Every finding on record at Brickyard Healthcare - Bloomington Care Center

A. Based on observation, interview and record review, the facility failed to provide supervision to prevent a cognitively impaired resident with a history of exit seeking behavior from leaving the facility property without staff knowledge for 1 of 3 residents reviewed. (Resident B)B. Based on observation, interview, and record review, the facility failed to ensure the secured unit courtyard gate was locked for 2 of 3 observations. This deficient practice resulted in an Immediate Jeopardy. The Immediate Jeopardy began on, 5/8/26 at approximately 9:30 a.m. when the facility failed to provide supervision to prevent a cognitively impaired resident with a history of exit seeking behavior from leaving the facility property for an unknown amount of time without staff knowledge. The Administrator, the Director of Nursing, the Regional Nurse were notified of the Immediate Jeopardy on 5/13/23 at 3:45 p.m. The Immediate Jeopardy was removed on 5/14/26 at 1:30 p.m., but noncompliance remained at a lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Findings include: A. During an interview on 5/13/26 at 8:50 a.m., Licensed Practical Nurse (LPN) 1 indicated on 5/8/26 at approximately 10:00 a.m., Resident B left the facility property without staff knowledge and was found almost a mile away.During an interview on 5/13/26 at 10:12 a.m., CNA 1 indicated on 5/8/26 during day shift, she was the nursing aide that worked with Resident B. CNA 1 had last seen Resident B at approximately 9:00 a.m. when Resident B told CNA 1 he was going to smoke. During an interview on 5/13/26 at 12:46 p.m., the Administrator indicated on 5/8/26 at approximately 9:30 a.m., he saw Resident B's walker outside in a grassy area across from the main entrance. The Administrator did not see Resident B, so he searched around the area and then went inside and notified the staff to begin looking inside and outside the facility. After approximately thirty minutes, staff located Resident B at a carwash approximately 0.7 miles from the facility. Resident B returned to the facility with the Administrator in the facility van. Resident B told the Administrator he was trying to go to the store to buy more cigarettes and was going to return to the facility.On 5/13/26 from 1:30 p.m. until 1:40 p.m., the path Resident B walked when he left the facility without staff knowledge on 5/8/26 at approximately 9:30 a.m. was observed. From the main entrance Resident B walked approximately 0.1 miles down the facility parking lot and driveway to the sidewalk and street. Resident B crossed over a side street and turned to the right and walked approximately 0.1 miles on an uneven sidewalk. At the intersection of the side street and the main road Resident B turned to the left and walked approximately 0.5 miles on an uneven sidewalk of a busy main road with a speed limit of 40 miles per hour to a business at a busy intersection where Resident B was located by staff.The clinical record for Resident B was reviewed on 5/13/26 at 2:01 p.m. The diagnoses included, but were not limited to, dementia, seizure disorder, and psychotic disorder.An Elopement Risk Evaluation, dated 10/29/25, indicated Resident B was an elopement risk due to verbally expressing the desire to go home.An Elopement Risk Evaluation, dated 2/26/26, indicated Resident B was not at risk for elopement.A Quarterly Minimum Data Set (MDS) assessment, dated 4/30/26, indicated Resident B was moderately cognitively impaired.A physician's order started on 1/10/25, indicated the resident may go on a leave of absence with supervision. There was no stop date noted.A physician's order started on 2/26/26 and discontinued on 5/8/26 (after Resident B returned to the secured unit), indicated to check wanderguard for placement and function every shift.A care plan, dated 4/4/25, and resolved on 4/24/26, indicated Resident B was at risk for wandering and elopement related to a history of attempt to leave the facility and impaired safety awareness. Interventions included, but were not limited to, distract Resident B by offering pleasant diversions and identify patterns of wandering. A nurse's progress note, dated 4/20/26 at 7:30 p.m., indicated Resident B was outside on supervised smoke time and was making inappropriate gestures with his tongue toward another resident. Another resident told Resident B to stop then all of the residents started yelling at each other. Resident B threw his walker and unintentionally hit another resident in the right leg.A nurse's progress note, dated 4/21/26 at 9:15 a.m., indicated Resident B became upset when going to smoke break and started walking in the parking lot. Staff immediately redirected Resident B back inside the facility. A Nurse Practitioner progress note, dated 4/28/26 at 7:37 p.m., indicated Resident B had behavioral episodes on 4/20/26 and 4/21/26, that included becoming upset and walking into the parking lot during a smoke break, making inappropriate gestures toward other residents, and yelling and throwing his walker.The Medication Administration Record, dated 5/1/26 at 12:00 a.m. through 5/13/26 at 2:00 p.m., indicated Resident B's wanderguard was in place and functioning properly every shift from 5/1/26 at 12:00 a.m. until 5/8/26 on evening shift.During an interview on 5/13/26 at 2:17 p.m., the Activity Assistant indicated on 5/8/26 at 9:00 a.m., she provided supervision for the residents who wanted to go smoke. She knew Resident B smoked cigarettes, but Resident B was not with the smokers the Activity Assistant supervised. The Activity Assistant had not seen Resident B outside during smoke time on 5/8/26 at 9:00 a.m. She had been made aware of Resident B's past exit seeking behavior that occurred on 4/21/26.B. During an interview on 5/13/26 at 8:41 a.m., Resident B indicated, a few days ago, he left the facility to walk to the store. Resident B thought he walked through the gate on the secured unit's courtyard to leave the facility.On 5/13/26 from 8:52 a.m. until 9:10 a.m., observed the enclosed courtyard outside the secured memory care unit. The courtyard was located past the secure unit dining room and required a passcode to unlock the exit door. Once outside in the courtyard, there was a concrete walkway that encircled the courtyard and a privacy fence approximately seven feet tall. At the end of the courtyard the sidewalk led to a privacy gate that had a latch to close the door. The gate was latched but not locked and easily opened. The gate led to another sidewalk that led left or right with another privacy fence approximately seven feet tall on the other side of the sidewalk. Going left, the sidewalk led to another courtyard to a separate secured memory care unit. Going right, the sidewalk led to another gate that was open. Outside that gate was a grassy area that led up a hill to a chain-link fence approximately six feet tall. The gate ran along the facility property and an apartment complex parking lot. Going left at the top of the hill led to a narrow grassy pathway approximately 20 feet long that led around the facility to overgrown brush that was not passable. Going right at the top of the hill led to a narrow grassy pathway approximately twenty feet long with weeds. The facility roof was easily accessible. Just past the narrow path a larger grassy area that eventually led to the facility parking lot and driveway.During an interview on 5/13/26 at 9:12 a.m., the Maintenance Manager indicated the gate should have been locked. He believed the lawn crew left the gate unlocked a couple days ago but would make sure the gate was locked.On 5/14/26 from 8:10 a.m. until 8:17 a.m., observed the enclosed courtyard outside the secured memory care unit. The courtyard was located past the secure unit dining room and required a passcode to unlock the exit door. Once outside in the courtyard, there was a concrete walkway that encircled the courtyard and a privacy fence approximately seven feet tall. At the end of the courtyard the sidewalk led to a privacy gate that had a latch to close the door. The gate was latched but not locked and easily opened. The gate led to another sidewalk that led left or right with another privacy fence approximately seven feet tall on the other side of the sidewalk. Going left, the sidewalk led to another courtyard to a separate secured memory care unit. Going right, the sidewalk led to another gate that was open. At that time, the Maintenance Manager indicated, the gate would be locked immediately.On 5/13/26 at 8:50 a.m., the Director of Nursing provided a copy of an undated facility policy, titled Elopements and Wandering Residents. A review of the policy indicated residents who exhibit wandering behavior and or are at risk for elopement receive adequate supervision to prevent accidents. The Immediate Jeopardy, that began on 5/8/26, was removed on 5/14/26 when the facility inserviced the facility staff on elopements policies and behaviors, but the noncompliance remained at the lower scope and severity of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy because a systemic plan of correction had not been developed and implemented to prevent recurrence.This citation relates to Intake 3009486.410 IAC (Indiana Administrative Code) 16.2-3.1- 3.1-45(a)

Based on interview and record review, the facility failed to protect the resident's right to be free from physical restraints for 1 of 4 residents reviewed for restraints. A restraint was applied by unlicensed personnel, there was no physician's order, consent, or documentation for release of the restraint. (Resident B, CNA 3)Finding includes:On 7/14/25 at 12:00 p.m., Resident B's clinical record was reviewed. The diagnoses included, but were not limited to, hemiplegia affecting right dominant side (paralysis or severe weakness on the right side of the body), dementia, and aphasia (a language disorder that affects the ability to communicate).A progress note, dated 6/26/25 at 5:59 p.m., indicated an incident was reported by CNA 1 that when she came on shift, Resident B was noted to have a sock tied around his left hand. The CNA reported the observation to a licensed nurse. A head-to-toe assessment was completed by the licensed nurse, the resident was noted to have swelling of his left hand and red linear indentation (indentation that is long and narrow) on his left wrist.A Care Plan, dated 5/27/25, indicated the resident had a behavior problem of putting hands in his pants and smearing bowel movements. The care plan lacked interventions for use of a glove or sock to prevent behavior.The physician orders lacked documentation of an order for restraint use.The clinical record lacked consent for the use of physical restraints.The clinical record lacked documentation of release of the physical restraint.During an interview on 7/14/15 at 2:45 p.m., CNA 1 indicated during report on 6/26/25 around 3:00 a.m., CNA 2 indicated Resident B kept soiling himself and he had a sock on his left hand. At 4:50 a.m., CNA 1 went to check on Resident B, and he had a sock on his left hand and wrist. When she removed the sock from the left hand, he had a waistband from a pair of boxers wrapped around his palm and wrist. His left hand was severely swollen, had red and purple areas, and indentations where the waistband was. He was unable to use his left hand and had a contracture (permanent tightening of muscles and tendons) of his right hand.During an interview with CNA 3, on 7/14/25 at 3:30 p.m., the CNA indicated he worked the evening of 6/25/25. CNA 3 indicated at 7:00 p.m., he entered Resident B's room and there was feces on the wall, the floor, the resident's left hand, the resident's face and hair, CNA 3 indicated the resident was unable to use his right hand due to a weakness. CNA 3 indicated he cleaned the resident and the surroundings. CNA 3 indicated he then went to check on other residents. CNA 3 indicated when he came back to Resident B's room, he found there was feces on the resident's left hand and face. CNA 3 indicated he cleaned the resident up again. CNA 3 indicated he continued to help other residents with care, after an unknown amount of time he went back to check on Resident B and found the resident to have feces again on his left hand and face. CNA 3 indicated he asked a nurse for a glove to place on the resident's left hand to keep him from getting his feces near his face and he was told there was no glove available to use at that time. CNA 3 indicated at that time he placed a sock on the resident's left hand because he did not want the resident to continue to play with his poop or eat his poop, and it had taken him 45 minutes to clean the resident up the first time. CNA 3 indicated the resident kept pulling the sock off with his mouth, so he took an elastic band from a pair of underwear and placed it around the sock. CNA 3 indicated the sock covered the left hand and went up to the left wrist. CNA 3 indicated CNA 2 relieved him at 10:00 p.m., CNA 3 indicated he forgot to tell CNA 2 that he had placed the sock on Resident B's hand.On 7/15/25 at 2:07 p.m., the Director of Nursing (DON) provided the facility policy, Restraint Free Environment, undated and indicated it was the policy currently being used by the facility. A review of the policy indicated, .1. The resident has the right to be treated with respect and dignity, including the right to be free from any physical or chemical restraint imposed for the purpose of discipline or staff convenience, and not required to treat the resident's medical symptoms .This citation relates to Complaint 1495326.3.1-3(w)

