Every finding on record at Core of Bedford

Based on interview and record review, the facility failed to ensure the appropriate discharge information was provided for 5 of 5 residents reviewed for hospitalization. Information was not communicated to the receiving health care institution or provider, Notice of Transfer and Discharge was not provided, bed hold policies were not provided. (Resident 4, Resident 6, Resident 8, Resident 17, Resident 36)Findings include: 1. On 3/16/26 at 11:23 a.m., Resident 6's clinical record was reviewed. The diagnosis included, but was not limited to COPD (chronic obstructive pulmonary disorder). On 1/15/26 at 3:25 a.m., a progress note indicated the resident was sent and admitted to the hospital. The clinical record lacked the following information: - Documentation that a written notice of transfer and discharge was provided to the resident and resident representative. - Documentation that the bed-hold policy was provided to the resident and/or resident representative. - Documentation that the required information was conveyed to receiving facility upon transfer. 2. On 3/16/26 at 12:03 p.m., Resident 8's clinical record was reviewed. The diagnosis included, but was not limited to cerebral infarction (stroke). On 3/10/26 at 8:54 a.m., a progress note indicated the resident was sent and admitted to the hospital. The clinical record lacked the following information: - Documentation that a written notice of transfer and discharge was provided to the resident and resident representative. - Documentation that the bed-hold policy was provided to the resident and/or resident representative. - Documentation that the required information was conveyed to receiving facility upon transfer. 3. On 3/16/26 at 11:23 a.m., Resident 17's clinical record was reviewed. The diagnosis included, but was not limited to, dementia. On 12/15/25 at 11:34 a.m., a progress note indicated the resident was sent and admitted to the hospital. The clinical record lacked the following information: - Documentation that a written notice of transfer and discharge was provided to the resident and resident representative. - Documentation that the bed-hold policy was provided to the resident and/or resident representative. - Documentation that the required information was conveyed to receiving facility upon transfer. 4. On 3/17/26 at 2:31 p.m., Resident 4's clinical record was reviewed. The diagnoses included, but were not limited to, osteomyelitis (a serious infection of the bone), paraplegia (a medical condition causing impairment or loss of motor and sensory function in the lower half of the body), and cellulitis (a skin infection caused by bacteria entering through a break in the skin). A review of the resident's progress notes indicated the resident was transferred to the emergency room on 3/7/26 and returned to the long-term care facility on 3/16/26. The clinical record lacked the following information: - Documentation that a written notice of transfer and discharge was provided to the resident and resident representative. - Documentation that the bed-hold policy was provided to the resident and/or resident representative. - Documentation that the required information was conveyed to receiving facility upon transfer. 5. On 3/18/26 at 11:03 a.m., Resident 36's clinical record was reviewed. The diagnoses included, but were not limited to, hemiplegia (a form of paralysis causing total or partial loss of voluntary movement, strength, or control on one entire side of the body), gastrostomy (a feeding tube placed through the abdomen into the stomach), and urinary tract infection. A review of the resident's progress notes indicated the resident was transferred to the emergency room on 1/10/26 and returned to the long-term care facility on 1/14/26. The clinical record lacked the following information: - Documentation that a written notice of transfer and discharge was provided to the resident and resident representative. - Documentation that the bed-hold policy was provided to the resident and/or resident representative. - Documentation that the required information was conveyed to receiving facility upon transfer. During an interview with the Administrator and Minimum Data Set (MDS) Coordinator on 3/18/26 at 3:05 p.m., it was indicated that the facility did not have documentation of; a written notice of transfer and discharge provided in writing to the resident and resident representative, a copy of the bed-hold policy was provided to the resident and/or resident representative, and that required information was conveyed to receiving facility upon transfer on 5 of 5 residents reviewed. On 3/19/26 at 12:00 p.m., a copy of the Transfer and Discharge (including AMA [Against Medical Advice] policy, undated, was provided by the Administrator, she indicated this was a current policy used by the facility. A review of the policy indicated, .10. For transfer to another provider, for any reason, the following information must be provided to the receiving provider: a. Contact information of the practitioner who was responsible for the care of the resident, b. Resident Representative information, including contact information, c. Advanced directive information, d. All other information necessary to meet the resident's needs.e. All special instructions and/or precautions for ongoing care.12. Emergency Transfers/Discharges – initiated by the facility for medical reasons to an acute setting such as a hospital.c. For a transfer to another provider, ensure necessary information listed.is provided along with, or as part of, the facility's transfer form.f. Document assessment findings and other relevant information regarding the transfer in the medical record.g. Provide a notice of transfer and the facility's bed hold policy to the resident and the resident representative. 410 IAC (Indiana Administrative Code) 16.2-3.1-12(a)(6)(A)(i) 410 IAC 16.2-3.1-12(a)(6)(A)(ii) 410 IAC 16.2-3.1-12(a)(6)(A)(iii) 410 IAC 16.2-3.1-12(a)(25)(A)410 IAC 16.2-3.1-12(a)(25)(B)410 IAC 16.2-3.1-12(a)(26)

Based on observation, interview, and record review, the facility failed to ensure a clean, homelike environment in 3 of 4 resident shower/bathrooms used by 34 of 34 residents, and for 2 of 12 resident rooms reviewed for environmental concerns (Northeast Bathroom, Southwest Bathroom, Southeast Bathroom, room [ROOM NUMBER], room [ROOM NUMBER])Findings include:1. On 3/17/26 at 10:20 a.m. and 2:00 p.m., on 3/18/26 at 10:05 a.m. and 2:50 p.m., and on 3/19/26 at 11:20 a.m., gnats were observed flying around in the northeast resident bathroom. 2. On 3/17/26 at 9:50 a.m. and on 3/18/26 at 3:05 p.m., and black and brown substance was observed around the base of the toilet in the southwest resident bathroom. 3. On 3/17/26 at 9:55 a.m. and on 3/18/26 at 3:10 p.m., a gray fuzzy substance was observed on and in the ceiling vent, a black substance was observed around the base of the toilet, and the toilet was observed to be anchored at an angle towards the wall in the southeast resident bathroom. 4. On 3/16/26 at 11:16 a.m. and at 2:30 p.m., on 3/18/26 at 10:10 a.m., and on 3/19/26 at 11:55 a.m., gnats were observed flying around residents' beds and sink in room [ROOM NUMBER]. 5. On 3/18/26 at 10:15 a.m. and on 3/19/26 at 11:10 a.m., gnats were observed flying around residents' beds and sink in room [ROOM NUMBER]. The old floor-based heating/air conditioning unit was observed to be missing the base cover, exposing a black substance on the interior surface, and the wallpaper on the south wall was peeling off, exposing a brown substance on the wall beneath it. During an interview on 3/19/26 at 2:25 p.m., the facility Administrator indicated the aforementioned environmental concerns existed and were in need of correction. On 3/19/26 at 2:00 p.m., the facility Administrator provided the Resident Rights, dated 1997, and indicated these were the resident rights currently used by the facility. A review of the resident rights indicated, The facility must provide a safe, clean, comfortable, and homelike environment . 410 IAC (Indiana Administrative Code) 16.2-3.1-19(f)

Based on observation, interview, and record review, the facility failed to provide at least 80 square feet (sq. ft.) per resident in multiple occupancy resident rooms. This was observed in 3 of 18 resident rooms in the facility (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER]).Findings include: A review of the facility's Rooms Size Certification, received from the Administrator on 3/16/26 at 11:00 a.m., indicated the following:The floor areas of the following multiple resident rooms measured: room [ROOM NUMBER]: 2 beds, 153.19 sq. ft. 76.59 sq. ft. per resident, SNF/NF.room [ROOM NUMBER]: 2 beds 157.98 sq. ft. 78.99 sq. ft. per resident, SNF/NF. room [ROOM NUMBER]: 2 beds 152.97 sq. ft. 76.48 sq. ft. per resident, SNF/NF. room [ROOM NUMBER], 6, and 8, rooms with the variances, were observed on 3/16/26. The rooms were observed to have the following number of beds:room [ROOM NUMBER] - 2 bedsroom [ROOM NUMBER] - 2 bedsroom [ROOM NUMBER] - 2 bedsDuring an interview on 3/16/26 at 11:00 a.m., the Administrator indicated rooms [ROOM NUMBER] had the variance waivers. The rooms were licensed for double occupancy and currently had two beds in the room. 410 IAC (Indiana Administrative Code) 16.2-3.1-19(l)(2)

Based on observation, interview, and record review, the facility failed to ensure a resident received the necessary interventions to prevent dislodgement of a gastrostomy tube (feeding tube) for 1 of 1 resident reviewed for feeding tubes. This deficient practice resulted in a hospitalization to remove the G-tube, sepsis, and cannot have a new G-tube placed for 6 weeks. (Resident B) Finding include: On 10/24/25 at 10:40 a.m., Resident B was observed to be sitting in a reclining wheelchair. A yellow nasogastric tube (a flexible tube inserted through the nose and down the throat into the stomach) was observed to have feeding infusing from a feeding pump. On 10/24/25 at 11:05 a.m., Resident B's clinical record was reviewed. The diagnoses included, but were not limited to, cerebral infarction (stroke), hemiplegia (paralysis or weakness on one side of the body), dysphagia (difficulty swallowing), and methicillin resistant staphylococcus aureus infection. An Operative Report, dated 9/5/25 at 5:21 p.m., indicated a Percutaneous Endoscopic Gastrostomy tube was placed. The care plan, dated 9/18/25 (dated prior to Resident B's admission), indicated Resident B had a tube feeding related dysphagia. The interventions were check for tube placement prior to medication administration, check for tube placement and gastric contents/residual volume per facility protocol and record. Baseline Care Plan, dated 9/29/25, indicated Resident B had a G-tube placed on 9/5/25 due to recent stroke. He had continuous feeding per G-tube. The Progress notes indicated the following: -On 9/26/25 at 9:43 a.m. Resident B arrived at the facility. He had a 20 French (size of G-tube) inserted in the left upper abdomen. He tolerated bolus feeding well. He had a grimaced facial expression with feeding and flush. -On 10/2/25 at 10:43 a.m., Resident B's G-tube was leaking around the insertion site. He winced when checking for placement of the G-tube and when medication was flushed. The nurse practitioner was notified and received an order to send him the emergency room. -On 10/2/25 at 11:00 a.m., Resident B was transported to the emergency room. -On 10/2/25 at 4:35 p.m., Resident B was transferred to the hospital for aspiration pneumonia and replacement of G-tube due to displacement. An untitled physician's hospital progress note, dated 10/2/25 at 7:58 p.m., indicated Resident B's G-tube was dislodged at the nursing facility. The hospital assessment/plan had hypotension, likely to septic shock secondary to aspiration pneumonia due to the malposition of the G-tube. The malposition of the G-tube caused feeding in his chest wall and abdomen. A Surgical Cosultation, dated 10/3/25 at 2:00 p.m., indicated the G-tube was dislodged. The G-tube site had a hard area with redness near the site and purulent drainage (a thick, cloudy fluid that is typically yellow, green, or brown in color) coming from around the G-tube. Resident B grimaced when the area was palpated and indicated pain. The G-tube was removed with large amount of purulent drainage and cottage cheese appearing material from the site. An untitled physician's hospital progress note, dated 10/6/25 at 10:40 a.m., indicated on evaluation in the emergency room (ER), it was discovered that the anchoring gastrostomy button had been retracted into the abdominal wall. The resident was diagnosed with sepsis/septic shock (a life-threatening response to infection with acute failure of multiple organs), likely due to combination of aspiration and dislodged G-tube. The assessment/plan indicated, for dislodged gastrostomy tube, G-Tube cannot be placed until infection and tube feeds have cleared, time frame indicated was approximately 6 weeks. The Physician orders indicated the following: -Vancomycin 750 milligrams intravenously every 12 hours for sepsis for 14 days (start date 10/21/25) -Amoxicillin-Pot Clavulanate tablet 875-125 milligrams by mouth every 12 hours for sepsis (start date 10/13/25) The clinical record lacked documentation of confirming the placement of feedings tube for Resident B on 9/27/25, 9/28/25, 9/29/25, and 10/1/25. On 10/24/25 at 11:15 a.m., Resident B was observed to be sitting in a reclining wheelchair. A yellow nasogastric tube was observed to have feeding infusing from a feeding pump. During an interview on 10/24/25 at 11:40 a.m., with LPN 1 indicated that she had taken care of Resident B when he was admitted on [DATE]. She indicated she completed a full assessment and verified placement of the G-tube. She indicated there were no issues with flushing the G-tube or with continuous feeds. LPN 1 indicated she also cared for Resident B on 9/30/25. She indicated there was no concerns with the G-tube at that time. She indicated placement confirmation of the G-tube would be completed prior to any medication administration or tubing changes for enteral feeds and this would be documented on the MAR/TAR (medication administration record/treatment administration record). During an interview on 10/24/25 at 12:00 p.m., the Director of Nursing (DON) indicated she worked the night of 10/1/25 and helped care for Resident B. She indicated there were no concerns with the G-tube at that time. The DON indicated Resident B had no pain or grimacing and no drainage was noted during G-tube care. She indicated on 10/2/25 she was notified by a staff nurse that the G-Tube was leaking and the resident had grimacing anytime the area was touched and with an attempt to flush the tube. She indicated the nurse immediately stopped all care and contacted the Nurse Practitioner and an order was obtained to transfer the resident to the emergency room. The DON indicated the staff would document G-tube placement verification in the MAR/TAR During an interview on 10/24/25 at 12:25 p.m., the DON presented the September and October 2025 Medication and Treatment Record (MAR and TAR). She indicated she could not find the documentation of checking for placement prior to him going to the hospital on October 2, 2025. On 10/24/25 at 12:45 p.m., the DON presented the G-tube policy and procedures in-service attendance, dated 9/26/25. All nurses had signed the G-tube training and policy and procedures except LPN 2. On 10/24/25 at 1:50 p.m., the DON indicated LPN 2 worked on 9/27/25, 9/28/25, and 10/1/25 and would been the nurse taking care of Resident B. On 10/24/25 at 12:30 p.m., the DON provided a facility policy labeled Administering Medications through an Enteral Tube (feeding tube), revised November 2018. She indicated this was a current policy being used by the facility. A review of the policy indicated, .5. Verify placement of feeding tube, .Using stethoscope and syringe: push 5-10 ml (milliliters) of air into g-tube while listening to abdomen [above g-tube] to ensure placement by hearing a swish/movement . On 10/24/25 at 1:58 p.m., the DON provided a facility policy labeled Confirming Placement of Feeding Tubes, revised November 2018. She indicated this was a current policy being used by the facility. A review of the policy indicated, .The purpose of this procedure is to ensure proper placement of an existing feeding tube prior to administering enteral feedings or medication .Documentation - The person performing this procedure should record the following information in the resident's medical record: 1. The date and time the procedure was performed. 2. The name and title of the individual(s) who performed the procedure. 3. All assessment data obtained during the procedure . This citation relates to Intake 2646692. 3.1-44(a)(2)

Based on interview and record review, the facility failed to ensure a resident's representative was notified of an assessed significant weight loss for 1 of 3 residents reviewed for notification of change. (Resident B) Findings include: On 3/6/25 at 11:25 a.m., Resident B's clinical record was reviewed. The diagnosis included, but was not limited to, dementia with behavior disturbance. A review of Resident B's weights indicated the following: - On 1/2/25, the resident weighed 156.8 pounds. - On 1/17/25, the resident weighed 157.1 pounds. - On 1/23/25, the resident weighed 144.2 pounds. - On 1/30/25, the resident weighed 146.2 pounds. - On 2/11/25, the resident weighed 137.4 pounds. - On 2/19/25, the resident weighed 127.9 pounds. There was an assessed significant weight loss of 18.59% from 1/17/25 to 2/19/25. The resident's progress notes indicated the following: - A Nutrition/Dietary note from 2/17/25 at 12:30 p.m., indicated Resident B had a significant change of 19.4 pounds and 12.4% weight loss over 30 days. The clinical record for Resident B lacked documentation of the resident's representative having been notified of the assessed significant weight loss. During an interview on 3/6/25 at 12:00 p.m., the Minimum Data Set Coordinator (MDS) indicated the resident had lost weight and the resident's representative should have been notified but was not. On 3/6/25 at 1:15 p.m., the Administrator provided the facility policy, Family Notification of Changes to a Resident's Plan of Care, dated 7/2009, and indicated it was the policy currently being used by the facility. A review of the policy indicated, . Policy: It is the policy of this facility to immediately inform the resident . notify the resident's legal representative . when there are changes to the resident's care . This citation relates to Complaint IN00454567. 3.1-5(a)(2)

Based on interview and record review, the facility failed to ensure a fall was documented for 1 of 3 residents reviewed for accidents. (Resident B) Findings include: On 3/6/25 at 11:25 a.m., Resident B's clinical record was reviewed. The diagnosis included, but was not limited to, dementia with behavior disturbance. The resident's nursing progress notes indicated the following: - On 2/8/25 at 1:47 p.m., new orders for X-ray of right ribs, right femur, right hip, total views of all X-rays. - On 2/8/25 at 2:45 p.m., follow-up day 2 of 3 awaiting X-rays of right ribs, right femur and right hip due to complaints of pain with movement. - On 2/9/25 at 7:20 a.m., nurse was notified by CNA's that resident was unable to straighten right leg, while assessing resident it was noted pain and discomfort while attempting to change and reposition resident. He was noted to have a recent fall on 2/6/25 and orders were obtained 2/8/25 for X-rays. - On 2/9/25 at 8:05 a.m., hospital ambulance arrived to transport resident to emergency room for evaluation and treatment. - On 2/9/25 at 11:15 a.m., resident returned to facility via ambulance stretcher. The resident was treated for a right hip contusion. The clinical record for Resident B lacked documentation of the resident having had a fall on 2/6/25. During an interview on 3/6/25 at 12:00 p.m., the Minimum Data Set Coordinator (MDS) indicated Resident B's last fall was on 2/2/25, and was unaware of the resident having had a fall on 2/6/25. During an interview on 3/6/25 at 12:23 p.m., RN 1 indicated Resident B had a fall during the night shift on 2/6/25. She worked the next day and was the nurse who ordered the X-rays due to the resident's pain in the right leg. On 3/6/25 at 1:22 p.m., the Administrator provided the facility policy, Procedure for Falls, undated, and indicated it was the policy currently being used by the facility. A review of the policy indicated, . Procedure for Falls 6. Chart incident in nurses notes . This citation relates to Complaint IN00454567. 3.1-50(a)(2)

