Based on record review and interview, the facility failed to document the transfer process and communication to the receiving health care facility for 1 of 4 residents reviewed for hospitalizations. (Resident 41) Findings include: Resident 41's clinical record was reviewed on 5/23/25 at 11:45 a.m. Diagnoses included pneumonia, unspecified organism, chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, and acute on chronic combined systolic and diastolic congestive heart failure. An admission Minimum Data Set (MDS) assessment, dated 3/16/25, indicated the resident was cognitively intact and required maximal assistance with toileting hygiene, showering, lower body dressing and applying footwear. He needed moderate assistance with upper body dressing and mobility. A progress note, dated 4/7/25 at 4:45 p.m., indicated that Resident 41 was agitated, restless, had an oxygen saturation of 97% while wearing oxygen, and had a respiratory rate of 32. The resident had wheezing and a productive cough. The physician (MD) was notified of the resident's status. The MD instructed the facility to administer as needed albuterol. The resident's family remained at bedside. A progress note, dated 4/7/25 at 5:01 p.m., indicated Resident 41's family requested for the resident to be transferred to the Emergency Room. The emergency transport system was contacted, and the family remained at bedside. Resident 41's clinical record lacked indication the receiving health care facility had been notified of the resident being transferred to their care, the resident's condition at the time of the transfer, and a transfer form. During an interview on 5/27/25 at 11:18 a.m., the DON indicated proper documentation was to be completed at the time of the transfer. Documentation included physician, family, emergency transport, and the receiving facility notifications. The SBAR communication form (Situation, Background, Appearance, Review and Notify) and an Interact transfer form were to be completed. A packet, which consisted of the resident's history and physical, code status, recent vital signs, progress notes, and the completed SBAR and Interact forms, was to be given to EMS at time of transport. During an interview on 5/27/25 at 1:57 p.m., RN 4 indicated the SBAR and the Interact transfer form were to be completed at the time of a resident's transfer from the facility. The facility was to notify the receiving facility of the resident transfer and status. During an interview on 5/27/25 at 2:12 p.m., the DON indicated that Resident 41's medical record lacked proper facility transfer documentation. The Interact transfer form had not been completed and the record did not indicate the hospital was notified and given a status report. A facility policy, revised on 11/2016, titled CHANGE IN RESIDENT CONDITION/EMERGENCY TRANSFER TO ACUTE CARE HOSPITAL, provided by the DON on 5/27/25 at 2:20 p.m., indicated the following: POLICY: In the event a resident's condition changes warranting medical attention, the licensed nurse shall complete the SBAR Communication Form and contact the physician if the physician cannot come to the facility to examine the resident, the nurse shall request an order to transport resident to the emergency room for evaluation, if indicated .PROCEDURE: 4. Complete Nursing Home to Hospital Transfer Form 3.1-12(3) 3.1-12(5) 3.1-12(6)(A)

Based on interview and record review, the facility failed to ensure a nurse, who was employed to work in the facility in the nursing department, had a valid Indiana nursing license (LPN 3). This deficient practice had the potential to impact 56 of 56 residents who resided in the facility. Finding include: Employee records were reviewed on 5/22/25. Licensed Practical Nurse (LPN) 3 was listed on the Employee Records form, which was completed by the facility. The form indicated the employee's job title as LPN. The form indicated the nurse had been employed by the facility since 6/20/24. The facility's provided a binder containing nursing licenses verification, for facility employees. The information located in the binder for LPN 3 indicated the following: The employee had a Multi-State LPN license, which was issued by Ohio Professional Licensure agency. The facility nursing schedule for 5/18/25 to 5/31/25, which was provided by the DON on 5/21/25 at 8:46 a.m., indicated LPN 3 was scheduled to work: Sunday 5/18/25- 10 a.m. to 10 p.m.,evenings 5/21/25, 5/22/25, 5/23/25, 5/26/25, 5/29/25, and 5/30/25, and Sunday 5/31/25 - 10 a.m. to 10 p.m. During an interview on 5/23/25 at 9:46 a.m., the Administrator indicated LPN 3 should have applied for an Indiana nurse's licenses within 60 days of moving to the state. LPN 3 moved to Indiana in August 2024. A document titled Nurse Licensure Compact, which was provided by the Administrator on 5/23/24 at 9:46 a.m., was identified as the guidance the facility used regarding licensure and compact agreements. The document indicated: A multistate licensee who changes primary state of residence (PSOR) to another party state shall apply for a multistate license in the new party state within 60 days. 3.1-13(b)

Based on observation, interview, and record review, the facility failed to ensure food was prepared and distributed in a safe, sanitary manner. This deficient practice had the potential to impact 55 of 55 residents who received meals from the facility kitchen. Findings include: During a kitchen tour on 4/15/24 at 10: 15 a.m., accompanied by the Dietary Manger, the following concerns were observed: a. Varied sizes of empty boxes were on the floor in front of the three compartment sink. b. A 1/4 sized shallow steam table pan, in the clean storage, had a baked on brownish-black sticky residue on the pan lip and descending into the food contact area. Three pea-sized spots of dark residue were on the food contact surface. c. A 1/2 sized shallow steam table pan, in the clean storage, had a baked-on, sticky, golden brown residue around the lip and descending into the food contact sides of the pan. d. A full-size large steam table pan, in the clean storage, had chunks of food residue on the center bottom food contact surface of the pan. The lip had a dark black, sticky baked on residue. During an interview, at the time of the observation, the Dietary Manager indicated it appeared the previous night's dish crew had not been attentive to the washing of the pots and pans. e. Three of three coated non-stick skillets had missing stick-resistant