Every finding on record at Copper Trace Health & Living Community

Based on observation, interview and record review, the facility failed to ensure an orthopedic surgeon was notified when the frequency of a resident's narcotic pain medication was changed, when the resident's condition failed to improve, and when the resident had continued complaints of pain following a right hip surgery for 1 of 3 residents reviewed for notification. (Resident B) This deficient practice resulted in Resident B experiencing continued pain for two weeks related to a dislocated hip after a hemiarthroplasty (a surgical procedure which replaces only one half of a joint-the ball while leaving the socket) of the right hip. Findings include:During a telephone interview, on 3/16/26 at 11:39 p.m., Resident B's family member 8 indicated the resident was in severe pain every time she was moved by staff from the day she was admitted to the facility, to the day she had her follow-up appointment with the orthopedic surgeon. Resident B yelled out Ouch, Ouch, Ouch whenever the staff moved her. The facility staff minimized her pain when she complained. Family member 8 told the facility staff three to four times a week something was not right with her right leg because she yelled out in pain whenever someone moved her and did not want anyone touching her right leg due to the pain. Resident B's right knee looked mangled (deformed) and the right leg was shorter than her left. The facility never notified her they had contacted the orthopedic surgeon regarding the continued right leg pain, the shortened right leg and/or the internal rotated right foot greater than normal for the resident.During an interview, on 3/16/26 at 1:18 p.m., the Therapy Manager indicated it was normal for a person to have a shorter operative leg than the other leg after a hip repair especially if the person had a hemiplegic side (paralysis or severe weakness of one entire side of the body usually involving the arm, leg and face caused by a stroke, tumor or a brain injury). Resident B not only had a right hemiplegic side, but she also had a right foot drop, which caused her right foot to turn inward. She did not complain of pain while doing therapy. Her right leg was slightly shorter than her left leg, but it was not that noticeable. She was a one-person transfer and weight bearing as tolerated when she was discharged from the hospital. She did 30 minutes of physical therapy each day. She had no orders for hip precautions when she was released from the hospital. The nursing staff did not call the orthopedic surgeon's office to clarify if the resident was supposed to have any hip precautions. Resident B's therapy progress was slow.The clinical record for Resident B was reviewed on 3/16/26 at 1:59 p.m. The diagnoses included, but were not limited to, hemiarthroplasty of the right hip, hemiplegia of the right side, right foot drop, anxiety disorder, and pain.Resident B was admitted to the facility, on 11/11/25 at 10:56 p.m., for rehabilitation related to her right hip hemiarthroplasty.A physician's order, dated 11/12/25, indicated hydrocodone-acetaminophen 10/325 milligrams (mg) was ordered every four (4) hours as needed for severe pain. The order was discontinued on 11/13/25.An occupational therapy note, dated 11/12/25 at 2:03 p.m., indicated Resident B's pain level in her right lower extremity was an 8-9 out of a pain scale of 10. The nurse practitioner was present during the pain assessment and was going to review the resident's pain medication regimen.A physical therapy note, dated 11/12/25 at 4:42 p.m., indicated Resident B required maximum assistance and left upper extremity support of a hemi-walker. She was unable to come to a full stand on her first attempt; however, she was able to come to a full upright posture on her second attempt and continued to require maximum assistance. She required maximum assistance and reassurance to stand and pivot transfer from the bed to the wheelchair and vice versa.A physician's order, dated 11/13/25, indicated hydrocodone-acetaminophen 10/325 mg was ordered every four (4) hours routinely for severe pain and the as needed order was discontinued.There was no documentation in the medical record to indicate the orthopedic surgeon was notified Resident B's pain medication was changed from an as needed dose to a routine dose on 11/13/25.A physical therapy note, dated 11/14/25 at 2:43 p.m., indicated Resident B required maximum assistance in scooting forward for proper sitting position. She completed a transfer from the bed to the wheelchair with maximum assistance with scooting back for proper positioning. An occupational therapy note, dated 11/15/25 at 10:58 a.m., indicated Resident B demonstrated increased pain with movement of her right lower extremity.No pain scale was documented. Resident B had received pain medication prior to the start of therapy.A physical therapy note, dated 11/15/25 at 12:38 p.m., indicated Resident B completed two (2) sitting reputations with 50% verbal instruction, 75% physical assistance, and 75% tactile cues due to her compromised functional activity tolerance. An occupational therapy note, dated 11/17/25 at 12:26 p.m., indicated Resident B attempted to take steps but was unable to complete the task.A physical therapy note, dated 11/17/25 at 2:34 p.m., indicated Resident B completed sit to stand exercise while inside the parallel bars with maximum assistance and left upper extremity pulling. She was unable to ambulate this day.A physical therapy note, dated 11/18/25 at 11:17 a.m., indicated Resident B completed a sit to stand exercise while inside the parallel bars with maximum assistance. She required frequent breaks due to low endurance. She required maximum assistance when scooting back in her wheelchair for proper sitting position and safety.An occupational therapy note, dated 11/18/25 at 1:14 p.m., indicated Resident B stood from the wheelchair two times with maximum assist. She tolerated standing for 30 seconds before she demonstrated increased pain in the right lower extremity knee.No pain scale was documented.A physical therapy note, dated 11/19/25 at 10:34 a.m., indicated Resident B completed a sit to stand exercise while inside the parallel bars with maximum assistance and cueing for the proper pull up and positioning. She required maximum assistance for standing balance with cueing to put weight on her bilateral lower extremities as she tended to stand on the left lower extremity only.A physical therapy note, dated 11/20/25 at 11:33 p.m., indicated the resident was unable to take steps on this date. She tried standing on the side of the parallel bars with maximum assistance. Her leg lengths were measured on this date and there was a one-inch discrepancy between the two leg lengths. She required maximum assistance from a supine to sitting position and to transfer back into the wheelchair.There was no documentation in the medical record to indicate the orthopedic surgeon was contacted about the one-inch discrepancy between the resident's leg length.A physical therapy note, dated 11/21/25 at 2:04 p.m., indicated there was limited active range of motion to the right lower extremity. The resident reported her right lower leg continued to feel numb. The complaint of her right lower extremity feeling numb was reported to the unit manager. Resident B completed gait training inside the parallel bars which required maximum assistance with right lower extremity advancement and placement. There was no documentation in the medical record to indicate the orthopedic surgeon was contacted about Resident B's complaint of the right lower leg feeling numb.An occupational therapy note, dated 11/24/25 at 8:30 a.m., indicated Resident B was in constant pain and discomfort in her right hip area and the nursing department was made aware.A physical therapy note, dated 11/24/25 at 10:17 a.m., indicated Resident B complained of pain to the right hip and knee.A hospital document, dated 11/24/25, indicated Resident B was seen for a follow-up visit in the orthopedic office when imaging demonstrated a dislocation. Resident B rated her right hip pain at 8/10 and a dull ache, and indicated activity made her pain worse. The physical exam indicated the resident's right lower extremity was shortened compared to the left lower extremity and externally rotated. The right lower extremity full hip exam was deferred secondary to pain. Her foot drop brace was in place. The plan was to do surgery and control her pain.There was no documentation in the medical record to indicate the orthopedic surgeon was contacted by the facility at any time before the resident's already scheduled follow-up orthopedic appointment.During a telephone interview, on 3/17/26 at 12:30 p.m., Nurse Practitioner 6 who worked with the orthopedic surgeon indicated there should be no limb discrepancy after hip surgery. Both lower limbs should be equal. The orthopedic surgeon who operated on Resident B measured each patient prior to and after hip surgery. When Resident B's family member indicated the resident's knee looked mangled she was describing a hallmark sign the hip was dislocated. A mangled knee would be internally rotated and flexed. Resident B came to the orthopedic surgeon's office for her regularly scheduled follow-up appointment. Nurse Practitioner 6 indicated as soon as she observed Resident B sitting in her wheelchair, she knew her right hip was dislocated because her pelvis was tilted forward, and her right knee was internally rotated with her knee flexed. The facility had not notified their office regarding Resident B's pain medication frequency being changed to a scheduled dose, the shortening of the right leg, the complaint of numbness, her right knee being internally rotated, or her right foot being internally rotated more than it usually was due to her footdrop and the facility should have called their office.During an interview, on 3/17/26 at 2:42 p.m., the Assistant Director of Nursing (ADON) indicated Resident B's pain medication never changed in strength but was changed from as needed to a scheduled to coordinate with her therapy sessions in the morning and afternoon.During an interview, on 3/17/26 at 2:42 p.m., the Therapy Manager indicated Resident B's right foot turned inward due to the hemiplegia from her stroke. She had calluses on the outside of her right foot from walking on the outside of her foot. She wore two braces on her right foot because of the inward turning of her foot. Due to the hyperextension of her right knee, the therapy department ordered her a knee brace. A resident with chronic foot drop like Resident B would have an inverted foot (the foot turned inward) from the stroke. The therapy department did not see a concern with a possible dislocation of the right hip because Resident B arrived at the facility from the hospital in that condition. There was never any change in her right leg or hip to indicate there was a concern of a dislocated hip. Resident B's family member visited her therapy sessions daily, and she did not voice any concerns regarding a shortening of her leg or the resident being in severe pain.During a telephone interview, on 3/18/26 at 9:38 a.m., Resident B's family member 8 indicated she had mentioned her concerns about Resident B's right leg being shorter than her left leg during the first care conference. She had told LPN 10 at the time of Resident B's admission she had concerns with the right leg being shorter than the left one and her knee looked mangled (deformed). She told the Therapy Manager as well about her concern over the shortened right leg and the Therapy Manager indicated they assumed when a resident was admitted to the facility from the hospital, they were therapy ready. At some point, the facility measured both Resident B's legs to see how shortened the right leg was compared to her left leg. She felt like everyone minimized my mother's pain. Every time someone tried to move her, she cried out ouch, ouch, ouch and this was not normal for her, but no one did anything to find out why she was having so much pain. When the facility physician came to see Resident B, she told him Resident B was in excruciating pain whenever she was moved and her pain medication was ordered as needed every four hours, so he changed the time she was allowed to have her pain medications to every four hours around the clock to try to control her pain better. Resident B walked on the right side of her foot due to her stroke and had a slight inward turn of her right foot because of her foot drop. After she arrived at the facility, her right foot was turned inward so much she looked like she was walking [NAME] toed and that was not normal for her.During an interview, on 3/18/26 at 10:15 a.m., Resident B's family member 9 indicated she managed an orthopedic surgeon office who performed hip and shoulder replacements, so she had some knowledge in this area. She indicated she visited the resident's therapy sessions twice. She had asked why her right leg was shorter than the left leg and told the therapists this was not normal for her mother. The resident could not bear weight on her right leg, and both therapists were trying to make her walk. Resident B had a high pain tolerance, so if she was crying out in pain, she was hurting. She had videotaped a therapy session because she wanted her family member to see how the therapy staff just drug my mom along between the parallel bars. In one of the videos, the therapist had to pick up her right foot and move it forward so she could take a step, and Resident B was crying because she was in severe pain. Family member 9 indicated she observed the resident's right hip bulging outwards, her right leg was shortened, and her right hemiplegic foot was turned inward to the pointe her right foot was in a [NAME] toe position, which was not normal for the resident. She was told the resident's hip bone was completely out of the hip socket at her follow-up appointment by the orthopedic physician. A video recording was provided by family member 9 and the following was observed:The first video was an audio and visual video, dated 11/21/25 at 11:15 a.m., and was 30 seconds in length. Resident B, the Therapy Manager, and Physical Therapist Assistant (PTA) 7 were in between the parallel bars. The Therapy Manager was standing behind the resident with a wheelchair. PTA 7 was in front of the resident with both of her arms under the resident's arms and holding onto the waistband of Resident B's pants. Resident B did not bear weight on her right leg. She stood on her left leg with her right leg slightly flexed and her right foot was not touching the floor. Her right knee was bent, which did not allow her to put full weight on her right foot. Resident B can be heard saying, Oh, Oh, Oh, Oh. Resident B was held up by the therapist in the video for 16 seconds until she sat down in her wheelchair.The second video was an audio and visual video, dated 11/21/25 at 11:18 a.m., and was 30 seconds in length. Resident B, the Therapy Manager, and Physical Therapist Assistant (PTA) 7 were in between the parallel bars. The Therapy Manager was standing behind the resident with a wheelchair. PTA 7 was in front of the resident with both of her arms under the resident's arms and holding onto the waistband of Resident B's pants. The resident was not taking any steps. PTA 7 picked up Resident B's right leg, by placing her hand behind her right knee, pulled the right lower leg forward, and placed the foot onto the ground, then the resident brought her left leg forward towards the right leg. Resident B can be heard saying, Oh, Oh, Oh, Oh. This continued for three steps until she sat down in her wheelchair.A current facility policy, titled Change in a Resident's Condition or Status, dated as revised 2007 and provided by the Executive Director (ED) on 3/16/26, indicated .The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been.a significant change in the resident's physical/emotional/mental condition.a need to alter the resident's medical treatment significantly.This citation relates to Intake 2748922.410 IAC (Indiana Administrative Code) 16.2-3.1-5(a)(2)

Based on observation, interview and record review, the facility failed to ensure medications were labeled and dated and insulin was removed and discarded after 28 days in 2 of 4 medications carts reviewed for medication storage. (Ambassador Cart 1 and Heritage Cart 1)Findings include:1. During an observation, on [DATE] at 10:14 a.m., with LPN 2, the Heritage medication cart 1 had the following:a. One (1) Novolog insulin pen which was opened and not dated. There were 200 of 250 units left in the insulin pen.b. One (1) Basaglar insulin pen which was opened and dated [DATE].c. A bubble pack of Tramadol 50 milligrams (a controlled substance pain relieving medication) was found to have open packaging at the number two dose. During an interview, on [DATE] at 10:14 a.m., LPN 2 indicated the Novolog insulin should have had an open date. The Basaglar insulin pen was only good for 30 days. The Norco pill should have been removed and discarded. 2. During an observation, on [DATE] at 8:42 a.m., with LPN 3, the Ambassador medication cart 1 had the following:a. an Advair inhaler was in the drawer, not in a box, and was not labeled with a resident's name or a date to indicate when it had been opened. There were 98 doses left. The metal cannister inside the plastic was removed and was also found to not have a resident's name or an open date.b. a Fluticasone nasal spray bottle was found open (no seal), outside of the box, and did not have an open date or a resident's name on the bottle. During an interview, on [DATE] at 8:43 a.m., LPN 3 indicated the medications should have had a resident's name and dates on them.A current facility policy, titled DRUG STORAGE, undated and received from the Executive Director on [DATE] at 10:29 a.m., indicated .All expired, damaged and/or contaminated medications are removed from resident care areas and stored separately from medications available for administration .Insulin .injectable vials or pens must be discarded after 28 days 3.1-25(j)3.1-25(k)(1)

