Every finding on record at Brickyard Healthcare -Sycamore Village Care Center

Based on observation, interview and record review, the facility failed to ensure the kitchen was maintained in a safe and sanitary condition in 1 of 1 kitchen reviewed. This deficient practice had the potential to affect 95 of 95 residents who received food from the kitchen.Findings include:During the kitchen observation, on 1/4/26 at 10:58 a.m., with the Dietary Manager (DM), the following were observed:a. The walk-in refrigerator contained two 16-ounce cans of Pepsi open, two cans of Pepsi not open, one 16-ounce bottle of water opened, a thirty-two-ounce bottle of Coffee Mate French Vanilla liquid creamer with no sugar and a Gordons choice whipped topping. All without a date or label.b. Four empty cardboard boxes were not broken down and stacked on the floor by the back exit door. c. The floor under the serving station had dried unknown food and unopened condiment packets. d. The floor under and around the oven had unknown food substances and grease.e. The floor in the refrigerator had small particles of unknown food, pieces of carboard, pieces of clear tape, and lids to unknown containers.f. The floor in the dry food area had dried sticky liquid of unknown substance, small particles of dried food, plastic white fork and spoon, and small pieces of paper.g. The floor in the dishwashing station had food, pieces of paper, aluminum foil, and grimy scuffing.h. Eight rolling carts had dried food products and dried liquid.i. The chemical storage closet had a pint [NAME] jar with clear orange liquid with no date or label.j. The juice dispenser station next to the hand-washing station had an open can of coke and a can of glass cleaner.k. The microwave had dried unknown food particles on the exterior and interior.l. The stove top had dried food product on it with a pan of butter uncovered with a brush in pan.During an interview, on 1/4/26 at 11:20 a.m., the Dietary Manager indicated the employees were not supposed to store their drinks in the refrigerator.During an interview, on 1/4/26 at 11:24 a.m., the Dietary Manager indicated cardboard boxes should not be stored on the floor.During an interview, on 1/4/26 at 11:28 p.m., the Dietary Manager indicated the flooring through the kitchen, refrigerator, freezer, and dry food pantry should be clean and free of debris.During an interview, on 1/4/26 at 11:29 p.m., the Dietary Manager indicated rolling carts should be clean.During an interview, on 1/4/26 at 11:30 a.m., the Dietary Manager indicated chemicals in storage area should be labeled.During an interview, on 1/4/26 at 11:34 a.m., the Dietary Manager indicated the juice station shelf should not have employee drinks or cleaning products on it.During an interview, on 1/4/26 at 11:40 a.m., the Dietary Manager indicated cooking appliances should be clean.During an interview, on 1/09/26 at 10:10 a.m., the Registered Dietician (RD) indicated no liquid substances should be stored in a [NAME] jar and kept in the chemical storage closet anywhere in the facility.A current facility policy, titled Sanitation Inspection, with no revision dated and received from the Executive Director (ED) on 1/9/26 at 11:45 a.m., indicated .It is the policy of this facility, as part of the department's sanitation program, to conduct inspections to ensure food service areas are clean, sanitary and in compliance with applicable state and federal regulations.All food service areas shall be kept clean, sanitary, free from litter, rubbish.A policy for chemical storage was not provided.3.1-21(i)(3)

Based on observation, interview and record review, the facility failed to ensure medications were dated when opened in 1 of 3 medication carts reviewed for medication storage. (East Hall)Findings include:During an observation, on 1/8/26 at 11:01 a.m., with the Infection Preventionist Nurse, the East Hall medication cart had the following:a. One multi-use tube of Triad Wound paste was not labeled with an open date.b. One multi-use tube of Diclofenac gel 1% was not labeled with an open date.During an interview, on 1/8/26 at 11:06 a.m., the Infection Preventionist Nurse indicated the medications should have been labeled with a date when they were opened.During an interview, on 1/9/26 at 10:52 a.m., RN 3 indicated if a new tube of medication was opened, it would be dated with the date opened and placed in the treatment cart with the residents' other medications.During an interview, on 1/9/26 at 12:46 p.m., Pharmacist 8 indicated she was unsure of the shelf life of Diclofenac gel and Triad Wound paste once opened, but they should be dated when they were opened.A current facility policy, titled Labeling of Medications and Biologicals, dated as revised 2025 and provided by the Executive Director on 1/8/26 at 2:00 p.m., indicated .Labels for multi-use vials must include: a. The date the vial was initially opened. 3.1-25(j)

Based on observation, interview and record review, the facility failed to ensure a resident was kept safe during care and transfers for 1 of 4 residents reviewed for accidents. (Resident C)Findings include:During an interview, on 1/7/26 at 10:39 a.m., Resident C's daughter indicated the resident had fallen twice. The first was from her bed. The resident's bed was smaller than her current bed, she rolled out and fell on the floor during incontinence care. There was only one CNA in the room, and the CNA pushed the resident too hard, and she fell out of her bed. The second was from the mechanical lift. The facility did not call her when the resident's lift strap on the pad broke. The resident called from the ambulance. When the resident was in the emergency room, the Executive Director called but it was at least 30 minutes after the resident was in the emergency room. The Executive Director had asked if she wanted to see the broken pad and then when she asked to see the pad the Executive Director indicated it was no longer available. The clinical record for Resident C was reviewed on 1/6/26 at 10:34 a.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disorder, congestive heart failure, hypertension, morbid obesity, and osteoarthritis of the right and left knee.An annual Minimal Data Set (MDS) assessment, dated 10/23/25, indicated Resident C was dependent on staff with transfers.A care plan, dated 12/18/24, indicated Resident C had a self-care performance deficit. Interventions included, but were not limited to, 1/28/25, trapeze bar above the bed to assist with repositioning. 12/18/24, Resident C required substantial assistance to complete bed mobility, was dependent on toileting, and totally dependent on transfers. Encourage Resident C to participate, when possible, with each interaction.A care plan, dated 12/18/24, indicated Resident C was at risk of falls. Interventions included, but were not limited to, 12/18/24, assistance with transfers, ensure resident wore appropriate non-skid footwear, and the environment remained safe.1. A facility's change of condition note, dated 11/26/25 at 11:50 a.m., indicated Resident C was receiving incontinence care. While the resident turned towards the window on her left side, the resident fell out of the bed. The resident held herself with the trapeze, her hand slipped off, and she fell out. The resident received a small scratch on the back of her right lower leg. The new intervention was for two (2) people to assist with care. A fall risk evaluation, dated 11/26/25, indicated Resident C had a low risk for falls.A physician's progress note, dated 11/28/25 at 8:00 a.m., indicated Resident C was seen for follow-up of right ankle pain experienced post fall. Her x-ray did not show acute fracture. She had right ankle pain with no acute fracture or dislocation seen.An interdisciplinary team note, dated 12/4/25 at 11:11 a.m., indicated Resident C had a fall and slid off the edge of the bed during care, on 11/26/25. The new intervention was two (2) caregivers when providing peri care.During an interview, on 1/4/26 at 2:51p.m., Resident C indicated she had fallen when she was too close to the edge of the bed while staff were providing incontinence care, and she rolled off the bed. The bed was too small. During an interview, on 1/7/25 at 1:00 p.m., the Executive Director indicated Resident C did fall out of bed during incontinence care. Resident C did not get hurt.During an interview, on 1/7/26 at 5:04 p.m., CNA 17 indicated she was completing peri care on the resident. Resident C helped with turning from her back towards the window. She grabbed the overhead trapeze and rolled to the left. The bed was close to the window, Resident C slid off the bed, and her left foot went to the floor, and her right leg went up in the air. She landed on the floor and was in a split position between the bed and the window. CNA 17 yelled for the nurse, and they used the mechanical lift to help Resident C off the floor.2. An interdisciplinary team note, dated 12/4/25 at 12:45 p.m., indicated Resident C returned from the emergency room after a recent fall. Resident C had complaints of pain related to the fall.A facility's change of condition note, dated 12/4/25 at 3:00 p.m., indicated Resident C was being transferred with the Hoyer lift. Resident C was approximately an inch off the bed when the Hoyer sling snapped and the resident fell to floor. Three (3) staff members were present at the transfer. Resident C had significant pain in her lumbar area and was sent to the emergency room for evaluation.A fall risk evaluation, dated 12/4/25 at 3:30 p.m., indicated Resident C had 1-2 falls in the past 3 months. Resident C was chairbound and incontinent.An interdisciplinary team note, dated 12/5/25 at 10:01 a.m., indicated Resident C fell from Hoyer sling. The Hoyer sling broke and the resident was sent to the emergency room for evaluation.A nursing progress note, dated 12/5/25 at 12:40 p.m., indicated Resident C returned from the hospital. She reported new back pain. New physician's orders were received for as needed Norco (a pain medication), Robaxin (a muscle relaxing medication), and routine Lidoderm patches (a topical patch used for pain) to her back.A nursing progress note, dated 12/5/25 at 2:53 p.m., indicated Resident C was assessed for side rails and passed the assessment.A post fall evaluation, dated 12/8/25 at 4:24 p.m., indicated Resident C was being transferred with the Hoyer lift when the Hoyer sling strap broke. The resident had a bruise on her hand and lower back pain.A hospital document, dated 12/26/25, indicated an x-ray of the spine was completed with no fractures detected. The hospital was unable to obtain a CT (computed tomography) scan due to patient's weight. The resident had a fall from a height of less than 3 feet and reported experiencing pain localized to the thoracic (middle section of the spine), right shoulder, and noted discomfort associated with positional changes in bed.A fall risk evaluation, dated 1/2/25, indicated Resident C was at moderate risk for falls. During an observation, on 1/6/26 at 11:11 a.m., Certified Nursing Assistant (CNA) 13 and CNA 14 were transferring Resident C into her recliner. Resident C was lying flat in her bariatric bed. Resident C grabbed the trapeze handle and assisted in rolling herself over onto her left side. CNA 13 placed the large blue Hoyer pad underneath the resident and instructed the resident to roll onto her right side. Once the pad was under the resident; CNA 14 pushed the mechanical lift to the right side of the bed. The CNAs attached the straps of the pad onto the hooks and began to lift Resident C off the bed. Resident C asked the CNAs to stop and to cross the straps at her feet. CNA 13 informed Resident C they could not cross the straps. CNA 13 indicated the pad was the correct pad for Resident C and the nurse had told her which pad to use. During an interview, on 1/6/26 at 11:19 a.m., Unit Manager 16 indicated the mechanical lift pads were based on the resident's weight and were normally stored in each resident's room. During an observation and interview, on 1/6/26 at 11:25 a.m., Unit Manager 16 indicated the lift pads were normally kept in the clean storage room or the resident's room. Unit Manager 16 pulled a lift pad out from a large blue barrel to look at the tag with the weight. The pad did not have a weight limit on tag and Unit Manager 16 indicated she was not sure why. The Patient Lift Safety Guide indicated assess the patient's size, weight, and hip measurement and choose the size of the sling based on the manufacturer's recommendation for the patient's measurements. Choosing the correct sling size was critical for safe patient transfer. If the sling was too large, the patient could slip out. If the sling was too small, the patient could fall out. If the sling was between sizes, the smaller size could keep the patient more secure. Using the wrong sling or attaching the sling incorrectly could cause an accident which could result in serious injury or death.During an interview, on 1/6/26 at 11:30 a.m., Resident C indicated the staff had crossed the straps down by her feet on more than one occasion. When staff used the large pad, she felt like she would slide out. The CNAs not normally assigned to her would use the incorrect pad. Resident C indicated the pad the staff used the day of the incident felt smaller. She told the CNAs and they said it would be okay then shortly after was when the strap broke and she fell. She hit her right shoulder and back on the mechanical lift legs. She felt like she broke her back. During an interview, on 1/7/25 at 4:22 p.m., CNA 10 indicated on the day of the incident, CNA 11, CNA 12, and herself hooked the straps to the lift. She could not remember how they attached the straps. CNA 12 raised the resident up about 2 inches off the bed and pulled the lift out. CNA 11 was guiding the resident when the stitching on the strap came loose, the resident fell and landed on the mechanical lift legs. Resident C hit her left lower back on the mechanical lift. CNA 10 was not sure which pad they used or if the pad was the correct weight limit for Resident C. During an interview, on 1/9/26 at 10:30 a.m., the Ombudsman indicated Resident C's family member had called him with concern. Resident C had fallen from a mechanical lift and had also fallen from the bed during peri care. During an interview, on 1/9/26 at 10:39 a.m., LPN 2 indicated Resident C required a mechanical lift. During an interview, on 1/9/26 at 10:42 a.m., RN 3 indicated to use the mechanical lift, you should know the weight of the resident. The pads were labeled with the weights. She believed the resident used a pad for 500 pounds. The CNAs should know which pad Resident C used. During an interview, on 1/9/26 at 12:50 p.m., CNA 11 indicated on the day of the incident, she helped CNA 10 and 12 with Resident C. They used the bigger pad which crossed under the resident at the legs. CNA 12 began to raise the resident up while she guided the resident off the bed. Resident C had just cleared the bed when the right strap unraveled and broke. The resident fell to the ground and hit her back on the mechanical lift legs. 3. During an interview, on 1/9/25 at 1:22 p.m., Resident C indicated earlier this morning two (2) guys, and a girl (unable to recall their names) came in with the mechanical lift to transfer her back to bed. The resident had an overhead trapeze at the head of bed. During the transfer, the mechanical lift hit her overhead trapeze bar and knocked the trapeze bar down. The trapeze bar bumped the back of her head. The resident indicated her head was a little sore but did not bleed. During an interview, on 1/9/25 at 9:45 a.m., the Executive Director (ED) indicated Resident C did have an incident with the mechanical lift today. The trapeze bar dropped and hit the back of her head. She had a small bump on her head, but it was not open. She spoke to the resident who stated she was fine.At the exit conference, the ED indicated she had no additional information provided related to the incidents. The facility did not have a policy on the use of mechanical lifts.A current facility policy, titled Accidents and Supervision, dated 12/4/25 and received from the ED on 1/9/25 at 11:30 a.m., indicated .The residents' environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents.All staff.are to be involved in observing and identifying potential hazards in the environment.This citation relates to Intake 2680656.3.1-45(a)(1)3.1-45(a)(2)

Based on observation, interview and record review, the facility failed to ensure privacy was provided for a resident during care for 1 of 1 resident randomly reviewed for privacy. (Resident 5)Findings include: During a random observation, on 1/7/26 at 11:21 a.m., RN 9 and QMA 15 entered Resident 5's room to administer medication through the resident's gastrostomy tube (a tube placed through the abdomen directly into the stomach for long-term feeding, hydration, and medication delivery). RN 9 placed the medication on the bedside table and asked QMA 15 to watch the medication while she washed her hands. RN 9 returned and QMA 15 exited the room. RN 9 did not have water to flush the medication and asked the Executive Director (ED) to get a cup of water off the medication cart. The ED brought the water to RN 9 and left the room. Resident 5's door and privacy curtain remained open. RN 9 pulled the resident's covers back, lifted his gown, and exposed his abdomen. The privacy curtain and the door remained open. A visitor in the facility walked by the resident's room and looked inside. The clinical record for Resident 5 was reviewed on 1/6/26 at 3:11 p.m. The diagnoses included, but were not limited to, cerebral infarction, diabetes mellitus, atrial fibrillation, acute kidney failure, and gastrostomy tube.A care plan, dated 4/21/25, indicated the resident required enteral feeding.During an interview, on 1/7/26 at 11:21 a.m., RN 9 indicated she did not close the door or the curtain to provide privacy for Resident 5. During an interview, on 1/7/26 11:41 a.m., QMA 15 indicated the privacy curtain, or door should always be closed when completing any kind of care with the resident. A current facility policy, titled Resident Rights, undated and received from the ED on 1/9/25 at 11:30 a.m., indicated .The resident has a right to a dignified existence, self-determination and communication with, and access to, persons and services inside and outside the Facility .Information about resident rights and responsibilities will be given to the resident both orally and in writing 3.1-3(p)(4)

Based on interview and record review, the facility failed to ensure staff obtained another weight after a documented weight gain for 1 of 3 residents reviewed for quality of care. (Resident 23) Findings include:The clinical record for Resident 23 was reviewed on 1/7/26 at 9:53 a.m. The diagnoses included, but were not limited to, cerebral palsy, conversion disorder with seizure or convulsions, anxiety disorder, hypertension, cognitive communication deficit, and intellectual disabilities. A care plan, dated 6/23/25, indicated Resident 23 triggered for obesity and a body mass index (BMI) greater than 30. Interventions included, but were not limited to, weights according to the physician's order.A clinical record indicated Resident 23 had the following weight:On 7/1/25, the resident's weight was 244.0 pounds. On 8/5/25, the resident's weight was 270.0 pounds. Resident 23 had a significant weight gain of 10.66% in 36 days. There was no documentation located in the medical record to indicate another weight had been obtained to determine if the weight was correct or the physician was notified.During an interview, on 1/9/26 at 10:55 a.m., LPN 2 indicated if the resident had a significant weight gain or loss the physician should be called. If the resident had a weight gain and a diagnosis of congestive heart failure, the physician could order a diuretic. During an interview, on 1/9/26 at 10:58 a.m., RN 3 indicated it was very important to notify the physician if there was a significant weight change. The resident could need additional orders, or the physician could want to see the resident. RN 3 indicated she would also complete an assessment to determine if the resident had edema. During an interview, on 1/9/26 at 11:25 a.m., the Registered Dietician (RD) indicated nursing staff should complete another weight on a resident if there was a significant weight loss or gain. There was no documentation in the clinical record to indicate the resident was reweighed.During an interview, on 1/9/25 at 11:27 a.m., the Executive Director (ED) indicated there was no documentation the physician was notified of the weight gain. A current facility policy, titled Weight Monitoring, undated and received from the ED on 1/9/26 at 11:47 a.m., indicated .A significant change in weight is defined as: 5% change in weight in 1 month (30 days) .The physician should be informed of a significant change in weight and may order nutritional interventions 3.1-37(a)

