indicated he displayed no signs or symptoms of depression, very happy, had supper with his wife and then back to his room and watched television. An IDT (Interdisciplinary Team) progress note, dated 1/27/22 at 8:57 a.m., indicated they had discussed his plan of care. He had behaviors of being tearful on January 22 and 23, and a behavior of packing up his belongings on January 12. A progress note, dated 1/31/22 at 9:11 p.m., indicated he had been in a pleasant mood, enjoyed having supper with his wife and then visiting in his room. Later that evening he had came to the lounge and joined in an activity. A psychiatric progress note, dated 2/9/22 at 2:19 p.m., indicated follow-up routine visit and review of the resident's response to GDR of Zoloft. Had met with the resident, he was awake and alert and able to carry on meaningful conversation and he reported no issues with mood, sleep and/or appetite. The plan indicated no changes to current plan of care and he appeared to be responding well to GDR of Zoloft. A progress note, dated 2/9/22 at 5:00 p.m., indicated he had questioned his wife where she had been during supper, his voice had been raised and agitated. Staff member visited with him and his spouse at the table and redirected the conversation. A progress note, dated 2/12/22 at 9:30 a.m., indicated he had been upset, thought he hadn't seen his wife in three or four days and was worried about her. Staff member provided reassurance that his wife visited daily. A Behavior Management Meeting note, dated 2/14/22 at 10: 42 a.m., indicated during the month of January he had presented with tearfulness, increased confusion and asking about his wife (1/22 and 1/23/22) and delusions on 1/21/22. During the month of February he had presented with tearfulness, increased confusion, agitation and asking about his wife leaving (2/5 and 2/9/22), this was an increase in mood and behaviors, the team decided this was a failed GDR and recommended to increase Zoloft back to 75 mg once a day. A Behavior Management Meeting note, dated 2/14/22 at 10:45 a.m., indicated an order had been received to increase Zoloft to 75 mg once a day. A progress note, dated 2/28/22 at 5:12 a.m., indicated he had hardly slept that night, thought his wife was coming to see him. A progress note, dated 2/28/22 at 2:03 p.m., indicated he had been confused, staff attempts to re-direct had been effective for short periods of time. A progress note, dated 3/2/22 at 6:26 a.m., indicated at 4:00 a.m. he had been frantic because he thought he was late for a meeting with his wife. He walked to the lounge, questioned staff member several times during the next hour about meeting his wife and returned to sit in the lounge. A Behavior Management Meeting note, dated 3/14/22 at 1:27 p.m., indicated during the month of February he had presented with three episodes of insomnia, three episodes of delusions and one refusal of care. In March he had presented with three episodes of insomnia. No order changes had been recommended. A progress note, dated 3/25/22 at 4:31 a.m., indicated he had been trying to get hold of his wife for the past half-hour. He was able to be re-directed. A progress note, dated 4/3/22 at 9:24 p.m., indicated he had increased confusion and had tried to pack up his belongings, his wife requested assistance from staff and they were able to re-direct him. A Behavior Management Meeting note, dated 4/11/22 at 10:30 a.m., indicated his episodes of insomnia had been discussed. New order for blood work to be done had been received. A Behavior Management Meeting note, dated 4/11/22 at 12:30 p.m. (recorded as a late entry on 4/21/22 at 12:32 p.m.), indicated during the month of March he had presented with nine episodes of insomnia and one episode of delusions. In April he had presented with two episodes of insomnia and four episodes of delusions. A recommendation was discussed to change the time he received his Zoloft from 9:00 a.m. to 7:00 p.m. A Behavior Management Meeting note, dated 5/9/22 at 11:11 a.m., indicated he had presented with three episodes of increased confusion, two episodes of delusions and two episodes of insomnia. No recommendations had been discussed. During an interview, on 6/27/22 at 9:54 a.m., LPN 21 indicated the resident had a failed GDR attempt of his anti-depressant because he misses living with his wife. During an interview, on 6/27/222 at 11:57 a.m., the Social Service Director indicated he had failed the GDR related to episodes of crying and increased confusion. Review of a current facility policy, titled PSYCHOACTIVE MEDICATIONS OTHER THAN ANTIPSYCHOTICS AND SEDATIVES/HYPNOTICS, with a revised date of 4/2015 and provided by the Social Service Director on 6/27/22 at 2:38 p.m., indicated .7. a. During the first year in which a resident is admitted on a psychopharmacological medication (other than an antipsychotic or a sedative/hypnotic), or after the facility has initiated such medication, the facility should attempt to taper the medication during at least two separate quarters (with at least one month between the attempts), unless clinically contraindicated. After the first year, a tapering should be attempted annually, unless clinically contraindicated 3.1-48(b)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A. Based on observation, interview and record review, the facility failed to prevent falls with major injury and fall with injury for 2 of 7 (Resident 39 and Resident 22) and the facility failed to follow care plan interventions for 2 of 7 residents reviewed for falls (Resident 46 and Resident 47). Findings include: 1. On 6/22/22 at 12:59 p.m., the door to Resident 39's room was closed. On 6/23/22 at 9:20 a.m., he sat in his recliner in his room with his walker in front of him. On 6/23/22 at 1:09 p.m., his door was closed. On 6/24/22 at 11:15 a.m., he ambulated independently to common area outside of dining room with a rollator walker. On 6/24/22 at 2:31 p.m., he sat in his recliner in his room with a visitor in his room. On 6/27/22 at 3:06 p.m., he was in his recliner in his room with visitors. Resident 39's clinical record was reviewed on 6/23/22 at 10:17 a.m. Diagnoses included, but were not limited to, wedge compression fracture of third lumbar vertebra, subsequent encounter for fracture with routine healing, need for assistance with personal care, history of falling, difficulty in walking, not elsewhere classified, unsteadiness on feet, cognitive communication deficit, low back pain, age-related osteoporosis without current pathological fracture, other malaise and vitamin D deficiency. His medications included, but were not limited to, atenolol (blood pressure) 25 mg (milligram) daily and gabapentin (neuropathy) 100 mg daily. An admission MDS (Minimum Data Set), dated 3/3/22, indicated he was moderately cognitively impaired. He required supervision of one staff member for bed mobility, walking in his room and the corridor and locomotion off the unit. He required supervision for locomotion on the unit. He required limited assistance of one staff member for transfers. He required extensive assistance of one staff member for dressing, toilet use, personal hygiene. He used a walker. He had a fall in the last month prior to admission/entry or reentry. He had problem care plan for falls, dated 2/24/22, that indicated he was at risk for falling related to new admission and environment intrinsic factors; 1. Over age [AGE] 2. Lower extremity and core weakness as evidenced by unable to complete even one on a 30 second Chair Stand Assessment 3. Balance deficit - could not complete 10 seconds on tandem 4-Stage Balance Test 4. Cognitive impairments with ACL ([NAME] Cognitive Level) score 3.6 - 3.8 5. Urinary incontinence 6. History of falls in residential with compression fracture 7. Chronic disorders - Severe Osteoporosis and Arthritis extrinsic factors - 1. Use of assistive device - rollator 2. Four or more medications. His most recent fall was 4/14/22. His goal was he would remain free from injury through next review. His interventions included, but were not limited to, keep call light in reach, provide proper, well-maintained, individualized, non-skid footwear, provide resident with safety device/appliance: rollator, routine rounding 4P's- 1.) Pain 2.) Position 3.) Personal Needs (Bathroom) 4.) Personal Items (everything within easy reach - call light, water, phone, Kleenex, remote) started on 2/24/22 and encourage use of non-skid shoes, gripper socks at all times started on 3/11/22. His nurses notes indicated, but was not limited to, the following: On 3/11/22 at 8:45 p.m., he was found on the floor in his room by the CNA. Upon arrival he was laying on his left side in between his recliner and his bed. He attempted to self-transfer, his walker appeared to be in use as it was tipped over next to him. Approximately 30 minutes prior to the fall, he rested comfortably in his chair, CNA asked him if he was ready to go to bed, since that was his preferred bedtime and he denied at that time that he was not ready. When nurse asked him what he was trying to do he stated he was walking over to get in bed. His call light was not on. He did not have slipper socks on as he changed clothing without assistance. He was educated on asking for assistance when transferring and he verbalized understanding. 