Based on observation, interview, and record review, the facility failed to ensure food was stored in accordance with professional standards for food service safety for 2 of 2 kitchen observations. Findings include: During an initial kitchen tour on 2/17/25 at 10:45 a.m., a large container containing opened bags of rice was observed without a lid in the dry storage area. During a follow-up visit on 2/20/25 at 12:01 p.m., the same rice container was observed uncovered in the dry storage area. During an interview at that time, the Dietary Manager indicated the container should have a lid since there were opened bags of rice in it. On 2/20/25 at 12:40 p.m., the Administrator provided a copy of the facility policy, Storage of Dry Food and Supplies, undated, and indicated it was the policy currently being used. A review of the policy indicated, . Use seamless or plastic containers with tight-fitting covers to store products . On 2/21/25 at 10:45 a.m., the Indiana State Department of Health, RETAIL FOOD ESTABLISHMENT SANITATION REQUIREMENTS. TITLE 410 IAC 7-24, dated 11/13/04, was reviewed. A review of the rule indicated, . food shall be protected from contamination by storing the food as follows: . (2) Where it is not exposed to splash, dust, or other contamination . (5) In packages, covered containers, or wrappings 3.1-21(i)(2) 3.1-21(i)(3)

Based on interview and record review, the facility failed to ensure a resident's choice of code status was documented accurately for 1 of 3 residents reviewed for advanced directives. (Resident 12) Finding includes: On [DATE] at 2:37 p.m., Resident 12's clinical record was reviewed. The diagnoses included, but were not limited to, Alzheimer's disease and a history of transient ischemic attack (temporary blockage of blood flow to the brain, causing stroke like symptoms). The Advanced Directives, a choice of treatment document, dated [DATE], was signed by the Resident's POA (power of attorney), and indicated the resident was to be comfort measures only (No CPR to be performed). The Physician's Orders, dated [DATE], indicated resident had a current order for CPR (cardiopulmonary resuscitation). A Provider Note, dated [DATE], indicated the resident's advanced directive was DNR (do not resuscitate). A Provider Note, dated [DATE], indicated the resident's advanced directive was DNR. A Provider Note, dated [DATE], indicated the resident's advanced directive was DNR. No additional documentation was in the clinical record to reflect the change in advanced directive. During an interview with the Administrator on [DATE] at 11:05 a.m., she indicated she was unsure why the advanced directive was changed. The Administrator indicated there was no documentation noted in the record indicating a request from the POA to change resident's advanced directive from DNR to CPR. During an interview with the DON on [DATE] at 11:00 a.m., she indicated that according to resident's medical record and current order, the code status was CPR. She indicated that staff would initiate CPR, if needed (contradictory to the resident's advanced directive). On [DATE] at 12:00 p.m., the Administrator provided the choice of treatment policy. The policy was undated, the administrator indicated this was a current policy for the facility. The policy indicated . each resident is afforded the privilege of death with dignity if he/she so desires. In the event the resident is unable to make this determination and the family desires a NO CODE this wish shall be carried out . 3XXX,d+[DATE](f)(5)

Based on observation, interview, and record review, the facility failed to ensure oxygen tubing was labeled with the date for 1 of 3 residents reviewed for respiratory care. (Resident 1) Findings include: On 2/18/25 at 2:40 p.m., Resident 1 was observed sitting in his wheelchair outside his room with oxygen being administered via nasal cannula (N/C) at 4L (liters). There was no date observed on the N/C tubing. On 2/19/25 at 9:55 a.m., Resident 1 was observed sitting in his wheelchair in the dining room with oxygen being administered via N/C at 4L. There was no date observed on the N/C tubing. On 2/19/25 at 11:43 a.m., Resident 1 was observed sitting in his wheelchair in the dining room with oxygen being administered via N/C at 4L. There was no date observed on the N/C tubing. On 2/20/25 at 2:44 p.m., Resident 1 was observed sitting in his wheelchair inside his room with oxygen being administered via N/C at 4L. There was no date observed on the N/C tubing. On 2/20/25 at 10:42 a.m., Resident 1 was observed laying asleep in bed with oxygen being administered via N/C at 4L. There was no date observed on the N/C tubing. Resident 1's clinical record was reviewed on 2/18/25 at 3:09 p.m. The diagnoses included, but were not limited to, hemiplegia (paralysis) and traumatic brain injury. Current physician orders, dated 2/20/25, indicated, . O2 [oxygen] per nasal cannula at 4 lpm [liters per minute] every shift for low O2 sats [saturations] . During an interview on 2/20/25 at 10:20 a.m., the MDS (Minimum Data Set) Coordinator indicated the tubing was changed every Sunday, however, Resident 1 wanted a longer tubing so hospice brought it and must not have marked it with the date. During an interview on 2/20/25 at 10:39 a.m., the MDS Coordinator indicated Resident 1 did not have an order to change the oxygen tubing every Sunday. On 2/20/25 at 12:00 p.m., the Administrator provided the facility policy, Oxygen Concentrator, undated, and indicated it was a policy currently being used. A review of the policy did not indicated putting a date on the oxygen tubing. 3.1-47(a)(6)

Based on record review and interview, the facility failed to ensure an accurate assessment for 1 of 1 residents reviewed for resident assessment. (Resident 234) Finding includes: On 2/18/25 at 2:04 p.m., Resident 234's clinical record was reviewed. The diagnoses included, but not limited to, schizoaffective disorder (condition that combines symptoms of schizophrenia and a mood disorder) and dementia. Notice of PASARR (Preadmission Screening and Resident Review) Level II Outcome, dated 2/15/23, indicated, Final Determination By: Determination Date: 2/15/23, Level II Outcome: Long Term Approval without Specialized Services. A Significant Change MDS (Minimum Data Set) assessment, dated 9/24/24, did not indicate the resident was a PASARR level II. During an interview with the MDS coordinator on 2/20/25 at 10:10 a.m., she indicated section A1500 on MDS assessment, dated 9/24/24, was marked no in error and indicated it should have been marked yes for PASARR Level II. She indicated they did not have a MDS assessment coding policy, they followed the Resident Assessment Instrument (RAI) manual for coding the MDS assessment. On 2/20/25 at 11:30 a.m., a review of the RAI,Version 3.0 User's Manual, 10/2023, for section A1500 of MDS, Code 1, yes: if PASARR Level II screening determined that the resident has a serious mental illness and/or ID [Intellectual disability]/DD [Developmental disability] or related condition . 3.1-31(d)

Based on observation, interview, and record review, the facility failed to provide at least 80 square feet (sq. ft.) per resident in multiple occupancy resident rooms for 3 of 18 resident rooms in the facility. (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER]). Findings include: Review of the facility's Rooms Size Certification, received from the Administrator on 2/17/25 at 12:50 p.m., indicated the following: The floor areas of the following multiple resident rooms measured: room [ROOM NUMBER]: 2 beds, 153.19 sq. ft., 76.59 sq. ft. per resident, SNF/NF. room [ROOM NUMBER]: 2 beds 157.98 sq. ft., 78.99 sq. ft. per resident, SNF/NF. room [ROOM NUMBER]: 2 beds 152.97 sq. ft., 76.48 sq. ft. per resident, SNF/NF. room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER], were observed on 2/19/25 at 2:00 p.m The rooms were observed to have the following number of beds two beds in each room. During an interview on 2/19/25 at 2:10 p.m., the facility Administrator indicated room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER] had the room variance waivers. The rooms were licensed for double occupancy and currently had two beds in the room. 3.1-19(l)(2)(A)

Based on interview and record review, the facility failed to ensure accurate reconciliation and disposition of controlled substances for 1 of 3 residents reviewed for medication reconciliation. (Resident B) Findings include: During an interview on 1/17/25 at 9:45 a.m., the Administrator (ADM) indicated she was notified regarding missing pills for Resident B. The ADM's investigation singled out two nurses, the Director of Nursing (DON) and LPN 1, during the time the pills went missing. The facility never found the missing pills. On 1/17/24 at 9:50 a.m., Resident B's clinical record was reviewed. The diagnoses included, but were not limited to, malignant neoplasm of the breast, history of malignant neoplasm of the brain, and low back pain. An 11/7/24 physician's order indicated the resident was ordered oxycodone (a controlled substance medication used to treat moderate to severe pain) 7.5-325 milligrams every 6 hours, as needed for pain. A review of the drug disposal form did not indicate the resident's oxycodone was disposed. A review of the controlled substance inventory count sheet indicated one card was removed from the A cart, on 12/4/24 for Resident B. The form did not contain the signatures of two licensed nurses for verification. During an interview on 1/17/25 at 10:41 a.m., the DON indicated she conducted an audit and discovered there was a discrepancy between the pill count and inventory sheet. Someone had signed off they had removed a card, but there was no initial so she did not know who pulled the medication. She asked LPN 1 if she removed the medication and LPN 1 informed the DON they had destroyed the pills on 12/4/24. She indicated two nurses should sign off on the drug disposal sheet when the drug was destroyed. The DON indicated she did not destroy Resident B's medication, rather it was different resident's medication. On 1/17/25 at 1:30 p.m., the ADM provided the facility policy, DISPOSAL OF MEDICATIONS AND MEDICATION-RELATED SUPPLIES, dated 3/12/12, and indicated it was the policy currently being used. A review of the policy indicated, . B. When a dose of a controlled medication is removed from the container for administration . it is destroyed in the presence of two licensed nurses, and the disposal is documented on the accountability record on the line representing that dose . This citation relates to Complaint IN00448728 3.1-25(e)(2) 3.1-25(e)(3)

Based on observation, interview, and record review, the facility failed to provide at least 80 square feet (sq. ft.) per resident in multiple occupancy resident rooms for 3 of 18 resident rooms in the facility. (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER]) Findings include: room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER] were observed on 4/23/24 at 11:00 a.m. The rooms were observed to have the following number of beds: room [ROOM NUMBER] - 2 beds room [ROOM NUMBER] - 2 beds room [ROOM NUMBER] - 2 beds A review of the facility's Rooms Size Certification, received from the Administrator on 4/26/24 at 11:00 a.m., indicated the following: The floor areas of the following multiple resident rooms measured: room [ROOM NUMBER] - 2 beds, 153.19 sq. ft., 76.59 sq. ft. per resident, SNF/NF. room [ROOM NUMBER] - 2 beds 157.98 sq. ft., 78.99 sq. ft. per resident, SNF/NF. room [ROOM NUMBER] - 2 beds 152.97 sq. ft., 76.48 sq. ft. per resident, SNF/NF. During an interview on 4/26/24 at 11:15 a.m., the Administrator indicated room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER] had the room variance waivers. The rooms were licensed for double occupancy and currently had two beds in the room. 3.1-19(l)(2)(A)

Based on observation, interview, and record review, the facility failed to implement infection control measures to prevent the spread of infections for 34 of 34 residents residing in the building. A water management program was not implemented to prevent water borne pathogens and gloves were not worn while obtaining a blood glucose level. (Resident 4, RN 1) Findings include: 1. On 3/17/23 at 12:00 p.m., the Administrator (ADM) presented the Water Management Binder. The binder contained the Water Borne Pathogen Prevention Policy which indicated the facility would implement a water management program which follows a preventative guide. The binder lacked documentation of monthly, semi-annually, and annually preventative maintenance. On 3/17/23 at 12:36 p.m., the ADM indicated the Water Management binder lacked documentation of any completed preventative maintenance. On 3/17/23 at 12:50 p.m., the ADM provided the facility policy, Water Borne Pathogen Prevention Policy, dated 11/2017 and indicated this was the policy currently being used by the facility. A review of the policy indicated .1. The facility will conduct risk assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility water system 2. The facility will implement a water management program which follow the preventative maintenance guide .: MONTHLY: CENTRAL BATHING SEMI-ANNUALLY: RESIDENT ROOMS .ANNUALLY: DOMESTIC WATER SYSTEMS . 35318 2. On 3/16/23 at 11:05 a.m., Registered Nurse (RN) 1 was observed to obtain a blood glucose level for Resident 4 by pricking the finger with a lancet (small, sharp needle) and obtaining a small amount of blood. No gloves were observed to be worn during the procedure. During an interview on 3/16/23 at 11:20 a.m., RN 1 indicated she should have worn gloves during the blood glucose check for Resident 4. On 3/17/23 at 12:47 p.m., the Minimum Data Set (MDS) Coordinator provided the policy, Blood Glucose Meters Cleaning and Disinfecting, and indicated it was the policy currently being used by the facility. A review of the policy indicated, . Procedure: 1. Gloves should be worn for all blood glucose monitoring checks and hands washed after removal of gloves . 3.1-18(b)(1)

Based on observation, interview, and record review, the facility failed to develop a comprehensive care plan for 1 of 1 residents reviewed for a colostomy (a surgical operation in which a piece of the colon is diverted to an artificial opening in the abdominal wall so as to bypass a damaged part of the colon). (Resident 6) Findings include: On 3/17/23 at 11:00 a.m., Resident 6 was observed to have a colostomy bag attached to his side. During an interview on 3/17/23 at 11:02 a.m., the resident indicated he usually changed the colostomy bag when needed. Nursing staff assisted him when he needed assistance. During an interview on 3/17/23 at 11:20 a.m., LPN 1 indicated the resident frequently changed his colostomy bag, and sometimes required nursing staff assistance with this task. During an interview on 3/17/23 at 11:54 a.m., the DON indicated there was no care plan in place in reference to the resident's colostomy care. On 3/17/23 at 12:10 p.m., Resident 6's clinical record was reviewed. The diagnoses included, but were not limited to, paraplegia and diabetes. The Quarterly Minimum Data Set (MDS) assessment, dated 2/23/23, indicated the resident had an ostomy (an ostomy is surgery to create an opening from an area inside the body to the outside). A physician's order, dated 6/7/22 through 3/31/23 indicated, colostomy change as needed. The Resident Care Plan Conference document, dated 3/2/23, indicated the resident had an ostomy. The resident's clinical record lacked a care plan regarding the care of the resident's colostomy. 3.1-35(a)

Based on observation, interview, and record review, the facility failed to provide services to maintain the residents highest practicable quality of care for 1 of 1 residents reviewed for positioning. A resident was not provided positioning assistance. (Resident 8) Finding includes: On 3/16/23 at 11:15 a.m., Resident 8 was observed self-propelling down the hallway in a wheelchair. She was observed slouching down and to the right side in her wheelchair without any positioning aides. On 3/17/23 at 10:00 a.m., Resident 8 was observed self-propelling down the hallway in a wheelchair. She was observed slouching to the right side in her wheelchair without any positioning aides. On 3/17/23 at 12:31 p.m., Resident 8 was eating lunch in the main dining room. She was observed slouching to the right side in her wheelchair without any positioning aides. During an interview, at that time, the resident indicated she would like a pillow on her right side to help with positioning. During an interview on 3/17/23 at 1:00 p.m., CNA 4 indicated she tried to put a pillow under the resident's affected (right) arm to help with positioning and prevent her from getting any scratches on her elbow. On 3/17/23 at 1:07 p.m., Resident 8's clinical record was reviewed. The diagnoses included, but were not limited to, stroke and hemiplegia (paralysis) and hemiparesis (weakness). A Quarterly Minimum Data Set (MDS) assessment, dated 2/9/23, indicated the resident had moderately impaired cognition and had one-sided impairment in her upper and lower extremities. A review of the resident's care plans indicated no care plans were implemented to address the resident's positioning. A review of the resident's record indicated no occupational therapy notes. A review of the March, 2023, physician's orders indicated there were no orders which addressed the resident's positioning. During an interview on 3/17/23 at 2:51 p.m. the MDS Coordinator indicated she did not have any clinical documentation related to the staff addressing the resident's positioning. She further indicated the facility did not have a policy in regard to positioning. 3.1-37(a)