Based on observation, interview and record review, the facility failed to ensure compromised controlled substance medications were not stored in the medication cart for 2 of 4 medication carts observed for medication storage. (North cart and South cart) Findings include: 1. During an observation, on 12/18/24 at 10:45 a.m., the North medication cart had five compromised controlled substance cards. a. The clinical record for Resident 14 was reviewed on 12/18/24 at 11:35 a.m. The diagnoses included, but were not limited to, insomnia and anxiety disorder A card of quviviq (for insomnia) 25 milligram (mg) tablet for Resident 14 had clear tape covering the back of the number 6 slot. b. The clinical record for Resident 42 was reviewed on 12/18/24 at 11:40 a.m. The diagnoses included, but were not limited to, pain and anxiety. A card of oxycodone (for pain) 10 mg tablet for Resident 42 had a slit on the back of the card in the number 22 slot. A card of alprazolam (for anxiety) 1 mg tablet for Resident 42 had a slit on the back of the card in the number 23 slot. c. The clinical record for Resident 51 was reviewed on 12/18/24 at 11:47 a.m. The diagnoses included, but were not limited to, pain. A card of Norco (for pain) 10-325 mg tablet had a slit on the back of the card in the number 8 slot. d. The clinical record for Resident 23 was reviewed on 12/18/24 at 11:55 a.m. The diagnoses included, but were not limited to, pain. A card of tramadol (for pain) 50 mg tablet had a slit on the back of the card in the number 30 slot. During an interview, on 12/18/24 at 12:00 p.m., LPN 13 indicated there should not be tape or slits on the back of the cards. She did not look at the back of the cards when counting the narcotics. 2. During an observation, on 12/18/24 at 12:15 p.m., the South medication cart had one compromised controlled substance card. The clinical record for Resident 75 was reviewed on 12/18/24 at 12:35 p.m. The diagnoses included, but were not limited to, insomnia and anxiety disorder A card of Clonazepam (for anxiety) 0.5 mg had a slit on the back of the card in the number 29 slot. During an interview, on 12/18/24 at 12:00 p.m., Licensed Practical Nurse (LPN) 12 indicated the pills should not be taped or opened on the back of the cards. The pills should be destroyed by two nurses. During an interview, on 12/18/24 at 12:30 p.m., the Director of Nursing (DON) indicated the staff should not tape the backs of the narcotics cards. The pills needed to be destroyed. A current policy, titled Controlled Substance Administration & Accountability, dated 2024 and received from the DON on 12/19/24 at 9:43 a.m., indicated .Obtaining/Removing/Destroying Medication .The entire amount of controlled substances obtained or dispensed is accounted for. Two licensed staff must witness any disposal or destruction of a controlled substance and document same on the Drug Disposition Record, Control Drug Record, or via the automated dispensing system 3.1-25(n) 3.1-25(o)

Based on interview and record review, the facility failed to ensure pharmaceutical services were obtained and maintained timely to support a resident's healthcare needs for 1 of 5 residents reviewed for pain management. (Resident E) Finding includes: An Indiana Department of Health intake form indicated Resident E was made to detox from his medications. There was no physician's order to stop the medication, and the resident was discharged from the facility without his Multiple Sclerosis (a disease in which the immune system eats away at the protective covering of nerves) medication. The clinical record for Resident E was reviewed on 12/17/24 at 9:15 a.m. The diagnoses included, but were not limited to, Multiple Sclerosis, anxiety disorder, and muscle spasms of back. A Preadmission Screening and Resident Review (PASRR), dated 6/7/24, indicated Resident E would need support from staff to take his medications safely and correctly. A hospital history and physical, dated 6/13/24, indicated Buprenorphine (an opioid medication used to treat opioid use disorder, acute pain, and chronic pain) was on Resident E's current medication list. The resident was admitted to the facility from the hospital on 6/14/24. The hospital discharge orders, dated 6/14/24, indicated to continue to administer Buprenorphine 8 milligram (mg), 0.5 tablet three times a day. A physician's order, dated 6/17/24, indicated Resident E was to receive Buprenorphine 8 mg, 0.5 tablet three times a day for Multiple Sclerosis. The Medication Administration Record (MAR) indicated the Buprenorphine 0.5 tablet three times a day was not administered in the afternoon or evening of 6/27/24. A physician's order, dated 6/28/24, indicated Resident E was to take Buprenorphine 8 mg, 1.5 tablets one time a day. A physician's order, dated 7/8/24, indicated Resident E was to take Buprenorphine 8 mg and to give 4 mg three times a day. A nursing progress note, dated 7/9/24, indicated the medication had been held due to the administration instructions had been changed. A nursing progress note, dated 7/14/24 at 3:40 p.m., indicated the facility was out of the Buprenorphine. A nursing progress note, dated 7/16/24, indicated Resident E had asked about being out of his medication. The facility contacted the pharmacy and was informed a new prescription was needed before the pharmacy could fill the order. A nursing progress note, dated 7/17/24, indicated the Nurse Practitioner (NP) 10 agreed to send a new order of Buprenorphine with enough doses to last until 7/31/24. NP 10 was seeing other patients and would not send the order until the evening. The medication would not be available until 7/18/24. A nursing progress note, dated 7/21/24, indicated the facility received a fax from the pharmacy and the order for the medication needed clarified. A nursing progress note, dated 7/24/24, indicated the medication was unavailable and could not be administered. A nursing progress note, dated 7/25/24, indicated Resident E requested to be discharged early. The resident was discharged from the facility on 7/25/24. The medical record for Resident E indicated the resident missed 19 days of Buprenorphine. A facility discharge summary, dated 7/25/24, indicated medications were sent home with Resident E. The facility was to print and attach a copy of discharge medications to Resident E's discharge packet. A copy of the discharge medication list was not found in the discharge packet provided by the facility for review and no appointment for the pain clinic had been made. During an interview, on 12/17/24 at 11:47 a.m., the Director of Nursing (DON) indicated she was unaware the medication order of Buprenorphine was to be given for the resident's Multiple Sclerosis. During an interview, on 12/19/24 at 1:33 p.m., the Executive Director (ED) indicated the facility did not have any further information to submit regarding Resident E's medication or the facility being unable to obtain the medication from the pharmacy. A current facility policy, titled Pharmacy Services, dated 2024 and received from the DON on 12/19/24 at 8:35 a.m., indicated .It is the policy of this facility to ensure that pharmaceutical services, whether employed by the facility or under an agreement, are provided to meet the needs of each resident, are consistent with the state and federal requirements, and reflect current standards of practice .The process (including documentation, as applicable) of receiving and interpreting prescriber's orders; acquiring, receiving .reconciling .distributing, administering .of all medications .The facility will provide pharmaceutical services to include procedures that ensure accurate acquiring, receiving, dispensing, and administering of all routine and emergency drugs and biologicals to meet the needs of each resident, are consistent with state and federal requirements, and reflect current standards of practice .The licensed pharmacist will collaborate with facility leadership and staff to coordinate pharmaceutical services within the facility, guide development and evaluation of pharmaceutical services procedures, and help the facility identify, evaluate, and resolve pharmaceutical concerns which affect resident care, medication care, or quality of life .The pharmacist is responsible for helping the facility obtain and maintain timely and appropriate pharmaceutical services that support residents' healthcare needs, goals and quality of life that are consistent with current standards of practice and meet state and federal requirements. The pharmacist, in collaboration with the facility and medication director, should include within its services to .Develop mechanisms or communicating, addressing, and resolving issues related to pharmaceutical services .Strive to assure that medications are requested, received, and administered in a timely manner as ordered by the authorized prescriber (in accordance with state requirements), including physicians, advanced practice nurses, pharmacists, and physician assistants .The pharmacist, in collaboration with the facility and medical director, may include other aspects of pharmaceutical services such as .Development of procedures and guidance in relation to medication issues This citation relates to Complaint IN00439869. 3.1-25(a) 3.1-25(g)(1) 3.1-25(g)(2) 3.1-25(g)(3)

Based on interview and record review, the facility failed to ensure the SNF-ABN (Skilled Nursing Facility-Advanced Beneficiary Notice) forms were accurately completed for 2 of 3 residents discharged from Medicare services and remained in the facility. (Resident 45 and 91) Findings include: 1. The Advance Beneficiary Notice of Non-coverage (ABN) form for Resident 45 was reviewed on 12/13/24 at 2:03 p.m. On 10/8/24, the facility provided Resident 45 the ABN form which indicated their coverage was ending on 10/10/24. The form was blank in response to the options of coverage for physical therapy and occupational therapy. The blank section of the ABN form read as follows: Read this notice to make an informed decision about your care, ask any questions and choose an option below about whether to receive therapy. Check only one box. We cannot do this for you. There were no options chosen for this section of the form. 2. The ABN form for Resident 91 was reviewed on 12/13/24 at 2:03 p.m. On 12/4/24, the facility provided Resident 91 the ABN form which indicated their coverage was ending on 12/2/24. The form was blank in response to the options for remaining in the facility. The blank section of the SNF ABN form read as follows: Read this notice to make an informed decision about your care, ask any questions and choose an option below. Check only one box. We cannot do this for you. There were no options chosen for this section of the form. During an interview, on 12/16/24 at 10:48 a.m., the Business Office Manager (BOM) indicated the Social Service department was responsible for assisting the residents to complete the forms. The Business Office would only assist with completion of the forms if Social Services was not present at the time the forms were to be completed. She indicated if one form had an option chosen, then she would assume all the forms would have an option chosen. During an interview, on 12/16/24 at 10:53 a.m., the Social Service Director indicated one of the three options for coverage should have been chosen and should not have been blank. A current facility policy, titled Advance Beneficiary Notices, dated 2024 and received from the Executive Director on 12/19/24 at 12:15 p.m., indicated .Contents of the form shall comply with related instructions and regulations regarding the use of the form .The Business Office Manager, or designee, is responsible for issuing notices .Documentation shall comply with form instructions .A notice must be completed before delivery 3.1-4(f)(3)

Based on interview and record review, the facility failed to ensure Preadmission Screening and Record Review (PASARR) evaluations were updated and accurate for 2 of 4 residents reviewed for PASARR. (Resident 95 and 52) Findings include: 1. The clinical record for Resident 95 was reviewed on 12/16/24 at 8:56 a.m. The diagnoses included, but were not limited to, major depressive disorder, post-traumatic distress disorder, insomnia, and anxiety disorder. A PASARR notice of level I screen outcome, dated 10/23/24, indicated a Level II screen was not required. The rational for the determination indicated there was no evidence of a serious mental health condition. The PASARR level I screen indicated major depressive disorder was listed as a current mental health condition and the current mental health medications prescribed were duloxetine and bupropion for depression. The PASARR did not include the diagnoses of anxiety disorder, post-traumatic stress disorder, or insomnia. Physician's orders, dated 11/12/24, indicated Resident 95 was taking Buspirone 5 mg (milligrams) for anxiety disorder and trazadone 50 mg for insomnia. During an interview, on 12/18/24 at 11:57 a.m., the Social Service Director indicated the PASARR did not include the diagnoses of anxiety, post-traumatic stress disorder, or insomnia and was missing the medications buspirone and trazadone. 48525 2. The clinical record for Resident 52 was reviewed on 12/16/24 at 2:44 p.m. The diagnoses included, but were not limited to, anxiety disorder, post-traumatic distress disorder, depression, and adjustment disorder. A notice of PASARR level 1 screen outcome, dated 10/24/24, indicated no level 2 was required and no mental illness was suspected. The current mental health medications included aripiprazole (an antipsychotic medication) and duloxetine (an antidepressant medication). If changes occur or new information refuted these findings, a new screen must be submitted. Physician's orders, with a start date of 11/18/24, indicated clonazepam and buspirone (antianxiety medications) and zolpidem tartrate (a hypnotic medication for sleep). Clonazepam, buspirone and zolpidem were not included on the PASARR mental health medication section. During an interview, on 12/17/24 at 10:24 a.m., the Social Service Director indicated another PASARR would be completed if new psychotropic medications were added and another PASARR was not completed. A current facility policy, titled Resident Assessment - Coordination with PASARR Program, dated 2024 and received from the Executive Director on 12/17/24 at 10:35 a.m., indicated .All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening .Negative Level I Screen - permits admission to proceed and ends the PASARR process unless a positive serious mental disorder or intellectual disability arises later .Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review 3.1-16(d)(1)(A) 3.1-16(d)(1)(B)

Based on interview and record review, the facility failed to ensure the physician ordered parameters to hold blood pressure medications were followed for 1 of 1 resident reviewed for quality of care. (Resident 87) Finding includes: The clinical record for Resident 87 was reviewed on 12/16/24 at 8:35 a.m. The diagnoses included, but were not limited to, essential primary hypertension, type 2 diabetes mellitus with diabetic chronic kidney disease, chronic kidney disease stage 3, and dementia. A physician's order, dated 5/9/24 and discontinued 12/5/24 at 5:15 p.m., indicated to give diltiazem (a blood pressure medication) by mouth two times a day and to hold the medication for a systolic blood pressure less than 120. A physician's order, dated 12/6/24, indicated to give lisinopril (a blood pressure medication) by mouth one time a day and to hold the medication for a systolic blood pressure less than 120. A Medication Administration Record (MAR), dated October 2024, indicated diltiazem was given on 10/23/24 with a systolic blood pressure of 117. A Medication Administration Record (MAR), dated November 2024, indicated diltiazem was given on 11/22/24 with a systolic blood pressure of 109. A MAR, dated December 2024, indicated diltiazem was given, on 12/4/24, with a diltiazem was given on 12/4/24 with a systolic blood pressure of 105, on 12/5/24 with a systolic blood pressure of 115, and lisinopril was given on 12/15/24 with a systolic blood pressure of 118. During an interview, on 12/19/24 at 9:39 a.m., the Dementia Unit Manager 8 and LPN 9 indicated a check mark on the MAR indicated the medication had been given. If the blood pressure was below the ordered parameter, then the medication should have been held and marked with a code 3 or 7 to show it had not been given. A current facility policy, titled Medication Administration, received from the Director of Nursing (DON) on 12/19/24 at 12:02 p.m., indicated .When applicable, hold medication for those vital signs outside the physician's prescribed parameters 3.1-37(a)

Based on interview and record review, the facility failed to ensure an admission weight was obtained for 2 of 5 residents reviewed for nutrition. (Resident D and H) Finding includes: 1. The clinical record for Resident D was reviewed on 12/16/24 at 9:10 a.m. The diagnoses included, but were not limited to, type 2 diabetes mellitus, muscle wasting and atrophy, and chronic heart failure. A weight summary indicated Resident D weighed 284 pounds on 11/11/24. This was the first weight the facility recorded in the electronic medical record (EMR). Resident D was admitted on [DATE]. The resident was not weighed until 5 days after admission. The facility's clinical admission assessment, dated 11/6/24, included a spot to enter the weight. There was no weight entered. 2. The clinical record for Resident H was reviewed on 12/16/24 at 10:45 a.m. The diagnoses included, but were not limited to, muscle wasting and atrophy, essential hypertension, and morbid obesity. A weight summary indicated Resident H weighed 306 pounds on 12/13/24. This was the first weight the facility recorded in the EMR. Resident H was admitted on [DATE]. The resident was not weighed until 6 days after admission. The facility's clinical admission assessment, dated 12/9/24, included a spot to enter the weight. There was no weight entered. During an interview, on 12/19/24 at 9:56 a.m., Licensed Practical Nurse (LPN) 6 indicated the first day a resident was admitted an admission weight would be obtained. During an interview, on 12/19/24 at 10:16 a.m., Regional Dietician 11 indicated if the resident had a history of heart failure an admission weight would be obtained the day they were admitted . During an interview, on 12/19/24 at 11:25 a.m., LPN 7 indicated the day a resident was admitted , the facility would obtain an admission weight. The facility did not have a policy which addressed admission weights. 3.1-46(a)(1)

Based on observation, interview and record review, the facility failed to ensure policy and procedures were followed for medications administered through a gastrostomy tube (g-tube) for 1 of 1 resident reviewed for a gastrostomy tube. (Resident 67) Finding includes: During an observation, on 12/17/24 at 1:58 p.m., Registered Nurse (RN) 5 opened a medication capsule and poured the medicine into an unmeasured cup of water. RN 5 entered Resident 67's room and placed the cup with the medication, a piston (used to delivery medication into the g-tube) and a 10 milliliter (ml) syringe of normal saline solution on the bedside table. She removed the cap of the prefilled normal saline syringe and placed the end of the syringe to the g-tube port. RN 5 pushed the normal saline into the residents g-tube port, then took the larger piston and filled the piston with the medication. She then quickly pushed the medication into the g-tube. The clinical record for Resident 67 was reviewed on 12/13/24 at 11:35 a.m. The diagnoses included, but were not limited to, gastrostomy tube (g-tube) and dysphagia (difficulty swallowing). A physician's order, dated 8/20/24, indicated to check placement of the g-tube prior to medication administration and to flush the g-tube with 30 ml of water before and after the medication administration. A physician's order, dated 9/26/24, indicated to give gabapentin (a medication used for nerve pain) 400 milligram (mg) capsule via g-tube three times a day. During an interview, on 12/17/24 at 1:58 p.m., RN 5 indicated she flushed the g-tube with the prefilled normal saline solution syringe to make sure the tube was not clogged. She forgot to check placement or residual prior to the giving the medication. During an interview, on 12/17/24 at 2:14 p.m., the Director of Nursing (DON) indicated a prefilled normal saline solution syringe should not be used on a g-tube. The nurse should use water before and after the medication was given through a g-tube and not use normal saline. A current facility policy, titled Medication Administration via Enteral Tube, dated 2024 and received from the DON indicated .Verify physician orders for medication and enteral tube flush amount .Enteral tube placement must be verified prior to administering any fluids or medication .Flush enteral tube with at least 15 ml of water prior to administering medication unless otherwise ordered by prescriber. Dilute the solid or liquid medication .Flush tube again with at least 15 ml water taking into account resident's volume status .Flush the tube with a final flush of at least 15 ml of water to ensure drug delivery and clear the tube 3.1-44(a)(2)