Based on observation, interview, and record review, the facility failed to provide a homelike environment free of damage, disrepair, and odor of urine for 1 of 2 secured units and 5 of 7 resident rooms reviewed for environment. (Reflections 2 Unit, room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER]) Findings include: 1. On 4/23/25 at 1:20 p.m., 4/24/25 at 2:10 p.m., and 4/25/25 at 10:40 a.m., the bathroom off the dining room on the Reflections 2 unit was observed to emit a strong odor of urine and had brown stained substance around the base of the toilet. 2. On 4/25/25 at 10:45 a.m., the 2 shower room stalls in the Reflections 2 unit shower room were observed to have a brown stained substance around the junctions where the walls meet the floors. 3. On 4/25/25 at 10:50 a.m., the base of the bathroom door in the Lounge room [ROOM NUMBER] was observed to have broken wall board. 4. On 4/25/25 at 10:55 a.m., room [ROOM NUMBER] was observed to have damaged drywall a the head of the 2 beds. There was a brown stained substance around the baseboards and closet track. 5. On 4/25/25 at 10:57 a.m., room [ROOM NUMBER] was observed to have holes in the wall by the bathroom, damaged walls and baseboard on both sides of the air conditioning unit, 4 nails and 4 screws protruding from the wall across from both beds, and brown stained substance around the base of the toilet. 6. On 4/25/25 at 11:00 a.m., the shared bathroom of rooms [ROOM NUMBERS] was observed to have brown stained substance around the base of the toilet. 7. On 4/25/25 at 11:05 a.m., room [ROOM NUMBER] was observed to have an oversized thumbtack pressed into the wall next to the clock. The closet door tracks had brown stained substance in them and one of the closet doors was missing. 8. On 4/23/25 at 1:30 p.m., 4/24/25 at 2:20 p.m., and 4/25/25 at 1:45 p.m., the inside of the Reflections 2 entry/exit door was observed to be sticky to the touch. During an interview on 4/25/25 at 1:50 p.m., the Administrator indicated the aforementioned environmental concerns existed and were in need of attention in order to provide a clean, comfortable, homelike environment for the residents. On 4/25/25 at 2:05 p.m., the Director of Admissions provided the Residents Rights, undated, and indicated these were the resident rights currently used by the facility. A review of the Residents Rights indicated, .you have the right to a safe, clean, comfortable, and homelike environment . 3.1-19(f)

Based on interview and record review, the facility failed to ensure the notification of the bed-hold policy required for a resident who transferred to the hospital was provided in writing to the resident or the resident representative for 1 of 1 resident reviewed for hospitalization. (Resident 53) Findings include: Resident 53's clinical record was reviewed on 4/23/25 at 2:15 p.m. The diagnoses included, but were not limited to, congestive heart failure and kidney failure. Resident 53's progress notes indicated the resident was sent to the hospital on 1/9/25 and 3/11/25. The clinical record lacked documentation of written notification which specified the facility's bed-hold policy was provided to the resident or the resident representative. During an interview on 4/24/25 at 12:11 p.m., the Director of Nursing Services (DNS) indicated the facility did not have documentation which indicated the bed-hold forms were provided in writing to Resident 53 or the resident's representative. On 4/25/25 at 1:07 p.m., the Administrator provided the facility's policy,Bed Hold Notice undated, and indicated it was the policy currently being used by the facility. A review of the policy indicated, . It is the policy of this facility to provide written information to the resident and/or the resident representative regarding bed hold practices both well in advance, and at the time of, a transfer for hospitalization or therapeutic leave . 3.1-12(a)(25) 3.1-12(a)(26)

Based on interview and record review, the facility failed to ensure the written notification required for a transfer and discharge was provided to the resident and the resident representative for 1 of 1 resident reviewed for hospitalization. (Resident 53) Findings include: Resident 53's clinical record was reviewed on 4/23/25 at 2:15 p.m. The diagnoses included, but were not limited to, congestive heart failure and kidney failure. Resident 53's progress notes indicated the resident was sent to the hospital on 1/9/25 and 3/11/25. The clinical record lacked documentation of written notification of the transfer and discharge forms having been provided to the resident and the resident representative. During an interview on 4/24/25 at 12:11 p.m., the Director of Nursing Services (DNS) indicated the facility did not have documentation which indicated the transfer and discharge forms were provided in writing to Resident 53 and the resident's representative. On 4/25/25 at 12:06 p.m., the DNS provided the facility's policy,Transfer and Discharge undated, and indicated it was the policy currently being used by the facility. A review of the policy indicated, . 3. The facility's transfer/discharge notice will be provided to the resident and the resident's representative in a language and manner in which they can understand . 3.1-12(a)(6)(A)(i) 3.1-12(a)(6)(A)(iii)

Based on observation, interview, and record review, the facility failed to ensure care plan fall interventions were in place for a resident who was at risk for falls for 1 of 4 residents reviewed for accidents. (Resident 107) Findings include: On 4/21/25 at 11:37 a.m., Resident 107 was observed to be resting in his bed. The bed was against the wall with no mat observed to be beside his bed. On 4/22/25 at 10:32 a.m., Resident 107 was observed to be resting in his bed. The bed was against the wall with no mat observed to be beside his bed. On 4/23/25 at 2:04 p.m., Resident 107 was observed to be resting in his bed. The bed was against the wall with no mat observed to be beside his bed. On 4/24/25 at 11:20 a.m., Resident 107's clinical record was reviewed. The diagnoses included, but were not limited to, traumatic brain injury, major depressive disorder, muscle weakness, anxiety, glaucoma, and dementia. The quarterly MDS (Minimum Data Set), dated 3/31/25, indicated Resident 107 had moderate cognitive impairment and had 2 or more falls with no injury. A care plan, dated 8/8/24, indicated Resident 107 was at risk for falls. On 3/19/25, the intervention was to place a mat by the bed. During an interview on 4/24/25 at 10:23 a.m., LPN 1 indicated Resident 107 had history of falls. LPN 1 indicated Resident 107 did not have a mat beside his bed. During an interview on 4/24/25 at 11:20 a.m., LPN 2 indicated Resident 107 had history of falls. She was unsure if Resident 107 required a mat beside his bed. When a resident gets a new fall interventions, they would be in the physician orders. She looked in the physician orders and did not see an order for mat beside the bed. She did not look at the Kardex (system used by nurses to quickly assess resident information for their daily care plan) or the care plan. During an interview on 4/25/25 at 2:15 p.m., the Director of Nursing Services (DNS) indicated all nursing staff could find resident's fall interventions in the Kardex or in the care plan. On 4/25/25 at 2:57 p.m., the DNS provided the facility's policy, Fall Prevention Program, undated, and indicated it was the policy being used. A review of the policy indicated, .d. Provide additional interventions as directed by the resident's assessment, including but not limited to: i. Assisi devices 3.1-35(g)(2)

Based on interview and record review, the facility failed to provide care per the plan of care for 1 of 5 residents reviewed for unnecessary medications. Insulin was not held per physician's orders. (Resident 107) Findings include: On 4/24/25 at 11:20 a.m., Resident 107's clinical record was reviewed. The diagnoses included, but were not limited to, diabetes mellitus, traumatic brain injury, and dementia. The April 2025 Medication Administration Record (MAR) indicated to inject Humalog (insulin) 3 units subcutaneoulsy (under the skin) before meals. Hold if the blood sugar is less than 150 mg/dl (milligrams per deciliter), ordered 3/21/25. The MAR indicated the following: - On 4/5/25 before breakfast, the Humalog 3 units were administered. The blood sugar was 128 which was less than 150. The clinical record lacked documentation the insulin was held. - On 4/5/25 before lunch, the Humalog 3 units were administered. The blood sugar was 121 which was less than 150. The clinical record lacked documentation the insulin was held. - On 4/5/25 before dinner, the Humalog 3 units were administered. The blood sugar was 130 which was less than 150. The clinical record lacked documentation the insulin was held. - On 4/6/25 before lunch, the Humalog 3 units were administered. The blood sugar was 132 which was less than 150. The clinical record lacked documentation the insulin was held. - On 4/6/25 before dinner, the Humalog 3 units were administered. The blood sugar was 130 which was less than 150. The clinical record lacked documentation the insulin was held. - On 4/19/25 before dinner, the Humalog 3 units were administered. The blood sugar was 140 which was less than 150. The clinical record lacked documentation the insulin was held. - On 4/20/25 before dinner, the Humalog 3 units were administered. The blood sugar was 147 which was less than 150. The clinical record lacked documentation the insulin was held. A care plan, dated 8/8/24, indicated Resident 107 had diabetes mellitus. On 8/8/24, the intervention was to administer diabetes medication as ordered by the physician. During an interview on 4/25/25 at 2:03 p.m., the Director of Nursing Services (DNS) indicated Resident 107 was administered Humalog 3 units when his blood sugar was less 150. On 4/25/25 at 2:57 p.m., the DNS provided the facility's policy, Medication Administration, undated, and indicated it was the policy being used. A review of the policy indicated, .8. Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters 3.1-35(g)(2)