Based on interview and record review, the facility failed to ensure assessments were completed according to the policy and weights were obtained and documented in the clinical record for 2 of 2 residents reviewed for quality of care. (Resident 42 and 6)Findings include:1. The clinical record for Resident 42 was reviewed on 12/15/25 at 11:29 a.m. The diagnoses included, but were not limited to, major depressive disorder, anxiety disorder, and dementia.A physician's order, dated 5/10/25, indicated to administer olanzapine (an atypical antipsychotic medication) 10 milligrams (mg) one time a day.A care plan, dated 5/6/25, indicated to complete a routine AIMS observation.An Abnormal Involuntary Movement (AIMS) assessment (used to detect, track, and measure the severity of involuntary movements in patients on antipsychotic medications) was completed on 5/9/25.An AIMS assessment was completed on 12/16/25.There was a greater than 6-month lapse between completing the AIMS assessments.During an interview, on 12/16/25 at 3:31 p.m., the Director of Nursing (DON) indicated the staff should complete AIMS assessments quarterly.During an interview, on 12/17/25 at 2:04 p.m., Clinical Support 1 indicated the staff should complete the AIMS assessments every 6 months.A current facility policy, titled Behavioral Health Management Program, dated January 2024 and received from Clinical Support 6 on 12/18/25 at 9:09 a.m., indicated .AIMS monitoring will be done every 6 months after the initial AIMS assessment.2. During an interview, on 12/17/25 at 11:05 a.m., Licensed Practical Nurse (LPN) 3 indicated when a resident was admitted to the facility, the staff would obtain weights for the first 3 days and according to the physician's order. The weights would be documented in either the MAR (Medication Administration Record) or the vitals tab.The clinical record for Resident 6 was reviewed on 12/15/25 at 1:33 p.m. The diagnoses included, but were not limited to, Parkinson's disease, fracture of the right femur, and weakness.A physician's order, dated 5/1/25, indicated to obtain a monthly weight once a day, on the 1st of the month.A Registered Dietitian (RD) note, dated 6/4/25 at 8:14 p.m., indicated to obtain a reweight due to a 35-pound weight gain in 27 days.The reweight was not located in the electronic medical record.The clinical record indicated on 6/23/25, Resident 6 was discharged to the hospital for surgical repair after experiencing a fall and was re-admitted to the facility on [DATE].A readmission weight was not located in the electronic medical record.A physician's order, dated 7/1/25 to 8/5/25, indicated to obtain weekly weights once a day, on Mondays.A care plan intervention, dated 8/12/25, indicated to obtain weights as ordered.A Registered Dietitian note, dated 9/10/25 at 11:13 a.m., indicated to obtain weekly weights for four (4) weeks due to a significant weight loss.A progress note, dated 9/17/25, indicated Resident 6 had a 12-pound weight loss in 27 days with an intervention of weekly weights.A care plan intervention, dated 9/18/25, indicated Resident 6 was a monthly weight.A physician's order, dated 10/14/25 to 11/4/25, indicated to obtain weekly weights for four (4) weeks, once a day on Tuesdays.The vitals tab in the electronic medical record indicated Resident 6's weights were marked as invalid on 4/28/25, 5/5/25, 6/1/25, 6/5/25, 7/3/25, 9/4/25, 9/22/25, 9/25/25, 9/29/25, and 10/1/25.The electronic Medication Administration Record (MAR) indicated the following weight documentation:1. Monthly:On 5/1/25, no weight was documented.On 6/1/25, the weight was documented as invalid.On 9/1/25, no weight was documented.On 10/1/25, the weight was documented as invalid. 2. Weekly:On 6/1/25, the weight was documented as invalid.On 7/16/25, no weight was documented.On 7/28/25, no weight was documented.On 9/15/25, the weight was documented as invalid.On 9/29/25, the weight was documented as invalid.On 10/14/25, no weight was documented. There was no documentation in the MAR to indicate weekly weights were obtained from 7/1/25 to 7/16/25 according to the physician's order. A physician's order or documentation of the weekly weights obtained for four (4) weeks as recommended by the Registered Dietitian, on 9/10/25, was not located in the electronic medical record.During an interview, on 12/17/25 at 11:10 a.m., LPN 5 indicated invalid in the vitals tab and the MAR indicated a reweight had been completed due to a significant loss or gain when compared to the previous weight. When a reweight was obtained, the weight would be documented in the clinical record, and she was not sure why the vitals tab and the MAR did not reflect the reweight.During an interview, on 12/18/25 at 10:12 a.m., the Director of Nursing (DON) indicated she had invalidated Resident 6's weights in the clinical record after obtaining a reweight.A current facility policy, titled Weight Assessment and Intervention, dated as revised December 2008 and received from the Clinical Support Nurse on 12/18/25 at 12:30 p.m., indicated .The nursing staff will measure resident weights on admission and weekly for four weeks thereafter.Weights will be recorded in the resident's medical record.A current facility policy, titled Weight Management Policy, dated March 2015 and received from the DON on 12/18/25 at 9:09 a.m., indicated .Initial weight: upon admission/re-admission.will be inserted into the resident's medical record.4 weeks post admit weights: New admission/re-admission resident's will be weighed at admission and weekly X4 weeks and monthly thereafter if the weight is determined to be stable.If the resident has a previous weight in the medical record that weight will be compared to the current weight being obtained to ensure that a reweight is done immediately if there is a significant change in weight.Significant weight lose/gain protocol.weekly weight monitoring.Documenting resident compliance/non-compliance.Document refusals, document refusals of alternatives and document the resident has the right to refuse once all alternative options are offered.3.1-37(a)

Based on observation, interview and record review, the facility failed to ensure consents were obtained and the ability to safely use an enabler bar for bed mobility and transfers assessments were completed for 2 of 7 residents reviewed for accident hazards. (Resident 115 and 11)Findings include:1. During an observation, on 12/11/25 at 12:03 p.m., Resident 115 was in bed and had bilateral grab bars. During an observation, on 12/12/25 at 2:02 p.m., Resident 115 was in bed and had bilateral grab bars. During an observation, on 12/15/25 at 10:04 a.m., Resident 115 was in bed and had bilateral grab bars. During an observation, on 12/16/25 at 10:32 a.m., Resident 115 was in bed and had bilateral grab bars. The clinical record for Resident 115 was reviewed on 12/12/25 at 2:31 p.m. The diagnoses included, but were not limited to, difficulty in walking, insomnia, memory deficit following cerebrovascular disease, mild dementia with mood disturbance, speech and language deficits following cerebrovascular disease, and Alzheimer's disease. A care plan, dated 11/4/25, indicated transfer bars were used while in bed to aid in transfers and bed mobility. A physician's order, dated 12/8/25, indicated Resident 115 used mobility devices. A speech language pathology report, dated 12/9/25 at 7:05 a.m., indicated Resident 115 had severe cognitive impairment. A care plan meeting summary, dated 12/12/25, did not include the transfer assist rails being discussed with the resident's representative. A bed rail assessment dated [DATE] 10:46 a.m., (completed after the start of the survey) indicated the resident required an assist rail for transfers. The assessment did not indicate the type of rail used, the risks and benefits, alternatives initiated prior to use, consent, or a safety assessment of Resident 115's ability to use the assist rails. A progress note, dated 12/16/25 at 12:30 p.m., indicated Resident 115 gave verbal consent for the use of the assist rails on his bed. The risks and benefits had been discussed with Resident 115. The electronic medical record did not include a bed rail consent from the resident's representative and did not include the required safety assessment. During an interview, on 12/17/25 at 10:15 a.m., the Director of Nursing (DON) indicated Resident 115 had a bedrail assessment completed, on 12/16/25, and consent was obtained. During an interview, on 12/15/25 at 2:59 p.m., the Executive Director (ED) indicated Resident 115 was very confused. During a previous incident, he had called 911 and told them he had fallen and was on the floor, but he was safe in the bed and had not fallen. 2. During an observation, on 12/12/25 at 11:28 a.m., Resident 11's bed had bilateral grab bars. The grab bars were attached to the bed frame and could not be lowered from their raised position. The clinical record for Resident 11 was reviewed on 12/12/25 at 2:52 p.m. The diagnoses included, but were not limited to, dementia, repeated falls, and Parkinson's disease with dyskinesia (involuntary, erratic muscle movements, ranging from mild fidgeting to severe writhing, often affecting the face, limbs, or trunk). A care plan, dated 3/25/25, indicated Resident 11 was unable to independently perform activities of daily living. An intervention indicated to utilize transfer bars while in bed to aid in transfers and bed mobility. The electronic health record did not include a bed rail assessment or consent for the use of bed rails at the time of the clinical record review. During an interview, on 12/16/25 at 9:45 a.m., the Clinical Support Nurse indicated the facility would not have consents or assessments for the enabler bars or transfer bars. During an interview, on 12/17/25 at 10:45 a.m., the Clinical Support Nurse indicated the beds were delivered to the facility with the rails already attached, not added to the bed due to the residents' decline resulting in a need for them, therefore consents and assessments were not done. A current facility policy, titled Proper Use of Side Rails, dated as last revised December 2007 and received from the Clinical Support Nurse on 12/16/25 at 10:52 a.m., indicated .The purpose of these guidelines are to ensure the safe use of side rails as resident mobility aids.Side rails are only permissible if they are used to treat a resident's medical symptoms or to assist with mobility and transfer of residents.An assessment will be made to determine the resident's symptoms or reason for using side rails. When used for mobility or transfer, an assessment will include a review of the resident's: bed mobility; and.Ability to change positions, transfer to and from bed or chair, and to stand and toilet.Consent for side rail use will be obtained from the resident or legal representative, after presenting potential benefits and risks. 3.1-45(a)(1) 3.1-45(a)(2)

Based on interview and record review, the facility failed to ensure medication was available and administered as ordered by the physician for 1 of 6 residents reviewed for pharmacy services. (Resident 116)Findings include:The clinical record for Resident 116 was reviewed on 12/16/25 at 10:57 a.m. The diagnoses included, but were not limited to, Parkinson's disease, difficulty walking, unsteadiness on feet, orthostatic hypotension, and memory deficit. A physician's order, dated 12/6/25, indicated to administer two (2) Rytary (an extended-release medication used to treat symptoms of Parkinson's disease) 61.25-245 milligram (mg) capsules three (3) times a day.A prescription order report sent to the pharmacy indicated the new electronic prescription order was sent successfully on 12/6/25 at 5:40 p.m.A physician's history and physical, dated 12/10/25, indicated the resident was admitted for rehabilitation and care after a fall related to the diagnosis of Parkinson's disease with dyskinesia. The plan was to continue the home dosing of Rytary 61.25-245 mg three (3) times a day. A current care plan, dated 12/16/25, indicated the resident was unable to independently perform activities of daily living related to Parkinson's disease, and required assistance with bed mobility, transfers, toileting and eating.A Medication Administration Record (MAR), dated December 2025, indicated the resident did not receive the ordered Rytary for Parkinson's disease due to the medication being unavailable on the following dates and times:On 12/14/25 at 6:00 a.m., 12:00 p.m., and 6:00 p.m. On 12/15/25 at 6:00 a.m., 12:00 p.m., and 6:00 p.m.On 12/16/25 at 6:00 a.m.A nursing progress note, dated 12/15/25 at 10:56 p.m., indicated the nurse had called the pharmacy to get a STAT (immediate) order of Rytary.A nursing progress note, dated 12/16/25 at 12:40 p.m., indicated Resident 116 reported dizziness and did not feel well. A nursing progress note, recorded as a late entry on 12/16/25 at 2:53 p.m., indicated the Assistant Director of Nursing (ADON) had been notified the resident did not have his Rytary. The medical record did not indicate the pharmacy was notified of the need for the Rytary until after the 6th missed dose. During an interview, on 12/16/25 at 1:49 p.m., the Assistant Director of Nursing (ADON) indicated she was not aware the resident missed several doses of his Parkinson's medication. She checked the medication cart and found 26 tabs in a box dated as delivered on 12/7/25. The box indicated it held 30 of 90 tablets. The ADON indicated the nurse would order medications when the medication was getting down to the last few doses. If the medication had run out, then staff would call the pharmacy and order a STAT (immediate) delivery of the medication.During an interview, on 12/16/25 at 3:27 p.m., the Director of Nursing (DON) indicated the pharmacy was aware of the need for the Parkinson's medication but had refused to make deliveries over the weekend due to the weather. During an interview, on 12/17/25 at 10:55 a.m., the facility's contracted pharmacist indicated the pharmacy had sent a 15-day supply of the medication on 12/7/25. The pharmacy then sent a refill out this week. The pharmacist indicated she did not see any medication order requests in their system from the facility other than the original 12/6/25 order which had been supplied on 12/7/25. The resident should have arrived with his medications from the previous facility which was a 14-day supply sent from the same pharmacy on 12/2/25. The resident should not have been out of his Parkinson's medication on 12/14/25. The pharmacy did not cancel any medication deliveries over the past week and had made deliveries every day the entire month of December. Even with severe weather, the pharmacy made deliveries, especially STAT (immediate) deliveries.During an interview, on 12/18/25 at 9:03 a.m., LPN 4 indicated routine medications were set to automatically refill. If a nurse noticed a medication was running low and the refill had not arrived, they would send a refill request in the electronic medical record. If the medication was completely out and not available in their floor stock, the nurse would call the pharmacy and request the medication immediately. The pharmacy would send the medication the same day, usually within a few hours. A pharmacy services agreement, dated 10/1/22 and provided by the DON on 12/16/25 at 3:15 p.m., indicated .agrees to deliver to the Facility any.prescriptions.daily, seven (7) days per week.with an additional delivery if an emergency arises.In the event the Pharmacy cannot furnish an ordered medication on a prompt and timely basis, the Pharmacy will make arrangements with another pharmacy supplier in the Facility's local community to provide such service(s) to the Facility at the Pharmacy's expense.A document, titled Full Prescribing Information, dated as revised 12/2019 and retrieved from https//rytaryhcp.com, indicated .Warnings and Precautions.Avoid sudden discontinuation or rapid dose reduction in patients taking RYTARY. If the decision is made to discontinue RYTARY, the dose should be tapered to reduce the risk of hyperpyrexia and confusion.Avoid sudden discontinuation or rapid dose reduction of RYTARY. 3.1-25(a)3.1-25(b)(3)