Based on observation, interview and record review, the facility failed to ensure a physician's order, a care plan, a signed consent, and an assessment was obtained prior to the use of side rails for 1 of 7 residents reviewed for accidents. (Resident 95) Finding includes: During an observation and interview, on 12/12/24 at 10:07 a.m., Resident 95 was in his room lying in bed with bilateral side rails attached to the bed. He indicated the side rails were on the bed when he moved in, and he believed the side rails were to keep him from rolling out of the bed. The facility did not have him sign a consent for the use of the side rails. During an observation, on 12/13/24 10:14 a.m., Resident 95 was lying in bed with bilateral side rails attached to the bed. During an observation, on 12/16/24 at 11:31 a.m., Resident 95 was sitting up on the side of his bed with bilateral side rails attached to the bed. The clinical record for Resident 95 was reviewed on 12/16/24 at 8:56 a.m. The diagnoses included, but were not limited to, muscle wasting and atrophy, cellulitis of left lower limb, acquired absence of left great toe, and impaired balance. A physician's order, an informed consent, and an assessment for the use of the side rails were not found in the resident's medical record. A care plan, dated 11/17/24 and last revised 11/22/24, indicated Resident 95 had a self-care performance deficit. Interventions included, but were not limited to, providing limited assistance with bathing, dressing, toileting, personal hygiene, transfers, and bed mobility. Resident 95's care plans did not include the current use of the side rails. During an interview, on 12/16/24 at 2:19 p.m., the Director of Nursing (DON) indicated an assessment, and consent should be completed before side rails are attached to a resident's bed. Resident 95 was placed into a bed which already had the side rails attached and the facility did not obtain the consent and assessment. A current facility policy, titled Proper Use of Bed Rails, dated 2024 and received by the Executive Director (ED) on 12/17/24 at 12:16 p.m., indicated .It is the policy of this facility to utilize a person-centered approach when determining the use of bed rails. If bed rails are used, the facility ensures correct installation use and maintenance of the rails .Examples of bed rails include, but are not limited to side rails, bed side rails, safety rails, grab bars and assist bars 3.1-45(a)(1)

Based on observation, interview and record review, the facility failed to ensure staff wore PPE (personal protective equipment) and to ensure the correct isolation signs were posted for 2 of 3 residents reviewed for transmission-based precautions. (Resident 67 and 61) Finding includes: 1. During an observation, on 12/17/24 at 1:58 p.m., Registered Nurse (RN) 5 entered Resident 67's room to administer medication. The resident was in enhanced barrier precautions. RN 5 did not put on a gown when entering the room. The clinical record for Resident 67 was reviewed on 12/13/24 at 11:35 a.m. The diagnoses included, but were not limited to, hypoxia, cardiomegaly, anxiety disorder, pressure ulcers, gastrostomy tube (g-tube), and dysphagia (difficulty swallowing). A physician's order, dated 8/20/24, indicated enhanced barrier precaution with a sign outside the resident's room and to wear a gown and gloves for high contact resident care. A care plan, dated as revised on 10/25/24, indicated Resident 67 required enhanced barrier precautions. Interventions included, but were not limited to, follow enhanced barrier precaution guidelines as ordered, PPE for high-contact resident care and for residents with urinary catheters and feeding tubes. During an interview, on 12/17/24 at 1:58 p.m., Registered Nurse (RN) 5 indicated she should have put on an isolation gown. During an interview, on 12/17/24 at 2:35 a.m., Licensed Practical Nurse (LPN) 4 indicated a gown and gloves were required when providing care to Resident 67. Staff providing direct care to the resident was responsible to wear the proper PPE. 50956 2. During observations, on 12/12/24, 12/13/24, and 12/17/24, no enhanced barrier precautions (EBP) sign was noted outside Resident 61's room per the physician's order. During observations, on 12/18/24 and 12/19/24, both an enhanced barrier precautions and Contact Precaution signs were noted in the hallway outside the resident's door. The clinical record for Resident 61 was reviewed on 12/16/24 at 10:09 a.m. The diagnoses included, but were not limited to, enterocolitis due to clostridium difficile (C-diff), urinary tract infection, retention of urine, and benign prostatic hyperplasia with lower urinary tract symptoms. A current physician's order, dated 8/20/24, indicated enhanced barrier precautions were to be in place and a sign was to be outside the resident's room. A physician's order, initiated on 11/7/24 and completed on 12/7/24, indicated the resident was to be on contact precautions for enterocolitis due to clostridium difficile. A care plan, initiated 8/20/24, indicated Resident 61 required enhanced barrier precautions. Interventions included, but were not limited to, follow enhanced barrier precaution guidelines as ordered. During an interview, on 12/17/24 at 11:25 a.m., Licensed Practical Nurse (LPN) 2 indicated Resident 61 should be on contact precautions and a sign should be up outside the resident's door. During an interview, on 12/18/24 at 1:25 p.m., the Director of Nursing (DON) indicated both contact precaution and enhanced barrier precautions signs were in place outside of Resident 61's door. The enhanced barrier precautions sign was placed to the left of the door and the contact precaution sign was placed to the right over a personal protective equipment (PPE) cart. She indicated staff were to follow the contact precautions. During an interview, on 12/19/24 at 9:42 a.m., CNA 2 indicated Resident 61 was on contact precautions and staff were to wear gowns and gloves every time they entered the room. During an interview, on 12/19/24 at 9:45 a.m., LPN 3 indicated there was a current physician's order for enhanced barrier precautions. The order for contact precautions was completed on 12/7/24 and the contact precaution sign should not be outside the resident's door. A current facility policy, titled Enhanced Barrier Precautions, dated 3/20/24 and received from the Executive Director (ED) on 12/17/2024 at 4:04 p.m., indicated .Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multi-drug resistant organisms that employs targeted gown and gloves use during high contact resident care activities .An order for enhanced barrier precautions will be obtained for residents with any of the following .wounds .feeding tubes .Implementation of Enhanced Barrier Precautions .PPE for enhanced barrier precautions .when performing high-contact care activities .High-contact resident care activities include .Device care or use .feeding tubes .Wound care A current facility policy, titled Transmission-Based (Isolation) Precautions, dated May 2024 and received from the DON on 12/19/24 at 12:02 p.m., indicated .contact precautions refer to measures that are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment .Initiation of Transmission-Based Precautions .signage that includes instructions for use of specific PPE will be placed in a conspicuous location outside the resident's room 3.1-18(b)

Based on interview and record review, the facility failed to ensure staff were being supervised when a staff member physically kicked a resident in his back for 1 of 3 residents reviewed for abuse. (Resident B) The deficient practice was corrected on 10/15/2023, prior to the start of the survey, and was therefore past noncompliance. Finding includes: An incident report to the Indiana Department of Health indicated a staff member struck Resident B in the back while he was standing next to the medication cart in the facility. The resident complained of back pain, on 10/3/2023, after the kick to his back. The resident was sent to the hospital for evaluation per physician's order, on 10/3/2023. The staff member was suspended when the hospital staff indicated the resident alleged abuse by the staff member. Family was notified and the investigation continued. The resident returned to the facility with no new orders from the hospital and was not admitted to the hospital. The local police department was notified of the abuse allegation. The record for Resident B was reviewed on 10/25/2023 at 10:31 a.m. Diagnoses included, but were not limited to, discitis (an infection of the intervertebral disc space) of the lumbosacral region, osteomyelitis (inflammation of the bone) of the vertebra and lumbar region, electrocution, chronic pain, and acquired absence of the left and right upper limbs. An emergency room (ER) report from the hospital, dated 10/3/2023, indicated no acute fracture or traumatic subluxation was identified. Vertebral body heights were preserved. Sacral joints were congruent. The impression was no evidence of acute fracture or traumatic subluxation of the lumbar. The police were notified and spoke with the resident. The resident spoke with the facility, and he returned to the facility with no new orders. In a facility investigation note, dated 10/3/2023, Staff Member 3 indicated the resident came to her around 8:00 p.m., and indicated Staff Member 2 ran up to him jokingly and kicked him in the back while he was at the medication cart earlier in the day. He did not report it until now because Staff Member 2 asked him not to report the incident. The resident said he had called his lawyer and his lawyer wanted him to have an x-ray. Staff Member 3 notified the Director of Nursing (DON) and began an investigation. In a facility investigation note, dated 10/3/2023, Staff Member 2 indicated she did jokingly kick the resident in his back, on 10/3/2023 at 5:00 p.m., while he was standing near the nurses medication cart on the south hall. She meant to kick the medication cart but missed and kicked the resident instead. She indicated the resident was in some pain but was not eligible for pain medication for another hour. The resident was okay with the incident and knew it was not intentional and she was just playing around. She did not report the incident. In a facility investigation note, dated 10/4/2023, Staff Member 4 indicated she was at the nursing medication cart with the resident at 5:00 p.m., on 10/3/2023, when Staff Member 2 came walking by and playfully kicked her foot up and her foot made contact with the residents lower back area. The resident was not upset nor in pain. The resident signed himself out of the facility to go and play with his dog outside. Later in the evening, around 7:30 p.m., the resident complained of pain in the lower back area. The area was red, no bleeding was noted, and medication was given to the resident for pain. The staff member did not report the incident. A facility investigation note, dated 10/3/2023 at 11:25 p.m., indicated during an interview with the Executive Director (ED) and the resident, the resident indicated he did feel the staff member intended to kick him but not to cause him any harm. It was a lack of professionalism from Staff Member 2. She was just playing around and made a bone head move. He was not afraid of Staff Member 2 and was not afraid to be at the facility. A facility investigation note, dated 10/3/2023 at 11:30 p.m., indicated during an interview with the DON and the resident while the resident was in the hospital ER, the resident indicated he felt a jolt on his back while he was standing at the medication cart. The resident indicated he was kicked by Staff Member 2 with her boot to his back. The resident indicated it could have been unintentional. The resident indicated he was not afraid of Staff Member 2. She meant him no harm. The x-rays of his back were okay, and the police had been notified. He felt safe to return to the facility. A facility investigation note, dated 10/4/2023 at 8:30 a.m., indicated during an interview with the ED and the resident, the resident indicated he did not want to talk without his lawyer present. The resident did indicate he and Staff Member 2 were friends and he felt bad he got her into trouble. He indicated he felt safe at the facility and wanted to stay until he was discharged . A staff member notification, dated 10/3/2023, indicated Staff Member 2 was suspended pending investigation of an alleged abuse allegation. Staff member 2 made contact with a resident's back potentially causing injury and did not report the unusual occurrence immediately. A staff member notification, dated 10/5/2023, indicated Staff Member 2 was terminated. Staff Member 2 made contact with a resident's back potentially causing injury and did not report the unusual occurrence immediately. A staff member notification, dated 10/4/2023, indicated Staff Member 4 was given disciplinary action for not reporting an unusual occurrence which involved a violation of safety rules. During an interview, on 10/25/2023 at 1:19 p.m., the ED indicated Staff Member 2 kicked Resident B in his back. Resident B was sent to the ER for evaluation after complaining of pain 3 hours after the incident occurred. His x-rays were negative for trauma or a fracture. Staff Member 2 was suspended immediately and then terminated after the investigation. Staff Member 4 received disciplinary action for not immediately starting an investigation when the incident occurred. During an interview, on 10/25/2023 at 2:47 p.m., the DON indicated she was not notified of the abuse allegation until 3 hours after the incident occurred. The staff thought Staff Member 2 was horseplaying with the resident and he had no pain nor was upset about the incident. The resident complained of pain and requested an x-ray of his back which was when they notified her of the incident. The deficient practice was corrected, by 10/15/23, after the facility implemented a systemic plan that included the following actions: The facility investigated the incident involving Resident B and the abuse allegation, terminated Staff Member 2, educated the staff on abuse, residents rights and professionalism and the facility began audits on residents which included skin assessments and interviews. This Federal tag relates to Complaint IN00418925. 3.1-45(a)(2)

Based on interview and record review, the facility failed to notify residents' family representatives prior to staff spending the residents' personal funds for 4 of 4 residents reviewed for protection of resident funds. (Residents B, E, F and D) Findings include: A facility incident report, dated 9/12/23, indicated Unit Manager 10 was utilizing Kohl's cash which was rewarded when purchasing resident items to assist them in spending down their resident accounts. During the investigation, it was discovered Unit Manager 10 had purchased items for 4 residents between 2022-2023 and had received Kohl's cash during the purchases and it was not returned to the residents. 1. The record for Resident B was reviewed on 9/27/23 at 5:02 p.m. Diagnoses included, but were not limited to, anxiety disorder, bipolar disorder, cognitive communication disorder, and depressive disorder. During an interview, on 9/28/23 at 11:49 a.m., the Business Office Manager (BOM) indicated the Social Service Director (SSD) and Unit Manager 10 were able to shop for the residents. They would go to the BOM and request money. They would ask for $1,000.00 or more to shop for the residents' personal items. The families were not notified of the funds being removed from the personal accounts. 2. The record for Resident E was reviewed on 9/27/23 at 3:59 p.m. Diagnoses included, but were not limited to, dementia, anxiety disorder, and depressive disorder. During an interview, on 10/02/23 at 9:09 a.m., the Executive Director (ED) indicated the families were not notified of the money taken out of the resident's funds. 3. The record for Resident F was reviewed on 9/27/23 at 4:0 p.m. Diagnoses included, but were not limited to, dementia with agitation, anxiety disorder, and delusional disorders. An email, dated 8/2/22 at 2:52 p.m., indicated the family representative asked to be informed of all purchases made on the resident's behalf. During an interview, on 9/28/23 at 11:49 a.m., the BOM indicated the former Activity Director was the one mainly shopping for the resident. Unit Manager 10 would shop for the residents on the dementia unit. The staff would request money for the residents. They would provide receipts and bring in the purchased item. 4. During an interview, on 9/27/23 at 4:07 p.m., Resident D's family member indicated the BOM gave permission to Unit Manager 10 to use the resident's money to buy clothes for the resident. The facility did not get her consent to spend the money. Unit Manager 10 had spent some of the money for herself. The record for Resident D was reviewed on 9/27/23 at 4:07 p.m. Diagnoses included, but were not limited to, dementia, generalized anxiety disorder, down syndrome, and a communication deficit. During an interview, on 10/2/23 at 9:09 a.m., the ED indicated Unit Manager 10 only admitted to using 360 dollars of [NAME] cash and she was aware there was a lot more than Unit Manager 10 admitted to. The Power of Attorney (POA) was not notified prior to shopping. A current policy, titled Resident Personal Funds, dated 2023 and received from the ED on 9/28/23 at 10:56 a.m., indicated .The resident has a right to manage his or her financial affairs to include the right to know, in advance, what charges a facility may impose against a resident's personal funds .The facility will establish and maintain a system that assures a full and complete and separate accounting, according to generally accepted accounting principles, of each resident's person funds entrusted to the facility on the resident's behalf .The individual financial record must be available to the resident through quarterly statements and upon request This Federal Tag relates to Complaint IN00418241. 3.1-6(e)