Based on observation, interview, and record review, the facility failed to provide services for a pressure ulcer for 1 of 2 residents reviewed. A wound care referral was not completed and the weekly wound assessments were not completed. (Resident 4) Findings include: During an interview on 3/14/23 at 2:51 p.m., Resident 4 indicated he had a black-colored pressure ulcer on the bottom on his left foot for the last 3-4 months. He has not had any wound care from anyone outside of the facility. He had his right foot amputated and did not want to have the same thing happen to his left foot. At that time, during an observation, Resident 4 was observed to be wearing a pressure relieving device to his left foot and had a below the knee amputation of his right foot. During an observation on 3/16/23 at 10:23 a.m., Resident 4 was observed to be sitting in his wheelchair participating in therapy with his pressure relieving device on his left foot. During an observation on 3/17/23 at 12:54 p.m., Resident 4 was observed to be sitting in his wheelchair his pressure relieving device on his left foot. On 3/16/23 at 10:45 a.m., Resident 4's clinical record was reviewed. The diagnoses included, but were not limited to, below the knee amputation, diabetes mellitus, osteomyelitis (infection of the bone), and arteriosclerosis (hardening of the walls of the arteries). The care plan, dated 1/2/23 and current through 4/2/23, indicated Resident 4 had a pressure area to his left heel. His interventions were to measure the area weekly, document the measurements and the appearance of the wound; the wound team to assess the area weekly; change treatment per wound team and physician recommendations; and a pressure relieving device to the left foot. The Nurse's Notes indicated the following: - On 1/14/23 at 2:00 p.m., Resident 4's left heel had a moderate amount of pink drainage. The area of deep tissue injury became open during his shower. - On 1/24/23 at 11:00 a.m., Resident 4 received an order for referral of wound care. The Physician's Progress notes, dated 1/24/23, indicated Resident 4 had a heel wound. Resident 4 indicated he had a painful heel ulcer and was interested in starting with wound care. The physician ordered wound care for further evaluation and management. The March 2023 Physician's Order indicated the following: - Cleanse left heel with normal saline; pat dry; paint with iodine; cover with dressing and secure with tape daily (start date 1/14/23). - Referral of wound care (start date 1/24/23). - Pressure relieving device to left foot (start date 2/7/23) The Weekly Wound Assessment and Summary indicated the following: - On 1/3/23, Resident 4's left heel unstageable pressure injury measurements were 4.5 centimeter (cm) length and 6.5 cm width. - On 1/12/23, Resident 4's left heel unstageable pressure injury measurements were 4.0 cm length and 7.0 cm width. - On 1/19/23, Resident 4's left heel unstageable pressure injury measurements were 4.0 cm length and 7.0 cm width. - On 1/26/23, Resident 4's left heel unstageable pressure injury measurements were 4.2 cm length and 7.0 cm width. - On 2/2/23, Resident 4's left heel unstageable pressure injury measurements were 4.4 cm length and 7.0 cm width. - On 2/9/23, Resident 4's left heel unstageable pressure injury measurements were 4.5 cm length and 6.8 cm width. - On 2/16/23, Resident 4's left heel unstageable pressure injury measurements were 4.7 cm length and 6.7 cm width. - On 2/23/23, the weekly wound assessment and summary lacked documentation of wound measurements or assessment. - On 3/2/23, the weekly wound assessment and summary lacked documentation of wound measurements or assessment. - On 3/9/23, Resident 4's left heel unstageable pressure injury measurements were 4.0 cm length and 2.5 cm width. The clinical record lacked documentation of Resident 4 refusing a wound care referral or wound care assessment. The targeted behaviors symptoms lacked documentation of refusal of care. During an interview on 3/16/23 at 11:34 a.m., the Director of Nursing (DON) indicated Resident 4 refused to have referral for wound care. She indicated the clinical record lacked documentation of Resident 4 refusing wound referral. During an interview on 3/17/23 at 11:07 a.m., the DON indicated pressure ulcers are measured and assessed weekly and documented on the Weekly Wound Assessment and Summary. If the resident refused to have pressure ulcer assessed or measured, the nurse would document the refusal on wound summary or nurses notes. During an interview on 3/17/23 at 11:25 a.m., the DON indicated Resident 4's Weekly Wound Assessment and Summary lacked documentation on 2/23/23 and 3/2/23. On 3/17/23 at 2:20 p.m., the MDS nurse provided the facility policy, Pressure Injury Prevention, dated 11/1/22 and indicated this was the policy currently being used by the facility. A review of the policy indicated .8. Each resident who has a skin issue that has been identified (pressure or non-pressure) will be kept in the wound book and measure weekly . 3.1-40(a)(2)

Based on observation, interview, and record review, the facility failed to provide at least 80 square feet (sq. ft.) per resident in multiple occupancy resident rooms for 3 of 18 resident rooms in the facility. (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER]) Findings include: Review of the facility's Rooms Size Certification, received from the Administrator on 3/17/23 at 12:50 a.m., indicated the following: The floor areas of the following multiple resident rooms measured: room [ROOM NUMBER]: 2 beds, 153.19 sq. ft., 76.59 sq. ft. per resident, SNF/NF. room [ROOM NUMBER]: 2 beds 157.98 sq. ft., 78.99 sq. ft. per resident, SNF/NF. room [ROOM NUMBER]: 2 beds 152.97 sq. ft., 76.48 sq. ft. per resident, SNF/NF. room [ROOM NUMBER], 6, and 8, rooms with the variances, were observed on 3/15/23. The rooms were observed to have the following number of beds: room [ROOM NUMBER] - 2 beds room [ROOM NUMBER] - 2 beds room [ROOM NUMBER] - 2 beds During an interview on 3/17/23 at 12:50 p.m., the facility Administrator indicated rooms [ROOM NUMBER] had the room variance waivers. The rooms were licensed for double occupancy and currently had two beds in the room. 3.1-19(l)(2)(A)

Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent a resident, with a history of smoking in the room, from smoking a cigarette in the residents' room with an operating oxygen concentrator. This resulted in a systemic failure which presented the potential for combustion of oxygen from a burning cigarette and could have caused harm to residents in the room, adjacent rooms, and hallways for 1 of 1 resident randomly observed for accidents (Resident 13) The Immediate Jeopardy began on 4/21/22 when the facility failed to ensure Resident 13 did not smoke a cigarette in the resident's room approximately 6 feet away from Resident 30's oxygen concentrator. The oxygen concentrator was in operation delivering 4 liters per minute of oxygen through oxygen tubing which was lying on Resident 30's bed. The Administrator was notified of the Immediate Jeopardy on 4/21/22 at 3:00 p.m. The Immediate Jeopardy was removed on April 22, 2022 at 2:50 p.m., but noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Finding includes: On 4/18/22 at 11:45 a.m., the Administrator provided a list of residents who smoke and the status of each resident's level of supervision. Resident 13 was listed as an independent smoker. The list indicated the designated area for resident smokers was the fenced-in outdoor space located at the rear of the facility. On 4/21/22 at 12:10 p.m., LPN 1 was observed to enter Resident 13's room, pull the privacy curtain between the residents, and perform a blood sugar test on Resident 30. A strong cigarette odor was immediately observed, cigarette smoke was observed in the room, Resident 13 was observed sitting up at the side of the bed while smoking a lit cigarette. Resident 30's oxygen concentrator was observer to be on, the oxygen tubing was not in use, and piled up in the bed. After approximately 5 minutes, the nurse was observed to pull back the curtain and had begun to exit the bedroom. At that time LPN 1 was asked about Resident 13 actively smoking a cigarette. The nurse indicated she did not notice the resident was smoking, and confirmed that Resident 30's oxygen concentrator was running. The nurse then told the resident he was not allowed to smoke in his room and threw the cigarette butt outside. The nurse indicated the resident was not allowed to have a cigarette lighter because he had a cognitive impairment and she was unsure how the resident obtained a lighter. The nurse further indicated the resident had been caught smoking in his bedroom prior to this day. The smoking resident was approximately 6 feet away from the running oxygen concentrator. On 4/21/22 at 12:15 p.m., Resident 30 indicated Resident 13 smoked in their shared bedroom all the time and he had asked him not smoke in the room because he did not want to 'explode' but he responded with profanities. During an interview on 4/21/22 at 12:20 p.m., LPN 1 indicated Resident 13 kept his pack of cigarettes with him at all times and was given a non-working cigarette lighter in order to manage negative behaviors related to smoking. On 4/21/22 at 12:30 p.m., Resident 13's clinical record was reviewed. The diagnoses included, but were not limited to: [CONDITION(S)], Alzheimer's disease, [CONDITION(S)] (stroke), and dementia. The Quarterly Minimum Data Set (MDS) assessment, dated 2/3/22, indicated the resident had moderate cognitive impairment. Resident 13's Outdoor Court Yard [sic] / Smoking Assessment, dated 9/13/22, indicated the resident was cognitively impaired with poor decisions-making skills, the resident had a pertinent diagnoses of dementia, Alzheimer's, anxiety, and the resident was aware he could not have any matches or lighters on his person. The most recent review, dated 2/3/22, indicated the resident continued to smoke unsupervised. A smoking care plan, initiated on 9/21/21 and current through 5/3/22, indicated the resident was able and approved to go outdoors on his own and would become upset if he had to wait to smoke. The interventions included but were not limited to, smoking policy given to the resident, resident oriented to smoking area and procedures, may obtain 2 cigarettes from nurse. On 2/15/22, Resident 13 signed the facility's smoking policy which indicated they understood and would follow the policy. On 4/21/22 at 1:00 p.m., Resident 30's clinical record was reviewed. The diagnoses included, but not limited to: [CONDITION(S)] (Chronic Obstructive Pulmonary Disease) and obstructive sleep apnea. Resident 30's April, 2022, current physician's orders indicated, on 9/29/21, the resident was ordered to have 4 liters of oxygen flowing via a nasal cannula. The Quarterly MDS assessment, dated 3/17/22, indicated the resident was cognitively intact. On 4/21/22 at 2:40 p.m., the Administrator provided the facility policy, Smoking and/or Vaping, undated, and indicated it was the policy currently being used by the facility. A review of the policy indicated, .Smoking and/or Vaping are not permitted inside the facility including but not limited to (resident rooms) . The policy further indicated unsupervised residents were allowed to keep cigarettes in their possession and all residents were not allowed to keep a lighter/matches. During an interview on 4/21/22 at 3:00 p.m., the Administer indicated he was not aware of Resident 13 smoking inside of the facility, however, they were aware of another resident smoking in the bathrooms. He further indicated residents were allowed to keep their cigarettes, however, they were not allowed to have lighters; somehow the lighters kept making their way back into the facility. The Immediate Jeopardy, that began on 4/21/22, was removed on 4/22/22 when the facility inserviced the facility staff and residents on the smoking policy, but the noncompliance remained at the lower scope and severity of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy because a systemic plan of correction had not been developed and implemented to prevent recurrence. 3.1-45(a)(1) 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure a sanitary environment in 4 of 4 resident shower/bathrooms used by 32 of 32 residents. Toilets were not anchored to the floors, dark substance was around toilet bases, a sink was not anchored to the wall, a floor drain was full of a dark liquid, and an odor of sewage was emitted in shower/bathrooms. (Northeast, Northwest, Southeast, Southwest) Findings include: 1. The Northeast resident shower/bathroom floor drain emitted an odor of sewage on the following dates and times: - 4/19/22 at 10:00 A.M., 12:20 P.M., and 3:10 P.M. - 4/20/22 at 11:15 A.M. and 2:50 P.M. - 4/21/22 at 10:15 A.M. and 3:00 P.M. - 4/22/22 at 11:30 A.M. and 2:00 P.M. 2. The Northwest resident shower/bathroom floor drain was full of a dark fluid which emitted an odor of sewage, the toilet was not anchored to the floor, and there was a dark substance around the toilet base on the following dates and times: - 4/19/22 at 10:05 A.M., 12:25 P.M., and 3:15 P.M. - 4/20/22 at 11:20 A.M. and 2:55 P.M. - 4/21/22 at 10:20 A.M. and 3:05 P.M. - 4/22/22 at 11:35 A.M. and 2:05 P.M. 3. The Southeast resident shower/bathroom toilet base was observed to have a dark substance around it on the the following dates and times: - 4/19/22 at 10:10 A.M., 12:30 P.M., and 3:20 P.M. - 4/20/22 at 11:25 A.M. and 3:00 P.M. - 4/21/22 at 10:25 A.M. and 3:10 P.M. - 4/22/22 at 11:40 A.M. and 2:10 P.M. 4. The Southwest resident shower/bathroom toilet was not anchored to the floor, a dark substance was observed around the toilet base, and the sink was not anchored to the wall on the following dates and times: - 4/19/22 at 10:15 A.M., 12:30 P.M., and 3:25 P.M. - 4/20/22 at 11:30 A.M. and 3:05 P.M. - 4/21/22 at 10:30 A.M. and 3:15 P.M. - 4/22/22 at 11:45 A.M. and 2:15 P.M. During an interview on 4/22/22 at 2:20 P.M., the Administrator indicated the resident shower/bathrooms were in need of attention to address the odor of sewage, dark fluid in the drain, unanchored toilets, dark substances around toilet bases, and unanchored sink. On 4/22/22 at 10:50 A.M., the Minimum Data Set assessment Coordinator provided the Resident Rights policy, undated, and indicated these were the Resident Rights currently used by the facility. A review of the Resident Rights indicated, .the facility must provide .a safe, clean, comfortable environment . 3.1-19(f)

Based on observation, interview, and record review, the facility failed to ensure a resident (Resident E) was free from abuse by another resident (Resident D) which resulted in an emergency room (ER) visit due to a facial laceration that required wound glue (medical adhesive) for wound closure for 1 of 1 resident reviewed for abuse. (Resident E) Findings include: On 11/9/21 at 11:10 a.m., Resident E was sitting in the dining room. He was observed to have a dime-size laceration (a tear in the skin) on his forehead. On 11/9/21 at 11:30 a.m., Resident D's clinical record was reviewed. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident D's Nurse's Progress notes indicated the following: -On 10/26/21 at 9:00 p.m., Resident D went out back alone. The nurse approached him and encouraged him to come back inside. Resident D became agitated and indicated he would, hurt his self [sic]. He began punching himself on the right side of his face and head. The nurse was able to redirect him back inside. Resident D became, more and more agitated. Once inside, he began yelling, cursing, and punching himself repeatedly on the right side of his face and head. A large hematoma (swelling of clotted blood within the tissues) appeared to the right upper forehead. The nurse took Resident D outside to smoke and he calmed down. -On 10/27/21 at 6:00 p.m., Resident D requested to be an unsupervised smoker. A smoking assessment was completed and he was determined to be safe smoking unsupervised. Resident D verbalized the understanding of the facility's policy and procedure related to smoking. -On 11/3/21 at 11:45 a.m., Resident D threw his meal trays out in the hallway when he does not like the food. -On 11/4/21 at 5:20 p.m., Resident D poured a coke over a peer resident. A physical altercation occurred. -On 11/4/21 at 10:30 p.m., Resident D was found in Resident E's room. Resident E was in bed. Resident D was yelling at Resident E and waving a fork around. When the nurse called for the Certified Nursing Assistant (CNA), Resident D stabbed Resident E with the fork on his forehead. Resident E had a small laceration to his forehead. Resident D's Social Progress notes indicated the following: -On 11/2/21, Social Services Director (SSD) was talking to Resident D in the hallway. Another resident came to SSD wanting to talk. Resident D was upset when other residents came to close. Resident D stomps around saying I'm talking to you. He started to point at the other resident and calling them names. -On 11/4/21, Resident D came in from smoking and poured pop on another resident's head. The other resident and Resident D had physical altercations. Later in the night, Resident D went into another resident's room. Resident D stabbed the other resident in the forehead with a fork. Resident D's Outdoor Court Yard / Smoking Assessment, dated 10/25/21, indicated the following: -He was not cognitively impaired with poor decision making skills. -He ambulated independently. Resident D's Social Progress Note: Resident Interview, dated 11/1/21, indicated the following: -He felt down, had trouble concentrating at times, and did not sleep well. -He had verbal and other behavioral symptoms. He had behaviors of hitting himself and getting upset when others are around when wanted to talk to staff. An admission care plan, initiated on 10/26/21 and current through target 1/26/22, for Resident D indicated: Problem: .Potential for aggressive behavior related to yelling out, throwing things, cursing at staff and other residents, punching self in face or hurting self 11/3/21 yelling @ [at] another Rd [resident] 11/4/21 incident with another resident .Goal: Resident will have no injury to self or others .Interventions: .psych [psychiatry] 15 minutes checks, 1:1 [one on one] prn [as needed], offer resident to go outside when appropriate. Resident D's Psychiatry Initial Consult, dated 11/4/21, indicated he had behaviors of irritability and frequent conflict with other residents since admission. His mental status exam indicated he was oriented to person, place, and situation and his thought process was intact. On 11/9/21 at 12:00 p.m., Resident E's clinical record was reviewed. The diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) assessment, dated 8/19/21, indicated Resident E had moderate cognitive impairment. Resident E's Nurse's Notes indicated the following: -On 11/4/21 at 10:30 p.m., upon entering Resident E's room, Resident D was standing over him yelling at him and waving a fork around. When the nurse yelled for other staff assistance, Resident D stabbed Resident E's forehead causing a 2 centimeter cut with bleeding. Resident D was removed from the room by staff. -On 11/5/21 at 12:00 a.m., Resident E returned from the ER. His laceration was closed with wound glue. Resident E's Emergency Department Progress note, dated 11/4/21, indicated he was sent from facility for a laceration to the forehead. Resident [D's name] stabbed him in the forehead . The wound was reapproximated (closed) in one layer utilizing wound glue. On 11/9/21 at 12:45 a.m., video surveillance was observed with the Administrator. The video surveillance, dated 11/4/21 at 10:13 p.m., observed Resident D ambulating by himself in the hallway and a peer resident was observed to have come out of the community bathroom. During an interview, at that time, the Administrator (ADM) indicated the peer resident observed Resident D go into Resident E's room. The peer resident went to the nurse and reported to the nurse Resident D had gone into Resident E's room. The nurse went to Resident E's room and found Resident D standing over Resident E, as Resident E was lying in bed. During an interview, on 11/9/21 at 12:00 p.m., CNA 1 indicated she had worked night shift on 11/4/21. Resident D had been on 15 minutes checks from a previous altercation from earlier that day. The nurse called out for help, because Resident D was in Resident E's room. When she got in Resident E's room, Resident D was standing over Resident E while he was laying in bed. Resident E's face was bloody. Resident D threw something under the bed. On 11/9/21 at 3:20 p.m., the Director of Nursing (DON) provided the facility's policy, Core Abuse Policy, dated 9/22/11, and indicated it was the policy currently being used by the facility. A review of the policy indicated, .To ensure that each resident is free of physical .abuse . This Federal tag relates to Complaint IN 503. 3.1-27(a)(1)

