Every finding on record at Aperion Care Peru

Based on observation, interview and record review, the facility failed to maintain a safe and sanitary environment in resident rooms and resident areas for three of four halls. (100 Hall, 200 Hall and 400 Hall)Finding includes:During the initial observations of residents, conducted between 1/25/2025 at 11:04 A.M. through /27/2025 at 2:30 P.M, the following observations were made:-In room [ROOM NUMBER], the inside of the door was missing paint in numerous areas.-In room [ROOM NUMBER], the inside of door had paint scraped off in several places.-In room [ROOM NUMBER], the door had multiple scrapes without paint and the wall next to the resident's bed was dirty. -In room [ROOM NUMBER], the bathroom ceiling vent above the shower had a heavy build-up of dust and there was blue masking tape wrapped around the smoke alarm.-In room [ROOM NUMBER], the wall surrounding the window was buckled and cracked. -In room [ROOM NUMBER], there were three holes behind the bed.-In room [ROOM NUMBER], the window well above the window had black spots, the windowsill had a heavy buildup of debris and the wall above the window was buckled. -In room [ROOM NUMBER], the blinds were broken and had missing sections.-In room [ROOM NUMBER], there was writing on the north wall, on the closet door and the blinds hanging in the window were bent or missing sections.-In room [ROOM NUMBER], the closet door was missing paint in some areas.-in room [ROOM NUMBER], the door had a large gouge. During a facility tour, conducted on 1/30/2026 at 10:17 A.M. with the Regional Nurse Consultant, the Housekeeping Supervisor (HS) and the Maintenance Director (MD) the following was observed:In room [ROOM NUMBER], the inside of the door was missing paint in numerous areas.-In room [ROOM NUMBER], the inside of door had paint scraped off in several places.-In room [ROOM NUMBER], the door had multiple scrapes without paint and the wall next to the resident's bed was dirty. -In room [ROOM NUMBER], the bathroom ceiling vent above the shower had a heavy build-up of dust and there was blue masking tape wrapped around the smoke alarm.-In room [ROOM NUMBER], the wall surrounding window is buckled and cracked. -In room [ROOM NUMBER], there were three holes behind the bed.-In room [ROOM NUMBER], the window well above the window had black spots, the windowsill had a heavy buildup of debris and the wall above the window was buckled. -In room [ROOM NUMBER], the blinds were broken and had missing sections.-In room [ROOM NUMBER], there was writing on north wall, on the closet door and the blinds hanging in the window had bent or missing sections.-In room [ROOM NUMBER], the closet door was missing paint in some areas.-In room [ROOM NUMBER], the door had a large gouge. During an interview with the Maintenance Director, on 1/30/2026 at 10:35 A.M., he indicated he completed daily walk throughs of the facility to identify repairs that were urgent. He indicated if he identified urgent repairs as anything that could affect resident safety, for example, blown light bulbs or exposed wiring. He indicated he utilized paper work orders submitted by staff to take care of routine repairs. The MD indicated he was the only full time employee for maintaining the building and did receive some help when he needed it. The MD indicated the walls that were buckled and cracked were due to a roof issue and he was not able to address the dry wall because he would have to move the resident's who currently occupied the rooms. The MD indicated there were open rooms at the time of the facility walk-through. He indicated the rooms and doors with unpainted scrapes and gouges were on his list of to-dos, but he had not been able to address all of the rooms yet. He indicated the room with writing on the wall was from a previous resident, who had been moved to another room, and the room was on his list to repaint. He indicated he planned to replace the blinds in the rooms that had broken blinds. In room [ROOM NUMBER], the blue masking tape covering the smoke detector had been like that since 12/2/2025 when a local pest company treated the room for bed bugs. During an interview with the HS on 1/20/2026 at 10:40 A.M. she indicated the walls, window sills and vents were the responsibility of housekeeping. She confirmed room [ROOM NUMBER]'s wall were dirty, room [ROOM NUMBER]'s ceiling vent was covered in dust and the window sill and window well was dirty in room [ROOM NUMBER]. 2. During an observation on 1/29/2026 at 9:15 A.M., the pole used for Resident 40's gastrostomy tube (g-tube) feeding (a tube surgically placed directly into the stomach to provide nutrition via liquid formulas) had tube feeding formula dripped down the pole and on the base of the pole.During an interview on 1/29/2026 at 11:10 A.M. the DON indicated the pole for the tube feeding should have been clean. During an interview on 1/30/2026 at 10:27 A.M. the Housekeeping Supervisor indicated it was housekeeping's responsibility to clean the tube feeding pole. On 1/29/2026 at 12:15 P.M., the ED provided a policy, dated 1/25/20218 and titled, Cleaning & Sanitizing- Wheelchairs and Other Medical Equipment. The policy indicated, .Medical equipment/devices will be cleaned and sanitized weekly or more often if needed On 1/30/2025 at 11:59 A.M., the Executive Director provided undated document titled, Resident Room Daily Cleaning Check Off Sheet, and identified it as the check off sheet currently used by the facility. The check off sheet included: dust windowsill and scrub if needed, spot wash the walls and ensure all cobwebs, dust and debris are removed.On 1/30/2025 at 11:59 A.M., the Executive Director provided an undated policy titled, Housekeeping Guidelines, and identified the policy as the one currently used by the facility. The policy indicated, .6. Housekeeping personnel shall adhere to daily cleaning assignments developed so to maintain the facility in a clean and orderly manner On 1/30/2026 at 11:59 A.M., the Executive Director provided an undated policy titled, Environmental Services Policy, and identified it as the policy currently used by the facility. The policy indicated, .To ensure that the facility is designed, equipped and maintained in accordance with all governing rules and regulations and standards 3.1-19 (f)

Based on observation, interview and record review, the facility failed to ensure medications were secure on 2 of 4 carts observed and in 1 of 16 resident rooms) (Wound Cart, South Treatment Cart and Resident 14's room) Findings include: 1. During an observation on 1/25/2026 at 10:55 P.M., the South Treatment Cart was unlocked and had medicated ointments, powders and sharp supplies, such as needles and scissors noted in the cart. During an interview on 1/25/2026 at 11:01 A.M., Licensed Practical Nurse (LPN) 2 indicated the Treatment Cart was unlocked. 2. During an observation 1/27/2025 at 9:45 A.M., the Wound Treatment Cart was unlocked and contained medicated ointments, powders and sharp supplies, such as needles and scissors in the cart. During an interview on 1/27/2025 at 9:50 A.M., Registered Nurse 3 indicated she had been responsible for the Wound Treatment Cart and the cart was not locked. 3. Upon entering the room of resident 14 on 1/25/2026 at 11:08 A.M , a medication cup with 10 pills was observed on the bedside tray. During an interview with the Director of Nursing on 1/25/2026 at 11:25 A.M., she indicated the pills shoul'sd not have been left at the bedside. She disposed of the pills in a biohazard container. During an observation and interview, conducted on 1/25/2026 at 11:30 A.M , LPN 3 entered Resident 14 room. She indicated she had forgotten to make sure the resident took her medications before she had left the room. On 1/20/2026 the Administrator provided a policy, Medication Administration General Guidelines. She indicated this is their current policy. Under section Administration 3. When medications are administered by mobile cart taken to the residence location (room, dining area, etc.) medications are administered at the time they are prepared. 16. The resident is always observed after administration to ensure the dose was completely ingested. 3.1-25(m)

Based on observation and interview, the facility failed to ensure a resident's right to communicate with staff providing services was protected for 1 of 3 residents reviewed for Resident's rights. (Resident 36)Finding includes:During an interview and observation on 1/27/2026 at 11:01 A.M., Resident 36 indicated, There he is ., and further stated he is a great guy when Employee 6 arrived to deliver the resident's clean laundry. However, Employee 6 did not acknowledge Resident 36 after the resident made the statements nor did the employee attempt to communicate with the resident. When Employee 6 was putting the Resident 36's clothes in his closet, the resident again indicated, There is my guy and attempted to engage the employee with conversation, but Employee 6 never acknowledged the resident before he put away the resident's clean laundry and left the room. During an interview on 1/27/2026 at 11:03 A.M., Employee 6 was asked if he could answer a few questions but he walked away without responding. Employee 6 was wearing a pink colored earbud in both of his ears. During an interview on 1/27/2026 at 11:07 A.M., the Housekeeping Supervisor (HS) indicated the Housekeeping Aides (HA) were permitted to wear one earbud at a time so that if someone was speaking to the HA, the HA would be able to hear what was being said. The HS indicated Employee 6 should have acknowledged Resident 36's attempt to talk to him. Resident 36's record review was completed on 1/28/2025 at 10:05 A.M. Diagnoses included, but were not limited to: dementia, generalized anxiety disorder and muscle atrophy. A Quarterly Minimum Data Set (MDS) assessment dated , 1/4/2026 indicated Resident 36 had clear speech, had been able to make himself understood, had significant cognitive impairment and had not had any behaviors or rejection of care. During an interview with the Executive Director on 1/28/2026 at 2:26 P.M., the ED indicated the facility did not have a policy related to the use of earbuds while working, but the facility allowed the staff to wear one earbud, in either ear, but not two earbuds. 3.1-3 (a)

Based on interview and record review, the facility failed to ensure a person-centered comprehensive care plan was updated for a resident with a significant weight loss for 1 of 1 residents reviewed for nutrition. (Resident 52)Findings include:The record for Resident 52 was reviewed on 1/28/2026 at 10:34 A.m. Diagnoses included, but were not limited to: Alzheimer's disease, chronic obstructive pulmonary disease, asthma, anxiety and dementia. The most recent Minimum Data Set (MDS) assessment, completed as a quarterly review on 12/1/2025, indicated Resident 52 had severe cognitive impairment, required supervision for eating needs and was a smoker. Resident 52 was observed, on 01/25/2026 at 10:40 AM, walking around the unit. She was thin, her skin was dry and flaky and her clothes did not fit and were loose and baggy.A current care plan, initiated on 12/10/2024, indicated the following problem: I have an unplanned/unexpected weight gain related to improved intake.(sic) The goal for the plan was . The interventions included. The plan indicated it had been reviewed on 12/9/2025 but there were no interventions to address the resident's weight loss and the problem was not revised to reflect the resident's current nutritional status or the development of continued significant weight loss.3.1-35(c)(1)

Based on observation, interview and record review, the facility failed to provide showers or bed baths for a dependent resident for 1 of 4 residents who were reviewed for Activities of Daily Living needs. (Resident 3)Finding includes: During an observation on 1/25/2026 at 12:08 P.M., Resident 3's hair was sticking up and was unbrushed. During an interview on 1/25/2026 at 1:59 P.M., Resident 3's right hand was sticky and she was unable to recall the last time she had had a shower. Resident 3's record review was completed on 1/28/2025 at 10:30 A.M. Diagnoses included but were not limited to: schizophrenia, epilepsy, major depressive disorder, dementia with moderate behavioral disturbances and generalized anxiety disorder. A Quarterly Minimum Data Set (MDS) assessment, dated 1/9/2025, indicated Resident 3 had clear speech, usually made herself understood and had been able to understand others, had severe cognitive impairment, had had no behaviors and had not rejected care and was dependent on staff for all transfers and for showering or bed baths needs. Resident 3's January showers were reviewed and indicated the resident was to receive a shower or bed bath on Tuesdays and Fridays. Resident 3's record lacked the documentation that the resident had been showered or had received a bed bath on 1/2, 1/6 or 1/9/2026. A current Care Plan, initiated on 11/21/2023, indicated Resident 3 required assistance with activities of daily living. A current intervention, initiated on 11/21/2023, indicated Resident 3 received showers and her usual performance for showers was dependent on staff. During an interview on 1/29/2025 at 9:45 A.M., CNA 5 indicated the facility charted showers or bed baths in the record and if the resident refused the shower, the refusal was documented in the record. CNA 5 indicated there was no other place in the record where showers or bed baths were charted. During an interview on 1/30/2025 at 9:00 A.M., the Director of Nursing (DON) indicated there had not been any documentation Resident 3 had received a shower or bed bath on 1/2, 1/6 or 1/9/2026 or any documentation the resident had refused a shower or bed bath for the month of January 2026 in her record. On 1/29/2025 at 2:45 P.M., the Executive Director (ED) provided a policy dated, 11/28/2012, and titled, Bathing, Showering and Tub Bath. The ED indicated the policy was the one currently used by the facility. The policy indicated, . A shower, tub bath or bed/sponge bath will be offered according to resident's preference two times per week or according to the resident's preferred frequency and as needed or requested 3.1-39(a)(3)

Based on observation, record review and interview, the facility failed to implement physician recommendations in a timely manner after a fall with injury for 1 of 1 resident reviewed for falls. (Resident 5)Finding includes:During an interview, on 1/27/2026 at 2:23 P.M., Resident 5 indicated he had a recent fall and had elbow pain.During an interview and observation, on 1/29/2026 at 8:51 A.M., Resident 5 indicated his elbow painful and there was obvious swelling around the elbow. In addition he wore a compression stocking on his right arm.During an observation, on 1/30/2026 at 9:15 A.M., Resident 5 was observed to have purple and red bruising below and above the left elbow.A record review for Resident 5 was completed on 1/28/2026 at 9:15 A.M. Diagnoses included, but were not limited to: neuropathy, gout, peripheral vascular disease, diabetes mellitus type 2 and schizoaffective disorder.A Quarterly Minimum Data Set (MDS) assessment, dated 12/3/2025, indicated Resident 5 had moderate cognitive impairment and required supervision for transfers. A Nursing Progress Note, on 1/25/2026 at 11:51 P.M., indicated Resident 5 had been observed at 11:11 P.M. walking from his room to the dining room to watch television with a friend. Resident 5 had been observed to stagger backwards and had fallen on his back.A Nursing Progress Note, on 1/26/2026 9:49 A.M., indicated Resident 5 had fallen earlier and a new order had been obtained for a left elbow x-ray due to swelling. In addition, an order to hold his prescribed Eliquis (blood thinner) for five days was received.A Physician Note, on 1/26/2026 at 11:23 A.M., indicated Resident 5 had fallen and had a swollen left elbow. Resident 5 was also documented to have pain to the left elbow. New orders for Voltaren gel (Diclofenac Sodium External Gel, a nonsteroidal anti-inflammatory drug), ice (to the left elbow) , x-ray and holding Eliquis were prescribed.Although the physician note included treatment orders, the orders were not documented and implemented timely in the clinical record.A Nursing Progress Note, on 1/28/2026 at 10:24 A.M., indicated Resident 5 had edema and discoloration to the left elbow and voiced discomfort to the left elbow.A Physician's Order, dated 1/28/2026, indicated Diclofenac Sodium External Gel 1 %, apply gel to the left elbow every eight hours as needed.A Physician's Order, dated 1/28/2026, indicated to hold Eliquis 5 milligrams twice daily for five days. The medication began being held on 1/28/2026 for the evening dose.A Care Plan, initiated on 3/20/2021 and revised on 1/27/2026, indicated Resident 5 was on an anticoagulant and the Eliquis was to be held for five days. During an interview, on 1/30/2026 at 9:28 A.M., the Director of Nursing indicated the Eliquis should have been stopped right away on 1/26/2026 and an order for the ice treatment to the elbow should have been written. A current policy was provided by the Executive Director, on 1/20/2026 at 12:11 P.M. The policy titled, Physician Orders-Entering and Processing, indicated, .To provide general guidelines when receiving, entering, and confirming physician or prescriber's orders.5. Following a physician visit, a licensed nurse will check for any orders that require confirmation.The orders will be confirmed by the nurse and the instructions for the order will be completed.3.1-37(a)

Based on record review and interview, the facility failed to obtain ordered laboratory orders for 1 of 5 residents reviewed for unnecessary medications. (Resident 1)Finding includes:A record review for resident 1 was completed on 1/28/2026 at 10:00 A.M. Diagnoses included, but were not limited to: bipolar disorder, hepatitis C, diabetes mellitus and history of alcohol use. A Quarterly Minimum Data Set (MDs) assessment, dated 12/18/2025, indicated Resident 1 had severe cognitive impairment and was administered medication of an antipsychotic, antidepressant, opioid and anticonvulsant.A Physician's Order, dated 11/18/2024, indicated laboratory orders for a prealbumin, vitamin D, vitamin B12 and folate level annually in October. However, these laboratory values, due in October 2025, could not be located in the medical record, nor provided by the laboratory facility.During an interview, on 1/30/2026 at 9:02 A.M., LPN 3 indicted the ordered laboratory values could not be located and the laboratory orders should have been drawn.A current policy was provided by the Executive Director, on 1/20/2026 at 12:11 P.M. The policy titled, Physician Notification of Laboratory/Radiology/Diagnostic Results, indicated, .To assure physician ordered diagnostic test are preformed, and to assure test results are reported to the physician so that prompt, appropriate action can be taken if indicted for the resident's care.A licensed nurse is responsible for assuring the laboratory is notified of physician's orders for testing.A nurse is responsible for monitoring the receipt of test results.3.1-49(a)

