Every finding on record at Brickyard Healthcare - Willow Springs Care Center

Based on interview and record review, the facility failed to accurately transcribe a physician's order for 1 of 1 resident reviewed for pharmacy services. (Resident H) The deficient practice was corrected on 12/8/25, prior to the start of the survey, and was therefore past noncompliance.Findings include:The clinical record for Resident H was reviewed on 6/1/26 at 11:45 a.m. The diagnoses included, but were not limited to, endocarditis, cellulitis, and infection in the knee.A hospital discharge instruction, dated 10/14/25, indicated to administer ceftriaxone (a third-generation cephalosporin antibiotic) 2 grams (gm) IV (intravenous) push every 24 hours for cellulitis for 14 days.A physician order, with a start date of 10/14/25 and an end date of 10/15/25, indicated to administer ceftazidime (a third-generation cephalosporin antibiotic) 2 gm IV every 24 hours for an infection in the knee.A physician order, with a start date of 10/15/25 and an end date of 10/23/25, indicated to administer ceftazidime 2 gm IV every 24 hours for an infection in the knee for 6 weeks.A physician order, with a start date of 10/23/25 and an end date of 11/17/25, indicated to administer ceftazidime 2 gm IV every 24 hours for cellulitis and endocarditis for 6 weeks.The clinical record indicated the wrong antibiotic was ordered (ceftazidime) compared to the hospital discharge instructions (ceftriaxone).A nursing progress note, dated 11/14/25, indicated the facility nurse spoke with a nurse from the infectious disease office related to the resident's antibiotics. Resident H's antibiotics were to be held until further notice.A nursing progress note, dated 11/17/25, indicated the facility nurse spoke with a nurse from the infectious disease office. Orders were received to discontinue Resident H's IV and antibiotics.A nursing progress note, dated 11/18/25, indicated the infectious disease office staff requested Resident H's medical records regarding the previous antibiotic medications ordered.During an interview, on 6/3/26 at 1:52 p.m., Nurse 3 from the ordering infectious disease physician's office indicated that ceftazidime was ordered and administered by the facility instead of the intended ceftriaxone.During an interview, on 6/4/26 at 9:39 a.m., the Director of Nursing (DON) indicated a medication error had occurred. The medication was transcribed incorrectly. The admitting nurse entered the wrong medication into the system and there was no second nurse verification completed.During an interview, on 6/5/26 at 9:17 a.m., the DON indicated the facility did not have a policy on transcribing medications. Their process was one nurse should enter the orders, and another nurse should check the orders to verify they were the correct orders.An article, titled Comparison of Ceftazidime and Ceftriaxone Spectrum of Activity, last updated 8/5/25, was retrieved on 6/8/26 from the Dr Oracle website at https://www.droracle.ai/articles/250447/is-ceftazidime-a-third-generation-cephalosporin-antibiotic-more-broad-spectrum-than The guidance included: .Ceftazidime has a broader spectrum of activity than ceftriaxone specifically due to its superior activity against Pseudomonas aeruginosa, while ceftriaxone has better coverage against certain Gram-positive organisms and anaerobes.A current facility policy, titled Medication Errors, dated 2025 and received from the DON on 6/4/26 at 10:05 a.m., indicated .It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by ensuring residents receive care and services safely in an environment free of significant medication errors. Medication error means the observed or identified preparation or administration of medications or biologicals which are not in accordance with prescriber's order; manufacturers specifications (not recommendations) regarding the preparation and administration of the medication or biological; or accepted professional standards and principles which apply to professionals providing services .The facility shall ensure medications will be administered as follows: a. According to physician's orders This deficient practice was corrected by 12/8/25 after the facility implemented a systemic plan that included the following actions: all residents with antibiotic orders were reviewed, audits of the antibiotics orders were completed and were on-going, in-servicing education to staff related to transcribing medications were completed, the facility implemented a new transcription process and procedure, and ongoing monitoring by Quality Assurance and Performance Improvement (QAPI).This citation relates to intake 2675455.410 IAC (Indiana Administrative Code)16.2-3.1-25(g)(1)

Based on interview and record review, the facility failed to ensure a person-centered, comprehensive care plan was reviewed by the Interdisciplinary team (IDT) and updated to reflect the behavior care needs for 1 of 3 residents reviewed for care plans. (Resident B)Findings include:The clinical record for Resident B was reviewed on 7/22/25 at 1:15 p.m. The diagnoses included, but were not limited to, Parkinson's disease, dementia, metabolic encephalopathy, bipolar disorder, and the need for assistance with personal care.Resident B was admitted to the facility on [DATE].A care plan, dated 3/25/25, indicated Resident B had behavioral symptoms related to bipolar disorder as evidence by racial slurs and derogatory comments directed at staff, verbal and physical aggression towards staff, making contact with others, throwing items, and refusing care at times. The interventions included, but were not limited to, 3/25/25, to administer medications as ordered and monitor/document for side effects and effectiveness, care in pairs, provide opportunity for positive interaction and attention, stop and talk with him, discuss the resident's behavior to him and explain and reinforce why his behavior was inappropriate and unacceptable, intervene as necessary to protect the rights and safety of others, approach and speak in a calm manner, divert his attention, remove him from the situation and take him to an alternative location as needed, monitor his behavior episodes and attempt to determine the underlying cause of the behavior, consider the location, time of the day, and the persons involved in the behavior, and document the behavior and the potential causes of that behavior. 5/8/25, give the resident his space as needed.A Nurse Practitioner's (NP) progress note, dated 5/5/25, indicated the resident was seen for a re-admission to the facility from a psychiatric hospital stay from 4/24/25 to 5/1/25.A NP's progress note, dated 5/15/25, indicated the resident was seen for a re-admission to the facility from a psychiatric hospital stay. He was content with all male care givers.A NP progress note, dated 6/26/25, indicated the resident was seen for re-admission after a psychiatric hospital stay.Resident B's clinical record lacked IDT progress notes after each re-admission from the psychiatric hospitalizations to indicate the care plan had been reviewed and revised with new or modified interventions for Resident B's behaviors to be effectively managed. During an interview, on 7/23/25 at 4:00 p.m., the Regional [NAME] President of Operations indicated the care plans were to be reviewed and updated upon re-admission to the facility if needed. A current facility policy, titled Care Plan Revisions Upon Status Change, undated and provided by the Director of Nursing on 7/23/25 at 3:45 p.m., indicated .The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change.The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change .Interdisciplinary Team will discuss the resident condition and collaborate on intervention options. c. The team meeting discussion will be documented in the nursing progress notes. d. The care plan will be updated with the new or modified interventions. e. Staff involved in the care of the resident will report resident response to new or modified interventions This citation relates to Complaint 1369834.3.1-35(e)

Based on interview and record review, the facility failed to allow a resident to return to the facility where the resident had resided for several months without documentation of any needs or behaviors which were not previously present and could not be met by the facility for 1 of 3 residents reviewed for an inappropriate discharge. (Resident B)Findings include: An email from the local hospital, dated 7/10/25, indicated Resident B was sent to the emergency room due to alleged aggression at the facility where he resided. The psychiatric department cleared him while in the emergency room to return to the facility. The facility refused to accept him back. The clinical record for Resident B was reviewed on 7/22/25 at 1:15 p.m. The diagnoses included, but were not limited to, Parkinson's disease, dementia, metabolic encephalopathy, bipolar disorder, and the need for assistance with personal care.Resident B was admitted to the facility, on 3/24/25, from a psychiatric hospital.The nursing progress notes, dated 3/24/25 to 4/24/25, indicated Resident B had behaviors of cussing at the staff, being aggressive with the staff, refusing to take his medications, refusing to allow staff to change his wet bed linens, calling the staff the N word, and he was physically and verbally abusive toward the staff members. The nursing progress notes did not include any documentation Resident B was putting other residents in danger.A nursing progress note, dated 4/24/25, indicated Resident B was admitted to a psychiatric hospital for the behaviors he had been displaying. A nursing progress note, dated 5/1/25 at 7:22 p.m., indicated Resident B was re-admitted to the facility after a psychiatric hospital stay for behaviors. A Nurse Practitioner's (NP) note, dated 5/5/25, indicated the resident was being seen for a re-admission to the facility from a psychiatric hospital stay from 4/24/25 to 5/1/25. He was started on Divalproex (a medication used as a mood stabilizer for persons with a diagnosis of bipolar disorder) and his quetiapine (a medication used to treat psychosis, delusions and hallucinations) was increased during his stay at the hospital. The NP note lacked documentation Resident B's needs could not be met at this facility.The nursing progress notes, dated 5/1/25 to 5/7/25, indicated Resident B had behaviors of hitting and scratching staff members, using racial slurs to staff members and calling them the N word. He would spit out his medications. When Resident B attempted to get a female resident's attention, she dismissed him and he became angry, aggressive, and attempted to grab and scratched her right forearm. He yelled negative verbalizations at her in the hallway. When interventions were ineffective, the police were called, and Resident B attempted to punch a police officer. A physician's order was obtained to send him out for a psychiatric evaluation related to being a continued harm to himself and other people despite de-escalation and redirection. A progress nursing note, dated 5/14/25 at 3:33 p.m., indicated Resident B was re-admitted to the facility after a recent psychiatric hospital stay. A NP note, dated 5/15/25, indicated the resident was visited for re-admission back into the facility from a psychiatric hospital stay for behaviors. He was content with all male care givers and none of his psych medications were changed. The psychiatric team had questioned if his Sinemet (a medication used to treat Parkinson's disease) could have been the cause of his behaviors. A neurology consultation would be scheduled. The NP note lacked documentation Resident B's needs could not be met at this facility.The clinical record lacked documentation the facility had scheduled a neurology consultation or had tried to implement all male caregivers for Resident B's care. A physician's note, dated 5/16/25, indicated the resident was sent to a psychiatric hospital for being verbally and physically aggressive. Multiple attempts to redirect him failed and he was at risk to himself and to the staff. He had some changes completed for his mental health treatments. He calmed down some and was eventually transferred back to the facility for further care of his chronic medical conditions. He had his psychiatric medications increased during his hospital stay from 4/24/25 to 5/1/25. The physician's note lacked documentation Resident B's needs could not be met at this facility or documentation Resident B was putting other residents in danger.The nursing progress notes, dated 5/14/25 to 5/30/25, indicated Resident B was displaying behaviors of calling staff members the N word, using racial slurs toward staff members, and being aggressive and punching staff. He was touching the staff's private areas while they were providing personal care for him, telling the staff to suck his private parts, punching staff members in between their legs, verbalizing sexually inappropriate comments to the staff and being verbally abusive to staff. A nursing progress note, dated 5/30/25, indicated Resident B had new episodes of physical aggression, sexual inappropriateness, and used racial slurs throughout the day. A physician's order was received to send the resident out for an acute psychiatric episode.The nursing progress notes did not include any documentation Resident B was putting other residents in danger.A nursing progress note, dated 5/31/25, indicated Resident B was sent out to a psychiatric hospital due to behaviors.A nursing progress note, dated 6/25/25 at 3:48 p.m., indicated Resident B was re-admitted back to the facility from the psychiatric hospital. He would now always require two caregivers. Resident B presented with aggressive and sexually inappropriate behaviors toward staff members. The clinical record lacked documentation to indicate the facility tried to implement 1 of the 2 staff members required to provide care to Resident B would be a male caregiver.A NP note, dated 6/26/25, indicated the resident was re-admitted yesterday after being sent to a psychiatric hospital due to inappropriate verbal and physical aggression toward female staff. The resident had bipolar disorder with some psychosis, dementia, and Parkinson's disease.A low dose of haloperidol, 0.5 mg ordered twice daily in the morning and at night to assist with behavior since the patient is on an oral female staff unit. being made for the patient to go to a different facility with all males. Since he returned, he had stood in the hallway with only his brief on yelling at the staff and was verbally and physically inappropriate with the female staff. The NP note lacked documentation Resident B's needs could not be met at this facility or documentation Resident B was putting other residents in danger.A physician's note, dated 6/27/25, indicated the resident was sent to the hospital due to being verbally and physically aggressive. Multiple attempts to redirect him failed. He was at risk to himself and the staff. He had increased agitation and restlessness and was physically, verbally, and sexually aggressive. He was asking his care givers to perform sexual requests on him. He refused his medications. There was some mental health changes to his treatment made, then he was transferred back to the facility. The physician's note lacked documentation Resident B's needs could not be met at this facility or documentation Resident B was putting other residents in danger.The nursing progress notes, dated 6/25/25 to 7/4/25, indicated Resident B refused lab draws, was aggressive and physical with the staff members, and said racial slurs to them. A nursing progress note, dated 7/4/25, indicated Resident B kicked an aide in the middle of her chest, grabbed her arm, scratched her on the right upper arm, spit at her and said multiple racial slurs. The police were called, and a physician's order was given to send the resident out to a different psychiatric hospital. The nursing progress notes did not include any documentation Resident B was putting other residents in danger.A nursing progress note, dated 7/7/25, indicated Resident B was re-admitted to the facility. He refused his skin assessment. A physician's progress note, dated 7/8/25, indicated the resident was sent to the hospital because he was being verbally and physically aggressive with staff. He was confused at the time of the history and physical exam. The physician's note lacked documentation Resident B's needs could not be met at this facility or documentation Resident B was putting other residents in danger.A nursing progress note, dated 7/9/25 at 11:00 a.m., indicated Resident B was roaming the hallways. While in the dining room, he spit on another resident. While the nurse was attempting to remove him from the dining room, he grabbed her breasts and private area. The unit manager was called and arrived in the resident's room to speak to him. He called the unit manager the N word, swatted his hand into the Social Worker's face and hit the Director of Nursing. Interventions were ineffective, so the resident was sent to the emergency room for an evaluation and treatment. A nursing progress note, dated 7/9/25, indicated the resident was discharged to the emergency room.Resident B's record lacked documentation he was allowed to return to the facility after he was sent to the emergency room on 7/9/25. A document, titled Admissions/Marketing Referral Intake Form, dated 7/9/25 and provided by the Director of Nursing on 7/23/25 at 12:30 p.m., indicated Resident B was hospitalized for behaviors. He had been a previous admission and had refused care. The notes section indicated Upon entering hospital room of [Name of Resident], resident was in restraints, resident asked Nurse 'What do want N*****?' Nurse read notes about resident kicking at nurse and spitting on a security officer. Resident also swung on EMS [Emergency Medical Service] driver.The document was dated the same day the resident was sent to the hospital and indicated the resident had been a previous admission and had refused care. The document did not indicate Resident B was a current resident.During an interview, on 7/23/25 at 12:31 p.m., the Director of Nursing indicated the Admissions/Marketing Referral Intake Form was an assessment completed by LPN 1 on Resident B which determined he could not come back to the facility. During an interview, on 7/22/25 at 12:58 p.m., CNA 2 indicated Resident B only had behaviors toward the females. He never had any problems with the resident while he was providing care for him. During an interview, on 7/22/25 at 3:21 p.m., the Director of Nursing indicated LPN 1 went to assess the resident at the hospital prior to him returning to the facility. He was in need of antipsychotic medication as well as restraints to protect the safety and well-being of the hospital staff in the emergency room. Resident B had indicated he wanted to hurt the security guard who put him in the emergency room bed. The facility was seeking a new place for Resident B to stay due to his behavioral outbursts. On 6/25/25, he was supposed to be admitted to a sister facility with an all-male behavioral unit. While EMS was in route with Resident B, the facility was contacted and told the accepting facility was full, so Resident B was brought back to their facility. After the resident was sent to the hospital, on 7/9/25, the facility refused to accept him back because they could not meet his needs due to, he was in restraints at the hospital. The facility worked to get placement for him at a sister facility. The hospital called the sister facility who indicated they had accepted him, but the next day they decided he could not come because he did not have a payor source. Throughout his admission at the facility, the social worker had tried many facilities to move him to because they were not able to meet his needs.During an interview, on 7/30/25 at 10:40 a.m., the LTC Ombudsman indicated the facility had never contacted her for assistance with Resident B's care or behaviors. Her job is to be a resource and an advocate. If the facility would have reached out, she would have helped find Resident B a facility more suitable to meet his needs and behaviors. The current facility assessment, dated 8/8/24, indicated .The purpose of this assessment is to determine what resources are necessary to care for our residents competently during both day-to-day operations (including nights and weekends) and emergencies.This facility assessment will be used to: Inform staffing decisions to ensure that there are a sufficient number of staff with the appropriate competencies and skill sets necessary to care for its residents' needs as identified through assessments and plans of care; Consider specific staffing needs for each resident unit in the facility and adjust as necessary based on any changes to its resident population.Behavioral/Mental Health was 38 residents in the facility.Services and Care We Offer Based On Our Resident's Needs.Behavioral and Mental Health Specific Care of Practices: Manage the medical conditions and medication-related issues causing psychiatric symptoms and behavior, identify and implement interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment, care of individuals with depression, trauma/PTSD, other psychiatric diagnoses, intellectual or developmental disabilities. Diseases/Conditions & Physical/Cognitive Disabilities for Which We Provide Care: Psychiatric/Mood Disorders-Psychosis (Hallucinations, Delusions, etc.), Impaired Cognition, Mental Disorder, Depression, Bipolar Disorder (i.e., Mania/Depression), Schizophrenia, Post Traumatic Stress Disorder, Anxiety Disorder, Behavior that Needs Interventions.Behavioral/Mental Health Providers: Psychiatrists-One and Licensed Counselors-One.Information About Our Staffing Patterns.Behavioral Health Services: Staffing is adequate for caring for residents with dementia, mental health conditions or history of trauma.A current facility policy, titled Transfer and Discharge (including AMA), undated and provided by the Director of Nursing on 7/22/25 at 1:29 p.m., indicated .It is the policy of this facility to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility, except in limited circumstances. This policy applies to all residents regardless of their payment source.The facility will evaluate and determine the level of care needed for the resident prior to admission to ensure the facility's ability to meet the resident's needs. 2. Once admitted , the resident has the right to remain at the facility unless their transfer or discharge meets one of the following specified exemptions: a. The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility .The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident .The facility's transfer/discharge notice will be provided to the resident and resident's representative in a language and manner in which they can understand. The notice will include all of the following at the time it is provided: a. The specific reason and basis for transfer or discharge. b. The effective date of transfer or discharge. c. The specific location (such as the name of the new provider or description and/or address if the location is a residence) to which the resident is to be transferred or discharged . d. An explanation of the right to appeal the transfer or discharge to the State .Generally, the notice must be provided at least 30 days prior to a transfer or discharge of the resident. Exceptions to the 30-day requirement apply when the transfer or discharge is affected because: a. The health and/or safety of individuals in the facility would be endangered due to the clinical or behavioral status of the resident .Emergency Transfers to Acute Care.The resident will be permitted to return to the facility upon discharge from the acute care setting. Not permitting a resident to return following hospitalization constitutes a discharge. j. Because the facility was able to care for the resident prior to hospitalization or therapeutic leave, documentation related to the basis for discharge will clearly show why the facility can no longer care for the resident.This citation relates to Complaint 1369834.3.1-12(a)(5)(A)