Based on interview and record review, the facility failed to provide prompt medical care to a resident who had a significant decline in physical health that resulted in unresponsiveness, acute [MEDICAL CONDITION], and the need for the resident to be lifelined from an acute care hospital to a higher acuity hospital for 1 of 1 resident reviewed for hospitalization (Resident B). The immediate jeopardy began on (MONTH) 16, 2019 when the facility failed to ensure a resident with a significant change in physical health condition, decreased oxygen saturation, and change in level of consciousness, was not provided prompt medical intervention. The Interim Administrator, the Social Services Director, and the Director of Nursing were notified of the immediate jeopardy at 4:15 p.m. on (MONTH) 3, 2019. The immediate jeopardy was removed on (MONTH) 4, 2019, but noncompliance remained at the lower scope and severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: During an interview, on 4/30/19 at 11:26 a.m., Resident B was observed to become tearful and indicated, I was left to die in my room. The Director of Nursing had refused to send me out to the hospital. I don't know why. My sister and my nurse wanted to send me out, but she blocked 911 from getting me. I was completely out of it and I don't remember anything, but I ended up being air lifted and coded in the helicopter. They were going to kill me. I was sent to (Hospital Name) and then I had to be sent to a rehabilitation hospital for 27 days. I have lost all of my strength and independence. I cannot use my arms, hands, legs, or feet like I once could. I can't walk or even stand. I don't know if I ever will be able to. I'm very upset. This place is not my home anymore. They want me out of here. On 5/2/19 at 10:00 a.m., Resident B's clinical record was reviewed. The [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment, dated 2/7/19, indicated Resident B was cognitively intact. Resident B's Nursing Assessment, dated 2/7/19, indicated the resident was independent and needed no help with locomotion (how the resident moved between locations in his/her room and adjacent corridor on the same floor. If in a wheelchair, self-sufficiency once in chair). The resident was a limited assistance of one staff member when he walked in his room, walked in the corridor, when he dressed himself, and when he bathed. The resident was an extensive assistance of one staff member with personal hygiene. A physician's orders [REDACTED]. Review of the Nurse's Notes indicated the following: -3/8/19 at 6:45 a.m., Res (Resident) left via transport . in electric w/c (wheelchair) to (Hospital Name) for cervical spine surgery . -3/14/19 at 2:40 p.m., readmitted rd (resident) from (Hospital Name) post op (operative) neck survey C3-T2 (vertebrae) decompression fusion. Cervical collar on . Res c/o (complained of) too weak to stand . Resident immediately went to sleep . -3/14/19 at 7:25 p.m., Res c/o pain (severe) Oxy ([MEDICATION NAME]) IR (immediate release) 15 mg (milligrams) given per order . -3/15/19 at 1:00 a.m., Oxy IR 15 mg given PO (by mouth) for severe pain surgical area. -3/15/19 at 1:30 a.m., [MEDICATION NAME] 5 mg PO given for muscle spasm. -3/15/19 at 9:00 a.m., Resident requested [MEDICATION NAME] 30 mg ER (extended release) be given at 12 N (Noon) and 12 AM (midnight). -3/15/19 at 8:00 a.m., B/P (blood pressure) 98/53 - P (pulse) 90, -R (respirations) 16, T (temperature) 97.4 SpO2 (amount of oxygen in the blood. Normal range 94-99%) 88% R.A. (on room air). O2 (oxygen) started per nurses discretion for comfort. Resp (respirations) shallow. Rd (resident) stated weak all over and muscle spasms. C/O neck pain 7-8 out of 10 scale. [MEDICATION NAME] (narcotic medication) 10/325 mg give at 9 am. SpO2 (up) to 95% (with) 2L (liters) of O2/NC (nasal cannula) . Rd very weak acting - not moving self as well as expected. Call put in to (Doctor Name) for instructions and clarification regarding narcotic orders. -3/15/19 at 12:00 p.m., B/P 88/68, P 101, R 14 (shallow) . [MEDICATION NAME] 30 mg ER held d/t (due to) V.S. (vital signs) and awaiting MD call back. -3/15/19 at 1:30 p.m., (Doctor's Name) nurse calls back and my concerns discussed regarding decrease VS and full code and my fear of over sedation . -3/15/19 at 7:20 p.m., pt (patient) very uncomfortable requested [MEDICATION NAME] giver per PRN (as needed) order. O2 sat (saturation) 91% (blood pressure) 100/59 (respirations) 18, (temperature) 97.9. 3/15/19 at 8:00 p.m., Res continually c/o pain neck, rectum, and right shoulder. [MEDICATION NAME] given per PRN order . just can't get him comfortable. Res called 911, operator phone me to check on him I tried to call (Dr's Name) to see what else he might want me to do. When I asked res where he hurt the most he stated, My rectum. 3/16/19 at 12:00 a.m., (Dr. Name) not called back yet. Oxy 30 mg given per routine order . 3/16/19 at 1:30 p.m., (Dr. Name) called DC'd (discontinued) [MEDICATION NAME] 30 mg . -3/16/19 at 10:00 a.m., Sister in to visit resident unable to stay awake was offered water multiple times was able to drink small amount . -3/16/19 at 12:00 p.m., Resident refused lunch X (times) 3 . -3/16/19 at 2:00 p.m., Sister stated she is going home if anything happens or you send him out to the hospital please call. -3/16/19 at 2:50 p.m., Resident requested to be send to hospital. VS (blood pressure) 113/80, (pulse) 84, (respirations) 17, (temperature) 98.8, O2 sat 90% . call placed to D.O.N. D.O.N. stated there's no reason to be sent to hospital if V/S are ok. Placed call to (Dr. Name) to let him know about the request to be send to hospital. reported V/S (Dr's Name) stated He is having anxiety does he have anything for that? . (Dr. Name) said to give the [MEDICATION NAME] for spasms/anxiety. Resident was given [MEDICATION NAME] 5 mg po. -3/16/19 at 5:27 p.m., VS (blood pressure) 82/47 - (pulse) 80 - (respirations) 17 - (temperature) 96.9 - (O2 sat) 89%. Notified (Dr's Name) and D.O.N. about resident's health (at) this time (Dr's Name) stated 'Just Monitor'. 3/17/19 at 8:30 a.m., (late entry for 3/16/19 at 8:30 p.m.) Pt (patient) unresponsive. O2 on (at) 4 L . BP 70/58, R 26, (temperature) 97.3, (O2) 78% on RA. Pt does not respond to sternal rub. Eyes rolled back in head. O2 on. 911 called. Pt sent to (Hospital Name). 3/17/19 at 2:00 a.m., Sister (Name) called et (and) notified that pt was being transferred to (Hospital Name) . During an interview, on 5/2/18 at 10:00 a.m., LPN 2 indicated they had known the resident very well and knew he was sick. She spoke with the MD (Medical Doctor) and the DON more than once, however, they said just to monitor. She told the next nurse to keep a really close eye on him. His sister was here during the afternoon and even was worried about him, because she noticed he was acting different. He was very lethargic and hard to wake up. During an interview, on 5/2/19 at 2:30 p.m., LPN 3 indicated the day shift nurse reported off to her she had wanted to send the resident out multiple times during her shift, however, the DON and MD did not want to send out the resident. The DON thought he was faking being sick and the MD thought it was an anxiety attack. I knew he was too sick to be back in the facility right after having spinal surgery. I think the DON was going to let him just die. I know there are people there that are afraid they will lose their jobs if they go against the DON. I didn't care though, I sent him out. Resident B's EMS (Emergency Medical Service) report dated, 3/16/19 at 9:15 p.m., indicated the resident was unresponsive upon arrival to the nursing facility. His skin was cold and clammy. Nurse stated that he returned with decreased level of consciousness yesterday. Facility staff notified his physician yesterday and was advised to resume medication as ordered. Patient was breathing shallow, skin was cold, pale, and clammy. Pupils were constricted. GCS (Glasgow Coma Scale is used to assess patients in a coma. The initial score correlates with the severity of [MEDICAL CONDITION] and prognosis. The Glasgow Coma Scale provides a score in the range 3-15; patients with scores of 3-8 are usually said to be in a coma.) was 6. Resident B's emergency room (ER) Hospital notes, dated 3/16/19, indicated resident was comatose upon arrival to the ER and appeared to have drug overdose. Given 2 doses of [MEDICATION NAME] (treat narctic overdose) without much change, the resident was diagnosed with [REDACTED]. When he arrived (his) GCS was 3; got up to 13.5 at one point, but was up and down. The resident was intubated (the process of inserting a tube, called an endotracheal tube (ET), through the mouth and then into the airway. This is done so that a patient can be placed on a ventilator to assist with breathing) and was lifelined out to a higher acuity hospital. I think that between 2 p.m. and 10 p.m., he had a very long spell just laying there, blood pressure drifting down, pulse was getting faster and [MEDICAL CONDITION] taking over . Discharge Condition: Critical, but improved, stable as we could make him for transfer. We did transfer by helicopter because I felt it was much better that trying to go with him by ground . Confidential interviews were conducted during the course of the survey. The confidential interview indicated Resident B had greatly declined since this incident and seems to have lost his will to live. He is very depressed, he cannot stand, walk, or use his body like he could before. He's not the same person. A staff member begged the DON and MD to send the resident out, however, they indicated they wanted to only monitor his condition. He had tried to call 911 the day before, but the DON refused him to go out. Staff indicated they believed the DON does not like the resident due to his sexual offender history and likely would have let him die. During an interview, on 5/3/19 at 12:15 p.m., the DON indicated she would never tell a nurse to not send out a resident, but I would tell them make sure they know what they are going to say to the hospital because sometimes they will send someone right back if they don't need to be there. When the nurse told her his vital signs she didn't think there was any reason to send him out. The DON indicated she was only informed of his vitals 1 time. Nurse's notes indicated the DON was notified of Resident B's vitals on 3/16/19 at 2:50 p.m. (blood pressure 113/80, pulse 84, respirations 17, temperature 98.8, and O2 sat 90%) and at 5:27 p.m. (blood pressure 82/47, pulse 80, respirations 17, temperature 96.9, and O2 sat 89%). On 5/4/19 at 10:00 a.m., the Interim Administrator provided the facility policy, Change in Condition Transfer/Discharge Policy, undated, and indicated it was the updated policy currently being used. A review of the policy indicated, Charge nurses will assess residents during their shift for . a significant change in the resident's physical, mental . status . any significant change in/or unstable vital signs . a significant change from baseline or recent level of consciousness such as agitation, lethargy, sudden lock of responsiveness . other significant changes from resident's baseline physical or mental status . The immediate jeopardy that began on (MONTH) 16, 2019 was removed and the deficient practice corrected on (MONTH) 4, 2019 when the facility implemented and in-serviced staff on a new Change of condition/transfer discharge policy and new form, but the noncompliance remained at the lower scope and severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy because a systemic plan of correction had not been developed and implemented to prevent recurrence. This Federal tag relates to Complaint IN 789. 3.1-37(a)

Based on interview and record review, the facility failed to ensure residents were able to communicate with the administrator without being verbally degraded and threatened with discharge from the facility which resulted in residents being tearful and indicating feeling like they lived in a prison rather than their home for 7 of 7 residents reviewed for abuse of 33 residents who resided at the nursing facility (Resident B, C, D, E, F, G, and H). Findings include: During an interview, on 4/29/19 at 1:56 p.m., Resident C indicated, We're not ever allowed to go out and smoke independently anymore. I have no idea why. We were allowed to, but 2 weeks ago she (Administrator) changed that on us. This is worse than a prison. I have not been able talk to the Administrator about smoking concerns, because she gets mad and argues with me. I've tried to talk to her about my concerns and she has threatened to, kick me out 7 or 8 times. She has said we can consider this, your 30 day's notice (notice of discharge) if I go to her with any problems. She's trying to get rid of me. During an interview, on 4/29/19 02:18 p.m., Resident D indicated, This place is awful! It's just like a prison! During an interview, on 4/29/19 at 2:42 p.m., Resident [NAME] indicated, We cannot go outside whenever we want. We have scheduled supervised smoke times, but we are not allowed to ever go outside by ourselves when not smoking. Sometimes I'd like to go outside and read a book, listen to the birds, or just be by myself. I can't do that. I feel trapped. I tried to make suggestions to the administrator, but she gets defensive and has refused to listen. During an interview, on 4/30/19 at 11:26 a.m., Resident B was observed to become tearful and indicated, the Administrator doesn't listen to any concerns and wants to get rid of me. I've had some outdoor plants that have been destroyed and some planting equipment that had been stolen and she told me that I should stop putting so much money into the garden out back. It's not home to me anymore. I don't know what to do. During an interview, on 4/30/19 at 10:35 a.m., Resident F was observed to be tearful, and her facial expression indicated sadness and distress. The resident indicated she used to be an independent smoker who had the door code and could go outside to get fresh air or smoke when she wished, but now everyone is supervised and she is not allowed outside except during scheduled times. This has been distressing to me, as I am very limited in what I am able to do. Having independence was my one freedom and was very important to my dignity and mental health. It is degrading to me. The facility Administrator had spoken to her on numerous occasions in a manner that made her feel, demeaned and non-cared for as a human being. During an interview, on 5/02/19 at 10:30 a.m., Resident G's facial expression indicated agitation and distress. The resident indicated, I used to be able to step out and smoke or just get some air when I wanted and then that changed and it feels like it's run like a prison. The place doesn't feel like home, because I don't have much independence anymore. It's like we are treated like bad kids being punished. During an interview, on 5/02/19 at 10:46 a.m., Resident C's facial expression indicated agitation and distress. The resident indicated, I used to be able to go out on my own and smoke or get fresh air, and enjoy the outside, but now I'm restricted on when I'm allowed to go outside. It can't be a safety issue, because there is a camera out there and a button to alert staff of any problems, if anything, it's safer to be out there because staff would know right away if there were any problems. This place feels like a prison and I've already served my prison time, so I don't think I should be made to feel like I'm in jail again, but that's what it feels like to me. On 5/2/19 at 4:05 p.m., Resident E's clinical record was reviewed. The [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment, dated 3/21/19, indicated Resident [NAME] was cognitively intact and the resident was independent with locomotion (how the resident moved between locations in his/her room and adjacent corridor on the same floor. If in a wheelchair, self-sufficiency once in chair.) and utilized a wheelchair for a mobility device. Resident E's, April, 2019, current physician's orders [REDACTED]. A Wandering/Elopement Risk Assessment, dated 3/14/19, indicated Resident [NAME] was not at risk for elopement/wandering. On 5/2/19 at 4:05 p.m., Resident D's clinical record was reviewed. The [DIAGNOSES REDACTED]. The quarterly MDS assessment, dated 4/4/19, indicated Resident 19 was cognitively intact, the resident was independent with locomotion, and utilized a walker and wheelchair for mobility devices. Resident D's, April, 2019, current physician's orders [REDACTED]. A Wandering/Elopement Risk Assessment, dated 9/25/17 and reviewed on 4/4/19, indicated Resident D was not at risk for elopement/wandering. On 5/2/19 at 4:05 p.m., Resident B's clinical record was reviewed. The [DIAGNOSES REDACTED]. The quarterly MDS assessment, dated 2/7/19, indicated Resident B was cognitively intact, the resident was independent with locomotion, and utilized a walker and wheelchair for mobility devices. On 5/2/19 at 4:05 p.m., Resident C's clinical record was reviewed. The [DIAGNOSES REDACTED]. The quarterly MDS assessment, dated 2/28/19, indicated Resident C was cognitively intact, the resident was independent with locomotion, and utilized a wheelchair for a mobility device. A care plan, initiated on 12/11/17 and current through target date 5/28/19, for Resident C indicated, PROBLEM Medication, Self-Administration. Resident has a physician's orders [REDACTED]. Resident has been assessed by Interdisciplinary care plan team to be capable of self administration insulin . A Wandering/Elopement Risk Assessment, dated 10/11/17 and reviewed 12/13/18, indicated Resident C was not at risk for elopement/wandering. A Smoking Assessment, dated 10/11/17, for Resident C indicated the following: -3/29/18, Rd (resident) cont (continues) to smoke safely in designated area. -6/21/18, Cont to be unsupervised smoker. -9/13/18, Cont on unsupervised smoking. 0 (No) risk. -12/6/18, Cont on unsupervised smoking 0 risk. -2/28/19, Cont on supervised smoking r/t (related to) smoking. On 5/2/19 at 4:05 p.m., Resident G's clinical record was reviewed. The [DIAGNOSES REDACTED]. The annual MDS assessment, dated 2/21/19, indicated Resident G had moderate cognitive impairment, the resident was independent with locomotion, and utilized no mobility devices. A Wandering/Elopement Risk Assessment, dated 2/19/19, indicated Resident G was not at risk for elopement/wandering. A Smoking Assessment, dated 3/20/18, for Resident G indicated the following: -6/8/18, Rd (resident) doing well (with) unsupervised smoking. -9/6/18, Rd cont (continues) on unsupervised smoking. -11/29/18, Rd cont to smoke unsupervised. 0 (no) decline. -4/23/19, (MONTH) smoke (with) supervision only. On 5/2/19 at 4:05 p.m., Resident F's clinical record was reviewed. The [DIAGNOSES REDACTED]. The quarterly MDS assessment, dated 3/21/19, indicated Resident 18 was cognitively intact. Resident F's, April, 2019, current physician's orders [REDACTED]. A Wandering/Elopement Risk Assessment, dated 7/12/18 and reviewed 3/21/19, indicated the Resident F was not at risk for elopement/wandering. A Smoking Assessment, dated 7/12/18, for Resident F indicated the following: -10/4/18, Rd (resident) cont (continues) to smoke unsupervised. 0 (no) problems. -12/27/18, Cont to smoke unsupervised (without) problems. -3/21/19, Cont to smoke per supervised smoke schedule. -4/26/19, Cont to smoke (with) supervision only per facility policy. Confidential interviews were conducted during the course of the survey. The confidential interview indicated the Administrator was very degrading and rude to residents. She has made the building feel just like a prison, because no one was allowed to go outside by themselves. Staff indicated the moral was very low among residents and the residents were afraid of retaliation from the Administrator if they speak out about any concerns. The Administrator has been unwilling to listen to residents or staff who make suggestions and she won't speak to anyone if she's mad. Staff gave the following examples: -The Administrator mocked a resident who was known to cry a lot. She made the exact same crying noise as the resident and said she is a faker towards the resident. -The Administrator has called residents sex offenders. -The Administrator has called residents, drug addicts. -The Administrator has threatened residents with a 30 day notice of discharge from the nursing facility if they disagreed with her. -The Administrator has not helped residents or touched anything they have. -The Administrator does not care about them (residents). -The Administrator has had the residents feel like they are in prison. The only things they looked forward to were food and smoking. Now they can't even smoke when they want to. -The Administrator has made the facility a very tense environment for staff and residents. This is not their home anymore. -Staff are not able to honestly tell the Corporate Staff their concerns out of fear of retaliation. It doesn't do any good. Nothing changes. On 5/2/19 at 9:30 a.m., the Interim Administrator provided statements from residents and staff in regard to the Administrator's treatment of [REDACTED]. -Resident H's statement indicated, Ordered pizza for lunch (Administrator's Name) said I could not have the meal tray also. When I found I had money stolen, (Adm Name) in a roundabout way made me feel like I done it myself . Resident B's statement indicated, (Adm Name) makes me feel like I wasn't welcome here anymore. I should find somewhere else to live. I should not put anymore $ (money) into gardening. I had tools stolen, (ADM Name) response was well maybe you shouldn't do it anymore. Plants were destroyed, (ADM Name) response was well maybe you shouldn't be doing it anymore . Resident E's statement indicated, I think (ADM Name) treats us different. I don't think she likes working here or with us. She listens to suggestions but before done talking, she turns us down. Has her own agenda and don't have our best interest in mind . Resident F's statements indicated, When (I) had items missing (I) asked to call police, (ADM Name) said no, why don't you go someplace closer to family. Some place with better care . -Resident C's statement indicated, (ADM Name) and (DON name) don't even look at me. (ADM Name) gave me hairy eye balls, mean mugging, trying to intimidate me every time I'm in the office and threatens with 30 days notice. -Resident D's statement indicated, (I) don't get along with (ADM Name), I think she is 2-faced. Nice to face, around corner talks s---, feel like I'm threatened to be moved from here. Threatened me a couple of times. (I) have done nothing to be moved . On 5/2/19 at 9:30 a.m., the Interim Administrator provided a Grievance/Complaint/Concern Report, dated 5/2/19, which was completed by staff. The report indicated, I witnessed my Administrator tell the resident (Resident H's Name) that when the state surveyor (Surveyor's Name) is here he needs to sit up straight and not slouch to the side of his chair. Since then I have heard her tell him on multiple occasions '(Surveyor's Name) here' followed by 'sit up.' This has been her way of teach (Resident 's Name) to sit up properly when state surveyors are here. Last week she had asked him how he had torn the side cushions to his brand new chair. She told him that she had some new ones ordered and that when '(Surveyor's Name)' was here he would use those but that any other time he would use the torn ones, that there was no use in ruining both sets. On one occasion (Resident H's Name) had tried to hand (ADM Name) his lap tray to be put on. She stepped backwards saying that he could do it, to put it on himself. As he struggled to do it himself I could clearly see he was getting frustrated so I approached him saying I would help. (ADM Name) put her arm out stopping me from stepping any further and said, 'I said he could do it, he can do it.' (ADM name) stood there for a few more minutes while watching him get frustrated. When she finally walked away (Resident H's Name) threw his lap tray on the floor. I was finally able to assist him with his tray. Another instance I would like to speak up about is regarding the resident council mtg (meeting). I am the meeting facilitator and a few days before our meeting (ADM Name) went around asking what could possibly be brought up asking if there were any complaints. After I gathered the residents while they were waiting to start their meeting (ADM Name) stepped in telling them to remember she had already addressed any complaints that they might have. When she returned to her office and shut the door . the Resident Council President started the meeting by saying that this was their meeting and their time to address concerns and to not be afraid to speak freely. It was the first month ever in my time here that the meeting was 'complaint free'. During an interview, on 5/1/19 at 3:45 p.m., the Administrator, Social Services Director, and Director of Nursing were informed of the allegations of abuse against the Administrator. During an interview, on 5/2/19 at 9:30 a.m., the Interim Administrator indicated the Administrator would be back in the building at 10:00 a.m. to complete Resident Rights and Abuse, training and give her statement. On 5/2/19 at 11:00 a.m., the Interim Administrator provided a written statement from the Administrator, dated 5/2/19. A review of the statement indicated, Seeking counsel on the matter, I contacted (Ombudsman Name) . In good conscious I can not (sic) allow residents to keep lighters on their person and smoke where they like, as this may put all residents safety at risk . During an interview, on 5/4/19 at 10:00 a.m., the Interim Administrator indicated his investigation was completed and the Administrator was terminated. On 5/2/19 at 4:05 p.m., the Minimum Data Set coordinator provided the facility policy, Resident Rights, undated, and indicated it was the policy currently being used. The policy indicated, All residents residing in this facility are entitled to retain their dignity and self respect. To them, we have both a moral and legal responsibility to communicate and preserve their rights with our very best effort. As a resident of this facility, you have the right to a dignified existence, self-determination . This facility must treat you with respect and dignity and care for you in a manner and in an environment that promotes maintenance or enhancement of your quality of life, recognizing your individuality. This facility must protect and promote your right to exercise these rights . Respect and Dignity: You have the right to be treated with respect and dignity . You have the right to be free from abuse, neglect, misappropriation of your property and exploitation . This Federal tag relates to Complaint IN 575. 3.1-27(a) 3.1-27(b)