Based on interview and record review, the facility failed to ensure specific discharge instructions related to the resident's current cognitive status and memory deficit, medication administration, and food preparation needs were provided to the home health provider for 1 of 3 residents reviewed for discharge. (Resident B)Findings include:The clinical record for Resident B was reviewed on 10/27/25 at 10:05 a.m. The diagnoses included, but were not limited to, risk for malnutrition, dementia with psychotic and mood disturbance, memory deficit, speech and language deficits, dysphagia, pain, anxiety disorder, hypertension, difficulty walking, and age-related macular degeneration.A physician's order, dated 10/1/25, indicated Resident B could discharge home, on 10/3/25, with current medications and home health.A speech therapy Discharge summary, dated [DATE], indicated the recommendations were for Resident B to have supervision and assistance with medication management to ensure she was taking appropriate dosages and to utilize a pillbox to assist her. It was recommended for Resident B to have visual cues throughout her apartment to complete tasks such as taking her medicine and locking the door. She was not considered safe to use the stove and needed to have a calendar to help her remember appointments. Her discharge diet was minced and moist. The summary indicated Resident B was being discharged to live alone with no assistance or support.A social services progress note, dated 10/2/25 at 8:54 p.m., indicated Resident B's health literacy (defined by the CDC as the degree to which individuals had the ability to find, understand, and use information and services to make inform health-related decisions and actions for themselves) was sometimes and home health was set up.An occupational therapy Discharge summary, dated [DATE], indicated Resident B required supervision or touching assistance to safely and efficiently bathe, including washing, rinsing, and drying with the use of a long-handled sponge and shower chair. Resident B had a medical history of failure to thrive with no social support at home.A physical therapy Discharge summary, dated [DATE], indicated the resident needed a walker to safely ambulate. The resident indicated she had a walker at home.A Brief Interview for Mental Status (BIMS) assessment, dated 10/3/25, indicated Resident B had severe cognitive impairment.A transition of care/Discharge summary, dated [DATE], indicated Resident B was not responsible for herself and listed contact information for a home healthcare provider. The summary indicated Resident B was cognitively impaired and needed assistance with eating, oral, toileting, and personal hygiene, upper and lower body dressing, rolling left and right, sitting to standing, and toilet and shower transfers. It did not include any medication instructions. It did not include therapy notes, speech therapy recommendations, the use of a rolling walker, or local caregiver contact information. It was signed by Resident B.A nursing progress note, dated 10/3/25 at 12:09 p.m., indicated Resident B was discharged home with all medications. The discharge paperwork and instructions were gone over with the resident only and she signed the paperwork. The facility driver transported the resident home alone.There was no documentation to indicate anyone else was present in the apartment to see the discharge instructions, set up the resident's medication, help the resident with visual cues and reminders, or get her groceries.A Minimum Data Set (MDS) assessment, dated 10/3/25, indicated Resident B was discharged home. It did not indicate the resident was discharged home under the care of an organized home health service or a current reconciled medication list was provided to the subsequent provider.A facility referral packet indicated the home health care provider was provided with a face sheet, current orders, and the facility physician's history and physical. It did not include care plan information, speech therapy notes, occupational therapy notes, physical therapy notes, or psychiatric physician notes.A home health initial visit note, dated 10/8/25 at 3:23 p.m., indicated Resident B was oriented to self and place, forgetful, confused, anxious, and depressed. There was no capable caregiver present, inadequate environmental cleaning, and no support network available. The resident indicated she felt isolated and alone most of the time. Resident B had poor hygiene, hydration, nutrition, and mobility. Resident B required assistance with walking and all activities of daily living, including basic grooming. Resident B required 24-hour supervision, but no supervision was available. She could not manage her medications without supervision and was not taking her medications. She was not eating and indicated she was constipated and in pain.A hospital history and physical note, dated 10/9/25, indicated Resident B was brought to the emergency room by emergency medical services (EMS). She had a new T12 compression fracture in her back. She did not remember falling. The resident was confused and did not know who had called EMS. She was confused about her medical history and reported she had only been drinking chocolate and strawberry milk since going home. She indicated she was not taking any medications. She was frail with severe muscle wasting. The hospital was unaware of the resident's duloxetine prescription and had incorrect oxycodone and risperidone doses because the resident was unable to provide an accurate history. The resident was admitted to the hospital.During an interview, on 10/27/25 at 1:45 p.m., Resident B's brother indicated the resident had wanted to stay at the facility and he wanted her to as well, but she could not afford it. He had not realized Resident B did not understand how to take her medicine. He believed the resident had friends who helped her, but he could not verify who they were. He had not spoken with them so he could not say what they were capable of or agreeable to do. He did not know any actual names and did not have any contact information. He was unable to verify any equipment the resident had in her apartment. During an interview, on 10/27/25 at 2:55 p.m., the Social Services Director (SSD) indicated Resident B would not give the facility any names or phone numbers of her support network, so they were unable to verify the capabilities or willingness of any caregivers. Education was only given to Resident B. Despite the impaired cognition, the resident sounded fine when she talked with the resident. She did not believe the resident was impaired enough to be incapable of making her own decisions or to have impaired judgment. She indicated the resident did not need any durable medical equipment, despite the therapy summaries which indicated the resident needed a walker, pill box, long handle shower sponge, and a shower chair.During an interview, on 10/28/25 at 9:42 a.m., the Therapy Director indicated Resident B had cognitive impairments at discharge and did not have any direct in-home support. The home health agency was taking over Resident B's care and was going to be responsible for managing the medications. Normally, therapy would have educated the resident's family or caregivers since the resident had a cognitive issue, but the resident would not let them talk to any of the friends or neighbors who the resident said would help her. The resident would not let therapy go to her apartment for a home evaluation. Based on the speech therapy discharge notes, Resident B could not safely prepare her medications. The home health agency would have needed to place the pills in a pill box when they first visited the resident. Until then, the resident would not be able to safely take her medications. Without prompting, the resident would not necessarily remember to take the medication in the pill box. There was no verification when the home health agency had planned on visiting the resident. Resident B had a walker and did not need any other equipment.During an interview, on 10/28/25 at 9:50 a.m., the Executive Director (ED) indicated home health agencies tried to see residents within 24-48 hours, but it could take as long as few days. The facility had not worked with this home health agency very much, but this was the only agency which would accept this resident. She believed the home health agency had called the resident over the weekend but was not able to see the resident until 10/8/25. Resident B would not have been able to safely take her medications until home health assisted her. The resident was discharged and taken to her apartment on 10/3/25 around noon by the facility van driver. She indicated the facility had not verified the resident had food available in the apartment. During an interview, on 10/28/25 at 11:15 a.m., LPN 2 indicated nursing did not assess Resident B's ability to safely manage her medications, her recall knowledge of her medications, or the ability to remember to safely take her medications at the correct time and correct dose.During an interview, on 10/28/25 at 11:20 a.m., LPN 1 indicated he went over all the discharge instructions, medications, and follow up appointments with the resident at discharge. He believed she understood things at the time while he was talking to her, but she did have memory issues, so home health was taking over her care. She was not allowed to administer any of her medications by herself or keep any medications in her room while in the facility. Residents with memory issues and cognitive scores like Resident B usually had caregivers or family with them for discharge education, but Resident B never had any as far as he could remember. She did not have anyone present with her when he gave her the discharge education.During an interview, on 10/28/25 at 12:15 p.m., the Nursing Services Director for the home health agency indicated she had not received the discharge summary with a medication list from the facility. It was unavailable to the home health care nurse when she arrived to evaluate the resident on 10/8/25. The agency attempted to initiate services within 24 to 48 hours, but weekends were more difficult. They were not notified of any urgency and did not usually set up medications. Monitoring the doses and managing as needed medications was not a service home health care provided. Home health would only be visiting Resident B a few times a week and would not provide the level of supervision Resident B required with her poor cognition and memory. The nurse would only see the resident once a week.A current facility policy, titled Discharge Planning, dated 6/4/19, indicated .The discharge summary shall include a description of the resident's.mental functional status; F. Ability to perform activities of daily living including: 1. Bathing, dressing and grooming, transferring and ambulating, toilet use, eating, and using speech, language, and other communication systems; 2. Need for staff assistance and assistive devices or equipment to maintain or improve functional abilities; and.Nutritional status and requirements: 1. Weight and height; 2. Nutritional intake; and 3. Eating habits, preferences and dietary restrictions. J. Mental and psychosocial status (ability to deal with life, interpersonal relationships and goals, make health care decisions, and indicators of resident behavior and mood);.Cognitive status (the ability to problem solve, decide, remember, and be aware of and respond to safety hazards); and P. Medication therapy (all prescription and over-the-counter medications taken by the resident including dosage, frequency of administration, and recognition of significant side effects that would be most likely to occur in the resident). III. As part of the discharge summary, the nurse will reconcile all pre-discharge medications with the resident's post-discharge medications. The medication reconciliation will be documented.The post-discharge plan will be developed by the Care Planning/Interdisciplinary Team with the assistance of the resident and his or her family and will include.The degree of caregiver/support person availability, capacity and capability to perform required care.What factors may make the resident vulnerable to preventable readmission, and G. How those factors will be addressed.A copy of the following will be provided to the resident and any receiving provider .The discharge summary A current facility job description, titled Social Services Director, dated February 2021, indicated .Provides advice and appropriate referrals to minimize social and economic obstacles to discharge, and coordinates discharge planning communications and documentation This citation relates to Intake 2639611.3.1-12(a)(3)3.1-12(a)(4)(B)3.1-12(a)(18)3.1-12(a)(19)3.1-12(a)(20)3.1-12(a)(21)