Based on observation, record review, and interview, the facility failed to complete a timely nutritional assessment and initiate interventions to prevent weight loss for 1 of 1 residents reviewed for nutrition. (Resident 52) This resulted in continued significant weight loss of 15.38% over the previous 5 months. Findings include:The clinical record for Resident 52 was reviewed on 1/28/2026 at 10:34 A.M. Diagnoses included but were not limited to: Alzheimer's disease, chronic obstructive pulmonary disease, asthma, anxiety and dementia. The most recent Minimum Data Set (MDS) assessment, completed for a quarterly review, on 12/1/2025, indicated the resident was severely cognitively impaired, required supervision for eating needs and was a smoker. Resident 52 was observed, on 01/25/2026 at 10:40 AM walking around the nursing unit. She was thin, her skin was dry and flaky, her clothes were loose, baggy and did not fit her. A care plan dated 12/10/2024, indicated I have a nutritional problem or potential nutritional problems related to Alzheimer's disease, anxiety, chronic obstructive pulmonary disease, depression, etc The Goal indicated the following: I will consume 50/100% of two of three meals a day. Interventions included: Monitor and record food intake at each meal.Physician orders indicated the resident was to receive a regular diet with regular texture and consistency. Physician orders on 1/22/2026 added an intervention to provide a nutritional house supplement twice a day.Nursing progress notes documented the following weights for Resident 52: 8/5/2025, the resident weighed 117 pounds9/5/2025 , the resident weighed 115 pounds10/2/2025, the resident weighed 114 pounds11/6/2025, the resident weighed 112 pounds12/3/2025, the resident weighed 108.5 pounds1/6/2026, the resident weighed 104.5 pounds - a 9% weight loss in the past 90 days1/30/2026, the resident weighed 99 pounds - 5.25% weight loss in the past 30 days and 15.38% weight loss since August 2025 A nutritional assessment was completed by a registered dietician on 4/25/2025 but did not reflect any concerns with the resident's weight at the time it was completed. There were no other nutritional assessments completed by the dietician until 1/22/2026. The assessment completed on 1/22/2026 indicated the following: A 9% weight loss in 90 days, Body Mass Index (BMI) was 21.1, within normal limits. May suggest a house nutritional supplement to be given twice daily to help increase calories and a protein. The assessment occurred 16 days after the nutritional consultation had been requested. During an interview with a Registered Dietician supervisor, on 1/30/2026 11:40 A.M., she indicated the nutritional assessment should have been completed within 72 hours after receiving the resident's weight (which indicated the resident had experienced a significant weight loss) from the facility on 1/6/2026. In addition, she indicated the intervention of nutritional supplement shakes were meant to prevent weight loss, not treat the weight loss.During an interview with Assistant Director of Nursing, on 1/30/2026, she indicated she was responsible for overseeing and monitoring residents' weights. She indicated she was not aware that a 5% weight loss in one month, a 7.5% weight loss in 90 days or a 10% weight loss in 6 months required notifying a physician or dietician.On 1/30/2026 at 12:18 p.m., the Administrator, provided a policy, dated 11/14/2012, titled Weights, and indicated it was the policy currently being used by the facility. The policy indicated, 6. Undesired or unanticipated weight gains/loss of 5% in 30 days, 7.5% in three months, or 10% in six months shall be reported to the physician, dietician and/or dietary manager as appropriate.3.1-46(a)(1)

Based on observation, record review, and interview, the facility failed to notify the physician of a significant weight loss for 1 of 1 resident reviewed for nutrition. Findings include:The clinical record for Resident 52 was reviewed on 1/28/2026 at 10:34 A.M. Diagnoses included but were not limited to: Alzheimer's disease, chronic obstructive pulmonary disease, asthma, anxiety and dementia. The most recent Minimum Data Set (MDS) assessment, completed as a quarterly review, on 12/1/2025 indicated the resident was severely cognitively impaired and required supervision for eating needs. Nursing Progress notes indicated on 12/3/2025, the resident weighed 108.5 pounds. On 1/6/2026, the resident weighed 104.5 pounds a -3.69% loss in one month.On 1/6/2026, the resident weighed 104.5 pounds, on 1/30/2026, the resident weighed 99 pounds a -5.26% loss in less than a month. There was no documentation the physician had been notified of the significant weight loss.On 8/5/2025, the resident weighed 117 pounds, on 1/30/2026, the resident weighed 99 pounds a -15.38% loss in less than 6 months. There was no documentation the physician had been notified of the significant weight loss.Resident 52 was observed, on 01/25/2026 at 10:40 AM walking around the nursing unit. She appeared thin, her skin was dry and flaky, her clothes were loose, baggy and did not fit.During an interview with the Assistant Director of Nursing (ADON), on 1/30/2026, she indicated she was responsible for overseeing the monitoring of residents' weights. She indicated she was not aware that a 5% weight loss in one month or a 10% weight loss in 6 months required the facility to notify the physician.On 1/30/2026 at 12:18 p.m., the Administrator, provided a policy, dated 11/14/2012, titled Weights, and indicated it was the policy currently being used by the facility. The policy indicated, 6. Undesired or unanticipated weight gains/loss of 5% in 30 days, 7.5% in three months, or 10% in six months shall be reported to the physician, dietician and/or dietary manager as appropriate.3.1-5 (a)(2)

Based on interview and record review, the facility failed to complete dental recommendations from the in-house dentist for 1 of 1 resident reviewed for dental care. (Resident 77) Finding includes:During an interview, on 1/25/2026 at 1:59 P.M. Resident 77 indicated he had mouth pain due to something messing with his teeth. He indicated, I have some cavities.A record review for Resident 77 was completed on 1/28/2026 at 1:05 P.M. Diagnoses included, but were not limited to: diabetes mellitus type 2, dementia and obstructive sleep apnea.A Quarterly Minimum Data Set (MDS) assessment, dated 12/3/2025, indicated Resident 77 had severe cognitive impairment and had no dental issues.A Physician's Order, dated 1/2/2025, indicated dental care as needed.A Dental Consult Note, dated 12/8/2025, indicated Resident 77 had upper right mouth pain sometimes and lower left nerve pain if his tongue touched his teeth. Resident 77 also had a draining fistula between teeth number 20 and 21 (lower left bicuspids). An outside referral for full mouth extraction was made.A Dental Hygienist Encounter Form, dated 12/10/2025, indicated Resident 77 had pain in his mouth and would not allow brushing, but a soft sponge moistened with mouthwash to remove some plaque. The note indicated Resident 77 was awaiting an appointment for full mouth extraction. A Care Plan, initiated on 11/24/2021 and revised on 10/1/2025, indicated Resident 77 had oral/dental health problems related to requiring assistance with oral care. The goal was to be free of infection, pain or bleeding in the oral cavity. Interventions included, but were not limited to: coordinate arrangements for dental care, transportation as needed or ordered and monitor/document/report as needed any signs or symptoms of oral/dental problems needing attention as pain, abscess or debris in the mouth.During an interview, on 1/30/2026 at 9:30 A.M., the Director of Nursing indicated for dental appointments an order should have been obtained and the transportation director would have made the appointment.During an interview, on 1/30/2026 at 10:28 A.M., the transportation director indicated she scheduled all outside appointments. She indicated an outside dental appointment for extraction had not been set up for Resident 77. She indicated no one at the facility had informed her of the need for an outside dental appointment for Resident 77.A current policy was provided by the Executive Director, on 1/20/2026 at 12:11 P.M. The policy titled, Dental Services and Loss or Damage of Dentures, indicated, .The facility will, if necessary or requested by the resident, assist with scheduling appointments for dental services, arranging for transportation to and from the dental service location and promptly refer residents with lost or damaged dentures for dental services.If a referral does not occur in 3 days, the facility will implement interventions and document these interventions to ensure the resident could still eat and drink adequately while awaiting dental services and the extenuating circumstances that led to the delay.3.1-24(a)(3)

Based on observation, interview and record review, the facility failed to ensure room temperatures were at the appropriate temperatures on the Behavior Unit (BHU). This deficient practice had the potential to affect 27 of 27 residents residing on the BHU. Finding includes: During an observation on the Behavior Unit on 12/20/2024 at 9:40 A.M., with the Maintenance Director the following ambient air temperature readings were obtained utilizing the facility's laser thermometer inside resident room, pointed at the following walls: Rm. 400--the inside wall temperature was 63 degrees Fahrenheit, and the outside wall temperature was 64 degrees Fahrenheit. Rm. 401--the inside wall temperature was 66 degrees Fahrenheit, and the out side wall temperature was 62 degrees Fahrenheit. Rm. 402--the inside wall temperature was 67 degrees Fahrenheit, and the out side wall temperature was 63 degrees Fahrenheit. Rm. 403--the inside wall temperature was 67 degrees Fahrenheit, and the out side wall temperature was 63 degrees Fahrenheit. Rm. 404--the inside wall temperature was 69 degrees Fahrenheit, and the out side wall temperature was 64 degrees Fahrenheit. Rm. 405--the inside wall temperature was 71 degrees Fahrenheit, and the out side wall temperature was 67 degrees Fahrenheit. Rm. 406--the inside wall temperature was 69 degrees Fahrenheit, and the out side wall temperature was 64 degrees Fahrenheit. Rm. 407--the inside wall temperature was 71 degrees Fahrenheit, and the out side wall temperature was 67 degrees Fahrenheit. Rm. 408--the inside wall temperature was 67 degrees Fahrenheit, and the out side wall temperature was 63 degrees Fahrenheit. Rm. 409--the inside wall temperature was 69 degrees Fahrenheit and the out side wall temperature was 64 degrees Fahrenheit. Rm. 410--the inside wall temperature was 67 degrees Fahrenheit, and the out side wall temperature was 62 degrees Fahrenheit. Rm. 411--the inside wall temperature was 67 degrees Fahrenheit, and the out side wall temperature was 63 degrees Fahrenheit. There were 2 blankets rolled up along and placed on the window ledge. The resident was observed to have blankets on his lap. Rm. 412--the inside wall temperature was 68 degrees Fahrenheit, and the out side wall temperature was 64 degrees Fahrenheit. Rm. 413--the inside wall temperature was 63 degrees Fahrenheit, and the out side wall temperature was 62 degrees Fahrenheit. Rm. 414--the inside wall temperature was 63 degrees Fahrenheit, and the out side wall temperature was 58 degrees Fahrenheit. The resident was observed wrapped in a blanket sleeping. In the common area behind the nursing station and outside of resident rooms 405, 406 and 407, the ambient air temperatures registered 70 and 71 degrees Fahrenheit. During an observation of the [NAME] unit, on 12/202024 at 10:57 A.M with the Maintenance Director., the following ambient air temperature readings were obtained utilizing the facility's laser thermometer inside resident rooms, pointed at the following walls Rm. 400--the inside wall temperature was 64 degrees Fahrenheit, and the outside wall temperature was 64 degrees Fahrenheit. Rm. 401--the inside wall temperature was 65 degrees Fahrenheit, and the out side wall temperature was 61 degrees Fahrenheit. Rm. 402--the inside wall temperature was 66 degrees Fahrenheit, and the out side wall temperature was 63 degrees Fahrenheit. Rm. 403--the inside wall temperature was 67 degrees Fahrenheit, and the out side wall temperature was 68 degrees Fahrenheit. Rm. 404--the inside wall temperature was 67 degrees Fahrenheit, and the out side wall temperature was 63 degrees Fahrenheit. Rm. 405--the inside wall temperature was 70 degrees Fahrenheit, and the out side wall temperature was 66 degrees Fahrenheit. Rm. 406--the inside wall temperature was 68 degrees Fahrenheit, and the out side wall temperature was 66 degrees Fahrenheit. Rm. 407--the inside wall temperature was 69 degrees Fahrenheit, and the out side wall temperature was 67 degrees Fahrenheit. Rm. 408--the inside wall temperature was 69 degrees Fahrenheit, and the out side wall temperature was 62 degrees Fahrenheit. Rm. 409--the inside wall temperature was 67degrees Fahrenheit, and the out side wall temperature was 63 degrees Fahrenheit. Rm. 410--the inside wall temperature was 66 degrees Fahrenheit, and the out side wall temperature was 64 degrees Fahrenheit. Rm. 411--the inside wall temperature was 67 degrees Fahrenheit, and the out side wall temperature was 62 degrees Fahrenheit. Rm. 412--the inside wall temperature was 65 degrees Fahrenheit, and the out side wall temperature was 61 degrees Fahrenheit. Rm. 413--the inside wall temperature was 66 degrees Fahrenheit, and the out side wall temperature was 63 degrees Fahrenheit. Rm. 414--the inside wall temperature was 67 degrees Fahrenheit, and the out side wall temperature was 68 degrees Fahrenheit. During an interview, on 12/20/2024 at 10:00 A.M., the Maintenance Director indicated that someone must had shut off one of the facility's boilers and that was the reason why the temperatures were too cool. He indicated the previous maintenance director had shown some of the nurses how to turn off the boiler He indicated the nurses would go outside the facility to the garage door, put in the code to open the garage door, go in and turn off the boiler using the toggle switch. No reason was given as to why the nursing staff would have turned off one of the boilers. During an interview, on 12/20/2024 at 10:04 A.M., QMA 2 indicated she could not control the temperature in the building as there was no thermostat. She indicated no residents had complained to her of being too cold on the unit. She indicated the residents usually wore sweaters to stay warm. During an interview, on 12/20/2024 at 10:10 A.M., the Maintenance Director indicated there were no thermostats in the facility. He indicated someone had shut the boiler off and he had turned it back on earlier in the morning. He indicated once the boiler was activated, the temperatures in the resident rooms would rise. During an interview, on 12/20/2024 at 10:18 A.M., Resident B, a resident on the BHU, indicated it was colder at night time and she used two blankets. She indicated her room was cold at times. During an interview, on 12/20/2024 at 10:37 A.M., Resident C was observed wearing the following clothing:: a t-shirt, a long sleeve flannel shirt and 2 fleece blankets folded over on his lap and extending down to his legs. Resident C indicated it got too cold in his room. He indicated he had a thermometer in his room and stated it was current reading 70 degrees. Resident C indicated the staff had placed towels on the window ledge because there was cold air coming in around the window blowing on him when he was in bed. He indicated the cold was like a fan going- it was cold. Resident C indicated he used to have a room on the other side of the unit and that room was too cold too When asked if he had informed any of the staff about the cold air temperature, Resident C indicated yes, the nurse especially. He indicated staff would come in his room and state boy it's cold in here. During an interview, on 12/20/2024 at 10:45 A.M., Resident E indicated he liked it cool and would put on extra clothes when it got too cold in his room. During an interview, on 12/20/2024 at 10:28 A.M., CNA 3 indicated since the facility had gotten the boiler fixed, it did not get very cold on the unit. During an interview, on 12/20/2024 at 10:20 A.M., the Maintenance Director indicated he completed temperature checks throughout the facility weekly, but had not completed the checks every week. The Maintenance Director provided a binder of papers titled, Building Temperatures that indicated the following: A building temperature log sheet, dated 10/17/2025, indicated: no temperatures were documented for rooms 400, 406, 408, 410. The air vent temperature by room [ROOM NUMBER] was documented at 68.4 degrees Fahrenheit and the air vent temperature by room [ROOM NUMBER] was documented 68.1 degrees Fahrenheit. A building temperature log sheet, dated 10/25/2024, indicated: there were no temperatures documented for rooms: 406, 408 and 414. The air vent temperature by room [ROOM NUMBER] was 68.6 degrees Fahrenheit and the air vent temperature by room [ROOM NUMBER] was 68.4 degrees degrees Fahrenheit. A building temperature log sheet, dated 11/1/2024, indicated: there were no temperatures documented for rooms: 400, 410, and 414. The air vent temperature by room [ROOM NUMBER] was blank and the air vent temperature by room [ROOM NUMBER] was 74.6 degrees Fahrenheit A building temperature log sheet, dated 11/8/2024, indicated: there were no temperatures documented for rooms: 400, 406, 408, and 410. The air vent temperatures by rooms [ROOM NUMBERS] were blank. A building temperature log sheet, dated 11/15/2024, indicated: there were no temperatures documented for rooms: 406, 408, 410, and 414. The air vent temperatures by rooms [ROOM NUMBERS] were blank. A building temperature log sheet, dated 11/20/2024, indicated: there were no temperatures documented for rooms: 400, 406, 408 and 410. The air vent temperatures by rooms [ROOM NUMBERS] were blank. A building temperature log sheet, dated 12/10/2024, indicated: there were no temperatures documented for rooms: 406, 408, 410 and 414. The air vent temperatures by rooms [ROOM NUMBERS] were blank. During an interview, on 12/20/2024 at 11:55 A.M., the Administrator indicated the facility had not been without heat and the boiler was never broken. She indicated there were some gauges that needed to be be replaced on the boiler, but it was still functional. A policy was requested, on 12/20/2024 at 11:58 A.M., related to monitoring of resident room temperatures. On 12/20/2024 at 12:00 P.M., the Administrator indicated the facility had no policy regarding the monitoring of resident room temperatures. This citation relates to Complaints IN00448692 and IN00448302. 3.1-19(h)