Based on observation, interview, and record review, the facility failed to ensure that a resident maintained acceptable parameters of nutritional status, such as body weight and protein levels, which resulted in significant weight loss for 1 of 7 residents reviewed for significant weight loss. (Resident #10) and failed to ensure a resident, identified as nutritionally at risk received services to ensure adequate daily nutrition for 1 of 7 residents reviewed for weight loss. (Resident #3) Findings include: 1. On 1/26/15 at 12:13 p.m., Resident #10 was observed to eat less than 50% of her lunch in the main dining room. During an interview, on 1/27/15 at 9:51 a.m., RN #2 indicated, "Resident #10 has an order for [REDACTED]. Resident #10's clinical record was reviewed on 1/27/14 at 10:32 a.m. [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Care plans included, but were not limited to, the following: "DATE: 3/7/14. PROBLEM: At risk for decline in eating. GOALS: Rd (resident) to perform eating prog (program) TID (three times daily) with divided plate, large handled silverware.... INTERVENTIONS: 1. Provide verbal cues for resident as needed. 2. Monitor for any signs of choking or difficulty chewing. 3. Ensure that resident is sitting in an upright position. 4. Set up meals within reach. 5. Discuss at IDT (interdisciplinary team) weekly meeting if decline and make changes as appropriate. 6. Notify charge nurse with any concerns. 7. Restorative review quarterly. 8. Allow independence and praise accomplishment." "DATE: 7/26/13 (updated on 11/26/14). PROBLEM: chewing problem and swallowing problem. Hx (history): anorexia, poor intake of food and fluids. GOALS: Resident will consume adequate food and fluid intake without difficulty thru next review. APPROACH: Divided plate, slip mat, lrg (large) utensils, monitor for weight wkly (weekly), monitor food intake daily, monitor fluid intake, report loss or gain of 5% in 1 mo (month), 7.5% in 3 mo (months), or 10% in 6 mo (months) to physician and family, assist with opening packets, provide at least 2000 cal (calories) a day." "DATE: 7/11/13 (updated on 11/26/14). PROBLEM: Insufficient caloric intake. Insufficient fluid intake. GOAL: Resident will remain free of complications r/t (related to) use of a feeding tube AEB (as evidence by) no s/s (signs/symptoms) of aspiration, no nausea/vomiting/diarrhea, and no abdominal distention through next review. APPROACH: Administer tube feeding an flushes as ordered. Report to the physician: Complication/side effects of tube feeding or significant weight changes.... [MEDICATION NAME] 1.5 cal/can 10 p.m. and 2 a.m." The "Weight Flow Sheet" for Resident #10 indicated the following: On 05/05/14, the resident weighed 137.0 pounds. On 06/09/14, the resident weighed 134.1 pounds. On 07/07/14, the resident weighed 128.4 pounds. On 09/01/14, the resident weighed 119.5 pounds. On 10/06/14, the resident weighed 115.2 pounds. On 11/06/14, the resident weighed 119.6 pounds. On 11/24/14, the resident weighed 120.4 pounds. On 12/02/14, the resident weighed 104.1 pounds. On 12/08/14, the resident weighed 105.2 pounds. On 12/14/14, the resident weighed 104.6 pounds. On 12/22/14, the resident weighed 105.2 pounds. On 12/29/14, the resident weighed 103.4 pounds. On 01/05/15, the resident weighed 103.8 pounds. On 01/12/15, the resident weighed 104.0 pounds. On 01/19/15, the resident weighed 101.0 pounds. On 01/26/15, the resident weighed 101.4 pounds. During this time the weight sheet did not indicate the physician, family, or dietary was notified of weight loss. Resident #10's lab reports indicated the following: On 11/3/14, the resident had a total serum protein of 5.3 (reference range 6.3-8.2), and [MEDICATION NAME] level of 3.0 (reference range 3.2-4.8). On 12/29/14, the resident had a magnesium level of 2.3 (reference range 1.7-2.2). The DON (Director of Nursing) provided, on 1/29/15 at 11:30 a.m., the RD's (Registered Dietician) "Dietary Progress Note" and "Nutritional Screening and Assessment" form for Resident #10. The dietary note, dated 10/20/14, indicated, "Wt (weight) 119 lbs (pounds), weight decrease of 15.1 lbs (11%) in 180 days- significant wt. loss. Wt fairly stable for 1 month. Diet change to puree consistency 9/16/14. Resident utilizes a divided plate and large utensils. PO (by mouth) intake averages (equivalent) 50% of meals. Resident continue to receive supplement of [MEDICATION NAME] 1.5 at 10 p.m. and 2 a.m. providing 710 calories and 30.2 gm (grams) of protein. Will continue to monitor po intakes and wts." The RD "Nutritional Screening and Assessment," dated 11/14/14, indicated the following, "Avg (average) consumption of meals: 25-50%.... Recommend diet (change), new diet recommend: (increase) [MEDICATION NAME] bolus feeds to 3 cans/day or TID (three times daily). Resident insidious weight loss and PO intake overtime, rec (recommend) to increase [MEDICATION NAME] 1.5 to TID to provide 720 mls and 1080 kcal's." This form was signed by the RD and the Dietary Manager (DM). The physician's recapitulation orders for the months of November, December, and January 1st through the 28th, indicated Resident #10 received [MEDICATION NAME] 1.5 twice a day, at 10:00 p.m. and 2:00 a.m. The Medication Administration Records (MARs) did not indicate an order reflecting the RD's order for an increase in [MEDICATION NAME]. During an interview, on 1/28/15 at 2:56 p.m., the DON indicate she did not know about the RD's order to increase the [MEDICATION NAME] to three times a day. During an interview, on 1/29/15 at 1:18 p.m., the NP (Nurse Practitioner) indicated, "The reason she lost all of the weight was due to the resident wheeling herself around in her wheelchair. Her bowel regimen was changed around that time and since then her weights have stabilized." The NP also indicated, "I think we tried to increase her to 3 cans of [MEDICATION NAME] a day on a trial basis, but I don't think she would keep it down, I guess we can try it again." The chart lacked documentation or any order which indicated an increase to 3 cans of [MEDICATION NAME] was attempted. When the lack of documentation was brought to the NP's attention, she was observed to write a physician's orders [REDACTED].) D/C (discontinue) current order for feeding. 2.) [MEDICATION NAME] 1.5 1 can (at) 8 p.m., 12 a.m., and 4 a.m...." During an interview, on 1/29/15 at 2:52 p.m., the RD indicated she fills out the "Nutritional Screening and Assessment" forms electronically for the residents and then emails the results to the DM and Administrator. The RD indicated she had trouble communicating the forms with the DON, but thinks it's corrected at this time. During an interview, on 1/29/15 at 3:14 p.m., the DON indicated, "The RD sends the form to either the administrator or DM and who ever gets the form is supposed to give it to me. We had a problem with the forms getting to me for awhile, but I got the January notes in my mailbox so I think we're getting better." During an interview, on 2/2/15 at 11:10 a.m., the DON indicated, "Doctor (Name) comes in every month and we review weights with him when he comes in." On 1/29/14 at 1:27 p.m., the DON provided the policy Nutrition Risk Program, revised on 12/3/13, and indicated the policy was the one currently used by the facility. The policy indicated, "...2. If a resident experiences a weight loss of 5% or more in one month, 7.5% in three months or a 10% weight loss in six months, which was not anticipated loss, Family (sic) and physician will be notified. 3. Interventions will be put in place to prevent further weight loss/gain. 4. Interventions may include, but not limited to, weekly weights; supplement shakes; MedPass; fortified cereal; double portions at meals..." 2. Resident #3's clinical record was reviewed on 1/30/15 at 8:30 a.m. [DIAGNOSES REDACTED]. On admission 6/2/14, Resident #3's Body Mass Index (BMI) was 21.6% and his Ideal Body Weight (IBW) on admission was 117-143 pounds. Resident #3's admission's weight was 139 pounds and current weight dated 1/9/15, was 131 pounds. That was a 8 pound weight loss. The current Minimum Data Set (MDS) assessment dated [DATE], indicated a Brief Interview of Mental Status (BIMS) score of 99, when 8-15 was interviewable and cognitively intact. Resident #3 needed setup only of staff for meals set up and supervision for encouragement with meals. Review of Nutritional Screening and assessment dated [DATE], the Dietary Manager (DM) indicated, "... weight 139 pounds on admission, ... (Body Mass Index) BMI of 22.7, ... able to feed self." The range for BMI was Underweight: < 18.5, Normal weight: 18.5 - 24.9, Overweight: 25 - 29.9, Obese: = 30. On 1/29/15 at 2:28 p.m., the DM indicated Resident #3 had August 2014, BMI of 23.09; November BMI of 22.56; December BMI of 21.59; and Current BMI of 21.83. Review of admissions dietary assessment dated [DATE], indicated "... weight 138.6, current appetite average, 100% of snack intake, ... independent in eating, ... no low lab levels ... resident refuses supper meal and does not want assistance, resident at snack machine frequently. 11/20/14 weight 135.4 ... refused snack intake, ... independent of eating, ... resident refuses most meals and snacks. Frequently eats snack from the vending machine." Review of the Dietary Progress notes dated 1/29/15, Resident #3 had a August BMI of 23.09 %, November 22.56%, December 21.59% and January BMI 21.83% Quarterly dietary progress report dated 11/20/14, indicated, Resident #3 refuses most meals and snacks. Frequently eats snacks from the vending machine." Careplan dated 11/26/14, "AT RISK FOR ALTERED NUTRITION RELATED TO [MEDICAL CONDITION], DM type II (diabetes mellitus) , RESIDENT WILL CONSUME FOOD AND FLUIDS ADEQUATE TO MAINTAIN STABLE BODY WEIGHT THRU NEXT REVIEW, 1. ...DIETARY LIKES, DISLIKES, EATING HABITS , ... 3. MONITOR WEIGHTS MONTHLY, 4. REPORT WEIGHT LOSS,.. 5%(1 MON), 7.5% (3 MON), 10% (6 MON) TO PHYSICIAN/FAMILY, 5. ADD TO AT RICK LIST IF WEIGHT LOSS/GAIN OCCURS FOR FURTHER DIETARY RECOMMENDATIONS, 6. MONITOR FOOD CONSUMPTION DAILY, 7. PROVIDE HS (HOUR SLEEP) Prefers to dine in his room Eats out of vending machine. Refuses meals on daily Basis." Review of food and fluid intake records dated June-October 2014, indicated Resident #3 constantly refused supper (evening meal) and evening snack. The November 2014-January 2015, indicated Resident #3 had declined in eating all meals and snacks. On 1/29/15 at 12:54 p.m., interview with DON indicated Resident #3 refuses meals often due to paranoid. He will get things out of the vending machine or he will have staff go out and get him something to eat. On 2/2/15 at 10:40 a.m., the DON indicated there was no documentation for Resident #3's meal consumption, because he usually gets items out of the vending machine or will send staff to get him something to eat outside of the facility food. On 2/2/15 at 3:00 p.m., the DON indicated, "He can tell us his nutritional needs are being met. He has the right to eat what he wants and we don't document it." There was no care plan intervention provided to ensure Resident #3 received adequate nutrition daily when he refused to eat or would only eat food from the vending machine. On 2/2/15 at 2:58 p.m., the DON provided policy "NUTRITION RISK PROGRAM" revised date 12/3/13 and indicated that was the policy currently used by the facility. The policy indicated, "... It is the policy of this facility to monitor the weight status of each resident to ensure weight remains stable and that appropriate interventions are initiated should weight decline. ...3. Interventions will be put in place to prevent further weight loss, ... 4. Interventions may include, but not limited to, weekly weights; supplements shakes; Med pass; fortified cereal; double portions at meals; ..." 3.1-46(a)(1)