Based on interview and record review, the facility failed to ensure a resident, the resident's representative, and the Office of the State LTC Ombudsman was notified, provided the necessary paperwork, and was involved in the discharge process before a resident was sent to the emergency room and was not permitted to return for 1 of 3 resident reviewed the for discharge process. (Resident B)Findings include:An email from the local hospital, dated 7/10/25, indicated Resident B was sent to the emergency room due to alleged aggression at the facility where he resided. The psychiatric department cleared him while in the emergency room to return to the facility. The facility refused to accept him back. The clinical record for Resident B was reviewed on 7/22/25 at 1:15 p.m. The diagnoses included, but were not limited to, Parkinson's disease, dementia, metabolic encephalopathy, bipolar disorder, and the need for assistance with personal care.Resident B was admitted to the facility, on 3/24/25, from a psychiatric hospital.A social worker progress note, dated 4/23/25 at 4:30 p.m., indicated she attempted to call Resident B's son to participate in a care plan meeting, but his children were unreachable. The resident needed a guardian. She would continue to contact his children. The clinical record did not indicate the attempts the facility had made to obtain a guardian for Resident B.A nursing progress note, dated 4/24/25, indicated Resident B was admitted to a psychiatric hospital for the behaviors he had been displaying. A nursing progress note, dated 5/1/25 at 7:22 p.m., indicated Resident B was re-admitted to the facility after a psychiatric hospital stay for behaviors. The nursing progress notes, dated 5/7/25, indicated a physician's order was obtained to send Resident B out for a psychiatric evaluation.A progress nursing note, dated 5/14/25 at 3:33 p.m., indicated Resident B was re-admitted to the facility after a recent psychiatric hospital stay.A nursing progress note, dated 5/31/25, indicated Resident B was sent out to a psychiatric hospital due to behaviors.A nursing progress note, dated 6/25/25 at 3:48 p.m., indicated Resident B was re-admitted back to the facility from the psychiatric hospital.A nursing progress note, dated 7/4/25, indicated Resident B kicked an aide in the middle of her chest, grabbed her arm, scratched her on the right upper arm, spit at her and said multiple racial slurs. The police were called, and a physician's order was given to send the resident out to a different psychiatric hospital. A nursing progress note, dated 7/7/25, indicated Resident B was re-admitted to the facility.A nursing progress note, dated 7/9/25, indicated the resident was discharged to the emergency room.Resident B's record lacked documentation he was allowed to return to the facility after he was sent to the emergency room on 7/9/25. A document, titled Admissions/Marketing Referral Intake Form, dated 7/9/25 and provided by the Director of Nursing on 7/23/25 at 12:30 p.m., indicated Resident B was hospitalized for behaviors. He had been a previous admission and had refused care.The document was dated the same day the resident was sent to the hospital and indicated the resident had been a previous admission and had refused care. The document did not indicate Resident B was a current resident.During an interview, on 7/23/25 at 12:31 p.m., the Director of Nursing indicated the Admissions/Marketing Referral Intake Form was an assessment completed by LPN 1 on Resident B which determined he could not come back to the facility. During an interview, on 7/22/25 at 3:21 p.m., the Director of Nursing indicated after the resident was sent to the hospital, on 7/9/25, the facility refused to accept him back because they could not meet his needs due to, he was in restraints at the hospital. The facility was seeking a new place for Resident B to stay due to his behavioral outbursts. On 6/25/25, he was supposed to be admitted to a sister facility with an all-male behavioral unit. While EMS was in route with Resident B, the facility was contacted and told the accepting facility was full, so Resident B was brought back to their facility. The facility worked to get placement for him at a sister facility. The hospital called the sister facility who indicated they had accepted him, but the next day they decided he could not come because he did not have a payor source. Throughout his admission at the facility, the social worker had tried many facilities to move him to because they were not able to meet his needs.During an interview, on 7/23/25 at 2:51 p.m., the Social Service Director indicated she did not play any role in the discharge planning for Resident B because his discharge was an unplanned discharge. She did not notify the family (his sons) regarding the unplanned discharge because they lived out of state. They did not return calls to the facility even when the facility left messages for them.During an interview, on 7/30/25 at 10:40 a.m., the LTC Ombudsman indicated the facility had never contacted her for assistance with Resident B's care or behaviors. Her job is to be a resource and an advocate. If the facility would have reached out, she would have helped find Resident B a facility more suitable to meet his needs and behaviors. There was no documentation in the medical record to indicate the facility had tried to obtain a guardian for the resident, had provided the resident with a 30-day discharge at any time during his stay, provided the necessary paperwork for the appeals process, or had involved the Office of the State LTC Ombudsman in the resident's care or discharge planning prior to sending Resident B to the emergency room for an evaluation and not permitting him to return to the facility.The current facility assessment, dated 8/8/24, indicated .The purpose of this assessment is to determine what resources are necessary to care for our residents competently during both day-to-day operations (including nights and weekends) and emergencies.This facility assessment will be used to: Inform staffing decisions to ensure that there are a sufficient number of staff with the appropriate competencies and skill sets necessary to care for its residents' needs as identified through assessments and plans of care; Consider specific staffing needs for each resident unit in the facility and adjust as necessary based on any changes to its resident population.Behavioral/Mental Health was 38 residents in the facility.Services and Care We Offer Based On Our Resident's Needs.Behavioral and Mental Health Specific Care of Practices: Manage the medical conditions and medication-related issues causing psychiatric symptoms and behavior, identify and implement interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment, care of individuals with depression, trauma/PTSD, other psychiatric diagnoses, intellectual or developmental disabilities. Diseases/Conditions & Physical/Cognitive Disabilities for Which We Provide Care: Psychiatric/Mood Disorders-Psychosis (Hallucinations, Delusions, etc.), Impaired Cognition, Mental Disorder, Depression, Bipolar Disorder (i.e., Mania/Depression), Schizophrenia, Post Traumatic Stress Disorder, Anxiety Disorder, Behavior that Needs Interventions.Behavioral/Mental Health Providers: Psychiatrists-One and Licensed Counselors-One.Information About Our Staffing Patterns.Behavioral Health Services: Staffing is adequate for caring for residents with dementia, mental health conditions or history of trauma.A current facility policy, titled Transfer and Discharge (including AMA), undated and provided by the Director of Nursing on 7/22/25 at 1:29 p.m., indicated .The facility's transfer/discharge notice will be provided to the resident and resident's representative in a language and manner in which they can understand. The notice will include all of the following at the time it is provided: a. The specific reason and basis for transfer or discharge. b. The effective date of transfer or discharge. c. The specific location (such as the name of the new provider or description and/or address if the location is a residence) to which the resident is to be transferred or discharged . d. An explanation of the right to appeal the transfer or discharge to the State .Generally, the notice must be provided at least 30 days prior to a transfer or discharge of the resident. Exceptions to the 30-day requirement apply when the transfer or discharge is affected because: a. The health and/or safety of individuals in the facility would be endangered due to the clinical or behavioral status of the resident .Emergency Transfers to Acute Care.The resident will be permitted to return to the facility upon discharge from the acute care setting. Not permitting a resident to return following hospitalization constitutes a discharge. j. Because the facility was able to care for the resident prior to hospitalization or therapeutic leave, documentation related to the basis for discharge will clearly show why the facility can no longer care for the resident.This citation relates to Complaint 1369834.3.1-12(a)(6)(A)(ii)3.1-12(a)(6)(A)(iii)3.1-12(a)(6)(A)(iv)

Based on interview and record review, the facility failed to complete an elopement assessment accurately to ensure hazard risks were evaluated, analyzed, and interventions were implemented for 1 of 4 residents reviewed for accidents hazards. (Resident 35) Findings include: The clinical record for Resident 35 was reviewed on 5/2/25 at 10:47 a.m. The diagnoses included, but were not limited to bipolar disorder, post-traumatic stress disorder (PTSD), and autistic disorder. A hospital discharge report, dated 12/24/24, indicated the resident presented to the hospital with burns on her bottom. The resident's caregiver indicated the resident eloped from home frequently and had been gone for several days. A facility elopement assessment, dated 1/15/25, indicated the resident had no history of elopement or an attempted elopement while at home. A progress note, dated 1/16/25, indicated the resident's caregiver stated the resident eloped from home frequently and had been missing from home for several days. The resident came back home with burns on her bottom. During an interview, on 5/6/25 at 2:36 p.m., the Social Services Director (SSD) indicated the resident was not in the elopement book. The nurse completed the elopement assessment incorrectly and it should have indicated the resident did have a history of eloping at home. She was not aware the resident had eloped prior to coming to the facility. Moving forward, the facility needed to monitor Resident 35. A current facility policy, titled Elopements and Wandering Residents, dated 2024 and received from the Clinical Support Nurse 2 indicated .Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team 3.1-45(a)(1) 3.1-45(a)(2)