coating. The missing coating created large sections of pan with no coating and exposed metal. The stick resistant areas on all three pans were covered with thick black, sticky, residue. f. The top surface of the mounted knife holder was dusty in appearance and sticky to touch. g. The commercial food processor was covered in a clear, sticky substance. h. The large table mounted can opener had a thick, sticky, and dark residue on both the cutting blade and the mounted base. i. One of three inspected serving ladles, in the clean storage drawer had a pooled, clear liquid in the bowl shaped ladle. j. The lip of the vent hood covering the stove, oven, and griddle, had a heavy coating of a black, greasy residue on the hood internal lip. k. The drip pan, located under the burners on the stove, had a heavy dark brown and black build up of baked on residue, covering approximately 1/2 of the surface. During a kitchen observation on 4/17/23 at 10:55 a.m., three empty boxes were on the floor in front of the three compartment sink. During an observation of the food washer process on 4/19/24 at 9:36 a.m., the dish washer had been in operation and dishes had been washed. The Dietary Manger tested the chemical levels in the rinse/sanitation cycle and found the chemical level was reading less than 10 parts per million (PPM). During an interview at the time of the observation, he indicated the chemical should read 100 PPM. The Dietary Manager indicated he would need to contact the facility's contracted dishwasher service company. At this time the Dishmachine Temperature/Sanitizer Log.was reviewed and found no temperatures or chemical levels had been recorded on 4/18/24 at supper, or on 4/19/24 prior to beginning the breakfast dishes. During an interview on 4/19/24 at 11:57 a.m., the DON indicated 55 of the 55 residents who resided in the facility consumed food orally. A current, undated, facility document titled Cleaning Schedule, provided by the Corporate RN Consultant on 4/19/24 at 10:14 a.m., indicated the following: .Cook (clean) Daily, Can Opener, Food Processor .Utensil Drawers .if needed Stove/grill .weekly .Tuesday Stove/Grill .Saturday Vent hood & Lights A current, 5/2018, facility policy titled Dish Machine Operation-Low Temperature, provided by the Corporate RN Consultant on 4/19/24 at 10:14 a.m., indicated the following: .e. Record both temperature and sanitizer levels on the Dishmachine Temperature/Sanitizer Log 3.1-21(i)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the resident representative was notified immediately of a fall with injury for 1 of 5 residents sampled for falls (Resident B). Findings include: Resident B's record was reviewed on 2/15/23 at 2:33 p.m. Her diagnoses included acute posthemorrhagic anemia (a condition that develops when a large amount of blood is lost quickly). Her physician's orders included apixaban (blood thinner) 2.5 milligrams (mg) twice a day. An admission Minimum Data Set Assessment (MDS) dated [DATE] indicated the resident was cognitively intact and required extensive assist of one person for walking and transfers. A nursing progress note, dated 12/27/22 at 12:10 a.m., indicated the resident was found sitting on the foot of her bed. She had blood on her, the bed, on the floor near the bedside table, and on the floor near her wheelchair. A laceration to her right outer eyebrow, a skin tear to her right wrist, and two skin tears to her right elbow were identified. The resident would not answer most questions. She would state she did not know when asked what happened. She continued to have confusion. She did not answer when asked if she was experiencing pain. A nursing progress note, dated 12/27/22 at 12:45 a.m., indicated the physician was notified of the resident's injuries. A nursing progress note, dated 12/27/22 at 6:20 a.m., indicated the resident's daughter was notified of the resident's injuries. A nursing progress note, dated 12/27/22 at 8:12 a.m., indicated the resident's speech was slurred. She was unable to follow commands. She seemed confused and unable to answer questions. The physician was notified. He advised to send the resident to the hospital for evaluation and treatment. During an interview, on 2/17/23 at 10:26 a.m., LPN 6 indicated the family and physician should be notified right away if a resident fell and had injuries, especially if the resident was on a blood thinner. A current policy, dated 10/2014, provided by the Corporate Nurse Consultant on 2/20/23 at 3:57 p.m., and titled Notification of Change, indicated .Facility personnel shall immediately inform resident, consult resident's physician; and, if known, notify the resident's legal representative or an interested family member when there is an accident involving the resident that results in injury and has the potential for requiring physician intervention This Federal tag relates to complaint IN00399681. 3.1-5(a)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure resident fall frequency, injuries and antiplatelet/anticoagulant medications were discussed and documented prior to administration of the above mentioned medications for a resident with recent repeated falls with head injuries for 1 of 5 residents reviewed for falls. (Resident C) Findings include: During an observation on 2/14/23 at 11:30 a.m., Resident C was in her low bed ,with sutures to her right forehead near her right eyebrow. Her eyes were closed. During an observation on 2/15/23 at 9:02 a.m., the resident's eyes were open and she was assisted with her breakfast by a staff member as she remained in bed. The sutures remained in place to the resident's right forehead near her right eyebrow. Resident C's clinical record was reviewed on 2/15/23 at 4:16 p.m. Diagnoses included essential (primary) hypertension, generalized muscle weakness, osteoporosis without current pathological fracture, primary osteoarthritis unspecified site, spinal stenosis site unspecified, and unspecified severity vascular dementia without behavioral disturbance. Review of a Fall Risk Assessment, dated 10/2/22, indicated the resident was at high risk for falls. Current medications included the following: isosorbide mononitrate (blood pressure) 60 milligram (mg) tablet once daily, metoprolol tartrate (blood pressure/heart rate) 25 mg tablet twice daily, clopidogrel (antiplatelet) 75 mg daily, and aspirin (blood thinner) 81 mg tablet once daily. A 12/24/22, annual, Minimum Data Set (MDS) assessment indicated the resident had