Based on observation, interview, and record review, the facility failed to provide supervision to prevent a cognitively impaired resident, who had an appointed guardian and history of exit seeking, from exiting the facility without staff knowledge for 1 of 3 residents reviewed for elopements. This deficient practice resulted in the resident being located by local law enforcement 1.8 miles away. (Resident B) This deficient practice resulted in an Immediate Jeopardy. The Immediate Jeopardy began on, 3/29/25 at approximately 9:45 p.m., when the facility failed to prevent a cognitively impaired resident from leaving the facility without staff knowledge. The Area [NAME] President and Regional Nurse were notified of the Immediate Jeopardy on 4/2/25 at 12:20 p.m. The Immediate Jeopardy was removed, and the deficient practice corrected, on 3/30/25, prior to the start of the survey and was therefore Past Noncompliance. Finding includes: During an interview on 4/2/25 at 8:06 a.m., LPN 1 indicated she arrived at work on 3/29/25 at approximately 10:50 p.m. Resident B had already left the facility. His wheelchair was found outside the front door. Resident B was located by the police approximately 1.8 miles from the facility, on a busy main road. When the police brought Resident B back to the facility, he told LPN 1 he left to get cigarettes and then was going to go to another city where his family lives. On 1/22/25, Resident B was moved from the secured unit because he was not at risk for elopement. On 4/2/25 at 8:14 a.m., Resident B was observed resting in bed on the secured unit. At that time, Resident B indicated he left the facility, on 3/29/25, to obtain cigarettes. During an interview on 4/2/25 at 8:17 a.m., LPN 2 indicated when Resident B was admitted , he was placed on a secured (locked) unit and had exit seeking behaviors when he was on that unit. During an interview on 4/2/25 at 8:21 a.m., LPN 3 indicated approximately a month ago, Resident B attempted to exit the facility through the front door but was stopped. The clinical record for Resident B was reviewed on 4/2/25 at 8:30 a.m. The diagnoses included, but were not limited to, major depressive disorder, dementia, cognitive communication deficit, and psychoactive substance abuse. The census information tab, indicated Resident B was admitted to the secured unit on 1/3/25 and moved to the unsecured unit on 1/22/25. An Order Appointing Successor Guardian, dated 9/10/19, indicated Resident B was appointed a guardian over person and estate. A referral packet from the previous facility, dated 12/31/24, indicated, on 12/30/24, Resident B was agitated and set on leaving the facility. Resident B attempted to leave that facility against medical advice and was sent to the emergency department. An Elopement Evaluation, dated 1/4/25, indicated Resident B did not have a history of elopement nor an attempted elopement while at home. Resident B was identified as not at risk for an elopement on this evaluation. An Admission Minimum Data Set (MDS) assessment, dated 1/10/25, indicated Resident B was moderately cognitively impaired. The Baseline Care Plan, dated 1/6/25, indicated Resident B was at risk for elopement and resided on the secured unit. A Care Plan, dated 1/9/25, indicated Resident B had impaired cognitive function related to altered mental status. The interventions included, but were not limited to, placement on a secured unit (1/9/25) and supervise as needed (1/9/25). This care plan was not updated after Resident B was moved out of the secured unit to the unsecured unit on 1/22/25. A Care Plan, dated 1/10/25, indicated Resident B had a history of psychoactive substances abuse. The interventions included, but were not limited to, educate on the leave of absence policy (1/10/25) and assess for elopement risk (1/10/25). This care plan was not updated after Resident B was moved out of the secured unit to the unsecured unit on 1/22/25. A Nurse Practitioner (NP) progress note, dated 1/23/25 at 12:00 a.m., indicated exit seeking behaviors remained to be an issue. A Progress Note, dated 2/27/25 at 9:56 a.m., indicated Resident B was upset and wanted to discharge and walk to another city. Resident B and the Social Service Director (SSD) discussed the risks of leaving the facility. Resident B was adamant that he was leaving. Resident B's guardian did not want Resident B to discharge from the facility. Resident B became increasingly agitated and packed belongings in his wheelchair and blocked the front door. Resident B indicated he was going to throw his wheelchair through the front door to exit facility. Resident B was unable to be redirected or calmed down. A Hospital Emergency Department note, dated 2/27/25 at 1:02 p.m., indicated Resident B was in his wheelchair blocking access to the front door. Resident B indicated he wanted to leave the facility because he wanted to stay with his daughter though he has not spoken to her recently. The clinical record lacked an updated Elopement Evaluation and Care Plan following Resident B's desire to leave the facility and emergency room visit for agitated elopement behavior on 2/27/25. A Progress Note, dated 2/28/25 at 1:22 p.m., indicated Resident B was located outside the facility smoking a cigarette unsupervised. An Elopement Evaluation, dated 3/22/25, indicated Resident B had not verbally expressed the desire to go home nor packed his belongings to go home nor stayed near an exit door. Resident B was identified as not at risk for an elopement on this evaluation. A Progress note, dated 3/30/25 at 1:46 a.m., indicated nurse was unable to locate Resident B. This writer initiated a code silver. Staff were unable to locate Resident B inside the facility or on facility grounds and notified local law enforcement. Local law enforcement was able to locate Resident B and brought him back to the facility. Resident B indicated that he was trying to get back to the city where he was from. On 4/2/25 at 9:45 a.m., the Area [NAME] President provided a copy of the reportable incident regarding Resident B's elopement from the facility. The incident indicated on 3/29/25 at 10:47 p.m., Resident B was unable to be located in the facility or on facility property. Local law enforcement were able to locate Resident B at approximately 11:45 p.m. and returned him to the facility. On 4/2/25 at 10:31 a.m., the ADON (Assistant Director of Nursing) indicated Resident B was admitted to the facility on the secured unit at the request of Resident B's guardian. Resident B was moved to the unsecured side of the facility due to Resident B's improvement in cognition on 1/22/25. The ADON indicated she was unaware Resident B had elopement behaviors. On 4/2/25 at 10:57 a.m., the Memory Care Director indicated Resident B did not exhibit any elopement behaviors on the secured unit. On 4/2/25 at 11:30 a.m., the Regional Nurse provided a copy of the Alzheimer's/Dementia Special Care Unit Disclosure, dated 12/30/24, and indicated this was the facilities current process and criteria for admission to the secured unit and transfers out of the secured unit. A review of the disclosure indicated a transfer out of the secured unit to the unsecured unit included a physician's evaluation. The clinical record lacked documentation of a physician's evaluation to be transferred out of the secured unit before 1/22/25, when Resident B was transferred out of the secured unit to the unsecured unit. During an interview on 4/3/25 at 9:10 a.m., LPN 4 indicated when she worked on the secured unit with Resident B, Resident B would become very frustrated about residing on the secured unit. On 4/2/25 at 9:45 a.m., the Area [NAME] President provided a copy of an undated facility policy, titled Elopements and Wandering Residents, and indicated this was the current policy used by the facility. A review of the policy indicated adequate supervision will be provided to help prevent elopements. The past noncompliance Immediate Jeopardy began on 3/29/25. The Immediate Jeopardy was removed and the deficient practice corrected by 3/30/25 after the facility implemented a systemic plan that included the following actions: audits of elopement evaluations and care plans, inservicing staff on elopement procedures, and ongoing monitoring. This citation relates to Complaint IN00456505. 3.1-45(a)(2)

Based on interview and record review, the facility failed to ensure staff accurately documented wound care treatments for 1 of 3 residents reviewed for documentation. (Resident C) Findings include: Resident C's clinical record was reviewed on 1/27/25 at 2:05 p.m. The diagnoses included, but were not limited to, pressure ulcer and osteorarthritis of the knee. Current physician orders, dated 1/27/25, indicated Resident C's treatments included, but were not limited to: Left lateral foot: cleanse with wound cleaners, apply collagen to wound bed and cover with bordered gauze dressing once daily and prn (as needed). Left lateral lower leg: cleanse with wound cleanser, apply collagen to wound bed and cover with bordered gauze dressing once daily and prn. Right medial ankle: cleanse with wound cleanser, apply xeroform cover with bordered gauze, change daily. The clinical record lacked documentation which indicated the above treatments had been completed on 1/3/25, 1/6/25, 1/15/25, 1/17/25, 1/21/25, 1/24/25 and 1/25/25, nor had the resident refused the treatments on those dates. During an interview on 1/27/25 at 2:10 p.m., the Interim Director of Nursing (DON) indicated she could not find in the clinical record where Resident C's treatments had been completed or where the resident had refused on the above dates. On 1/27/25 at 2:28 p.m., the Interim DON provided the facility's policy, Documentation in Medical Record undated, and indicated it was the policy currently being used by the facility. A review of the policy indicated, . 1. Licensed staff . shall document all . services provided in the resident's medical record in accordance with state law and facility policy . This citation relates to Complaints IN00450128 and IN00450202. 3.1-50(a)(1)

Based on observation, interview, and record review, the facility failed to ensure a licensed practical nurse observed medication administration for a resident who did not self administer medications for 1 of 1 resident observed during a random observation. (Resident B) Findings include: During an interview with Resident B on 1/27/25 at 9:40 a.m., a medication cup with eight different medications was observed on the bedside table. The medication cup contained a mixture of tablets and capsules. Resident B indicated there had been ten different medications in the cup however, he had taken two already. Resident B indicated staff did not typically observe him when taking medications. During an interview with LPN 1 on 1/27/25 at 9:42 a.m., LPN 1 indicated she had observed Resident B take all his medications that morning and was unsure where the medications in the cup had come from. During an interview with LPN 1 on 1/27/25 at 11:35 a.m., LPN 1 indicated Resident B's morning medications included eleven different medications. He was currently out of one of his medications therefore, she drew up ten and observed the resident taking all morning medications that morning. During an interview on 1/27/25 at 1:00 p.m., the Interim Director of Nursing indicated LPN 1 had been educated on not leaving medications at the residents bedside and LPN 1 had indicated she would not do it again. Resident B's clinical record was reviewed on 1/27/25 at 11:30 a.m. The diagnoses included, but were not limited to, acute kidney failure and chronic obstructive pulmonary disease. Current physician orders, dated 1/27/25, indicated Resident B's medications included, but were not limited to, Aspirin 81 milligrams (mg), one tablet by mouth one time a day. Clopidogrel bisulfate tablet (a blood thinner) 75 mg, one tablet by mouth one time a day. Duloxetine (for depression) 30 mg, two tablets by mouth one time a day. Ferrous sulfate (iron) 325 mg, by mouth one time a day. Flomax (to treat an enlarged prostate) 0.4 mg, one tablet by mouth one time a day. Folic acid (supplement) 1 mg, one tablet by mouth one time a day. Gabapentin (to treat nerve pain) 300 mg, one capsule by mouth three times a day. Hydroxyzine pamoate (for anxiety) 25 mg, one capsule by mouth two times a day. Magnesium oxide (supplement) 400 mg, one tablet by mouth two times a day. Metoprolol (anti-hypertensive) 25 mg, one tablet by mouth one time a day. Multivitamin give one tablet by mouth one time a day. The clinical record lacked a self medication administration assessment. During an interview on 1/27/25 at 1:02 p.m., the Interim DON indicated Resident B did not self administer medications and the medications should not have been left on the bedside table. On 1/27/25 at 1:02 p.m., the Interim DON provided the facility's policy, Medication Administration undated, and indicated it was the policy currently being used by the facility. A review of the policy indicated, . Policy: Medications are administered by licensed nurses . 18. Observe resident consumption of medication . This citation relates to Complaints IN00450128 and IN00450202. 3.1-11(a)