Based on interview and record review, the facility failed to ensure residents' personal property was not used by staff for 4 of 4 residents reviewed for misappropriation of property. (Residents B, E, F and D) Findings include: A facility incident report, dated 9/12/23, indicated Unit Manager 10 was utilizing Kohl's cash which was rewarded when purchasing resident items to assist them in spending down their resident accounts. During the investigation, it was discovered Unit Manager 10 had purchased items for 4 residents between 2022-2023 and had received Kohl's cash during the purchases and it was not returned to the residents. 1. The record for Resident B was reviewed on 9/27/23 at 5:02 p.m. Diagnoses included, but were not limited to, anxiety disorder, bipolar disorder, cognitive communication disorder, and depressive disorder. A Withdrawal Transaction Report for a Kohl's receipt, dated 10/8/22, indicated Unit Manager 10 was using her personal account and receiving Kohl's cash and Kohl's rewards. The amount Unit Manager 10 received was Kohl's cash of $400.00 and Kohl's rewards of $106.73. During an interview, on 9/29/23 at 3:32 p.m., the Executive Director (ED) indicated she took the Kohl's receipts and verified the receipts with the items in the resident's room. The item on the receipt indicated a bottle of Juicy [NAME] cologne was purchased for $119.00. The items purchased did not get put on the resident's inventory sheet, however the ED indicated the facility took the receipts and matched the items on the receipt with what was in the residents room. The Juicy [NAME] cologne was not verified. During an interview, on 9/28/23 at 11:49 a.m., the Business Office Manager indicated the former Activity Director was the one mainly shopping for the resident. Unit Manager 10 would shop for the residents on the dementia unit. The staff would come to her and request money. The residents had to spend down their money so nothing was really said. They would provide receipts and bring in the purchased items. They would ask for 1000's of dollars before and now anything over $300 must be approved by the ED. The families were not called to notify them of the funds being removed from the resident's account. 2. The record for Resident E was reviewed on 9/27/23 at 3:59 p.m. Diagnoses included, but were not limited to, dementia, anxiety disorder, and depressive disorder. A Withdrawal Transaction Report for a Kohl's receipt, dated 8/26/23, indicated Unit Manager 10 was using her personal account and receiving Kohl's cash and Kohl's rewards. The amount Unit Manager 10 received was Kohl's cash of $360.00 and Kohl's rewards of $91.88. 3. The record for Resident F was reviewed on 9/27/23 at 4:0 p.m. Diagnoses included, but were not limited to, dementia with agitation, anxiety disorder, and delusional disorders. A Withdrawal Transaction Report for a Kohl's receipt, dated 8/26/23, indicated Unit Manager 10 was using her personal account and receiving Kohl's cash and Kohl's rewards. The amount Unit Manager 10 received was Kohl's cash of $400.00 and Kohl's rewards of $11.68. 48525 4. During an interview, on 9/27/23 at 4:07 p.m., Resident D's family member indicated the BOM gave permission for Unit Manager 10 to use the resident's money to buy clothes for the resident. The facility did not get her consent to spend the money. Unit Manager 10 had spent some of the money for herself. The record for Resident D was reviewed on 9/27/23 at 4:07 p.m. Diagnoses included, but were not limited to, dementia, generalized anxiety disorder, down syndrome, and a communication deficit. An investigation report, dated 9/25/23, indicated Unit Manager 10 made the following purchase, on 8/8/22 at 7:12 p.m.: a. The receipt total was $1,122.32. b. Unit Manager 10's charge card ending in 4201 was charged $300. c. The rest of the bill was paid with the resident's funds totaling $900 in cash. $77.68 was issued in change. d. A total of $200 in Kohl's cash was issued. The $200 [NAME] cash was not returned to the resident. An investigation report, dated 9/25/23, indicated Unit Manager 10 made a purchase which used $900 from the resident's funds. $160 in Kohl's cash was issued. The $160 in Kohl's cash was not returned to the resident. During an interview, on 10/2/23 at 9:09 a.m., the ED indicated Unit Manager 10 only admitted to using $360 of [NAME] cash and she was aware there was a lot more than Unit Manager 10 admitted to. The Power of Attorney (POA) was not notified prior to shopping. During an interview, on 9/28/23 at 11:49 a.m., the Business Office Manager indicated the former Activity Director was the one mainly shopping for the residents. Unit Manager 10 would shop for the residents on the dementia unit. The staff would request money for the residents. They would provide receipts and bring in the purchased items. They would ask for 1000's of dollars before. The families were not called to notify them of the funds being removed from the resident's account. A current policy, titled Abuse, Neglect and Exploitation, dated 2023 and received from the ED on 9/29/23 at 4:46 p.m., indicated .by developing and implementing written policies and procedures that prohibit an prevent abuse, neglect, exploitation and misappropriation of resident property .Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent This Federal Tag relates to Complaint IN00418241. 3.1-28(a)

Based on observation, interview and record review, the facility failed to ensure activities were offered daily for 5 of 5 residents reviewed for activities. (Resident 18, 23, 29, 43 and 85) Findings include: 1. During an interview, on 9/28/23 at 1:34 p.m., Resident 18 indicated there had been a volunteer coming in twice a week for bingo. They had not had an Activity Director for months. The record for Resident 18 was reviewed on 9/29/23 at 4:16 p.m. Diagnoses included, but were not limited to, depressive disorder, anxiety disorder, hypertension, and heart failure. A care plan, dated 12/24/19, indicated the resident made their activity interests known. Interventions included, but were not limited to, enjoyed attending group functions such as bingo, trivia, and parties/socials at her discretion. A documentation survey report, for 9/1/23 to 9/28/23, indicated the resident participated in 8 activities marked for dayshift and 3 activities marked for evening shift. 2. During an interview, on 9/28/23 at 1:35 p.m., Resident 23 indicated she was so bored and depressed because she had nothing to do. The record for Resident 23 was reviewed on 9/2/23 at 4:16 p.m. Diagnoses included, but were not limited to, anxiety disorder, bipolar disorder, and hypertension. A care plan, dated 11/17/21, indicated the resident made their activity interests known. Interventions included, but were not limited to, enjoyed attending group functions such as socials, spiritual programs, resident council, bingo/other games, and exercise at her discretion and parties/socials at her discretion. A documentation survey report, for 9/1/23 to 9/28/23, indicated the resident participated in 8 activities marked for dayshift and 1activity marked for evening shift. 3. During an interview, on 9/28/23 at 1:37 p.m., Resident 29 indicated all the facility had to do was bingo twice a week. The record for Resident 29 was reviewed on 10/2/23 at 4:16 p.m. Diagnoses included, but were not limited to, depressive disorder, anxiety disorder, bipolar disorder, and schizophrenia. A care plan, dated 3/27/23, indicated the resident had personal preferences and activities of interest. Interventions included, but were not limited to, it was important for the resident to make her own decisions related to group activities and her level of participation. A documentation survey report, for 9/1/23 to 9/28/23, indicated the resident participated in 8 activities marked for dayshift and 2 activities marked for evening shift. 4. During an observation, on 9/29/23 at 9:23 a.m., the resident was lying in her bed. She indicated no activities were offered to her yesterday or today and she was bored. During an interview, on 9/26/23 at 12:10 p.m., Resident 43 indicated she enjoyed doing activities and had not participated in them for a while. The Activity staff quit and had been gone for a few months. The only activity they had was bingo once or twice a week and a volunteer came in for bingo. The record for Resident 43 was reviewed on 9/2/23 at 4:16 p.m. Diagnoses included, but were not limited to, depressive disorder, anxiety disorder, hypertension, and heart failure. A care plan, dated 12/24/19, indicated the resident made their activities of interest known. Interventions included, but were not limited to, enjoyed attending group functions such as bingo, trivia, and parties/socials at her discretion. A documentation survey report, for 8/24/23 to 9/14/23, indicated the resident participated in 3 activities marked for dayshift. During an interview, on 9/28/23 at 11:49 a.m., the Business Office Manager indicated the previous Activity Director was no longer employed and it had been several months since there had been an Activity Director for the skilled side of the building. During an interview, on 9/29/23 at 8:40 a.m., the Director of Nursing Services (DNS) indicated they hired two different people for activities and they both quit. The old Activities Director quit without notice a few months ago. The facility had a volunteer coming in twice a week for bingo and a lady once a month played a [NAME] during meals. The skilled side did not have activities and the dementia unit did. She could not pull activities from the dementia unit. The dementia unit went to Indiana beach on an outing and the skilled side had not been on any outings. During an interview, on 9/29/23 at 9:12 a.m., the DNS indicated they offered the residents coloring pages and bingo twice a week. During an interview, on 10/02/23 at 10:00 a.m., the Executive Director (ED) indicated she was aware activities was an issue. 36454 5. During an observation, on 9/27/23 at 10:52 a.m., Resident 85 was lying in bed in his room. During an observation, on 9/28/23 at 1:41 p.m., the resident was lying in bed in his room with his eyes closed. The television was on. During an observation, on 9/29/23 at 12:32 p.m., the resident was lying in bed in his room with his eyes closed. The television was on. During an observation, on 10/3/23 at 9:59 a.m., the resident was lying in bed with his eyes closed. The room was darkened, the television was not on and there was no reading material on his bedside table, nightstand, or dresser. The record for Resident 85 was reviewed on 9/29/23 at 3:52 p.m. Diagnoses included, but were not limited to, bipolar disorder with current episode depressed, type 2 diabetes mellitus with diabetic neuropathy, generalized anxiety disorder, weakness, and mild cognitive impairment of an unknown cause. A care plan, dated 6/26/23, indicated the resident had impaired cognitive function as evidenced by a diagnosis of mild cognitive impairment of an unknown cause. The interventions included, but were not limited to, involve in activities not dependent on the resident's ability to communicate, music, parties, games and involve in enjoyable activities which orient to reality. An activity assessment, dated 6/17/23, indicated the resident's leisure preferences included reading, television, music, and visiting with family. An activity report, dated August 2023, indicated the resident had activities on 8/5, 8/6, 8/12, 8/13, 8/19, 8/26 and 8/27/23. This was a total of 7 days out of 31. An activity report, dated September 2023, indicated the resident had activities on 9/1, 9/2, 9/3, 9/9, 9/10, 9/11, 9/16, 9/17, 9/24 and 9/25. This was 10 days out of 30 days. During an observation and interview, on 10/3/23 at 10:50 a.m., an anonymous staff indicated the resident did not have any reading material in his room currently. He did like the daily handout provided by the facility although for some reason he did not have one in his room. There was no reading material on his dresser, nightstand or on his bedside table. He would play bingo sometimes. During an interview, on 10/3/23 at 11:27 a.m., the Director of Nursing Services (DNS) indicated the resident's son was very active and would bring stuff in and out of the resident's room. The resident would go to bingo sometimes. During an interview, on 10/3/23 at 11:39 a.m., the DNS indicated the facility had not had a full-time staff for activities since June 2023. The Executive Director (ED) indicated they had volunteers twice a week for bingo. There was music entertainment once monthly and therapy animals every 2 weeks. A current policy, titled Activities, dated 2023 and received from the Medical Record staff on 10/2/23 at 10:00 a.m., indicated .It is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. Facility-sponsored group, individual, and independent activities will be designed to meet the interests of each resident, as well as support their physical, mental and psychosocial well-being. Activities will encourage both independence and interaction with the community .'Activities' refer to any endeavor, other than routine ADLs [activities of daily living], in which a resident participates that is intended to enhance her/his sense of well-being and to promote or enhance physical cognitive, and emotional health. These include, but are not limited to activities that promote self-esteem, pleasure, comfort, education, creativity, success, and independence .Each resident's interest and needs will be assessed on a routine basis .Activities will be designed with the intent to .Enhance the resident's sense of well-being, belonging, and usefulness .Create opportunities for each resident to have a meaningful life .Promote or enhance physical activity .Promote or enhance cognition .promote or enhance emotional health .Reflect resident's interests and age .Reflect choices of the resident .Activities will include individual, small and large group activities as well as .Indoor and Outdoor Activities .Activities away from the facility .Religious Programs .Exercise Programs .Community Activities .Social Activities .In-Room Activities .Individualized Activities .Educational Programs 3.1-33(a) 3.1-33(b)(1) 3.1-33(b)(2) 3.1-33(b)(3) 3.1-33(b)(4) 3.1-33(b)(5) 3.1-33(c)

Based on interview and record review, the facility failed to notify the physician of a blood glucose level greater than the physician's call orders for 1 of 1 resident reviewed for notification. (Resident B) Finding includes: The record for Resident B was reviewed on 9/27/23 at 5:02 a.m. Diagnoses included, but were not limited to, type 2 diabetes mellitus and dependence on renal dialysis. A care plan, dated 11/27/20, indicated the resident was at risk for alteration in blood glucose due to diabetes mellitus. The interventions included, but were not limited to, give insulin per order, report abnormal results per parameters/guidelines. A physician's order, dated 9/17/22, indicated to give Lispro (insulin for blood glucose levels) solution 100 unit/ml(milliliter). Inject the insulin as per sliding scale if the blood glucose levels were as follows: a. 150-200 = 1 units. b. 201-250 = 2 units. c. 251-300 = 3 units. d. 301-350 = 4 units. e. 351-400 = 5 units. Call the physician if the blood glucose levels were less than 70 or more than 400. A facility vital sign document indicated the following blood glucose levels: a. The blood glucose level, on 4/10/23, was 446. The physician was not notified. b. The blood glucose level, on 4/14/23, was 475. The physician was not notified. c. The blood glucose level, on 4/21/23, was 423. The physician was not notified. d. The blood glucose level, on 9/24/23, was 447. The physician was notified 3 days later, on 9/29/23. There was no documentation to indicate the physician was notified of the blood glucose levels out of the call parameter. During an interview, on 10/3/23 at 11:16 a.m., the Nurse Manager indicated if a blood glucose level was out of range, they would call their endocrinologist. The nurses would sometimes take a second blood glucose level when they received a high reading. It was preferred, the nurses not chart a high blood glucose level until they have tested it twice. The facility policy indicated when a resident had a blood glucose level out of the physician's call orders, the nurse should call the physician if it was out of the range. During an interview, on 10/3/23 at 4:14 p.m., the Director Nursing Services (DNS) indicated the facility did not contact the physician with the blood glucose levels above 400. A current policy, titled Blood Glucose Monitoring, revised 2022 and received from the Director of Nursing on 10/3/23 at 9:00 a.m., indicated .The facility will perform blood glucose monitoring as per physician's orders .Verify the physician's orders .Report critical test results to physician timely .Document the procedure 3.1-5(a)(2) 3.1-5(a)(3)

Based on observation, interview and record review, the facility failed to ensure residents were dressed in regular clothing like other residents unless their preferences were identified for alternative clothing for 1 of 1 resident reviewed for dignity. (Resident 75) Finding includes: During an observation, on 9/28/23 at 1:15 p.m., Resident 75 was in her room, sitting in her wheelchair. She was wearing a hospital gown and had a blanket covering her legs. During an observation, on 9/28/23 at 3:44 p.m., the resident was in a wheelchair propelling herself in the hallway and common area wearing a hospital gown. The other residents in the facility were observed wearing regular clothing. The record for Resident 75 was reviewed on 9/27/23 at 4:39 p.m. Diagnoses included, but were not limited to, fracture of the right femur (thigh bone), chronic obstructive pulmonary disease, and post-traumatic stress disorder. A resident personal belongings inventory sheet, dated 9/13/23 and signed by the resident, indicated one black sleeveless top, one brownish colored pair of slippers, one white [NAME] sweater, one pair of black biker shorts, two brushes, one black cell phone, one charger and extra black box, two (2) word search books, and one coloring book. A care plan for wearing a hospital gown in the hallway and common areas was not located. During an interview, on 9/29/23 at 3:11 p.m., the resident indicated she preferred to wear her clothes and did not like to wear a gown in the halls. The resident was admitted with one pair of yellow pants, one red shirt, and a pair of white socks. There were no clothes in her room and the staff told her they were down in the laundry being washed. She indicated they had not washed her clothes since she had been there. During an interview, on 9/29/23 at 3:13 p.m., the Executive Director (ED) and the Director of Nursing (DNS) indicated last Friday they had a conversation with the resident about calling her loved one to bring clothes in. They both indicated her family brought clothes into her. On 9/28/23, there was a late note put in, for 9/27/23, indicating the resident's clothes were being labeled and in the laundry. During an interview, on 9/29/23 at 3:20 p.m., the ED and DNS asked the resident if she remembered talking to them. The ED and DNS asked if they could get clothes for her. The DNS and ED asked the resident if she called her loved one to bring her clothes as was mentioned in their conversation. During an interview, on 9/29/23 at 3:21 p.m., the resident indicated she remembered talking to them. The resident did not call her loved one to bring in the clothes and her boyfriend never brought her clothes. The resident indicated she wanted to wear something other than a hospital gown. During an interview, on 9/29/23 at 3:35 p.m., the resident indicated she only had the outfit she was admitted to the facility. She came with one pair of yellow pants, one red shirt, and one pair of white socks. Her boyfriend did not bring her clothes. She was wearing a Colts short sleeved shirt, a white pair of pants, and a pair of short white socks given to her by staff. During an interview, 9/29/23 at 3:09 p.m., the Clinical Support Nurse indicated there was no care plan or documentation to indicate the resident's preference was to wear a hospital gown. A current policy, titled Resident Rights, not dated and received from the ED at the entrance conference, indicated .The facility will inform the resident both orally and in writing in a language that the resident understands of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility 3.1-3(t)