severe cognitive impairment. She required extensive assistance for bed mobility, transfers, and toileting. The resident had frequent incontinence of bladder and was always incontinent of bowel. Since her prior MDS assessment, she had two or more falls, with no injuries. A current care plan for falls, last revised on 2/8/23, indicated the resident was at risk for falls. Interventions included utilize footwear with non-skid soles, monitor resident frequently when the call lights were not available such as common areas, keep frequently used items within reach of the resident, toilet prior to meals, non-slip pad to wheelchair, neurological checks as indicated, ensure shoes are in place while up, non-skid strips by bed, urinalysis, wheelchair pad alarm, and pull tab alarm in wheelchair. A health conditions care plan, last reviewed on 1/11/23, indicated the resident was at risk for complications related to altered mental status and high fall risk. Interventions included, monitor for complications and report findings to the nurse for further evaluation and possible physician and resident representative notification, and monitor for any change in cognitive status which could be related to the condition and intervene as indicated. An anticoagulant care plan, last reviewed on 1/11/23, indicated the resident has the potential for hemorrhage due to aspirin and clopidogrel medication used to treat coronary artery disease. Interventions included administer medication as ordered, monitor for signs and symptoms of adverse reaction: diarrhea, headache, hemorrhage, fever, rash, bruises, and notify the nurse of noted concerns for evaluation and possible physician and resident representative notification. In the event of occult or overt bleeding, hold the medication until the physician has been notified. Signs of occult or overt bleeding include: bleeding gums, bruising, tarry stools, hematemesis, and hematuria. A bruising care plan, last reviewed on 1/11/23, indicated the resident was at risk for bruising due to aspirin and clopidogrel medication use. Interventions included administer medications as ordered, observe skin for bruising, assist as needed with transfers or mobility, and notify the physician should significant increase in bruising be observed. Review of the resident's Fall Event Reports indicated the following: a. A witnessed fall in the day room on 12/29/22 resulted in a contusion to left eye, pain, and headache. b. An unwitnessed fall in the resident's room on 2/3/23 resulted in a bruise to right forearm 7.5 centimeters (cm) by 4.5 cm. c. A witnessed fall in the lobby on 2/4/23 resulted in an abrasion to the forehead. Neurological checks were restarted. d. A witnessed fall in the day room on 2/6/23 resulted in a left eyebrow laceration that required steri-strips. Neurological checks were restarted but were not completed. e. An unwitnessed fall in the resident's room on 2/8/23 resulted in a laceration to the right forehead 1.5 inches long. A review of the Root Cause Analysis and Three-Day IDT Review documentation for the above mentioned falls, from 2/3/23 through 2/8/23, lacked documentation of antiplatelet/anticoagulant medication revisions. This area was left blank on page one of each review. The clinical record lacked documentation of communication with the provider regarding the recent falls and clarification whether to hold or administer the resident's aspirin and clopidogrel during the resident's falls with bruising and/or head injuries from 2/3/23 through 2/8/23. Review of the electronic Medication Administration Record (MAR) indicated the resident was administered aspirin 1/2/23 through 2/7/23. She was administered clopidogrel 1/2/23 through 2/8/23, with the exception of 2/5/23. A Nurse's Note, dated 12/26/22 at 9:27 a.m., indicated the provider ordered to hold aspirin and clopidogrel for 3 days due to a fall. A Nurse's Note, dated 12/28/22 at 9:12 p.m., indicated the resident remained at baseline with no injuries noted. She self propelled in the wheelchair as usual to/from meals, in the common lounge, and asked if her son or parents were coming to get her. A Nurse's Note, dated 12/29/22 at 3:07 p.m., indicated the resident sat in the lounge and was seen leaned forward and fell out of the chair. A contusion was noted above the left eye. The resident complained of a headache, Tylenol was given, and the provider and family were notified. A Nurse's Note, dated 12/29/22 at 5:10 p.m. indicated a new order was received to hold clopidogrel and aspirin for three days related to the fall. A Nurse's Note, dated 12/30/22 at 2:45 p.m., indicated vital signs and neurological checks were within normal limits. Resident denied pain. A large bruised area was noted to the left side of her face. A Nurse's Note, dated 12/30/22 at 4:37 p.m., indicated the resident remained on neurological checks with no complaint of pain. Neurological checks were within normal limits. The resident had bruising noted to both eyes and forehead. The clinical record lacked indication of physician notification regarding the significantly increased bruising on 12/30/22. A Nurse's Note, dated 2/3/23 at 5:55 a.m., indicated the nurse was called to the resident's room where the resident was laying beside her bed in the prone position with her blanket under her. The resident was assisted by staff onto her back, assessed, and assisted back into bed with assistance of four staff members. A bruise was noted to the right forearm and measured 7.5 cm long by 4.5 cm wide, with no signs or symptoms of pain or discomfort. The Medical Doctor, Director of Nursing (DON) and family representative were notified of the fall. A Nurse's Note, dated 2/3/23 at 10:46 a.m. indicated the resident displayed increased confusion status post fall. A Nurse's Note, dated 2/4/23 at 11:38 a.m., indicated the resident was in her wheelchair in the lobby before breakfast and tipped forward on the floor. The resident suffered an abrasion to the forehead which measured 3 cm long by 1.5 cm wide. The Medical Doctor and family were aware of the fall. A Nurse's Note, dated 2/6/23 at 5:57 p.m., indicated the resident sat in her wheelchair in the lobby and fell out of her wheelchair. She hit her head and suffered a laceration above her left eyebrow that required steri strips. The Medical Doctor and family were made aware. A Nurse's Note, dated 2/7/23 at 11:53 a.m., indicated the resident continued on neurological checks related to recent fall. The resident was