Based on interview and record review, the facility failed to ensure a resident was discharged to a location which met the resident's needs and provided the support and resources needed for 1 of 3 residents reviewed for discharge. (Resident B)Findings include:The clinical record for Resident B was reviewed on 10/27/25 at 10:05 a.m. The diagnoses included, but were not limited to, risk for malnutrition, dementia with psychotic and mood disturbance, memory deficit, speech and language deficits, dysphagia, pain, anxiety disorder, hypertension, difficulty walking, and age-related macular degeneration.A speech therapy note, dated 9/4/25 at 9:43 a.m., indicated Resident B was severely cognitively impaired and required a mechanically ground diet.A physician's history and physical note, dated 9/4/25 at 3:22 p.m., indicated Resident B reported a 10-15-pound weight loss in one (1) month and currently weighed 78 pounds. Resident B had impaired cognition/dementia at the hospital, anxiety, constipation, insomnia, and macular degeneration. The hospital had been concerned Resident B was unable to care for herself and reported possible self-neglect to APS (adult protective services). Resident B had a brother in Florida and a local friend which she did not see often. While in the hospital, Resident B had extreme anxiety and cognitive difficulties.A Montreal Cognitive Assessment (MOCA), dated 9/4/25, indicated Resident B scored 6 out of a 30, and normal cognition was considered a score of 26 or more.A care conference summary, dated 9/5/25, indicated the Social Services Director (SSD) discussed options for Resident B such as hiring caregivers, assisted living facility, or long-term care. Resident B's brother indicated the resident could not afford any of those options. He believed she had some support from a few friends. No names or contact information was given. There was no documentation, a discussion of Medicaid applications or offers to assist with the application process was completed.A Preadmission Screening and Resident Review (PASRR) level I assessment, dated 9/12/25, indicated the level I showed Resident B had evidence of a primary neurocognitive disorder/dementia. Further PASRR evaluation was not required because Resident B's neurocognitive disorder/dementia was so progressed, it was the primary condition which required treatment.A psychiatric physician's progress note, dated 9/23/25, indicated Resident B's memory, insight, judgement, and nutritional status was poor. Her mood was dysphoric at times, and her thought processes were confused. Her diagnoses included moderate major neurocognitive disorder with psychotic disturbances, anxiety, and mood symptoms.A physician's order, dated 10/1/25, indicated Resident B could discharge home, on 10/3/25, with current medications and home health. Therapy to evaluate and treat.A speech therapy Discharge summary, dated [DATE], indicated Resident B's ability to manage activities of daily living such as taking medications safely and independently was moderate to severely impaired. Resident B had a moderately severe cognitive decline/possible dementia. Her cognitive problem solving and short-term memory was impaired. The discharge recommendations were for the resident to have supervision and assistance with medication management to ensure she was taking appropriate dosages and to utilize a pillbox to assist her. It was recommended for Resident B to have visual cues throughout her apartment to complete tasks such as taking her medicine and locking the door. She was not considered safe to use the stove and needed to have a calendar to help her remember appointments. Her discharge diet was minced and moist. The summary indicated Resident B was being discharged to live alone with no assistance or support.The clinical record did not contain documentation of an assessment of Resident B's ability to prepare minced and moist food for herself. There was no documentation caregivers were educated about providing Resident B with cues or minced and moist food options.A social services progress note, dated 10/2/25 at 8:54 p.m., indicated Resident B's last covered day by her managed Medicare plan was 10/3/25, so she would discharge on that day. Resident B's health literacy (defined by the CDC as the degree to which individuals had the ability to find, understand, and use information and services to make inform health-related decisions and actions for themselves) was sometimes. Resident B's brother was notified of the discharge date and home health was set up. There was documentation the brother received discharge paperwork, and the brother did not sign the discharge paperwork.An occupational therapy Discharge summary, dated [DATE], indicated Resident B required supervision or touching assistance to safely and efficiently bathe, including washing, rinsing, and drying with the use of a long-handled sponge and shower chair. Resident B had a medical history of failure to thrive with no social support at home. The resident was anxious about returning home. Resident B was discharged from skilled occupational therapy due to insurance denied coverage and she would be returning home alone with no support. The clinical record did not contain documentation of an assessment of Resident B's ability to bathe herself safely. There was no documentation caregivers were educated about providing Resident B with safe assistance with bathing.A Brief Interview for Mental Status (BIMS) assessment, dated 10/3/25, indicated Resident B had severe cognitive impairment.A transition of care/Discharge summary, dated [DATE], indicated Resident B was not responsible for herself and listed contact information for a home healthcare provider. The summary indicated Resident B was cognitively impaired and needed assistance with eating, oral, toileting, and personal hygiene, upper and lower body dressing, rolling left and right, sitting to standing, and toilet and shower transfers. It did not include any medication instructions. It did not include therapy notes, speech therapy recommendations, the use of a rolling walker, or local caregiver contact information. It was signed by Resident B and not her brother.A continuity of care document, dated 10/3/25, indicated Resident B was prescribed the following medications which were last administered on 10/2/25:1. Acetaminophen (a pain reliever) 1000 milligrams (mg) three times a day, not to exceed 4000 mg in 24 hours.2. duloxetine (an antidepressant) 60 mg once a day.3. risperidone (an antipsychotic) 1 mg once a day, do not chew or split the tablet.4. ferrous sulfate (an iron supplement) 325 mg once a day.5. gabapentin (an anticonvulsant also used for nerve pain) 300 mg once a day.6. melatonin (a supplement for sleep) 6 mg once a day.7. naloxone (used to reverse opioid overdose) 4 mg spray, 1 nasal spray 5 times per day as needed.8. oxycodone (a schedule II narcotic) 5 mg three times a day.9. oxycodone 5 mg every 12 hours as needed for moderate pain.10. pantoprazole (used to reduce the amount of acid in the stomach) 40 mg twice a day.11. MiraLAX (a laxative)17 grams mixed in 8 ounces of water, juice, or soda twice a day.12. senna (a laxative) 8.6 mg twice a day.13. multivitamin with folic acid 400 mcg once a day.14. tizanidine (a muscle relaxer) 2 mg every 12 hours as needed.15. trazadone (an antidepressant) 50 mg once a day for insomnia.16. vitamin B-1 100 mg once a day. A nursing progress note, dated 10/3/25 at 12:09 p.m., indicated Resident B was discharged home with all medications. The discharge paperwork and instructions were gone over with the resident only and she signed the paperwork. The facility driver transported the resident home alone.There was no documentation to indicate anyone else was present in the apartment to see the discharge instructions, set up the resident's medication, help the resident with visual cues and reminders, or get her groceries.A Minimum Data Set (MDS) assessment, dated 10/3/25, indicated Resident B was discharged home. It did not indicate the resident was discharged home under the care of an organized home health service or a current reconciled medication list was provided to the subsequent provider. She was occasionally incontinent with urine and stool and required partial/moderate assistance with showering and bathing.A home health initial visit note, dated 10/8/25 at 3:23 p.m., indicated Resident B was oriented to self and place, forgetful, confused, anxious, and depressed. There was no capable caregiver present, inadequate environmental cleaning, and no support network available. The resident indicated she felt isolated and alone most of the time. Resident B had poor hygiene, hydration, nutrition, and mobility. Resident B required assistance with walking and all activities of daily living, including basic grooming. Resident B required 24-hour supervision, but no supervision was available. She could not manage her medications without supervision and was not taking her medications. She was not eating and wished she could live at the facility she discharged from so she could eat a hot meal because she was not able to cook. The resident indicated she was constipated and in pain. The resident's weight was 70 pounds.This was an additional 6% weight loss from 74.6 pounds at the facility on 9/29/25. A hospital history and physical note, dated 10/9/25, indicated Resident B was brought to the emergency room by emergency medical services (EMS). She had a new T12 compression fracture in her back. She did not remember falling. The resident was confused and did not know who had called EMS. She was confused about her medical history and reported she had only been drinking chocolate and strawberry milk since going home. She indicated she was not taking any medications. She was frail with severe muscle wasting. The hospital was unaware of the resident's duloxetine prescription and had incorrect oxycodone and risperidone doses because the resident was unable to provide an accurate history. The resident was admitted to the hospital.During an interview, on 10/28/25 at 9:42 a.m., the Therapy Director indicated Resident B had cognitive impairments at discharge and did not have any direct in-home support. Normally, therapy would have educated the resident's family or caregivers since the resident had a low BIMS, but the resident would not let them talk to any of the friends or neighbors who the resident said would help her. The resident would not let therapy go to her apartment for a home evaluation. During an interview, on 10/28/25 at 9:50 a.m., the Executive Director (ED) indicated Resident B was discharged and taken to her apartment, on 10/3/25 around noon, by the facility van driver. The van driver watched Resident B enter her apartment. The facility trusted Resident B and her brother when they said the resident had a strong support system and believed the resident would be fine. The ED indicated Resident B's brother was aware of the discharge and approved. No one at the facility spoke to any potential caregivers or verified any of their competencies because Resident B would not let them. She indicated the resident had stated she was very [NAME] and would not let her friends see her like this, but she believed the resident would let them help her at home. She indicated the facility had been using the brother for all decision making because the resident was not able to make decisions. The discharge plan had always been for Resident B to return home alone, and the facility had not determined any reason for that to change.During an interview, on 10/28/25 at 11:20 a.m., LPN 1 indicated he went over all the discharge instructions, medications, and follow-up appointments with Resident B at discharge. He believed Resident B understood at the time he talked to her, but she did have memory issues. Home health was to take over her care. She was not allowed to administer any of her medications by herself or keep any medications in her room while at the facility. Residents with memory issues and cognitive scores like Resident B usually had caregivers or family with them for the discharge education, but Resident B never had any as far as he could remember. She did not have anyone present with her when he gave her the discharge education.During an interview, on 10/27/25 at 2:55 p.m., the Social Services Director (SSD) indicated Resident B would not give the facility any names or phone numbers of her support network, so they were unable to verify the capabilities or willingness of any caregivers. Education was only given to Resident B. Despite the impaired cognition, the resident sounded fine when she talked with the resident. She did not believe the resident was impaired enough to be incapable of making her own decisions or to have impaired judgment. The brother declined any other discharge plans except going home with home health because he said the resident could not afford any other options. She believed she mentioned Medicaid to him, but she did not document any conversations. She did not offer to help him apply for Medicaid for the resident.During an interview, on 10/27/25 at 1:45 p.m., Resident B's brother indicated the resident had wanted to stay at the facility and he wanted her to as well, but she could not afford it. He was not educated on her care after discharge because he could not take care of her from Florida. The facility never mentioned Medicaid and there were no offers to help him try to get Medicaid for Resident B. With the insurance ending payment on 10/3/25, the social worker did not offer any options other than discharging home with home health or staying and paying out of pocket. The resident could not afford to stay and pay out of pocket. He believed the resident had friends who helped her, but he could not verify who they were. He had not spoken with them so he could not say what they were capable of or agreeable to do. He did not know any actual names and did not have any contact information. The facility had not offered to assist him with obtaining power of attorney (POA) paperwork. He did not know who to contact, how to apply for Medicaid or how to proceed with getting access to the resident's banking information until the current hospital case manager gave him information and helped him.A current facility policy, titled Discharge Planning, dated 6/4/19, indicated .The discharge summary shall include a description of the resident's.mental functional status; F. Ability to perform activities of daily living including: 1. Bathing, dressing and grooming, transferring and ambulating, toilet use, eating, and using speech, language, and other communication systems; 2. Need for staff assistance and assistive devices or equipment to maintain or improve functional abilities; and.Nutritional status and requirements: 1. Weight and height; 2. Nutritional intake; and 3. Eating habits, preferences and dietary restrictions. J. Mental and psychosocial status (ability to deal with life, interpersonal relationships and goals, make health care decisions, and indicators of resident behavior and mood);.Cognitive status (the ability to problem solve, decide, remember, and be aware of and respond to safety hazards); and P. Medication therapy (all prescription and over-the-counter medications taken by the resident including dosage, frequency of administration, and recognition of significant side effects that would be most likely to occur in the resident). III. As part of the discharge summary, the nurse will reconcile all pre-discharge medications with the resident's post-discharge medications. The medication reconciliation will be documented.The post-discharge plan will be developed by the Care Planning/Interdisciplinary Team with the assistance of the resident and his or her family and will include.The degree of caregiver/support person availability, capacity and capability to perform required care.What factors may make the resident vulnerable to preventable readmission, and G. How those factors will be addressed.A copy of the following will be provided to the resident and any receiving provider .The discharge summary A current facility job description, titled Social Services Director, dated February 2021, indicated .Provides advice and appropriate referrals to minimize social and economic obstacles to discharge, and coordinates discharge planning communications and documentation This citation relates to Intake 2639611.3.1-12(a)(3)3.1-12(a)(4)(B)3.1-12(a)(18)3.1-12(a)(19)3.1-12(a)(20)3.1-12(a)(21)

Based on interview and record review, the facility failed to ensure a resident was transferred with a gait belt to prevent a fall according to the policy and procedure for 1 of 3 residents reviewed for accidents. (Resident B) The deficient practice was corrected on 1/16/25, prior to the start of the survey, and was therefore past noncompliance. Findings include: A document titled Indiana State Department of Health Survey Report System, indicated CNA 2 was assisting Resident B to transfer, the resident lost her balance, and the CNA assisted the resident to the floor. The resident complained of pain to her left lower extremity and X-rays were obtained at the facility. The X-ray results indicated Resident B had a left femoral neck fracture. The party responsible for the resident decided to keep her at the facility and not to proceed with surgical intervention. She remained in hospice services. Additional education was provided to CNA 2 on the use of a gait belt and safe transfers. The record for Resident B was reviewed on 2/10/25 at 11:03 a.m. The diagnoses included, but were not limited to, pain, difficulty in walking, attention and concentration deficit, dementia, hypocalcemia, and unsteadiness on feet. A nursing progress note, dated 1/7/25 at 8:10 a.m., indicated RN 3 was alerted by a CNA to come to Resident B's room as the resident had fallen. CNA 2 was getting the resident up for the day from the bed when the resident lost her balance due to bilateral lower extremity weakness and they fell . The resident and CNA 2 were found on the floor by the resident's bed. CNA 2 and the resident denied the resident hit her head. The resident initially did not complain of any pain, however after about an hour she complained of pain to her left lower extremity. The hospice provider was notified. A facility document, titled The Fall Huddle, undated, indicated on 1/7/25 at 8:10 a.m., Resident B had an assisted fall. The CNA was assisting Resident B to get up for the day when she lost her balance due to bilateral lower extremity weakness. CNA 2 was not using a gait belt at the time when the resident had the assisted fall. A nursing progress note, recorded as a late entry on 1/9/25 at 11:46 a.m., indicated Resident B's X-rays results of her pelvis and left hip indicated an impacted and minimally displaced subcapital femoral neck fracture and soft tissue swelling overlayed the fracture. The resident's family wished to not seek treatment at this time. A nursing progress note, dated 1/9/25 at 11:46 a.m., indicated RN 3 spoke with a family member in the resident's room. The family member confirmed again today that the resident would continue with hospice care and comfort medications and would not seek treatment for the impacted and minimally displaced subcapital femoral neck fracture. An Interdisciplinary team (IDT) progress note, dated 1/10/25 at 7:37 a.m., indicated CNA 2 was getting Resident B up for the day from bed on 1/7/25 when the resident lost her balance due to bilateral lower extremity weakness. The resident and CNA 2 were found on the floor by the resident's bed. CNA 2 and the resident denied the resident hit her head. She had incontinent care provided prior to the transfer. The root cause of the fall was the resident's overall decline, and she lost her balance. The intervention initiated by IDT would be to provide two persons transfer with a gait belt. During an interview, on 2/10/25 at 11:20 a.m., the Director of Nursing indicated CNA 2 should have used a gait belt during the transfer. During an interview, on 2/10/25 at 11:37 a.m., CNA 2 indicated she went to get Resident B out of bed for the day. She stood her up, so she could pivot her into the wheelchair. The resident moved one of her legs back, then she fell backwards on top of CNA 2. CNA 2 yelled for help, but no one came, so she got her cell phone and called another CNA to come and help her. She did not place a gait belt on Resident B prior to transferring her and she should have had a gait belt on her. A facility document, titled Using a Gait Belt to Assist with Ambulation, was signed by CNA 2 on 1/16/25, and indicated .Place belt around resident's waist with the buckle in front (on top of resident's clothes) and adjust to a snug fit ensuring that you can get your hands under the belt. Position one hand on the belt at the resident's side and the other hand at the resident's back. 4. Assist the resident to stand on count of three. 5. Allow the resident to gain balance. Ask the resident if dizzy. 6. Stand to side and slightly behind resident while continuing to hold onto belt A current facility policy, titled Procedure #26: Transfer to Wheelchair, undated and provided by the Director of Nursing on 2/10/25 at 11:30 a.m., indicated .Stand in front of resident and apply gait belt around the resident's abdomen. 5. Grasp the gait belt securely on both sides of the resident .11. Align resident's body and position footrests. Remove gait belt The deficient practice was corrected by 1/16/25, after the facility implemented a systemic plan which included CNA 2 was given additional education on transferring a resident while using a gait belt, all nursing staff was all educated on transferring a resident to a wheelchair and using a gait belt, and transfers with a gait belt audits were being completed daily by the Director of Nursing. This citation relates to Complaint IN00450891. 3.1-45(a)(2)

Based on observation, interview and record review, the facility failed to ensure oxygen equipment was turned on and the physician's orders were followed for 1 of 3 residents reviewed for respiratory care. (Resident 66) Finding includes: During an observation, on 1/2/25 at 11:21 a.m., Resident 66 was sitting in her recliner wearing oxygen tubing. The resident was having a hard time breathing and was not getting supplemental oxygen. The oxygen concentrator (a device used to provide supplemental oxygen therapy) was not turned on. During an observation, on 1/2/25 at 11:23 a.m., LPN 3 entered the room and checked the oxygen concentrator. The nurse turned on the concentrator and left the room to get the vitals machine to check the resident oxygen saturation. The nurse attached the pulse oximeter to the resident's finger and the resident's saturation was 82%. During an observation, on 1/2/25 at 12:51 p.m., Resident 66's door was closed, and a high-pitched whistling noise was heard coming from the resident's room. The oxygen concentrator had a red light on the top of the machine, the humidity bottle was not bubbling, and the concentrator was making a high-pitched sound. The nurse entered the room and indicated the concentrator was not working. The Minimum Data Set (MDS) Coordinator entered the room to assist the nurse. A new concentrator was brought into the room and the resident's oxygen tubing was attached. The nurse turned the oxygen on 2.5 L (liter/min). The nurse took the resident's oxygen saturation, and it was 82%. During an observation, on 1/2/25 at 12:55 p.m., the MDS Coordinator indicated the physician's order was for continuous oxygen at 3L via nasal canula. The oxygen concentrator was switched to 3L. The clinical record for Resident 66 was reviewed on 1/3/25 at 9:24 a.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD), pneumonia, and heart failure. A care plan, dated as revised 12/5/24, indicated the resident was on oxygen therapy. Interventions included, but were not limited to, administer oxygen as ordered and monitor lung sounds. A physician's order, dated 2/20/23 and discontinued on 1/3/25, indicated continuous oxygen at 3L. A physician's order, dated 1/3/25, indicated may titrate oxygen (0-4 liter/min) to maintain oxygen saturation greater than 88%. During an interview, on 1/2/25 at 11:30 a.m., LPN 3 indicated the resident was on 3L and needed the oxygen to assist with her breathing. The resident had returned from a physician's appointment. LPN 3 was not aware of the time she returned or how long the resident was without oxygen. The resident had COPD and needed the oxygen to help her breath. When the concentrator was turned off, the resident was not receiving any supplemental oxygen and the resident's oxygen level was low. During an interview, on 1/2/25 at 12:51 p.m., LPN 3 indicated she could not hear the concentrator making high pitch sounds when sitting at nurses' station. She thought the concentrator had stopped working. During an interview, on 1/2/25 at 12:53 p.m., the MDS Coordinator indicated the oxygen concentrator was set on 2.5L and the machine was increased to the physician ordered amount. A current policy, titled Protocol for Following Physician Orders, dated 4/3/17 and received from the Administrator on 1/6/25 at 10:43 a.m., indicated .All licensed staff will verify and follow the physician orders as written. If for any reason, the physician order cannot be followed, the licensed professional will contact the physician for further instructions .The resident's plan of care will reflect the physicians order and direction for the resident's plan of care .Upon discontinuation of the physician's order, the resident's plan of care will be updated to reflect the new resident orders A current policy, titled Oxygen Administration, dated 3/2004 and received from the Clinical Support Nurse on 1/8/25 at 2:10 p.m., indicated .Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration .Assemble the equipment and supplies as needed .Turn on the oxygen. Unless otherwise ordered, start the flow of oxygen at the rate of 2 to 3 liters per minute .Observe the resident upon setup and periodically thereafter to be sure oxygen is being tolerated .Periodically re-check water level in humidifying jar 3.1-47(a)(6)