Based on interview and record review, the facility failed to protect the resident's right to be free from verbal abuse by a staff member for 1 of 3 residents reviewed for abuse. (LPN 1, Resident C) Findings include: On 10/17/24 at 12:07 p.m., Resident C's clinical record was reviewed. The diagnosis included, but was not limited to, discitis (inflammation that develops between the intervertebral discs of the spine). Physician orders, dated 9/29/24, indicated Resident C's medications included, but were not limited to meropenem (an antibiotic) intravenous (IV) solution reconstituted 1 gm (gram) intravenously every 8 hours for discitis. The Admission Minimum Data Set (MDS) assessment, dated 8/15/24, indicated Resident C had no cognitive impairment. During a phone interview on 10/17/24 at 2:36 p.m., Resident C indicated he had a PICC line (a long, thin tube that's inserted through a vein in the arm and passed through to the larger veins near the heart) inserted and received an IV medication each evening which took about 30 minutes to infuse. He had had trouble with LPN 1 in the past because she would not unhook the IV tubing when the medication was finished. On 9/29/24, he woke up about 4:00 a.m., with his arm caught in the tubing. He got out of bed, pulled his IV pole down the hall and found LPN 1. He asked her if she could take this F------ [curse word] thing out of his arm. LPN 1 then indicated to Resident C you are making a big deal out of nothing. Resident C indicated he then replied you are on the only nurse who doesn't unhook the medication and LPN 1 replied, shut the F---- [curse word] up. Resident C indicated the verbal abuse escalated from there and as he walked back down the hall, LPN 1 continued to follow him and use expletives and to curse at him. During an interview on 10/18/24 at 9:30 a.m., the Assistant Director of Nursing (ADON) indicated the verbal abuse incident between Resident C and LPN 1 happened about 4:00 a.m. on 9/29/24. There was another nurse (LPN 2) who witnessed the incident but she was no longer employed at the facility. LPN 1 was no longer employed by the facility. On 10/18/24 at 10:00 a.m., a statement from Resident C regarding the incident was reviewed. The statement, dated 9/30/24 at 10:00 a.m., indicated, . I woke up around 4:00 a.m. I could feel the tubing pulling. I went to nurse to have her take off the IV and flush my line. I said to nurse will you take this F------ [curse word] thing off of my arm? She said, I don't know why you're making a big deal of this. Then I said, if you would do your job. She then said F--- [curse word] you. I went back to my room after I cussed back at her and called her names. Then went to my room. I know I didn't come at her very nicely either but she's the professional . On 10/18/24 at 10:10 a.m., a statement from LPN 1 regarding the incident was reviewed. The statement, dated 9/30/24, indicated, . Resident C approached her about flushing his PICC line. She said just a minute and then he began cursing and calling her names. She stated it's not a big deal and he said if you would do your F------ [curse word] job and said F--- [curse word] you and she replied F--- [curse word] you too. We did exchange explicative's with each other. I had a bad night and I was having a hard time dealing with people getting in my face and reacting in an unkind manner. I had another guy who got in my face and cussed me before that . On 10/18/24 at 10:20 a.m., a statement from LPN 2 regarding the incident was reviewed. The statement, dated 9/29/24, indicated, . I was in a patient's room and I heard a loud yelling and profanities. This nurse over heard Resident C and LPN 1 exchanging profanities. I told LPN 1 to go into the lounge. I approached Resident C to calm down and I walked him outside for a while and brought him back in. I notified nursing manager on call who told me to send her home pending investigation. I came back and told LPN 1 she needed to clock out and go home and I would take over her responsibilities. I watched LPN 1 clock out and leave the building . On 10/18/24 at 10:44 a.m., the Clinical Nurse Consultant provided the facility's policy Abuse, Neglect and Exploitation undated, and indicated it was the policy currently being used by the facility. A review of the policy indicated, . Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident . Verbal Abuse means the use or oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to resident or their families, or within their hearing distance regardless of their age, ability to comprehend . This deficient practice was corrected on 9/30/24 after the facility implemented a systemic plan of correction that included the following actions: all staff was educated on the abuse policy with ongoing monitoring and audits. This citation relates to Complaint IN00444330. 3.1-27(b)

Based on interview and record review, the facility failed to ensure the written notification required for a transfer and discharge was provided to the resident and the resident representative for 2 of 3 residents reviewed for hospitalization . (Resident 54 and Resident 64) Findings include: 1. Residents 54's clinical record was reviewed on 6/24/24 at 9:55 a.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease and chronic kidney disease. Resident 54's progress notes indicated the resident was sent to the hospital on 1/27/24 and 2/15/24. The clinical record lacked documentation of written Notice of Transfer and Discharge forms having been provided to the resident and the resident representative. 2. Resident 64's clinical record was reviewed on 6/24/24 at 9:45 a.m. The diagnoses included, but were not limited to, type II diabetes mellitus and chronic kidney disease. Resident 64's progress notes indicated the resident was sent to the hospital on 6/17/24. The clinical record lacked documentation of written Notice of Transfer and Discharge forms having been provided to the resident. During an interview on 6/24/24 at 10:04 a.m., the Director of Nursing Services (DNS) indicated the facility did not provided the resident nor the resident representative the Notice of Transfer and Discharge forms in writing. The facility sent the forms with the resident when they were transferred to another facility. On 6/24/24 at 1:50 p.m., the DNS provided the facility's policy,Transfer and Discharge undated, and indicated it was the policy currently being used by the facility. A review of the policy indicated, 4. The facility's transfer/discharge notice will be provided to the resident and the resident's representative . 3.1-12(a)(6)(A)(i) 3.1-12(a)(6)(A)(iii)

Based on observation, interview, and record review, the facility failed to ensure a self medication administration assessment was complete for residents with medications left at bedside for 1 of 1 random observations. (Resident 80) Findings include: On at 6/19/24 at 9:50 a.m., Resident 80 was observed in her room lying in bed next to the bedside table. On the bedside table in a plastic medication cup were 2 tablets of medication identified as 800 mg (milligrams) each of Sevelamer HCL (a medication used for persons on dialysis to lower blood phosphate levels). No facility staff members were present in the room at that time. Resident 80 indicated she took the medication with food, but she did not eat that morning, and the nurse left the medication on her bedside table and left the room. During an interview on 6/19/24 at 9:55 a.m., the Director of Nursing indicated the medication should not have been left with the resident, as medication administration was to be observed by the administering qualified staff unless the resident was assessed to be able to self administer medications. On 6/19/24 at 10:45 a.m., Resident 80's clinical record was reviewed. The diagnoses included, but were not limited to, end stage renal disease and hypertension. The State Optional Minimum Data Set assessment, dated 3/21/24, indicated the resident was cognitively intact. A physician's order with a start date of 1/23/24 indicated the resident was prescribed 2-800 mg tablets of Sevelamer HCL three times a day with meals. The clinical record lacked a self medication administration assessment. 3.1-11(a)