noted with purple color surrounding the left eye and rested in bed at this time. Pain or discomfort was not voiced. The clinical record lacked documentation of physician notification with the increased bruising after fall with a head injury and use of antiplatelet and/or anticoagulant medication use . A Nurse's Note, dated 2/8/23 at 3:15 p.m., indicated the resident was found at the foot of her bed face down with blood noted at her head. A deep laceration,1.5 inches in length, dripped blood, and was noted at the outer edge of her right eyebrow. A dinner plate-sized pool of blood was under her head. The Medical Director assessed her and ordered to send the resident to the emergency room for evaluation and treatment as soon as possible. A Nurse's Note, dated 2/8/23 at 8:50 p.m., indicated the resident returned to the facility. The report received from the emergency room was the resident had a laceration to the right eyebrow repaired, and a diagnosis of UTI with a prescription for treatment sent. The resident had four sutures to the right outer eyebrow laceration, with the right eye purple and swollen closed. Hospital emergency room Patient discharge instructions, dated [DATE], indicated the resident was being discharged with the following primary diagnoses: closed head injury, forehead laceration, fall, dehydration, contusion of right wrist, and hypothermia. A Nurse's Note, dated 2/9/23 at 12:13 p.m., indicated the resident was responsive to painful stimuli only, unable to open eye related to recent falls, edema, bruising, and lacerations to bilateral eyebrows. Her lungs were noted with rhonchi (abnormal lung sounds) throughout, and she was unable to take fluids, food or medications at this time. The physician and family were notified, and hospice evaluation and treatment was ordered related to vascular dementia. During an interview, on 2/20/23 at 2:04 p.m., LPN 7 indicated she was familiar with the residents' care on the 100 unit. The resident was a high fall risk due to the following reasons: she required assistance of 2 staff members for transfers, frequent falls, history of urinary tract infections, dementia diagnosis, she does not remember she can not walk and was spontaneous, she reached for items, blood pressure medications, and clopidogrel. For residents who have fallen and hit their head, with orders for antiplatelets/anticoagulants, the nurse would have typically contacted the physician for a hold order on those medications. If the nurse was not on duty during the falls, but the antiplatelet/anticoagulant was still ordered, the physician should have been consulted to discuss a hold on the medication rather than just administering the medication. During an interview, at the time of observation on 2/20/23 at 2:31 p.m., LPN 6 indicated the physician should have been notified if a resident with multiple falls was prescribed anticoagulants or antiplatelets to determine if the physician wanted the medications held. The resident's clopidogrel was administered 2/1/23 through 2/4/23 and 2/6/23 through 2/8/23. Aspirin was administered to the resident 2/1/23 through 2/7/23. The physician should have been notified immediately with any increased bruising after falls in a resident that was prescribed anticoagulants or antiplatelets. During an interview, on 2/20/23 at 3:02 p.m., the DON indicated she expected the nurses to clarify with the physician regarding the potential need to hold antiplatelet/anticoagulant medications with residents who exhibited frequent falls and/or head injuries. It should have been documented in the progress notes if it was discussed with the physician, as well as the physician's response. During an interview, on 2/20/23 at 4:00 p.m., the Corporate Nurse Consultant indicated the Interdisciplinary Team could have requested the provider to review the medications. A current policy, dated 10/2014, titled Fall Prevention Program, provided by the Corporate Nurse Consultant on 2/20/23 at 3:28 p.m., indicated the following: .POLICY: It is the policy of this facility to identify any resident who is at increased risk for falls. Identified residents shall be monitored by the Interdisciplinary Team (IDT) in an effort to implement fall prevention interventions that minimize occurrence of falls thereby minimizing resident risk of injury. The IDT shall review those residents identified as being at risk for falls or those resident who have sustained falls and are at risk for recurrent falls 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 provide adequate supervision to prevent falls with injuries for a dependent resident for 1 of 5 residents reviewed for falls. (Resident C) Finding includes: During an observation, on 2/14/23 at 11:30 a.m., the resident was noted in her low bed with sutures to her right forehead near her right eyebrow. Her eyes were closed. During an observation, on 2/15/23 at 9:02 a.m., the resident's eyes were open and she was assisted as with her breakfast by a staff member as she remained in bed. The sutures remained in place to the resident's right forehead near her right eyebrow. Resident C's clinical record was reviewed on 2/15/23 at 4:16 p.m. Diagnoses included essential (primary) hypertension, generalized muscle weakness, osteoporosis without current pathological fracture, spinal stenosis site unspecified, unspecified severity vascular dementia without behavioral disturbance, and transient cerebral ischemic attack (TIA). Review of a Fall Risk Assessment, dated 10/2/22, indicated the resident was at high risk for falls. Medications included the following: isosorbide mononitrate (blood pressure) 60 milligram (mg) tablet once daily, metoprolol tartrate (blood pressure/heart rate) 25 mg tablet twice daily, clopidogrel (antiplatelet) 75 mg daily, and aspirin (blood thinner) 81 mg tablet once daily. These medications were discontinued on 2/9/23 when the resident was admitted to hospice. A 12/24/22, annual, Minimum Data Set (MDS) assessment, indicated the resident had severe cognitive impairment. She required extensive assistance for bed mobility, transfers, and toileting. The resident had frequent incontinence of bladder and was always incontinent of bowel. Since her prior MDS assessment, she had two or more falls, with no injuries. Rejection of care behavior was not exhibited. A current care plan for falls, last revised on 2/8/23, indicated the resident was at risk for falls. Interventions included utilize footwear with non-skid soles, monitor