Based on observation, record review and interview, the facility failed to provide showering, shaving and nail care services related to ADL's (activities of daily living) for 2 of 8 residents reviewed for ADL's. (Resident D and 4) Findings include: 1. During an observation, on 10/21/2024 at 9:58 A.M., Resident D was observed to have facial hair. During an observation, on 10/22/2024 at 9:11 A.M., Resident D was observed to have facial hair and disheveled hair. At 1:30 P.M., Resident C was observed to have a baseball hat on and continued have facial hair. During an observation, on 10/23/2024 at 9:13 A.M., Resident D was observed with more than a days growth of facial hair and his hair was disheveled. At 1:29 P.M., Resident D's face continued to be unshaven and his hair disheveled. During an observation, on 10/24/2024 at 10:03 A.M., Resident D was observed to be wearing a baseball hat on top of unbrushed, greasy hai. His facial hair continued to be unshaven. During an observation, on 10/25/2024 at 10:22 A.M., Resident D was observed with an unshaven beard and wearing a baseball cap over greasy hair. A record review for Resident D was completed, on 10/23/2024 at 10:01 A.M. Diagnoses included, but were not limited to: dementia and illiteracy. An Admission Minimum Data Set (MDS) assessment, dated 9/25/2024, indicated it was very important for Resident D to choose between a tub bath, shower, bed bath, or sponge bath. A Quarterly MDS assessment, dated 10/11/2024, indicated Resident D had moderate cognitive impairment and required partial/moderate assistance with hygiene and showering. Resident D had behaviors of, but not limited to: -Delusions -Verbal behavioral symptoms directed towards others for 1-3 days of the 14-day assessment period. -Wandering for 1-3 days of the 14-day assessment period. Resident D had mood indicators of, but not limited to: -Little interest or pleasure in doing things for 12-14 days of the 14-day assessment period. -Feeling down, depressed, or hopeless for 12-14 days of the 14-day assessment period. -Trouble concentrating on things, such as reading the newspaper or watching television for 12-14 days of the 14-day assessment period. A review of the CNA's (Certified Nursing Assistant) tasks tab in the electronic medical record, indicated Resident D preferred showers or bed baths. Resident D was to receive showers on Tuesday and Friday evenings. Showers recorded for Resident D from 9/26/2024 through 10/22/2024 indicated he only received showers on the following dates: -9/26/2024 -10/1/2024 -10/8/2024. A Care Plan, dated 9/20/2024, indicated Resident D had an ADL self-care/mobility performance (functional abilities) deficit that may fluctuate with activity throughout the day related to dementia, vitamin D deficiency, benign prostatic hypertrophy, smoker, infrarenal aneurism, weakness and impaired cognitive deficiency. The goal included to maintain Resident D's existing ADL self-care/mobility performance. Interventions included, but were not limited to: -If Resident D was resistive to ADL's, reassure Resident D and leave him alone, return 5-10 minutes later and try again. -Resident D will take a bath and his usual performance of supervision to physical assistance as needed. During an interview, on 10/24/2024 at 2:27 P.M., CNA 9 indicated that showers were documented in the electronic medical record, and the dementia unit did not use shower sheets for supplemental documentation. She indicated all residents received a shower twice a week. When CNA 9 reviewed the shower documentation of only 3 showers in 30 days, she indicated maybe someone did not document Resident D's showers. She indicated Resident D does get shaved, but he was difficult to shave since he cursed and yelled. 2. During an observation and interview, on 10/21/2024 at 11:41 A.M., Resident 4 had long fingernails with a brown substance underneath all his fingernails and indicated he only got an occasional shower. During an observation and interview, on 10/22/2024 at 2:25 P.M., Resident 4 still had a brown substance under all of his long fingernails and more than a days growth of facial hair was present. Resident 4 indicated he liked a clean-shaven face and it had been quite a few days since his last shower. During an interview, on 10/22/2024 at 2:30 P.M., CNA 2 indicated resident showers were completed at least twice a week and sometimes three times a week, if needed. During an interview, on 10/23/2024 at 11:40 A.M., CNA 1 indicated showers were documented in the electronic medical record (EMR). During an interview, on 10/23/2024 at 1:58 P.M., CNA 2 indicated nail care was done two times per week during the resident's scheduled showers. During an interview, on 10/24/2024 at 2:00 P.M., the Director of Nursing (DON) indicated there was no documentation of showers completed for Resident 4 due to agency staffing and facility staff call-ins. The DON indicated the resident's behavioral care plan regarding his ADL refusal history, should count as his refusals of showers. The DON indicated the ADL refusal history was to be documented in the behavioral care plan. The DON indicated residents should receive showers twice a week and refusals of showers should be documented in the EMR. The medical record for Resident 4 was reviewed on 10/23/2024 at 9:20 A.M. Diagnoses included but were not limited to: Parkinson's disease with dyskinesia, unspecified psychosis, diabetes mellitus, anorexia, depression, hypertension, heart failure, chronic kidney disease, dementia, peripheral vascular disease, bipolar disease and myoneural disorder. A Quarterly Minimum Data Set (MDS) assessment, dated 9/18/2024, indicated the Resident 4 was severely cognitively impaired, displayed no delusions or hallucinations, required substantial assistance with personal hygiene and was dependent for showering and bathing needs. A current Care Plan, dated 5/10/2024, indicated Resident 4 had an ADL self-care performance deficit. Interventions included, but were not limited to: if resident resists with ADLs, reassure resident, leave and return five to ten minutes later and try again; monitor and document resident's abilities for ADLs and assist resident as needed. The Care Plan indicated Resident 4's usual performance for showering and/or bathing was total assist or dependent. The October 2024 Documentation Survey Report for bathing indicated Resident 4 received a shower on 10/2/2024, 10/12/2024 and 10/16/2024 and Resident 4 had refused a shower on 10/10/2024. There was no documentation Resident 4 received showers for the dates of 10/3/2024 through 10/9/2024 and 10/17/2024 through 10/23/2024. Resident 4's medical record lacked documentation of nail care for the month of October 2024. On 10/25/2024 at 10:54 A.M., the Regional Director of Nursing Services (RDNS) provided a policy titled, Bathing: Shower and Tub Bath, dated 1/31/2018 and indicated the policy was the one currently used by the facility. The policy indicated, .a shower will be offered according to resident's preference two times per week . A policy titled, Shower and Tub Bath, was provided by the Regional Director of Nursing Services on 10/25/2024 at 10:54 A.M. The policy indicated, .To ensure resident's cleanliness to maintain proper hygiene and dignity .A shower, tub bath or bed/sponge bath will be offered according to resident's preference two times per week or according to the resident's preferred frequency and as needed or requested .Document bathing task and assistance provided in the electronic record, including pertinent observations This citation relates to complaint IN00442512. 3.1-38(a)(3) 3.1-38 (a)(3)(B) 3.1-38(a)(3)(D) 3. 1-38(a)(3)(E) 3.1-38(b)(2)

Based on observation and interview, the facility failed to provide sanitary serving of food plates for 1 of 3 dining rooms observed during the lunch meal service. This had the potential to affect 14 residents on the dementia unit. Finding includes: During a continuous observation, on 10/21/2024 from 11:52 A.M. through 12:17 P.M., the activities assistant was observed to serve plates with her thumb over the rim of the plate to 5 of 12 residents in the dining room. During an interview, on 10/21/2024 at 12:02 P.M., the activity assistant indicated she had not been educated on how to properly serve dinnerware. She indicated her thumb should not have been on the top of the plate. A current policy titled, Resident Tray Delivery, was provided by the Regional Director of Nursing Services, on 10/25/2024 at 10:54 A.M. The policy did not address proper handling of dinnerware when serving the residents. 3.1-21(i)(3)

Based on record review and interview, the facility failed to limit an as needed (PRN) antianxiety medication to 14 days for 1 of 5 residents reviewed for unnecessary medications. (Resident B) Finding includes: A record review for Resident B was completed, on 10/22/2024 at 1:44 P.M. Diagnoses included, but were not limited to: psychosis, adult failure to thrive, alcoholic dementia and generalized anxiety. An Annual Minimum Data Set (MDS) assessment, dated 9/26/2024, indicated Resident B had severe cognitive impairment. The assessment indicated Resident B was on an antipsychotic, antianxiety and opioid medications. He had behaviors including, but not limited to: -Delusions. -Verbal behavioral symptoms directed towards others as threatening others, screaming at others and cursing at others. -Other behavioral symptoms not directed towards others as physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds. A Physician's Order, dated 7/26/2024 through 8/16/2024, indicated lorazepam (antianxiety) medication 0.5 milligrams every eight hours as needed for anxiety. A Consultant Pharmacist Recommendation, dated 8/10/2024, indicated Resident B had an order for lorazepam 0.5 milligrams every eight hours as needed for anxiety with no stop date. The nurse practitioner responded to the recommendation on 8/16/2024 with continuance of the lorazepam for 30 days as the benefit outweighed the risk. A Physician's Order, dated 8/16/2024 through 8/26/2024, indicated lorazepam 0.5 milligrams every eight hours as needed for anxiety. A Physician Progress Note, dated 8/16/2024 at 11:50 A.M., indicated Resident B was seen for a follow-up psychiatric assessment and continued evaluation of psychotropic medications. For generalized anxiety disorder, Resident B was to continue clonazepam 0.5 milligrams twice daily. The nurse practitioner did not mention the use of lorazepam or document a reasoning for the continuance of the as needed lorazepam beyond 14 days. Resident B received lorazepam 0.5 milligrams beyond the 14 days on 8/9/2024 at 7:31 P.M., 8/11/2024 at 9:42 P.M. and on 8/15/2024 at 6:54 P.M. During an interview, on 10/24/2024 at 2:40 P.M., LPN 10 indicated an as needed (IPRN) psychotropic medication could only be ordered for 14 days. A current policy titled, Psychotropic Medication-Gradual Dose Reduction, was provided by the Regional Director of Nursing Services, on 10/25/2024 at 10:54 A.M. The policy indicated, .To ensure that residents are not given psychotropic drugs unless psychotropic drug therapy is necessary to treat a specific or suspected condition as per current standards of practice, and are prescribed at the lowest therapeutic dose to treat such conditions .PRN [as needed] hypnotic, antianxiety or antidepressant medications shall not be used beyond 14 days unless the prescribing practitioner indicates the clinical rationale for extended use and the expected duration for PRN id of the medication This citation relates to complaint IN00442512. 3.1-48(a)(2)

Based on observation, record review and observation, the facility failed to ensure the use of an appetite stimulant medication was necessary for 1 of 5 residents reviewed for unnecessary medications. (Resident C) Finding includes: During an observation, on 10/21/2024 at 12:10 P.M., Resident C was observed to be feeding herself a meal of a quesadilla, corn and refried beans. A record review for Resident C was completed on 10/23/2024 at 8:44 A.M. Diagnoses included, but were not limited to: dementia, major depressive disorder, chronic kidney disease and heart failure. A Quarterly Minimum Data Set (MDS) assessment, dated 9/4/2024, indicated Resident C had severe cognitive impairment and had not experienced a significant weight loss (weight loss of five percent in one month or 10 percent in 6 months). A Dietary Quarterly Review note, dated 9/6/2024, indicated the resident's fluid intake were good, their appetite was good and staff were to continue the plan of care. A Dietary Assessment for the MDS assessment, dated 9/6/2024, indicated there had been no significant weight loss of five percent or more in the last month or loss of ten percent in the last six months. A Physician Progress Note, dated 9/9/2024 at 4:12 P.M., indicated, .Patient is having progressive weight loss and it (sic) with loss of more than 20 pounds in a few weeks. Patient had history of recent COVID infection with anorexia. For that reason, patient will be started on Megace A Physician's Order, dated 9/10/2024, indicated Megace Acetate Suspension 400 milligrams per 10 milliliters, give 10 milliliters by mouth one time a day for weight loss. A Physician Progress Note, dated 9/26/2024 at 11:15 A.M., indicated, .we will not make any changes as she still continues to be stable and eating better The following weights were recorded in the electronic medical record for Resident C: 10/8/2024 1:44 P.M. 162.0 lbs. (pounds) 9/9/2024 10:54 A.M. 164.8 lbs. 8/6/2024 11:30 A.M. 168.0 lbs. 7/1/2024 11:27 A.M. 171.0 lbs. 6/21/2024 2:45 P.M. 171.5 lbs. 6/7/2024 2:04 P.M. 170.4 lbs. 6/4/2024 3:48 P.M. 169.2 lbs. A Care Plan, dated 6/5/2024, indicated Resident C had a nutritional problem or a potential nutritional problem related to dementia, may not recognize thirst or hunger, hypertension, hyperlipidemia, heart disease, chronic kidney disease, vitamin deficiency, impaired mobility and impaired cognitive status. The goal was to maintain adequate nutritional status as evidenced by no signs or symptoms of malnutrition and consuming at least 75 percent of at least two meals daily. Interventions included, but were not limited to: -Assist with nutritional intake as needed. -Encourage oral intake of meals and snacks. -Monitor/record/report to the physician as needed signs and symptoms of malnutrition: emaciation, muscle wasting, significant weight loss of 3 pounds in 1 week, greater than 5 percent in one month, greater than 7.5 percent in three months and greater than ten percent in six months. -Provide and serve diet as ordered. Monitor intake and record every meal. -The registered dietician to evaluate and make diet change recommendations as needed. During an interview, on 10/25/2024 at 10:10 A.M., the Director of Nursing (DON) indicated the resident's medical provider, dietician, medical director or nurse practitioner made the decision regarding the use of an appetite stimulant. She indicated there was usually a collaboration between the medical provider and the dietician. The DON indicated there were no nursing interventions specific to the required documentation when a resident was on an appetite stimulant. On 10/25/2024 at 10:44 A.M., the DON indicated Resident C's husband was supposed to be on Megace for 2 weeks, and not Resident C. On 10/25/2024 at 11:44 A.M., the DON later indicated she was aware that Resident C had an order for Megace, and the medical provider had placed the couple on the medication together. There was no documentation provided to support the need and use of Megace for appetite supplementation. A current policy titled, Weight Assessment and Intervention, was provided by the Regional Director of Nursing Services, on 10/25/2024 at 10:54 A.M. The policy indicated, .Weights are monitored monthly or more as recommended by the interdisciplinary care team. The goal is to ensure adequate parameters of nutritional status are maintained by preventing unintentional weight loss. Weight data will be used as one step in determining if changes to the nutritional plan of care are needed to prevent or slow unintentional weight loss with the limits of the resident's clinical condition .4. Any weight change of 5% or more since the previous weight assessment shall be re-taken the next day to confirm. If the weight is verified, nursing will notify the appropriate designated individuals such as the physician, Registered Dietician, Dining Services Manager, or other members of the interdisciplinary team within 24 hours. Verbal notifications must be confirmed in writing. 5. The Registered Dietician will review the weight log each month to follow individual weight trends. Negative trends will be evaluated by the treatment team to determine whether or not significant weight changes has occurred. 6. The threshold for significant unplanned and undesired weight loss shall be based on the following criteria: 1-month significant loss 5%, severe loss greater than 5%; 3 months significant loss 7.5%, severe loss greater than 7.5%; 6 months significant loss 10%, severe loss greater than 10% This citation relates to complaint IN00442512. 3.1-48(a)(4)

Based on observation, record review and interview, the facility failed to transcribe and administer ordered comfort medications for 1 of 1 resident reviewed for hospice services. (Resident B) and failed to ensure controlled narcotics were reconciled, counted and documented every shift for 2 of 3 narcotic count log books reviewed. ([NAME] Terrace & Behavioral Unit) Findings include: 1. A record review for Resident B was completed, on 10/22/2024 at 1:44 P.M. Diagnoses included, but were not limited to: pneumonia, chronic obstructive pulmonary disease (COPD), acute respiratory failure and generalized anxiety. A Nursing Progress Note, dated 10/10/2024 at 3:50 P.M., indicated Resident B was admitted to Hospice services with a diagnosis of senile degeneration of the brain. He was prescribed hydrocodone (pain medication) 5-325 milligrams every six hours as needed and lorazepam (antianxiety medication) 0.5 milligrams every six hours as needed for anxiety/agitation. A Nursing Progress Note, dated 10/12/2024 at 4:11 P.M., indicated Resident B had audible gurgling with secretions/mucus. The nurse had attempted multiple attempts to suction Resident B to ensure a clear airway, but Resident B started screaming, No and placed his hands over his mouth, not allowing the nurse to perform suctioning. A Nursing Progress Note, dated 10/12/2024 at 2:13 P.M., indicated the nurse called the Hospice company to determine if a Hospice nurse would come to the facility due to Resident B refusing to be suctioned. The Hospice company indicated a nurse would come to the facility later in the day to assess and provide care for Resident B. A Nursing Progress Note, dated 10/12/2024 at 4:05 P.M., indicated the Hospice nurse had arrived at the facility and assessed Resident B. The Hospice nurse ordered hyoscyamine tablets to help with Resident B's secretions. The hospice nurse evaluated Resident B, noting his respirations were increased, labored and had periods of apnea (temporary cessation of breathing). A Hospice Nursing Note, dated 10/12/2024 at 5:46 P.M., indicated LPN 6 was instructed to administer Tylenol and to administer hyoscyamine for excess secretions once the medication was delivered. LPN 6 had voiced understanding. A Nursing Progress Note, dated 10/16/2024 at 12:48 A.M., indicated Resident B required suctioning to remove excess secretions. His respirations were even, but elevated to 28 breaths per minute. A Nursing Progress Note, dated 10/16/2024 at 2:20 A.M., indicated Resident B required suctioning to remove excess secretions. A Nursing Progress Note, dated 10/18/2024 at 12:31 P.M., indicated the Hospice nurse came to the facility and assessed Resident B. The Hospice nurse indicated Resident B's respirations were 32 breaths per minute, his oxygen saturation was 56 percent on room air and Resident B appeared uncomfortable. The Hospice nurse indicated Resident B needed Morphine (a narcotic pain medication). The Hospice nurse left an order for the Morphine and indicated a prescription would be sent to the pharmacy for the Morphine medication, 0.25 milliliters every three hours as needed for dyspnea and pain. A Hospice Nursing Note, dated 10/18/2024 at 4:59 P.M., indicated an order was provided to LPN 6 for Morphine as needed for Resident B and LPN 6 was encouraged to administer the Morphine as soon as possible. LPN 6 had verbalized understanding. A Care Plan, dated 10/10/2024 and revised on 10/22/2024, indicated Resident B has a terminal condition and was under hospice care. The Care Plan goal was to be free from unrelenting pain and discomfort. Interventions included, but were not limited to: -Maintain good communication with hospice. -Notify the physician and hospice if pain or discomfort was not alleviated by current medication or treatment regimen. -Notify the physician and then hospice for a change in condition. -Observe for signs and symptoms of pain or discomfort, such as facial grimacing, complaints of pain, moaning or restless movements and promptly treat per order. A Care Plan, dated 8/9/2024 and revised on 10/24/2024, indicated Resident B was on pain medication therapy related to impaired mobility, frail condition, shortness of breath and pain. The goal was for Resident B to be free of any discomfort or adverse side effects from the pain medication. Interventions included, but were not limited to: -Administer analgesic medications as ordered by the physician. Monitor/document side effects and effectiveness every shift. -Review for pain medication efficacy. Assess whether pain intensity is acceptable to resident. Review of the October MAR (Medication Administration Record) for October 2024 for Resident B indicated neither the hyoscyamine nor the Morphine had been administered. During an interview, on 10/23/2024 at 2:52 P.M., LPN 6 indicated she did not note the order or administer the recommended hyoscyamine because she needed to confirm the order with the facility's house doctor. She indicated she did not note the order or administer the Morphine pain medication either. LPN 6 indicated she could not give the Morphine until an actual prescription was sent to the pharmacy and she was unsure if or when it had been sent by the Hospice doctor. She indicated she could have called a nurse practitioner to get the script fo the medications sent to the pharmacy so the morphine could be administered, but she had not called. LPN 6 did not indicate a reason why she had not taken the time to confirm the Hospice order for hyoscyamine with the facility's house physician when the order from Hospice had been received on 10/12/2024. In addition, although the 10/18/2024 Nursing Progress Note and the Hospice Progress note both indicated LPN 6 had received an order from Hospice for Morphine for Resident B and LPN 6 had voiced understanding that Hospice has sent the order for the Morphine to the pharmacy, she still indicated she was unsure if the prescription for the Morphine had been sent to the pharmacy. The Regional Director of Nursing Services indicated on 10/25/2024 at 10:54 A.M., the facility does not have a policy for following physician order, but the facility followed the standard of practice. 2. A Medication Storage observation for the Garden Medication Cart was completed on 10/25/2024 at 10:20 A.M., with RN 18. The narcotic log book lacked signatures for the following dates and times: 9/4 for the night shift signing on. 9/4 for the night shift signing off. 9/5 for the day shift signing on. 9/5 for the day shift shift signing off. 9/5 for the night shift signing on. 9/6 for the night shift signing off. 9/9 for the day shift signing off. 9/16 for the day shift signing on. 9/16 for the night shift signing on. 9/17 for the night shift signing off. 9/18 for the night shift signing off. 9/23 for the night shift signing off. 10/4 for the day shift signing off. 10/5 for the day shift signing off. 10/5 for the night shift signing on. 10/5 for the night shift signing off. 10/6 for the day shift signing on. 10/7 for the night shift signing on. 10/8 for the night shift signing off. 10/13 for the night shift signing on. 10/13 for the night shift signing off. 10/14 for the night shift signing off. 10/18 for the night shift signing off. 10/20 for the day shift signing off. 10/20 for the night shift signing on. 10/21 for the night shift signing off. 10/21 for the day shift signing off. 3. A Medication Storage observation of the Behavior unit medication cart was completed on 10/25/2024 at 10:30 A.M., with Qualified Medication Aide (QMA) 16. The narcotic log book lacked signatures for the following dates and times: 10/3 for the day/evening shift signing off. 10/4 for the day/evening shift signing off. 10/7 for the day/evening shift signing off. 10/8 for the day/evening shift signing off. 10/11 for the day/evening shift signing off. 10/14 for the day/evening shift signing off 10/15 for the day/evening shift signing off. During an interview, on 10/25/2024 at 10:37 A.M., QMA 16 indicated two licensed nursing staff should have signed the narcotic book between shifts. On 10/25/2024 at 10:54 A.M., the Regional Director of Nursing Services (RDNS) provided the policy titled, Narcotic/Controlled Substance-Counting, with a revised date of 11/26/2017, and indicated the policy was the one currently used by the facility. The policy indicated . Purpose: 1. To count controlled substances with a partner and to verify the accuracy of the log sheets. 2. Knowledge of correct response should an error be discovered in the control substance count. General Guidelines: 1. Always participate in the counting of the controlled substances at the beginning and ending of your shift. General Procedure for Counting Controlled Substances: 1. Follow your facilities specific guidelines and use their specific log sheet .16. Sign name, time and date of completed count This citation relates to complaint IN00442512. 3.1-37(a) 3.1-25(e)(2) 3.1-25(e)(3)