Based on interview and record review, the facility failed to ensure residents at high risk of falls were supervised to prevent repeated falls for Resident #101 and #100, resulting in Resident #100 receiving a laceration that required Durabond (glue used in place of sutures), for 2 of 5 residents reviewed for falls in the sample of 7. Resident #100 and #101 Findings include 1. The clinical record for Resident # 100 was reviewed on 12/14/11 at 9:30 A.M. The record indicated Resident # 100 had [DIAGNOSES REDACTED]. The MDS (minimum data set) assessment, dated 12/6/11, indicated Resident # 100 had short and long term memory problems and severely impaired cognition. Resident # 100 required extensive assistance of one with transfers and ambulation. Resident # 100 had fallen two or more times since the previous assessment with one fall resulting in injury. The Nurses Notes, dated 11/28/11 at 2:30 P.M., indicated "....Transfers done with 2 A (assist) to BR (bathroom)...low PVC bed with mat to floor initiated R/T (related to) freq (frequent) falls at hospital." A Fall Risk Assessment, dated 11/28/11, indicated a score of 16. The form indicated "Total score of 10 or above represents HIGH RISK." A care plan, dated 11/28/11, indicated a problem of "Potential for injury: Fall risk related to post CVA, cognitive deficits weakness." The interventions were "Keep call light and most frequently used personal items within reach. Provide verbal reminders to resident to call when needing assistance. Maintain room and pathways free of clutter, and insure (sic) adequate lighting provide night light if needed. Toilet resident per schedule and request. PT/OT (physical therapy/occupational therapy) evaluation as indicated. Make sure resident's shoes are well fitting with non-slip soles. Modify clothing if necessary. Educate resident in safety awareness. Assess medications for contributing factors. Maintain record of falls, and evaluate for patterns. Make sure that all staff members are aware that resident is at high risk for falls. 11/28/11 Tab alarm in bed. 11/28/11 PVC bed with mat." A Physician order, dated 11/28/11, indicated "Tab alarm while in bed and w/c to decrease risk of fall R/T (relate to) weakness dx (diagnosis) of CVA." The Nurses Notes, dated 11/30/11 at 1:00 P.M., indicated "resident restless in w/c (wheelchair), stood up and slid from w/c in dining room no injury noted, self release belt initiated per orders." A Physician order, dated 11/30/11, indicated "Self release belt while up in w/c." The fall care plan was updated on 11/30/11 to include the intervention of "Self release belt w/c." The Nurses Notes, dated 12/1/11 at 5:05 A.M., indicated "Res (resident) released self release belt and stood up and fell to floor hitting her L (left) eyebrow resulting in a l" laceration...Neuro check WNL (within normal limits) did note L pupil is smaller than R (right) but both = (equal) and reactive to light...order received to send to (hospital name) for eval (evaluation)..." The Nurses Notes, dated 12/1/11 at 9:00 A.M., indicated "Rd (resident) returned from ER (emergency room ) visit. Durabond in place to L eyebrow area..." The Nurses Notes, dated 12/2/11 at 3:30 P.M., indicated "Res alert with confusion...Requires extensive assistance with ADLs (activities of daily living)...Res continues to take off self release belt and tries to get up..." A Physician order, dated 12/2/11, indicated "Lap buddy to w/c." The fall care plan was updated on 12/2/11 to include the intervention of "Lap buddy to w/c." The Nurses Notes, dated 12/4/11 at 11:15 A.M., indicated "resident was reported to have shoved herself from the table in the dining room and tipped her chair over backwards hit her head on floor..." The Nurses Notes, dated 11:45 A.M., indicated "Pt (patient) was in the Dr (dining room) with other pts when she pushed against the table to push herself away et her chair (wheelchair) tipped backwards. Pt hit her head on the floor. No open areas noted. (goose egg) hematoma approximately 4 cm to the occipital area..." On 12/14/11 at 10:20 A.M., the Director of Nursing indicated Resident # 100 had only tipped her wheelchair backwards one time. She stated she could not remember if the resident had a lap belt or a lap buddy in place. She indicated when she had assessed Resident # 100 at the hospital, she knew that the resident would need a restraint. On 12/14/11 at 10:30 A.M., the Director of Nursing provided a Resident Incident Report of Known/Unknown Etiology, dated 12/4/11, which indicated "...Pt shoved herself away from the table in the dining room tipping her chair over backwards, hitting her head on the tile floor. No open areas...has a golf ball size/goose egg to back of head...Immediate interventions put in place to prevent further recurrence: Pt had lap belt on et (and) lap buddy on the chair. Pt moved to the nurses station Pt has been entering into others rooms et redirected many times. Neuros initiated, met with family regarding getting resident to more controlled environment staff instructed not to lock w/c..." In an interview, on 12/14/11 at 11:00 A.M., the Director of Nursing indicated she had not intended to restrain Resident #100 with three different restraints. She stated the resident was able to release the lap belt at times so that was why the lap buddy was started, but the family wanted both restraints on her. She stated the resident was in an activity at the time of the incident. 2. Review of Resident #101's clinical record on 12/14/11 at 9:30 a.m. indicated the following: Resident #101 had [DIAGNOSES REDACTED]. Fall risk assessments dated 11/03/11 and 11/12/11 indicated Resident #101 was a high risk for falls. A nurse's note, dated 11/06/11 at 6:30 p.m., indicated Resident #101 was walking back from group and stubbed his shoe on a landscape stone causing him to lose his balance and fall onto his left "hip/thigh et elbow." The nurse's note indicated Resident #101's only injuries from this fall were superficial scrapes to his left elbow. Interview of the DON (Director of Nursing) on 12/14/11 at 11:00 a.m. indicated the intervention for this fall was to show the resident where the stones were and directing the resident to watch for the stones and watch where he was walking. A nurse's note, dated 11/09/11 at 7:30 a.m., indicated, "Res (Resident #101) sat in floor beside bed. 0 (No) apparent injuries....(Resident #101.) ambulates (walks) per self c (with) unsteady gait at times....." A nurse's note, dated 11/12/11 at 6:20 p.m., indicated, "Rec'd (Received) report that res had fallen in outside sheltered area. Upon entering area noted res sitting on base floor of smoking area between stationary chair et a co-resident seated in w/c (wheelchair)....Denies pain or discomfort. States that he hit his arm on co-resident's w/c. Note skin tear to posterior (R) (right) hand c small amt (amount) bleeding....Res ambulates to room accompanied by CNA et reminded to use call light to request assistance as needed." A nurse's note, dated 11/14/11 at 11:10 a.m. indicated, "Resident attempting to sit down in dining room (sic) when moving from walker to chair, sat down on arm of dining room chair, lost balance & fell to floor, abrasion on (R) elbow....Walker removed....notified PT (physical therapy) for further evaluation and teaching...." Interview of the DON on 12/14/11 at 11:00 a.m. indicated Resident #101. would not cooperate with therapy. A nurse's note, dated 11/18/11 at 10:20 p.m., indicated, "Resident was found in (sic) floor (sic) sitting beside bed. When ask (sic) what happened resident stated 'When I went to get up I slid'...Voices 0 c/o (complaints of ) pain. Noted area scraped on outside of (L) (left) leg knee area...." An incident report, dated 11/18/11, was provided by the DON on 12/14/11 at 11:40 a.m. The incident report indicated the intervention for this fall was, "Applied magnetic clip alarm in bed. Referral to PT for screen." A nurse's note, dated 12/01/11 at 3:10 a.m., indicated, "A CNA went to Res room to toilet him. He (Resident #101) was sitting on his bed & told CNAs he fell and hit his head. Slt (Slight) pink area on (L) forehead, ROM (range of motion) WNL ('within normal limits). 0 (No) other areas." An incident report, dated 12/01/11, was provided by the DON on 12/14/11 at 11:40 a.m. The incident report indicated the intervention for this fall was to educate the resident to use his call light and to keep his call light within reach. The incident report lacked documentation supporting whether or not the clip alarm sounded when the resident fell . Interview of the DON on 12/14/11 at 11:50 a.m. indicated the DON was not aware of whether or not the resident's alarm sounded when he fell on [DATE]. A nurse's note, dated 12/04/11 at 5:15 a.m., indicated, "CNA went into (Resident #101's) room to toilet res & found him sitting on floor leaning against his bed, (sic) he stated he slid down side of bed. Denies pain...." The nurse's note indicated the resident sustained [REDACTED]. An incident report provided by the DON on 12/14/11 at 11:40 a.m. indicated the intervention for this fall was to speak with the resident in regards to asking for assist & spoke c CNAs about toileting him more frequently. Interview of the DON on 12/14/11 11: 50 a.m. indicated Resident #101. had a "neurological thing going on." The DON indicated no time frames were given for how often the resident was to be toileted. A nurse's note, dated 12/05/11 at 10:00 a.m., indicated, "resident (sic) found on floor beside bed, reports ' I was going to the bathroom,' clip alarm in place (sic) disengaged, resident placed in low bed c mat on floor, no injuries noted...." An incident report provided by the DON on 12/14/11 at 11:40 a.m. indicated, the interventions for this fall were to place the resident in a low bed with mat to floor and place a motion alarm on resident to alarm when removing self from bed. An MDS (Minimum Data Set) assessment, dated 12/03/11, indicated Resident #101's cognition was severely impaired; the resident required supervision when walking, the resident had sustained 2 or more falls since admission; the resident was not on a toileting program; and the resident's balance when walking was not steady. A care plan, dated 11/04/11, indicated Resident #101 was at risk for potential injury and was a fall risk related to his cognitive deficits and weakness. The fall care plan included the following interventions: 11/12/11 - PT screen requested for potential for walker to assist in ambulation, 12/3/11 - Pressure alarm to bed (This intervention had a line drawn through it), 12/5/11 - Clip alarm while in bed, 12/5/11 - Motion sensor to bed, 12/5/11 Low bed c mat @ bedside...." Review of physical therapy progress records dated 11/15/11, 11/16/11, 11/17/11, and 11/18/11 indicated Resident #101 refused therapy. 3.1-45(a)(2)

Based on interview and record review, the facility failed to ensure allegations of mistreatment voiced by staff members were immediately reported to the Administrator and thoroughly investigated, for 2 of 3 residents reviewed for mistreatment in the sample of 3 (Residents A and B). This had the potential to affect all 33 of 33 residents residing within the facility. The Immediate Jeopardy began on 7/8/11 when a LPN used a gait belt to keep a resident from getting up from his chair and was not suspended pending an investigation resulting in another resident being tied to a chair with a bed sheet by this same LPN on two different days. The staff working with the LPN did not report this to the Director of Nursing or Administrator immediately, resulting in a delayed investigation of the mistreatment and allowed the LPN to continue to work on the floor with the residents. The Administrator was notified of the Immediate Jeopardy at 4:30 P.M. on 9/22/11. The immediate jeopardy was removed on 9/19/11, but noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include 1. The clinical record for Resident B was reviewed on 9/22/11 at 12:50 P.M. The record indicated Resident B had [DIAGNOSES REDACTED]. The MDS (minimum data set) assessment, dated 8/25/11, indicated Resident B had short term memory problems and had moderately impaired decision making. Resident B required limited assistance of one with bed mobility, transfers and ambulation. The Nurses Notes lacked any documentation from 7/6/11 to 7/13/11. The Social Services Notes lacked any documentation from 7/6/11 to 7/19/11. In a telephone interview with CNA # 5, on 9/22/11 at 10:10 A.M., she stated about 3 or 4 months ago, LPN # 1 had tied Resident B in his wheelchair, and she had contacted the Administrator by telephone. She indicated he told her to remove the restraint from Resident B immediately. She stated she did not know why LPN # 1 had placed the gait belt on Resident B. In an interview with the Administrator, on 9/22/11 at 10:15 A.M., he indicated CNA # 5 had called him immediately when LPN # 1 had placed a restraint across Resident B. He indicated he had contacted the interim Director of Nursing and she had contacted LPN # 1 and told her not to do it again. He further indicated he had contacted the Interim Director of Nursing and she had contacted LPN # 1 at the facility and told her this was not allowed. In interview with the interim DON on 9-22-11 at 10:55 a.m., she indicated she first began working at this facility in July 2011. She indicated she received a phone call from the Administrator some time in July regarding Resident #B. She indicated she recalled this resident had been in his wheelchair and facility staff had placed a gait belt across the arms of the wheelchair. She indicated the phone call was received while driving home. She indicated she spoke to a (an unidentified) CNA (Certified Nursing Assistant) who had immediately reported this to the Administrator and then spoke with LPN #1. She indicated she recalled LPN #1 said the gait belt "wasn't touching his skin." She indicated she had told LPN #1 that the gait belt was preventing him from getting out of the wheelchair, so would be considered a restraint. She indicated LPN #1 then told her the gait belt had already been removed. On 9/22/11 at 11:05 A.M., the Interim Director of Nursing provided a statement, dated 7/9/11, which indicated "July 9, 2011. Approx. (approximately) 5:30 P CST (LPN # 1 name) This nurse received a telephone call from the Administrator 7/8/11, stating that he had received a telephone call concerning (LPN # 1) placing a gait belt across the armrests of (Resident B) wheelchair. This nurse called the facility and asked the CNA that answered the telephone, if she had placed a gait belt on (Resident B) in that fashion. The CNA stated that she had for a minute, but (Administrator name) told her to take it off. (LPN # 1) was asked about the incident, she stated to this nurse that she had placed it on the chair, then thought differently of it, and removed it after a CNA had told her she couldn't do that. (LPN # 1) was verbally counseled over the telephone that it was illegal and that she could lose her license for unwillingly restraining that resident. She stated it was not touching the resident. I instructed her that it prevented him from rising and considered a restraint. CNA at the facility stated that (LPN #1) was told she was doing wrong and immediately removed it...When CNA was asked how long the resident had belt across his chair, they state that it was immediately taken off." The Interim DON indicated there was no further investigation of the incident and LPN # 1 was not suspended pending investigation. 2. The clinical record of Resident A was reviewed on 9-21-11 at 2:33 p.m. His [DIAGNOSES REDACTED]. Review of Resident A's most recent Minimum Data Set (MDS) assessment, a significant change assessment dated [DATE], indicated a moderate cognitive impairment. It indicated he was able to move about the facility without assistance with the use of a wheelchair or walker. The MDS indicated no mood or behavioral issues. Nursing notes, dated 9-13-11 at 1:30 a.m., indicated Resident #A was in and out of his wheelchair, talking loudly and demanding breakfast. On the same date at 11:15 a.m., notes indicated he was weepy at times, and not oriented to time. On 9-14-11 at 12:00 a.m., nursing notes indicated he was "tearful one moment, agitated the next. Very confused...cursing...delusional." On 9-15-11 at 11:00 p.m., nursing notes indicated Resident #A was, "Talking loudly, packing his belongings. Res (resident) thought this nurse was putting 'handcuffs' on him (sign for with) wrist monitor B/P (blood pressure cuff). On 9-16-11 at 9:15 a.m., nursing notes indicated Resident #A "continues to remove clip alarm & refuses to use, 'I will get up whenever I want to.'" On same date at 10:30 a.m., notes indicated the resident was sent to an area emergency room for evaluation and treatment after a fall. On the same date at 3:35 p.m., nursing notes indicated he returned from the emergency room with no apparent injury. On 9-17-11 at 7:30 p.m., nursing notes indicated, "Resident has been yelling. Delusional. Threatening staff. Rolling (signs for up and down) halls in w/c (wheelchair) yelling, 'call 911, call 911, I want to go to jail.' Unable to calm resident, swinging fist @ (at) staff." Notes indicated a nurse practitioner was contacted who provided a one time order for [MEDICATION NAME] (an anti-anxiety medication) to be given at that time. Nursing notes one hour later indicated the resident had calmed down, but remained up in a chair. Nursing notes on 9-18-11 at 6:00 p.m. indicated the resident was, "very agitated, tense, non-redirectable, paranoid, threatening staff." It again indicated a nurse practitioner was notified and ordered the same medication as the evening prior. Nursing notes for 9-19-11 were not present. Nursing notes for 9-20-11, with no time listed, indicated Resident #A continued to be tense, argumentative, non-cooperative and non-redirectable. On the same date at 10:00 p.m., notes indicated the resident was apologetic. Nursing notes indicated earlier in the shift, the resident had been belligerent, yelling out and cursing. During interview with the Administrator on 9-21-11 at 4:05 p.m., he indicated Resident #A was waiting for him when he came into the building on Monday, 9-19-11, around 9:30 a.m. He indicated this was something the resident did on a regular basis. He indicated Resident #A told him the "weekend nurse was mean to him and tied him to a bed." He indicated he immediately began an investigation. He indicated he had RN#1 come in and "he told her the same thing." The Administrator indicated he was unsure exactly when this (the allegation of abuse) took place, "just over the weekend." He indicated he spoke with the nurse involved (LPN #1), and "she admitted that she did use a sheet to restrain (name of Resident #A)." He indicated LPN #1 was terminated. In interview with the interim Director of Nursing (DON) on 9-21-11 at 4:05 p.m., she indicated, "A lot of what we have so far as an investigation is only alleged." She indicated that it was determined the resident had been restrained with a sheet into a geri-chair, not a bed. She indicated LPN #1 "allegedly told someone about the restraints that she might get fired over this." She indicated the facility spoke to as many of the staff on duty as possible. She indicated, "The aides seemed to be uncomfortable reporting anything." She indicated LPN #1 apparently made a reference to using a sheet (for a restraint) to the other nurse at shift change. The DON also provided a nursing schedule which indicated LPN # 1 had worked on 9/17 and 9/18/11 from 5:00 P.M. to 5:00 A.M. both days. In an interview with RN # 1, on 9/22/11 at 9:30 A.M., she indicated the first time she had heard anything concerning Resident A being tied down with a bed sheet was when the resident reported it to the Administrator on 9/19/11. She indicated she had been in the facility on both 9/17 and 9/18/11 between the hours of 3:30 P.M. to around 7:00 P.M. to help out. She stated she had not seen Resident A tied with a bed sheet. She further indicated that no staff had reported to her that Resident A had been tied in a chair. In an interview with the Administrator, on 9/22/11 at 10:00 A.M., he indicated he had spoke with several staff members during the investigation. He paraphrased the following written statements for the following: RN # 1- stated she was aware Resident A was tied to a chair with a sheet during shift change on 9/18/11. CNA # 1- stated she thought RN # 1 was aware Resident A was tied with a sheet. She stated Resident A was checked at 7:30 P.M. and was tied to the chair at that time. CNA # 2- stated didn't know anything about it. CNA # 3 had seen Resident A tied in chair on Saturday at 8:00 P.M. CNA # 4- had seen no restraints during the weekend. The Administrator provided a Grievance/Complaint/Concern Report, dated 9/19/11, which indicated "Resident Name: (Resident A)...Person Filing Report: (Administrator's name)...9:30 AM Resident came to Administrator's office reported that he was tied to bed last 2 nights by the night shift nurse. I told resident that I would investigate and get back with him. I had DON (Director of Nursing) come to my office so that Resident could tell her so we could start investigation ...Measures take to resolve this grievance/complaint/concern: I instructed DON to get list of employees that worked and phone numbers and to talk to and to have them all fill out statements DON came back to my office and stated nurse (RN # 2 name) stated (LPN # 1) night shift nurse told her she had tied Resident to chair with a sheet and would probably get fired. I interviewed (RN # 2 name) and she stated (LPN # 1) did tell her that. Called (LPN # 1) at 2:23 p.m. asked her about (Resident A) she said I did tie him up Saturday [DATE]. I told LPN # 1 that's abuse and you are terminated at this time. 2:45 (LPN # 1) called back and said she would never hurt a resident and was trying to protect him. I restated you can not tie up residents. Started inservicing staff again on abuse." Attached to this was a written note, dated 9/18/11, which indicated "8 AM (Resident A) said he was tied down last night. 6 PM Nurse said resident was having behaviors after my shift ended. She ordered [MEDICATION NAME] IM (intramuscularly) one time only. She stated that she may get fired but she tied him to chair with sheet because she didn't know what else to do he was kicking and hitting at the girls. She said she had to do this the night before also. I asked if she called DON. She said she did and that DON said we would see if we could get him to behavior unit." In a telephone interview with CNA # 5, on 9/22/11 at 10:10 A.M., she indicated over the weekend Resident A had increased behaviors and had to have a shot both evenings. She stated she was aware Resident A had been tied to a chair both days with a sheet. She stated she thought it was about 1 to 2 hours each evening. In an interview with RN # 2, on 9/22/11 10:20 A.M., she stated LPN # 1 had told her she had tied Resident A to a chair with a bed sheet on 9/19/11 during shift change. She further indicated LPN # 1 had informed her she had done this before. She stated she had asked LPN # 1 if she had told anyone about this, and LPN # 1 replied she had talked to the DON. RN # 2 stated she had assumed this meant the use of the bed sheet as a restraint. 3. The Abuse Policy, not dated, was provided by the Interim Director of Nursing, on 9/21/11 at 12:50 P.M., and indicated "...Procedure when observing alleged abuse: 1. Intervene-stop the abuse immediately...report the alleged abuse to the unit supervisor. Unit supervision (sic) must report the incident within hour to Director of Nursing or the Administrator..." The policy and procedure lacked any documentation of the need to do a thorough investigation, the need to complete interviews with staff and/or residents, or the need to suspend the staff involved in alleged abuse. The Immediate Jeopardy that began on 7/8/11 was removed on 9/19/11, when the facility terminated the employment of LPN #1 and demonstrated policies and procedures had been put in place to ensure staff were knowledgeable concerning the abuse protocol which included how to report abuse and the procedures for investigating, but the noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy, because all staff had not been inserviced. This federal tag relates to Complaint IN 102. 3.1-28(c) 3.1-28(d)