Based on interview and record review, the facility failed to ensure a blood pressure medication was held according to the physician's ordered hold parameter, to give an ordered antibiotic prior to a dental visit, and to treat an elevated blood sugar with the physician's ordered sliding scale for 3 of 3 residents reviewed for quality of care. (Resident 256, 4 and 52) Finding includes: 1. The clinical record for Resident 256 was reviewed on 1/2/25 at 10:29 a.m. The diagnoses included, but were not limited to, anemia, essential primary hypertension, and memory deficit following other cerebrovascular disease. A physician's order, dated 12/27/24, indicated to give lisinopril (a medication to lower blood pressure) 10 milligrams (mg) tablet once a day, with special instructions to hold the medication for a systolic blood pressure less than 140. A Medication Administration Record (MAR), dated 12/27/24 through 1/7/25, indicated lisinopril 10 mg was not held according to the physician's order on the following dates: a. On 12/28/24, with a systolic blood pressure of 132. b. On 12/31/24, with a systolic blood pressure of 112. c. On 1/1/25, with a systolic blood pressure of 124. d. On 1/5/25, with a systolic blood pressure of 137. e. On 1/6/25, with a systolic blood pressure of 108. f. On 1/7/25, with a systolic blood pressure of 134. The electronic medical record did not include documentation the physician had been notified of the lisinopril administrations when the systolic blood pressure was below the hold parameter of 140. During an interview, on 1/7/25 at 11:55 a.m., RN 7 indicated the staff initials would be in parenthesis on the MAR when the medication had not been given. If there were no parenthesis around the initials, then the medication had been given. During an interview, on 1/7/25 at 3:00 p.m., the Director of Nursing (DON) indicated the lisinopril dose was given on the listed dates against the physician's ordered hold parameter. 44598 2. The clinical record for Resident 4 was reviewed on 1/3/25 at 12:16 a.m. The diagnoses included, but were not limited to, angina pectoris, chronic artery disease, congestive heart disease, hypertension, myasthenia gravis, depression, and anxiety disorder. A physician's order, dated 12/17/24, indicated azithromycin (an antibiotic) 500 mg (milligrams) tablet was to be given prior to dental appointments and cleanings. A progress note, dated 12/17/2024 at 2:02 p.m., indicated the resident was seen by the dental hygienist on 12/17/24. The resident's Medication Administration Record (MAR) indicated the medication was to be given prior to the resident's dental appointment and was not signed off by the nurse. During an interview, on 1/7/25 at 11:53 a.m., the Minimum Data Set (MDS) Coordinator indicated she would need to check why the antibiotic (ATB) was not signed off. The nurse should have signed the medication off on the Medication Administration Record (MAR) when it was given. During an interview, on 1/7/25 at 1:35 p.m., the Clinical Support Nurse indicated the medication was not signed off on the MAR. The nurse should have signed the medication off in the MAR after giving the medication. There was no way to prove the ATB was given prior to going to the appointment. 38872 3. The clinical record for Resident 52 was reviewed on 1/6/25 at 9:48 a.m. The diagnoses included, but were not limited to, type 2 diabetes without complications, type 2 diabetes mellitus with ketoacidosis (high levels of ketones cause the blood to become more acidic) without coma, and dementia. A physician's order, initiated on 7/21/24, indicated to check the resident blood sugar before meals and at bedtime and to notify the physician if the blood sugar was less than 60 or greater than 400. A physician's order, initiated on 7/21/24, indicated to check the resident's blood sugar prn (as needed) for symptoms of hypoglycemia (low blood sugar) or hyperglycemia (high blood sugars) and to notify the physician if the blood sugar was less than 60 or greater than 400. A physician's order, initiated on 7/21/24, indicated if the blood sugar was less than 60 and the resident could swallow, administer 4 ounces of juice or soda and a short acting carbohydrate. Repeat the blood sugar and notify the physician. A physician's order, initiated on 7/21/24, indicated to give Humalog insulin per the following sliding scale: If the blood sugar was 150 to 190, give 3 units. If the blood sugar was 191 to 230, give 6 units. If the blood sugar was 231 to 270, give 9 units. If the blood sugar was 271 to 310, give 12 units. If the blood sugar was 311 to 350, give 15 units. If the blood sugar was greater than 350, call the physician. A physician's order, initiated on 11/13/24, indicated to give Humalog Insulin 8 units daily at 12:00 p.m. The resident had a documented high blood sugar level of 414, on 11/29/24 at 11:08 a.m. The Medication/Treatment (MAR/TAR) record indicated the physician was notified. There was no progress note found to indicate the physician had given additional orders to treat the high blood sugar. The resident was given the scheduled 8 units at 12:00 p.m. Per the MAR/TAR, zero (0) units of the sliding scale were given for the resident's high blood sugar. There were no additional orders found for the treatment of the high blood sugar. The resident's blood sugar level was checked on 11/29/24 at 4:00 p.m., and the residents blood sugar was 453. During an interview, on 1/8/25 at 2:12 p.m., the Clinical Support Nurse indicated the documented 0 units for the sliding scale was most likely an error. At this time, any progress notes and any orders which pertained to holding or giving additional insulin were requested. A nursing progress note, dated 12/12/24 at 8:05 a.m., indicated Resident 52 had a blood sugar result of 50. The resident was given two (2) eight-ounce glasses of orange juice and the blood sugar was rechecked 30 minutes later. There was no documentation to indicate the physician had been notified of the low blood sugar. The blood sugar was not documented on the Medication/Treatment record or under the vital signs. During an interview, on 1/8/25 at 2:33 p.m., RN 8 indicated if a resident was found to have a high or low blood sugar, the staff would notify the physician and follow the orders for the hyper/hypoglycemia protocol. No additional information was provided by the facility. A current facility procedure, titled Obtaining a Fingerstick Glucose Level, dated as last revised in April 2001 and received from the Corporate Support Nurse on 1/8/25 at 2:12 p.m., indicated .Follow facility policies and procedures for appropriate nursing interventions regarding blood sugar results .Report abnormal results promptly to the Attending Physician A current facility policy, titled Medication Administration: General Policies and Procedures, not dated and received from the Administrator on 1/7/25 at 12:15 p.m., indicated .Medications are administered as prescribed in accordance with good nursing principles and practices .All medications are to be administered only as prescribed by a physician .Medication errors .shall be immediately reported to the attending physician, charted in detail in the resident's medical record and described in a full incident report A current facility policy, titled Protocol for Following Physician Orders, dated 4/3/17 and received from the Administrator on 1/6/25 at 10:43 a.m., indicated .All licensed staff will verify and follow the physician orders as written 3.1-37(a)

Based on interview and record review, the facility failed to ensure catheter urine output was accurately recorded and to document the removal of a urinary catheter with post-removal bladder scan measurements for 2 of 2 residents reviewed for urinary catheters. (Resident 258 and 259) Findings include: 1. The clinical record for Resident 258 was reviewed on 1/3/25 at 11:36 a.m. The diagnoses included, but were not limited to, aphasia following cerebral infarction, memory deficit, stage 3 chronic kidney disease, depression, hypotension, neuromuscular dysfunction of bladder, chronic myeloid leukemia, type 1 diabetes mellitus, and Alzheimer's disease. A physician's order, with a start date of 12/23/24, indicated to empty the Foley catheter every shift and to document the output. A current care plan, with a start date of 12/23/24, indicated to accurately document outputs on the flowsheet every shift. A Treatment Administration Record (TAR), dated 12/23/24 through 1/3/24, indicated to empty the Foley catheter every shift and document the output. On 12/23/24, the night shift had no output recorded. On 12/24/24, the day and evening shifts had medium urine outputs recorded. On 12/25/24, the evening shift had medium recorded, and the night shift had large recorded. On 12/26/24, the day and evening shift had large recorded. On 12/27/24, the evening shift had medium recorded. On 12/28/24, the evening shift had medium recorded. On 12/29/24, the evening shift had large recorded. On 12/30/24, the evening shift had medium recorded. On 12/31/24, the day shift had large recorded, and the evening shift had medium recorded. On 1/3/25, the day shift had none recorded, the evening shift had small recorded, and the night shift had small/150ml recorded. During an interview, on 1/7/25 at 12:06 p.m., RN 7 indicated she did not know why the exact urine amount was not documented when the CNAs (certified nursing assistant) were emptying the catheter in a graduated cylinder. They should not have been using small, medium, and large for the urine output amounts. During an interview, on 1/7/25 at 3:00 p.m., the Director of Nursing (DON) indicated if there was an order to document outputs then it should have been the actual amount which was charted. 2. The clinical record for Resident 259 was reviewed on 1/7/25 at 11:32 a.m. The diagnoses included, but were not limited to, urinary tract infection and retention of urine. A care plan, with a start date of 12/19/24, indicated to accurately document intakes and outputs. A care plan, with a start date of 1/1/25, indicated the resident had an indwelling urinary catheter. A nurse practitioner's progress note, dated 12/23/24, indicated the resident had significant post void residuals and urology had placed the Foley catheter while the resident was in the hospital. The plan was to order a voiding trial on Friday, 12/27/24. A physician's order, dated 12/20/24 and discontinued 12/29/24, indicated to obtain the Foley catheter output every shift. A physician's order, dated 12/27/24 and discontinued 12/30/24, indicated to remove the Foley catheter and complete a bladder scan every 8 hours. A TAR, dated 12/20/24 through 1/8/25, indicated to record the Foley catheter output every shift: On 12/21/24, there was no Foley catheter output for the day or evening shifts. On 12/27/24, there was no Foley output for the day or night shift. A note for the night shift indicated not administered due to item not being present. A TAR, dated 12/20/24 through 1/8/25, indicated to remove the Foley catheter and complete a bladder scan every 8 hours. On 12/27/24, no treatment was recorded for the day or evening shift, and small was recorded for the night shift. The comments for no treatment on the day and evening shift were other. On 12/28/24, no treatment was recorded for the night shift with the comment Foley removed. On 12/29/24, no treatment was recorded for the day shift. During an interview, on 1/7/25 at 2:41 p.m., the DON indicated staff should document the amount of urine in milliliters when there was a physician's order to document output. When staff discontinued a catheter, there should be a note in the progress notes. She was unable to find a note regarding the removal of the catheter except for the notes in the MAR which indicated the catheter was not present or had been discontinued. The notes were confusing with some shifts saying the catheter was present after a previous shift appeared to indicate it was discontinued. The DON indicated she thought the catheter was removed some time on 12/27/24. There were missing bladder scan recordings but without knowing exactly when the catheter was removed, she could not determine exactly how many. A current skills validation procedure, titled Measuring and Recording Intake and Output Skills Validations, and received from the DON on 1/7/25 at 3:00 p.m., indicated .Resident's with Foley Catheters are emptied every shift .The bag should be emptied per protocol into either a graduated drainage cup or urinal .After the fluid is gathered, the container should be held at eye level to view the level of the fluid and the amount obtained should be recorded for later documentation into the resident's permanent medical record .Document .source of .output and volumes 3.1-41(a)(2)

Based on observation, interview and record review, the facility failed to ensure insulin was labeled with an open date, to lock a medication cart before staff walked away, and to store antifungal nail solution separately from eye drops for 2 of 4 medication carts. (Ambassador Square and Heritage Court) Finding includes: 1. During an observation, on 1/7/25 at 7:51 a.m., a Lantus insulin pen was found for Resident 353. The pen had been previously opened and did not have an open date. During an interview, on 1/7/25 at 7:51 a.m., RN 9 indicated the insulin pen had been used prior and did not have an open date. 2. During a random observation, on 1/3/25 at 3:15 p.m., the Ambassador Square unit medication cart 1 was found unlocked. There were two dietary staff in the dining room with a wall obscuring the view of the cart. The nurse was found at the opposite end of the unit. The medication cart could not be observed from her position. During an interview, on 1/3/25 at 3:19 p.m., RN 10 indicated the cart was to be locked before walking away. 3. During an observation of medication storage, on 1/7/25 at 4:27 p.m., Jublia (an antifungal) topical nail solution was found stored with eye drops in the top drawer of medication cart 2 on the Heritage Court unit. During an interview, on 1/7/24 at 4:32 p.m., QMA 2 indicated the items should not have been stored together. A current facility policy, titled MEDICATION LABELING, provided by the Director of Nursing on 1/2/25 at 3:10 p.m., did not address putting open dates on medications. A current facility policy, titled DRUG STORAGE, undated and received from the Corporate Support Nurse on 1/8/25 at 2:16 p.m., indicated .Medication .carts .are locked or attended by persons with authorized access. 3.1-25(k)(6) 3.1-25(m)