Based on observation, interview and record review, the facility failed to ensure proper labeling and storage of respiratory equipment and provide necessary respiratory services according to physician orders for 2 of 2 residents reviewed for respiratory care. (Residents 7 and 238) Findings included: 1. During an observation, on 10/21/2024 at 10:54 A.M., Resident 7 was receiving 2 liters (L) of oxygen via nasal cannula (NC) and the resident's oxygen tubing was undated and without a bag. During an observation, on 10/22/24 at 9:54 A.M., Resident 7 was receiving 2L oxygen via NC and oxygen tubing was undated and without a bag. During an observation, on 10/23/2024 at 1:57 P.M., Resident 7 was receiving 2L oxygen via NC and oxygen tubing was undated and without a bag. The medical record for Resident 7 was reviewed on 10/23/2024 at 11:55 A.M. Diagnoses included but were not limited to: delusional disorder, diabetes mellitus, peripheral vascular disease, obstructive sleep apnea, heart failure, acquired absence of left leg below knee, hypertension, depression, anxiety, chronic obstructive pulmonary disease and history of transient ischemic accident and cerebrovascular accident. A Quarterly Minimum Data Set (MDS) assessment, dated 8/5/2024, indicated Resident 7 had a diagnosis of chronic obstructive pulmonary disease and did not receive oxygen therapy. 2. During an observation, on 10/22/2024 at 9:30 A.M., Resident 238's oxygen tubing was without date or bag and the humidification bottle was undated. During an observation, on 10/23/2024 at 9:37 A.M., Resident 238's oxygen tubing was without a bag and the tubing and the humidification bottle were undated. During an observation, on 10/24/2024 at 11:21 A.M., Resident 238's oxygen tubing was without a bag and was undated and there was no date on the humidification bottle. The medical record for Resident 238 was reviewed on 10/22/2024 at 2:12 P.M. Diagnoses included but were not limited to: fracture of the left fibula, acute and chronic respiratory failure, hemiparesis and hemiplegia following cerebrovascular accident, chronic obstructive pulmonary disease, nontraumatic subdural hemorrhage, morbid obesity, chronic kidney disease, atrioventricular block, bipolar disease, dependence on wheelchair, pacemaker and celiac disease. An Admission MDS assessment, dated 10/10/2024, indicated the resident was receiving oxygen therapy. Resident 238's current Physician Orders included, but were not limited to: change out, date, and label oxygen humidifier 500cc and oxygen tubing every Sunday - every night shift every Sunday when in use. During an interview, on 10/23/2024 at 2:50 P.M., LPN 2 indicated both the oxygen tubing and the humidification bottle should be changed and dated every Sunday night. During an interview, on 10/24/2024 at 9:51 A.M., the Director of Nursing (DON) indicated all oxygen tubing should be stored in a bag that was dated but the humidification bottles did not need to be dated. On 10/24/2024 at 10:25 A.M., the Director of Nursing provided a policy titled, Oxygen and Respiratory Equipment: Changing/Cleaning, dated 1/17/2019 and indicated the policy was the one currently used by the facility. The policy indicated, .nasal cannulas are to be changed once a week and as needed .a clean plastic bag .will be provided to store the cannula when it is not in use. It will be dated with the date the tubing is changed . 3.1-47(a)(6)

Based on interview and record review, the facility failed to check gastric residual volumes (GRV) and contact the resident's physician as ordered for 1 of 1 resident reviewed for tube feedings. (Resident 3) Finding includes: A record review for Resident 3 was completed on 10/22/2024 at 1:30 P.M. Diagnoses included, but were not limited to: Schizoaffective disorder, non-Alzheimer dementia, malnutrition, Bi-polar, autism, and dysphagia. A Quarterly Minimum Data Set (MDS) assessment, dated 9/19/2024, indicated Resident 3 received a mechanically altered diet and had a feeding tube. Resident 3's Physician Order's regarding the feeding tube included: Jevity1.5 of 300 ml (milliliter) bolus (single large dose given at once) four times a day, and a 240 ml bolus at bedtime with 175 mls of water before and after each bolus. Check residuals before beginning the feedings and before medication administration. If the residuals amounts are greater than 100 ml, hold the feedings and recheck in 1 hour. If not resolved, call the physician. A Care Plan, initiated on 8/22/2024, indicated Resident 3 received enteral feeding related to dysphagia, poor oral intake: combine feedings and oral intake for pleasure foods. Interventions included but were not limited to: the resident is dependent with tube feeding and water flushes; check for tube placement and gastric contents/residual volume per facility protocol and record; and hold feedings as ordered. The Medication Administration Record (MAR), dated October 2024, indicated Resident 3's residual checks were only documented twice daily. In addition, there were documented residuals over 100 mls with no documentation to support the feedings had been held and/or the physician had been notified. During an interview, on 10/23/2024 at 2:50 P.M., LPN 5 indicated nursing staff should be checking residuals 5 times a day and if the residual was over 100 mls, they should be holding the feeding, based on the physician orders. The current facility policy, titled Transcription of Physician Orders-Procedure, dated 11/3/2022, was provided by the Director of Nursing on 10/23/2024 at 3:33 P.M., and indicated the policy was the one currently used by the facility. The policy indicated . 2. To document and give clear indication that physician orders have been processed and action taken 3.1-44(a)(2)

Based on observation, record review and interview, the facility failed to provide splinting to prevent further contractures of a resident's upper extremity for 1 of 3 residents reviewed for mobility. (Resident 18) Finding includes: During an observation, on 10/21/2024 at 11:06 A.M., Resident 18 was unable to move her right hand, which was partially closed with contractures (shortening of muscles, tendons, skin and nearby soft tissues that causes the joints to shorten and become very stiff preventing normal movement). During an interview, on 10/21/2024 at 11:07 A.M., Resident 18 indicated the staff were supposed to stretch her hand, but they did not do it. A record review for Resident 18 was completed on 10/23/2024 at 10:23 A.M. Diagnoses include but were not limited to: Hemiplegia and hemiparesis, Lung and Brain Cancer, depression and anxiety. An Admission Restorative Observation Form, dated 7/30/2023, indicated Resident 18 had no existing contractures or limited Range of Motion (ROM). A Care Plan, initiated 7/31/2023 and revised on 6/28/2024, indicated Resident 18 had an ADL (activity of daily living) self-care performance and functional mobility deficit related to flaccid (limp) right side due to an old stroke. Interventions initiated on 7/31/24 included: The resident has a contracture of the right hand and wrist: Provide skin care daily as ordered to keep clean and prevent skin breakdown; keep hand roll in palm of hand. A Restorative Observation Form, dated 10/31/2023, indicated Resident 18 had an existing contracture or limited ROM of the right wrist at 75 percent of normal mobility and the right hand/fingers at 75 percent of normal mobility. A Restorative Observation Form, dated 2/2/2024, indicated Resident 18 had no existing contractures or limited ROM. A Restorative Observation Form, dated 5/2/2024, indicated Resident 18 had an existing contracture or limited ROM. The right wrist, hand and fingers were now fixed with no mobility. The form indicated Resident 18 was not receiving any restorative programs. During an interview, on 10/23/2024 at 11:07 A.M., Resident 18 was asked if staff had been stretching or putting anything in her hand. She indicated they had not stretched her hand nor placed anything in her hands. Resident 18 was observed with nothing in her right hand nor was she wearing a splint to her right hand. A Hospice Nurse's Visit Note, dated 11/14/2023, indicated the following: .nurse delivered to patient. The writer placed brace on patient's right hand/wrist. Patient noted brace felt good. Updated facility SN of brace. A Hospice Nurse Visit Note, dated 2/19/2024, indicated the following: Patient has her sling on her right shoulder and brace on her right wrist. Patient reports these two items are helping her shoulder and wrist to not hurt so much . The Hospice Social Worker note, dated 12/6/2023, indicated the following: Patient voicing desire to have a brace that keeps her hand straight with goal of retaining use of right arm. Patient currently has hand piece to prevent further contraction of right hand.'' A Hospice Care Plan, dated 10/24/24 at 1:56 P.M., indicated: DME/assistive device needs. Interventions included, but were not limited to: 5 hand/wrist brace start 11/14/2023. During an interview, on 10/24/2024 at 2:04 P.M., CNA 14 indicated Resident 18 had a contracture to her right hand and there should have been a hand pillow (small pillow with a strap that goes over the back of her hand) in her right hand. CNA 14 indicated staff completed basic ROM (Range of Motion) while providing routine care. During an observation, on 10/24/2024 at 2:10 P.M., Resident 18 was in bed with no device in her right hand. During an interview, on 10/24/2024 at 2:11 P.M., Resident 18 indicated she did not have a pillow in her hand and she did not know where it was but she knew she was supposed to be wearing something in her hand. During an interview, on 10/24/2024 at 2:10 P.M., the Director of Rehabilitation indicated Resident 18 had transitioned into hospice care once she was admitted and therapy had not worked with her. During an interview, on 10/25/2024 at 12:05 P.M., LPN 13 indicated Resident 18 had contractures identified on the Restorative Assessment of minimal impairment completed on 10/31/2023. In addition, the May 2024 assessment had identified the resident's right hand contratures as fixed/no mobility. LPN 13 indicated Resident 13 was on no formal ROM or restorative program and staff completed basic ROM with routine care. During an interview, on 10/25/2024 at 2:10 P.M., the Corporate Nurse indicated the facility did not have a formal restorative program and they did not have a policy speciic to contracure prevention. 3.1-42(a)(2)

Based on observation, record review and interview, the facility failed to ensure care plans related to respiratory status were revised for 1 of 25 residents reviewed. (Resident 7) Finding includes: During an observation, on 10/21/2024 at 10:54 A.M., Resident 7 was receiving 2 liters (L) of oxygen via a nasal cannula (NC). During an observation, on 10/22/24 at 9:54 A.M., Resident 7 was receiving 2L of oxygen via a NC. During an observation, on 10/23/2024 at 1:57 P.M., Resident 7 was receiving 2L of oxygen via a NC. The medical record for Resident 7 was reviewed on 10/23/2024 at 11:55 A.M. Diagnoses included, but were not limited to: delusional disorder, diabetes mellitus, peripheral vascular disease, obstructive sleep apnea, heart failure, acquired absence of left leg below knee, hypertension, depression, anxiety, chronic obstructive pulmonary disease and history of transient ischemic accident and cerebrovascular accident. There was no physician's order for the use of oxygen for Resident 7. During an interview, on 10/24/2024 at 9:51 A.M. with the Director of Nursing, she indicated a physician's order was not required because the oxygen use was a nursing measure. She indicated she was unaware of Resident 7's oxygen use and did not know how long the resident had been receiving oxygen. A Quarterly Minimum Data Set (MDS) assessment, dated 8/5/2024, indicated Resident 7 had a diagnosis of chronic obstructive pulmonary disease and had not received oxygen therapy. Resident 7's current Care Plan, dated 8/5/2024, lacked documentation including oxygen therapy as a current intervention for the resident. During an interview, on 10/25/2024 at 9:44 A.M., LPN 4 indicated Resident 7's care plan should have been updated to include oxygen therapy. On 10/25/2024 at 2:55 P.M., the Director of Nursing provided a policy titled, Comprehensive Care Plan, dated 11/17/2017 and indicated the policy was the one currently used by the facility. The policy indicated, .the care plan should be revised on an ongoing basis to reflect changes in the resident and the care that the resident is receiving . 3.1-35(d)(2)(B)

Based on observation, interview and record review, the facility failed to prevent resident to resident abuse from reoccurring for 2 of 2 residents reviewed for abuse allegations.(Resident 40 & 45) The immediate jeopardy began on 11/27/2019 with recurrent events of Resident to Resident physical alterations when Resident 45 pushed Resident 75 on 2 occasions, hit Resident 77 and Resident 23, and Resident 40 hit Resident 61, yelled at Resident 64 who then hit Resident 40. Corporate Administrator and the Director of Nursing were notified of the immediate jeopardy on 1/10/2020 at 1:03 P.M. The immediate jeopardy was removed on 1/13/2020, but noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: 1. On 1/6/2020 at 12:33 P.M., Resident 45 was observed to punch Resident 23 in the stomach. A clinical record review was completed on 1/6/2020 at 3:30 P.M., and indicated Resident 45's [DIAGNOSES REDACTED]. A form, titled COMPREHENSIVE CLINICAL REVIEW MEETING NOTE, dated 12/3/2019, indicated .continue with current interventions Resident 45's plan of care lacked individualized behavior interventions. A BEHAVIOR/MOOD CHARTING form, dated 11/25/2019, indicated Resident 45 was .screaming yelling at staff calling staff $2 w*****, hitting at staff, res (resident) was blocking his room doorway so room mate could not come in and out Immediate interventions to attempt included: 1:1 with staff, music, reassured and redirected, however no individualized interventions were attempted at this time. A BEHAVIOR/MOOD CHARTING form, dated 11/26/2019, indicated Resident 45 was physically aggressive in the hallway. Immediate interventions to attempt included: activity, assessed for pain, conversation, left alone and reaproached, offered snack, reassured, redirected and toileted, however no individualized interventions were attempted at this time. A facility reported incident, dated 11/27/2019, indicated Resident 75 accidentally .touched Resident 45 and Resident 45 pushed Resident 75 and caused Resident 75 to fall. A BEHAVIOR/MOOD CHARTING form, dated 11/30/2019, indicated Resident 45 .has been very agitated this shift. He has randomly started screaming at staff and other residents, cursing loudly, threatening to kick your a**, shut the f*** up as well as others Immediate interventions to attempt included: back rub, conversation, given food, left alone and reaproached, massage/touch, offererd snack, reassured, redirected and toileted, however no individualized interventions were attempted at this time. A BEHAVIOR/MOOD CHARTING form, dated 12/3/2019, indicated Resident 45 .began yelling and calling staff b****** in the dining room. Immediate interventions included: 1:1 with staff, PRN(as needed) medication given, redirected and reoriented, however no individualized interventions were attempted. A facility reported incident, dated 12/15/2019, indicated Resident 77 was sitting at the dining room table across from another resident. The other resident started screaming, but Resident 45 thought Resident 77 was screaming so he .made contact with Resident 77's right arm. A facility reported incident, dated 1/3/2019, indicated Resident 75 was wandering on the unit .as per usual and made contact with Resident 45. Resident 45 pushed Resident 75 away causing Resident 75 to fall. Resident 45's plan of care lacked individualized behavior interventions and no documented updates to the careplan were made following the facility incidents of resident to resident abuse to prevent them from reoccurring. During an interview, on 1/8/2020 at 4:32 P.M., the DON (director of nursing) indicated she was unable to find anything the facility was doing to prevent the abuse from reoccurring for Resident 45. 2. A clinical record review was completed, on 1/10/2020 at 12:15 P.M., and indicated Resident 40's [DIAGNOSES REDACTED]. A quarterly Minimum Date Set (MDS), dated [DATE], indicated physical and verbal aggression were demonstrated during the assessment dates referenced. A care plan with the focus area of .Behavior Problem related to Anxiety ., Interventions included: Administer medications as ordered. Monitor/document for side effects and effectiveness, explain all procedures to me before starting and allow me time to adjust to changes, minimize potential for disruptive behaviors by offering tasks which divert attention such as talking a walk, monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved and situations. Document behavior and potential causes, however lacked target behaviors and individualized interventions. A facility reported incident, dated 11/9/2019, indicated Resident 40 .made contact with Resident 61's right shoulder. A progress note, dated 11/20/19, indicated Resident 40 continued to demonstrate argumentative and aggressive approaches. A facility reported incident, dated 11/25/2019, indicated Resident 40 scratched Resident 72, following an argument in their room. A facility reported incident, dated 12/1/2019, indicated Resident 40 and Resident 61 were witnessed by staff grabbing each others arms and pinching. A facility reported incident, dated 12/9/2019, indicated Resident 40 hit Resident 61 in the stomach. A facility reported incident, dated 12/11/2019, indicated Resident 40 was yelling at Resident 64 and Resident 64 hit Resident 40 with .an open hand on the right side of her face/cheek area Progress notes, dated 12/2/19, 12/4/19, 12/9/19, 12/14/19 and 12/16/19, failed to indicate a system to identify, track and prevent future resident to resident abuse incidents. Resident 40's care plan lacked individualied interventions and updates specific to Resident 40's behavioral needs, to prevent reoccurring resident to resident abuse. A policy was provided by the Corporate Administrator, on 1/12/2019 at 2:07 P.M., titled Abuse Prevention and Reporting- Indiana, dated 11/28/2016, and indicated this was the policy currently used by the facility. The policy indicated .The facility will take steps to prevent potential abuse while the investigation is underway. Residents who allegedly abused another resident will be removed from contact with other residents during the course of the investigation. The accused resident's condition shall be immediately evaluated to determine the most suitable therapy, care approaches, and placement, considering his or her safety, as well as the safety of other residents and employees of the facility and .Quality Management Review: Any investigation that concluded that abuse, neglect, exploitation, mistreatment or misappropriation of resident property occurred shall be reviewed by the facility Quality Management committee for possible changes in facility practices to ensure that similar events do not occur again The immediate jeopardy that began on 11/27/2019, was removed on 1/13/2020 when the facility reviewed and implemented an individualized behavior management plan for all residents considered to be at risk including potential triggers, monitoring and interventions to prevent or reduce reoccurrence of resident to resident altercations, implemented a systemic plan that included the following actions: newly identified behaviors monitored for 72 hours in addition to daily behavior monitoring, a behavior management binder as a form of communication and monitoring and in-serviced staff on abuse and neglect including types, triggers and preventing resident to resident abuse, but noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy because of the need for further education and continued monitoring. 3.1-27(a)(1) 3.1-27(b)