resident frequently when the call lights are not available such as common areas, keep frequently used items within reach of the resident, toilet prior to meals, non-slip pad to wheelchair, neurological checks as indicated, ensure shoes are in place while up, non-skid strips by bed, urinalysis, wheelchair pad alarm, and pull tab alarm in wheelchair. An activities of daily living (ADL) assistance care plan, last reviewed on 1/11/23, indicated the resident required staff assistance for ADLs. Interventions included provide assistance with ADLs as resident requires, monitor for changes in ADL participation, and notify the nurse of any changes for further evaluation and possible physician and resident representative notification. A health conditions care plan, last reviewed on 1/11/23, indicated the resident was at risk for complications related to altered mental status and high fall risk. Interventions included monitor for complications and report findings to the nurse for further evaluation and possible physician and resident representative notification, and monitor for any change in cognitive status which could be related to the condition and intervene as indicated. A urinary incontinence care plan, last reviewed on 1/11/23, indicated the resident is incontinent of bladder and at risk for infection related to recent urinary tract infection (UTI), incontinence, history of falls, and weakness. A bruising care plan, last reviewed on 1/11/23, indicated the resident was at risk for bruising due to aspirin and clopidogrel medication use. Interventions included, administer medications as ordered, observe skin for bruising, assist as needed with transfers or mobility, and notify the physician should significant increase in bruising be observed. Review of the resident's Fall Event Reports indicated the following information: a. An unwitnessed fall in the resident's room on 10/16/22 resulted in no injury. b. An unwitnessed fall in the hallway on 10/24/22 resulted in no injury. c. An unwitnessed fall in the resident's room on 12/4/22 resulted in no injury. d. An unwitnessed fall in the resident's room on 12/25/22 resulted in no injury. e. A witnessed fall in the day room on 12/29/22 resulted in a contusion to left eye, pain, and headache. f. An unwitnessed fall in the resident's room on 2/3/23 resulted in a bruise to right forearm 7.5 centimeters (cm) long by 4.5 cm wide. g. A witnessed fall in the lobby on 2/4/23 resulted in an abrasion to the forehead. Neurological checks were restarted. h. A witnessed fall in the day room on 2/6/23 resulted in a left eyebrow laceration that required steri-strips. Neurological checks were restarted but were not completed. i. An unwitnessed fall in the resident's room on 2/8/23 resulted in a laceration to the right forehead 1.5 inches long. Each of the above reports indicated the resident's falls had a pattern related to self-transfers. Her usual ambulatory status required the assistance of two staff members. The clinical record lacked any documentation of further increased supervision when the resident continued to have falls while on neurological checks. A review of the Root Cause Analysis and Three-Day IDT Review documentation for the above mentioned falls from 2/3/23 through 2/8/23 lacked any documentation of medication revisions. This area was left blank on page one of each review. A Nurse's Note, dated 10/16/22 at 11:56 p.m., indicated the resident was noted sitting on the floor beside her bed and stated there was a big hole in the floor. No injuries or pain were noted. A Nurse's Note, dated 10/24/22 at 7:46 p.m., indicated the resident slid to the floor at the lounge as she searched for a watch she had not worn for days. No injuries were noted. The resident was toileted and wanted to get ready for bed. Then she decided she wanted to visit with another resident in the hallway. A Nurse's Note, dated 12/4/22 at 3:33 p.m., indicated the resident was found sitting on the floor with her back against her recliner. No injuries were noted. The resident was assisted into her recliner with assistance of 2 staff member and then assisted to the toilet. A Nurse's Note, dated 12/5/22 at 9:55 p.m., indicated the resident was currently in bed and had been up in her wheelchair and self-propelled as usual to/from her room. A Nurse's Note, dated 12/25/22 at 11:50 p.m., indicated the resident was noted sitting on the floor beside the bed and the resident stated she got up to answer the phone. No injuries were noted. A Nurse's Note, dated 12/28/22 at 9:12 p.m., indicated the resident remained at baseline with no injuries noted. She self propelled in the wheelchair as usual to/from meals, in the common lounge, and asked if her son or parents were coming to get her. A Nurse's Note, dated 12/29/22 at 3:07 p.m., indicated the resident sat in the lounge and was seen leaned forward and fell out of the chair. A contusion was noted above the left eye. A Nurse's Note, dated 2/3/23 at 5:55 a.m., indicated the nurse was called to the resident's room where the resident was laying beside her bed in the prone position with her blanket under her. The resident was assist by staff onto her back, assessed, and assisted back into bed with assistance of 4 staff members. A bruise was noted to the right forearm and measured 7.5 cm by 4.5 cm with no signs or symptoms of pain or discomfort. A Nurse's Note, dated 2/3/23 at 10:46 a.m. indicated the resident displayed increased confusion status post fall. A new order was received from the provider for a urinalysis with culture. A Nurse's Note, dated 2/4/23 at 11:38 a.m., indicated the resident was in her wheelchair in the lobby before breakfast and the wheelchair was observed tipping forward with the resident on the floor. The resident had an abrasion to the forehead that measured 3 cm by 1.5 cm. The resident was assisted back into the wheelchair and neurological checks were restarted at the time of the fall. A Nurse's Note, dated 2/6/23 at 5:57 p.m., indicated the resident was sitting in her wheelchair in the lobby and fell out of her wheelchair. She hit her head and caused a laceration above her left eyebrow. The Medical Doctor and family were made aware. The resident was assisted into her wheelchair with assistance of 2 staff members. A new order was received for steri strips. A Nurse's Note, dated 2/7/23 at 5:03 p.m., indicated a discussion with family regarding the resident's declining cognitive status and multiple falls. The family declined