Based on observation, interview and record review, the facility failed to ensure the Minimum Data Set (MDS) assessment was correctly coded for 3 of 3 residents reviewed for resident assessments. (Resident 38, 4 and 222) Findings include: 1. The clinical record for Resident 38 was reviewed on 5/2/25 at 11:45 a.m. The diagnoses included, but were not limited to, hypertension, end stage renal disease, and hyperlipidemia. An MDS assessment, dated 4/16/25, indicated Resident 38 did not receive dialysis. A nursing progress note, dated 5/2/25 at 11:45 a.m., indicated the resident did receive dialysis. During an interview, on 5/2/25 at 11:45 a.m., the MDS Coordinator indicated the resident did receive dialysis and the resident should have been marked as receiving dialysis on the MDS assessment. 2. During an observation and interview, on 4/30/25 at 3:05 p.m., Resident 4 was lying in her bed with bilateral bed rails in the raised position. Resident 4 indicated she used the bed rails to assist with bed mobility and for support when getting out of bed. The clinical record for Resident 4 was reviewed on 5/6/25 at 10:00 a.m. The diagnoses included, but were not limited to, morbid obesity, muscle weakness, and abnormalities of gait and mobility. An admission MDS assessment, dated 11/27/24, did not indicate bed rails were in use. A quarterly MDS assessment, dated 4/24/25, did not indicate bed rails were in use. Resident 4's care plans did not include interventions related to the use of bed rails. 3. During an observation, on 4/30/25 at 11:33 a.m., Resident 222 was lying in bed with bilateral bed rails in the raised position. The clinical record for Resident 222 was reviewed on 5/5/25 at 10:08 a.m. The diagnoses included, but were not limited to, insomnia, major depressive disorder, and anemia. An admission MDS assessment, dated 4/28/25, did not indicate bed rails were in use. Resident 222's care plans did not include interventions related to the use of bed rails. During an interview, on 5/6/25 at 9:20 a.m., the Director of Nursing (DON) indicated the residents' care plans would indicate the use of bed rails. A document, titled Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.20.1, indicated .nursing homes are responsible for ensuring that all participants in the assessment process have the requisite knowledge to complete an accurate assessment 3.1-31(c)(1)

Based on observation, interview and record review, the facility failed to ensure enhanced barrier precautions (EBP) signs were posted, Personal Protective Equipment (PPE) was available and worn, and medications were prepared in a sanitary manner for 3 of 3 residents reviewed for infection control. (Resident 47, 6 and 10) Findings include: 1. During an observation, on 5/2/25 at 10:35 a.m., LPN 6 was observed to provide wound care to the pressure wound on the back of Resident 47's left upper thigh. LPN 6 was observed to clean the wound, starting in the center of the wound bed and moving outward. She was observed to move back into the wound bed using the same gauze dressing to finish cleaning the wound. She was not observed to discard the dressing and use a new gauze dressing when she returned to the wound bed to clean it. After cleaning the wound, LPN 6 was observed to use a towel, which was on the bedside table, to pat dry the wound. She completed the wound care and secured a dressing to the area. LPN 6 was not observed to wear a gown at any time during wound care. The clinical record for Resident 47 was reviewed on 5/1/25 at 11:01 a.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD), back pain, and obesity. A physician's order, dated 5/1/25, indicated .Enhanced Barrier Precautions: Sign outside resident's room. Gown and Gloves for high contact resident care activities. Used for residents with known MDRO or have an increased risk of MDRO acquisition (Residents with wounds or indwelling medical devices). Face shield should be used for any tasks that have a high potential of splash or spray The care plans for Resident 47 did not address the use of enhanced barrier precautions. During an interview, on 5/2/25 at 11:08 a.m., LPN 6 indicated the wound was supposed to be cleaned from the inside to the outside. A EBP sign was not posted, and she was not aware of the PPE which should be used for enhanced barrier precautions. During an interview, on 5/2/25 at 11:09 a.m., the Director of Nursing indicated there was not a sign posted, related to Resident 47's enhanced barrier precautions, a sign was there. The nurse was not aware of the enhanced barrier precautions in place. The Director of Nursing indicated she would replace the sign. 2. During an observation, on 5/6/25 at 8:26 a.m., RN 8 was observed preparing medications for Resident 6. During the preparation of the medications the nurse was observed dropping one tablet onto her medication cart. She picked up the medication with her fingers and put the pill into the medication cup. During an interview, on 5/6/25 at 8:31 a.m., RN 8 indicated she picked up the pill with her fingers after it had fallen on the medication cart surface. It was not the correct infection control procedure, and she should have replaced the medication.3. During an observation and interview, on 4/30/25 at 10:29 a.m., Resident 10 was in her room, lying in bed. Wound supplies, which consisted of Betadine, Sure prep wipes, sterile water, and absorbent dressings were sitting on top of the dresser. Resident 10 indicated she had wounds on her vagina and butt. She indicated the staff did treatments on the wounds. When asked if the nurses wore gowns and gloves while performing treatments on her wounds, Resident 10 replied no, they only wear gloves. No EBP sign was observed on the resident's door or in her room and PPE was not observed outside of the resident's room. The clinical record for Resident 10 was reviewed on 5/2/25 at 1:31 p.m. The diagnoses included, but were not limited to, type 2 diabetes, hemiplegia and hemiparesis following cerebral infarction affecting the right side, and lack of coordination. A physician's order, dated 4/29/25, indicated wound care was to be completed every day. A physician's order, dated 5/1/25, indicated Resident 10 was placed on EBP. The order indicated a sign needed to be outside the resident's room and a gown and gloves were to be worn for high contact resident care activities. The order for wound care to be completed daily was started three days before the order for EBP. Resident 10's care plans did not include EBP at the time the care plan for her pressure ulcer was initiated on 3/31/25. The discontinued orders, for Resident 10, indicated EBP had not been ordered, at any time, prior to 5/1/25. During an interview, on 5/5/25 at 11:07 a.m., Clinical Support 3 indicated EBP orders would be initiated when a wound had started and the order for EBP should have been initiated before 5/1/25. During an interview, on 5/7/25, the Infection Preventionist (IP) indicated a resident would need EBP if they had wounds. A sign would be posted on the resident's door and an EBP cart for PPE supplies would be outside of the resident's room. A current facility document, titled Validation Checklist Wound Care, indicated .Reviewed physician's order .donned appropriate personal protective equipment .Cleanse wound thoroughly .taking care not to contaminate other skin surfaces or other surfaces of the wound A current facility policy, titled Destruction of Unused Drugs, dated 2025 and received from Corporate Support Nurse 2 on 5/7/25 at 1:25 p.m., indicated .taking care not to touch medication with bare hands A current facility policy, titled Enhanced Barrier Precautions, dated as last revised 2025 and received from Clinical Support 2 on 5/7/25 at 3:32 p.m., indicated .It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms .[Enhanced barrier precautions] (EBP) refers to an infection control intervention designed to reduce transmission of multidrug-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 .Enhanced barrier precautions should be used .until resolution of the wound A current facility policy, titled Personal Protective Equipment, dated as last revised May 2024 and received from the ED on 5/6/25 at 12:14 p.m., indicated .All staff who have contact with residents and/or their environments must wear person protective equipment as appropriate during resident care activities and at other times which exposure to blood, body fluids .is likely .Gloves .Wear gloves when direct contact with blood, body fluid .non-intact skin .is anticipated .Gowns .Wear gowns to protect arms, exposed body areas, and clothing from contamination with blood, body fluids A current facility policy, titled Infection Prevention and Control Program, undated and received from the ED upon entrance, indicated .All staff shall use personal protective equipment (PPE) according to established facility policy governing the use of PPE 3.1-18(b)(1)(A) 3.1-18(b)(2)

Based on observation, interview and record review, the facility failed to ensure medications were stored in their original packaging, open dates were placed on medications, and discontinued medications were removed from the cart for 2 of 3 medication carts reviewed for medication storage. (200-unit and 300-unit) Findings include: 1. During an observation, on [DATE] at 1:19 p.m., with RN 8, the 200-unit medication cart had the following: a. one bottle of latanoprost 0.005% eye drops without an open date. b. one bottle of liquid protein 30 ounces opened without a resident's name. c. 19 pills not in a package loose in the drawers. During an interview, on [DATE] at 1:26 p.m., RN 8 indicated the eye drops should have had an opened date, and the liquid protein was for a resident who had discharged . She was supposed to give the liquid protein to the resident at discharge, or it should have been discarded. During an interview, on [DATE] at 1:45 p.m., the Corporate Support Nurse 2 indicated there should not be free (unpackaged) pills in the cart. 2. During an observation, on [DATE] at 1:59 p.m., with LPN 6, the 300-unit north cart had the following: a. one bottle of latanoprost 0.005% eye drops without an open date. b. one bottle of olopatadine 0.1% eye drops without an open date. c. one bottle of carboxymethylcellulose eye drops without an open date. At that time, LPN 6 indicated the resident had discharged from the facility and the medication should have been removed from the cart. d. one bottle of moxifloxacin 0.5% eye drops without an open date. The medication had a discontinued date of [DATE]. LPN 6 indicated the medication had been discontinued. e. one container of potassium chloride 10% solution without an open date. f. one container of lactulose without an open date. g. 16 pills not in a package loose in the drawers. During an interview, on [DATE] at 2:07 p.m., LPN 6 indicated staff were supposed to place open dates on the medications when they were opened. A current facility policy, titled Medication Administration, dated 2025 and received from Corporate Support Nurse 2 on [DATE] at 1:25 p.m., indicated .All unused, contaminated, or expired prescription drugs shall be disposed of A current facility policy, titled Labeling of Medications and Biologicals, dated 2025 and received from the Executive Director on [DATE] at 12:14 p.m., indicated .All medications and biologicals used in the facility will be labeled in accordance with current state and federal regulations to facilitate consideration of precautions and safe administration of medications 3.1-25(j) 3.1-25(o) 3.1-25(p) 3.1-25(r)

Based on interview and record review, the facility failed to ensure baseline Abnormal Involuntary Movement Scale (AIMS) assessments were completed for evaluation of adverse reactions related to antipsychotic medication use for 2 of 5 residents reviewed for unnecessary medications. (Resident 4 and 222) Findings include: 1. The clinical record for Resident 4 was reviewed on 5/6/25 at 10:00 a.m. The diagnoses included, but were not limited to, acute and chronic respiratory failure with hypoxia and major depressive disorder. A physician's order, dated 11/14/24, indicated Resident 4 was prescribed Latuda (an antipsychotic medication) 60 milligrams (mg) daily at bedtime. A care plan, dated 11/15/24, indicated Resident 4 used psychotropic medications with an intervention to monitor adverse reactions including, but not limited to, tardive dyskinesia (repetitive involuntary movements). Resident 4's assessments from 11/13/24 to 4/30/25 did not include a baseline AIMS assessment. 2. The clinical record for Resident 222 was reviewed on 5/5/25 at 10:08 a.m. The diagnoses included, but were not limited to, insomnia and major depressive disorder. A physician's order, dated 4/24/25, indicated Resident 222 was prescribed Aripiprazole (an antipsychotic medication) 10 mg daily. A physician's order, dated 4/30/25, indicated to monitor for side effects of antipsychotic medications, including but not limited to, EPS (extrapyramidal symptoms), which could include involuntary movements. A care plan, dated 4/24/25, indicated Resident 222 was on antipsychotic therapy related to major depressive disorder with an intervention to monitor side effects of the medication. Resident 222's assessments from 4/23/25 to 5/5/25 did not include a baseline AIMS assessment. During an interview, on 5/5/25 at 3:30 p.m., the Director of Nursing indicated an AIMS assessment was not completed upon admission for Resident 4 or Resident 222. A current facility policy, titled Use of Psychotropic Medication(s), dated as last revised 2025 and received from the Executive Director on 5/6/25 at 12:14 p.m., indicated .Residents who receive an antipsychotic medication will have an Abnormal Involuntary Movement scale (AIMS) test performed when indicated .The effects of the psychotropic medications on a resident's physical, mental and psychosocial well-being will be evaluated on an ongoing basis, such as .Upon physician evaluation (routine and as needed) .During MDS review .In accordance with nurse assessments and medication monitoring parameters consistent with clinical standards of practice 3.1-48(a)(3)

Based on observation, interview and record review, the facility failed to ensure staff followed facility policy and procedure for reconciliation of controlled substances for 2 of 6 medication carts reviewed for controlled medications. (South and Southwest) Findings include: 1. During an observation of medication storage, on 5/5/25 at 1:33 p.m., the South medication cart had the following: a. A document, titled CONTROLLED SUBSTANCE SHIFT CHANGE COUNT RECORD, for February 2025, indicated: On 2/1/25, the form was missing the signature for the off-going nurse from 6:30 a.m. to 6:30 p.m. On 2/6/25, the form was missing the signature for the on-coming nurse from 6:30 a.m. to 6:30 p.m., and the off-going nurse from 6:30 a.m. to 6:30 p.m. On 2/9/25, the form was missing the signature for the on-coming nurse from 6:30 p.m. to 6:30 a.m. On 2/10/25, the form was missing the signature for the off-going nurse from 6:30 p.m. to 6:30 a.m., the on-coming nurse from 6:30 a.m. to 6:30 p.m., and the off-going nurse from 6:30 a.m. to 6:30 p.m. On 2/11/25, the form was missing the signature for the off-going nurse from 6:30 p.m. to 6:30 a.m. On 2/14/25, the form was missing the signature for the on-coming nurse from 6:30 p.m. to 6:30 a.m. On 2/15/25, the form was missing the signature for the off-going nurse from 6:30 p.m. to 6:30 a.m. There were an additional 5 missing signatures for the on-coming and/or off-going nurses from 2/22/25 to 2/28/25. b. A document, titled CONTROLLED SUBSTANCE SHIFT CHANGE COUNT RECORD, for April 2025, indicated: On 4/1/25, the form was missing the signature for the off-going nurse from 6:30 p.m. to 6:30 a.m., and the on-coming shift from 6:30 p.m. to 6:30 a.m. On 4/2/25, the form was missing the signature for the off-going nurse from 6:30 p.m. to 6:30 a.m. On 4/3/25, the form was missing the signature for the on-coming nurse from 6:30 p.m. to 6:30 a.m. On 4/4/25, the form was missing the signature for the off-going nurse from 6:30 p.m. to 6:30 a.m. On 4/18/25, the form was missing the signature for the off-going nurse from 6:30 a.m. to 6:30 p.m. c. A document, titled CONTROLLED SUBSTANCE SHIFT CHANGE COUNT RECORD, for May 2025, indicated: On 5/1/25, the form was missing the signatures for the off-going nurse from 6:30 p.m. to 6:30 a.m., the on-coming nurse from 6:30 a.m. to 6:30 p.m., and the off-going nurse from 6:30 a.m. to 6:30 p.m. On 5/2/25, the form was missing the signature for the on-coming nurse from 6:30 p.m. to 6:30 a.m. On 5/3/25, the form was missing the signature for the off-going nurse from 6:30 p.m. to 6:30 a.m. 2. During an observation of medication storage, on 5/5/25, the Southwest medication cart had the following: a. A document, titled CONTROLLED SUBSTANCE SHIFT CHANGE COUNT RECORD, for May 2025, indicated: On 5/2/25, the form was missing the signature for the on-coming nurse from 6:30 p.m. to 6:30 a.m. On 5/3/25, the form was missing the signature for the off-going nurse from 6:30 p.m. to 6:30 a.m. During an interview, on 5/5/25 at 1:51 p.m., LPN 6 indicated staff were supposed to count the narcotics with the other nurse and sign the narcotic log before they left their shift and when they came on shift. A current facility document, titled CONTROLLED SUBSTANCE SHIFT CHANGE COUNT RECORD, undated and received from the Corporate Support Nurse 2 on 5/5/25 at 1:50 p.m., indicated .Signing below acknowledges that you have counted the controlled drugs on hand and have found that the quantity of each medication is in agreement with the quantity stated on the Controlled Substance Shift Change Count Records A current facility policy, titled Controlled Substance Administration & Accountability, dated 2025 and received from the Executive Director on 5/6/25 at 12:14 p.m., indicated .two licensed nurses account for all controlled substances and access keys at the end of each shift 3.1-25(e)(2) 3.1-25(e)(3)

