Premier Healthcare Of New Harmony

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

redirected. During an interview on 10/16/25 at 10:15 A.M., the Social Service Director (SSD) indicated it would have been appropriate to update Resident D' plan of care following an increase in Resident D's behavior of wandering following incidents on 10/6/25 and 10/7/25 that involved other residents and an increase in Resident D's agitation and difficulty with redirection. On 10/16/25 at 10:30 A.M., the Assistant Director of Nursing (ADON) indicated the facility did not have a policy regarding resident behavior and wandering prevention. 2. During record review on 10/15/25 at 9:45 A.M., Resident D's diagnoses included but was not limited to Alzheimer's disease and vascular dementia. Resident D's most recent quarterly MDS assessment dated [DATE REDACTED] indicated the resident had severe cognitive impairment. Resident D' physician orders included but were not limited to; triple antibiotic external ointment - apply to wound on left forearm topically in the morning for wound care until 10/28/25, cleanse with wound cleanser and cover with dry dressing daily (received 10/13/25 and started 10/14/25 at 9:00 A.M.) Resident D's nurse's progress notes included, but were not limited to:10/13/25 at 2:30 A.M. - Staff intervened in altercation between Resident D and Resident C. Resident C had Resident D by the right arm and was biting her forearm. Residents were separated and Resident D assessed for injury. Resident D had pale blue bruising and some edema to right forearm but no open wound. Resident D complained of pain to wrist and pain on moving her fingers.

Physician notified and gave order for Xray of right wrist/forearm.10/13/25 at 10:41 A.M. - Resident complained of pain to left forearm.10/14/25 at 10:50 A.M. - Resident's left arm cleaned. Triple Antibiotic Ointment (TAO) and bandage applied.A Physical Aggression Received report for Resident D, dated 10/13/25 at 12:30 A.M., included an incident description, CNA observed another resident in resident's room, holder her by the right forearm/wrist. CNA observed other resident to bite (Resident D) on the Left forearm/wrist. Injuries observed at the time of the incident included a bruise to the Right forearm and a skin tear to the Left forearm.A Shower Sheet with Resident D's name, dated 10/13/25 indicated the resident had skin tears and an open area. A handwritten note, Bite 1 (inch) in diameter with a line drawn to the outer aspect of the left forearm was noted and signed by the ADON.During an observation on 10/15/25 at 1:10 P.M., Resident D was lying in bed with a dressing over the outer aspect of the left forearm. LPN 4 removed

the dressing to reveal what appeared to be a healing skin tear approximately 1 inch long. The skin was closed, dark red in color, and without edema present.During an interview on 10/16/25 at 10:20 A.M., the ADON indicated that when she arrived at the facility the morning of 10/13/25 at the beginning of the day shift, she assessed Resident D and observed a dressing over her left forearm and indicated the area had been bleeding. The ADON then measured the wound to the left forearm and documented on a facility Shower Sheet.On 10/16/25 at 9:40 A.M., the ADON supplied a facility policy titled Assessment of Skin Alteration, dated 11/2017. The policy included, Residents with skin alteration will be assessed and treatment will be provided as ordered by the physician. Procedure: The assessment of any skin alteration should be started immediately upon identification.This citation relates to Intake 2642554. 3.1-45(a)(2)

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