a head computed tomography (CT). The physician was updated and in agreement. A Nurse's Note, dated 2/7/23 at 7:16 p.m., indicated the resident attempted to move herself in the wheelchair but was unable to due to weakness. A Nurse's Note, dated 2/8/23 at 3:15 p.m., indicated the resident was found at the foot of her bed face down with blood noted at her head. The resident responded and was able to move feet and hands on command. The alarm was sounding. A tennis shoe was on and one had slipped off. A deep laceration,1.5 inches in length, dripped blood, and was noted at the outer edge of her right eyebrow. A dinner plate-sized pool of blood was under her head. The Medical Director assessed her and ordered to send the resident to the emergency room for evaluation and treatment as soon as possible. A Nurse's Note, dated 2/8/23 at 8:50 p.m., indicated the resident returned to the facility as report was received from the emergency room. Report indicated the resident had a laceration to the right eyebrow repaired and a diagnosis of UTI with a prescription for treatment sent. The resident had four sutures to the right outer eyebrow laceration with the right eye purple and swollen closed. Hospital emergency room Patient discharge instructions, dated [DATE], indicated the resident was being discharged with the following primary diagnoses: closed head injury, forehead laceration, fall, dehydration, contusion of right wrist, and hypothermia. A Nurse's Note, dated 2/9/23 at 12:13 p.m., indicated the resident was responsive to painful stimuli only, unable to open eye related to recent falls, edema, bruising, and lacerations to bilateral eyebrows. Her lungs were noted with rhonchi throughout and she was unable to take fluids, food or medications at this time. Hospice evaluation and treatment was ordered related to vascular dementia. A Nurse's Note, dated 2/9/23 at 4:07 p.m., indicated the resident was admitted to hospice on this date. Review of the Local Coverage Determination Document, dated 2/9/23, in the hospice binder indicated the following information: A. Clinical Status - Recurrent or intractable serious infections such as pneumonia, sepsis or pyelonephritis. emergency room visits current: 2/9/23 - Falls x four, with head injury. Current stage: Ability to hold head up lost. During an observation, on 2/16/23 at 8:33 a.m., the resident was resting in bed in low position with her feet swung over and hanging off the foot of the bed on the side near the door. The fall mat was on the opposite side of the bed towards the window. Her right forehead near the right eyebrow remained with sutures/scab. During an observation, on 2/20/23 at 9:35 a.m., the resident was in her low bed on her left side with her eye closed. She did not answer when her door was knocked on or when her name was spoken. During an interview, on 2/20/23 at 1:41 p.m., CNA 4 indicated prior to the resident's recent falls, when she had multiple falls in a week, she was assisted to get up and ready in the morning. Staff assisted her into her wheelchair, then she could propel herself in her wheelchair with her feet. Some days, she could feed herself and some days she had to be assisted, then she would go back to bed about 45 minutes after meals. They assisted her back into her wheelchair prior to her meals, and she even did puzzles sometimes. She was not known to refuse care. The resident was impulsive and randomly attempted to stand up. The resident had multiple falls recently, had bruising like the shape of a mask on her face, and she had to get stitches on her right eyebrow from the last fall. Since her last fall, she had remained in bed most of the time and she had been placed on hospice. During an interview, on 2/20/23 at 2:04 p.m., LPN 7 indicated she was familiar with the residents' care on the 100 unit. The resident was a high fall risk due to the following reasons: she required assistance of 2 staff members for transfers, frequent falls, history of urinary tract infections, dementia diagnosis, she did not remember she was unable to walk and was spontaneous, she reached for items, blood pressure medication use, and clopidogrel use. During an interview, at the time of observation on 2/20/23 at 2:31 p.m., LPN 6 indicated residents who exhibited frequent falls could have had increased supervision to 15 minute checks. One on one supervision was also available if the resident had multiple falls in one day. One on one documentation was found documented in the electronic progress notes if it was done. He indicated the resident had neurological checks completed, but he was unable to find any further increased supervision documentation in the clinical record for the week of 2/3/23 to 2/8/23. During an interview, on 2/20/23 at 3:02 p.m., the DON indicated she expected the nurses to have increased supervision to prevent falls if a resident continued to fall, while neurological checks were underway. During an interview, on 2/20/23 at 4:08 p.m., the DON indicated she was unable to provide any documentation to support the resident having increased supervision after she continued to fall while on neurological checks. A current policy, dated 10/2014, titled Fall Prevention Program, provided by the Corporate Nurse Consultant on 2/20/23 at 3:28 p.m., indicated the following: .POLICY: It is the policy of this facility to identify any resident who is at increased risk for falls. Identified residents shall be monitored by the Interdisciplinary Team (IDT) in an effort to implement fall prevention interventions that minimize occurrence of falls thereby minimizing resident risk of injury. The IDT shall review those residents identified as being at risk for falls or those resident who have sustained falls and are at risk for recurrent falls This Federal tag relates to complaint IN00399681. 