Based on interview and record review, the facility failed to ensure staff notified the responsible party/Power of Attorney (POA) of a resident's change in condition timely for 1 of 1 resident reviewed for notification. (Resident B) Finding includes: The clinical record for Resident B was reviewed on 12/5/24 at 9:12 a.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD), emphysema, and vascular dementia. A nursing progress note, dated 6/7/24 at 1:57 p.m., indicated the resident had a change in condition to include a bad cough, trouble clearing her throat, and her oxygen saturation was 82 percent. The resident did refuse supplemental oxygen, but did eventually allow the oxygen. The resident needed to be fed, toileted, and was not waking up. The Nurse Practitioner was notified of the change in condition. There was no note to indicate the family had been notified at the time of the change in condition. A nursing progress note, dated 6/7/24 at 4:28 p.m., indicated the family was notified of the new orders. A nursing progress note, dated 6/7/24 at 4:59 p.m., indicated the resident was sent out to the hospital and the family was notified of the transfer. During an interview, on 12/5/24 at 9:38 a.m., the Director of Nursing indicated the family should have been contacted immediately for the change of condition. During a telephone interview, on 12/5/24 at 10:25 a.m., RN 3 indicated the resident had a change of condition on 6/7/24 at 1:57 p.m. The only reason she would not have documented contacting the family about the change in condition was if the Nurse Practitioner or the physician was going to notify the family. RN 3 indicated the facility policy was to notify the physician/nurse practitioner of the change and notify the responsible party/POA. A current facility policy, titled Change in a Resident's Condition or Status, dated as last revised in April 2007 and received from the Director of Nursing on 12/6/24 at 12:30 p.m., indicated .Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status This citation relates to Complaint IN00444037. 3.1-5(a)(2)

Based on interview and record review, the facility failed to protect a resident from misappropriation of medication for 1 of 3 residents reviewed for misappropriation of property. (Resident C) The deficient practice was corrected on 11/22/24, prior to the start of the survey, and therefore was past noncompliance. Finding includes: During an interview, on 12/5/24 at 10:12 a.m., the Director of Nursing indicated the facility had not been aware of any missing items for Resident C, until an investigator from the Office of the Attorney General came to the facility to investigate the concern on 11/14/24. The investigator informed the facility during a domestic dispute, the local police entered the home of LPN 7, they saw the medication and reported the finding to the Office of the Attorney General (OAG). The facility found the prescription number was for Trulicity (a medication for diabetes), it belonged to Resident C and was filled by the resident's pharmacy. The facility began their own investigation of the incident and found the nurse had worked on the unit and had provided nursing care to Resident C prior to her termination. The nurse was terminated from employment on 6/16/24 for failure to report to her scheduled shift without notice. The clinical record for Resident C was reviewed on 12/5/24 at 1:38 p.m. The diagnoses included, but were not limited to, type 2 diabetes, dementia, and anxiety disorder. A physician's order for Trulicity injector pen 1.5 milligrams /0.5 milliliters was found in the orders. A current facility policy, titled Abuse, Neglect, and Misappropriation Prohibition and Prevention Policy, dated as last revised on 6/4/19 and received from the Director of Nursing on 12/6/24 at 12:50 p.m., indicated .It is the policy .to provide each resident with an environment that is free from .misappropriation of their property The deficient practice was corrected on 11/22/24 after the facility implemented a systemic plan that included the following actions: the facility investigated the incident involving Resident B, educated the staff on misappropriation of property and documentation in the Medication Administration Record. LPN 7 had been terminated prior to knowledge of the misappropriation of the insulin pen. The facility continued daily audits of medication disposal and medication disposal was to be completed with two (2) nurses. This citation relates to Complaint IN00447334. 3.1-28(a)

Based on observation, record review, and interview, the facility failed to properly label stored food under sanitary conditions related to unlabeled food. 93 of 136 residents residing in the facility received food prepared in the kitchen. Findings include: On 10/31/2023 at 9:37 a.m., the full kitchen sanitation tour with the Resource Manage (RM) indicated the following: 1. At 9:38 AM, in the walk-in fridge, the following was observed: There was an open container of cooked potatoes with no cover or date located. A tub of mixed salad with no open date. A tub of lemon pudding with a use by date of 10/28/23. A carton of eggs were observed with one egg cracked opened next to the other un-cracked eggs. The RM took the carton of eggs out and threw them away. RM indicated the opened food should have open dates. 2. At 9:41 AM, in the walk-in freezer, the following was observed: On the top shelf there was a bag of bread sticks with no open date. Inside of a box, there was a package of pepperoni that were opened wide with exposed food and no open date, the RM indicated they should have been sealed. The RM took them out and threw them away. RM indicated they should have open dates. 3. At 9:44 AM, in the single door freezer (reach-in), the following was observed: on the shelf there was a bag of opened carrots with no open date. A bag of opened waffle fries with no open date, a bag of chicken tenders with no open date, a bag of tator tots with no open date. There was a bag of chicken breasts with use by date 10/26/23. The RM took all of the items that had been opened with no date and threw them away. 4. At 9:46 AM, in the single door fridge (reach-in), the fol;lowing was observed: there was a tub of parmigiana cheese with a used date of 10/19/23. The RM took the tub of cheese and indicated it should have a date and will throw it away. An interview on 11/02/23 at 10:39 AM, the assistant Director of Nursing indicated there were 93 residents who eat food prepared in the kitchen. A current facility policy, Food and NON-food storage, was provided by the Regional Dietary Manager on 11/1/2023 at 10:03 AM. The policy indicated . All opened foods are covered to protect from contaminates .Foods that have been removed from their original containers are clearly marked with contents, date that package was opened and wrapped to exclude as much air as possible 3.1-21(i)(1) and (3)

Based on observation, interview, and record review the facility failed to ensure infection control practices were followed for 2 of 3 residents reviewed regarding catheter care (Resident 28, and Resident 32). Findings include: 1) During an observation and interview on 11/1/23 at 1:52 PM, Certified Nurse Aide (CNA) 5 and the Staff Development Coordinator (SDC) entered Resident 28's room with the surveyor. Resident 28's catheter bag was resting directly on the floor. The SDC indicated the bag should not have touched the floor, and normally a container was utilized to provide a barrier between the catheter bag and the floor. Resident 28's record was reviewed on 11/1/23 at 2:31 PM. Diagnoses included urinary tract infection, site unspecified, benign prostatic hyperplasia with lower urinary tract symptoms, and obstructive and reflux uropathy. A review of Resident 28's current annual Minimum Data Set (MDS) dated [DATE] indicated his Basic Interview for Mental Status (BIMS) score was 12 (mild cognitive impairment). The MDS indicated the resident utilized an indwelling catheter. A review of Resident 28's current care plan titled Resident has a suprapubic catheter . indicated the resident had a problem of potential for complications with a goal date of 12/10/23. Interventions included not allowing the tubing or any part of the drainage system to touch the floor. 2) During an observation and interview on 11/1/23 at 9:10 AM Resident 32 indicated he emptied his catheter himself. He pulled down the waistband of his pants, held the catheter with unwashed hands and discussed how he performed the task. He indicated he preferred to use a leg bag all the time and empty the bag himself. Resident 32 indicated he had not received any teaching from facility staff, nor had staff observed him performing the task. Resident 32 indicated he would notify staff if he had pain or leakage around the site but was unable to state any other signs of catheter problems or signs of infection. He indicated the leg bag got full at times during the night, but he did not want to use a bedside drainage bag because it was too cumbersome to manage when getting up to go to the bathroom. He indicated staff did not check on him during the night because they knew he took care of the bag himself. Resident 32's record was reviewed on 11/1/23 at 9:32 AM. Diagnoses included urinary tract infection, unspecified, obstructive and reflux uropathy, and chronic kidney disease. A review of Resident 32's current quarterly MDS indicated his BIMS score was 15 (cognitively intact). The MDS indicated the resident used an indwelling catheter. A review of Resident 32's current care plan titled Resident has an indwelling suprapubic catheter . indicated the resident had a problem of potential for complications with a goal date of 12/15/23. Interventions included educating and involving the resident in the plan of care. In an interview on 11/1/23 at 9:32 M, Licensed Practical Nurse (LPN) 4 indicated a resident performing care tasks such as catheter care should be educated and evaluated every 3 months for the ability to perform the skill properly. LPN 4 indicated staff cleaned the suprapubic site and applied a gauze pad, and Resident 32 performed all other care of his catheter. In an interview on 11/3/23 at 9:25 AM the Director of Nursing indicated teaching and return demonstration of catheter care had not been done for Resident 32. A current policy, undated, provided by the Clinical Specialist on 11/1/23 at 3:00 PM did not address placement of the drainage bag in relation to the floor. The policy did not address resident teaching. No further policies were received from the facility at the time of exit. 3.1-41(a)(2)

Based on record review and interview the facility failed to ensure medications were given as ordered for 1 of 3 residents reviewed for prevention of significant medication errors. (Residents F) Findings include: During an investigation on 11/1/2023 at 3:15 PM, Resident F, was given another resident's medication which resulted in a medication error. The following statements were given by Licensed Practical Nurse 1 (LPN) and Qualified Medication Aide 4 (QMA): QMA 4's statement dated 10/26/2023 indicated on Saturday 10/21/2023, they were assigned to work as a QMA. At 7:00 AM they were asked to step down and work as a Certified Nursing Aide (CNA) due to a call off. Before they handed the keys to LPN 1, QMA 4 gave report. LPN 1 wrote down everything on a report sheet. QMA 4 indicated medications were already given to certain residents, LPN 1 wrote the residents name down. QMA 4 indicated they pre-set 3 other resident's medications and LPN 1 took note and put a check mark symbol next to the rooms. QMA 4 indicated they learned in nursing school was when you don't prep the medications, don't give the medications; and since you did not give the medications, don't sign for them. She further indicated- to be clear all of this could have been prevented by simply trashing the medication or asking QMA 4 to administer the medication they had pre-set. LPN 1 chose not to. QMA 4 indicated by pre-setting the medication, LPN 1 gave the medication to the wrong resident. LPN 1's medication error was caused by LPN 1 not following the 6 rights of medication administration: 1. Right patient. 2. Right medication. 3. Right dose. 4. Right time. 5. Right documentation. Even when QMA 4 pre-set the medication they always made sure to check the medication, the room, and the right resident and re-check the medication before administering the medication. Although they had 2 residents with the same last name, they were both in different rooms not even close to each other.The pre-set was for one of the residents, but not the other. LPN 1's statement dated 10/22/2023, indicated they were scheduled to work as the float nurse. When they started the shift they realized they were short CNAs and would be taking the medication cart from QMA 4. QMA 4 had a few medications set up already in medication cups in the medication boxes. LPN 1 indicated they pulled out and wrote last names on them. LPN 1 was going to pass them first but got pulled away for insulin's and blood sugars, since it was a late start and they were starting to serve breakfast. When LPN 1 was done with that task, they saw Resident F and remembered the medication was ready. LPN 1 gave Resident F the medication. Then Resident F was given breakfast in the dining room. This was approximately 8:00 AM. LPN 1 went to sign out the medications and realized the new admit from the night before had the same last name, and LPN 1 had given Resident F their medications. LPN 1 checked Resident F's allergies and saw they did not have any. LPN 1 went and obtained vital signs and assessed for respiratory status both were with in normal limits. LPN 1 then reported to the Nurse practitioner (NP) who gave an order to send Resident F out to be seen in ER. LPN 1 called transportation while keeping Resident F in their line of sight. Resident F fell asleep, so LPN 1 asked assistance from another nurse. Oxygen was applied. LPN 1 called the NP back and asked if they should administer Narcan. The NP declined and indicated since Resident F did not received any opiods, and Resident F was breathing. Resident F would only arouse to sternal rubs. Resident F was taken to hospital and family notified. A record review of Medication Error Report regarding Resident F dated 10/22/2023 indicated the following: Date and time of error: 10/21/2023 approximately 8:00 AM. Reported by LPN 1. Facility error: wrong medication. Resident outcome: adverse reaction (describe) sent to emergency room via 911 for lethargy. Quality review: Ativan 0.5 milligram (mg). Asipring 81 mg. Risperdal 1 mg. Sertraline 200 mg. Pantorazole 20 mg. tab-a vite 400 micrograms. Notification: NP notified on 10/21/2023 at 8:10 AM. NP response: send resident to emergency room . Responsible party notified at 8:15 AM. Nurse responsible for error: LPN 1. This report did not specify how many tablets of each medication were given to Resident F. A review of the medication actions and side effects that were given to Resident F in the medication error from the Mayo Clinic indicated . Ativan (lorazepam) 0.5 mg: Descriptions: Lorazepam is used to treat anxiety disorders. It is also used for short-term relief of the symptoms of anxiety or anxiety caused by depression. Lorazepam is a benzodiazepine that works in the brain to relieve symptoms of anxiety. Benzodiazepines are central nervous system (CNS) depressants, which are medicines that slow down the nervous system. Side Effects: Along with its needed effects, a medicine may cause some unwanted effects. Although not all of these side effects may occur, if they do occur they may need medical attention. Check with your doctor immediately if any of the following side effects occur: More common Drowsiness, relaxed and calm, and sleepiness. Incidence not known drowsiness, feeling of constant movement of self or surroundings and lethargy . Risperdal (RisperiDONE) 1 mg: Descriptions: Risperidone is used to treat schizophrenia, bipolar disorder, or irritability associated with autistic disorder. This medicine should not be used to treat behavioral problems in older adults who have dementia. Side Effects Along with its needed effects, a medicine may cause some unwanted effects. Although not all of these side effects may occur, if they do occur they may need medical attention. Check with your doctor immediately if any of the following side effects occur. More common, Aggressive behavior, agitation, anxiety changes in vision, including blurred vision, difficulty concentrating, difficulty speaking or swallowing, inability to move the eyes, increase in amount of urine, loss of balance control, mask-like face, memory problems, muscle spasms of the face, neck, and back, problems with urination, restlessness or need to keep moving (severe), shuffling walk skin rash or itching, stiffness or weakness of the arms or legs, tic-like or twitching movements, trembling and shaking of the fingers and hands, trouble sleeping, and twisting body movements . Zoloft (Sertraline) 200 mg: Descriptions: Sertraline is used to treat depression, obsessive-compulsive disorder (OCD), panic disorder, premenstrual dysphoric disorder (PMDD), posttraumatic stress disorder (PTSD), and social anxiety disorder (SAD). Sertraline belongs to a group of medicines known as selective serotonin reuptake inhibitors (SSRIs). It works by increasing the activity of a chemical called serotonin in the brain. Along with its needed effects, a medicine may cause some unwanted effects. Although not all of these side effects may occur, if they do occur they may need medical attention On 11/1/2023 at 3:15 PM, Resident F's record was reviewed. Diagnoses included Parkinson's disease, and contacture of muscle, multiple sites. A facility policy, Medication Administration general polices and procedures, was provided by the Executive Director on 11/1/2023 at 3:23 PM. The policy indicated . Medications re to be pre-poured at the time they are administered .No drugs are to be pre-poured except liquid med's used with a med-card .The label on each medication container shall be read 3 times and compared against the order on the Medication Administration Record: when taking from the shelf or drawer, before pouring, when putting it back onto the shelf or into the drawer .The nurse approved designee is responsible for checking to see that they drug and dosage schedule on the resident's medication administration record matches the label on the drug's container This citation relates to Complaint IN00420683. 3.1-48(c)(2)