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for a resident with a diagnosis of epilepsy who received medications for seizure control for 1 of 2 residents reviewed for comprehensive care plans. (Resident 23) Findings include: The clinical record for Resident 23 was reviewed on 5/2/25 at 10:47 a.m. The diagnoses included, but were not limited to, epilepsy with status epilepticus (seizures which are not well controlled and complicated by prolonged seizure events), aphasia following cerebral infarction (a language disorder following a stroke) and hemiplegia and hemiparesis following cerebral infarction (weakness and paralysis on one side of the body following a stroke). A quarterly Minimum Data Set (MDS) assessment, dated 3/27/25, indicated the resident had a diagnosis of seizure disorder or epilepsy. A physician's order, dated 4/17/25, indicated to give Depakote Sprinkles (a medication for seizures) 125 milligrams (mg) once a day for epilepsy. A physician's order, dated 4/17/25, indicated to give lacosamide (a medication for seizures) 200 mg twice a day for epilepsy. A physician's order, dated 4/17/25, indicated to give levetiracetam (a medication for seizures) 750 mg twice a day for epilepsy. A seizure care plan was not located in the resident's record. During an interview, on 5/6/25 at 2:34 p.m., the Director of Nursing indicated the resident previously had a seizure care plan in the facility's old system. A current facility policy titled, Comprehensive Care Plans dated 2025 and received from Corporate Support Nurse on 05/07/25 at 9:50 a.m., indicated, .It is the policy of this facility to develop and implement a comprehensive person-centered care plan .that includes measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality 3.1-35(a) 3.1-35(b)(1)

Based on interview and record review, the facility failed to ensure a new pre-admission screening and resident review (PASARR) was completed after the number of approved days expired for 1 of 1 resident reviewed for PASARR. (Resident 35) Findings include: The clinical record for Resident 35 was reviewed on [DATE] at 10:47 a.m. The diagnoses included, but were not limited to, bipolar disorder, post-traumatic stress disorder (PTSD), and autistic disorder. A notice of PASARR level I screen outcome, dated [DATE], indicated the PASARR level I determination was a temporary approval of 60 days. If you or your care provider thinks you need to stay longer than the number of approved days listed on the PASARR level I screen outcome which came with this letter, a nursing facility staff member must submit a new level I screen to Maximus. This must be completed by or before the last approved day. A new level 1 PASARR was not resubmitted after 60 days. During an interview, on [DATE] at 10:14 a.m., the Social Services Director (SSD) indicated a new PASARR was not completed. During an interview, on [DATE] at 10:16 a.m., the Minimum Data Set (MDS) Coordinator indicated the PASARR level I was completed but only approved for 60 days. The facility should have submitted another one. During an interview, on [DATE] at 12:02 p.m., a PASARR help desk staff member indicated a level of care determination would not trump the most recent level I PASARR. A PASARR level I with an approval period of 60 days must be followed up on and was no longer valid after 60 days. A new PASARR screening would need to be resubmitted. A current facility policy, titled Resident assessment - Coordination with PASARR Program, dated 2024 and received from Clinical Support 2, 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 3.1-16(d)(1)(A) 3.1-16(d)(1)(B)

Based on interview and record review, the facility failed to ensure the ombudsman was notified after a discharge and there was documentation the bed hold policy was provided to a resident for 3 of 5 residents reviewed for hospitalization. (Resident 19, 173 and 27) Findings include: 1. The clinical record for Resident 19 was reviewed on 5/5/25 at 9:31 a.m. The diagnoses included, but were not limited to, cognitive communication deficit, muscle weakness, and vitamin D deficiency. A nursing progress note, dated 1/14/25, indicate the resident had jerking movements with coffee ground secretions in her mouth. The physician was notified, and the resident was sent to the hospital. There was no documentation the bed hold information was provided to the resident. A transfer form, dated 1/14/25, indicated the resident was transferred to the hospital due to jerking movements and coffee ground emesis. There was no documentation the bed hold information was provided to Resident 19 in the record. 2. The clinical record for Resident 173 was reviewed on 5/5/25 at 9:09 a.m. The diagnoses included, but were not limited to, respiratory failure with hypoxia, dysphagia, and hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body). A nursing progress note, dated 4/20/25, indicated the residents' respiratory status was declining and Resident 173 was transferred to the hospital. There was no documentation the bed hold information was provided to the resident. A completed transfer form was not located in the resident's record. There was no documentation the bed hold information was provided to the resident in the record.3. The clinical record for Resident 27 was reviewed on 5/2/25 at 11:01 a.m. The diagnoses included, but were not limited to, chronic respiratory failure with hypoxia, end stage renal disease, and major depressive disorder. a. Resident 27 was discharged from the facility on 10/30/24 and returned on 11/7/24. A document, titled Ombudsman Notice of Resident Discharges, for the month of October 2024, did not indicate the Ombudsman was not notified of Resident 27's discharge, as the resident was not identified on the notice. b. Resident 27 was transferred to the hospital on [DATE] and returned to the facility on [DATE]. The electronic health record did not indicate the bed hold policy had been given to Resident 27 at the time of the transfer. During an interview, on 5/5/25 at 10:24 a.m., Clinical Support 2 indicated transfer forms and bed hold policies were filled out and sent to the hospital with the residents. Staff did not document in the electronic health record the forms were given to the residents at the time of transfer. During an interview, on 5/5/25 at 10:22 a.m., the Director of Nursing (DON) indicated she was not sure if the ombudsman was notified. During an interview, on 5/5/25 at 10:24 a.m., Clinical Support 2 indicated Resident 27 was not on the ombudsman notification list for the month of October 2024. A document, titled Family of Social Service Administration, last updated October 2024, indicated .Dear Nursing Home Administrator: As you know, CMS requires nursing facilities to notify the Long-Term Care (LTC) Ombudsman of the majority of residents' transfers and discharges .When a resident is transferred on an emergency basis to an acute care facility and expected to return, the SLTCO must be notified. Information from facilities regarding emergency transfers should be provided in a monthly list to the SLTCO, which should include residents' names, dates of transfer, facilities to which residents were transferred, and reasons for the transfers A current facility policy, titled Bed Hold Notice, dated as last revised 2025 and received from the Executive Director (ED) on 5/6/25 at 12:14 p.m., indicated .It is the policy of this facility to provide written information to the resident and/or the resident representative regarding the bed hold practices both well in advance, and at the time of, a transfer for hospitalization or therapeutic leave .The facility will keep a signed and dated copy of the bed-hold notice information given to the resident and/or resident representative A current facility policy, titled Transfer and Discharge, dated as last revised 2025 and received from the ED on 5/6/25 at 12:14 p.m., indicated .The facility will maintain evidence that the notice was sent to the Ombudsman .Provide notice of transfer and the facility's bed hold notice policy to the resident and representative as indicated .The Social Service Director, or designee, will provide copies of notices for emergency transfers to the Ombudsman .such as in a list of residents on a monthly basis 3.1-12(a)(6)(A)(iv) 3.1-12(a)(25)(A) 3.1-12(a)(25)(B)

Based on observation, interview and record review, the facility failed to ensure the call system was within reach for 1 of 8 residents reviewed for accommodation of needs. Findings include: During an interview, on 4/30/25 at 10:43 a.m., Resident 8 indicated she was left wet and was not changed as often as she needed. During an observation, on 5/5/25 at 2:13 p.m., Resident 8 was sitting in her wheelchair in her room. She was alert and able to voice her needs. Resident 8 indicated she was wet and did not have the call light. The call light was not in view or reach of the resident. The resident indicated she was aware of when she needed to use the restroom. During an observation and interview, on 5/5/25 at 2:15 p.m., CNA 10 found the call light behind the resident and out of reach. CNA 10 indicated the call light was supposed to be left where the resident could reach it. The clinical record for Resident 8 was reviewed on 5/7/25 at 8:46 a.m. The diagnoses included, but were not limited to, hypertension, weakness, and hemiplegia and hemiparesis (weakness and paralysis on the left side) following cerebral infarction (stroke). A care plan, dated 3/26/25, indicated the resident had a communication problem and to leave the call light in reach of the resident. A care plan, dated 3/26/25, indicated Resident 8 had bladder incontinence related to a need for assistance with toileting due to impaired mobility. The care plan did not address leaving the call light in reach. A current facility policy, titled Call Lights: Accessibility and Timely Response, dated 2024 and received from the Executive Director on 5/6/25 at 12:14 p.m., indicated .Staff will ensure the call light is within reach of resident and secured, as needed This citation relates to Complaints IN00451279 and IN00451331. 3.1-3(v)(1)

Based on observation, interview, and record review, the facility failed to address the incontinence care of a resident with a colostomy in a timely manner for 1 of 1 resident reviewed for colostomy care. (Resident 42) Finding includes: During an observation, on 6/25/24 at 11:35 a.m., Resident 42 returned from therapy where his colostomy bag had ruptured. The resident was in his wheelchair with a foul smelling, stool-stained shirt. Licensed Practical Nurse (LPN) 8 came into his room and acknowledged the resident's need for a colostomy bag and clothing change, his discomfort, and his need to get back into bed. LPN 8 indicated she would be back as soon as the Certified Nursing Assistant (CNA) was available. The resident indicated to please hurry because he was very uncomfortable with the bowel movement on his abdomen. During an observation, on 6/25/24 at 11:45 a.m., the resident pushed his call light and called out for help. He indicated the smell was bothering him, he was very uncomfortable, and indicated again to please hurry. LPN 8 was at the computer in the nurses' station. CNA 9 was with Resident 30 with the door closed. During an observation, on 6/25/24 at 12:02 p.m., CNA 9 got on the elevator to go to laundry to get clothes for Resident 30. She did not indicate she was aware of Resident 42's situation, or the LPN needed her assistance. During an observation, on 6/25/24 at 12:07 p.m., Resident 42 continued to loudly call out for help and indicated he could not wait any longer. LPN 8 went back into the room and indicated the CNA was still with another resident. LPN 8 returned to the nurse's station. The resident continued to yell for help, express his discomfort, and for staff to hurry up until 12:17 p.m., when CNA 9 entered his room with the Hoyer lift (mechanical lift device). The clinical record for Resident 42 was reviewed on 6/26/24 at 11:18 a.m. The diagnoses included, but were not limited to, anoxic brain damage, stage 4 pressure ulcer of sacral region, diabetes mellitus with diabetic neuropathy, muscle weakness, old myocardial infarction, mild cognitive impairment, history of other mental and behavioral disorders, and vascular disorder of intestine with colostomy. A Minimum Data Set (MDS) assessment, dated 6/7/24, indicated the resident was dependent for transfers, toileting hygiene, and dressing. A physician's order, dated 5/30/24, indicated to change the colostomy bag every 3 days and as needed (PRN). A physician's order, dated 5/30/24, indicated ileostomy care every shift and PRN. A care plan, dated 5/31/24 and revised on 6/14/24, indicated the interventions were to observe the ostomy bag for leakage or a broken seal, to provide ostomy care daily and PRN, toileting assistance of extensive assist of 1-2 as needed, transfers with a total assist of 2 staff utilizing mechanical lift, and to provide thorough skin care after incontinent episodes. During an interview, on 6/25/24 at 11:25 a.m., Resident 42 indicated the staff were often too busy and could not get to him quickly since there were usually only 2 staff on the floor. During an interview, on 6/28/24 at 11:18 a.m., CNA 9 indicated the resident required the assistance of 2 staff members with the Hoyer lift for all transfers. She indicated if they really needed extra help on the unit there were always other staff they could call from the other unit. The facility indicated they did not have a bladder program and/or incontinence program policy they could provide. 3.1-47(a)(3)