Based on record review, observation and interview, the facility failed to implement placement criteria within the facility, behavior tracking, individualized care plans for behaviors with interventions and monitoring following a gradual dose reduction resulting in escalating behaviors and eventual placement in a psychiatric hospital for 1 of 3 residents. (Resident 4) In addition, the facility failed to implement behavior tracking and individualized care plans for behaviors with interventions for 2 of 3 residents reviewed for behaviors. (Residents 4, 40 and 45) The immediate jeopardy began on 12/02/2019 when the facility failed to appropriately assess, treat and monitor behaviors for Resident 4, after she had a gradual dose reduction, moved to another unit and had escalating behaviors, causing fear in another resident. The Corporate Administrator and the Director of Nursing were notified of the immediate jeopardy on 01/10/2020 at 1:03 P.M. The immediate jeopardy was removed on 1/13/2020, but noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: 1. During an interview with Resident 69 and her family member, on 01/07/20 at 11:35 AM, Resident 69 indicated Resident 4 had come into her room on multiple days/nights and yelled at her, accused her of stealing the nurse light and bed, Resident 4 screamed in the hallway and threw things against the walls. Resident 69 indicated she was scared of Resident 4 and a couple days ago while her family member was there, Resident 4 was in her doorway yelling at her. The family member indicated, at this time, Resident 4 was acting very aggressive and yelling so she jumped up and shut the door to keep her out of the room. After it quieted down in the hall, the daughter talked to a CNA (certified nurses aide) and was told the CNA took care of it. Resident 69 then indicated, Resident 4 had thrown things out of her room and into the hallway before so staff kept her door shut and also once when Resident 4 came into Resident 69's room at night and was told it was not her room, Resident 4 cussed her out and had said she was going to stab her. Resident 69 indicated she had anxiety problems and Resident 4 scared her and she had been so upset she cried because staff wouldn't fix the situation. During an observation, on 1/07/2020 at 12:00 P.M., Resident 4's door was shut. During an interview, on 1/07/2020 at 12:03 P.M., LPN (Licensed Practical Nurse) 3 indicated Resident 4 had been banging her bedside table into the wall, throwing things and threw a cup of water in her face that morning. During observations, on 1/07/2020 at 2:30 P.M., 2:45 P.M. and 2:58 P.M., staff members were taking turns sitting in a chair outside of Resident 4's room with the door shut, while Resident 4 was screaming and making loud banging noises inside the room. A clinical record review was completed, on 1/08/2020 at 3:33 P.M., and indicated Resident 4's [DIAGNOSES REDACTED]. A MDS (minimum data set) assessment, dated 12/31/2019, indicated Resident 4 had a BIMS (brief interview for mental status) score of 5, severe cognitive impairment, and required limited assist of 1 person for walking inside her room. Active physician orders, dated 06/14/2019, indicated .Resident may remain in locked/harmony/behavioral unit A behavior/mood charting, dated 12/02/2019 at 3:32 P.M., indicated .resident (4) was in bedroom when writer heard loud screaming noise. When writer got to room resident told writer that she was going to cut her insides out A physician progress notes [REDACTED].resident was seen today for routine visit.still isolating self and can be psychotic and has received [MEDICATION NAME] IM (intramuscular). patient is a poor historian and still has occasional behavior with meds and will need to be in behavioral unit A behavioral management team review note, dated 12/02/2019, indicated .GDR (Gradual dose reduction) [MEDICATION NAME] (antipsychotic) to 100 mg (milligrams) daily. Minimal behaviors noted .Resident remains appropriate for continued placement on the secured unit A progress note, dated 12/02/2019, indicated a gradual dose reduction of [MEDICATION NAME] of 25 milligrams three times a day. A progress note by social services, dated 12/11/2019, indicated .(Resident 4's family member) feels that resident will attend more activities on the main unit Action: Resident has been moved to main hallway. Response: resident is adjusting well to new room A behavior/mood charting, dated 12/12/2019 at 5:47 [NAME]M., indicated .Res (resident) got up several times and urinated on the floor and then tipped her bedside table over onto the bed. Res was heard yelling in her room. Staff attempted to educate resident on using call light to ask for help, resident continued to yell obscenities while sitting in her wheelchair in her room. Staff attempted to talk one on one w/ (with) resident and redirect, reorient. Unsuccessful A physician progress notes [REDACTED].still isolating self and can be psychotic but has been better controlled and currently in a main hall after she left behavioral hall. we will be monitoring the behaviors carefully A behavior/mood charting, dated 12/15/2019 at 2:46 [NAME]M., indicated .Res sat in room yelling obscenities and was approached by staff. Attempted to re-direct, re-orient, offered one on one, snack, toileted. Res remained verbally aggressive and socially inappropriate A behavior/mood charting, dated 12/29/2019 at 5:30 P.M., indicated .Resident was yelling and cursing at staff and other residents. Resident flipped the bedside table over and refused medications. Resident then stood up beside her bed and urinated on the floor; then demanding staff clean it up A behavior/mood charting, dated 12/30/2019 at 3:26 [NAME]M., indicated .Res was screaming in room and urinating on the floor. Would not allow staff to assist her to bathroom. Res flipped over bedside table and was threatening to staff A behavior/mood charting, dated 12/30/2019 at 8:06 P.M., indicated .Resident is screaming and cursing at God. The demons won't leave her alone, she states. Resident is disturbing other residents and her roommate A behavior management review team meeting, dated 12/30/2019, indicated .Resident does not currently reside on the secured unit, and does not meet criteria for placement on the unit During an interview, on 01/08/2020 at 4:30 P.M., the DON indicated the facility did not have criteria for placement within the behavior unit at the facility and does not targeted behavior monitoring, just the behavior/mood charting. A behavior/mood charting, dated 1/01/2020 at 10:58 P.M., indicated .Res knocked over bedside table and yelled obscenities at staff. Continued yelling, staff attempted to reorient, redirect and calm resident. Resident remained verbally aggressive and yelling. Offered snack and drink and resident stated she didn't want it and cussed at staff then threw drink onto floor A behavior/mood charting, dated 01/03/2020 at 3:51 [NAME]M., indicated .Res screaming at wall and yelling at staff when they approach her to redirect. Yelling obscenities at staff and roommate. Writer attempted to redirect and reorient resident. Resident remains upset and staff unable to calm her. Resident left in room to calm down. Res continues to yell at the wall in her room periodically A behavior/mood charting, dated 1/07/2020 at 1:03 [NAME]M., indicated, .Res was in room and was screaming and banging the walls. Writer talked to res to calm her down and redirect. Res was redirected with snack and drink A behavior/mood charting. dated 01/07/2020 at 6:05 P.M., indicated, .Res in room stating that 'they are trying to kill my family and that they already killed my son'. Res flipping over her bedside table and nightstand. also taking bathroom door and continuously slamming it into the wall. Staff offered TV, one to one to calm and redirect. Res denies pain. Res continues yelling obscenities and urinating on the floor. When approached, resident screams that staff wants her family killed. Resident left in room to calm herself A progress note, dated 1/07/2020, indicated .notified physician - got an order for [REDACTED].>A progress note, dated 1/08/2020, indicated . Ambulance here at the facility accompanied by two EMT's. Resident hallucinating at this time causing distress to herself. Resident denies s/s (signs and symptoms) or c/o (complaint) of pain or disc (discomfort). Paperwork sent with driver. Resident loaded onto gurney. Three days of clothes sent with resident . During an interview, on 01/08/2020 at 3:10 P.M., the Administrator indicated she was not aware of the behaviors on 12/02/2019 prior to moving Resident 4 to the main hall. During an interview, on 01/08/2020 at 3:40 P.M., the Administrator and DON indicated they were unaware of the Social Services note, dated 12/11/2019, that indicated Resident 4 and her family member requested a room change. The DON indicated Resident 4 had not been having behaviors for a long time and she wanted to give her more freedom. During an interview, on 01/08/20 at 4:08 PM, Resident 43 indicated she resided next door to Resident 4 and she yelled and banged on the wall every night, sometimes the wall vibrated because Resident 4 hit it so hard and she wondered if she would come through the wall. .It happened almost every night and I wondered what happened on the nights that it was quiet During an interview, on 01/09/2020 at 4:28 P.M., LPN 3 indicated they were supposed to complete behavior/mood charting under assessments for every behavior but she felt lucky if she got the time to put in a progress note for each resident. During an interview, on 1/10/2020 at 10:11 [NAME]M., Resident 80 indicated Resident 4 was her roommate on the behavior unit and again when they were transferred to the main hall together. She indicated Resident 4 was angry and her behaviors escalated, she would throw furniture and yell. .I was afraid of her, she had demons inside her and she was fighting them. When she would yell and throw things I would go get help from nursing staff There was no care plan available with documented targeted behaviors and individualized interventions for Resident 4. 2. On 1/6/2020 at 12:33 P.M., Resident 45 was observed to punch Resident 23 in the stomach. A clinical record review was completed on 1/6/2020 at 3:30 P.M., and indicated Resident 45's [DIAGNOSES REDACTED]. A form, titled COMPREHENSIVE CLINICAL REVIEW MEETING NOTE, dated 12/3/2019, indicated .continue with current interventions Resident 45's plan of care lacked individualized behavior interventions. A BEHAVIOR/MOOD CHARTING form, dated 11/25/2019, indicated Resident 45 was .screaming yelling at staff calling staff 2 w*****, hitting at staff, res was blocking his room doorway so room mate could not come in and out A BEHAVIOR/MOOD CHARTING form, dated 11/26/2019, indicated Resident 45 was physically aggressive in the hallway. A facility reported incident, dated 11/27/2019, indicated Resident 75 accidentally .touched Resident 45 and Resident 45 pushed Resident 75 and caused Resident 75 to fall. A BEHAVIOR/MOOD CHARTING form, dated 11/28/2019, indicated Resident 45 was verbally aggressive in the dining room. A BEHAVIOR/MOOD CHARTING form, dated 11/30/2019, indicated Resident 45 .has been very agitated this shift. He has randomly started screaming at staff and other residents, cursing loudly, threatening to kick your a**, shut the f*** up as well as others A BEHAVIOR/MOOD CHARTING form, dated 12/3/2019, indicated Resident 45 .began yelling and calling staff b****** in the dining room. A BEHAVIOR/MOOD CHARTING form, dated 12/5/2019, indicated Resident .yells at staff and residents for unknown reasons. Resident is making comments like she's in the junk yard, I'm not lying, she is. Resident easily frustrated this shift A facility reported incident, dated 12/15/2019, indicated Resident 77 was sitting at the dining room table across from another resident. The other resident started screaming. Resident 45 thought Resident 77 was screaming so he .made contact with Resident 77's right arm. A BEHAVIOR/MOOD CHARTING form, dated 1/1/2020, indicated Resident 45 was verbally aggressive and socially inappropriate in the dining room. A facility reported incident, dated 1/3/2019, indicated Resident 75 was wandering on the unit .as per usual and made contact with Resident 45. Resident 45 pushed Resident 75 away causing Resident 75 to fall. Resident 45's medical record lacked an individualized behavior plan or behavior assessment. Resident 45's plan of care lacked individualized behavior interventions and no documented updates to the careplan were made following the facility incidents or documented behaviors to prevent them from reoccurring. During an interview, on 1/8/2020 at 4:32 P.M., the DON(director of nursing) indicated Resident 45 did not have any further individualized interventions following his behaviors. 3. A clinical record review was completed, on 1/10/2020 at 12:15 P.M., and indicated Resident 40's [DIAGNOSES REDACTED]. A quarterly Minimum Date Set (MDS), dated [DATE], indicated physical and verbal aggression were demonstrated during the assessment dates referenced. A care plan with the focus area of .Behavior Problem related to Anxiety ., indicated a lack of individualized target behaviors and indicated no system for monitoring behavioral episodes that occurred. A facility reported incident, dated 11/9/2019, indicated Resident 40 .made contact with Resident 61's right shoulder. A progress note, dated 11/20/19, indicated Resident 40 remained argumentative and aggressive in approach. A facility reported incident, dated 11/25/2019, indicated Resident 40 scratched Resident 72, following an argument in their room. Resident 40's medical record indicated no interventions present to prevent/manage episodes of physical and verbal behavioral demonstrations. A facility reported incident, dated 12/1/2019, indicated Resident 40 and Resident 61 were witnessed by staff, grabbing each others arms and pinching. A facility reported incident, dated 12/9/2019, indicated Resident 40 hit Resident 61 in the stomach. A facility reported incident, dated 12/11/2019, indicated Resident 40 was yelling at Resident 64 and Resident 64 hit Resident 40 with .an open hand on the right side of her face/cheek area During an interview, on 1/12/2019 at 12:35 P.M., Corporate Nurse indicated there were no individualized interventions put in place to prevent reoccurring behaviors. A policy was provided, on 01/09/2020 at 2:45 P.M., titled Behavior Management Program with a revision date of 10/30/17, by the DON and indicated this was the current policy in use. The policy indicated .establish a system for identifying behaviors and implementing appropriate interventions consistent with the individualized plan of care and to ensure that each resident receives appropriate treatment and services to attain the highest practicable mental and psychosocial well-being The immediate jeopardy that began on 12/02/2019 was removed on 01/13/2020 when the facility reviewed identified residents for triggers to behaviors, compiling individualized care plans with appropriate interventions, completing audits to identify any residents with a gradual dose reduction recently and known behaviors, started a system for monitoring behavioral concerns, and inserviced staff on behaviors, including triggers and individualized interventions, but noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy because of the need for further education and continued monitoring. 3.1-43(a)(1)

Based on observation, interview and record review, the faclity failed to ensure a gait belt was used and 2 person assist as required during a transfer, resulting in a witnessed fall with a tibial [MEDICAL CONDITION] lower leg for 1 of 3 residents reviewed for accidents. (Resident 11) Finding includes: On 1/10/2020 at 10:30 [NAME]M., Resident 11 was observed laying in his bed positioned on his side with pillows. A clinical record review was completed on 1/8/2020 at 2:26 P.M., and indicated Resident 11's [DIAGNOSES REDACTED]. A MDS (minimum data set) assessment, dated 9/4/2019, indicated Resident 11 required extensive assistance of two staff, for transfers. A nurses note, dated 10/3/2019, indicated .Resident had a witnessed fall 10/3/2019 7:10 PM Location of Fall: residents room, next to bed CNA (certified nurses aide) reported to nurse resident on floor, nurse observed resident on floor next to bedroom wall on LT (left) side with head near electrical outlet, moderate amount of bleeding near back of head, pressure applied with clean, dry drsg, noted small amount of bleeding from LT nare, small abrasion on RT (right) lower lip and .Employee reeducation on importance on the proper use of gait-belt, knowledge of level of resident transfer before transferring, have a second person if transfer requires the second person A nurses note, dated 10/5/2019, indicated Resident 11 was sent to the emergency room for placement of a right knee immobilizer. A CT test from a local hospital of Resident 11's right lower leg, dated 10/5/2019, indicated .IMPRESSION: Comminuted lateral and medial tibial plateau fractures (fracture in the shinbone involving the knee) as described above with apparent dissociation from tibial metadiaphysis A nurses note, dated 10/5/2019, indicated .Three staples intact ot back of head During an interview, on 1/16/2020 at 9:13 [NAME]M., the Administrator indicated a gait belt with two person assist should have been used when transferring Resident 11. On 1/13/2020 at 12:30 P.M., Resident 11 was observed sitting up in his wheelchair in his room. No brace was observed to his right leg at this time. A policy was provided by the facility leison 6, on 1/13/2020 at 3:14 P.M., titled Transfers- Manual Gait Belt and Mechanical Lifts, dated 11/28/2012, and indicated this was the policy currently used by the facility. The policy indicated .9. Use of gait belt for all physical assist transfers is mandatory 3.1-45(a)(2)