Based on interview and record review, the facility failed to ensure a resident and her representative's choice of caregiver was consistent with her plan of care for 1 of 3 residents reviewed for choices. (Resident B) Finding includes: A document, titled Indiana State Department of Health Survey Report System, undated and provided by the ED (Executive Director) indicated on July 10, 2023, a family member reported a concern with the provision of care given to Resident B by a male caregiver. A sexual trauma examination was completed with no findings. The family sought alternate placement for the resident and the transfer was facilitated on 7/12/23. The record for Resident B was reviewed on 7/21/23 at 12:38 p.m. Diagnoses included, but were not limited to, vascular dementia with mild psychotic disturbance, anxiety disorder, hallucinations, attention and concentration deficit, cerebral infarction, and restlessness and agitation. An email, addressed to the ADON (Assistant Director of Nursing), UM, ED and Hospice Nurse on 6/21/23 at 4:50 p.m., indicated Resident B's daughter spoke to the ADON regarding her mother's fears about the disgraceful man she described and feared was touching her behind her brief. The ADON's intervention was to have only female caregivers for her mother and that was a reasonable intervention for the daughter. The progress notes were reviewed, which included, but were not limited to, the following notes: On 6/21/2023 at 5:13 p.m., the writer had a conversation with the resident's daughter that afternoon regarding her concerns and fears. Resident B indicated men came through her window with three trees they had chopped down, then began making breakfast burritos in her room. They threw her house coat on the floor, indicating to a place on the floor, they scared her and touched her inappropriately. There was no clothing observed on the floor at that time. The window was closed and locked. The daughter indicated she believed the resident was having increased delusions. Adjustments were made to the residents ADL care plan, which her daughter was in agreement with. On 7/11/23 at 10:19 p.m., Resident B's daughter requested she be sent to the ER (emergency room ) for further examination. Police called EMS (Emergency Medical Services) and gave hospital report. The resident was sent to hospital by ambulance. On 7/11/23 at 9:35 p.m., Resident B arrived back to her room by stretcher and ambulance. She was alert and oriented to self with incoherent speech. On 7/12/23 at 8:31 a.m., Social Services (SS) was notified Resident B's daughter was interested in transferring her to an alternate facility. On 7/12/23 at 8:39 a.m., Resident B was at the dining room table eating. She took a bite of food, then fell asleep and was hard to arouse. The food was removed from her mouth, and she would not take her medications. When the daughter was notified, she indicated her mother had a rough and invasive day the day before and she was probably tired. The nurse agreed and had the CNA lay the resident back in bed to rest. On 7/12/23 at 10:50 a.m., SS spoke with Resident B's daughter regarding scheduling a care plan meeting. The daughter declined the care plan meeting and indicated she wanted to discuss a discharge planning meeting between herself, and SS. SS started the discharge process to the facility of the daughter's choosing. On 7/12/23, a Nurse Practitioner's note indicated Resident B was being seen that day following a recent trip to theER on [DATE], as requested by her daughter due to an accusation of sexual assault. She returned to the facility on [DATE] and was observed to have speech incoherent nests (unintelligible words). She was discharged to another facility on 7/13/23. On 7/12/23 at 4:51 p.m., Resident B was transferred to the alternate facility. Resident B's care plans were reviewed, which included, but were not limited to, the following: The resident had a care plan, which addressed she and her responsible party preferred female caregivers to provide ADL care (dated 6/21/23). The approaches included, but were not limited to, 6/21/23, female caregiver to provide incontinence care with toileting as needed, and 6/21/23, female caregivers to assist/encourage resident in proper transfer bed mobility, toileting/hygiene and eating techniques as needed. The resident had a care plan which addressed the problem she had a history of experiencing past trauma for example, negative interactions with caregivers and history of allegation of abuse at a previous LTC (long term care) facility prior to admitting to this facility (dated 2/14/23). The goal was Resident B would show minimal signs/symptoms of negative psychosocial wellbeing related to experience of past trauma. The resident had a care plan, which addressed the problem she had a history of hallucinations, delusions, and paranoia. She had a history of seeing persons/objects not present, becoming fixated on items, history of exhibiting beliefs that negative life events would occur because she prays, believed someone was speaking negatively about her, persons/little boy was outside her window attempting to harm her and she would exhibit hallucinations and delusions that persons and animals were in front of her and telling her she was able to walk (dated 2/9/23). The resident had a care plan, which addressed the problem she had a diagnosis of anxiety disorder and had a history of symptoms of anxiety, anxiousness, restlessness, excessive worry, and paranoia were her most common symptoms. Resident B's quarterly MDS (Minimum Data Set) assessment, dated 2/7/23, indicated her preference to have her family involved in discussions about her care was very important to her. Her functional status indicated she required extensive assist with two-person physical assist for these ADL's: bed mobility, transfer, and toileting. A current as worked schedule, dated July 9, 2023, indicated LPN 1 and CNA 2 was on the schedule and worked on the 500 unit the night shift of July 9,2023 going into the early morning of July 10, 2023, which was the unit Resident B lived on. During an interview, on 7/21/23 at 11:51 a.m., the Unit Manager for the 500 unit indicated Resident B was not to have any male care givers providing intimate care to her, but a male care giver could be in her room as the second person to help turn and reposition her or get her out of the bed with the Hoyer lift. The no male care giver started back at the end of June when Resident B thought a man with a green face came through her window and touched her inappropriately. As the intervention, the facility told her daughter and her there would be no male caregivers providing care for her, but that meant intimate care, not going in her room to help turn her or get her up with a female caregiver. During an interview, on 7/21/23 at 2:25 p.m., CNA 2 indicated on the nightshift of 7/9/23, he worked on the opposite hallway, which Resident B lived on. Between 3 and 4 a.m., LPN 1 asked him to assist her with Resident B, so he did. The nurse had already given the peri care and all he did was assist the resident with turning, so she could get her bed linens changed. He knew over the past month no men were to be taking care of her, so he did not give her peri care. He did go into that room during the night and assist her roommate to the bathroom, but he did not touch Resident B any of those times. During a phone interview, on 7/24/23 at 12:39 p.m., Resident B's daughter indicated when she talked with the ADON (Assistant Director of Nursing) on 6/21/23, she had told them Resident B's preference for caregivers was female only. She was told by the ADON there would be no male caregivers in her mother's room. She was told after the 7/10/23 incident, by the ED, there had been a male caregiver in the facility, but he had not been in her mother's room, even though there was one scheduled for her unit on the night shift of 7/9/23. She asked why the facility would allow a male caregiver to go into her room even with a female caregiver and place her mother in the position they placed her and placed an innocent male caregiver in the position they placed him in, on the morning of 7/10/23. She had a concern the facility would continue to allow the male caregiver to enter Resident B's room, so she transferred her to an alternate facility even though she knew transferring her might cause her health and cognitive function to decline further. This Federal tag relates to Complaint IN00412733. 3.1-3(t)

Based on observation, interview and record review, the facility failed to develop person centered care plans for 1 of 20 residents reviewed for care plans (Resident 286). Finding includes: On 9/9/22 at 10:09 a.m., during a random observation on the Cherished Memories, memory care unit, Resident 286 was observed in a wheel chair with her right arm in a sling. An unidentified staff member was wheeling her in the hall. The resident was alert and calling out Help me help me. On 9/9/22 at 2:22 p.m., the medical record was reviewed for Resident 286. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 286 had multiple care plans in place. A care plan, dated 9/1/22, indicated Resident experienced bladder incontinence related to _____. The section was blank with no indication. Another care plan, dated 9/1/22, indicated Resident has ____(impaired, moderately impaired, slightly impaired, or severely impaired) vision R/T [related to] ______. The blanks were not completed, choices were offered. A care plan dated 9/1/22, indicated Resident requires ____ assistance with oral hygiene r/t _____. Blanks were not filled in with a response. Another care plan, dated 9/1/22, indicated Resident is at risk for adverse consequences R/T receiving antianxiety medication for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview, on 9/13/22 at 10:48 a.m., the Director of Nursing indicated they used care plan templates and all the information, specific to the resident should have been filled in to make it resident specific. A current policy, titled Care Plans- Comprehensive, dated October 2009 and provided by the Executive Director (ED) on 9/13/22 at 10:25 a.m., indicated .An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs is developed for each resident 3.1-35(a)

Based on record review and interview, the facility failed to ensure a Minimum Data Set (MDS) assessment was coded correctly to indicate a resident's correct discharge status for 1 of 3 closed records reviewed for discharge (Resident 87). Finding includes: On 9/14/22 at 10:06 a.m., Resident 87's closed medical record was reviewed for hospitalization . The progress notes, dated 7/06/22 at 3:15 p.m., indicated Resident 87 had discharged back to her assisted living facility, following a rehabilitation stay, from 6/17/22 to 7/6/22. A review of the discharge MDS assessment, dated 7/6/22, indicated Resident 87 was discharged to an acute hospital and return was not anticipated. During an interview, on 9/14/22 at 10:24 a.m., the Director of Nursing (DON) indicated the MDS assessment was coded wrong. There was no policy, they followed the Resident Assessment Instrument (RAI) manual for coding of the MDS assessments. During a review of CMS's (Centers of Medicare and Medicaid) RAI (Resident Assessment Instrument) Version 3.0 Manual, on 3/26/18, it indicated .Residents should be the primary source of information for resident assessment items . and instructions for discharge information .Review the medical record including the discharge plan and discharge orders for documentation of discharge location 3.1-31(i)