Based on interview and record review, the facility failed to ensure allegations of mistreatment voiced by staff members were immediately reported to the Administrator and thoroughly investigated according to the facility's abuse prevention policy and procedure, for 2 of 3 residents reviewed for mistreatment in the sample of 3 (Residents A and B). This had the potential to affect all 33 of 33 residents residing within the facility. The Immediate Jeopardy began on 7/8/11 when a LPN used a gait belt to keep a resident from getting up from his chair and was not suspended pending an investigation resulting in another resident being tied to a chair with a bed sheet by this same LPN on two different days. The staff working with the LPN did not report this to the Director of Nursing or Administrator immediately, resulting in a delayed investigation of the mistreatment and allowed the LPN to continue to work on the floor with the residents. The Administrator was notified of the Immediate Jeopardy at 4:30 P.M. on 9/22/11. The immediate jeopardy was removed on 9/19/11, but noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include 1. The clinical record for Resident B was reviewed on 9/22/11 at 12:50 P.M. The record indicated Resident B had [DIAGNOSES REDACTED]. The MDS (minimum data set) assessment, dated 8/25/11, indicated Resident B had short term memory problems and had moderately impaired decision making. Resident B required limited assistance of one with bed mobility, transfers and ambulation. The Nurses Notes lacked any documentation from 7/6/11 to 7/13/11. The Social Services Notes lacked any documentation from 7/6/11 to 7/19/11. In a telephone interview with CNA # 5, on 9/22/11 at 10:10 A.M., she stated about 3 or 4 months ago, LPN # 1 had tied Resident B in his wheelchair, and she had contacted the Administrator by telephone. She indicated he told her to remove the restraint from Resident B immediately. She stated she did not know why LPN # 1 had placed the gait belt on Resident B. In an interview with the Administrator, on 9/22/11 at 10:15 A.M., he indicated CNA # 5 had called him immediately when LPN # 1 had placed a restraint across Resident B. He indicated he had contacted the interim Director of Nursing and she had contacted LPN # 1 and told her not to do it again. He further indicated he had contacted the Interim Director of Nursing and she had contacted LPN # 1 at the facility and told her this was not allowed. In interview with the interim DON on 9-22-11 at 10:55 a.m., she indicated she first began working at this facility in July 2011. She indicated she received a phone call from the Administrator some time in July regarding Resident #B. She indicated she recalled this resident had been in his wheelchair and facility staff had placed a gait belt across the arms of the wheelchair. She indicated the phone call was received while driving home. She indicated she spoke to a (an unidentified) CNA (Certified Nursing Assistant) who had immediately reported this to the Administrator and then spoke with LPN #1. She indicated she recalled LPN #1 said the gait belt "wasn't touching his skin." She indicated she had told LPN #1 that the gait belt was preventing him from getting out of the wheelchair, so would be considered a restraint. She indicated LPN #1 then told her the gait belt had already been removed. On 9/22/11 at 11:05 A.M., the Interim Director of Nursing provided a statement, dated 7/9/11, which indicated "July 9, 2011. Approx. (approximately) 5:30 P CST (LPN # 1 name) This nurse received a telephone call from the Administrator 7/8/11, stating that he had received a telephone call concerning (LPN # 1) placing a gait belt across the armrests of (Resident B) wheelchair. This nurse called the facility and asked the CNA that answered the telephone, if she had placed a gait belt on (Resident B) in that fashion. The CNA stated that she had for a minute, but (Administrator name) told her to take it off. (LPN # 1) was asked about the incident, she stated to this nurse that she had placed it on the chair, then thought differently of it, and removed it after a CNA had told her she couldn't do that. (LPN # 1) was verbally counseled over the telephone that it was illegal and that she could lose her license for unwillingly restraining that resident. She stated it was not touching the resident. I instructed her that it prevented him from rising and considered a restraint. CNA at the facility stated that (LPN #1) was told she was doing wrong and immediately removed it...When CNA was asked how long the resident had belt across his chair, they state that it was immediately taken off." The Interim DON indicated there was no further investigation of the incident and LPN # 1 was not suspended pending investigation. 2. The clinical record of Resident A was reviewed on 9-21-11 at 2:33 p.m. His [DIAGNOSES REDACTED]. Review of Resident A's most recent Minimum Data Set (MDS) assessment, a significant change assessment dated [DATE], indicated a moderate cognitive impairment. It indicated he was able to move about the facility without assistance with the use of a wheelchair or walker. The MDS indicated no mood or behavioral issues. Nursing notes, dated 9-13-11 at 1:30 a.m., indicated Resident #A was in and out of his wheelchair, talking loudly and demanding breakfast. On the same date at 11:15 a.m., notes indicated he was weepy at times, and not oriented to time. On 9-14-11 at 12:00 a.m., nursing notes indicated he was "tearful one moment, agitated the next. Very confused...cursing...delusional." On 9-15-11 at 11:00 p.m., nursing notes indicated Resident #A was, "Talking loudly, packing his belongings. Res (resident) thought this nurse was putting 'handcuffs' on him (sign for with) wrist monitor B/P (blood pressure cuff). On 9-16-11 at 9:15 a.m., nursing notes indicated Resident #A "continues to remove clip alarm & refuses to use, 'I will get up whenever I want to.'" On same date at 10:30 a.m., notes indicated the resident was sent to an area emergency room for evaluation and treatment after a fall. On the same date at 3:35 p.m., nursing notes indicated he returned from the emergency room with no apparent injury. On 9-17-11 at 7:30 p.m., nursing notes indicated, "Resident has been yelling. Delusional. Threatening staff. Rolling (signs for up and down) halls in w/c (wheelchair) yelling, 'call 911, call 911, I want to go to jail.' Unable to calm resident, swinging fist @ (at) staff." Notes indicated a nurse practitioner was contacted who provided a one time order for [MEDICATION NAME] (an anti-anxiety medication) to be given at that time. Nursing notes one hour later indicated the resident had calmed down, but remained up in a chair. Nursing notes on 9-18-11 at 6:00 p.m. indicated the resident was, "very agitated, tense, non-redirectable, paranoid, threatening staff." It again indicated a nurse practitioner was notified and ordered the same medication as the evening prior. Nursing notes for 9-19-11 were not present. Nursing notes for 9-20-11, with no time listed, indicated Resident #A continued to be tense, argumentative, non-cooperative and non-redirectable. On the same date at 10:00 p.m., notes indicated the resident was apologetic. Nursing notes indicated earlier in the shift, the resident had been belligerent, yelling out and cursing. During interview with the Administrator on 9-21-11 at 4:05 p.m., he indicated Resident #A was waiting for him when he came into the building on Monday, 9-19-11, around 9:30 a.m. He indicated this was something the resident did on a regular basis. He indicated Resident #A told him the "weekend nurse was mean to him and tied him to a bed." He indicated he immediately began an investigation. He indicated he had RN#1 come in and "he told her the same thing." The Administrator indicated he was unsure exactly when this (the allegation of abuse) took place, "just over the weekend." He indicated he spoke with the nurse involved (LPN #1), and "she admitted that she did use a sheet to restrain (name of Resident #A)." He indicated LPN #1 was terminated. In interview with the interim Director of Nursing (DON) on 9-21-11 at 4:05 p.m., she indicated, "A lot of what we have so far as an investigation is only alleged." She indicated that it was determined the resident had been restrained with a sheet into a geri-chair, not a bed. She indicated LPN #1 "allegedly told someone about the restraints that she might get fired over this." She indicated the facility spoke to as many of the staff on duty as possible. She indicated, "The aides seemed to be uncomfortable reporting anything." She indicated LPN #1 apparently made a reference to using a sheet (for a restraint) to the other nurse at shift change. The DON also provided a nursing schedule which indicated LPN # 1 had worked on 9/17 and 9/18/11 from 5:00 P.M. to 5:00 A.M. both days. In an interview with RN # 1, on 9/22/11 at 9:30 A.M., she indicated the first time she had heard anything concerning Resident A being tied down with a bed sheet was when the resident reported it to the Administrator on 9/19/11. She indicated she had been in the facility on both 9/17 and 9/18/11 between the hours of 3:30 P.M. to around 7:00 P.M. to help out. She stated she had not seen Resident A tied with a bed sheet. She further indicated that no staff had reported to her that Resident A had been tied in a chair. In an interview with the Administrator, on 9/22/11 at 10:00 A.M., he indicated he had spoke with several staff members during the investigation. He paraphrased the following written statements for the following: RN # 1- stated she was aware Resident A was tied to a chair with a sheet during shift change on 9/18/11. CNA # 1- stated she thought RN # 1 was aware Resident A was tied with a sheet. She stated Resident A was checked at 7:30 P.M. and was tied to the chair at that time. CNA # 2- stated didn't know anything about it. CNA # 3 had seen Resident A tied in chair on Saturday at 8:00 P.M. CNA # 4- had seen no restraints during the weekend. The Administrator provided a Grievance/Complaint/Concern Report, dated 9/19/11, which indicated "Resident Name: (Resident A)...Person Filing Report: (Administrator's name)...9:30 AM Resident came to Administrator's office reported that he was tied to bed last 2 nights by the night shift nurse. I told resident that I would investigate and get back with him. I had DON (Director of Nursing) come to my office so that Resident could tell her so we could start investigation ...Measures take to resolve this grievance/complaint/concern: I instructed DON to get list of employees that worked and phone numbers and to talk to and to have them all fill out statements DON came back to my office and stated nurse (RN # 2 name) stated (LPN # 1) night shift nurse told her she had tied Resident to chair with a sheet and would probably get fired. I interviewed (RN # 2 name) and she stated (LPN # 1) did tell her that. Called (LPN # 1) at 2:23 pm asked her about (Resident A) she said I did tie him up Saturday [DATE]. I told LPN # 1 that's abuse and you are terminated at this time. 2:45 (LPN # 1) called back and said she would never hurt a resident and was trying to protect him. I restated you can not tie up residents. Started inservicing staff again on abuse." Attached to this was a written note, dated 9/18/11, which indicated "8 AM (Resident A) said he was tied down last night. 6 PM Nurse said resident was having behaviors after my shift ended. She ordered [MEDICATION NAME] IM (intramuscularly) one time only. She stated that she may get fired but she tied him to chair with sheet because she didn't know what else to do he was kicking and hitting at the girls. She said she had to do this the night before also. I asked if she called DON. She said she did and that DON said we would see if we could get him to behavior unit." In a telephone interview with CNA # 5, on 9/22/11 at 10:10 A.M., she indicated over the weekend Resident A had increased behaviors and had to have a shot both evenings. She stated she was aware Resident A had been tied to a chair both days with a sheet. She stated she thought it was about 1 to 2 hours each evening. In an interview with RN # 2, on 9/22/11 10:20 A.M., she stated LPN # 1 had told her she had tied Resident A to a chair with a bed sheet on 9/19/11 during shift change. She further indicated LPN # 1 had informed her she had done this before. She stated she had asked LPN # 1 if she had told anyone about this, and LPN # 1 replied she had talked to the DON. RN # 2 stated she had assumed this meant the use of the bed sheet as a restraint. 3. The Abuse Policy, not dated, was provided by the Interim Director of Nursing, on 9/21/11 at 12:50 P.M., and indicated "...Procedure when observing alleged abuse: 1. Intervene-stop the abuse immediately...report the alleged abuse to the unit supervisor. Unit supervision (sic) must report the incident within hour to Director of Nursing or the Administrator..." The policy and procedure lacked any documentation of the need to do a thorough investigation, the need to complete interviews with staff and/or residents, or the need to suspend the staff involved in alleged abuse. The Immediate Jeopardy that began on 7/8/11 was removed on 9/19/11, when the facility terminated the employment of LPN #1 and demonstrated policies and procedures had been put in place to ensure staff were knowledgeable concerning the abuse protocol which included how to report abuse and the procedures for investigating, but the noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy, because all staff had not been inserviced. This federal tag relates to Complaint IN 102. 3.1-27(a)(3) 3.1-27(a)(4) 3.1-28(a)