15-minute checks were initiated. A fall risk assessment, dated 3/31/22, indicated he was at a high risk for falls. On 4/14/22 at 6:39 a.m., he was found on the floor in a sitting position. He said he was getting dressed and slid off the bed. He had no complaints of pain when first assessed. At that time, he complained that his back was sore and that the concrete floor caused it. PRN (as needed) medication to be given and back pain monitored. On 4/14/22 at 9:38 a.m., an IDT (Interdisplinary) note, indicated he had a fall that morning with complaints of back pain now. His preferred time to get up was 7:00 a.m. - 7:30 a.m., but was getting up and getting dressed at 5:30 a.m. The SSD (Social Service Director) would meet to re-evaluate preferred time for waking. He was barefoot at time of fall, SSD would also address non-skid slippers/gripper socks. He currently had his own personal bed. Care plans were reviewed and updated. On 4/14/22 at 11:11 a.m., he complained of back pain and stated it hurt to move. New order received for an x-ray STAT (immediately). On 4/14/22 at 8:09 p.m., Lumbar spine anteroposterior (AP) and lateral (LAT) conclusion indicated there was a compression deformity at the L2 (Lumbar vertebrae), and L5 level, age indeterminate. Otherwise, degenerative changes. Sacrum/coccyx x-ray conclusion indicated no acute findings. Degenerative changes and consider a repeat study if symptoms continued to persist or progress. On 4/15/22 at 1:12 p.m., x-ray results from 4/14/22 and previous MRI (Magnetic Resonance Imaging) to orthopedic doctor as he had performed kyphoplasty procedure on 12/28/21. On 4/21/22 at 3:43 p.m., MRI results were received, a new compression fracture at L2 with approximately 25% vertebral body height loss. Fluid is seen within the fracture. A prior vertebroplasty to T12 (Thoracic vertebrae), L1, L3 and L4. Degenerative changes as above. On 5/3/22 at 6:17 p.m., he returned from orthopedic appointment. He was scheduled for L2 kyphoplasty on 5/9/22. On 5/4/22 at 6:45 p.m., small multiple white, macerated lesions to right and left side of gluteal fold. Skin breakdown is a mirrored image. He was incontinent of bladder and bowel. Denied pain related to area of skin breakdown. He had moderate amount of pain and awaited surgery next week and kept him from being active and mostly wanted to stay sitting in his recliner. He was medicated with hydrocodone (narcotic pain reliever) for pain. A new order was received for foam dressings. On 5/9/22 at 7:36 a.m., he left the facility for surgical procedure. On 5/9/22 at 1:56 p.m., he returned from surgical procedure. His dressing was to remain clean, dry, and in place for two days, may remove dressing on day three and shower and was to keep head elevated while lying for the first 48 hours, no lifting over 10 pounds until instructed after follow up. On 5/26/22 at 2:10 p.m., he was admitted to hospice, for diagnosis of cerebral atherosclerosis effective 5/26/22. On 6/1/22 at 8:34 a.m., he had a stage 2 pressure injury to his right gluteus 0.8 cm (centimeter) x 0.8 cm x 0.1 cm. A new order was received for hydrocolloid dressing change every three days and PRN dislodgement/soilage. He was started on magic cup and two cal 60 cc (cubic centimeter) three times daily due to weight loss. He would be encouraged to lay down after breakfast and lunch to relieve pressure to area. He had his own mattress and would discuss with hospice nurse for airloss mattress to replace personal bed. During an interview with RN 33, on 6/22/22 at 9:03 a.m., she indicated he had a fracture to his back and sat up a lot and he didn't like to lay down, essentially that's how he developed the stage 2 pressure ulcer. During an interview with CNA 38, on 6/27/22 at 9:24 a.m., she indicated she assisted him with walks and used a gait belt, he was encouraged to use the call light. He got up unassisted and that was how he fell, she did frequent checks on him. When she walked by his room, she offered him to use the bathroom, he was a more independent kind of guy, he came from residential. If his door was closed, she cracked it opened and peeked in on him. If you did not shut his door he would get up and shut it. During an interview with the DON and ADON, on 6/27/22 at 10:41 a.m., the ADON indicated his initial intervention was an x-ray and his preferred bedtime was 7:00 a.m. - 7:30 a.m., he was re-approached to his preferred get up time. He got up earlier now. He did not use his call light. They checked on him and tried to keep him busy. They did purposeful rounding, he did use his call light some but, on the whole, did not use it every time. Mobility wise, he was getting back to his baseline from when he came over from residential. The DON indicated he was [AGE] years old, family did not want him to move to healthcare. He had a history of compression fracture and vertebroplasties/kyphoplasties. ADON