Based on observation, interview and record review, the facility failed to ensure a resident with a [DIAGNOSES REDACTED]. Resident C exited the facility during the night shift and was found outside by a dumpster. The resident's where about's were unknown until alerted by other residents residing on the Assisted Living (AL) area of the facility (Residents D, E, F and G). The Immediate Jeopardy began on (MONTH) 12, 2019, when the facility failed to ensure Resident C who resided in a room at the end of an unsecured unit, with a [DIAGNOSES REDACTED]. The last time, he was witnessed in the facility by a staff member was on 12/12/19 at 12:30 a.m., in his room, where he expressed to RN 1 he was downtown and looking for his keys and I'm confused, I know. The Administrator, the Director of Nursing (DON) and the Clinical Specialist (CS) were notified of the Immediate Jeopardy on 12/16/19 at 5:35 p.m. The Immediate Jeopardy was removed on 12/18/19, but noncompliance remained at the lower scope and severity level of no actual harm with the potential for more than minimal harm that was not immediate jeopardy. Findings include: During the course of the Administrators investigation of Resident C's elopement, she obtained AL residents' interviews on 12/16/19. The Administrator provided the AL resident interviews on 12/17/19 at 4:03 p.m. During the Administrator's investigation of Resident C's elopement events, she discovered he went into two AL female residents' apartments (one at 1:34 a.m. and one at 2:00 a.m.) and was rummaging through one of those AL resident's closets prior to exiting the facility. CNA 2 found Resident C by the dumpster, yelling out faintly Help at approximately 2:35 a.m. Staff were alerted by call lights on the AL side and two residents indicated they heard someone knocking on a window approximately 30 minutes prior to the resident being found outside. At one point, an Egress door alarm sounded on a locked exit door, to notify staff someone exited. The only way to exit this door when the alarm was engaged was to press the bar on the door for 15 seconds, which unlocked the door and sounded an alarm to alert staff someone exited a secured door. The length of time the Egress door alarm was sounding was unknown. CNA 3 happened to come across the sounding door alarm as she was on her way to the AL to answer call lights, she then alerted CNA 2 who came to investigate the alarm and shut the alarm off without looking outside. The temperature range between 12 a.m.-6 a.m. was 23-25 F (Fahrenheit). The resident sustained [REDACTED]. During a skin assessment, he had a small clotted laceration to his right knuckle, two small abrasions to his left palm and a jagged fingernail, documented as it had appeared to have bled earlier possibly due to the resident trying to get into the door on the AL side of the building. He had cold and painful hands rated as a level 4 on a pain scale of 0 to 10 with 0 being no pain and 10 being excruishiating pain, this was resolved with warming his body slowly. During an interview, on 12/16/19 at 4:02 a.m., CNA 2 indicated on 12/12/19 at 2:20 a.m., while working she was told to go to the AL side of the facility and assist CNA 3 because she was over there and she was scared. CNA 2 indicated CNA 3 did not specify why she was scared. As she walked towards the AL area of the facility, she heard the stairwell Egress door alarm sounding, so she told CNA 3 to go answer Resident D's call light and she would check the alarm on the door. When she approached the stairwell door, she was able to open it without any problems, she shut the alarm off and the stairwell door locked. She did not open the outside door to check to see if a resident exited the facility at that time, because she thought an employee had set off the Egress alarm by using the door to go up the stairwell. She indicated the staff were allowed to use the door and stairwell until a certain time of the day and she thought a new employee did not know or forgot and used the door to go up the stairwell. After checking the stairwell, she went up the stairwell to the second floor. She ran into CNA 3 who was going to answer Resident G's call light, so both CNA's went to answer the resident's call light. Resident G told both CNA's he heard someone knocking on a window downstairs approximately 30 minutes ago. CNA 3 told CNA 2, when she went to answer Resident D's call light, the resident told her someone was knocking on her window approximately 30 minutes ago. CNA 2 exited the AL area of the facility through the AL doors and turned right at approximately 2:35 a.m., walking the perimeter of the AL area of the facility to see if someone was outside knocking on the residents' windows. As she was walking the AL facility perimeter, she could see the dumpster area as she walked past the AL facility unit wall, as she walked by the dumpster area she could hear someone faintly yelling help. Between the dumpster area and the Rehabilitation unit wall was a grassy area, so she walked over there and she noticed a male leaning onto the facility by the windows leading to the rooms on the Rehabilitation unit. She called CNA 3 to let her into the facility, but when CNA 3 came to let her and the resident in, she closed the kitchen dock doors, which locked all three of them out of the facility. She called LPN 4 to let them into the facility and CNA's 2 and 3 assisted Resident C back into the facility. Resident C was able to tell the staff members his name, but he did not know his room number, so they walked him to the AL area of the facility and while LPN 4 figured out what room he was in because none of the staff with him knew who he was. CNA's 2 and 3 got a wheelchair for Resident C and wrapped him in warm blankets. He was dressed in non-skid socks with moccasins on his feet, flannel pajama pants, a sweatshirt and a baseball cap. It was cold outside. He had a small cut on his hand. On 12/16/19 at 4:36 a.m., the Administrator and the Director of Nursing (DON) were in attendance at a set of doors on the AL area of the facility. During an interview, at that time, the Administrator indicated the doors were Exit Door 6 on the Map of the facility and they were the doors she thought Resident C used to exit the facility the night he was found outside. The doors were observed to be double doors with a small window in each one. There was a push handle bar on each of these two doors with a sticker that read Push until alarm sounds. Door will open in 15 seconds. The Administrator indicated the resident had [MEDICAL CONDITION]([MEDICAL CONDITION] to the left side of his body) and she thought when he exited his room that morning he held onto the railings, in the hallways, and continued to make right handed turns up to the point he exited the facility. He continued to the right of the building walking in the grass and following along side the building, which would make sense as to why the Residents D and G who lived in the AL area of the facility heard him knocking on the window. He continued the path until he got to the health care side of the facility, which was where CNA 2 found him. He was not identified on admission as an elopement risk, so we had no idea he would attempt to exit the facility without a staff member. During an interview, on 12/16/19 at 4:44 a.m., with the Administrator and the DON in attendance, RN 1 indicated she sat with Resident C on 12/12/19 and left his room after placing him into bed at 12:30 a.m. He thought he was downtown and was looking for his car keys and he indicated to her I'm confused, I know. She had him call his wife and he left a voicemail for her, then she tucked him into his bed and left his room. She did not go back again to check on him because it was busy on the Rehabilitation unit (Rehab unit) which was where the resident resided, with only one CNA and one Nurse on the night shift. There were high acuity residents to care for during his confused state of mind and she indicated they were unprepared for his elopement. The CNA assigned to her unit that night had to go over to the AL area of the facility and help another CNA answer call lights. RN 1 indicated she heard a phone ring somewhere after 2:00 a.m., but did not know where the phone was. After she and CNA 3 looked, they found the AL facility phone and when she answered it, she discovered it was the phone, which notified AL staff the AL call lights were ringing. LPN 4 was supposed to have the AL phone on her person for the night, while she worked on the Cherished Memories unit, on the health care side of the facility, but she forgot it while she was on the Rehab unit earlier in the shift. When CNA 3 went over to the AL area of the facility to answer their call lights, she found out someone was knocking on a female resident's window. She did not know how long Resident C was outside because the last time any staff saw him was at 12:30 a.m. After he was brought back over to the Rehab unit at approximately 3:00 a.m., she took his vitals and his temperature was 96.5 F. He was placed in bed and given warm blankets to slowly warm his body up. He complained of his hands being cold and painful. Resident C was trying to exit off the unit through the closed unit double doors again tonight 12/16/19. He was cussing at her and threatening her and she called the Assistant Director of Nursing (ADON) who was working on another unit to come help. The ADON talked to him and got him back to his room. RN 1 indicated she was the only person on the unit at the time when Resident C was attempting to exit off the unit and she was worried and concerned regarding his exit seeking behaviors, so she called for assistance from a nurse from another unit. During an interview, on 12/16/19 at 5:04 a.m., the Administrator indicated when a copy of the investigation of the elopement for Resident C was requested, she would provide a copy, but she had not completed her investigation of his elopement yet. On 12/16/19 at 11:14 a.m., the Therapy Supervisor was observed using a rolling measuring tool to calculate the distance, in feet, Resident C ambulated from his previous room (Room #) to the dumpster outside, which totaled 775 feet. On 12/16/19 at 11:44 a.m., the Administrator provided a copy of the documents she had for the investigation of Resident C's elopement and indicated she was continuing to investigate the event. A handwritten document by CNA 3 was reviewed. She indicated Resident D's AL call light went off and after three minutes as she was walking to the AL area of the facility to answer the resident's call light she heard a beating sound, but she thought it was coming from an AL apartment upstairs because Resident G's call light was also ringing. As she got closer to the AL nurses' station, she heard an alarm going off, which sounded like a light ringing noise and it was the emergency exit door alarm at the stairwell door sounding. She called CNA 2 and asked her to check the alarm out and she went to Resident D's apartment to answer her light. Resident D asked CNA 3 what was going on because she heard a beating noise and a man saying let me in. CNA 3 met CNA 2 upstairs and they went to answer Resident G's call light and the resident in that apartment said he heard someone beating on the window downstairs, which his apartment was exactly above Resident D's apartment. CNA 2 went outside to make sure no residents had gotten out of the facility and then CNA 2 called CNA 3 and told her she was near the dumpster because she heard someone calling for help and she walked over there and she found a resident leaning against the Rehab wall. CNA 3 ran out of the facility and this was when she and CNA 2 found Resident C leaning up against the window out of breath. During an interview, on 12/16/19 at 12:00 p.m., the Administrator indicated they did not have a definite timeframe of when Resident C exited the facility. When she came into the facility on [DATE] at 6:00 a.m., her car thermometer read 24 F. He did complain of being cold when he returned inside the facility, but the staff immediately placed warmed blankets on him to start warming him up. A record review for Resident C was completed on 12/16/19 at 12:15 p.m. [DIAGNOSES REDACTED]. An Admission MDS (Minimum Data Set) Assessment, dated 12/10/19 at 10:59 a.m., indicated Resident C's BIMS (Brief Interview Mental Status) was a 12, which indicated his cognitive status was moderately impaired. A progress note, dated 12/12/19 at 12:30 a.m., indicated In residents room at 12:30 am with resident sitting on side of bed. Sat down to talk with resident. He stated he was downtown and looking for his keys. I re-oriented resident and told him he was at (Name of facility) for rehabilitation. He then stated 'I'm confused, I know .' Resident then tucked in bed for the night. A progress note, dated 12/12/19 at 3:12 a.m., indicated Resident was found walking outside building at 3am near the dumpsters fully dressed with flannel shirt, layered clothing with socks shoes and hat on head. Resident was brought back inside of building by CNA on her way to AL. Bp (Blood Pressure) 134/92; P (pulse) 84; RR (Respiratory Rate) 22; temp (temperature) 96.5 temporal; O2 (oxygen) sat (saturation) 97% .Temp up to 97.0 now. Resident in bed with warm blankets to body. A progress note, dated 12/12/19 at 3:32 a.m., indicated Temp 97.3 temporal A Pain/Discomfort Event, dated 12/12/19 at 6:47 a.m., indicated a pain assessment was completed after an elopement. The resident complained of pain to his hands at a level 4 on a pain scale from 0 to 10 with no pain being a level 0 and 10 being excruciating. The resident had not experienced this pain before. The onset of pain was in the morning. The symptoms of pain he was displaying was frowning/grimacing. What brought the pain on or increased the pain was Post elopement: Resident outside building in winter weather. The new interventions were heat and rest. On 12/16/19 at 4:03 p.m., the Administrator provided a document titled Investigation for (Name of Resident C) Elopement 12/12/19 Timeline and she indicated two female residents in the AL area of the facility brought to her attention today (12/16/19), they had concerns with a male resident meeting the description of Resident C coming into their rooms on 12/12/19. The Administrator provided handwritten statements signed by the following AL residents in regards to someone in their room and they heard a beating noise. A statement, dated 12/16/19 from Resident F, indicated someone walked up beside her bed (she guessed a man by stature and the person had a baseball cap on), entered her apartment at 1:34 a.m. She knew it was 1:34 a.m. because she looked at her clock. He asked her if she could help him get out of here? The person was headed for her closet, so she got out of bed, turned on the light and she pointed toward the door of the apartment and he left. A statement, dated 12/16/19 from Resident E, indicated someone was in her apartment rummaging in her coat closet at approximately 2:00 a.m., (but she was not certain of the timeframe). She heard the door close and seen light from the hallway, so knew someone had left the apartment. In the morning, she found things in her closet in disarray. A statement, dated 12/16/19 from Resident G, indicated a banging noise woke him up. At first the banging noise sounded like it was indoors and someone was banging on wood, maybe around 1:00 a.m. Then, later there was a banging noise outside on the first floor, but he could not remember the exact time. He stayed in bed and went back to sleep. He was not scared, he thought it was strange. During an interview, on 12/18/19 at 3:05 p.m., Resident [NAME] indicated she could not remember the date, but she thought it was around 2:00 a.m., because she was not feeling well and it was difficult for her sleep. She heard the hallway door close, then she heard some activity in the front room area. It was difficult for her to get out of bed, so she did not get up when she heard the noise and she did not think about turning on her call light when she heard the noise. She saw a flash of light when the door closed as the person left. The next morning, her coat closet was in disarray. Her hangers and clothes were on the floor and her cane was pulled out of the closet. She went down and told the nurse about it and she told her she was the second person to report strange behavior during the night. When she went to breakfast her neighbor Resident F told her a man with a baseball cap was in her room also and she kicked him out. During an interview, on 12/18/19 at 3:35 p.m., Resident G indicated he just moved into the facility the night before this incident. He indicated on 12/12/19, he thought around 1:00 a.m., he heard a knocking on a wood door and someone saying let me in. Around 2:00 a.m., he heard someone knocking on a window outside saying let me in. He indicated the person's voice sounded like a male on both occasions, but he did not get up to check anything. The staff told him a resident got out of the facility, so he figured it was the resident locked out and trying to get back into the facility. During an interview, with LPN 5 in attendance on 12/19/19 at 1:56 p.m., Resident D indicated someone was knocking on her window. She was not sure about the time and she could not remember the date. It was last week sometime and this person sounded like a male's voice when he talked and he asked if anyone was there, can't you answer the door and I want to get in. She did not get out of bed because she figured it was someone outside drunk and she was scared, so she turned on her call light to have one of the aides go outside to check it out for her. During an interview, LPN 5 indicated the morning of 12/12/19 two residents voiced concerns to her about someone being in their apartment during the night and a resident voiced concerns to her about someone beating on her window. The AL residents voiced the following concerns to LPN 5: Resident D indicated she heard someone knocking on her window and she was scared to get out of bed, so she turned on her call light to have someone come and check the noise out. Resident [NAME] indicated someone was in her apartment rummaging around in her coat closet at 2:00 a.m. She knew someone was in her apartment because she heard the noise in the other room, but she was scared to get out of bed and it was difficult for her to get out of bed, so she waited until morning came. She heard the door close to her apartment and saw the light from the hallway, so she knew someone had went out her door. When she got out of bed in the morning, her coat closet was in a disarray with items laying on the floor. Resident F indicated her door was not locked that morning. When she woke up someone was in her bathroom (the person was a male by stature she guessed and had a baseball cap on), then the person walked up beside her bed and asked her if she could help him get out of here. He was headed to the closet, so she got out of bed and turned her light on and pointed toward the door and he left her apartment. She checked her apartment after he left and nothing was missing. A current policy, titled Elopement Risk Policy, dated 2/17/15 and provided by the Administrator on 12/16/19 at 11:44 a.m., contained the following, Policy Statement: This policy serves as guidance to the (Name of the Company) on identifying and initiating a plan of care for residents with history of elopements and/or risk for elopement. Definitions: Elopement is when a resident leaves the premises without authorization (i.e. without a discharge order or leave of absence order) and/or without the supervision to do so. (State mandate) resident elopement is defined as a cognitively impaired resident who was found outside the facility and whose whereabouts had been unknown; any circumstance of elopement which required police notification. Key Program components: Identifying residents at risk for elopement, Plan of care for the residents at risk for elopement. Identifying residents: Residents will be identified for elopement risk by the following: Nursing assessment upon admission, New or worsening behavior event of wandering, exit seeking or elopements after admission to the community. Upon either assessment or event outlined above, the resident is determined to be at risk for elopement if they are cognitively impaired and have one or more of the following risk behaviors: Wanders aimlessly in a non-secured area, Exit seeking, Expresses the need to go home,, leave, search for something or someone in a non-secured area, Expresses anger/agitation about being placed in the community, 'dropped off, left or abandoned.' History of elopements from home or another facility. Plan of Care: If the resident is determined to be at risk for elopement the community will initiate a plan of care that will ensure the residents safety, the plan may include interventions such as; placement of a wandering guard alarm device, 1:1 staff monitoring or placing the resident on a secured unit. The community will initiate a nursing order for the use of [REDACTED]. The community will imitate a physicians' order for the secured unit intervention The immediate jeopardy that began on 12/12/19 was removed on 12/18/19, when the facility continued education to associates related to the elopement policy, elopement risk including identifying signs and/or indications of increased verbalization of desire to go home, putting on outer wear, asking for loved ones, changes in mood or behavior, in addition to physically wandering or exit seeking. Response to doors with the egress alarms and the expectation the associates would conduct an immediate perimeter check outside to include a walk around the building when responding to door alarms prior to working any shifts. The majority of the associates were educated by the exit conference on 12/19/19. Elopement risk re-assessments were completed for 100% of residents to determine if they were at risk for elopement or had experienced a change in their elopement risk status. Interventions with education of associates regarding the new interventions were put into place for residents noted with acute exit seeking behavior including looking for car keys or family members or elopement attempts would be immediately place on increased monitoring to include 1:1 supervision, 15 minute checks and/or orders for wander guard alarm bracelets. New admission elopement risk assessments would be reviewed daily in the facility stand up meeting to ensure interventions were in place to prevent an elopement. A transmitter was ordered for the Egress door alarms on the AL doors to program the alarm to place a call to the AL phone and a second nurses' station phone on the skilled area of the facility. An associate would be present on the night shift on the AL area of the facility within hearing distance of the alarm and perform visual checks of the door every 15 minutes until the alarms were reprogrammed by the (Name of Company). An associate would be scheduled each night shift dedicated to the AL area. The schedule would be reviewed daily to ensure the dedicated person was present for the night shift in the AL area. The Maintenance Supervisor or designee will perform door alarm drills and perform exterior perimeter checks weekly times 12 weeks, then monthly times 9 months for a total of 12 months, to ensure associates were responding appropriately to the Egress door alarms. The noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that was not immediate jeopardy, because the Egress door alarms on the AL area of the facility did not have the transmitter installed as of the exit date of 12/19/19. 3.1-45(a)(2)