Based on interview and record review, the facility failed to provide mental health services to a resident with a [DIAGNOSES REDACTED]. (Resident C) This resulted in harm when Resident C received a self-inflicted wound and was admitted to a psychiatric hospital. Finding includes: The record for Resident C was reviewed on 2/8/2021 at 2:13 p.m. [DIAGNOSES REDACTED]. An admission Election of Ancillary Services, not dated, indicated the resident agreed to behavioral health services. A physician's orders [REDACTED]. A Minimum Data Set (MDS) assessment, dated 11/6/2020, indicated the residents PHQ 9 (patient health questionnaire) was 10. The score of 10 indicated the resident was exhibiting moderate symptoms of depression. A Psychosocial Assessment, dated 11/4/2020, indicated the resident's Mood or Behavior concerns since last assessment included, but were not limited to, the resident scored a 10 on the PHQ-9. She was feeling down and depressed, feeling like she failed, feeling fidgety and restless and had trouble falling asleep. The resident was offered mental health services for depression and anxiety. A referral was made to (name of company). The discharge plan was for the resident to remain in the facility for Long Term Care. The resident managed her own health care and financial decision making. A care plan, dated 11/5/2020, indicated the resident had a [MEDICAL CONDITION] and anxiety which was evidenced by the resident feeling down and depressed, difficulty falling asleep, poor appetite, feeling like a failure, trouble concentrating and feeling fidgety and restless. The goal was to minimize the depressed and anxious symptoms. The interventions included, but were not limited to, refer to (name of company) for psychiatric and counseling, go on scheduled smoke breaks and take prescribed [MEDICATION NAME] (an anti-anxiety medication), quietiapine and [MEDICATION NAME] (an antidepressant medication). A care plan, dated 11/6/2020, indicated the resident expressed comments regarding the times and dosing of her medications and exhibited negative attention seeking behaviors with being controversial to provoke a reaction. The goal, dated 11/6/2020, indicated the resident would be given her medications and be agreeable with the physician orders. Approaches included, but were not limited to, consult with the physician regarding times and dosing of medications, consult with the resident as needed, do not reinforce the negative behaviors and ignore when safe to do so, give the consequences of her actions when appropriate, give the resident ample time to express her wishes regarding medication times and respect the resident's right to change the times and doses of medications as long as the physician approves. A physician's progress note, dated 11/5/2020, indicated the present illnesses included, but were not limited to, major [MEDICAL CONDITION] and chronic pai[DIAGNOSES REDACTED]. The past medical history included, but was not limited to, major [MEDICAL CONDITION]. The review of systems included the psychiatric symptoms of anxiety and depression were present. The medications included, but were not limited to, [MEDICATION NAME] 20 mg daily, [MEDICATION NAME] (an antidepressant medication) 50 mg once a day and quetiapine 50 mg at bedtime. The assessment included, but was not limited to, recurrent major [MEDICAL CONDITION]. A Social Services progress note, dated 11/17/2020 at 11:15 a.m., indicated the resident had been referred for psychiatric services and therapy with (name of company). The resident had declined all other ancillary services. There was no other documentation in Resident C's record to indicate behavioral health services were initiated or behavioral monitoring for increased depression and anxiety were put in place. A progress note, dated 1/8/2021 at 2:33 p.m., indicated the resident had refused physical therapy and stated she was depressed. A Change of Condition note, dated 2/2/2021 at 1:05 p.m., indicated another resident had called out for help to Resident's C's room since she was trying to cut herself. There was a pair of scissors with the handles protruding from the resident's mid chest. A (name of hospital) note, dated 2/2/2021, indicated the resident had a stab wound in the superficial tissues of the chest on the left side, a psychiatric work up would be continued and a psychiatric hospitalization was anticipated. The resident had a history of [REDACTED]. The admission [DIAGNOSES REDACTED]. A physician's note, dated 2/4/2021, indicated it was an addendum to the progress note on 11/5/2020. The resident was stable and doing well from a psychiatric stand point. The medications for the psychiatric condition were [MEDICATION NAME] 20 mg daily, [MEDICATION NAME] 50 mg daily and [MEDICATION NAME] 1 mg three times daily. A psychiatric services consult was suggested and the resident refused. The physician's note, dated 2/4/2021 did not include the quetiapine 50 mg at bedtime for the [DIAGNOSES REDACTED]. A progress note, dated 2/5/2021 at 11:30 a.m., indicated the hospital stated a 10 day stay was anticipated with counseling daily. The resident's family thought she needed mental health services for longer than 10 days. The facility instructed the family they were unable to provide the care the resident needed and the resident would require one to one supervision for a while to ensure her safety. Before the hospitalization , the facility was looking into placement for the resident in an Assisted Living facility since her level of care wasn't appropriate for Skilled Nursing placement and the Skilled Nursing environment might contribute to her mental health concerns. During an interview, on 2/9/2021 at 1:47 p.m., the Director of Nursing (DON) indicated Resident C had used her own craft scissors to stab herself. The physician had recommended psychiatric services, the resident stated she did not need it and the physician did not write orders for psychiatric services on 11/5/2020. The DON did not include if the SSD (social services director) had completed a referral for psychiatric services on 11/17/2020. During an interview, on 2/10/2021, the SSD indicated the facility had changed providers for psychiatric services, he had given a referral for the psychiatric services to the nursing staff and the referral was lost. The resident did not receive psychiatric services. A current policy, titled Behavioral Health Services, not dated and received from the DON on 2/10/2021 at 3:00 p.m., indicated .It is the policy of this facility that all residents receive necessary behavioral health care and services to assist him or her to reach and maintain the highest level of mental and psychosocial functioning .Behavioral health encompasses a resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of [REDACTED].The facility utilizes the comprehensive assessment process for identifying and assessing a resident's mental and psychosocial status and providing person-centered care. This process includes .PASARR screening .Obtaining history from medical records, the family, and the resident regarding mental, psychosocial, and emotional health .MDS and care area assessments .Ongoing monitoring of mood and behavior .Care plan development and implementation .Evaluation .Behavioral health care and services shall be provided in an environment that promotes emotional and psychosocial well-being, supports each resident's needs and includes individualized approaches to care .The Social Services Director shall serve as the facility's contact person for questions regarding behavioral services provided by the facility and outside sources such as physician, psychiatrists, or neurologist This Federal Tag relates to Complaint IN 846. 3.1-43(a)(1)

Based on interview and record review, the facility failed to obtain a urinalysis and culture and sensitivity sample in a timely manner for 1 of 3 residents reviewed for laboratory samples (Resident G). Resident G was admitted to the hospital for a Urinary Tract Infection [MEDICAL CONDITIONS]. Finding includes: The record review was completed for Resident G on 10/10/19 at 1:00 p.m. [DIAGNOSES REDACTED]. The progress notes included, but were not limited to, the following: On 9/14/19 at 12:02 a.m., the resident's Foley urinary catheter (a thin sterile tube inserted into the bladder to drain urine) was intact and draining straw colored urine, large amount of sediment in bag. On 9/15/19 at 2:35 a.m., the resident was alert and oriented times 3 with intermittent confusion. He told staff he felt like he had a UTI again. He told the staff he has had 11 total UTI's. His urine was an amber color. On 9/16/19 at 2:31 p.m., the resident complained of pain and burning from his catheter. The NP was notified regarding the resident's pain and burning from the catheter and a new order was given for a urine sample. A physician progress notes [REDACTED].He complains of dysuria (painful urination) he has a history of Urosepsis (type of potentially life-threatening condition caused by the body's response to an infection in the urinary tract) and he states that he felt burning like he did the last time he had an infection. Plan: Dysuria: Check for UTI (Urinary Tract Infection) with U/A (Urinalysis) .Pt (Patient) and/or staff Encg'd (encouraged) to report changes or concerns .Assessment: Dysuria, Personal history of urinary tract infections On 9/20/19 at 11:00 a.m., Resident lethargic. Slow to respond to staff. (Blood pressure) 88/52 bs (blood sugar)-269 -resp (respirations)- 12 shallow, pulse 75 -92% RA (percentage of oxygen on room air), temp(temperature) 98.2. NP in facility and assessed resident. New order to send to (Name of Hospital) ER (emergency room ) for eval (evaluation) and treat (treatment). A History and Physical from (Name of Hospital) dated 9/20/19 at 6:54 p.m., indicated .Chief Complaint: altered mental status (AMS). History of Present Illness: Presenting Symptoms Details: .present to the ED (Emergency Department) via EMS (Emergency Medical Service) for AMS. EMS reports they received a call from (Name of facility) for a pt (patient) with AMS . Pt is nonresponsive. O2 (oxygen) in the 80's and hypotensive. HR (heart rate) 73 O2 100% Nonrebreather BP 73/45 There are no other modifying factors .Assessment and Plan: Problem 1: [MEDICAL CONDITION] with end organ damage/septic shock poa (present on admission). A/P (Assessment/Plan): aki (acute kidney injury and acute toxic metabolic [MEDICAL CONDITION]. suspected source is catheter associated uti, with hx (history) of [MEDICATION NAME] faecalis (gram-positive bacterium) and proteus (gram- negative bacterium) in past. significant leukocytosis with [MEDICAL CONDITION] update: patient started on [MEDICATION NAME] (a medication used to raise the blood pressure) as bp (blood pressure) borderline despite receiving 4L (liters) crystalloid fluid and minimal urine output continue iv (IV fluids) but monitor for signs of volume overload with fluids and min (minimal) urine output .Problem 3: catheter associated uti . suspected source: patient with chronic indwelling foley at snf (skilled nursing facility) for unknown reason. hx of proteus and e ([MEDICATION NAME]) faecalis uti in past -ct (computerized tomography scan) abd/pelvis (abdomen/pelvis) to evaluate for obstruction with uti and aki A test result received from (Name of Laboratory Company), dated 10/10/19, indicated the urinalysis was collected on 9/17/19 at 3:45 a.m. A urine culture result, dated 10/10/19, from (Name of Laboratory Company) indicated the urine culture was collected on 9/19/19, and grew Proteus species 50,000-100,000 CFU/ml (colony forming unit/milliliter) with the sensitivity to follow. The doctor signed the report on 9/23/19. Pathology and Micro Results of Urine Results, dated 9/20/19 at 11:34 a.m. indicated the sample had Organism > (greater than) 100,000 CFU/ml Proteus Mirabilis. During an interview on 10/10/19 at 4:20 p.m., the DON (Director of Nursing) indicated the resident's urine sample, which was collected and picked up the morning of 9/17/19, but it was lost by the laboratory technician employee by their contracted laboratory. The facility sent a new urine sample out on 9/19/19, after realizing the first sample was lost. They had to put a new order in for the new sample to be picked up. They typically wait 24-48 hours on the urine results, so they did not realize the sample was lost until they were looking for the results and called the lab for the results. The DON indicated even though the resident was complaining of urinary symptoms, yelling out and pouring ice water on his genitals, they would not have called for the results any sooner than 48 hours because they thought those were part of his behaviors from the previous facility. A request was made at that time from the DON for a copy of the physician's orders [REDACTED]. As of the exit conference date on 10/11/19, this information was not provided. Resident G's record lacked documentation regarding when the facility was notified the first sample was lost by the lab and when the new sample was collected and sent to the laboratory. This information was requested from the DON. By the end of the exit conference on 10/11/19, the DON was unable to provide the information requested. During an interview on 10/11/19 at 12:11 p.m., Call Center Representative 16 indicated the urinalysis for Resident G was collected from the facility by the laboratory on 9/17/19 at 3:45 a.m. The facility was notified a new order needed to be placed in the computer and the urine needed to be recollected. On 9/18/19 the laboratory received a new order from the facility for Resident G for a urine culture only. The urine was collected on 9/19/19 and the laboratory picked the urine sample up for processing. The only test ran on that urine sample was a urine culture. A current policy titled, Laboratory, Radiology, and Other Diagnostic Services, dated 12/21/17, with a last reviewed date of 11/17/18, contained the following: Guideline Statement: (Name of the Facility) will follow State and Federal Regulations related to Laboratory, Radiology, and Other Diagnostic Services to include: Providing and obtaining quality and timely Laboratory services to meet the needs of its residents .If the facility does not provide laboratory services on site, they must maintain a provider agreement with a laboratory that meets the appropriate requirements This Federal tag relates to Complaint IN 587. 3.1-49(a)