indicated he fell a lot in residential and went through therapy. The DON indicated he had fallen in residential on 10/18/21, 10/31/21, 11/4/21, 1/1/22, 1/9/22, 1/15/22 and 1/19/22. The fall on 4/14/22, he was bare foot, he had his own personal bed and now had a hospital bed. Family wanted to wait to move him to healthcare, they had even stayed with him in residential and didn't want him to move. 2. On 6/22/22 at 12:55 p.m., Resident 22 was in his recliner with his feet elevated. On 6/23/22 at 9:17 a.m., his door was slightly ajar but unable to observe him from the doorway. On 6/24/22 at 11:11 a.m., his door was slightly ajar but unable to observe him from the doorway. On 6/24/22 at 1:10 p.m., he ambulated to his room with his walker and a staff member On 6/27/22 at 3:27 p.m., he was riding the Nustep (exercise bike) across from the nurse's station. Resident 22's clinical record was reviewed on 6/22/22 at 2:43 p.m. Diagnoses included, but were not limited to, unsteadiness on feet, repeated falls, vascular dementia without behavioral disturbance, personal history of other drug therapy on Eliquis (blood thinner), frequency of micturition, cognitive communication deficit and chronic fatigue. His medications included, but were not limited to, apixaban (blood thinner) 5 mg twice daily, insulin glargine (insulin) pen 100 unit/mL (milliliter) (3 ml)12 units subcutaneous twice daily, furosemide (diuretic) 20 mg daily, lisinopril (blood pressure) 5 mg daily and metoprolol tartrate (blood pressure) 12.5 mg daily. A quarterly MDS, dated [DATE], indicated he was moderately cognitively impaired. He required extensive assistant of one staff member for bed mobility, transfers, walking in his room and the corridor, locomotion on the unit, dressing, toilet use and personal hygiene. He used a walker. He had one fall with no injuries and one fall with injury since admission/entry or reentry or the prior assessment. He had a problem care plan for falls, dated 10/7/21, that indicated he was at risk for falling related out-toeing gait, osteoporosis, incontinent of bladder, poor balance while standing, history of falls in residential, high-risk medications - antihypertensives, diuretics, antidepressants and his most recent fall was on 4/7/22. His goal was he would remain free from injury through next review. Interventions included, but were not limited to, routine rounding 4P's- 1.) Pain 2.) Position 3.) Personal Needs (Bathroom) 4.) Personal Items (everything within easy reach - call light, water, phone, Kleenex, remote) started on 12/1/21, reminder sign to be placed on his stand-up rollator with his permission started on 12/28/21, turn off his television before assisting him out of his recliner for transfers and ambulation to prevent distractions while walking started on 1/9/22. A fall risk assessment, dated 2/9/22, indicated he was at a high risk for falls. His nurses notes indicated, but were not limited to, the following: On 2/27/22 at 4:09 p.m., the nurse was called to his room, by the CNA assigned to him, due to him being found floor. Nurse and the QMA went to assist and observed him on floor in front of the recliner laying toward his left side with his arm under him and faced towards the floor. He was assisted to his recliner and assessed for injuries. No injuries were noted. He stated he dropped a flashlight on floor in front of him and reached to grab it and slid from his chair to his knees and continued forward and fell to the floor. He was reminded to call for help when needed. On 2/28/22 at 8:35 a.m., an IDT note indicated his most recent fall was discussed and root cause of fall was he reached for his flashlight from his recliner. Questioned if he would be able to use a reacher/grabber appropriately. He did have a lift recliner as well. His care plan intervention was keep reacher close to him while he sat in his recliner so that he could safely pick items off floor if needed started on 2/27/22. A nurses note, dated 4/8/22 at 12:32 a.m., indicated the writer was informed by CNA that he was on the floor. Writer and went to his room. He talked and was able to answer questions. There was a moderate amount of blood from a head laceration. He denied pain related to range of motion. His pupils were equal and round, his handgrips were equal and firm. He was assisted up to the edge of the bed. The CNA and the writer applied pressure to his head laceration and 911 was called. He stated he had gotten up out of bed and attempted to go to the bathroom when he lost his balance. There was blood on the nightstand. He had grippy socks on. The CNA stated that his call light had just come on and she answered it right away. When she went in he was on his buttocks with his head leaned back against