Based on interview and record review, the facility failed to ensure medications were administered with adequate indications for use for 1 of 5 residents reviewed for unnecessary medications. Medications were administered outside of physician order parameters. (Resident 88) Findings include: On 6/21/24 at 11:38 a.m., Resident 88's clinical record was reviewed. The diagnoses included, but were not limited to, congestive heart failure, hypertension, and dementia. Resident 88's physician orders dated 6/24/24 indicated the following: - Lisinopril (medication used to treat high blood pressure) 20 milligrams (mg) by mouth one time a day for hypertension. Hold medication if the systolic blood pressure was less than 90 or diastolic blood pressure less than 60. If systolic blood pressure was greater than 160 and diastolic blood pressure was greater than 90, administer the medication and notify the MD. Recheck blood pressure in 30 minutes and document blood pressure (start date 4/18/24). - Metoprolol succinate extended release (medication used to treat high blood pressure) 25 mg by mouth one a day for hypertension. Hold medication if the systolic blood pressure was less than 90 or diastolic blood pressure less than 60. If systolic blood pressure was greater than 160 and diastolic blood pressure was greater than 90, administer the medication and notify the MD. Recheck blood pressure in 30 minutes and document blood pressure. Hold medication if pulse was less than 60 (start date 4/18/24). Resident 88's May 2024 Medication Administration Record indicated the following on: - On 5/2/24 at 9:00 a.m., lisinopril 20 mg was administered. Her blood pressure was 106/54 (diastolic blood pressure was less than 60). The clinical record lacked documentation of medication being held. - On 5/2/24 at 9:00 a.m., metoprolol succinate extended release 25 mg was administered. Her blood pressure was 108/54 (diastolic blood pressure was less than 60). The clinical record lacked documentation of medication being held. - On 5/12/24 at 9:00 a.m., metoprolol succinate extended release 25 mg was administered. Her pulse was 52. The clinical record lacked documentation of medication being held. - On 5/24/24 at 9:00 a.m., metoprolol succinate extended release 25 mg was administered. Her pulse was 56. The clinical record lacked documentation of medication being held. - On 5/25/24 at 9:00 a.m., lisinopril 20 mg was administered. Her blood pressure was 110/50 (diastolic blood pressure was less than 60). The clinical record lacked documentation of medication being held. - On 5/25/24 at 9:00 a.m., metoprolol succinate extended release 25 mg was administered. Her blood pressure was 110/50 (diastolic blood pressure was less than 60). The clinical record lacked documentation of medication being held. - On 5/28/24 at 9:00 a.m., lisinopril 20 mg was administered. Her blood pressure was 124/56 (diastolic blood pressure was less than 60). The clinical record lacked documentation of medication being held. - On 5/28/24 at 9:00 a.m., metoprolol succinate extended release 25 mg was administered. Her blood pressure was 124/56 (diastolic blood pressure was less than 60). Her pulse was 58. The clinical record lacked documentation of medication being held. Resident 88's June 2024 Medication Administration Record indicated the following on: - On 6/2/24 at 9:00 a.m., lisinopril 20 mg was administered. Her blood pressure was 142/59 (diastolic blood pressure was less than 60). The clinical record lacked documentation of medication being held. - On 6/2/24 at 9:00 a.m., metoprolol succinate extended release 25 mg was administered. Her blood pressure was 142/59 (diastolic blood pressure was less than 60). Her pulse was 53. The clinical record lacked documentation of medication being held. - On 6/9/24 at 9:00 a.m., lisinopril 20 mg was administered. Her blood pressure was 106/58 (diastolic blood pressure was less than 60). The clinical record lacked documentation of medication being held. - On 6/9/24 at 9:00 a.m., metoprolol succinate extended release 25 mg was administered. Her blood pressure was 106/58 (diastolic blood pressure was less than 60). - On 6/17/24 at 9:00 a.m., lisinopril 20 mg was administered. Her blood pressure was 130/48 (diastolic blood pressure was less than 60). The clinical record lacked documentation of medication being held. - On 6/17/24 at 9:00 a.m., metoprolol succinate extended release 25 mg was administered. Her blood pressure was 130/48 (diastolic blood pressure was less than 60). The clinical record lacked documentation of medication being held. - On 6/18/24 at 9:00 a.m., metoprolol succinate extended release 25 mg was administered. Her pulse was 50. The clinical record lacked documentation of medication being held. A care plan, dated 7/27/23, indicated she had hypertension. Her interventions were to administer medication as ordered; obtain and document her vital signs as ordered; and report abnormalities to the MD. During an interview on 6/24/24 11:12 a.m., Registered Nurse (RN) 1 indicated Resident 88 had hypertension and was on lisinopril and metoprolol. If her systolic blood pressure was less than 90 or her diastolic blood pressure was less than 60, her lisinopril and metoprolol was held and the nurse practitioner would be notified. If her pulse was less than 60, her metroprolol would be held. If the medication was held, they would document the medication being held in the medication administration record. During an interview on 6/24/24 at 11:50 a.m., the Director of Nursing Services (DNS) indicated the lisinopril and metoprolol was administrated to Resident 88. The clinical record lacked documentation of lisinopril and metoprolol being held per physician orders. On 6/24/24 at 1:37 p.m., the DNS provided the facility policy, Medication Administration, undated, and indicated it was the policy currently being used. A review of the policy indicated, .8. Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters . 3.1-48(a)(4)

Based on interview and record review, the facility failed to have an ongoing communication with the dialysis center regarding dialysis care while at dialysis for 1 of 1 residents reviewed for dialysis care. (Resident 63) Findings include: On 6/20/24 at 10:13 a.m., Resident 63's clinical record was reviewed. The diagnoses included, but were not limited to end stage renal disease, hypertension, and dementia. The physician orders, dated 6/24/24 indicated the following: - Dialysis treatment on Monday, Wednesday, and Friday (start date 11/3/23). - Monitor Post Dialysis dressing for bleeding every Monday, Wednesday, and Friday (start date 7/28/23). - Post Dialysis Assessment every Monday, Wednesday, and Friday (start date 7/28/23). - Pre Dialysis Assessment every shift (start date 7/28/23). - Send Dialysis Communication Binder with resident to dialysis on Monday, Wednesday, and Friday (start date 7/31/23). A care plan, dated 7/28/23, indicated Resident 63 received hemodialysis due to end stage renal disease. The care plan lacked any documentation of dialysis facility communicating with the facility. The In-Facility Post Dialysis Form, dated 6/3/24, lacked any documentation of dialysis center communication. The In-Facility Post Dialysis Form, dated 6/5/24, lacked any documentation of dialysis center communication. The Dialysis/Observation Communication Form, dated 6/10/24, lacked documentation of dialysis center communication. The Dialysis/Observation Communication Form, dated 6/12/24, lacked documentation of dialysis center communication. The In-Facility Post Dialysis Form, dated 6/14/24, lacked any documentation of dialysis center communication. The Dialysis/Observation Communication Form, dated 6/17/24, lacked documentation of dialysis center communication. The Dialysis Communication Form, dated 6/19/24, lacked documentation of post-dialysis information. The Dialysis Communication Form, dated 6/21/24 at 9:00 a.m., lacked documentation of the dialysis center information. The Dialysis Communication Form, dated 6/24/24 at 8:48 a.m., lacked documentation of the dialysis center and post-dialysis information. During an interview on 6/21/24 at 10:30 a.m., the Assistant Director of Nursing Services (ADNS) indicated Resident 63 was at the dialysis center with his dialysis communication binder. The dialysis center did not fill out the dialysis center information on the communication forms. During an interview on 6/24/24 at 11:42 a.m., the ADNS indicated when Resident 63 goes to dialysis, they would send his dialysis binder with the top of the dialysis communication fill out. While at dialysis, the dialysis center would fill out the dialysis center information. When he returns from dialysis center, the dialysis center information was blank. On 6/24/24 at 2:00 p.m., the Director of Nursing Services provided the facility policy, Hemodialysis. revised on 2/23, and indicated it was the policy currently being used. A review of the policy indicated, .3. The facility will coordinate and collaborate with dialysis facility to assure that: d. There is ongoing communication and collaboration for the development and implementation of the dialysis care plan by nursing home and dialyses staff . 3.1-37(a)

Based on interview and record review, the facility failed to ensure the notification of the bed-hold policy required for a resident who transferred to the hospital was provided in writing to the resident or the resident representative for 2 of 3 residents reviewed for hospitalization . (Resident 54 and Resident 64) Findings include: 1. Residents 54's clinical record was reviewed on 6/24/24 at 9:55 a.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease and chronic kidney disease. Resident 54's progress notes indicated the resident was sent to the hospital on 1/27/24 and 2/15/24. The clinical record lacked documentation of written notification which specified the facility's bed-hold policy having been provided to the resident or the resident representative. 2. Resident 64's clinical record was reviewed on 6/24/24 at 9:45 a.m. The diagnoses included, but were not limited to, type II diabetes mellitus and chronic kidney disease. Resident 64's progress notes indicated the resident was sent to the hospital on 6/17/24. The clinical record lacked documentation of written notification which specified the facility's bed-hold policy having been provided to the resident. During an interview on 6/24/24 at 10:04 a.m., the Director of Nursing Services (DNS) indicated the facility did not provided the resident nor the resident representative the notification of Bed-Hold forms in writing. The facility sent the forms with the resident when they were transferred to another facility. On 6/24/24 at 1:50 p.m., the DNS provided the facility's policy,Bed Hold Notice Upon Transfer undated, and indicated it was the policy currently being used by the facility. A review of the policy indicated, Policy: At the time of transfer for hospitalization or therapeutic leave, the facility will provide to the resident and/or the resident representative written notice which specifies the duration of the bed-hold policy . 3.1-12(a)(25) 3.1-12(a)(26)

Based on interview and record review the facility failed to ensure staff documented neurological assessments for 1 of 1 residents reviewed for falls. (Resident 105) Findings include: On 6/24/24 at 10:18 a.m., Resident 105's clinical record was reviewed. The diagnoses included, but were not limited to, morbid (severe) obesity, abnormalities of gait and mobility, and edema. Progress notes indicated the following: - On 4/20/24 at 11:10 a.m., the resident was transferring self with a walker to his wheelchair and stepped on barbell weights instead of the floor. The resident complained of left knee pain and a 6 centimeter (cm) by 0.5 cm abrasion was assessed on his left knee. - On 4/20/24 at 2:06 p.m., a telehealth note indicated the resident was found on the floor. He did not know his bed was elevated when he tried to get up and lost his balance. The resident complained of left knee pain, but refused treatment. - On 4/20/24 at 2:30 p.m., the resident was playing game system. The author indicated neuro checks continue and were within normal limits. No documentation was noted in regard to neurological assessment findings. - On 4/20/24 at 3:22 p.m., the resident wanted to see what the x-rays before going to the ER (emergency room ). The author indicated neuro checks continue and were within normal limits. PERRLA (pupils are equal, round and reactive to light and accommodation). No additional documentation was noted in regard to neurological assessment findings. A review of the resident's Neuro Checks, documentation, dated 4/20/23 at 3:24 p.m., indicated neurological assessments were performed 15 minutes after the fall, 1 and 1/2 hours the fall, and 4 hours after the fall. The documentation indicated neurological assessments were not completed 30 minutes post fall, 45 minutes post fall, 60 minutes post fall, 2 hours post fall, 2 and 1/2 hours post fall, 3 hours post fall, 5 hours post fall, 6 hours post fall, 7 hours post fall, 11 hours post fall, 15 hours post fall, 19 hours post fall, nor 23 hours post fall. During an interview on 6/24/24 at 1:53 p.m., the Director of Nursing Services (DNS) indicated the neuro check flowsheet was kind of new to them so some nurses would use the form and then others would make a progress note. She indicated there were holes in the resident's Neuro Checks documentation and progress notes, and the standard of care is for staff to perform neuro checks on any unwitnessed falls. 3.1-50(a)(2)