3.1-45(a)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a random observation, on 2/16/23 at 12:41 p.m., CNA 9 donned a gown, gloves, and an N95 mask prior to entering a room (room [ROOM NUMBER]) requiring transmission-based precautions for COVID-19. She wore her regular eyeglasses into the room, with her eye protection goggles on the top of her head. During an interview, at the time of the observation, CNA 9 indicated she usually put the eye protection glasses on her eyes, but she had forgotten they were up on the top of her head. During a random observation, on 2/16/23 at 12:54 p.m., Laundry Assistant 8 donned gloves, a gown, and N95 mask prior to entering a room (room [ROOM NUMBER]) requirng transmission-based precautions for COVID-19. She did not utilize the bottom strap when donning the N95 mask. She wore regular eyeglasses and did not apply additional eye protection. She exited the room, after doffing the gown, gloves, and N95 mask in the doorway of the room. She immediately adjusted the covering of the clean linen cart after exiting the room, without performing hand hygiene. During an interview, at the time of the observation, Laundry Assistant 8 indicated she should have put the other strap on the N95 mask on. She had eye protection in the laundry room, and had forgotten to bring it with her. She was unaware of what needed to be done upon removing personal protective equipment (PPE) to protect other residents. Licensed Practical Nurse (LPN) 5 indicated to Laundry Assistant 8 she needed to perform hand hygiene upon PPE removal and exiting the room, and instructed her to get her eye protection. During an interview, on 2/20/23 at 2:46 p.m., the Director of Nursing (DON) indicated CNA 9 should have applied the eye protection prior to entering transmission-based precaution rooms. Nursing and other departments were trained, and expected to utilize, PPE appropriately when entering and exiting transmission-based precaution rooms. A current facility policy, dated 10/2015, provided by the DON on 2/20/23 at 4:07 p.m., and titled Isolation (Transmission-based Precautions) Guidelines, indicated the following: .The health care team and visitors should be instructed on the importance and necessity of maintaining precautions before entering the resident's rooms .All personnel must follow transmission-based precautions, as indicated A current facility policy, dated 10/2015, provided by the DON on 2/20/23 at 4:07 p.m., and titled Handwashing/Hand Hygiene, indicated .Situations that require hand hygiene include .Before and after entering isolation precaution settings 3.1-18(l) A. Based on observation, interview, and record review, the facility failed to properly prevent and/or contain COVID-19 by ensuring infection prevention and control strategies were utilized during a facility COVID-19 outbreak, including failure to follow infection control guidelines upon entering and leaving rooms under transmission-based precautions, and during medication administration. Findings include: 1. During an interview at entrance conference, on 2/14/23 at 9:41 a.m., the Administrator indicated the facility was in a COVID-19 outbreak. Thrity-three out of 50 residents were currently positive for COVID-19. Review of the Residents Positive for COVID-19 log on 2/14/23 at 10:39 a.m., indicated Resident 44 tested positive for COVID-19 on 2/12/23. During a continuous medication administration observation, on 2/16/23 at 8:35 a.m., LPN 5 performed hand hygiene and prepared Resident 36's medications. After the medications were prepared, she donned gloves to count the pills by placing the pills from one medication cup to another medication cup. A barrier was not placed on top of the medication cart where the medication cups were placed. While she moved the pills to the other cup, the medication cup tipped over and she dropped two of the 19 pills onto the unprotected medication cart top. She picked up the two contaminated pills with her right gloved hand, and placed them back into the medication cup with the other pills for administration. She dropped another pill onto the floor off of her cart, bent over, and picked it up off of the floor with her gloved hands. She doffed her gloves and did not perform hand hygiene. She then opened the medication cart and picked up a pre-set cup of medication out of the medication cart left drawer with Resident 15's name on it in her left hand. She shut the cart and locked the cart with her right hand and picked up Resident 36's medication cup off of the top of the medication cart in her right hand. She then went to the residents' room, as they were roommates, and entered without any hand hygiene. She approached Resident 36 with his medication cup, handed it to him with her right hand, and asked him to wait as she placed her pulse oximeter on the resident's middle finger of his left hand. She told him he could take his medications (which contained the contaminated pills) as she removed the pulse oximeter from his finger and placed it back into her right hand. Resident 36 swallowed all of his medications. Hand hygiene was not performed during the adminsitration. She continued on to the resident's roommate, with the cup of pills in her left hand. She moved the medication cup to her right hand, picked up Resident 15's cup, and handed it to him so he had a drink with his medication. Hand hygiene was not performed until she exited the residents' room. During a continuous medication administration observation, on 2/16/23 at 9:25 a.m., LPN 5 unlocked her cart and prepared Resident 44's medication, including six pills and two topical medication patches. She opened the patches and used a marker to write the date and initials on the patches. She slid them back down into the outside wrapper for transport. She closed and locked her cart and approached Resident 44's room, which required contact/droplet precautions, with the medication cup in her left hand and the topical patches in her right hand. The medication was placed on the personal protective equipment (PPE) container outside the residents room. Hand hygiene was not performed. She removed a gown out of the drawer, and closed it with her right hand. She donned her gown and gloves, picked up the medication cup with her left hand and the topical patches with her right hand, and entered the resident's room with her N95 and eye protection in place. When she attempted to set the pill cup on the resident's night stand, she dropped the pills and cup onto the floor. With her right hand, she placed the topical patches on the night. She then got on the floor and found all six pills, and placed them back into the contaminated cup and sat the cup down. LPN 5 doffed her gloves but did not perform hand hygiene. She donned new gloves from the resident's restroom and then placed the topical patches, one to the right ribs and the other one on the left ribs. She doffed her personal protective equipment and exited the room with the contaminated cup of medications. She performed hand hygiene, then carried the contaminated cup in her hands back to the medication cart, unlocked the cart, and placed the