Based on interview and record review the facility failed to notify a Physician of a resident's complaints of pain and missing laboratory results for 1 of 3 residents being reviewed for notification of the Physician for a condition change (Resident G) which resulted in Resident G being admitted to the hospital with [REDACTED]. The facility failed notify residents' legal representatives regarding 71 missing [MEDICATION NAME] (a narcotic pain medication) for 5 of 5 residents reviewed for notification of abuse (Residents B, C, D, [NAME] and F). Findings include: 1. The record review was completed for Resident G on 10/10/19 at 1:00 p.m. [DIAGNOSES REDACTED]. A nursing progress note, dated 9/15/19 at 2:35 a.m., indicated the resident was alert and oriented times 3 with intermittent confusion. He remained able to make his wants and needs known to staff. He told staff he felt like he had a UTI again. He told the staff he had had 11 total UTI's. His urine was an amber color. A physician progress notes [REDACTED].He complains of dysuria (painful urination) he has a history of Urosepsis (type of potentially life-threatening condition caused by the body's response to an infection in the urinary tract) and he states that he felt burning like he did the last time he had an infection. Plan: Dysuria: Check for UTI (Urinary Tract Infection) with U/A (Urinalysis) .Pt (Patient) and/or staff Encg'd (encouraged) to report changes or concerns .Assessment: Dysuria, Personal history of urinary tract infections A nursing progress note, dated 9/16/19 at 2:31 p.m., the resident complained of pain and burning from his catheter. The NP was notified regarding the resident's pain and burning from the catheter and a new order was given for a urine sample. A nursing progress note, dated 9/18/19 at 2:30 p.m., the resident complained to the rehab staff about being uncomfortable with his bottom and he was in, so much pain, that I feel that I want to get a gun to shoot myself, When Social Services (SS) checked on the resident, he told (SS) that his bottom was in much pain and it was unbearable to live with. When asked if he had plans to harm himself, he stated, no, I just want this pain to go away. SS talked with the counselor from (Name of Company) on this date and informed her Resident G had no plans to hurt himself, but he was in much pain. A nursing progress note, dated 9/18/19 at 8:26 p.m., Resident G was yelling. He yelled all evening. He was talking to his echo to call someone to bring him a gun. After being told by staff, if someone brought him a gun into the facility, the police would have to be called. The resident cancelled the echo call. He yelled out all afternoon. The staff were unable to meet resident's request no matter how we tried. The resident continued to yell until the end of that nurse's shift. A nursing progress note, dated 9/19/19 at 1:21 a.m., .Continues to talk about wanting the pain to go away . Nurse noted res (resident) dumping his ice/ice water onto his genitals and peri area. When asked why he was doing that his statement was that he had a UTI. Linen has been changed x (times) 3x. Complained about roommates fan, he was cold, pulled curtain between beds. He requested a bag of ice, wanted place against his genital. Call light is (sic) has been in use almost continually this shift. He has also been yelling out for help. Complaints have been made by his roommate and nearby neighbors about the noise and commotion. A nursing progress note, dated 9/19/19 at 3:00 a.m., Res continues to use call light excessively, most recent cause of 10/10 pain has been stated as he is constipated A nursing progress note, dated 9/19/19 at 7:28 a.m., Res yelling out for nurse. Nurse in res room and asked what is wrong. Res C/O (complaints/of) pain to buttocks. Res attempting to roll OOB (out of bed). Res accepted PRN (as needed) pain medicine A nursing progress note, dated 9/19/19 at 10:05 a.m., Called NP (Nurse Practitioner) (Name of Nurse Practitioner) called discussed res (resident) behaviors new Rx (prescription) notes Res informed. A nursing progress note, dated 9/19/19 at 1:00 p.m., .Resident seen by (Name of Counselor) today and indicates that he is not suicidal. She states that resident was so focused on pain and wanting Dolodid (sic) and that his penis was burning .Resident continues to yell out. A nursing progress note, dated 9/19/19 at 6:02 p.m., (Name of Physician) in and seen Res. reviewed chart and orders. No new orders noted. A physician progress notes [REDACTED].HPI: Nursing staff requested that I evaluate this patient there were reports of him acting differently last night and doing a lot of screaming and being confused This morning he had been sleeping after having a long night when the nurse went in to check on him he was not responding appropriately .his respirations are slow and intermittent respiratory rate is 12. He's pale and unresponsive. He will blink his eyes but not in response to stimulation at this time I requested that he be sent to the emergency room VIA AMBULANCE. BG (blood glucose) 269 P (pulse) 75 O2 (oxygen sat) on RA (room air) 92 .Plan: To ER (emergency room ) by AMBULANCE STAT .Pt and/or staff encg'd to report changes or concerns. Physical Examination: Constitutional exam reveals: Lying in bed. Unresponsive .in distress .Respiratory exam reveals: Slow shallow respirations .Neurology exam reveals: Unresponsive .Assessment: Altered mental status, unspecified-Acute An Interdisciplinary Note from (Name of Hospital), dated 9/21/19 at 12:56 a.m., indicated CT (computerized tomography) showed balloon of catheter in proximal urethra. Removed 25 ml (milliliters) saline from 10 ml balloon, removed catheter, approximately 50 ml of pus poured out of penis tip. 14 fringe (sic) coude placed. 300 ml pink cloudy sludge-like urine drained A Progress Note-Communication note from (Name of Hospital), dated 9/21/19 at 6:39 p.m., indicated .patient admitted yesterday with [MEDICAL CONDITION]/septic shock due to CAUTI (catheter associated UTI) and aki A test result received from (Name of Laboratory Company), dated 10/10/19, indicated the urinalysis was collected on 9/17/19 at 3:45 a.m. A urine culture result, dated 10/10/19, from (Name of Laboratory Company) indicated the urine culture was collected on 9/19/19, and grew Proteus species 50,000-100,000 CFU/ml (colony forming unit/milliliter) with the sensitivity to follow. The doctor signed the report on 9/23/19. During an interview on 10/9/19 at 3:50 p.m., the DON (Director of Nursing) indicated on the day Resident G was sent to the hospital he was fine up until the time the nurse went into his room and found him lethargic and slow to respond to staff, then the staff asked the NP (Nurse Practitioner) to assess him and he was sent to the hospital immediately by 911. The resident was on 15 minute checks for [MEDICAL CONDITION], so he was being checked on every 15 minutes by the nurse or the CN[NAME] He did not have a change of condition until that time when the nurse went into his room to check on him. Resident G's record lacked documentation regarding when the facility was notified the first sample was lost by the lab and when the new sample was collected and sent to the laboratory. This information was requested from the DON. By the end of the exit conference on 10/11/19, the DON was unable to provide the information requested. During an interview on 10/10/19 at 4:20 p.m., the DON (Director of Nursing) indicated they thought Resident G pouring ice water on his genitals and yelling out was part of his behaviors. A request was made at that time, from the DON for a copy of the resident's behaviors indicating he yelled out and poured water on his genitals at his previous facility as part of his behaviors. As of the exit conference date on 10/11/19, this information was not provided. During an interview on 10/10/19 at 5:10 p.m., RN 2 indicated she made rounds with Physician 5 the night prior to Resident G being admitted to the hospital (on 9/19/19), but no new orders were written. During an interview on 10/11/19 at 12:11 p.m., Call Center Representative 16 indicated the urinalysis for Resident G was collected from the facility by the laboratory on 9/17/19 at 3:45 a.m. The facility was notified a new order needed to be placed in the computer and the urine needed to be recollected. On 9/18/19 the laboratory received a new order from the facility for Resident G for a urine culture only. The urine was collected on 9/19/19 and the laboratory picked the urine sample up for processing. The only test ran on that urine sample was a urine culture. During an interview on 10/11/19 at 3:55 p.m., Physician 5 indicated while reviewing his notes at the office he did not visit Resident G on 9/19/19, prior to him being hosptalized on [DATE]. He indicated if he would have visited the resident he would have dictated a visit note on him for his visit. His last visit note for that resident was 9/12/19, prior to his hospitalization and he was seen by a NP (Nurse Practitioner) on 9/16/19. He did make a visit round on this resident's (Name of family member) on 9/19/19. A current policy titled Notification of Change in Resident Health Status dated 10/12/16, with a last reviewed date of 6/24/18, provided by the DON on 10/10/19 at 4:20 p.m., contained the following, Guideline Statement: To ensure that proper notifications are made when a resident has a change in health status. Definitions (As Needed): Immediate: As soon as possible no longer than 24 hours. The center will consult the resident's physician, nurse practitioner or physician assistant, and if known notify the resident's legal representative or an interested family member when there is: (B) Acute illness or a significant change in the resident's physical, mental or psychosocial status (i.e. deterioration in health, mental psychosocial status in either life-threatening conditions or clinical complications.) Criteria: Life threatening conditions are such things as a [MEDICAL CONDITION] or stroke. Clinical complications are such things as development of a stage 2 pressure sore when no ulcers were previously present at stage 2 or higher, onset or recurrent periods of [MEDICAL CONDITION], recurrent urinary tract infection, or persistent decline in psycho social status. Appropriate notification time: immediate. (C) A need to alter treatment significantly (i.e. a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment). Criteria: a need to alter treatment 'significantly' means a need to stop a form of treatment because of adverse consequences (e.g. an adverse drug reaction), or commence a new form of treatment to deal with a problem (e.g. abnormal laboratory results, the use of any medical procedure, or therapy that has not been used on that resident before). Notification: Depending on the nursing assessment appropriate notification may be immediate to 48 hours 2. During an interview on 10/9/19 at 4:15 p.m., the Director of Nursing (DON) provided the information from the investigation of the missing narcotics from the ADU (Automated Drug Dispensing Unit). She indicated after the investigation was completed she found out LPN 3 had taken 71 [MEDICATION NAME] tablets from five different residents from the ADU. A handwritten note provided by the DON on 10/9/19 at 4:15 p.m., indicated on 9/28/19 at 11:40 a.m., she and the Administrator questioned LPN 3 regarding the missing 71 [MEDICATION NAME] and she had no clue what happened to the medication. She received a phone call on 9/27/19 sometime after 11:00 p.m., from LPN 11 regarding LPN 3 and missing [MEDICATION NAME] from the ADU. She knew there could have been reasonable explanations for the missing count of the narcotics and this was out of the character for this nurse, so she decided to wait until she could run the report the next morning. She ran the report the next morning, then she went to the facility and talked with LPN 3, who told her the medication she pulled from the ADU was in the narcotic drawer and now it was missing. After reconciling the printed list of all the narcotics LPN 3 had pulled from the ADU with the residents EMAR's (Electronic Medication Administration Record) she figured LPN 3 had stolen 71 [MEDICATION NAME] from five residents. She indicated on 10/4/19, she and the Administrator called LPN 3 to terminate her employment with the facility. The nurses would take 2-3 prn (as needed) doses of narcotics out of the ADU at a time to save them time from running back and forth to the ADU when they had residents who typically took their prn narcotic medication frequently. The narcotic system was a check and balance system. They dispensed a certain number of pills from the ADU and that was the number they were supposed to document on the narcotic sheet. Then when the resident asked for a pain pill, that nurse or other nurses signed out the narcotic from the drawer. The DON indicated the ADON (Assistant Director of Nursing) was reconciling the ADU Dispensary report sheet and the Narcotic sheet reports to watch for discrepancies until she left on 9/3/19, but since then they have not been reconciled because she did not have the time to do it. The DON indicated the families of the five residents involved with the missing [MEDICATION NAME] were not informed LPN 3 had their medications inappropriately as of this interview. A Indiana State Department of Health Survey Report System report, dated 10/8/19, indicated on the evening of 9/27/19, RN 10 went to the ADU (Automated Drug Dispensing Unit) to pull a PRN (as need) [MEDICATION NAME] (a narcotic pain medication) for (Name of Resident C), this was in anticipation of his pain management needs. She was unable to pull the medication from the ADU and called the pharmacy. She was informed that the maximum allowed pills had been pulled for the day. (Name of Resident C) did receive [MEDICATION NAME] 500 mg (milligrams) (an anti-[MEDICAL CONDITION] medication used for pain) .(Name of the Director of Nursing) was notified of potential concerns the evening at 11:00 p.m. On the morning of 9/28/19, the ADU reports were able to be accessed and it verified that (Name of LPN 3) did in fact pull 6 [MEDICATION NAME] from the ADU on the day of 9/27/19. On 9/28/19 at 10:45 a.m., (Name of Director of Nursing) notified (Name of the Administrator) of concerns .Upon investigation it was noted that from 9/24/19 to 9/27/19, 18 [MEDICATION NAME] were pulled by (Name of LPN 3) from the ADU, which were accounted for. This includes 10 for (Name of Resident C) and 8 for (Name of Resident B) .The investigation was completed. 71 total [MEDICATION NAME] pills, from 5 different residents were noted to have been pulled from the ADU by (Name of LPN 3) that could not be accounted for . (Name of Director of Nursing) and (Name of Administrator) spoke with (Name of LPN 3) via the phone on 10/4/19. She did not have an explanation for where the missing pills had gone. Her employment was terminated at that time During an interview on 10/9/19 at 4:59 p.m., RN 10 indicated on the evening of 9/27/19, Resident C was asking for a pain pill before his four hours was up and she knew the night shift nurse would not have time to get down to the ADU until after 11:00 p.m., which was when the resident's pain medication was due, so she went to get the medication to help her out. When she went to pull the three [MEDICATION NAME] out of the ADU, the unit indicated the resident had already had her maximum supply for that particular 24 hours and no medication was available. She thought the machine had made a mistake. She told the midnight nurse about the issue when she came on and she told RN 10 there had to be a problem because Pharmacy only put the exact amount of pills in the machine the resident was allowed to have for that 24 hour period and this particular resident had not taken his six tablets. The midnight nurse called the Pharmacy, who told her all of Resident C's PRN (as needed) pain pills had been dispensed for that 24 hour period and he could have a pain pill after 12:00 a.m., that a person with the initials (LPN 3's initials) had dispensed three [MEDICATION NAME] at 6:50 a.m. and three more around 1:00 p.m. Then a minute or two after dispensing Resident C's [MEDICATION NAME] pills, she dispensed the same number for Resident B. She pulled three [MEDICATION NAME] out for Resident B in the morning and three out in the evening for Resident B and depleted her PRN supply also. The following residents were the five residents who had the 71 missing [MEDICATION NAME]: a. The record review for Resident B was completed on 10/10/19 at 1:30 p.m. [DIAGNOSES REDACTED]. A Controlled Substance Accountability Sheet indicated Resident B had an order for [REDACTED]. The following dates [MEDICATION NAME] 7.5-325 mg was written on the Controlled Substance Accountability Sheet by LPN 3 on the following dates and times to account for the amount of narcotic medications she withdrew from the ADU. On 9/24/19 at 10:00 a.m.--2 tablets were dispensed 1 tablet was administered 2 tablets were remaining, but 5 tablets were removed from the ADU by LPN 3 according to the Dispensary report for this date, so 3 tablets were missing. On 9/26/19 at 1:20 p.m.--3 tablets were dispensed 1 tablet was administered 2 tablets were remaining, but 6 tablets were removed from the ADU by LPN 3, so according to the Dispensary report from the ADU for this date, 3 tablets were missing. On 9/27/19 at 7:00 a.m.--4 tablets were dispensed 1 tablet was administered 3 tablets were remaining, but 6 tablets were removed from the ADU by LPN 3, so according to the Dispensary report from the ADU for this date, 2 tablets were missing There was no documentation in the resident's record indicating the legal representative was notified of the missing [MEDICATION NAME]. b. The record review for Resident C was completed on 10/10/19 at 1:00 p.m. [DIAGNOSES REDACTED]. A Controlled Substance Accountability Sheet indicated Resident C had an order for [REDACTED]. The following dates [MEDICATION NAME] 7.5-325 mg was written on the Controlled Substance Accountability Sheet by LPN 3 on the following dates and times to account for the amount of narcotic medications she withdrew from the ADU. On 9/3/19 at 7:00 a.m.--2 tablets were dispensed 1 tablet was administered 1 tablets were remaining, but 3 tablets were removed from the ADU by LPN 3 according to the Dispensary report for this date, so 1 tablet was missing. On 9/4/19 at 7:00 a.m.--2 tablets were dispensed 1 tablet was administered 1 tablets were remaining, but 5 tablets were removed from the ADU by LPN 3, so according to the Dispensary report from the ADU for this date, 3 tablets were missing. On 9/5/19 at 11:00 a.m.--1 tablet was dispensed 1 tablet was administered 0 tablets were remaining, but 3 tablets were removed from the ADU by LPN 3, so according to the Dispensary report from the ADU for this date, 2 tablets were missing. On 9/6/19 at 7:00 a.m.--1 tablet was dispensed 1 tablet was administered 1 tablet was remaining, but 3 tablets were removed from the ADU by LPN 3, so according to the Dispensary report from the ADU for this date, 2 tablets were missing. On 9/9/19 at 11:30 a.m.--1 tablet was dispensed 1 tablet was administered 0 tablets were remaining, but 3 tablets were removed from the ADU by LPN 3, so according to the Dispensary report from the ADU for this date, 2 tablets were missing. On 9/11/19 at 11:00 a.m.--1 tablets was dispensed 0 tablet was administered 1 tablet was remaining, but 3 tablets were removed from the ADU by LPN 3, so according to the Dispensary report from the ADU for this date, 2 tablets were missing. On 9/12/19 at 7:00 a.m.--3 tablet were dispensed 1 tablet was administered 2 tablets were remaining, but 4 tablets were removed from the ADU by LPN 3, so according to the Dispensary report from the ADU for this date, 2 tablets were missing. On 9/14/19 at 4:00 p.m.--2 tablet were dispensed 2 tablet was administered 0 tablets were remaining, but 5 tablets were removed from the ADU by LPN 3, so according to the Dispensary report from the ADU for this date, 3 tablets were missing. On 9/16/19 at 11:00 a.m.--1 tablet was dispensed 1 tablet was administered 0 tablets were remaining, but 4 tablets were removed from the ADU by LPN 3, so according to the Dispensary report from the ADU for this date, 3 tablets were missing. On 9/18/19 at 11:00 a.m.--2 tablets were dispensed 0 tablet was administered 2 tablets were remaining, but tablets were removed from the ADU by LPN 3, so according to the Dispensary report from the ADU for this date, 3 tablets were missing. On 9/18/19 at 11:00 a.m.--2 tablets were dispensed 0 tablet was administered 2 tablets were remaining, but tablets were removed from the ADU by LPN 3, so according to the Dispensary report from the ADU for this date, 3 tablets were missing. On 9/20/19 at 9:00 a.m.--2 tablets were dispensed 0 tablet was administered 0 tablets were remaining, but tablets were removed from the ADU by LPN 3, so according to the Dispensary report from the ADU for this date, 2 tablets were missing. On 9/24/19 at 7:00 a.m.--0 tablets were dispensed 1 tablet was administered 2 tablets were remaining, but 2 tablets were removed from the ADU by LPN 3, so according to the Dispensary report from the ADU for this date, 2 tablets were missing On 9/25/19 at 11:15 a.m.--0 tablets was dispensed 1 tablet was administered 2 tablet was remaining, but 3 tablets were removed from the ADU by LPN 3, so according to the Dispensary report from the ADU for this date, 3 tablets were missing On 9/26/19 at 11:00 a.m.--2 tablets were dispensed 1 tablet was administered 1 tablet was remaining, but 6 tablets were removed from the ADU by LPN 3, so according to the Dispensary report from the ADU for this date, 4 tablets were missing On 9/27/19 at 7:00 a.m.--3 tablet was dispensed 1 tablet was administered 2 tablet were remaining, but 6 tablets were removed from the ADU by LPN 3, so according to the Dispensary report from the ADU for this date, 3 tablets were missing There was no documentation in the resident's record indicating the legal representative was notified of the missing [MEDICATION NAME]. c. The record review for Resident D was completed on 10/11/19 at 3:00 p.m. [DIAGNOSES REDACTED]. On 9/10/19 at 9:00 a.m.--0 tablets were dispensed 1 tablet was administered 0 tablets were remaining, but 2 tablets were removed from the ADU by LPN 3 according to the Dispensary report for this date, so 1 tablet was missing. On 9/14/19 with no specified time--0 tablets were dispensed 1 tablet was removed from the ADU by LPN 3, so according to the Dispensary report from the ADU for this date, 1 tablet was missing. On 9/15/19 with no specified time--0 tablets were dispensed 1 tablet was removed from the ADU by LPN 3, so according to the Dispensary report from the ADU for this date, 1 tablet was missing. On 9/18/19 with no specified time--0 tablets were dispensed 1 tablet was removed from the ADU by LPN 3, so according to the Dispensary report from the ADU for this date, 1 tablet was missing. On 9/19/19 at 1:00 p.m.--0 tablets were dispensed 1 tablet was administered 2 tablets were remaining, but 1 tablet was removed from the ADU by LPN 3, so according to the Dispensary report from the ADU for this date, 1 tablet was missing. On 9/24/19 at 11:00 a.m.--0 tablets were dispensed 1 tablet was administered 2 tablets were remaining, but 3 tablets were removed from the ADU by LPN 3, so according to the Dispensary report from the ADU for this date, 3 tablets were missing. On 9/27/19 at 5:00 a.m.--0 tablets were dispensed 1 tablet was administered 3 tablets were remaining, but 1 tablet was removed from the ADU by LPN 3, so according to the Dispensary report from the ADU for this date, 1 tablet was missing. There was no documentation in the resident's record indicating the legal representative was notified of the missing [MEDICATION NAME]. d. The record review for Resident [NAME] was completed on 10/11/19 at 3:30 p.m. [DIAGNOSES REDACTED]. A Controlled Substance Accountability Sheet indicated Resident [NAME] had an order for [REDACTED]. The following dates [MEDICATION NAME] 7.5-325 mg was written on the Controlled Substance Accountability Sheet by LPN 3 on the following dates and times to account for the amount of narcotic medications she withdrew from the ADU. On 9/9/19 at 8:40 a.m.--0 tablets were dispensed 1 tablet was administered 1 tablet was 0 tablets were remaining, but 2 tablets were removed from the ADU by LPN 3 according to the Dispensary report for this date, so 1 tablet was missing. On 9/14/19 with no specified time--0 tablets were dispensed 1 tablet was removed from the ADU by LPN 3, so according to the Dispensary report from the ADU for this date, 1 tablet was missing. On 9/15/19 with no specified time--0 tablets were dispensed 1 tablet was removed from the ADU by LPN 3, so according to the Dispensary report from the ADU for this date, 1 tablet was missing. On 9/18/19 with no specified time--0 tablets were dispensed 1 tablet was removed from the ADU by LPN 3, so according to the Dispensary report from the ADU for this date, 1 tablet was missing. On 9/19/19 at 1:00 p.m.--0 tablets were dispensed 1 tablet was administered 2 tablets were remaining, but 1 tablet was removed from the ADU by LPN 3, so according to the Dispensary report from the ADU for this date, 1 tablet was missing. There was no documentation in the resident's record indicating the legal representative was notified of the missing [MEDICATION NAME]. e. The record review for Resident F was completed on 10/11/19 at 4:30 p.m. [DIAGNOSES REDACTED]. A Controlled Substance Accountability Sheet indicated Resident F had an order for [REDACTED]. The following dates [MEDICATION NAME] 7.5-325 mg was written on the Controlled Substance Accountability Sheet by LPN 3 on the following dates and times to account for the amount of narcotic medications she withdrew from the ADU. On 9/11/19 at 6:45 a.m.--0 tablets were dispensed 1 tablet was administered 1 tablets were remaining, but 0 tablets were removed from the ADU by LPN 3 according to the Dispensary report for this date, 2 tablets were missing. There was no documentation in the resident's record indicating the legal representative was notified of the missing [MEDICATION NAME]. A current policy titled, Investigation and Reporting of Alleged Violations of Federal and State Laws Involving Mistreatment, Neglect, Abuse, Injuries of Unknown Source and Misappropriation of Resident's Property, dated 9/26/17, with a last reviewed date of 12/25/17, provided by the Director of Nursing on 10/9/19 at 4:15 p.m., contained following Policy .Misappropriation of Resident Property: Misappropriation of property means the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent. This applies to spouses, family members, friends and staff . Reporting: .Reporting Responsibility: .The ED (Executive Director), DNS (Director of Nursing Services) .shall notify the resident's representative regarding the alleged violation and assessment findings and reassure the resident's representative that an investigation has been initiated and appropriate action will be taken. This contact shall be documented This Federal tag relates to Complaint IN 587. 3.1-5(a)(2)