Based on interview and record review, the facility failed to ensure routine blood sugars for an insulin dependent diabetic were obtained for 1 of 2 residents reviewed for quality of care. (Resident 260) Findings include: During an interview, on 6/28/24 at 8:48 a.m., Resident 260 indicated her glucose monitoring system sensor had not been in place for over a week and no staff had been checking her blood sugar. The resident indicated she had been trying to watch what she ate since she did not know what her blood sugar was running. The clinical record for Resident 260 was reviewed on 6/26/24 at 12:41 p.m. The diagnoses included, but were not limited to, periprosthetic fracture around the internal prosthetic right hip joint, stage 4 pressure ulcer of sacral region, and type 2 diabetes mellitus. Physician's orders, dated 6/7/24, included, but were not limited to, the following: a. To apply a Freestyle Libre 2 Reader Device (Continuous Blood Glucose System Receiver) sensor to the upper extremity topically on the day shift every 14 days and as needed for diabetic monitoring, and to call the provider for a blood sugar less than 60 and greater than 400. b. Lantus Solostar Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Glargine), inject 12 units subcutaneously at bedtime. c. Metformin (a medication for diabetes) HCl 500 mg, 1 tablet by mouth two times a day. A vitals record, dated 6/1/24 through 6/27/24, indicated the resident had a blood sugar of 139 on 6/8/2024 at 12:14 p.m., and 181 on 6/22/2024 at 3:57 p.m. There were no other blood sugars documented in the electronic medical record. During an interview, on 6/28/24 at 11:09 a.m., LPN 12 (Unit Manager for the 200 hall) indicated she was calling the pharmacy to check on obtaining a sensor for the resident. She was unaware it had been over a week since the resident had a sensor in place and the staff should have assessed her blood sugar with the facility glucometer in the meantime. Routine glucose monitoring was typical for residents on insulin and blood sugars should be recorded in the electronic medical record. During an interview, on 6/28/24 at 11:50 a.m., the Clinical Support Nurse indicated she could only find 2 blood sugars recorded for the resident for the month of June. There was no order for routine glucose checks or to use the glucometer when the sensor was unavailable. She indicated there was no documentation of the physician being notified of the sensor being unavailable or the lack of glucose monitoring orders for the resident while on daily insulin with a stage 4 pressure ulcer. A current policy, titled Continuous Glucose Monitors, not dated and received from the Clinical Support Nurse on 6/28/24 at 8:15 a.m., indicated .Continuous glucose monitor values will be recorded as part of daily vital signs .An adequate supply of CGM sensors/transmitters will be kept on hand for a resident with physician orders. CGM sensors/transmitters will be reordered and stored 3.1-37(a)

Based on interview and record review, the facility failed to notify the ombudsman when a resident was hospitalized and discharged for 1 of 3 residents reviewed for hospitalization . (Resident 254) Finding includes: The clinical record for Resident 254 was reviewed on 6/25/24 at 2:44 p.m. The diagnoses included, but were not limited to, respiratory failure with hypoxia (absence of enough oxygen to sustain bodily functions), unstageable pressure ulcer of sacral region, anxiety disorder, depression, bradycardia (slow heart rate), and anemia. A nursing progress note, dated 6/14/24 at 5:58 a.m., indicated the resident was transferred to the hospital. The Nurse Practitioner (NP) and the Director of Nursing (DON) were notified. The electronic medical record did not include notification or indicate a copy of the notice was sent to the Office of the State Long-Term Care Ombudsman at the time of the transfer to the hospital or later when the resident was discharged . During an interview, on 6/28/24 at 11:52 a.m., the Clinical Support Nurse indicated the facility had provided all the transfer and discharge paperwork and no notice to the ombudsman was found or provided. A current policy, titled Transfer and Discharge (Including AMA) Policy, not dated and received from the Clinical Support Nurse on 6/27/24 at 2:20 p.m., indicated .will provide copies of notices for emergency transfers to the Ombudsman .In situations where the facility has decided to discharge the resident while the resident is still hospitalized , the facility will send a notice of discharge to the resident and must also send a copy of the discharge notice to a representative of the Office of the State Long-Term Care Ombudsman 3.1-12(a)(6)(A)(iv)

Based on observation, interview and record review, the facility failed to ensure residents were dressed in their own clothing instead of hospital gowns and to ensure the residents' clothing were located or replaced for 2 of 3 residents reviewed for resident rights. (Resident 46 and 42) Findings include: 1. During an observation and interview, on 6/25/24 at 10:50 a.m., Resident 46 was sitting up in his bed and was wearing a hospital gown. He indicated the only clothing he had now was the hospital gowns. He did not put his name on his clothes, and they were missing from laundry. During an interview, on 6/25/24 at 4:07 p.m., the Social Services Designee (SSD) indicated she was not aware the resident was wearing hospital gowns. The clinical record for Resident 46 was reviewed on 6/26/24 at 1:28 a.m. The diagnoses included, but were not limited to, cerebral infarction due to occlusion or stenosis of small arteries, generalized muscle weakness, generalized anxiety disorder, and major depressive disorder. A personal inventory list for Resident 46, dated 5/20/24, indicated the resident had two pairs of blue sweatpants, one yellow shirt, one pair of navy-blue shorts and one pair of gray shorts. The inventory list was not in the electronic health record (EHR) and the Clinical Support Nurse indicated the form was in the Medical Records room and had not been scanned into the EHR yet. The personal inventory list showed the resident had clothes at admission. During an observation, on 6/26/24 at 10:26 a.m., Resident 46 was wearing a yellow shirt and blue pants and was standing next to the window in his room. During an observation, on 6/27/24 at 2:09 p.m., Resident 46 was propelling himself in his wheelchair in the hallway and was wearing a white t-shirt and green plaid pants. During an interview, on 6/26/24 at 10:24 a.m., the SSD indicated the resident's clothes were in the laundry and they had not been labeled yet. During an interview, on 6/27/24 at 2:12 p.m., the Director of Nursing (DON) indicated the facility had clothes which did not belong to any resident, and they were able to use those clothes for Resident 46. The resident did not have clothes for a long time and wore hospital gowns until someone finally brought the resident clothes. The resident did not have a care plan to wear hospital gowns. During an interview, on 6/27/24 at 4:31 p.m., the Executive Director (ED) indicated the resident's clothes were labeled when he arrived at the facility and the labels fell off. The SSD went to the laundry and found the resident's clothes. Today, he was wearing clothing which was not on his inventory list. They were able to find clothes in his size today. 49891 2. During an observation, on 6/26/28 at 11:00 a.m., the resident was sitting in his wheelchair wearing shorts and a hospital gown. The resident indicated he did not have any clean shirts because his new shirts had been missing for at least 3 weeks. He indicated he really wanted his shirts back because they were all wicking fabric rather than cotton. The clinical record for Resident 42 was reviewed on 6/26/24 at 11:18 a.m. The diagnoses included, but were not limited to, anoxic brain damage, stage 4 pressure ulcer of sacral region, diabetes mellitus with diabetic neuropathy, muscle weakness, old myocardial infarction, mild cognitive impairment, history of other mental and behavioral disorders, and vascular disorder of intestine with colostomy. There was no inventory sheet in the electronic medical record. An undated inventory sheet, provided by Clinical Support Nurse on 6/28/24 at 8:15 a.m., indicated the resident had 8 shirts, 8 shorts, and 5 pairs of socks. A second inventory sheet, dated 6/27/27, provided by Clinical Support Nurse on 6/28/24 at 8:15 a.m., indicated the resident currently had 7 shirts, 1 pair of shorts, and 2 pairs of socks. During an interview, on 6/26/24 at 11:06 a.m., the resident indicated his clothing was labeled with his name on admission and many items were missing for about 3 weeks. He received one shirt back on Friday. His mother had started doing his laundry to try to decrease the missing items. He had to wear a hospital gown whenever he did not have clean clothes, and he preferred his own clothes because he only liked wicking material because he was frequently hot in the facility. During an interview, on 6/27/24 at 1:24 p.m., the resident's mother indicated a staff member from laundry took the clothing she had brought in for him on admission, on 5/30/24, to label the items with the facility's labels. All the clothing already had his name on it when they went down to the laundry. Most of his shirts had been missing since shortly after admission. She had gone down to laundry with staff to look for the items, on 6/17/24, but did not find anything. She had inquired again about the clothing on 6/21/24 and was told she would need to bring in receipts to show what she had spent on the items. During an interview, on 6/28/24 at 11:47 a.m., the Executive Director (ED) and Clinical Support Nurse indicated all but 2 shirts had been found on 6/27/24, and a new inventory sheet had been completed. The facility would be reimbursing the mother for the remaining missing items. A current policy, titled Resident Personal Belongings, not dated and received from the Clinical Support Nurse on 6/28/24 at 12:25 p.m., indicated .It is the policy of this facility to protect the resident's rights to possess personal belongings such as clothing and furnishings for their use while in the facility and assure the personal belongings and/or possessions are rightfully returned to the resident, or to the resident's representative in the event of the resident's death or discharge from the facility .All resident possessions, regardless of their apparent value to others, will be treated with respect .The facility will support the resident's right to retain and use personal possessions to promote a homelike environment and maintain their independence .All resident personal items will be inventoried at the time of admission by the social services designee, or another designated staff member and documentation shall be maintained in the medical record .Additional possessions brought in during the duration of the individual's stay shall be added to the existing personal belongings inventory listing .The facility will ensure resident belongings are kept in a neat and orderly fashion and maintained in each resident's room .The facility will exercise reasonable care for the protections of the resident's property from loss or theft 3.1-3(t) 3.1-3(v)(1)

Based on interview and record review, the facility failed to ensure a resident's code status was reviewed and updated after returning from an inpatient hospitalization for 1 of 4 residents reviewed for advanced directives. (Resident 39) Finding includes: The clinical record for Resident 39 was reviewed on 6/26/24 at 10:43 a.m. The diagnoses included, but were not limited to, muscle atrophy, type 2 diabetes mellitus, diabetic polyneuropathy, depressive disorder, bipolar disorder, generalized anxiety disorder, and agoraphobia with panic disorder. A hospital discharge summary, dated 3/12/24, indicated the resident was a full code. A POST (Physician Orders for Scope of Treatment) form, dated 4/4/23, indicated the resident was a no code. The resident's face sheet showed the resident was a full code During an interview, on 6/26/24 at 10:55 a.m., the Director of Nursing (DON) indicated the resident was listed as a full code when she returned from the inpatient hospitalization . The electronic health record did not include information if the resident's code status and POST form were reviewed when the resident returned from the hospitalization . The resident was interviewed and wanted to be a no code as the POST form on 4/4/23 had indicated. A current policy, titled Residents' Rights Regarding Treatment and Advance Directives, not dated and received from the Clinical Support Nurse on 6/28/24 at 4:56 p.m., indicated .It is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an advance directive .'Advance directive' is a written instruction, such as a living will or durable power of attorney for health care, recognized under State law .relating to the provision of health care when the individual is incapacitated .On admission, the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident would like to formulate an advance directive .During the care planning process, the facility will identify, clarify, and review with the resident or legal representative whether they desire to make any changes related to any advance directives 3.1-4(f)(4)(A)(ii) 3.1-4(f)(5)

Based on interview and record review, the facility failed to provide the facility's bed hold policy to 2 of 3 residents reviewed for discharge. (Residents 254 and 154) Findings include: 1. The clinical record for Resident 254 was reviewed on 6/25/24 at 2:44 p.m. The diagnoses included, but were not limited to, respiratory failure with hypoxia (absence of enough oxygen to sustain bodily functions), unstageable pressure ulcer of sacral region, anxiety disorder, depression, bradycardia (slow heart rate), and anemia. A nursing progress note, dated 6/14/24 at 5:58 a.m., indicated the resident was transferred to the hospital. The Nurse Practitioner (NP) and the Director of Nursing (DON) were notified. The electronic medical record did not include the facility's bed hold policy was provided to the resident or resident's representative at the time of the transfer to the hospital or later when the resident was discharged . During an interview, on 6/28/24 at 11:52 a.m., Clinical Support Nurse indicated the facility had provided all the transfer and discharge paperwork, and a facility bed hold policy was not found in the paperwork or provided to the resident. 46961 2. The clinical record for Resident 154 was reviewed on 6/25/24 at 4:01 p.m. The diagnoses included, but were not limited to, dementia unspecified severity without behavioral disturbance, mood disturbance and anxiety, atherosclerosis of the native arteries of the left leg with ulceration of heel and mid foot, type 2 diabetes with foot ulcer and circulatory complications, dysphagia, morbid severe obesity due to excess calories, and pneumonia. A progress note, dated 6/7/2024 at 11:01 a.m., indicated the resident was noted to have coffee ground emesis and bowel movement. The resident was sent to the local emergency room for further evaluation. A hospital note, dated 6/17/24, indicated the resident had bilateral pneumonia and was treated and returned to the facility. The electronic medical record did not include the facility's bed hold policy was provided to the resident or resident's representative at the time of the transfer to the hospital. During an interview, on 6/28/24, the Clinical Support Nurse indicated there were no transfer documents or bed hold policy found in the electronic health record. A facility bed hold policy was not found in the paperwork or provided to the resident. A current policy, titled Transfer and Discharge (including AMA), not dated and received from the Clinical Support Nurse on 6/27/24 at 2:20 p.m., indicated .emergency transfers or discharges .initiated by the facility or medical reasons to an acute care setting such as a hospital, for the immediate safety and welfare of a resident (nursing responsibilities unless otherwise specified) .obtain physicians' orders for emergency transfer or discharge is necessary on an emergency basis .the original copies of the transfer form and Advanced Directives accompany the resident .copies are retained in the medical record .provide a notice of transfer and the facility's bed hold policy to the resident and representative as indicated .the social services director, or designee, will provide copies of notices for emergency transfers to Ombudsman, but they may be sent when practicable, such as in a list of residents on a monthly basis, long as the list meets all the requirements for content of such notices 3.1-12(a)(25(A) 3.1-12(a)(25(B)