Based on observation, interview and record review, the facility failed to ensure a resident with severe cognitive deficits, who was identified as a high risk for elopement and resided on a secure unit, did not exit the building unattended, which resulted in the elopement of 1 of 5 residents reviewed for elopement, in an universe of 35 residents at risk for elopement. (Resident B) The Immediate Jeopardy began, on 6/12/19 at 9:28 P.M., when Resident B was last observed on the facility's video surveillance system, and was returned to the facility by the local police department, who found the resident walking in the dark, on a county road approximately 1 mile from the facility. The Administrator and the Director of Nursing (DON) were notified of the Immediate Jeopardy on 6/14/19 at 6:29 P.M. The Immediate Jeopardy was removed on 6/16/19, but noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that was not Immediate Jeopardy. Finding includes: During an interview, on 6/14/19 at 10:15 A.M., Resident B indicated he remembered leaving the facility, the police bringing him back, but would not explain how he got out of the building. He was going home to Michigan. Resident B was alert to self but wasn't sure what month it was, he had a wife, and she was in his home. Resident B indicated at this time I didn't say I went out the window During an observation with the Maintenance Director, on 6/14/19 at 10:20 A.M., the window in Resident B's room was noted with no screen located in the window sill and a flat bracket was in the window slide. The Maintenance Director indicated the bracket was there to stop the window from opening all the way. There was some wiggle room in the window pane and the resident must have maneuvered and/or lifted the window over the flat bracket, to get the window all the way opened, in order to get out of the window. Otherwise the window would only opened 6 inches, not allowing anyone to exit through the window. A L shaped bracket was observed, drilled into the window slide, up against the window- which would prevent the window from being opened at all. Outside of the window, to the right, was a water hydrant which had a cement base. On the left was a water hose draining from the gutter system. The Maintenance Director indicated he was contacted in the early morning of 6/13/19 and was told a resident had gotten out of the window. He fixed the window with the L shaped bracket around 3:30 A.M. A chair was observed, in a corner, near the window. Resident B's bed was not next to the window, his bed was located near the doorway. An observation of the window, outside the facility was conducted with the Maintenance Director. The measurement from window sill to the ground was 61 inches and if opened the window opening measured 31 inches across. Two screens were lying on the ground on the far side of water hydrant, and leaves were observed on the top of them. The Maintenance Director indicated the screens had been there for a while. The Maintenance Director indicated he questioned whether the resident went out the window, as the distance the resident would haven fallen, would have caused an injury of some sort. He indicated he was not in the building during the elopement and had been told the resident went out the window. On 6/14/19 at 10:50 A.M., the resident was observed for any abrasions and/or bruising to his arms and legs with the DON. He had a small old bruise on the lateral left knee, otherwise skin was intact. The resident was asked if he got the bruise when he went out the window and he indicated he didn't go out the window and smiled. On 6/12/19 at 11:33 A.M., a review of the clinical record for Resident B was conducted. [DIAGNOSES REDACTED]. Incident #387, dated 6/12/19, indicated Resident B was identified to have left the building after 9:45 P.M., through his bedroom window. The resident was located and returned at 10:45 P.M., by the local police department. The screen to his window was noted to be on the ground. A Quarterly Minimum Data Set (MDS) Assessment, dated 5/9/19, indicated the resident's Brief Interview for Mental Status (BIMS) score was 5 (severe cognitive deficits) with behaviors of disorganized thinking and delusions and resident was without a wandering/elopement guard device. The assessment indicated the resident transferred, ambulated on/off unit with 1 assist of cueing and/or supervision, with no concerns with maintaining his balance and he used no assistive devices. An elopement risk care plan, dated 1/22/19, indicated the resident was exit seeking. The interventions included the following: . o I will not leave facility unattended through the review date. o Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. o Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. o Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes A Quarterly Elopement/Unauthorized Leave Risk Review, dated 4/22/19, indicated the resident was .at risk to elope and should be placed on the Elopement Risk Protocol. A care plan for Elopement is indicated Resident B's elopement risk score was 11, out of a possibly 13, and he was considered high risk for elopement. On 6/14/19 at 11:38 A.M., an interview was conducted with the Administrator and the DON. The Administrator indicated she received a call at 10:44 P.M., informing her Resident B had left the building and the police were bringing him back to the facility. The Administrator indicated the staff, present at the time, were interviewed and had no knowledge of the resident leaving the unit and/or facility. The Administrator indicated all residents on the Harmony/Behavior unit were an elopement risk. The Administrator indicated she watched the facility's video footage and resident was last observed via the camera at 9:28 P.M. and not observed again until approximately 11:00 P.M., re-entering the unit, with a police officer. The DON indicated the resident was ordered to be on 15 observation checks prior to this, due to his risk of elopement. The DON indicated the resident would not allow the staff to assess him or tell them how he got out of the building. The resident was placed on one to one observations with a CNA immediately upon his return. The Administrator indicated a flat screw/bracket had already been placed in the window slide and would prevent the window from opening only 6 inches. The Administrator reported the resident did not want her to examine the window. The Administrator and the DON indicated the only way out of the room was through the window. The DON indicated everyone on the Harmony/Behavior unit had been on 15 minute checks. The staff had not completed the 15 minute observation checks on Resident B between 9:45 P.M. and 10:45 P.M. The residents on the Behavior unit were independent, go to the bathroom by themselves, etc. and residents tend to get very annoyed if staff were always checking them. At night, if resident's doors were shut and the residents were in there sleeping, the staff would not always go into the room to check/observe the residents. A form titled Documentation Survey Report for (MONTH) 2019, for Resident B was received from the DON. The form indicated the intervention was to complete visual safety checks every 15 minutes. Fifteen minute checks were documented as completed on 6/12/19 from 9:00 P.M. to 11:45 P.M., including the time Resident B was known to be out of the building. During an interview, on 6/14/19 at 12:29 P.M., RN 2 indicated she worked the Behavioral unit, on 6/12/19 from 6:00 P.M. to 6:00 AM. on 6/13/19. She last saw Resident B on 6/12/19 at approximately 9:30 P.M., standing near the medication cart at the nurses station. The next time she saw him was when the police were standing outside the unit's door, knocking to let them in. The police indicated they had found the resident walking along County Rd 400 going north. The RN assessed the resident and he had no complaints of pain or look of distress. The resident would not tell her how he got out of the building. She had worked with CNA 3, who worked the 10 P.M. to 6 A.M. shift and CNA 4 who had worked the 2 P.M. to 10 P.M. shift. The CNA's should have been completing the 15 minute checks, on Resident B. She was not notified by either CNA the resident had not actually been observed during the observation checks. On 6/13/19 at 1:45 P.M., a facility video was observed, dated 6/12/19 from 9:24 P.M. thru 10:51 P.M., of the doorways in/out of the Harmony/Behavioral unit and the Resident B's hallway, near his doorway. There were no staff members observed coming towards the resident's room, to do a 15 minute check on him or his roommate. The resident was observed on the video at 9:24 P.M., standing at the medication cart, at 9:26 P.M., the resident left the cart and walked back to his room. At 9:27 P.M. the resident was observed, on the video, leaving his room again and walked to the medication cart, where RN 2 was located. At 9:28 P.M., the resident was observed to return to his room. At 10:51 P.M., RN 2 was observed to open the entrance to unit and resident walked in and went directly to his room, he was noted to have a [NAME]et and a baseball cap on, which he didn't have on during previous video times. During an interview, on 6/14/19 at 3:05 P.M. CNA 5 indicated the 15 minute checks that were completed could be documented at any time and documented in the computer sometimes at the end of the shift or anytime during the shift. Resident's on 15 minute checks, were to be visualized every 15 minutes, but indicated, that didn't always happen. The Administrator provided a statement from CNA 3 and CNA 4 who had worked on 6/12/19. The statement indicated they had not completed their 15 minute observation checks on Resident B, even though they were documented. During an interview, on 6/12/19 at 3:12 P.M., with Resident B and his roommate Resident C. Resident B indicated he would not say how he got out of the building. His roommate (Resident C) indicated when Resident B returned he thought he was long gone. Resident B indicated for everyone not to worry he couldn't get out again, because they had put all kinds of bolts and screws in the window to keep him from opening it again. During an interview, on 6/12/19 at 3:50 P.M., with the Social Service Director (SSD) and DON, the SSD indicated the protocol for elopement risk for Resident B, his room was to be on a secure unit. The DON indicated the 15 minute checks were not ordered by a physician, but were put into place to get staff to check on the residents. The SSD indicated she had not update the resident's care plan after the elopement, as the interventions were still appropriate. On 6/14/19 at 11:11 A.M., the DON provided a policy titled, Elopement Risk Assessment, undated and indicated the policy was the one currently used by the facility. The policy indicated .1. A Social Service Department will conduct the elopement assessment during the admission process, when there is a significant change in mood or behavior(s), and quarterly .5. Interdisciplinary care plans of those at risk for elopement will address specific interventions that are unique to the risk factors assessed .6. The Social Service Department will notify Facility Staff and initiate interventions necessary to protect the resident. Interventions include, however, are not limited to the following: a. Relocation to Secure Unit b. Bed Alarm and/or Chair Alarm c. Use sign in/sign out record d. Psychological Consultation e. Personal Alarm Arm or Ankle Bracelet f. 15 minute to 1 hour observations g. One-on-one observation h. Behavior management programs The Immediate Jeopardy that began on 6/12/19 was removed on 6/16/19 when the facility implemented systematic changes, such as: in-serving all staff on elopement guidelines,window checks/secured, elopement drills and observation monitoring of residents, with high risk of elopement, completed as directed, but the non-compliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that was not Immediate Jeopardy because of the facility's need to continue in-services and monitoring of the resident. This Federal tag relates to complaint IN 125. 3.1-45(a)(1) 3.1-45(a)(2)

Based on record review and interview, the facility failed to prevent sexual abuse to 2 female residents from a male resident with known sexual behaviors. This deficiency had the potential to affect 7 females out of 16 residents who resided on the locked behavior unit. This deficiency resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 8/14/18 when a female resident reported an allegation of sexual assault. The Administrator and Director of Nursing Services were notified of the Immediate Jeopardy on 8/28/18 at 6:07 P.M. The Immediate Jeopardy was removed on 8/31/18, but noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that was not Immediate Jeopardy. Finding includes: On 8/28/18 at 9:25 A.M., the clinical record for Resident B was reviewed. Resident B had [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) quarterly assessment reference date of 7/3/18 indicated Resident B had a BIMS (Brief Interview for Mental Status) score of 10, moderate cognitive impairment. A Nursing Note Narrative, dated 7/5/18 at 11:17 A.M., indicated .Resident reported today that male resident (Resident D) entered her room last night and asked to get into bed with her, she told him no he then stood up using her rail to stand up female again told him no he then sat back down into his wheelchair and exited females room. Resident was offered reassurance and encouraged if he comes to her room to turn on her light immediately. Resident states he did not touch her she just did not want him in her room On 8/27/18 at 9:50 A.M., the clinical record for Resident D was reviewed. Resident D had [DIAGNOSES REDACTED]. A Quarterly MDS assessment dated , 6/6/18 indicated Resident D had a BIMS score of 14, cognitively intact. A Nurses Progress Note, dated 7/5/18 at 11:11A.M., indicated .Description of the behavior: Female resident reported to writer that male resident came to her room last eve, asked her if he could get into bed with her, females response was no, (Resident D) then proceeded to grab the rail on her bed stood up, female asked (Resident D) to leave and he did so. Intervention: Social services and administrator was made aware, currently seeking placement at behavioral hospital A Nurses Progress note, dated 7/5/18 at 11:25 A.M., inidcated .(name of medical doctor) notified and new orders to send out for treatment and evaluation for psychiatric services A Social Service Note, dated 7/5/18 at 12:55 P.M., indicated .Notfication was provided to (Resident D), on 07/05/2018, regarding Resident D of pending room change. (name of medical doctor) was notified of room change that will occur on 07/05/18 for the reason of Behaviors. The new location of where the resident will be moving to (room number - same unit). The resident advocacy program, who was notified is Area 5 Ombudsman. The resident states s/h (she/he) would like to relocate prior to the expiration of this 2 day notice Yes. The facility or home the resident is requesting to relocate to is (name of hospital unit). The new facility was notified on 07/05/2018 A Psycho Therapy Note- Narrative, dated 7/5/2018 at 8:40 P.M., indicated . Focus: I am/have potential to be verbally aggressive and use inappropriate language towards people r/t developmental disorder . Resident D first requested to see me when I first arrived at the facility and then shortly thereafter the DON (Director of Nursing) asked me to see him after (Resident D) had become angry. One entry door was damaged and some question exists that if it was the result of Resident D's behavior or not . In general, he stated that he did not belong in the facility with which I agreed but little progress has been made for a referral that will accept him . A Nursing Progress Note, dated 7/16/2018 at 10:30 A.M., indicated . Other/General Note: Received call from (name of representative alternative program), writer explained that resident went to (psychiatric facility ) 7/9/18 and returning today. Leaving (name of city) at 1 P.M (name of hospital staff) had called again and stated resident did not want to return back to our facility was given the number to call and speak with hospital staff. Writer also informed (manager of field support) that facility would be (sic) completing a 30 day discharge paperwork for non-payment. (name of representative) has only approved LTC (long term care) until 4/14/18. Facility has not received any payment since last approval date. Facility has been working with (name of alternate representative group) and placement has been unsucessful A Nursing Progress Note, dated 7/16/18 at 5:25 P.M. indicated Resident D was readmitted to the facility. A Psycho Therapy Note- Narrative, dated 8/8/18 at 9:19P.M., indicated . I have a behavior problem of being sexually inappropriate towards staff including telling them you have a nice butt, trying to smack their butt, and trying to put his head on their breasts r/t (related to) [MEDICAL CONDITION]. I spoke with (Resident D) at some legnth today. Last week he was stating after being confronted by the police that he would fly right and that he had learned his lesson. By Friday night and certainly over he weekend he had returned to his attempts at dominating other residents and staff. He continues to exhibit very strong antisocial patterns of behavior with a sexual involvement if he thinks he can get away with it .I do not think (Resident D) is appropriate for (name of facility) since he needs DD (developmentally disability) services and the structure of a behavior modification program. At (name of facility) there are individuals with a mixture of BSPD and other Demential related conditions along with some very ill [MEDICAL CONDITION] that his antisocial behaviors result in him targeting and possibly harming them. While he is not subtle in his behaviors, he often waits till the staff's backs are turned to do his worst . A Nursing Progress Note dated 8/14/18 at 5:35 P.M., indicated . Resident D was found in another female residents room (Resident B) on the unit. Staff went into the room due to her call light being on. Upon arrival staff removes (Resident D) from room. Female Resident (Resident B) makes accusations against (Resident D) stating that he touched her inappropriately and was stating inappropriate things to her. That he just came into her room and was not invited. (Resident D) stated everything was false that he got invited into her room and they were only watching tv. That he did not say anything inappropriate to her, nor touch her Resident put on 15 minute checks. Resident is not showing any emotional distress post allegation from situation During an interview conducted with Resident B on 8/28/18 at 1:10 P.M., regarding the incident that occurred on 8/14/18, Resident B indicated that Resident D had come into her room by himself. He moved the table and put his hands up my brief. He asked me if he could suck on my t****. Resident B indicated she would call police and he asked if he could see it (her breast), she indicated the male resident kept saying I bet you never had a boyfriend love you as much as I do. .I moved his hand and put my call light on, the nurse came and got him out of my room. I don't know how many times I said no. I am still afraid. People come in and out of here. I don't want to be in here A Nursing Progress Note, dated 8/15/18 at 4:09 P.M., Resident D was .angry at staff for redirecting him out of another rsidents room, lost his balance and fell . Resient was agitated and charging staff at time of fall A Nursing Progress Note, dated 8/15/18 at 4:08 P.M., indicated . It was reported to writer that resident went into another resident's room to watch tv and made inappropriate advances toward her. Writer spoke with (Resident D) and he stated that he did ask to go into her room to watch tv and that's what they did. Resident denied touching her or speaking to her in a sexual manner. Resident stated that he became upset wtih the CNA for making him leave the females room. He stated that she CNA was being rude and it made him angry so he got up from his wheelchair and went after CNA because nobody talks to me that way. I only acted like I was gonna hit her, I don't think I would. Writer encouraged resident to show respect to the nurses and CNA's and come to me wtih any concerns or complaints about the staff A Nursing Progress Note, dated 8/15/18 at 4:14 P.M., indicated . Writer was notified that resident went into another female's room (Resident B) and would not leave. Resident B was asleep at the time. Writer assisted in encouraging Resident D to leave female's room due to the fact that she was asleep. Resident became verbally aggressive with all staff, he began swearing and running into staff with his wheelchair. He continued this hostile behavior all morning, requiring this writer to remain on the unit. He demonstrated high levels of aggression both verbal and physicial towards staff and resident, such as throwing water and yelling at reisdents A Nursing Progress Note, dated 8/15/18 at 8:04 P.M., indicated . Resident C notified CNA 1 upon arrival to her room that another male resident (Resident D) on the unit had touched her private area inappropriately and touched her breast. Writer went into the room to assess resdient. No c/o pain or discomfort. Writer did a head to toe on resident. No injuries noted. No new skin concerns noted. Resident told writer that the male resident came into her room uninvited. He told her don't yell and he took his fist and put it in her private area. And that he touched her breast and he invited her to his room. After the alleged assault the male resident left the room. Resident was provided with emotional and physical support. She did state she did feel safe if he didn't come back into her room. Resident was reassurred that male resident wouldn't come into her room again A Nursing Progress Note, dated 8/15/18 at 8:12P.M., indicated . Resident alerted to CNA 1 that another female resident on the unit needed to go to the bathroom. CNA 1 wondering how he knew that. Went into the female residents room upon arrival to room resident told CNA that the male resident had came into her room and sexually assaulted her. Resident were kept apart. Resident D was a 1 on 1 with nursing staff. No c/o (complaint of) pain or discomfort. No injuries noted. Resident C did have post emotional distress and was provided comfort and assurance. Resident D stated that he wanted company and just went into her room to hang out. He did state that he wasn't invited in. He stated that he did not touch her inappropriately and he stated that she was a lying b****. Resident D then became aggressive with staff and trying to break through the glass door and type in a code on the panel. Resident was taken with the cops who were taking him to (name of local hospital) During an interview conducted with Resident C on 8/28/18 at 1:20 P.M., Resident C indicated that a male resident (Resident D) had clenched his fist and put it in my vagina. Resident C indicated it was embarassing for her and painful. Resident C indicated she told staff and the police came and took that bad man that did those terrible things to me. Resident C indicated she is still scared. During an interview, on 8/28/18 at 4:13 P.M., LPN 1 indicated she was aware of an incident regarding Resident C and D that occurred approximately 2 weeks prior. LPN 1 indicated she came back from her luch break to find Resident D was attacking the glass door and attempting to type the code to exit. Resident D indicated he was upset with that lying b**** in there, (Resident C). LPN 1 indicated she was approached by CNA 1 and notified that she was told by Resident C that Resident D had come into her room and touched her breast and private area. LPN 1 indicated she entered Resident C's room and ensured her safety then took her statement and did a head to toe assesssment with no abnormal findings. She indicated that management had called the police and they had come to the facility and took statements and Resident C's brief (disposable underwear) as well as Resident D. Resident C was placed on 72 hour post emotional distress charting. During an interview, on 8/28/18 at 4:25 P.M., CNA 1 indicated she was sweeping Resident C's room and noticed Resident D in her room. I asked if he was supposed to be in her room. Resident C told me he (Resident D) touched her in places and made her feel dirty and that he (Resident D) did not have her permission to be in her room. CNA 1 indicated that the facility had just gone through a similar incident the day before and that Resident D had a history of [REDACTED]. CNA 1 indicated Resident C told her to keep Resident D away from her room. CNA 1 indicated at the time she felt Resident D had done something wrong because he had instantly indicated to her that he had done nothing. CNA 1 indicated Resident D was a sexual predator and needed to be stopped, she felt it was horrible if he did this to women. During an interview, conducted on 8/28/18 at 10:00 A.M., the Administrator indicated that she had been working for months on finding alternative placement for Resident D. The Administrator indicated that she had sought different agencies seeking assistance only to be put off. She indicated that when the incident occurred she separated the residents and did everything she could to prevent a reoccurrance. The resident's room had been moved, he had been placed on 15 minute checks and she was actively seeking alternative placement, the problem in discharging was in that fact that he she could not find a facility to take him with his history. An Abuse Prevention and Reporting policy, with the effective date of 11/28/16, was provided by the Administrator of the facility on 8/27/18 at 3:30 P.M. The policy indicated .Protection of Residents: Residents who allegedly abused another resident will be removed from contact with other residents during the course of the investigation. The accused resident's condition shall be immediately evaluated to determine the most suitable therapy, care approaches, and placement, considering his or her safety, as well as the safety of other residents and employees of the facility The Immediate Jeopardy that began on 8/28/18, was removed on 8/31/18, when the facility implemented training and prevention methods to ensure all residents were free from the threat of sexual abuse, but noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that was not Immediate Jeopardy because of the facility's need to continue monitoring and in-services. 3.1-27(a)(1)