Based on interview and record review, the facility failed to ensure residents were free from mistreatment, related to one resident restrained with a sheet and another restrained with a gait belt, for 2 of 3 residents reviewed for abuse in the sample of 3. Residents A and B. Findings include: 1. The clinical record for Resident B was reviewed on 9/22/11 at 12:50 P.M. The record indicated Resident B had [DIAGNOSES REDACTED]. The MDS (minimum data set) assessment, dated 8/25/11, indicated Resident B had short term memory problems and had moderately impaired decision making. Resident B required limited assistance of one with bed mobility, transfers and ambulation. The Nurses Notes lacked any documentation from 7/6/11 to 7/13/11. The Social Services Notes lacked any documentation from 7/6/11 to 7/19/11. In a telephone interview with CNA # 5, on 9/22/11 at 10:10 A.M., she stated about 3 or 4 months ago, LPN # 1 had tied Resident B in his wheelchair with a gait belt, and she had contacted the Administrator by telephone. She indicated he told her to remove the restraint from Resident B immediately. She stated she did not know why LPN # 1 had placed the gait belt on Resident B. In an interview with the Administrator, on 9/22/11 at 10:15 A.M., he indicated CNA # 5 had called him immediately when LPN # 1 had placed a restraint across Resident B. He indicated he had contacted the interim Director of Nursing (DON) and she had contacted LPN # 1 and told her not to do it again. He further indicated the Interim Director of Nursing had told LPN #1 this was not allowed. In interview with the interim DON on 9-22-11 at 10:55 a.m., she indicated she first began working at this facility in July 2011. She indicated she received a phone call from the Administrator some time in July regarding Resident #B. She indicated she recalled this resident had been in his wheelchair and facility staff had placed a gait belt across the arms of the wheelchair. She indicated the phone call was received while driving home. She indicated she spoke to a (an unidentified) CNA (Certified Nursing Assistant) who had immediately reported this to the Administrator and then spoke with LPN #1. She indicated she recalled LPN #1 said the gait belt "wasn't touching his skin." She indicated she had told LPN #1 that the gait belt was preventing him from getting out of the wheelchair, so would be considered a restraint. She indicated LPN #1 then told her the gait belt had already been removed. On 9/22/11 at 11:05 A.M., the Interim Director of Nursing provided a statement, dated 7/9/11, which indicated "July 9, 2011. Approx. (approximately) 5:30 P CST (LPN # 1 name) This nurse received a telephone call from the Administrator 7/8/11, stating that he had received a telephone call concerning (LPN # 1) placing a gait belt across the armrests of (Resident B) wheelchair. This nurse called the facility and asked the CNA that answered the telephone, if she had placed a gait belt on (Resident B) in that fashion. The CNA stated that she had for a minute, but (Administrator name) told her to take it off. (LPN # 1) was asked about the incident, she stated to this nurse that she had placed it on the chair, then thought differently of it, and removed it after a CNA had told her she couldn't do that. (LPN # 1) was verbally counseled over the telephone that it was illegal and that she could lose her license for unwillingly restraining that resident. She stated it was not touching the resident. I instructed her that it prevented him from rising and considered a restraint. CNA at the facility stated that (LPN #1) was told she was doing wrong and immediately removed it...When CNA was asked how long the resident had belt across his chair, they state that it was immediately taken off." The Interim DON indicated there was no further investigation of the incident and LPN # 1 was not suspended pending investigation. 2. The clinical record of Resident A was reviewed on 9-21-11 at 2:33 p.m. His [DIAGNOSES REDACTED]. Review of Resident A's most recent Minimum Data Set (MDS) assessment, a significant change assessment dated [DATE], indicated a moderate cognitive impairment. It indicated he was able to move about the facility without assistance with the use of a wheelchair or walker. The MDS indicated no mood or behavioral issues. Nursing notes, dated 9-13-11 at 1:30 a.m., indicated Resident #A was in and out of his wheelchair, talking loudly and demanding breakfast. On the same date at 11:15 a.m., notes indicated he was weepy at times, and not oriented to time. On 9-14-11 at 12:00 a.m., nursing notes indicated he was "tearful one moment, agitated the next. Very confused...cursing...delusional." On 9-15-11 at 11:00 p.m., nursing notes indicated Resident #A was, "Talking loudly, packing his belongings. Res (resident) thought this nurse was putting 'handcuffs' on him (sign for with) wrist monitor B/P (blood pressure cuff). On 9-16-11 at 9:15 a.m., nursing notes indicated Resident #A "continues to remove clip alarm & refuses to use, 'I will get up whenever I want to.'" On same date at 10:30 a.m., notes indicated the resident was sent to an area emergency room for evaluation and treatment after a fall. On the same date at 3:35 p.m., nursing notes indicated he returned from the emergency room with no apparent injury. On 9-17-11 at 7:30 p.m., nursing notes indicated, "Resident has been yelling. Delusional. Threatening staff. Rolling (signs for up and down) halls in w/c (wheelchair) yelling, 'call 911, call 911, I want to go to jail.' Unable to calm resident, swinging fist @ (at) staff." Notes indicated a nurse practitioner was contacted who provided a one time order for [MEDICATION NAME] (an anti-anxiety medication) to be given at that time. Nursing notes one hour later indicated the resident had calmed down, but remained up in a chair. Nursing notes on 9-18-11 at 6:00 p.m. indicated the resident was, "very agitated, tense, non-redirectable, paranoid, threatening staff." It again indicated a nurse practitioner was notified and ordered the same medication as the evening prior. Nursing notes for 9-19-11 were not present. Nursing notes for 9-20-11, with no time listed, indicated Resident #A continued to be tense, argumentative, non-cooperative and non-redirectable. On the same date at 10:00 p.m., notes indicated the resident was apologetic. Nursing notes indicated earlier in the shift, the resident had been belligerent, yelling out and cursing. During interview with the Administrator on 9-21-11 at 4:05 p.m., he indicated Resident #A was waiting for him when he came into the building on Monday, 9-19-11, around 9:30 a.m. He indicated this was something the resident did on a regular basis. He indicated Resident #A told him the "weekend nurse was mean to him and tied him to a bed." He indicated he immediately began an investigation. He indicated he had RN #1, the interim DON,come in and "he (the resident) told her the same thing." The Administrator indicated he was unsure exactly when this (the allegation of abuse) took place, "just over the weekend." He indicated he spoke with the nurse involved (LPN #1), and "she admitted that she did use a sheet to restrain (name of Resident #A)." He indicated LPN #1 was terminated. In interview with the interim Director of Nursing (DON) on 9-21-11 at 4:05 p.m., she indicated, "A lot of what we have so far as an investigation is only alleged." She indicated that it was determined the resident had been restrained with a sheet into a geri-chair, not a bed. She indicated LPN #1 "allegedly told someone about the restraints that she might get fired over this." She indicated the facility spoke to as many of the staff on duty as possible. She indicated, "The aides seemed to be uncomfortable reporting anything." She indicated LPN #1 apparently made a reference to using a sheet (for a restraint) to the other nurse at shift change. The DON also provided a nursing schedule which indicated LPN # 1 had worked on 9/17 and 9/18/11 from 5:00 P.M. to 5:00 A.M. both days. In an interview with RN # 1, on 9/22/11 at 9:30 A.M., she indicated the first time she had heard anything concerning Resident A being tied down with a bed sheet was when the resident reported it to the Administrator on 9/19/11. She indicated she had been in the facility on both 9/17 and 9/18/11 between the hours of 3:30 P.M. to around 7:00 P.M. to help out. She stated she had not seen Resident A tied with a bed sheet. She further indicated that no staff had reported to her that Resident A had been tied in a chair. In an interview with the Administrator, on 9/22/11 at 10:00 A.M., he indicated he had spoke with several staff members during the investigation. He paraphrased the following written statements for the following: RN # 1- stated she was aware Resident A was tied to a chair with a sheet during shift change on 9/18/11. CNA # 1- stated she thought RN # 1 was aware Resident A was tied with a sheet. She stated Resident A was checked at 7:30 P.M. and was tied to the chair at that time. CNA # 2- stated didn't know anything about it. CNA # 3 had seen Resident A tied in chair on Saturday at 8:00 P.M. CNA # 4- had seen no restraints during the weekend. The Administrator provided a Grievance/Complaint/Concern Report, dated 9/19/11, which indicated "Resident Name: (Resident A)...Person Filing Report: (Administrator's name)...9:30 AM Resident came to Administrator's office reported that he was tied to bed last 2 nights by the night shift nurse. I told resident that I would investigate and get back with him. I had DON (Director of Nursing) come to my office so that Resident could tell her so we could start investigation ...Measures take to resolve this grievance/complaint/concern: I instructed DON to get list of employees that worked and phone numbers and to talk to and to have them all fill out statements DON came back to my office and stated nurse (RN # 2 name) stated (LPN # 1) night shift nurse told her she had tied Resident to chair with a sheet and would probably get fired. I interviewed (RN # 2 name) and she stated (LPN # 1) did tell her that. Called (LPN # 1) at 2:23 p.m. asked her about (Resident A) she said I did tie him up Saturday [DATE]. I told LPN # 1 that's abuse and you are terminated at this time. 2:45 (LPN # 1) called back and said she would never hurt a resident and was trying to protect him. I restated you can not tie up residents. Started inservicing staff again on abuse." Attached to this was a written note, dated 9/18/11, which indicated "8 AM (Resident A) said he was tied down last night. 6 PM Nurse said resident was having behaviors after my shift ended. She ordered [MEDICATION NAME] IM (intramuscularly) one time only. She stated that she may get fired but she tied him to chair with sheet because she didn't know what else to do he was kicking and hitting at the girls. She said she had to do this the night before also. I asked if she called DON. She said she did and that DON said we would see if we could get him to behavior unit." In a telephone interview with CNA # 5, on 9/22/11 at 10:10 A.M., she indicated over the weekend Resident A had increased behaviors and had to have a shot both evenings. She stated she was aware Resident A had been tied to a chair both days with a sheet. She stated she thought it was about 1 to 2 hours each evening. In an interview with RN # 2, on 9/22/11 10:20 A.M., she stated LPN # 1 had told her she had tied Resident A to a chair with a bed sheet on 9/19/11 during shift change. She further indicated LPN # 1 had informed her she had done this before. She stated she had asked LPN # 1 if she had told anyone about this, and LPN # 1 replied she had talked to the DON. RN # 2 stated she had assumed this meant the use of the bed sheet as a restraint. 3. The Abuse Policy, not dated, was provided by the Interim Director of Nursing, on 9/21/11 at 12:50 P.M., and indicated "...Procedure when observing alleged abuse: 1. Intervene-stop the abuse immediately...report the alleged abuse to the unit supervisor. Unit supervision (sic) must report the incident within hour to Director of Nursing or the Administrator..." This federal tag relates to Complaint IN 102. 3.1-27(a)(3) 3.1-28(a)

Based on observation, interview and record review, the facility failed to ensure 1 of 3 residents reviewed who were risk for elopement in a sample of 3 (Resident A) was monitored to ensure his whereabouts, with the resident eloping while doors were unlocked during a fire drill and staff not monitoring the doors or the residents. Resident A was discovered missing from the facility approximately 2 and 1/2 hours after the fire drill and found by police approximately 60 miles away. This deficient practice resulted in Immediate Jeopardy past non compliance. The Immediate Jeopardy was identified on 12/20/10 and began on 12/13/10. The Administrator and Director of Nursing were notified of the Immediate Jeopardy on 12/20/10. The Immediate Jeopardy was removed and corrected on 12/13/10 as confirmed by the resident was returned to the facility on [DATE], the policy and procedure for fire drills and assuring all residents are accounted for at all times was revised and all staff members inserviced on the new policy and procedures. All exit doors were observed and locked. Findings include: During the initial tour of the facility on 12/20/10 at 12:00 p.m., the Director of Nursing indicated Resident A required a code alert bracelet to prevent elopement. Upon entrance to the facility on [DATE] at 12:00 p.m., all exit doors were observed to have a key pad entry. During interview with the health facility administrator on 12/20/10 at 12:40 p.m. he indicated the front and side doors had the code alert system that would lock down and not open when a resident was near with the code alert on. The doors would release after the door bar was held down for 15 seconds but an alarm sounded to alert staff. He indicated the back door only had a key pad alarm and not the code alert system. Staff had to let all residents in and out of the fenced backyard with the key pad. The facility administrator further indicated all doors unlocked when the fire alarm system was activated, such as during a fire alarm. On 12/20/10 at 12:00 P.M., Resident A was observed in the facility. He was unable to appropriately answer questions concerning recent events. He was observed to ambulate freely about the facility. Resident A's clinical record was reviewed on 12/20/10 at 12:45 P.M. Social Service notes indicated the resident was admitted on [DATE] at 5 P.M. from a facility in another city, because they did not have a secure unit. The note indicated the resident was "confused" and "will monitor on 1 on 1 for 2 hours then 15 minute checks times 72 hours." A social service note dated 11/18/10 at 6 p.m., indicated the resident was placed on a behavioral management program for exit seeking. During interview with the Social Service Director on 12/20/10 at 12:45 p.m., she indicated they had gone to the facility in the other city to assess the resident. She indicated the other facility did not have a secure unit or code alert, and the resident was transferred because he was an elopement risk. A wandering/elopement risk assessment, dated 11/19/10, indicated the resident was at risk for elopement, with "code alert on and functioning" and "on behavior management program for exit seeking." The form indicated the resident exhibited aimless ambulation at times, looks out exit doors and had a stressor of new admission to the facility. A behavioral risk assessment, dated 11/19/10, indicated the resident was cognitively impaired. A history and physical, dated 5/31/10, indicated: "status [REDACTED]. He was alert and oriented only times one..." The admission Minimum Data Set assessment, dated 11/24/10, indicated the resident had short term memory loss, could not recall three words after five minutes, did not know the year or month, or day of week, he had unclear speech and sometimes made himself understood, and at times missed some part of message told to him. The care plan, dated 11/18/10, included problems for "cognitive deficit, impaired decision making short term memory problem as evidenced by moderately impaired, decision poor," "resident wished to smoke and is designated as impaired smoker," "potential for injury fall risk related to cognitive deficit, impaired safety awareness." The care plan did not include a plan for the resident's elopement risk. A Behavior Management Plan, dated 11/18/10, indicated "Behavior problem: Exit seeking. Potential for exit seeking behavior related to confusion." The interventions included "1. redirect with diversional activity. 2. explain to resident why he cannot leave the facility unattended. 3. 1:1 (one to one) supervision, 15 minute checks prn (as needed). 4. notify MD/SSD (MD/Social Services Director) if behavior increases. 5. code alert bracelet, check q (every) shift for proper functioning." admission orders code alert bracelet" and medications for seizures which included Dilantin and Valproic acid. Nurses' notes indicated the resident was admitted on [DATE] at 4:35 p.m., and the code alert was placed on his right ankle. Nurse notes for 11/20/10 at 12 A.M. indicated "...exit seeking all evening...ambulates around facility checking doors exit...." Nurses' notes dated 12/13/10 indicated: "830 a.m. resident up ad lib code alert checked and working properly..." "1230 p.m. unable to locate res in facility no lunch eaten looked in all facility area and res not found..." "200 P.M. adm (administrator) returning res to facility..." "245 p RD (resident) back in facility. placed one on one monitoring resident stated he does not want to be in nursing home that he wants to live with his brother...called placed to (family member) to explain to her that resident is his own person and that it is difficult for us to keep him here against his will. spoke with her about the process of obtaining guardianship...." The Wandering Resident Monitor Implementation policy, dated 3/28/06, was provided by the Administrator, on 12/20/10 at 12:10 P.M. The policy indicated "...Residents identified as being at high risk for harm due to wandering or elopement behavior will be monitored when necessary to insure a safe environment...." The Report of Monthly Fire Drill, dated 12/13/10, was provided by the Administrator, on 12/20/10 at 12:10 P.M. The form indicated "...Date: 12-13-10. Time of Alarm: 9:48 AM. Duration of Alarm: 10:00 AM...Exit Doors Released: Front: Y (yes), West Side: Y, Back: Y...Head Count: (this section was left blank)...." In an interview with the Administrator, on 12/20/10 at 12:20 P.M., he indicated when he did the fire drills, a head count was only done when the building was evacuated. The Director of Nursing provided her investigation statement, on 12/20/10 at 12:05 P.M. The statement, dated 12/18/10, indicated "...I received a call that (Resident A) was not in the building. An initial search inside of the building and outside perimeter was conducted and the resident could not be located. The Lawrence County Police Department was immediately notified. The resident was located at a Mc Donald's in Seymour (approximately 1 hour away from where facility located) at approximately 2:15 p.m...After interview of staff on duty, it was determined that a fire drill had been conducted earlier that morning, during which time there was an approximately 20 minute time period that the doors were unlocked. After interviewing the staff on duty, it was deduced that the resident could only have left during this time period. Upon return, the resident had stated that he followed a visitor out of the building, but this could not be verified...Resident placed on 1:1 supervision until magnetic locks are ordered and installed. Motion sensor placed on door of resident's room to alert staff when he is out of his room...." In an interview with CNA (Certified Nursing Assistant) #1 on 12/20/10 at 12:20 P.M., she indicated that she was in facility at the time of the fire drill on 12/13/10. CNA #1 further indicated that Resident A was in his room between the 10:00-10:30 A.M. on that day because "I checked him personally." She further indicated that she had delivered his lunch tray at 11:40 A.M. on 12/13/10 and she did not see Resident A. "I thought he was in the bathroom." CNA #1 indicated she was alerted by another CNA who was picking up hall trays after lunch that Resident A "hadn't touched his lunch" and they began looking for him. CNA #1 further indicated she had not done a head count after the fire drill. In an interview with PTA (Physical Therapy Assistant) #1 on 12/20/10 at 12:30 P.M. she indicated, "I came out the back door at 10:00 A.M. and it was unlocked from the fire drill. I told (name of maintenance man) immediately." She further indicated she had done a head count of 11 people in the front dining room, but he was not in the front dining room with her. In an interview with Housekeeping Assistant #1 on 12/20/10 at 12:40 P.M. she indicated, "I noticed him around the back door at around 10:30 A.M., that is not unusual, I didn't tell anyone." She further indicated she had not done a head count after the fire drill. In an interview with the Dietary Manager/Activity Director on 12/20/10 at 12:45 P.M., she indicated, "I took smokers out to smoke break at 10:10 A.M.-he missed it, I didn't see him." She further indicated she had not done a head count after the fire drill. During interview with the maintenance man on 12/20/10 at 2 P.M., he indicated he had problems resetting the fire alarm system on 12/13/10 and could not reset the doors until the alarm for the fire system was reset. He indicated he had to phone the company who services the fire alarm system and they helped him to reset the system. He then started to go reset the door alarms when staff told him the back door was not locked. During interview with the facility Administrator on 12/20/10 at 2:00 P.M., he indicated all door alarms must be manually reset after a fire drill, and there were three exit doors with alarms which required being reset. He indicated on 12/13/10 the maintenance man had been in the process of resetting the fire and door alarms when a staff member was taking the residents out to smoke and noticed the back door was not alarmed yet. He indicated the maintenance man was in the process of resetting the doors at that time. He indicated the resident had been located by police at a town approximately 60 miles from the facility. He further indicated he thought he had hitchhiked with a driver or drivers to the Mc Donald's in that town. He indicated the facility had changed the system for fire alarms following the elopement. Now staff will monitor each exit door during a fire alarm as the doors are not alarmed, a head count will be conducted after each fire drill to ensure all residents are accounted for and specific staff will be assigned to any resident with a risk of elopement. All staff were inserviced on this system on 12/13/10 after the resident was returned to the facility. An Immediate Jeopardy of past non compliance was identified on 12/20/10. The Immediate Jeopardy began on 12/13/10 when a resident eloped from the facility and was not discovered missing for 2 and 1/2 hours following a fire drill. The Administrator was notified of the Immediate Jeopardy on 12/20/10 at 2:30 P.M. related to failure to assure the safety and whereabouts of residents at risk for elopements. The Immediate Jeopardy was removed and corrected on 12/13/10 when the facility had implemented a plan of action to remove the Immediate Jeopardy. The resident was returned to the facility on [DATE], and the policy and procedure for fire drills and assuring all residents are accounted for at all times was revised and all staff members inserviced on the new policy and procedures. All staff members were documented to have been inserviced. All exit doors were observed and locked. This federal tag relates to Complaint IN 661. 3.1-45(a)(1) 3.1-45(a)(2)