Based on interview and record review, the facility failed to ensure a resident was free from neglect when a facility staff member failed to thoroughly assess the resident, report accurate information to the management staff regarding the resident's condition, and notify the physician timely when the resident experienced a change of condition for 1 of 3 residents reviewed for neglect (Resident B). Resident B coded and was sent to the hospital where she later passed away. The Immediate Jeopardy began on [DATE], between 8:00 and 8:30 a.m., when a CNA noticed Resident B was not responding as normal and went to the Assistant Director of Nursing (ADON) office for help after she had notified LPN 1 and did not feel LPN 1 took her seriously. LPN 1 indicated to the ADON she checked the resident, and her vitals were within normal limits and her blood sugar was low. At approximately 11:30 a.m., the CNA contacted the ADON for help a second time due to the resident was still declining and LPN 1 was not responding to the CNAs request to re-evaluate the resident, the resident then coded, was sent to the hospital, and later passed away. The Executive Director (ED) and Director of Nursing (DON) were notified of the immediate jeopardy at 4:25 p.m., on [DATE]. The immediate jeopardy was removed on [DATE], but noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Finding includes: An anonymous complaint sent to the Indiana Department of Health indicated, on [DATE], it was reported to the nurse a female resident was not responding several times, the resident then coded and died from neglect. The record for Resident B was reviewed on [DATE] at 9:35 a.m. Diagnoses included, but were not limited to, nonrheumatic mitral (valve) stenosis, nonrheumatic aortic (valve) stenosis, atrial fibrillation, atherosclerotic heart disease of native coronary artery without angina pectoris, hypertension, end stage renal disease, anemia in chronic kidney disease, hypotension of hemodialysis, dependence on renal dialysis, personal history of sudden cardiac arrest, dependence on supplemental oxygen, and chronic respiratory failure with hypoxia. The progress notes for Resident B were reviewed and indicated the following: a. On [DATE] at 7:58 a.m., entered as a late entry on [DATE] at 4:35 p.m., LPN 1 indicated she went to give medications to the resident when the resident was observed lethargic. Vital signs were taken, and the resident's blood pressure was ,d+[DATE]. The resident was given her medications along with her midodrine medication she received three times a day (a medication used to treat orthostatic hypotension which was a sudden fall in blood pressure which occurred when a person assumed a standing position). The resident was able to swallow her pills whole with water. b. On [DATE] at 7:59 a.m., entered as a late entry on [DATE] at 4:51 p.m., LPN 1 indicated the resident's oxygen was 67% and her oxygen was turned up to 5 lpm (liters per minute). Her oxygen returned to 97% then went back to 87% on 5 lpm currently at that time. c. On [DATE] at 11:50 a.m., entered as a late entry on [DATE] at 11:39 a.m., the ADON (Assistant Director of Nursing) indicated at approximately 11:40 a.m., she was notified by the floor CNAs to assess the resident. Resident was found lethargic and unresponsive to sternal rub. The resident's vital signs were checked, and the resident was found to be hypotensive and hypoxic. The ADON ran down the hall to get the physician. LPN 1 was notified to call 911. Emergency interventions were implemented once no pulse was detected. Code Blue was called, crash cart was obtained, and compressions were initiated. EMS arrived at approximately 12:05 p.m. and took over emergency interventions. d. On [DATE] at 12:00 p.m., entered as a late entry on [DATE] at 12:14 p.m., the Unit Manager indicated at approximately 11:51 a.m., she was notified by the ADON to come help with an emergency. She went to get the Ambu bag and crash cart. Approximately 12:09 p.m., LPN 1 started giving compressions. At 12:10 p.m., the DON took over for the nurse and at 12:16 p.m., EMS arrived. e. On [DATE] at 12:08 p.m., entered as a late entry on [DATE] at 11:34 p.m., the DON indicated a code blue was called overhead. He entered the resident's room and relieved the staff nurse doing compressions until EMS arrived. f. On [DATE] at 2:19 p.m., LPN 1 documented the resident was observed cold, diaphoretic, lethargic and unresponsive. Vital signs were unstable with a blood pressure of ,d+[DATE], pulse was 41 and was weak and thready. Blood sugar was 148 at 7:00 a.m., and 223 at 11:20 a.m. She called for help from the ADON and physician. The resident's oxygen saturation was 46% on 5 lpm per mask. Compressions were started by LPN 1, then the DON took over compressions as LPN 1 went to call 911. EMS arrived on site and took over. The resident was unstable when she left. The vital signs for Resident B, on [DATE], were reviewed and the following were documented: a. On [DATE] at 7:00 a.m., the resident's blood pressure was ,d+[DATE], respirations were 18 breaths per minute, heart rate was 59 beats per minute, oxygen saturation was 67% with oxygen via nasal cannula, and her blood sugar was 148. b. On [DATE] at 9:22 a.m., the resident's blood pressure was ,d+[DATE], heart rate was 86 beats per minute, and her blood sugar was 148. c. On [DATE] at 11:54 a.m., the resident's blood pressure was ,d+[DATE], respirations were 18 breaths per minute, heart rate was 58 beats per minute, oxygen saturation was 55% with oxygen via nasal cannula, and her blood sugar was 223. A written statement by CNA 2, undated, indicated she went to check on Resident B and get her ready for dialysis. She noticed she was not herself and notified the nurse. The nurse went to check on her, indicated everything was normal and gave her medications. She still was not acting herself; she did not see the nurse, so she went the Unit Manager. The Unit Manager found the nurse, the nurse said her blood sugar was low, so the resident was given sugar water. She was asked to keep an eye on the resident. She noticed how loud she was snoring and told the nurse something was wrong, and she was not any better. The nurse said when the sugar was low it took a minute to get back up. CNA 2 saw the ADON and asked her to please come look at the resident as she was not herself. The ADON took all vitals and had the doctor come to her room. A written statement by the Unit Manager, dated [DATE], indicated CNA 2 told her Resident B was not acting right. She went to the resident's room. She asked the resident's nurse what was wrong and was told her blood sugar was low. The Unit Manager could not get the resident to drink orange juice, so she gave her some sugar water. She said the resident's name and the resident responded. She then left and went to morning meeting. After morning meeting, she heard a call from the ADON, there was an emergency upstairs. The physician, ADON, and CNA were in the resident's room. Code blue was called, and she went to get the crash cart and AED. Emergency Medical Services (EMS) arrived and took over compressions. A written statement by the ADON, dated [DATE], indicated at 8:00 a.m., she was informed by the floor nurse Resident B had a low blood sugar. She went to the resident's room and noted the resident was verbally responsive and able to drink a cup of orange juice and took a few bites of her breakfast. She informed the resident's nurse to monitor for signs and symptoms of hypoglycemia. After morning meeting, she returned to the floor and was informed by the resident's nurse the resident was stable. At approximately 11:40 a.m., the second floor CNAs approached her in her office and requested her to come assess the resident because they were concerned, their reports to the nurse were not being acknowledged and the resident was lethargic. When she arrived in the room, the resident was lethargic and not responding to her name or sternal rubs. LPN 1 had followed her into the room. She asked LPN 1 what the resident's last blood pressure was and was told it was in the 140's. The ADON left the room to obtain a stethoscope, manual blood pressure cuff, and other equipment to assess the resident. The resident's blood pressure when taken with the manual cuff was ,d+[DATE]. The ADON had a hard time obtaining the resident's oxygen saturation and asked LPN 1 what the resident's oxygen saturation was this morning. LPN 1 indicated it was 67% and she had bumped the resident oxygen up to 5 lpm from her ordered 2 lpm via nasal cannula. The ADON asked LPN 1 if she notified the physician regarding the low oxygen level and if she had reassessed the resident. LPN 1 did not directly answer and began to get off the subject. The second floor CNA remained with the resident while the ADON ran to get the physician. Emergency interventions were immediately implemented. A hospital ER (emergency room ) Exam and Disposition, dated [DATE] at 1:36 p.m., indicated Resident B was brought into the ER, on [DATE] at 12:55 p.m., for a cardiac arrest (no respirations and no pulse). She did not feel well that morning and did not go to dialysis. According to the physician at the facility, who came with the resident to the ER, she had an episode of being short of breath and complained of shortness of breath, then began having agonal respirations. After the EMS (Emergency Medical Services) arrived at the facility, the resident was intubated by the physician attending to her care while at the facility. EMS ran the code, while the physician intubated her. When she was received in the ER, she was unresponsive, with an ET (Endotracheal tube-to help a resident breathe easier) and CPR (Cardiopulmonary Resuscitation) was in progress. Her respirations became agonal, then she cardiac arrested at that the facility. The ER physician indicated it was unclear how long Resident B was down, but she received three doses of epinephrine (a medication, which helps start a resident's heart after it had stopped). She had a brief second round of CPR in the ER after arriving at the hospital. Resident B passed away on [DATE] at 2:08 a.m. A hospital discharge summary, dated [DATE] at 6:46 p.m., indicated Resident B presented to the ER after being seen by the facility physician for complaints of not feeling well. The resident had agonal breathing and quickly developed cardiac arrest for ,d+[DATE] minutes. Resuscitation efforts were achieved on arrival to the ER, then she had a second cardiac arrest in the ER, which lasted less than 10 minutes. She was placed on four pressor medications (medications used to help keep her blood pressure up). She was intubated and shocked at the facility. The resident remained unresponsive without any sedation. Her condition continued to deteriorate overnight and even though she was on the ventilator for breathing support, she continued to desaturate and was unable to obtain adequate oxygenation. She passed away on [DATE]. Resident B's number one diagnosis was acute hypoxic respiratory failure due to cardiac arrest. During an interview, on [DATE] at 11:18 a.m., CNA 3 indicated on [DATE], before breakfast, she went into Resident B's room to get her up for dialysis and she would not get up because she was in a deep sleep and would not open her eyes, which was not normal for her. She immediately went to LPN 1, who was the resident's nurse and informed her the resident was not acting like herself. She and CNA 2 went back into her room, between 8:00 and 8:30 a.m., to try to get her up and she was still in the deep sleep and was clammy. CNA 2 immediately went to LPN 1 and informed her the resident was not right and she was clammy. LPN 1 told CNA 2 the resident's vital signs were fine. CNA 2 told LPN 1 again this was not the normal for this resident. Before 9 a.m., CNAs 2 and 3 went to ask the Unit Manager to assess the resident because they did not believe LPN 1 was doing everything she could for Resident B. The Unit Manager (UM) and the Assistant Director of Nursing (ADON) went to her room to check on her, then they left the floor. The UM gave the resident some sugar water for her low blood sugar. CNAs 2 and 3 went to LPN 1, two to three additional times to tell her Resident B's condition was declining. They believed LPN 1 was not responding to their updates on the resident's condition. When the ADON came back to the floor before lunch, CNA 2 asked her to assess the resident because her condition was declining, and LPN 1 was not responding to their requests to help Resident B. The ADON and the resident's physician went to her room and were preparing to start a code on her. 911 had been called, LPN 1 was doing chest compressions, then the DON took over for her, while the ADON and the physician was at the head of the bed with the ambu mask. During an interview, on [DATE] at 11:38 a.m., the Unit Manager indicated on [DATE] at approximately 8:00 a.m., CNA 2 asked her to assess Resident B because she was a little bit out of it. The resident could talk, and her blood sugar was 67. She told LPN 1 to give the resident some sugar water because she would not drink the orange juice. She went to the morning meeting at approximately 9:00 a.m., and got out at approximately 10:30 a.m. She went on to do other things, while the ADON went to her office. At approximately 11:51 a.m., a call came over the overhead speakers for a Code Blue for the second floor. When she got to Resident B's room, CNA 2, RN 3, and the resident's physician was in the room with the resident. The physician was listening to the resident's lungs, the ADON was feeling for a pulse and CNA 2 was doing whatever they asked her to do. 911 was called. Approximately 12:00 p.m., she went and got the ambu bag, the crash cart, and the AED machine. LPN 1 started CPR, then the DON took over the compressions and the ADON was using the ambu bag. The resident was going downhill before EMS arrived. EMS took over once they arrived at the facility. LPN 1 was terminated from the facility for Neglect and Gross Misconduct and the incident with Resident B played a part in her being terminated from the facility. During an interview, on [DATE] at 12:21 p.m., the ADON indicated on [DATE] between 8:00 a.m., and 8:30 a.m., CNA 2 and 3 came to her and asked her to check Resident B. The ADON was told Resident B had a low blood sugar. She did not verify the resident had a low blood sugar that morning. The Unit Manager gave the resident sugar water and told the CNAs to make sure she ate her breakfast. The ADON went to the morning meeting around 9:00 a.m., and got out around 11:00 a.m., and at 12:00 p.m., she went to her office. She was retrieved from her office by CNA 2 and 3 to assess Resident B because they had asked LPN 1 to check on her throughout the morning and she would not do it. As soon as she went into the room, LPN 1 followed her in the room. Resident B was not responding to verbal stimuli or a hard sternal rub. Her blood pressure was super low and her oxygen (O2) was in the 70's on 5 L/min (liters/minute) of oxygen. The physician order was for 2 L/min. When she asked LPN 1 why she was on 5 L/min, LPN 1 indicated her O2 sats were low (67%) that morning, so she bumped her oxygen up to 5 L/min. LPN 1 had told the ADON the resident's blood sugar was low that morning not her oxygen level. She placed her on a non-rebreather oxygen mask, then ran to get the resident's Physician, who was in the building at that time. When the ADON was questioning LPN 1 regarding the resident's condition status, between 8:00 a.m. and 8:30 a.m., LPN 1 should have given her the correct information about her oxygen levels being low instead of her blood sugar being low, because she would have been sent out to the hospital then. The ADON indicated this was plain and simple Neglect of a resident by LPN 1. LPN 1 had issues prior to that incident, she was given verbal counseling for issues such as; leaving medications at the bedside and not communicating resident information with the other shift. She openly admitted she did not listen to the resident's lungs because she did not have a stethoscope to listen to them. The physician assessed Resident B, a code was called, 911 was called, and they coded the resident for 30 minutes until EMS got there and took over. The AED machine shocked the resident after the EMS got to the facility. EMS was coding her on the way to the hospital and her physician intubated her prior to leaving the facility and followed her to the hospital. After EMS left with the resident, the ADON went to her office and immediately started writing her statement of the account of what happened that day. She had a sick feeling in the pit of her stomach about LPN 1, so she looked up her Nursing license and discovered she had a probationary nursing license which she did not know about. She immediately went to the DON to inform him of LPN 1 having a probationary license since 2016, which he was not aware of either. During an interview, on [DATE] at 2:59 p.m., the DON (Director of Nursing) and ED (Executive Director) were in attendance. The HR Manager was responsible for pulling the licenses and certificates and notifying the DON of any issues with those prior to hiring the individuals. The DON indicated he was not aware LPN 1 had a probationary license. The HR Manager never told him LPN 1 had a probationary license since 2016. When he asked the HR Manager why she did not tell him LPN 1 had a probationary license, she indicated she thought LPN 1 had told him. He should have been writing quarterly follow-ups on her to the Indiana State Board of Nursing. When he asked LPN 1 why she did not tell him she had a probationary Nursing license, she indicated she was going to tell him when he had to fill out her Quarterly probation performance report. At that time, the ED indicated she was not aware LPN 1 had a probationary license either. LPN 1 was terminated for using her personal cell phone in front of residents and attendance issues. During an interview, on [DATE] at 3:20 p.m., with the DON and ED in attendance. The DON indicated LPN 1's duties included, but were not limited to, passing medications including controlled substances, completing assessments of residents such as skin and change of condition, documenting in the resident records, overseeing and supervising CNA's and QMA's, and calling the physician for orders. During an interview, on [DATE] at 11:30 a.m., LPN 1 indicated she always took her residents' vital signs when she first came on duty. Resident B's blood pressure (BP) at 6:15 a.m., was ,d+[DATE], then at 8:00 a.m., her BP was ,d+[DATE] and her blood sugar was 147. Breakfast came, but the resident did not eat. When she administered the resident's medications to her at approximately 8:00 a.m., she was not responding, so she had to give her a hard sternal rub to get her to wake up and take her medications. When she went down to the resident's room at the time the ADON and the physician was in her room, she was snoring, then she started having agonal breathing. She did not know the UM gave the resident sugar water for a low blood sugar. She did not send her out to the hospital for a condition change because the nurses were not allowed to call 911 or send residents out to the hospital until they contacted the DON first, according to the hidden policy. LPN 1 indicated a hidden policy was a policy which was not an official policy, but it was a note written by the DON for the staff to follow. During an interview, on [DATE] at 3:01 p.m., CNA 2 indicated Resident B had an appointment the morning of [DATE], so she had to get her up and ready. She was not talking and would not wake up for her, which was unusual, so she went to get CNA 3 to ask her if she was able to wake the resident up. CNA 2 went to get LPN 1 to inform her Resident B did not look good and was not acting like herself and she was clammy. Between 8:00 a.m. and 11:00 a.m., CNA 2 tried to feed the resident, but she would not wake up to eat. She was able to hear her snoring while in another resident's room which was not normal for her. She went to LPN 1 again trying to get some help for the resident because she did not look good. LPN 1 indicated the resident's vital signs were good. CNA 2 had the UM go look at the resident and she gave her some sugar water because she had gotten information her blood sugar was low. She asked LPN 1 to assess Resident B once again, but LPN 1 never went into the resident's room to assess her. When the ADON got back into her office, from the morning meeting, CNA 2 and CNA 3 went to her office and asked her to go assess Resident B due to LPN 1 was not assessing her when she was told there was a change in her condition. The resident ended up being coded shortly thereafter. LPN (Licensed Practical Nurse) 1's nursing license indicated, on [DATE], Reinstatement of a Suspended License Once the Board Feels the Licensee is able to Practice with Reasonable Skill and Safety Probation. A facility document indicated LPN 1 was terminated for Category I, which was gross misconduct due to her failing her 90-day probationary period related to not following up with a provider on a resident status decline and she had multiple verbal counseling moments/teachable moments to correct performance as evident by phone usage while on the floor and leaving medications at the bedside. A current policy, titled Notification of Changes, dated [DATE] and provided by the DON on [DATE] at 2:08 p.m., indicated Policy: The purpose of this policy is to ensure the facility promptly .consults the resident's physician; and notifies, consistent with his or her authority .when there is a change requiring notification. Definitions: 'Life-Threatening conditions .Need to alter treatment significantly' means a need to stop a form of treatment because of adverse consequences (such as adverse drug reaction), or commence a new form of treatment to deal with a problem (for example the use of any medical procedure, or therapy that has not been used on that resident before) .Circumstances requiring notification include .Significant change in resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status. This may include: Life-threatening conditions, or Clinical complications. Circumstances that require a need to alter treatment. This may include: New treatment. Discontinuation of current treatment due to: Adverse consequences. Acute condition. Exacerbation of a chronic condition. A transfer or discharge of the resident from the facility .Competent individuals: The facility must still contact the resident's physician and notify resident's representative, if known A current policy, titled Abuse, Neglect and Exploitation dated [DATE] and provided by the ED on [DATE] at 4:16 p.m., indicated Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property .'Neglect' means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress .IV. Identification of Abuse, Neglect and Exploitation .B. Possible indicators of abuse include, but are not limited to .8. Failure to provide care needs such as comfort, safety, feeding, bathing, dressing, turning & [and] positioning The Immediate Jeopardy that began on [DATE] was removed on [DATE] when all nursing staff were educated on what to do for a resident with a change of condition, educated on reporting accurate information about a resident's condition to the management staff, management staff were educated to verify the information given from nursing staff was accurate and staff were educated to notify the physician when a change a condition had occurred. This Federal tag relates to Complaints IN00409512 and IN00409907. 3XXX,d+[DATE](a)(3)