the corner of the arm of his recliner and his walker was nearby within reach and not overturned. On 4/8/22 at 5:08 a.m., he returned to the facility at 3:00 a.m., his bandage was redressed to his head. Seven Staples in place to his head laceration. Paperwork reviewed and laceration to be kept dry for 24-48 hours and then he may shower patting cut dry. Do not soak the cut. Wash around cut with clean water two times daily. May cover laceration with thin layer of petroleum jelly or Vaseline and nonstick bandage. Staples were usually removed in 7 to 14 days depending on how incision was healing and to follow up with primary physician for suture removal. Emergency department documentation, dated 4/8/22, indicated he fell striking the back of his head and nursing home personnel stated they found him lying on the floor and there may had been a brief loss of consciousness. He received a 5 cm laceration over the occipital area and required 8 staples. On 4/8/22 at 8:44 p.m. (Recorded as late entry on 4/11/22 at 2:42 p.m.) his primary physician stated to go to emergency department if the bleeding from his scalp laceration got worse or had neurological changes. On 4/8/22 at 10:17 a.m., a call was received from the local physician's office with new order to hold the Eliquis for 24 hours and let cardiologist know. On 4/9/22 at 1:45 a.m., he continued to bleed through bandages this evening. Writer applied pressure, and used an ice pack on the area, he continued to bleed through the bandage. The CNA went in to assist resident to the restroom and found that he had once again bled through his bandage. Writer called on call doctor and informed him of need to send resident to the hospital due to considerable amounts of blood on present bandage. On 4/9/22 at 5:47 a.m., he returned from local hospital with four staples that were added to the pre-existing ones. Paperwork advised removal in 7-14 days. On 4/9/22 at 12:33 p.m., fall follow up, no latent injury were noted. The dressing to his head was dislodged with no bleeding noted from laceration. He had 12 staples. During an interview with CNA 38 on 6/27/22 at 9:27 a.m., she indicated he was on frequent checks to go to the bathroom, he was a one assist at all times, and he was encouraged to use his call light. He liked to get up and take himself to the bathroom, she offered him every two hours or so to use the bathroom. During an interview with RN 33, on 6/27/22 at 10:25 a.m., she indicated they walk with him everywhere. He was able to use a wheelchair when his blood sugars were low, he was a fragile diabetic. He normally walked with a stand-up walker. She read his interventions from his care plan and indicated he wore shoes most of the time. During an interview with the ADON and DON, on 6/27/22 at 10:51 a.m., the DON indicated he fell on 4/7/22 at 11:20 p.m., and was sent out on 4/8/22 at 12:30 a.m. The ADON indicated he did use his call light some, he was assisted with walking. The immediate interventions were therapy due to falls and lab work. The DON indicated he had the fall on 6/24 where he was lowered to the floor. The ADON indicated he had an odd gait, therapy called it out-toeing. 3. On 6/23/22 at 1:10 p.m., CNA 36 indicated to Resident 46 that she was going to take her to the bathroom but needed to get the stand-up lift. On 6/23/22 at 1:11 p.m., CNA 36 was observed pushing the stand-up lift up to Resident 46 in her room and indicated to her to put her feet up. Resident 46 leaned forward, and CNA 36 placed the lift pad behind her and snapped the lift pad strap around her torso and indicated to her to hang on. Resident 46 place her hands onto hand bars and CNA 36 lifted her from her wheelchair located in her room and pushed her to the bathroom while she stood on the mechanical lift. CNA 36 placed Resident 46 in front of the toilet on the stand up lift with her back side to the toilet, she pulled her pants down and took soiled brief off and lowered her to the toilet. Resident 46 indicated she was done CNA resituated the lift pad and strap then lifted her in a standing position, provided incontinent care and placed brief on her and pulled up her pants. Resident 46 held onto the handlebars while CNA 36 pushed her while she stood on the mechanical lift and lowered her to sitting in her wheelchair. She unhooked her and indicated to put her feet up, she pulled the mechanical lift from in front of her and placed her foot pedals on her wheelchair. CNA 36 indicated she always lifted her with the stand-up lift by herself except for in the mornings when she first gets up due to her arms and her being sleepy. Resident 46's clinical record was reviewed on 6/22/22 at 2:31 p.m. Diagnoses included, but were not limited to, need for assistance