Based on interview and record review, the facility failed to prevent a fall when staff did not use a gait belt (an assistive device used by staff that wraps around a resident to assist the resident and staff with a transfer) to transfer a resident who was dependent on staff for transfers for 1 of 3 residents reviewed for falls. (Resident B) Finding included: During an interview on 4/2/24 at 9:37 a.m., Resident B indicated she had more than one fall. Resident B thought she had a fall when she took a shower. During an interview on 4/2/24 at 11:22 a.m., CNA 1 (Certified Nursing Aide) indicated CNA 1 and CNA 2 took Resident B to the shower room. When CNA 1 and CNA 2 attempted to transfer Resident B, Resident B's knee went out and CNA 1 and CNA 2 lowered Resident B to the floor. Neither CNA 1 nor CNA 2 used a gait belt to assist Resident B transfer from a wheelchair to the shower chair. CNA 1 should have used a gait belt During an interview on 4/2/24 at 11:27 a.m., CNA 2 indicated CNA 2 and CNA 1 took Resident B to the shower room. CNA 2 and CNA 1 tried to transfer Resident B and Resident B's knee went out. Resident B was lowered to the floor. CNA 2 should have used a gait belt for the transfer. The clinical record for Resident B was reviewed on 4/2/24 at 9:45 a.m. The diagnoses included, but were not limited to, multiple sclerosis, anxiety, and bipolar disorder. A Quarterly MDS (Minimum Data Set) assessment, dated 3/9/24, indicated Resident B was moderately cognitively impaired. Resident B was dependent (staff did all effort for transfers) for chair to chair transfers. A Post Fall Evaluation, dated 2/19/24 at 11:47 a.m., indicated Resident B lost balance and was lowered to the floor by CNA 1 and CNA 2 in the shower room. CNA 1 and CNA 2 did not use a gait belt. During an interview on 4/2/24 at 12:15 p.m., the DON (Director of Nursing) indicated CNA 1 and CNA 2 should have used a gait belt to transfer Resident B. On 4/2/24 at 10:32 a.m., the DON provided a copy of an undated facility policy, titled Use of Gait Belt, and indicated this was the current policy used by the facility. A review of the policy indicated it was the policy of the facility to use gait belts with residents that cannot independently ambulate or transfer for the purpose of safety. This citation relates to Complaint IN00430007. 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure food was stored in a sanitary manner for 3 of 3 kitchen observations. Food was stored beneath a water line on which water had condensed and the kitchen walk-in freezer door and walk-in refrigerator seal gasket was in disrepair. Findings include: 1. During a tour of the facility's walk-in freezer on 7/24/23 at 10:30 a.m., food was observed to be stored beneath the freezer condenser water line, upon which water had condensed and ice had formed. Beneath the freezer condenser was a box of dough and a large covered pan of lasagna covered in ice that originated from the condenser water line. During an interview on 7/24/23 at 10:35 a.m., the Dietary Manager indicated the food should not have been kept under the freezer condenser. 2. During tours of the kitchen walk-in freezer on 7/18/23 at 10:30 a.m. and 7/24/23 at 10:20 a.m., the following observations were made: the freezer door seal gasket was observed to be out of alignment and in misshaped condition, preventing a tight seal. The door required excessive force to completely close. The freezer entry way strip curtains were ice covered, the freezer condenser was leaking water which formed into ice, and the shelves and ceiling had ice formed on them. 3. During tours of the kitchen walk-in refrigerator on 7/18/23 at 10:35 a.m. and 7/24/23 at 10:25 a.m., the refrigerator door seal gasket was observed to have a black powder-like substance on the top and sides. During an interview on 7/24/23 at 10:25 a.m., the Dietary Manager indicated the walk-in freezer door did not properly seal, resulting in the formation of ice on multiple surfaces, and the walk-in refrigerator door seal gasket was in need of cleaning to be rid of the black powder-like substance. During an interview on 7/24/23 at 2:10 P.M., the Corporate Dietary Manager indicated the facility used the Indiana State Department of Health Retail Food Establishment Sanitation Requirements, effective date, November 13, 2004, as the facility policy and procedure regarding food storage. A review of the policy indicated, .410 IAC 7-24-178 Food storage; prohibited areas Sec. 178. (a) Food may not be stored as follows: .(2) Under the following: .under lines on which water has condensed .equipment shall be maintained in a state of repair .equipment components, such as (1) doors (2) seals (3) hinges . 3.1-21(i)(2) 3.1-21(i)(3)

Based on interview and record review, the facility failed to ensure a Minimum Data Set (MDS) assessment accurately reflected the residents status for 2 of 3 residents reviewed for resident assessment. (Resident 34, Resident 36) Findings include: 1. On 7/24/23 at 10:40 a.m., Resident 34's clinical record was reviewed. The diagnoses included, but were not limited to, post-traumatic stress disorder (PTSD), other psychotic disorder, schizophrenia, anxiety, and major depressive disorder. An Annual MDS assessment, dated 12/19/22, indicated the resident was not evaluated by Level II Preadmission Screening and Resident Review (PASRR) and determined to have a serious mental illness. A Notice of PASRR Level II Outcome, dated 3/22/22, indicated based on the diagnoses, treatment history, current symptoms, and service needs, she met PASRR criteria. The Level II outcome indicated she was approved for long term care without specialized services. During an interview on 7/24/23 at 3:50 p.m., the MDS coordinator indicated the resident's MDS assessment was coded inaccurately because she had a Level II assessment. 2. On 7/24/23 at 10:05 a.m., Resident 36's clinical record was reviewed. The diagnoses included, but were not limited to, unspecified psychosis, generalized anxiety disorder, mood disorder due to known physiological condition with mixed features, depressive episodes, and delusional disorders. An Annual MDS assessment, dated 3/15/23, indicated the resident was not evaluated by Level II Preadmission Screening and Resident Review (PASRR) and determined to have a serious mental illness. A Notice of PASRR Level II Outcome, dated 2/15/18, indicated he was approved for long term care without specialized services. During an interview on 7/24/23 at 3:50 p.m., the MDS coordinator indicated the resident's MDS assessment was coded inaccurately because he had a Level II assessment. 3.1-31(d)

Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from physical abuse for 1 of 3 residents reviewed for abuse. A resident punch another resident in the face. This resulted in a resident being sent to the emergency room with bruising and a small laceration above the right eye and bridge of the nose. The resident required sutures above his right eye. (Resident C, Resident D) Finding includes: During an interview on 2/7/23 at 1:06 p.m., the Social Service Director indicated he received a phone call that there had been a resident to resident altercation between Resident C and Resident D. He came to the facility and interviewed Resident C and Resident D. Resident C wandered into Resident D's room. Resident D attempted to redirect Resident C out of his room. Resident C attempted to hit Resident D, so Resident D hit Resident C. The residents were separated, and Resident C was placed on 1 on 1 observation. Resident C was sent to the emergency room for evaluation and treatment. On 2/9/23 at 11:25 a.m., Resident C was observed resting in bed. A small purple discoloration to the side and just above Resident C's right eye was observed. At that time, Resident C was unable to remember any altercation with another resident and denied any pain. During an interview on 2/9/23 at 11:31 a.m., Resident D indicated Resident C entered his room. When Resident D tried to get him to leave his room by moving his hand to show him the way out of the room, Resident C swung at him. Resident D swung back and punched him in the face. During an interview on 2/10/23 at 9:29 a.m., LPN 1 (Licensed Practical Nurse) indicated she was the nurse on duty when there was a physical altercation between Resident C and Resident D. She did not see the altercation. Around 8:30 p.m., she heard a yell, and saw the CNA (Certified Nursing Aide) bringing Resident C down the hallway and to his room. When LPN 1 entered Resident C's room, he was sitting on his bed. He had a small laceration above his right eye and some discoloration. When LPN 1 asked Resident C what happen, he indicated to her that he was hit by Resident D. The CNA indicated to her that Resident C had wandered into Resident D's room and when Resident D tried to push Resident C out of his room, Resident C tried to hit Resident D, so Resident D hit Resident C. When LPN 1 asked Resident D what happened, Resident D indicated to her that Resident C wandered into his room and when he tried to redirect him out of the room Resident C punched him 3 times, so Resident D punched Resident C in the face. The clinical record for Resident C was reviewed on 2/9/23 at 11:26 a.m. The diagnoses included, but were not limited to, traumatic brain injury, fractures, and multiple traumas. An Admission MDS (Minimum Data Set) assessment, dated 12/13/22, indicated Resident C was not cognitively intact. A progress note, dated 2/1/23 at 8:47 p.m., indicated CNA notified this nurse Resident C was struck in the face by Resident D. Resident C had a laceration to the right eye, an abrasion and laceration to bridge of nose, and complained of pain to the left side of his ribcage. Resident C was sent to the emergency room for evaluation and treatment. A progress note, dated 2/2/23 at 8:07 a.m., indicated Resident C returned from the emergency room . Three sutures to laceration on outside of his right eye that was open to air. Resident C denied any pain and did not have any acute distress. The clinical record for Resident D was reviewed on 2/9/23 at 11:40 a.m. The diagnoses included, but were not limited to, anxiety, depression, and diabetes. A Quarterly MDS assessment, dated 1/3/23, indicated Resident D was cognitively intact. A progress note, dated 2/1/23 at 8:17 p.m., indicated CNA reported to this nurse Resident D struck Resident C in the face. Resident D stated Resident C attempted to enter Resident D's room. Resident D attempted to push Resident C out of his room. Resident C struck Resident D in the face 3 times. Resident D then struck Resident C in the face. CNA then took Resident C to his room. Nurse assessed Resident D. On 2/8/23 at 8:05 a.m., the Administrator provided a copy of an undated policy, titled Abuse, Neglect and Exploitation, and indicated this was the current policy used by the facility. A review of the policy indicated physical abuse includes, but is not limited to, hitting, slapping, punching, biting, and kicking .the facility will develop and implement written polices and procedures that prohibit and prevent abuse. This Federal tag relates to Complaints IN00400730 and IN00400735. 3.1-27(a)(1)