Based on interview and record review, the facility failed to identify, assess and implement effective interventions in a timely manner to prevent severe weight loss in a resident, which resulted in abnormal lab values and hospitalization . (Resident B). Finding includes: During an interview on 10/13/17 at 1:10 P.M., a family member of Resident B indicated the facility had not notified any family member that the resident was unable to feed herself and therefore was losing a significant amount of weight. A closed clinical record review was completed on 10/13/17 at 1:40 P.M., and indicated Resident B was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. An admission MDS (Minimum Data Set) assessment, dated 8/15/17, indicated Resident B had a BIMS (Brief Interview for Mental Status) of 15, cognitively intact and required supervision only for eating. A discharge MDS assessment, dated 9/27/17, indicated Resident B required extensive assistance with eating. A care plan, dated 8/10/17, indicated the resident was on a reduced consistent carbohydrate diet. Goals for this problem included, resident will consume 75-100%, have nutrition related lab values within normal limits and have stable weight and intact skin. Interventions for this problem, included, monitor weight and food and fluid intakes, obtain and honor food preferences and monitor lab values and skin assessments. A care plan, dated 9/8/17, indicated the resident had the potential to develop pressure ulcers. The goal for this problem was to have intact skin, free from redness, blisters or discoloration. Interventions included, educate the resident, family and caretakers on the importance of good nutrition, follow facility policies/protocols for the prevention/treatment of [REDACTED]. Report results to the physician and follow up as indicated. The following weights were obtained for Resident B: 8/8/17 222.6 lbs (pounds) 8/14/17 211.4 lbs 8/21/17 199.4 lbs 8/22/17 199.4 lbs 8/28/17 199.6 lbs 9/1/17 196.2 lbs 9/8/17 187 lbs 9/18/17 184.2 lbs 9/25/17 174.2 lbs An admission wound report, dated 8/8/17, indicated, .Wound #1 . L(NAME)ATION . coccyx . Type of wound . Pressure injury A Comprehensive Clinical Review Meeting Note, dated 8/15/17, indicated, .REASON FOR REVIEW . New Admission . Chronic wound . No current order for (dietary) supplements A Comprehensive Clinical Review Meeting Note, dated 8/25/17, did not address nutritional concerns. A Comprehensive Clinical Review Meeting Note, dated 8/29/17, did not address nutritional concerns. A Comprehensive Clinical Review Meeting Note, dated 9/5/17, indicated, .REASON FOR REVIEW . Significant Weight Loss . Chronic Wound . Comments: 09/01/2017 3.4# weight loss noted since admission on 08/08/2017 . No current order for supplements . Average Meal Consumption . 26-50% . Comments: 3.4 # weight loss noted. Physician notified. Gradual weight loss desirable. Current BMI (Body Mass Index) 33.7 A progress note, dated 9/5/17, indicated, .Physician notified of 3.4# (pound) weight loss noted in one week. Also notified of 26.4# weight loss since 8/8/17. No new orders received A laboratory report, dated 9/7/17, indicated the resident's [MEDICATION NAME] (a protein that is made in the liver and released in the blood) level was 13 (low), with a reference range of 14-37 mg/dL (milligrams per deciliter). A Comprehensive Clinical Review Meeting Note, dated 9/12/17, indicated, .Significant weight loss . 9.2 # weight loss noted. Physician notified . No current order for supplements . Average Meal Consumption . 26-50% . Comments . BMI 32.1. No N.O. (new orders) Received. Continue to monitor A Nutrition Assessment, dated 9/14/17, indicated, .RD (Registered Dietician) Progress Note . Unplanned weight decrease 11.9% x 1 month rt (related to) UTI. UTI stat (a urinary tract health supplement) ordered 8/23/17. Reviewed at interdisciplinary meeting 9/12/17. MD aware of weight decrease. Labs ordered 9/7/17 -weekly wts ordered A Comprehensive Clinical Review Meeting Note, dated 9/19/17, indicated, .Significant weight loss . 2.8# weight loss noted. Physician notified. N.o. (new order) health shakes tid (three times daily) . List any recent pertinent Labs: noted low [MEDICATION NAME] with other slight irregularities . No changes to current plan of care A progress note, dated 9/27/17, indicated, .Family in visiting with (Name of Resident). Spoke with them about their concerns with her recent labs and weight loss . Spoke with physician. N.O. received for . [MEDICATION NAME] (an antidepressant medication) 7.5 mg daily for increased appetite . Discussed new orders with the family . They felt (Name of Resident) may have other underlying conditions and wanted her evaluated at the ER (emergency room ). Physician agreed to disregard recent orders and send . to . ER for a work up A (Name of Hospital) History and Physical, dated 9/28/17, indicated, .Physical Examination . Skin . She has on her sacrum a stage 3 ulcer that measures 4 cm x 2 cm . Assessment and Plan . Decubitus ulcer. We will check [MEDICATION NAME] A laboratory report, dated 9/29/17, indicated the resident's [MEDICATION NAME] level was 13.4 (low) with a reference range of 18.0 - 35.7 mg/dL. A (Name of Hospital) Discharge Summary, dated 10/2/17, indicated, .was noted at the time of admission to have a 4 x 2 cm stage III sacral decubitus ulcer . has received [MEDICATION NAME] infusions and protein supplements with her meals . appetite has been intermittent . PLAN . encourage p.o. (by mouth) intake including protein supplementation During an interview on 10/16/17 at 1:55 P.M., the DON (Director of Nursing) indicated the physician and family had not been notified of the resident's weight loss prior to 9/5/17. The nurse practitioner started UTI stat on 8/23/17 because the resident had recurring UTIs that were affecting her appetite. No other nutritional interventions had been put into place prior to 9/19/17 because the physician considered her weight loss to be desirable. The physician started supplemental health shakes on 9/19/17 because he wanted to slow down and keep consistent the amount of weight the resident lost. The [MEDICATION NAME] level obtained on 9/7/17 was low and could have been indicative of poor nutrition. There were no nutritional interventions in place to address the pressure area. On 10/16/17 at 4:37 P.M., the DON provided the policy titled NUTRITIONAL INTERVENTION PR(NAME)EDURE, dated 8/2016, and indicated the policy was the one currently used by the facility. The policy indicated .Purpose: To establish guidelines for the Charge Nurse and the R.D. when the nutritional intervention is required. To assure the nutritional needs of the residents are met . Policy: It is the policy of the Nursing Department to routinely evaluate resident food and beverage consumption, and to notify the resident or their legal representative, dietary supervisor, dietitician, and physician of resident nutritional problems . Standards . 2. Residents are considered to be at nutritional risk if they have any of the following conditions: a. Food consumption of less than fifty (50%) b. Significant or severe weight loss by time interval: Interval . 1 week . Significant Loss 1 - 2.5% . Severe Loss >1 - 2.5% 1 month . Significant Loss 5% . Severe Loss >5% . d. Development of skin breakdown including pressure sores . f. Abnormal lab values . 3. Problems and changes in the resident's nutritional status requiring nursing intervention include the following . b. Poor appetite or loss of appetite for three consecutive days . g. Inability to feed self or need for assistance . m. Unanticipated weight loss or gain . 4. The Registered Dietician will complete a comprehensive nutritional assessment within 14 days of admission . 5. The Registered Dietician and physician will be notified when nutritional problems are observed and validated . 6. Specialized rehabilitative services and the Dietician may be contacted to assist staff in developing appropriate interventions, as determined by the assessment findings. 7 . Residents with a weight variance of more than 2 1/2% in one week, 5% in a month or 10% in six months will be reweighed within 72 hours . 10. The Consulting or Registered Dietician is responsible for: a. Recommending nutritional interventions to meet the resident's identified needs (nutrient, caloric and fluid). b. Meeting with the D.O.N. at the time of each visit to discuss residents at significant nutritional risk or other pertinent issues . 11. Teaching, diet instruction and resident compliance shall be documented in the resident's medical record and in the plan of care. Licensed nurses and the Dietician shall meet with the resident and explain the importance of eating the prescribed diet and encouraging the resident This Federal tag relates to complaint IN 344. 3.1-46(a)(1)

Based on observation, interview, and record review, the facility failed follow physician orders [REDACTED]. (Resident #71) Finding includes: 1. During an observation on 11/30/2016 at 5:24 P.M., the Wound Nurse (WN) removed the foam dressing dated 11/30 from the sacral region of Resident #71. Pale yellow slough was observed in the base of wound the size of a nickel. The WN indicated wound measurement was 2.0cm (centimeters) x 1.4cm x 0.7cm. She described the base of wound as 90% slough and 10% [MEDICATION NAME] tissue and the current stage III wound was now unstageable wound. During an interview on 11/30/2016 at 5:30 P.M., the Wound Nurse indicated the current dressing was collagen covered with foam to be changed every other day, and she indicated collagen was not present in the wound dressing during observation of dressing removal and measurement. Wound nurse indicated wound measurement completed on 11/28 are not available. She indicated measurements from 10/18/16 to 11/7/16 were not completed. She indicated she used the measurements from the wound doctor and did not measure the wounds herself. During an interview on 12/01/2016 at 2:16 P.M., WN indicated that wound measurements from left and right buttocks observed on 10/18/16 were not completed, she indicated wound physician incorporated all wound measurements together. She indicated she used the measurements from the physician for facility wound log and skin reports. During an interview on 12/01/2016 at 2:50 P.M., the DON (Director of Nursing) indicated the wound nurse has not had any wound education other than a one day wound seminar attended in late October. She indicated there was not a job description for wound nurse in employee's file. She indicated that wound measurements should be completed every seven days and physician orders [REDACTED]. During an interview on 12/2/2016 at 10:00 A.M., the DON indicated Resident #71 had two different orders. Santyl was ordered daily at 6:00 A.M. and collagen covered with foam was ordered every other day. She indicated on 11/30/2016 the order was for Santyl and not collagen. She indicated she was not aware of physician order [REDACTED]. The 72 HR ADMISSION/RE-ADMISSION CHARTING dated 10/18/16 at 5:33 A.M. indicated SKIN CONCERNS: skin concerns observed: WN follows res Sacrum 3 x 1.2 x 0.1 CM. SKIN- PRESSURE/DIABETIC/VENOUS/ARTERIAL WOUND REPORT dated 11/7/2016 at 10:47 A.M. indicated wound to coccyx was unstageable and measured 2.5 x 1.8 CM, wound base 100% slough, dressing was Santyl and foam cover daily. SKIN- PRESSURE/DIABETIC/VENOUS/ARTERIAL WOUND REPORT dated 11/14/2016 at 5:20 P.M. indicated wound to coccyx was unstageable measured 2.5 x 1.3 CM, wound base 60% yellow slough and 40% granulation, dressing Santyl and foam cover daily. SKIN- PRESSURE/DIABETIC/VENOUS/ARTERIAL WOUND REPORT dated 11/21/2016 at 4:36 P.M. indicated wound to coccyx was a Stage 3 and measured 1.4 x 1.2 x 0.5 CM, wound base 100% granulation, dressing collagen, foam cover, change every other day. The WOUND CARE SPECIALIST EVALUATION physician notes dated 11/14/2016 indicated wound to sacrum was unstageable and measured 2.5 x 1.3, wound base not measurable, and dressing Santyl once daily with dry protective dressing. Wound to left buttock was Stage 2 and measured 1.0 X 1.0 CM, and dressing was foam daily. The WOUND CARE SPECIALIST EVALUATION physician notes dated 11/21/2016 indicated wound to sacrum was Stage 3 and measured 1.4 X 1.2 X 0.5 CM, wound base 100% granulation and dressing collagen dressing three times per week covered with foam, discontinue Santyl once daily. Record review of Treatment Administration Record for the month of November indicated that Santyl was applied to dressing once daily at 7:30 A.M. from 11/21/2016 through 11/30/2016. Order to wound cleanse, pat dry, apply collagen with bordered foam to cover in the morning every other day at 6:00 A.M. was completed 11/23/16, 11/25/2016, 11/27/2016, and 11/29/2016. The care plan indicated resident had a pressure area to the coccyx admitted with related to immobility last revision date 9/08/2016 with interventions that included, but were not limited to pressure reducing mattress on bed, and administer treatments as ordered and monitor effectiveness. The Measurement & Assessment of Pressure Ulcers, Wounds, and Other Skin Problems was provided by the Director of Nursing on 12/1/2016 at 10:00 A.M. This current guideline indicated the following: Policy: At first observation of any skin condition, the charge nurse or treatment nurse is responsible to measure and describe skin conditions . All ulcers (Pressure, arterial, diabetic, and venous) will be measured weekly and results recorded on a Wound Assessment Form The Dressing- Non Sterile (Aseptic) was provided by the Director of Nursing on 12/1/2016 at 3:00 P.M. This current guideline indicated the following: PURPOSE: To Protect open wounds from contamination . PROCEDURE: 1. Prior to beginning treatment: a. Check physician order [REDACTED]. 3.1-40(a)(2)

Based on interview and record review, the facility failed to provide timely pain management for 2 of 3 residents reviewed for pain resulting in Resident B and Resident C experiencing 10/10(a pain scale - 0 being no pain at all, 10 being the worst pain you have experienced) pain, with no relief. Findings include: 1. A clinical record review was completed on 12/1/2016 at 9:30 A.M., and indicated Resident B was admitted on [DATE]. His [DIAGNOSES REDACTED]. A physician order [REDACTED]. A CONTROLLED DRUG RECIEPT/RECORD/DISPOSITION FORM indicated Resident B did not receive [MEDICATION NAME] 5/325mg until 11/29/2016 at 4:23 P.M A nurses note dated 11/28/2016 at 2:00 P.M., indicated Resident B returned from a dental appointment with dentures in place and received a prescription for [MEDICATION NAME] 5/325mg. During an interview on 11/29/2016 at 8:40 A.M., Resident B indicated he had his upper teeth removed yesterday and dentures put in place. He indicated he was supposed to go back to the dentist because the facility had not filled his prescription as of yet and they are waiting on the pharmacy to fill his prescription this morning. He further indicated he was in pain. During an interview on 11/30/2016 at 2:45 P.M., Resident B indicated he feels a lot better since he received his pain medication. Resident B was observed sitting in his wheelchair with gauze in his mouth. His dentures and the gauze had areas of saliva and blood to them. He was observed to have bruising to his cheeks. During an interview on 11/30/2016 at 3:00 P.M., the DON (Director of Nursing) indicated Resident B was offered tylenol and [MEDICATION NAME] when he returned on 11/28/2016 and was educated that the facility would have to get a release from the pharmacy to pull a [MEDICATION NAME] from their EDK (emergency drug kit). She than indicated Resident B agreed to take Tylenol for his pain. The DON indicated Resident B should not have gone 24 hours without his prescription pain medication. During an interview on 12/1/2016 at 1:48 P.M., Resident B indicated he was in pain the evening of his oral surgery. He scored his pain a 10 out of 10 on a pain rating scale (0 being no pain at all and 10 being the worst pain you have ever experienced). He further indicated the facility did not give him any pain medication that helped with his pain that evening. He indicated the facility gave him Tylenol and this did not help his pain. He indicated the staff told him his prescription medication was not available in the facility and that it would take longer to obtain pain medication other than Tylenol. 2. A clinical record review was completed on 12/1/2016 at 2:45 P.M., and indicated Resident C was admitted on [DATE]. His [DIAGNOSES REDACTED]. During an interview on 12/1/2016 at 9:15 A.M., a family member indicated Resident C had contacted him to tell him that he was in pain and the facility did not have his pain medication. A nurses note indicated Resident C arrived at the facility following back surgery on 10/28/2016 at 5:50 P.M. and physician orders [REDACTED]. A physician order [REDACTED]. A nurses note dated 10/28/2016 at 9:28 P.M., indicated facility staff contacted a physician for a one time order to give two [MEDICATION NAME]-[MEDICATION NAME] 10/325 mg (a pain medication) and again at 6:00 A.M. and until his prescription medication arrives from the pharmacy. MAR (Medication Administration Record) reviewed and indicted Resident C did not recieve a pain medication on 10/28/2016 until 11:59 P.M. During an interview on 12/1/2016 at 1:15 P.M., DON indicated it should never take 3 to 6 hours for the facility to dispense a pain medication to a resident. She indicated that at the very longest, it should take one hour. During an interview on 12/1/2016 at 1:40 P.M., LPN #31 and LPN #32 indicated Resident C did not receive a pain medication the day he was admitted to the facility. They indicated Resident C should have received a pain medication when he returned from the hospital, however the medication was not available at the facility for the nurses to dispense to Resident C. They further indicated that pharmacy does sometimes take longer than they should to fill a prescription for residents. A policy was provided by the DON on 12/1/2016 at 12:22 P.M., titled PAIN MANAGEMENT PROGRAM dated 1/1/2014, and indicated this was the policy currently used by the facility. The policy indicated .It is the policy of the facility to facilitate resident independence, promote resident comfort, preserve and enhance resident dignity and facilitate life involvement. The purpose of this policy is to accomplish that goal through an effective pain management program This Federal tag relates to complaint IN 797. 3.1-37 (a)