with personal care and unspecified dementia without behavioral disturbance. A significant change MDS, dated [DATE], indicated she was severely cognitively impaired. She required extensive assistance of two staff members for bed mobility and transfers. She required extensive assistance of one staff member for dressing, toilet use and personal hygiene. She used a wheelchair. A quarterly MDS, dated [DATE], indicated she was severely cognitively impaired. She required extensive assistance of two staff members for bed mobility, transfers and toilet use. She required extensive assistance of one staff member for dressing and personal hygiene. She used a wheelchair. A problem care plan for falls, dated 1/22/20, indicated she was at risk for falling related to impaired mobility - wheelchair bound, osteoarthritis, use of psychotropic medications, knees gave out during transfer with staff, reaches for items from wheelchair, her most recent fall was 11/19/21. Her goal was she would remain free from injury through next review. Her interventions included, but were not limited to, transfers: mechanical stand-up with two assist started on 11/19/21. She had a problem care plan for ADL Functional / Rehabilitation Potential, dated 1/22/20, indicated she was limited in ability to own ADL's related to Dementia. Her goal was to assist as much as possible with cues and prompts through next review. Her interventions included, but were not limited to, transfers: mechanical stand-up with two assist started 9/28/21 and toilet use: extensive assist with stand lift started on 1/22/20. A 10/14/21 fall risk assessment indicated she was not at risk for falls. A nurses note, dated 11/19/21 at 9:30 p.m., indicated the CNA was transferring Resident 46 to bed and the CNA voiced she decided to clean and to change her brief from the stand-up lift. She was unable to hold anymore and was slowly letting go, the CNA helped lower her slowly to the floor. No injury was noted at that time. It took three staff members with extensive assistance and gait belt to transfer her to bed. She was to be two assist with all transfers via stand up lift. A 6/8/22 fall risk assessment indicated she was not at risk for falls. During an interview with the DON, on 6/23/22 at 1:46 p.m., she indicated according to the care plan and CNA assignment sheets she was to be a two person assist with stand up lift. Although she felt like she was a one person assist, she would have restorative evaluate her to see if she needs to be a one or a two assist. 4. During an interview, on 6/21/22 at 1:26 p.m., Resident 47 indicated he had recently moved to the healthcare center, as he no longer met criteria for assisted living and had fallen a few times. He had a walker next to his chair with a storage pocket hanging from the handlebar. There was a plastic caddy on the floor next to the chair. On 6/23/22 at 8:45 a.m., he was seated in the main dining room for breakfast. His walker was on his right side with a storage pocket on the handlebar. On 6/23/22 at 1:10 p.m., he was in his room. The plastic caddy was on the floor next to his recliner chair. On 6/24/22 at 3:23 p.m., he was near the nurses station using the exercise machine. His walker was on his right side with a storage pocket on the handlebar. On 6/27/22 at 8:49 a.m., he was seated in the main dining room for breakfast. His walker was on his right side with a storage pocket on the handlebar. Resident 47's clinical record was reviewed on 6/22/22 at 2:24 p.m. Diagnoses included, but were not limited to, compression fracture of lumbar and thoracic vertebra, repeated falls, low back pain, edema, congestive heart failure, chronic kidney disease, and chronic pain. Current physician orders included, but were not limited to, furosemide (water pill) 20 mg daily, furosemide 20 mg daily with routine dosage from 6/21/22-6/23/22 for congestive heart failure exacerbation, and weekly weight on Monday. A 6/1/22, quarterly, Minimum Data Set assessment indicated he was moderately cognitively impaired and required extensive assistance with walking in his room and for transfers. He had a current, 3/3/22 (revised 6/21/22), care plan problem of risk for falls. Interventions included, but were not limited to, raise plastic caddy next to recliner to higher level, change personal bed to hospital bed, assure he is wearing eyeglasses, keep cinnamon candies in drawer of bedside stand for easy access, sign to remind to use call light on walker, and frequent safety checks. A 3/3/22 event note indicated at 9:30 p.m., the resident was found sitting on the floor with his back against the bed, his right hand holding his left arm, rocking back and forth. He indicated he had hit his head, and an abrasion was found to his