Based on observation, interview, and record review, the facility failed to ensure a resident was free from abuse by another resident for 1 of 2 residents reviewed for abuse. This resulted in left [CONDITION(S)] and fourth and fifth metatarsal (bones in the foot) fracture of the left foot (Resident B). Findings include: On 6/8/22 at 2:42 p.m., Resident B was observed to be lying in her bed with two nonskid strips (strips to prevent falls) on the floor beside her bed. On 6/9/22 at 10:52 a.m., Resident B was observed to be lying in her bed in a low position. On 6/10/22 at 9:49 a.m., Resident B was observed to be lying in her bed in a low position with nonskid strips on the floor beside her bed. On 6/7/22 at 12:17 p.m., Resident B's clinical record was reviewed. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) assessment, dated 3/29/22, indicated Resident B had moderate cognitive impairment and required limited assistance of one staff member for transfers, walking on the corridor, and locomotion on the unit. A care plan, revised on 3/8/22 and current through target date 6/2722, indicated Resident B had behaviors which included other behaviors not directed towards others. The interventions were to attempt interventions before my behaviors begin, help me avoid situations or people that are upsetting me, offer me something I like as a diversion, tell me what you are going to do before you begin, and speak to me in an unhurriedly and in a calm voice. The Progress Notes indicated the following: -On 5/28/22 at 5:10 p.m., Resident B attempted to pull her chair to sit and another resident had pushed her. Her injury was a left [CONDITION(S)]. She had left hip and knee pain. -On 5/28/22 at 5:10 p.m., Resident B tried to sit down in a chair. Resident C did not want her to sit in the chair and moved the chair. Resident B tried to take the chair back. Resident C pushed her, and Resident B fell on her left side. Resident B's left lower leg was rotated outward, and she was not able to perform any range of motion to the left lower leg. Resident B complained of hip and knee pain. Resident B was sent to the emergency room . -On 5/28/22 at 5:30 p.m., Resident B attempted to take a seat in the dining room before a meal. She was pushed by another resident. Resident B fell and complained of left hip pain. She was sent to the emergency room and was admitted with a left [CONDITION(S)]. The History and Physical, dated 5/31/22, indicated Resident B was sent to the emergency room after an assault at her extended care facility. She was pushed off a chair by another resident and fell to the ground. An extensive x-ray revealed left [CONDITION(S)] and 4th and 5th metatarsal fracture of the left foot. On 6/10/22 at 3:00 p.m., Resident C's clinical record was reviewed. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The psychiatric note, dated 9/8/21 at 3:33 p.m., indicated Resident C had been anxious and tearful. The plan was to increase [MEDICATION(S)] sprinkles (medication for mood stabilization). The Annual Minimum Data Set (MDS) assessment, dated 3/5/22, indicated Resident C had severe cognitive impairment. A care plan, revised on 3/8/22 and current through target date 9/3/22, indicated Resident C had behaviors which included an one time event of agitation with another resident. The interventions were to attempt interventions before my behaviors begin, help me avoid situations or people that are upsetting me, offer me something I like as a diversion, and speak to me in an unhurriedly and in a calm voice. Resident C's progress notes, dated 5/28/22 at 5:31 p.m., indicated a resident was trying to sit down and Resident C moved the chair. Resident C pushed the resident. The resident fell on her left side. The May 2022 Behavior Log indicated behavior monitoring of physical aggression towards staff. The log indicated no episodes of the behavior. During an interview on 6/10/22 at 11:34 a.m., the Unit Director indicated Resident C was the unit bully. You never knew when she was going to snap, and it would often be unprovoked. During an interview on 6/10/22 at 3:34 p.m., Registered Nurse (RN) 1 indicated Resident B and C were getting ready to eat dinner in the small dining room across the nurse's station. Resident B went to pull out the chair to sit down, when Resident C moved the chair. Resident B tried to get the chair back, when Resident C pushed Resident B down. Resident B left leg was rotated outward. She was sent to the emergency room . On 6/10/22 at 5:11 p.m., the Regional Director of Clinical Operations provided the facility's policy, Abuse, Neglect and Exploitation, undated, and indicated this was the policy currently being used by the facility. A review of the policy indicated, .Abuse means the willful infliction of injury . This Federal tag relates to Complaint IN 488. 3.1-27(a)(1)

Based on observation, interview, and record review, the facility failed to ensure a resident was free from abuse by another resident (Resident 326) which resulted in multiple skin tears, multiple bruises, and a hematoma for 1 of 1 resident reviewed for abuse (Resident 69). Findings include: Interview, on 6/25/19 at 10:37 a.m., Resident 69's wife indicated she had received a phone call on, 6/23/19 at 3:58 a.m., that Resident 69 had been assaulted by another resident (Resident 326). The other resident had hit Resident 69 with his walker and fist. During the interview, Resident 69 was observed to have a baseball-size purple bruise on the left side of his chin; multiple bruises on his bilateral arms; hematoma (localized swelling that is filled with blood) above his right eye; and a white dressing to his left upper arm. Resident 69's wife indicated he had a skin tear with a bruise to the left upper arm and had a skin tear and bruise to the right great toe. Interview on, 6/25/19 at 3:43 p.m., Registered Nurse (RN) 1 indicated Resident 69's roommate came up to the nurses station and informed her there was a fight in his room. Resident 69 was in front of his TV. Resident 69 and Resident 326 were having a tugging war with Resident 69's walker. Resident 326 wanted Resident 69 out of his house. Resident 326 was assisted to his room and placed on 15 minute checks at that time. Resident 69 was assessed with [REDACTED]. On 6/25/19 at 2:10 p.m., Resident 326's clinical was reviewed. [DIAGNOSES REDACTED]. His admitted was 6/21/19. Resident 326's admission Clinical Health Status Assessment, dated 6/21/19, indicated he had short term and long term memory problems; had a history of [REDACTED]. Resident 326 had increased signs and symptoms of anxiety, exit seeking, and wandering behaviors upon admission. He was difficult to redirect. When able to redirect, redirection was effective for short periods. Resident 326's progress notes indicated the following: -On 6/21/19 at 6:36 p.m., Resident 326's received a new order for [MEDICATION NAME] (medication for anxiety) 0.25 milligrams (mg) twice a day for 3 days for anxiety. -On 6/21/19 at 7:01 p.m., Resident 326 was admitted to the facility at approximately 3:45 p.m. Resident 326 had been exit seeking since arrival, banged on the doors, and made threats to break the glass to get out. He was aggressive towards staff and raised his fist several times. He was redirected to watch TV and snacks were accepted. -On 6/22/19 at 12:27 p.m., Resident 326 yelled at staff and raised his fist. He threatened to shoot all of you if you don't get out of my house. He was ambulating through the hallway with a cup in his hand, banged on residents' doors, and threw other residents' clothing on the floor. Resident 326 was not compliant with redirection at that time. The on-call physician was notified and gave a new order to send Resident 326 to the ER (emergency room ) for evaluation and treatment. -On 6/22/19 at 3:23 p.m., Resident 326 returned from the ER with new orders to stop [MEDICATION NAME] and start [MEDICATION NAME] (medication to treat anxiety) 5 mg three times a day. -On 6/22/19 at 6:40 p.m., the Nurse Practitioner (NP) indicated to continue [MEDICATION NAME] 0.25 mg twice a day and [MEDICATION NAME]. On 6/22/19 at 8:56 p.m., Resident 326 was exit seeking and said he would break down the doors or windows. He was said I'm not staying here tonight, I'm done, I want to go home, I'll call the sheriff and attorney. He was attempted to be redirected. -On 6/22/19 at 9:58 p.m., Resident 326 was very agitated throughout the evening. He was exit seeking and had to be redirected multiple times throughout the evening. He used profanity while speaking to staff and others. -On 6/22/19 at 10:28 p.m., Resident 326 used the bathroom in the woman's bathroom across the hall. He was upset because a female resident attempted to use the woman's bathroom. The nurse attempted to assist Resident 326 back to his room. He was noncompliant. He used profanity and yelled. He was combative with staff. He threatened to hit staff and residents. The attempts to redirect were not successful. The staff tried to explain the bathroom was for women only. He refused to comply and continued to be aggressive and threatened the staff. Resident 326 slammed the door several times and punched the wall several times. -On 6/22/19 at 10:42 p.m., Resident 326 continued with the profanity in his room. -On 6/23/19 at 2:30 a.m., Resident 69's roommate called the nurse into his room. When the nurse entered the room, Resident 326 and Resident 69 were standing in front of the TV holding onto Resident 69's walker. Resident 69 was holding onto the legs of the walker and Resident 326 was holding onto the top of the walker. Resident 326 indicated this was his house and to get out. The nurse intervened and redirected Resident 326 back to his room. -On 6/23/19 at 3:10 a.m., the on-call physician was notified and a new order was received to send Resident 326 to the ER for evaluation and treat. While the police were talking with Resident 326, he began hitting a police officer with a closed fist. The staff and officer attempted to redirect Resident 326 without success. An ambulance arrived at that time. Resident 326 refused to go to the ER. Resident 326 cursed and swung at the Emergency Medical Technician (EMT) and police officer. Resident 326 was given sedation by the EMT staff. Resident 326 continued to curse and swing at staff. The EMT placed Resident 326 in wrist restraints and left the facility to transport him to the ER. -On 6/23/19 at 5:30 a.m., Resident 326 was admitted to psychiatric unit. On 6/25/19 at 2:00 p.m., Resident 69's clinical record was reviewed. [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS) assessment, dated 5/14/19, indicated Resident 69 had severe cognitive impairment. Resident 69's progress notes indicated the following: -On 6/23/19 at 2:30 a.m., Resident 69's roommate called the nurse into his room. When the nurse entered the room, Resident 69 and Resident 326 were standing in front of the television holding onto Resident 69's walker. Resident 69 was holding onto the legs of the walker and Resident 326 was holding onto the top of the walker. Resident 326 indicated this was his house and to get out. The nurse intervened and redirected Resident 326 back to his room. The nurse went to check on Resident 69 and noted red drainage on the floor beginning at the bathroom and leading to where Resident 69 was seated, with his sock off, in his recliner. Resident 69's glasses were on his bed and broken. Resident 69 had a skin tear to his first toe on the right foot, a bruise to his abdomen, a bruise to his chin line, a bruise to the back of his right hand, a bruise and skin tear to his left arm, and an abrasion to his lip. -On 6/23/19 at 3:10 a.m., the nurse received a new order to send Resident 69 to the emergency room (ER) for an evaluation and treatment. -On 6/23/19 at 4:34 a.m., Resident 69's wife was at the facility. Resident 69 left via the ambulance to the ER. -On 6/23/19 at 10:00 a.m., Resident 69 returned from the ER. Skin assessment was completed. Resident 69 had multiple bruises, a hematoma to the forehead, and 3 skin tears. Interview on, 6/25/19 at 2:10 p.m., the Director of Nursing (DON) indicated Resident 326 was an emergency admit from home on 6/21/19. After Resident 326 was admitted to the facility, he became anxious and wanted to go home. The NP (nurse practitioner) was still at the facility on the evening Resident 326 was admitted and ordered [MEDICATION NAME] for 3 days to help him adjust to the new facility. On the morning of 6/22/19, Resident 326 was having behaviors and was sent to the ER. He returned from the ER with medication changes. Interview, on 6/25/19 at 3:38 p.m., Certified Nursing Assistant (CNA) 1 indicated around lunch, on 6/22/19, Resident 326 was upset because family members were visiting with another resident. Resident was upset and was arguing with the family because he thought all these people were in his house. Resident 326 was physically abusive with care. CNA 1 had been provided direction to, keep a close eye on Resident 326. On 6/26/19 at 2:51 p.m., the DON provided the facility's policy, Investigation and Reporting of Alleged Violations of Federal and State Laws . Abuse ., and indicated the policy was current. A review of the policy indicated, .It is the policy of the Company to take appropriate steps to prevent the occurrence of abuse .Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish .Physical abuse includes hitting, slapping, punching and kicking . 3.1-27(a)(1)