contaminated cup of pills in the middle compartment of her top drawer with her right hand. Hand hygiene was not performed. The drawer did not contain a barrier where other resident medications were stored. She opened the next drawer with her right hand and pulled out the six medication cards to replace the pills she had dropped in the floor. With both hands, she placed the medications into the medication cup for Resident 44. She opened the medication cart, placed the medication cards back in to the drawer with her right hand and touched other cards in the process. The cart was closed and locked with her right hand. Hand hygiene was not performed. She returned to Resident 44's room, sat the pill cup on the PPE cart outside the door, opened the cart with her right hand and removed a gown. She donned the gown and removed two gloves from deep in the box. LPN 5 donned the gloves and entered the resident's room with the cup of medications in her left hand. The resident's medications were administered and the nurse doffed the PPE prior to exiting the resident's room. Hand hygiene was only performed as she exited the resident's room. During an interview, on 2/16/23 at 9:44 a.m., LPN 5 indicated she would not typically administer contaminated pills off of the unprotected medication cart. It also was not appropriate to pick pills up off of the floor, nor fail to perform hand hygiene prior to donning your next gloves. Contaminated items from a COVID-19 isolation room should not be placed back into the medication cart without a barrier where other medications were stored. At 9:55 a.m., she indicated seven other residents' medications were stored in the top drawer middle compartment of the 100 unit medication cart, where the contaminated pills and cup were placed. The contaminated pills from Resident 44's isolation room should have been destroyed immediately, rather than placing them in the medication cart to avoid cross contamination. She donned a glove and removed the contaminated pills from the medication cart for destruction. The cart was not cleaned. LPN 5 returned to the cart, unlocked the drawers with the keypad she touched with contaminated hands, and continued on with her regular medication pass. During an interview, on 2/20/23 at 3:20 p.m., the Director of Nursing (DON) indicated hand hygiene was required between the care of different residents, especially during a COVID-19 outbreak. Pills dropped on the unprotected medication cart should not have been administered to a resident, and contaminated items from a COVID-19 isolation room should not have been placed back into the medication cart on the 100 unit.

Based on interview and record review, the facility failed to implement their antibiotic stewardship program for antibiotic use for 5 of 10 residents prescribed antibiotics for urinary tract infections in December 2022 and January 2023. (Residents 43, 16, 22, 27, and 253) Findings include: The facility infection surveillance records were reviewed on 2/17/23 at 10:36 a.m., and indicated the following: a. Resident 43 was prescribed amoxicillin/clavulanate potassium (antibiotic) 875 - 125 milligrams (mg) twice a day for 10 days for a suspected urinary tract infection. A urinalysis (U/A) with a culture and sensitivity (C&S) was completed. The C&S indicated no growth (no laboratory evidence of urinary tract infection). The amoxicillin/clavulanate potassium 875 - 125 mg order was not discontinued. b. Resident 16 was prescribed amoxicillin (antibiotic) 875 milligrams (mg) for a suspected urinary tract infection. A U/A was completed and lacked a C&S. c. Resident 22 was prescribed ceftriaxone (antibiotic) 1 (one) gram per injection two times and ciprofloxacin (antibiotic) 500 mg twice a day for 10 days for a suspected urinary tract infection. A U/A was completed and lacked a C&S. d. Resident 27 was prescribed nitrofurantoin (antibiotic) 100 mg twice a day for a suspected urinary tract infection. A U/A was completed and lacked a C&S. e. Resident 253 was prescribed sulfamethoxazole-trimethoprim (antibiotic) 800-160 mg twice a day for seven days for a suspected urinary tract infection. A U/A was completed, but lacked a C&S. During an interview, on 2/17/23 at 1:31 p.m., the Director of Nursing (DON) indicated she utilized McGeer's criteria and for surveillance purposes to indicate infection. If a family determined a resident was confused, the facility would check the urine, even if the resident had not met the criteria for urinary tract infection. They did this to try to appease the families. A urine was checked for nitrites (can indicate bacteria in the urine) and leukocytes (white blood cells) typically before being sent to the lab. The physician often wanted the urine sent for a U/A with C&S, whether the urine test in the facility was positive or negative. If the family wanted the resident treated before the facility received the laboratory results, the physician would order the treatment per the family's request. Once the culture was obtained, the medication order would be changed as needed. If the culture indicated no growth, the physician would continue the medication if the family requested the continuation. During an interview, on 2/20/23 at 1:56 p.m., LPN 7 indicated if the family felt the resident was confused, the urine was checked for nitrites and leukocytes. A positive urine specimen was sent to the lab for a U/A with C&S. Sometimes a negative urine specimen was sent. If the culture indicated no growth, the physician was notified. A current facility policy, revised 6/2018, provided by the Administrator on 2/14/23 at 10:39 a.m., and titled Antibiotic Stewardship Program (ASP), indicated .It is the policy of the facility to implement an Antibiotic Stewardship Program (ASP) which will promote appropriate use of antibiotics while optimizing the treatment of infections .the facility shall implement measures to address .An antibiotic review process, also known as 'antibiotic time-out' (ATO) for all antibiotics prescribed in the facility. ATO can be considered a stop order of an antibiotic when diagnostic test results or symptoms of resident do not support the diagnosis of 'infection' . When infection or colonization with epidemiologically important organisms is suspected, cultures may be sent, if appropriate, to a contracted laboratory for identification or confirmation. Cultures will be further screened for sensitivity to antimicrobial medications to help determine treatment measures