posterior scalp. He gave various explanations as to what he had been doing. He had been in bed at 9:20 p.m. for a bladder scan. He had been restless and anxious, as he had just moved into healthcare the same day. New immediate interventions of an assistive device and personal care items, including candy, kept within reach was added, as he had been looking for his candy earlier in the evening. He was sent to the emergency department for evaluation. Review of a 3/3/22 emergency department report indicated no acute injury. A 3/23/22 event note indicated at 11:00 a.m., he had a witnessed fall and was found sitting on the floor parallel to the bed with one shoe on and one off. He was not injured. He had stood to give a visitor a hug, when his shoe fell off and he lost his balance. A witness confirmed this and stated the resident did bump his head on the floor. His shoes were noted to not be tied properly. An intervention of corrective footwear was to be implemented. A 3/26/22 progress note indicated increasing back pain, and an x-ray was ordered. A 3/28/22 report indicated compression deformities at L1-L2 (lumbar spine) and T11 (thoracic spine) compression deformities. A 3/29/22 Social Service note indicated a message was left with the resident's family for his need of a new pair of shoes and he could also benefit from a small table or stand to put next to his chair to keep his papers and phone off of the floor. Staff encouraged him to place items on the bedside table, but he often refused. A 4/11/22 CT scan of his lumbar spine indicated compression fractures of T11 and L1 were favored to be acute or subacute. A 4/14/22 progress note indicated his new shoes were brought in by his family. There was no indication in the clinical record of his family being contacted further about his new shoes since 3/29/22. A 4/23/22 event note at 1:20 p.m. indicated he was found on the floor beside his recliner. He complained of pain to lower back. He had lost his balance and would continue to ambulate without asking for assistance. He had been standing and bent over to get something out of the container next to his chair. A new intervention was added to use his call light at all times for assistance. A root cause analysis note indicated he had likely lost his balance as he was bending over, reaching for something out of plastic container next to recliner. He had been sent to the emergency department for evaluation and an intervention would be added to raise his container from the floor. Review of a 4/23/22 emergency department note indicated probable acute T2, T11, and L5 compression fractures and age-indeterminate, likely chronic, L1, L3, and L4 compression fractures. A 6/13/22 event note indicated at 10:56 a.m., he had an unwitnessed fall in front of his recliner. He had abrasions to his right back, each measuring 23 centimeters (cm) length (L) x 1.3 cm width (W), and 28.5 cm L x 2 cm (W). He had been trying to sit in his recliner and lost his balance. A new intervention was added for a Call for Assistance sign on his walker. During an interview, on 6/27/22 at 9:36 a.m., the ADON indicated the delay on receiving the resident's new shoes in April was due to his family having difficulty finding wide-width shoes. The facility had tried to place a table near his chair, but he hadn't liked it. The sign had been on his walker as of the previous week. During an interview, on 6/27/22 at 9:15 a.m., CNA 52 indicated the resident's fall interventions included assistance to walk to and from the dining room and 15-minute checks. He had kept taking the reminder sign off of his walker. During an interview, on 6/27/22 at 9:22 a.m., CNA 53 indicated the resident's fall interventions included using a gilt belt for transfers, and frequent rounding to ensure his needs were met. He was also supposed to have a sign on his walker to remind him to call for assistance. Review of a current, undated, facility policy titled, FALLS, PREVENTION AND FOLLOW UP, provided by the DON on 6/27/22 at 11:22 a.m., indicated the following: .Anyone with a history of falls within the past 30 days is likely to fall again A current facility policy titled, TRANSFER ASSESSMENT TOOL, provided by the DON, on 6/27/22 at 11:22 a.m., indicated the following: All residents in the Healthcare and Crestwood should be given on of the following transfer designations. This code should represent the resident's weakest time of the day for transferring. Amount of assistance required will be determined by the nurse .STAND UP LIFT requires weight bearing support of 25 pounds and is able to tolerate weight bearing on lower extremities during transfer. An additional dot will be posted identifying one or two person assist with stand up lift 3.1-45(2)