Based on interview and record review, the facility failed to ensure monitored blood glucose levels as indicated by the hospital discharge orders which resulted [DIAGNOSES REDACTED] (low blood sugar) and required medical intervention for 1 of 5 residents reviewed for medication monitoring (Resident 159). Findings include: On [DATE] at 2:08 p.m., Resident 159's closed clinical record was reviewed. [DIAGNOSES REDACTED]. The resident was admitted on [DATE] and was to be discharged home on [DATE]. Resident 159's hospital discharge instructions, dated [DATE], indicated an order to check blood glucose one to two times a day. A review of Resident 159's February through March, 2017 physician's orders [REDACTED]. On [DATE], the resident was ordered [MEDICATION NAME] (oral diabetic medication) 1000 mg (milligrams) twice daily, [MEDICATION NAME] (oral diabetic medication) 10 mg daily, and [MEDICATION NAME] (insulin) 14 units injected daily at bedtime. There was no order for blood glucose monitoring. A Registered Dietician Nutritional Assessment, dated [DATE] indicated, wt (weight) 115# (pounds) . ConCHO (consistent carbohydrate) diet; he has been attending the MDR (main dining room) for most meals . has been eating approx. 100% since his admission-meeting estimated nutrient needs; res (resident) reports a good appetite . Resident 159's clinical record lacked documentation of blood glucose monitoring. The Wolters Kluwer Nursing 2014 Drug Handbook, 34th edition, copyright 2014, nursing consideration for long-acting insulins indicated, Assess patient for signs and symptoms of [DIAGNOSES REDACTED] (sweating, shaking, trembling, confusing) . Increase frequency of glucose monitoring in patients who are acutely ill or under emotional stress, or if changes in medication regimen occur as these may affect the rate of insulin absorption. Also, closely monitor patient after changes to insulin dosage . A review of Resident 159's progress notes indicated the following: [DATE] at 7:52 a.m., Resident found in bed fairly unresponsive and clammy to touch. Vital taken and resident was found to have a blood glucose level of 42 (normal range 70 to 100 mg). [MEDICATION NAME] (medicine is used as an emergency treatment for [REDACTED]. glucose levels varied from 42 to 38 . received orders to send out. 911 called. during intermediate time resident given orange juice and pb and j (peanut butter and jelly) sandwich. upon ambulance arrival BG (blood glucose) levels up to 51. Ambulance crew then treated with own [MEDICATION NAME] and raised levels to 59. resident became more responsive and refused transport. resident then leapt to 111 at 5:30 a.m. and stated he was fine . Resident 159's clinical record lacked documentation of continually monitoring or daily monitoring of blood glucose. [DATE] at 5:17 a.m., Resident c/o (complained of) pain on right side. vitals taken and glucose level of 75. snacks and OJ (orange juice) given and glucose level up to 174. Resident 159's clinical record lacked documentation of continually monitoring or daily monitoring of blood glucose. [DATE] at 8:09 a.m., Resident found unresponsive by aide at approx (approximately). 7:59. began CPR (cardiopulmonary resuscitation) and called 911. CPR performed until arrival of ambulance crew. retrieval was unfortunately unsuccessful. On [DATE] at 2:51 p.m., the Director of Nursing indicated staff would only obtain accuchecks (blood finger stick) if they had an order by physician. At the same time, Resident 159's Medical Doctor indicated the hospital order must have been overlooked. On [DATE] at 3:54 p.m., interview with LPN 2 indicated staff should have routinely performed accuchecks on Resident 159. On [DATE] at 3:00 p.m., the Director of Nursing provided the facility policy, Clinical Health Status-Change of Condition Guideline, reviewed [DATE], and indicated it was the policy currently being used. The policy indicated, Monitoring/Compliance . IPOC (interdisciplinary plan of care) are implemented appropriately according to areas of risk . 3XXX,[DATE](a)(3)

Based on record review and interview, the facility failed to assess and notify the MD (Medical Doctor) of 11 loose stools in 4 days for 1 of 1 resident reviewed for [MEDICAL CONDITION] which resulted in emergency hospitalization for the treatment of [REDACTED].#C) Findings include: Resident #C's clinical records were reviewed on 10/11/16. On admission to the facility on [DATE] at 2:55 p.m., Resident #C's diagnoses included, but were not limited to: benign intracranial hypertension, [MEDICAL CONDITION], traumatic hemorrhage of cerebrum. No [DIAGNOSES REDACTED]. A Pre-admit screening\resident review report dated 09/29/16, indicated Resident #B was free from any infectious diseases and was alert and oriented. Progress noted dated 10/01/2106 19:50 p.m. (7:50 p.m.), by LPN#1, indicated temp was 101.0 F (Fahrenheit). On 10/01/2016 at 20:29 (8:29 p.m.), indicated Resident #C ate well, but remained febrile with 99.3 to 102.3 fever. Tylenol and [MEDICATION NAME] had reduced the fever some. On 10/02/16 at 20:51 (8.51 p.m.), Resident continued to be febrile, never lower than 100.7 no greater than 101.8. Tylenol was given as much as possible. No record of informing NP(Nurse Practitioner) or MD of continued fever. Change of Condition dated 10/03/2016, indicated a CBC (complete blood count) had indicated Resident #C's WBC (white blood count) was elevated at 13.3, and results were faxed to the NP (Nurse Practitioner) office at 5:29 p.m On 10/4/2016 at 18:56, (6:56 p.m.), NP indicated to obtain a chest x-ray and another CBC on 10/04/2016, and to started [MEDICATION NAME] 500 mg for potential infection along with a [MEDICATION NAME] once a day for 10 days, with first dose obtained from facility EDK (emergency drug kit) on 10/04/2016 at 20:02 (8:02 p.m.). NP was not notified of previous loose stools x 2 prior to [MEDICATION NAME] order. On 10/5/2016 at 18:19 (6:19 p.m.), order noted on progress notes to give [MEDICATION NAME] A-D 2 mg tab at 2 mg by mouth every 6 hours as needed for diarrhea. LPN#1 progress note below order indicated diarrhea x 4. On 10/05/2016 at 19:56 (7:56 p.m.), new orders received to discontinue [MEDICATION NAME] ([MEDICATION NAME]) related to diarrhea. On 10/06/2016 at 09:34 (9:34 a.m.), noted Resident #C received another dose of [MEDICATION NAME] A-D 2 mg tablet for diarrhea which noted at 10:54 (10:54 a.m.), the prn (when necessary) medication was effective. On 10/06/2016 at 12:57 (12:57 p.m.), indicated Resident #C received another dose of [MEDICATION NAME] 2 mg tablet for diarrhea. On 10/06/2016, at 16:58 (4:58 p.m.), Resident #C received another dose of [MEDICATION NAME] 2 mg tablet for diarrhea. On 10/09/2016 at 0:345 (3:45 a.m.), indicated Resident #C was noted to have labored breathing, with a background of having loose stools and a negative chest x-ray on 10/04/2016. B/p (blood pressure) was noted to be 87/51, axillary (under the arm) temperature 102.4 F, pulse 136 and respirations 36 with oxygen saturation on room air at 91%. Crackles noted in right upper lobe. On call MD notified, order to send to ER for evaluation and treatment received, and family notified. Bowel and bladder detail report from 09/30/16 at 9:44 p.m. until Resident # C was transferred to the local emergency roiagnom on [DATE], Resident #C had 11 recorded episodes of diarrhea. The clinical record lacked documentation of physician notification. Interview with DON on 10/13/2016 at 10:40 a.m., inquiring why an assessment was not requested for Resident #C after the number of episodes of diarrhea, the DON stated no one thought it was [MEDICAL CONDITION], because the stools did not look or smell like [MEDICAL CONDITION]. Interview with Resident #C's MD on 10/13/2016 at 12:10 p.m., indicated the MD nor the NP was ever notified of Resident #C's continuous episodes of diarrhea. The MD indicated that if more than 2 days of diarrhea are observed, then an order for [REDACTED].>On 10/13/2016 at 3:00 p.m., DON indicated the facility did not have a policy/procedure related to assessment for [MEDICAL CONDITION] related to diarrhea. Review of hospital records dated 10/09/2016 at 06:35 (6:35 a.m.), lab CBC indicated a WBC (white blood count) of 31.3 (critical level) (Diagnosis: [REDACTED].#C was placed on [MEDICATION NAME] precautions in the emergency room for [MEDICAL CONDITION] related to the number of episodes of diarrhea Resident #C had at the facility. On 10/09/2016 at 10:30 a.m., Resident #C had an CT (cat scan ) of the abdomen and pelvis without IV (intravenous) contrast which indicated an impression of indicating pseudomembranous [MEDICAL CONDITION] and clinical correlation with [DIAGNOSES REDACTED]icile ([MEDICAL CONDITION]) status is recommended. No bowel obstruction was seen. On 10/09/2016 (no time given), the [MEDICATION NAME] MD performed a flexible sigmoidoscopy which was performed in the intensive care unit, and immediately entering the rectum pseudomembranes consistent with [MEDICAL CONDITIONS] ([MEDICAL CONDITION]) were readily identified. [MEDICATION NAME] MD's assessment and plan indicated leukocytosis, [MEDICAL CONDITION], severe pseudomembranous [MEDICAL CONDITION] consistent with severe [MEDICAL CONDITION] infection ([MEDICAL CONDITION]). Surgical intervention was discussed, with Resident #C's prognosis was considered grim. Resident #C passed away in the local hospital on [DATE]. This Federal tag relates to Complaint IN 307. 3.1-37(a)