Based on interview and record review, the facility failed to assess and request medical intervention for a resident who complained of pain related to anchored catheter and failed to follow up on Urinalysis results resulting in Resident G being admitted to the hospital with [REDACTED]. The facility failed to monitor residents' urine outputs from a urinary catheter drainage bags according to their policy and procedure for 3 of 3 residents being reviewed for monitoring of catheter outputs (G, H and J), the facility failed to correctly transcribe the physician's orders [REDACTED]. Findings include: 1.During an interview on 10/9/19 at 3:50 p.m., the DON (Director of Nursing) indicated on the day Resident G was sent to the hospital he was fine up until the time the nurse went into his room and found him lethargic and slow to respond to staff, then the staff asked the NP (Nurse Practitioner) to assess him and he was sent to the hospital immediately by 911. The resident was on 15 minute checks for [MEDICAL CONDITION], so he was being checked on every 15 minutes by the nurse or the CN[NAME] He did not have a change of condition until that time when the nurse went into his room to check on him. The record review was completed for Resident G on 10/10/19 at 1:00 p.m. [DIAGNOSES REDACTED]. Resident G's Electronic Treatment Administration Record (ETAR) orders, dated (MONTH) 2019, included, but were not limited to, the following orders: 9/11/19--Change Foley catheter (20 French 30 cc (cubic centimeters) balloon) one time a day every 1 month starting on the 15th for 28 days. (Discontinued on 9/19/17). The dates 9/15/19, 9/16/19 and 9/17/19 on the ETAR were all initialed. 9/19/19--Change F/C (Foley Catheter) every 30 days and PRN (as needed) occlusion at bedtime every 30 days for [MEDICAL CONDITIONS] (enlarged prostrated gland). The date 9/19/19 on the ETAR was initialed. Resident G's Catheter output amounts for (MONTH) 2019, were reviewed, which indicated there were several shifts without any catheter output amounts documented: 9/12/19--dayshift 9/13/19 through 9/17/19--dayshift and evening shifts 9/18/19 and 9/19/19--midnight, dayshift and evening shifts 9/20/19--midnight shift A nursing progress note, on 9/11/19 at 3:34 p.m., the resident was admitted to the facility with an indwelling Foley catheter in place. A nursing progress note, on 9/11/19 at 5:00 p.m., the resident was alert times 3 (person, place and time), his speech was clear and he was able to vocalize his needs. His Foley catheter was draining clear yellow urine. He told the staff he was totally dependent on staff for care. A Physicians progress note, dated 9/12/19, indicated .Date of Visit: 9/12/19 .Chief Complaint: New Admission. History of Present Illness: .The patient has a history of .recurrent urinary tract infection .Systemic Review: .Past Medical History: .recurrent urinary tract infection, chronic Foley indwelling catheter .depression A nursing progress note, on 9/14/19 at 12:02 a.m., the resident's Foley catheter was intact and draining straw colored urine, large amount of sediment in bag. A nursing progress note, on 9/15/19 at 2:35 a.m., the resident was alert and oriented times 3 with intermittent confusion. He remained able to make his wants and needs known to staff. He told staff he felt like he had a UTI again. He told the staff he had had 11 total UTI's. His urine was an amber color. A physician progress notes [REDACTED].He complains of dysuria (painful urination) he has a history of Urosepsis (type of potentially life-threatening condition caused by the body's response to an infection in the urinary tract) and he states that he felt burning like he did the last time he had an infection. Plan: Dysuria: Check for UTI (Urinary Tract Infection) with U/A (Urinalysis) .Pt (Patient) and/or staff Encg'd (encouraged) to report changes or concerns .Assessment: Dysuria, Personal history of urinary tract infections A nursing progress note, on 9/16/19 at 2:31 p.m., the resident complained of pain and burning from his catheter. The NP was notified regarding the resident's pain and burning from the catheter and a new order was given for a urine sample. A nursing progress note, on 9/18/19 at 2:30 p.m., the resident complained to the rehab staff about being uncomfortable with his bottom and he was in, so much pain, that I feel that I want to get a gun to shoot myself, When Social Services (SS) checked on the resident, he told (SS) that his bottom was in much pain and it was unbearable to live with. When asked if he had plans to harm himself, he stated, no, I just want this pain to go away. SS talked with the counselor from (Name of Company) on this date and informed her Resident G had no plans to hurt himself, but he was in much pain. A nursing progress note, on 9/18/19 at 8:26 p.m., Resident G was yelling. He yelled all evening. He was talking to his echo to call someone to bring him a gun. After being told by staff, if someone brought him a gun into the facility, the police would have to be called. The resident cancelled the echo call. He yelled out all afternoon. The staff were unable to meet resident's request no matter how we tried. The resident continued to yell until the end of that nurse's shift. A nursing progress note, on 9/19/19 at 1:21 a.m., .Continues to talk about wanting the pain to go away . Nurse noted res (resident) dumping his ice/ice water onto his genitals and peri area. When asked why he was doing that his statement was that he had a UTI. Linen has been changed x (times) 3x. Complained about roommates fan, he was cold, pulled curtain between beds. He requested a bag of ice, wanted place against his genital. Call light has been in use almost continually this shift. He has also been yelling out for help. Complaints have been made by his roommate and nearby neighbors about the noise and commotion. A nursing progress note, on 9/19/19 at 3:00 a.m., Res continues to use call light excessively, most recent cause of 10/10 pain has been stated as he is constipated A nursing progress note, on 9/19/19 at 7:28 a.m., Res yelling out for nurse. Nurse in res room and asked what is wrong. Res C/O (complaints/of) pain to buttocks. Res attempting to roll OOB (out of bed). Res accepted PRN (as needed) pain medicine A nursing progress note, on 9/19/19 at 10:05 a.m., Called NP (Nurse Practitioner) (Name of Nurse Practitioner) called discussed res (resident) behaviors new Rx (prescription) notes Res informed. A nursing progress note, on 9/19/19 at 1:00 p.m., .Resident seen by (Name of Counselor) today and indicates that he is not suicidal. She states that resident was so focused on pain and wanting Dolodid (sic) and that his penis was burning .Resident continues to yell out. A Psychology Initial Assessment note, dated 9/19/19 at 3:00 p.m., indicated .Reason for Referral: Depression Patient's Self Reported Concerns: Depression Active Signs & Symptoms of Diagnostic Codes: Depressed Mood. Behaviors: Pleas for Help, Over-Reactive. Assessment Summary: Depression .Summary: Pt (Patient) presents with signs and sx (symptoms) consistent with dep (depression) .Behavior: Restless, Agitated, Distracted .Mood: Anxious .Behaviors: Hyper-vigilant, Pleas for help, Over-Reactive .Geriatric Depression Scale-Short Form: Are you basically satisfied with your life? No .Are you afraid that something bad is going to happen to you? Yes Do you feel happy most of the time? No . Do you think it is wonderful to be alive now? No .Do you think that most people are better off than you are? Yes A physician progress notes [REDACTED].HPI: Nursing staff requested that I evaluate this patient there were reports of him acting differently last night and doing a lot of screaming and being confused This morning he had been sleeping after having a long night then the nurse went in to check on him he was not responding appropriately .his respirations are slow and intermittent respiratory rate is 12. He's pale and unresponsive. He will blink his eyes but not in response to stimulation at this time I requested that he be sent to the emergency room VIA AMBULANCE. BG (blood glucose) 269 P (pulse) 75 O2 (oxygen saturation) on RA (room air) 92 .Plan: To ER (emergency room ) by AMBULANCE STAT . Physical Examination: .Lying in bed. Unresponsive .in distress .Slow shallow respirations .Altered mental status, unspecified-Acute A nursing progress note, on 9/20/19 at 11:00 a.m., Resident lethargic. Slow to respond to staff. (Blood pressure) 88/52 bs (blood sugar)-269 -resp (respirations)- 12 shallow, pulse 75 -92% RA (percentage of oxygen on room air), temp(temperature) 98.2. NP in facility and assessed resident. New order to send to (Name of Hospital) ER (emergency room ) for eval (evaluation) and treat (treatment). A nursing progress note, on 9/20/19 at 12:49 p.m., Called (Name of Hospital) and requested update on res .RN stated res will probably be admitted A History and Physical from (Name of Hospital) dated 9/20/19 at 6:54 p.m., indicated .Chief Complaint: altered mental status (AMS). History of Present Illness: Presenting Symptoms Details: .present to the ED (Emergency Department) via EMS (Emergency Medical Service) for AMS. EMS reports they received a call from (Name of facility) for a pt (patient) with AMS . Pt is nonresponsive. O2 (oxygen) in the 80's and hypotensive. HR (heart rate) 73 O2 100% Nonrebreather BP 73/45 There are no other modifying factors .Assessment and Plan: Problem 1: [MEDICAL CONDITION] with end organ damage/septic shock poa (present on admission). A/P (Assessment/Plan): aki (acute kidney injury and acute toxic metabolic [MEDICAL CONDITION]. suspected source is catheter associated uti, with hx (history) of [MEDICATION NAME] faecalis (gram-positive bacterium) and proteus (gram- negative bacterium) in past. significant leukocytosis with [MEDICAL CONDITION] update: patient started on [MEDICATION NAME] (a medication used to raise the blood pressure) as bp (blood pressure) borderline despite receiving 4L (liters) crystalloid fluid and minimal urine output continue iv (IV fluids) but monitor for signs of volume overload with fluids and min (minimal) urine output .Problem 3: catheter associated uti . suspected source: patient with chronic indwelling foley at snf (skilled nursing facility) for unknown reason. hx of proteus and e ([MEDICATION NAME]) faecalis uti in past -ct (computerized tomography scan) abd/pelvis (abdomen/pelvis) to evaluate for obstruction with uti and aki An Interdisciplinary Note from (Name of Hospital), dated 9/21/19 at 12:56 a.m., indicated CT (computerized tomography) showed balloon of catheter in proximal urethra. Removed 25 ml (milliliters) saline from 10 ml balloon, removed catheter, approximately 50 ml of pus poured out of penis tip. 14 fringe (sic) coude placed. 300 ml pink cloudy sludge-like urine drained A Progress Note-Communication note from (Name of Hospital), dated 9/21/19 at 6:39 p.m., indicated .patient admitted yesterday with [MEDICAL CONDITION]/septic shock due to CAUTI (catheter associated UTI) and aki .under went ct abdomen and pelvis which showed foley catheter to be in proximal penis. Patient had very little urine output prior to obtaining ct scan and that was one of the reasons the ct scan was obtained. foley was removed and new foley replaced with return of very thick, pus appearing urine. urine output has improved since placement of new foley The Interdisciplinary Note from (Name of Hospital) indicated the catheter, which was inserted at the facility prior to the resident being hospitalized , had the balloon blown up into the proximal penis of the urethra. The size of catheter used was a 14 french coude catheter with a 10 ml (milliliter) balloon. Twenty-five mls of fluid was removed from the 10 ml catheter balloon prior to removing the catheter. A test result received from (Name of Laboratory Company), dated 10/10/19, indicated the urinalysis was collected on 9/17/19 at 3:45 a.m. A urine culture result, dated 10/10/19, from (Name of Laboratory Company) indicated the urine culture was collected on 9/19/19, and grew Proteus species 50,000-100,000 CFU/ml (colony forming unit/milliliter) with the sensitivity to follow. The doctor signed the report on 9/23/19. Pathology and Micro Results of Urine Results, dated 9/20/19 at 11:34 a.m., indicated the sample had Organism > (greater than) 100,000 CFU/ml Proteus Mirabilis. During an interview on 10/10/19 at 4:20 p.m., the DON (Director of Nursing) indicated the resident's urine sample was collected and picked up the morning of 9/17/19, but it was lost by the laboratory technician employee by their contracted laboratory. The facility sent a new urine sample out on 9/19/19, after realizing the first sample was lost. They had to put a new order in for the new sample to be picked up. They typically wait 24-48 hours on the urine results, so they did not realize the sample was lost until they were looking for the results and called the lab for the results. The DON indicated even though the resident was complaining of urinary symptoms, yelling out and pouring ice water on his genitals, they would not have called for the results any sooner than 48 hours because they thought those were part of his behaviors from the previous facility. A request was made at that time from the DON for a copy of the physician's orders [REDACTED]. As of the exit conference date on 10/11/19, this information was not provided. Resident G's record lacked documentation regarding when the facility was notified the first sample was lost by the lab and when the new sample was collected and sent to the laboratory. This information was requested from the DON. By the end of the exit conference on 10/11/19, the DON was unable to provide the information requested. During an interview on 10/10/19 at 4:20 p.m., the DON (Director of Nursing) indicated they thought Resident G pouring ice water on his genitals and yelling out was part of his behaviors. A request was made at that time, from the DON for a copy of the resident's behaviors indicating he yelled out and poured water on his genitals at his previous facility as part of his behaviors. As of the exit conference date on 10/11/19, this information was not provided. During an interview on 10/10/19 at 5:10 p.m., RN 1 and RN 2 were in attendance. RN 1 reviewed the ETAR (Electronic Treatment Administration Record) orders for Resident G's catheter orders on the computer. She indicated those orders were not transcribed correctly. She transcribed his admission orders [REDACTED]. She indicated the nurse's should have questioned the order with the doctor. The catheter should not have been changed every day, it should only have been changed once a month. When inserting a male catheter, the catheter was to be inserted until urine was seen, then the catheter was advanced farther into the bladder prior to the balloon being blown up to be sure it cleared the prostate gland. While RN 1 was reviewing the resident's catheter order on his ETAR, she noted on 9/19/19, RN 4 changed the resident's catheter order from a daily catheter change to a monthly catheter change. RN 4 initialed the box dated 9/19/19. RN 1 indicated a box on the ETAR with an initial indicated the nurse completed the task or it would have a number in the box to correlate why that treatment was not completed. At that time, RN 4 walked up to the nurses' station and RN 1 asked RN 4 if she had changed this resident's catheter on 9/19/19. RN 4 indicated she could not remember that far back, but if she initialed the box that she changed the catheter. According to the 9/19/19, documentation on the ETAR, RN 4 was the last nurse to have changed Resident G's catheter prior to being admitted to the hospital. At that time, RN 4 was asked what her procedure was for anchoring a Foley catheter on a male. RN 4 indicated she inserted the Foley catheter until she saw urine, then she blew the bulb up. During an interview on 10/11/19 at 6:00 p.m., the DON (Director of Nursing) indicated the resident should have had 30 cc of fluid in his catheter bulb because his order was written for a 20 French catheter with a 30 cc balloon. During an interview on 10/11/19 at 6:45 p.m., RN 2 provided Resident Observation Tracking Log sheets dated 9/12/19, 9/13/19 and 9/14/19 for the resident's 15 minute checks indicating these were the only 15 minute check sheets she was able to locate. Resident G's record lacked progress note documentation regarding the catheter insertions according to the facility policy, on the following dates 9/15/19, 9/16/19, 9/17/19, and 9/19/19. This information was requested from the DON. By the end of the exit conference on 10/11/19, the DON was unable to provide the information requested. 2. During an interview on 10/10/19 at 5:00 p.m., with RN 2 in attendance, Resident H indicated his suprapubic catheter had not been changed since he was admitted to the facility and that was over a month ago. His suprapubic catheter leaked onto his sheets. He had told several people he needed his catheter changed and no one had changed it as of this date. During an interview on 10/10/19 at 5:10 p.m., with RN 1 and RN 2 present, RN 1 reviewed Resident H's catheter orders on the ETAR. She indicated he was admitted to the facility on [DATE], and he had not had his suprapubic catheter changed since he was admitted . He did not get his suprapubic catheter changed due to his order, which as written did not have a specific date of the month to change his catheter. Both his catheter orders indicated to change them PRN (as needed) instead of every month and PRN. The record review for Resident H was reviewed on 10/11/19 at 2:00 p.m. [DIAGNOSES REDACTED]. Resident H's ETAR orders for (MONTH) 2019, (MONTH) 2019 and (MONTH) 2019, included, but were not limited to, the following orders: 8/29/19--Change S/P (Suprapubic) catheter every month and PRN (22 FR, 30 cc balloon) every 30 hours as needed for [MEDICAL CONDITION] (Discontinued on 10/11/19). There was no nurse's initials documentation prior to 10/11/19 on any of the three months ETAR'S to indicate this resident's suprapubic catheter was changed as ordered by the Physician. Resident H's Catheter outputs amounts for (MONTH) 2019, were reviewed, and indicated there were several shifts without any catheter output amounts documented: 9/01/19 through 9/10/19--dayshift and evening shifts 9/11/19 through 9/13/19--dayshift 9/14/19 through 9/16/19--dayshift and evening shifts 9/17/19--dayshift 9/18/19 through 9/23/19--dayshift and evening shifts 9/24/19 and 9/25/19--dayshift 9/26/19--dayshift and evening shifts 9/27/19--dayshift and midnight shifts 9/28/19--midnight shift, dayshift and evening shifts 9/29/19 and 9/30/19--dayshift and evening shifts Resident H's catheter output amounts for (MONTH) 2019, were reviewed, which indicated there were several shifts without any catheter output amounts documented. 10/1/19 through 10/6/19--dayshift and evening shifts 10/7/19--dayshift 10/8/19 through 10/10/19--dayshift and evening shifts 3. The record review for Resident J was reviewed on 10/10/19 at 5:22 p.m. [DIAGNOSES REDACTED]. Resident J's Catheter outputs amounts for (MONTH) 2019, were reviewed, which indicated there were several shifts without any catheter output amounts documented: 9/01/19 through 9/10/19--dayshift and evening shifts 9/11/19 through 9/12/19--dayshift 9/14/19 through 9/16/19--dayshift and evening shifts 9/17/19 and 9/18/19--dayshift 9/19/19--dayshift and evening shift 9/20/19 and 9/23/19--dayshift 9/24/19--dayshift and evening shift 9/25/19 and 9/26/19--dayshift 9/27/19--dayshift and midnight shifts 9/28/19--dayshift and evening shifts 9/29/19--midnight, day and evening shifts 9/30/19--dayshift Resident J's catheter output amounts for (MONTH) 2019, were reviewed, which indicated there were several shifts without any catheter output amounts documented. 10/1/19--midnight shift During an interview on 10/11/19 at 5:00 p.m., the DON indicated Residents G, H and J's urinary outputs for their catheter amounts would be documented on Cath Output documentation she provided for the three residents. When asked about the blanks on the documentation, she indicated the outputs, which were documented were written on those papers only. There were no other documentation for the catheter outputs. This documentation was where the CNA's and Nurses wrote the amounts when they emptied the catheters. A current policy titled, Catheter (Indwelling), Insertion and Removal of (Female and Male), dated 1/8/15, with the last reviewed date of 6/24/18, provided by the DON on 10/11/19 at 5:00 p.m., contained the following: Procedure Purpose: To provide continuous drainage of the urinary bladder. To prevent contact of urine with open areas on the body. To obtain accurate measurement of urinary output .Assessment Guidelines: (MONTH) include, but are not limited to: Color, consistency, amount of urine. Condition of skin. Any pain, burning, discomfort .Hydration and fluid balance status .Procedure Details: Insertion of Indwelling Catheter Equipment: .9. Advance catheter one to one and one-half inches beyond the point of free flow of urine. 10. Check size of balloon; draw up sterile water to this amount. (If not using prefilled syringe attach the syringe to the balloon port on the catheter) . 11. DO NOT FORCE WATER INTO BALLOON. IF RESISTANCE IS ENCOUNTERED OR THE RESIDENT COMPLAINS OF PAIN, DEFLATE BALLOON, ADVANCE FARTHER INTO THE BLADDER AND INFLATE .Documentation may include: Date, time, procedure, amount of urine obtained, color, consistency, odor, and presence of blood, pus or anything unusual. How well resident tolerated procedure. Signature and title. Care Plan Documentation Guidelines: Enter the catheter insertion/instillation as an approach under the appropriate underlying problem on the resident's care plan A current policy titled Intake and Output Measurement dated 1/8/15, with the last reviewed date of 3/8/19, provided by the DON on 10/11/19 at 6:00 p.m., contained the following: Procedure Purpose: To maintain an accurate measurement of the resident's intake and output to assess fluid balance. Assess the following Residents' Need For Intake And/Or Output Measurement: Residents with indwelling catheter for the first 30 days or per facility procedure .Residents with specific physician's orders [REDACTED].Procedure Details: 1. Initiate intake and output measurement as necessary. Begin intake and output record per facility procedure. 2. Measure and record all liquids ingested .8. Intake and output measurement is usually recorded each shift and totaled every twenty-four hours. 9. Evaluate intake and output measurement to determine adequacy. Notify the physician if not adequate or if output exceeds intake A current policy titled Catheter Care, Indwelling Catheter dated 8/9/16, with the last reviewed date of 3/8/19, provided by the DON on 10/11/19 at 5:00 p.m., contained the following: Procedure Purpose: To prevent infection .Documentation Guidelines: Date, time, procedure, condition of the perineum and catheter insertion site. Any unusual condition or change in condition. Color, amount, consistency and odor of urine. Notification of the physician of any condition change. Intake and output and evaluation of intake and output per facility procedure. Signature and title. Care Plan Documentation Guidelines: Enter the catheter care as an approach under the appropriate underlying problem on the resident's care plan. Identifying the underlying problem will assist the nursing staff to develop an individualized care plan. The use of an indwelling catheter is an approach to a specific problem. Develop a care plan with the objective of removing the catheter when the problem is resolved, whenever possible This Federal tag relates to Complaint IN 587. 3.1-41(a)(2)