Based on interview and record review, the facility failed to provide care and services to an existing pressure injury which was identified on admission from the hospital, but not thoroughly assessed, monitored, and preventative and treatment orders obtained, to prevent the worsening of the existing pressure injury or 1 of 3 residents reviewed for pressure injury. (Resident E) Finding includes: The record for Resident E was reviewed on 1/3/2022 at 1:40 p.m. The resident was admitted to the facility on [DATE] and discharged to the hospital on 11/17/2021. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission MDS (Minimum Data Set) assessment, dated 11/11/2021, indicated the resident required extensive assistance of two plus persons for bed mobility and total assistance of two plus persons for transfer from bed to chair. Progress notes indicated the following: On 11/04/2021 at 6:00 p.m., admitted [AGE] year female into facility, from (name of hospital), via ambulance .Alert to name, sleepy and tired at this time and therefore unable to perform thorough assessment .dressing on .coccyx On 11/05/2021 at 6:06 a.m., .dime size heart shaped r (right) buttock open area On 11/05/2021 at 2:43 p.m., .Assistance with bed mobility: yes; Assistance with transfers: yes; Assistance with eating: yes; Assistance with toilet use: yes .Wounds present: no .Medications orders received: no; Treatment orders received: no On 11/05/2021 at 4:43 p.m., [physician note] .Skin: No rashes or [CONDITION(S)] in visually inspected areas On 11/06/2021 at 9:04 a.m., .Is the residents skin: warm, dry, and skin color WNL (within normal limits): yes; Wounds present: no On 11/07/2021 at 5:45 p.m., .Is the residents skin: warm, dry, and skin color WNL: yes; Wounds present: no On 11/08/2021 at 2:48 p.m., .Is the residents skin: warm, dry, and skin color WNL: yes; Wounds present: no On 11/09/2021 at 10:30 a.m., [physician note] .Resident in room sitting up in wheelchair. Spouse in chair next to resident. Spouse reports the goal for patient to discharge home is she can take her own shower, she is able to cook like she did before and she is able to transfer herself. Resident during this interaction has eyes closed and responds intermittently appropriately to this writer's questions. Resident reports is ready to go back to bed has been up for a while .Nursing has no concerns On 11/11/2021 at 6:24 a.m., .Wound present: yes; Dressing changed as per orders: no; Changes were noted to wound: no On 11/11/2021 at 5:13 p.m., .had virtual visit with (name of doctor) wound doctor. (Doctor) called sacrum wound a Kennedy ulcer. (Doctor) mentioned that this is not the type of wound you get overnight it takes a month or longer to get. (Doctor) order wound care for her. (Doctor) suggest outside wound clinic due to conflict with schedule, will continue to monitor On 11/11/2021 at 5:22 p.m., .Resident has current skin issues. Skin Issue: Pressure Ulcer / Injury. Skin Issue Location: Sacrum/buttocks Pressure Ulcer / Injury Stage: Suspect deep tissue injury - depth unknown. Length:10.0 cm (centimeters) Width cm: 10.0 cm Wound Bed: Necrotic. Wound Exudate: Serous. Peri Wound Condition: [CONDITION(S)]. Dressing Saturation: Minimal (<25%). No wound odor. No tunneling. No undermining. Tissue: Warm . Clinical Suggestions: Evaluated for pain, discomfort. Dressing changes/treatments performed as ordered. Resident is turned, ambulated, moved at least every 2 hours. Area evaluated for signs of infection: redness, warmth, swelling, increased temperature, drainage, etc. Area evaluated for signs of healing: approximation, pink tissue, scabbing On 11/11/2021 at 11:27 a.m., CP (Care Plan) meeting held with DOA (Director of Admission), ADON (Assistant Director of Nursing), Therapist, (Resident E) and (Name of spouse) (spouse). Therapy reported max (maximum) assist, dependent of 2 for transfers, discussed hoyer lift, reported total for al (sic) therapy needs. Therapy reported barriers of c/o (complaints of) pain. Therapy will cont. (continue) to focus on cognitive tasks, increasing endurance and strength. Discussed DC (discharge) plans, plans to DC back home with (name of spouse) as long as (Resident E) is able to increase mobility and transfer from bed to bathroom. Discussed house is w/c (wheelchair) accessible, high bed at home. (Name of spouse) stated he can accommodate home, place ramp outside of front door. No issues/concerns voiced at this time A Weekly Skin Review_COMS, dated 11/04/2021, the date of the resident's admission to the facility, indicated the resident had a pre-existing wound described with redness from coccyx to bilateral buttocks A Weekly Skin Review_COMS, dated 11/11/2021, indicated the resident had an open area which was pre-existing at the sacrum with a description indicating this area was a pressure ulcer. An additional assessment, dated 11/11/2021 and titled COMS-Skin Only Evaluation, indicated Resident E had a Pressure Ulcer/Injury, Suspected deep tissue injury - depth unknown. The documented measurement of the area was 10cm wide and 10cm long, with no depth documented. The assessment indicated the wound bed was necrotic with a minimal amount of serous (thin, watery, clear) drainage. On 01/04/2022 at 9:31 a.m., the Director of Nursing Services (DNS) presented a copy of a wound care evaluation, conducted virtually by the wound care physician, completed on 11/11/2021. The evaluation indicated .a thorough wound care assessment and evaluation was performed today. (Resident E) has an unstageable (due to necrosis) sacrum for at least 1 days duration. There is moderate serous exudate The assessment indicated the resident had an Unstageable (Due to Necrosis) Sacrum Full Thickness ulcer due to pressure. Wound measurements were documented to be 10 x 10 x 0.4cm with moderate serous drainage with 100% eschar tissue observed on the area. Recommendations were Off-load wound, Reposition per facility protocol; Turn side to side and front to back in bed every 1-2 hours if able; Group-2 mattress. In addition, the evaluation included the following: Coordination of Care .The total length of this visit was 45 minutes and greater than 50% were spent in counseling and coordination of care specific to Un-Nec Pressure wound of the Sacrum .Called to evaluate patient as she has un-nec pressure wound, and husband (name) very upset that wound was not seen by myself and wound team yesterday .the wound appears to be kennedy in nature, but unable to prove until post-mortem. Patient with bacteremia c/b (caused by) [CONDITION(S)] d/t (due to) pacemaker lead infection and multiple surgeries. I suspect this wound developed while in ICU. I suspect she was on pressors, but ultimately it is impossible for me know what occurred outside the facility (sic) . During an interview, on 01/04/2022 at 9:52 a.m., the DNS indicated she observed Resident E's sacral area a couple of days following the resident's admission and it was her opinion the resident had a Kennedy ulcer (a terminal skin ulcer caused by skin failure at the end of life) and called a wound doctor to evaluate the wound. When questioned regarding the resident's skin condition at the time of admission, the DNS stated she was unaware of the resident's skin condition at the time of admission. Documentation was lacking a plan of care or treatment to the sacral area from the date of the resident's admission on 11/04/2021 until the virtual visit with the doctor, on 11/11/2021, 8 days later. At that time, the doctor ordered a [MEDICATION(S)] agent treatment to the area, advised nursing measures to decrease pressure to the resident's sacrum and ordered the resident to receive a pressure reducing mattress. Copies of MARs (medication administration records) and TARs (treatment administration records) were requested and received from the DNS on 01/05/2022 at 12:28 p.m. During interview, at this time with the DNS, she verified wound care or nursing interventions to the resident's sacrum had not been documented for the period of 11/04/2021 through 11/11/2021, at the time of the virtual doctor visit. The only plan of care was dated 11/11/2021. During the interview, the DNS stated the facility was doing treatments to her bottom but was unable to produce evidence of the treatment or services given to the resident during this time. The DNS stated she knew if it's not documented it's not done and stated they were putting a pink foam dressing on the area from 11/4/2021 - 11/11/2021. She further stated, according to the hospital discharge summary from the hospital at the time of the resident's admission, the resident had been receiving [MEDICATION(S)] (an autolytic [MEDICATION(S)] agent) to an area of her body, but she didn't know for sure where. The DNS then stated she authorized staff to use [MEDICATION(S)] on the resident's sacral area and cover with a pink foam dressing. A current facility policy, titled Pressure Injury Surveillance, undated and received from the DNS on 1/4/2022 at 2:42 p.m., indicated .A system of surveillance is utilized for preventing, identifying, reporting and investigating any new or worsening pressure injury in the facility. 1. The Director of Nursing or designee serves as the leader in surveillance activities, maintains documentation of incidents, findings and any corrective action made by the facility and reports surveillance findings to the facility's Quality Assessment and Assurance Committee. 2. RN's and LPNs participate in surveillance through assessment of residents and reporting changes in condition to the resident's physician and management staff, per protocol for notification of changes and in-house reporting of new or worsening pressure injuries This Federal tag relates to Complaints IN 147. 3.1-40(a)(2)