Based on interview and record review, the facility failed to ensure a resident received prompt medical attention regarding increased pain for a fracture following a fall for 1 of 3 residents reviewed for falls. This resulted in the resident lying in pain until further evaluated 2 days later. (Resident B) Findings include: The clinical record for Resident B was reviewed on 7/11/16 at 8:45 a.m. [DIAGNOSES REDACTED]. The most recent Annual Minimum Data Set (MDS) assessment, dated 4/18/16, indicated Resident B was severely cognitively impaired. Resident B received the following Activities of Daily Living (ADL) assistance; transfer-extensive assist with 1 person physical assist, dressing, bathing and eating- extensive assist with 1 person physical assist. Resident B had bilateral lower extremities impairment. Review of a Current Care plan, dated 6/29/16, indicated the following: Focus (name of resident) had a fall characterized by multiple risk factors .Interventions chair alarm .Ensure environment is free of clutter .Trial of self releasing velcro alarming seat belt Review of a Witnessed Fall investigation, dated 6/28/16 at 4:00 p.m., indicated LPN #1 was notified by staff that Resident B had fallen and upon entering the unit, she noted the resident was on the floor, facing up. Resident B was assessed and found to have bilateral lower extremities within normal range of motion. She showed no facial discomfort or voiced any discomfort, according to the investigation. A Pain Screen assessment, done on 6/28/16 at 4:00 p.m., indicated an After Fall/incident. The assessment included the following: .B. New pain - 5. Any new pain . F. Frequency of pain - 1. Intermittent/Occasional H. Intensity of pain - 1. Moderate pain I. Observation of pain - 2. Other pain (facial expressions, guarding, moaning, restlessness, rubbing area). A 72- hour Occurrence Follow-up Charting, dated 6/29/16 at 11:00 a.m., indicated the following: .E. PAIN .b. Location/Description of Pain: sl (slight) guarding r (right) leg . .G. POST-FALL RANGE OF MOTION 1. RANGE OF MOTION: .New Limitations: 2. Describe Change in ROM: .sl guarding r leg During an interview on 7/12/16 at 10:39 a.m., Unit Manager #2 indicated she put in the initial x-ray order in the computer for the wrong leg and hip. She then put in the correct order for the right leg and hip on 6/29/16. She indicated the x-ray was not done on 6/28/16 because the resident had vomited. During an interview on 7/12/16 at 3:07 p.m., LPN #1 indicated she told the CNA not to move Resident B after she was back in bed. She indicated when they rolled Resident B onto her side, she got sick (vomited). She indicated she was not able to get back to the locked unit every 15 minutes to complete the neurological assessments so they were not done. During a second interview on 7/12/16 at 3:16 p.m., Unit Manager #2 indicated she was in the building late on 6/28/16 and was assisting with another fall. She indicated a CNA said something about pain, so they (herself and LPN #1) stood Resident B up. Review of the Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. The x-ray was charted as done at 6:01 p.m. Resident B received [MEDICATION NAME] (an opioid pain medication) 10-325 mg three times daily for pain at 8:00 a.m., 12:00 p.m. and 4:00 p.m. The pain medication was unavailable on 6/29/16 at 12:00 p.m. A Progress Note, dated 6/28/16 at 10:58 p.m., indicated Resident has had emesis x 1 for shift during x-ray which will be done in the am. RT (related to) hip and lower extremity assessed for any bruising or swelling and none was noted A Progress Note, dated 6/29/16 at 8:00 a.m., indicated Resident B had a temperature of 100.3 Fahrenheit. An x-ray done in the facility on 6/29/16 at 10:26 am., indicated suspicious deformity of the basicervical region of the right femoral neck .possible fracture. A Progress Note, dated 6/29/16 at 3:11 p.m., indicated the following: X-ray results received today and forwarded to medical director. (Name of physician) gives new order to send res to (name of hospital) ER Review of the hospital records began on 7/12/16 at 12:30 p.m. It indicated a computed tomography (CT) scan was done on 6/29/16 at 5:10 p.m. The CT scan indicated an impacted fracture involving the intertrochanteric region. On 7/1/16, Resident B had surgery to repair the fracture. Confidential CNA and Nurse interviews for staff working 6/28-6/29/16 and 7/11-7/12/16 were completed. Exact times and dates withheld to maintain anonymity. Staff #3 indicated when they (staff) laid the resident down, she vomited 2-3 times and at dinner she was putting her hand on her hip. She indicated there was usually only one CNA in the locked unit to care for the residents. Staff #4 indicated when Resident B was weight bearing, she would say oh, oh oh. Staff #5 indicated she was told to not get Resident B out of bed. When Resident B was being assisted, she would growl when they moved her. They knew it hurt her. Staff #6 indicated Resident B was in a lot of pain. She had a history of [REDACTED]. Staff #7 indicated Resident B was in a lot of pain. She indicated the facility could not get nurses to work. When they did, the nurses were overwhelmed and too busy to reorder medication or chart correctly. She indicated management was aware Resident B's hip and/or leg was probably broken, but management was worried about losing money by sending residents out. This Federal tag relates to Complaint IN 435. 3.1-37(a)

Based on observation, record review and interviews, the facility failed to provide pressure reducing interventions for a dependent resident which resulted in 2 stage III (full thickness tissue loss) pressure areas for 1 of 4 residents reviewed for skin issues in a sample of 6. (Resident C) Finding includes: The record of Resident C was reviewed on 07/27/15 at 10:20 a.m. Resident C was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Annual MDS (Minimum Data Set) assessment, dated 05/01/15, indicated Resident C was cognitively intact, required extensive assistance of 2 or more for toileting, bed mobility (moving to and from lying position, turning side to side, and positions body while in bed), was always incontinent of bladder and frequently incontinent of bowel. A Care Plan, initiated 06/25/14 and revised 11/14/14, indicated: Focus: Potential for pressure ulcers related clinical complicating factors, [MEDICAL CONDITION](hypertension), weakness, .obesity, history of pressure ulcers .Goal: Will not develop new open areas related to pressure .Interventions/Tasks: .Pressure reducing mattress, Turn and reposition every two hours . The WEEKLY SKIN OBSERVATIONS for Resident C indicated: 07/01/15 SKIN PROBLEMS .SKIN INTACT- NO CONCERNS. 07/15/15 SKIN PROBLEMS .2. Are any of the areas observed NEW? .YES. The SKIN-PRESSURE/DIABETIC/STASIS/ARTERIAL WOUND REPORT, dated 07/15/15, indicated: .New Wound Development .SKIN PROBLEMS .open area to posterior thighs . MEASUREMENT/TYPE/STAGE .Site: Right thigh (rear) Type: Pressure Unit of measure: centimeters: Length 3.0 Width 15 Depth 0.2 Stage: III Left thigh (rear) Type: Pressure Unit of measure: . Length 0.7 Width 4.0 Depth 0.2 Stage: III . The form indicated the wounds were required in house. The physician was notified and orders were received. The measurements from the 07/27/15 visit, when the resident was seen by the wound physician, indicated the area measurements as: The measurements from the 07/27/15 visit, when the resident was seen by the wound physician, indicated the area measurements as: Right thigh (rear) Type: Pressure; Unit of measure: centimeters: Length 2.0 Width 2.5, Depth 0.2 Stage: III Left thigh (rear) Type: Pressure Unit of measure: .Length 0.6 Width 6.0 Depth 0.2 Stage: III. Resident C was interviewed on 07/27/15 at 9:55 a.m. Resident C indicated staff checks and changes her as able but due to minimal feeling from the waist down, she is not always aware when she has been incontinent to call for assistance. Resident C was observed lying in bed on a regular mattress. The skin areas were observed on 07/28/15 at 10:10 a.m., while accompanied by the wound nurse. The open areas were noted to be ruddy (rosy red) granulating (filling in with normal skin tissue), oblong in shape and to have a small amount of serous (clear to pink) drainage. The wound nurse was queried regarding Resident C being on a regular mattress. The nurse indicated the resident was supposed to be on a specialty mattress. The wound nurse indicated the staff nurse does weekly skin assessments. If an area was noted, the staff nurse is to notify the wound nurse who in turn notifies the physician and obtains treatment orders if indicated. The wound nurse indicated the staff nurse's weekly skin assessments are to address any new skin issues and do not include any previous identified skin areas already being monitored. On 07/29/15, at 12:45 p.m., the DNS (Director of Nursing Services) provided a copy of the current facility Policy & Procedure, Skin Condition and Pressure Ulcer Assessment: 06/2012, which indicated: Purpose: To establish guidelines for assessing, monitoring, and documenting the presence of skin breakdown and pressure ulcers and assuring interventions are implemented Frequency: Pressure ulcers and/or skin problems will be assessed and measured at least every seven (7) days by a licensed nurse and documented Standards: 1. All residents known or not known to have skin problems, will have a body check/assessment by a licensed nurse at least weekly 4. Skin observations are made daily, during the performance of bathing and dressing residents and administering treatment procedures. 5. Each resident will be observed for skin breakdown or problems on their scheduled shower/bath days by the CNAs. Changes are to be promptly reported to a licensed nurse who will then perform a complete assessment, as appropriate This Federal tag relates to Complaint IN 351. 3.1-40(a)(1) 3.1-40(a)(2)

Based on observation, interviews and record review, the facility failed to ensure a treatment for [REDACTED]. This resulted in deep tissue injuries and stage III and unstageable open areas to both of Resident C's feet. Findings include: The closed clinical record of Resident C was reviewed, on 11/9/11 at 11:10 a.m., and indicated the resident had lived in the facility since 2006. Her [DIAGNOSES REDACTED]. The most current Minimum Data Set (MDS) assessment, dated 7/8/11, indicated the resident was confused and in need of extensive assistance for transfers. The assessment indicated no open skin areas were present. physician's orders [REDACTED]. Physical therapy notes, dated 8/2/11 at 12:30 p.m., indicated, "Requires continued skilled [MEDICAL CONDITION] management. Spoke to Nursing who is calling MD and explained her presence of [MEDICAL CONDITION] L (left) greater than R (right) and current use of TED ([MEDICAL CONDITION] embolic deterrent) hose. [MEDICAL CONDITION] still present and she could benefit from management/lymph massage. Nursing to explain current medical condition to MD of [MEDICAL CONDITION] and [MEDICAL CONDITION] diagnosis. She has slightly shiny and hairless toes unable to determine capillary refill due to fungus. Nursing and PT (physical therapy) requested arterial doppler. Plan to order materials for [MEDICAL CONDITION] wrapping and initiate after doppler results is (sic) appropriate and then secure correct garment and wearing schedule. Will write orders ect. after doppler and materials obtained and initiate goals as well at that time along with measurements." Nurses notes, dated 8/5/11 at 11:45 a.m., indicated, "Resident out for arterial doppler at approx (approximately) 0930 (9:30 a.m.) this day at (name of hospital) with Caring Hands bus. Appointment had been pushed back an hour for appointment at 1000 (10:00 a.m.) instead of 0900. Resident sent with transfer papers and bed hold. Resident back at facility at approx 1145 this day. No new orders. Tech (technician) at (name of hospital) had called (physician's name) office for clarification orders and arterial doppler was changed to venous doppler due to [MEDICAL CONDITION]. Preliminary Lower Venous Findings show that all vessels compress consistent within normal study. Dr (physician's name) has been notified as well as therapy." Therapy notes, dated 8/17/11 at 9:27 a.m., indicated, "spoke to staff involved in care. [MEDICAL CONDITION] management to be initiated once supplies obtained from outside source. Contract pending. ABI (ankle brachial index, or arterial doppler) completed and NORMAL. Md (sic) authorized program. Will initiate with orders once appropriate." The note indicated a second time that the arterial doppler was normal. The test which had been done was a venous doppler, rather than an arterial one. Review of a faxed information sheet, dated 8/5/11 from the hospital to the facility and included in the resident's record, indicated the test which had been done was a lower venous study, and the preliminary results were normal. Therapy notes, dated 8/22/11 at 11:49 a.m., indicated the compression wraps had been applied. Nurses notes, dated 8/22/11 at 10:27 a.m., also indicated the [MEDICAL CONDITION] management had begun with therapy and if the wraps became loose, nursing would apply double layer of [MEDICATION NAME] to the lower legs until physical therapy could reapply the wraps. Nurses notes, of 8/24/11 at 10:53 a.m., indicated physical therapy had been notified of red areas on top of the right foot and on the outer portion of the right foot near the little toe. Physical therapy notes, of 8/24/11 at 2:15 p.m., indicated petechia was observed on the foot and the wound team was aware. The note indicated no open area and a fluid filled blistered area was observed by the therapist. The entry indicated, "L (left) Lateral 5th stylus with slight errythema (sic) after wrap removal and noted fluid filled blister just distal to MCP (metacarpal) UNKNOWN (SUSPECT POSSIBLE FRICTION.)" The entry indicated the area would be inspected the next day and the wrappings would be stopped if the petechia worsened. The therapy note, of 8/25/11 at 12:27 p.m., indicated the petechia was not worse and had subsided slightly. The note indicated more padding was used for both feet. The next therapy note, dated 8/26/11 at 10:07 a.m., indicated the wraps would be padded with more layers and the tension decreased for the application for the weekend. Therapy notes, on 8/29/11 at 11:49 a.m., indicated "....Her skin does not tolerate the wrappings despite increased padding and significantly decrease tension on Friday's application." A second entry on 8/29/11 at 1:06 p.m., indicated, "Due to foot bruising (pressure deep tissue injury) the team determined the best support would be the B (bilateral) foot boots in place 24 hours and to ensure she does not cross her legs or apply pressure to her feet across the boney prominences. Suspect there are underlying issues causing this significant amount of discoloration and lab tests/values are being requested by MD and D/C (discontinuance) of wraps and compression this date....." During an interview with the wound nurse (LPN #3), on 11/9/11 at 12:40 p.m., she indicated the first she saw Resident C's feet was on 8/29/11 and she initiated a wound report. She provided the wound report which identified 9 areas of "suspected deep tissue injury." The areas were identified as: L (left) dorsal foot 3.8 centimeters (cm) long by 2.9 centimeters wide with no depth. L anterior ankle 4.7 cm by 0.3 cm with no depth R (right) dorsal foot 9.2 cm by 4.7 cm with no depth L gt (great) metatarsal 2.4 cm by 2.9 cm with no depth L 5th metatarsal 6.0 cm by 3.0 cm with no depth R gt metatarsal 2.0 cm by 2.0 cm with no depth R 5 th metatarsal 6.2 cm by 3.0 cm with no depth L Achilles 7.0 cm by 1.0 cm with no depth R Achilles 7.0 cm by 1.7 cm with no depth Physical therapy notes, dated 8/31/11 at 12:24 p.m., indicated, "Chart reviewed extensively by wound care nurse, myself and corporate liaisons (sic) after significant compromise noted in vessel study performed today. After review it was noted that study performed on 8-5-11 was actually a venous study. Wraps had already been discontinued. Plan after consultation is to continue with hematoma reduction on lateral border of foot and posterior section. Reportedly by wound care nurse the areas all look improved in color and the blistered area had indeed ruptured and drained but is intact in its covering. All goals currently on hold and management for bruising has become only needed skilled intervention at this time to prevent skin breakdown on BLE (bilateral lower extremities) ankle/feet areas. With much input determination of best plan of care and determination of course of care has been decided to focus on wound healing of deep tissue injury and then refocus on goal attainment with total cessation of [MEDICAL CONDITION] management due to NON compressibility of the RLE (right lower extremity) and LLE (left lower extremity) at. 79 from study performed at this date (8-31-11)." Nurses notes, dated 9/2/11 at 13:09 (1:09 p.m.) indicated "MD here to see resident, viewed bilateral lower extremities, slight [MEDICAL CONDITION] noted, area to top of right foot purple in color, blister no longer intact, moderated (sic) amount of brown/yellow drainage noted, no foul odor noted, pedal pulses palpable bilaterally. area to right lateral foot near pinky toe, purple in color, not open, area to achilles tendon area right foot, purple/pink in color. skin prep applied to all areas, non stick [MEDICATION NAME] applied then wrapped foot loosely with [MEDICATION NAME]. left foot area top of foot, pink/purple, not open, area noted to back of ankle as well, dark pink in color, skin prep applied to areas, covered with non stick [MEDICATION NAME], wrapped loosely with [MEDICATION NAME]. no signs of any pain, currently up in wc (wheelchair) only for meals and light PT/OT (physical therapy/occupational therapy), has air flow mattress as well." Nurses notes, dated 9/8/11 at 15:50 (3:50 p.m.), indicated the physician had been updated about the wounds and informed that the Left dorsal foot now was a stage III area. The entry indicated Santyl was ordered for daily application. Wound notes, dated 9/19/11 at 13:40 (1:40 p.m.), indicated the areas on the right dorsal foot and left dorsal foot were stage III, both with depths of less than 0.1 cm. The right 5th metatarsal and left 5th metatarsal were described as unstageable with black eschar and the right achilles area was also described as unstageable. During an interview with Physical Therapist #13, on 11/10/11 at 10:40 a.m., she indicated she had seen the faxed doppler study of 8/5/11, but had not noticed the test was a venous doppler rather than the arterial one needed prior to initiating a compression wrapping of Resident C's lower extremities. She indicated she would not have started the wraps if she had realized the doppler was not an arterial one. Review of an arterial doppler test, dated 8/31/11, indicated "Conclusions Lower Arterial Doppler *The ankle brachial index on the right indicated moderate arterial occlusive disease. *The ankle brachial index on the left indicated moderate arterial occlusive disease." The product information sheet for the [MEDICATION NAME] Compression Wrap system was provided by Therapist #8, on 11/10/11 at 10:00 a.m. The information sheet indicated a lower leg assessment including an ankle brachial index must be done prior to the use of the wraps and the contraindication for the use was, "1. Do not use in the presence of arterial insufficiency." Resident C was transferred to another facility, on 9/26/11. She was observed in the new facility, on 11/10/11 at 8:15 a.m., with the unit nurse of the current facility. The resident was sitting in a wheel chair with her feet supported by pressure relieving boots. According to the admission assessment at the new facility, which was reviewed with the unit nurse, on 11/10/11 at 8:30 a.m., the resident had been admitted on [DATE] with areas described as, "Back of R leg/foot sore/wound 5X2 cm yellow sloth. Top (R) foot wound 6x2 cm, R lateral foot sore/dry 2X0.5 cm. (L) outer foot blood blister /dry 2X1 cm. (L) top foot wound 1X2 cm c (with) yellow sloth..." The unit nurse indicated the family was considering hospice care for the resident. This federal tag relates to Complaint IN 470. 3.1-37(a)