Based on record review and interview the facility failed failed to implement interventions for resident's who were identified at risk for falls, in that when resident's fell and sustained injuries to include fractures and subdural hematoma's, the nursing staff failed to develop other strategies or assistive devices to alert the nursing staff of unassisted ambulation in order to supervise and keep the resident's safe and free from additional injuries. In addition, the facility failed to ensure supervision and establish a system to prevent accidents, in that when a resident was transported via a wheelchair to her room, the nursing staff failed to ensure the resident's arm was not bumped into inanimate objects which resulted in a skin tear. This deficient practice affected 4 of 7 resident's sampled for injuries in a total sample of 10. (Resident's "G", "B", "F" and "I"). Resident G was identified as a fall risk, therapy was implemented as ordered timely and the resident had a fall sustaining a hip fracture with subsequent falls after the fall with a fracture. Findings include: 1. The record for Resident "G" was reviewed on 07-25-14 at 12:30 p.m. [DIAGNOSES REDACTED]. anxiety. These [DIAGNOSES REDACTED]. A review of the pre-admission assessment, dated 09-09-11 indicated the resident required safety cues and reminders. A review of the resident's MDS assessment, dated 04-16-14 indicated the resident had severe cognitive impairment, was not steady, and only able to stabilize with human assistance in the areas of moving from seated to standing position, walking, turning around, moving on and off the toilet and surface to surface transfer. The resident had plans of care which identified the resident at risk for falls, related to impaired cognition and decision making skills, poor safety awareness and a [DIAGNOSES REDACTED]. The record indicated that on 03-26-14 at 9:15 p.m., the resident was found on the floor on the back in hallway. The resident sustained [REDACTED]. A subsequent notation dated 05-20-14 at 10:30 a.m., indicated the resident was found on the floor in the den. "Staff heard a thud and found resident sitting on floor in front of chair." The record contained documentation the nursing staff requested on 05-23-14 to the physician that "the resident's family requested her to be seen and evaluated by PT (physical therapy) due to increased falls and unsteady gait." The physician responded on 05-23-14 and agreed the resident could be evaluated by the therapy staff. On 06-17-14 at 1:15 p.m., the resident had fallen and was laying on her left side in hallway. A progress note dated 06-20-14 at 3:30 p.m., indicated the resident was found on the floor in the den sitting between the shelf and another resident's wheelchair. The resident was sent to the local area hospital for evaluation and treatment. The resident was assessed with [REDACTED]. The resident was readmitted to the facility and once again fell to the floor. The progress notes, dated 07-08-14 at 2:24 p.m., indicated "resident was trying to climb out of wheelchair while sitting at dining room table. CNA (certified nurses aide) removed resident to hallway when CNA turned to go get foot pedals for chair resident flipped back in chair. Resident has tip bars but they failed to work." During an interview on 07-25-14 at 1:30 p.m., the Unit Manager indicated the resident did not receive the physical therapy evaluation as directed by the physician on 05-23-14. The Unit Manager indicated the "therapy staff missed it but caught it in June." When interviewed about the date the resident was evaluated by physical therapy in June (2014), the Unit Manager indicated the resident was evaluated on 06-19-14 and the following day she fell and fractured her hip." The therapy notes dated 06-10-14 indicated "precautions indicated low endurance - needs frequent rests, balance precautions." The facility failed to provide interventions to alert the staff of the resident's unassisted attempts at ambulation or moving from surface to surface. 2. The record for Resident "B" was reviewed on 07-23-14 at 12:00 p.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. A review of the resident's Minimum Data Set (MDS) assessment dated [DATE] indicated the resident was cognitively impaired, frequently incontinent of bladder always incontinent of bowel and was not steady, and only able to stabilize with human assistance in the areas of moving from seated to standing position, walking, turning around, moving on and off the toilet and surface to surface transfer. The record indicated the resident had a fall on 07-07-14 at 4:32 a.m. The progress note indicated the resident was "found sitting on buttocks on floor in doorway of bathroom facing room - stating she had gone to the bathroom. Wheelchair was at bedside - bed was in low position with matt at bedside - call light was not on. Resident <sic> has poor safety awareness/judgement for self - forgets to use call light for assist - wears brief and is generally incontinent." During an interview on 07-25-14 at 9:30 a.m., the Unit Manager indicated this was the fall which resulted in a fractured ankle. The resident was transported to the local area hospital for evaluation and treatment, and returned to the facility on [DATE] with a cast to the lower leg. Review of the resident's MDS assessment, dated 07-17-14, indicated the resident had a decline in transfer, bed mobility ambulation, toileting and continued to have problems with balance in the areas of moving from a seated to standing position, moving on and off toilet and surface to surface transfer. Further review of the progress notes dated 07-10-13 at 9:00 p.m., indicated the resident fell "forward out of wheelchair bumping area just immediately above left eyebrow causing superficial skin tear measuring 2.5 cm (centimeters) in length with slight bleeding - hematoma surfaced almost immediately about dime size immediately above left eyebrow, slight bleeding occurred for short time. Resident has dx. (diagnosis) of Alzheimer's disease and has poor safety awareness for self." The progress notes indicated the resident had two additional falls since she was readmitted to the facility after having sustained a fractured ankle. The resident was found on the floor of another resident's room on 07-19-14 at 2:35 p.m., and then again on 07-21-14 at 6:15 p.m., when staff found resident sitting on the bathroom floor with her w/c (wheelchair) behind her. A small reddened area was present to right side of mid back. The facility failed to provide supervision to prevent accidents or interventions to alert the staff of the resident's unassisted attempts at ambulation or toileting. During an interview, a concerned family member indicated she was not satisfied with the wheelchair positioning of the resident and felt as long as the resident had "one leg dangling while she was seated in the wheelchair, she would continue to make attempts to ambulate or stand up on her own while the fracture was healing." 3. The record for Resident "F" was reviewed on 07-25-14 at 1:15 p.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. A review of the resident's MDS assessment, dated 04-23-14 indicated the resident had severe cognitive impairment, and was not steady,and only able to stabilize with human assistance in the areas of moving from seated to standing position, walking, turning around, moving on and off the toilet and surface to surface transfer. The resident's care plans indicated the resident was at risk for falls and fall related injury r/t (related to) impaired cognition,visual impairment, impaired mobility d/t (due to) recent hip fracture and surgical repair. The record further indicated the visual impairment referred to macular degeneration and could only see shadows against a contrasting background and required extensive assistance with bed mobility, transfers, toileting, dressing, grooming, personal hygiene/t impaired cognition, loss of vision, decline in mobility and overall function. A review of the progress notes indicated the resident fell on [DATE] at 2:05 p.m. - "found on floor in room near bathroom." This fall resulted in a fractured hip. The resident was transferred to the local area hospital for evaluation and treatment and returned to the facility. Continued review of the Progress notes indicated the resident was found on the floor on 06-03-14 at 1:54 p.m. - "in front of wheelchair." The resident indicated to the facility staff she had to "go to the bathroom." The record indicated the resident sustained [REDACTED]. On 06-16-14 at 4:20 p.m., the resident was noted to be sitting at the dining room table and when attempted to sit back down in wheelchair went backwards and the resident fell to floor landing on buttocks hitting her head on the door. The wheelchair was not in a locked position. On 06-29-14 at 1:17 a.m., the resident was found on the floor in bathroom - fell after using restroom and slipping in urine. The resident indicated she hit her head. The record indicated on 07-21-14 at 5:20 p.m., the resident was found on the floor in the doorway to her room. The facility failed to provide interventions to alert the staff of the resident's unassisted attempts at ambulation, toileting or ensuring the wheelchair was in the locked position. 4. The record for Resident "I" was reviewed on 07-24-14 at 1:55 p.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. A review of the MDS assessment dated [DATE] indicated the resident had severe cognitive impairment and required the assistance of two plus staff members while transferring. During an interview on 07-23-14 a concerned family member indicated her mother had a significant skin tear on her right arm. The concerned family member indicated that when she came to visit, the resident kept repeating that her right arm hurt. The family member then indicated she pulled back the covers and discovered bright red blood on her mother's white sweater. She then indicated as she rolled back the sleeve of the sweater she could see the extent of the injury. She reported this to the administrator, who began an investigation. A review of the facility investigation report indicated two CNA's were interviewed. CNA #7 indicated she "got (name of resident) up and in her wheelchair and that she had put the sweater on her starting with the left arm and them her right arm." CNA #8 indicated she transported the resident back to her room after the resident had completed breakfast. The CNA indicated she did bump the resident's wheelchair on the dresser during the transport and then transferred the resident to her bed by standing her and pivoting her." The CNA's failed to ensure the resident was transferred with the appropriate numbers of staff members in attendance and failed to ensure the resident was not bumped into inanimate objects during transport which could have led to the skin tear. A review of the record indicated the skin tear measured 5.0 cm by 1.0 cm and required physician intervention/treatment in order for the area to heal This Federal tag relates to Complaint IN 546. 3.1-45(a)(1) 3.1-45(a)(2)

Based on record review and interview, the facility failed to ensure the resident was assessed for dehydration after decreased fluid intakes without intervention, resulting in hospitalization for severe dehydration for 1 of 5 reviewed for assessments in a sample of 6. (Resident B) Findings include: The clinical record for Resident B was reviewed on 12/19/12 at 10:30 A.M. [DIAGNOSES REDACTED]. The nurses notes indicated the resident was having [MEDICAL CONDITION] on 8/14/12 at 11:09 P.M. The physician in his progress notes on 8/23/12 indicated to increase [MEDICATION NAME] to 40 milligrams twice a day for five days and then continue [MEDICATION NAME] 40 milligrams daily. The progress notes on 9/20/12 indicated the resident was on [MEDICATION NAME] secondary to [MEDICAL CONDITION] and the resident was experiencing low sodium levels. The progress notes from August through October when the resident was admitted to hospital indicated physician aware of patient status with lab levels. There was no mention of any concern with her hydration status. The nurses notes indicated on 9/4/12 at 6:43 P.M. the resident received adequate hydration. 9/11/12 at 8:00 P.M. - Eats fair with adequate hydration. 9/21/12 5:00 p.m. the resident does not want some things that have dairy in them because she feels she is lactose intolerant. These were the only nurses notes regarding hydration status and no notes regarding assessment of mucosa, mouth or lips for potential dehydration concerns. The dietary intakes the facility provided only had the total percentage of the meal consumed including fluids. The total average intake for the month was 47.2 percent. The October intakes indicated: B= breakfast, AL= lunch and D= Dinner. NP = None to very little 10/1- B-50 % AL - 25% D- NP 10/2- B- 50 % AL - 25 % D- NP 10/3- B - 100% AL-NP D -50 % 10/4- B 100 % AL- NP D- 75% 10/5- B 50 % AL- 50 % D- NP 10/6- B - 100% AL- NP D 25% 10/7- B - NP, AL- NP , D- 100% 10/8- B -75 % - AL not documented D- 50 % 10/9- B- 50 % , AL- 50 % D- 50% 10/10-B- 75% , AL- 50% D- 75% 10/11- B- 75% , AL- 50% D- 50% 10/12- B- NP AL- NP, D- 50% 10/13- B- NP, AL- NP, D- NP 10/14- B -NP, AL-NP, D-25% 10/15-B- NP, AL-NP, D- NP 10/16-B -NP, AL-NP, D- 25% 10/17-B- 25%, AL-NP, D- did not receive meal The care plans dated 6/26/12 and 8/16/12 were reviewed on 12/19/12 at 11:00 A.M. There was no care plan found for monitoring or assessing for dehydration related to taking the medication [MEDICATION NAME] which is a diuretic. The Nursing assessment titled "Quarterly Interdisciplinary Resident Review" dated 9/18/12, did not include anything pertaining to hydration status. The hospital records obtained on 12/19/12 at 9:30 A.M. indicated the resident was admitted with severe dehydration. In an interview with the Director of Nursing Services on 12/20/12 at 3:00 P.M. she indicated that all of the nurses notes and care plans were in the chart provided. This federal tag relates to complaint number IN 904. 3.1-37(a)

Based on record review and interview the facility failed to ensure the resident was monitored for dehydration after decreased fluid intakes without intervention, resulting in hospitalization for severe dehydration for 1 of 5 reviewed for assessments in a sample of 6. (Resident B) Findings include: The clinical record for Resident B was reviewed on 12/19/12 at 10:30 A.M. [DIAGNOSES REDACTED]. The nurses notes indicated the resident was having [MEDICAL CONDITION] on 8/14/12 at 11:09 P.M. . The physician in his progress notes on 8/23/12 indicated to increase [MEDICATION NAME] to 40 milligrams twice a day for five days and then continue [MEDICATION NAME] 40 milligrams daily. The progress notes on 9/20/12 indicated the resident was on [MEDICATION NAME] secondary to [MEDICAL CONDITION] and the resident was experiencing low sodium levels. The progress notes from August through October when the resident was admitted to hospital indicated physician aware of patient status with lab levels. There was no mention of any concern with her hydration status. The nurses notes indicated on 9/4/12 at 6:43 P.M. the resident received adequate hydration. 9/11/12 at 8:00 P.M. - Eats fair with adequate hydration. 9/21/12 5:00 p.m. the resident does not want some things that have dairy in them because she feels she is lactose intolerant. These were the only nurses notes regarding hydration status and no notes regarding assessment of mucosa, mouth or lips for potential dehydration concerns. The dietary intakes the facility provided only had the total percentage of the meal consumed including fluids. The total average intake for the month was 47.2 percent. The October intakes indicated: B= breakfast, AL= lunch and D= Dinner. NP = None to very little 10/1- B-50 % AL - 25% D- NP 10/2- B- 50 % AL - 25 % D- NP 10/3- B - 100% AL-NP D -50 % 10/4- B 100 % AL- NP D- 75% 10/5- B 50 % AL- 50 % D- NP 10/6- B - 100% AL- NP D 25% 10/7- B - NP, AL- NP , D- 100% 10/8- B -75 % - AL not documented D- 50 % 10/9- B- 50 % , AL- 50 % D- 50% 10/10-B- 75% , AL- 50% D- 75% 10/11- B- 75% , AL- 50% D- 50% 10/12- B- NP AL- NP, D- 50% 10/13- B- NP, AL- NP, D- NP 10/14- B -NP, AL-NP, D-25% 10/15-B- NP, AL-NP, D- NP 10/16-B -NP, AL-NP, D- 25% 10/17-B- 25%, AL-NP, D- did not receive meal The care plans dated 6/26/12 and 8/16/12 were reviewed on 12/19/12 at 11:00 A.M. There was no care plan found for monitoring or assessing for dehydration related to taking the medication [MEDICATION NAME] which is a diuretic. The Nursing assessment titled "Quarterly Interdisciplinary Resident Review" dated 9/18/12, did not include anything pertaining to hydration status. The hospital records obtained on 12/19/12 at 9:30 A.M. indicated the resident was admitted with severe dehydration. This federal tag relates to complaint number IN 904. 3.1-46(b)