Based on record review and interview the facility failed to provide medication as ordered by the physician for 1 of 3 residents reviewed for medication distribution (Resident B ). Resident B did not receive an as needed (PRN) medication for [MEDICAL CONDITION] activity. The medication was to be administered if resident had [MEDICAL CONDITION] activity. Resident was sent to the emergency room (ER) and while she was in route to the hospital the paramedical team administered medication for [MEDICAL CONDITION] activity which stopped the [MEDICAL CONDITION] activity. Resident was admitted to the hospital (Resident B ) Findings include: The record for Resident B was reviewed on 6/13/2019 at 3:37 p.m. Resident B [DIAGNOSES REDACTED]. A current Doctor order dated 10/04/2018 indicated [MEDICATION NAME] solution 5 MG/ML (milligrams/milliliter) / inject 5 mg intramuscularly every 24 hours as needed for [MEDICAL CONDITION] A nursing progress note dated 5/19/2019 indicated the nurse was notified by staff that the resident was found jerking in bed and drenched with sweat. The nurse arrived and noted BP reading to be 83/43 and pulse 71. Resident was noted to be jerking. Resident not responsive when nudged or called by name. Oxygen was at 2 liters and at 94%. The Nurse Practitioner was notified and she gave an order to send the resident to the hospital. 911 was called. Director of Nursing was notified. The nurse attempted to reach emergency contact but was unsuccessful and left voice mail message. PRN medication for [MEDICAL CONDITION] was not administered by nursing staff. A review of the Medication Administration Record [REDACTED]. An ER record dated 5/19/2019 indicated in route to the hospital the resident began to vomit, the paramedics were unable to start IV so resident was given [MEDICATION NAME] intranasally and when she arrived to the hospital the [MEDICAL CONDITION] activity had stopped. The resident was admitted to the hospital with [REDACTED]. During an interview on 6/13/2019 at 3:39 p. m., via telephone contact with the Acting Director of Nursing in (MONTH) 2019, she indicated she was aware of the incident and that the resident was sent to the hospital. She indicated the resident was sent to the hospital for low oxygen and the resident was unresponsive. She did not indicated medication had been given to the resident or that she was aware of resident [MEDICAL CONDITION] activity. During an interview on 6/13/2019 at 4:30 p.m., with CNA 11 she indicated she had found the resident shaking and wet with sweat. She indicated she notified the nurse on duty. The nurse came into the residents room to assess the resident. No medication was injected into the resident and she indicated 911 was called. She was not aware the resident had vomited but the resident did continue to shake. A current policy and procedure titled Medication Administration- General Guidelines dated 6/2015, received from RN 5 on 6/14/2019 at 2:00 p.m. indicated .B 1. Medications are administered only by licensed nursing staff, medical, pharmacy or other personnel authorized by state laws and regulations to administer medications 2. Medications are administered in accordance with written orders of the prescriber . This Federal tag related to complaint IN 220 3.1-48(c)(2)

Based on observation, interview and record review, the facility failed to assess pressure wounds for 2 of 3 residents reviewed for pressure ulcers (Residents B and D) and failed to provide consistent interventions and treatment to prevent the worsening of a pressure ulcer for 1 of 3 residents reviewed for pressure ulcers (Resident B). Findings include: 1. During an observation at (name of hospital) of peri-care on 4/14/16 at 9:45 a.m., Resident B was observed to have a stage IV pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling) with tunneling. During an interview on 4/14/16 at 10:00 a.m., Resident B's (name of hospital) nurse indicated Resident B was very cooperative with treatment and her wound was beginning to improve since her hospitalization . The nurse indicated Resident B had been diagnosed with [REDACTED]. The record of Resident B was reviewed on 4/14/16 at 11:00 a.m. [DIAGNOSES REDACTED]. An Admission MDS (Minimum Data Set) Assessment, dated 12/29/15, indicated Resident B required extensive assistance with bed mobility and was at risk for developing pressure ulcers. A care plan, dated 12/15/15, indicated pressure ulcer, actual or at risk, related to assistance required in bed mobility and bowel incontinence. Interventions included, but were not limited to, weekly skin inspections. A care plan, dated 1/5/16, indicated pressure ulcer, actual or at risk, related to assistance required in bed mobility, bowel incontinence, and impaired mobility. Interventions included, but were not limited to, weekly skin inspections by a licensed nurse, float heels, provide pressure reducing wheel chair cushion, turning and repositioning assistance required, and treatments as ordered. A review of Treatment Administration Records, dated December 2015 through March 2016, did not indicate documentation of floating heels, pressure reducing wheel chair cushion, or turning and repositioning. A review of nursing progress notes, dated December 2015 through March 2016, indicated some documentation of turning and repositioning, however it was not consistent across all shifts. A nursing admission assessment and Braden Scale for Predicting Pressure Sore Risk could not be located in Resident B's clinical record. However, a nursing progress note, dated 12/16/15, indicated skin was warm, dry and intact. A Nursing Progress note, dated 12/31/15 indicated Resident B had a reddened area to the sacral area. A physician's orders [REDACTED]. The intervention was documented in the January 2016 Treatment Administration Record for 8 days during the month of January. A physician's orders [REDACTED]. Weekly Wound Evaluation documentation, dated 1/04/16, indicated Resident B had a suspected deep tissue injury (purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/or shear) to her coccyx, measuring 0.5 cm x 1.5 cm x 0.2 cm. The wound was described as .edges curled in. dry bed Weekly Wound Evaluation documentation, dated 1/13/2016, indicated Resident B had a stage II pressure wound (Partial thickness loss of dermis presenting as a shallow open ulcer with a red/pink wound bed, without slough) to her coccyx measuring 2 cm x 1.5 cm x 0.2 cm. The wound bed was pink and the wound had irregular edges. A small amount of serosanguinous (yellowish fluid with small amounts of blood) fluid was present. Weekly Wound Evaluation documentation, dated 1/19/2016, indicated Resident B had an unstageable pressure ulcer ( full thickness tissue loss in which the base of the ulcer is covered by slough or eschar in the wound bed) to her coccyx, measuring 1.9 cm x 3.0 cm x 0.1 cm. A small amount of serosanguineous fluid was present. The center of the wound presented with yellow tissue (slough). A physician's orders [REDACTED]. Apply to coccyx topically every evening shift for open area to coccyx. Cleanse coccyx area with wound cleanser. Pat dry. Apply nickel size amount of Santyl to wound bed. Place 2 x 2 Hydrogel gauze (a gel supported by a thin fiber mesh) over wound. Place abdominal pad over Hydrogel gauze and secure with cloth tape. Change daily and as needed for soilage. The January 2016 Treatment Administration Record indicated the treatment was not completed on 1/25/2016. A nursing progress note, dated 1/25/2016, indicated the facility did not have the necessary ointment to complete the dressing change as ordered. Weekly Wound Evaluation documentation, dated 1/25/2016, indicated Resident B had a stage II pressure wound measuring 2.7 cm x 1.5 cm x 0.1 cm. Wound edges were .undefined. White and pink in color, surrounding yellow tissue. Deep red/black wound bed. Small to moderate amount of drainage noted to dressing. No odor detected No wound evaluation documentation was found for the month of February 2016. A physician's orders [REDACTED]. Apply to coccyx topically every evening shift for pressure ulcer. Apply nickel thick. A physician's orders [REDACTED]. Pat dry. Apply nickel size amount of Santyl to wound bed. Place 2 x 2 Hydrogel gauze over wound. Place abdominal pad over Hydrogel gauze and secure with cloth tape. Change daily and as needed for soilage. No treatment was documented for 02/09/16, 2/25/16, or 2/27/16 in the February 2016 Treatment Administration Record or nursing progress notes. Resident B discharged to the hospital on [DATE] and returned to the facility 2/23/16. A nursing admission assessment and Braden Scale for Predicting Pressure Sore Risk could not be located in Resident B's clinical Record for her readmission to the facility on [DATE]. A hospital discharge summary, dated 2/22/16, indicated Resident B had a stage III pressure ulcer (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed. May include undermining and tunneling) to her right sacrum upon discharge from the hospital. The wound measured 4 cm x 1.6 cm x 0.2 cm. Upon return from the hospital, Resident B continued the same treatment for [REDACTED]. Weekly Wound Evaluation documentation, dated 3/2/16, indicated Resident B had a stage III pressure ulcer to her coccyx, measuring 2.6 cm x 1.5 cm x 0.1 cm. A small amount of drainage was present. Weekly Wound Evaluation documentation, dated 3/07/16, indicated Resident B had a stage III pressure ulcer to her coccyx, measuring 3.4 cm x 2.6 cm x 0.1 cm. There was no drainage present. The March 2016 Treatment Administration Record indicated no treatment was provided for Resident B on 3/13/16. No notes regarding the treatment were located in the nursing progress notes. Weekly Wound Evaluation documentation, dated 3/16/16, indicated Resident B had a stage III pressure ulcer to her coccyx, measuring 3.4 cm x 2.6 cm x 0.1 cm. There was a moderate amount of serous drainage present. Weekly wound evaluation documentation, dated 3/23/16, indicated Resident B had a stage III pressure ulcer to her coccyx, measuring 4 cm x 2.5 cm x 1.9 cm. Moderate serosanguineous drainage was present. A physician's orders [REDACTED]. Apply to sacrum topically every day shift for pressure ulcer. Cleanse area with wound cleanser, apply Santyl to wound bed, pack with calcium alginate (no silver), cover with foam. Change daily and as needed for soilage. The above order was discontinued on 3/29/16 and rewritten to be completed on evening shift A Treatment Administration Record, dated March 2016, indicated the dressing changes were not completed on 3/24, 3/25, 3/27, 3/28, and 3/29/16. A nursing progress note dated 3/29/16 indicated the dressing change time had been changed to evening shift. However, no documentation of the dressing change completion was found in the clinical record. Weekly wound evaluation documentation, dated 3/30/16, indicated Resident B had a stage IV pressure ulcer to her coccyx, measuring 5.5 cm x 4.0 cm x 2.4 cm. A moderate amount of thick, serosanguineous fluid was present. No odor was present. The documentation indicated .wound deteriorated since last review. Refer to wound center for consult and debridement. Will limit time spent up in wheelchair to reduce pressure to area A nursing progress note, dated 3/31/16, indicated Resident B's wound had a foul smell and a change in appearance since 3/30/16. Resident B was sent to emergency room for evaluation and treatment. (Name of Hospital) wound care consult documentation, dated 4/1/16, indicated Resident B had a .Large gangrenous, necrotic, foul smelling, probably infected sacral ulcer (Name of Hospital) documentation of a magnetic resonance imaging to the pelvis, dated 4/1/16, indicated .osteo[DIAGNOSES REDACTED] involving the coccyx with areas of frank bone destruction During an interview on 4/15/2016 at 4:35 p.m., RN #1 indicated the nurses were responsible for completing the dressing changes for residents on a daily basis. The wound team completed dressing changes once per week. Nurses were finding that they were out of supplies on occasion for dressing changes, but things were beginning to improve in that area. She indicated if an ointment or necessary medication was missing, staff were to notify the physician and pharmacy and obtain a new order for alternate treatment until the necessary medication could be obtained. RN #1 indicated admission assessments, including assessments of all wounds, was to be completed upon resident admission to the facility. During an interview on 4/15/2016 at 10:25 a.m., the DNS (Director of Nursing Services) indicated there were no additional weekly skin evaluations or wound assessment documentation available. She also indicated there was no additional documentation showing interventions and treatments were in place or had been completed. During an interview on 4/15/16 at 11:00 a.m., the DNS indicated the Braden scale was included in the admission assessment, but the admission assessment was not completed for Resident B during her December 2015 admission or her readmission in February 2016. 2. The record of Resident D was reviewed on 4/15/16 at 9:15 a.m. [DIAGNOSES REDACTED]. A care plan, dated 2/24/16, indicated pressure ulcer, actual or at risk, due to Stage IV pressure ulcer present upon admission, assistance required in bed mobility, skin desensitized, Braden score of 18 or less, and [MEDICAL CONDITION]. Interventions included, but were not limited to, weekly wound assessments and wound center consults. An admission assessment, dated 2/22/16, indicated Resident D was admitted to the facility with Stage IV pressure ulcers to his sacrum, right hip, left hip, and left buttock. The resident refused measurements upon admission. A Weekly Wound Evaluation was performed on 3/8, 3/24, 3/31, and 4/6/16. Additional skin assessments were not found in the clinical record. No facility wound assessments were available for the time between 2/22/16 and 3/8/16 or between 3/8/16 and 3/24/16. Resident D began attending the wound center for treatment on 3/16/16. On 3/16/16, the wound center identified a stage II pressure ulcer to the left lateral ankle, stage II pressure ulcer to the right lateral proximal lower leg, and stage II pressure ulcer to the right lateral distal lower leg. A physician's orders [REDACTED]. Apply silver alginate and cover with foam dressing every evening shift. A physician's orders [REDACTED]. Cleanse with sterile water, cleanse peri-ulcer area with sterile water and apply zinc oxide to peri-wound to protect. Use silver alginate 4.25 x 4.25 as primary dressing. Use abdominal pad and paper tape as secondary dressing one time a day. A physician's orders [REDACTED]. Cleanse peri-ulcer area with sterile water. Use Xeroform (helps maintain moist environment for wound healing) as primary dressing. Use gauze 4 x 4 and Kerlix (a gauze) as secondary dressing. A review of February 2016 and March 2016 Treatment Administration Records indicated Resident D did not receive his treatments on 2/25/16 to his right hip. No documentation of any wound treatments on 3/8 or 3/20/16 was available. During an interview on 4/15/16 at 2:20 p.m., the DNS indicated there were no additional skin assessments or wound assessments documented. She indicated the facility was unaware of the wounds to Resident D's lower extremities until the wound center informed them of the wounds. An undated policy, titled Skin Integrity Guideline, provided by the Executive Director on 4/14/16 at 11:30 a.m., indicated Patients/Residents will be assessed or observed for risk of skin breakdown within 24 hours of admission or readmission .Licensed nurse will be responsible for performing a skin evaluation/observation weekly, utilizing the Weekly Skin Review UDA .Licensed nurse to document weekly on identified wounds using the Wound Evaluation Flow Sheet (WEFS) UDA (one UDA per wound identified) .Care plan is to be implemented, evaluated and revised based on the needs of the resident This Federal tag relates to complaints IN 132 and IN 876. 3.1-40(a)(2)